A 5‐year‐old, castrated, male domestic short‐haired cat presented with neurological deficits in the pelvic limbs, back pain and dysuria. Magnetic resonance imaging showed a mass lesion caudal to the L4 vertebrae. In addition, suspected haemorrhage was observed at the cranial aspect of the mass. There was no evidence to support the presence of extravertebral intrusion or vertebral body, osteolysis. Dorsal laminectomy and durotomy were performed to debulk the intraspinal mass. Histopathological and immunohistochemical assessment revealed a primitive neuroectodermal tumour (PNET). To our knowledge, this is the first report to describe the clinical and pathological features and imaging diagnosis of intraspinal PNET without extraspinal invasion in a cat. Graphical Abstract: A 5‐year‐old, castrated, male domestic short‐haired cat presented with neurological deficits in the pelvic limbs, back pain and dysuria. Magnetic resonance imaging showed a mass lesion caudal to the L4 vertebrae. In addition, suspected haemorrhage was observed at the cranial aspect of the mass. There was no evidence to support the presence of extravertebral intrusion or vertebral body, osteolysis. Dorsal laminectomy and durotomy were performed to debulk the intraspinal mass. Histopathological and immunohistochemical assessment revealed a primitive neuroectodermal tumour (PNET).  They occur most often in the head and very rarely in the spinal cord . Perineal reflex and deep pain were normal; however, dysuria was demonstrated. The remainder of the clinical examination was unremarkable. A complete blood cell count, serum biochemical evaluation, echocardiography and thoracic and abdominal radiographs identified no clinically significant abnormalities.A 24‐G over‐the‐needle catheter was placed in the cephalic vein of the cat. The cat was premedicated with intravenous butorphanol tartrate (0.2 mg/kg) and intubated after induction with intravenous alfaxalone (5 mg/kg). General anaesthesia was maintained by mechanical ventilation with sevoflurane (2.5%–3%) and oxygen (2 L/min). Computed tomography (CT) imaging of spine (including the thorax and abdomen) was performed using a 16‐slice multi‐slice CT scanner . This identified no significant findings. In particular, there was no evidence to support tumour formation, metastasis or embolization of the aorta and no evidence of osteolysis.Under the same anaesthetic condition, magnetic resonance imaging (MRI) was performed using a 1.5‐T superconducting unit  in the following planes: T1‐weighted imaging (T1WI) and T2‐weighted imaging (T2WI) in the sagittal, transverse and dorsal planes and T2‐star‐weighted imaging (T2*WI) in the transverse plane. T1WI in the sagittal, transverse and dorsal planes was performed after intravenous administration of 0.2 mg/kg bodyweight gadodiamide .T2WI showed hyperintense spinal cord lesions at the level of the L5 vertebrae and mild hyperintense lesions caudal to the L5 vertebrae Figure . These lDorsal laminectomy and durotomy of the L4–7 vertebrae were performed 1 week after the initial investigations to improve pelvic limb paraparesis and back pain. The dura in the surgical field (L4–7) was dark‐pink, and caudal to L4 vertebral, it was partially torn with a honeycomb appearance. Durotomy was performed, and a dark red jelly‐like tumour was found occupying the space between the spinal nerve fibres. This was associated with multiple adjacent haematomas. The tumour was removed carefully to avoid damaging the spinal cord; however, the spinal cord parenchyma was partially dissolved the level of the L4 vertebra, suggesting a transition to myelomalacia. The patient initially recovered uneventually following surgery but experienced respiratory failure 12 h postoperatively. Mechanical ventilation was initiated, and the patient was treated with antibiotics  and steroids ; however, 2 days postoperatively, the patient died due to cardiac arrest. The cause of death was suspected to be the progression of myelomalacia. An autopsy was offered but declined.2) were observed using an ocular lens of field number 22, and a presumptive diagnosis of PNET was made. Immunohistochemical examination was performed to further characterize the neoplastic cells using the 12 antibodies listed in Table The resected spinal mass was fixed in 10% neutral‐buffered formalin for 2 days, routinely processed and embedded in paraffin. Four‐micrometer‐thick sections were stained with haematoxylin and eosin for histopathological examination. The lesion was composed of dense sheets and short interlacing bundles of small, round‐to‐short spindle cells Figure . The cel3PNETs are rare malignant neuroendocrine tumours composed of small, undifferentiated or neuroectodermal cells ; data curation (supporting); investigation (supporting); methodology (supporting); visualization (lead); writing – original draft ; writing – review and editing : Takamasa Itoi, Ikki Mitsui, Natsuki Akashi, Teppei Kanda, Keisuke Sugimoto, Yuki Shimizu and Kazuaki Yamazoe. Conceptualization (lead); data curation (lead); investigation (lead); methodology (lead); project administration (lead); supervision (lead); visualization (supporting); writing – original draft ; writing – review and editing : Kenji Kutara.The authors have no potential conflicts of interest to disclose.The authors received no financial support from the research authorship and/or publication of this article.This case report was approved by the ethics committee of the Okayama University of Science Veterinary Medical Teaching Hospital .https://publons.com/publon/10.1002/vms3.1283.The peer review history for this article is available at


An appendiceal mucocele is a rare disease characterized by the dilation of the appendix lumen with mucus accumulation. Although this disease is often found incidentally during appendectomy, it is crucial to differentiate it from acute appendicitis preoperatively to select adequate surgical management. We present a case of a 31-year-old male, medically free, with right-sided abdominal pain associated with nausea and vomiting. He was diagnosed with appendiceal mucocele and underwent laparoscopic appendectomy. The absence of a distinct clinical presentation and biochemical parameters necessitates a comprehensive and collaborative diagnostic approach for mucocele of the appendix. Achieving an accurate diagnosis prior to surgery is imperative to ensure the appropriate surgical technique is chosen, thereby minimizing the risk of serious intraoperative and postoperative complications such as pseudomyxoma peritonei. Appendectomy is considered the most common emergency surgical operation performed worldwide . AlthougA 31-year-old male patient, medically free, presented to the clinic complaining of lower right-sided abdominal pain for 15 days associated with nausea and vomiting. The pain was recurrent, localized, and non-radiating and was not relieved by analgesics. There was no relieving or exacerbating factors of the pain as well as no history of loss of appetite or documented weight loss. There was neither a history of hematemesis nor melena. His surgical, medical, and family histories were insignificant. He is a non-smoker and non-alcoholic and has no history of drug abuse. The patient was afebrile and hemodynamically stable. Abdominal examination revealed mild tenderness over the right iliac fossa (RIF), and rebound tenderness was elicited. The digital rectal examination revealed a normal anal tone and an empty rectum with no signs of bleeding. His laboratory workup including complete blood count, serum creatinine, and liver function tests was all within normal limits. Abdominal and pelvis computed tomography (CT) scan with oral and intravenous contrast was performed. It demonstrated a fluid-filled tubular mass in the RIF. The wall of the lesion shows specks of calcification; fat infiltration was also seen. No enlarged or suspicious regional mesenteric lymphadenopathy was detected Figure . The cecAn appendicular mucocele is a rare condition characterized by the presence of groups of mucus-filled lesions that obstruct the ileocecal appendix. This condition is relatively uncommon. However, it is important to note that appendicular mucocele is a significant contributor to appendiceal tumors, representing approximately 8% of all cases . DespiteMucinous cystadenocarcinoma is a more severe form of appendiceal mucocele that features high-grade cellular dysplasia and stromal invasion, along with muscularis mucosae involvement. The classification of appendiceal mucocele is essential in making an accurate diagnosis and determining the appropriate treatment approach . The diaAppendiceal mucocele is a rare condition having a clinical picture that resembles acute appendicitis. The diagnosis of this condition involves a lengthy, multidisciplinary diagnostic process, as it lacks specific clinical features and biochemical parameters. Accurate preoperative diagnosis is essential for selecting appropriate surgical techniques and avoiding potentially severe intraoperative and postoperative complications.


