Endodermal sinus tumor (EST) is a malignant tumor originating from the ovary or testis. In most case, ultrasound examination shows ovarian mass. But there is a special kind of extra-gonadal endodermal sinus tumor, which occur in organs other than gonads with insidious onset. Here we reported a case of endodermal sinus tumor, which originated from the sacral ligament presenting as an acute lower abdominal pain.A 14-year-old girl was admitted to the hospital because of acute lower abdominal pain. The ultrasound showed a mass with 72 mm × 64 mm × 50 mm in Douglas, and there was no abnormality in bilateral ovaries and fallopian tubes. Laparoscopic exploration showed a large amount of blood clots in the pelvic cavity. After removal of the blood, we found rotten fish-like tissue in the left sacral ligament, rapid pathology suggested endodermal sinus tumor. After the operation, we retrospectively examined the value of alpha-fetoprotein (AFP), which was found to be elevated, and post-operative paraffin pathology confirmed the diagnosis. After four cycles of BEP chemotherapy, exploratory laparotomy was performed to remove the visible lesion, but postoperative pathology showed no abnormality. At the one-year follow-up, the patient remained recurrence-free.Extra-gonadal germ cell tumors are rarely reported. When young teenagers complain of acute lower abdominal pain with elevated AFP, but there was no lesion in bilateral ovaries and fallopian tubes, we must think about the possibility of endodermal sinus tumors. Accurate diagnosis facilitates complete resection of lesions and improves patient’s outcomes. Endodermal sinus tumor (EST), also known as yolk sac tumor (YST), is a typical germ cell tumor (GCT), which can occur in the gonads or extra-genital glands. Germ cell tumors are more common in the testes and ovaries. Extra-gonadal germ cell tumors are very rare, with an overall incidence of 1.8 to 3.4 per 1 million in the United States . Extra-oA 14 years old girl was admitted in our hospital complaining with severe lower abdominal pain accompanied with nausea and vomit, which occurred during dinner. Menarche is 11 years old and the menstrual cycle is irregular. Gynecological examination was not performed because the girl was not sexually active. Physical examination showed mild tenderness and rebound tenderness. General hematological parameters such as blood routine and electrolyte check were normal. Ultrasonography showed the bilateral ovaries and fallopian tubes was normal, but an uneven slightly higher echo photophore was found at the back of the uterus, the size was about 72 mm × 64 mm × 50 mm, the boundary was unclear, the morphology was irregular. But the boundary of the ovaries was very clear. Meanwhile, we found a lot of fluid in liver and kidney fossa and bilateral iliac fossa (Fig. Considering relief of the pain and the possibility of intra-abdominal bleeding, we performed laparoscopy. During the operation, we found liquid blood about 500 ml in the abdominal cavity Fig. a. After When removing the mass, we detected some rotten fish fleshy tissue Fig. d. Rapid Twenty-two days after the laparoscopy, this girl experienced 4 courses of BEP chemotherapy. At the end of the third chemotherapy, we found AFP decreased to 6.5 ng/ml. Two months after the last chemotherapy, the patient underwent CT examination, which showed a lesion about 1 cm in the douglas sac (Fig. 90% of GCT are found in the gonad and 10% of case existed in different extra-gonadal sites. Moreover, the most common extra-ovarian sites of EST are mediastinum, vagina, brain and retroperitoneum . EST oriSerum AFP measurement has an important role in the diagnosis of EST, assessment of efficacy and monitoring of recurrence or metastasis , 6.On ulHowever, the diagnosis still depends on pathological examination. Typical histological features include reticular microcystic areas with hyaline globules and amorphous acellular basement membrane material . Among tExtra-glandular germ cell tumors are rare and are found in most structures along the midline, with the probability of 46% to experience of occurrence in the brain. The mechanism of extra-gonadal EST is still not well defined. Nowadays, there are two main hypotheses about the causes of extra-gonadal germ cell tumors. The first hypothesis maintains that the anomaly in somatic cells differentiation is responsible for the origin of the tumor. This could be a possible explanation for the occurrence of yolk sac tumors in stomach, endometrium or lung . The secTo date, no treatment guidelines have been developed for extra-gonadal YST because of the rarity of the disease. Previously, the conventional view was that the prognosis of EST was extremely poor, regardless of the primary site. In the last decade, the treatment paradigm of adjuvant chemotherapy after surgery has significantly improved the survival rate of patients. Vincristine, actinomycin D, cyclophosphamide and vincristine, bleomycin and cisplatin have been used to treat patients with ovarian and extra-ovarian EST , 21. RecOur case was a typical extra-gonadal germ cell tumors originated from the left sacral ligament with normal ovarian structure. Maybe, it results from the misplace during embryonic migration. The mass envelope was ruptured with bleeding, which may contribute to the patient’s abdominal pain. The mass was seen to be rotten fish-like with abundant blood flow. After complete resection of the mass, intraoperative rapid pathology suggested that the mass was suspicious for a malignant tumor of genital system. Regrettably, we did not resect the omentum and lymph nodes intraoperatively. Postoperatively, we diagnosed EST by paraffin pathology and the above mentioned tumor markers.In general, in adolescent girls, pelvic masses occurring outside the uterus and bilateral adnexa mainly included endometriosis, inflammatory pelvic masses, and gastrointestinal malignancies. In our case, a girl without sex activity had a huge mass in the posterior part of the uterus, it is impossible to have endometriosis or pelvic inflammatory diseases. Therefore, we should have been alert to the possibility of malignancy tumor to test the tumor markers and performed imaging prior to surgery when possible. Unfortunately, we made a misdiagnosis for no testing of tumor markers, such as AFP and did not resect the omentum and lymph nodes during the operation. Fortunately, the tumor did not metastasize and we intactly removed the mass. Four courses of standardized chemotherapy were given after surgery, and the patient’s AFP decreased significantly after surgery. We found no recurrence during follow-ups. As mentioned above, less invasive surgery accompanied with standard chemotherapy seems to be the better treatment modality for patients with EST. In addition, in China, adolescent girls do not routinely undergo ultrasound examinations. Ultrasound examinations are performed only experiencing lower abdominal pain or abnormal vaginal bleeding. In this case, if the patient had not had lower abdominal pain, she would not have been able to detect a mass in her pelvis, let alone to detect a malignant tumor. Therefore, we should pay more attention to the routing medical examination for women especially for those who has family history of malignant. In conclusion, we must remind the existence of extra-gonadal germ cell tumors, especially for those teenagers who present with mass in pelvic, but no lesion in the ovary, which helps us to make appropriate treatment for them.


Case Presentation. We report the case of acute gallbladder volvulus in an 80-year-old woman complaining of constant pain in the right upper quadrant of the abdomen.  A gallbladder torsion typically presents as an acute abdomen presentation with nonspecific clinical signs. When not detected by a clinician preoperatively, it can lead to the delay of emergency surgery and possible misdiagnosis for other, more common causes of an acute abdomen.  The patient was successfully treated with cholecystectomy. The case highlights the high index of suspicion required to diagnose the condition preoperatively in this population of patients to reduce complications such as biliary peritonitis and death. The gallbladder volvulus is defined as the rotation of the gallbladder on its mesentery along the axis of the cystic duct and cystic artery . Since iAn 80-year-old woman was admitted to Dar Al Amal University Hospital complaining of constant pain in the right upper quadrant of the abdomen for approximately 12 hours in duration. The pain was associated with nausea and vomiting, without jaundice or hyperthermia. The patient's past surgical history revealed a bipolar fixation of the left hip for a fracture. Her observations were all within normal ranges.A focused examination elicited right upper quadrant tenderness and a positive Murphy's sign. Laboratory data showed a high C-reactive protein (CRP) of 336.6 mg/L, but other lab tests such as bilirubin and other liver function tests were within the normal range. It was decided to commence intravenous fluids and broad-spectrum antibiotics. Abdominal ultrasound (US) demonstrated a large cystic lesion in the right infrahepatic region, suggestive of a distended gallbladder with wall thickening without stones. A computed tomography (CT) examination showed the gallbladder to have marked wall edema suggestive of acalculous acute cholecystitis, measuring 10 cm in largest diameter, as shown in The patient was scheduled for laparotomy after presenting with right upper quadrant pain with elevated inflammatory markers and having associated nausea and vomiting. This was decided as compared to laparoscopy to reduce the surgical time and possible deterioration of the patient. Intraoperatively, a distended gangrenous gallbladder, as shown in The diagnosis of gallbladder volvulus, preoperatively, is difficult. The nonspecific signs and symptoms suggest an acute infective pathology and prompt clinicians to manage it with resuscitation and appropriate antibiotic therapy . TherefoIt had initially described a triad known as “the triad of triads” which was recommended to aid clinicians in discriminating this condition from acute cholecystitis . It inclParticularly in our case, CT imaging suggested a diagnosis of acalculous cholecystitis or cholecystitis without a stone. Acalculous cholecystitis accounts for 10% of all cases of acute cholecystitis . The conThe diagnosis of this disease should be considered in all patients  presenting with right upper quadrant pain (RUQ) that is unremitting despite adequate medical treatment. Our case was diagnosed intraoperatively, but it is recommended that, when suspected, gallbladder volvulus should be diagnosed as soon as possible. This is essential to prompting early surgical exploration. If not, it can result in further unresponsiveness and deterioration of patients. It is also important to consider other possible differentials which can lead to similar presentations of deterioration such as cholecystitis with an unidentified stone or other causes of blockage of the cystic duct which can also develop into a necrotic or perforated gallbladder. Early diagnosis and treatment can eliminate many sequels such as gallbladder rupture and biliary peritonitis.The strength highlighted in our case includes revealing risk factors that should be considered when suspecting a case of gallbladder volvulus to reinforce the need for early diagnosis and improve the prognosis for patients. Nonetheless, requesting high-resolution imaging for early diagnosis of the suspected case using MRI and MRCP is practically more difficult to achieve in the hospital environment. This would be a preferable imaging modality for stable patients. This was exemplified using CT imaging to provide more nonspecific findings which could potentially delay intervention in such critical cases. Despite a laparotomy being performed in this case, a laparoscopic approach remains easy and feasible and is the first choice for intervention in this case. Given the potential deterioration of the patient and the availability of resources in the Lebanese hospital, a laparotomy was undertaken. Detorsion is not always necessary if structures are well identified.Despite the disease being known for centuries, the management has not significantly changed. A gallbladder torsion is a rare surgical emergency which requires a high index of suspicion to diagnose the condition preoperatively and to intervene promptly. Optimal patient outcomes are seen when combining early diagnostic imaging and surgical intervention to remove the gallbladder. Emergency surgery as a treatment option should be carried out based on clinical deterioration and suspicion of complicated cholecystitis. Gallbladder volvulus could be kept in mind but it is not necessary, even futile, useless, and potentially deleterious in terms of further delay.


