Non-Hodgkin lymphoma (NHL) of the ileum, presenting as perforation and peritonitis, is a rare disease, derived from intestinal intraepithelial T lymphocytes. The degree of malignancy is extremely high. The pathogenesis of ileal perforation caused by NHL remains unclear, as well as the chromosome and immune system abnormalities, which may be related to NHL, and are indistinguishable from other benign and malignant conditions and are clinically nonspecific.We describe an 84-year-old man with abdominal pain for 4 days, which was aggravated for 3 h. The pain was in the upper abdominal region and was initially considered to be due to gastrointestinal perforation. He had persistent insidious pain, accompanied by nausea, vomiting, and fever. Physical examination indicated that the patient had pain all over the abdomen; also, rebound pain and muscle tension, and bowel sounds were reduced on auscultation. An abdominal CT scan showed free gas in the abdominal cavity. The patient was diagnosed with peritonitis due to hollow viscus perforation. A prompt exploratory laparotomy was performed. Intraoperative findings showed perforations in the ileum that are approximately 40 cm from the ileocecal region, which were 3–8 mm in size. A segmental distribution was observed, and the intestinal contents overflowed with purulent discharge around the perforation surface. Resection and ileostomy were performed, and the clinical histopathological examination confirmed T-cell lymphoma. The patient was advised to visit the Oncology Department for further chemotherapy.Timely emergency surgery is the key to the treatment of ileal perforation caused by T-cell lymphoma. Resection and ileostomy were performed as intervention measures, and subsequent histopathological examination manifested T-cell lymphoma. Non-Hodgkin lymphoma (NHL) of the ileum is an intestinal tumor of intraepithelial T-lymphocytes, usually presenting as a neoplasm composed of large lymphoid cells and is associated with necrosis and inflammatory background, as well as the presence of large numbers of histiocytes and eosinophils . The smaIn our daily clinical practice, most acute abdominal syndromes are characterized by pain, which requires an early diagnosis and treatment, while most require emergency surgery. Common acute abdominal diseases include appendicitis, gastric and intestinal perforation, volvulus, acute pancreatitis, and ectopic pregnancy. Therefore, in most cases, the intestinal perforation can only be detected by a laparotomy, and a definite diagnosis can only be made after a histopathological examination. We report the rare case of a male suffering from peritonitis with a non-Hodgkin lymphoma located in the small intestine. This case is reported in accordance with the SCARE 2018 guidelines .The 84-year-old male patient has an uncommon case of suffering from perforation and peritonitis, with a T-cell lymphoma located in the small intestine and treated in Tongren People's Hospital in September 2020. The medical history, clinical symptoms, signs, laboratory results, imaging data, and histopathological examination results were reported as follows.An 84-year-old male patient was presented to the hospital with abdominal pain for 4 days, which was aggravated for 3 h. The pain was initially located in the upper abdominal area and was a persistent insidious pain. The patient felt unbearable pain accompanied by nausea, vomiting, and fever due to the gradual deterioration of the disease. The patient had a history of valvular heart disease and coronary atherosclerosis for 10 years, but no history of peptic diseases or black feces, weight and appetite loss, hepatitis, tuberculosis, typhoid, smoking, and alcohol consumption.He does not have a history of familial hereditary disease. A clinical examination revealed a heart rate of 132 beats per minute, respiratory rate of 22 breaths per minute, blood pressure of 130/80 mmHg, and temperature of 36.5°C. A physical examination indicated that the patient had pain all over the abdomen, rebound pain, and muscle tension. The liver and spleen were not palpable, and the percussion demonstrated a drumming sound around the umbilicus. The shifting dullness was negative, and bowel sounds were reduced on auscultation. Other systems were normal. There were no palpable lymph nodes in the cervical, axillary, or inguinal regions.9, with a neutrophil composition of 94.4%, and hemoglobin content of 86 g/L. The biochemical indices were within the normal limits. C-reactive protein content was 255.55 mg/L. The coagulation test was normal. The patient was negative for hepatitis B, syphilis, and HIV. The electrocardiogram and chest X-ray were also normal. An abdominal CT scan revealed a free gas in the abdominal cavity  on the tumor cells, and negative CyclinD1, CD56, and CD30 were observed , indicatThe patient was discharged postoperatively in 8 days in good condition, and had a good spirit and diet, without any special discomfort. The patient was advised to visit the Oncology Department for further chemoradiotherapy.An acute abdomen signifies the need for prompt diagnosis and early treatment, but not necessarily a surgical treatment all the time; the pain is the main symptom in most patients .In the clinical work, perforation of the digestive tract caused by lymphoma is uncommon, and the small intestine  is the most common site of involvement followed by the stomach, colon, and rectum , 6. A smPrevious research reported that the primary intestinal lymphoma is a predominantly male disease, the male:female ratio is 2.5:1. The clinical presentation of small intestinal lymphoma is non-specific, and the patients mainly have acute abdominal pain symptoms 70–80%), weight loss (30%), hematochezia (25.9%), diarrhea (16.9%) nausea, vomiting, and bad appetite 0%, weigh, but rarWe report the case of an 84-year-old male patient with a primary ileum T-cell lymphoma. The first symptom was acute abdominal pain, which has gradually manifested as peritonitis. We excluded relevant contraindications and identified numerous perforations in the ileum by performing an emergency laparotomy, which required an ileum resection and ileostomy. We conclude that a temporary enterostomy may be a better choice for patients with unexplained spontaneous intestinal perforation, rather than an intestinal resection and intestinal anastomosis.Given its rarity and its low incidence rate, the intestinal perforation caused by lymphoma is often neglected and is difficult to distinguish from Crohn's disease, intestinal tuberculosis, intestinal typhoid, and other types of gastrointestinal disease. For patients with abdominal pain, fever, gastrointestinal perforation, and bloody stool, especially when multiple ulcers of the intestinal wall are observed during colonoscopy, the possibility of lymphoma should be considered to avoid misdiagnosis or missed diagnosis . TherefoSurgery followed by chemotherapy is the recommended treatment and surgery followed by an adjuvant multi-agent chemotherapy, with cyclophosphamide, doxorubicin, vincristine, and prednisolone (CHOP), has led to improved outcomes. In most cases, the NHL is usually treated with anthracycline-based therapy consisting of CHOP .In conclusion, the prognosis of patients with NHL remains exceedingly poor , 15. TheWe followed up with the patient by telephone every month. He received 5 cycles of postoperative chemotherapy. At present, he has a good mental state and diet, no recurrence of tumor, no cough, expectoration, no abdominal pain, distention, fever, or other symptoms. There were no signs of recurrence on the physical examination and the CT scan, with contrast enhancement of the chest, abdomen, and pelvis (C/A/P CT Scan), was within the normal limits and was carried out every 3–6 months for the first 5 years, then, every 12 months for each subsequent year. We were unable to perform the PET as this technique is not available in our hospital.The clinical presentation of a primary small intestinal lymphoma is usually nonspecific, which easily leads to a delayed diagnosis and a misdiagnosis. Early diagnosis and treatment are important for improving the prognosis of bowel perforation in patients with NHL. A surgery followed by chemotherapy is the recommended treatment for improving the overall survival of patients.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.Written informed consent was obtained from the participant and the study protocol was approved by the Research Ethics Board of the Tongren City People's Hospital, Tongren City, Guizhou Province, China.YT studied the literature and wrote the manuscript. CL, QT, and RT operated on the patient and had the idea for this case report. SQ checked the manuscript and made the corrections. All authors read and approved the final manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


We report on a case of a large atypical cartilaginous tumor of the pelvis and its novel surgical resection with an anterior hemipelvectomy and reconstruction with an iliac crest graft. Surgical intervention is the mainstay treatment of pelvic chondrosarcomas. However, there have been reports of concern regarding preventing pelvic visceral herniation and adequately reconstructing the pelvis. This report is unique within the literature and has yielded good functional outcomes whilst achieving satisfactory surgical margins and minimizing morbidity. The patient consented to the production of this report and it was approved by our ethics committee.See In addition to an abdominal and pelvic CT scan, the patient underwent further staging studies. These included a magnetic resonance imaging (MRI) which demonstrated a large heterogenous T2 bright lesion measuring 9 ×6 cm emerging from the posterior aspect of the right body of the pubis. The mass projected postero-superiorly with a large, 1 cm thick cartliagenous cap and an underlying stalk that communicated with the medullary cavity of the pelvis. There was also significant effacement of the bladder with compression of the right ureter and resulting hydronephrosis. There was no infiltration of any surrounding structures.Functional imaging including both thallium-201 and technetium-99 pentavalaent dimercaptsouccinic acid (DMSA V) scintigraphy were utilized and demonstrated minimal metabolic activity within the tumor. A CT scan of the chest was performed which excluded pulmonary metastatic disease. Following these investigations, a CT-guided tissue biopsy targeting an area of increased metabolic activity demonstrated a cartilaginous lesion with mild atypia and some focal calcification. This case was discussed at a multidisciplinary meeting involving sarcoma specialist surgeons, radiologists and pathologists. Given the size and histological nature of the lesion, the decision was made to manage this lesion as an atypical cartilaginous tumor.This surgical intervention represents a unique approach to the management of a complex chondrosarcoma of the pelvis. The patient was given a general anesthetic and positioned in supine. The procedure commenced with a cystoscopy, bilateral retrograde pyelography and insertion of a left ureteral stent to alleviate obstruction. Significant distortion of the bladder and urethra were noted secondary to the external compression from the tumor. There was no local infiltration of the tumor into surrounding structures. The tumor was then approached via a longitudinal lower midline abdominal incision. Meticulous haemostasis was undertaken whilst dissection was performed to the level of the pubic body. This allowed the displacement of the pelvic viscera from around the tumor within the lesser pelvis, and detachment of the origins of the adductor musculature from the anterior external pelvic wall. At this stage, navigation pins were inserted into the iliac crest and registration of important bony pelvic landmarks with the computer navigation system was confirmed (Stryker Navigation System with Spinemap 3D 3.1 software®)  Figure . Using nPost-operatively, the patient was allowed to fully weight bear and had a post-operative course consistent with a grade II Clavien-Dindo surgical complication  . She wasThis case report provides an insight into the diagnosis and management of pelvic chondrosarcoma as well as a novel approach in its surgical resection and reconstruction. It has been well-established within the literature that pelvic chondrosarcoma is difficult to diagnose pre-operatively . FirstlyPelvic chondrosarcomas also represent a surgical challenge, with local recurrences rates being higher and the tumors conveying a poorer prognosis than peripheral bone chondrosarcomas , 19, 20.Type 3 hemipelvectomies are relatively uncommon and account for ~10% of internal hemipelvectomies , 23. TraWe report on a case of a large atypical cartilaginous tumor of the pelvis and its novel surgical resection with an anterior pubic hemipelvectomy and reconstruction with an iliac crest graft. This report is unique within the literature and has yielded good early functional outcomes whilst safely treating the malignancy.Over many years I sought treatment from several different general practitioners for recurring urinary infections and urinary incontinence. It seemed to me that many courses of antibiotics were having only short-term effects. My urinary frequency had reached the point where urgent hourly visits to the toilet made work and sleep difficult.Since my surgery I have observed reduced urinary frequency to only 2–3 times nightly and therefore much improved sleep. Also, I have much improved ease of bowel movements. My pain post-surgery was minimal and the use of strong pain medication only lasted 8 days. Additionally, after only 4 weeks, even with the extent of the surgery, I was able to move around the house unaided and walk for about 600 m in 20 min with the aid of my wheelie walker. Now, after 8 weeks I am walking over 1 km in 30 min also with the aid of my walker with current physio advice to start walking this distance unaided which I see as quite achievable.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.The studies involving human participants were reviewed and approved by St Vincent's Hospital (Melbourne) Human Research Ethics Committee (HREC). The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.All authors listed have made a substantial, direct and intellectual contribution to the work, and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


