Sigmoid volvulus (SV) is an exceptionally rare but potentially life-threatening condition in children.Abdominal distention for 1 week.Sigmoid volvulus.We present a case of a 12-year-old boy with mechanical ileus who was finally confirmed to have SV with the combination of abdominal plain film, sonography, and computed tomography (CT) with the finding of mesenteric artery rotation.Because bowel obstruction was suspected, abdominal plain film, sonography, and CT were performed. The abdominal CT demonstrated whirlpool sign with torsion of the sigmoid vessels. In addition, lower gastrointestinal filling study showed that the contrast medium could only reach the upper descending colon. Therefore, he received laparotomy with mesosigmoidoplasty for detorsion of the sigmoid.The postoperative recovery was smooth under empirical antibiotic treatment with cefazolin. A follow-up lower gastrointestinal series on the seventh day of admission showed no obstruction compared with the previous series. He was finally discharged in a stable condition 8 days after admission.SV is a congenital anomaly and an uncommon diagnosis in children. Nevertheless, case series and case reports of SV are becoming more prevalent in the literature. Failure to recognize SV may result in life-threatening complications such as sigmoid gangrene/perforation, peritonitis, sepsis, and death. Thus, if the children have persistent and recurrent abdominal distention, abdominal pain, and vomiting, physicians should consider SV as a “do not miss diagnosis” in the differential diagnosis. It is more common among Eastern countries and accounts for about 20% to 50% cases of colonic obstructions. However, SV is responsible for about 2% to 5% of colonic obstruction cases in the Western world. In the United States, the annual incidence of SV has been reported to be 1.67 in 100,000 persons. While SV is common in the elderly, it is rare in children and can resolve spontaneously. Because of this, the diagnosis is usually missed or delayed. In Salas et al, there are 63 cases of SV in children in a case series from 1941 to 2000. Besides, Smith et al reported 48 cases of SV in children in a comprehensive review of literature in 1990. The majority of patients with SV present with the insidious onset of slowly progressive nausea, abdominal pain and distention, and vomiting after the onset of pain for several days. It is often relieved by the passage of stool or flatus, and therefore constipation is a common misdiagnosis. Due to its insidious presentation, most patients present 3 to 4 days after the onset of symptoms. If SV is untreated, it may progress to ischemic colon, hemorrhagic infarction, and even death; as these consequences are potentially life-threatening, physicians should consider SV in the differential for patients presenting with acute or recurrent abdominal pain and bowel obstruction. Herein, we present the case of a 12-year-old boy with persistent abdominal distension for 1 week diagnosed of SV.The prevalence of sigmoid volvulus (SV) varies widely in the world, with some places called “volvulus belts” where high-fiber diets are the norm.2This case report was approved by the Institutional Review Board of Cathay General Hospital, Taipei, Taiwan. Informed consent was obtained from the patients and parents.2.1Written informed consent was obtained from the patient and parents for publication of this case report and any accompanying images.2.23 cells/mm3 [normal reference (NR): 4–10 × 103/μL] with elevated segments (86.4%) [NR: 40–75%], normocytic anemia   and a C-reactive protein (CRP) level of 0.284 mg/dL [NR: 0.01–0.5 mg/dL]. Abdominal plain film revealed severe colonic distention with gas over his abdomen suggesting ileus  was actually not in our consideration. According to our patient's history, he did not fail to pass the meconium within 48 hours of delivery which is typical HD symptom. There were no vomiting green or brown substance, bloody diarrhea, swollen belly, excessive intestinal gas, and explosive stools after a doctor inserts a finger into the rectum before his age of 10. Therefore, HD could be excluded Fig. .However, there was no clinical improvement even under parental metoclopramide and Bisacodyl spp. Abdominal ultrasound showed ascites and meteorism Fig. . The ima3 reported 63 cases of SV in children (median age: 7 years old) and males outnumbered females by a ratio of 3.5:1 from 1941 to 2000. Mellor and Drake in 1994 reported only 14 cases of colonic volvulus in children, with 10 cases of SV. SV occurs when a redundant sigmoid loop rotates around its narrow and elongated mesentery leading to venous and arterial obstruction of the affected segment followed by rapid distention of the closed loop. If untreated, it can result in hemorrhagic infarction, perforation, septic shock, and death. Obstruction of the intestinal lumen and impairment of vascular perfusion occurs when the degree of torsion exceeds 180° and 360°, respectively. This is consistent with our patient, where his SV was twisted at about 270° so that the barium enema could not pass from his rectum to his descending colon.Volvulus can develop in any portion of the large bowel; however, it is most common in the sigmoid colon because of the mesenteric anatomy. In the pediatric surgical practice, SV remains a rare incidence. Only few isolated case reports and case series have been reported. Salas et al In addition, typical imaging features have been reported to be absent in one-fourth of CT scans, as with our patient. A gas pattern is often not helpful diagnostically, and the single U-shaped sigmoid loop characteristic of SV is absent in adults. Other supportive features of SV include the absence of rectal gas, apparent separation of the sigmoid walls by adjacent mesenteric fat due to incomplete twisting or folding , and 2 crossing sigmoid transition points projecting from a single location. In addition, when a dilated, twisted sigmoid colon is seen in association with a proximal obstruction, the findings are diagnostic; the diagnosis of SV cannot be made from plain films unless this configuration is seen.The diagnosis of SV is made from a detailed history, physical examination, and careful interpretation of plain abdominal films. The diagnostic findings of SV include a whirlpool pattern caused by the dilated sigmoid colon around its mesocolon and vessels, and a bird-beak appearance of the afferent and efferent colonic segments. However, abdominal X-rays in children are often nonspecific and are less useful in distinguishing volvulus from other disorders. All nonoperative modalities for decompression carry the risk of perforation. However, the management of SV is controversial. Some experts recommend that endoscopy be reserved for patients who are not candidates for definitive surgical therapy, while others recommend surgery be reserved for patients in whom sigmoidoscopic reduction is unsuccessful, since approximately 40% to 50% of patients with SV will not experience recurrence.In patients with no evidence of peritonitis or ischemic bowel, treatment should start with resuscitation and detorsion of the SV, which can be accomplished by sigmoidoscopy and concomitant rectal tube placement. A barium enema, which is a treatment option for SV, can also be of diagnostic value. As in adults, a barium enema increases radiographic diagnostic sensitivity in pediatric patients (71–82%).,11 whereas recurrent SV after sigmoidectomy has never been reported, In conclusion, SV is a congenital anomaly and an uncommon diagnosis in children. Nevertheless, case series and case reports of SV are becoming more prevalent in the literature. Failure to recognize SV may result in life-threatening complications such as sigmoid gangrene/perforation, peritonitis, sepsis, and death. Thus, if the children have persistent and recurrent abdominal distention, abdominal pain, and vomiting, physicians should consider SV as a “do not miss diagnosis” in the differential diagnosis.The goal of SV treatment is to reduce the SV and prevent recurrent episodes. In our case, on account of our patient's symptoms presenting not so urgent and no severe abdominal pain initially, we did not take prompt notice to the surgeon until 48 hours of admission with the abdominal plain film suggesting ileus. Medical treatment with intravenous metoclopramide and fluid infusion were instead preferred. However, we perform immediate laparotomy when endoscopic detorsion is unsuccessful or in patients with signs and symptoms suggestive of peritonitis at our hospital. The definitive treatment for SV is sigmoidectomy, either with primary anastomosis or colostomy. Recurrence is common when detorsion is attempted without resection ,


Wernicke encephalopathy is a neurological complication of thiamine deficiency, usually in the setting of poor diet, classically with alcoholism. Patients present with acute onset of encephalopathy, oculomotor dysfunction, gait ataxia and memory impairment. If untreated, the disorder can result in severe morbidity and possibly death; patient outcomes are entirely dependent on prompt diagnosis and administration of parenteral thiamine. Although diagnosed clinically, the radiologist may be able to alert the referring clinician to the possibility of the disease when imaging features are observed, thereby improving the chance of treatment success. Although various imaging features have been ascribed to alcohol and non-alcohol related forms of Wernicke encephalopathy, recent literature suggests that such a distinction is not reliable, and that the causes of Wernicke encephalopathy are not readily distinguishable on MRI, as in the index case presented here. Wernicke encephalopathy is a neurological complication of thiamine deficiency. It is usually caused by a poor diet accompanied by alcoholism -3. AcuteA 45-year-old female presented after four days of nausea, vomiting, dizziness and falls. She had a history of alcohol abuse and admitted to currently drinking 1-2 bottles of wine daily. She was a poor historian, displaying impaired memory/cognition, stating that she was on vacation but unable to provide details regarding when she arrived or how she would return home.On a general physical exam, she appeared disheveled, slightly pale and malodorous. She spoke with a slight delay and stuttered periodically. She had multiple bruises over her body in various stages of healing. Her neurological exam was significant for ataxia and dysmetria with intention tremor, positive Rhomberg’s test, and positive heel-to-shin test.A CT of her brain revealed cerebellar vermian atrophy but was otherwise unremarkable Figure .MRI of her brain demonstrated cerebellar volume loss, increased FLAIR signal in the cerebellar vermis, normal corpus callosum and normal mammillary bodies Figures -7.The patient’s symptoms dramatically improved following administration of IV thiamine 500 mg.Wernicke encephalopathy (WE) is a part of Wernicke-Korsakoff syndrome, the neurological complication of thiamine deficiency due to malnutrition from chronic alcoholism, malabsorption, AIDS, anorexia nervosa, and hyperemesis gravidarum among other causes -3. WE isThiamine is an essential B vitamin, with its active form functioning as a co-factor for pyruvate dehydrogenase and alpha-ketoglutarate dehydrogenase . DeficieAlthough not required for a diagnosis of acute WE, “typical” MRI findings include hyperintense FLAIR/T2 signal in the thalami, mammillary bodies, tectal plate, periphery of the third ventricle, and periaqueductal area ,6. ApproA diagnosis of WE is made based on the clinical presentation. A delayed or missed diagnosis occurs more frequently in non-alcoholic patients, especially if the classic triad is absent ,8. To avTreatment for WE rests entirely on prompt thiamine supplementation. As IV thiamine is safe, inexpensive, and effective, empiric treatment prior to acquiring labs is highly recommended . The preWernicke encephalopathy is a serious medical condition resulting from thiamine deficiency. Consequences of delayed treatment are dire, making prompt diagnosis and management critical. Although the diagnosis is clinical, laboratory and MRI findings may help support a diagnosis and can establish response to therapy. Prompt parenteral thiamine supplementation is recommended in patients who meet the Caine criteria, prior to administering glucose.