This case involves a 62-year-old man with persistent abdominal pain, diagnosed with jejunoileal intussusception. A 4 cm inflammatory fibroid polyp was discovered during surgery, leading to distal jejunal resection. Despite the rarity of adult intussusceptions, they should be considered in abdominal pain diagnoses. The optimal management approach, whether  Inflammatory fibroid polyp (IFP) is an unusual, idiopathic, benign gastrointestinal tumor, classified as a submucosal connective tissue tumor. Vanek  first deThe suggested etiologies are related to chemical, physical, or metabolic triggers  even if Rarely, IFP could coexist in a Crohn disease (6). The symptoms include abdominal pain with or without vomit, altered small bowel peristalsis, gastrointestinal bleeding, and/or weight loss depending on both localization and size of the lesion.IFPs arising below the Treitz ligament can cause acute abdomen for obstructive ileus, usually because of intussusception , 7, whicSmall bowel intussusception in adults has to be always considered a pathological condition, and surgical intervention is strongly recommended . FurtherWe present the following case, in accordance with the CARE reporting checklist, concerning an adult man operated for intussusception with the finding of a rare jejunal Vanek’s tumor with a literature overview.We performed a double literature research (without year filters nor patient’s age) using the PubMed database with the following codes:(inflammatory fibroid polyp) AND : 156 results;(Vanek) AND : 31 results.Of them, 23 articles were removed because of duplicates. Subsequently, we excluded all articles regarding “ileal” or “ileo-ciecal” IFPs with or without intussusception, focusing on the jejunal tumors. Only 15 articles were found .A 62-years-old man with a medical history of diabetes mellitus, hypertension, chronic gastritis, and cholelithiasis was admitted to the emergency room (ER) for persistent cramping abdominal pain, began about 40 days earlier. He was first discharged at home after the visit and an abdominal X-ray  with a diagnosis of “undetermined acute colitis.”The patient decided to get back to ER for the exacerbation of the symptoms and diaphoresis, without manifesting nausea, vomit, or bowel movement pattern alterations. The physical examination of the abdomen revealed abdominal guard and pain localized in the lower quadrants of the abdomen.He was later admitted to the Short-Stay Emergency Department Observation Unit, where a second abdominal X-ray was performed, with the finding of fluid levels in the upper left quadrant.The day after, the new abdominal X-ray documented increasing distension of the bowel, with multiple hydro-aerial levels and it was decided to perform an abdominal CT scan with iodinated contrast agent: this revealed an ileo-ileal invagination extending in the mesogastrium region for about 10 cm, without showing the characteristics of expansive neoformations .The laboratory exams showed only mild neutrophilic leukocytosis, without increased inflammatory indexes. The patient was finally admitted to the surgical department for urgent laparotomy and the intraoperative findings revealed an intussusception involving a stretch of about 10 cm and supported by a 4 cm thick, rounded tense-elastic neoformation, possibly originated from the intestinal wall. A segmental jejunal resection and side-to-side mechanical anastomosis were performed.The clinical course was complicated by an episode of enterorrhagia that required a blood transfusion of 1 unit of concentrated red cells, but the patient was discharged after 11 days in good clinical conditions, without manifesting abdominal symptoms, even after 6 months of telephonic follow-up.Histological examination later showed a 3.5 cm grayish color mass without aspects of cellular atypia or mitotic activity; the immunohistochemical analysis did not present aspects referable to GIST or leiomyomatosis; the overall morphological and immunophenotypic picture allowed the diagnosis of IFP (Vanek’s tumor) . “All pret al. [IFPs were first described in the stomach by the Czech pathologist Josef Vanek, in 1949: the first IFP was an indolent, non-capsulated, submucosal granuloma, composed mainly of loose connective tissues, vessels, and with an eosinophilic inflammatory component . The namet al. , who diset al. , whereaset al. .The most common site of development by IFPs is the gastric antrum 66%–75%), followed by small intestine 18%–20%), colorectal region (4%–7%), gallbladder (1%), esophagus (1%), duodenum (1%), and appendix (<1%). The ileal tract, however, is the site where such tumors cause more often intussusception , 13. Whi%, follow%–20%, coBased on our literature overview , jejunalIntussusceptions, although rare in adults , have to be considered in the differential diagnosis of abdominal pain.Exploratory laparoscopy or laparotomy is frequently recommended as the best treatment for intussusceptions caused by IFPs; surgery should be performed as early as possible in order to prevent the intussusception’s complications such as ischemia, necrosis, and perforation of the invaginated bowel segment. When the operation is delayed and intestinal perforation with peritonitis occurs, there is a considerable increase in morbidity and mortality.en bloc resection and initial reduction followed by more limited resection. Thus, the most important factors in the surgical decision process before histologic diagnosis of the lesions are localization and size of the mass and viability of the invaginated segment [The appropriate management of intussusceptions in adults remains controversial, and the debate focuses mostly on the choice between primary  segment , 19, 20.Much more evidence concerning Vanek’s tumors is necessary to improve our knowledge on such particularly rare lesions.N.F., F.R., V.S., A.P., and S.G. obtained patient’s consent, reviewed literature, and drafted the manuscript. C.V.F. and N.F. were the surgeons on the case. They reviewed the manuscript, as senior authors. S.G. was the pathologist on the case. He reviewed and edited the manuscript.Authors confirm this is original research that has not been published elsewhere. Authors have no relevant financial or nonfinancial conflict of interest to disclose.No funds, grants, or other support were received for this study.This patient’s non-nominal data are available from corresponding author (N.F.), upon reasonable request.The patient here in presented gave informed written consent for this case report to be shared and published.For this case report, formal approval by the Research Ethics Committee of area Vasta di Bologna (Avec-CE) was waived.


