Intussusception is a rare cause of bowel obstruction caused by both benign and malignant pathology. We are presenting the case of an elderly patient who had been diagnosed with irritable bowel syndrome for many years prior to presenting to us with ileocecal intussusception causing a small bowel obstruction. Laparoscopic resection of the terminal ileum and cecum was performed. Pathology revealed multiple submucosal lipomas as the underlying cause. Intussusception is defined as the invagination of a proximal bowel segment into the lumen of an adjacent distal segment. It is the cause of 1% - 5% of small bowel obstructions in adults . IntussuA 67-year-old Caucasian male, who been diagnosed for many years with irritable bowel syndrome, presented to our emergency room with a five-day history of abdominal pain, nausea, vomiting, and obstipation. The patient's past medical history also included hypertension and an appendectomy. His examination revealed a soft, distended abdomen. A computed tomography (CT) scan of the abdomen and pelvis was consistent with small bowel obstruction secondary to ileocecal intussusception Figure .He was admitted to the hospital, and a laparoscopic right hemicolectomy with resection of the terminal ileum and an extracorporeal side-to-side stapled ileocolic anastomosis was performed Figure . The patGross pathology revealed two submucosal lipomas with an ischemic terminal ileum loop Figure . HistopaThe incidence of intussusception is two to three cases per 1,000,000 per annum. Intussusception is defined as the invagination of a proximal bowel segment into the lumen of an adjacent distal segment and being the cause of 1% - 5% of small bowel obstructions in adults . IntussuIntussusception in adults is rare and is usually caused by an underlying tumor, most often malignant. Reduction in adults of an ischemic bowel and possible malignancy should not be attempted. Surgical resection either via laparoscopy or laparotomy is the best therapeutic option. A thorough gastrointestinal evaluation is also recommended prior to assigning the diagnoses of irritable bowel syndrome. In our case, the cause was multiple submucosal lipomas.


Synovial cell sarcomas are usually seen in a juxta-articular location. However, they occur rarely in the head and neck region.We report a rare case of brachial plexus synovial sarcoma in a 24-year old South Asian man treated successfully with surgical excision followed by radiotherapy.Synovial sarcoma arising from the brachial plexus is rare. The treatment is multimodal with complete excision  and adjuvant therapy. Synovial sarcomas are malignant soft tissue tumors arising from mesenchymal cells, which resemble synovial cells . They arSynovial sarcoma of the brachial plexus is extremely rare .Fourteen cases of synovial sarcoma associated with a peripheral nerve have been reported ; only siWe report a case of synovial sarcoma of the brachial plexus abutting the subclavian artery. The tumor was successfully excised with no functional deficit or recurrence at 6 months. Information about this type of tumor in current medical literature is very limited and hence our work-up plan and treatment plan had to be formulated based on worldwide experience.A 24-year-old South Asian man presented to our hospital with a progressively enlarging swelling that started on the left side of his neck and extended inferior to the clavicle Fig.  increasiOn examination a 10 × 12 cm globular, firm, non-pulsatile and immobile swelling was palpable on the left side of his neck. Tinel’s sign was negative on percussion. The lateral border of swelling was felt in the apex of axilla; it had smooth lobulated borders. He did not have any motor or sensory deficits. However, the brachial, radial, and ulnar artery pulses were absent. There was no locoregional lymphadenopathy and no metastasis. The clinical staging was stage 3 tumor  according to the tumour, nodes and metastasis (TNM) classification.SYT-SSX1 translocation in immunohistopathology. At a multidisciplinary team (MDT) meeting with medical oncology it was suggested that excision of the lesion be attempted  followed by adjuvant chemotherapy and radiotherapy (RT).Magnetic resonance imaging (MRI) showed a well-encapsulated 7.4 cm × 9.2 cm × 13.6 cm, ovoid-shaped, heterogeneous lesion in the left interscalene and posterior triangle, the costoclavicular space, and retropectoralis minor space with hypointense areas on T2/short T1 inversion recovery (STIR) and hyperintense with isointense areas on T1 with fluid levels  guidelines [The histopathology was reported as intermediate grade synovial sarcoma with idelines . He undeSYT-SSX1 rather than with SYT-SSX2 [Synovial sarcoma accounts for 8% of soft tissue sarcomas , 4. TheySYT-SSX2 , 14.Pluripotent mesenchymal stem cells give rise to synovial sarcomas rather than the synovial membrane, but the name, synovial sarcoma, is due to its resemblance. They have both spindle and epithelioid cells in the biphasic form but only one of them in the monophasic variant. The biphasic variant is easy to detect but the monophasic form has some close differentials like spindle cell carcinoma, hemangiopericytoma, leiomyosarcoma, fibrosarcoma, and melanoma. The use of tumor markers like keratin, vimentin, and EMA, and electron microscopy can confirm the diagnosis . ChromosThe goals have been to remove the tumor completely, to control the local growth of the tumor and prevent local recurrence/systemic metastasis. The best management protocol as per current literature for these rare tumors is surgical excision followed by RT. Excision with positive margins is a predictor of local recurrence . Preoperet al. reported survival rates at 5, 10, and 15 years of 60%, 50%, and 45% [Bergh  and 45% .Our patient was a young man who benefitted from total surgical excision and postoperative RT. At a 6-month follow-up, there was no evidence of recurrence clinically and on MRI.Synovial sarcoma arising from the brachial plexus is rare. The treatment is multimodal with complete excision  and adjuvant therapy.