The choice of the sex of rearing in patients with ovotesticular differences of sex development (OT-DSD) is difficult. The final decision should be given by the patient himself or herself, but families’ opinion is not to neglect especially when the diagnosis is precocious and the patient can’t give the consent to medical or surgical procedures. How should we behave if the parents refuse to raise a child with genital ambiguity?We describe and comment on our multidisciplinary approach in three patients with neonatal diagnosis of OT-DSD. The families expressed a strong desire for that which concerned the sex of rearing of their babies in contrast to the International trend of “wait and see”. A specific counselling and a constant psychological support were given.Recent trends suggest of postponing surgery to involve the patient in the decision. Child’s well-being is the goal of therapy. When medical and psychological support is not able to force parents to accept a child suffering from genital ambiguity, we think that it is better to opt for reversible medical/surgical treatments rather than allowing patients to grow up within a family that does not accept them. Matsui reports that the most common gonadal combination is ovotestis and ovary (33.9%), followed by ovary and testis (24.2%), bilateral ovotestis (20.6%) and ovotestis and testis (16.4%). The gonadal combination of ovotestis and streak gonad occurs in only 1.2% of the cases  pre-hCG was 0.68 ng/ml, post-hCG 1.23 ng/ml. Serum Anti-Müllerian Hormone (AMH), inibin B and dihydrotestosterone (DHT) level were normal. Uterus and vagina were identified on ultrasound scan and Magnetic Resonance Imaging (MRI) see Fig. , this waCase 3 had the same external genital appearance of case 2  for Sex determining Region Y (SRY) was negative and cytogenetic investigations excluded a mosaicism. Ultrasound scan revealed the presence of the uterus with a cystic female-like gonad on the right side and a male-like gonad on the left inguinal position. Serum testosterone pre-hCG was 0.62 ng/mL, post-hCG 1.91 ng/mL. Serum AMH and Inibin B level were detectable. The family didn’t accept a baby with an indeterminate sex. A multidisciplinary discussion, which considered the views of the family, suggested a female sex of rearing. After surgery, at the age of twelve months, a right ovary and a left ovotestis were histologically confirmed: the testicular part was separated and removed from the ovary.Most children with OT-DSD present ambiguous genitalia as newborns or infants. Rarely, OT-DSD has been detected later in individuals with female or male normal phenotype.The ovarian tissue is usually normal and demonstrates follicular growth. The testicular tissue is often dysgenetic with hyalinization of the seminiferous tubules and poor germ cell development almost always resulting in infertility in patients assigned to the male gender .Annual ultrasound surveillance is recommended for gonadal cancer risk. If precancerous lesions are suspected, more invasive procedures  are mandatory.Surgery is necessary after gender assignment and includes removal of gonads and internal ducts inappropriate to the sex of rearing and genitoplasty to construct the appropriate external appearance . In our Gender assignment is difficult to decide for OT-DSD patients. Families often ask for an early surgical solution to ensure child well-being within the family, the school and the society. What should the surgeon do in this case? Which kind of surgical consent form, should the families sign? We think that a multidisciplinary approach can define the best opportunity. All the treatments require excellent medical, surgical and psychological expertise. The fertility potential must be respected and a satisfactory result must be obtained. As far as our case series is concerned, in case 1 we removed the female gonad because of its macroscopic aspect of streak gonad with a potential tendency to degeneration. Although the fertility potential in a male OT-DSD is doubtful , the futIn cases 2 and 3 we maintained the ovarian part of the ovotestis for preserving a potential fertility even if in case 3 the uterus was not found. The families of the last two cases were strongly oriented to a female sex of rearing.Sexual assignment in OT-DSD is a challenge: to date only few studies about gender dysphoria in this group of patients and no specific well coded guidelines exist. For appropriate management of these patients we refer to the general principles of the Consensus Conference of Chicago .We consider the important role of the psychologist within the multidisciplinary team, both for the role of family support, both to guide the choice on the sex of rearing.Conservative treatment is the goal in the treatment of DSD, especially when the gender assignment is required during neonatal period.Surgery must be as conservative as possible, granting the future possibility of a sex reverse genitoplasty and maintaining Müllerian structures in situ in a male patient.Waiting for the pre-pubertal age is the best choice when an expert psychologist and a multidisciplinary team can support the family. In our opinion, when the parents refuse any explanation and support, child’s well-being is the most important right and the principal goal of the multidisciplinary DSD team. We think it is better a conservative surgery instead of leave the child growing in a non-acceptance’s atmosphere.The family doesn’t accept a constant psychological supportCultural or social issue are too deepThe family does not accept genital ambiguity: e.g. parents with psychological diseases, very low socioeconomic status.In such cases, we prefer a precocious surgery, considering dangerous “wait and see” in the following cases:To collect new cases of OT-DSD and participate to multicenter studiesTo create a surgical consent form with a part reserved to the psychological interview.Our future aims are:


Small bowel obstruction resulting from the mesodiverticular band is a rare complication of Meckel’s diverticulum and usually presents a diagnostic challenge. We present a case of small bowel obstruction due to the mesodiverticular band of Meckel’s diverticulum with CT scan findings. His past medical history was unremarkable. On physical examination, the abdomen was distended. Laboratory tests performed showed elevated levels of white blood cell count  was obtained from the patient(s) for publication of this case report.


A 39-year-old male with no past history presented with three months of left inguinal pain and a left groin lump that became progressively larger and more painful. He was seen at another hospital over one month prior where they were unable to manually reduce the lump. He could not recall the computed tomography (CT) findings, and no surgery was performed. Since then, he has experienced persistent left inguinal pain and nausea. He denied fever, vomiting, dysuria, hematuria, penile discharge, testicular pain, or history of sexually transmitted diseases.Physical exam revealed a firm, tender, and non-reducible mass in the left inguinal canal and along the spermatic cord. Remainder of examination was normal. Complete blood count, basic metabolic panel, lactate, urinalysis and urine culture were normal. CT of the abdomen and pelvis was suggestive of pampiniform plexus thrombosis . Formal Pampiniform plexus thrombosis is a rare cause of inguinal pain, which is often misdiagnosed as hernia or orchitis. Accurate diagnosis can prevent unnecessary treatment including surgical intervention. There are limited references in the literature to this condition, and there are no evidence-based approaches to management. The majority of reported cases involved the left venous plexus, and most were diagnosed intra-operatively for pre-operative diagnoses of incarcerated inguinal hernia or orchitis.3What do we already know about this clinical entity?Pampinifom plexus thrombosis is a rare cause of inguinal pain. There is little consensus about the appropriate treatment at this time.What is the major impact of the image(s)?This disease process is often mistaken for incarcerated inguinal hernia. Multiple cases were not accurately diagnosed until the patient was on the operating table.How might this improve emergency medicine practice?This case reminds physicians of rare clinical entities and may help avoid unnecessary surgery.


