Adrenal tumours are common in urology and endocrinology, and the diagnosis of adrenal tumours were mainly depends on imaging diagnosis. Howerver, misdiagnosis can still occur for some adrenal space-occupying lesions without specific manifestations or abnormal biochemical indexes.We report the case of a 55-year-old patient with a soft-tissue mass in the left adrenal region, and have no specific manifestations or abnormalities in biochemical indexes. The patient had undergone open splenectomy 20 years ago for splenic rupture caused by traffic-accident trauma, and had a 10-year special history of hypertension. Because of the uncertain nature of the mass, surgical treatment was recommended.The surgeon managed to remove the left adrenal region mass. During the surgery, the adrenal source was excluded. In the histological examination, the splenic corpuscle and splenic medullary structure were seen under the microscope, and an accessory spleen was diagnosed.The accessory spleen was located in the adrenal region rarely, and can easily be misdiagnosed as an adrenal tumour. When the cases show abnormal adrenal space-occupying lesions in imaging examinations, non-adrenal diseases should be considered. we need to combine different imaging techniques for analysis, and think more about it, avoid misdiagnosis leading to unnecessary surgery. Adrenal tumours are common in urology and endocrinology –3. With The reporting of this study conforms to CARE guidelines , 5. In DAfter admission, his maximum monitored blood pressure was 138/87 mmHg (1 mmHg = 0.133 kPa), and his monitored heart rate ranged from 86 to 103 bpm. The patient denied a history of diabetes, centripetal obesity or specific manifestations of cortisol signs, such as full-moon face and buffalo hump. All biochemical tests, including blood potassium: 3.57 mmol/L; cortisol (0AM): 1.67 µg/dl; cortisol (8AM): 7.79 µg/dl; cortisol (16PM): 4.46 µg/dl; adrenocorticotropic hormone (0AM): 2.47 pmol/L; adrenocorticotropic hormone (8AM): 3.76 pmol/L; adrenocorticotropic hormone (16PM): 2.97 pmol/L; renin (standing position): 41.68 pg/ml; aldosterone (standing position): 141 pg/ml; renin (recumbent position): 16.07 pg/ml; aldosterone (recumbent position): 129 pg/ml, and 24-h urinary 3-methoxy-4-hydroxymandelic acid, 24-h urinary catecholamines were normol. Ultrasound (US) was performed which identified a 42 × 30 × 35 mm adrenal mass in the left-adrenal region. In order to confirm the diagnosis, computed tomography (CT) scan was conducted, the CT scan confirmed the US findings, showing a 42 × 28 × 36 mm soft-tissue mass shadow in the left adrenal region, and the internal density was heterogeneity . The CT Adrenal tumours are common in urology and endocrinology –3. The cAccessory spleen, also called supernumerary spleen, refers to tissue with the same structure and function as the normal spleen that exists in addition to the normal spleen, and it is a common congenital anatomical abnormality, with an incidence of 10%–30% . Accessoin vitro99mTc-labelled heat-denatured red blood cells (99mTc-DRBC) are intravenously injected into the human body and then absorbed by the spleen, followed by the liver and reticuloendothelial tissues, such as bone marrow. In these tissues, haem in RBC is destroyed, digested and metabolised to form bilirubin, so only the spleen can aggregate 99mTc-DRBC, and has a high-uptake rate, followed by the liver and bone marrow, but other tumour tissues and lymph glands cannot. The radioactive concentration per unit volume is 2–3 times higher in the spleen than in the liver. False-negative results only are obtained in accessory spleens which were the relatively small sizes because there is no accumulation of radioactive tracers (99mTc-DRBC scintigraphy can well distinguish ectopic accessory spleen from tumour recurrence, new tumours and enlarged lymph nodes, with high accuracy (At present, it is generally recognised that Tc-99m-labelled heat-denatured red-blood-cells scintigraphy is a reliable, sensitive and non invasive imaging method for confirm the qualitative clinical diagnosis of accessory spleen , 17. The tracers . 99mTc-Daccuracy . It is aGenerally, the accessory spleen has no clinical symptoms and is mostly detected by physical examination or other examinations . CurrentIn this case, because of our lack of experience, the patient underwent unnecessary surgery. We analysed the causes of our misdiagnosis and had to admit that different imaging techniques for the suspected case were not performed, and the single examination had some defects. Additionally, this patient had a history of splenectomy, and the accessory spleen was located in the adrenal region, which is relatively rare. The patient also had a history of hypertension, which greatly interfered with the preoperative diagnosis, but the main reason was the lack of understanding of accessory spleen before surgery. During the surgery, the adrenal source was excluded, we also questioned the source of the tumour. To ensure the integrity of the tumour and the principle of “no tumour”, we did not perform a frozen-section examination. However, it would be worth discussing whether a better outcome can be obtained if such tumours are subjected to frozen-section examination during surgery.In summary, the diagnosis of space-occupying lesions in the left-adrenal region remains challenging, especially in some patients who have no specific manifestations or abnormalities in biochemical indexes. When the cases show abnormal adrenal space-occupying lesions in imaging examinations, non-adrenal diseases should be considered. we need to combine different imaging techniques for analysis, and think more about it, avoid misdiagnosis leading to unnecessary surgery.


Deviation from the normal development of the biliary tree and gall bladder gives rise to numerous different types of anomalies. One of the anomalies is the Phrygian cap. The Phrygian cap is an even rarer condition. We report a case that was asymptomatic. In a rare case, the Phrygian cap anomaly may cause symptoms that are mainly due to superadded cholelithiasis. A detailed pre-operative history and thorough physical examination should be done. Many of the cases may be missed during the routine examination. The diagnosis, with the help of radiological investigations, will be helpful to keep the location and anatomy of the anomalous gall bladder in mind during the intra-operative period. The patient was operated on to seal off a perforation, where a Phrygian cap was observed as an incidental finding. The patient did not have any complaints pointing toward the presence of cholelithiasis or cholecystitis. Due to the asymptomatic incidental presentation of the condition, the operating surgeons decided on avoiding further dissection and an increase in the morbidity load. Thus, we report this case to focus on this rare entity and consider it a differential while dealing with a case of pain in the abdomen. Numerous anomalous deviations from the normal development of the gall bladder have been documented. The symptoms and their severity may vary. These conditions should be kept in mind while dealing with cases of pain in the abdomen, especially in the right hypochondrium. The Phrygian cap is an infrequently encountered congenital anomaly . As the Early diagnosis of the condition is crucial to decreasing morbidity and mortality. A detailed preoperative history and a thorough physical examination should be done. The diagnosis, with the help of radiological investigations, will be helpful to keep the location and anatomy of the anomalous gall bladder in mind during the intra-operative period. This helps in avoiding intra-operative complications.The differentials to be kept in mind while dealing with a case of duplication of the gall bladder are diverticula of the gall bladder, fold of the gall bladder, Phrygian cap, choledochal cyst, pericholecystic fluid, etc. . In a feA 65-year-old female presented to our emergency department with complaints of pain in the abdomen for 15 days. On palpation, the patient had mild tenderness in the epigastric region, and the vitals were normal. All routine blood investigations were done and were within normal limits. The X-ray abdomen was erect, and contrast-enhanced computed tomography revealed pneumoperitoneum and a suspected anomaly of the gall bladder Figures .Thus, the patient was taken for emergency surgery. The emergency exploratory laparotomy revealed a sealed-off perforation at the pyloric part of the stomach. The abdomen was examined, and there was no evidence of any other perforation or intestinal pathology. The visible abdominal viscera were normal. The gall bladder region was dissected carefully until the Calot’s triangle was visualized. The surgeons observed a single artery and a single cystic duct without any evidence of duplication of the gall bladder. The diagnosis of a rare anomaly of the gall bladder, namely the ‘Phrygian cap’, was confirmed Figures -4.As the anomaly was asymptomatic, the operating surgeons avoided further dissection in this case. The perforation at the pyloric part of the stomach was a sealed-off perforation, and Graham's patch repair was done by the surgeons. Post-operatively, cancer antigen (CA) 19.9 and alpha-fetoprotein were sent, which came back within the normal limits. The core needle biopsy from the gall bladder wall was negative for any evidence of malignant cells. Post-operatively, the patient was stable and was discharged with advice to follow up at a later date.The autopsy reports of about 2-6% of the cases show the congenital abnormality famously known as the Phrygian cap, which is mentioned as a rare abnormality in the literature . It reseIn our case, there was a sealed-off perforation at the pyloric end of the stomach and an incidental finding of a Phrygian cap. However, the pre-operative diagnosis of the anomaly helps decrease possible morbidity and mortality. Various investigation modalities such as ultrasonography, oral cholecystography (OCG), endoscopic retrograde cholangiopancreatography (ERCP), computed tomography scan, and magnetic resonance imaging (MRI) are performed for diagnosing a Phrygian cap type of anomaly. ERCP is an invasive kind of method, thus it is seldom advised. The most commonly advised method of investigation is an ultrasonographic examination, though, in confused patients, CT and MRI scans can also be preferred for making out the anatomical structure of the hepatobiliary tree. Prophylactic cholecystectomy is not usually recommended in every case of an abnormal gall bladder . In sympWith this case, we would like to bring the attention of our fellow surgeons toward this rare entity, which should always be kept in mind as a differential while dealing with cases presenting with complaints consistent with gall bladder diseases. Early and pre-operative diagnosis of the condition helps decrease the morbidity and mortality load on society; thus, a proper medical history and a thorough physical examination are very important. Radiological modalities are of utmost importance as the condition may be silent, as in our case, and can precipitate intra-operative complications if missed pre-operatively.


