A bezoar is a solid mass of indigestible material that usually forms in the gastrointestinal (GI) tract. Gastric bezoars, located in the stomach, can present variably. They can be asymptomatic or present with GI symptoms like nausea, vomiting, abdominal pain, or more serious complications, such as GI obstruction or perforation. Diagnostic modalities are mainly radiological, and treatment may either be conservative or interventional. Herein, we disclose the case of a 47-year-old female who presented with a two-week history of abdominal pain with an incidental finding of a possible gastric phytobezoar, co-existing with gallbladder disease. Although not previously reported, this study highlights the possibility of an association between gallbladder disease and the formation of a bezoar. Bezoars are a rare pathological collection of foreign material in the gastrointestinal (GI) tract. The classification of bezoars is based on their prime constituents, namely, phytobezoars which contain non-absorbable food or fibres, lactobezoars which contain mucous or milk products (in infants), trichobezoars which are made of hair, or pharmacobezoars, from medications. Amongst these, phytobezoars are the most commonly occurring . Bezoars may be asymptomatic or present with various GI symptoms, for instance, nausea, bloating, and abdominal pain . They maA 47-year-old female presented to her general practitioner (GP) with abdominal pain for the past two weeks. Her symptoms had worsened in severity over the last one week before presentation. The pain was localised to right upper quadrant with radiation to the right shoulder. There was no history of fever, nausea, vomiting, or altered bowel habits; however, there was generalised itching. Her background history included anxiety and depression for which she was taking selective serotonin re-uptake inhibitors. She admitted to having intentional weight loss of three stones over the past one year, which she managed by keto diet and intermittent fasting.An outpatient ultrasound (US) abdomen was requested by the GP, which revealed an unexpected finding of "a solid heterogeneous mass of ovoid shape in the epigastric area, measuring 107×58×93 mm. Moderate vascularity was demonstrated during power Doppler study along with an over-distended stomach around the mass". Additionally, "the gall bladder contained multiple calculi casting an acoustic shadow with common bile duct (CBD) of normal shadow and no evidence of calculi". The US abdomen showed no signs of a gastric outlet or intestinal obstruction and there was no mention of any pericholecystic fluid collection. The radiology team flagged the findings and referred the patient to the emergency department from where she was admitted to the acute medical unit (AMU).On admission, her observations were unremarkable. On inspection, she had generalised scratch marks on her skin but was not jaundiced. Systemic examination revealed a positive Murphy’s sign, while rest of the systemic examination was unremarkable. Routine blood investigations showed alanine aminotransferase 242 IU/L , gamma-glutamyl transpeptidase 650 IU/L , alkaline phosphatase 411 IU/L , total bilirubin of 42 μmol/L , c-reactive protein 8.1 mg/L , and serum amylase 101 IU/L . A computed tomography (CT) scan of the abdomen and pelvis was done, which showed a 100×40 mm intraluminal density within the stomach surrounded by fluid and small gas locules in the periphery. These findings were consistent with a gastric bezoar. Furthermore, the CT showed mild thickening of the gall bladder with minimal pericholecystic fluid and a mildly dilated CBD of 8 mm  . She experienced symptomatic relief over the next few days and on the fifth day of admission a gastroscopy was carried out. The procedure involved scanning till the third part of the duodenum and the study was essentially unremarkable. Despite being seen on two serial imaging modalities, the absence of the bezoar on endoscopy concluded that the gastric bezoar had self-resolved and the constituents likely to be in line with a phytobezoar.Based on the CT findings of a mildly dilated CBD, she underwent an endoscopic retrograde cholangiopancreatography with a sphincterotomy the same day, which yielded 9-10 small calculi from the CBD. The following day she underwent laparoscopic cholecystectomy, which later identified underlying chronic cholecystitis on histopathology. She was discharged on the ninth day with outpatient general surgery clinic follow-up.There are several investigation modalities for the diagnosis of bezoar, including abdominal x-ray (AXR), abdominal US, CT, and endoscopy . In a caThe treatment for bezoars depends on the size, location, severity of symptoms, and the associated complications. Smaller bezoars can resolve spontaneously or be dissolved using various medical therapies . One of Since Coca-Cola is an effective treatment for phytobezoars , which aThe case references theories from prior literature that propose a link between gallbladder disease and delayed gastric motility. Decreased gastric motility can be a risk factor for the formation of a bezoar. One type is the phytobezoar, composed of indigested intake. While there are endoscopic and surgical options for removing bezoars, this report elaborates an approach to treating gastric bezoars with conservative treatment strategies like dissolution therapy using carbonated drinks such as Coca-Cola. Dissolution therapy can be effective for phytobezoars and should be considered before intervention.


Endoscopic resection of a follicular lymphoma (FL) presenting as a gastric subepithelial tumor (SET), along with periodic follow up can be a treatment option because gastrointestinal FL cells tend to reside in the primary site, which may explain its indolent nature.A gastric lesion was found incidentally during a screening endoscopy in 73-year-old woman without any gastrointestinal symptom.The patient was diagnosed with a grade I FL that was 1.4 cm large, at the greater curvature of lower-body.We performed underwater endoscopic mucosal resection (UW-EMR), and there was no serious complication, such as bleeding and perforation.Complete en bloc resection was achieved with UW-EMR. Follow-up endoscopic biopsy after 3 months revealed no residual tumor on the resection site.UW-EMR may be a simple and safe resection method for gastric FL without metastases, that measure >1 cm. Since primary gastrointestinal FLs mostly appear as subepithelial tumors (SETs), endoscopic forceps biopsies are often inconclusive.Follicular lymphoma (FL) is the most common form of non-Hodgkin lymphoma. In FL, tumor cells originate from germinal center B cells; therefore, FL predominantly occurs at lymph nodes. Primary gastrointestinal FL is extremely rare, among the several cases of primary extranodal FL. UW-EMR has been described as an effective and safe treatment modality for SETs embedded in the submucosa.–6 Water immersion during underwater endoscopic mucosal resection (UW-EMR) decreases the luminal extension force, increases the mucosal and submucosal buoyancy, and keeps the muscularis propria circular behind the submucosa. A water-filled stomach makes tumors to float without submucosal injection and facilitates snaring of the tumor by the creation of a pseudopedicle.Endoscopic submucosal dissection (ESD) for gastric SETs measuring more than 1 cm requires prolonged operative time and an experienced therapeutic endoscopist.2A 73-year-old woman was referred to our hospital to undergo an endoscopic ultrasonography (EUS) for a gastric SET that was covered with normal gastric mucosa, which was located on the greater curvature, at the lower part of the gastric body; it was found incidentally during screening endoscopy Fig. A. EUS sh3 Gastric FL presenting as SET is uncommon and its incidence rate has not been reported. A primary gastric FL may be misdiagnosed as an extra-nodal marginal zone B-cell lymphoma on biopsy specimens. The overlying normal mucosa over the FL presenting as a SET could hinder the accurate diagnosis through endoscopic mucosal biopsy. Most small SETs covered with normal mucosa are identified during periodic endoscopic follow-up. In SETs that are >1 cm in size, EUS can help physicians to decide the management strategy through details such as the origin of the layers and the echogenicity of the tumor. The EUS findings in this case revealed a hypoechoic lesion that originated from the submucosal layer, and biopsy findings were inconclusive. Hypoechoic SETs that originate from the submucosal layer include neuroendocrine tumors (NETs), lymphomas, and adenocarcinomas. Therefore, tissue diagnosis of submucosal layer origin SETs with hypoechogenicity is important to decide the treatment strategy.FL involving the gastrointestinal tract by may be rare. Most reported cases of primary gastric FL presented with a localized disease and single or multiple submucosal tumors. ESD is a good alternative that can be used to overcome the limitations of conventional EMR.,12 The disadvantages of ESD are prolonged procedure time, technical burden, and a higher incidence of adverse event, such as perforation compared to EMR. Systemic review and meta-analysis of UW-EMR versus conventional EMR for the treatment of colorectal polyps revealed that UW-EMR was associated with an increase in en-bloc resection rate . A recent study reported that UW-EMR was effective in removing rectal NETs and showed similar treatment outcomes and a short procedure time compared to ESD. There is also a report of successful UW-EMR for an esophageal granular cell tumor that was >1 cm. Therefore, we performed UW-EMR for a gastric SET that was >1 cm in diameter and achieved complete resection. The patient's final diagnosis was a grade I FL measuring 1.4 cm.Conventional endoscopic mucosal resection (EMR) is a simple method that can be used to diagnose and treat small SETs embed in the submucosal layer. Submucosal injections during the procedure sometimes makes EMR difficult due to the cushion effect of the injected fluid.This is the first reported case of the removal of a gastric FL using the UW-EMR technique. We proposed that gastric lesions that originate from the mucosa or submucosa and are <1.5 cm in size can be an indication for UW-EMR. SET originated proper muscle is contraindication of EMR. Small gastrointestinal SETs sometimes can be hard to capture during UW-EMR. However, the complication rate was not significantly different between UW-EMR and conventional EMR.Heterogeneous treatment modalities, such as radiotherapy, chemotherapy, and surgery are used in the treatment of FL. In contrast to nodal FL, tumor cells in gastrointestinal FL tend to reside in the primary site and have an indolent nature. Therefore, the “watch and wait” strategy can be an option after the resection of the primary gastrointestinal FL. A previous report on performing endoscopic resections for gastric FL without lymph node enlargement on abdominal computed tomography showed that there was no recurrence after complete resection.In conclusion, UW-EMR appears to be a simple and safe resection method for gastrointestinal FL without metastases that measure more than 1 cm.This work was supported by 'Supporting Project to evaluation New Domestic Medical Devices in Hospitals’ funded by ’Ministry of Health and Welfare (MOHW)’ and ’Korea Health Industry Development Institute (KHIDI)’.Conceptualization: Su Jin Kim.Data curation: Tae Un Kim, Cheol Woong Choi.Supervision: Cheol Woong Choi.Writing – original draft: Tae Un Kim.Writing – review & editing: Su Jin Kim.


