Thymoma is a rare malignancy with usual location in the antero-superior mediastinum. Occurrence of an extra-mediastinal thymic malignancy in the neck with lung metastasis and without involvement of the mediastinum is an extremely rare condition. Staging systems and treatment guidelines are defined for mediastinal thymomas but not for ectopically located thymomas.38-year-old female presented with the chief complaint of a progressive neck swelling, located predominantly in the right lateral neck, extending to the midline. Computed Tomography showed a heterogenous peripherally enhancing mass with likely origin from the thyroid gland. The mass measured 12 x 6 x 3.5 cm in size and extended from the hyoid bone superiorly to the suprasternal location inferiorly. Additionally, there were multiple, variable sized subpleural nodules scattered in both lungs, suggestive of lung metastases. Histopathology and immunohistochemistry findings from neck mass confirmed the diagnosis of Thymoma Type A. Thymoma is a rare tumor that typically does not show aggressive behaviour. Extra-mediastinal neck thymoma with bilateral lung metastasis is an extremely rare presentation. Thymoma presenting as neck swelling without mediastinal extension on radiology, poses a diagnostic dilemma. Histopathology with immunohistochemistry helps to confirm the final diagnosis. Surgery is the mainstay for the management of localized tumors with adjuvant treatment reserved for incompletely resected tumors or advanced stage. Systemic metastasis are rare in this indolent tumor and chemotherapy regimens are investigational. Clinical presentation, prognostic factors, staging and management guidelines are still not well defined for this rare tumor with atypical location. Thymoma is a rare neoplasm arising from thymic epithelial cells, 90% of which are present within the anterior mediastinum and the rest occur in the middle and posterior mediastinum . These rare tumors usually present in the 4th decade and are commonly associated with myasthenia gravis. In patients without myasthenia gravis, the peak age of presentation is in the seventh decade or later -7. The iEmbryologically, thymus has an endodermal origin from the lower part of the third pharyngeal pouch which originates in the neck during the early foetal life and reaches the mediastinum after descend. Rarely, the thymus fails to descend and may appear as a remnant along the cervical pathway from the angle of mandible to the thyroid gland; thyroid gland being the most common site of ectopic thymic tissue. Ectopic thymus has been most commonly reported in prepubertal paediatric populations due to age-related involution. These ectopic thymic tissues may develop hyperplasia or thymic neoplasms like thymoma, thymic carcinoma and lymphomas -14. ThymA 38-year-old premenopausal woman presented to us with the chief complaint of a progressive neck swelling which appeared 8 months ago and was initially located in the right side of the neck but gradually progressed to involve the anterior neck also . The swelling was associated with difficulty in breathing and voice change. On physical examination, there was a visible neck mass occupying the anterior and right lateral side of neck, measuring approximately 12 x 6 x 3.5 cm in size. The swelling had a smooth surface, was firm in consistency, non-mobile, non-tender, extending superiorly from the level of hyoid bone to the suprasternal notch inferiorly. Laterally the swelling extended from right sternocleidomastoid muscle to the left sternocleidomastoid muscle. The swelling did not move with tongue protrusion or deglutition. On examination, Kocher’s sign and Pemberton sign were absent. On palpation using Lahey’s method, separate lobes of the swelling could not be appreciated. Mobility in both vertical and horizontal planes was restricted. No signs of thyrotoxicosis were seen.ck also . The swAll blood investigations including hemogram, peripheral blood film, renal function tests, liver function tests and serum electrolytes were within normal range. Thyroid function tests (TFT) showed Free triiodothyronine value of 2.17pg/ml (low) and Thyroid Stimulating Hormone (TSH) value of 34.03 (high) suggestive of hypothyroidism. Serum alpha-feto protein (AFP) and beta-human chorionic gonadotrophin (HCG) were within normal limits. Anti-acetyl choline receptor antibodies, diagnostic of myasthenia gravis, were not detected. Ophthalmic examination revealed restriction of lateral extraocular movements in both eyes. Seventy-degree endoscopic examination of larynx revealed right side vocal cord palsy.  Contrast-enhanced computed tomography (CECT) of the neck and chest showed a large heterogenous peripherally enhancing mass measuring 5.9 x 7.8 x 7.9 cm predominantly on the right side of neck likely arising from the right lobe of thyroid gland. The mass also involved the left lobe of thyroid and extended from the hyoid level superiorly to thoracic D1 vertebra inferiorly. No retrosternal extension was seen. Superiorly, the mass was abutting the submandibular gland with ill-defined fat planes. Medially, it was compressing the larynx, trachea and the oesophagus without involvement of the laryngeal cartilages. Laterally, it involved the sternocleidomastoid muscle on the right side. Posteriorly, it extended from C3 to C7 levels. A prominent lymph node 13 x 9 mm size was seen at level II on the right side . CECT Chest showed multiple, variable-sized, subpleural and parenchymal nodules, diffusely scattered in both lungs with the largest in the left lower lobe, 12 x 12 mm in size. CT orbit and MRI brain were normal.side , . CECT CThe patient underwent an incisional biopsy from the neck swelling and an emergency tracheostomy for stridor. The histopathological report revealed thymoma Type A  with epithelial cells arranged in nests and islands . islands . The immunohistochemistry showed strong positivity for cytokeratin and leucocyte common antigen . The patient was treated with palliative intent in view of multiple pulmonary metastases. She was planned for palliative chemotherapy with CAP regimen consisting of Inj.Cisplatin 50mg/m2, Inj.Doxorubicin 50mg/m2 and Inj. Cyclophosphamide 500mg/m2. She received 2 cycles of chemotherapy till her last follow up.igen , . The paThe thymus gland is a lymphoepithelial organ, located in the anterior mediastinum which helps in the production and maturation of immune cells . ThymomaChan et al have reported 16 cases of ectopic cervical thymomas. In their series, thymomas were more commonly seen in females of middle age and were commonly left-sided in location  T cells throughout the tumor. In addition, the atypical variant of Type A thymoma includes comedo-type tumor necrosis, increased mitotic count and nuclear crowding. It is also called as spindle cell thymoma or medullary thymoma and usually has a good prognosis . BiochemMasaoka staging system is the most commonly used staging system for thymomas. Recently the tumor, node and metastasis (TNM) system of staging has also been incorporated for thymomas. However, all these staging systems cater to mediastinal lymphomas and there is no specific staging system for cervical thymomas. CECT remains the radiological investigation of choice and investigations like Positron Emission Tomography (PET) may not be useful in view of thymoma being a low grade tumor. CECT neck in our patient showed an extensive tumor that extended from the hyoid to D1 vertebra without any mediastinal extension. CECT chest showed multiple, variable-sized, subpleural and parenchymal nodules seen diffusely scattered in both the lungs. Based on these findings our patient was labelled as metastatic stage IV cervical thymoma and was considered unfit for surgical resection.Upfront surgery with R0 resection is the primary treatment for thymomas. No adjuvant treatment is required if the capsule is intact and margins are clear in early stage I and II tumors -22. HighChemotherapy for thymomas includes the use of platinums, anthracyclines, taxanes, ifosfamide, etc with modest activity. National Comprehensive Cancer Network (NCCN) Panel recommends the cisplatin/doxorubicin/cyclophosphamide(CAP) regimen because it seems to yield the best outcomes. Non-anthracycline based regimens (cisplatin/etoposide) may be used in patients who cannot tolerate aggressive regimens -28. TherPrognostic factors for the mediastinal thymomas include stage, size of primary tumor, age at presentation and extent of resection. Tumors more than 10 cm in size have adverse prognosis while patients more than 30 years do better than younger patients. Complete surgical resection with clear margins is associated with favorable outcomes -33. UntiThymoma is an uncommon tumor that typically does not present as an aggressive tumor. Ectopic thymic malignancy should be considered as a differential diagnosis during evaluation of a malignant neck mass. Histopathological and immunohistochemical confirmation would help in early detection, timely treatment and better outcomes. Cervical thymoma with lung metastases and without mediastinal involvement is a rare presentation and future studies on extra-mediastinal thymomas would help in better management of these rare tumors.