Wuchereria bancrofti, Brugia malayi, or Brugia timori. Extralymphatic filariasis presenting as a primary retroperitoneal mass is very rare despite filariasis being endemic in many regions of India. On review of literature, only a few isolated case reports have been described.Filarial infections are common in most tropical and subtropical regions of the world. Lymphatic filariasis is caused by either We report a case of a huge retroperitoneal cystic mass in a 46-year-old patient who presented with a long-standing, painless progressive abdominal swelling. On examination, there was a large, non-tender, firm swelling of size around 20 × 15 cm occupying the left upper and lower quadrant. The computed tomography of the abdomen was suggestive of thin-walled hypodense cyst of size 25.7 × 15 × 14.3 cm. Laboratory investigations and cyst aspirate were inconclusive for a definite diagnosis. On exploration, a 3-kg cystic mass was removed. The diagnosis of filarial origin was confirmed by the demonstration of microfilaria in the cyst wall and immunochromatographic test (ICT) which was positive.Retroperitoneal lymphatic cyst of filarial origin is very unusual and requires a high index of suspicion if the patient is an inhabitant of an endemic area. The clinical dilemma cannot be resolved with imaging modalities alone, unless a disease-specific manifestation is there. The retroperitoneal cysts often pose a challenge in their diagnosis and management. Small cysts might respond to medical management, whereas large symptomatic cysts will require excision for the final diagnosis and treatment. Retroperitoneal cysts are uncommon masses whereas primary filarial retroperitoneal cysts are rare . The repA 46-year-old male patient, a native of district Gorakhpur, Uttar Pradesh state, India, in October 2017 presented to us with complaints of a painless progressive swelling in the left side of the abdomen with abdominal distension for the last 8 years. The swelling was not associated with any symptom therefore the patient did not seek any medical attention for the same; however, for the last 2 years, the swelling has increased considerably as per the patient and causes dragging discomfort. It was not associated with any bladder or bowel complaints or any other systemic symptoms like fever, weight loss, or loss of appetite. Apart from dragging discomfort, there was no history of anorexia, paroxysmal hypertension, tachycardia, headache, perspiration, or palpitations. The socioeconomic status was lower middle (class III) as per modified Kuppuswamy scale [3 with 60% lymphocytes and 40% neutrophils whereas glucose was 45 mg/dl, protein 4.5 g/L, and amylase 24 U/L. The culture of cyst fluid was sterile and malignant cytology was negative.Blood and laboratory investigations were within normal limits. Abdominal contrast-enhanced computed tomography was suggestive of a thin-walled hypodense cystic mass of size 25.7 × 15 × 14.3 cm in the left side of the abdomen extending from the lesser sac till the left iliac fossa. The lesion was compressing the body and tail of the pancreas. It was also displacing the head of the pancreas, stomach, first and second parts of the duodenum, small bowel loops, abdominal aorta, and superior mesenteric vessels to the right side. It was compressing the left ureter causing mild hydro-ureteronephrosis. The head of the pancreas was mildly bulky but there was no focal lesion and no evidence of free fluid or lymph nodes in the abdomen suggesting a possible diagnosis of cystic pancreatic lymphangioma (Fig. The patient posed to us a diagnostic dilemma and we were unable to reach a definite diagnosis even after extensive investigations. The patient was planned for exploration with a probable diagnosis of pancreatic pseudocyst or lymphangioma. The patient was operated on February 2018, on exploration, and there was a cystic mass of size 25 × 15 × 15 cm Fig. , which wWucheria bancrofti was positive. Ultrasound of the scrotum, groin, and lower extremity was reviewed again for possible adult worm and, however, was negative. The patient was doing fine up to 8 months of follow-up.Histopathology of the cyst revealed a unilocular cyst with walls composed of fibro-collagenous tissue lined by flattened epithelium and focal areas of calcification along with a few fragments of microfilaria Fig. . The fea.[Filariasis is a parasitic zoonotic endemic infection seen in the tropical and subtropical regions of the world. Approximately 120 million people are infected all over the globe whereas about 856 million people in 52 countries worldwide remain threatened by lymphatic filariasis and require preventive chemotherapy to stop the spread of this parasitic infection.. As per Wuchereria bancrofti and the remainder by Brugia spp. whereas in India, 99.4% of the cases are caused by the Wuchereria bancrofti and other species Brugia malayi responsible for 0.6%. It commonly presents with lymphatic dysfunction in the form of lymphocele, hydrocele, chyluria, or groin lymphadenovarix along with severe disability and social stigma. The clinical manifestations of extralymphatic disease caused by filariasis are multiple and range from symptoms due to tropical pulmonary eosinophilia to skin rashes, hematuria, proteinuria, granulomata, subcutaneous nodules, splenomegaly, and rarely arthritis.Worldwide, 90% of infections are caused by Cystic retroperitoneal mass may be due to many causes including benign lesions such as lymphocele, urinoma, mesothelial cyst, lymphangioma, traumatic cyst, and parasitic cyst, as well as malignant lesions such as mucinous cystadenocarcinoma, pseudomyxoma retroperitonei, parachordoma, and cystic teratoma . In thisCT is the investigation of choice as it may provide important information regarding lesion location, size, and shape; the presence and thickness of a wall; the presence of septa, calcifications, or fat; and involvement of adjacent structures .Despite extensive imaging evaluation, the diagnosis very often can only be obtained on some form of histopathology such as aspiration of fluid and cytology or excision and biopsy. Often, primary retroperitoneal parasitic cysts are hydatid cysts . PrimaryThe exact pathogenesis of the extralymphatic manifestation remains speculative. The dilatation of retroperitoneal lymphatic channels due to obstruction and their rupture and the presence of ectopic lymphatic tissue have been proposed as the possible etiologies .The peculiar presentation of this patient of a long-standing retroperitoneal cyst, without other common manifestations of filariasis like hydrocele and lymphedema, was adding diagnostic dilemma. It was decided to perform surgery as the patient had large retroperitoneal cyst with diagnostic uncertainty even after contrast-enhanced computed tomography and cyst fluid analysis. The final diagnosis was reached, based on a microscopic demonstration of fragments of microfilariae in the cyst wall and positive filarial antigen ICT test. Small retroperitoneal lesions may resolve with antifilarial therapy, but most cases including our case require surgical removal because of their large size , 14, 15.Retroperitoneal lymphatic cyst of filarial origin is very unusual and requires a high index of suspicion if the patient is an inhabitant of an endemic area. The clinical dilemma cannot be resolved with imaging modalities alone, unless a disease-specific manifestation is there. The retroperitoneal cysts often pose a challenge in their diagnosis and management. Small cysts might respond to medical management, whereas large symptomatic cysts will require excision for the final diagnosis and treatment.


Liposarcoma is the most common histologic subtype of soft tissue sarcoma in the retroperitoneum. The distinction of primary cord liposarcomas, which arise in and are confined to the inguinal canal, from inguinoscrotal extension of a retroperitoneal tumor is mandatory. Both can be found incidentally in inguinal hernia sac specimens. Preoperative diagnosis is essential for adequate surgery with clear margins. We present a clinicopathological correlation of two men with slowly growing right para-testicular masses diagnosed as inguinal hernias. Pathological examination revealed well-differentiated lipoma-like liposarcoma and well-differentiated liposarcoma mixed type (lipoma-like and sclerosing types), respectively. The first tumor was considered a primary cord liposarcoma with no recurrence on follow-up. The second tumor showed an unusual growth pattern of discontinuous nodules that gave the false impression of complete resection. This growth pattern may explain why inguinal liposarcomas have a high recurrence rate despite apparently negative surgical margins. A follow-up CT scan exposed a fatty tumor in the retroperitoneum of the second patient. Careful interpretation of imaging studies in patients with fatty inguinal masses is mandatory to rule out a retroperitoneal or intraperitoneal component. Although the two cases herein discussed represent less than 0.1% of the total inguinal hernia sacs examined over the past five years in our pathology department, we recommend routine examination of all “mass-containing” hernia sacs as missing the diagnosis of liposarcoma can lead to substantial morbidity and mortality. Liposarcomas are malignant soft tissue neoplasms that can show adipocytic differentiation and represent up to 50 percent of the estimated 15,000 soft tissue sarcomas diagnosed each year in the United States. Most occur in middle-aged to elderly adults with similar incidence in both genders . The higA 78-year-old man presented with a slowly growing, painless, immobile right hemiscrotal mass over a nine-month period. An ultrasound study revealed a large right inguinal hernia containing herniated intra-abdominal fat Figures . On surgA 49-year-old man presented with a painless, nontender, nonreducible, firm, immobile, slowly enlarging right hemiscrotal mass over a one-year period. CT imaging revealed a right inguinal hernia with intraperitoneal fat extending inferiorly into the scrotal sac Figures . SubsequLiposarcomas in the inguinal canal are rare. They are usually discovered incidentally during inguinal hernia repair surgery. The incidence of inguinoscrotal extension of retroperitoneal liposarcomas was 3.6% in a series of 168 patients . There aCord liposarcomas often present as a slowly enlarging, recurrent inguinal hernia with a predilection for the right side , 8. LipoImaging of mass-containing inguinal hernias is critical for planning the surgical approach. Identification of well-differentiated liposarcomas can be a challenge because they are usually poorly demarcated from surrounding normal fat, homogenous, and low density. In contrast, high-grade liposarcomas present as solid, heterogeneous, high-density masses –7. They Surgical management involves radical high orchiectomy with margins as close to the inguinal canal as possible. As with primary testicular malignancies, the ideal approach is via an inguinal incision as opposed to a trans-scrotal approach. Retroperitoneal lymph node resection is not recommended. There is still debate about the effectiveness of radiotherapy in the management of liposarcomas. Radio/chemotherapy has often been added as an adjuvant therapy to high-grade liposarcomas, but there is no benefit in overall mortality or recurrence rates , 2. As t en bloc resection with radical orchiectomy and close follow-up with imaging. Lymph node dissection and radio/chemotherapy have not been shown to improve mortality.In summary, tumors in the inguinal canal should be managed with caution. Liposarcomas involving the inguinal canal are rare but should be considered in the differential diagnosis. Further imaging workup is mandatory to rule out a retroperitoneal or intraperitoneal component. A preoperative distinction between cord liposarcomas and retroperitoneal liposarcomas with inguinoscrotal extension is relevant for adequate surgical resection and accurate determination of the margin status. The current treatment of choice is


Appendiceal inversion with neoplasia in adults is an extremely rare event with a reported incidence of < 0.01%. Preoperative diagnosis is very important for surgical treatment; however, it is very difficult to be exact.The patient was a 60-year-old woman with complaints of intermittent abdominal pain. Computed tomography and colonoscopy revealed a cecal mass, which was diagnosed as a tubulovillous adenoma in the preoperative colonoscopic biopsy. At surgery, the appendix was found to be completely inverted into the cecum. The cecum was partially resected, and surgical pathology examination confirmed a tubulovillous adenoma of the appendix with local high-grade intraepithelial neoplasia.Although preoperative diagnosis of appendiceal inversion with neoplasia may be often difficult due to its non-specific symptoms, clinicians should consider this disease entity when they encounter an intraluminal protruding cecal mass without visualization of the normal appendix on CT and colonoscopy. Appendiceal inversion in adults is a rare event, with a reported incidence of approximately 0.01% , 3. Neop9/L and a hemoglobin level of 10.6 g/dL (106 g/L); her stool was negative for occult blood. Abdominal CT revealed a long, annular mass in the proximal ileocecal portion of the ascending colon. The mass was hollow in the center, and there were no enlarged peripheral lymph nodes (Fig. A 60-year-old woman was referred to the authors’ hospital with a 30-year history of intermittent abdominal pain, sometimes with nausea and vomiting, and occasionally with fainting. The symptoms usually subsided after a few minutes. The patient had no relevant surgical history. On physical examination, she was afebrile, and the abdomen, including McBurney’s point, was non-tender. Laboratory investigations revealed a white blood cell count of 4.41 × 10On laparoscopy, the appendix was not visible at the end of the cecum; rather, the appendix and its mesentery were completely inverted into the cecum and could not be flipped out Fig. a. No regDuring the operation, after fully dissecting the mesenteries of the distal ileum and ascending colon, the cecum was lifted out and incised under direct vision. A mucosa-extroverted appendix was found completely inverted into the cecal cavity Fig. b. The apOn gross pathology, the appendix measured approximately 11 cm in length and 1.5 cm in external diameter. The extroverted mucosa was diffusely thickened and granular in appearance Fig. a. HistopAppendiceal inversion is a very rare condition, with an incidence of < 0.01% among surgical patients. It was first described by Mc Kidd in 1858 and, since then, there have been only a few cases reported in the literature . NeoplasEarly and correct diagnosis of appendiceal inversion is important but difficult. First, patients usually experience no obvious symptoms. As in our case, the patient only experienced intermittent abdominal pain, accompanied by occasional nausea and vomiting. Second, there are no typical signs on ancillary examinations, and clinicians are likely to overlook it because of its rare incidence. In this case, CT revealed an occupying lesion in the cecum that mimicked an intracavitary tumor. Colonoscopy revealed a long polypoid mass, which was diagnosed on local biopsy as a tubulovillous adenoma.McSwain categorized 5 types of appendiceal intussusceptions as follows: type I, the tip of the appendix is invaginated into the proximal appendix, which forms the intussusception; type II, the invagination starts at some point along the length of the appendix, and the intussusception is the appendiceal body; type III, the invagination starts at the junction of the appendix and cecum, and the intussusception is the cecum; type IV, the proximal appendix is invaginated into the distal appendix, which is the retrograde intussusception; and type V, the appendix is completely invaginated into the cecum. According McSwain’s classification of appendiceal intussusception, complete inversion of the appendix in the present case was type V , 7, 8.Surgery is the primary mode of diagnosis and treatment for this type of disease. However, due to the lack of clear guidelines, the choice of surgical approach to appendiceal inversion remains controversial. Recommended surgical methods include appendectomy, partial cecal resection, ileocecal resection, and right hemicolectomy with peripheral lymph node dissection. The choice of surgical method depends mainly on the classification and estimation of the degree of malignancy of this disease by clinicians. Appendectomy, partial cecal resection, and ileocecal resection are usually considered in cases with low malignant potential. Right hemicolectomy or ileocecal resection with peripheral lymph node dissection should be performed when carcinoma is diagnosed preoperatively or during surgery. In the present case, only laparoscopic colectomy without lymph node dissection was performed based on the colonoscopic findings and nodal status, which is recommended in McSwain’s classification system . The posIn conclusion, appendiceal inversion is a very rare condition, especially when accompanied by premalignant lesion or carcinogenesis. Because of its non-specific clinical manifestations, most cases are misdiagnosed as appendicitis or cecal mass, which can lead to delayed or inappropriate treatment. Therefore, clinicians should devote a high degree of attention when they encounter an intraluminal protruding cecal mass without visualization of the normal appendix.