Primary cancer of the fallopian tube is very rare. The diagnosis is rarely made before surgery or histological study.We report the observation of a tubal adenocarcinoma in a 42-year-old female patient, discovered following an abdomino-pelvic mass. A total hysterectomy without adnexal preservation with omentectomy, appendectomy and partial bladder resection were performed, followed by platinum-based chemotherapy. Despite this observation, the authors report a review of the literature concerning the epidemiology, diagnosis, treatment and prognosis of this cancer.Primary fallopian tube cancers are rare, representing 0.3 to 1.1 % of gynecological cancers. They are frequently confused with ovarian cancers in case of locally advanced disease and are clearly underestimated.The positive diagnosis is difficult because the clinical picture is polymorphic, MRI is of great diagnostic interest, the prognosis depends on the FIGO stage. •Primary tubal cancer is very rare, frequently confused with ovarian cancers•Abdomino-pelvic ultrasound is the key examination when a suspicious adnexal mass is found, which leads to pelvic MRI and, if necessary, surgical exploration•The histological types are similar to those of the ovary, represented almost exclusively by epithelial tumors, 75% of which are high-grade serous carcinomas•The therapeutic management of cancers of the tube is similar to that of the ovary and is based on the combination of maximum cytoreduction surgery and chemotherapy Averages of 20 to 30 new cases are reported each year. The incidence of this cancer varies between 0.3 and 1.1 % among all gynecological cancers 2Patient aged 42 years, single, with no personal or family history. She consulted for pelvic pain with a one-month-old pelvic mass. Examination revealed a hard abdominal-pelvic mass, measuring eight centimeters, which could not be displaced from the uterus. Ultrasound showed a solid, Doppler-vascularized mass measuring 112 × 85 mm. Abdominal-pelvic CT scan showed a patchy necrotic pelvic-abdominal tissue lesion, poorly enhanced by contrast injection, measuring 100 × 70 × 60 mm . There w3Primary fallopian tube cancers are rare, representing 0.3 to 1.1 % of gynecological cancers The fallopian tube is an organ with low oncogenic potential, which contrasts with its vulnerability to infection. Its prognosis is generally poor This disease affects middle-aged patients with a peak incidence at 50–60 years of age and rarely affects young or very old women. Some risk factors have been suggested such as infertility, chronic salpingitis or nulliparity, although no clear etiology has been demonstrated The clinical picture is constituted by the pathognomonic triad of Latzko or “Hydropstubaeprofluens” associating abdomino-pelvic pain, vaginal discharge  and a pelvic mass Primary cancers of the tube are distinguished from ovarian cancers by their more noisy symptomatology, with pain appearing rapidly due to early tubal distension. Metrorrhagia with negative endometrial curettage is also a warning sign In the end, these early and noisy clinical signs mean that tubal localization has a better prognosis than ovarian localization because it is discovered more quickly.The first paraclinical examination to be requested is ultrasound, which often shows the same appearance as epithelial carcinomas of the ovary in the form of a mixed adnexal mass, solid and cystic, hypervascularized on Doppler [8]Staging is based on ovarian cancer Treatment is also identical to the management of ovarian cancer, but their prognosis is better because they are most often diagnosed at an earlier stage[11]The prognosis depends on the size of the tumor, the stage, the invasion, and the existence of a macroscopic postoperative residue The overall 5-year survival of tubal malignancies is estimated at 44 % according to large series 4Tubal adenocarcinoma is a rare entity, of unknown etiology, underestimated or often confused with ovarian pathology with which it shares the same treatment and staging, the positive diagnosis is difficult because the clinical picture is polymorphic, MRI brings a great diagnostic interest, the prognosis depends on the FIGO stage.Not commissioned, externally peer-reviewed.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.I declare on my honor that the ethical approval has been exempted by my establishment.None.Dr. watik fedouaNone.The following information is required for submission. Please note that failure to respond to these questions/statements will mean your submission will be returned. If you have nothing to declare in any of these categories then this should be stated.WATIK Fedoua:Corresponding author writing the paperHARRAD Mouna: writing the paperSAID HASNAA :writing the paperBOUFETTAL Houssein: correction of the paperMAHDAOUI Sakher: correction of the paperBOUHYA Said : correction of the paperThe authors declare having no conflicts of interest for this article.


Acute pancreatitis (AP) is rarely seen in the paediatric population and is typically not associated with those aetiologies seen in adult pancreatitis. This case describes a 12-year-old female who presented with acute abdominal pain and constipation, with biochemical evidence of elevated serum amylase, calcium (Ca) and parathyroid hormone (PTH) levels. A diagnosis of AP was made, which was settled with conservative management. Further investigations, namely CT and technetium 99m (Tc-99m) sestamibi scans, revealed a solitary parathyroid adenoma. She subsequently underwent minimally invasive parathyroidectomy (MIP), following which Ca and PTH levels normalized postoperatively. The typical causes of acute pancreatitis (AP) in adults are not the usual culprits in the paediatric population. We present the case of a 12-year-old girl with AP secondary to hypercalcaemia. Further investigations revealed primary hyperparathyroidism (PHPT) due to a solitary parathyroid adenoma. The patient underwent successful minimally invasive parathyroidectomy (MIP), after resolution of acute pancreatitis. On three-year follow-up, the patient remains symptom-free, with normal plasma Ca levels.A 12-year-old female with a four-day history of generalized abdominal pain and constipation was referred to our unit. The pain was constant, maximal in the epigastrium, without radiation and showed mild relief on leaning forward. Additionally, movement and oral intake aggravated the abdominal pain. The patient reported a three-week history of polyuria and polydipsia, but denied any history of musculoskeletal pain, psychiatric symptoms or renal colic. Previous surgical history revealed an uncomplicated open appendicectomy at eight years of age. Further enquiry indicated no prior medical history, medication usage or any known family history of comorbidities.Examination revealed tachycardia with a pulse of 124 beats per minute, but no derangement in blood pressure and normal mucous membranes. An abdominal examination demonstrated a soft abdomen, with notable guarding in the epigastric region but no flank tenderness, peritonitis or abdominal wall bruising. Rectal and cardiopulmonary examinations were normal.Abdominal X-ray displayed faecal loading. Laboratory investigations showed an elevated serum amylase of 1400 U/L, serum Ca of 18 mg/dl and alkaline phosphatase (ALP) of 1849 IU/L. PTH levels were found to be 1244 pg/ml . Renal function tests were within normal limits. CT scans of the abdomen and pelvis revealed findings suggestive of acute pancreatitis , diffuse bony sclerosis and incidental bilateral non-obstructing renal calculi at the lower poles.The patient was kept fast and placed on appropriate analgesia and intravenous fluids. Loop diuretics and intravenous fluids facilitated normalization of the serum calcium to 9.1 mg/dl. Over five days, the attack of acute pancreatitis resolved with conservative management.CT scan of the neck showed a 1.7 cm x 1.2 cm well-circumscribed mass in the right retrothyroid region, suggestive of a parathyroid adenoma. Technetium 99m (Tc-99m) sestamibi scan revealed an area of increased uptake overlying the right lower pole of the thyroid gland Figure .Ultrasound scanning preoperatively localized the lesion and allowed skin marking to aid in minimal dissection at the surgery. The patient then underwent a minimally invasive right inferior parathyroidectomy Figure -D. On grSix weeks after initial presentation, an abdominal ultrasound revealed the development of a 4 cm x 4 cm x 5 cm pancreatic pseudocyst, with no compressive symptoms. Conservative management was employed in this instance and there was complete resolution within three months of diagnosis. The renal calculi seen on the previous CT scan also resolved spontaneously. Final histology confirmed a parathyroid adenoma with no features of malignancy. On three-year follow-up, the patient continues to be symptom-free, with normal serum Ca levels.While the leading causes of AP in adults include gallstones and alcohol (>60%), in children the major cause is abdominal trauma 23-40%). Pancreaticobiliary anomalies 15%), systemic disease (14%), drugs and toxins (12%), viral infections (10%), hereditary disorders (2%) and metabolic disorders including hypercalcaemia (2%) account for the rest [5%, syste3-40%. PaThe diagnosis of AP in the paediatric population does not readily come to mind as a differential for acute abdominal pain. Due to under-reporting or non-diagnosis, the true incidence is unknown. Currently, only limited data is available on the incidence of paediatric AP in the Caribbean region and there are no reported cases.PHPT in children has an incidence of 2-5 per 100,000, of which the most common cause is a solitary adenoma -6. The aWhile PHPT has been reported in adolescents, it is rarely found in the under-10-year-old age group. Despite the lower incidence, symptoms of PHPT are more common and more severe in children and adolescents when compared to adults. 70-90% of adolescent patients with PHPT would present with symptoms as opposed to their adult counterparts, who would be symptomatic on presentation 20-50% of the time.Despite the high frequency of symptoms in children with PHPT, definitive diagnosis is often significantly delayed . This isIn the routine investigation of abdominal pain, serum amylase should be analysed. As in our patient, the presence of abdominal pain and elevated amylase (more than three times the upper limit) aided in further investigation of the aetiology. Electrolytes were checked and the underlying cause of the AP was then found to be hypercalcaemia.The combined presentation of AP and renal calculi adds to the uncommon nature of this case. However, the presence of the renal calculi hastened the search for the source of elevated Ca levels. Imaging studies revealed a solitary adenoma on Tc-99m sestamibi scanning and a likely diagnosis of PHPT. Metabolic imaging with Tc-99m sestamibi scintigraphy allowed precise localization and has a reported sensitivity of 86% in children. Ultrasound is also reported to have a good sensitivity of 79% [Surgical management of PHPT in children due to a single adenoma can be via MIP. This technique is dependent on successful preoperative localization of a single adenoma by Tc-99m sestamibi scan or ultrasound . This mePostoperatively, this patient spent an uneventful course, with transient hoarseness from endotracheal intubation being the only acute complication. PTH levels fell by 90.43% intraoperatively and serum Ca levels fell by 38.88% postoperatively. Studies have shown that a decrease in intraoperative PTH levels of 80% or more is a risk factor for the development of postoperative hungry bone syndrome (HBS) . HoweverIn this uncommon case of paediatric PHPT presenting as AP with renal calculi, the need to be mindful of this diagnosis is highlighted. Children do not have the typical aetiologies of AP seen in adults, and investigations should be tailored to this fact. Successful MIP was done with the help of adequate preoperative localization. Despite the drastic decline in PTH levels following the successful removal of the adenoma, our patient did not develop HBS. However, a high index of suspicion should be maintained, as this is a well-documented complication of parathyroid surgery. On three-year follow-up, the patient remains asymptomatic and clinically well.