Neuroendocrine carcinoma (NEC) arising from the extrahepatic biliary tracts (EHBTs) is rare, and thus its management and prognosis remain poorly clarified. We herein describe a case of NEC in the perihilar EHBTs, and review the literature, together with a comparison between NECs in the perihilar and distal EHBTs, to elucidate the management strategy and oncological outcome of this rare entity.A 62-year-old Chinese male was admitted with complaints of painless jaundice. Imaging studies revealed a 2-cm mass in the hepatic hilum, regional lymph node involvement, and severe stenosis at the junction of the common hepatic ducts.The histopathological examination of the resected specimen demonstrated small tumor cells with round hperchromatic nuclei and scant cytoplasm. A detailed immunohistochemical analysis showed that the tumor was strongly positive for synaptophysin, CD56 and chromogranin A, with a Ki-67 labeling index greater than 80%. These results led to a diagnosis of NEC in the perihilar bile duct.The patient underwent surgical resection including a left hemihepatectomy, cholecystectomy, lymphadenectomy and Roux-en-Y hepaticojejunostomy.During the two months of follow-up, repeated imaging studies indicated tumor recurrence in the liver. The patient died 6 months after surgery.NEC in the EHBTs is extremely challenging to diagnose preoperatively because of mimicking other bile duct cancers. The prognosis of this disease entity is dismal, and most patients die within 2 years after diagnosis. Subtyping of NECs into perihilar NECs and distal NECs is beneficial for clinical applications, including guiding therapy selection and predicting survival. Given this context, NENs are currently classified as neuroendocrine tumors (NETs) and neuroendocrine carcinomas (NECs). NECs are defined as malignant NENs with poor differentiation and high proliferation rates (Ki-67 > 20% and/or mitotic count >20 per 10 high-power fields). Accordingly, NECs show an increased tendency for distant metastasis, leading to a poor prognosis.Derived from neuroendocrine cells, neuroendocrine neoplasms (NENs) are a group of heterogeneous tumors with variable clinical and pathologic features.,4 Occasionally, NECs occur in the biliary system, with the gallbladder representing the most common site. NECs in the extrahepatic biliary tract (EHBT) are extremely rare, with a total of 21 cases reported in the English literature, and thus its management strategy and oncologic outcome remain poorly clarified.The NECs are predominantly located in the lung and gastrointestinal tract. The most common malignancy of the EHBTs is cholangiocarcinoma (CCA), which accounts for 90% of cancers in this location. It is well-established that perihilar CCA (pCCA) and distal CCA (dCCA) have distinct biologic and epidemiologic characteristics, diagnostic and therapeutic approaches, and even prognoses. Thus, it is rational to hypothesize that certain distinctions also exist between NECs in the perihilar and distal EHBT.The EHBT refers the bile tract outside the liver and extending to the level of the ampulla. Separated by the cystic duct, EHBTs are classified into perihilar and distal EHBT.For a better established recognition of this rare entity, we herein present a case of an NEC of the hilar bile duct in a 62-year-old Chinese male and a literature review of previously reported cases. Furthermore, despite the paucity of cases, we sought to compare the clinicopathologic characteristics of perihilar NEC (pNEC) and distal NEC (dNEC).2A 62-year-old Chinese male was referred to our center with complaints of painless jaundice. He had no family history of cancer. His medical history was significant for pulmonary tuberculosis, which had been treated with medications. On admission, a physical examination showed moderately icteric sclera and jaundice. The circulatory, respiratory, and abdominal examinations were unremarkable. The initial laboratory tests revealed the following: elevated total bilirubin, 403 μmol/L ; aspartate aminotransaminase, 153 U/L ; alanine aminophosphatase, 93 U/L ; carcinoembryonic antigen (CEA), 10.2 ng/mL , and carbohydrate antigen 19-9 (CA19-9), 1073.6 U/mL . A pulmonary computed tomography (CT) scan was negative except for a few areas of fibrosis resulting from the previous tuberculosis infection. Magnetic resonance cholangiopancreatography showed severe stenosis at the junction of the left and right common hepatic ducts and marked dilation of the intrahepatic bile ducts , abdominal pain (6/22 patients), anorexia/nausea/fatigue (5/22 patients), and fever (2/22 patients). Compared with dNECs, pNECs were less common, with only 8 cases reported.,27,29,32 Patients with pNEC exhibited abdominal pain less frequently. Other baseline characteristics, including age, gender, and tumor size, did not significantly differ between the 2 entities.Of the 22 cases of NECs in the EHBT (including the present case), the mean age of the patients was 68.0 years (range 32–82 years). Males predominated with a male: female ratio of 15:7. Concurrent  The absence of elevated hormone levels and corresponding hormonal symptoms suggests that biliary NECs tend to be functionally indolent. However, these features may discourage clinicians from suspecting a diagnosis of NEN.Laboratory findings of biliary NECs usually highlight elevated serum levels of CEA and CA19-9, which are classical but nonspecific biomarkers of bile duct tumors. Serum hormone levels are mostly within normal limits, in contrast to other types of NECs, such as pancreatic or bronchial NECs, that are frequently associated with hormone production.18F-fluorodeoxyglucose on positron emission tomography. Upstream bile duct dilations, lymph node involvement and adjacent stricture invasions are frequently observed on imaging. Similar to previous cases of NECs in the EHBT, our patient displayed obstructive jaundice, elevated serum CEA and CA19-9, and without hormone-related signs or specific imaging features.Radiologic techniques generally fail to distinguish NECs from other bile duct cancers because of their overlapped imaging appearance, which contributes to the high rate of misdiagnosis. On CT, NECs typically appear as solid, homogeneously hypo-intense, slightly, or moderately enhanced masses. Cholangiography often yields stenosis or an asymmetric filling defect in the EHBT. NECs could also exhibit an abnormal high uptake of  Arakura et al reported a case of pNEC in which the patient received endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosis. The author concluded that EUS-FNA facilitated diagnosis for this entity. However, EUS-FNA is generally not recommended for patients with perihilar bile duct cancers because of the high risk of tumor seeding (83%). Taken together, in most cases, a definitive diagnosis cannot be made until postoperative pathology or autopsy results are available.Histologic biopsy may carry a high false negative rate. In a review of reports, brush cytology was performed in 6 cases, and an NEC was detected in only 1 case.,28,30,32 Compared to SCC, LCC tumor cells are larger in size and have a lower nuclear to cytoplasmic ratio. IHC analysis is required to confirm histologic identification. A panel of 3 IHC staining markers, chromogranin, synaptophysin, and CD56, is used to support the diagnosis of NEC and distinguish it from adenocarcinoma. Uccella et al suggested a combined expression of chromogranin and synaptophysin was adequate to confirm neuroendocrine differentiation. Although it is not a neuroendocrine marker, Ki-67 is crucial for the proliferative activity assessment and distinction of NECs from NETs.Pathologic and IHC investigations are usually required for a definitive diagnosis of biliary NECs. Macroscopically, typical findings of NECs include a whitish or yellowish, solid mass, and thickened bile duct walls. Microscopically, NECs are traditionally divided into small-cell carcinoma (SCC) and large-cell carcinoma (LCC) on the basis of cytologic morphology. SCC is typically characterized by small, round, atypical cells, with hyperchromatic nuclei, and scant cytoplasm. These cytologic features are unique and similar to pulmonary SCC. Only 5 cases of LCC have been reported in the literature. NECs in the EHBT are relatively aggressive. In our review, regional lymph node invasion was noted in 12 patients on initial admission, and distant metastasis occurred in 16 cases. dNEC and pNEC most commonly metastasize to the liver, followed by the brain and bone. Notably, dNEC and pNEC both spread rapidly; all metastases occurred within 1 year after surgery (ranging from 8 days to 11 months postoperatively). Furthermore, multimodal treatment appeared to be ineffective in delaying metastatic events.The NEC is typically a devastating malignancy with an increased tendency for metastasis. It is estimated that over half of patients with gastroenteropancreatic NECs exhibit distant metastasis at the initial diagnosis.,38 The surgical strategy of NECs in the EHBT depends greatly on the tumor location. Resections of pNEC usually involved lobectomy with bile duct resection, lymph node dissection, and Roux-en-Y hepaticojejunostomy. Surgical resection of dNEC frequently involved pancreatoduodenectomy.The experience of clinicians in the treatments of NECs in the EHBT is greatly limited because of its rarity. In these reported cases, surgery was the main treatment  and was regarded as the only curative option. To obtain adequate oncologic margins, extensive radical excisions are generally required for biliary NECs, similar to CCAs or other NECs.,31 Extrapolating from pulmonary NECs, chemotherapy regimens for biliary NECs commonly consist of cisplatin and etoposide. However, the effectiveness does not appear to be promising; evolving data show that the response rates are much lower in patients with extrapulmonary NECs than in those with pulmonary NECs, and NECs in the hepatic-biliary-pancreatic systems have the worst response rates, as well as relatively severe toxicity. In cases of tumor recurrence or metastasis, radiotherapy should be considered.,34 Liver transplantation, a potentially curative option for a subset of patients with localized pCCA, may also be an appealing option in select cases of pNEC.,40The role of adjuvant therapies in biliary NECs remains largely undetermined. Due to the lack of standard indications, chemotherapy was employed in 7 cases, with the intent to help improve resectability or control tumor progression.,41 For NEC in the EHBT, the prognosis is extremely dismal. In the 17 reported cases in which surgeries were performed, the survival duration ranged from 21 days to 45 months. In the patient who had the longest survival, the Ki-67 labeling index was <10%, which indicates that, according to the current World Health Organization (WHO) classification system, the appropriate diagnosis was NET rather than NEC. This correct distinction makes the longest survival time 23 months rather than 45 months, which is particularly disappointing. Regarding the remaining 4 patients treated without surgical intervention, none survived more than one year. A Kaplan–Meier analysis of 19 patients with survival data was performed, which showed that survival was worse in patients with pNEC than in those with dNEC; the mean survival times of pNEC and dNEC were 7.6 months and 13.6 months, respectively, although this difference was not statistically significant. The postoperative survival appeared slightly worse in our case (6 months) when compared with the previous cases, presumably due to the combination of the highly invasive tumor biology, as measured by a high Ki-67 index (>80%), and the unfavorable tumor location (pNEC) in our patient.A worse survival outcome is observed when NECs are primarily located in the lung, gastrointestinal tracts, and hepatic-biliary-pancreatic systems, in decreasing order, despite sharing similar histology.One of the major limitations of the present study is the small number of cases available for analysis. However, this is inevitable due to the rarity of the disease entity. Additional reported cases are needed to establish a clearer consensus on the management and prognosis of NECs in the EHBT.4Establishment of a preoperative diagnosis of NEC in the EHBT is extremely challenging due to the tendency of NECs to mimic other bile duct cancers, in addition to the rarity of this type of cancer. Patients with this entity have extremely dismal survival times due to its aggressive course, and most die within 2 years after diagnosis. Analogous to CCA, we suggest that subtyping of NECs into pNEC and dNEC is beneficial for clinical applications, including guiding therapy selection and survival prediction.The authors acknowledge the support of the Department of Radiology, the First Affiliated Hospital, Zhejiang University School of Medicine.Conceptualization: Liang Zhang, ShengZhang Lin.Data curation: Qing Chen.Investigation: Qing Chen.Methodology: DaLong Wan.Supervision: ShengZhang Lin.Validation: ShengZhang Lin.Visualization: HaiYang Xie, ShiGuo Xu.Writing – original draft: Liang Zhang, DaLong Wan, Li Bao.Writing – review & editing: HaiYang Xie, ShiGuo Xu, ShengZhang Lin.


Primary adrenal leiomyosarcoma (PAL) is an extremely rare mesenchymal tumor with only a few isolated case reports in the medical literature. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or endoscopic ultrasound-guided core biopsy (EUS-CB) is a safe, effective modality for sampling lesions in the gastrointestinal tract and adjacent organs, including the adrenal glands. We describe the case of a 50-year-old male presenting with abdominal pain and unintentional weight loss over the course of one year. CT imaging revealed an 8.1 cm heterogeneous left adrenal mass with PET-confirmed metastases to the liver and lung. Pheochromocytoma was ruled out. Adrenal cortical carcinoma was the other critical differential diagnosis. As the patient was not a candidate for surgery, an EUS-FNA and CB were performed on this left adrenal mass revealing a spindle cell neoplasm with extensive necrosis confirming the diagnosis of primary leiomyosarcoma. The patient was treated with chemotherapy with palliative radiation. This case demonstrates the utility of EUS-FNA or CB as modalities that can aid in the diagnosis of adrenal lesions in specific circumstances. Primary adrenal leiomyosarcoma (PAL) is an extremely rare mesenchymal tumor with less than 35 cases reported in the medical literature . AdrenalEndoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) or endoscopic ultrasound-guided core biopsy (EUS-CB) is a safe, effective modality for sampling lesions in the gastrointestinal tract and adjacent organs, including the adrenal glands . SeveralA 50-year-old male presented with abdominal pain and unintentional weight loss over the course of one year. Physical exam and labs were normal. Computed Tomography (CT) of abdomen showed an 8.1 cm heterogeneous left adrenal mass, several bibasilar lung nodules, and several hypodense liver lesions concerning metastatic disease . PositroLeiomyosarcomas are soft tissue neoplasms of smooth muscle origin that primarily occur in the myometrium, retroperitoneum, or dermis . PALs, wSince our patient described abdominal pain and weight loss for one year, it was not surprising that metastatic disease was present at the time of diagnosis as PALs are rapidly progressive tumors. Complete surgical resection is the mainstay of treatment for nonmetastatic disease, and the role of chemotherapy or radiation is not well defined . AdriamyEUS-FNA is a novel method for diagnosing adrenal lesions in specific circumstances such as in the case described. Before the biopsy was considered, adrenal hormone testing was performed and the possibility of ACC was considered. Since the patient was to undergo chemotherapy, a tissue biopsy was needed; therefore, EUS-FNA was performed. It is a safe procedure with good results, minimal morbidity, and shorter hospital stay . In prev