Teaching point: A space-occupying lesion should be considered in the differential diagnosis of progressive unilateral carpal tunnel syndrome. A 56-year-old women presented with long-lasting, radial-sided paraesthesia in her left hand, having suffered from a conservatively treated ipsilateral distal radius fracture six years prior. A mass was palpable in the palm of the hand, which moved proximally under the transverse carpal ligament upon flexion of the fingers accompanied by a painless “snap” (trigger phenomenon). Carpal tunnel syndrome (CTS) provocative tests were positive, and electromyography (EMG) confirmed CTS.Figure 1, arrow). On magnetic resonance imaging (MRI), the signal intensity was similar to that of subcutaneous fat, except for thin intralesional strands of non-lipomatous tissue, showing enhancement . The preferential diagnosis of fibrolipoma was made, although an atypical lipoma could not be excluded. Resection followed by histopathological examination showed multiple adipocytes with absence of atypical cells and fibrous bands were seen in between, confirming the diagnosis of a fibrolipoma .Conventional radiography was unremarkable. Ultrasound (US) showed a well-delineated fusiform lesion at the ulnar side of the carpal tunnel, extending between the third and fourth metacarpal. The lesion was homogeneously hyperechoic with absence of increased intralesional doppler signal (A lipoma is a benign tumour, originating from adipose tissue. Although it is the most common soft tissue tumour in the body, it is rarely seen in the hand . They arCTS usually presents as a bilateral disorder. In case of long-standing unilateral symptoms, secondary causes due to a space-occupying lesion should be suspected. Further work-up with EMG, US, and MRI is needed for detection and characterization of the lesion . Althoug


A 29-year-old male, involved in a motorcycle accident 10-days prior and referred from a private hospital, presented with a history of abdominal pain, distension, and vomiting. On presentation, he was conscious, oriented, tachycardic with a heart rate of 112 beats/min, systolic blood pressure of 115 mmHg, tachypneic with a respiratory rate of 24/min, and febrile with a temperature of 38°C. After initial resuscitation, he underwent a Pan-computed tomography (CT) scan. Computed tomography abdomen revealed pneumoperitoneum, displaced fracture of left inferior pubic rami, and a moderate amount of free fluid with linear contrast extravasation along the dome of urinary bladder extended diffusely with intraperitoneal free fluids indicating the possibility of intraperitoneal bladder rupture. Cervical CT showed a rounded nondisplaced fracture of the C1 arch and a type 1 oblique odontoid minimally displaced fracture. Initial urea (BUN) of 22 mmol/L  and serum creatinine of 412 umol/L  also supported intraperitoneal bladder injury. We performed an emergency laparotomy and repaired the bladder. His postoperative course was uneventful. He improved in general and a repeat CT cystogram on day 8 revealed no contrast leak. Concerning his cervical injury, a dilemma existed regarding fractures versus ossicles. The spinal surgeon requested a cervical magnetic resonance imaging (MRI), which showed no acute ligamentous injuries and a rare occurrence of dual cervical ossicles. In terms of his neck, he was asymptomatic. We removed his C- collar and discharged him from the hospital on day 11 post-admission.


Bladder exstrophy is a severe malformation characterized by the lack of the anterior sub-umbilical abdominal wall, and the front wall of the bladder. We present a rare case of a 26-year-old woman without any previous medical or surgical history, that we treated for bladder exstrophy. We performed an iliac osteotomy, bladder enlargement using the ileum and a Monti-type continent urinary derivation and a Promentofixation. A vesico-cutaneous fistula was diagnosed after surgery and we failed to manage it after two surgical revision. Therefore, we performed a cystectomy and a non-continent Bricker external urinary derivation. On examination, we discovered an inflammatory hypogastric bladder plate measuring 7 cm . We alsoOn X-ray of the pelvis, we found the typical abnormalities of bladder exstrophy, including lateral rotation and shortening of the pubic bone, and a pubic diastasis . On CT sThe first step consisted of an iliac osteotomy and an implant of external fixation on both iliac bones a. We the3Exstrophy of the bladder is a complete defect of the urogenital sinus and the skeletal system. The hypogastric area is occupied by the inner surface of the posterior wall of the bladder, whose mucosa is fused with the skin.Total reconstruction of bladder exstrophy in neonatal period is treatment of choice with good results. Expert centers with high recruitment volume may have better results. Extrophy in adulthood is very rare, as the obvious leaking urine cannot be unnoticed.Management of bladder extrophy in adults is a surgical challenge. Good knowledge of different methods of anterior abdominal wall reconstruction following cystectomy or cystoplasty is mandatory. Urinary diversion and abdominal wall closure in one surgical procedure without osteotomy is feasible and potentially successful.Matsuda et al.Gulati et al.The surgical management of bladder extrophy in adults is complex and postoperative complications are possible as in our patient. The aim of this management must be to obtain continence and, at least, preserve the nephrological prognosis.4Adult bladder extrophy is a real sexual, psychological and social tragedy for patients. The improvement of the prognosis depends on early treatment, if possible from birth, aiming at reconstructing a urinary and genital system as close to normal as possible.Signed consent was obtained from the patient.The authors declare that there are no conflicts of interest regarding the publication of this article.


While autonomic disturbances resulting from a hypothalamic injury are uncommon complications following surgery for craniopharyngioma, they can lead to postoperative death. Herein, we discuss the case of a multicompartmental craniopharyngioma in a 13-year-old child who died due to unexpected hypothalamic injury, resulting in rapid deterioration in the hemodynamic and neurological status of the patient. Craniopharyngiomas are rare, benign sellar/parasellar tumors derived from embryonic tissue . Even thRadical excision of craniopharyngiomas usually leads to injury to the hypothalamus. However, complications arising from autonomic dysfunction, which was seen in our case, are uncommon and do not respond well to treatment.A 13-year-old child was admitted with an eight-month history of headache and recurrent seizures. Neurological examination was unremarkable with no motor or sensory deficits preoperatively. There was, however, bilateral papilledema. MRI was done which revealed that the tumor was multicompartmental, extending from the suprasellar cistern to the right subtemporal region and invading the prepontine cistern, loosely adherent to the basilar artery  of the tumor was performed with sufficiently safe margins to avoid the risk of recurrence. Except for the hypothalamus, there was a good cleavage plane from the surrounding neural and vascular structures and the tumor.The whole operative procedure was uneventful. The patient was hemodynamically stable with a normal sensorium immediately after surgery. The only abnormalities noticed were right lateral rectus weakness concomitant with subtle right-sided pyramidal weakness. On the fifth day, he developed diabetes insipidus with a serum sodium concentration of 165 mEq/L and an increased urine output of approximately 2.5 L - 3 L per day. He was treated with desmopressin spray and intravenous fluids. On the evening of postoperative Day 7, the patient started developing hypothermia with a temperature of 33°C and started shivering. Arterial blood gas (ABG) analysis was done frequently and was found to be normal. A postoperative CT scan of the brain showed a left frontotemporal craniotomy defect with postoperative changes at the sellar and suprasellar region and minimal residual tumor with perilesional edema.The next morning, he was found to be in a Glasgow Coma Scale (GCS) of 7 which required immediate intubation and ventilation. The next day, the patient developed wide blood pressure ﬂuctuations. An echocardiogram identified a left ventricular dysfunction. Soon after, despite the resuscitative measures, the patient succumbed to a fatal cardiac arrest. Despite all of the recent advances in operative techniques and surgical equipment, craniopharyngioma is considered difficult to treat; the optimal treatment strategy for it remains ambiguous .A craniopharyngioma is a benign tumor, GTR is considered to be the gold standard. However, this approach can be challenging due to the location of these tumors, which is usually in close proximation with structures, such as the optic chiasm, hypothalamus, and internal carotid arteries -4. A morPostoperative morbidities due to GTR commonly encompass endocrinopathies leading to panhypopituitarism; however, death as a result of hypothalamic damage is rarely reported , 7. ClinBased on the clinical characteristics of the patient, it can be hypothesized that the following areas of the hypothalamus were damaged: supraoptic and paraventricular nuclei (causing diabetes insipidus) as well as the posterior hypothalamus, ventromedial, lateral, paraventricular, and anterior nuclei . The cardiac dysfunction was a result of the injury to the autonomic region of the hypothalamus resulting in ventricular failure and eventually death. It is our belief that our attempt at GTR proved to be fatal due to the damage to multiple hypothalamic nuclei. This injury to the hypothalamus may have been a result of direct trauma to it or an infarction following injury to the vessels that supply the hypothalamus. A less radical approach, such as SR with RT, would have probably avoided the patient’s mortality, especially when we noticed multiple hypothalamic nuclei adherent to the surface of the tumor. This is further substantiated by a systematic review done by Yang et al. that showed that SR + RT was an acceptable approach to achieve tumor control while limiting hypothalamic morbidity associated with GTR .GTR is considered to be the gold standard treatment for craniopharyngioma and is successful in most cases as it hinders the chances of recurrences of the tumor. However, in our case, the tumor was noted to be multi-compartmental and was adherent to multiple nuclei of the hypothalamus. The use of GTR in such circumstances led to damage of various nuclei of the hypothalamus, resulting in deterioration in the patient’s health and, finally, led to his demise. We conclude that, in cases such as ours, the idea of SR followed by RT may prove to be a better approach despite having a higher recurrence rate because the life-threatening extreme damage to the hypothalamic nuclei can be avoided.