Chronic otitis media is a significant health problem, but middle ear and mastoid neoplasms, either benign or malignant, are extremely rare.Here is a report from a 51-year-old female who presented persistent otorrhea with an aural polyp. The patient was operated on with the probable diagnosis of cholesteatoma. During surgery, a fragile mass was discovered, and histopathologic examination reported the diagnosis of a primary oncocytic Schneiderian papilloma. Microscopically it has pseudostratified epithelium of columnar cell epithelium with eosinophilic granular cytoplasm and hyperchromatic nuclei. The treatment of choice for Schneiderian papillomas is complete surgical removal.Although very rare, oncocytic Schneiderian papilloma should be considered a differential diagnosis of ear neoplasms such as auditory canal polyps. Schneiderian papilloma is a benign neoplasm of the sinonasal respiratory mucosa. Most cases are seen in adults, but can also occur in children.There are three distinct clinicopathologic variants of Schneiderian papilloma: exophytic, inverted, and oncocytic. Oncocytic papilloma is the least common and usually, occurs in the sinonasal area, although it is rarely reported in the middle ear .Here we prepared a report from a primary, middle ear oncocytic Schneiderian papilloma as an educational example and a reminder to consider it a differential diagnosis of auditory canal polyps.A 51-year-old woman complained of a polypoid lesion in the external auditory canal. She suffered from purulent otorrhea nonresponsive to medical treatment and hearing difficulty in the last 12 months. Otomicroscopy showed a bulky polypoid tissue blocking the canal completely and therefore obscuring the tympanic membrane . Computed tomography scan of temporal bone showed a soft tissue density in the external, middle ear, and mastoid with the destruction of ossicles and mastoid air cells and lateral cortex of mastoid . The patient was operated with the probable diagnosis of cholesteatoma. Mastoidectomy was performed, and, fragile hemorrhagic tissue was found in the mastoid antrum and middle ear with the destruction of ossicles. The canal wall down approach was chosen for eradication of infection. Histologic diagnosis was reported to be inverted oncocytic Schneiderian papilloma.The postoperative course was good with unremarkable two-week, three-, and six-month follow-ups. The nasal endoscopy was normal with no remarkable lesion. The cavity was clear of pathology six months after surgery, and no recurrence was detected.The external auditory canal polyp in a patient, with chronic otitis media is approached as cholesteatoma until proven otherwise. The patient in this case report had an aural polyp and a history of otorrhea for ten years with a CT scan diagnosis of cholesteatoma. We performed surgery without previous biopsy as routine, and surprisingly the histologic result was oncocytic Schneiderian papilloma of the middle ear.Ear polyps are granular tissues usually found at the connection of cholesteatoma and bone. However, other ear lesions, including malignancies, may also appear as a mass of the external auditory canal. So, this is not surprising that oncocytic Schneiderian papilloma was not considered the initial diagnosis. Schneiderian papilloma is an unusual diagnosis, estimated at an annual rate of 2.3 per 100,000 people (Formerly, only one case of oncocytic Shneiderian papilloma of the middle ear was reported .Direct spread through the Eustachian tube seems to be the main cause of this disease . Two othEpithelial cells may have cilia. This lesion may have intraepithelial mucin-filled cysts with neutrophilic microabscess. The stromal component may be myxoid to fibrous with infiltration of inflammatory cells and variable degrees of vascularity .The treatment of all Schneiderian papilloma is complete surgical removal, including the adjacent non-involved mucosa. Oncocytic and inverted subtypes may undergo malignant transformation. The incidence of this phenomenon for oncocytic variants ranges from 4% to 17% . SchneidAlthough incidence in the middle ear is rare, oncocytic Schneiderian papilloma should be assumed as a differential diagnosis of middle ear neoplasms.


Primary glioblastoma multiforme tumors of the medulla oblongata are rare, especially in the adult population. Perhaps due to this rarity, we are not aware of any previous reports addressing the resection of these tumors or their clinical outcomes.In this surgical video, we present a 43-year-old man with a 1-month history of left-sided paresthesia. The paresthesia initiated in the left hand, along with weakness and reduced fine motor control, and then spread to the entire left side of the body. He had recent weight loss, imbalance, difficulty in swallowing, and hoarseness in his voice. He also had a diminished gag reflex, and significant atrophy of the right side of the tongue with an accompanying deviation of the uvula and fasciculations of the tongue. MRI showed an infiltrative expansile mass within the medulla with peripheral enhancement and central necrosis. In T2/FLAIR sequences, a hyperintense signal extended superiorly into the left inferior aspect of the pons and left inferior cerebellar peduncle and inferiorly into the upper cervical cord.The decision was made to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of this infiltrative expansile intrinsic mass in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials and monitoring of lower cranial nerves IX, X, XI, and XII. A gross-total resection of the enhancing portion of the tumor was performed, along with a subtotal resection of the nonenhancing portion. The surgery and postoperative course were uneventful. Histopathology revealed a grade IV astrocytoma. The patient received radiation therapy.In this surgical video, we demonstrate important steps for the microsurgical resection of this challenging glioblastoma multiforme of the medulla oblongata.https://youtu.be/QHbOVxdxbeU.The video can be found here:  In this surgical video, we demonstrate important steps for the microsurgical resection of a large challenging glioblastoma multiforme in the medulla oblongata with intraoperative subcortical stimulation and mapping.(0:33) 1-month history of left-sided paresthesias. The paresthesia initiated in the left hand, along with weakness and reduced fine motor control, and then spread to the entire left side of the body. He had recent weight loss, imbalance, difficulty in swallowing, and hoarseness in his voice. He had also had a (0:52) diminished gag reflex, and significant atrophy of the right side of the tongue with an accompanying deviation of the uvula and fasciculations of the tongue. MRI (1:01) showed an infiltrative expansile mass within the medulla with peripheral enhancement and central necrosis. In T2/FLAIR sequences, a hyperintense signal extended superiorly into the left inferior aspect of the pons and left inferior cerebellar peduncle and inferiorly into the upper cervical cord.The patient is a 43-year-old man with a (1:25) to proceed with surgical resection. The patient underwent a midline suboccipital craniotomy with C1 laminectomy for surgical resection of the infiltrative expansile intrinsic mass in the medulla oblongata, with concurrent monitoring of motor and somatosensory evoked potentials and monitoring of lower cranial nerves IX, X, XI, and XII.The possible differential diagnosis was a high-grade glioma or ependymoma. The decision was made (1:47). A midline skin incision was marked just above the inion extending down to the level of C4 spinous process. A pericranial graft above the inion was harvested for duraplasty at closure (1:56). A T-shape fascial incision was done and a muscle cuff along the nuchal line was left for muscle closure at the end of case. Paravertebral muscle dissection was then performed in a subperiostal plane in the midline nuchal avascular line and retracted laterally.The patient was placed in the prone position (2:16) was then performed by placing two burr holes on either side of the occipital keel. The posterior arch of the C1 was also removed. We then opened the dura in a Y fashion (2:27). Baseline neuromonitoring responses (2:30) of both somatosensory and motor evoked potentials were obtained before and after positioning and were continuously monitored throughout the remainder of the surgery.A midline suboccipital craniotomy (2:40). The posterior aspect of the medulla oblongata and upper cervical spinal cord were inspected, and an expansile mass in the left half of the medulla was noted. The location of this mass was also confirmed with intraoperative neuronavigation (2:54).Under microscopic magnification and illumination, the arachnoid of the cisterna magna was opened sharply with a diamond knife and microscissors (3:02). The stimulator was then used to ensure that we avoid the lower cranial nerve nuclei as we made the cortical incision in the medulla. Multiple locations were probed with the stimulator (3:07). On the left side of the medulla, stimulation was negative at up to 1 mA at multiple spots. On the right side and on the ventricle surface of the firm mass, there was firing from the right side of the tongue at low stimulation. With stimulation, there were also positive responses from the tongue and vocal cords at 0.9 to 1 mA, mostly on the right side (3:25). In this section of the video, we can see the stria medullaris at the floor of the fourth ventricle (3:42). At the left side and centered on the central necrosis, which was negative for stimulation, the surface pial vasculature was coagulated and a small vertical incision was done sharply with a diamond knife (3:54). With a spreading motion of the bipolar, the tissue was dissected with a small portion resected and sent off for intraoperative pathology. The pathology was later reported as compatible with a high-grade glioma.In this section of the video, we observe the inferior aspect of the fourth ventricle We continued our dissection using microsurgical techniques, including blunt spreading with the bipolar, suction aspiration, and use of an ultrasonic aspirator. This was done in a stepwise fashion until the central necrotic tissue had all been resected, upon which we reached a surrounding firmer tissue which had a contrast-enhancing rim. Intermittently, subcortical stimulation was done and whenever it was negative, the resection was continued. The extent of resection was guided with neuronavigation and the aforementioned periodic use of subcortical stimulation. The goal of resection was to safely remove the entire contrast-enhancing rim and some nonenhancing T2 flair areas. Cautiously, we continued using subcortical stimulation to stay away from motor fibers, which were pushed anteriorly.(5:06). The resection was continued at negative stimulation spots (5:14) until we reached the part of the resection cavity which was positive for right lower extremity and right hand at 1.5 to 2 mA (5:18). When we felt the resection was sufficient, with a margin of safety, we elected to stop. A final test of the motor and somatosensory evoked potentials was done and were unchanged (5:30).We then addressed the firmer portion of the tumor that were to the right and superior. On the right side, subcortical stimulation was positive for the right lower extremity and right hand at 2 mA (5:38). The craniectomy site was covered with titanium mesh (5:45). The wound was then closed in layers.Hemostasis was obtained in the tumor cavity. The dura was then closed in a watertight fashion using the previously harvested pericranial tissue for grafting The surgery and postoperative course were uneventful. Histopathology revealed a grade IV astrocytoma. The patient is currently about to complete radiation therapy.In conclusion, in some selected high-grade glioma cases of the medulla oblongata, gross-total resection of the contrast-enhancing portions of the tumor can be accomplished. In our experience, gliomas of the medulla tend to occupy only one side of the brainstem, which may allow maximal safe resection.Our aim is to achieve maximal resection without functional compromise with both low- and high-grade gliomas, since the mounting evidence suggests that more extensive surgical resection is associated with longer life expectancy in all high-grade gliomas. Although primary GBMs of the medulla oblongata are a rarity, and while initial reports documented no survival with or without treatment, recent reports have documented a longer median survival after tumor removal and radiation and chemotherapy. radiation and chemotherapy was performed without biopsy and the patient died from respiratory arrest 18 days after administration of chemoradiotherapy. The autopsy revealed glioblastoma. Thus, better treatment options are desired. We believe that in our current era of microsurgery with advanced neuromonitoring adjuncts, in selected cases, gross-total resection can be accomplished. In our viewpoint, just performing a biopsy is not acceptable in such cases. A major objective of our video is to suggest that maximal safe resection with chemoradiation is a preferable option to improve the median survival of these challenging histopathology in the eloquent medulla oblongata, in contrast to traditional, no treatment, or conservative treatment.In the report by Yoshikawa et al.,Preoperative assessment of motor fibers with diffusion tractography MRI is limited in this tight part of the brainstem comparing to other parts of the brainstem. Although a thorough understanding of the anatomy of the brainstem safe entry zones is of great importance, electrophysiological mapping provides a safer approach to this part of the brainstem since tumors can alter the anatomy. In our opinion, although we are still in learning phase of the subcortical stimulation in the brainstem, this approach may be helpful to avoid causing iatrogenic motor deficits.