With few cases of PUNLMPs in young adults being reported in the literature, we hope to raise clinical awareness of prompt and effective diagnosis, while maintaining a high index of suspicion among health professionals. Even in the absence of red blood cells in the urine and subsequent negative imaging workup, clinicians should not delay performance of diagnostic cystoscopy. Herein, we report a case of papillary urothelial neoplasm of low malignant potential (PUNLMP) in a 19‐year‐old young male. Interestingly, reddish discoloration of urine was the only clinical warning sign. Flexible diagnostic cystoscopy was performed followed by complete resection of the tumor.2Α 19‐year‐old healthy male presented to our urology department complaining about one single painless episode of reddish urine discoloration. No other symptoms or sexual intercourse were reported at that time. There was no family history of hereditary or other serious acquired diseases. Moreover, no significant predisposing risk factors for bladder cancer were identified. Initially, our patient consulted a private urologist and underwent a full blood count test, urinalysis, transabdominal ultrasound, and computed‐tomography urography (CTU). All laboratory tests were within normal limits and imaging modalities failed to indicate an intravesical papillary mass Figures . A seconThereafter, our patient sought advice from our department and flexible cystoscopy was immediately performed. A well‐defined single papillary mass, approximately <10 mm in size, involving the dome of the bladder was identified. Transurethral resection of bladder tumor (TURBT)was subsequently performed with excision of the papillary lesion. Histopathology revealed a papillary urothelial neoplasm of low malignant potential (PUNLMP) with minimal atypia in the mid‐to‐basal cell layers of the urothelium and prominent atypia of the superficial cells . Some areas suggested an inverted component not regarded as an invasion.Our patient recovered uneventfully and was suitable for discharge following day surgery with recommendations for follow‐up at three and six months. At 3‐ and 6‐month visits, cystoscopic findings were normal with no signs of recurrence. Follow‐up screening strategy included urine tests and flexible cystoscopy on a yearly basis for the next five years.3The majority of bladder cancers in young adults below the age of 20 years are low‐grade transitional cell carcinomas (TCCs) with a low recurrence rate.It was not until recently that the Surveillance, Epidemiology and End Results (SEER) study conducted between 1973 and 2003 identified 140 cases of bladder tumors in children aged below 18 years. Papillary urothelial neoplasms of low malignant potential (PUNLMPs) comprised 50.7% of these tumors, with overall survival rates being reported as favorable.The most prominent clinical sign is painless visible hematuria.Healthcare professionals need to be vigilant about every single episode of hematuria. Even in cases where urine reddish discoloration is the sole presenting symptom, as in our case, further investigation should not be omitted. Owing to low recurrence rates, even in low‐grade bladder tumors, close follow‐up is recommended.Meanwhile, in the current body of literature dearth of data about the administration of adjuvant chemotherapy still exists.4Papillary urothelial neoplasms of low malignant potential (PUNLMP) are rare in young population. Various noninvasive diagnostic modalities have been introduced. Nevertheless, cystoscopy remains the mainstay of diagnosis for every episode of hematuria, while transurethral resection of tumor represents the treatment of choice. A high index of clinical suspicion is required for prompt and effective investigation even in cases of patient‐reported symptoms. Patient adherence to follow‐up plays a crucial role in diminishing recurrences and improving overall survival. Well‐designed epidemiological studies which will efficiently define the characteristics of urothelial neoplasms in young patients are warranted.Written informed consent was obtained from the patient for publication of this case report and accompanying images.The authors have no conflict of interests to disclose.ENS: conceived and designed the study, acquired the data, analyzed and interpreted the data, wrote the manuscript, approved the final manuscript. AS, CG, CG, AM, MP: analyzed and interpreted the data, drafted the manuscript, approved the final manuscript.


The aneurysms of the extracranial segment of the internal carotid artery are not common and are associated with severe neurologic deficits. They could be misdiagnosed with several lesion of the cervical region. We herein report a case of internal carotid artery aneurysm misdiagnosed as paraganglioma. A 23-year-old man presented with progressive growing mass in right enlarging mass in the upper part of the neck below the angle of the mandible. The patient underwent surgery by the ear, nose, throat (ENT) surgeon through submandibular approach with impression of paraganglioma but severe pulsatile bleeding was encountered intraoperatively. Two vascular clamps were applied and the patient was transferred to the vascular ward. Computerized tomography (CT) angiogram revealed a huge aneurysm of the internal carotid artery in the extracranial segment with injured wall. After 2 days of medical therapy the patient was transferred to the operating room and the aneurysm was repaired using Dacrons. The patient had an uneventful hospital course and was asymptomatic after 1 year of follow-up. Precise preoperative assessment and evaluation with different modalities should be performed to avoid fatal complications. Surgery is a safe and effective method in experienced hands for repair of such aneurysms. The aneurysms of the extracranial segment of the internal carotid arteries are nor very common but are considered an important clinical entity because of their association with high risk of neurological thromboembolic events, cranial nerve compression, and, more rarely, rupture , 2. The A 23-year-old man presented to our outpatient clinic with painless gradually enlarging mass in the upper part of the neck below the angle of the mandible. Computed tomography (CT) scan of the lesion demonstrated homogenous, hyperdense, lesion at the mandibular angle which was diagnosed as aparaganglioma. The patient underwent surgery by the ear, nose, throat (ENT) surgeon through submandibular approach. After manipulation of the lesion, severe pulsatile bleeding was encountered and a vascular lesion was suspected. Thus two vascular clamps were placed proximal and distal to the lesion and the bleeding was controlled. Vascular surgeon was consulted immediately. A CT-angiogram revealed a huge (8×4 cm) aneurysm located at the distal part of the right internal carotid artery (ICA) aneurysm which was injured . Anticoath postoperative day. The postoperative angiogram revealed the patent internal carotid artery without any aneurysm residue. The patient received anticoagulation for 3 months and was followed in outpatient clinic. After 1 year of follow-up he was completely asymptomatic and the angiogram revealed patent parent vessel without residue. The patient and his family provided their informed written consent for publication of the case and the images. After 2 days with available neurovascular surgeon for possible intracranial bleeding control and craniotomy, the patient was transferred to operating room. The previous skin incision was re-opened and the two gauzes were removed . ApproprIn the current study we have described a rare case of extracranial segment of the internal carotid artery misdiagnosed as paraganglioma. The patient underwent a first surgery for resection of the lesion but severe pulsatile bleeding stopped the operation and the second operation was performed after angiographic evaluation. The aneurysm was successfully repaired. Aneurysms can be categorized as either true or false aneurysms. True ones are a full-thickness, segmental dilation of a vessel with at least a 50% increase in diameter compared with the expected normal diameter . As a reTrue aneurysm to pseudoaneurysm proportion varies. A review from the Mayo Clinic over a 15-year study period (1998 to 2012) which included 141 carotid aneurysms, reported that 82 percent were pseudoaneurysms and 18 percent were true aneurysms . More meThe most frequent site reported for true aneurysm in the literature reviews is the bifurcation of the carotid artery or proximal internal carotid artery , 8. In tA variety of other pathologies that are known to weaken the integrity of the arterial wall can also lead to true aneurysm formation, although ECA as manifestation of connective tissue disease is rare , 14. TheCarotid artery ligation without bypass reported to be associated with high rates of morbidity up to 25%) and mortality (20%) , 15, and% and mor In conclusion, the aneurysms of the extracranial segment of the internal carotid artery are no common and could be misdiagnosed with other lesion of the cervical region. Thus precise preoperative assessment and evaluation with different modalities should be performed to avoid fatal complications. Surgery is a safe and effective method in experienced hands for repair of such aneurysms. There isn’t any conflict of interest to be declared regarding the manuscript.


Transformation and progression of lymphoma after treatment is well known; however, since the advent of chemotherapy and radiotherapy, progression in untreated lymphoma is seldom seen. We present a case which was misdiagnosed and treated as abdominal tuberculosis later presented with progression and involvement of oral cavity.A 41-year-old male who presented with urinary symptoms and abdominal pain was diagnosed as abdominal tuberculosis and treated. Two years later, he presented with B symptoms and oral cavity lesion that was diagnosed as diffuse large B cell lymphoma. The patient was treated with R-CHOP chemotherapy with complete regression of the lesion.Involvement of extranodal sites in predominantly nodal disease does occur; however, involvement of oral cavity is rare. Though primary extranodal lymphoma is reported to occur in oral cavity and oropharynx, natural progression in untreated disease is seldom documented. Involvement of oral cavity in lymphoma is rare, having a reported incidence of extranodal involvement in 2–5% cases . It is nA 41-year-old male presented to the urology OPD in September 2014 with complaints of colicky pain in the right flank and dysuria of 3 months duration. Examination revealed right renal angle tenderness. The renal function was normal, and an ultrasonography revealed 2.3 × 1.5 cm renal abscess, 1.5 cm left calyceal cyst, 2.8 mm right renal calculus, with a normal bladder, and post-void residual urine (PVRU) of 16 ml. A mild splenomegaly (13 cm), with multiple enlarged lymph nodes in periumbilical region, largest measuring 20 × 19 mm, was also identified; there were no other nodes and no free fluid in the abdomen. A FNAC from lymph nodes was performed which was inconclusive; however, a clinical diagnosis of tuberculosis was made and the patient was started on antitubercular treatment.The patient completed the prescribed antitubercular treatment and remained asymptomatic for 2 years. No follow-up scans were done. In October 2016, the patient again presented to the urology OPD with complaint of recurrent pain in the right flank for 10 days. The pain was moderate in intensity, radiating to the back along with high-grade fever with rigors. There were no urinary complaints this time. Abdominal examination was normal, the renal function was normal, no scans were done, and the patient was referred to orthopedics for treatment of back pain, wherein symptomatic treatment was given. In November 2016, the patient presented to the surgical oncology OPD with complaints of painless progressive ulceroproliferative lesion in the oral cavity, fever, and abdominal pain. On examination of the oral cavity, there was a grayish-brown ulcerative growth starting from the first premolar and continuing till retro molar trigone (RMT) region, involving the right lower gingivobuccal sulcus (GBS), alveolus, and floor of mouth , buccal mucosa, and RMT measuring approximately 54 × 30 × 19 mm; the mass was seen infiltrating the masseter muscle, and destruction of the right inferior alveolus in the molar region and floor of mouth medially was also noted Fig. . MultiplA punch biopsy was taken from the right buccal mucosal lesion that showed features suggestive of round cell tumor Fig. . The IHCNon-Hodgkin’s lymphoma of B cell lineage is the third most common malignant lesion in the oral cavity and maxillofacial region. The oral cavity, including the palate, gingiva, tongue, buccal mucosa, floor of mouth, and lips, is the primary site of approximately 2% of extranodal NHL. Waldeyer’s ring is the most frequently involved site, being second only to the GIT in extranodal NHL. Involvement of the muscles and bone is rare in primary extranodal lymphomas –7. Non-iPatients with disseminated disease course and the presence of an immunosuppressed condition like AIDS have poor prognosis. EBV and HHV-8 have also been reported to accelerate the process in immunosuppressed patients causing PBL which is a subtype of DLBCL .Since the differentials of an oral lesion are manifold, it becomes mandatory to device good diagnostic methods and representations. Though the morphology of the lesions is different from squamous carcinoma, the spindle cell variant of squamous carcinoma, soft tissue tumors, and melanoma have to be considered as differential diagnosis. Imaging is important for staging the disease, even though it may not have any diagnostic importance as there are no local specific features to suggest a diagnosis of lymphoma. IHC remains the cornerstone of confirmation of diagnosis in such patients. Lymphomas respond very well to chemotherapy, with lesions starting to shrink with the first cycle itself. Hence, inadvertent dental procedures and mutilating surgeries should be avoided especially in patients with disease elsewhere like in the present case and also in cases where there are isolated oral lesions.There have been a number of case control studies that have found association of chronic infections with lymphoma , 13. TheAs most of the lymphomas are diagnosed and treated at an early stage, it is rare to find cases that demonstrate the natural history of untreated lymphoma.Extranodal involvement of the buccal mucosa as part of the natural progression in untreated predominantly nodal lymphoma is never reported before. In patients with oral lesions that have round cell histology, lymphoma should be considered as differential diagnosis. A careful history, radiology, and immunohistochemistry clinches the diagnosis.Fine needle aspiration cytology is not a reliable investigation in intraabdominal lymphadenopathy.An inconclusive FNAC should not be taken as negative for malignancy and repeat cytology, and biopsy should be considered.Tuberculosis should not be the only diagnosis in intraabdominal lymphadenopathy, and other causes of lymphadenopathy should always be considered.Antitubercular treatment should not be started till the diagnosis of tuberculosis is confirmed with demonstration of AFB or by TB PCR.Lymphoma responds very well to chemotherapy, and surgery should not be considered as treatment till the lymphoma has been ruled out.