Extragonadal germ cell tumors at the mediastinum are rare and comprise of 3–4 % of all germ cell tumors. Mixed GCTs can remain asymptomatic for long periods and often present with complications. We present a case of a young male patient with a mediastinal tumor infiltrating the heart and obstructing the right ventricular outflow tract, causing cardiogenic shock.A 16-year-old male came with chief complain of shortness of breath and underwent an echocardiogram which revealed a mass in the right atrium and right ventricle. On CT scan, a solid mass in the mediastinum, expanding and infiltrating the right atrium was found. Our patient underwent surgical treatment. Histopathology results were consistent with mixed germ cell tumor comprised of seminoma, yolk sac, and mature teratoma at the right atrial and mediastinum.The pathogenesis of extragonadal GCTs has been linked to abnormal and/or incomplete migration of the primordial germ cells from the endoderm yolk sac to gonads. Mediastinum GCT can become clinically problematic through its growth patterns, especially its expansive profile, which can cause compression on surrounding mediastinal structures, including major vessels, which in turn diminish blood flow. Overall survival improvement is strongly linked with surgical resection of the tumor, which achieve removal of tumor tissue resistant to chemotherapy and provides sample for histological examination, which helps assessment of pathological response to chemotherapy and planning of further management.The mediastinum is a site of different neoplasia, including germ cell tumors. Despite its low incidence, the diagnosis of a mediastinal mixed germ cell tumor should be considered in young patients with a mediastinal mass. This tumor is aggressive and often infiltrates surrounding structures and metastasis. Physicians must be aware of the difficulties and complications associated with the diagnosis. •Mixed germ cell tumors of the anterior mediastinum are a sporadic and aggressive disease that often invades and infiltrates surrounding structures and metastasis. These tumors can present in a life-threatening condition, such as cardiogenic shock.•These tumors can get big enough to compress on mediastinal structures leading to a medical emergency.•Primary GCT of the mediastinum often has a poor prognosis.•Surgery contributed to long-term survival as part of a multimodal aggressive treatment approach.•A better understanding of this disease's clinical and imaging knowledge is the key to early diagnosis, early intervention treatment, and improved prognosis. ExtragoWe present a rare case of a life-threatening mixed GCT of the mediastinum that infiltrated the heart causing cardiogenic shock in a 16-year-old male patient.2A 16-year-old male patient came to the hospital complaining of shortness of breath in 1 month, worsening two weeks before admission. Complaints get worse if the patient is in a supine position or with strenuous activities. The patient also complained of chest pain, nausea, dizziness, and fatigue. The patient has no fever, no history of prolonged cough, and no coughing up blood. Because of his complaint, the patient came to the nearest hospital for four days. The patient underwent echocardiography examination which revealed a myxoma extending from the right atrium to the right ventricle. He was then transferred to our hospital for further management. A repeat echocardiography was conducted at our hospital, which confirmed these findings, showing a mass filling the right atrium and right ventricle seen at PA with minimal pericardial effusion at the anterior and posterior .Fig. 1TrThe patient's vital signs findings include tachycardia (heart rate 120 beats per minute), tachypnea (respiratory rate of 34 breaths per minute), and hypoxemia (oxygen saturation of 78 % on room air). There were no abnormalities on the physical examination and no pathological murmurs in areas of valve auscultation. Laboratory examination may show non-specific changes such as increased hemoglobin, hematocrit, leukocytosis, thrombocytopenia, hyponatremia, hyperkalemia, and hypocalcemia. Liver function tests showed an increase in SGOT and SGPT. Blood gas analysis revealed increased blood pH and decreased pO2, pCO2, HCO3, and base excess.Chest computed tomography (CT) scan revealed a solid mass in the superoanterior mediastinum, which appeared to be attached to the brachiocephalic trunk, ascending aorta, right pulmonary artery, compressing and constricting the superior vena cava, and expanding and infiltrating the right atrium, suspected lymphoma .Fig. 2CTBecause of the unstable hemodynamics, the patient underwent the removal of the tumor. Following median sternotomy, anterior mediastinal tumor tissue appears to fill the entire anterior mediastinal space. The tumor was found to have invaded the innominate vein and caused extensive adhesions. The tumor was excised, the injured innominate vein was ligated, and the tumor was successfully evacuated. The pericardium is opened, and the heart appears normal in size and pericardial fluid was also within normal limits. We performed aortic cross clamp and antegrade cardioplegia to stop the heartbeat temporarily. A Myxoma mass was seen in the right atrium, originating at the roof of the SVC, and myxoma evacuation was performed . The car3Germ cell tumors (GCTs) are approximately 15 %–20 % of all anterior mediastinal masses, occurring most often in the ages of 20 to 40 years, with equal distribution on both male and female. Most of GCTs are benign, with teratoma being the most common type ,7.Mediastinum GCT predominantly affects males. Increased risk of mediastinum GCT is observed in individuals with Klinefelter syndrome. Hence investigation of this syndrome in young patients with mediastinum GCT is strongly recommended .GCTs are classified based on its histologic characteristics, in the similar classification as the gonads: seminomatous (pure), nonseminomatous , and teratomas . MediastThe pathogenesis of extragonadal GCTs has been linked to abnormal and/or incomplete migration of the primordial germ cells from the endoderm yolk sac to gonads. This abnormal localization may later result in malignant transformation of the midline germ cells along the urogenital ridge .The spreading of the tumor to the heart may occur through four different mechanisms, including direct extension, via the bloodstream, via lymphatic drainage, and intracavitary diffusion through superior vena cava or pulmonary veins .Most patients of mixed GCT present with symptoms similar to those of other mediastinal GCTs, as well as elevated serum tumor markers . CardiacMediastinum GCT can become clinically problematic through its growth patterns, especially its expansive profile, which can cause compression on surrounding mediastinal structures . This chIncreased values of serum alpha phetoprotein (AFP), human chorionic gonadotropin (HCG), and lactate dehydrogenase (LDH) might be seen in mixed GCT patients . ImagingHistopathological examination is vital for the diagnosis of mixed GCTs . On macrChemotherapy and subsequent surgical resection of persistent disease is the current standard treatments for patients with mediastinal mixed GCTs, which is required in >95 % patients . A critiContacts between mediastinal GCTs and surrounding structures may be further complicated by connections in between fibrous bands or infiltrative growth patterns of neoplastic cells. In these cases, surgical interventions consist of removal of infiltrated organs together with the tumor . Since aOverall survival improvement is strongly linked with surgical resection of the tumor, which achieve removal of tumor tissue resistant to chemotherapy and provides sample for histological examination, which helps assessment of pathological response to chemotherapy and planning of further management . HoweverMixed germ cell tumors have an unfavorable prognosis. The overall 5-year survival rate is 45 %. The most favorable outcomes are in patients aged <30 years with the localized disease to the mediastinum and normal hCG levels. Children have a better prognosis [4Mixed GCTs of the anterior mediastinum are a sporadic and aggressive disease that often invades and infiltrates surrounding structures and metastasis. These tumors can present in a life-threatening condition, such as cardiogenic shock, prompted by an increase in size causing compression on mediastinal structures leading to a medical emergency. Primary GCT of the mediastinum often has a poor prognosis, which can be improved through deeper knowledge of this disease's clinical manifestations and imaging findings, so as an early diagnosis and multi-disciplinary intervention might be accomplished.Written informed consent was obtained from patient about these case reports writing and publishing. The patient understood well and gave consent. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.All supporting data are available within this study.As it is a case report, ethical approval is exempted by our institution: Dr. Hasan Sadikin Hospital Bandung and Padjadjaran University.None declared.Conception and design of study, acquisition of data, analysis and interpretation of data, drafting the manuscript, revising the manuscript critically for important intellectual content, approval of the version of the manuscript to be published: Muhammad Hilmy Ayundra, Navy Laksmono, Tri Wahyuni Murni.All authors have read and agreed to the final manuscript.Muhammad Hilmy Ayundra acts as the guarantor of this study.Not applicable.All authors declare that there is no conflict of interest regarding the publication of the article.


The pleural and peritoneal cavity share many related features due to their common celomic origin. Normally these two spaces are completely separated with the development of the diaphragm. Defects in diaphragm morphogenesis may result in congenital diaphragmatic hernias, which is the most known form of communication between the pleural and peritoneal cavity. However, in several cases, findings of pleuroperitoneal communication (PPC) have been described in adults through an apparently intact diaphragm. In this comprehensive review we systematically evaluate clinical scenarios of this form of “unexpected” PPC as reported in the literature and focus on the possible mechanisms involved. Peritoneal and pleural cavities are considered to be separated since fetal life, with the development of the diaphragm. Defects in diaphragm morphogenesis may result in congenital diaphragmatic hernias (CDH), which is the most known form of communication between the pleural and peritoneal cavity. The etiology of CDH remains unclear and factors including genetic, environmental, and nutritional defects have been proposed. The majority of the cases (70–75 %) present with an isolated defect, usually at the posterolateral site of the diaphragm , followed by the less infrequent Morgagni hernias 23–28 %), which present as an anterior defect . In both3–28 %, wThis review aims to explore the basis of pleuroperitoneal communication (PPC) from the perspective of embryology, histology, and anatomy and the clinical consequences of this communication.The diaphragm, as a muscle, derives from the mesoderm. The major contributors to the developing diaphragm are the septum transversum, the pleuroperitoneal folds, the mesenchyme ventral and dorsal to the esophagus, and the cervical somites C3–C5 or C2–C6 , , , 19], , , 21], , . The mesThe flattened mesothelium is disrupted in some areas by the lymphatic stomata, which are covered  by cuboidal mesothelium. The lymphatic stomata are a projection of the lymphatics to the cuboidal mesothelium. These gaps communicate with the blind ends of the lymphatic capillaries in the loose connective tissue  through the submesothelial channels . It shouAlthough the pleural and peritoneal cavities are considered separate, several reports of PPC are available in the literature. Hydrothorax is more common, although reverse flow from the pleural cavities to the peritoneal cavity has also been observed. In many cases, the mechanisms are multifactorial or undetermined. Below we present several reported clinical entities with pleuroperitoneal communication.PD-induced hydrothorax is likely the most common form of PPC, observed in approximately 2% of the patients undergoing PD , 25], , , 27], , , 29], , , 31]. C. C31]. CAnother mechanism of PD-induced pleural effusion involves the lymphatic stomata in the serosal surfaces of the diaphragm . These mThe flow of the PD dialysate from the abdomen to the thorax is presented mainly as a right rather than a left pleural effusion. Occasionally, PD is complicated by right and left pleural effusion simultaneously . This prAnother well described presentation of PPC is hepatic hydrothorax. Hepatic hydrothorax refers to pleural effusion in cirrhotic patients due to the movement of peritoneal fluid in the pleural cavities . It is observed in at least 5 % of patients with cirrhosis , 37], , . AscitesM. tuberculosis through the diaphragm.Inflammation of the serosal cavities contributes to the remodeling of the peritoneum, the pleura and the diaphragm, increasing the risk of acquired PPC. It is well established that