Chondrosarcoma is a highly aggressive malignant tumor originating from cartilaginous and mesenchymal tissues. The aim of this report is to describe a rare case of nasosinusal chondrosarcoma with orbito-cerebral extension. Our patient was a 55-year-old with a right cheek swelling evolving over a year, with unilateral right nasal obstruction gradually becoming bilateral associated with hyposmia, bilateral exophthalmos, reduced bilateral deep visual acuity and permanent headaches. The clinical examination found a tumor obstructing the two nasal cavities. Imaging showed a lobulated heterogeneous tissue process occupying the paranasal sinuses, with calcifications and enhancement at its periphery, extending to the orbito-cerebral area. The histopathological analysis was in favor of chondrosarcoma. The patient was first treated with an incomplete surgical resection by an endonasal route due to the extension to the orbit and the brain and received adjuvant radiotherapy. Surgical excision is a prognostic factor in this type of sarcomas and reduces recurrence rates. Chondrosarcoma is a primary malignant bone tumor that develops from the cartilage without producing bone tissue . RepreseOur patient was a 55-year-old woman, without significant pathological history, presenting a right cheek swelling evolving over 1 year, with unilateral right nasal obstruction gradually becoming bilateral which was associated with a hyposmia, a bilateral exophthalmos, decrease bilateral deep visual acuity and intense permanent frontal headaches that were resistant to the usual analgesics. The clinical examination found a straight cheek and fixed painful mass of firm consistency, with irregular contours. The nasal flow was abolished on the right side and reduced on the left. Nasal endoscopy revealed a budding tumor process obstructing the two nasal cavities, without bleeding and it was masked by purulent secretions. Craniofacial computed tomography (CT) scan showed a large tumor process in the center of the nasosinusal region containing peripheral and central popcorn calcifications, with irregular contours, weakly enhancing after injection of contrast product and measuring ~65 × 62 mm . The hisChondrosarcoma is a heterogeneous group of malignant bone tumors of cartilaginous and mesenchymal origins , 4. The The treatment of chondrosarcomas is essentially based on surgical removal of sarcomatous tissues in combination with adjuvant radiotherapy despite the immature evidence supporting its effect on chondrosarcomas. The external route in which a complete tumor resection can be performed but with poor esthetic outcomes and quality of life due to its extension to the adjacent tissues . FurtherNasosinusal chondrosarcoma is very rare and aggressive. Imaging is of crucial importance in the management of these rare types of sarcomas. The quality of surgery is a determinant factor that affects patients’ outcomes.All the authors contributed to the conduct of this work. All authors also declare that they have read and approved the final version of the manuscript.None declared.None.The patient’s data are available upon reasonable request from the corresponding author.Supplementary_material_1_rjac286Click here for additional data file.


SHDB mutation who was found to have two cardiac paragangliomas in the right atrium.Paragangliomas are extra-adrenal chromaffin cell tumors. A small percentage of these tumors can be found in the thoracic cavity and, when in the heart, are typically in the left atrium. In this case report, we discuss the case of an individual with a history of several paragangliomas with the  Paragangliomas are extra-adrenal chromaffin cell tumors . The appSDHB) or succinate dehydrogenase complex subunit D (SDHD) genes are common in individuals with thoracic paragangliomas [There are two general classes of cardiac paragangliomas, sympathetic and parasympathetic. Sympathetic paragangliomas produce catecholamines (particularly norepinephrine or epinephrine) while parasympathetic paragangliomas are usually nonfunctional and mainly located in the head and neck . Cardiacngliomas .α-) adrenoceptor and beta- (β-) adrenoceptor blockers at least 2 weeks prior to the surgery [Frequently, cardiac paragangliomas are close to the great vessels and can involve any of the cardiac cavities , 5. More surgery . In thisA 26-year-old male with a past medical history of pheochromocytoma and multiple head and neck paragangliomas presented for worsening shortness of breath for the last “couple of weeks.” His dyspnea was present both on exertion and at rest. He had no associated chest pain, palpitations, sweating, nausea, or vomiting. Additionally, he states that he had no similar events to this shortness of breath. He had no reported “significant” change in weight over the last 3 months and states that his hypertension had been “well managed” with his reported systolic blood pressures ranging from 110 to 130 on his current antihypertensive regimen. At an outside facility, an echocardiogram and cardiac magnetic resonance imaging were performed and a right atrial mass was appreciated prompting transfer to a specialized cardiac care center. He did not require supplemental oxygen; his lungs were clear to auscultation bilaterally, and no murmurs were appreciated on physical exam. He was admitted for a planned resection of his cardiac tumor with review of preoperative imaging to be completed for assistance in guiding the operative approach.SDHB gene mutation. His first case of an identified paraganglioma occurred when he was 14 years of age and was found to have the SDHB mutation. Per report, he had undergone at least 6 surgical excisions for a variety of paragangliomas though the dates of these procedures were unknown. His most recent surgical excision was 7 years prior to presentation per patient and family report. In addition, his past medical history also includes adrenal insufficiency following adrenalectomy, hypertension, asthma, and tobacco use. His family history was significant for pheochromocytoma in his sister, father, uncle, and paternal grandfather with each requiring surgical excision and no further recurrences of catecholamine secreting tumors in those family members. Additionally, his mother had a history of hypertension.As previously stated, his past medical history was significant for multiple paragangliomas in his head and neck, pheochromocytoma requiring adrenalectomy, and an His medication regimen as an outpatient included hydrocortisone for adrenal insufficiency as well as carvedilol, amlodipine, and doxazosin for management of his hypertension associated with his paragangliomas.9/L, platelet count of 325 × 109/L, sodium of 142 mEq/L, potassium of 3.5 mEq/L, creatinine of 0.91 mg/dL, and blood urea nitrogen (BUN) of 9 mg/dL. His coagulation studies were unremarkable, and liver function studies did not identify any abnormalities. His serum troponin was assessed preoperatively and was less than 0.04 ng/mL. His plasma norepinephrine level was 1186 pg/mL, and plasma normetanephrine level was 283.3 pg/mL. Additionally, his epinephrine level was less than 15 pg/mL and plasma metanephrine was 12.4 pg/mL. His baseline catecholamine levels as an outpatient were not available for review. Radiograph of the chest did not identify an acute cardiopulmonary disease.Lab work following transfer was performed and demonstrated a hemoglobin of 13.9 g/dL, white blood cell count of 7.0 × 10For surgical evaluation, review of prior imaging was performed. A transesophageal echocardiogram (TEE) identified two tumors within the right atrium Figures  and 2. TAs an outpatient, the patient had been compliant with his regime of carvedilol, amlodipine, and doxazosin. For preoperative management, he was continued on his outpatient medication regimen.Following review of the echocardiogram and cardiac magnetic resonance imaging, surgical excision of the two masses were performed. The first tumor was small, measuring 1.0 cm in greatest dimension on the right atrium and close to the atrial appendage on the atrioventricular groove. The second tumor was larger and measured to be 2.5 cm in greatest dimension and attached to the atrioventricular groove, close to the right coronary artery (RCA) on the acute angle of the heart. For excision of the tumors, the patient was placed on full cardiopulmonary bypass. The tumors were then successfully excised and hemostasis was achieved using electrocautery, followed by the placement of several sutures. He had 500 cc of reported fluid loss and did not require transfusion of blood products.After resection of the tumors, each excised mass was then sent to the pathologist for review. Histologic review confirmed paraganglioma for each of the resected tumors. Immunohistochemistry confirmed neoplastic cells which stained positive for chromogranin and GATA binding protein 3 (GATA-3) and a solid nest-like arrangement partially demarcated by S100-positive sustentacular cells in a “Zellballen” pattern Figures  and 4.Pheochromocytomas are chromaffin cell tumors located within the adrenal medulla while paragangliomas are extra-adrenal. Approximately 1.2% of paragangliomas are located within the thoracic cavity, most in the posterior mediastinum , 9. In a111- or Tc99m-labeled octreotide or magnetic resonance imaging [Evaluation for paragangliomas begins with the patient history and physical exam. Usually, patients complain of episodic headache, diaphoresis, tachycardia, or hypertension; and less commonly can present with palpitations, panic attacks, dyspnea, or orthostatic hypotension . Then bi imaging , 16. ThiThe hemodynamic effects and management of cardiac paragangliomas and are dependent on their size, location, and presence of obstruction associated with the tumor. Additionally, paragangliomas are associated most commonly with a catecholamine surge leading to labile elevations in blood pressure which precipitate cardiovascular collapse, pulmonary edema, and occasionally acute respiratory failure . This maThe definitive treatment for cardiac paragangliomas is