Small bowel injury is uncommon after blunt abdominal trauma. Repeated clinical assessment is important, especially when investigative imaging is negative.39-year-old male presented to the emergency department following a blunt abdominal trauma. No initial hemodynamic abnormalities were found. Abdominal CT scan was negative for small bowel perforation. Repeated clinical assessment revealed increasing abdominal pain with tachycardia, and an emergent laparotomy was undertaken. Four grade II and one grade I small bowel perforations were found, all repaired with interrupted sutures. Patient was discharged home on day 7.The diagnosis of small bowel injury is difficult and a low threshold of suspicion is crucial to reduce morbidity and mortality. Hemodynamic instability or abdominal tenderness after blunt abdominal trauma are indications for immediate surgical exploration, despite negative imaging findings. Serial clinical assessment is the main decision tool to perform an abdominal exploration. Only 0,3% of all blunt abdominal traumas will have a small bowel perforation (SBP) .Early diagnosis is of paramount importance to reduce morbidity and mortality . There iA low threshold of suspicion and serial clinical evaluation  are of extreme importance in order to anticipate peritoneal spillage of enteric fluid, and reduce morbidity and mortality associated with delayed diagnosis, especially when imaging findings are negative for SBP . Since tThe authors present a case of a 39-year-old male with multiple small bowel perforations following a blunt abdominal trauma. He was submitted to emergent laparotomy based on the clinical evaluation, which was contrasting with a normal abdominal CT scan. The main purpose of this case report is to highlight the importance of a serial clinical assessment.2A 39-year-old white male was brought in by ambulance to the Emergency Department of a Tertiary Hospital, 1 h after suffering a blunt abdominal trauma. The patient presented hemodynamic stability without hypotension, tachycardia or tachypnea . The abdomen was plain and skinny without wounds or bruises, with diffuse tenderness without guarding. The abdominal eco-FAST showed a small volume of inter-loop fluid “trapped” in the left flank. Thorax X-ray showed no pneumoperitoneum. Blood work showed no anemia . An abdominal CT was performed, which revealed intramural small bowel hemorrhage without pneumoperitoneum . AnalgesEmergent laparotomy through a midline incision was performed. A small amount of free hematic fluid was found, as well as adhesions. The small bowel was carefully inspected from the ligament of Treitz up to the ileocecal valve. Four grade II jejunoileal perforations and one grade I seromuscular partial thickness laceration without perforation were found. One of the grade II lacerations was located at the mesenteric border of the small bowel .Fig. 2Sm®). The peritoneal cavity was washed-out with warm saline solution, and three Jackson-Pratt drains were placed in the peritoneal cavity . Surgery was uneventful and the patient was transferred to the surgical ward.The jejunoileal lacerations were repaired with interrupted serosubmucosal Lembert 3/0 absorbable sutures and covered with a sealant matrix coated with humanfibrinogen and thrombin , and even rarer when isolated . To the Abdominal trauma with SBI can occur due to compression or deceleration forces. A direct blow to the abdomen with external compression of the small bowel against a fixed object increases its intraluminal pressure, causing rupture. On the other hand, deceleration forces cause sheering of the small bowel near its fixing point, such as the ligament of Treitz, ileocecal valve, or the mesentery, which might cause a perforation. In this case a combination of both may have been present since the patient had adhesions from the previous surgery, which can be points of bowel rupture together with compression forces .If a small bowel perforation is confined or temporarily covered, or only liquid is leaking, pneumoperitoneum may be absent. Kahn et al. suggest that, in the presence of intra-abdominal fluid with no solid organ injury, there should be high suspicion of bowel or mesenteric injury. However, the authors state that the presence of free peritoneal fluid is not a specific finding of bowel injury . MoreoveThe laparoscopic approach should be considered in hemodynamically stable patients who suffered blunt abdominal trauma with suspected intra-abdominal organ injuries, and equivocal imaging findings. Furthermore, it has the advantage of avoiding negative laparotomies, allows diagnostic and therapeutic measures, reduces post-operative morbidity with shorter hospital stay and fastest recovery . HoweverIn the present case, the patient had already been submitted to a splenectomy in an emergent setting due to blunt abdominal trauma through a mid-line laparotomy. Given the likely presence of adhesions that could difficult the establishment of the pneumoperitoneum along with the risk of iatrogenic bowel lesions, the surgical team decided to perform a median laparotomy. This would reduce time-consuming adherence freeing and avoid eventual hollow viscus lesions related do pneumoperitoneum and port placement.Five lacerations were detected, which were corrected according to the American Association for the Surgery of Trauma (AAST) guidelines. The outcome was very good, with a post-operative period without complications. Early diagnosis and surgical treatment are of extreme importance to obtain good results. A close surveillance with frequent abdominal evaluation together with hemodynamic status, are essential to detect early changes that indicate the need for surgical intervention.This case report was written according to the Surgical CAse REport guidelines .4In conclusion, the diagnosis of small bowel injury is difficult, therefore a low threshold of suspicion is crucial to reduce morbidity and mortality ,7. The pNone.None.The present study is exempt from ethical approval in our institution.Written consent from the patient was obtained.João Mendes Louro — Surgeon of the patient, conception of study design, review of clinical data, analysis and interpretation of data, drafting of the article, revising it critically for important intellectual content, final approval of the version to be submitted.Carlos Costa Almeida — Surgeon of the patient, acquisition and analysis of data, revising it critically for important intellectual content, final approval of the version to be published.Miguel Albano, Teresa Caroço, Luís Reis — Analysis and interpretation of data, revising it critically for important intellectual content.None.Carlos Eduardo Costa Almeida.Not commissioned, externally peer reviewed.


This is the first clinical report on this issue in Vietnam.•Most of the vessel revascularization cases were meningiomas.•Saphenous vein graft (SVGs) was the most commonly reported graft, followed by radial artery graft (RAGs).•STA-MCA bypass was a safe and helpful choice, especially the collateral vessels were present and the need for blood flow augmentation was minimal. Sphenoid meningioma engulfed cerebral arteries has always been a challenge. To achieve a gross total resection, vessel sacrifice may be unavoidable.A 22-year-old man with a history of head trauma a week ago complained of a headache for one week. On examination, he was alert, denied paralysis and cranial nerves palsies. Preoperative MRI showed a hypervascular left sphenoid wing meningioma embedding left internal carotid artery and proximal segment of the middle cerebral artery. In operation, a branch of the MCA was divided when dissecting the tumor. The MCA was clipped but was still difficult to dissect vessel ends in the Sylvian fissure. We decided to extend craniotomy and did superficial temporal artery to M4 segment of MCA bypass. Then, the patient was resuscitated in surgical high dependency unit for 3 days. Surgical outcome in one year postoperative was good with KPS 90 out of 100 points and no neurological deficits. On postoperative MRA, STA-MCA bypass shown acceptable flow.There were a few cases of skull base tumors requiring vessel revascularization. Most of the revascularization cases were meningiomas. Saphenous vein graft (SVGs) was the most commonly reported graft, followed by radial artery graft (RAGs). In case of difficulty in dissecting the vessel ends due to the tumor infiltration, STA-MCA bypass was a safe and helpful choice, especially the collateral vessels were present and the need for blood flow augmentation was minimal.STA-MCA bypass was effective surgical management for MCA injury in sphenoid wing meningioma resection. Vessel revascularization should be considered if vessel sacrifice would cause symptomatic cerebral ischemia.There were numerous cerebral revascularization techniques, which can be used for reconstruction after tumor resection. Choosing appropriate graft and bypass techniques depend on indications and variances in patient anatomy. Considered factors include the size of the recipient`s vessel, the desired amount of blood flow, the size and availability of donor`s vessels, the nature of the operation (emergent or elective), and the anatomy of the revascularization site and the pathology being treated ,2.There have not been yet any clinical reports on this issue in Vietnam before. This is because cerebral revascularization is a difficult technique for our country and the patients need to be evaluated carefully the blood supply of revascularization after removing the tumor. This article aims to report the first case emergent STA-MCA bypass due to MCA injury during sphenoid wing meningioma resection in Vietnam.The work has been reported in line with the SCARE criteria .2A 22-year-old man with a history of head trauma a week ago was admitted to our hospital with complaints of headache for one week. He had no nausea, vomiting and blurred vision. On examination, he was alert, oriented, but malaise. He denied of paralysis and cranial nerves palsies. His muscle strength was grade V.The preoperative MRI showed a hypervascular left sphenoid wing meningioma, which enhanced heterogeneously and embedded the intracranial portion of the left internal carotid artery and proximal segment of the middle cerebral artery D and E.FThe frontotemporal approach craniotomy was used. In operation, the tumor was hypervascular and infiltrated dura of inferior orbital fissure, temporal fossa and the MCA. A branch of the MCA was divided when dissecting the tumor. We clipped the MCA but it still was difficult to dissect its ends in the Sylvian fissure. We decided to extend craniotomy and did superficial temporal artery to M4 segment of MCA bypass. MCA was clipped for 45 min. Intraoperative blood loss was 1000 ml. The surgery took 7 h.After that, the patient was resuscitated in surgical high dependency unit for 3 days. Pathological findings proved transitional meningioma, WHO grade I. Surgical outcome in one year postoperative was good with KPS 90 out of 100 points. No neurosurgical deficits were reported. On MRA, STA-MCA bypass shown acceptable flow D and E.F3There were a few cases of skull base tumors requiring vessel revascularization. In a recent systematic review, Wolfswinskel et al showed that only about 368 cases of EC-IC bypass due to vessel injury for skull base tumors resection were reported from 1950 to 2018 . AccordiSkull base tumors include pituitary tumors, sellar/parasellar tumors, meningioma, chordomas, chondrosarcomas, and squamous cell carcinoma… Most of the vessel revascularization cases were meningiomas . This isIndications of cerebral revascularization in skull base tumors were still controversial. This depends on the nature of the tumors, history of radiotherapy, recurrent tumors and relation to nearby critical structures. Sekhar at al recommended four criteria for EC-IC bypass in the patients with skull base tumors . In our In the previous studies, saphenous vein graft (SVGs) was the most commonly reported graft, followed by radial artery graft (RAGs) , 8], , [4Meningiomas, especially huge sphenoid wing ones, were the most common skull base tumors requiring revascularization. Despite the popularity of SVGs and RAGs, STA-MCA bypass was a safe and effective surgical management for vessel injury in sphenoid meningioma resection.Nothing to declare.This research did not receive any specific grant(s) from funding agencies in the public, commercial, or not-for-profit sectors.Nothing to declare, as this is a single case report. At our center, we do not require ethical review by the Institutional Review Board for single case report studies.Written informed consent was obtained from the patient and his wife, for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.•Anh Duc Nguyen: Helped with study concept, interpretation and writing the paper•Tam Duc Le: Contributed to data collection and analysis, interpretation, writing the initial draft, editing and reviewing of the final manuscript and final submission of the paper.•Hung Manh Ngo: Contributed to study concept and data collection.•Hung Dinh Kieu: Contributed to conceptualization, supervision, and review of the final manuscriptNot applicable – this is a single case report, not a systematic review or meta-analysis. Moreover, we attest that it is not a ‘first in man’ study, either.Anh Duc Nguyen.Not commissioned, externally peer-reviewed.