peritonitis is a risk factor for acquired porous diaphragm syndrome, as mentioned above , 33. ThiA particular case of peritonitis presenting with PPC is pseudo-pseudo-Meigs syndrome (PPMS) or Tjalma syndrome , 42. PPMPPC may be associated with many gynecologic conditions. Common examples include ovarian fibromas and other neoplasms , endometriosis, and ectopic pregnancy.Meigs syndrome is the triad of the ovarian fibroma , ascites, and pleural effusion , 44. PseOvarian hyperstimulation syndrome is classified together with the Meigs and the pseudo-Meigs syndrome, as it refers to a similar pathophysiology and clinical presentation. The same mechanisms are implicated in the pathogenesis of ascites and pleural effusion in ovarian hyperstimulation syndrome .Another rare clinical presentation of PPC in gynecological patients has been described as hemothorax secondary to a twisted ovarian neoplasm. In this case, a twisted tumor led to red infarct of the ovary, resulting in bloody ascites and concomitant hemothorax, due to a small (5 mm) fenestra, centrally at the right hemidiaphragm .Endometriosis is primarily found in the pelvis and its location in the diaphragm or the thorax is considered rare . Most caEctopic pregnancy has rarely been found in the thorax and it has been associated with hemothorax, when found in the pleural cavity. Several mechanisms, including retrograde flow with intestinal peristaltic and respiratory movements and the piston effect of the liver, may lead the embryo under the right hemidiaphragm , 46. TheFollowing endoscopic procedures and abdominal surgery, PPC may be revealed as pleural effusion or pneumothorax. In these cases, PPC either pre-exists or develops during the procedure.Endoscopic procedures involving the gastrointestinal (GI) system may be complicated by abnormal fluid or air movement from the abdomen to the thorax. A case of acute hydrothorax has been reported in a patient with liver cirrhosis after upper GI endoscopy . This ca2 gas passes from the abdomen to the thorax through congenital pores or hiatus of the diaphragm [Pneumothorax is also a rare complication of laparoscopic operations, providing evidence for PPC , 51, 52.processus vaginalis was complicated by the accumulation of ascitic fluid, and concomitant decompensated liver cirrhosis, may explain the deterioration of the pleural effusion.Pelvic surgery may also be complicated by hemoperitoneum combined with hemothorax due to PPC, as in cases of laparoscopic hysterectomy and myectomy , 54. As Microwave ablation (MWA) is a novel surgical approach in the treatment of hepatocellular carcinoma (HCC). A rare complication of this technique is pleural effusion due to the development of an acquired PPC. Possible mechanisms include the thermal injury of the diaphragm and the penetration of the diaphragm by the needle during the procedure , 57. TheChylous ascites rarely causes chylothorax in the presence of PPC. This condition may result from abdominal surgery, such as pancreatectomy . ChylousPPC rarely occurs in patients with cancer and ascites, presenting as an unexplained pleural effusion, usually unilateral. However, the prevalence of pleural effusions associated with ovarian cancer (OC) may be underestimated and underreported. In a recent retrospective study of 189 women with OC, pleural effusion was as high as 43 %, presenting early or during the course of the disease . The pseThe lymph system plays an essential role in the absorption of peritoneal and pleural fluid. It is also involved in the pathogenesis of PPC. Hence, its structural anomalies can present as concomitant chylous ascites and chylothorax.In a pediatric case report, a patient with generalized lymphatic anomaly (GLA), developed chylous ascites which was complicated by chylothorax . ConservAn additional case of an adult female patient with lymphangioleiomyomatosis (LAM) presenting with chylous ascites and chylothorax has also been reported . A papilPPC occasionally manifests as reverse flow from the thorax to the abdomen, despite the average pressure gradient between them. The primary risk factor is mechanical ventilation, due to the significant increase in intra-thoracic pressure, which exceeds the intra-abdominal pressure. As a result, the reversed thoracoabdominal pressure gradient can push the pleural air or fluid to the peritoneal cavity, leading to pneumoperitoneum or ascites, respectively. In both cases, atrophy of the diaphragm is a common underlying disorder . Disuse Mechanical ventilation is rarely complicated by pneumoperitoneum. These patients are affected by pneumothorax, pneumomediastinum, or both . This reAlthough the pleural and peritoneal cavities are commonly separated, communication between the two cavities is possible, under certain congenital or acquired conditions. Physicians should abandon the notion that only congenital diaphragmatic hernias and large defects are allowing for communication between the thorax and the abdomen. Although the underlying mechanisms are not always clear, PPC remains a possibly underreported condition, associated with increased morbidity and mortality and should be suspected in patients with right or bilateral pleural effusion when other causes have been ruled out.


Abdominal wall hernia is a protrusion of abdominal contents through an acquired or congenital weakness or wall defect. A ventral hernia, including an appendix, is a rare condition. The appendix in the hernial sac is already known as inguinal and femoral hernia and has been named Amyand hernia and De Garengeot hernia, respectively.We have presented a 74-year-old woman with complaints of point tenderness in the right lower abdomen and para-umbilical and a palpable non-reducible mass over the para-umbilicus with some erythema on the skin, which started two days ago. With the help of imaging, diagnosis of abdominal wall hernia was made, with the appendix as the possible content, as there was evidence of an inflamed appendix lumen incarcerated through the abdominal wall.We have provided a detailed review of recent articles. Our comprehensive discussion includes an exploration of the typical manifestations, the significance of imaging in accurate diagnosis, and the appropriate measures to facilitate optimal surgical preparation. The treatment for ventral hernia typically involves appendectomy and abdominal wall hernia repair, with the specific approach depending on the severity of inflammation.Although abdominal wall hernia containing appendicitis is extremely rare, its clinical manifestations are hernia and acute appendicitis, the most common diseases in general surgery. Imaging may be helpful in diagnosis. According to our study, diagnostic laparoscopy could be used in case of clinical suspicion of abdominal wall hernia containing an appendix, although more studies are needed. •Patients with concomitant symptoms of appendicitis and inguinal hernia should have a diagnostic suspicion of ventral hernia.•Abdominal wall hernia containing appendicitis is an extremely rare phenomenon, its clinical manifestations are hernia and appendicitis.•diagnostic laparoscopy could be used in case of clinical suspicion of abdominal wall hernia containing appendix. When abThe most common mechanism of hernia formation in the abdominal midline is in the postoperative setting . The con22.1A 74-year-old obese woman with a (BMI = 30) presented to our emergency department with respiratory distress and chest pain. During her hospitalization in the cardiology ward, the patient experienced a rapid increase in creatinine levels, necessitating hemodialysis. On the 10th day of hospitalization, a surgical consultation was requested due to the sudden onset of abdominal pain, which the patient had not experienced previously in recent months. Her medical history included controlled hypertension, ischemic heart disease dating back 20 years, and a cholecystectomy performed 15 years ago. There were no notable family history details, and she has not experienced any previous trauma. She is married and has four children. The patient was a non-smoker and did not consume alcohol. She was taking regular oral antihypertensive medications with no reported allergies.2.2During the surgery consult, initial assessment demonstrated that the patient was febrile (38 °C) with blood pressure of 110/70 mmHg and pulse rate of 88/beats per minute. On examination, she was hemodynamically stable, and she had a point tenderness in the right side of the abdomen and para-umbilical and a palpable non-reducible mass over the para-umbilicus with some erythema on the skin, which started two days ago. The pain was mild to moderate in intensity. She had the passage of gas and defecation. She did not have nausea or vomiting. She had a slight loss of appetite. Physical examination was otherwise unremarkable, with no guarding or rebound. There was no evidence of abdominal distension. Laboratory findings included elevated inflammation markers: White Blood Cell count of 24, granulocytes of 87 %, and C-reactive protein level of 7.5 mg/dl. Creatinine was 5 mg/dl, and potassium was 5.9 mmol/l.Abdominal radiography did not show any signs of free air or air-fluid levels. A CT scan with IV contrast showed a defect of abdominal wall in right quadrant with a 9 mm diameter, including an inflamed appendix and lumen and tended loop with fat stranding within the sac of an abdominal wall hernia, with no associated intra-abdominal free fluid or free air . A diagn2.3The patient underwent dialysis before the operation. Then the appendectomy was performed through a mid-line incision by the attending surgeon. The abdomen was explored with no pathologic point. The sac was opened, and reactive fluid, omentum and an inflamed and edematous appendix were relieved . The app2.4The postoperative period was uneventful, and the patient was able to resume per oral intake (PO) a day after the surgery. After 48 h, the patient was discharged and scheduled for follow-up appointments on the tenth day and one month after the procedure, without any complications. Histopathology examination confirmed a diagnosis of acute appendicitis.3Hernias are defined as defects in an aponeurotic layer, resulting in the protrusion of an organ out of a cavity in which it usually resides. This occurs due to increases in intra-abdominal pressure that exceed abdominal wall counter pressure. However, the exact pathogenesis of this entity is not well understood. The factors known to contribute to hernia development include a physiologic change in fascial integrity, proteolysis associated with cigarette smoking, direct mechanical trauma, physical overexertion, and familial genetic tendency ,6. FurthThere was no evidence of abscess or perforation. Co-morbidities factors such as constipation and risk factors are associated with intermittently increased intra-abdominal pressure, in this case notable. However, the herniated appendix is at a higher risk of developing an infection. It is postulated that the narrow hernial neck causes restricted blood flow, leading to edema and inflammation, and the size of the hernia defect has important implications for recurrence. Surgical experience would suggest that the larger the hernia defect, the more likely the possibility of recurrence. Studies have borne this out, with a threshold of approximately 4 cm representing a 3-fold risk for recurrence ,2,4.In the present case, the appendix was found to be inflamed, and a defect of abdominal wall in the right quadrant with 9 mm in diameter as per the CT contrast findings. The presence of appendicitis within the hernia sac has essential surgical implications. For instance, the surgeon needs to perform an appendectomy instead of a simple hernia repair with anatomical fascial defect repair in the case of an abdominal wall hernia with acute appendicitis. Early diagnosis and management of abdominal wall hernia containing appendicitis are crucial, while it may cause infection, recurrence of hernia, edema, abscess, and abstractions of the intestine ,2. The w4While the occurrence of abdominal wall hernias containing appendicitis is exceedingly rare, their clinical presentation includes both hernia and acute appendicitis, which are among the most common conditions encountered in general surgery. Preoperative clinical diagnosis of this phenomenon is challenging, although CT scans and ultrasounds can provide some assistance. Based on our study, diagnostic laparoscopy can be considered in cases where there is a clinical suspicion of an abdominal wall hernia involving the appendix. However, further comprehensive studies are required to determine the optimal preoperative diagnostic approach.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval is exempt/waived at our institution  for deidentified case reports.This article did not receive fund.Dr. Majid Samsami is the main author and he has designed this report.Dr. Seyed Pedram Kouchak Hosseini participated in Conceptualization.Dr. Alireza Haghbin Toutounchi participated in writing and Methodology.Dr. Farah Qaderi is the writer of this article and corresponding author.Dr. Majid Samsami accepts all responsibility of this article.Not applicable.All authors declare that they have no conflicts of interest.