This study aims to report a rare case of a respiratory epithelial adenomatoid hamartoma (REAH) of the lateral nasal wall that had initially presented as a fungating mass, similar to that of a sinonasal malignancy, and its complete removal from the lateral nasal wall.We report the case of a 58-year-old woman who presented to us with a chief complaint of recurrent right-sided epistaxis and nasal blockage for the past 4 months, which was progressively worsening. Histopathological examination confirmed the presence of a REAH instead of a sinonasal malignancy. The tumor was surgically excised from the lateral nasal wall using electrocautery under endoscopic guidance. The patient was then carefully followed-up after surgery, and the wound was successfully healed 3 months after the initial surgery. There was no evidence of recurrence 6 months after the initial surgeryThis case demonstrates the rare presentation of a REAH, which had arisen from the lateral nasal wall. Clinically, it is difficult to distinguish a REAH from a more notorious mass such as a sinonasal malignancy. Therefore, biopsy is mandatory in all cases of lateral nasal mass in order to rule out malignancy before confirming nasal REAH. Fortunately, as seen in this case, a lateral nasal REAH, once diagnosed, can be safely and easily removed from the lateral nasal wall using electrocautery with good surgical outcomes and a low rate of recurrence. A hamartoma is a benign tumor-like malformation consisting of a disorganized mixture of tissue cells or inborn errors in tissue development that result in an aberrant proliferation of normal tissue components . HamartoA 58-year-old woman with a history of diabetes and hypertension presented to us with chief complaints of recurrent right-sided epistaxis and nasal blockage for the past 4 months, which were progressively worsening. She had no history of headaches, facial numbness, hyposmia, epiphora, aural symptoms, neck swelling or any constitutional symptoms. There was no history of allergy, trauma or smoking in the past. On nasoendoscopic examination, the patient was found to have a mass occupying the right nasal cavity, which was arising from the right lateral nasal wall and free from the nasal septum. The mass was friable and painless on touching . A flexiA contrasted computed tomography (CT) scan of the paranasal sinuses revealed a homogenous non-enhancing soft tissue lesion in the right middle meatus measuring 2 × 2 cm, with no extension into the paranasal sinuses, nasopharynx or contralateral nasal cavity . Upon coOn the basis of these findings, the mass was carefully excised from the right lateral nasal wall using a bipolar electrocautery device. Postoperatively, the patient was discharged with penicillin-group antibiotics and was advised to perform regular nasal douching. An intraoperative biopsy of the 2.5 × 1.5 cm mass  showed pThe lesion also exhibited an absence of atypia, necrosis and basement membrane infiltration .In view logical features and benign appearance of the mass endoscopically and radiologically, a diagnosis of REAH was made. The lesion was not confirmed through immunohistochemistry because the characteristic features were obtained through histopathology. The patient was carefully followed-up after surgery and the wound had successfully healed 3 months after the initial surgery. There was no evidence of recurrence 6 months after the initial surgery .REAH is an uncommon presentation of a nasal mass, which occurs more commonly in men in their third-to-ninth decades of life. There have been approximately 60 cases reported in the literature as case reports or case series and, to a lesser extent, on the immunohistochemical and molecular genetic features of REAH . A studyThe identification of a nasal REAH remains a diagnostic conundrum as it is often indistinguishable from more common tumors of the nasal cavity, especially squamous cell carcinoma. The distinguishing feature of a REAH is often found during histopathological analysis of the excised tumor. Its histologic pattern is characterized by the abundance of ciliated columnar-lined glandular tissue in a polypoidal fashion. Stromal tissues often separate the glands and may be edematous, with evidence of acute and chronic inflammation . AlthougFurthermore, Ki-67 panels may serve as a marker of proliferation in REAH, whereby REAH would be expected to have an intermediate labeling index and sinonasal carcinomas are expected to have a high KI-67 labeling index . This inHistologically, REAH closely resembles findings seen in adenocarcinoma. The World Health Organization has classified malignant sinonasal carcinoma into epithelial intestinal and non-intestinal varieties . Approximately 20% of low-grade sinonasal non-intestinal-type adenocarcinomas exhibit varied architectural forms with exophytic papillae and glandular patterns , with loImmunochemistry can also be misleading when distinguishing between a REAH and a sinonasal non-intestinal adenocarcinoma, as the latter are also usually consistently positive for CK7 but negative for CK20 and CDX-2 . Intestinal sinonasal adenocarcinomas, however, tend to show resemblance to mucosa found in normal and neoplastic small intestine and large intestines. These tumors also show variable positivity to CK7, but are usually positive for CK20, CDX-2, villin and MUC2 ,14, whicWhen presenting as a lateral nasal mass, a nasal REAH can be safely excised using simple electrocautery with good outcomes. Hence, in patients with a suspected sinonasal malignancy, histological samples should be thoroughly investigated prior to committing to aggressive sinonasal surgeries with resulting severe aesthetic and functional disabilities.


Intradural arachnoid cysts are common entities that can be congenital, or caused by infectious, inflammatory, or even traumatic processes. However, true "inter"-dural cysts formed between the two lamellae of the lumbar dura without any fistulous arachnoid connection are rare. We present the case of a post-traumatic interdural cyst formation of the lumbar spine that compressed the roots of the cauda equina causing acute unrelenting pain. The cyst walls were formed by the true dural layers, and the cavity was filled with blood degradation products without any arachnoid connection to the subdural space. A commented video that details the diagnostic and surgical aspects of this case, alongside intraoperative footage is provided. Intradural cyst of the spinal cord usually consist of spinal fluid-filled diverticula that can be found incidentally, or result in the compression of the nerve roots of the cauda equina, or of the spinal cord itself. While some can be congenital, other etiologies include inflammatory or infectious processes, or even traumatic events -3. TheseA previously healthy 37-year-old man experienced an acute onset of back pain radiating to bilateral S1 territories after a soccer match while bending over to tie his shoes. His pain worsened over the course of 6 months which prompted a magnetic resonance scan (MRI). The MRI showed a cystic lesion ventral to the thecal sac at L4-5 which was compressing the roots of the cauda equina (Figure He was taken to the operating room, where a midline durotomy revealed a bulging cystic mass compressing the nerve roots Video .The mass appeared to be intradural. It did not originate from the disc space and had no ventral tract or fistulous connection. The wall of the cyst was sharply opened and had the consistency and feel of dura. The cyst was filled with motor-oil fluid that resembled the old blood. The cavity was lined with fibrous material that was sent for pathology with part of the wall Figure .The cyst was completely marsupialized and then cauterized. The patient did well after surgery and was discharged home on post-operative day two neurologically intact. His symptoms were completely resolved.True interdural cysts of the spinal cord are rare entities . InflammThis is the first report of a traumatic lumbar interdural cyst with compression of the cauda equina roots. Treatment of these lesions requires careful dissection of the intradural space. Adequate cyst fenestration is required in order to prevent recurrences.