Dear Editor,A 22-year-old male patient presented with a nonpulsatile, diffuse headache ofmoderate-intensity, with no aura or other associated symptoms. In the neurological exam,he presented paralysis of the vertical conjugate gaze with fixed downward glance,bilateral eyelid retraction, insufficiency of ocular convergence, pupils nonreactive tolight, and preserved pupillary reaction to accommodation, characterizing Parinaud’ssyndrome. Magnetic resonance imaging (MRI) showed an expansive lesion in the pinealregion, with a discrete hyperintense signal in T1-weighted sequences and isointense inT2-weighted sequences, with cystic areas of diffusion, a discrete hyperintense signal inthe diffusion, and marked gadolinium enhancement . The les(1-3). The World Health Organization classifiesPTPR as a grade II or III tumor. It is rare, fewer than 200 cases having been reported.The mean age at onset is 35 years, and PTPR has no predilection for eithergender(4).Its origin is uncertain, the most widely accepted hypothesis is that it originates fromependymal cells of the subcommissural organ. Histologically, PTPR is characterized by the presenceof epithelial and papillary aspect structures with high cellularity and moderate-to-highmitotic activity(4-6). It can cause headache, due to obstructivehydrocephalus, and Parinaud’s syndrome(7), due to compression of the dorsal midbrain,specifically the periaqueductal region(8).The role of MRI in the diagnosis of brain tumors has been expanding. After intravenous administration of gadolinium,moderate heterogeneous enhancement is observed. Dissemination into the cerebrospinalfluid, although rare, occurs in up to 7% of cases. Advanced MRI sequences can reveal signs ofhypoperfusion, whereas proton spectroscopy can show increases in the peaks of choline,lactate, and myo-inositol, as well as a decrease in the N-acetyl-aspartatepeak(11).On MRI, PTPR typically presents as a heterogeneous, well-circumscribed mass in the pinealregion, containing cystic areas, without calcifications or hemorrhages. Classically, itis described as showing a hyperintense signal in T1-weighted sequences, as observed inour case, the high signal intensity potentially being related to the high proteincontent of the lesion .The differential diagnosis of lesions in the pineal region is broad, including germinoma,ependymoma, meningioma, pineocytoma, pineoblastoma, and glioma, although those tumorsrarely present a hyperintense signal in T1-weighted sequences(11). Partial resection and tumors with higher mitoticand proliferative activity (high Ki-67 expression) tend to be related to a poorprognosis and to recurrence, which is reported in up to 72% ofcases.The treatment of choice is surgical resection, there being no proven benefits of the useof radiotherapy or chemotherapyIn conclusion, Parinaud’s syndrome is a warning sign of the possibility of expansileprocesses in the pineal region. Albeit rare, the diagnosis of PTPR should be rememberedamong the hypotheses, especially when there is a hyperintense signal in a T1-weightedsequence.


Endometriosis of the appendix is an uncommon mimicker of acute appendicitis which makes for a diagnostic dilemma.We present a rare case of a menstruating woman presenting with classic symptoms of appendicitis, without the characteristic inflammatory changes seen on laparoscopy consistent with appendicitis. Instead, the appendix appeared unusually contracted on itself. Pathologic review of the appendix revealed microscopic findings of endometriosis.We theorize the growth and shedding of the endometrial tissue during menstruation caused compression of the neural plexi in the wall of the appendix leading to the presentation mimicking acute appendicitis.Given the potential for endometrial appendicitis, we propose appendectomy in reproductive age female patients with right lower quadrant pain, regardless of appendix appearance on laparoscopy. Endometriosis is common, affecting 6–10% of women of reproductive age.l public . This pr2A 29-year-old healthy African American female presented to the emergency department complaining of a 1-day history of peri-umbilical pain migrating to the right lower abdominal quadrant with associated anorexia, nausea, and vomiting. She had an onset of menses the day prior to onset of abdominal pain. On physical exam, the abdomen was soft, non-distended, but tender to palpation over McBurney’s point. Vital signs were within normal limits without notable fever or tachycardia. Blood work revealed an elevated white blood count of 17.4 K/UL. Alvarado score was calculated to be 9. CT of the abdomen with IV contrast exhibited no evidence of acute intra-abdominal or intra-pelvic process. Ultrasound of the pelvis disclosed dilated non-compressible distal appendix suggestive of appendicitis.Diagnostic laparoscopy was performed which found 30 cc of blood in the pelvis attributed to a ruptured 3 cm left hemorrhagic ovarian cyst. The appendix appeared unusually contracted upon itself without evidence of erythema or surrounding acute inflammation. No peritoneal studding or endometrial implants were identified on laparoscopic evaluation of the abdomen or pelvis, and the omentum was not found in the right lower quadrant. She recovered uneventfully from her operation, and in follow-up her pre-operative pain had disappeared.Microscopic examination of the appendix showed no pathologic evidence for acute appendicitis. The appendiceal lumen was lined by normal-appearing appendiceal mucosa , and the3The commonalities between the presentation of this case and that of a classic case of acute appendicitis include: 1) abdominal pain beginning in the periumbilical region followed by migration to the right lower quadrant 2) nausea and vomiting 3) leukocytosis. However, a key component of the history was the fact that this patient was menstruating. Multiple case reports have described the involvement of menstruation in the presentation of endometriosis of the appendix ,6. This This case did not have the classic macroscopic findings of either acute appendicitis or endometriosis. Instead, the appendix appeared to have been unusually contracted upon itself. Fifteen to thirty percent of appendices removed for symptoms of appendicitis are grossly normal and there is question to the efficacy of removing the appendix in this scenario . This caThere are currently three leading theories for the pathogenesis of endometriosis: retrograde menstruation with implantation and failure of immunologic clearance, coelomic metaplasia, and hematologic or lymphatic metastasis . This ca4This case details a female of reproductive age presenting with signs of acute appendicitis during menstruation with subsequent findings of endometriosis on pathology. This supports the need for laparoscopic examination and appendectomy even if there are no characteristic gross abnormalities identified. Surgical management with pathologic evaluation merits designation as the gold standard for treating and identifying appendiceal endometriosis.None.No sources of funding were obtained for this project.This study was exempt from ethical approval at our institution as it was an observational finding in regular practice.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Dr. James Nottingham and Dr. Alicia Snider performed the operation. Dr. Harry Kellermier performed the pathology read and interpretation. Bradley St. John wrote and formatted the original manuscript. Dr. Snider and Dr. Nottingham reviewed and edited the manuscript. Shubhanjali Minhas produced the images and formatted the original manuscript.This case report does not qualify as research as it was an observational finding on routine procedureDr. Alicia Snider, Dr. James Nottingham, and Bradley St. JohnNot commissioned, externally peer reviewed.