A 38-year-old woman presented at Orotta National Referral Hospital emergency department in May 2017 with pain in the epigastric region and vomiting. Physical examination revealed no pertinent findings. Blood and urine tests were normal, and erect abdominal x-ray revealed a distended small intestine with multiple layers of “air-fluid levels”. CT scan and MRI were not done due to their temporary unavailability. During laparotomy a large mass of 20x20 cm in size was detected in the mid-jejunum of the small intestine. This leading tumor caused intussusception and coiling of the small intestine. As there are no typical symptoms of intussusception, it is very important to do CT scan for patients with long-standing abdominal pain and vomiting to achieve a definitive diagnosis of intussusception. The incidence of intussusception is 1–3 cases per 1,000,000 population per year7. The condition is more frequent in children than in adults1. Patients present sometimes with nonspecific symptoms9. The majority of patients come to hospital with abdominal pain and vomiting9. As these are unspecific symptoms, diagnosis of intussusception could be missed or even delayed before one would entertain intussusception as a cause of abdominal pain10. The unspecific presentation makes it difficult to define clearly the diagnosis before surgical operations11. Ordinarily, half of these cases are diagnosed in theater12. Helpful diagnostic tests include plain abdominal film14, abdominal CT scan15 and ultrasound16. Operative procedures to reduce the intestine is the treatment modality of intussusception17. In this paper we present a patient with intussusception with nonspecific symptoms who presented to Orotta National Referral Hospital, and emphasize the importance of early CT scan for quick and definitive diagnosis.Intussusception is commonly defined as telescoping of a proximal part of an intestinal loop towards the distal part of the loopA 38-year-old female patient presented to Orotta National Referral Hospital, Asmara, Eritrea, in May 2017 with abdominal pain and vomiting of 3-month duration. The pain was diffuse, intermittent and more on the periumbilical area. She only vomited after ingesting food, otherwise she does not. There is no history of abdominal distension and she was passing gas. Her condition gradually worsened from time to time. There was no history of fever, no bloody vomiting, and no history of jaundice or urinary complaints. There was no known family history of intestinal obstruction.On physical examination, the patient appeared sick and emaciated, although vital signs where within normal limits. She had slightly pale conjunctiva and dry mucosa. She had good air entry on both lungs with normal heart sound. There was diffuse tenderness on the abdomen but more on the epigastric region. There was no guarding or rebound tenderness. There was no any palpable mass on the abdomen until 1 day before the operation, when a large suprapubic mass was detected. Bowel sounds were present.3/µl , platelet count of 350×103/µl . Urinalysis reveled no abnormal finding and blood chemistry values were aspartate transaminase levels of 57 U/l serum , alanine aminotransferase level of 43 U/l , amylase of 191 U/l . Several plain abdominal x-rays were done with no pertinent findings. The last time plain abdominal x-ray was done showed a distended small intestine and with multiple “air-fluid levels”. Ultrasound of the abdomen depicted pockets of fluid collections. No abnormality was observed upon gastroscopic study . CT scan and MRI were not available.Laboratory findings showed that complete blood count was within the normal limit. Hemoglobin of 10 g/dl , white blood cell count of 7×10Despite the diagnostic challenges, several differential diagnoses were entertained, such as chronic peptic ulcer disease cholecystitis acute pancreatitis and partial intestinal obstruction and was managed conservatively. The patient was being treated as case of peptic ulcer disease before her surgical operation and was taking amoxicillin 1g twice daily and metronidazole 500mg twice daily for 10 days.At 1 day before surgery, an abdominal mass was felt during repeated physical examination. Non-operative reduction using hydrostatic or pneumatic pressure by enema was not attempted. Surgical intervention was decided and performed 2 weeks after initial presentation, with an impression of small intestine obstruction secondary to malignancy. The patient was kept nothing per mouth (NPO) and was given normal saline intravenous fluid, broad-spectrum ceftriaxone (1 g intravenous twice a day) and metronidazole (500 mg intravenous three times a day). She was also given hydrocortisone (100 mg intravenous three times a day for 3 days). The patient was also administered 2 units of blood were before surgery. During laparotomy a large mass of 20×20 cm was identified in mid jejunum and a leading tumor had caused intussusception and coiling of the small intestine . During 11. CT scans aid diagnosis considerably and usually shows a “bull’s-eye” sign19. Early in her presentation, the patient did not have signs of intestinal obstruction, but because of her persistent vomiting and epigastric pain other diagnoses were suggested. The diagnosis was greatly delayed partly because of diagnostic constraints. The temporary unavailability of the only CT scanner in the whole country made it difficult for early and accurate diagnosis. Looking at the importance of CT scan and MRI in the diagnosis of many medical and surgical conditions, it is highly recommended that the Eritrean Ministry of Health should import several additional CT scans or MRIs for a successful diagnosis and management of such health conditions. It is recommended as well to use CT scan as early as possible when a patient is suffering from a long-standing abdominal pain and vomiting.The preoperative diagnosis of intussusception remains challenging as the patients usually have nonspecific symptoms during their presentation to medical facilitiesNo data is associated with this article.Written informed consent for publication of their clinical details and clinical images was obtained from the patient. I now approve this article for indexing.Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?PartlyIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?PartlyIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Gastrointestinal surgeryI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Intussusception is 1-5% of causes of intestinal ileus and double intussusception is an even more exceptional observation. CT and MRI are the gold standard for diagnosis but ultrasonography can be an effective diagnostic tool and demonstrates multiple concentric rings associated with an abdominal echogenic mass and echolucent rings representing the mucous covering of the intussuscepted bowel segment. I think that this description is due in the presentation of ultrasonography. for the differential diagnosis. Some English errors like bowl in figure 1. Add in references this article which well describe a case like this:1 , Pierluigi Lobascio, Gennaro Martines, Angela D Di Franco, Marcella Rinaldi, Donato F Altomare Double jejunal intussusception in an adult with chronic subileus due to a giant lipoma: a case report Chir Ital Mar-Apr 2005;57(2):239-42.1 Fabio MarinoAre enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?YesIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?YesIs the background of the case’s history and progression described in sufficient detail?PartlyReviewer Expertise:General surgeryI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. et al. describe a rare case of adult small bowel-small bowel intussusception caused by an intestinal hemangioma that was treated with surgical resection.Lyassu The diagnosis was challenging because of the lack of institutional availability of cross-sectional imaging (CT/MRI). It would be informative to add an image of the abdominal x-ray showing air-fluid levels. Also, it is unclear what the "pockets of fluid collections" visualized on abdominal ultrasound represent. It would be interesting to show histopathological correlation of the intestinal hemangioma (H&E section). There are only a handful of such cases causing intussusception in the literature, and the authors may want to summarize this experience in the discussion. Figure 1. legend should read "bowel", rather than "bowl".Are enough details provided of any physical examination and diagnostic tests, treatment given and outcomes?PartlyIs the case presented with sufficient detail to be useful for other practitioners?YesIs sufficient discussion included of the importance of the findings and their relevance to future understanding of disease processes, diagnosis or treatment?PartlyIs the background of the case’s history and progression described in sufficient detail?YesReviewer Expertise:Gastrointestinal surgeryI confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.


Most patients with bowel cancer are symptomatic at the time of the diagnosis. They may present with a change in bowel habit, bleeding per rectum, abdominal pain, anaemia, weight loss or bowel obstruction. Colonic carcinoma can also be diagnosed incidentally during screening programs. Moreover, it may be incidentally detected in CT scans being performed for other indications or encountered during surgery for other causes. Some patients with colonic bowel ischaemia have associated large bowel cancer, where the ischaemic segment is usually proximal to the tumour and not necessarily associated with bowel obstruction. We are presenting a rare case of incidental malignant colonic polyp detected in a resected ischaemic large bowel in an 88-year-old gentleman. This was a very small tumour that was not visible macroscopically or detectable by imaging. Pathological examination of non-tumour colorectal resection specimens, as in this case, should include careful macroscopic examination and sequential block selection along the length of the colon, and where there is diffuse mucosal abnormality, block selection at 100mm interval is also advised. Attention to and block selection from any suspicious-looking area is warranted in all cases of non-tumour colorectal resections if such microscopic-sized malignancies of the type seen in our patient are to be picked up. Colonic malignancy occupies fourth place among the most common cancers in the UK and is regarded as the second most frequent cause of cancer-related mortality. Every year, more than 42,000 new cases are diagnosed, and currently around 268,000 people are living with colonic cancer in the UK. The diagnosis of colonic cancer is usually made by histological examination of a biopsy that is gotten during colonoscopy or from a surgical specimen, with the vast majority of tumours of the colon being carcinomas. Of the carcinomas, more than 90% are adenocarcinomas . IncidenAn 88-year-old male presented with a recent history of acute abdominal pain and vomiting. His past medical history included ischaemic heart disease, cerebrovascular accident and an open repair of abdominal aortic aneurysm 10 years earlier, in addition to an unoperated incisional hernia. On examination, the patient was septic and in cardiogenic shock. Urgent CT abdomen and pelvis showed free intra-abdominal air Figure , 3, 4. TPathological examination of the resected bowel revealed colectomy with terminal ileum specimen; the appendix was not identified. On opening the colon, there were extensive but patchy areas of mucosal ulceration with elevated edges. The margins of the ulcers appeared elevated. A focus of colonic perforation was identified. No tumours were identified macroscopically. The mucosa was extensively sampled sequentially from the ileum through the distal colon to include both resection margins. Microscopic examination of the ileum appeared normal, while sections from the large bowel showed extensive areas of mucosal ulceration with features of transmural acute ischaemic necrosis and associated suppurative serositis. Arteriosclerotic vascular changes in several blood vessels with some vessels showing marked luminal narrowing supportive of ischaemic colitis are noted. A single 8mm polyp of mainly poorly differentiated adenocarcinoma in addition to well-differentiated adenocarcinoma that had invaded into the pericolic adipose tissue (pT3) was found in a single section from the ascending colon. The poorly differentiated adenocarcinoma was present in both the mucosal surface and deeper layers of the colonic wall beyond the muscularis propria Figure , 5B. TheSo CK7−/CK20− pattern as seen in the tumour we report is a known phenotype for colorectal cancer, which is now being shown to be heterogeneous in its molecular profile and therefore patient outcome . CDX2 imThis tumour was shown by immunohistochemistry to be MMR protein deficient (MHL1 & PSM2 negative) Figure , 8A, 8B,The risk factors for colorectal cancer can be divided into three groups: sporadic, inherited and familial. Sporadic cases account for 70% of colorectal cancer patients and are due to dietary and environmental factors. Familial cases with known genetic syndromes make up about 5% of patients and can be divided into those with/without polyposis, while total inherited cases account for 20-30% of all colorectal cancer patients . HoweverThere are three main molecular pathways in the development of colorectal cancers. First is the chromosomal instability pathway which is involved in up to 80% of colorectal carcinomas. It results from gain of function mutations which can lead to activation of oncogenes, or decreased activity of tumour suppressor genes. Mutations in APC and genes that activate the Wnt pathway are included in this pathway. The tumours are characterized by gross chromosomal abnormalities including deletions, insertions, and loss of heterozygosity. The second molecular pathogenetic pathway is the microsatellite instability (MSI) pathway where the presence of microsatellite instability accounts for about 12% of sporadic cases of colorectal cancers. This is seen with the detection of two or more unstable markers during testing for mismatch repair deficiency using a polymerase chain reaction (PCR)-based assay, or the detection of the affected protein gene products by immunohistochemistry for MMR protein products . The third pathway is the CpG island hypermethylation pathway and was first elucidated in 1999 by Suzuki . It invoPremalignant lesions for colon cancers are local tumours that precede the development of cancers. Overwhelming evidence points to adenomas and this is referred to as the adenoma-carcinoma sequence. The adenomas could be polypoid (sessile or pedunculated), flat or depressed lesions of epithelial origin and the concerning histology feature is dysplasia. Other potential premalignant tumours include hyperplastic polyps, hamartomatous polyps, aberrant crypt foci and dysplasia in inflammatory bowel disease . The parColorectal cancer is a common malignancy and not uncommonly asymptomatic. This case presentation highlights the importance of careful and systematic gross and patho-morphological examination of the non-cancer bowel specimen as it may harbor early malignancy, especially in higher-risk groups.