Dear Editor,Botryomycosis is a chronic infectious disease of bacterial origin, granulomatous and suppurative with a worldwide distribution. The incidence and prevalence are unknown, although it is considered an infrequent entity, with approximately 200 cases reported around the world.3A 42-year-old male patient, a farmer, arrives at the dermatology service with a slow-growing lesion that had appeared 2-years earlier in the great toe finger of the right foot. The patient reported pain of moderate intensity that was enhanced with daily walking, as well as self-limited bleeding. Physical exam reveals in the dorsal aspect of the great toe finger an exophytic ulcerated tumor, erythematous, with hematic crust on the surface and some areas of bleeding, measuring 5×5 centimeters .Figure 1A biopsy was taken for the clinical hypothesis of squamous cell carcinoma vs. amelanotic melanoma; the result of the histopathological study showed pseudoepitheliomatous hyperplasia with basophilic granular bodies (grains) with numerous neutrophils . MicrobiBotryomycosis derives from the Greek “botrys” (bunch of grapes) and “myces” (fungus) because initially, a fungal etiology was suspected. Two types of the presentation can be described, cutaneous and visceral.4The cutaneous presentation represents 75% of the reported cases, the remaining 25% correspond to the visceral type. Botryomycosis can occur at any age, although it rarely occurs in ‘children’s and adults over 70-years old, it mainly involves areas with greater susceptibility to trauma such as hands, feet, head and neck.4mellitus, liver disease, alcoholism, systemic lupus, cystic fibrosis, malnutrition, immunoglobulin deficiency, glomerulonephritis, HIV/AIDS, or surgery history.4The history of trauma is the most important risk factor, in the case presented in this article, this was the probable method of inoculation since the patient works in agriculture. Other risk factors linked are immunosuppression, diabetes The pathogenesis of this entity is not well understood, and many authors agree that this reaction corresponds to a Splendore-Hoeppli phenomenon, in which antigen-antibody complex, immunoglobulin G and C3 are precipitated, a process in which phagocytosis and intracellular bacterial destruction is prevented.The 'patient’s present nodules, fistulas, abscesses, and ulcers with seropurulent exudate in which 3‒5 mm white-yellowish granules can be seen and the systemic infection has not been observed.4The differential diagnosis is other infectious granulomatous diseases such as mycetoma, actinomycosis, sporotrichosis, cutaneous tuberculosis, and malignant tumor diseases such as squamous cell carcinoma and amelanotic melanoma.Antibiotic treatment should be directed to the causative agent, in the case of extensive lesions, failure of systemic treatment, or severely immunocompromised patients, excision and drainage of the lesions are recommended.We present the clinical case of exophytic botryomycosis, an unusual clinical presentation previously not reported in the literature.None declared.Lina Paola González-Cardona: Critical literature review; critical manuscript review; preparation and writing of the manuscript; study conception and planning.Adriana Mercedes Alejo Villamil: Data collection, analysis and interpretation.Carolina Cortés Correa: Approval of the final version of the manuscript; effective participation in research orientation.Elkin Omar Peñaranda Contreras: Approval of the final version of the manuscript; intellectual participation in propaedeutic and/or therapeutic; management of studied cases.None declared.


Mucocele of the appendix (MA) is a rare disease characterized by chronic accumulation of mucin within an appendix. Although MA can be an asymptomatic finding, some patients with MA may present with right lower quadrant (RLQ) pain, pelvic pain, or even hernias. The later presentation is usually related to rupture of the mucin-filled appendix, a condition referred to as pseudomyxoma peritonei (PMP). Herein, we present a case of ruptured MA presenting as an irreducible paraumbilical hernia, where the patient presented with a lump to the surgical clinic. computed tomography (CT) of the abdomen revealed an RLQ lesion extending through the hernial neck. Further characterization of the lesion was performed with magnetic resonance imaging (MRI), revealing an appendiceal origin of the lesion. The patient underwent an exploratory laparotomy during which an omental sample was taken. Histopathology confirmed the diagnosis of metastasizing low-grade appendiceal mucinous neoplasm. We believe that our case is unique due to the rarity of ruptured MA as well as the rarity of it presenting as a paraumbilical hernia. Mucocele of the appendix (MA) was first described by Rokitansky in 1842 and defined as appendiceal lumen dilatation due to accumulation of mucus . MA coulA 52-year-old woman with known history of diabetes presented to the surgical clinic complaining of a midline lump which she noticed recently. The patient also complained of diffuse abdominal bloating with discomfort that she had been feeling for three months. There was no history of nausea, vomiting, fever or chills. On examination, the patient was discovered to have an irreducible abdominal midline hernia. The patient was vitally stable with normal bowel motion and no signs of obstruction. The surgical team requested a CT scan with oral contrast for evaluation of the contents of the hernial sac. CT showed an irregular, predominantly low-density structure at the right adnexa with a focus of thin curvilinear peripheral calcification Figure . This leMA is defined as chronic accumulation of mucin within an appendix, resulting in cystic dilatation of its lumen. The entity was first described by Rokitansky in 1842 and it is uncommon, with an incident rate of 0.2%-0.7% . LaboratImaging features of non-complicated MA overlap with findings of acute appendicitis as both present as dilated appendices. However, the presence of cystic dilatation (> 1.4 cm) and luminal calcification can reliably differentiate between the two entities . On MRI,Complications of MA include ureteral obstruction and appendiceal torsion. MA can also serve as a leading point for intussusception . Garg etPMP is characterized by the presence of mucinous ascites within the peritoneal cavity. The condition occurs secondary to rupture of a mucinous tumor, commonly from the appendix or ovaries. Although benign, PMP exhibits a “borderline malignant” behavior . On imagAbdominal hernias, characterized by the protrusion of abdominal contents from the abdominal cavity, are a common asymptomatic finding. Patients may present with a reducible or irreducible hernia. When an irreducible hernia is encountered the differential diagnosis includes incarceration of the hernial sac . In our In females, the clinical presentation may be confusing for the physician. One study reports a case that was initially misdiagnosed on US and MRI as an adnexal mass until the final diagnosis was reached on pathology. This is thought to be related to the non-specific appearance on imaging, especially on transvaginal ultrasound . AnotherAppendiceal mucoceles are treated surgically. A laparoscopic appendectomy can be performed, with a risk of port side recurrence. Other operations that can be performed in cases of MA include right hemicolectomies, omentectomies and laparoscopic colectomies, based on the extent of the disease and the presence of complications. When the lesion is limited to the appendix a right hemicolectomy is favored . PatientAlthough MA is a rare entity, it is important for physicians to consider this pathology in the differential diagnosis of non-specific abdominal pain, acute appendicitis and even pelvic masses. As discussed previously, this is due to the various clinical presentations it could present as. Even when dealing with a female patient who presents with a right adnexal lesion, the radiologist should be mindful of this entity and keep a high level of suspicion when encountering typical imaging findings of MA. These include low-density lesions with curvilinear calcification at the appendix on CT and thick ascites presenting as dense fluid with scalloping of the liver and spleen on all modalities. As in this case, searching for other origins of the lesion in the lower abdomen is the key to reaching the correct diagnosis. Radiological studies aid in the process of making a diagnosis and ruling out complications. However, histopathology is the most important tool for reaching the final diagnosis. Early diagnosis is paramount in cases of MA not only to avoid the risk of rupture but to also allow enough time for the treating physician to tailor the most suitable treatment for the patient.