Synovial sarcoma is a relatively rare type of soft tissue sarcoma. The commonly observed symptom is a deep-seated palpable mass accompanied by pain or tenderness. Thus, it is considered a soft tissue sarcoma and rarely occurs primarily in bone. However, only few studies have been reported on intraosseous synovial sarcoma, and reports on cases with cytogenetic or molecular confirmation are even rarer. We report a case of intraosseous synovial sarcoma of the distal ulna that has been confirmed using histopathological examination and molecular analysis.A 77-year-old female was referred to our hospital with a 1-month history of right wrist pain after housework. Clinical and imaging findings suggested a benign bone tumor that was enhanced by Gd-DTPA. It was thought that the tumor was possibly an enchondroma. Initially, we planned to evaluate the benignancy of the tumor with intraoperative frozen section, followed by curettage and bone graft at one stage However, when considering carefully, characteristics of the tumor did not perfectly match those of any diagnostic categories including enchondroma. Therefore, an incisional biopsy was performed and revealed that the tumor was synovial sarcoma. Following an elaborate plan, the patient underwent a wide resection of the tumor at the distal part of the right ulna. Reverse transcription-polymerase chain reaction (RT-PCR) from the resected specimen and sequencing of RT-PCR products demonstrated a chimeric SYT-SSX1 transcript, confirming the diagnosis of synovial sarcoma.Synovial sarcoma is seldom considered in differential diagnosis of bone tumors because it is difficult to line up such an unusual diagnosis as a differential diagnosis. When the lesion does not perfectly fit into any diagnostic category, when the initial image diagnosis appears unconvincing, biopsy and pathology are indicated, recalling Jaffe’s triangle. According to these diagnostic processes, the patient successfully completed the treatment for this rare intraosseous synovial sarcoma, following a careful plan based on the preoperative diagnosis. Bone and soft tissue tumors do not always show typical clinical presentations or imaging findings. Although many bone tumors can be diagnosed using clinical and imaging findings, clinicians at times encounter a case where these findings do not fit into any diagnostic category. In such cases, it becomes crucial to comprehensively consider clinical, radiological, and pathological findings. Skipping this process and making an uncertain diagnosis increases the risk of unsatisfactory patient outcomes.Synovial sarcoma is a relatively rare type of soft tissue sarcoma. It is prevalent in adolescents and young adults, occurring predominantly in the extremities, especially in the lower extremities. The commonly observed symptom is a deep-seated palpable mass accompanied by pain or tenderness. Radiographic examinations often reveal calcification of the tumor. Histologically, synovial sarcoma is classified as biphasic or monophasic type. It displays a variable degree of epithelial differentiation, including glandular structures, and it is characterized by a specific chromosomal translocation t X; 18)  that leads to the SYT-SSX fusion gene formation [8  of 112 cases, and it correctly suggested a malignancy in 11 (46%) of 27 pathologically-confirmed malignancies . JonathaSynovial sarcoma is seldom considered in differential diagnosis of bone tumors because it is difficult to line up such an unusual diagnosis as a differential diagnosis. There are many cases of bone tumors where the patient’s age, medical history, physical findings, and imaging findings are sufficient for an accurate diagnosis and to omit pathological confirmation; these cases underwent surgical resection or received watchful waiting without biopsy. For example, a simple bone cyst, fibrous dysplasia, or digital bone enchondroma often follow such a course. However, when the lesion does not perfectly fit into any diagnostic category, when the initial image diagnosis appears unconvincing, or when the course of the tumor does not match the initial image diagnosis, biopsy and pathology are indicated, recalling Jaffe’s triangle.In our case, plain radiography demonstrated a comparatively well-outlined osteolytic lesion, and PET-CT showed no abnormal FDG uptake. Although the lesion was heterogeneously enhanced using Gd.-DTPA on T1-WI MRI, the findings did not lead us to suspect a malignant tumor. Radiologists supposed that the lesion was possibly an enchondroma based on the imaging findings. Nevertheless, the physical and imaging findings did not precisely suggest enchondroma and something was out of place in the diagnosis. Actually, the enhancement pattern on MRI did not match that of enchondroma. Therefore, an incisional biopsy was planned and the results led to the diagnosis of the lesion as synovial sarcoma. Thus, the patient successfully completed the treatment for intraosseous synovial sarcoma, following a careful plan based on the preoperative diagnosis. If curettage was performed based on the initial plan, treatment for this patient would be complicated.We encounter rare cases in daily practice where malignant tumors mimic benign tumors. In cases where the lesion seems to be benign at first impression, a differential diagnosis may identify findings that do not perfectly fit the preliminary diagnosis of benign tumors. In such situations comprehensive consideration of clinical, radiological, and pathological findings is critically important. Especially, biopsy and pathological findings are important in the case that clinical and radiological findings do not fit into any diagnostic category. These diagnostic processes are crucial for establishing certain diagnosis and providing patients with the best possible treatment.


Ossifying fibroma (OF) is classified as, and behaves like, a benign bone neoplasm. It is often considered to be a type of fibro-osseous lesion (FOL). It can affect both mandible and the maxilla, particularly the mandible. This bone tumour consists of highly cellular, fibrous tissue that contains varied amounts of bone or cementum resembling calcified tissue. Present case is an unusual report of central ossifying fibroma involving the left side of mandible in an 18 year old female patient, who presented to the department with a painless hard swelling. The lesion was treated by surgical resection and reconstruction. Clinicaguration . Treatmeguration . AlthougA female patient aged 18 years reported to our department with a chief complaint of painless swelling in the lower left side of the face since 5 months, her history revealed that swelling started spontaneously 5 months back and was slowly progressing in size to current status. Extra oral examination revealed solitary hard swelling with diffuse borders in lower left side of the face, approximately 8cm X 7cm in size. The swelling was extending from 1cm anterior to angle of mandible to the symphysis region. Swelling was non-tender and overlying skin was inflamed with temperature slightly raised . IntraorHistopathology report: Microscopic examination of Hematoxylin & Eosin stained section showed highly cellular connective tissue composed of interlacing fascicles of plump and proliferating spindle shaped fibroblast with delicate collagen fibres. Area of multiple and varying sized dystrophic calcifications were evident ( evident .grouped together since 1968 . In 1971Histologically, ossifying fibromas consist of fibrous tissue that exhibits varying degrees of cellularity and contains mineralized mineral. The hard tissue portion may be in the form of trabeculae of osteoid and bone or cementum resembling basophilic and poorly cellular spherules. The bony trabeculae vary in size and frequently demonstrate a mixture of woven and lamellar pattern. Peripheral osteoid and osteoblastic rimming are usually present. The spherules of cementum-like material often demonstrate peripheral brush borders that blend into the adjacent connective tissue. Significant intralesional hemorrhage is unusual . DiffereWe reported and treated an unusual case of a large Ossifying fibroma in a 18 year old female patient who presented with a multilocular radiolucent swelling in lower left side of the mandible. Based on our experience, we suggest that proper correlation of the clinical, radiological and histological features is necessary to establish a definitive diagnosis, as well as for proper surgical intervention. As reported in literature, the rate of recurrence is not very high but long term periodic follow up is warranted.


The occurrence of foreign bodies in paranasal sinuses is extremely rare. The symptoms are vague and usually discovered after extra/intracranial complications. They may, therefore, go unnoticed if there isn't a strong clinical suspicion. We present a clinical case of a 64-year-old woman with a paranasal sinus microsurgery history more than 30 years ago, who presented with headache and purulent rhinorrhea. A glass tubular structure was discovered in the ethmoid complex. She underwent functional endoscopic sinus surgery. Since glass is an inert material that doesn't cause foreign body reaction, the patient may not present any symptom or sign. However, if there is obstruction in the drainage of the ostiomeatal complex, it can manifest itself as rhinosinusitis, which we believe happened in our case. To the best of our knowledge, this is probably the first reported case of a glass removed from the ethmoidal sinuses, diagnosed with more than 30 years of evolution. The occurrence of foreign bodies in paranasal sinuses is extremely rare, and approximately 70% of these cases are associated with some form of maxillofacial trauma, while others are related to surgical treatments after dental problems . Due to Thus, the authors present a case of a rhinolith in the ethmoidal sinuses, with more than 30 years of evolution.The authors present a clinical case of a 64-year-old female patient, with no relevant medical history (including trauma), who went to the emergency department of our hospital presenting a clinical scenario with a few years of left intense headache and left hemifacial pain that worsen with head movements, purulent and sometimes greenish rhinorrhea, and cacosmia.The patient had a history of microsurgery of paranasal sinus more than 30 years ago in another hospital, due to complaints compatible with chronic rhinosinusitis.The otorhinolaryngologic examination, in particular anterior rhinoscopy complemented with nasofibroscopy, revealed a congested nasal mucosa, a dark friable lesion at the middle meatus, and the first diagnostic hypotheses were rhinolith/fungal rhinosinusitis. In the emergency department, she underwent a cranial computed tomography (CT) scan that identified “… lesion at the level of the left paranasal sinuses compatible with fungal rhinosinusitis.”She was referred to an Ear, Nose, and Throat appointment. A paranasal sinus CT scan identified “… tubular foreign body, about 37 × 5 mm prehypertensive, filled with soft tissues inside the left nasal fossa, the left middle meatus and anterior ethmoid. Also, signs of chronic inflammation were observed, with thickening of the right frontal sinus mucosa, the ethmoidal cells, the sphenoid and the maxillary sinuses, associated with sclerotic osteitis of the bone walls that delimit the maxillary and sphenoidal sinuses” .She was also subjected to a complementary study with magnetic resonance of the SPN to best characterize the lesion which revealed “… centred on the left middle meatus, but extending to the posterior portion of the complex anterior ethmoid on the same side, where there is apparently a focal bone continuity solution of the base of the anterior floor, a cylindrical/tubular configuration void with peripheral soft tissue component. It is about 3.8 cm larger in diameter and probably corresponds to extrinsic material and, given its regular configuration, it is unlikely that the alternative hypothesis is a mycetoma.”She underwent functional endoscopic sinus surgery (FESS) with antrostomy, anterior and posterior ethmoidectomy, debridement of the necrotic tissue and removal of the foreign body that proved to be a cylindrical structure, which was a piece of glass. During the follow-up, in 6 months after surgery, the patient remained completely asymptomatic and performed another CT scan which showed no signs of inflammation.With the recent best availability of computerized tomography and magnetic resonance, it is now unlikely that foreign bodies in paranasal sinuses go unnoticed. Since glass is an inert material that does not cause foreign body reaction, the patient may not present any complaint or symptom unlike other materials that can generate osteomyelitis, frontal sinusitis, or CSF fistula , 4. In oThis case warns us of the need and importance of always maintaining a high degree of clinical suspicion so as not to devalue some symptoms that, appearing benign, could lead to severe complications, both extracranial and intracranial.