Osteonecrosis of femoral head (ONFH) is clinically common and easily diagnosed via imaging examination, especially when there is a definite cause, such as a fracture, long-term hormonotherapy, etc. However, some rare neoplastic lesions of the femoral head can mimic its image performance in some situations, leading to misdiagnosis. We present the case of a 57-year-old male with bone pain in the left hip joint that persisted for 2 years. CT and MRI images were performed and both were suggestive of ONFH. Unexpectedly, the histopathologic results of left proximal femur resection revealed the diagnosis of phosphaturic mesenchymal tumor (PMT), a rare mesenchymal tumor. His hip pain was obviously relieved after surgery, and the course of 1-year follow-up was uneventful. We report the case of a 57-year-old man with bone pain, which mainly manifested in the left hip joint, persisting for two years. He came to our hospital because of his inability to walk, turn over, and perform other activities. The patient’s medical history involved having type 2 diabetes for 20 years. Physical examination showed significant tenderness to palpation of the left hip and positive Thomas sign, and the Gaenslen test could not be completed. Meanwhile, his laboratory data showed normal serum alkaline phosphatase (ALP) of 41 U/L , calcium 2.16 mmol/L (2.15–2.55), parathyroid hormone (PTH) 6.6 pmol/L (1.6–7.9) but mild hypophosphatemia of 0.72 mmol/L (0.81–1.45). Additionally, tumor markers were all negative. 99mTc-MDP bone scintigraphy showed one focal intense area of tracer uptake in the left proximal femoral region (99mTc-MDP was displayed. Subsequent magnetic resonance imaging (MRI) revealed the presence of an oval area with a hypointense signal on the T1-weighted image (Computed tomography (CT) of the bilateral hips showed low-density bone destruction in the left femoral head A,B. The l region C, corresed image A,B and aed image C,D. The Pathology results are the gold standard for validating a patient’s diagnosis of PMT. This patient’s features were as follows: 1) Clinical presentation: left hip bone ache for 2 years, unable to walk, mobility limitations, and so on. (2) Laboratory tests: ALP, blood calcium, PTH, liver and renal functions are all normal, blood phosphorus is slightly low, and so on. (3) Imaging manifestations: CT: hypodense destruction foci in the left femoral head; Whole-body bone imaging: left proximal femur restricted tracer concentration region; MR: T1-weighted picture oval low signal shadow, T2 image high and low mixed signal intensity, and so on. Generally, MRI has a high sensitivity for diagnosing ONFH, which is demonstrated by a limited linear low signal intensity under the cartilage on the T1 image and a bilinear sign-like pattern on the T2 image. Whole-body bone imaging usually shows a cold zone at the site of necrosis in the acute phase and a cold zone in the middle of a hot zone in the repair phase [ ClinicalAdditionally, various causes of ONFH are associated with trauma, alcohol consumption, glucocorticoid application, diabetic patients, etc. When asked about their medical history, the patient denied any association with these conditions except for diabetes. Therefore, common conditions such as OFNH cannot be ruled out either.These things considered, we suspected an incomplete subchondral bone fracture . In addiThe diagnosis of PMT in this patient was an unexpected finding in the postoperative pathology. From the correct diagnostic standpoint, this patient presented with “ischemic necrosis of the femoral head” as a result of tumor destruction of the femoral head. Generally, due to the characteristic overexpression of fibroblast growth factor-23 (FGF-23), PMT possesses phosphaturic activity, which inhibits the conversion of 25 hydroxyvitamin D into osteotriol, as well as the absorption of phosphate by the renal tubules [There is no better way to treat OFNH than surgical treatment, but secondary trauma from surgical intervention remains an unavoidable clinical problem . Whether


Retroperitoneal masses present a diagnostic challenge due to their elusive origin and varied clinical manifestations. Among these masses, retroperitoneal liposarcomas, rare tumors of mesenchymal origin, often grow asymptomatically until compressing surrounding structures, necessitating accurate and early diagnosis. Renal angiomyolipomas (AMLs) have also been reported to mimic retroperitoneal liposarcomas on radiographic imaging, further complicating diagnostic processes.The presented case report describes a rare instance of a large well-differentiated liposarcoma that mimicked a renal angiomyolipoma on imaging in a 58-year-old male patient. The patient initially presented with worsening abdominal distension, early satiety, and left-sided flank pain for the past year. Radiographic imaging revealed a large mixed echogenic lesion measuring 22 x 13 cm in the left kidney with diffuse fat contribution, suspected to be a giant renal angiomyolipoma. The patient underwent selective arterial embolization by interventional radiology. Follow-up imaging eight months later showed an increase in the size of the mass, raising suspicion of a liposarcoma. Surgical resection of the mass and a radical left nephrectomy were performed, with final pathology confirming the diagnosis of a well-differentiated liposarcoma. This case highlights the importance of accurate diagnosis and the potential for liposarcomas to mimic other masses on imaging, despite their rarity. Retroperitoneal masses, which arise in the retroperitoneum but do not originate from retroperitoneal organs, can be reactive or neoplastic. Due to their location, diagnosing these masses by imaging can be challenging, increasing the importance of being aware of the characteristic imaging features and clinical information to generate an accurate differential diagnosis . PrimaryRetroperitoneal liposarcomas, rare tumors of mesenchymal origin, can grow asymptomatically until they begin to compress surrounding structures such as kidneys, ureters, lymphatic drainage, and other abdominal organs. They are commonly underdiagnosed due to the lack of symptoms and the rarity of such tumors . In the In the literature, there are a few prior cases of a giant extrarenal retroperitoneal angiomyolipoma that mimicked a liposarcoma ,6,7. AltA 58-year-old African American male presented to the urology office with a chief complaint of abdominal distention, early satiety, abdominal and left-sided flank pain that was progressively worsening for the past year. The patient denied any gross hematuria or dysuria, but endorsed 12 month history of early satiety, abdominal pain, and significant weight gain. His past medical history, family history, and surgical history had no significant relevance to the case. The patient had previously presented to emergency department (ED) for abdominal pain, and was thought to have diverticulitis in the sigmoid colon. On physical exam, patient was noted to have abdominal distention with a large palpable left sided mass. He had an abdominal CT with intravenous (IV) contrast, which found hypodensities along the lateral margin of the right kidney measuring 1.5 cm in size, thought to represent cysts. Adjacent to the left kidney, a large mixed echogenic lesion measuring 22 x 13 cm with diffuse fat contribution and soft tissue elements, suspicious for a giant renal AML with mass effect was discovered, however no definitive acute hemorrhage or enhancing blood vessels were identified . The external surface of the tumor is tan-yellow, smooth, and glistening and was resected intact. The histologic type of the tumor was determined to be a WDL histologic grade 1  microscopic images show WDL on the right and kidney tissue on the left. The tumor abuts but does not invade adjacent kidney tissue Figure . H&E micThe patient's post-operative course was uncomplicated and the patient was discharged on day five. At the follow-up visit one week after discharge, the patient was found to be recovering well and was pending follow-up imaging. Soft tissue sarcomas account for less than 1% of malignancies in adults, and around 10-15% of soft tissue sarcomas in adults occur in the retroperitoneal space . Of all This case reports a liposarcoma that was treated with SAE therapy due to radiologic tumor characteristics mimicking an angiomyolipoma ,5,6. TheIn the literature, there are some cases of renal AMLs mimicking WDLs due to similarities in radiographic imaging ,7,8,9. ICT and MRI are the standard imaging tools used for the evaluation of retroperitoneal liposarcomas and can help distinguish the composition, relationship to neighboring organs, size, and enhancement . TypicalAlthough CT and MRI imaging are used to evaluate these masses, the final diagnosis is determined using pathological analysis. There are five different subtypes of liposarcomas, which include well-differentiated, dedifferentiated, myxoid, round cell, and pleomorphic. A negative prognostic factor for patients with retroperitoneal liposarcomas is a high histological grade. The subtypes that are classified as high-grade are round cell, dedifferentiated, and pleomorphic, while myxoid and well-differentiated are considered low-grade . The twoIn McGrath et al., it was reported that complete resection of liposarcomas can be carried out in up to 70% of cases when the tumor was >10 cm . RetropeIn the present case, the tumor was identified as a renal AML and treated with SAE without prior urologic consultation. If a core-needle biopsy had been performed this could have provided additional information in guiding the diagnosis and avoided the patient undergoing unnecessary procedures. We report a case of a large retroperitoneal WDL that mimicked a renal AML on radiographic imaging. The clinical diagnosis of retroperitoneal liposarcomas is difficult since these tumors are typically asymptomatic until they become large enough to compress neighboring abdominal organs. It is important to correctly diagnose these entities as AML and WDLs because they require different treatment modalities. Given the similarities between renal AML and WDLs, a high index of suspicion is needed for the diagnosis. A core-needle biopsy could be helpful in the diagnosis of WDLs. This screening method could have provided additional information to guide the diagnosis and helped the patient avoid unnecessary procedures.