This case describes an 80-year-old obese woman who presented with a giant, incarcerated umbilical hernia. The hernia was present for over 15 years, continuously increasing in size. The only symptom was the pain which lasted about two hours before arrival at the hospital. In an emergency laparotomy, gangrenous colon ascendens, transversum, and lienal flexure have been found. A subtotal colectomy with the creation of terminal ileostomy without hernia repair has been done. The recovery was uneventful, and the patient was discharged on the fifth postoperative day. After one month, the reconstruction of the digestive continuity with an L-L ileo-descendo anastomosis followed. The patient decided against the hernia repair.  A hernia is a protrusion of an organ or a part through connective tissue or through a wall of the cavity in which it is normally enclosed. The umbilical cord, consisting of two arteries and a vein, connects the fetus and placenta and is responsible for the nourishment and oxygen supply from the placenta to the fetus and the removal of waste products . After b2, had never been operated on, and has regularly taken antihypertensives (Amlopin) and occasionally diuretics and analgesics (NSAID).An 80-year-old, obese woman presented in the early morning, to the emergency department with a giant incarcerated umbilical hernia. She complained about abdominal pain, which lasted about two hours before the presentation. The hernia was present for over 15 years, continuously increasing in size; on several occasions reduced by the patient by lying down and applying pressure on the hernia. On examination, there have not been any signs of acute abdomen (guarding or tenderness). An 18 x 18 cm irreducible swelling was present at the umbilicus and infraumbilical. The skin was bluish-colored Figures . The patThe presentation with the incarceration has led us to the decision to operate urgently and not to lose time on an additional investigation (abdomen CT). Intraoperatively we found the ascendant and transverse colon and lineal flexure in the hernia sac, gangrenous but luckily not perforated Figure . The herIn that environment, we decided against anastomosis creation . We follOne month later, a restoration of the continuity of the gastrointestinal tract with the creation of an L-L ileo-descendo anastomosis followed Figure . The patThe first recorded mention of an umbilical hernia was made by Celsus, who in 100 AD called it “an indecent prominence of the navel” . The umbGiant hernias with large hernia necks can also incarcerate and strangulate. The presentation of strangulation, especially in older people, can occur with far fewer symptoms (pain) than expected. There is often a high discrepancy between the clinical presentation and the intraoperative findings. This case highlights a unique dilemma, physicians managing chronic large abdominal hernias in the elderly are facing, which carries potentially high morbidity and mortality with minor symptoms and subtle clinical findings. As the population of the elderly is growing worldwide, further research is urgently needed to establish criteria to clearly recognize such cases. An urgent operation should always be undertaken in case of incarceration. Always thinking of possible strangulation, independent of the clinical unreliability of the presentation  and the anamnestic unreliability of the data.


Sporadic Spinal Psammomatous Malignant Melanotic Nerve Sheath Tumor (SSP-MMNST) is a rare subgroup of peripheral nerve sheath tumors arising along the spine. Only a few reports of SSP-MMNST have been described. In this paper, we review the literature on SSP-MMNST focusing on clinical, and diagnostic features, as well as investigating possible pathogenetic mechanisms to better implement therapeutic strategies. We also report an illustrative case of a young female presenting with cervicobrachial pain due to two SSP-MMNSTs arising from C5-6 right spinal roots.We report a case of a 28-year-old woman presenting with right arm weakness and dysesthesia. Clinical examination and neuroimaging were performed, and, following surgical removal of both lesions, a histological diagnosis of SSP-MMNST was obtained.The literature review identified 21 eligible studies assessing 23 patients with SSP-MMNST, with a mean onset age of 41 years and a slight male gender preference. The lumbar district was the most involved spinal segment. Gross-total resection (GTR) was the treatment of choice in all amenable cases, followed in selected cases with residual tumor by adjuvant radiotherapy or chemotherapy. The metastatic and recurrence rates were 31.58% and 36.8%, respectively.Differently from common schwannomas, MMNST represents a rare disease with known recurrence and metastatization propensity. As reported in our review, SSP-MMNST has a greater recurrence rate when compared to other forms of spinal MMNST, raising questions about the greater aggressiveness of the former. We also found that residual disease is related to a higher risk of systemic disease spreading. This metastatic potential, usually associated with primary lumbar localization, is characterized by a slight male prevalence. Indeed, whenever GTR is unachievable, considering the higher recurrence rate, adjuvant radiation therapy should be taken into consideration. Malignant melanotic nerve sheath tumor (MMNST) represents a rare variant of nerve sheath neoplasms and accounts for less than 1% of all primary peripheral nerve sheath tumors . ConsideMMNSTs are categorized according to two main groups. The first one is represented by its association with Carney Complex (CC). This entity features autosomal dominant inheritance and is characterized by patchy skin pigmentation, endocrine hyperactivity, and cardiac, mammary, and cutaneous myxomas , 10. AboMMNST displays both malignant and metastatic potential depending on its histology. Microscopically, MMNST features spindle-shaped and epithelioid cells in intertwining fascicles, with a significant concentration of melanin both in the neoplastic cells and in the associated melanophages .Clinical presentation depends on anatomical location. MMNST typically arises along the spinal nerve sheath , thus exTo date, the literature has reported approximately 150 cases of MMNST. In this paper, we review the literature on SSP-MMNST in order to improve the knowledge of this disease, focusing on clinical, and diagnostic data, as well as investigating possible pathogenetic mechanisms to better implement therapeutic strategies. We also report a case of a young female presenting with cervicobrachial pain due to two SSP-MMNSTs arising from C5 and C6 right roots.A PRISMA flowchart is presented in A 28-year-old woman presented with a one-year history of cervical pain radiating to the right arm. She had no history of other illnesses, surgeries, related traumas, or a family history of spinal diseases. No skin pigmentary abnormalities were observed. Neurological examination revealed mild weakness in the right arm and dysesthesia in the C5-C6 right dermatome. Electromyography (EMG) testing was performed and did not disclose any abnormality. Spinal cord Magnetic Resonance Imaging (MRI) demonstrated two right intracanal extradural and intra/extra-foraminal lesions at the cervical level: the first lesion measured 20x10mm and was located at the C6-C7 level with paravertebral extension and “dumbbell” shape; the other smaller one was located at C5-C6 level Figure 2PRKAR1A gene was performed using Sanger sequencing, and no germline pathogenic variant in PRKAR1A was identified. Concerning the young age of the patient, research on the pathogenic variant in phacomatosis susceptibility genes  and other 24 genes relevant in the pathogenesis of nervous system tumors , was performed using a customized gene panel on lymphocyte DNA and tumor tissue. No pathogenic variants of those genes were detected in both tissues. 