An adenomyoma is a well circumscribed form of adenomyosis and can be located within the myometrium, in the endometrium as a polyp, or extrauterine with the last being the rarest presentation amongst the three. With the ongoing advancement in gynecological surgery, the use of electromechanical morcellators have made the removal of large and dense specimens possible with minimally invasive techniques. However, it has also caused an increase in complications which were previously rare. Whilst the tissue is being grinded within the abdominal cavity, residual tissue can spread and remain inside, allowing for implantation to occur and thereby giving rise to recurrence of uterine tissue as a new late postoperative complication.Case presentationA 45-year-old woman presented with worsening constipation and right iliac fossa pain. Her past surgical history consists of laparoscopic supra-cervical hysterectomy that was indicated due to uterine fibroids. Computerized tomography and magnetic resonance imaging were done, which showed an irregular lobulated heterogeneous mass seen in the presacral space to the right, located on the right lateral aspect of the recto-sigmoid, measuring 4.5 × 4.3 × 4.3 cm in size. A transvaginal ultrasound revealed a cyst in the left ovary. The patient had a treatment course over several months that included Dienogest (progestin) and Goserelin  with add-back therapy. In line with the declining response to medications, the patient was advised for a laparoscopic ovarian cystectomy. During the surgery, an additional lesion was found as a suspected fibroid and the left ovarian cyst was identified as pockets of peritoneal fluid which was sent for cytology. The surgical pathology report confirmed adenomyosis in both specimens, namely the right mass and the initially suspected fibroid.In this case report, we showcase a rare occurrence of an extrauterine adenomyoma presenting two years post laparoscopic morcellation at hysterectomy. This poses questions regarding the benefits versus risks of power morcellation in laparoscopic hysterectomy. An adenomyoma is a well circumscribed form of adenomyosis. It is a nodular aggregate that has the properties of smooth muscle, endometrial glands and endometrial stroma. It may be located within the myometrium, in the endometrium as a polyp or exist as an extrauterine adenomyoma. Extrauterine adenomyomas are the rarest presentation amongst the three . While tWith the ongoing advancement in gynecological surgery, multiple options have taken lead in yielding minimally invasive surgical options, those inclusive of electromechanical morcellator, laparoscopic myomectomy and laparoscopic hysterectomy. Additionally, conservative options include high intensity focused ultrasound (HIFU) which involves using great ultrasound energy targeted at abnormal tissues and their vascularity directly. This is done via heating and cavitation exempting the surrounding normal tissue of any damage. This process can be guided via magnetic resonance imaging (MRgHIFU) or via ultrasound (USgHIFU) . AnotherA 45-year-old woman presented with worsening constipation and right iliac fossa pain in late October 2019. She had a similar episode in May 2019 that required admission. Her past surgical history consists of laparoscopic supracervical hysterectomy which was indicated due to uterine fibroids. The surgery was done in November 2017. The patient also has a history of immune thrombocytopenia, autoimmune hemolytic anemia—Evan’s Syndrome, iron deficiency anemia as well as hypertriglyceridemia. The serum levels of CA125 and Ca19-9 were 169 U/mL and 36 U/mL respectively. CT and MRI showed an irregular lobulated heterogeneous signal intensity mass seen in the presacral space to the right, located on the right lateral aspect of the recto-sigmoid measuring 4.5 × 4.3 × 4.3 cm in size. The mass showed heterogeneous enhancement with areas of non-enhancing cystic component. The mass was abutting the right piriformis muscle and right anterior aspect of the rectum. A right internal iliac enhancing node was seen measuring 1.1 × 0.8 cm in size with fluid in the pouch of Douglas. The uterocervical stump and both ovaries appeared normal. This was followed by a colonoscopy that revealed no abnormal findings. A CT guided fine needle biopsy of the pelvic mass was done, that revealed endometriosis with microscopic findings of focal areas of benign endometrial epithelium, and stroma involving smooth muscle tissue on histology with no morphological features of dysplasia or malignancy.Her previous supracervical hysterectomy was carried out for a 14-week to 16-week size uterus consisting of fibroids confirmed on histopathology. During the surgical procedure the uterus was morcellated with current evidence of endometrial deposits that were left behind. These residual deposits may have given rise to the endometriotic cysts noted on the latest CT scan. The patient was given Dienogest (progestin) for two months in aims of shrinking the lesion. This is to be monitored with subsequent ultrasound at follow up post completion Fig. . The rigWe report a case of a 45-year-old woman that was diagnosed with a late presentation of two extrauterine adenomyomas two years after laparoscopic power morcellation at hysterectomy, confirmed by histopathology. Power morcellation is the process of cutting tissue into smaller pieces and has emerged as an advancement in gynecological surgery, making removal of bulky lesions minimally invasive. With small entry points such as those measurable of less than 2 cm in length, removing large tissues through morcellation provides enhanced clinical outcomes such as faster patient recovery, decreased postoperative pain, and respectively fewer wound complications. The process of morcellation consists of inserting a long, tube-like portion of the device into small incisions in the abdomen. A rotating circular blade at the tip allows for the specimen to be drawn out in cylindrical portions without the need for extending the incision. Side effects with power morcellation include: bleeding, infection, bowel obstruction, bruising, oozing or pain at incision site, organ damage, pelvic and abdominal pain, intra-abdominal abscesses, and peritonitis . In addiLaparoscopic tissue removal is often carried out with morcellation. This was previously “open” morcellation where tissue was directly removed from the peritoneal cavity with a morcellator. Because of concerns regarding possible seeding of tumor cells in cases of unknown malignancy, newer techniques have developed to reduce these risks by morcellating the tissue in a body or extending all of the port incisions and carrying out morcellation at the wound surface using a scalpel.With trends of rising cases showing numbers of 1 in 350 having a risk of spreading cancer as opposed to it previously being 1 in 10,000, this data reviewed by Food and Drug Administration (FDA) prompted them to announce their first warning in April 2014 about the risk of laparoscopic power morcellators spreading cancer. In addition, multiple societies released statements in regard to the use of morcellation, which brought forth a variety of queries in aims of progress. The first of many societies was the Society for Gynecologic Oncology (SGO), which suggested evaluation of coexisting uterine or cervical malignancy along with effective communication involving informed and voluntary consent with respect to risks, benefits and alternatives as part of the process of qualifying patients as candidates for morcellation. The American Congress of Obstetricians and Gynecologists (ACOG) presented a statement in aims of conveying the pressing matter around morcellation and their contribution towards tackling it. The American Association of Gynecologic Laparoscopists (AAGL) displayed their stance on morcellation through various actions all governed by striking a balance between acknowledging its advantages as a minimally invasive procedure whilst stating its risk for increased morbidity . The EurChanges implemented by the FDA in accordance with the ongoing updates, consisted of guidance to manufacturers to modify the morcellator product labeling to include contraindications and a boxed warning. These changes were supported by AAGL as well. While some gynecologists became hesitant towards the use of morcellation for liability concerns after the release of FDA warnings; on the other hand, AAGL went forth to encourage improvements towards morcellation and not abandonment in one of their statements .Furthermore, in December 2020, the FDA released an updated safety communication inclusive of the boxed warning and stated, “laparoscopic power morcellators are contraindicated for removal of uterine tissue containing suspected fibroids in patients who are or post-menopausal, or over 50 years of age, or are candidates for en bloc tissue removal” . This enProspectively, the debate around morcellation truly stems down to two main reflections. The first being the process for evaluation of medical device safety and efficacy. This is relevant as data based on the efficacy of a product can lead to a better understanding about its complications. In the case of morcellation, some pertinent complications would be dissemination of malignancy and port-site metastasis, which can be recognized only after a widespread use and reporting of the product. However, there is an evident lack of centralized reporting of data regarding the usage of a morcellator and its outcomes, all of which has led to the Federal Bureau of Investigation posing queries concerning the transparency of delivering information between manufacturers and consumers .The second reflection is based on the morcellators directly, when comparing with open abdominal procedures. Improved postoperative outcomes, shorter hospital stay and decreased blood loss and surgical site infections are some of strengths of a minimally invasive approach, thereby making it an increasing trend. Assessing the benefits of morcellation vs the theoretical risk of spreading an undetected malignancy is important moving forward, especially until alternatives to morcellation come forth stronger. It is reported that “The risk of dying from an abdominal hysterectomy for fibroids, ranging from 1 in 1,000 to 1 in 2,500, may be equal to or higher than the risk of having an occult malignancy” .Power morcellation in a bag, which allows for the tissue to be contained with minimal intraperitoneal spill.Manual morcellation is another option, where the tissue is cut manually by a scalpel inside the bag.Vaginal hysterectomy where the uterus is taken out through the vagina.Abdominal Hysterectomy & Myomectomy done entirely through an incision directly.En Bloc resection where the uterus, cervix, bladder and partially the rectum is removed in cases of confirmed cancer to avoid spread.With this came room for alternatives which include:In April 2016, the first containment system to be used with laparoscopic power morcellators was allowed for marketing by the FDA .Estimation of the prevalence of adenomyosis is difficult as it varies from 5 to 70% with a mean frequency of findings at hysterectomy being at roughly 20–30%. The wide range is due to its diagnosis being confirmed at the time of hysterectomies and its variability amongst racial groups . To the Typically, the extrauterine adenomyomas were found in the pararectal space, ovary and broad ligaments as well as other pelvic sites including paraovarian and parametrial locations . The patIn regards to imaging, several studies have shown that both transvaginal ultrasonography (TVUS) and magnetic resonance imaging (MRI) displayed high sensitivities and specificities. TVUS has an estimated pooled sensitivity of 72–82% and pooled specificities of 81–85%. With these numbers reported for TVUS in adenomyosis, it makes it the first line modality in comparison to MRI which has reported sensitivities of between 70 and 93% and specificities between 86 and 93%. Moreover, the differences between the use of MRI and TVUS at diagnosing adenomyosis pertains to a cost difference and accessibility which is in favor of ultrasound, despite it being operator dependent, demanding the operator to have in depth knowledge of uterine anatomy and its cyclic variation. On the other hand, although MRI could provide detailed images that would aid in the detection and diagnosis of adenomyosis, and is less operator dependent, it requires more reader experience at imaging technique optimization to achieve a higher diagnostic accuracy. Computed tomography (CT) is not generally used to diagnose adenomyosis due to its inability to resolve differences between soft tissues which limits its diagnostic capabilities exhibiting poor diagnostic accuracy , 19, 20.During the surgery, there was difficulty locating the larger mass on the right side although the final location of the mass reflected the description from CT images quite closely. CT and MRI revealed the mass to be an irregular lobulated heterogeneous signal intensity mass seen in the presacral space to the right, located on the right lateral aspect of the recto-sigmoid. The mass measured 4.5 × 4.3 × 4.3 cm in size and exhibited heterogeneous enhancement with areas of non-enhancing cystic component whilst abutting the right piriformis muscle with fluid seen in the pouch of Douglas. Given the detailed description of the mass, ideally it shouldn’t have been very challenging localizing the lesion. Possible factors that made it difficult could be the extensive adhesions she had from her previous surgery. Nonetheless, perhaps having the CT images in the operating theatre to refer back could have aided the localization and may be a point of future changes in management of such cases. The ultrasound images moreover mostly described the size of the lesions over time, with no other descriptive features noted, making it a tool more useful for recording the lesions’ response to treatment.While the frozen section represents a highly prime purpose, it is only indicated in an intraoperative consultation in the event that the next step of surgery relies on it or if the next immediate step in patient care is to be influenced by it . MoreoveThe modality of treatment of adenomyosis stems from the concept that adenomyosis is an estrogen dependent lesion, such as its kin endometriosis and uterine myomas, as they regress after menopause. Hence rationalizing the use of medications such as Dienogest, a GnRH agonist that induces a hypoestrogenic effect by suppressing the hypothalamic-pituitary-ovarian (HPO) axis. This would consequently help reduce painful symptoms and shrink the size of adenomyotic lesions. Nonetheless, this disruption of the HPO axis will be accompanied by adverse effects such as hot flashes, vaginal dryness and bone mineral loss, that will require the need for add-back therapy if used long term , 26. TheIn conclusion, in the case of this patient, she presented with the adenomyoma 2 years after laparoscopic power morcellation in hysterectomy, making power morcellation a significant point of concern. While the procedure of morcellation consists of possible surgical complications as seen in this case, these occurrences can be notably reduced when done by a trained surgeon complimented by credible equipment and safe methods. Moreover, advancing interventions such as the containment bags and its various types available aim to decrease these numbers of adverse events all in aims of producing the safest, and minimally invasive outcomes. Ongoing collaboration and efforts between surgeons, medical engineers and manufacturing companies can raise the number of successful outcomes and provide better patient care.