The optimal treatment for aneurysmal bone cysts (ABCs) of the spine remains controversial. No treatment guidelines exist for the use of denosumab in aneurysmal bone cysts. In this report, we describe the results from a representative case and compare our experience with those of previously published reports.A 38-year-old male was referred for pain in the lower back and left leg. Radiographs and a needle biopsy specimen revealed a lumbar aneurysmal bone cyst, which was treated with denosumab chemotherapy. The pain in the lower back and left leg gradually improved, and at 16 weeks, the symptoms had resolved. Once a satisfactory local effect was achieved, denosumab therapy was discontinued. However, the erosive lesion subsequently expanded. After re-initiation of treatment, there was no subsequent evidence of recurrence.Single-therapy denosumab is an option for aneurysmal bone cysts. However, recurrences have been documented after denosumab termination, and the timing for cessation of denosumab is controversial. Aneurysmal bone cysts (ABCs) are rare, benign skeletal tumors. These tumors account for 1%-2% of all primary bone tumors, usually present in the first two decades of life, exhibit a slight female preponderance, and occur in the vertebral column in approximately 3%-30% of cases. Although benign, the lesions may involve all parts of the vertebrae, including the vertebral body, and frequently the posterior elements [There are various therapeutic options for ABCs; however, the optimal treatment for ABCs of the spine remains controversial. Treatments include curettage, excision, embolization, radiotherapy, and chemotherapy. The decision regarding the optimal option is based on personal and institutional experience and preferences, the location of the mass, and lesion size in most cases . AccordiDenosumab has recently been used to treat ABCs ,7. DenosThe aim of this study was to report the results from a representative case and compare our experience with those of previously published reports.A 38-year-old Japanese male presented with gradually progressive pain in the lower back and left leg for two months, and he was referred to our hospital for management. He had no other medical history. Examination of the spine showed localized tenderness of the L3 spinous process without a palpable mass. He had no lower limb muscle weakness or sensory disturbances. The Japanese Orthopedic Association score was 10/17.Plain lumbar radiographs showed an osteolytic lesion involving the left posterior portion of the L3 vertebra with a pedicle sign observed in the anteroposterior view Figure .Reconstructed computed tomography (CT) images revealed an expansile and destructive bone lesion in the body and left pedicle of the L3 vertebra Figure .Sagittal magnetic resonance imaging showed iso- and high-signal intensities on T1- and T2-weighted images, respectively, in the anterior portion of the L3 vertebra Figure .A needle biopsy was performed under CT fluoroscopy, and histological reports confirmed the diagnosis of an ABC without malignant features.Surgery was planned to prevent neurological symptoms and pathological fractures. However, tumor removal was difficult because of its proximity to the spinal canal and foramina, and due to his fear of surgical intervention, he wished for the treatment of denosumab based on sufficient informed consent. Therefore, the patient was treated with denosumab chemotherapy. The protocol used in treating giant cell tumors was followed: 120 mg denosumab was administered subcutaneously on days 1, 8, 15, and 29; subsequently, 60 mg denosumab was administered subcutaneously once every four weeks; and calcium carbonate (600 mg) and natural vitamin D (400 IU) were dispensed orally once daily to prevent hypocalcemia during denosumab administration.No adverse events occurred during denosumab therapy. The pain in the lower back and left leg gradually improved, and at 16 weeks, the symptoms disappeared. The size and number of cysts were noted to decrease on CT images, and the lesion completely ossified over time Figure , 4B. SubHerein, we present a case of lumbar spinal ABC treated with denosumab. The lesion regressed with denosumab therapy, and no side effects were observed. Locally aggressive ABC lesions invade not only the vertebral body but also the posterior elements, such as the pedicle and lamina. Boriani et al.  reportedZhu et al.  reportedDenosumab has recently been used to treat ABCs successfully ,7. DenosWe have reported the case of a 38-year-old Japanese male with lumbar ABC that involved the posterior portion of the vertebral body and left pedicle, resulting in radiculopathy. The optimal treatment of ABCs of the spine remains controversial; however, this case illustrates that single-therapy denosumab is an option for ABC.


Teaching Point: Bouveret syndrome can be diagnosed on plain film, ultrasound, computed tomography and magnetic resonance imaging by demonstrating Rigler’s triad which includes a dilated stomach, pneumobilia, and ectopic gallstone. An 81-year-old female presented at the emergency department with intermittent epigastric pain, coffee ground vomitus, and melena for four days.An esophagogastroduodenoscopy showed a fluid-filled stomach and multiple bulbar duodenal ulcers. A large round obstructing mass in the duodenal bulb covered in old blood caused gastric outlet obstruction. A contrast-enhanced computed tomography (CT) scan was performed to characterize the bulbar mass.A 3.7 cm diameter gallstone . There wTreatment included prepyloric gastrostomy with stone extraction.Bouveret syndrome refers to gastric outlet obstruction due to large, displaced gallstones in the duodenal bulb through a biliodigestive fistula. It is the rarest type of gallstone ileus, accounting for up to 3% of cases .The disease usually involves elderly females . ClinicaThe rarity of the disease combined with the nonspecific clinical presentation makes fast and accurate diagnosis difficult, facilitating morbidity and mortality rates .The disease starts with a calculous cholecystitis leading to adhesions between the gallbladder and duodenum. The gallstones can form pressure necrosis in the walls and eventually a cholecystoduodenal fistula. The gallstone dislodges through the fistula in the duodenum. When the gallstones are large, typically larger than 2.5 cm, they may obstruct the duodenal lumen causing gastric outlet obstruction . PressurImaging diagnosis is made by looking for Rigler’s triad: dilated stomach, pneumobilia, and ectopic gallstone. Diagnosis can be made on abdominal radiographs in 33% of cases. When a series of these radiographs are made, different locations of the gallstone confirm ectopic location. In that case it is called Rigler’s tetrad . During Treatment involves stone extraction preferably by esophagogastroduodenoscopy, but this is often unsuccessful, requiring surgical intervention .


Our case report describes the presence of a leiomyoma in the left-hand thumb of a 69-year-old woman, an extremely uncommon location for such a tumor. Leiomyomas are typically benign tumors that arise from smooth muscle, but their occurrence in the hand is unusual. While leiomyomas are more commonly found in the uterus, they may occasionally develop in the extremities, though this is more frequently observed in the lower limbs. These tumors typically present in patients in their third to fourth decades of life, and they are often not diagnosed until surgery because histological pathology is necessary to confirm the diagnosis. Leiomyoma is a benign, solitary tumor of the soft tissue that can arise from any area where smooth muscle is present . The uteVascular leiomyomas develop from the tunica media layer of veins . When thSurgical excision is the curative treatment for leiomyoma of the hand. This procedure is generally straightforward and effective, but the tumor may occasionally be located in close proximity to a nerve or vessel, particularly when it is situated on the volar aspect of the hand. In such cases, the use of magnifying loupes is recommended ,9.A female patient, aged 69 and in good health, visited the clinic due to a painless mass on the volar aspect of her left thumb that had been present for one year. The mass was a single subcutaneous nodule with a firm consistency that gradually increased in size over time but did not affect sensory function. The patient had no history of finger nodules or trauma. Hand X-rays did not show any bone abnormalities in the affected area. Surgical excision was performed with local block anesthesia using an incision over the flexion crease of the thumb. The mass was found to be attached to the flexor sheath and neurovascular pedicle Figure  and measLeiomyoma, also known as a fibroid, is a benign mesenchymal tumor that commonly grows in areas where smooth muscle is abundant . Such arLeiomyomas have been identified into three subtypes that include vascular, cutaneous, and deep soft tissue. Many studies claim that the most common type is vascular leiomyoma, which mainly arises from the tunica media layer of the vein . AlthougLeiomyoma is rarely found in the hand, and only a limited number of cases have been reported in the literature. Clinically, it may mimic other more common hand tumors, so it is important to consider other differential diagnoses as they may alter the treatment and surgical approach. Diagnosis is mainly achieved through surgical excision and immunohistochemistry. In our case, a preoperative diagnosis of ganglion cyst was made, and only after excision and postoperative analysis was it confirmed to be leiomyoma.


Abomasal ulcers, an economic concern for all calf-raising farms, are usually silent until perforation occurs, at which time management is complicated and often unrewarding. This case study describes perforating ulcer in a 3-day-old Brahman heifer, occurring secondary to a congenital narrowing of the pylorus and proximal duodenum and leading to marked abomasal distention, leakage, and eventual peritonitis and sepsis. Abomasal ulcers are lesions in the abomasum that penetrate the entire thickness of the mucosa and may extend through the submucosa and muscularis externa and reach the serosa. These may be single or multiple lesions , 2, and Ante-mortem diagnosis is often challenging. Clinical signs may be absent, subtle, or severe, ranging from general signs of gastrointestinal discomfort such as non-specific abdominal pain, dehydration, anorexia, and hypomotility of the rumen , 6 to heThe factors contributing to the development of the abomasal ulcers are numerous, with stress factors topping the list , 12. DieA 3-day-old Brahman heifer was presented for necropsy after written informed consent was obtained from the owner. History included failure to thrive and suspected sepsis that progressed to signs of abdominal distension and discomfort. The calf was treated at the University of Georgia Veterinary Teaching Hospital with a variety of therapeutic modalities, most notably intravenous fluid therapy, including dextrose supplementation, antibiotics, and non-steroidal anti-inflammatory drugs. Abomasal decompression was performed as well. However, in the absence of significant clinical improvement, the calf was humanely euthanized.External examination at necropsy revealed a state of dehydration, with sunken eyes and tacky subcutaneous tissues. The umbilicus was dry and unremarkable. A distinct red line was present at the gingiva adjacent to the teeth (“toxic line”), indicating probable sepsis, as suspected clinically.Internally, the most remarkable gross finding was a massively expanded, milk-filled abomasum. The expected size of the abomasum was 3–4X, and distinct plaques of fibrin were present at one area of the serosa along the greater curvature. Small amounts of fibrin were seen elsewhere in the abdominal cavity. The pyloric opening was markedly small (8 mm in diameter), and the proximal duodenum was similarly constricted, with a markedly decreased diameter compared with normal, for the proximal 20 cm see . AlthougHistologically, the abomasum in a focal area showed a marked diminution of the tunica mucosa and scattered inflammatory cells, predominantly neutrophils, present throughout the submucosa and muscularis, both of which were markedly stretched and with abundant edema see . Subjacein vitro.The cause of this calf's clinical problem was presumed sepsis. The marked narrowing of pylorus and duodenum created difficulty in passage of milk, undoubtedly also contributing to the animal's decline. Minimal ingesta was able to pass through the small opening, which resulted in milk accumulation and marked distension of the abomasum, with sufficient compromise of the wall to allow bacteria or milk molecules to enter the peritoneal space. Fibrin plaques directly over the area of the greater curvature which was where the most mucosal compromise was noted are strongly suggestive that leakage was occurring. The lack of significant aerobic bacterial growth from the joint swab is likely because the calf received antibiotics prior to death, resulting in inhibited growth in utero stress  for the publication of this case report.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.