30 days after the surgical procedure, a whole-body Fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT) was performed, showing no residual focal pathology nor metastasis, and an echocardiogram revealed no cardiac myxoma. One year after surgery, the patient was in clinical and radiological remission without any signs of recurrence of the disease as confirmed by a recent one-year FDG-PET/CT.The case was discussed by a multidisciplinary team which set the indication for surgical removal of the lesions. The patient gave written informed consent for the procedure. On the day of surgery, the patient was positioned supine, and a laminectomy was performed at the C5-C7 levels. Through a microscopic technique and an extended transcanalar approach, a GTR of intracanal, intra-foraminal, and paravertebral components of the two lesions was performed. Fat tissue was placed to reinforce the dural closure. The postoperative course was uneventful and characterized by strength recovery. On the other hand, dysesthesia slightly improved, but never recovered completely. The patient underwent a postoperative cervical MRI, which confirmed radical excision of both lesions Figure 2SSP-MMNST is a rare, aggressive, and diagnostically challenging tumor of spinal nerves. We reviewed cases of SSP-MMNST by performing a literature search on PubMed and Embase databases. Their features are summarized in MMNST, formerly known as Melanotic Schwannoma or Schwannian melanotic tumor, was classified as a malignant lesion in the 2020 WHO classification of soft tissue tumors . The neoMMNST generally arises from spinal nerves and sympathetic ganglia as a single lesion , 9, 23. The clinical presentation of spinal MMNST is related to its anatomical location. Approximately one-third of cases are asymptomatic . On the Unlike common schwannomas, MMNST is prone to local recurrence and displays metastatic potential , 9, 39. Our review on SSP-MMNST demonstrated metastasis occurrence in 31.58% of cases, with male prevalence (66.6%) and with no statistically significant difference from the metastatic rate of spinal MMNST (p=0.463) . The maiIn 83% of cases of metastasis, the primitive tumor developed in the lumbar region with a slightly greater risk in males . The mean age in patients with metastatic disease was lower than non-metastatic ones (37.33 ± 9 vs 42 ± 15 years), with no significant difference.Comparing whole-body MMNST data  with ourHistologically, MMNST generally consists of a single ovoid lesion, and it is rarely multifocal. Adjacent bone erosion may be observed , 23, 41.MMNST pathogenesis is still poorly understood. Several theories about histogenesis of the tumor have been described. Schwann cells and melanocytes share both their neuroectodermal origin and migration routes. Given this common developmental lineage, Schwann cells may be capable of synthesizing melanin under specific circumstances , 51, 52.PRKAR1A) gene  gene , 42. CC mutation . MMNST mmutation , 48. Recmutation .MMNST diagnosis is based on clinical, histopathological, and instrumental findings. The histological diagnosis requires careful differential considerations between neurofibroma, pigmented dermatofibrosarcoma protuberans, melanocytoma, and malignant melanoma.Our case matched previous literature, with both tumors being positive for HMB-45, S100, Synaptophysin, Melan-A, and Collagen-IV. MIB-1 proliferative index was 4-5%. Phacomatosis susceptibility and CNS tumorigenesis genes were also investigated with negative results. Their negativity allowed us to exclude melanoma, CC, and Neurofibromatosis.Radiologically, SSP-MMNST is characterized by hyperintensity in T1-weighted sequences, hypointensity in T2-weighted sequences, and homogeneous post-contrast enhancement Table 2.FDG PET/CT provides a unique contribution to: (a) the differential diagnosis of benign and malignant lesions, (b) the detection of covert metastases, (c) the monitoring of treatment response, and (d) the evaluation of MMNST prognosis , 60, 61.Surgery represents the cornerstone of treatment for MMNST, with GTR being the gold standard for all subtypes. During surgery, a residual tumor capsule may be left to prevent spinal cord injury if the tumor is closely adherent , 63.In our review on SSP-MMNST, the most common approach was GTR in 73.91% of cases. Among these, only 23.53% developed disease recurrence, as opposed to 60% of patients who underwent STR. The total recurrence rate was 36.84%, and 57.14% of that percentage was associated with metastasis. This finding may suggest that recurrent SSP-MMNSTs tend to be more aggressive and, therefore more prone to spread systemically.Given the limited number of cases, post-surgical management is controversial. No current guidelines for adjuvant treatment in MMNST are available , 50. SomDifferently from common schwannomas, MMNST represents a rare disease with known recurrence and metastatization propensity. As reported in our review, SSP-MMNST has a greater recurrence rate when compared to other forms of spinal MMNST, raising questions about its greater aggressiveness. We also found that residual disease is related to a higher risk of systemic spreading. This metastatic potential, usually associated with primary lumbar localization, is characterized by a slight male prevalence. Indeed, whenever GTR is unachievable, considering the higher recurrence rate, adjuvant radiation therapy should be taken into consideration.The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the study on human participants in accordance with the local legislation and institutional requirements. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article. Patient signed informed consent regarding publishing his data and photographs.GB, EM, and MB performed the clinical assessment. GB, AG, EM, ER, PA, and GI critically reviewed the literature and drafted the manuscript. All authors were responsible for important intellectual content. All authors contributed to the article and approved the submitted version.


Vascular ectasia is a common cause of lower gastrointestinal (GI) bleeding in older patients. They typically present as flat or slightly raised fern-like bright red lesions. We report a rare case of a vascular ectasia presenting as a pedunculated polypoid lesion in a young patient with rectal prolapse. The pedunculated polyp was removed using hot snare polypectomy. This case highlights a unique presentation of a rare lesion and endoscopic management of these lesions. Colonic vascular ectasia (VE) is not an uncommon cause of lower gastrointestinal (GI) bleeding, especially in the elderly. They typically present as flat or slightly elevated reddish lesions. On the other hand, colonic submucosal VE presenting as pedunculated polypoid lesions are rare. We report an interesting case of colonic vascular ectasia pedunculated polypoid lesion (VEPPL) in a patient presenting with rectal prolapse. The abstract of this study was presented as a poster at the American College of Gastroenterology Annual Scientific Meeting on 24 October 2021.A 44-year-old male with no significant past medical history presented to the emergency department with rectal prolapse and bleeding that developed while straining to have a bowel movement. His mother was diagnosed with colon cancer in her 50s. Physical examination was consistent with a complete external rectal prolapse. A complete blood count (CBC) was unremarkable with a hemoglobin of 16 g/dL. Computed tomography of abdomen and pelvis confirmed rectal prolapse, but could not exclude an underlying mass. The prolapsed rectum was reduced, and a colonoscopy was recommended. During the colonoscopy, a 20 mm-pedunculated polyp (Paris class Ip) with hyperemic mucosa and a long stalk was found in the distal sigmoid colon (Figure The polyp was removed with hot-snare polypectomy without immediate or delayed complications. Histopathologic examination showed colonic mucosa with erosion, reactive epithelial change, and underlying submucosal dilated vessels with extensive thrombosis Figures , 3. The The incidence of VE discovered on colonoscopy was reported as 1-6% . HistoloOf the 16 previously reported VEPPL cases, these lesions were typically removed endoscopically via snare polypectomy or mucosal resection. During one reported case, the polyp was removed with snare polypectomy that resulted in excessive bleeding and required injection of epinephrine and argon plasma coagulation . The othTypical flat vascular ectasia lesions are most commonly found in the cecum and ascending colon . InteresIn contrast to flat or slightly raised classical vascular ectasia which are reported in 1-6% of colonoscopies, submucosal vascular ectasias presenting as pedunculated polypoid lesions are rare and have only been described in 16 other cases in the literature. Endoscopically, vascular ectasia pedunculated polypoid lesions can appear similarl to adenomatous polyps which makes it difficult to diagnose these lesions during colonoscopy. Other cases have treated this pedunculated polyp with polypectomy. The most common location of VEPPL was within the sigmoid colon. In conclusion, while all other reported cases of submucosal vascular ectasia pedunculated polypoid lesions were either asymptomatic or presented with lower gastrointestinal bleeding or iron deficiency anemia, we present a rare case of a submucosal vascular ectasia pedunculated polypoid lesion with a unique presentation of rectal prolapse.