Hiatal herniations are most commonly diagnosed during work-up for gastroesophageal reflux disease. Here, we present a patient with retrosternal pain for whom the computed tomography scan showed a lipomatous formation in the lower posterior mediastinum, and further examination indicated the origin to be paraesophageal herniation (PEH) of the greater omentum. This was confirmed by laparoscopy, the herniated part of the greater omentum was repositioned and the hiatal hernia was repaired. During recovery the patient complained of dysphagia, a common and transient postoperative occurrence, but which later proved to be a mechanical obstruction caused by a bolus. This case raises awareness of potential differential diagnoses pre- and postoperatively in conjunction with PEH, and the management of such differential diagnoses is discussed. Numerous complications can occur after surgical treatment of a paraesophageal hernia (PEH), such as postoperative leakage, early recurrence of the hernia and stenosis resulting from oedema or poor operative technique. In the latter situation, contrast oesophagogram and/or oesophagogastroscopy are needed to confirm diagnosis. If stenosis is caused by oedema, the therapeutic approach would be to wait and see, with optional support by oral decongestive medication. In cases without improvement, balloon dilatation via endoscopy would be performed to ameliorate passage. In situations where postoperative clinical deterioration is caused by tight hiatoplasty or oesophageal or vascular lesions, surgical revision is required. Intrathoracic displacement of a portion of the greater omentum is frequently seen in large type III hernias due to herniation of major parts of the stomach. Exclusive omental herniation with near-orthotopic position of the cardia is rare , 2. Here2, he was in good physical condition and no further pathological findings were revealed during clinical examination. Chest X-ray showed a retrocardiac mass (A 63-year-old male patient underwent a medical check-up due to acute bronchitis. The patient’s body mass index was 24.7 kg/miac mass  and a suiac mass . The patGiven these findings, a laparoscopic exploration with omental reposition followed by hiatoplasty was scheduled. A wide oesophageal hiatus was found, with herniation of the entire greater omentum despite near-orthotopic positioning of the cardia. A 3-cm axial herniation was observed in the cardia. The greater omentum was repositioned laparoscopically. No histologic examination was performed as the lipomatous mass intraoperatively undoubtedly turned out to be a vital portion of the greater omentum just like preoperatively suggested. Hiatal dissection was performed with mobilization of the distal oesophagus as well as complete resection of the large hernial sac. After complete dissection of both diaphragmatic crus and partial detachment of the left triangular ligament, a dorsal crurorhaphy was performed . BecauseWe restricted the intervention to an anatomical repair of the hiatal region. Fundoplication was not indicated because preoperative examination revealed no symptoms of reflux disease. The first three postoperative days were uneventful, and the patient responded well to puréed food. After receiving solid food on postoperative day four, the patient was regurgitating multiple times per day and complaining of globus sensation. A contrast-enhanced oesophagogram showed near-complete stenosis of the esophagogastric junction . GastrosHere, we present a rare but important differential diagnosis of postoperative complete obstruction of the oesophagus after surgical repair of a paraesophageal hernia. Early postoperative bolus obstruction requires endoscopic management and removal of the bolus, and unnecessary surgical revision must be prevented. Postoperative oesophagogastric endoscopy should therefore be implemented early and often.Sole herniation of the greater omentum through the oesophageal hiatus does not fit into the existing hiatal hernia classification . In the The diagnostic approach for a mediastinal mass involves detailed history-taking, physical examination, laboratory examination and imaging studies. Commonly, a chest and abdominal CT scan with intravenous contrast agent is recommended to define the herniated structures. In the present case, CT showed a lipomatous mass and a vascular pedicle reaching into the abdominal cavity which was indicative for a PEH. Radiologically visualised continuity of the herniated structure above and below the diaphragm can be a sign of either lipomatous tumour or paraesophageal omental herniation . In thisEarly postoperative bolus obstruction after surgery for hiatal hernia is a rare complication that requires endoscopic management. This is in marked contrast to the more frequent complications which require surgical intervention.None declared.The authors have not received grant support or research funding for this study.


Colorectal perineuriomas are rare benign fibroblastic polyps of the colon found on colonoscopy and usually present as a sessile polyp distal to the splenic flexure. We report a case of sessile sigmoid perineurioma in a young healthy male. He presented with chronic constipation and underwent colonoscopy, which showed a 3-4 mm sessile polyp in the sigmoid colon. Biopsy results were significant for a perineurioma. These polyps are peripheral nerve sheath tumors composed of bland spindle cells with ovoid nuclei in a whorling appearance. The differential diagnosis of these nerve sheath tumors includes ganglioneuromas, schwannomas, neuromas, neurofibroma, or Schwann cell hamartomas, and gastrointestinal stromal tumor (GIST). While these polyps are regarded as benign, it is prudent to rule out other tumors that have malignant potential. Colorectal perineuriomas are uncommon benign fibroblastic polyps of the colon that have been better described histologically in the last 20 years. They comprise only about 0.1% to 0.46% of colonic polyps found on routine colonoscopy and generally present as a sessile polyp distal to the splenic flexure. We report a case of sessile sigmoid perineurioma in a young healthy male.This case report was previously presented at the American College of Gastroenterology (ACG) ePoster Hall .A 30-year-old male with a history significant for chronic constipation since childhood presented for his third diagnostic colonoscopy. He has a family history significant for a paternal uncle who was diagnosed with colon cancer at age 40. The patient suffered severe constipation since childhood despite the use of multiple over-the-counter medications including polyethylene glycol, senna, and docusate sodium. This history prompted his initial colonoscopic examination at age 18. His initial colonoscopy had shown three polyps. Unfortunately, histology of these polyps was unknown as the procedure was performed at an outside hospital. At presentation to our gastroenterology clinic, he still complained of mild constipation with occasional scant blood noted on stools. He denied weight loss, abdominal pain, nausea, and vomiting. His physical exam was unrevealing without any abdominal or distention, rashes, or skin lesions. He underwent colonoscopy; however, it was deemed incomplete due to poor prep in the right colon. His colonoscopy showed a 3-4 mm sessile polyp in the sigmoid colon that was removed with cold snare Figure . The patPerineuriomas  are peripheral nerve sheath tumors, similar to neurofibromas, schwannomas, and ganglioneuromas. They are most commonly seen on the skin as flesh-colored papules . They arPerineuriomas comprise only about 0.1% to 0.46% of colonic polyps found on colonoscopy and are often found incidentally in asymptomatic patients. Around 150 case reports of colonic perineuriomas have been published and most had presented as small sessile polyps ,7. HistoWhile these polyps are currently regarded as benign, it is prudent to rule out other tumors that have malignant potential such as GIST. This case report adds to growing literature highlighting incidences of colonic perineuriomas in the last 20 years.