Here, we present one of the largest GISTs reported in the literature with a total volume of 25.3 × 20 × 14 cm + 27.9 × 23 × 8 cm and an overall weight of 7.3 kg, which developed in a 43-year-old female patient with NF1 and was resected on an emergency basis due to the rapid deterioration and development of abdominal compartment syndrome. Pathology assessment showed a malignant GIST composed of spindle cells with elongated nuclei with necrosis, marked pleomorphism and numerous giant cell. The mitotic count was >15/50 HPF, Ki 67 was 80%, and the lymphovascular invasion was clear. Immunohistochemistry investigations showed that Vimentin, CD117, and DOG1 were positive, while BCL-2 and CD99 were focal positives. Pan-CK, S-100, CD34, Desmin, SMA, and HMB-45 were negatives.Gastrointestinal stromal tumours are rare tumours of the gastrointestinal tract (GIT) accounting for 0.1%–3% of all gastrointestinal tumours. The most common location is the stomach (55%) followed by the small bowel (31.8%), colon (6%), other various locations (5.5%), and the oesophagus (0.7%). They may also occur in extraintestinal locations. The signs and symptoms of GIST depend on the tumour's location and size. Gastrointestinal bleeding is one of the most common symptoms. Other signs and symptoms include abdominal discomfort, pain or distention; intestinal obstruction, and weight loss. The association between the development of GISTs and neurofibromatosis 1 (NF1) has been established. NF1-associated GISTs tend to have a distinct phenotype, and the absence of KIT/PDGRF Gastrointestinal stromal tumours are rare tumours of the GIT (see comment above) accounting for 0.1%–3% of all gastrointestinal tumours . The mosThe tumour shows no strong sex predilection and usually occurs in adults , with a α) mutations play a role in GIST pathogenesis [GISTs are believed to arise from the interstitial cells of Cajal or related stem cells . In mostogenesis .Benign GISTs outnumber the malignant ones by a margin of 10 : 1. Clinical presentation depends on the site and size of the tumour and may include abdominal pain, gastrointestinal bleeding from ulceration of the overlying mucosa, or signs of obstruction. However, small tumours may be asymptomatic. The major clinical findings are upper abdominal ulcer-like pain, dyspepsia, iron-deficiency anaemia, gastrointestinal bleeding, nausea, vomiting, palpable abdominal mass, and weight loss . Also, Gα mutations which has, in turn, an implication on further management where they do not respond well to Imatinib treatment [Many studies confirmed the association between the development of GISTs and neurofibromatosis 1 (NF1) –17. GISTreatment –20.Here, we present a case of a huge pelvic-abdominal GIST in a known patient of NF1 who showed rapid progression over a short time mounting to abdominal compartment syndrome. Consequently, she underwent emergency surgical excision.A 42-year-old female is a known case of familial NF1. She and her identical twin in addition to her only brother are all affected by NF1. She has no family history of malignancy, has not had previous surgery, and has no other comorbidities. Initially, she presented with fatigue, cough, and shortness of breath. She sought medical advice, and a low haemoglobin of 4 g/dl was discovered. She was resuscitated and received a blood transfusion. She had a history of constipation and change of stool calibre and melena. Clinical examination showed an abdominal mass which was confirmed by the US ultrasound later. An urgent OGD and a colonoscopy were done. OGD revealed normal upper GI study while the colonoscopy showed external compression on the sigmoid and descending colon with neither obstruction nor intraluminal lesion .After stabilisation, the patient was then referred to our tertiary oncology centre for further evaluation. A CT scan  was doneμg/L), CA 125 (154.7 U/ml), CA 15-3 (10.5 U/ml), CEA (0.3 μg/L), CA 19-9 (5.4 U/ml), and B-HCG (0.9 mIU/ml). For staging, a whole-body PET CT scan  with tumour invasion into the left paratubal tissue, small and large bowel, in addition to the right and left peritoneal tissues. The patient had an uneventful postoperative course and was discharged home. Her case was discussed in the national tumour board—MDT, which recommended starting Imatinib therapy and genetic analysis. Unfortunately, genetic analysis was not available in any local centre. Every effort was made to send the tissue blocks abroad for genetic analysis; however, logistical obstacles aborted these endeavours.Although the patient received the first dose of Imatinib, her condition started to deteriorate over the next 2 months after surgery with persistent vomiting and gradual abdominal distention. However, her stoma was functioning and a barium follow-through study confirmed the patency of her bowel. Because of the multiple admissions due to persistent vomiting and abdominal distention, a CT scan was done which confirmed an aggressive recurrence. Because of the severe distention and again abdominal compartment syndrome, the patient was taken to the theatre where an aggressive inoperable tumour was encountered. Laparostomy was performed. The abdomen was left open and covered with a Bogota bag. A few days after the second surgery, the patient passed away.The signs and symptoms of GIST depend on the tumour's location and size, with highly malignant GISTs typically being large and symptomatic at the time of diagnosis. Gastrointestinal bleeding is one of the most common symptoms. Other signs and symptoms include abdominal discomfort, pain or distention, intestinal obstruction, and weight loss .In this case, there was a typical presentation with anaemia, melena, and gradual abdominal distention. Although there was no complete obstruction, the patient gave a history of change of stool calibre and constipation, manifestations that go with the external compression exerted by the huge tumour on the bowel.GISTs arise in the muscularis propria layer of the stomach or intestinal wall. Small GISTs form intramural or serosal nodules and, as they grow and expand, may develop intraluminal, intramural, and extraluminal components to varying degrees. The extraluminal component of a malignant GIST may be so large that it is difficult to determine the site of origin , 25.On the radiological basis, the tumour in our patient was first thought to have originated from the ovaries due to its pelvic-abdominal position and close proximity to the gonads. However, on histopathology assessment, it was proved to invade the left paratubal tissue planes only. Given its huge size and invasion of both the sigmoid colon as well as the small bowels, the origin is not clear; however, the invasion to the small bowel was more aggressive with perforation and stricture formation suggesting a small bowel origin.Given the weight and volume of our tumour , it is one of the largest GISTs reported in the literature. Koyuncuer et al.  reportedGISTs are potentially aggressive forms of cancer that may develop anywhere in the GI tract . They moIn our patient, the histopathology assessment classified the tumour as a high-risk malignant tumour. Although distant spread to the liver or bones is excluded based on radiological staging, the tumour is proved to be locally aggressive spreading to the peritoneum, bowels, and paratubal tissues. This is expected given the huge nature of the tumour, a mitotic count of >15/50 HPF, and Ki-67of 80%.Association between GIST and NF1 is established since an old autopsy study had documented a GIST in one-third of the NF1 patients . NF1-assIn our case, the patient was young (43 years old), with the tumour most probably originating from the small bowel—criteria that go with the previous literature. However, the tumour was huge and of the high-risk category, which were both striking features.The genetic basis for the association between NF1 and GISTs is being elucidated. The genetic defect of NF1 disease is a mutation in the NF1 gene which encodes neurofibromin, a tumour suppressor protein that regulates the cellular proliferation via inactivation of RAS through GTPase activity. RAS is known to stimulate signal transduction through the MAP kinase pathway when activated. The resultant loss of the function of neurofibromin predisposes to the development of benign and malignant tumours –39. NF1-α gene. However, 10%–15% of GISTs lack KIT or PDGFRα mutations. These GISTs can be associated with NF1 or can represent succinate dehydrogenase (SDH)-deficient GISTs that include GIST in the Carney triad and the Carney-Stratakis syndrome [GISTs in adults are typically sporadically occurring and are associated with somatic mutations in the KIT or PDGFRsyndrome , 44.GISTs associated with Carney Triad, Carney Stratakis syndrome, along with young and paediatric GISTs have been documented to have a loss of succinate dehydrogenase subunit B (SDHB) expression , 45, 46.α mutations, and, generally, may benefit from the Imatinib treatment. SDHB-negative GISTs occur usually in paediatric and young female patients, locate almost exclusively in the stomach and present an epithelioid morphology. These tumours are usually c-kit and PDGFRα wild-type and do not respond to the molecular treatment with Imatinib [Based on the SDHB expression, it has been recently proposed that GISTs could be differentiated into two characteristic subgroups: type 1 SDHB-positive and type 2 SDHB-negative . SDHB-poImatinib , 48.α wild type); and they are KIT-positive with hyperplasia of ICCs. Moreover, and alike the SDHB type 2 tumours, they do not respond well to Imatinib treatment [Even though NF1-associated GISTs have been documented to be type 1 SDHB-positive tumours , they coreatment , 49–51.Given the above, the therapeutic challenges for advanced NF1-associated GISTs are evident with expected resistance to Imatinib therapy. However, Sunitinib is the second-line tyrosine kinase inhibitor and has shown activity with clinical benefit in 56% of wild-type patients and can be used for the patients who develop resistance to Imatinib as well .NF1-related GISTs represent a unique entity of GISTs relevant to their different molecular basis and presentation. When advanced and unresectable, they pose a great challenge due to resistance to Imatinib therapy. Here, we present one of the largest GISTs reported in the currently available literature with an overall weight of 7.3 kg and volume of 25.3 × 20 × 14 + 27.9 × 23 × 8 cm, which was resected on an emergency basis due to the rapid deterioration and development of abdominal compartment syndrome.


Complete colonic duplication is rare, and usually occurs as a part of the caudal duplication syndrome. In such cases, the diagnosis is clinically evident by the presence of two ani arranged side by side in the perineum, which is commonly associated with duplication of the external genitalia as well . In this report, we present a special case of anorectal anomaly that was associated with complete tubular colonic duplication. The diagnosis was initially missed due to the uncommon sagittal arrangement of duplicated rectum: one rectum was ending externally into the perineum by rectoperineal fistula, while the other was hidden by its internal termination into the vagina. Our final diagnosis for this case was a variant of anorectal anomaly in the female, which was associated with complete colonic duplication. One colon (which was in the free mesenteric border) terminated anteriorly into the vagina as a part of a “short common channel” cloaca, while the other colon terminated by rectoperineal fistula. Although the anomaly seems to be rather complex and confusing, yet our case was associated with an excellent outcome due to the benign type of anorectal anomalies  and absence of significant sacral dysplasia; in addition to adequate identification of the abnormal anatomy by appropriate investigations and the staged approach for surgical reconstruction. Anorectal Anomalies (ARA) represent a major category in pediatric surgery with different phenotypes in the male and female.Here, we present a special case of ARA in which the clinical picture was further complicated by the presence of complete tubular colonic duplication.A 2-year-old girl presented by abnormal passage of stools through her vestibule. She had a history of operation (anorectoplasty) during the neonatal period. The patient operative files revealed a limited sagittal anorectoplasty performed (without colostomy) for a rectoperineal fistula, with uneventful postoperative recovery.The history would suggest an iatrogenic rectovaginal fistula, and, therefore, the patient was scheduled for examination under anesthesia with the possibility of performing a diverting colostomy. Examination under anesthesia revealed a well-positioned neoanus with good caliber; however, the vestibule showed a shallow common urogenital sinus with a septated vagina. The common sinus was short and wide that the anatomy was well-exposed for inspection upon labial retraction. Stools were seen emerging out of the vagina upon applying pressure on the lower abdomen. A decision was taken for fecal diversion as a first step for a staged repair. An oblique left lower abdominal incision was made to perform a pelvic (sigmoid) colostomy which revealed the presence of double colon sharing a common mesentery. A pelvic colostomy was done for the double colon that consisted of two proximal stomas and two distal mucous fistulae.Diagnostic workup before definitive repair:we performed contrast X-ray studies  communicating with the vagina, while keeping the posterior distal colon and rectum (R1) as a single exit for fecal stream after reanastomoses with proximal double colon . The distal colon to be excised was incised along its free antimesenteric border , followfashion andE. fashion . PostopThe patient has been followed-up for the last 3 years, with a satisfactory functional and cosmetic outcome. She has voluntary fecal and urinary control; occasional constipation showed good response to stimulant laxatives. A follow-up MRI has been prescribed to check for postreconstruction pelvic anatomy andE.Complete colonic duplication is rare and usually occurs as a part of the caudal duplication syndrome.Another point that was missed during the initial management of this case was the presence of associated urogenital anomaly in the form of a short common urogenital sinus and a septated vagina. This highlights the importance of proper exposure  during inspection that would help to identify all aspects of the anomaly. A short common channel in cloaca (< 1 cm) has been reported as a benign type with excellent prognosis.Our final diagnosis for this case was a variant of anorectal anomaly in the female, which was associated with complete colonic duplication. One colon (which was in the free mesenteric border) terminated anteriorly into the vagina as a part of a ‘short common channel’ cloaca ;