Squamous cell papilloma is a benign proliferation of the stratified squamous epithelium, which results in a papillary or warty mass, which is presumably induced by the human papilloma virus (HPV).Clinically, oral papillomas usually present as an exophytic, isolated, pedunculated, painless growth of less than 1 cm, the surface of which shows fingerlike or warty projections resembling a cauliflower, exhibiting color ranging from pink to pale white, depending on the degree of associated keratinization. They are more frequently found in the tongue and palate, affecting both genders equally and, commonly, individuals between 30 and 50 years.2 laser, cauterization or cryosurgery also being acceptable.The treatment for oral papilloma is conservative, requiring complete removal of the lesion, but excision of a surrounding margin of safety is not mandatory. Untreated lesions usually do not change over time. Conservative surgical excision is a good choice, with the destruction by COAlthough the squamous papilloma normally presents with small dimensions, some cases develop and reach larger sizes. The purpose of this paper is to report a rare case of extensive oral squamous papilloma with involvement of the tongue, treated by partial glossectomy.A 73-year-old female patient presented with complaints of an enlargement and change of consistency of the tongue over the prior 15 years. The patient denied any systemic disease or medication of continuous use. Extra oral physical examination including cervical palpation revealed no noteworthy abnormalities. The intra-oral physical examination showed a vegetative lesion of verrucous aspect involving virtually the entire right portion of the tongue, extending from the lingual apex to the posterior region, close to vallate papillae, being approximately 6 cm in its greatest length , but witUnder local anesthesia, incisional biopsy was performed on various regions to minimize the risk of an underdiagnosis of a malignant lesion, which confirmed a diagnosis of squamous papilloma. Thus, we opted for surgical treatment to completely remove the lesion by partial glossectomy. Under general anesthesia, a needled 2.0 cotton suture was placed at the lingual apex region for better traction and lingual repair. This way, an atraumatic resection of the lesion was accomplished with the use of electrocautery , preservThe definitive histopathological examination confirmed the initial diagnosis, and was characterized by parakeratosis, acanthosis, papillomatosis, mild atypical cells, and white blood cell exocytosis; chorion with hyperemia, foci of hemorrhage, and mild diffuse inflammatory infiltrate of mononuclear cells and eosinophils.At the follow-up visit, points of dehiscence were observed postoperatively, which were treated with strict oral hygiene, and healed with no signs of infection during the whole period of tissue repair, with adequate formation of granulation scar tissue on the site. After 10 days, the nasoenteric tube was removed.The patient has been followed in an outpatient clinic for 20 months with no signs of recurrence . From thOral papillomas are usually clinically asymptomatic, exophytic, and have a cauliflower-like surface. They are most commonly found in the tongue, lips, buccal mucosa, gums, palate, and their size range from 0.2 to 1 cm. Authors such as Kumar et al.The occurrence of such lesions is influenced by smoking, coexisting infections, nutritional deficiencies, hormonal changes and immunological changes, such as in cases of HIV-positive patients, who are generally affected by multiple oral lesions.Carneiro et al.Similar to this study, Martins Filho et al.Although the definitive treatment under local anesthesia is the most common procedureThe literature suggests several modalities of treatment for oral squamous papilloma. Among these are conventional surgical excision, cryosurgery, laser ablation, intralesional injection of interferon, and application of salicylic acid.As the papilloma is usually asymptomatic lesion, and usually presents with small dimensions, it is usually treated with surgical removal during excisional biopsy. However, some cases are larger and cause discomfort, difficulty in speech and chewing, social impairment, and their treatment can result in greater deformity after the final treatment.The authors declare no conflicts of interest.


For decades MRI has been utilized for diagnosing spine pathology. However, like many imaging modalities utilized today, a conventional MRI is a static study. The spine is a complex, dynamic structure whose loading characteristics change with the position of the spine and the type and direction of force applied. This gives rise to dynamic pathologies that are often masked if attempted to be imaged using conventional MRIs. This is where a weight-bearing MRI (WBMRI) shines. We report the case of a 66-year-old female in whom an L3-L4 synovial facet cyst was diagnosed on a WBMRI. Several pathologies of the spine are better delineated when the physiologic stress of weight-bearing is applied. For instance, MRI conducted in the upright seated position is better able to detect posterior disc herniations . Other sA 66-year-old female presented to our clinic with a chief complaint of low back pain for several years, which became acutely worse over the past few weeks. In addition to her chronic low back pain, she now complained of right leg radiculopathy with numbness and tingling in the right lateral thigh, knee, and leg. Her radiculopathy was exacerbated by activities such as extension and walking downstairs. No recent injury had been sustained. Past medical history was significant for sleep apnea, hypertension, chronic obstructive pulmonary disease, depression, diabetes, heart attack, chronic kidney disease, asthma, and a lower extremity deep vein thrombosis. Her back pain was eight out of ten and her right leg pain was seven out of ten. No bowel or bladder incontinence was present. She could walk for approximately five minutes before having to rest. She consumed hydrocodone/acetaminophen 10/325 mg for her chronic back pain. She underwent physical therapy two years ago and continued home exercises, although she reported minimum improvement in her symptoms from her exercises. No other treatments were undergone by the patient.Anterior-posterior (AP), lateral, flexion, and extension X-rays of the lumbosacral spine were significant for an L3-L4 grade I dynamic spondylolisthesis with 6.8 mm of listhesis on flexion Figure  and 3.8 The patient was scheduled to undergo a total knee arthroplasty (TKA) within the next few weeks of her office visit and deferred any spinal surgical intervention until she recovered from her TKA. She elected to undergo epidural steroid injections in the interim. If her symptoms did not improve or if she developed any acute neurological deficits, it was decided that an L3-L4 decompression and fusion would be performed.Several imaging modalities are utilized in the field of spine surgery to elucidate spinal pathology. Most imaging modalities are static in nature and hence are excellent at revealing static pathologies. Dynamic imaging is utilized to diagnose dynamic pathologies. Of these, flexion-extension X-rays of the spine are routinely used. WBMRIs, however, are not commonly employed. Even though the use of WBMRIs has been documented in the literature, to our knowledge, there have been no other reports of a patient with minimal disc degeneration and facet hypertrophy with a dynamic spondylolisthesis that has been evaluated with a WBMRI demonstrating a synovial cyst. We, therefore, propose a new indication for obtaining a WBMRI.In our patient, after an initial conventional MRI revealed no underlying pathology explaining the patient’s symptoms, a WBMRI was performed due to tall L3-L4 disc space, a spondylolisthesis, and radiculopathy being aggravated by extension. Although symptoms worsening with extension could indicate spinal stenosis, the tall disc space hinted at a lower likelihood of intradiscal pathology and drew our attention to the posterior elements such as the ligamentum flavum and facet joints. The dynamic spondylolisthesis raised suspicion for an incompetent facet articulation. Being posterior elements of the spinal column, facets joints are offloaded with flexion and loaded with extension . In theiBeyond radiculopathy, WBMRIs can help to better characterize disc herniations and spondylolistheses, especially if they are dynamic. Spondylolisthesis by itself can be evaluated on flexion-extension radiographs. However, the effects of these pathologies on nearby neural elements can be underrepresented by conventional MRIs. In their study, Ferreiro Perez et al. illustrated the superiority of upright MRIs by showing that posterior disc herniations and anterolisthesis were either underestimated or missed in 58% of patients undergoing conventional recumbent MRIs . TherefoCentral canal stenosis is yet another aspect of spinal pathology that can be better highlighted with WBMRIs. Multiple studies assessing upright MRIs have demonstrated that a decrease in foramina, lateral recess, and central canal cross-sectional areas is caused by extension -8. SchmiWhile WBMRIs impart valuable additional information, they have a few drawbacks that need to be considered prior to ordering this imaging modality. The availability of WBMRIs is not widespread. Furthermore, the cost can be prohibitive. Since multiple images with and without the weight-bearing sequence are obtained, this can, unfortunately, lead to an increased cost of the study. As an example, as compared to conventional MRI facilities, imaging conducted in upright MRI facilities in Washington State billed 2.5 times higher as per Chung et al. . FurtherWeight-bearing MRI is a modality with exciting prospects. Its ability to delineate occult spinal pathology makes it a very useful tool in diagnosing patients, especially if patients have already obtained a conventional MRI which fails to elucidate spinal pathology that correlates with their symptoms. However, obtaining WBMRIs is not feasible for every patient. We suggest obtaining a WBMRI in patients presenting with postural radiculopathy with a tall disc space and with an associated spondylolisthesis, especially in the setting of a negative conventional MRI. This case study demonstrates one of the many ways in which a WBMRI can aid in diagnosing dynamic pathology in the lumbar spine.