Case Presentation. This paper presents a rare case of an unusual site of a lymphoepithelial cyst (LEC) in the oral cavity. The lesion was located in the tonsil of a 20-year-old woman with a chief complaint of a painless, white lump in the back of the mouth for nine months. Discussion. The differential diagnosis of a white lesion on the palatine tonsil is caused by several factors, such as bacterial, viral, and fungal infections; trauma; stones; cysts; abscess; or cancer. In this case, both the clinical presentation and extra- and intraoral examinations were highly associated with LEC. Oral LEC etiopathogenesis is uncertain, and several theories have been proposed to discuss the causes of LEC. In addition, oral LEC could be monitored without surgical intervention if the nodule is asymptomatic.  Palatine tonsils are part of the mucosa-associated lymphoid tissue, located in the oropharyngeal region. Although these tissues protect the body from foreign intruders, they are more prone to infections due to their anatomical structure and location. For instance, the differential diagnosis of a white lesion on the palatine tonsil can range from benign to malignant lesions. Oral lymphoepithelial cysts commonly arise as painless, yellowish nodules on the floor of the mouth and the ventral or lateral surface of the tongue.  We emphasize the importance of a thorough clinical examination of oral and oropharyngeal lesions, which are usually neglected. The palatine tonsil is a component of the posterior oropharynx lymphoid tissue ring called Waldeyer's ring. The location of the palatine tonsil makes it more amenable to bacterial infections and cyst formation .The differential diagnosis of a white lesion on the palatine tonsils encompasses benign and malignant lesions. Benign lesions are more common in this location, including oral lymphoepithelial cysts (LECs), tonsilloliths, and lipomas and infectious entities such as tonsillitis, strep throat, infectious mononucleosis, oropharyngeal candidiasis, and peritonsillar abscess . It coulLECs are rare, benign, developmental, and nonodontogenic cysts. They may develop in any area of the body, which consists of lymphoid tissues. Usually, they are less than 1 cm in size. Oral LEC has a high occurrence on the floor of the mouth and in the lateral and ventral tongue. It affects females more than males 2 : 1) at any age [ : 1 at aThe phenomenon of oral LECs in the palatine tonsils is very unlikely. Additionally, very few reported cases in the literature present oral LECs in the tonsils. Herein, we present a rare case of an oral LEC that appeared in the left palatine tonsil and discuss its resolution without intervention.The work has been reported in line with the SCARE criteria .A 20-year-old woman visited the oral medicine clinic for evaluation of a nine-month history of a painless, white lesion at the back of the mouth. She believed that the lesion started as a pinhead size and then grew in size over time until it reached the present size. She did not recall any trauma or surgery in the area of the white patch. Her medical and dental histories were noncontributory. She denied taking any over-the-counter or prescribed medications, such as antibiotics or steroids. In addition, genetic problems, family medical history, and social history were unremarkable. Furthermore, the lesion was worrisome, which had a negative impact on daily life. Extraoral clinical examination was not significant. Routine laboratory blood test results were normal. The patient denied a history of fever, fatigue, body rashes, stuffy nose, headache, earaches, stiff neck, hoarseness, sore throat, coughing, sneezing, difficulty chewing or swallowing, halitosis, lymphadenopathy, and difficulty breathing. She also denied having hemoptysis and an unexplained weight loss in the last few weeks. Intraoral inspection revealed a 0.5 cm, asymptomatic, light yellow-white hued, smooth, raised, soft on palpation, movable, well-circumscribed, unilateral, localized submucosal nodule, exhibiting no exudate arising from the normal-sized left palatine tonsil . RadiogrThe differential diagnoses of the white lesion on the palatine tonsil, in this reported case, included tonsillar cyst, tonsilloliths, tonsillitis, papilloma, lipoma, strep throat, infectious mononucleosis, oropharyngeal candidiasis, and peritonsillar abscess.In this case, the distinct clinical appearance, features, and clinical examination highly indicated an LEC. The patient was assured that the clinical appearance of the white lump in the tonsil was highly associated with the diagnosis of a benign nodule called an oral lymphoepithelial cyst. She was also provided with information regarding the possible treatment options and associated outcomes.The ideal management for the white lesion on the palatine tonsil is to excise the lesion along with the whole tonsil. Therefore, an oral medicine specialist recommended performing a left palatine tonsillectomy. However, the surgical procedure of the affected palatine tonsil was not an option from the patient's side. Notably, the patient was anxious and worried about the surgical procedure and its consequences. Therefore, she refused to proceed with the surgical option. Because the nodule was asymptomatic and based on the lesion size (5 mm) and the patient's decision, the lesion was monitored regularly for an eight-month period. One-month, two-month, three-month, six-month, and eight-month follow-up periods were scheduled to monitor the lesion. The nodule did not change in size or color during this period. Surprisingly, the lesion ruptured and resolved spontaneously without any conventional or surgical intervention . At the The posterior oropharynx contains a lymphoid tissue ring called Waldeyer's ring, which mainly involves the palatine tonsils, pharyngeal adenoid tonsils, Eustachian tonsils, and lingual tonsils. These lymphoid tonsils have special anatomical structures and locations, which make them more susceptible to bacterial infections and cyst formation .The differential diagnosis of a white lesion on the palatine tonsil includes tonsillar cysts or oral LECs, tonsilloliths, papillomas, lipomas, tonsillitis, strep throat or streptococcal pharyngitis, infectious mononucleosis, peritonsillar abscess, oropharyngeal candidiasis, and palatine cancers .Tonsilloliths or tonsil stones are unilateral, painful, and hard on palpation and consist of calcium deposits in the lymphoid tissue crypts. These stones occur due to the accumulation of mucus, bacteria, and food particles, which are accompanied by dysphagia, halitosis, and otalgia . PapilloStreptococcus pyogenes. Bacterial infections commonly occur along with many symptoms such as fever, fatigue, sore throat, headache, and difficulty swallowing. If left untreated, it could progress to a peritonsillar abscess. Viral infections of the palatine tonsils, such as infectious mononucleosis or mono, are characterized by bilateral, white-yellowish pus covering both swollen tonsils. Infectious mononucleosis is caused by a contagious virus called the Epstein-Barr virus. Bacterial and viral infections commonly occur along with many symptoms such as fever, fatigue, sore throat, headaches, and difficulty swallowing [Bacterial infections of the palatine tonsils, such as tonsillitis and strep throat or streptococcal pharyngitis, are contagious and usually caused by allowing .Candida albicans. Low body immunity could be caused by uncontrolled diabetes, long-term use of antibiotics, or steroid medications. The diagnosis of the infection can be confirmed by collecting throat swab samples and culture from the site of the white patches or lesions [Patients with a suppressed body immune system are at a high risk of oropharyngeal candidiasis. It is the most common type of fungal infection in the oral cavity and is usually caused by  lesions .In our case, the patient was in a very good health condition and did not complain of any abnormal signs or symptoms; the nodule had a distinct clinical appearance and was highly associated with LEC. LEC is an uncommon developmental, nonodontogenic cyst that was first described as a branchial cleft cyst in 1962 by Gold .Yang et al.  studied The pathogenesis of oral LEC is controversial, and many theories have been proposed to discuss the etiology of LEC. However, the most accepted theory was proposed by Knapp. He believed that oral LECs are pseudocysts that develop from submucosal lymphoid tissue aggregates on the floor of the mouth, ventral tongue, and soft palate .Histopathological evaluation of oral LEC demonstrates a thick cystic cavity composed of parakeratinized stratified squamous epithelial lining filled with viscous fluid and desquamated keratin. The cystic wall is infiltrated by lymphocytes organized as germinal centers .Oral LEC can be managed either conservatively or surgically based on the medical history, lesion size, lesion location, and patient discomfort. For instance, patients who have asymptomatic, small oral LECs can be monitored periodically. These small-sized oral LECs may rupture and disappear without surgical procedures. In the present case, the lesion was painless, approximately 0.5 cm in its greatest dimension, and the patient refused any intervention, but follow-up visits were conducted to monitor the lesion. The lesion disappeared after eight months of periodic follow-up visits . FurtherThe incidence of oral LEC in the palatine tonsils is uncommon. Based on the lesion size and the symptoms reported by the patient, oral LEC may be managed only with follow-up and clinical intraoral examination. In addition, oral LECs can resolve spontaneously without any kind of intervention.The patient was assured that the lesion was benign and small in size and could resolve without intervention. The resolution of the lesion improved her self-confidence.