Introduction: Infected “mycotic” Aneurysm (IA) of the extracranial carotid artery is a rare condition that can be fatal if mistaken for other pathology. An 83-year-old man presented with a mass on the neck initially suspected malignant. Weeks later it grew rapidly and was found to be an IA, thus requiring acute surgery. Via this case report, we discuss diagnostics and approach when diagnosing masses in relation to vessels of the neck not readily explained.Case Report: After diagnostic imaging and clinical assessment an unknown primary tumor of the neck was suspected. Fine needle aspiration was inconclusive. The patient did not present with any signs of infection or neurological symptoms—only discomfort and pain. Approximately two weeks later, the mass grew and the patient became dysphagic, febrile, and confused. Computed tomography angiography revealed an IA of the right common carotid artery. The patient underwent acute surgery consisting of ligation of the internal and external carotid arteries and resection of the internal jugular vein. The pathogen found was E. coli, supposedly from the bladder after surgical intervention due to polyposis.Conclusion: IA is a very rare entity and can have many etiologies. Since it can be fatal, it is necessary to keep IA in mind when diagnosing masses in relation to vessels of the neck. As shown in this case of a E. coli-induced IA, patients can present with atypical symptoms, on diagnostic imaging it can be mistaken for other pathology, and pathogenesis can be unclear. Masses of the neck can be caused by immensely diverse pathologies. Among these are: lymphadenopathy , congenital neck lesions , and persistent masses with high potential for malignancy either as a primary tumor or metastases from Unknown Primary Tumor (UPT) .At the beginning of 2008, a national fast-track program for head and neck cancer was introduced in Denmark. The goal was to improve survival by reducing the waiting time from initial suspicion of malignancy to the start of treatment -angiography as an Infected “mycotic” Aneurysm (IA)—an extremely rare condition especially in the Common Carotid Artery (CCA) .in situ of the bladder for which we had undergone a transurethral resection whereafter he developed postoperative sepsis, and one perioperative episode of arrhythmia with consequent cardiac arrest during hip surgery in 2017. The process had developed over ~3 weeks. The patient had experienced pain and discomfort with right-sided otalgia upon swallowing. He had no signs of dysphonia, was afebrile, had no erythema or calor in relation to the mass, and no neurological abnormalities. Thus, infection was not a provisional diagnosis. Ultrasound showed a hypoechoic, ill-defined tumor mass sheathing ~50 percent of the right CCA. No flow in the mass was detected with Color Doppler Ultrasound. Therefore, UPT was suspected.An 83-year-old man was referred from an ENT specialist practitioner to the ENT-department due to a painful process situated in level II-III on the right side of the neck. He had a history of arterial hypertension, low-malignant carcinoma Fine needle aspiration was inconclusive twice. Open biopsy and core biopsy was not an option due to the uncertainty of malignancy and potential spreading and bleeding. Therefore, diagnostic imaging was ordered.Magnetic Resonance Imaging (MRI) and Positron Emission Tomography/Computed Tomography (PET/CT) showed what was concluded to be a tumor suspected of malignancy sheathing the carotid artery, though a slight dilation of ~2.3 cm of the right CCA was detected Figure . FurtherSixteen days after being enrolled in the ENT fast-track program, having undergone a colonoscopy and initial examination at the department of pulmonary medicine, the patient was admitted due to pain and further growth of the process on the neck. The patient was not able to eat or drink sufficiently and was experiencing general fatigue. The patient's family found that the patient's mental condition had deteriorated.Upon admission, his vital signs were: A temperature of 38.4°C, 172/98 mm Hg blood pressure, a heart rate of 105 beats/min, and an unlabored respiratory rate of 16/min.9/L, and 24.1 × 109/L neutrophils. A urine sample was sent to the laboratory for cultivation and analysis of sensitivity.Biochemistry showed markedly high inflammatory indices with a c-reactive protein of 266 mg/L, white blood cell count of 26.9 × 10E. coli and relevant antibiotics were administered.Initially, the patient was prescribed Piperacillin and Tazobactam, treating symptoms as an infection with unknown primary focus. A diagnostic ultrasound was performed, which raised the suspicion of an aneurysm. CT-angiography showed an IA of about 5.4 × 3.9 cm Figure . The patThe only sequela was dysphonia due to paralysis of the right recurrent nerve.E. coli with the same resistance pattern as seen in the IA was found in the urine samples from the admission date. This suggested the bladder to be the primary focus of infection.After the resection of the IA, growth of First described by Sir William Osler in 1885, the term “mycotic” relates to the initial description of aneurysms with fungal appearance seen in several cases of bacterial endocarditis . This maSymptoms of an infected aneurysm of the ECA can vary depending on the size and position. These include the following symptoms: a growing, pulsatile cervical mass associated with pain, locally or radiating to the ear, tenderness, fever, dysphonia, dyspnea, and dysphagia , 8. FurtTreatment options include total resection, endovascular stenting, and autologous interposition vein graft which is the preferred contemporary method due to fewer complications , 13–15. Our case has several unique clinically interesting characteristics. The aneurysm was initially not pulsatile, there were no neurological symptoms, and the patient did not have any initial signs of infection; thus the primary diagnosis was UPT. PET/CT and MRI were performed as defined in the Danish fast-track program of head and neck cancers . ImagingE. Coli-induced IA in the ECA has been reported since 1966 (Fusobacterium and methicillin-resistant staphylococcus aureus (An IA is characterized by a positive culture result or evidence of other organisms on histological examination of the arterial wall . Only sence 1966 , 16, 17.nce 1966  and septnce 1966 . Furthers aureus .Staphylococcus aureus, Salmonella, and streptococcus species (E. coli-induced IA, in this case the strain was not beta-lactamase-producing, but it has been argued that further cases may be seen in the future due to drug-resistant E. coli urinary-tract infections (Nowadays, the most prevalent pathogens are  species , 22. Pre species . Thought species –26. In rfections .A history of sepsis, surgery, signs of pharyngitis/tonsillitis, trauma or procedures involving vascular puncturing of vessels of the neck support the diagnosis of IA . Even thIn conclusion, clinicians should think of IA as a possible etiology when diagnosing tumors of the neck in close proximity to the vessels. As discussed, both the presentation of IA and etiology can vary considerably, and should therefore always be considered. Consequently, a broad anamnesis of prior risk factors is very important for the detection. Early detection of the disease is imperative; though rare, an aneurysm of the carotid artery can have a fatal outcome. Furthermore, early detection can have relevance for surgical options and later complications.Written informed consent was obtained from the patient specifically for publication of this case report.PE: General script, gathering information, photoshop, and consent from patient; GH: Specialist consulting, re-writing, reference search, and revisions; PH: Re-writing and revisions, reference search, and help with submission.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.


A 51-year-old nulliparous woman was referred to our department for an MRI scan of thepelvis in the work-up of pathologically proven cervical cancer. A HPV (humanepapilloma virus) DNA test was positive for high-risk HPV types. Pathologicalanalysis of a cervical biopsy showed poorly differentiated squamous cell carcinoma.The patient had a personal history of left renal agenesis, a presumed Müllerianduct anomaly, and surgery for endometriosis. At our department, the routine scanningprotocol for cervical cancer staging consists of sagittal, para-axial, andparacoronal T2 HASTE images adjusted to the cervical axis and axialdiffusion-weighted images. Based on this MRI exam, the tumor was locally staged ascT2bN1. Treatment consisted of surgical removal of a large external iliac adenopathyfollowed by concomitant radio-chemotherapy.In this patient, MRI also confirmed the presence of a uterine anomaly Figure . The lefBased on these observations, the diagnosis of right unicornuate uterus withnoncommunicating left cavitary horn was made. The junctional zone thickening wascompatible with adenomyosis. The complex cystic mass was consistent withendometrioma. A small amount of hemoperitoneum was the final important secondaryfinding.The female reproductive organs develop during the sixth week of gestation, when thepaired Müllerian (or paramesonephric) ducts fuse to create the uterus, cervix,and upper two-thirds of the vagina. Unicornuate uterus is a result of abnormal orfailed development of one of the Müllerian ducts. Unilateral renal agenesis isthe most frequently associated urinary tract abnormality .Four subtypes of unicornuate uterus have been described, based on the presence orabsence of a rudimentary uterine horn, which may or may not communicate with thenormal horn. If present, functional endometrial tissue within a rudimentary hornputs the patient at higher risk for endometriosis, hematometra, and hematosalpinx,as well as adenomyosis. Fetal implantation can occur in a noncommunicatingrudimentary horn, but it will generally result in a life-threatening uterinerupture. Therefore, the correct diagnosis of this entity has important clinicalimplications, especially in young patients with a desire for pregnancy.MRI, with its excellent soft tissue contrast and complete lack of radiation exposure,allows accurate diagnosis of all subtypes of unicornuate uterus. Unicornuate uteruswith cavitary noncommunicating horn can be classified as a Müllerian ductanomaly type A1b, according to the American Fertility Society. Differentialdiagnosis includes adnexal mass or pedunculated uterine fibroma.