Congenital retinal macrovessel (CRM) is a congenital anomaly where an aberrant vessel supplies both the macula on either side of the horizontal raphe. It is usually an incidental finding but may be associated with other retinal findings that may impact vision. We present an unusual case of bilateral congenital retinal macrovessel in a 40-year-old patient. The patient presented to the ophthalmology clinic for diabetic retinopathy screening and had no visual complaints. The patient underwent a complete ophthalmological examination including fundus imaging, fundus fluorescein angiography, and optical coherence tomography (OCT) imaging. Dilated fundus examination showed bilateral hypertensive retinopathy with optic disc collateral vessels and congenital retinal macrovessels. The multimodal imaging techniques that were used to confirm the finding indicated that the vessel is arterial. Congenital retinal macrovessel (CRM), first described by Mauthner in 1869 . Later, A 40-year-old male who is known to have diabetes mellitus, dyslipidemia, and hypertension for the last eight years presented to the ophthalmology clinic for diabetic retinopathy screening. He had no previous ocular history. On examination, his best corrected visual acuity was 6/6 in both eyes. Slit lamp examination of the anterior segment was normal in both eyes. Dilated fundus examination revealed bilateral grade 2 hypertensive retinopathy with optic disc collateral vessels. In both eyes, an aberrant vessel was found originating from the optic nerve head and traversing the papillomacular bundle inferotemporally. In the right eye, the vessel gives off a branch that crosses superiorly to supply the fovea, whereas in the left eye, the entire vessel crosses the horizontal raphe as shown in the fundus image below Figure . The calFundus fluorescein angiography showed the filling of the vessel early in the arterial phase, and no leakage was noted Figure . OpticalCongenital retinal macrovessel is an abnormal macular vessel with distribution above and below the horizontal raphe ,2. The tIn conclusion, we report the case of bilateral congenital retinal macrovessel, which we believe is arterial in origin. This finding was observed incidentally as the patient was asymptomatic. Further investigation with imaging modalities highlighted the presence of this retinal vascular anomaly bilaterally. No macular thickening or FAZ enlargement was observed on OCT and OCT-A imaging, respectively.


TFE3-rearranged RCC to be found harbouring metaplastic bone in a 47-year-old woman who presented with a slowly enlarging left flank mass over a 10 year period. This case report adds to the clinicopathological description of TFE3-rearranged RCC and suggests that larger studies are required to fully elucidate the prognosis of these tumours.TFE3-rearranged renal cell carcinoma (RCC) is a rare but well characterised histological subtype of RCC with an aggressive clinical course and propensity for late metastases. Osseous metaplasia is an uncommon but well documented finding in clear cell, papillary and chromophobe RCC. We present the first case of a  TFE3-rearranged RCC may metastasise late, up to 20–30 years after diagnosis, necessitating long term clinical follow up. Osseous metaplasia in renal tumours is an uncommon but well described phenomenon with several reports occurring in CCRCC, PRCC and chromophobe RCC. Two cases of TFE3-rearanged RCC with osseous metaplasia are described in the literature, one of which was confirmed with RT-PCR.,Renal cell carcinoma (RCC) is one of the leading causes of cancer worldwide, accounting for approximately 4% of new cancer diagnoses in 2021. We present the first case of TFE3-rearranged RCC harbouring osseous metaplasia to be confirmed with fluorescent in situ hybridisation (FISH), with an indolent clinical course and long interval period between presentation and definitive surgery.2A 47-year-old female, known HIV-positive (CD4 312 cells/uL), was referred to our unit with worsening abdominal discomfort and a progressively enlarging left flank mass. Further history revealed that the patient was diagnosed with "kidney cancer" at another hospital ten years ago. She had declined surgery then and had returned now due to worsening symptoms. On examination, vital signs were normal, and no haematuria was noted on urinalysis. The abdominal examination noted a large, firm, smooth, but mobile left flank mass that appeared to extend medially across the midline and caudally into the pelvis. Full blood count and renal function tests were within normal range. An abdominal x-ray revealed the presence of a calcified lesion in the left upper quadrant . ComputeTFE3 dual colour break apart probe confirmed rearrangement in the TFE3 gene.Gross examination revealed a large multinodular bosselated tumour which had engulphed most of the kidney. Upon sectioning, a think fibrous and calcified capsule was noted. The tumour comprised multilocular cysts, some of which contained papillary structures, as well as solid areas, with extensive necrosis. The tumour involved the renal sinus (pT3a). Histological examination demonstrated RCC with papillary, pseudopapillary, solid and cystic architecture. The tumoural cells contained moderate eosinophilic cytoplasm in areas, but other areas showed apical cytoplasmic clearing a. NucleoOur patient's postoperative course proved uneventful. She was discharged on the fifth day and remained asymptomatic and tumour-free at the last follow-up six months later.3TFE3-rearranged RCC is a relatively recently described histological subtype of RCC which is known to have a poor prognosis, similar to that of CCRCC.TFE3-rearranged RCC is limited in the adult population, with only a few small case series, and perhaps not entirely representative of the clinical course.TFE3-rearranged RCC should be suspected histologically in the presence of typical morphology  and strong diffuse nuclear TFE3 immunoreactivity. The papillary architecture and prominent cytoplasmic clearing may prompt the unwary pathologist to consider PRCC and CCRCC respectively. It is important to distinguish TFE3-rearranged RCC from its histological mimics as it has a poor prognosis. This can be achieved with TFE3 FISH or immunohistochemistry. The sensitivity and specificity of TFE3 immunohistochemistry is good, but due to difficulties in optimising the antibody, FISH is generally more reliable on formalin-fixed paraffin-embedded tissue samples.The diagnosis of TFE3-rearranged RCC with osseous metaplasia have been reported in the literature, one in an elderly woman and one in a teenager.,Osseous metaplasia is an uncommonly reported finding in RCC, but has been documented in several cases of CCRCC, PRCC and chromophobe RCC. There is controversy about whether the presence of osseous metaplasia has any clinical significance or holds any prognostic value. Some authors suggest a favourable prognosis, while others suggest that this histological finding is associated with more high grade tumours and resemble a poor prognosis.4TFE3-rearranged RCC is an uncommon histological subtype of RCC in adults, with an unfavourable prognosis, and requires a high index of suspicion on the part of the pathologist to correctly identify. TFE3 immunohistochemistry is difficult to optimise, and equivocal or patchy positive staining should prompt genetic confirmation of the translocation with FISH. Osseous metaplasia is uncommon in RCC, and this is the second description of this phenomenon in a genetically confirmed TFE3-rearranged RCC. We present a case of TFE3-rearranged RCC with indolent behaviour and an uneventful 10 year pre-operative course, suggesting that larger studies focusing on follow-up and outcome data are required to establish a clearer picture of the prognosis of these uncommon tumours.None.The authors declare no conflicts of interest.