In this report, we present a 57-year-old female with a history of mild alcoholic liver disease during a medical check-up. Abdominal computed tomography and magnetic resonance imaging showed a multicystic mass with a solid enhancing mural nodule in the right lobe of the liver. Subsequently, laparoscopic right liver lobectomy was performed and pathological findings revealed intraductal papillary neoplasm of the bile duct (IPNB) with an associated invasive carcinoma. IPNB is a relatively rare disease that should be considered in the differential diagnosis of hepatic cystic tumours. Our case report highlights the importance of capturing image findings of the IPNB as this disease has a high potential for malignancy. She was referred to our hospital for further investigation, and contrast-enhanced CT and Gadolinium (Gd)-enhanced magnetic resonance imaging (MRI) were performed.A 57-year-old female with a history of mild alcoholic liver disease underwent a medical check-up at her company. Initial non-enhanced abdominal computed tomography (CT) revealed a large cystic mass in the right lobe of the liver. Laboratory findings revealed elevated serum levels of tumour markers CA19-9  were suspected.Intraductal papillary neoplasm of the bile duct (IPNB), mucinous cystic neoplasm (MCN) and other hepatic cystic diseases  with a solid enhancing mural nodule in the right lobe includes segments 5, 6 and 7 of the liver . There wOn T2-weighted and T1-weighted MRI, we observed the mass with a slightly high signal intensity . These iA discussion with the patient regarding further management was undertaken, and finally, she agreed to the surgery. She had a history of mild alcoholic liver disease, but her Child-pugh score was 5 and her preoperative indocyanine green retention rate at 15 min (ICG-R15) was 8.7%. Therefore, she was able to undergo the right hepatic lobectomy without lymphadenectomy. No major postoperative complications were observed. The patient was discharged 13 days after the surgery. A CT scan performed 5 weeks after the surgery revealed two nodules in the lower lobe of the right lung, and the patient was diagnosed with lung metastases . For treThe pathological findings of the surgical specimen showed that the mural nodule with papillary proliferation of the atypical epithelium in the mass invaded the liver lesion . Several1 While the majority of these masses are benign simple cysts, 3–5% of diagnosed cases may represent biliary cystic tumours.1 Furthermore, 20–30% of patients with diagnosed cases of hepatic cystic masses are at risk of their malignant transformation.1The number of diagnosed hepatic cystic masses is increasing as a result of the rapid advancements in imaging studies. Currently, it has been estimated that 20% of the general population has cystic masses in the liver.2 Out of all diagnosed IPNB cases, approximately 40–80% presented with invasive carcinoma, or tubular, or mucinous adenocarcinoma.3 These findings suggest the high malignancy potential of IPNB. In contrast, MCN is a rare disease with a reported incidence of less than 5% of all hepatic cystic tumours.4 Additionally, only 20% of all diagnosed MCN cases are at risk of developing malignancy.5The most common bile duct cystic tumours are IPNB and MCN neoplasms. IPNB was found in 10% of all resected bile duct tumours.6IPNB tends to grow by connecting to the bile ducts compared with MCN. This is considered the imaging differentiation point between MCN and IPNB.7 but there are only a few studies mentioned because both IPNB and MCN are relatively new disease concepts.IPNB and MCN are described in the independent chapters in the fifth edition of the World Health Organization (WHO) series on the classification of human tumours, published in 2019,2 Among the 68 IPMN-B patients, type II was the most common (30 patients), followed by type V (13 patients) and type IV (11 patients). Among the 13 IPNB-NM patients, type I was the most common (11 patients), followed by type II (one patient) and type VII (one patient).In general, IPNB is classified as IPNB without mucin secretion (IPNB-NM) and IPNB with mucin secretion (IPMN-B). IPNB was classified by Ying et al into seven types based on morphology .2 In contrast, IPMN-B mostly presents as types Ⅱ–Ⅶ because it promotes mucin accumulation, where mucin is secreted in the bile ducts, subsequently causing aggravation of the bile ducts dilation. The case we experienced was classified as IPMN-B type V, which is not typical but is relatively frequent. Additionally, it is consistent with the features of IPMN-B showed by Ying et al.Ying et al also showed that IPNB-NM mainly manifests as type I because it does not cause mucus secretion.8 In these cases, the findings are consistent with the malignant IPNB.The imaging findings of IPNB are mucobilia, dilated ducts, enhancement and the metabolic activity of mural nodules. The majority of malignant IPNB presentations have wall nodules with contrast enhancement or solid components that infiltrate the adjacent liver parenchyma. They may appear as a small lesion or focal thickening of the wall leading up to the lesion.9 In the fifth edition of the WHO’s classification of human tumours, revised in 2019, IPNB was defined as a grossly visible premalignant neoplasm with intraductal papillary or villous growth of biliary-type epithelium. In addition, IPNB has been classified as low, intermediate and high grade in the fourth edition of the WHO’s classification of human tumours, revised in 2010.10 However, in the fifth edition, IPNB has been classified as low grade, high grade and an associated invasive carcinoma.7 As this indicates that IPNB is mostly recognized as a precancerous lesion, this case report emphasizes the importance of capturing the image findings of IPNB to aid in early diagnosis and timely resection and improvement of IPNB prognosis. It is expected that more cases of IPNB will be reported in the future as a well-established imaging disease, just as it is in pathology.Previously, IPNB was considered as a counterpart of the pancreatic intraductal papillary mucinous neoplasm.IPNB is a relatively rare disease that should be considered in the differential diagnosis of hepatic cystic tumours.Radiologists should be aware of the importance of capturing image findings of IPNB as this disease has a high potential for malignancy.


Stratified mucin-producing intraepithelial lesion (SMILE) is an intraepithelial lesion with overlapping features of the high-grade squamous intraepithelial lesion (HSIL) and adenocarcinoma in situ (AIS). Currently, it is well described in the cervix. We present a case showing similar SMILE-like lesions in the polypectomy specimen from the anal canal along with invasive adenocarcinoma components. This lesion showed an immuno-profile characteristic of a SMILE lesion described in the cervix, such as p63 negativity, high ki67 index, and nuclear positivity for p16. It might be arising from the Human papillomavirus prone transitional region of the anal canal as described in the cervix. However, we could not assure this association and etiological link due to insufficient material in the formalin-fixed paraffin-embedded block. Notwithstanding, we strongly suggest that the HPV is the main driver for this SMILE-like lesion similar to what is described in the cervix. To our knowledge, this is the first case report of a SMILE lesion in the anal canal. Further studies will be required to elucidate the underlying pathogenetic mechanism of SMILE-like lesions described in the anal canal. A stratified mucin-producing intraepithelial lesion (SMILE) is an intraepithelial lesion described first in the cervix by Park et al.This unique intraepithelial lesion is well described in the cervix and also observed in the vulvaA 40-year-old man presented to the gastroenterology outpatient department complaining of pain after defecation for 3 months. There was no history of bleeding or mucoid discharge per rectum. Rectal examination showed unremarkable perianal skin, but growth at the fingertip was palpable. Subsequent endoscopic examination of the large intestine showed friable polypoidal growth in the anal canal. The remaining parts of the colon up to the terminal ileum were normal. Abdominal contrast-enhanced computed tomography (CECT) showed a well-defined polyp measuring 18x13x12 mm in the anterior wall of the anorectal junction. There was no definite muscular layer and serosa involvement noted on the pelvic MRI, neither locoregional lymphadenopathy was identified. Perirectal and perianal fat were normal. Serum CEA level was 2.7 ng/ml . Anti-HIV was negative. Polypectomy was done, and tissue was submitted for histopathological examination.On microscopy, it showed fragmented polypoidal tissue with papillary folds lined by variably thickened truly stratified epithelial cell layers with a maximum of 20 cell thickness A, B. TheOn the immunohistochemistry, these stratified cells showed strong immunoreactivity for CK7 and negative expression for p63, excluding the possibility of a high-grade squamous intraepithelial lesion. Furthermore, these cells showed strong nuclear expression for p16, and Ki 67 index was 80% AD.Though the usual type adenocarcinoma component was noted in a few fragments in the invasive areas, the observation of truly stratified layers with intracytoplasmic mucin is unusual in the anal canal and not documented in the literature. Unfortunately, due to insufficient material in the formalin-fixed paraffin-embedded block, we could not perform the HPV-ISH or genetic sequencing for the human papillomavirus.After the polypectomy, whole-body FDG PET CT was performed, which showed mild diffuse FDG uptake in the anorectal region. The patient further received 16 cycles of chemotherapy for the residual tumor. Furthermore, now he is on the 8-month follow-up without symptoms.The in-situ carcinoma lesion with a true stratification, full-thickness dysplasia with intracytoplasmic vacuoles observed in this case is a distinct intraepithelial lesion not described in the anal canal till now. This lesion is very similar to SMILE lesions of the cervix. Histologically, the anal canal can be divided into three parts such as the external zone lined by squamous epithelium, the transitional zone, and the inner colorectal zone.,During the initial evaluation of this case with the H&E stain, the considered differential diagnosis was (i) a high-grade squamous intraepithelial lesion, (ii) a conventional adenoma giving rise to adenocarcinoma, and (iii) a rare transitional epithelial type of fistula-associated anal canal adenocarcinoma. However, the presence of diffuse intracytoplasmic mucin and lack of intercellular bridges, and no expression for p63 on immunostaining, excluded the possibility of the high-grade squamous intraepithelial lesion. Though the usual type adenocarcinoma component is noted in one fragment showing invasion, the presence of true stratification, even up to a maximum of 20 cell thickness in the in-situ lesion, makes this lesion different from a conventional adenoma. The nuclear stratification giving the pseudostratified appearance and the focal intracellular mucin can be seen in the transitional epithelial type of fistula- associated anal canal adenocarcinoma. Despite the lack of the HPV-ISH availability, the immuno-profile observed in the in-situ component, such as strong nuclear expression for p16, lack of expression for p63, and high ki67 index, in the index case, is very similar to the immuno-profile of SMILE lesion described in the cervix. Probably, similar to the SMILE lesion of the cervix, the lesion observed in our case might arise from the reserve cells or urothelial-like cells in the transitional region. On searching for SMILE-like lesions outside the cervix in the literature, we found that McCluggage et al.,Lack of material for molecular analysis is the major pitfall of this study. However, the observation of a SMILE-like lesion in the anal canal is a new finding for us, and this lesion exhibited an immuno-profile as in the cervix. It might be arising from reserve cells or urothelial-like cells of HPV-prone transitional zone. We believe the lesion observed in our case is very similar to the SMILE lesion described in the cervix. To our knowledge, this is the first case that describes SMILE-like lesion in the anal canal. Unquestionably, genetic studies will require further to determine the underlying molecular characterization and pathogenesis of SMILE-like lesion (SIL) in the anal canal.