Infantile hemangiomas (IHs) are common vascular tumors. In most cases, a benign course with favorable outcome can be anticipated. IH typically present as cutaneous lesions either with a localized or diffuse segmental distribution. Segmental hemangiomas in the face may be associated with brain and cardiac anomalies (PHACES syndrome), whereas airway involvement has been reported to be associated with hemangiomas in the “beard” area. Multiple cutaneous hemangiomas may be associated with visceral hemangiomas (commonly in the liver).In this report, we present a new association where deep paravertebral hemangiomatous lesions were observed to be associated with cutaneous back hemangiomas in two consecutive cases. Infantile hemangiomas (IHs) are common benign vascular tumors.IHs typically present as cutaneous lesions either with a localized or diffuse segmental distribution.In this report, we present a new association where deep paravertebral hemangiomatous lesions were observed to associate cutaneous back hemangiomas in two cases.A boy was born with a flat back hemangioma. Rapid increase in the size of the cutaneous lesion (proliferative phase) was noticed by the parents at the age of 1 month. The parents revealed a history of oral propranolol treatment that started at the age of 3 months and discontinued later at the age of one and a half years. At the age of 2 years, the patient was referred to our vascular anomaly clinic with a previously performed magnetic resonance imaging (MRI) study at the age of 3 months . BesideA 6-month-old girl presented with respiratory distress and a diffuse back hemangioma  that waReviewing the literature, one can still find confusing terminology in reports on mediastinal hemangiomas when authors described venous malformations using the old terminology of cavernous haemangiomas.The paravertebral hemangioma caused mediastinal compression in one of our cases who suffered from breathing difficulties at the age of 6 months. Propranolol was discontinued for bronchial obstruction, and systemic corticosteroids were used instead. Maybe a combination of both drugs would have achieved a synergistic effect.One of the two cases was also associated with a hepatic focal lesion displaying characteristic radiological features of hemangioma. Although a similar pathological diagnosis of IH might be suspected, focal hemangiomas of the liver are more commonly congenital (negative for Glut-1).This new association may prove to be important from two aspects. First, a diagnostic confusion may arise from the presence of the posterior mediastinal  mass.


A snapping tendon on the dorsal aspect of the thumb is a rare condition as opposed to the common triggering on the volar aspect of the thumb. This condition is known as triggering of the extensor pollicis longus (EPL). A 21-year-old female presented with a clicking or snapping sensation that was felt on the dorsum of her thumb when it is extended. There was no history of trauma. She worked in an ice-cream parlor with repetitive scooping ice-cream motions. Her triggering immediately resolved on releasing the EPL fascia ulnar to Lister’s tubercle. Upon wake-up surgery, we could immediately confirm this. We recommend dynamic ultrasound as an investigation and do not recommend MRI. The surgical method of choice is either wake-up surgery or wide-awake local anesthesia no tourniquet (WALANT) surgery. A snapping tendon on the dorsal side of the thumb has to be differentiated from the common trigger thumb on the volar aspect, which is due to thickening of the A1 pulley of the flexor tendon. This condition is named triggering of the extensor pollicis longus (EPL) and is rare.The literature is limited on this condition. Only three published articles reported triggering of the EPL of the thumb in a non-traumatic situation attributed to ectopic bone formation , tendon Another four articles mentioned EPL triggering attributed to trauma ,6-8. We We report a case of a 21-year-old female who presented with a four-month history of clicking or snapping sensation felt on the dorsum of the right thumb when the thumb was extended. Initially, there was no pain, but two months later her pain score was 6/10 when she extended the thumb. She had no pain at rest. She had no history of definitive trauma and works in an ice-cream parlor. She was right hand dominant.During examination, triggering was seen in three different regions: at the base of the metacarpal, at the carpometacarpal joint (CMCJ) area, and at Lister’s tubercle Figure . Out of A dynamic ultrasound study reported displacement of the EPL tendon radially during flexion movements at the level of the first CMCJ. An MRI was also performed, but the findings were totally unrelated to our diagnosis. It reported first MCPJ subluxation with sprain of the radial collateral ligament. We decided to operate based on her symptoms and ultrasonographic findings.Surgery was planned, and the patient offered either WALANT  or wake-up surgery (anesthesia awareness surgery). This was to determine the exact area of pathology and to ensure her condition is fully resolved. The patient selected the latter.Based on the history of the prominent triggering at the base of the first metacarpal region and the ultrasound results, we began the incision at the base of the first metacarpal region. However, no triggering was seen here. The incision was extended proximally to the CMCJ region, which again did not show any triggering. Finally, the incision was extended to Lister’s tubercle, and we were able to see triggering in this region Figure . The patAt three months post-surgery, she developed a keloid scar Figure  but she To differentiate this condition from the more common trigger thumb, Kardashian et al. has proposed to use snapping for triggering on the dorsal side . There aKardashian et al. mentioned that repetitive motion could be a causative factor in their case report, which listed a banker who is also a drummer . Other cThe area of impingement and hence triggering was noted to be between Lister’s tubercle and the base of the third metacarpal by Ferreres et al. . When atMcMahon and Posner , LanzettLuenam et al. discovered an intratendinous nodule in the EPL. However, after releasing the EPL tendon, there was still triggering . They thOur problem was that the triggering was most obvious at the base of the metacarpophalangeal joint (MCPJ) followed by the CMCJ and least obvious at Lister’s tubercle. Hence, we initially started our incision at the base of the MCPJ and discovered that there was no triggering in this region. We then moved proximally to the CMCJ and finally to Lister’s tubercle before we noted the triggering. This resulted in a very long incision. We suggest hand surgeons to disregard the triggering at the CMCJ and MCPJ and focus at only Lister’s tubercle.Our EPL tendon had three obvious grooves or indentations. Only McMahon and Posner described the indentation in the EPL . Luenam With regard to investigations, we do not advocate MRI but rather ultrasonography as the latter is a real-time investigation. We feel MRI is inaccurate and this is supported by De Maeseneer et al. who mentioned that due to the oblique orientation of the EPL this could result in a magic angle artifact .In conclusion, snapping of the thumb dorsally is a rare occurrence and the physician should be ever vigilant. Ultrasonography is the investigation of choice, with surgery to release the third extensor compartment ulnar to Lister’s tubercle.