Tracheal duplication cysts (TDCs) are congenital malformations that are rarely diagnosed in adulthood. The authors present a case of a 43-year-old female with no known comorbidities with a two-year history of chest and upper abdominal pain. Her previous imaging on an outpatient basis was suggestive of an esophageal duplication cyst, and she was lost to follow-up until the current admission. She gave a past surgical history of video-assisted thoracoscopic surgery for a "cyst" excision, with the relevant details unavailable. On examination, the findings were unremarkable. Repeat imaging was suggestive of an esophageal duplication cyst with no change in dimensions. She underwent a right-sided elective thoracotomy and cyst excision. Intraoperatively, a smooth globular mass was visualized next to the esophagus below the level of the carina. The biopsy revealed a TDC. The patient had an uneventful postoperative period and was asymptomatic on follow-up after three months.TDCs pose a diagnostic challenge as they can only be diagnosed by imaging and histopathology. However, when the imaging is atypical, histopathology clinches the diagnosis. Complete surgical excision is recommended for symptomatic patients after ruling out malignancy. Recurrence of the lesion must be considered in patients such as ours.Our case emphasizes the consideration of TDCs in the differential diagnosis and advocates the importance of complete surgical resection to prevent a recurrence. Tracheal duplication cysts (TDCs) are extremely rare congenital malformations. They are believed to result from abnormal budding of the bronchial tree in early embryogenesis .TDCs usually present in childhood, with stridor or dysphagia, secondary to mass effect. TDCs detected in adulthood are uncommon . We repoA 43-year-old female with no known comorbidities presented to our center with complaints of chest pain and upper abdominal pain for two years. The pain was mild in severity, located over the front of her chest, did not radiate, and was described as a dull ache. There was no relation to exertion or stress. She did report occasional difficulty swallowing food. There was no progression of the symptoms. She was previously evaluated for abdominal pain on an outpatient basis. Contrast-enhanced computed tomography (CECT) of the chest and abdomen was suggestive of an esophageal duplication cyst. The patient was lost to follow-up until the current admission where she gave a past surgical history of video-assisted thoracoscopic surgery (VATS) for a "cyst" excision, with the relevant details unavailable.On examination, she was hemodynamically stable. Physical examination revealed healed scars suggestive of previous thoracic surgery on the chest and no other abnormalities. Her cardiac and respiratory examination was unremarkable.Her biochemical and hematologic laboratory parameters were all within normal limits. Her chest X-ray was normal Figure . A repeaShe was taken up for elective thoracotomy and excision of the cyst. The approach was from the right side, and intraoperatively, a smooth globular mass measuring roughly 2 x 3 cm was visualized, adjacent to the esophagus well below the level of the carina. However, on dissection, the cyst ruptured and a thick pultaceous material was noted Figure . A biopsHPE of the cyst wall found fibromuscular tissue lined by pseudostratified columnar epithelium, with underlying subepithelial tissue showing foci of mucinous glands, and portions of cartilage, suggestive of a TDC Figure . The adjHer postoperative course was uneventful, and she had no complaints on follow-up.TDCs diagnosed in adulthood have been reported only a limited number of times in medical literature -4.Symptomatic patients typically present with symptoms due to compression of the trachea and esophagus. Many are asymptomatic. There are no clinical findings specific to TDCs, but congenital anomalies of the vertebra, vasculature, and lung have commonly been reported to coexist ,5. Our pThe clinical presentation of TDCs and findings of a well-circumscribed, mediastinal mass on imaging overlap with those of laryngeal duplication cysts and bronchogenic duplication cysts of the trachea . One difTheir mediastinal location makes mediastinal germ cell tumors of particular concern, especially when present in the anterior mediastinum. So, laboratory investigations should ideally include specific tumor markers such as alpha-fetoprotein and beta-human chorionic gonadotropin .The primary approach to TDCs depends on the presence of malignant transformation and metastases . In theiTDCs are rare congenital malformations that pose a significant diagnostic challenge. TDCs should be considered in the differential diagnosis of posterior mediastinal masses if, on imaging, the location is near the tracheal rings. HPE is necessary to confirm the diagnosis. Due to its rarity, there remains considerable confusion regarding the optimum management of a TDC. Symptomatic cases, such as ours, benefit considerably from complete surgical excision after ruling out malignant transformation.


Gastric duplication cysts are a rare finding in the adult population. Duplication cysts comprise 4% of the alimentary tract duplications, and about 67% are usually discovered within the first year of life. They can be located anywhere in the gastrointestinal tract, with the majority located in the greater curvature of the stomach. Duplication cysts may be identified on imaging studies in asymptomatic patients or may present with nonspecific symptoms that can include emesis and abdominal pain. We describe a case of a communicating cyst in the antrum of the stomach leading to gastric outlet obstruction in a 19-year-old male. Duplication of the alimentary tract is a relatively rare congenital anomaly. It can affect any part of the gastrointestinal tract with ileum being the most common site. Gastric duplication cysts comprise 4% of all gastrointestinal duplications. We present a case of a communicating duplication cyst in the gastric antrum leading to gastric outlet obstruction in an older teenage boy.A 19-year-old male with a medical history of mild intermittent asthma presented in the emergency department with epigastric pain associated with vomiting for 2 weeks. Symptoms worsened and the patient was unable to tolerate anything orally, having lost 3 pounds. Blood tests for complete blood count and chemistries were unremarkable. Ultrasound of the abdomen showed a cystic structure adjacent to the gastric pylorus. The patient underwent computed tomographic (CT) scan of the abdomen and pelvis that revealed a 6.4 × 3.2-cm cystic structure in the distal gastric antrum adjacent to the gastric pylorus, concerning for partial gastric obstruction.Adult Surgery and Pediatric Gastroenterology were consulted, and he was admitted to the pediatric floor.Esophagogastroduodenoscopy revealed an extrinsic mass pressing against the gastric antrum. A liter of fluid was aspirated from stomach. Linear erosions were found, consistent with prolapse gastropathy from vomiting.Exploratory laparotomy revealed a large cyst (5.1 × 1.2 × 1.2 cm) obstructing the pylorus. The cyst was excised completely, leaving behind the posterior wall that was communicating with the duodenum and pylorus.Histology revealed antral-type gastric mucosa with focally prominent chronic, rudimentary layer of muscularis propria and outer surface with fibroblastic proliferation and amorphous material deposition of fibrin, findings consistent with gastric duplication cyst. The patient’s postoperative course was uneventful.Gastrointestinal duplication is a relatively rare anomaly that may occur throughout the gastrointestinal tract, from the oral cavity to the rectum, with ileum being the most common site. Duplications of the digestive tract can be observed with an incidence of 1:4500 for the general population. They can be found along the entire scope of the digestive tract. Gastric duplications typically become symptomatic during childhood; 67% are diagnosed within the first year of life, and less than 25% are discovered after 12 years of age. Gastric duplication cysts are a rare phenomenon and account for only 2% to 9% of all gastrointestinal duplications.5Approximately 80% of gastric duplications are cystic and do not connect with the stomach lumen. The rest are tubular with some communication. When the lumens are contiguous, the structure is described as tubular, and when the lumens are not contiguous with the stomach lumen, it is described as cystic. The mucosal lining of duplication may be histologically comparable to the gut segment to which it is topographically connected. Some duplications, on the other hand, may comprise lining from other parts of the digestive or respiratory system. The presence of respiratory epithelium in cysts of the thorax, tongue, liver, and stomach implies that the foregut’s undifferentiated epithelium might undergo transition to differentiated specialized epithelium during the embryonic period.8The clinical presentation of gastric duplication cysts can be highly variable and nonspecific ranging from vague abdominal pain to nausea, vomiting, epigastric fullness, weight loss, anemia, dysphagia, dyspepsia with abdominal tenderness, and epigastric mass on physical examination. The cysts may also be manifested by complications such as infection, gastrointestinal bleeding, perforation, ulceration, fistula formation, obstruction, compression, pancreatitis, or carcinoma arising in the cysts.In our patient, the duplication cyst was communicating, which could explain the lack of symptoms for many years before presentation. Blockage of the communication, possibly from anatomical shifting, may have caused the cyst duplication to become significantly enlarged to cause the gastric outlet obstruction.6Although it is difficult to diagnose gastric duplication cysts preoperatively, recent imaging modalities have provided some informative findings. Computed tomography scan and endoscopic ultrasound are the best ways to identify gastric duplication cysts. Contrast-enhanced CT scan typically demonstrates gastric duplication cysts as a thick-walled cystic lesion with enhancement of the inner lining. Calcification is occasionally observed on CT. These findings are of diagnostic significance for gastric duplication cysts.6Complete removal of the duplication is the preferred treatment to avoid the risk of possible complications such as obstruction, torsion, perforation, hemorrhage, and malignancy. A noncommunicating gastric duplication cyst is classically treated by complete excision of the cyst and resection of the shared wall between stomach and the duplication cyst. Communicating gastric duplication cysts usually require no intervention when both gastric lumens are patent. Drainage and marsupialization of the cyst have been suggested.Although rarely seen in the young adult population, congenital gastric cysts should be considered in the differential diagnosis of patients with intractable vomiting and symptoms of gastric outlet obstruction for prompt diagnosis and management.