Oral cavity schwannoma is still considered a rare entity in the head and neck region. Schwannoma is a benign encapsulated nerve sheath tumour that originate from Schwann cells with an approximate incidence of 1% in the oral cavity. The tongue is the most common location among oral cavity tumours. We report a rare case of tongue schwannoma in 12-year-old boy who presented to our centre complaining of swelling of the tongue, which had increased in size and interfered with his speech in 2018; he had been previously asymptomatic since birth. A diagnosis was established based on the following imaging studies: computed tomography (CT) and magnetic resonance imaging (MRI). He underwent simple transoral excision of the ventral tongue mass under general anaesthesia with no complications, and the final pathological result confirmed the diagnosis of schwannoma. •Oral cavity schwannoma is a rare tumour in the head and neck region.•CT and MRI help in the diagnosis.•Transoral excision is the most common procedure.•Pathological examination confirms the diagnosis. There were no other masses in his mouth or other body areas. There was no history of allergies with negative family history of any head and neck masses or genetic disease. On examination, a smooth cystic mass was observed on the right side of the ventral tongue, with no other abnormalities detected in the nose, nasopharynx, larynx, ear or neck.. The patient was discharged on the same day with antibiotics and analgesia, with instruction to consume a soft diet before advancing, and with follow-up after 2 weeks. The patient currently undergoing follow-up in the clinic; since discharge, there have been no signs or symptoms of recurrence.In 2018 the tongue mass started to increase in size and interfere with speech, but laboratory investigations were normal. The patient underwent a contrast-enhanced CT scan, which was inconclusive, and the MRI with infusion results are show in . The pat3•Benign capillary haemangioma•Venolymphatic malformation•Retention cyst ranula4Grossly: round to oval mass measuring 2.3 × 2 cm in size. The outer surface was smooth.Microscopically: Serial sectioning revealed a tan-white cassette strongly positive for S100, focally positive for CD56 and negative for NFR.Final pathological diagnosis: schwannoma.5In 1908, Jose Verocay made the first description of the benign tumour known currently as schwannoma . Though The usual CT findings are a well-defined mass with heterogeneous enhancement with possible cystic or fatty degeneration, and these finding were inconclusive in our case . The MRI6Tongue schwannoma is a comparatively rare tumour. The clinical presentation ranges from a totally asymptomatic mass to a mass that is rapidly increasing in size and causes dysarthria, dysphagia snoring, sleep apnea and pain. Rarely, lingual schwannoma transformation occurs. Pathological examination confirms the diagnosis. Transoral excision is the most common procedure, but a variety of approaches have been established depending on the size and location of the tumour.Not commissioned, externally peer-reviewed.No funding.NilWritten informed consent was provide by the patient and his parents for publication purposes, with full awareness of the use of his images and information.Fayez A Alrohaimi, Sahar A Alsadah, Ghadeer A Althaqib all contribute in the study concept and design, writing the paper.1.Name of the registry:2.Unique Identifying number or registration ID:3.Hyperlink to your specific registration (must be publicly accessible and will be checked):Sahar A AlsadahThe authors declare that there are no conflicts of interest.


Jejunogastric intussusception following gastric surgery is a rare complication that, if not diagnosed early, can have catastrophic outcomes.We have reported a case, never described previously, of an acute spontaneous retrograde JGI, presenting with obstruction and hematemesis, in a 70-year-old woman who has never, previously, undergone abdominal surgery.As in all cases of intestinal intussusception, early diagnosis is important for acute JGI as mortality rates increase from 10% when the intervention occurs within 48 h. to 50% if treatment is delayed for 96 h.The diagnosis of JGI can be determined with many imaging studies, such as endoscopy, ultrasonography (US), barium stadium and CT scan.Although JGI, up to now, has been described as a rare complication after any type of gastric surgery, this disease must, however, be suspected also in patients who have never undergone abdominal surgery, if they present with non-sedable abdominal pain associated with signs of high intestinal obstruction and hematemesis.Our hope is to add to the available literature to aid physicians in their diagnostic work-up and in developing management plans for similar cases occurring in the future. •Jejunogastric intussusception following gastric surgery is a rare complication.•Primary jejunogastric intussusception in patient who never underwent previous abdominal surgery had never been described.•Early diagnosis of this condition is crucial for early surgical intervention.•Immediate treatment is critical to avoid catastrophic outcomes. In the literature, the incidence is less than 0,1% of all gastric resection Emergency surgery is the treatment of choice for acute JGI. Traditionally, laparotomy or laparoscopy for reduction or resection of the intussusception is the main surgical method Here, we present the first case of spontaneous jejunogastric intussusception in a 70-year-old woman who never underwent previous abdominal surgery.The present work has been reported in accordance with the Surgical Case Reports (SCARE 2020) criteria 2In February 2021, a 70-year-old woman presented to emergency department with a 5-day history of non-sedable diffuse epigastric pain. He was associated with vomiting, initially bilious and then hematemesis, fever, paroxysms of cough and dyspnea. No history of previous abdominal surgery in the past.Heavy smoker patient. In anamnesis: chronic obstructive bronchopathy, chronic atrial fibrillation, arterial hypertension, a primary hyperparathyroidism from known parathyroid adenoma and an inveterate umbilical hernia.The patient reported, for about 30 years, repeated episodes of epigastric pain, with alimentary vomiting, which resolved spontaneously a few hours after onset, attributed to episodes of incarceration of the umbilical hernia.At the admission in the emergency room: Blood pressure: 105/55 mm Hg; heart rate: 102/min; external body temperature: 38,2 °C; sPO2: 91% in ambient air.Physical examination of the abdomen revealed a voluminous umbilical hernia, not reducible, particularly painful on palpation. For the rest, the abdomen was flat, not breathing, hardly treatable and showed signs of defensive contracture and peritonism.3; hyperamylasemia (2768 IU/l) and hyperlipasemia (1577 IU/l), γGT: 63 IU/l; AST: 75 IU/l, creatinine: 1.20 mg/dl; CRP: 45 mg/l.Blood tests showed a hemoconcentration with HT: 50.5%, WBC: 10,600/mmArterial blood gas analysis: pO2: 42.4 mm Hg; pH: 7.48; pCO2: 51.7 mm Hg; HCO3: 39 mmol/l; K: 3.3 mEq/l, Na: 152 mEq/l.The indirect intra-abdominal pressure was 6 mm Hg but, under coughing, it reached values of 25 mm Hg and more.Real time polymerase chain reaction (RT-PCR) assay to detect SARS-CoV-2 RNA was positive.CT examination of the chest and abdomen diagnosed necrotic-exudative pancreatitis with peripancreatic fluid collections. Intrapancreatic choledochus diameter: 11 mm.In the umbilical area, a large hernia with a 50 mm diameter hernial port and engagement of the intestinal loops, the proximal duodenum, the distal stomach and the head of the pancreas . RetrogrMultiple ground glass foci in both lungs.3 of hemorrhagic fluid were aspirated.Once the gastric-nose tube was placed, approximately 250 cmAfter surgical evaluation and informed consent was obtained, the patient was immediately transferred to the operating room where she underwent an emergency laparotomy. After the lysis of viscero-parietal adhesions and the reduction of the hernial contents in the abdomen, a significant distension of the duodenum and gastric antrum from retrograde invagination of the jejunum from the Treitz to the stomach was highlighted in abdomen. Therefore, manual reduction of the invaginated intestine was carried out with the release of about 60 cm of intestine which showed significant signs of hemorrhagic infarction and multiple diastatic perforations , Fig. 5.A prompt resection of the intestinal piece was performed with jejuno-jejunal stapled side-to-side anastomosis.The surgery was completed with simple hernioplasty and placement of two abdominal drains.The surgery lasted 75 min.3.Blood losses were quantified as less than 50 cmaO2: 34 mm Hg; PaCO2: 60 mm Hg; PaO2/FiO2 < 100 mm Hg), linked to SARS-COV2 pneumonia, which unfortunately complicated the severe septic situation, leading to death the patient in the third postoperative day for severe ARDS.Transferred to the Resuscitation Unit, the post-operative course was characterized by progressive and constant worsening of respiratory exchanges  It is classified into 4 types:The cause(s) of the jejunogastric intussusception is (are) poorly understood. Various factors have been incriminated such as hyperacidity long afferent loop, jejunal spasm with abnormal motility, increased intra-abdominal pressure, retrograde peristalsis, etc. Probably, retrograde peristalsis, which can occur in normal people prior to gastric surgery, seems to be accepted as the cause of type 2 jejunogastric intussusception by most authors Two forms of JGI have been clinically recognized: an acute and a chronic form. In the acute form, incarceration and strangulation of the intussuscepted loop generally occur whilst spontaneous reduction is usual in the chronic type. Thus, the acute form is characterized by acute severe colicky epigastric pain, vomiting and, subsequently, hematemesis. Epigastric tenderness and a palpable abdominal mass can be observed in about 50% and signs of high intestinal obstruction can also be found Early diagnosis is important for acute JGI as mortality rates increase from 10% when the intervention occurs within 48 h. to 50% if treatment is delayed for 96 h The diagnosis of JGI can be determined with many imaging studies, such as endoscopy, ultrasonography (US), barium stadium and CT scan.Endoscopy is the diagnostic procedure for the patient with hematemesis, but the intussusception could be mistaken as an immobile clot or a bezoar. US findings of intussusception classically reveal a mass with echogenic center surrounded by concentric echogenic rings with a peripheral rim of hypo echogenicity, described as “pseudo kidney” sign.The typical CT finding of intussusception is a soft tissue mass with a “sausage” or “target” appearance -Manual reduction of the intussusception-Revision of the anastomosis-Anchoring of the efferent limb to the parietal peritoneum or suturing together of the afferent and efferent limbs after reduction of the intussusception-New gastrojejunostomy using a Roux-en-Y reconstruction.The treatment of JGI consists mainly of surgery using several approaches depending on the intraoperative findings:If the intussusception is gangrenous, resection and revision of anastomosis provide the correct treatment Endoscopic reduction has been reported in some case reports. However, endoscopic reduction of JGI is contraindicated when the peritoneal signs are suspected.Furthermore, endoscopic reduction of JGI has a significant risk of recurrence We reported a case, never described previously, of an acute spontaneous retrograde JGI, presenting with obstruction and hematemesis, in a 70-year-old woman never underwent to previous abdominal surgery. In this case, probably, the inveterate voluminous umbilical hernia with herniation of the stomach, duodenum and head of the pancreas, the increase in abdominal pressure under repeated coughing, acute pancreatitis and abdominal effusion, were the factors triggering a retrograde peristalsis with consequent invagination.The histological examination of the surgical piece did not reveal any neoplasms or lesions that could have acted as a lead point.Although the diagnosis was made immediately and the patient underwent emergency surgery, her delayed access to the emergency room, associated with concomitant severe acute pancreatitis and SARS-COV 2 pneumonia, was responsible for the unfortunate outcome.JGI is a rare but potentially fatal disease.For this reason, early diagnosis and surgical treatment are crucial.4This is a very rare case of gastric jejunum intussusception, never reported in the medical literature. Our hope is to add to the available literature in order to help physicians in their diagnostic work-up and in developing management plans for similar cases occurring in the future.Although JGI, up to now, has been described as a rare complication after any type of gastric surgery, this disease must, however, be suspected also in patients who have never undergone abdominal surgery, if they present with non-sedable abdominal pain associated with signs of high intestinal obstruction and hematemesis.Immediate treatment is critical to avoid catastrophic outcomes, and, therefore, a high index of suspicion is required for early diagnosis.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Not commissioned, externally peer-reviewed.Ethic approval has been exempted by our institution because this is a case report and no new studies or new techniques were carried out.This research did not receive any specific grant from funding-agencies in the public, commercial, or non-for-profit sectors.The guarantor for this case report is Giovambattista Caruso.This case report does not require registration as a research study.Giovambattista Caruso: conceptualization, writing original draft, review and editing, data curation.Chiara Toscano: Resources, data curation.Mariapia Gangemi: Conceptualization, software and video editing.Giuseppe Evola: Review and editing.Carlo Reina: Writing, review and editing.Giuseppe Reina: Supervision.All the authors certify that there is no conflict of interest regarding the material discussed in the manuscript.