surgical excision . The maj131I-MIBG; and peptide receptor radionuclide therapy either alone or in combination with octreotide or low-dose capecitabine [SDHB mutations, combination chemotherapy with CVD followed by temozolomide monotherapy is a first-line option [131I-MIBG or 177Lu/90Y-DOTA peptides should be considered [When individuals are considered poor candidates for surgical excision treatment options include chemotherapy and radionuclide therapy. Instances which may exclude patients from surgical excision include the location of the tumor, most typically head and neck paragangliomas; the extent of tumor invasion; and the size of the tumor, especially when greater than 5 cm in diameter , 16. Mulcitabine . In those option . In the e option . AlternaNext, identification of primary versus metastatic paragangliomas and pheochromocytomas is challenge. Primary tumors may develop in any location where sympathetic or parasympathetic ganglia are located . Due to RET protooncgene, neurofibromin 1 (NF1); succinate dehydrogenase genes SDHD, SDHAF2, SDHC, SDHB, SDHA; transmembrane protein 127 (TMEM127); and MYC-associated factor X (MAX) [SDHB, SDHD, or VHL [SDHB mutation. This gene as well as the other succinate dehydrogenase subunits  are proteins within the mitochondria and are involved in both the Krebs cycle and electron transport chain [SDHB, SDHC, and SDHD genes are associated with cardiac paragangliomas and the SDHB mutation being the having the strongest association with cardiac paragangliomas [SDHB mutation has been associated with extra-adrenal paragangliomas and metastases and is transmitted in an autosomal dominant inheritance pattern [The majority of paragangliomas occur sporadically, but up to 30-40% are familial and associated with a variety of genes . For ind X (MAX) . The tho, or VHL . In our rt chain . Patientngliomas . FurtherSDHA, SDHB, or SDHD mutations, MRI imaging including the skull base and neck, thorax, retroperitoneum and pelvis are recommended [Depending on the patient's genetic mutation that and clinical scenario identified will determine the patient's surveillance and recommended follow-up. For individuals with the ommended . Additioommended . Followiommended . It is rFor all individuals with first-degree relatives of an individual whom has been diagnosed with a paraganglioma and who also had an identified mutation should be offered predictive (or cascade) testing in the context of genetic counseling , the tesSHDB mutation is associated cardiac paragangliomas.Cardiac paragangliomas are extra-adrenal chromaffin cell tumors which are typically located in the left atrium but can present within all four chambers of the heart as well as the aortic and pulmonic valves. These tumors typically present with episodic tachycardia, hypertension, diaphoresis, and headache. Evaluation of paragangliomas will initially start with biochemical evaluation with 24-hour urine metanephrines or plasma metanephrines followed by magnetic resonance imaging or computed tomography. Treatment of these tumors is complete resection, and preoperative management consists of alpha-blockade followed by beta-blockade with consideration for use of calcium channel blockers for hypertension. When available, genetic analysis is recommended for individuals with paragangliomas and the


Intramural ectopic pregnancy (IMP) is a rare ectopic pregnancy with an unclear etiology, and standard treatment guidelines currently remain unclear. The main treatment option is local excision of IMP via laparoscopy or laparotomy.A 32-year-old woman with adenomyosis presented with amenorrhea for 7 weeks and a serum β-human chorionic gonadotropin (HCG) level of 6882 IU/L. The patient had a history of laparotomy for adenomyosis 5 years previously. Three-dimensional ultrasonography showed a live gestational sac (GS) of 9 × 15 × 18 mm located in the left posterior wall of the uterus and a sinus tract connecting the sac and the endometrial cavity. MRI revealed the GS located in the adenomyosis and a 1.0-cm sinus tract connecting the GS and the endometrial cavity.IMP with adenomyosis.High-intensity focused ultrasound (HIFU) treatment combined with systemic methotrexate (MTX) was performed to treat IMP, which would avoid operation and massive bleeding.Serum β-HCG levels decreased to normal 4 weeks after HIFU treatment and the GS was not found on MRI after 4 months. The sinus tract was significantly shortened after the HIFU treatment.HIFU ablation combined with systemic MTX is effective for the treatment of IMP and is favorable for maintaining fertility. IMP is a rare ectopic pregnancy with an unclear etiology. The majority of IMP cases occur in patients with a history of uterine trauma, such as myomectomy, salpingectomy, dilatation and curettage, assisted reproductive technologies and adenomyosis. Early management of unruptured IMP may provide patients with a chance to preserve their fertility. This report describes a case of IMP in a patient with a history of open adenomyomectomy. To our knowledge, it was the first case treated with high-intensity focused ultrasound (HIFU) ablation combined with the systemic use of methotrexate (MTX). Acceptability was obtained from the Institutional Review Board and Ethics Committee. The patient provided consent for publication of this report.Intramural ectopic pregnancy (IMP) is characterized by a gestational sac (GS) within the uterine wall that is partially or completely surrounded by the myometrium and is not connected to the fallopian tubes or endometrial cavity.A 32-year-old woman, gravida 1 para 0, was admitted to Shenzhen Maternity and Child Healthcare Hospital on June 12, 2020 for suspected intramural pregnancy. She previously had undergone open adenomyomectomy for adenomyosis in November 2015. The details of the surgical records are unclear. The patient was instructed to have strict contraception for 2 years postoperatively. The patient was treated with 6 cycles of gonadotropin releasing hormone agonists in 2019 because of adenomyomosis relapse. Due to fertility requirement and ovulation disorders, the patient was administered letrozole for ovulation induction after menstruation recovery. The last menstrual period began on April 22, 2020. The serum β-human chorionic gonadotropin (HCG) concentration measured on the 37th day post-amenorrhea was 6463 IU/L. Serum β-HCG level was 6882 IU/L on the 49th day post-amenorrhea and transvaginal ultrasonography scans revealed a gestational sac (GS) measuring 11 × 8 × 13 mm located in the posterior wall of the uterus and an empty endometrial cavity. An echogenic yolk sac and an embryo bud with primordial cardiac pulsation were observed within the GS. Meanwhile, diffuse adenomyosis can be seen on the posterior wall of the uterus. The patient was diagnosed with suspected IMP with adenomyosis by transvaginal ultrasound. Three-dimensional ultrasonography scans identified a live GS measuring 9 × 15 × 18 mm located in the left posterior wall of the uterus and a sinus tract connecting the sac and the endometrial cavity . The patient was required to complete all preoperative preparations before HIFU treatment, including specific skin preparation, bowel preparation, as well as preoperatively administration of fentanyl and midazolam for sedation and analgesia until HIFU treatment ended. The treatment was required to select the sagittal view of the ultrasound scanning model, conduct real-time monitoring on the treatment response and adjust the treatment parameters accordingly. The IMP at the left posterior side of the uterus was treated first, followed by adenomyosis at the posterior side of the uterus. The focus was placed close to the embedding area of the GS in the center slice at the beginning of the HIFU ablation. Then the focus was placed in adenomyosis lesions, and the focal point was at least 1.5 cm away from the margin of uterus and endometrial cavity to prevent intestinal and uterine endometrium damage. The lesion was divided into sections with 3 mm separation. Then, the HIFU treatment power was 400W and the ablation proceeded from the innermost section to the outside section until the entire lesion was covered. The end-point of HIFU ablation was that the blood flow in GS embedding area and adenomyosis area was significantly reduced or grayscale changes was observed on color Doppler ultrasound. The therapeutic effect was confirmed by contrast-enhanced ultrasound with SonoVue  and MRI post HIFU. Total ablation was performed for 578 seconds without bleeding. At the end of treatment, there was a significant decrease in blood supply around the GS in contrast-enhanced ultrasound. On MRI, a slight collapse of the GS was observed, the area around the GS of the IMP showed an estimated non-perfusion volume ratio of 80% approximately, and the effect of HIFU ablation for GS was satisfactory (Fig. The serum β-HCG level returned to normal after 4 weeks. Dysmenorrhea of the patient was partially relieved after HIFU treatment. MRI did not identify the sinus tract and GS in the posterior wall of the uterus and only revealed adenomyosis in the posterior wall of the uterus Fig. E–H 4 mon In our case, the patient had a history of adenomyomectomy 5 years previously. Sonography and MRI clearly showed that the sinus tract was connected to the sac and endometrial cavity, and hysteroscopy also confirmed the presence of sinuses, which proved the sinus tract in our case was formed traumatically during a prior adenomyomectomy and further supported the viewpoint that IMP can result from previous uterine trauma. This case leaves many issues associated with treatment among patients of reproductive age with adenomyosis open for discussion. There is no clear and unified standard for how to treat patients with adenomyosis who have fertility requirements. The patient in our case without infertility and miscarriage underwent surgical management of adenomyosis in 5-year prior, which increased her risk of future complications including ectopic pregnancy, placental adhesive disorders and uterine dehiscence in future