An obturator hernia is a relatively rare form of pelvic hernia, wherein abdominal organs protrude through an opening in the pelvis known as the obturator foramen. The majority of patients with this condition present to the emergency room with symptoms of bowel obstruction. Due to the non-specific nature of these symptoms, making a preoperative diagnosis of obturator hernia can be challenging. Any delay in the diagnosis and treatment of this condition can lead to a significant risk of mortality. In this report, we present the case of a 71-year-old patient who presented to the emergency department complaining of lower abdominal pain and nausea. An abdominal X-ray revealed bowel dilation, and based on the patient’s symptoms, a diagnosis of bowel obstruction was suspected. A CT scan of the abdomen and pelvis was performed to investigate the reason for bowel dilation, and the existence of an obturator hernia was confirmed. Obturator hernia has an incidence rate of 0.07-1% of all abdominal wall hernias . This tyOn presentation at the emergency department, a 71-year-old female patient complained of pain in the lower left quadrant of the abdomen and nausea that had started 36 hours prior. The patient had an unremarkable medical history. Upon clinical examination, the abdomen was soft with pain located at the left lower abdominal area. No palpable masses or groin masses were detected. In the emergency department, blood pressure was 113/74 mmHg, pulse rate was 69 beats/minute, and temperature was 36.9°C. The laboratory results showed a slightly elevated C-reactive protein.An X-ray revealed small bowel obstruction Figure . A CT scThe patient underwent surgical exploration with a midline incision. During the operation, a loop of small bowel protruding through the obturator canal was identified, which was then reduced back to the abdominal cavity. No signs of bowel ischemia were observed. The defect was repaired with interrupted sutures, and no mesh was used. A drainage was inserted, and the rest of the bowel was carefully checked before closing the abdominal cavity. The patient was discharged six days after admission in stable condition with normal vital signs and no fever.An obturator hernia is a rare and life-threatening type of hernia that occurs when intra-abdominal organs protrude through the obturator canal, which is penetrated by the obturator neurovascular bundle . This tyDue to the difficulty of preoperative diagnosis, the mortality rate of obturator hernia is high, ranging from 13% to 40% . PatientSurgery is the only treatment for obturator hernia. The classic surgical approach is through a midline exploratory laparotomy that allows a complete assessment of all abdominal organs, and it is preferred in patients with signs of perforated or strangulated obturator hernias. In hemodynamically stable patients, the laparoscopic approach, which includes the transabdominal preperitoneal (TAPP) and the total extraperitoneal procedures, may also be considered. The TAPP is more appropriate for emergency cases as it allows the exploration of the abdominal cavity. The repair can be performed with simple sutures or with the use of a mesh. The open transabdominal approach remains the gold standard ,7.An obturator hernia is an uncommon type of hernia with the highest mortality rate among all types of hernia. It predominantly occurs in elderly underweight patients. Obturator hernias are difficult to diagnose early, and most patients present with symptoms of small bowel obstruction. In many cases, there is perforation of abdominal viscera, mostly the small bowel. The abdominal CT is considered the diagnostic gold standard. Surgery is the only therapeutic option. Open access is preferred in cases where bowel ischemia is suspected, although the laparoscopic approach is also considered.


Echinococcus and is a major public health problem in developing countries. Solitary hydatid cysts located in the buttocks are very rare, and the unusual location of the cyst can aid in the differential diagnosis of subcutaneous masses in this area, particularly in endemic areas. In this report, we present the case of a 39-year-old man who was admitted to the emergency department with a painful, abscessed cyst in the buttock region. The cyst was completely excised, and histopathological examination confirmed the diagnosis of a hydatid cyst. Further investigations did not reveal any other locations. Although the buttock region is an extremely rare site of infection for a hydatid cyst, it should be considered in cystic lesions, especially in endemic areas.The hydatid cyst is a cosmopolitan parasitic infection caused by tapeworms of the genus  Echinococcus genus. In developing countries such as Morocco, cystic echinococcosis or hydatidosis is a significant public health concern in areas where livestock are raised [Echinococcus granulosus larva in humans. The primary host is the dog, and humans become accidental intermediate hosts by ingesting parasite eggs from contaminated food or through direct contact with infected dogs [Human echinococcosis is a zoonotic disease caused by parasites of the e raised . This coted dogs . The livted dogs ,4. PreopThe patient was a 39-year-old man who worked as a farmer and had a history of contact with dogs. He presented with a small right buttock mass that had been slowly growing for the past six months, which was painless and asymptomatic. A physical examination revealed a firm, tender, and poorly mobile mass with inflammatory signs, while the proctological examination was normal Figure .3 and a C-reactive protein level of 90 mg/L. A non-contrast pelvic CT scan showed a buttock mass containing air bubbles without extension to adjacent structures, while the chest radiograph was normal  and lung involvement (5%-27% of cases) [Hydatidosis is an endemic disease that affects many countries in Africa, the Middle East, the Mediterranean, and South America, which are developing livestock countries . It is af cases) . UnusualOur patient, who had a history of contact with dogs, presented with a painful, warm, red, and "orange peel" appearance on the skin overlying an isolated buttock mass. The proctological examination was crucial in this case to rule out a perianal abscess, given the location of the mass near the anal margin, and no anal fistula or fissure was found. Laboratory tests confirmed the presence of an infection, and empirical antibiotic therapy was initiated. Hydatid serology was not requested given the urgency of the situation and the lack of diagnostic orientation; besides, it is not very sensitive for localizations in soft tissues, given the frequency of false negatives. However, this serology is a means of monitoring treatment when positive . In our Isolated subcutaneous localization of hydatid cysts is rare, representing only 2.3% even in endemic areas, making etiological diagnosis sometimes difficult [The solitary hydatid cyst in the subcutaneous tissue is a rare occurrence, and its location in the buttocks is exceptional. In cases of complicated hydatid cysts in the buttocks with poor and nonspecific clinical presentation, surgery represents the only radical treatment, and histopathological examination confirms the diagnosis. Imaging methods such as ultrasound and CT scan can provide diagnostic guidance, but MRI remains the most effective examination. Hydatid serology has limited sensitivity. Despite the rarity of subcutaneous hydatidosis, it should always be considered in individuals living in endemic areas with any mass in the subcutaneous tissues, and additional tests should be requested to confirm the diagnosis and prevent therapeutic errors. The eradication of this condition relies on prophylaxis through health education of populations, monitoring of animal slaughter, and treatment of domestic dogs.