Appendicitis, an acute inflammation of the appendix, affects all demographic groups and exhibits various incidences and clinical manifestations. While acute appendicitis typically presents with colicky periumbilical abdominal pain that localizes to the right lower quadrant, atypical presentations are more common in children, geriatric, and pregnant patient populations, leading to delays in diagnosis. Clinical evaluation, clinical scoring systems, and inflammatory markers are commonly used, but their limitations have led to the increased use of diagnostic imaging in patients suspected of appendicitis. Acute appendicitis is managed by non-operative and operative management, depending on whether it is uncomplicated or complicated. Developing diagnostic pathways to improve outcomes and reduce complications is crucial. Although medical advancements have been made, diagnosing and managing appendicitis can be challenging, mainly when patients are present atypically. This literature review aims to comprehensively review typical and atypical presentations of appendicitis and their current implications for diagnosis and treatment modalities in pediatric, adult, pregnant, and geriatric patient populations. The appendix has a diverse evolutionary history, and its purpose has been debated and researched for many years . Thus, aIn contrast, mortality rates are higher in the elderly . Some auAccording to population-based ethnicity statistics, appendicitis is more common in white-non-Hispanic and Hispanic groups and less common in Blacks and other race-ethnicity groups ,8. HowevAlthough the etiology of appendicitis is not always determined, it is thought to be multifactorial, including but not limited to environmental influences and genetic factors . PredomiConsidering that the intestine constantly secretes mucus, when the flow is disrupted, the intraluminal and intramural pressure increases, causing appendiceal distension and pain due to the sensitivity of the visceral nerve fibers. Entering a vicious cycle, mucus and intestinal bacteria accumulate, activating white blood cells to invade the lumen Figure .The severity of appendicitis inflammation determines the presentation of signs, symptoms, and complications, with progressive edema and ischemia potentially leading to thrombosis of surrounding blood vessels, weakening of the epithelial wall, and necrosis, ultimately resulting in perforation and potentially fatal peritonitis, although the omentum may sometimes form a peri-appendiceal abscess or phlegmon; alternatively, appendicitis may resolve spontaneously or with antibiotics, resulting in either recurrent episodes or spontaneous alleviation ,13,15.Limited research exists on the risk factors associated with acute appendicitis. Nevertheless, certain factors that could potentially influence the likelihood of developing the condition include demographic factors such as age, sex, family history, and environmental and dietary factors . StudiesNew evidence suggests a potential correlation between elevated temperatures and acute appendicitis, proposing that high temperatures could augment the likelihood of developing the condition through dehydration . Other aThe typical presentation of appendicitis is characterized by epigastric pain that initially arises around the umbilicus and subsequently migrates towards the right lower quadrant of the abdomen, accompanied by nausea, vomiting, loss of appetite, and low-grade fever. However, atypical clinical features of appendicitis may also occur, leading to potential delays in diagnosis and management. Consequently, this medical literature review aims to synthesize available data on common and uncommon clinical presentations of appendicitis and evaluate their impact on diagnostic and therapeutic approaches.Signs and symptomsClinical presentation of acute appendicitis depends on various factors, including the patient's age, duration of onset of symptoms, and anatomical variation of appendiceal position . It can Typical Signs and Symptoms of AppendicitisIn children, appendicitis has a variability in presenting complaints according to age groups . It is sA typical presentation of appendicitis in adults includes migratory right iliac fossa pain, anorexia, nausea with or without emesis, fever, and localized muscle rigidity/ generalized guarding -39. ClasPrevious studies on signs and symptoms show strong evidence of the association of migratory pain with appendicitis ,28. InitIn comparison, the Obturator sign involves pain in the right lower quadrant with passive right hip flexion followed by a right hip internal rotation. These signs have varying sensitivity and specificity in diagnosing appendicitis ,36,40,41The clinical presentation of appendicitis can also vary based on the anatomical location of the inflamed appendix ,40. AnatWith age, as the anatomy of the appendix changes, elderly patients do not usually present with all typical signs and symptoms of acute appendicitis, are RIF pain, fever, anorexia vomiting . In eldeThe severity of acute appendicitis can be evaluated based on rebound tenderness and rigidity in the right lower quadrant, as these findings are highly correlated . ReboundSudden settling or decrease in the severity of pain is a possible indication of a ruptured appendix as the pressure within the appendiceal wall decreases. Physical examination may reveal a triad of symptoms, including tachycardia, low-grade fever (37.8°C), decreased bowel sounds, and increasing tenderness over time. A rigid abdomen is a clear perforation indicator and should be monitored to prevent further complications ,33.Atypical Signs and Symptoms of AppendicitisIn addition to the typical presentation of appendicitis, atypical signs, and symptoms may also be observed. These may include left-sided abdominal pain, which localizes to the left upper quadrant. While a left-side appendix is relatively rare, occurring in approximately 0.02% of the adult population, it is more likely to occur in individuals with gut malrotation or situs inversus . AppendiChildren mainly present with vague symptoms making diagnosis difficult on history and examination. Atypical presentation of appendicitis in children may involve pain and tenderness along the entire right flank, extending from the right upper quadrant to the right iliac fossa. This could result from arrested caecal descent of the appendix, where the caecum is in the subhepatic position . Adult mPregnant patients are more likely to present atypical complaints such as gastroesophageal reflux, malaise, pelvic pain, epigastric discomfort, indigestion, flatulence, dysuria, and altered bowel habits . FurtherDiagnosisDiagnosing acute appendicitis (AA) is challenging as it presents varied symptoms and signs, and AA has been called a 'chameleon' of surgery for this reason . Many diClinical parameters in the Diagnosis of Acute AppendicitisThe most common symptoms of acute appendicitis are umbilical pain migrating towards the right iliac fossa, anorexia, and nausea with or without vomiting . Common Biochemical Parameters in the Diagnosis of Acute AppendicitisBiochemical markers such as total leucocyte count (TLC) and C- reactive protein (CRP) have been widely used in diagnosing acute appendicitis and differentiating complicated and uncomplicated appendicitis. A normal TLC and CRP combination has a high sensitivity and negative predictive value . Newer mRole of Scoring Systems in the Diagnosis of Acute AppendicitisClinical and laboratory parameters alone have little diagnostic accuracy for acute appendicitis. Different scoring systems have thus been proposed for correct diagnosis and risk stratification of patients. Alvarado scoring system was initially used in diagnosing AA, and it has high sensitivity but low specificity . Other sRole of Imaging in the Diagnosis of Acute AppendicitisImaging modalities for diagnosis of acute appendicitis include ultrasonography (USG) and cross-sectional imaging such as contrast-enhanced CT scan (CECT) and magnetic resonance imaging (MRI). CECT scan is considered the gold standard in diagnosing AA. However, USG is recommended as the first-line imaging modality for diagnosing children and adults. In patients with equivocal USG findings, a low-dose CECT scan is recommended in patients with suspected appendicitis . In highRole of Diagnostic Laparoscopy in the Diagnosis of Acute AppendicitisDiagnostic laparoscopy is recommended in patients with an atypical presentation, equivocal imaging findings, and persistent or worsening symptoms. It can serve as a diagnostic and therapeutic tool . It can Differentiation Between Uncomplicated and Complicated Acute Appendicitis9/L, and age >60 years are associated with complicated appendicitis [Since the treatment of uncomplicated and complicated appendicitis differs, it is essential to differentiate between them. However, no diagnostic modality sufficiently differentiates between them . Clinicandicitis .Management of appendicitisManagement of appendicitis is broadly classified into non-operative and operative.Non-operative Management of AppendicitisThe goal of non-operative management (NOM) is for patients to avoid surgery through antibiotics . Early sThe 2016 Jerusalem Guidelines and EAES guidelines recommend appendectomy as the preferred treatment for acute appendicitis and caution against the routine use of NOM ,88. HoweThere is currently no established antibiotic regimen for the non-operative management of acute appendicitis. Based on a recent meta-analysis, the optimal antibiotic regimen for non-operative management was recommended to be carbapenems . For comOperative Management of AppendicitisThe primary approach for treating appendicitis has been surgical, which was first suggested by Reginald Heber Fitz in 1886 and later refined by Mc Burney in 1889 through emergency laparotomy and a muscle-splitting incision now known as Mc Burney's incision -100. OveLaparoscopic vs. Open AppendectomyOpen appendectomy was the traditional surgical approach for acute appendicitis before the advent of laparoscopic appendectomy in 1981 . InitialLaparoscopic Single Incision SurgeryPrevious studies conducted a meta-analysis of randomized controlled trials comparing single-incision laparoscopic surgery (SILA) with conventional multi-incision laparoscopic appendectomy (CLA). They demonstrated no significant difference between SILA and CLA regarding complication rates, length of hospital stay, or post-operative pain. Regarding operative time and analgesic requirements, CLA demonstrated significant superiority over SILA, whereas SILA yielded significantly better cosmetic outcomes ,105. RecEndoscopic Retrograde Appendicitis Therapy (ERAT)Endoscopic retrograde appendicitis therapy (ERAT) is a minimally invasive procedure for treating appendicitis, with reported success rates ranging from 92.1% to 99.36% and low complication rates -108. ERANatural Orifice Transluminal Endoscopic Surgery (NOTES)In 2008, Palanivelu performed the first natural orifice transluminal appendectomy (NOTES) using a transvaginal approach . Since tManagement of Appendicitis With Atypical PresentationDiagnosing and managing patients presenting with atypical symptoms of acute appendicitis can be challenging, particularly in children, pregnant females, and elderly patients ,117. DiaDiscussionAcute appendicitis is a prevalent cause of acute abdominal pain in the emergency department worldwide ,124. TheThe clinical diagnosis of appendicitis is typically based on characteristic symptoms, such as colicky abdominal pain, nausea, vomiting, and low-grade fever . HoweverThe management of appendicitis depends on whether it is uncomplicated or complicated by perforation, abscess, or phlegmon. Non-operative management, consisting of patient observation, oral intake restriction, and intravenous and oral antibiotics, is recommended for cases of uncomplicated appendicitis ,130,131.In conclusion, efficient triage and diagnostic planning for patients with suspected appendicitis are crucial in improving healthcare outcomes due to the diverse range of atypical presentations, which can result in delayed or missed diagnoses. Patient age, anatomical location of the appendix, and pregnancy status are key factors that can influence atypical presentations. Accurate diagnosis and optimal clinical management can be achieved through clinical scoring systems, laboratory findings, and imaging modalities. When used in combination, these tools can reduce the incidence of morbidity and mortality. Despite ongoing debate regarding the optimal approach for achieving curative outcomes, laparoscopic surgery remains the preferred treatment for simple and complex appendicitis. There is insufficient evidence to support alternative operative management options. However, non-operative management, which involves intravenous antibiotics followed by conservative oral therapy, remains viable for uncomplicated appendicitis. It is important to note that diagnostic and management approaches may evolve with advances in medical technology and accessibility. This literature review provides an overview of managing appendicitis with an atypical and atypical presentation in various patient populations, encompassing pediatric, adult, geriatric, and pregnant patients. It also outlines the latest recommendations for treating acute appendicitis with typical or atypical signs and symptoms in these populations. However, it is restricted by the inclusion of studies published only in the English language. Additionally, information regarding patient preferences in guiding treatment decisions is sparse, and there need to be more needs to be more studies reporting the long-term impact of treatment on patient quality of life.