Processus vaginalis in females or the canal of Nuck was first described by the Dutch anatomist Anton Nuck in 1691 . Its patency after birth predisposes to congenital presentations like hydroceles, encysted hydroceles and hernias presenting as an unusual inguino-labial swelling. It gets obliterated by first year of life and hence anomalies related to its patency in adult hood are even rare. It is hence important to be familiar with the clinico-radiological aspects of such a presentation when it is encountered.Case presentation is of an adult woman of 36 years with hydrocele of the canal of Nuck.We proceed to discuss the clinico-radiological features and variations of this entity in our case report.In conclusion, differential diagnosis of female inguino-labial swellings need detailed evaluation to exclude the possibility of rare entities. •Adult Hydrocele of Canal of Nuck is an uncommon entity.•It poses diagnostic dilemma in many circumstances.•An appropriate assessment is the key to diagnosis. Elaborate investigations become mandatory in rare incidences. Hydrocele of the canal of Nuck is one such clinical entity, though first described in 1691. Much required is the precision in treatment modalities and these are aided by a thorough clinico-radiological knowledge which the authors wish to emphasize and hence the case reporting.2A 36-year-old, married, multiparous house-wife, presented to our out patient's department with complaints of a painless swelling over right groin of 3 months duration. On examination a soft-cystic, fluctuant, right inguino-labial swelling was noted, which was transilluminant , Fig. 2.All along her case the SCARE 2020 criteria and checklist were followed and were adhered to Hematological and biochemical investigations which were performed were normal. With a clinical suspicion of Canal of Nuck cyst and differential diagnosis of a lymphatic cyst or lymphangioma, ultrasound was done. It was consistent with a cystic inguino-labial swelling, which was septated, measuring 6.3 cm × 2.2 cm × 1.9 cm , Fig. 4,An inguinal incision was taken under field block and the swelling was approached like an inguinal hernial sac. The cystic sac was multi-locular and hence was dissected towards the neck first. The neck was then opened and transfixed at the internal ring and fluid as also the sac was taken for investigations. The distal part of the sac revealed cysts within cyst for which subsequent dissection was meticulously carried out to remove all the cystic spaces till the distal limit of the swelling in the labia majora. Patient tolerated the procedure well , Fig. 6.The surgery performed was herniotomy along with complete excision of the distal cystic lesion till the labia majora. Histology confirmed the sac sent to be peritoneal sac with areas of fibrosis and there was no infection nor any abnormal cells detected in the peritoneal fluid. Her post-operative period was uneventful and she was discharged the next day. One year post intervention, she continues to remain symptom-free, without any ipsilateral recurrence or contralateral swellings.3The canal of Nuck, akin to the patent processus vaginalis in males, is an abnormal patent pouch of peritoneum, extending from anterior aspect of round ligament of uterus to the labia majora in females when it fails to obliterate completely. The quoted incidence in neonates is of 80–94 % while at one year age it drops to 30 % Three types of hydrocele of canal of Nuck are encountered: i) encysted variety has no communication with the peritoneal cavity. ii) Variety with persistent communication between hydrocele and the peritoneal cavity and iii) the hour-glass variety, as a result of constriction at deep inguinal ring so that part is communicating and part is enclosed The classical presentation of a painless inguinolabial swelling more commonly on the right side and occasionally bilateral, which reduces on lying down, indicates a hernia Preoperatively, it is necessary to differentiate conditions which may create a diagnostic dilemma: femoral hernia, inguinal hernia with irreducibility, lipoma, lymphangioma, leiomyoma, sarcoma and occasionally round ligament varicosities, cysts, abscesses and lymph nodes may mandate use of imaging modalities The most commonly used modality is ultrasound. Hydrocele of the canal of Nuck typically presents as a cystic mass superficial and medial to the pubic bone at the level of the superficial inguinal ring. In the case of a hydrocele, ideally peritoneal communication is absent but in a case like ours where loculations and adhesions caused the tense cystic collection, in spite of an existing communication, there is also no change with Valsalva maneuver. Ultrasound is excellent at picking up the presence of bowel loops and ovaries, ectopic pregnancy, or endometrial tissue in the canal When Ultrasound fails to elucidate findings, further investigations like CT scan or MRI may be required Once diagnosed, most surgeons opt for a surgical approach which could be either open 4Hydrocele of the canal of Nuck is a rare entity especially in adulthood. We encountered one such case and decided to operate on her and present the clinico-radiological features of this rare inguinolabial swelling in females which needs to be borne in mind while considering the differential diagnoses.Not commissioned, externally peer reviewed.There was no funding from sponsors or other sources utilized for this manuscript.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.Patient was taken into confidence at every step and willingly consented to get her clinical pictures published, and her identity details were not disclosed, maintaining the secrecy of her identity.The first author has actively participated in literature search and manuscript writing.The second and third authors were involved in taking case history, admitting and working up the patient for surgery. They were assisting surgeons and were also involved in post operative care of the patient.The fourth, corresponding author was the chief operating surgeon for this patient and envisaged the manuscript writing and supervised the entire process.N/A.Such rights in our publication lie with the Departmental Head, who has been kept in knowledge of our work and has approved of it.The authors declare no conflict of interest in preparing this article.The SCARE list has been adhered to in the preparation of this manuscript.


Intussusception is an extraordinary cause of acute abdomen in adults and has been defined as the telescoping of a bowel segment into the lumen of an adjacent segment. A 43-year-old female presented to our hospital's emergency department (ED) with 10+ episodes of bloody diarrhea per day, left-sided abdominal pain, and the inability to tolerate oral intake for one month. She was initially diagnosed with ulcerative colitis (UC) ten years ago and is currently on mesalamine oral and enema therapy. She presented to our gastroenterology clinic two weeks after the beginning of her flare and was started on prednisone 40 mg daily. This did not improve her symptoms, and she presented to the ED two weeks later. She underwent a computed tomography (CT) abdomen/pelvis which revealed intussusception in the left hemiabdomen with no definite lead point measuring 5.6 cm in the craniocaudal dimension with pneumatosis and no evidence of bowel obstruction. There were no other significant laboratory abnormalities. Acute care surgery was consulted and suggested obtaining a CT enterography for further evaluation which showed spontaneous resolution of intussusception with no evidence of pneumatosis, portal venous gas, or intraperitoneal free air. She reports that following oral contrast intake, she “felt movement and relaxation” in her abdomen with substantial pain relief. Infectious workup was negative, and therapy was initiated with intravenous steroids. In conclusion, intussusception has been very rarely reported in patients with UC with the most common treatment being surgical resection. However, conservative management in the absence of bowel obstruction can be attempted. Intussusception is a very rare cause of acute abdomen in adults and has been defined as the telescoping of a bowel segment into the lumen of an adjacent segment , 2. In pA 43-year-old female presented to our hospital's emergency department (ED) with 10+ episodes of bloody diarrhea per day, left-sided abdominal pain, and the inability to tolerate oral intake for one month. She was initially diagnosed with ulcerative colitis ten years ago and is currently on mesalamine oral and enema therapy. Most recent colonoscopy was done in 2020 and revealed extensive colitis of the transverse, descending, and sigmoid colon with active proctitis. She usually has two to three flares a year where she manages them by herself through diet modification and lifestyle changes , but this time her symptoms continued worsening causing her to come to the hospital. She presented to our gastroenterology (GI) clinic two weeks after the beginning of this current flare and was started on prednisone 40 mg daily. They recommended discontinuing the mesalamine enema due to excess diarrhea, which she did, but she inadvertently also stopped taking her oral mesalamine. The prednisone did not improve her symptoms, as she was still having 10+ bloody bowel movements per day and severe left-sided abdominal pain described as a constant throbbing sensation with swelling and warmth overlying the skin. She presented to our ED two weeks later and was found to have an elevated c-reactive protein of 4.4 mg/dL, erythrocyte sedimentation rate of 51 mm/Hr, blood pressure of 164/101 mmHg, pulse of 107 with a soft, nondistended, tender abdomen, and dry mucous membranes. A Truelove and Witts severity index scoring was utilized, resulting in a severe classification. Also, the Montreal classification for inflammatory bowel disease scoring was rated as E3 S3. She underwent a computed tomography (CT) abdomen/pelvis which revealed intussusception in the left hemiabdomen with no definite lead point measuring 5.6 cm in the craniocaudal dimension with pneumatosis and no evidence of bowel obstruction. Diffuse colorectal wall thickening, mucosal hyperenhancement, and fat stranding were also seen suggesting proctocolitis (Figures To the best of our knowledge, there have only been seven cases of patients with UC complicated with intussusception in the literature . In the CT scan has been regarded as the modality of choice for diagnosing intussusception . Due to In conclusion, intussusception has been previously reported with patients with UC with the most common treatment being surgical resection. However, based on our findings, conservative management with oral contrast could be attempted before surgical resection in adults in the absence of bowel obstruction.