Decidual change is a key process required by the uterus to make itself ready for implantation. Presence of ectopic decidual tissue outside the uterine cavity is known as deciduosis. The clinical presentation can vary from being totally asymptomatic and subtle to presenting in the form of life-threatening emergencies like hemoperitoneum, recurrent pneumothorax, or even bowel perforation. Here, we present a case of ectopic deciduosis of cervix presenting in the form of severe life-threatening antepartum hemorrhage in second trimester of pregnancy. Decidual change is a key process required by the uterus to make itself ready for implantation. Presence of ectopic decidual tissue outside the uterine cavity is known as deciduosis. Progesterone is the predominant hormone responsible for the growth of such tissues; therefore, apart from pregnant women, these tissues are also found in women on exogenous progesterone therapy. Although ovary and cervix are the most common sites, ectopic decidualization has also been reported to occur in other sites including peritoneal cavity,A 28-year-old primigravida, at 24th week of gestation period, presented to obstetrics emergency department with complaint of excessive bleeding per vaginum from last 4 hours. Bleeding was insidious in onset, but later became continuous with passage of clots. She had soaked 4 pads in last 4 hours. Bleeding was bright red in color and was not associated with any abdominal pain or tightening of uterus. There was no history of high blood pressure her antenatal period. There was no history of abdominal trauma or pelvic instrumentation and no history of exogenous progesterone therapy. She had experienced 2 episodes of spotting at 16 weeks and 20 weeks, respectively, which were managed conservatively. A per speculum examination done at 20 weeks showed a cervical polyp arising at the 4 o’clock position . It was On examination, she was found to be conscious, oriented to time, place, and person but extremely pale. Her pulse was 120 beats per minute (bpm), blood pressure was 80/50 mm Hg, and respiratory rate was 20/min. On abdominal examination, uterus corresponded to 24 weeks of pregnancy; it was relaxed, nontender and nontense. Fetal heart sound was 140 bpm regular. On local examination, active bleeding which was bright red in color and painless was observed. A low-lying placenta was already ruled out by her Level II scan. A repeat ultrasound confirmed the previous findings of fundal attachment of placenta and no signs of retroplacental clot or hemorrhage. A gentle per speculum examination was performed. After removing approximately 250 ml of blood clots from the vagina, a bright red polyp measuring 2x2 cm was observed at the 4 o’clock position of cervix . As it wThe histopathology report of polyp showed sheets of decidualized tissue surrounded by dense chronic inflammatory infiltrate in cervix suggestive of cervical deciduosis .Decidualization is an integral part of implantation and placental development. If it occurs at any site, other than the uterus, it is said to be ectopic. Although cervix and ovaries are the most common sites, it has been reported to occur in vagina, peritoneum, and even in the uterine cavity in the form of tumor-like mass.9Ectopic deciduais usually a microscopic finding detected on the histopathology reports of biopsy taken during caesarean section, postpartum tubal ligations, or in tubal ectopic.Various theories have been proposed regarding the origin of deciduosis. It is presently believed that decidual change in cervix is due to abnormal reaction of normal stromal cells to hormonal stimulation of pregnancy, especially progesterone.13Cervical deciduosis usually presents in the form of small sessile polypsor small elevated, single or multiple, highly vascular nodules.Although deciduosis is a benign cervical change in pregnancy and usually undergoes resolution spontaneously within 4–6 weeks postpartum, it should be kept in the differential diagnosis of local causes of antepartum hemorrhage.


Rectal-prostate fistulas are uncommon anatomical connections between the prostatic urethra and rectum that are typically iatrogenic but can also result from other underlying pathology. Here, we present a unique case of a rectal-prostate fistula causing the rectal passage of sperm.A 33-year-old male with a history of illicit drug use presented with five days of testicular pain and a substantial amount of sperm passage from his rectum with ejaculation for the past two years. Computed tomography and voiding cystourethrogram (VCUG) of the pelvis revealed evidence of a rectal-prostate fistula. He was treated with piperacillin-tazobactam, and a surgical fistula repair was performed. Further investigation divulged a three-week comatose state due to cocaine and phencyclidine intoxication two years prior with documentation suggesting a traumatic Foley catheter placement and strong suspicion for premature balloon dilation in the prostatic urethra. Repeat VCUG revealed resolution of the fistula with mildly reduced antegrade ejaculatory volume.Cases secondary to Foley catheter placement have not been previously reported in the literature. Even though urethral catheters have been shown to be effective tools in healthcare, it is crucial for clinicians to recognize the numerous potential complications that oftentimes become an afterthought to many providers. This case not only highlights a rare complication of catheter use but also emphasizes the importance of provider mindfulness when utilizing seemingly benign therapies such as Foley catheters. Rectourethral fistulas (RUF) are uncommon pathologic communications between the rectum and lower urinary tract with an incidence of 0.5 per 100,000 per year -4. AcquiThis article was previously presented as a meeting poster at the 2021 ACP National Abstract Competition in May 2021.A 33-year-old male with a history of illicit drug use presented with five days of testicular pain. He also noted a substantial amount of urine and sperm passage from his rectum in addition to pneumaturia and fecaluria for the past two years. Vital signs upon presentation were within normal limits. Physical examination was notable for left testicular swelling with a positive Prehn’s sign and a defect in the anterior rectal wall on digital rectal examination. Labs showed a neutrophilic leukocytosis and urinalysis was suggestive of a urinary tract infection. Computed tomography (CT) of the pelvis revealed evidence of left epididymo-orchitis and a gas-filled structure within the posterior aspect of the prostate communicating with the adjacent rectum, which was suggestive of a chronic appearing rectal-prostate fistula Figure . VoidingExtensive workup to rule out infectious causes including tuberculosis, inflammatory bowel disease, and malignancy was unremarkable. Additionally, the patient denied prior abdominal surgeries, rectal manipulation and penetration, or rectal trauma. Further investigation divulged a three-week comatose state due to cocaine and phencyclidine intoxication two years prior. Documentation suggested significant trauma with Foley catheter placement associated with hematuria during that hospitalization. The epididymo-orchitis was treated with piperacillin-tazobactam. A joint colorectal and urologic surgical fistula repair was performed creating a rectal urethral advancement flap from the excised rectal wall with successful closure of the prostatic fistula. A suprapubic catheter was placed postclosure and subsequently removed after recovery. Repeat VCUG revealed resolution of the fistula and the patient recovered with only mildly reduced antegrade ejaculatory volume over several months Figure .Several etiologies of acquired RUFs are well-established including prostate cancer with tumor invasion, rectal cancer, regional radiation, cryotherapy, surgery, diverticular disease, severe trauma, fistulizing Crohn’s disease, and abscess rupture Table  2,7,8].,7,8.2,7,Symptomatic urinary tract infections are seen in 80% of patients with colovesical fistulas while approximately 90% of patients experience pneumaturia and fecaluria . Rectal A definitive gold-standard modality of diagnosis is not well established even though many cases are diagnosed by clinical suspicion followed by direct visualization by rectoscopy or cystourethroscopy ,6. OtherConservative resolution by urinary or fecal diversion is variable ranging from 14% to 54% ,36. MoreThis case not only highlights a rare complication of catheter use but also emphasizes the importance of provider mindfulness when utilizing seemingly benign therapies such as Foley catheters.The importance of Foley catheters in healthcare is well-established. While it serves many uses in patient management, it is essential to stay wary of its complications as well. More frequent complications such as recurrent urinary tract infections and kidney and bladder damage have been reported in the literature; however, physicians should note other potential risks such as urethral injuries and RUFs. This case not only highlights a rare complication of catheter use but also emphasizes the importance of provider mindfulness when utilizing seemingly benign therapies such as Foley catheters.


A 92-year-old male presented from an outside hospital for treatment of a chronic obstructive pulmonary disease exacerbation (COPD) and subsequently developed worsening abdominal distention with pain during the course of his hospitalization. He was found to have a high-grade large-bowel obstruction with a dilated colon of 20 cm measuring upward. The patient ultimately underwent a hemicolectomy to prevent bowel ischemia and reformation of another volvulus. We present this case to elucidate the need for vigilant monitoring in patients with chronic bowel obstruction due to lack of typical symptoms, to demonstrate a successful management approach, and to exhibit an extreme example of the resulting megacolon. Volvuli are the most common benign etiology of large-bowel obstructions and account for 1%-7% of all cases . TypicalA 92-year-old male with a medical history significant for COPD, atrial fibrillation, and previous remote partial left hemicolectomy with anastomosis presented as a transfer for continued treatment of COPD exacerbation. Vitals at the time of initial presentation were within normal limits, and the patient's oxygen saturation was greater than 92% on room air. Physical exam was notable for wheezing along with abdominal distention but without tenderness to palpation. He was treated with glucocorticoids and nebulized ipratropium bromide/albuterol for his COPD exacerbation.Two days into his admission, the patient developed abdominal pain with reduced stool output and minimal passage of gas. Upon further assessment, the patient stated his abdominal distention was typically normal and reported regular bowel movements at home without blood. He also reported multiple previous surgeries "to get rid of the gas" that suggested he was having chronic issues with bowel obstruction; however, the treatment team was unable to obtain these medical records. During the time of the patient's initial onset of abdominal pain, vitals were within normal limits. Physical exam was notable for severe and interval progression of abdominal distention but without abdominal tenderness or peritoneal signs. Lactic acid was elevated at 3.5 mmol/L .An abdominal series x-ray demonstrated extensively distended bowel suggestive of large-bowel obstruction Figure . Non-conA diagnosis of megacolon is made when the colon diameter is found to measure >12 cm and is classified as either acute or chronic. Acute megacolon in the setting of inflammation is known as toxic megacolon, whereas acute megacolon without known colonic disease is known as Ogilvie’s syndrome . ChronicFor patients with acute abdominal pain with distention, x-ray imaging of the abdomen should be obtained to assess for an obstructive process along with follow-up CT imaging to determine the location of the obstruction. Obtaining a lactic acid level can be useful in determining whether bowel ischemia is occurring. Our patient’s lactic acid was elevated, with CT imaging remarkably impressive for dilated large bowel measuring 20 cm, with what appeared to be compression of organs against the posterior wall concerning for abdominal compartment syndrome.There are limited published case reports on patients with chronic non-toxic megacolon, making morbidity and mortality rates difficult to discern. Multiple studies have suggested an increase in perforation rates with the dilated colon as little as 9 cm, with a greater significant risk of perforation with cecal diameters greater than 10-12 cm ,9. One pThe development of megacolon, whether acute or chronic, should be quickly investigated and managed. Management of stable patients with the development of chronic megacolon is typically conservative and is directed at preventing ischemia and perforation. Pharmacologic approaches are often effective such as intravenous neostigmine, with alternative methods including colonic decompression . If consOur patient failed initial conservative measures, and he ultimately decided to pursue surgical intervention consisting of total colectomy with end ileostomy. Given the limited published studies on geriatric patients with the development of chronic non-toxic megacolon, this case report aims to demonstrate the clinical presentation and management strategies for this uncommon disease process.In conclusion, a diagnosis of megacolon should prompt thorough investigation with hastened management. While our patient was relatively stable and without signs of perforation, his markedly dilated bowel after failing conservative measures was significant enough for a total colectomy with end ileostomy to prevent an unfavorable outcome.