Tumors of the fourth ventricle account for 1%–5% of all intracranial neoplastic lesions and present with different configurations and anatomical challenges. Microsurgery represents the primary therapeutic strategy for the majority of fourth ventricular tumors, and adequate anatomical understanding and visualization are paramount to surgical planning and success. The authors present the case of a young patient with a complex fourth ventricular tumor, whose surgery was successfully planned using a novel mixed reality (MxR) system.We present a case of a 31-year-old woman with a lesion extending from the fourth ventricle to the lamina quadrigemina and causing symptomatic hydrocephalus occlusus. Through the combined use of routine 2D images and an interactive 3D anatomical model, an interhemispheric transtentorial approach was used to remove 98% of the lesion with successful functional outcomes.The application of advanced 3D visualization with a novel MxR system to the surgical planning of a complex fourth ventricular lesion proved relevant in designing the best surgical approach and trajectory to better identify potential intraoperative challenges and rehearse the patient-specific anatomy. The present case report endorses the implementation of advanced 3D visualization in routine perioperative practice. To date, the primary therapeutic strategy for tumors of the fourth ventricle is microsurgical removal –3. LesioThe authors describe a successful surgical approach for a complex fourth ventricular tumor extending until the lamina quadrigemina and infiltrating the basal veins designed using a novel mixed reality system.A 31-year-old woman presented with a 5-day history of double vision in all directions, holocephalic headaches, and nausea. Radiologic workup showed a hyperintense lesion extending from the fourth ventricle to the lamina quadrigemina and causing a hydrocephalus occlusus . An exteSurgical strategy and patient positioning were discussed based on routinely used 2D DICOM  images and further analyzed using 3D MxR technology.The novel MxR system utilized for holographic rendering and 3D visualization consisted of different components . The pri2D DICOM images from an external institution were loaded in a completely anonymized form on the novel CE-certified cloud environment  starting from the acquisition of an axial T1 MPRAGE with contrast medium . The magnetic resonance study was automatically segmented on the platform to highlight the skin, skull, brain, ventricular system, and tumor. Following the automatic segmentation, the tumor was further refined by means of manual segmentation on 3D Slicer (3D Slicer image computing platform | 3D Slicer) (Through the MxR glasses, the primary user could visualize the hologram in 3D and interact with it and project it onto the real anatomy of the patient, manually matching it using her head to review and plan surgical positioning and the approach .To manage the increased intracranial pressure caused by an occluded hydrocephalus due to the mass effect, a right frontal EVD was inserted a day prior to the removal of the tumor.Based on the combined analysis of 2D images and, most importantly, the 3D model, the patient underwent a parietal craniotomy with a subsequent interhemispheric transtentorial approach to the fourth ventricle. The MxR-3D visualization of the venous anatomy and the relationship of the tumor with the ventricular system was decisive in choosing a right parietal craniotomy to release maximally the right parietal vein frontally. This approach granted a straight trajectory posteriorly from the right parietal vein and right in the axis of the tumor. The 3D holographic visualization greatly helped in planning and rehearsing a surgical trajectory that could avoid the risk of injury of the basal cerebral veins. Furthermore, surgical planning with the 3D hologram endorsed the need to open the tentorium parallel to the straight sinus to achieve better intraoperative vision and control of the tumor . PatientTo confirm gross–total resection of the tumor, an intraoperative MRI was performed, revealing 98% removal of the lesion with a small remnant at the tectal level, which was too adherent to the great vein of Galen to be safely removed.Fourth ventricular tumors account for 1%–5% of all intracranial neoplastic lesions and represent two-third of the lesions of the ventricular system . To dateThe authors reported a complex case for which the use of MxR with an interactive patient-specific 3D anatomical model in adjunct with routine 2D images proved advantageous in gathering a better anatomical understanding and customizing the surgical approach and the intraoperative trajectory. Furthermore, surgical planning with MxR allowed a distinct patient positioning and a more realistic pre-operative analysis of the intraoperative surgical risks and challenges.The application of advanced 3D visualization with a novel MxR system to the surgical planning of a complex fourth ventricular lesion proved relevant to designing the best surgical approach and trajectory to better identify potential intraoperative challenges and rehearse the patient-specific anatomy. The present case report endorses the implementation of advanced 3D visualization in routine perioperative practice.


Traumatic diaphragmatic hernias (TDHs) can occur after both blunt and penetrating injury. Laparotomy and thoracotomy are commonly done for the management of TDHs. Minimally invasive surgery, especially laparoscopic surgery, is being accepted as an effective and safe alternative to open surgical repair even in trauma cases. Laparoscopy also allows for the detection and management of clinically occult TDHs, thereby preventing the complications of missed or delayed diagnosis. Our case highlights the importance of timely intervention with a minimally invasive approach.A 39-year-old male presented to the emergency room after a road traffic accident. Computed tomography scan confirmed left-sided diaphragmatic rupture with gastric herniation. Laparoscopic repair of the hernia was done. He had an uneventful post-operative period. At the one-year follow-up, he was asymptomatic and was doing well.TDHs have a variable clinical presentation and radiological findings are not always diagnostic. Such cases can progress to potentially life-threatening complications such as strangulation and perforation of the herniated viscera. Timely diagnosis and management are therefore essential. A minimally invasive approach such as laparoscopy should be used for the management of TDHs in the acute setting where the patient is stable, and resources are available. In this case, once the gastric contents were aspirated via a nasogastric tube in the middle of the night, the immediate need for surgery was converted to an urgent nature, and the patient underwent surgery the next morning in a more controlled setting. In addition, timely intervention can prevent future complications that may occur if the condition is left untreated during the initial admission. Traumatic diaphragmatic hernias (TDHs) can occur after both blunt and penetrating trauma. The diaphragm is a dome-shaped muscle separating the positive pressure in the abdominal cavity from the negative pressure in the thoracic cavity. This positive pressure gradient between the peritoneal and pleural spaces measures about 7-20 cm of water. When the diaphragm is ruptured, the viscera follow the pressure gradient and herniate from the abdominal cavity into the thoracic cavity .Laparotomy is commonly done for the management of TDHs. Although the first laparoscopic repair of a diaphragmatic injury was done in 1994 for a penetrating injury, the open approach is still commonly used as the standard . HoweverThis article was previously presented as a poster at the Biennial National Surgical Conference, Surgicon 2022, Society of Surgeons of Pakistan (Lahore chapter), on December 03, 2022.A 39-year-old male presented to the emergency room (ER) after his car rolled over and struck an oncoming sports utility vehicle (SUV). He was the driver of the car, while the passenger died on the spot. At presentation, he was tachycardic, with a GCS of 3/15, for which he was intubated in the ER. On examination, he had a 5 cm laceration on his forehead, along with decreased air entry at the base of the left lung.After initial resuscitation, a whole body computed tomography (CT) scan was done in the ER according to the trauma protocol, which showed a fracture of the tenth and eleventh ribs on the left side, as well as a large left-sided diaphragmatic hernia through which the stomach, omentum, and colon had herniated Figures , 2. BasiA laparoscopic repair of the TDH was planned, and the patient was taken to the operating room (OR) within a few hours. The open Hasson technique was used to create pneumoperitoneum, and a five-port approach was used. Intra-operative findings confirmed a 10 cm rupture of the medial end of the left dome of the diaphragm through which the stomach and omentum had herniated Figure . The gasThe herniated stomach and omentum were reduced into the abdominal cavity. Primary repair of the left dome of the diaphragm was done using 2/0 V-LocTM 90 sutures  in a continuous manner, as shown in Figure He was allowed clear liquids per oral from the first post-operative day, with progression to soft diet from the second post-operative day. His chest and abdominal drains were removed on the fourth post-operative day. He was discharged in stable condition on the eighth post-operative day. On the twentieth post-operative day, he developed gastroenteritis and went to a local hospital. Due to the recent surgery, the emergency physician vigilantly performed a CT scan of the chest to rule out any post-operative complications. It showed that the diaphragmatic repair was intact, without any evidence of herniation Figure . At the Traumatic diaphragmatic rupture and herniation are relatively uncommon. However, they are often occult injuries due to silent initial presentation and non-specific imaging findings. As a result, they often remain undiagnosed at the time of presentation. This can have long-term complications and is associated with significant morbidity and mortality. If left untreated, the mortality of TDHs can reach as high as 66% due to the incarceration and subsequent strangulation of the herniated viscera, as well as injury to the thoracic viscera. Therefore, the prompt identification of diaphragmatic hernias is essential and is an indication of immediate surgical intervention .The presentation of TDHs is highly variable. There are often both respiratory and abdominal symptoms . These dTDHs can be classified based on the time of diagnosis into three categories. Type 1 hernia is when the diagnosis is made immediately following trauma. In type 2 hernia, the diagnosis is made within the recovery period. Finally, type 3 hernia is when the diagnosis is delayed until the patient presents with ischemia or perforation of the herniated viscera .Various imaging modalities can be used for the diagnosis of blunt traumatic diaphragmatic rupture with or without herniation. These include chest X-ray, CT scan, and barium studies, for the evaluation of the diaphragmatic defect, including its size, location, and contents . HoweverThere are at least 19 documented CT signs, which can be classified into direct signs, indirect signs, and signs of