Echinococcus disease. However, even in the “classic” clinical scenario and setting, the clinician must maintain a broad differential diagnosis. Point-of-care ultrasound can be helpful in performing the rapid diagnosis and therefore direct appropriate treatment strategies based on the results.The use of point-of-care ultrasound (POCUS) has become increasingly important in resource-limited settings. It can rapidly diagnose both tropical infectious diseases and more common pathology at the bedside. In these practice settings, POCUS can have a significant impact on management strategies and patient care. Ultrasonography has been the gold standard for the diagnosis and staging of Echinococcus cyst. However, when POCUS was performed, the findings were not consistent with hydatid disease. Ultimately, surgical pathology revealed a choledochal cyst, a rare finding in adulthood.We present a case of a 27-year-old woman presenting to an emergency department in Peru with jaundice and abdominal pain. Initially given the region of her origin, the working diagnosis was an Echinococcus disease. It is important for the clinician sonographer to appreciate the features consistent with Echinococcus cysts and distinguish from those features that are more consistent with other pathology.This case initially appears as a “classic” finding of The online version of this article (10.1186/s13089-018-0091-6) contains supplementary material, which is available to authorized users. Point-of-care ultrasound (POCUS) was first introduced in the emergency department in the 1980s. Since that time, its use has become more widespread, extending across other subspecialties and into other practice environments. Point-of-care ultrasound can be particularly useful in resource-limited practice settings, such as in the developing world. There are often significant delays and prohibitive costs associated with advanced imaging studies, such as computerized tomography and magnetic resonance imaging. As an alternative, POCUS can facilitate diagnoses at the bedside and ultimately make a significant impact on management decisions.It is particularly important for clinicians practicing in resource-limited settings to maintain broad differential diagnoses and integrate the POCUS examination with history and physical examination findings and laboratory studies (if available). Point-of-care ultrasound may be the only imaging modality available, and it is therefore crucial to becoming familiar with normal findings, tropical infectious diseases, and some of the rarer pathology seen in these practice settings.A 27-year-old female from the Peruvian Highlands presented to the emergency department in Lima with intermittent diffuse abdominal pain and jaundice. There was no reported history of hepatitis or change in stool color. Physical examination revealed scleral icterus and mild tenderness at the right upper quadrant.Given the patient’s region of origin and clinical picture, the initial working diagnosis was a hydatid cyst. A point-of-care ultrasound was performed, which revealed a large multi-locular cyst, with multiple surrounding anechoic structures Fig. : Video 1Echinococcus) are endemic to the Peruvian Highlands, with a prevalence as high as 9.3% [Hydatid cysts ( as 9.3% . The hep as 9.3% , followeThe patient was taken to surgery for complete excision and was ultimately found to have a choledochal cyst by pathology. The diagnosis of a choledochal cyst is rare, with an incidence of 1/150,000 in Western populations. It is remarkably rare to be diagnosed in adulthood, since approximately 80% of choledochal cysts are diagnosed in infants and children. The most common symptoms at presentation are jaundice and abdominal pain for children and adults, respectively. The most widely accepted treatment is a complete excision, due to the risk of malignant transformation; long-term follow-up and monitoring for malignancy is warranted even after surgical intervention , 5.Echinococcus disease. It is important for the clinician sonographer to appreciate the features consistent with an Echinococcus cyst and distinguish it from other pathology. Overall, POCUS can be tremendously useful in the diagnosis and management of patients in the developing world with otherwise limited resources.This case initially appears as the “classic” finding for Additional file 1. Video ultrasound of the patient's right upper quadrant. There is a large anechoic cystic structure with adjacent smaller cystic structures; these smaller cystic structures are actually the dilated biliary tree. These could easily be confused for daughter cysts that are comonly seen with hydatid cysts of the liver.Additional file 2. Video ultrasound of an Echinococcus cyst. Note the separation of the wall from the cyst can be visualized. According to the WHO classification system, the cyst would be considered a type CE2 active cyst [ive cyst .


The authors presented a 63-year old female synchronously complicated with a thymic tumor located at the left-side of the superior mediastinum, and a paravertebral tumor located at the right-side of the lower thorax. Conventional thoracoscopic surgical procedure using rigid instruments to simultaneously resect the two tumors via the same ports might be technically challenging. To our knowledge, the use of a surgical robot allowed the surgeon to perform precise dissection from extreme angles with the characteristic of articulating surgical instruments.Two lesions were successfully dissected using the da Vinci Surgical System through the same four ports on the right side of the chest and two-step docking. Firstly, the patient cart came from the dorsal side of the patient and the paravertebral neoplasm was dissected. Afterwards, the patient cart was undocked and the operation table was rotated 180 degrees counterclockwise. The robot was re-introduced and the patient cart came from the ventral side of the patient and the whole thymus was resected.This case report suggests that two-step docking via the same four ports for these two tumors located at different directions of the thorax was safe and effective, demonstrating a clear advantage of the surgical robot. Anterior mediastinal tumors usually arise from the thymus and paravertebral masses usually originate from the nerve sheath. Generally, these tumors are well encapsulated and typically treated using complete resection with excellent outcomes. Currently, resection of anterior mediastinal or paravertebral neoplasm is typically performed using minimally invasive procedures. Intriguingly, the present case suffered from a left-sided thymic tumor and a right-sided lower thoracic paravertebral neoplasm. Accordingly, usual minimally invasive surgical procedure with rigid instruments to simultaneously resect the two tumors via the same ports might be technically challenging. Given that the surgical robot can provide magnified three-dimensional images, articulating forceps and tremor filtering, which could potentially facilitate simultaneous excision of the thymic neoplasm and the paravertebral tumor via the same ports. The da Vinci robotic system was introduced for the resection.A 63-year-old female was referred to our outpatient department for routine checkup and chest computed tomography scans revealed two tumors measuring 18 × 9 mm and 33 × 15 mm in diameter, located at the left-sided anterior mediastinum Fig. . Insufflrd post-operative day. Final pathological diagnoses of the anterior mediastinal tumor and paravertebral tumor were a bronchogenic cyst and a schwannoma, respectively, both of which had intact capsules.Total operating time was 180 min and the blood loss was less than 15 ml. The post-operative course was uneventful with no evidence of paralysis or motor weakness. The chest tube was removed on the following day, the chest radiograph was normal  injury is a catastrophe during robotic thoracoscopic thymectomy, port placement for the presented case was primarily based on the port arrangements for thymectomy. To provide an optimal visualization and instrument movement for the paravertebral tumor dissection, the usual port position for thymectomy was moved slightly backwards.Robotic surgery is a time-consuming procedure due to the time required to dock, undock and exchange instruments. In our opinion, the duration of surgery can be shortened with the experience of more cases. Due to the high cost of installation and maintenance, cost-effectiveness is a practical burden associated with the introduction of the da Vinci Surgical System. Most patients could not afford to the cost of robotic surgery without health insurance coverage. Over the years, many companies have tried to develop competing robotic devices which may challenge the monopoly situation of da Vinci surgical robots. A cost reduction of robotic surgery is expected in the future.


A 48-year-old male patient was referred by his general practitioner to the radiology department for evaluation of a mobile non tender abdominal mass. The patient did not report abdominal pain, nor any changes in bowel habits. His medical history included uncomplicated sigmoid diverticulitis, prostatitis and left nephrolithiasis. Previous surgeries included left kidney stone extraction. On clinical examination the abdomen was distended, soft and without tenderness, but a large tympanic mass was palpable in the left hypochondrium. Contrast-enhanced computed tomography (CT) showed a 10.4 × 8.1 cm gas-filled mass in the left hypochondrium and adjacent to the sigmoid Figure  and B. TA laparoscopic resection of the diverticulum and adjacent sigmoid, with primary colonic anastomosis was performed. No postoperative complication occured and the patient was discharged on post-operative day 5. The pathology examination revealed a giant sigmoid diverticulum consisting of a fibrosclerotic wall colonized by acute and chronic inflammatory elements with a complete destruction of the endodiverticular mucosal layer and was classified type 2 according to the classification of McNutt Figure . No evidGiant colonic/sigmoid diverticulum (GCD) is a rare complication of diverticular disease in which a diverticulum reaches 4 cm or greater in diameter. Less than 200 cases of GCD were published in the literature. GCD mostly is acquired but congenital forms have also been described. The most common clinical presentation is abdominal pain, but GCD can be asymptomatic. An abdominal mass is the most usual physical sign, but fever and abdominal tenderness can also be present. The reference and recommended examination is a computed tomography (CT) scan, which enables a correct diagnosis in nearly all cases. A smooth-walled gas-containing structure greater than 4 cm adjacent to the colon is the most common sign. GCD is not necessarily in communication with the bowel lumen. The most common complications are peritonitis caused by perforation of the GCD, abscess formation, intestinal obstruction, volvulus and infarction. A very rare complication is the development of a carcinoma.In our case the balloon sign was associated with lifting of the sigmoid out of the lower abdomen to the left hypochondrium. Enemas/abdominal X-ray are not necessary if CT scan is available. They typically show a well-defined large gas-filled cyst, with regular and smooth walls and can present an air-fluid level if communicating with the bowel lumen. Colonoscopy is generally avoided because of the risk of perforation.GCD are classified in three types according to the classification of McNutt et al. Type 1 diverticula are pulsion diverticula, which widen progressively, with remnants of muscularis mucosa and true muscularis, which ends at the colonic border of the diverticulum. Chronic inflammatory cells, granulation and fibrous tissue are present in its wall. Type 2 diverticula (inflammatory diverticula) are caused by a subserosal perforation, leading to an abscess cavity in the wall in communication with the bowel lumen and gradually enlarging. Their wall is composed of fibrous scar tissue, without a normal intestinal layer. Type 3 (true diverticula) consists of diverticula with all the bowel layers with a well-developed smooth muscle wall and in continuity with the bowel lumen. Type 3 diverticula usually have a congenital origin.en bloc resection of the diverticulum is the recommended option, even if asymptomatic. Excellent results are described with null post-operative mortality and very low morbidity [In our case, the giant diverticulum was a late complication of an earlier diverticulitis. According to the high incidence of complications associated with GCD, surgical treatment consisting predominantly of colonic resection with orbidity .