A 45-year-old male in a hypertensive emergency was admitted with complaints of frontal headache, progressive chest discomfort, shortness of breath, dysphagia, and right upper quadrant abdominal pain radiating across the epigastrium and to the back that increases in intensity with deep inspiration. He denied any history of abdominal pain, vomiting, dyspnea, nausea, and weight loss. A computed tomography (CT) scan of the chest showed a posterior mediastinal mass between the esophagus and descending aorta. A magnetic resonance imaging (MRI) scan revealed a non-enhancing posterior mediastinal mass possibly compressing both the esophagus and the airway. A 30-degree thoracoscope was inserted in the chest cavity revealing a large hemothorax from a possibly ruptured inflammatory myofibroblastic tumor (IMT) encompassing nearly the entire pleural space with both fresh and clotted blood. Two liters of fresh blood was removed via a right thoracotomy procedure. Once removed, a large fibrinous clot-filled mass was resected entirely and sent to pathology. Postoperative recovery was uneventful; dysphagia and shortness of breath resolved. The patient gradually resumed his regular diet. Inflammatory myofibroblastic tumors (IMTs) are complexes of myofibroblastic spindle cells that demonstrate an inflammatory infiltrate. Though these rare lesions can arise from any tissues in the human body, their development in the mediastinal region is very uncommon. Histologically, IMTs exhibit diverse appearances, ranging from fibroblastic and myofibroblastic proliferation to an inflammatory infiltrate rich in plasma cells, lymphocytes, and eosinophils . DiagnosA 45-year-old male presented in the emergency department in a hypertensive emergency 234/131) with complaints of frontal headache, progressive chest discomfort, shortness of breath, dysphagia, and right upper quadrant abdominal pain radiating across the epigastrium and to the back that increases in intensity with deep inspiration. He has a past medical history of asthma and obstructive sleep apnea on continuous positive airway pressure (CPAP) and has not been to a doctor's visit in over six years. A computed tomography (CT) scan of the chest was completed due to concerns of possibly ruptured posterior mediastinal mass versus mass effect with pleural effusion. A computed tomography (CT) scan in Figure 31 with cUpon the review of physical evaluation and imaging, surgical intervention was advised. Chest X-ray (CXR) result showed decreased right-sided consolidation and effusion compared with previous studies Figure .The thoracic team was consulted to proceed with elective thoracotomy, which confirmed a massive right hemothorax Figure . A diagnUpon the evacuation of the hemothorax and the stabilization of the bleeding, the fibrinous clot  was carefully removed from the cystic structure and sent to pathology. The underlying esophagus was identified in this region and appeared to have both acute and chronic inflammation in this region. The cyst wall appeared to be occupying the outer layer of the esophagus and was not removed. A portion of the lateral cyst wall was removed however adjacent to the aorta and sent to the laboratory for pathology analysis. Figure Histopathologic examinationThe histological examination revealed distinctive features of the tumor, including elongated nuclei and eosinophilic cytoplasm, composed of spindle-shaped cells. These cells were observed alongside a notable mixed lymphoplasmacytic inflammation. The lesion lacked significant nuclear pleomorphism and showed a brisk mitotic activity. Immunohistochemically, the tumor tested positive for smooth muscle actin (SMA), desmin, caldesmon, and activin receptor-like kinase 1 (ALK1). Conversely, myogenin staining was negative, ultimately confirming the diagnosis of an inflammatory myofibroblastic tumor as shown in Figure Inflammatory myofibroblastic tumors (IMTs) were first reported in the late 1930s as lesions of myofibroblastic spindle cells and infiltrates of lymphocytes, plasma cells, and eosinophils , while oThe diagnosis of such tumors prior to symptom presentation is very difficult as symptoms may go overlooked by patients as simple discomfort. Our patient presented with progressive dysphagia and shortness of breath along with vital signs of hypertensive emergency. Even when symptoms are reported by patients, approximately 6.3% of IMT cases are discovered via biopsy alone [In summary, we have presented an exceptionally rare occurrence of massive hemothorax attributed to the rupture of an inflammatory myofibroblastic tumor (IMT) located within the right thoracic cavity. While IMTs are infrequently encountered within the mediastinum of the general population, our report underscores the importance of considering IMT as a differential diagnosis when patients present with progressive dysphagia. This case serves as a poignant reminder of the intricate array of medical conditions that can manifest within the human body and emphasizes the necessity of maintaining a comprehensive differential diagnosis approach, especially in cases with atypical presentations. The management of hemothorax due to IMT rupture necessitates a multidisciplinary approach and collaboration in achieving an accurate diagnosis and implementing a tailored treatment plan.


Osteoblastoma is a benign bone tumor that can spread aggressively and is commonly found in the spine and long bones. When present in other areas of the body, it can be difficult to diagnose. While this tumor is rarely found in the hand, in reported cases, it typically presents with pain. Treatment is usually curettage and marginal excision. We report a rare case of osteoblastoma in the fifth proximal phalanx of the left hand in a 14-year-old right-handed female, presenting as a painless, progressively growing mass with associated flexion contracture over a seven-month period, with no history of trauma. An excision biopsy with curettage was performed, and histopathologic examination confirmed the diagnosis of osteoblastoma. This is a rare case of osteoblastoma of the proximal phalanx presenting as a painless mass in the finger with a progressive flexion contracture. Histopathologic examination is important in diagnosing osteoblastoma to determine the appropriate treatment and surgery. Post-operatively, close monitoring is important due to the high recurrence rates in these tumors. Osteoblastoma is a rare, aggressive benign tumor that accounts for approximately 0.5%-2% of all primary bone tumors and 3% of all benign bone tumors with a predilection for the axial skeleton, followed by the craniofacial bones , 2. ThisOsteoblastomas are usually identified as a mass larger than 1.5 cm in diameter, which causes pain that remains constant throughout the day and cannot be relieved by salicylates . On the The aim of this paper is to illustrate the presentation, diagnosis, and treatment of a rare case of osteoblastoma located at the proximal phalanx of the hand. The presentation of this osteoblastoma was atypical owing to its location and clinical presentation, making the diagnosis difficult and emphasizing the need to consider this condition in bony tumors of the hand.A 14-year-old right-handed female student was referred by a general practitioner for a seven-month history of a left little finger mass. She noted a painless lump on the proximal phalanx of her left little finger and an associated difficulty in extending the involved finger. There was no history of antecedent trauma. Clinical examination revealed a 2.5 x 2.0 cm, hard, non-tender mass on the radial side of the little finger, with a 50° contracture angle of the proximal interphalangeal joint , bone scans, and MRIs may be utilized to aid in diagnosis. A CT may provide information about the size and extent of the lesion in the cortical bone to aid in preoperative evaluation . Bone scThese tumors may expand the bone contour with a markedly thinned cortex and cause bone destruction, with or without periosteal new bone formation . RadiogrPrimary treatment of osteoblastomas is typically simple curettage or marginal resection with or without bone grafting . SurgicaA differential diagnosis for this case was an enchondroma, which is the most common primary bone tumor found in the hand, particularly in the proximal phalanx . It typiIn our patient, a dorsal approach was utilized since the tumor presented on the dorsal aspect of the affected finger. Marginal excision of the tumor was done with significant removal of the tumor mass and some soft tissue extension, which most likely caused the inability to actively extend the affected finger. Our patient was started on a rehabilitation program and advised on long-term follow-up due to the high likelihood of recurrence and possible progression of this tumor.Osteoblastomas in the hand and wrist are uncommon and usually cause localized pain, which is contradictory to the case of our patient. To the best of our knowledge, there are only a few case reports that describe osteoblastomas in the proximal phalanx of the hand. The clinical and radiographic similarities with other bone tumors highlight the importance of accurately confirming the diagnosis to limit recurrence. By describing our pediatric patient's case of osteoblastoma with an unusual presentation, we hope to assist in the diagnosis and treatment of future cases involving bony tumors of the hand.