uncertain or controversial origin. The direct signs include segmental diaphragmatic defect, Dangling Diaphragm sign, and absent diaphragm. The indirect signs can be further divided into those related to herniation, and those related to a loss of border between the thorax and abdomen. The indirect signs related to herniation include herniation through a defect, Collar sign , hump sign, band sign, dependent viscera, sinus cutoff sign, abdominal content peripheral to the diaphragm or lung, and elevated abdominal organs. The indirect signs related to loss of border between thorax and abdomen include abdominal fluid abutting a thoracic structure, abdominal viscera abutting thoracic fluid or a thoracic organ, pneumothorax/pneumoperitoneum, and hemothorax/hemoperitoneum. Finally, signs of uncertain or controversial origin include thickening of the diaphragm (curled diaphragm sign), diaphragmatic or peri-diaphragmatic contrast medium extravasation, hypoenhanced or hypoattenuated diaphragm, and fractured rib (with presumed laceration of diaphragm by rib trajectory) .The diaphragm tends to get ruptured at either the central tendon or the boundary between the central tendon and the muscular parts of the diaphragm. The left side is more commonly injured, with a reported 69 to 90% of TDH occurring on the left side. In contrast, the right side is only affected in about 9-24% of cases. The right-sided TDH tends to be more frequently undiagnosed, due to the low diagnostic accuracy of imaging modalities for the right-sided TDH than for the left-sided TDH ,8. The rMissed diagnosis of TDHs can result in long-standing, chronic, hernias. These can result in the formation of adhesions between the abdominal viscera and the thoracic structures, as well as with the diaphragm itself . This caLaparotomy and thoracotomy used to be the traditional surgical options available for the management of TDHs. Since the advent of laparoscopic surgery, it has become increasingly popular to opt for a minimally invasive approach for these cases . A minimThe usual method of management of TDHs involves the reduction of abdominal viscera into the abdomen, followed by repair of the diaphragmatic defect. This can be done via either the thoracic or the abdominal approach. Thoracic surgeons prefer the thoracic approach, whereas general surgeons usually prefer the abdominal approach. An abdominal approach is mandatory in case of suspicion of bowel ischemia and necrosis, or other traumatic injuries to the abdominal viscera.There is some debate over the type of closure. Most defects, especially smaller ones, can be repaired primarily. The American Association for the Surgery of Trauma (AAST) classifies diaphragmatic injuries into five grades; grade I (contusion), grade II (laceration ≤2 cm), grade III (laceration 2-10 cm), grade IV (laceration ˃10 cm with tissue loss ≤25cm2), and grade V (laceration with tissue loss ˃25cm2) . Larger The conventional strategy for trauma surgery has always been an open approach. However, this is no longer the standard of care. The laparoscopic management of surgical emergencies such as acute appendicitis, acute cholecystitis, and even perforated duodenal ulcers is now standard practice. The management of delayed presentation of diaphragmatic rupture is also commonly done with laparoscopy. Now, we are moving toward a minimally invasive approach for the management of TDHs in the acute setting provided that the patient is stable, and resources are available. Furthermore, a simple step like NG tube insertion and aspiration, after ruling out fracture of the base of the skull, can be life saving in certain situations.


Human hepatic fasciolosis has been reported in 81 countries, some of which are endemic areas. In Europe, case reports from humans were published in Portugal, Spain, France, and Italy. Regarding Romania, we do not have any data on the prevalence of this parasitosis, with the exception of two cases of twins that were born in Romania and diagnosed in the last 37 years in Italy after joining their mother that lived there. We report the case of a patient diagnosed in Romania with chronic fasciolosis, presented as a hepatic pseudotumor that was diagnosed during the histopathological examination of the hepatic lesion. The patient received oral treatment with triclabendazole, two doses of 10 milligrams (mg) per kilogram (kg) of body weight, given 12 h apart, with no side effects during or after the treatment. The evolution of the patient was favorable. In conclusion, even in areas free of human fasciolosis, the presence of an anemic syndrome especially in children, abdominal pain in the upper quadrants, associated or not with other digestive manifestations, even more so associated with eosinophilia in the acute phase, should be carefully evaluated for ruling out a parasitosis such as fasciolosis even in countries where this diagnosis seems unlikely. Fasciola spp. [Human hepatic fasciolosis has been reported in 81 countries, some of which are endemic areas, such as Bolivia, Peru, Ecuador, Iran, Egypt, Turkey, China, Vietnam, Nepal, Pakistan, and Syria. In North America, confirmed cases are attributed to foreign workers or immigrants from endemic areas. In Europe, case reports from humans were published in Portugal, Spain, France, and Italy. In total, 2.6 million people are estimated to be infected with We describe the case of a 55-year-old Caucasian female, who lived as a child in a rural area where sheep farming was practiced. She presents herself for investigations two months ago into the general surgery department for diffuse abdominal pain without dyspepsia, disturbances of gastrointestinal transit, fever, or weight loss. From the laboratory and imaging studies that were performed the following changes were reported: a slight eosinophilia of 0.360 k/microL , a C-reactive protein of 11.63 mg/L , and an abdominal ultrasound that highlighted a liver tumor. From the point of the serum tumor biomarker  the reported values were within reference values. An image from the abdominal ultrasound study is shown in The imaging studies were completed by an abdominal computerized tomography scan revealed the following pathological changes: liver with hypodense area in segments II–III in comparison with normal liver parenchyma, with an irregularly bossed contour, maximum dimensions of 50 × 47 × 30 mm, with enhancement following contrast administration in the periphery and transient hyperattenuation in the adjacent parenchyma in the arterial phase of the examination and a progressive loading with contrast and the tendency to homogenization in the venous and parenchymal phases. Cholecyst with homogeneous content, thin walls, without detection by computerized tomography scan cholelithiasis. The computerized tomography scan appearance is suggestive of an atypical hemangioma. Images from the abdominal CT-scan study are shown in −6 mm2/s . The lesion is imprecisely delimited, with an infiltrative pattern appearance, it involves both the capsule without its distortion and the medial contour of the third segment, where it does not show a plane of delimitation from the lesser curvature of the stomach on any of the pre-contrast and postcontrast images. The lesion presents a spontaneously inhomogeneous structure, with fine hypointense T2 discrete serpiginous images, that includes the distal branches of the bile and portal canaliculi without their distortion. Postcontrast sequences are suboptimal due to artifacts. Progressive contrast uptake from the portal phase, with quasi-complete homogenization in the late phase that becomes isointense compared to the rest of the parenchyma (fading), and in the arterial phase perilesional transient hepatic attenuation differences images are present—the described aspects suggest lesion with magnetic resonance characteristics of malignancy , or less likely, atypical hemangioma. No other suspicious local lesions in the rest of the hepatic parenchyma. Without dilation of the intrahepatic bile ducts and of the extrahepatic bile ducts. Cholecyst with homogeneous content, thin walls, without detectable by magnetic resonance imaging cholelithiasis. Images from the MRI study are shown in An abdominal magnetic resonance imaging (MRI) was also performed, and the following results were reported: hepatic measurements within normal range, clearly inhomogeneous capsular outline due to the presence of a slightly hyperintense T2 and T2-FS (Fat saturation), hypointense T1 lesion, without any changes in in-phase and out-of-phase sequences, located peripherally in segments II and III, markedly restrictive in Diffusion-weighted imaging/apparent diffusion coefficient (DWI/ADC), with a slight signal drop on high B acquisition (B800) and average ADC values of approx. 1100 × 10The decision to undergo a surgical intervention was made via a laparoscopic approach. Under ultrasound guidance, a tumor formation of approximately 2 cm is detected at the level of hepatic segment III. A laparoscopic liver segment III resection was performed.F. hepatica. On Trichome Masson staining, Charcot–Leyden crystals stand out better. Conclusion: Eosinophilic hepatic granulomas with massive central necrosis, with histological appearance of F. hepatica. Histopathological aspects are reported in The histopathological examination of the lesion reveals numerous giganto-epithelioid granulomas with a central area composed of a dense inflammatory infiltrate, predominantly represented by eosinophils, on the background of which Charcot–Leyden crystals, necrosis, and cellular detritus are identified. In the periphery, epithelioid histiocytes have been identified as palisade in the central area, with the presence of lymphocytes around the histiocytes. Kupffer cells hyperplasia is also associated with the inflammatory process. One of the granulomas contains eggs of the The patient received oral treatment with triclabendazole, two doses of 10 milligrams (mg) per kilogram (kg) of body weight, given 12 h apart, with no side effects during or after the treatment. The favorable evolution of the patient was the result of an interdisciplinary collaboration between multiple specialists, who helped to take care of this case.F. hepatica and F. gigantica species, with a geographical distribution in 81 countries [F. gigantica being responsible for most cases diagnosed in Asia and Africa [F. hepatica in the sampled material was observed. Genetic examination revealed remarkable differences from native specimens, excluding the infestation in Italy [Human fasciolosis is a zoonosis disease caused by the ingestion of food, water, and combinations of both ountries , being rd Africa ,5,6,7. Gin Italy . Areas win Italy ,10, Iranin Italy , and Sauin Italy . In Euroin Italy ,13, and in Italy ,14, whilin Italy ,17,18,19F. hepatica is a parasitic trematode of the class Trematoda, phylum Platyhelminthes, order Plagiorchiida, family Fasciolidae, which has snails as an intermediate host and ruminants  as being the typical definitive hosts. In terms of the morphological aspect, it is compared to pumpkin seeds, or leaves, with dimensions reaching up to 3–4 cm. As previously mentioned, two species of Fasciola are recognized as responsible for fasciolosis in humans, namely F. hepatica with the previously mentioned dimensions and F. gigantica, which can reach up to 75 mm. F. hepatica has a simple morphological structure, without circulatory