Laparoscopic right salpingo-oophorectomy was performed and a histological diagnosis of steroid cell tumor, not otherwise specified (SCT–NOS) was made. Hyperandrogenism and menstrual disturbances resolved postoperatively. A literature review revealed that 17-OHP-secreting SCT–NOS may uncommonly show positive responses to ACTH stimulation similar to 21-hydroxylase deficiency. Alternatively, USP might be useful in localizing the source of 17-OHP to the ovaries. Its diagnostic performance should be evaluated in further studies.We describe a case of a 24-year-old overweight woman who presented with hirsutism, secondary amenorrhea, clitoromegaly, and symptoms of diabetes mellitus (DM). While a diagnosis of polycystic ovary syndrome (PCOS) with its associated metabolic disturbances was initially considered, serum total testosterone, androstenedione, and 17-hydroxyprogesterone (17-OHP) measured by liquid chromatography tandem mass spectrometry (LC-MS/MS) were significantly increased. As 17-OHP did not increase upon ACTH (Synacthen) stimulation and the urinary steroid profile (USP) was compatible with an ovarian source of 17-OHP excess rather than adrenal, non classical congenital adrenal hyperplasia (NCCAH) was unlikely and an androgen-secreting tumor was suspected. Transabdominal ultrasound revealed the presence of an enlarged right ovary with a polycystic ovary morphology and no discrete mass. Transvaginal ultrasound and [ Identifying the underlying cause and localizing the source of elevated androgens or their precursors in woman with hyperandrogenism can be challenging. In the setting of female hyperandrogenism, a significant elevation of 17-hydroxyprogesterone (17-OHP) is often suggestive of a diagnosis of congenital adrenal hyperplasia (CAH), most commonly 21-hydroxylase deficiency. Nevertheless, androgen-secreting tumors, which may be of adrenal or ovarian origin, may also be responsible for such finding. Investigations into an increased 17-OHP generally include serum androgen profile, ACTH stimulation test, urinary steroid profile (USP), and if biochemically compatible with 21-hydroxylase deficiency, confirmation by molecular testing of the CYP21A2 gene. Here, we present the diagnostic challenges in a young woman with hirsutism and significantly elevated total testosterone, androstenedione, and 17-OHP in whom the diagnosis of a hormone-secreting steroid cell tumor, not otherwise specified (SCT–NOS), was made.3) right ovary with more than 12 small follicles (< 9 mm), which represents sonographic evidence of polycystic ovary based on the Rotterdam criteria  at the age of 12 with no specific underlying cause identified. Menarche occurred at the age of 12 years. Examination revealed that she is overweight (BMI 26.0) with normal blood pressure. Acne was present but there was no obvious hirsutism . Other clinical features of Cushing's syndrome were absent. Pregnancy test was negative. Transabdominal ultrasound showed an enlarged . No other negative prognostic features of steroid cell tumors  were found. No Reinke crystals were identified. Immunostaining was positive for inhibin, calretinin, and androgen receptor, weakly positive for Melan-A, and negative for CD99 . The dia3. She remained clinically well 9 months postoperatively.The patient recovered uneventfully after the operation, with a normalization of testosterone, androstenedione, and 17-OHP concentrations and attainment of a luteal phase progesterone concentration two weeks after the operation . PostopeAndrogen-secreting tumors are a rare cause of hyperandrogenism in women (0.2%) . In contThe patient had a number of features which were compatible with PCOS with its associated metabolic disturbances, including the presence of PCO morphology on ultrasound, diabetes mellitus, overweight and slightly high LH : FSH ratio of 2 . Nevertheless, the presence of clitoromegaly, deepening of voice and the significantly elevated serum 17-OHP and androgen levels prompted us to consider alternative diagnoses. The presence of polycystic ovaries has been reported in a patient with an androgen-secreting SCT–NOS  and an aSteroid cell tumors (SCTs), also known as lipoid cell tumors, are rare ovarian tumors presumably of stromal cell origin and account for 0.1% of ovarian neoplasms . SCTs arWe reviewed the literature for the association of high 17-OHP levels and SCT–NOS. A PubMed search for cases of SCT–NOS in English using the search string (“steroid cell tumor” or “steroid cell tumour” or “lipoid cell tumor” or “lipoid cell tumor”) was performed. A review of full texts for SCT–NOS with pre-treatment 17-OHP results identified a total of 21 such cases. One case was excluded from data analysis as it was associated with underlying poorly controlled NCCAH due to 21-hydroxylase deficiency  (see Tabβ-hydroxylase on 17-OHP [β-hydroxylase in SCT–NOS, as demonstrated by the presence of its mRNA in one reported case [11-oxopregnanetriol, also known as pregnanetriolone, is a metabolite of 21-deoxycortisol, which is an adrenal-specific metabolite produced by the enzymatic action of 11n 17-OHP , 40. In n 17-OHP , 41, 42.n 17-OHP  (hereinan 17-OHP . It appeted case . TherefoIn summary, we have described a hormonally active ovarian SCT–NOS in a 24-year-old woman resulting in significant androgen excess, hypersecretion of 17-OHP with a negative response to ACTH stimulation, and an “ovarian pattern” of metabolites of 17-OHP detected in the urine. The case required careful consideration of the clinical, biochemical, and radiological data to clinch the correct diagnosis. A literature review revealed that 17-OHP hypersecretion is commonly seen in SCT–NOS and some patients with SCT–NOS were misdiagnosed as having CAH. Both ACTH stimulation test and USP are helpful biochemical tests to determine the cause of 17-OHP hypersecretion in these patients.


Urinary stones are uncommon in children. Urethral location of calculi can give rise to various clinical manifestations. We report three cases of urethral lithiasis presenting with acute urinary retention in children. Acute urinary retention is commonly encountered in urological practice in adults, mostly from prostatic pathologies. In the male child, lower urinary tract symptoms are usually secondary to congenital uropathy, most often posterior urethral valves, and sometimes neurogenic bladders from spinal dysraphism. Urinary stones can be an obstacle to the normal flow of urine at any level of the lower urinary tract. In Europe, the prevalence of urolithiasis varies from 5 to 9% . It is 2In sub-Saharan Africa, the prevalence of lithiasis in children is variously appreciated according to the geographical location although literature is sparse and limited to hospital studies. In Cameroon, a series of 123 cases in two hospitals reported a prevalence of 17% in children aged from 7 to 15 years, including 2% of stones located in the urethra . HoweverThe article presents three cases of acute urine retention from stones located in the male urethra. Proteus vulgaris sensitive to ceftriaxone was isolated in one of the urine samples. He was circumcised at 6 months and there was no family history of urolithiasis.A 2-year-old male was referred to the Pediatric Surgery Department of the Yaoundé Gynaeco-Obstetric and Pediatric Hospital from the Western region of Cameroon, with an enlarged bladder, dribbling urine with overflow incontinence. He presented with progressive dysuria from age 3 months, without fever or hematuria, but with repeated urinary tract infections. E. coli sensitive to ceftriaxone. Blood count, urea, and creatinine were normal.On clinical examination, the infant was a well-developed, well-nourished male, with a temperature of 37.5°C, a heart rate of 106 beats per minute, a respiratory rate of 25 cycles per minute, and a weight of 12 kg. A tense and sensitive bladder was palpated in the suprapubic region as well as a hard mass, at the base of the penis . There wA suprapubic cystostomy was performed at bedside. At urethroscopy, a stone completely obstructing the lumen and encrusted in the urethral wall, prevented endoscopic extraction . UrethroThe postoperative period was normal and the infant was discharged from hospital with normal voiding. He has remained asymptomatic at 1-, 3-, and 6-month follow-up visits.Nucleus: urate ammonium acid (15%), calcium oxalate monohydrate (70%), and calcium oxalate dihydrate (15%)Surface: calcium oxalate dihydrate (100%)The results of infrared spectrophotometric analysis of the calculus are as follows: A urinary metabolic assessment for hyperoxaluria will complete the work-up as soon as funding is available.3. An abdominal ultrasound showed grade 2 right ureterohydronephrosis. A scout film confirmed an ovoid calculus in the proximal part of the anterior urethra  . Also, iEndoscopic lithotripsy has become the standard treatment in the management of bladder stones and urethral lithiasis. The latter is achieved after pushing back the stone into the bladder with success rates close to 80% . In all An underlying congenital or acquired pathology should be sought in the male child presenting with acute urinary retention. The urethra should be examined for an obstructing stone. The association of a plain abdominal X-ray and an ultrasound not only permits the identification of calculi but also appreciates the impact of obstruction on the upper urinary tract. Urgent urinary diversion and removal of the calculus with minimal urethral trauma is recommended treatment.


This report is of a rare case involving a 27-year-old female who presented to the hospital with the pathological couplet of colocolic intussusception and cecal bascule causing bowel obstruction. Up to the time of presentation to the hospital, this patient had not undergone a full investigation for a known iron deficiency, anemia. Subsequently, during the emergency admission and after having an operative surgical procedure, the patient was found to have both a congenitally malpositioned cecum and a benign colonic polyp-forming condition. The pertinent issues about this unusual case to be highlighted are its ambiguous clinical presentation; uncommon gender and age group for either condition; the simultaneous occurrence of dual anatomical anomalies; and the uncommon benign etiology of causes of bowel obstruction in adults. Intussusception, a common pediatric abdominal emergency commonly seen in patients ≤ two years of age, occurs when a loop of bowel (the “intussusceptum”) telescopes into an adjoining segment (the “intussuscipiens”). An intussusception in an adult is rare, accounting for 1%-5% of all adult bowel obstructions, and colocolic intussusceptions are similarly rare at 5% of all cases of intussusceptions in all age groups . A 10-yeColonic volvulus is caused by the en masse torsion of a segment of the colon and its mesentery with the supplying vessels, leading to intestinal obstruction. Cecal volvulus is uncommon, accounting for about 15% of all cases of colonic volvulus. These can be classified into three types: the axial-torsion type where cecal rotation is in the axial plane; the loop-type, where there are both cecal rotation and inversion; or the bascule-type -5. With A 27-year-old, 43-kg British woman presented to the emergency department with a four-day history of yellow-colored diarrhea followed by vomiting and periumbilical cramping abdominal pain. Eight years prior, the patient had been investigated by gastroscopy only for iron deficiency anemia, but no other investigations were done. Initial investigations showed no signs of sepsis, yet a plain abdominal X-ray showed small bowel obstruction in a surgically virgin abdomen in Figure As the patient had mild symptoms and was very reluctant for operative intervention, a period of non-operative management was commenced, involving observation overnight, and had a contrast-enhanced abdominal computed tomography (CT) scan the next morning. The formal reporting of the next-day CT scan stated that the patient had a 9 cm cecum “representing either a volvulus or congenital malrotation pulled to the right upper abdomen...in keeping with enteritis or inflammatory bowel disease” in Figure The patient underwent an emergent diagnostic laparoscopy with plans for a right hemicolectomy, which was quickly converted to a midline laparotomy incision due to poor intraperitoneal vision from a markedly distended cecum. A necrotic distended cecal bascule with a sealed subhepatic perforation was found, thus a stapled cecectomy across the twist was done to prevent the intravascular release of toxic metabolites and to allow uncrowded access into the abdominal cavity. Other findings were an inflamed mid-ascending colocolic intussusception and two unexplained areas of ischaemic ulceration on the lateral walls of the descending colon. An initial abbreviated laparotomy was done to excise these pathological areas of the colon. The intussusceptum's lead-point is seen in Figure There are several lessons to be learned from this case such that a different approach could be considered if a similar case were to present at the hospital in the future. These key points are making the diagnosis of either condition individually or in tandem; deciding on conservative versus operative management options; the timing and choosing of investigations and operative interventions; understanding the cause of the pathological couplet in this patient; explaining the cause of concomitant ischaemic ulcerations in the descending colon; and deciding the extent of colonic resection during the initial operation.Diagnosing a large bowel obstruction in a young adult is very straightforward but concluding from the historical and clinical examination that it is due to either an intussusception or a cecal bascule is tough. Diagnosing this pathological couplet in the same way would be doubly challenging. The unusual clinical presentation of this case would be abnormal in any patient age group and especially unexpected in a young adult with minimal specific clinical signs. In this case, the clinical features of currant jelly stools or a palpable mass were absent. If a similar patient is clinically stable, graduated radiological imaging with an abdominal ultrasound scan, abdominal X-ray, or contrast-enhanced CT scanning would be the mainstay of determining the diagnosis of either an intussusception or a cecal bascule. In this patient with a virgin abdomen, an argument could be made for diagnostic laparoscopy as the sole diagnostic tool.Timing and choosing the right intervention are challenging in unusual cases, thus an argument for a more initial aggressive approach could be made. In retrospect, an earlier operative intervention would have been better for this patient, as it may have prevented the cecal perforation. The factors of the patient’s condition, patient’s choice, and presumed enteritis delayed this choice. Numerous textbooks describe less invasive hydrostatic or pneumatic techniques to reduce either an intussusception or a cecal bascule mainly for use in pediatric patient populations. The clinical course in this reported case excluded any consideration of non-operative management, which followed the findings of Khan and colleagues who estimated that 70%-90% of adults with intussusception undergo a surgical resection [Trying to determine the cause of this rare couplet was a daunting task and, in some instances, the diagnoses are made only at the time of operative intervention. Shah et al. recently published a case of splenic colocolic intussusception in a young man due to hamartomas of Peutz-Jeghers polyposis . When anLastly, deciding on the extent of colonic resection is contentious. In this case, it was decided for a subtotal colectomy with a future ileorectal anastomosis to minimize the future risk of colorectal cancer for this yet-to-be-identified juvenile, polyp-forming condition. A brief consideration for preserving the externally normal-appearing, well-vascularised transverse colon for improved fecal continence. Fortuitously, this was realized as being unwise after a sizeable polyp was found post-excision. This dilemma could be assisted in the future with an intraoperative endoscopic evaluation of any segment of bowel considered for preservation.This is a very rare case involving a patient where every aspect was uncommon: young, female, a couplet of intussusception and cecal bascule, colocolic type, and a benign pathology as the lead-point. In possible, similar future cases, we would be inclined and hence endorse an early operative approach, possibly avoiding any radiological investigation, thus proceeding to diagnostic laparoscopy involving the resection of all obvious diseased colonic segments. Having such an abnormal pathological couplet often widens the extent of the surgical resection that is performed, but this invariably negates all consideration of simpler methods, such as the pneumatic or manual reduction of an intussusception or the pexying of a cecal bascule or volvulus.