Chilaiditi's Sign (CS) is a radiological finding on an abdominal radiograph due to colonic interposition between the liver and the diaphragm giving a false impression of free intra peritoneal air. When accompanied by abdominal symptoms, a syndrome with the same name is diagnosed. As elusive a finding, it can be a source of diagnostic misinterpretation causing an alarming illusion of a deceptive emergency.We report a four-year-old girl presenting with an acute abdomen in a background of long-standing constipation and an illusory radiograph suggesting left-sided, free sub diaphragmatic air. Further imaging with a CECT confirmed mesenteric lymphadenitis without free peritoneal air and chronic constipation as a cause of symptoms. Expectant management resulted in gradual clinical improvement.Chilaiditi's syndrome or CS is more often described in adults and more frequently over the right side, nevertheless, can occur in children too. Knowledge of its occurrence can avoid unnecessary surgical intervention.While evaluating a child with acute abdomen, if the finding of a radiographic free sub diaphragmatic air is discordant with clinical signs, further imaging to rule out CS is important to avoid unnecessary exploration. •Subdiaphragmatic radiolucency due to colonic interposition is termed as Chilaiditi’s sign.•Chilaiditi’s sign, often described on the right side, can also occur on the left.•If the clinical and radiological pictures are discordant, Chilaiditi’s syndrome should be considered.•Conservative treatment has been proven to be effective in cases of Chilaiditi syndrome. CS is reported when air under the diaphragm is seen as a result of colonic interposition between the liver and diaphragm Radiographic evidence of colonic interposition along with clinical symptoms is referred to as Chilaiditi syndrome We report a case of a four-years-child presenting with long-standing constipation and acute abdominal pain with a radiograph suggestive of air under the left hemidiaphragm, following the SCARE 2020 guidelines 2A four-year-old girl was evaluated for sudden onset severe periumbilical pain that later migrated towards the left lower abdomen for a day associated with multiple episodes of non-bilious and non-projectile vomiting. She did not have associated fever, abdominal distension, jaundice or urinary complaints although a history of similar pain of lesser severity and frequency was reported in the past associated with intermittent episodes of constipation that subsided after defecation.She was hemodynamically stable except for tachycardia of 120 beats per minute. Abdominal examination revealed mild tenderness over the left entire abdomen without guarding, distension or palpable organomegaly. Bowel sounds were normal and the rest of the systemic examination was unremarkable.Her hemogram showed a hemoglobin of 13.9 g/dl, leukocytosis with a white cell count of 12,720/cu.mm,  and C - reactive protein (CRP) was negative. Renal function tests and urinalysis were within normal limits.A plain abdominal erect radiograph revealed a doubtful free air under the left hemi diaphragm and colonic fecal loading .Fig. 1LeAbdominal sonography suggested multiple enlarged mesenteric lymph nodes the largest measuring 17 × 14 mm in size and absence of inflamed appendix. In view of a doubtful pneumoperitoneum that was discordant with clinical findings, a contrast enhanced computed tomography (CECT) scan of the abdomen was obtained that confirmed mesenteric lymphadenitis without free peritoneal air. A final diagnosis of Chilaiditi syndrome was made with underlying mesenteric lymphadenitis and constipation.Mesenteric lymphadenitis was treated with bed rest, hydration and analgesics while stool softeners and enemas were given for constipation. With this, gradual symptomatic improvement was noted. At discharge, long term measures in the form of dietary modifications and laxatives were advised. At follow-up a week and a month later, she remained symptom-free. A repeated abdominal radiograph at one month showed a decrease in colonic fecal loading and subsequent resolution of CS . The pat3Radiological sub diaphragmatic free air is a surgical emergency and most often attributable to bowel perforation unless otherwise proved. Apart from this, other conditions like sub diaphragmatic abscess can also present with similar findings CS first described by Demetrius Chilaiditi in 1910 is an uncommon radiological finding with a global incidence of 0.25–0.28% and poorly understood etiology The individuals are usually asymptomatic and the sign is often observed on the chest or abdominal radiographs incidentally. The symptomatic ones however can have a more dramatic presentation called Chilaiditi syndrome; the problems varying between mild abdominal pain, nausea, vomiting, loss of appetite, bloating, flatulence and constipation to surgical emergencies, like bowel obstruction and perforation. Interestingly, respiratory distress, chest pain and dyspnea have also been rarely described A plain radiograph is the initial investigation and reveals characteristic air below the diaphragm with visible colonic haustra that does not seem to follow a postural pattern. A cross sectional imaging like CT is mandatory to rule out perforated viscous in the background of abdominal symptoms and signs; more so, when the plain radiograph and ultrasound are inconclusive Long-standing constipation as an acquired cause of Chilaiditi syndrome causing colonic elongation, redundancy, anatomic distortion and pathological interposition resulting in CS has been implicated Chilaiditi syndrome may infrequently need surgical rectification in the form of colopexy or resection when conservative measures fail due to associated volvulus, intestinal ischemia or perforation Also considering constipation as the cause of CS, long-term management involving dietary modifications and laxatives were advised. Resolution of CS and reduction in colonic fecal loading in the subsequent abdominal radiographs confirmed objective improvement with long-term benefits.4When evaluating a child with abdominal pain and long-standing constipation, if radiological free air is discordant with clinical findings, the possibility of Chilaiditi Syndrome should be suspected. Further confirmation with CT and conservative care can often avoid unnecessary exploration.None.Not required.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.AM drafted the manuscript. ALS was the treating physician, senior author and supervisor and revised the manuscript.Not applicable.No patient and author details are included in the figure.Aakash Mishra accepts full responsibility for the work and/or the conduct of the study, had access to the data, and controls the decision to publish.Not commissioned, externally peer-reviewed.None of the authors has any conflict of interest to disclose. We confirm that we have read the Journal's position on issues involved in ethical publication and affirm that this report is consistent with those guidelines.


Pseudolipomas are an uncommon clinical manifestation appearing as a non-encapsulated prominence of subcutaneous fat on MRI. Post-traumatic pseudolipomas (PTLs) are thought to arise from neoadipogenesis following acute or chronic trauma. These are most commonly located on the lower extremities, gluteal, and trochanteric regions. Here, we report a case of PTL in a high school athlete, arising in the posterior neck after weight training with performing barbell squats without neck padding. To our knowledge, this case represents a novel association between PTLs and weight training exercises. A 16-year-old male high school athlete presented to the clinic with a progressively enlarging midline posterior neck mass. His symptoms began with “bruising” after a weightlifting session that included heavy barbell squats without neck padding. Over the next several months, this developed into a persistent, progressive, smooth lump without fluctuance, tenderness, or surrounding erythema.Initial cervical spine X-rays revealed a superficial, ovoid soft tissue density in the posterior neck on the lateral view. Subsequent ultrasonography revealed a 5.7 cm midline, elliptical, echogenic area with skin thickening overlying the area of concern. Further MRI of the cervical spine revealed a midline, unencapsulated, ovoid area of increased subcutaneous fat and thickened, stacked, fibrous septae with overlying dermal thickening , produci1 In fact, a recent single-institution retrospective study and systematic review of posterior neck masses revealed only 19 articles describing 36 patients.2 Of these patients, 97% had benign pathologies, including lipomas, nuchal fibromas, schwannomas, epidermal inclusion cysts, lipoblastoma, hemangioma, leiomyoma, lymphangioma, and benign meningioma. One patient (3%) was found to have malignant meningioma.2While neck masses have a broad range of differential diagnoses, the overwhelming majority arise in the anterior aspects of the neck.Treatment modalities for pseudolipoma may include conventional surgical excision or liposuction. Liposuction conveys several advantages over c3,4 However, surgical excision may be more appropriate for dense, multiseptated appearing lesions on imaging.4,5onventional surgery for lesions larger than 4 cm, including shorter operating times, reduced risk of intraoperative bleeding, reduced rates of pain, infection, and morbidity, and improved cosmesis.Due to COVID-19 pandemic, the patient is scheduled and waiting to see a dermatologist for further evaluation and management of this condition.6 First defined in 1932 as an accumulation of adipose tissue in abnormal locations, post-traumatic pseudolipomas (PTLs) are a poorly defined subgroup of pseudolipomas that seem to arise after either acute severe blunt trauma or chronic repetitive trauma.4 PTLs have a female predominance ranging from 3.8 to 12:1. This is possibly explained by a greater proliferative response to estradiol in pre-adipocytes in females compared to males.4,7 PTLs are commonly located on the lower extremity as well as the gluteal and trochanteric regions, however there have been cases of PTLs situated on the upper back.7 Known colloquially as “tar barreler’s humps,” these chronically induced PTLs are common in a community in Southwest England. Ottery St. Mary is home to a centuries-old annual tradition during which flaming barrels of tar are carried through the streets. In some families, the tradition begins at a young age, and there are stories of several community members with such humps on the back between the shoulders where the barrels rest. Similar to our 16-year-old weightlifter, a recent case was described by Olubaniyi et al of a 32-year-old “tar barreller” whose clinical presentation and imaging findings were consistent with nuchal PTL .8 The trauma induced by carrying a heavy barrel upon one’s back is comparable to that caused by heavy barbell during squats.Pseudolipomas are an uncommon clinical manifestation appearing as a non-encapsulated prominence of subcutaneous fat on MRI.9 There have been several cases in which no anatomical confirmation could be made, stimulating several new theories. Galea et al proposed that inflammation may be driving neoadipogenesis. Their review referenced studies demonstrating the adipogenic potential of inflammogens using in vivo murine models and tissue engineering chambers both with and without fat grafts. Blunt trauma-induced soft tissue inflammation was shown to generate localized elevations in inflammatory chemokines such as interleukin-8 and macrophage inflammatory protein-1β. It was further postulated that the blood matrix from the post-traumatic hematoma and surrounding fibrosis may induce durotactic migration of pre-adipocytes and serve as a nidus for mechanically induced differentiation and proliferation of adipocytes.4The pathogenesis of PTLs is not well defined, but several postulations have been made. Early theories centered around mechanical and anatomic etiologies such as a traumatic force causing fracture of fat compartments and shearing of anchoring points within Scarpa’s fascia, allowing for protrusion of adipose tissue.4,7 There is an average delay in presentation of 6 months in males compared to females.4 There has been no significant data collected that details the time from trauma to the onset of the pseudolipoma, however they have been described to be present upon resolution of the preceding post-traumatic hematoma.7The course of development of PTLs is not well defined. The time from trauma to presentation with a lesion ranges from 6 months to 5 years, with a mean between 1 and 2 years.To our knowledge, this case represents a hitherto undocumented association of PTLs with weightlifting exercises. PTLs have an unpredictable course and presentation and are thus poorly recognized by clinicians. It is crucial to elicit a thorough history when working-up lipomatous lesions and to identify any possible cause of acute or chronic trauma, including activities such as weightlifting. Having a benign course and simple, definitive treatment, a swift diagnosis of a PTL can help assuage patient concern and anxiety.PTLs are an uncommon clinical manifestation appearing as a non-encapsulated prominence of subcutaneous fat on MRI, following severe acute or chronic repetitive trauma.Practitioners who encounter young athletic patients with posterior neck masses, in the absence of malignant features, should evaluate their weight training history, particularly concerning barbell squats performed without padding.PTLs have a predilection for females and occur primarily in the lower extremities, gluteal, and trochanteric regions.