or respiratory systems, with two suction cups (suckers) on the ventral side (mouth and acetabulum), a digestive system with a simple structure—where waste materials are discharged—the mouth, which ensures the circulation of food principles and gases. An excretory system (with excretory and osmoregulatory functions) and a nervous system, represented by a pair of nerve ganglia grouped in the anterior segment of the F. hepatica  and lateral nerve cords, located in the posterior segment. The outer surface of F. hepatica is called tegument, a syncytial epithelium made up of a scleroprotein that protects against the lytic action in the digestive system of the host but also has a role in restoring the surface plasma membrane as well as in the absorption of nutrients, some of which are protective in the digestive system of the host, such as taurine. Through certain skin components, such as the Teg antigen, the immune response of the host is reduced contributing to the survival of the F. hepatica, which manages to complete its life cycle with the appearance of the adult form [F. hepatica is a hermaphrodite worm that multiplies both sexually and asexually. It lays eggs in the bile ducts, from where they are passed out through excrement and can be released into the freshwater environment, with the release of larvae. There are over 30 snail species shown to be intermediate hosts of F. hepatica particularly species in the genera Radix, and Galba. The distribution of the intermediate host represents the key to sustaining the parasite in endemic areas and its distribution in overlapped to the one of F. hepatica. Miracidia hatch from eggs and seek to penetrate the snail’s intermediate host. Snail infection generates large numbers of cercariae from a single miracidium. Free swimming cercariae disperse a few meters where they encyst into metacercariae, attach to aquatic plants, or reach the grass. The mammal  acquires the infection by ingesting metacercariae from water or leafy vegetables. Metacercariae excyst after ingestion in the intestine and release the immature parasites that migrate through the intestine wall, the abdominal cavity, and the liver to reach the bile ducts where another life cycle begins. Humans accidentally become definitive hosts in unusual circumstances by consumption of improperly cooked liver that is infected and contains immature forms of the parasite, from drinking contaminated water and eating freshwater plants such as watercress [Fasciola is reported in ult form . The genult form . At a hetercress ,20,21,22Saba et al. report clinical data from an observational study of 53 cases diagnosed in Antalya, Turkey, over a period of 5 years (1998–2003), more frequently in female patients , 28 of them being diagnosed in the acute phase, and 19 in the chronic one. There were 6 other cases in the latency stage, either serologically, starting from eosinophilia or by imaging studies that were requested by patients for different digestive manifestations .The infection in humans, in the acute phase, can evolve as a prolonged febrile syndrome, difficult to diagnose in areas where fasciolosis is not endemic, and liver lesions are suggestive of subcapsular hematomas. Cases with dyspeptic manifestations , and arthralgia are also described; other manifestations that have been reported are: liver abscesses, cholangitis, and biliary obstructions. The most common symptoms that were reported by the patients were epigastric abdominal, and then in the right hypochondrium pain, and malaise. For chronic cases, the most frequently described symptoms after pain in the same location were nausea and fatigue. Other symptoms described were pruritus, coughing, diaphoresis, and weight loss. In the chronic phase in animals, fasciolosis is characterized by the appearance of fibrosis, cirrhosis, or inflammation of the bile ducts. Aspects related to anemia both in the acute and chronic phases are described, especially in children, with weight loss and malnutrition, and neurocognitive disorders. Eosinophilia is present in the acute phase of the disease; it may be absent in the chronic phase ,26,27. SOther authors have reported cases of reactive hepatitis, subcapsular hemorrhages ,29, or sF. hepatica [The treatment of choice for patients over the age of 6 years old is with triclabendazole, a benzimidazole drug, active on the immature and adult parasite, which interferes with the β-tubulin polymerization balance, disrupts the skin of the parasite, and inhibits the protein synthesis of hepatica . It is rhepatica . Other aF. hepatica with nitazoxanide but it was discontinued due to oral intolerance, and later she received a single dose of 250 mg triclabendazole with a favorable outcome [Castillo Contreras et al. report a similar case of hepatic pseudotumor in acute fascioliasis, the lesion is localized in the 6th and 7th liver segments. The patient received initial treatment for  outcome .Except for the cases diagnosed in Italy, coming from Romania, we did not find in our literature review any case reports with human hepatic fasciolosis diagnosed in our country in the last 37 years. In terms of historical data, Neghina R. et al. report sporadic cases in Romania over time. The authors report between 1929 and 1986; 17 cases were described in Romania . UnfortuIn conclusion, even in areas free of human fasciolosis, the presence of an anemic syndrome, especially in children, and abdominal pain in the upper quadrants, associated or not with other digestive manifestations, even more so associated with eosinophilia in the acute phase, should be carefully evaluated for ruling out a parasitosis such as fasciolosis even in countries where this diagnosis seems unlikely.


Antibioma is a tough-walled abscess, which usually forms as a sequela of inadequate or lack of pus drainage during infection and inappropriate use of antibiotics by the patient. In this case report, we present a case of the development of antibioma due to infected polypropylene mesh used in umbilical hernia repair 10 years ago in a 59-year-old obese male. He had a history of umbilical and right inguinal hernioplasty 10 years back. Intraoperatively, we found antibioma whose wall was made up of fibrous mesh and the center was filled with pus and nonfibrous mesh remnants. The pus was found to be sterile, and the wall was made up of fibromuscular adipose tissue with chronic inflammatory cells around it. This is a very rare presentation of umbilical site deep mesh infection as it had no signs of acute inflammation, neither pain nor any pus discharge. We conclude that the possible explanation for the formation of antibioma and its very delayed presentation could be due to mesh infolding and seroma/hematoma formation during previous surgery may have led to the formation of abscess and thick fibrous wall without any fistulous tract and other complications of deep mesh infection. Use of mesh for hernia repair dates back to 1989 when Lichenstein introduced tension-free mesh repair for lower recurrence rates and less postoperative pain . PostopeAntibioma is a chronic tough fibrous abscess formed commonly due to prolonged and inappropriate use of antibiotics for infections. In this case report, the patient underwent umbilical hernia repair and an abscess was formed, but due to lack of pus drainage and lack of proper follow-up in the postoperative period with inappropriate use of antibiotics, he developed a sterile pus-containing antibioma, which was asymptomatic .mature fibrous cyst has been used by many authors. Until now, only 18 cases of giant abdominal pseudocyst post mesh hernioplasty have been described in the literature, which develops within a mean period of one to 24 months from index surgery, and in all the cases, the cyst contained serous fluid [Another rare complication following mesh hernia surgery is a mature fibrous cyst, which was first described in 1993 by Waldrep et al. . The terus fluid . We present a case report of late-onset deep mesh infection of umbilical hernia presenting as antibioma. The patient also had a recurrent umbilical hernia and epigastric hernia, 10 years after initial surgery, with no symptoms and signs of deep mesh infection and a positive history of obesity and smoking. This was a never seen or documented case of antibioma forming around a polypropylene mesh.Case historyA 59-year-old male presented with a complaint of epigastric and recurrent umbilical swelling for two years; the swelling was insidious in onset and progressive in nature and increased on coughing and decreased on lying down, not associated with pain. The patient had been known to be hypertensive and on medication for the last four years and smoking tobacco for 12 years, which is associated with chronic cough. The patient has a history of umbilical hernioplasty and right inguinal hernioplasty 10 years back, but no documents are available. Following surgery, he has a history of taking a prolonged antibiotic and pain medication for postoperative pain, but no documents are available. The patient has no bowel and bladder complaints, and sleep and appetite are normal. On examination, there is 10 cm  × 7 cm  swelling over the epigastric region in the midline with normal overlying skin and swelling becoming more prominent on head raising  suture in a continuous interlocking manner. Polypropylene microporous synthetic mesh measuring 20 cm × 15 cm was kept in the retrorectus plane after a thorough saline wash and fixed to the posterior rectus sheath using interrupted sutures and the anterior rectus sheath closed using interrupted Prolene 1-0 suture Figure . Two mulNo case of mesh antibioma has been found in the literature until now; we have discovered a new presentation of deep mesh infection. Classically, deep mesh infection presents as acute inflammatory changes around the surgical region whose presentation can vary from months to years after surgery . In the Antibioma can be confused with the diagnosis of a mature fibrous cyst or abdominal pseudocyst, which is a rare complication of hernia surgery, which follows seroma formation post mesh placement and usually presents at three to 24 months post index hernia surgery -15. It iWe conclude that late-onset deep mesh infection could also present silently as antibioma, without any acute inflammatory signs or fistulas. The mesh should be placed such as it is in full contact with the tissue, and no potential space should be left for seroma/hematoma/abscess formation. Sterile techniques to handle the mesh should be advocated in all cases. The use of negative suction drains over the mesh to eliminate the formation of seroma, or any collection in large hernia repairs has a very positive outcome and prevents postoperative and long-term complications. The placement of mesh in the retrorectus plane separates the mesh from both potential sites of bacterial translocation, i.e., the deep peritoneal cavity and subcutaneous space, as well as having less chance of recurrence. Mesh fixation in crucial places is of utmost importance to prevent mesh folding, migration, seroma, hematoma, and abscess formation. In retrorectus mesh fixation, we used Prolene 2-0 interrupted fixation to the posterior sheath meticulously, which is also a good way to fix the mesh, avoiding the full thickness fascial sutures, as described in classical Rives-Stoppa repair and hence less postoperative pain and faster recovery.