Maxillary sinus odontogenic keratocyst (OKC) is very rare and occupies less than 1% of the total OKC cases reported in the literature. OKCs have characteristic features that are unique compared to other cysts of the maxillofacial region. Considering their peculiar behaviour, varied origin, debated development, discourse treatment modalities, and high recurrence rate, OKCs have been a subject of interest for various oral surgeons and pathologists globally. This case report presents an unusual case of invasive maxillary sinus OKC into the orbital floor, pterygoid plates, and hard palate in a 30-year-old female. The case report confers that cystic maxillary sinus lesions should always be treated very extensively irrespective of the nature of the lesion as the site makes it highly susceptible to secondary infection and recurrence. The case also establishes a set of imaging modalities and specific treatment approaches to be followed for maxillary sinus OKC based on the literature of all the previous cases reported. Odontogenic keratocyst (OKC) is a distinctive form of developmental odontogenic cyst comprising 12% of the entire jaw cysts [The most common site as per the occurrence rate of OKC is the mandible 73%) compared with 27% in the maxilla % compare.This case report is of an unusual presentation of an aggressive left maxillary sinus OKC in a 30-year-old female. Lesions involving the sinus always pose a diagnostic challenge as the margins are difficult to identify and sinus pathology of odontogenic origin holds high chances of secondary infection . A briefA 30-year-old female patient reported to the department of dentistry with the chief complaint of swelling on the left upper back region of the jaw for three years with mild heaviness for a month on the same side of the face. The patient gave a history of gradual increase in the size of the swelling to the present size with no association of pain or any other symptom. No significant personal, medical, or family history was reported. Slight facial asymmetry was present extraorally on the affected side Figure .Intraoral examination revealed diffuse swelling on the buccal aspect of the maxilla completely obliterating the vestibule region of 23-27 extending palatally involving the hard palate  was done, and aspirate yielded cream-coloured fluid and cytology revealed the presence of necrosis with cholesterol crystals.The surgical enucleation of the lesion was planned under local anaesthesia and antibiotic coverage with an intra-oral approach Figure .During surgical exploration, an abundance of white-cheesy content was collected. The lesion was highly aggressive with invasion into the pterygoid plates and orbital floor. The fragile cyst lining was enucleated, and curettage was done. Considering the invasive nature of the lesion, extended chemical cauterization was done using freshly prepared Carnoy’s solution. The cyst cavity was inspected to ensure complete excision, and an iodoform-medicated gauze pack was kept inside the cavity with one end out. This gauze pack was removed after three days.The enucleated specimen was sent for histopathological examination. Gross examination showed a thin cyst wall, which on microscopy revealed a cystic lining with parakeratinized stratified squamous epithelium with palisaded cuboidal basal cells. The cystic wall was fibrous with focal areas of dense chronic inflammatory infiltrate predominantly plasma cells and lymphocytes Figure . TherefoThe patient was followed up after four months and had no fresh complaints in accordance with the site of the lesion operated, and intraorally the site seemed to have restored its normal anatomy Figure .The patient was kept in periodic follow-up, and OPG was repeated six months post-surgery, which showed no recurrence Figure . CECT isOKCs are the third most common developmental jaw cysts. The term was broadly used for all keratin-forming cysts during the 1950s. It was in 1956 that Phillipsen described OKC for epithelial developmental cysts ,3. OKCs The case reports of maxillary sinus OKC compiled in the table including ours were all non-syndromic. OKCs cover a wide age range, from the first decade of life to as late as the ninth decade ,3. The pIn the current case, the cyst extended into the floor of the orbit, hard plate, and pterygoid plates similar to the case reported by Goto et al. . The majOKCs have a multifactorial theory of origin. Initially, the primordium of the tooth was thought by many authors to be the origin of these cysts and hence the name primordial cyst but now the dental lamina is considered to be the most likely origin. The basal cell layer of the oral epithelium is also thought to possibly play a role in the aetiology of these cysts . The oriThe theory of intrinsic growth potential of a cyst due to expression of Ki67, proliferating cell nuclear antigen (PCNA), and p-63 has also been proposed according to which patients who have the predisposition to form keratocyst will always have a higher risk of developing a cyst as long as a dental lamina or its remnant are present . As per This theory could also be applied to the current case considering its behaviour and invasive potential but confirmation required evidence through genomic testing and immunohistochemistry (IHC) expression, which could not be done due to limited resources. Also, in the reported case, the cyst could have developed as a result of entrapment and proliferation of odontogenic epithelial cells or extensions of the basal cell layer of the epithelium of oral mucosa in the sinus. The patient had very poor oral hygiene and severe periodontitis, which could have additionally attributed to the infection of the sinus.Several theories have been proposed for explaining the invasive and destructive nature of OKC. Growth in OKC is linked to unknown growth factors inherent in the epithelium itself or enzymatic activity in the fibrous wall . Its invAggressive maxillary sinus OKCs tend to penetrate into the surrounding soft tissues with expansion and perforation of cortical bone. The expansion has been reported to occur in up to 60% of cases, similar to the current case reported . AdvanceThere is no universally accepted treatment for OKC. Considering its aggressive nature and history of recurrence, the primary aim of treatment is to achieve total eradication. The techniques involve decompression followed by enucleation and peripheral osteotomy, which show less recurrence, as compared to only enucleation, which has a recurrence rate of 17-56% . The appMaxillary sinus OKCs are less in occurrence and every case has a varied presentation. FNAC is of limited help and CT imaging should be considered as the baseline radiological investigation to diagnose and plan treatment. Histopathology, genomic testing, and IHC should be considered as diagnostic criteria as they add better explanatory data on the aetiology and behaviour patterns of OKCs. Post-operative periodic follow-up should be mandatory irrespective of the operative procedure followed.


Wilms' tumor (WT) is the most common pediatric kidney malignancy and is rarely found in adults. Nonspecific clinical symptoms and imaging features often lead to delayed diagnosis or misdiagnosis of adult WT, resulting in poor clinical outcomes. Ultrasound (US), as an efficient and noninvasive examination method, has been widely used in clinical diagnosis and treatment. Therefore, various US evidence is meaningful to improve understanding of adult WT characteristics in ultrasound.A 45-year-old female patient with uremia  with painless gross hematuria was diagnosed with a right kidney tumor penetrating to the lung. Preoperatively, B-mode ultrasonography showed an ill-defined hyperechoic mass in the right kidney, which revealed an unclear border, uneven internal echoes, and calcification. Besides, the internal blood flow signal of the tumor was detected. Contrast-enhanced ultrasound (CEUS) showed an uneven hyper-enhancement in the tumor (“fast in and slow out”). Contrast-enhanced computed tomography of the kidney indicated a similar result as the CEUS. Moreover, the chest CT identified multiple pulmonary metastatic nodules.An ultrasound-guided percutaneous core needle biopsy of the tumor proceeded to make a definite diagnosis of adult WT .The patient was treated with tislelizumab.No progress was found to date.We report the first case in which CEUS was performed in an adult WT patient with uremia and multiple pulmonary metastases. The features obtained by the US can help in the diagnosis of adult WT and direct further diagnostic procedures. The prognosis of adult WT patients is relatively poor because of the high malignancy, rapid growth, and early metastasis.,3 Due to the low incidence, the lack of specific imaging features, and clinical manifestations, adult WT is always characterized by difficult preoperative diagnosis and a high misdiagnosis rate, which is easily confused with renal cell carcinoma clinically.–6Wilms’ tumor (WT), also known as nephroblastoma, is the most frequently diagnosed renal malignant tumor in children, while is rarely found in adults. Therefore, it is valuable and favorable in the clinical diagnosis and treatment fields to understand and master the US features of adult WT.Ultrasound (US) examination is a safe and noninvasive method that has been widely used in renal imaging in general clinical diagnosis and treatment, making it an important initial method for the diagnosis of adult WT after the clinical examination.This report presented the first case of an adult WT patient with uremia and multiple pulmonary metastases. A female uremic patient with painless gross hematuria was diagnosed with adult WT after a series of medical examinations. Furthermore, we summarized its ultrasonographic features by conducting a comprehensive literature review.A 45-year-old uremic female  presented to the urology department for painless gross hematuria and took a series of medical examinations. B-mode ultrasonography revealed an ill-defined hyperechoic mass (5.6 cm × 6.3 cm in size) in the right kidney, with uneven internal echoes and calcification Fig. A–C. Addi The incidence of adult WT accounts for <1% of renal tumors, with a prognosis usually poorer as compared to children.,9 Besides, due to the extremely low incidence and lacking diagnostic features, it is difficult to distinguish WT from renal masses in adult patients, such as angiomyolipoma, renal cell carcinoma, and eosinophiloma. Therefore, it is essential to enrich the understanding of adult WT characteristics and diagnosis.WT was named after Dr Max Wilms who first extensively described it in 1899.The criteria for the diagnosis of adult WT proposed by Kilton et al in 1980 included: a primary renal neoplasm; primitive blastematous spindle or round cell component; formation of abortive or embryonic tubular or glomeruloid structures; no area of tumor diagnostic of renal carcinoma; pictorial confirmation of histology and age >15 years.,11 US examination is commonly the first harmless investigation in the diagnosis and treatment procedure due to its obvious advantages of real-time dynamic imaging, cheaper and more widely available than CT or magnetic resonance imaging. Adult WT can penetrate into the renal vein or inferior vena cava, while the US can identify tumor thrombi through multi-dimensional scanning of tumor blood vessels.The presenting symptoms of adult WT include pain, hematuria, and abdominal mass. However, due to the rarity of adult WT, more evidence needs to be collected for the diagnosis and prediction. Furthermore, for large solid tumors occurring outside the kidney, WT should not be easily excluded. M A Isaac et al reported a case in which a patient presented a right ovarian multilocular adult WT (19 cm). Serkan Keskin et al reported a 19-year-old man with a 4 cm mass in his lower pole of the right testis by scrotal ultrasonography, which was confirmed to be WT.Limited cases of adult WT with US evidence have been reported. We analyzed the US characteristics of as many cases found on Pubmed as possible, and the results mainly focused on the following aspects: locations, sizes, morphology, borders, internal echo, blood flow, and CEUS patterns. Generally, adult WT presents as a large ill or well-defined solid rapidly/slowly growing unilateral renal mass with or without variable echogenicity, cystic area, calcification, and internal vascular flow, and the appearances were basically relevant to the components of the tumor Table . Additio The US could directly show the extent of the tumor and its position to the adjacent organs; hence, ultrasonography also plays an important role in the follow-up of the treatment results due to the high rates of recurrence and metastasis of adult WT.This is the first case of an adult WT patient with uremia with CEUS evidence, which provides information valuable for the understanding of adult WT and for better diagnosis. Moreover, the ultrasound-guided percutaneous core needle biopsy is an effective method in the diagnosis with low post-biopsy complications.,19 which is quite matched with our case. In conclusion, due to the rarity and diversity of adult WT, no conclusive principles are available for the diagnosis and prognosis of this disease. As one of the most routine medical examination methods, the US is of great significance in improving the sensitivity of adult WT diagnosis by combining existing adult WT ultrasonic features with symptoms such as loin pain, asymptomatic gross hematuria, or abdominal masses. Besides, it is critical to consider the results of CT, magnetic resonance imaging, and laboratory examinations and stage the disease in a reasonable way, which is of great help for patients to receive timely treatment and a good prognosis.As for the laboratory results, the increasing level of neuron-specific enolase might indicate the diagnosis of WT,Conceptualization: Jing-Jing Zhang.Data curation: Jing-Jing Zhang, Li-Fei Yang, Xiao-Hong Xie.Investigation: Li-Fei Yang, Yi-Zhen Zhang.Methodology: Jing-Jing Zhang, Li-Fei Yang, Yi-Zhen Zhang.Supervision: Yi-Zhen Zhang, Xiao-Hong Xie.Writing – original draft: Jing-Jing Zhang, Li-Fei Yang.Writing – review & editing: Yi-Zhen Zhang, Xiao-Hong Xie.