Dentigerous cysts are characterised by the formation of cysts containing dental material with a variable level of development. They are the result of a distinct embryological phenomenon. Usually, they are of significant clinical relevance in horses, especially in tandem with ectopic tooth. Contrarily, supernumerary teeth or typical polyodontias usually have limited impact. In this case report, we describe the occurrence of a supernumerary first premolar (Triadan 105). Dissimilar to known scientific literature however was the formation of a cystic structure around the supernumerary tooth. Surgical removal of the dentigerous cyst is discussed, as are the possible causes for the formation of the cystic structure. Based on this case report, we suspect that the formation of a cystic structure may not be limited to atypical polyodontias, as they may also occur in supernumerary teeth. Dentigerous cysts or atypical polyodontias are a result of dental dysgenesis. They are described as epithelium-lined cystic structures in soft tissues or bone, which develop out of cellular debris of the Hertwig's epithelial root sheath. These cells are part of the enamel organ, which are a precursor of the later origin of the tooth roots. Up to now, the formation of cysts has only been related to ectopic dental tissues . BecauseSupernumerary teeth or typical polyodontias are not usually described with concurrent formation of a cystic structure around it. Usually, they refer solely to the development of a supernumerary tooth, often of minor clinical relevance. Irregular shapes or rotation of supernumerary teeth may sometimes be observed . The firA 3-year-old Quarter Horse mare was presented to the equine clinic am Kottenforst. Reasons for presentation were clear signs of pain while grooming the right side of the head. The mare was being broken in at the time, and the owner reported a fending reaction when grooming or applying the bit, specifically at the right side of the head. Increased salivation was also observed. No clinical examination or routine dental treatment had been performed before presentation.The clinical examination of the mare was uneventful, although the mare did clearly avoid palpation of the right rostral maxillary region. An examination of the oral cavity was performed under sedation. The gingiva rostral of the right maxillary second premolar (Triadan 106) was clearly hyperemic. On palpation, the gingiva in this area seemed hard and distended. The first premolar teeth were not visible at the time of examination. No further abnormalities were discovered in the oral cavity.A radiographic examination was performed of the right rostral maxillary region and of the left side for comparison. The radiographic examination is based on the hemisphere model . A rightTreatment consisted of surgical removal under standing sedation. After placing an in-dwelling catheter in the left jugular vein, the mare was sedated with detomidine hydrochloride (0.01 mg/kg) and butorphanol (0.05 mg/kg) as well as romifidine (0.04 mg/kg). A block of the right N. infraorbitalis was performed with 3 ml of lidocaine 2%; the gingiva in the affected area was also infiltrated with 10 ml lidocaine 2%. An incision of 1.5 cm was made over the distended gingiva. To enter and open the cyst, the maxillary bone was removed by means of an osteotome. A very thin (0.1 cm) membrane was lining the cyst. After opening, approximately 1 ml of milky-white to yellowish mucous fluid drained out of it. Two small dental structures were removed from this cavity afterwards . The fluThe resulting cavity was filled up with iodine gauzes and honey cream . There was no connection identified between the cavity and the nearby alveoli of the second premolar (Triadan 106).Postoperatively, the mare showed no signs of discomfort and feed intake was normal. She was treated with flunixin meglumin (1.1 mg/kg q24h i.v.) for 3 days postoperatively. The tamponade was replaced every second day for 8 days; afterwards, the cavity was flushed daily with saline solution. Three days postoperatively, the mare was discharged from the equine hospital. At check-up 14 days postoperatively, the cavity was almost fully filled with granulation tissue. The owner did not observe any pain or excess salivation after the surgical treatment.A cytological examination was performed of the fluid contents of the cavity and of the inner membrane of the cyst. The fluid was classified as transudate; few mesothelial cells and neutrophils were also seen. In the membrane lining, the cavity epithelial and goblet cells were identified. The two tooth structures were not examined separately. Macroscopically, both teeth were presented with a crown and a neck but had no inner filling. Roots however were not present, and there were no signs of pulp tissue.This case report describes the diagnosis and surgical treatment of a dentigerous cyst concurrent to a supernumerary first premolar or wolf tooth in a 3-year-old Quarter Horse mare.In this case, it is presumed that one of the two teeth in the cyst was a supernumerary first premolar or wolf tooth (Triadan 105), a so-called typical polyodontia. The region where both teeth were found is typical and has been described several times in scientific literature .In our case, however, a draining tract was not observed. It is still possible that a draining tract might have developed in the future and the increasing sensitivity on palpation and grooming may support this. One study on supernumerary teeth and dentigerous cysts reported a mean age at presentation of 3 years, like our patient. Over half of the patients reported draining tracts in connection with an ectopic tooth, but cases were also described in which only a swelling or irritation developed at the base of the ear . In our The two tooth-like structures within the cyst were not fully developed. There could be a possible connection between the incomplete development of the teeth and the development of the cyst. After the enamel organ preformed the tooth roots, dental sacs develop. Within these dental sacs, cells from the epithelial root sheath often remain behind. In case of inflammation because of doubled expression of 105, these cells can cause cyst proliferation . In lineThe prognosis for surgical excision of a dentigerous cyst relies mainly upon the anatomical position and whether the structure can be removed to a full extent or not . In the The cystic structure was opened by using an osteotome, and the membrane lining the cavity was removed by means of curettage and subsequent lavage. Should epithelial cells remain, a new membrane could reform and complaints could recur. In this case, however, no such complications were observed.To the authors' knowledge, this is the first report describing a supernumerary wolf tooth in a cystic structure. Based on our findings, we suspect that the formation of cystic structures may not only occur related to ectopic teeth such as an atypical polyodontia but may also occur in some forms of supernumerary teeth or typical polyodontias. Further research is warranted to confirm this suspicion.


Xanthogranulomatous pyelonephritis may, rarely, occur as a renal cystic mass. We report a case report of a 50-year-old with a history of medically treated renal lithiasis, who consults for left low back pain. Imaging findings concluded to a Bosniak type-3 hemorrhagic cystic mass of the left kidney. The diagnosis of xanthogranumolatous pyelonephritis on its focal form was made histologically. The diagnosis of xanthogranulomatous pyelonephritis is often difficult even with surgical findings and frequently a histological surprise. This points out the importance of identifying it in pre-operative staging; the diagnosis may be suggested by the association of chronic pyelonephritis, renal stones and hypovascular renal tumor syndrome without specificity at sonography and CT. Xanthogranulomatous pyelonephritis (XGP) is a rare form of chronic infection of the renal parenchyma which is histologically defined as a combination of chronic pyelonephritis lesions and xanthogranulomatous spume cells. Its pre-operative diagnosis is difficult due to the lack of evidence of specificity , 2. TherWe report a case of pseudo tumoral xanthogranulomatous pyelonephritis whose preoperative diagnosis was in favor of a cystic tumor, pointing out the pre-operative diagnostic difficulties of this affection.This is a 50-year-old patient with a history of medically treated renal lithiasis, who consults for left low back pain. The patient was apyretic and reported no urinary symptoms. The clinical examination was without any particularities. There was no organomegaly or lumbar contact on bimanual palpation. Biologically, there were no abnormalities, including no biological inflammatory syndrome, and renal function was preserved. The urine culture was sterile. Renal ultrasound revealed a 3-cm left cortical renal mass with moderate vascuarization. Abdominal CT scan confirmed the presence of a heterogeneous Bosniak type 3 cystic mass having a thickened wall . Abdominet al. [XGP is a rare chronic inflammatory disease firstly described in 1916  whose maet al.  reportedEscherichia coli and Proteus mirabilis [The physical examination in case of XGP is not of great diagnostic value because it is most often negative. A lumbar mass is only found in 20% of cases . This lairabilis , 8.et al. [Radiologically, the pre-operative diagnosis of XGP is only made in about half of cases from CT data. In the localized form of XGP, CT often reveals a cortical, hypodense and heterogeneous mass with calcifications in some cases. After contrast injection, the mass does not usually increase in density; however, an intense peripheral enhancement corresponding to compressed healthy renal tissue and/or inflammatory tissue is shown , 9. The et al.  reportedet al. , 12.XGP induces a variable and non-specific clinical and radiologic picture. Moreover, there is no pathognomonic clinical or radiologic sign of this condition as it resembles other inflammatory or neoplastic renal pathologies. The diagnosis is usually made on histological examination after surgical treatment.The histological examination usually shows a dense inflammatory infiltrate of all interstitial tissue with presence of lymphocytes, plasmocyts and neutrophils. We notice a replacement of renal parenchyma with CD68+ foamy histiocytes, occasional multinucleated giant cells and inflammatory cells.et al. [The treatment of focal XGP is both medical and surgical , 8. Althet al.  who repoXGP in its focal form is a rare benign disease of the kidney. Its treatment should be conservative based on partial nephrectomy or tumorectomy with antibiotic therapy. Lack of knowledge of this disease and the absence of clinic or radiologic specific signs may explain the high rate of misdiagnosis.The authors declare that they have no competing interests.Authors declared that they received written consent from the patient to publish this case report.