These studies suggested a broad differential diagnosis favoring benign osseous lesions. Given a more recent increase in the rate of growth, headache and large size, the lesion was excised via craniotomy followed by cranioplasty. Pathology confirmed fibrous dysplasia (FD) as the diagnosis. Interestingly, this report is the imaging evaluation of the exophytic subtype of FD, the so-called FD protuberance, an extremely rare variant of FD, of which only two case reports are found in the literature.This paper details the case report of a 26-year-old man who presented with a growing right-sided skull mass evaluated with ultrasound, non-contrast CT, contrast-enhanced MRI and


Wilms’ tumor (nephroblastoma) is mostly unilateral; however, bilateral Wilms’ tumors are seen in about 5–8% of patients. This can be synchronous or metachronous. It is uncommon to get liver metastasis from bilateral Wilms’ tumor.An 8-year-old male Ugandan presented with a history of abdominal swelling and flank pains for 1 year. There was no history of hematuria. Both ultrasound and computed tomography of the abdomen demonstrated multiple solid lesions in both kidneys and a huge solid mass in segments V, VI, VII and VIII of the liver. Histological examination of renal biopsy specimen was favorable for chemotherapeutic regimens. However, following a multidisciplinary tumor board consensus, a nephron-sparing surgery was deemed unsuitable, and he was managed conservatively with chemotherapy (adriamycin and vincristine) with a palliative intent.Metastatic bilateral Wilms’ tumor has a particularly poor prognosis. There are no clear evidence-based guidelines for the management of this rare presentation. This patient benefited from early palliative care and symptom management. Wilms’ tumor, also called nephroblastoma, is the most common malignant renal tumor of childhood, affecting approximately 1 in 10,000 children . In abouBilateral Wilms’ tumor accounts for 5–8% of all cases of Wilms’ tumors, which can be synchronous (occurring in both kidneys at the same time) or metachronous (occurring in both kidneys at different time points) . In spitWilms tumor with metastasis is a poor prognostic factor for patient’s survival . OccurreAn 8-year-old male Ugandan child presented with a 1-year history of a progressive abdominal swelling and flank pains. His mother reported they have been in and out of hospitals with the child due to frequent complains of abdominal discomfort. He was treated with antipyretics and unspecified antibiotics for 6 months prior to their referral to our facility for further investigation and management. There was no history of constipation, hematuria, jaundice, urinary retention, or bleeding diathesis. He was the third born in a family of 5 siblings. There was no history of similar condition in the family. There was no family history of malignancy. His father is a businessman, and the mother is a housewife. His childhood was uneventful.On clinical examination the child was stable and active . His vitals were within the normal limits. Conjunctivae was pink and Chest was essentially normal on physical examination. The abdomen was distended and had mild generalized tenderness. There was a palpable mass, approximately 7 finger breaths in the right upper quadrant, which was firm, non-tender, and not ballotable and did not cross the midline. The mass was dull to percussion and active bowel sounds appreciated. There were no enlarged peripheral lymph nodes.Complete blood count showed mild anemia with a hemoglobin level of 9.5 g/dl, while the other indices were normal. Renal function test and liver function tests were all normal.Ultrasound scan of the abdomen showed a heterogeneous huge mass in the right lobe of the liver, involving segment V, VI, VII and VIII measuring about 11.8 cm by 9.71 cm. The liver was enlarged in size measuring 17.88 cm at mid clavicular line. There was a moderate flow in color Doppler in the mass. Besides there were multiple hypoechoic solid lesions on both kidneys of varying sizes, the largest on the left measured 3.02 cm by 2.55 cm. The inferior venacava showed normal caliber and flow. The origins of the right and left renal veins were visualized but the mid and distal portions were compressed by the masses. There were no enlarged lymph nodes noted in the abdomen  scan showed huge ill-defined, homogeneously enhancing (43–70 HU) hypo-dense solid mass in V, VI, VII and VIII segments of the liver, measuring 16.39 cm by 11.21 cm by 10.2 cm. There was an ill-defined enhancing (30–63 HU) hypo dense solid mass in the right kidney measured 4.89 cm by 4.96 cm by 3.9 cm. There was an ill-defined enhancing (35–62 HU) hypo dense solid mass in the left kidney measured 4.88 cm by 5.92 cm by 4.5 cm with areas of central necrosis. The right renal vein was infiltrated. The right renal artery however was normal. The left renal artery and vein were normal. The ureters and urinary bladder were normal. The portal vein, intrahepatic ducts and common bile ducts were normal. The abdominal aorta and inferior vena cava were normal. There were no enlarged abdominal lymph nodes. There was no ascites. The visualized bones were normal with no focal bone lesion. The radiologic chest anatomy was normal  with a palliative intent. The dose of vincristine was 1.5 mg/mWilms’ tumor is a common childhood and commonly presents as a unilateral disease. However, bilateral disease is seen in about 5–8% of the cases and can be synchronous or metachronous . Our patSynchronous bilateral Wilms’ tumor presents at a much younger age with a mean age of 2.6 years, compared with 3.3 years in patients with unilateral disease . Our patSize discrepancies of solid tumors were observed when different imaging modalities being used. Studies show that masses measured on ultrasound mostly are larger and some smaller and very rarely the same compared to CT measurements. Ultrasound is a 2D imaging modality and is dependent on the technologist, while CT scan is 3D and least affected by inter/intra-observer reliability –15. In oThe management of Wilms’ tumor demands multidisciplinary approach. Surgery is considered critical as it is reduces the risk of tumor spread and the need for radiotherapy . ChemothThe management of synchronous bilateral Wilms’ tumor is challenging and has many controversies . There iIn conclusion, synchronous bilateral Wilms’ tumor is a rare occurrence. Late presentation to a health facility adds up to the existing challenge of lacking treatment guidelines. The current data on synchronous bilateral Wilms’ tumor with distant metastases is scarce. Therefore, management should be patient based until firmly established guidelines are provided.


Inguinal hernia is a prevalent surgical condition worldwide. The hernia sac typically contains the omentum and small intestine. However, it has been reported that some other organs might be seen, including the ovary, fallopian tube, bladder, and colon. We report the case of a 23-year-old man who presented to our emergency department with the complaint of scrotal pain for the last six days. The pain was mainly in the right side. There was no history of preceding trauma, and the pain developed gradually. He described the pain as having a sharp nature and was constant. He reported having a low-grade fever that resolved with the use of over-the-counter analgesics. There was no change in the urine or bowel habits. No penile discharge was reported. On examination, the patient had a low-grade fever and tachycardia. The patient appeared in pain and was not cooperative to have a complete genitalia examination. However, there was a positive cough impulse in the right inguinal region. The laboratory findings suggested the presence of inflammatory or infectious processes with elevated leukocytes, C-reactive protein, and erythrocyte sedimentation rate. The patient was prepared for emergency laparotomy for reduction of the hernia and resection of the appendix. During exploration, the appendix was reduced from the hernia sac. The appendix appeared edematous, with marked erythema representing acute appendicitis. The appendix was resected and the hernia sac was closed. The presence of an appendix in the inguinal hernia sac is very rare. The preoperative diagnosis of Amyand hernia, the inguinal hernia containing the appendix, can be difficult based on the clinical presentation. Early diagnosis is crucial to avoid the potential complications of Amyand hernia, including perforation and abscess formation. Imaging studies can establish the diagnosis of Amyand hernia with high accuracy and confidence. Inguinal hernia is one of the most common indications for abdominal surgeries worldwide. It is caused by a defect in the abdominal wall. The diagnosis of inguinal hernia is readily made by history taking and appropriate physical examination . ImagingA 23-year-old man presented to our emergency department with the complaint of scrotal pain for the last six days. The pain was mainly in the right side. There was no history of preceding trauma, and the pain developed gradually. He described the pain as having a sharp nature and was constant. He reported having a low-grade fever that resolved with the use of over-the-counter analgesics. He did not identify any factors that aggravated or alleviated his pain. On the 10-point severity scale, he scored his pain as 5 in severity. No previous similar episodes of this pain were reported. There was no change in the urine or bowel habits. No penile discharge was reported.The patient was otherwise healthy with no comorbidities and no previous abdominal surgeries. He underwent a tonsillectomy at the age of five years due to recurrence episodes of acute tonsillitis. The medication history included multivitamin tablets only. He smoked occasionally and had no history of alcohol consumption. He was a nursing student. The patient was single. He had no history of sexual activity or sexually transmitted diseases. The family history was positive for cystic fibrosis.On examination, the patient had a low-grade fever of 38.0℃ and tachycardia with a pulse rate of 112 bpm with normal blood pressure (115/78 mmHg) and respiratory rate (14 bpm). The patient appeared in pain and was not cooperative to have a complete genitalia examination. However, there was a positive cough impulse in the right inguinal region. Abdominal examination revealed tenderness in the lower abdomen with no rigidity or guarding. Other systems had normal findings on physical examination.The following laboratory findings suggested the presence of inflammatory or infectious processes: leukocytes 11,500/μL), C-reactive protein 17.2 mg/dL), and erythrocyte sedimentation rate (33 mm/hour). Other hematological and biochemical markers showed no derangement. The patient underwent computed tomography (CT) of the abdomen and pelvis, which demonstrated the right inguinal hernia containing the appendix that signs of inflammation, such as wall thickening and standing of the adjacent fat (Figures 1,500/μL, mg/dL, aThe patient was prepared for emergency laparotomy for reduction of the hernia and resection of the appendix. During exploration, the appendix was reduced from the hernia sac. The appendix appeared edematous with marked erythema representing acute appendicitis. The inflamed appendix Figure  was reseWe reported the case of acute appendicitis occurring in the setting of Amyand hernia. A hernia is defined as a protrusion of a viscus or its fascia through a defect in the containing cavity. Inguinal hernia classically contains the omentum. The presence of the appendix in the inguinal hernia sac is seen in less than 1% of all cases of inguinal hernia . FurtherPrevious studies indicated that Amyand hernia may have a mortality rate of up to 30% with a wound infection rate of 50% . Much ofThe diagnosis of Amyand hernia can be difficult because of the lack of specific clinical signs and symptoms. However, it is reported that frequent presentation includes the periumbilical pain that radiates to the right iliac fossa along with the presence of a right inguinal hernia . In the The presence of appendicitis in the inguinal hernia sac is very rare. The preoperative diagnosis of Amyand hernia can be difficult based on the clinical presentation. Early diagnosis is crucial to avoid the potential complications of Amyand hernia, including perforation and abscess formation. Imaging studies can establish the diagnosis of Amyand hernia with high accuracy and confidence.