Orbital lesions form a wide range of pathologies, that create challenges in diagnosis, management, and treatment. The high-resolution soft tissue detail provided by magnetic resonance imaging (MRI) has allowed for better lesion characterization. Especially in cases where history and clinical evaluation are insufficient, MRI plays a crucial role. MRI is also important in the detection of the extent of orbital diseases. The aim of this study was to examine the MRI characteristics of common and/or rare diseases arising from or extending into the orbita to aid radiologists in the correct diagnosis of orbital lesions. Orbital lesions form a wide range of pathologies that pose challenges in diagnosis, management and treatment. The soft tissue detail provided by magnetic resonance imaging (MRI) allows for better lesion characterization. MRI therefore plays a crucial role, especially in cases where history and clinical evaluation are inconclusive . There aThis pictorial essay consists of cases of orbital pathologies collected from the Ankara Training and Research Hospital over a period of 10 years. MRI was performed with a GE 1.5T Signa and a Siemens 1.5T Magnetom-Aera scanner. The protocol included T1- and T2-weighted (T1-WI and T2-WI) oblique axial and sagittal images along the plane of the optic nerve, and true coronal T2-weighted images. When an intravenous contrast agent was administered, axial and coronal fat suppressed sequences were included.Retinoblastoma originates from the retina in children younger than five-years of age, and may be hereditary or non-hereditary. Leukocoria is a common clinical finding (50%). Retinoblastoma is the most common primary intraocular tumour in children. Typical findings on non-contrast computed tomography (CT) is speckled calcification. MRI is useful for evaluating any possible extraocular or intracranial extension. Retinoblastoma appears hypointense on T2-WI and slightly hyperintense on T1-WI relative to the vitreous. After contrast, moderate enhancement is present. Heterogeneous enhancement and local thickening of the choroid adjacent to the tumour is a hallmark of choroidal invasion. MRI is the modality of choice for pre-treatment staging  originate from the choroid. Ocular melanomas are the most common primary intra-ocular tumours in adults. They represent only 5% of all melanomas. Patients generally present in the 5th–6th decade of life  . Choroid0% originColoboma is a congenital malformation that occurs due to the failure of fusion at the embryonic stage of the intraocular fissure, resulting in the absence of a part of the eye. On CT/MRI, a focal posterior defect in the globe with vitreous herniation is present. A retrobulbar fluid-density cyst may be seen Figure  10]..10].PHPV refers to a rare congenital developmental malformation of the eye. It arises due to a failure of normal regression of the embryonic hyaloid vascular system. Commonly, PHPV manifests with leukocoria and microphthalmia in full-term infants. Generally on MRI the vitreous body is infiltrated with soft-tissue. In addition, after contrast administration, the vitreal lesions enhance Figure  1112].12.1112].They are usually seen in the setting of neurofibromatosis type I (NF1). Almost all optic nerve gliomas are juvenile pilocytic astrocytomas and are seen in children < eight years of age. MRI is the method of choice. It is very useful in assessing involvement of the orbital apex, optic chiasm, hypothalamus, and other intracranial structures. The lesions are typically T1-WI isointense and T2-WI isointense to hyperintense. Enhancement is variable Figure  1314].14.1314].Optic neuritis describes the inflammation of the optic nerve, including infectious and less frequently non-infectious causes. Characteristically, on imaging, optic neuritis is seen as unilateral optic nerve swelling in its retrobulbar/intra-orbital segment, with high T2-WI signal and contrast enhancement. Chronically, the optic nerve might become atrophied rather than swollen. In some cases, T2-WI hyperintensity might persist. Contrast enhancement is best detected with fat-suppressed T1-WI. Contrast enhancement is present in >90% of patients within 20 days of visual loss Figure  15]..15].Tram-track enhancement along the sheath is an imaging characteristic for meningiomas , or secondarily, they can arise from the sphenoid ridge or tuberculum sellae and extend into the orbit. Meningiomas account for 2% of space-occupying orbital masses and they are the second most common optic nerve tumour. Secondary optic nerve meningiomas are more common than primary lesions. On both CT and MRI, fusiform enlargement of the optic nerve sheath is present. s Figure . DiffereEnlargement of the extraocular muscles is the main presentation of thyroid ophthalmopathy Figure . The infOrbital pseudotumor is an acute inflammatory condition of the orbital soft tissues. It is one of the most common causes of unilateral exophthalmos. Pseudotumor can be distinguished from thyroid ophthalmopathy by involvement of the tendinous portion of the muscles, and the retro-orbital soft tissue. The process is generally hypointense. The lesion shows marked enhancement Figure . Orbital18Orbital myositis Figure , is a noImmunoglobulin G4 (IgG4)-related disease is a systemic inflammatory process of unknown etiology, characterized by tissue infiltration by IgG4 plasma cells. In patients with extraocular muscle enlargement, sparing tendons IgG4–related disease should be kept in mind as a leading differential diagnosis, especially when the lateral rectus is the most enlarged muscle .Dacryocystocele occurs when tears accumulate in the lacrimal sac or lacrimal canal proximal to an obstruction in the lacrimal canal. The classic MRI appearance is similar to that of simple cysts if the content is homogenous, hyperintense on T2-WI and hypointense on T1-WI. Complicated (e.g. infectious) cysts may exhibit more heterogenous content, though there is generally no enhancement Figure  22]..22].Tolosa-Hunt syndrome is a recurrent, idiopathic, painful inflammatory condition caused by inflammation of the cavernous sinus or superior orbital fissure. On MRI, the lesion can be iso to hypointense on T1-WI and hypo/hyperintense on T2-WI Figure . After cIntraorbital dermoid cysts represent 5–10% of all dermoid cysts, while intraorbital epidermoids are more rarely observed. Histologically, both are lined by squamous epithelium. Differently, dermoid cysts include all three germ layers and are characterized by the presence of mesodermal elements such as hair follicles. Dermoid cysts usually show diffusion restriction on diffusion-weighted images. They do not enhance after contrast injection, have smooth margins, and cystic/solid components. Sometimes calcifications may be suspected Figures  and 16 25.Cavernous haemangioma is the most common benign intraorbital lesion in adults. It generally presents in the second to fifth decades. Painless, slowly progressive, proptosis is the most common complaint. They generally locate to the intraconal space. They are homogenous masses with smooth margins, uniform enhancement is common. They can be easily separated from the optic nevre and extraocular muscles. The orbital apex is usually spared Figure .Capillary hemangiomas are the main part of the differential diagnosis. They are the most common orbital tumours of infancy. The MRI characteristics are slight hypointensity on T1, iso- to hyperintensity on T2 with multiple serpiginous flow voids. Homogenous enhancement is common. Lobulated appearance with thin septa is characteristic for capillary hemangiomas .A compartmental approach to evaluating orbital disease can guide the differential diagnosis. Use of MRI is valuable for determining the extent of disease, describing its exact localisation and detecting involved orbital compartments. MRI is also a useful diagnostic tool for both orbital and intracranial pathologies. Indeed, intracranial diseases can present with orbital symptoms or as orbital masses, likewise orbital pathologies can extend into the cranium and present with central nervous system symptoms. In addition, with the guidance of MRI, possible involvement of the orbital apex and associated intracranial abnormalities can be shown.