The usefulness of laparoscopic and endoscopic cooperative surgery (LECS) for gastric submucosal tumors in the cardiac region has been reported in recent years. However, LECS for submucosal tumors at the esophagogastric junction with hiatal sliding esophageal hernia has not been reported, and its validity as a treatment method is unknown. The patient was a 51-year-old man with a growing submucosal tumor in the cardiac region. Surgical resection was indicated because a definitive diagnosis of the tumor was not determined. The lesion was a luminal protrusion tumor, located on the posterior wall of the stomach 20 mm from the esophagogastric junction, and had a maximum diameter of 16.3 mm on endoscopic ultrasound examination. Because of the hiatal hernia, the lesion could not be detected from the gastric side by endoscopy. Local resection was considered to be feasible because the resection line did not extend into the esophageal mucosa and the resection site could be less than half the circumference of the lumen. The submucosal tumor was resected completely and safely by LECS. The tumor was diagnosed as a gastric smooth muscle tumor finally. Nine months after surgery, a follow-up endoscopy showed reflux esophagitis. LECS was a useful technique for submucosal tumors of the cardiac region with hiatal hernia, but fundoplication might be considered for preventing backflow of gastric acid. Recently, the usefulness of local excision by laparoscopic and endoscopic cooperative surgery (LECS) for submucosal tumors in the region of gastric cardia has been reported, and it has become one of the treatment options . HoweverThe patient is a 51-year-old male, height 159.9 cm, and weight 67.8 kg. He had a gastric submucosal mass with a diameter of 10 mm at a medical checkup seven years earlier. The mass was followed up by ultrasound endoscopy every year and did not change in size, but this time, it was 16.3 x 14.7 mm in diameter and showed a tendency to increase. Thus, the patient underwent a thorough examination including fine needle aspiration under endoscopic ultrasonography.Upper gastrointestinal endoscopy revealed a hiatal hernia with a sliding esophageal hiatal hernia. The mass was located on the posterior wall just below the esophagogastric junction and was a lumen protruding lesion. It could be localized from the esophageal side but was not visible from the gastric lumen due to a hiatal hernia Figure , 1B. UltCT findings: A 17-mm large mass with well-defined margins was observed in the gastroesophageal junction Figure -2C. ContHistopathology: Hematoxylin and eosin (HE) staining showed that the majority of the lesion consisted of spindle-shaped cells with deposition of acidophilic material Figure . ImmunohSurgical findings: Under general anesthesia, the patient was placed in the open leg position. Five ports were placed at the umbilicus, right hypochondrium, right side of the abdomen, left hypochondrium, and left side of the abdomen. The extrahepatic area was elevated with a silicone disk to secure the field of view. First, the periampullary mesentery was treated, and the esophagogastric junction area was dissected from the diaphragmatic leg in preparation for resection of the lesion. The posterior trunk of the vagus nerve was taped and preserved. After dissection of the mesentery around the esophagogastric junction, the lesion could be easily identified by endoscopic inversion from the gastric side. An endoscopic submucosal incision around the mass was made Figure . The gasPostoperative pathology: HE staining showed spindle-shaped cells like a preoperative aspiration sample Figure . ImmunohPostoperative course: Fluid intake was started the day after surgery, a liquid diet was started on the third day, and the diet had been transitioned to ordinary food day by day. The patient started to eat a regular diet on day seven. He was discharged on the ninth postoperative day. An endoscopic survey was performed nine months after the surgery and showed hiatal hernia and reflux esophagitis graded Los Angeles B Figure , 6B. TheIn this case, LECS was useful for a gastric submucosal tumor in the esophagogastric junction region associated with a sliding hiatal hernia technically. However, adding fundoplication after local excision might be considered to prevent the recurrence of hiatal hernia and reflux esophagitis.According to the diagnostic algorithm of GIST practice guidelines, patients with resectable localized gastrointestinal submucosal tumors that are asymptomatic, biopsy-undiagnosed, and less than 2 cm in size are basically followed up [EUS-FNA is often sufficient to obtain a specimen for a gastric submucosal mass lesion, and a diagnosis can be made by combining HE staining and immunohistochemical staining . In thisFor gastrointestinal submucosal tumors for which a preoperative diagnosis cannot be made, a partial resection with a reserved resection margin is performed based on the GIST treatment plan. In the past, gastric submucosal tumors were often treated by laparoscopic wedge resection using an automated suture device ,10. HoweFurthermore, this case was accompanied by a slipped hiatal hernia of the esophagus. Thus, more ingenuity was required to ensure safe and reliable resection of the lesion. Although various techniques were used in the previous gastric submucosal tumor cases, there were no reports of cases with esophageal hiatal hernias. In LECS, it is of course important to have a good view laparoscopically, but it is also important to have a good view endoscopically as well. The lesion was difficult to see through the stomach preoperatively due to a hiatal hernia, but a good endoscopic view could be obtained by laparoscopic dissection of the esophagogastric junction Figure .Asymptomatic hiatal hernia without gastroesophageal reflux disease (GERD) is not usually treated surgically. According to the guidelines for the treatment of GERD, medication is the first step even in the presence of symptoms . In the However, we had to carefully consider the procedures for treatment. Because even if the patient had no symptoms before surgery, the diaphragm crus were dissected and separated from the gastrointestinal tract. As a result, it made gastric cardia looser. We decided to suture the diaphragm crus with a non-absorbable thread in order to reduce the risk of clinical manifestations associated with dissection around the diaphragmatic crus. Due to the lack of a related report, we were not sure whether to add fundoplication or not. However, because the original hernia was minor, we have not performed a fundoplication in this case. The results suggest that it may have been better to add fundoplication, but since this is a single case study, further case series are warranted to determine whether fundoplication is necessary after local resection of submucosal tumors in the esophagogastric junction region with esophageal hiatus herniation.We report a LECS technique for patients with sliding hiatal hernia in which the tumor site is located near the esophagogastric junction.LECS was technically useful as a treatment approach for a gastroesophageal submucosal tumor associated with a sliding hiatal hernia. However, we might consider adding fundoplication for preventing the recurrence of hiatal hernia and reflux esophagitis.


An 11-year-old boy presented to the Out Patient Department (OPD) with a slow growing, asymptomatic lesion on his left shoulder region. The lesion was present since birth and had gradually increased in size over time. The patient reported no pain or discomfort associated with the mass. Physical examination revealed erythematous clusters of translucent intact vesicles, containing clear fluid of varying sizes (2 mm - 5 mm) with few crusts on the left shoulder (A). Few vesicles had ruptured, however there was no evidence of local inflammation or cellulitis. Few of these channels were filled with clear fluid (B). Dermoscopy revealed frogspawn like lesions with white lined structures (C). Hence, the diagnosis of lymphangioma circumscriptum was made. The patient was referred to a plastic surgeon for excision of the lesion. Post-operative healing was uncomplicated, and the patient made a full recovery and was discharged and monitored for recurrence. Cutaneous lymphangiomas are a rare congenital malformation of the superficial cutaneous lymphatic ducts. Lymphangioma circumscriptum (LC) is a lymphatic malformation that is composed of superficial lymphatic vessels, microcysts on the skin or mucous membrane. They occur as a result of an error in the morphogenesis of the lymphatic vessels, leading to a disorder of lymph drainage. It is clinically defined by a clustering of vesicles with varying content in blood. The symptoms may include pruritus, pain, burning, lymphatic drainage, infection, and aesthetic concerns. Although dermoscopy plays a major role in the diagnosis, histology remains the gold standard for diagnosis.