pregnancies. Patients with adenomyosis who have fertility requirements should carefully choose surgical treatment.The pathogenesis of IMP remains unclear. The possible risk factors include prior uterine trauma, adenomyosis, pelvic surgery, and in vitro fertilization.,9,10 It has been suggested that the management of IMP should be individualized based on the lesion location, extent of myometrial involvement, gestational age at diagnosis, the patient’s condition and wishes for future fertility, the clinician’s judgment, as well as facilities available. Medical therapy is rarely used alone and often combined with conservative surgical treatment. The main surgical option is local excision of the IMP via laparoscopy or laparotomy and these main concerns are the long period of contraception and the subsequent risk of uterine rupture. Hysteroscopic surgery might be a choice if imaging techniques identify a sinus linking the GS with the uterine cavity, which will damage the structure of the uterus and is not conducive to subsequent pregnancy.Because of the rarity of IMP, standard treatment guidelines currently remain unclear. However, once the diagnosis is established, appropriate treatment should be carried out without delay before complications occur. The management options include medical therapy and surgery. In the past, hysterectomy or surgical resection was used to manage uterine rupture and severe hemorrhage secondary to IMP. With the early diagnosis of IMP, there are a variety of conservative management options for IMP, including local or systemic injection of methotrexate and laparoscopic or hysteroscopic lesion resection. which leads to reduce the blood supply around the GS in our patient. Several studies have examined the safety profile of ultrasound-guided HIFU in treating patients with adenomyosis, besides sustaining long-term clinical improvements and achieving better postoperative reproductive outcomes. HIFU ablation has also been performed to treat cesarean scar pregnancies and cornual ectopic pregnancy.,7 It is confirmed that HIFU could terminate cesarean scar pregnancies with no obvious adverse effects on subsequent pregnancy. These studies indicates the feasibility of HIFU for the treatment of ectopic pregnancy lesions in uterus, though no case in which a patient with IMP was treated by HIFU treatment has been reported previously. Here we report that IMP with a history of open adenomyomectomy could be successfully managed by HIFU combined with MTX during early pregnancy, which is less traumatic and capable of preserving the integrity of the uterus and has a short contraceptive time.HIFU ablation is a noninvasive therapy, which could make the in vitro low-energy ultrasound to be focused selectively on target tissues in the body, lead to a heat over 65℃, then induce coagulative necrosis, and spare the adjacent normal tissues at the same time. HIFU also can damage small vessels with a diameter less than 2 mm, Therefore, pregnancy related to adenomyosis is a very difficult problem.The particularity of this case is the concurrent adenomyosis, which was located at the posterior wall of the uterus and the IMP lesion was wrapped within the adenomyosis. The sinus tract linked the GS with the uterine cavity, which was resulted from previous adenomyomectomy. Local excision of the IMP via laparoscopy or laparotomy can simultaneously remove the sinus tract, but the contraceptive time is long. The diffuse adenomyosis lesions may also lead to poor healing of uterine incision and sinus formation again. HIFU treatment not only ablated ectopic pregnancy lesions, but also ablated a small part of adenomyosis lesions at the same time. However, the treatment of HIFU combined with MTX couldn’t remove the sinus tract. In the end there is an unexpected discovery that the sinus tract was significantly shortened after HIFU treatment. The possible reason is that the ectopic endometrial tissue in the sinus tract was also ablated by HIFU, which may lead to remodel of the sinus structure and shortening of the sinus tract. In our case, the patient’s second pregnancy located in the uterine cavity. HIFU treatment might be helpful for subsequent pregnancy because of the shortening of the sinus tract. Unfortunately missed abortion occurred in the end. Pregnancy patients with adenomyosis have a high rate of miscarriage.HIFU, a novel noninvasive therapeutic method, combined with MTX treatment is effective for the treatment of IMP and favorable for maintaining fertility. Hopefully, our findings will play an enlightening role and attract the attention of clinicians.Data curation: Yan Peng.Formal analysis: Yan Peng, Yu Dai.Investigation: Yan Peng, Guiyuan Yu.Methodology: Yan Peng, Yu Dai, Guiyuan Yu.Project administration: Yan Peng, Ping Jin.Resources: Yan Peng, Yu Dai.Supervision: Ping Jin.Writing – original draft: Yan Peng.Writing – review & editing: Yan Peng.


Murine double minute 2 (MDM2) is an oncogene that inhibits p53, leading to decreased apoptosis. Sarcomas showing MDM2 amplification are rare among pediatric patients.A 14‐year‐old boy presented with pleomorphic sarcoma of the head showing MDM2 amplification without a well‐differentiated liposarcoma component. Although chemotherapy was initially performed to reduce the tumor size before surgery, the tumor did not shrink. The patient underwent complete surgical resection. Microscopic examination revealed a positive surgical margin; thus, postoperative proton‐beam radiotherapy was performed. 3 years after the therapy, no sign of recurrence was observed.Macroscopic surgical resection combined with adjuvant postoperative radiotherapy was effective against MDM2‐amplified pleomorphic sarcoma refractory to neoadjuvant chemotherapy in a pediatric patient. These were similar to DDLPS in terms of their clinical courses and showed better prognosis than that of MDM2‐negative undifferentiated pleomorphic sarcomas.Sarcomas with MDM2 amplification are rare among pediatric patients. We report a pediatric case of pleomorphic sarcoma of the head showing MDM2 amplification without a WDLPS component.218F‐fluorodeoxyglucose positron emission tomography with CT (18F‐FDG PET/CT) demonstrated a lobulated mass on the right side of the masticator space with minimal FDG activity   revealed a lobulated mass  on the right side of the masticator space. Contrast‐enhanced magnetic resonance imaging (MRI) revealed iso signal intensity on T1‐weighted images and high signal intensity on T2‐weighted images in most areas of the mass. A non‐uniform contrast effect was noted inside the mass Figure , and fat) Figure A. No othHistologically, hematoxylin–eosin staining showed proliferation of atypical spindle‐shaped cells with fibro‐collagenous stroma. Pleomorphic tumor cells and adipocytes with minimal atypia were also observed. Immunohistochemically, atypical spindle‐shaped cells stained positive for MDM2 and cyclin‐dependent kinase 4 (CDK4) Figure , and neg2/day on days 1 and 2) and ifosfamide (2 g/m2/day on days 1–5). The tumor did not shrink after three courses of chemotherapy. Moreover, no change was observed in the FDG activity (SUVmax = 1.92) as per 18F‐FDG PET/CT  was performed against the microscopic residual disease. 3 years following therapy completion, the patient did not show any sign of recurrence Figure . Current3Our patient was clinically diagnosed with DDLPS owing to the positive immunostaining results for MDM2 and CDK4 and MDM2 gene amplification. The overall MDM2 amplification frequency in all human cancers is low, varying between 3.5% and 4.4%.18F‐FDG PET/CT is reported in DDLPS.Variable FDG uptake in Complete surgical resection remains the primary and most prevalent treatment for DDLPS.We considered complete surgical resection as the best treatment for our patient. However, based on the location, size, and extent of the tumor, we considered that surgical margins might be positive even if macroscopic complete surgical resection was possible. Therefore, we decided to administer postoperative radiotherapy if there was microscopic residual disease. Although the partial response rate of chemotherapy with doxorubicin and ifosfamide is approximately 30%,We report a rare pediatric case of pleomorphic sarcoma of the head showing MDM2 amplification by FISH. Following the World Health Organization (WHO) classification of tumors, the tumor of our patient was not DDLPS due to the absence of a WDLPS component. Molecular profiling could help diagnose in unusual pediatric cases; hence, it should be considered to assist with diagnosing rare pediatric sarcomas in the near future.Mitsuko Akaihata: Conceptualization ; writing – original draft . Ikuko Takahashi: Conceptualization (supporting). Yuko Kakuda: Conceptualization (supporting); visualization . Takuya Kawata: Conceptualization (supporting); visualization . Takashi Mukaigawa: Conceptualization (supporting). Testuro Onitsuka: Conceptualization (supporting). Shigeyuki Murayama: Conceptualization (supporting). Yuji Ishida: Conceptualization (lead); supervision ; writing – review and editing .The authors have stated explicitly that there are no conflicts of interest in connection with this article.Informed consent was obtained from the patient for the publication of this case report.Figure S1.18F‐fluorodeoxyglucose positron emission tomography with computed tomography (18F‐FDG PET/CT): (A)Image at diagnosis. A mass at the right side of the masticator space shows minimal FDG activity (SUVmax = 2.14). Two punctate accumulations (SUVmax = 3.61), which are consistent with lymph nodes, are found on the underside of the mass. These accumulations are considered as reactive lymph node enlargement. (B) Pre‐surgery image. FDG activity at the right side of the masticator space is similar to that at diagnosis (SUVmax = 1.92).Click here for additional data file.Figure S2. Hematoxylin–eosin staining shows that pleomorphic tumor cells (Yellow arrow) infiltrate outside the capsule (Blue arrows) on the surgically resected specimen . The surgical margin is positive.Click here for additional data file.