A 50-year-old man underwent laparoscopic hernia repair for a groin hernia, presenting acute abdominal pain and bowel obstruction syndrome 1 day post surgery. Diagnostic laparoscopy was performed at postoperative the day after the hernioplasty and a volvulus was found. The residual end of the barbed V-LOC adopted in the peritoneal closure was incidentally hooked to the mesentery and caused a small bowel obstruction as a volvulus. The redundant V-LOC strand was released and cut superficial to the peritoneum. A detorsion of volvulus was preformed. Neither bowel ischemia nor significant bowel injury was noted. The following day he was discharged without complication. The residual ‘free’ barbel suture in the peritoneal cavity invited adhesion formations and subsequently the Bowel obstruction. Laparoscopic trans-abdominal hernia repair is commonly preformed nowadays due to its advantages as a minimally invasive approach with less postoperative discomfort and a shorter hospital stay .To facilitate the closure of the peritoneum, barbed suture is often applied since no knots have to be tied.In recent years there has been an increasing uptake in the use of barbed suture, particularly in minimally invasive and laparoscopic procedures as they may ease the surgical procedure.The V-Loc™ suture consists of a monofilament with tiny barbs cut into the length of the surface, self-anchoring to the tissue. This self-anchoring capacity eliminates the need for surgical knots and laparoscopic procedure becomes easier by reducing operating time .However, as it has been demonstrated in several recent case reports , 4 a potPostoperative small bowel obstruction (SBO) is common and has often been linked to the presence of foreign materials, particularly surgical mesh . Here weThis case report describes an early complication of entrapment and volvulus of the small bowel following the use of barbed suture in TAPP repair.A 50-year-old man is presented as an emergency derived from another hospital with several abdominal pain and obstipation.One day before admission a TAPP procedure was performed with peritoneal closure using a V-LOC barbed suture.On the first day postoperative the patient developed diffuse abdominal pain and distension with associated vomiting and intolerance of feed.An abdominal computerized tomography (CT) demonstrated SBO with suspected volvulus Fig. .He was returned to theater for laparascopic exploration.SBO was noted secondary to the cut end V-LOC suture, which had become integrated into the small bowel mesenterium creating a volvulus with associated ischemia Fig. .Release of adherent suture and derotation resulted in a good re-perfusion and no resection was required.The patient recovered well and was discharged on the first postoperative day when the examination revealed a soft abdomen and he was able to tolerate food and passed bowel motion.This is a case of SBO by barbed suture used for peritoneal closure. Acute abdominal pain and small bowel volvulus occurred 1 day after surgery therefore in the same day the patient received emergent laparoscopy to release the barbed suture, and derotation of the small bowel was performed without complications.The mechanism of SBO documented in this case is comparable to these described in the literature .The V-Loc™ wire can be used for closure of the peritoneum during the TAPP procedure. Due to its barbed configuration, a gapless and continuous suturing of the peritoneum without laparoscopic knotting is fast and easily accomplished .Where the cut end of the barbed suture is left long, it may become firmly attached to underlying small bowel or mesentery producing kinking and a transition point of obstruction. Torsion of the small bowel around this point of fixation may result in volvulus and where mesenteric blood flow is impeded ischemia may occur.et al. [Apart from TAPP the use of the barbed suture in the closure of the peritoneum had also been implicated to cause bowel complications. Lee and Wong  reportedet al.  performeThe common feature of all reported cases was that the ends of the barbed suture was left in the abdominal cavity in contact with the small intestine.These cases highlight that although barbed sutures provide an attractive mean to allow easier and faster laparoscopic suturing, they should be used carefully. The residual ‘free’ barbed suture in the peritoneal cavity invites adhesion formations and subsequently the bowel obstruction. We suggest not to leave the free V-LOC suture in the peritoneal cavity. In the case of SBO complicating the early period after barbed suture it is important to consider barbed suture entanglement as a potential etiology for this condition.


Retained surgical material needs to be a possible differential diagnosis for patients presenting with unspecific abdominal pain after especially cavitary emergency surgery. Even though international standard checklists concerning sponge handling and counting exist, RSM could never be ruled out completely. Due to enhanced communication systems, based on less hierarchical structures, potential complications and structural shortcomings should be detected more frequently.Especially surgical procedures are known to be on higher risk for structural mistakes as wrong patient or site of surgery, equipment problems and retained surgical material (RSM) inside patients.One key element preventing serious adverse events like RSM, as for example Gossypiboma, is the final counting of sponges during abdominal surgery.Primary aim of this case report is therefore, even though standardized procedures and checklist should minimize the risk for RSM, to remind surgeons of Gossypiboma as potential reason for patients presenting with surgical complications.To the very best of our knowledge, this is the first case report presenting a Gossypiboma after vaginal hysterectomy resulting in a mechanical ileus due to sponge migration into the small bowel.2This case report was written in accordance with the CARE guidelines.A 80‐year‐old woman presented with history of recurrent vomiting and fatigue to the emergency department of our hospital. Last episode of bowel movement was reported the same day with substantial decrease in quantity. The patient had an episode of fever with up to 38° celsius two days ago. Furthermore, decreased intake of food for the last seven days was mainly due to persisting nausea and vomiting without specific abdominal pain.Clinical examination revealed a bulging abdomen with crampy epigastric pain radiating to the left lower abdominal quadrant and signs of local peritonism in the right lower quadrant. Sparse bowel sounds were found in each quadrant on auscultation. Further investigations showed a slight elevated heart rate with 91 beats per minute, inconspicuous blood pressure, and temperature. Blood tests indicated a systemic infection with a substantial leucocytosis of 14.7 × 10⁹/L and an elevated c‐reactive Protein (CRP) of 72 mg/L.Medical history revealed a left mastectomy due to an invasive ductal carcinoma 33 years ago followed by a systemic chemotherapy. The oncological and radiological follow‐up remained without suspicion for recurrency and was terminated years ago.Due to a descensus vaginalis grade two and a stress incontinence grade three 22 month ago, a vaginal hysterectomy was carried out at our hospital. During the same procedure, a sacrospinous fixation and a reconstruction of the urogenital diaphragm was performed without any peri‐ or postoperative complications.3The further diagnostic examinations included an ultrasound and subsequently a triple contrast‐enhanced computer tomography (CT).3.1Abdominal ultrasound showed signs of an ileus without clear evidence for a local infection. Dilated small bowel loops up to 2.5 cm with echogenic material within the lumen were seen.To detect the origin for the small bowel obstruction, we decided to perform a CT scan.3.2A triple contrast‐enhanced CT scan Figure  revealedThese findings confirmed a small bowel obstruction due to an intraluminal soft tissue mass accompanied by an interenteric abscess and a small bowel perforation. A RSM was discussed but the intraluminal position of material was misleading. We decided to perform an emergency laparotomy and an enterotomy revealed a surgical sponge that caused the dilation of the small bowel Figures  and 4.Subsequently, a small bowel resection of 55 cm length was performed followed by saline irrigation of the abdominal cavity. Before ending the operation, we checked for further hollow organ lesions and signs of injuries to the vaginal stump.We assume that during previous vaginal hysterectomy with sacrospinous fixation and diaphragmatic reconstruction, most probably a surgical sponge was left inadvertently. Due to a chronic inflammatory process, a small bowel perforation around 70 cm prior to the ileocecal valve occured. With the bowel movements, the sponge migrated and caused small bowel obstruction.4During the postoperative course persisting high CRP values (90 mg/L) led to another CT scan. A small intra‐abdominal abscess of 4 cm in diameter close to the small bowel was drained and antibiotic therapy administered.A small wound dehiscence was treated with vacuum assisted dressing (VAC‐therapy), and the patient was discharged 18 days after operation.Six weeks after the operation, the patient fully recovered with normal frequency of bowel movement, closed laparotomy wound and without further abdominal pain.The final histological examination performed for the resected small bowel showed a chronic inflammatory process with signs of foreign body reaction. No evidence for malignancy or bacterial infection was seen.5Gossypiboma, as well as retained surgical material in general, is clearly a serious adverse event. Untruthfully, this incidence is believed to be a mistake solely due to inattention that could be fully averted using standardized checklists as suggested by the World Health Organisation.Contrary, with only rare evidence due to a mediocre scientific reporting and an infrequent incidence, the cause for RSM remains most likely multifactorial. The increasing proportion of morbid obese patients, more invasive and complex operating procedures due to scientific advance and multidisciplinary operative approaches are only some that may contribute to an increase for the probability of RSM.Essential element in preventing RSM, after for example complex emergency operations, is the introduction of checklists with special sections regarding the count of surgical sponges and material. As introduced by the WHO and other scientists, these checklists proved to improve failure frequency in terms of so‐called never events .Nevertheless, in times when the perspective of policymakers and the society itself is shifting to economization and efficiency, time pressure rises not only for the surgeon but also for the complete operation room team (ORT). Thus, multitasking with distraction of each ORT member due to ongoing communication about further planning or switching between operation rooms (OR) which leads to distraction and the inability to follow the operation in an observant way is resulting. As we know from scientific reports,That RSM is impossible to be ruled out completely was shown by Inaba et al.Thus, surgeons need to be aware of the possibility of Gossypiboma, especially during postoperative course after emergency abdominal surgery.Clinical presentation might range from asymptomatic bulging to septic condition with hollow organ lesion due to persisting low grade infection. In case RSM remains undetected during the early postoperative course, Gossypiboma with fibrinous encapsulation is resulting,Standard diagnostic procedure should include imaging, as symptoms are not likely to directly link to the diagnosis Gossypiboma. Regularly, ultrasound is the first investigation with only limited value. Subsequently, a triple contrast‐enhanced CT is the diagnostic tool of choice for definitive diagnosis. The CT could display the location of the Gossypiboma using the topogram if a radio‐opaque marker is present. On reconstruction, the CT sequences could possibly display perforations of hollow organ lesion.In most cases, as the one presented, further investigations could be omitted. Once the diagnosis of Gossypiboma due to RSM is done, definitive treatment includes surgical intervention. In the present case, we decided primarily for a laparotomy. Nevertheless, successful reports of laparoscopic retrieval of RSM can be found in the literature.6Gossypiboma is a serious adverse event that should be omitted. Nevertheless, with increasing complexity during especially abdominal surgery and ongoing time pressure for ORT's as well as increasing BMI in patients, RSM could never be ruled out completely. Indoubtly, minimizing the frequency of RSM should be intended. The counting of surgical material needs to be performed from at least one surgeon and another team member separately. The counting itself has to be a separate stage of the operation that should be accomplished before finishing the operation. Nevertheless, RSM must be taken into account, even years after previous surgery and nonspecific symptoms.None of the authors or any member of their immediate family has funding or commercial associations  that might pose a conflict of interest in connection with the submitted article. I agree and confirm this statement as true.FO: Contributed to the conception and design of the work, drafting the work, and made the final approval as well as he agreed to be accountable for all aspects of the work; AR: Contributed to the conception and design of the work, drafting the work, revising the manuscript, and made the final approval as well as she agreed to be accountable for all aspects of the work; MS: Contributed to the analysis of the work, drafting the work, and made the final approval as well as he agreed to be accountable for all aspects of the work; JM: Contributed image material, approved the initial idea as solid to construct the case report, interims analysis with further processing ideas were contributed, and made the final approval as well as he agreed to be accountable for all aspects of the work; J‐MG: Contributed to the analysis of the work, drafting the work and made the final approval as well as he agreed to be accountable for all aspects of the work.