Congenital heterotopic colon and pancreas localized to the neck has not been reported. Herein, we describe an extremely uncommon case of congenital heterotopic colon and pancreas aberrantly presented within a cyst on the neck, and the thickened wall of the cyst on ultrasound may represent an important ultrasonic feature. Ectopic gastrointestinal cysts are rare lesions that mainly occur in the digestive tract, including the esophagus, small intestine, pancreas, gallbladder and Meckel's diverticulum , 2. The An ectopic pancreas is an anatomically isolated pancreatic tissue outside of and separate to the main pancreas, with no anatomical or vascular connection to the normal pancreas . It is uA female infant was admitted to our hospital due to a cyst on the right side of the neck. The cyst was initially revealed when her mother underwent ultrasound examination at 29 weeks gestation. The cyst was ~3.0 × 1.8 × 2.2 cm in size, oval in shape, and had clear boundaries. Her mother did not have complications during pregnancy nor was there family history of heterotopic lesions.During prenatal consultations, her mother learned about the risks and decided to continue the pregnancy. At 40 weeks of pregnancy, a cesarean section was performed to deliver the baby. Physical examinations showed that the birth weight was 3.1 kg and Apgar scoring was 9-10-10.Physical examinations revealed a soft neck, no mass on neck palpation, soft abdomen in the fasting state on abdominal palpation, no peristaltic wave, and normal stool. There were no respiratory or gastrointestinal symptoms in the patient. An ultrasound was performed and a cyst was detected on the right side of the neck, ~2.2 × 1.8 × 2.1 cm in size and with a wall thickness of 0.2 cm, clear boundaries, a regular shape, a translucent mass, and an unclear relationship with the esophagus. Color Doppler flow imaging (CDFI) showed no obvious blood flow signal on the edge and wall of the capsule . ComputeThe patient at the age of 3 days underwent surgical treatment for the cyst after her parent provided consent to the treatment procedures. The intraoperative findings showed that the mass was located close to the esophagus, trachea, and cervical spine. The wall of the capsule was thick, and the capsule fluid was light yellow and clear. Postoperative pathological examinations showed that the cystic wall consisted of smooth muscle and was lined with colonic mucosal tissue, and pancreatic components (acinar cells and ducts) were found in the focal area, and congenital colonic and pancreatic heterotopia were diagnosed and confirmed . NotablyThis case study illustrates an extremely rare case of a congenital heterotopic colon and pancreas tissue, with the neck as an uncommon site of the lesion in a 2-day-old female infant. The ultrasound findings in the patient indicated that the thickened wall of the cyst was an important ultrasonic feature of the congenital heterotopic colon and pancreas. Congenital heterotopic colon and pancreas is usually asymptomatic, which poses challenges for an early diagnosis and has even led to missed diagnoses in a proportion of patients. Therefore, the imaging characteristics may help to make an initial diagnosis. Furthermore, needle biopsy and histopathological examinations are required for a final diagnosis and confirmation. To the best of our knowledge, there has been no previous literature describing the ultrasound findings of a similar case, and as such this represents the first case report on this condition.In this case, both the antenatal and postnatal ultrasound examinations revealed a cyst on the right side of the neck, and CT demonstrated that the cyst was close to the cervical vertebrae. An initial diagnosis of a fissure cyst was made based on the imaging results. The presence of the cyst caused oppression of ambient tissue, which was the primary reason that surgical resection was performed in the patient. To our surprise, the lesion was finally diagnosed and confirmed to be a congenital heterotopic colon and pancreas based on histopathological examinations of the resected tissue. Furthermore, it was noted that the acinar cells and ducts were similar to those found in the normal pancreas, suggesting that the cyst was congenital.Ectopic gastrointestinal cysts are characterized by the presence of gastrointestinal smooth muscle, for which hypoechoic echo of the cystic wall is usually identified on the ultrasound image as an important ultrasonic feature of the disease. In this case, due to the lack of pancreatic tissue, it was difficult to identify the presence of an ectopic pancreas on the ultrasound image, and the final diagnosis only relied on pathological findings.Common congenital cysts of the neck usually have the following characteristics: (1) clear boundary and regular shape; (2) translucent mass, dense floating spots, flocculent echo, separated light band or mesh echo, equal echo or slightly hyperechoic light mass when complicated with bleeding or infection; (3) thin wall; and (4) no blood flow signal on the edge of the cyst or on the cystic wall, but the blood flow signal can be displayed when complicated with bleeding or infection. Considering this case in combination with previous reports, the identification of cystic masses in the neck are as follows: (1) branchial fissure cyst: cervical side, mainly at the middle and lower 1/3 junction of the anterior edge of the sternocleidomastoid muscle; (2) thyrohyoid cyst: in the anterior middle of the neck, mostly between the hyoid bone and the thyroid gland; (3) lymphangioma: multiple compartmentalized cystic structure; or (4) congenital heterotopic colon and pancreas: thick cystic wall, characteristically similar to a gastrointestinal myometrial echo . The finIn conclusion, a congenital heterotopic colon and pancreas can aberrantly present within a cyst on the neck as an extremely rare location. Ultrasonic characteristics have been identified in this condition, which may help to distinguish other cervical cysts. When a congenital heterotopic colon and pancreas is suspected, CT and/or magnetic resonance imaging (MRI) scans should be performed for further assessment. A needle biopsy is necessary to make a definitive diagnosis, and surgical treatment is recommended to prevent potential complications.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethical Committee, Guangdong Women and Children Hospital. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.ZP and CH: drafting of the manuscript. DC and YW: critical revisions of the manuscript for important intellectual content. XK: clinical data collection, analysis, and interpretation. All authors contributed to the article and approved the submitted version.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.


We describe a case of lung lobectomy and resection of the rib neck and head in a lung cancer patient with an invasion of the chest wall. The tumor was located in the upper lobe, adjacent to the neck of the third rib. We performed a right upper lobectomy and en bloc resection of the third rib, including the rib neck and head, by video-assisted thoracoscopic surgery with an additional 6 cm posterior incision along the right paravertebral line. The costovertebral joint incision procedure is a useful technique to ensure tumor-free margins in cases where the tumor is located close to the rib’s neck and head. Video-assisted thoracoscopic surgery (VATS) is the gold standard treatment for early-stage non-small cell lung cancer (NSCLC). In addition to being economical, VATS results in a shorter hospital stay and good quality of life post-surgery. It has recently been used in advanced cancer cases with larger lesions and invasion of the chest wall. However, the utility of VATS in advanced cases remains unknown.Here, we describe a case of advanced lung cancer with suspected invasion of the rib neck and head wherein lobectomy and en bloc resection of the chest wall was performed by VATS.A 67-year-old woman was referred to our hospital because of cough and sputum production. A chest computed tomography (CT) scan showed a 26 × 20 mm mass in the posterior segment of the right upper lobe adjacent to the third rib’s neck and head . No mediFive-port VATS, which is our standard treatment, was chosen at the beginning of the operation. The five ports were ~1 cm in length. Resection of the chest wall was required to achieve adequate margins before the right upper lobectomy because the tumor had invaded the parietal pleura adjacent to the third rib. An additional 6 cm posterior incision along the right paravertebral line was performed to resect the third rib . The traThere were no adverse events after the operation, and the patient was discharged on postoperative Day 7. The final pathological report revealed a 23 × 20 mm mass infiltrating the resected chest wall’s soft tissue close to the resected rib neck, and the surgical margin was negative. There was no evidence of recurrence on the 12-month follow-up CT scan .VATS lobectomy is the gold standard treatment for NSCLC. However, resection using VATS is often selected for advanced lung cancer due to fewer overall complications, reduced mortality rates, improved quality of life and shorter hospital stays, making it more economical , 2. GoodIn lung cancer cases with chest wall invasion, it is necessary to secure an adequate surgical margin. In patients where the tumor is close to the rib neck and head, incision of the costotransverse ligament and radiate costovertebral ligament of the costovertebral joint is very effective and can be performed without complicated devices or techniques , 7.A limitation of our case is that we adopted the multiport VATS procedure. The advantage of multiple assisted ports is that it provides accurate guidance because of multiple viewpoints and appropriate lung retraction. However, reduced port surgery is minimally invasive and may be an option for thoracoscopic surgery in cases requiring rib neck and head resection if an effective retraction procedure is developed.In conclusion, VATS lobectomy plus resection of the chest wall with the costovertebral joint incision is a very effective procedure in cases where the tumor is close to the rib’s neck and head.None declared.None.VATSCWR_rjab190Click here for additional data file.