Ameloblastoma is an uncommon benign epithelial neoplasm of odontogenic origin that accounts for about 18% of the odontogenic tumour. It is a slow-growing, locally invasive but rarely metastatic tumour. Extraosseously occurring peripheral ameloblastoma is a rare variant that comprises about 2-10% of all ameloblastoma. We report a case of peripheral ameloblastoma in a 43-years old male patient affecting the mandibular canine-premolar region with a histopathological diagnosis of acanthomatous ameloblastoma. This case report emphasises the clinical, radiographic, and histological features of a rare variant that distinguishes it from the other similar appearing lesion on gingiva along with its various treatment modalities. Here we report a rare case of peripheral ameloblastoma of the acanthomatous variant in the mandibular canine-premolar region in a male patient treated with surgical excision.Ameloblastoma is a neoplasm of odontogenic epithelium, particularly of enamel organ-type tissue that has not undergone differentiation to the point of forming hard tissue.A 43-year-old male patient reported to the Department of Periodontology and Oral Implantology with a chief complaint of swelling in the left lower front region of the jaw for 3 years, progressive in nature. The past medical and family history was non-relevant. Intraoral examination revealed a localised, ovoidshaped swelling of size 1 x 1.5 cm extending from the attached gingiva to the depth of the buccal vestibule between the right lower canine and first premolar. On palpation, it was firm, fixed, non-fluctuant, and non tender. The contiguous teeth were vital to the cold test. Clinically, the involvement of the lingual aspect of the mandible was not appreciable. No fluid was aspirated from the lesion. Based on the patient's history, clinical examination, and chairside investigations, a peripheral-ossifying fibroma was considered a provisional diagnosis. Differential diagnoses of a benign odontogenic tumour, peripheral giant cell granuloma, and fibroma were made.Radiographic evaluation with periapical and panoramic radiographs revealed missing 32 and slight displacement of the root of canine towards mesial aspect without root resorption. The computed tomography (CT) scan revealed a mild lytic lesion with an erosion of the alveolar cortex in the left lower canine-premolar region .After consultation with the Department of Oral and Maxillofacial Surgery, an excisional biopsy of the mass was planned. Informed and written consent were taken and the patient was subjected to biopsy. Under local anaesthesia, an envelope mucoperiosteal flap was elevated and the underlying mass was then localised. The complete excision of the mass along with adequate alveolar margin was resected .The operative site was then irrigated to remove any residual fragments and debris. The excised surgical specimen was sent for histopathological examination. The flap closure was done with sutures. Satisfactory postoperative healing was noted.Histopathological examination of the specimen revealed odontogenic tumour islands of variable shapes and sizes lining with peripheral tall columnar ameloblast-like cells with palisaded hyperchromatic nuclei and central stellate reticulum-like cells. Multiple areas demonstrated squamous metaplasia of stellate-reticulum-like cells. Numerous tumour cords and islands exhibited hyalinization at the periphery along with a focal area of bony trabeculae with osteocytes. The connective tissue stroma was fibrous with collagen fibres arranged in bundles along with a few inflammatory cells and blood vessels of variable sizes .The histopathological diagnosis of acanthomatous ameloblastoma was made. Clinical, radiographics, and histopathological findings finally led to the diagnosis of peripheral ameloblastoma of the acanthomatous variant in the mandibular canine-premolar region. A close, periodic clinical, and radiographic follow-up of the case was maintained. The most recent clinical revaluation at 18 months follow-up revealed no signs of recurrence at the treated site.3 According to the WHO classification of odontogenic tumours in 2005, ameloblastomas were divided macroscopically into four types: solid/multicystic, extraosseous/peripheral, desmoplastic, and unicystic. However, in 2017 it was simplified to ameloblastoma, unicystic ameloblastoma, and extraosseous/peripheral types.4 Among these, peripheral ameloblastoma is an uncommon variant with a prevalence of 1-5%.5 The most probable sources of PA are; the remnants of dental lamina so-called "glands of Serres", odontogenic remnants of the vestibular lamina, the pluripotent cells of the basal layer of the mucosal epithelium, and the pleuripotent cells of the minor salivary gland.6According to the World Health Organization (WHO), ameloblastoma is defined as a benign but locally invasive neoplasm consisting of proliferating odontogenic epithelium located in a fibrous stroma. Despite its aggressive local behaviour, it rarely metastasizes to other organs.7Similarly, various histological subtypes of ameloblastoma have been described, including follicular, plexiform, acanthomatous, granular, and basal cell types. Most literature showed that follicular ameloblastoma is the most prevalent histological variant (64.9%) followed by plexiform (13.0%), desmoplastic (5.2%), and acanthomatous (3.9%) varieties.8 Slight male predilection has been reported for all forms of ameloblastomas including PA.2 While about 80% of ameloblastoma occur in the mandible with 70% being located in the molar-ramus area, the lingual aspect of the mandibular premolar region is reported as the most commonly involved site of PA that accounts for 32.6% of all sites.9 These data were consistent with our case except for the involvement of the buccal aspect of the mandible rather than the lingual. Some other unusual sites for PA include buccal mucosa, the base of the tongue, and the floor of the mouth.8PA has the peak incidence in the fifth to sixth decades of life while other intraosseous ameloblastomas usually present at a younger age.10 However, immunohistochemical analysis differentiates these two entities as patterns of positivity for cytokeratins are different between PA and BCC.Similar to all other cysts and bone tumours, the diagnosis of ameloblastoma requires appropriate clinical and radiological examination. Clinically PA presents as a slow-growing exophytic mass arising from the soft tissue of the tooth-bearing region of the jaw and therefore may be misinterpreted as other peripherally occurring lesions like pyogenic granuloma, peripheral ossifying fibroma, and peripheral giant cell granuloma. PA usually is an indolent tumour that doesn't invade the underlying bone and therefore does not present any distinct radiographic evidence as in our case. CT and magnetic resonance imaging (MRI) usually depict PA as a well-demarcated mass but do not demonstrate invasion of the jaws and adjacent muscles. However, a mild erosion or local depression on the cortical bone without reaching the bone marrow known as cupping or saucerization has been reported to occur occasionally which was detected even in our case. An interesting issue regarding the histology of PA is that some authors consider PA and basal cell carcinoma (BCC) as the same lesion as both of them share some peculiar histopathologic characteristics such as basal cells and their island arrangements.8 According to the WHO classification, the term acanthomatous ameloblastoma should be applied when extensive squamous metaplasia, sometimes with keratin formation, is found within the islands of tumour cells as evident in our case.Various histopathological patterns are exhibited by PA with the tendency for acanthomatous variant as in our case.8Treatment modalities for ameloblastoma include both radical and conservative surgical excision, radiation therapy, or a combination of surgery and radiation. The basic principle for the cure remains complete removal of the neoplasm, regardless of how it is accomplished. Resection with a safety margin is reported as the best and the most preferred method in the treatment of ameloblastomas and the same was done in our case. A study reported a recurrence of 9% following the treatment of PA. Although rare, malignant transformation and metastasis of PA have also been reported.Peripheral ameloblastoma although benign neoplasm with no aggressive behavior or invasive potential unlike intraosseous ameloblastoma, owing to the possibility of its recurrence and malignant transformation, a long-term follow-up is recommended even after the definitive treatment.In the present case, although three-dimensional computed tomographic imaging, as well as complete surgical excision with adequate safety margin, further confirmed with histopathological examination and 18 months follow-up was done, longer clinical and radiographic follow-up was deemed necessary as there was even bony involvement in the form of cortical erosion.Early diagnosis of an uncommon but locally aggressive odontogenic tumor of the jaw like ameloblastoma is paramount for definitive treatment and minimizing reconstructive challenges. However, mere clinical and radiographic presentation of early-stage ameloblastoma may not be pathognomic as in our case of peripheral ameloblastoma. Therefore, a histopathological interpretation is highly indicated not only for the diagnosis of such mass but also for the identification of its histological variant based upon which its prognosis, definitive management, and treatment outcome can be determined.


Mesenteric ischemia is a fatal vascular emergency of the small intestine which, if not diagnosed and treated in time, has a very high mortality rate. Presenting with nonspecific symptoms such as abdominal pain, nausea, constipation, tachycardia, and gastrointestinal bleeds, it can masquerade as other causes of acute abdomen, particularly bowel obstruction. Ideal laboratory tests and markers are still lacking due to complexity in bowel's anatomy, physiology, blood supply, and drainage. We report 10 cases of mesenteric ischemia presented in our center with their demography, laboratory findings, approach to diagnosis, and treatment along with their outcomes at discharge. Out of the ten cases, six cases presented with signs and symptoms of acute bowel obstruction without passage of stool and one with passage of black stool. These seven patients underwent laparotomy, while the remaining three cases who either presented with milder symptoms or refused surgical interventions were managed conservatively. All patients were diagnosed with either acute or chronic mesenteric ischemia based on their operative and/or radiographic findings. Mesenteric ischemia is a potentially fatal vascular emergency with a mortality rate of about 60-90% –4 which The aim of our study is to describe the demography, presenting features, diagnostic approach, treatment, and outcomes of patients diagnosed with mesenteric ischemia.10 patients of both the sexes with postoperative and/or radiological diagnosis of mesenteric ischemia presenting in our center, in the Department of GI and General Surgery, within a year interval were included in this case series. This is a single-center case series. This series was conducted in a retrospective fashion reviewing patient's files. Demographic data like age and sex were analyzed. Any existing cardiac disease diagnosed either via electrocardiography (ECG) or echocardiography (ECHO) was taken into consideration as major risk factors for embolism. Basic laboratory parameters including total leukocyte count or white blood cell (WBC) count, pH, and lactate were analyzed in order to evaluate their roles in supporting the diagnosis of mesenteric ischemia as well as establishing the severity of the disease. Then, either a radiological or postoperative diagnosis was made and correlated with the treatment they received. Finally, the outcome was compared at the time of discharge of the patients.All these data were analyzed using statistical tools like Microsoft Excel.A 76-year-old man was admitted to the hospital with a history of sudden-onset abdominal pain, initially periumbilical in location with generalization later, accompanied by vomiting and no passage of stool for 2 days. On examination, irregular pulse was noted. Abdominal examination revealed mild tenderness in the central abdomen and an absence of bowel sound. Laboratory