Intradural lipoma without spinal dysraphism is a rare occurrence. Most of them are asymptomatic but can also present with neurological deficits. A 54-year-old male patient presented to us with progressive weakness in both lower limbs for six months. On physical examination and radiological workup, intradural lipoma was diagnosed. Due to progressive neurological deficit, the patient was treated surgically. On 2.5 years of follow-up, the patient showed complete neurological recovery. Intradural lipomas can also present with the neurological deficit at any age and should be managed surgically if the deficit is progressive in nature. Surgical management has a good outcome if done within two years of onset of symptoms. Intradural lipoma in the lumbar spine is a rare entity. They are well-known for spinal dysraphism. Lipomas not associated with spinal dysraphism comprise only 1% of all cases . More coSince lipomas without dysraphism are very rare, hence there is a scarcity of literature describing those lipomas causing the neurological deficit. We present a case of intradural lipoma at the lumbar region causing neurological deficit and managed surgically.The patient is a 54-year-old male who presented to us with complaints of weakness in bilateral lower limbs for six months. The weakness was progressive in nature. There was no bladder and bowel involvement. On examination, there were three of five power in bilateral L3, L4, L5, and S1. The sensations were intact. The perianal examination was normal. MRI showed Intradural mass on dorsal aspect at L2-3 region or conus region and hyperintense on both T1 and T2- weighted images Figures . At 2.5 Lipoma in the lumbosacral spine without spinal dysraphism is a rare occurrence. The most common site of lipoma in the lumbosacral spine is the conus region . VariousMRI shows the presence of intradural mass at the L2-3 region which was intermingled with the nerve roots. The mass appeared hyperintense on both T1 and T2-weighted sequences. Such adhesions with the nerve root may be the cause of the progressive neurological symptoms of the patient and also it creates a difficult situation for the operating surgeon. Hence, proper surgical planning is essential as the safety margin of neurological preservation is thin .As per the literature, the results are poor, in terms of neurological recovery, if the duration of symptoms is more than two years . Our patThough the extent of resection does not correlate with the surgical result, attempts should always be made to resect as much as safely possible . The lamIntradural lipomas without spinal dysraphism are a rare occurrence and mostly asymptomatic. When presents with neurological involvement, surgical resection is necessitated. Wide laminectomy should be performed to have wide exposure and complete resection of mass should not be attempted as there are adhesions that can result in injury to nerve roots.


Small bowel diverticulosis is a rare condition. It usually remains asymptomatic and undiscovered, until potentially severe complications such as diverticulitis or even perforation occur. We present an unusual case and discuss the pathophysiology, diagnostics strategies, and possible surgical intervention.A young woman was referred to our emergency department suffering from acute abdominal pain. A computed tomography scan showed signs of small bowel perforation of unknown origin. Exploratory laparotomy revealed multiple perforated jejunal diverticula (JD). The patient underwent segmental resection of the affected jejunum followed by primary anastomosis. Pathological examination confirmed the diagnosis of perforated JD.Due to its rarity and variable clinical presentation, it can sometimes be challenging to diagnose this potentially life-threatening condition. If the bowel is suspected from perforation; segmental resection is the treatment of choice, preferably followed by direct restoration of the bowel continuity. In pa2A 37-year-old woman with a history of laparotomic intestinal derotation during childhood was referred to our emergency department because of sudden onset pain in the lower and upper left abdomen. There was no relevant drug or family history. The pain was worsening over the past 48 h and now radiating to the right lower quadrant. The patient reported nausea without vomiting and the absence of stool since the start of the pain. The vital signs were slightly abnormal, with a sinus rhythm of 95 bpm, blood pressure of 121/90 mmHg, and a body temperature of 37.4 C. On physical examination, sparse peristalsis was auscultated over the abdomen. The pain was most prominently in the left upper quadrant, with guarding and rebound tenderness.Laboratory results showed a leukocyte count of 19 × 10E9/l and a C-reactive protein level of 317 mg/l. A computed tomography scan  showed sThe patient underwent a laparotomy (performed by SM and SH) which macroscopically revealed the diagnosis of perforated JD. Multiple JD were revealed, of which at least one was perforated. A segmental (80 cm) resection of the affected jejunum was carried out, followed by a side-to-side hand-sewn primary anastomosis. Postoperatively, a 5-day course of antibiotics was administered. The patient was able to tolerate oral intake after the removal of the nasogastric tube. On day six, the patient was discharged home. At the two-week follow-up visit, she was fully recovered. No adverse or unanticipated events were registered 6 months after.Histopathological examination , Fig. 3 3Small bowel perforations caused by JID are rare ,8. Consi3.1Despite true diverticula like the Meckel’s diverticulum, all diverticula are considered to be acquired pseudodiverticula; mucosal and submucosal protrusion through the muscular tissue of the gastrointestinal tract ,6,11. Th3.2Similar to the treatment of CDD, conservative medical treatment of SBD may be considered just to control diarrhea or mild anaemia . If unco4This case report demonstrates that not only elderly, male, patients can be affected by (complicated) JD. Failing to recognize and diagnose this disease timely might lead to severe complications, such as perforation. Therefore, this condition should be considered in the differential diagnosis of acute abdominal pain. If small bowel perforation is suspected, surgical resection followed by primary anastomosis is the treatment of choice.None.None.N/A.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.SH and SM admitted the patient and performed surgery. SH, TA, and GF collected patient data. SH, FB and SM desgined this report, reviewed the literature, analyzed data and drafted the manuscript. FB and SM made final approval of the manuscript.Not applicable.Sem F. Hardon, MD.Not commissioned, externally peer-reviewed.


Neurofibromatosis type 1 (NF-1) is known to be associated with increased risk of malignancy by at least fourfold. Malignant lymphomas are rare in adults with NF-1. Hereby, we present a 75-year-old male with NF-1 complaining of weakness, nausea, and vomiting associated with abdominal pain. Three months prior to presentation, he had suffered a motor vehicle accident (MVA) resulting in multiple rib fractures that was seen in chest X-ray. For the following three months, he had intermittent chest pain, but it was attributed to the recent rib fracture. During this admission, the severity of chest pain worsened and the associated vomiting inclined further investigation; including CT imaging and bone biopsy, it was revealed to be a rare case of diffuse B cell lymphoma in a patient with NF-1. However, we believe the recent MVA caused an anchoring bias in making a prompt diagnosis. In addition, the appearance of the neurofibroma, resulted in suboptimal physical examination, and hence, there was a delay in reaching the diagnosis. We will discuss here the presentation of this case, to highlight the rare association and to increase awareness of when encountering a challenging diagnosis. Neurofibromatosis type 1 (NF-1) or von Recklinghausen disease is known to be associated with increased risk of malignancy by at least fourfold . Malignaμl with predominant neutrophils, calcium 16.2 mg/dl, parathyroid hormone (PTH) 9.5 pg/ml, PTH-related protein 2.6 pmol/ml, and vitamin D level 15.9 ng/ml. A computed tomography (CT) scan of the abdomen showed a dominant, oval-shaped, soft tissue density in the middle of the upper abdomen, superficial to the abdominal aorta and multiple paraesophageal lymphadenopathy, the largest measuring 8 × 4 × 6 cm  that resulted in multiple rib fractures and a grade 1 liver laceration two months prior to presentation. Since the MVA, he has suffered from intermittent abdominal pain that required multiple urgent clinic visits; however, his complaints were attributed to the MVA and dismissed. Physical examination findings included a soft mass in the umbilical area that measured about 8 × 4 cm, was tender to palpation, and had well-defined margins. In addition, he had multiple, small-sized, flesh-colored, dome-shaped fibromas clustered on the trunk, abdomen, and upper extremities . Laborat4 × 6 cm . Patholo4 × 6 cm  and 4. BNF-1 is known to be a significant risk factor for malignancy, mainly the peripheral nerve sheath tumors, gliomas, and leukemia. Various studies have estimated the frequency of malignancy in NF-1 patients to be between 5% and 29% . OverallThis case emphasizes and enforce the importance of having a high index of suspicion for malignancies during follow-up of patients with a history of NF-1. Finally, physicians should be extremely cautious when examining patients that may impose a challenge on physical examination, in order to avoid biases and delay in diagnosis.