investigations were normal; however, ECG revealed atrial fibrillation with a ventricular rate of 99/min, and arterial blood gas (ABG) report was normal except increased lactate level of 2. CECT of the abdomen suggested an occlusion of superior mesenteric artery . The patA 22-year-old female was admitted with a history absence of passage of stool and flatus accompanied by abdominal distension for 3 days and 1 episode of vomiting. Laboratory reports were normal except for a low hemoglobin level (9.9 gm/dL) and increased white blood cells  and platelet  counts. ABG showed evidence of acidosis with a pH of 3.99. Ultrasonography (USG) abdomen and pelvis and X-ray abdomen  showed f3. An ABG analysis revealed a pH of 7.483 with lactate levels of 2.3 mmol/L, while an ECG showed sinus tachycardia (116/min). Echocardiography evaluation showed no clots or vegetations. CECT of the abdomen revealed findings suggestive of thrombosis in common hepatic artery and jejunal and ileal branches of superior mesenteric artery with an infarct in lower pole of right kidney. The patient was initially treated conservatively with anticoagulants due to refusal of surgery. With increasing abdominal pain, the patient was counseled and she underwent exploratory laparotomy with resection of gangrenous bowel and jejuno-ileal anastomosis. Intraoperative findings were gangrenous 110 cm of the small intestine extending from 70 cm distal to DJ flexure and a near perforation in the distal third of the resected segment. Postoperative, the patient was managed conservatively with anticoagulants for the renal infarct. Her condition improved and she was discharged home.A 47-year-old female presented to the emergency department with the history of acute-onset abdominal pain initially in the epigastric region which later generalized, along with abdominal distension. On examination, the abdomen was tense, distended with tenderness in the epigastric region, rebound tenderness, and reduced bowel sounds. Laboratory investigations were normal except elevated white cell counts of 18,700/mm3, and a platelet level of 706,000/mm3. USG Doppler of the leg revealed the features suggestive of deep vein thrombosis (DVT) of left lower limb. ECG showed sinus rhythm. With the diagnosis of acute mesenteric ischemia with peritonitis due to gangrenous bowel with sepsis, patient was subjected to the surgery on the same day and exploratory laparotomy with resection of gangrenous small intestine, and jejunostomy and ileostomy were performed. Intraoperative finding was a gangrenous small bowel extending 80 cm from DJ flexure to 20 cm proximal to IC junction. With continuous monitoring during the postoperative period and improvement in his condition, a follow-up jejuno-ileal anastomosis was performed. Later, as the patient's condition worsened, reexploration and double barrel jejunostomy and ileostomy were performed with intraoperative finding of leakage over the anastomotic site in the anterior and posterior aspect. With further improvement on the postoperative period, the patient was finally discharged on tab warfarin and was kept on follow-up.A 39-year-old man was admitted to the hospital with a history of abdominal pain and distension accompanied by vomiting and an absence of passage of stool. Examination revealed distended abdomen with tenderness in all quadrants, guarding, and absence of bowel sound. Laboratory investigations reported a hemoglobin level of 9 gm/dL, white cell count of 13,000/mm3 and a prothrombin time (PT)/international normalized ratio (INR) of 23/2.09. ABG report showed pH of 7.46 and lactate level of 2 mmol/L. With the diagnosis of chronic mesenteric ischemia, the patient underwent emergency laparotomy with jejunal resection with stapled functional end-to-end anastomosis with feeding jejunostomy. Intraoperative findings revealed stricture and impending jejunal perforation 70 cm distal to DJ flexure. However, the patient's condition did not improve postoperatively, and he succumbed to death 1 week after the operation due to refractory shock.A 64-year-old man with a previous history of SMA thrombosis under warfarin, self-discontinued 5 days back, presented with a history of abdominal pain, vomiting, and no passage of stool or flatus. On abdominal examination, generalized tenderness, guarding, and an absence of bowel sound were noted. ECG revealed findings suggestive of atrial fibrillation. USG scan of the abdomen was normal; however, laboratory results showed a white cell count of 2,600/mm3. Fecal stool occult blood test (FOBT) was positive. CT angiogram of left upper limb showed narrowing of vessel caliber, from the distal part of left axillary artery to proximal two-third of brachial artery with faint opacification of distal radial artery. Similarly, CT angiogram of the abdomen and pelvis including the thorax revealed eccentric thrombus in the arch and proximal descending part of thoracic aorta along with superior mesenteric artery thrombus, distal to the origin of proximal jejunal branches with edematous and reduced enhancing of ileal loops. Hence, with the diagnosis of acute mesenteric ischemia due to SMA thrombosis, the patient was immediately rushed to the operation theater, and emergency laparotomy was performed with resection of gangrenous jejunum and ileum with a double barrel jejuno-ileostomy. Intraoperative findings revealed gangrenous large segment of small bowel from 30 cm distal to DJ flexure to 20 cm proximal to IC junction. The patient improved on the postoperative period, was discharged, and readmitted later for ileostomy reversal.A 45-year-old male was admitted to the hospital with chief complaints of periumbilical pain and passage of black-colored loose stool. On examination, his vitals were stable but the radial pulse on left forearm was feeble compared to his right forearm. Laboratory investigations were normal except for the white blood cell count of 18,600/mmA 54-year-old man presented with chief complaints of acute-onset abdominal pain, vomiting, and not passing stool. Laboratory investigations were normal, ECG showed sinus rhythm, and ABG findings were not significant . However, CECT of the abdomen and pelvis showed intraluminal filling defect in celiac trunk which was suggestive of thrombosis. With no further delay, the patient was admitted and rushed for operation on the same day, and exploratory laparotomy with resection and anastomosis was performed. Intraoperative findings showed a gangrenous patch of the small intestine, approximately 100 cm, extending distal from 80 cm of DJ junction. Later, the patient improved postoperatively and was discharged with regular follow-ups.3. ECG showed atrial fibrillation and an ABG revealed normal findings except for an increase in lactate level of 2.5. Echocardiography showed dilated left atrium (LA) and moderate mitral regurgitation (MR), and a USG examination showed features suggesting chronic DVT and peripheral arterial disease. CECT of the abdomen and pelvis showed total occlusion of distal half of superior mesenteric artery and the right common iliac artery extending to the internal and external iliac artery. The patient was counseled of the need for surgery, its outcomes, and prognosis. However, she refused it, and hence, she was managed conservatively with anticoagulants and was discharged on patient request. The patient was subsequently lost for follow-up.An 86-year-old female was admitted with a history of pain in the abdomen. On examination, atrial fibrillation was found. Lab investigations were normal except white cell counts of 22,000/mmA 70-year-old man was admitted with a history of abdominal pain which was central and radiating to the back. On abdominal examination, there was tenderness on the left iliac fossa and bowel sounds were normal. Laboratory investigations were normal except for a hemoglobin of 10.4 gm/dL. ECG showed normal sinus rhythm and an ABG revealed a pH of 7.46 and a lactate level of 0.4 . CECT of the abdomen revealed the features suggestive of omental infarction with suspicious filling defect in one of the left branches of SMA. Mesenteric angiography then showed approximately 50% stenosis of SMA region and complete occlusion of distal portion of first left branch of SMA . With the diagnosis of Chronic mesenteric ischemia, the patient was managed conservatively first with injection heparin which was later switched to oral warfarin. With improvement in his condition, the patient was discharged on warfarin with further follow-ups.A 23-year-old lady was admitted in the hospital with the diagnosis of postsplenectomy pancreatic fistula with acute portal vein thrombosis. She was a known case of idiopathic thrombocytopenic purpura. CECT of the abdomen and pelvis revealed thrombosis of portal vein and superior mesenteric vein, with long segment diffuse edematous wall thickening of the distal ileum sparing the terminal ileum likely due to small bowel ischemia. The patient was managed conservatively and was discharged on warfarin.Mesenteric ischemia has a prevalence of about 1 in 1000 hospital admissions . Its peaThe presenting signs and symptoms of acute mesenteric ischemia are vague, with the classical complaint being abdominal pain out of proportion to physical findings and frequently accompanied by vomiting. In addition to this, it can present with signs and symptoms of bowel obstruction as well . Once boThe presence of cardiac findings supports the diagnosis of mesenteric ischemia in patients presenting with features described above. It has also been correlated with increased mortality with reviews showing up to 70% lethality in cases of mesenteric ischemia with atrial fibrillation . In our Leukocytosis, increased serum lactate, and metabolic acidosis with increased anion gap have been used as laboratory adjuncts for the diagnosis of intestinal ischemia , 15. ThoApart from the laboratory markers, various radiological techniques are used in the diagnosis of mesenteric ischemia. Pneumatosis intestinalis and thumb-print sign  are some of the signs suggestive of bowel infarction on a plain abdominal X-ray. Nonspecific findings such as adynamic and mechanical small bowel obstruction can also be seen on plain films of mesenteric ischemia , which hSplanchnic circulation receives approximately 25% of resting cardiac output, the major portion of which is distributed to the mucosa and submucosa (70% of mesenteric blood flow) . BecauseMesenteric ischemia can be either acute or chronic. Acute mesenteric ischemia can further be classified as being due to arterial embolism (40-50%), arterial thrombosis 25%), nonocclusive mesenteric ischemia (20%), and venous thrombosis (5-10%) 5%, nonoc. Emboli,Specific etiology demands specific management. Mesenteric arterial occlusion either by a thrombus or an embolus is treated with surgical laparotomy and/or thrombectomy/embolectomy or thrombolysis, the choice of which depends on the time course, extent, comorbidities, presence of symptoms of acute abdomen, and hemodynamic stability of the patient. All that mesenteric vein thrombosis requires is anticoagulation unless symptoms keep persisting which needs exploratory laparotomy. Two of our cases with SMA thrombosis without signs of acute abdomen with maintained hemodynamic stability were managed conservatively. Once intestinal ischemia is suspected, IV fluid resuscitation (because of third spacing), IV broad-spectrum antibiotics , and anticoagulation with heparin should be started immediately , 20, 23.A clinical diagnosis of acute mesenteric ischemia should be considered in patients presenting with features suggestive of bowel obstruction along with AF. While a positive fecal occult blood test further points towards the diagnosis, it is likely to be positive only after mucosal infarction sets in. In those with a diagnostic dilemma, we recommend using contrast enhanced computed tomography to aid in the diagnosis; however, in those presenting with features of peritonitis and unstable vitals, exploratory laparotomy without a prior CT scan is justified. Since time is everything in this disease, early exploratory laparotomy (within 24 hours) can be a life-saving procedure as exemplified in our case series. Postoperative complications especially anastomotic leakage are associated with a higher mortality rate despite early diagnosis and treatment. Therefore, the decision of a primary anastomosis vs. a diverting stoma should be made tactfully.