The misdiagnosis can result in recurrences in patients with sphenochoanal polyp.•Sphenochoanal polyps should be kept in mind in the differential diagnosis of unilateral nasal cavity or paranasal sinuses masses. Nasal polyps that originate from the sphenoid sinus and reach the nasopharynx are called sphenochoanal polyps. Reports on sphenochoanal polyps in children have thus far been limited only to case reports. This review aims to describe and summarize clinical presentation, diagnosis, management, surgical approaches to the sphenochoanal polyps with recurrence rate after surgery in pediatric patients reported in the literature.A systematic literature review was performed using PubMed, MEDLINE and Cochrane Library Databases for articles published prior to December 2021 to identify all studies reporting on pediatric patients with sphenochoanal polyps. Clinical presentation, management options, surgical approaches and outcomes of applied management were extracted from included studies.9 articles provided data on 11 eligible patients with an age range 3 years and 8 months–16 years. The commonest symptoms included: nasal obstruction, nasal discharge, and headache respectively. All patients were subjected to surgical treatment. No recurrences after the endoscopic sphenoidotomy were reported.Sphenochoanal polyps should be kept in mind in the differential diagnosis of unilateral nasal cavity or paranasal sinuses masses. Misdiagnosis can result in recurrences in patients with sphenochoanal polyp, who can be mistakenly diagnosed with antrochoanal polyp and underwent inadequate treatment not involving sphenoidotomy and exact identification of the site of implantation. The symptoms of sphenochoanal polyps are nonspecific. A choanal polyp is a benign solitary mass originating from the edematous and inflamed mucosa of the paranasal sinuses, passing through the sinus ostium, located within the nasal cavity, and extending to the nasopharynx with a wide pedicle.Antrochoanal polyp (ACP) is a maxillary sinus polyp that originates in the maxillary sinus, grows through the maxillary ostium into the nasal cavity, without bone erosion or expansion, and extends posteriorly towards the choana.Sphenochoanal polyps are an uncommon form of choanal polyp.Similarily to antrochoanal polyps, the treatment should be always surgical. All parts of the polyp should be resected to avoid recurrence.With the development in the endoscopic surgery, these less invasive methods of treatment gained popularity in pediatric antrochoanal polyps’ surgery. The endoscopic sinus surgery is now considered the ‘gold standard’ — the first choice for primary treatment in children.Reports on sphenochoanal polyps in children have thus far been limited to case reports. No systematic reviews on sphenochoanal polyps in children appeared up to date. Little attention has been paid to complex clinical presentation, diagnosis, management, surgical decision-making, and surgical approaches in children. As no larger studies exists, this review aims to describe and summarize clinical presentation, diagnosis, management, and surgical approaches to the sphenochoanal polyps in pediatric patients reported in the literature.A comprehensive literature search for all publications on sphenochoanal polyps in pediatric patients up to December 2021 was performed. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed .11 The lThe Cochrane Library, MEDLINE as well as PubMed search engine  were queried with the following search parameters: the term “sphenochoanal polyp”. The search query was further stratified by publication date in descending order. 38 publications were available; the list of publications was filtered by “Language — English”, reducing the total query to 30 publications. A two-researcher team then performed a systematic review of all 30 publications using the following inclusion criteria to select articles: (1) sphenochoanal polyp was the primary focus of the article; (2) sphenochoanal polyp was diagnosed in pediatric patient; (3) clinical presentation of the disease was described; (4) management of the sphenochoanal polyp was described; (5) follow-up period was described. If not available, the study was excluded. Data extraction from the articles included in the review was independently conducted by 2 reviewers and results were consistent.Due to heterogeneity of the included studies, meta-analysis was not considered appropriate; therefore, only a qualitative analysis was conducted.A diagram outlining the summary of the search process is shown in All studies combined encompassed 11 patients aged 18 years or younger. The overall mean age at diagnosis was 12 years with a range 3 years and 8 months–16 years. The male to female ratio was 4:7. 7 females and 4 males were included.The commonest reported symptoms included: nasal obstruction, nasal discharge, snoring and headache. In 10/11 patients’ nasal obstruction was primary symptom. 1 patient ‒ the youngest reported patient with sphenochoanal polyp – 3-year-old girl presented with 18-month history of mild to moderate obstructive sleep apnea as her only symptom.All reported symptoms are shown in Paranasal sinus Computed Tomography (CT) was done in 11 out of 11 patients (100%). Computed tomography of the nose and paranasal sinuses confirmed in all cases the presence of a mass in the nasal cavity, which extended to the choana with opacification of the sphenoid sinus. Magnetic Resonance Imaging (MRI) was performed for further evaluation in 1 child to exclude an encephalocele.11 out of 11 patients (100%) underwent surgical treatment. 10 out of 11 patients were subjected to endoscopic sinus surgery. In 2 patients, prior to endoscopic sinus surgery, nasopharyngeal part of the polyp was delivered through the mouth following disconnection from the pedicle.One case of spontaneous regression of a sphenochoanal polyp in a 3-year-old girl was observed during the surgery — bilateral transethmoid sphenoidotomy revealed normal sinuses.The follow up ranged from 3-months to 3-years (mean 16-months). No evidence of recurrence after endoscopic sphenoidotomy was observed during the last follow-up in all patients.However, in the group of patients subjected to endoscopic sinus surgery 1 recurrence was noted due to misdiagnosis and inadequate treatment  in 1 patient with sphenochoanal polyp. The antrochoanal polyp was primarily diagnosed in this 11-year-old boy.Sphenochoanal polyps are an uncommon form of choanal polyp. The first report of this rare entity is attributed to Zuckerkandl (1892).The symptoms of sphenochoanal polyps are nonspecific. Most nasal polyps produce the same symptoms, which can include nasal obstruction, nasal discharge, headache, snoring, nose bleeds, and ear fullness associated with eustachian tube obstruction.In pediatric population the exact frequency of sphenochoanal polyps has not been reported. In 2001 Tosun et al. noted that a few case reports addressing the resection of sphenochoanal polyps have appeared in the literature and almost fifty percent of the sphenochoanal polyps were reported in children.During the review process we identified 12 articles describing sphenochoanal polyps in children. All studies combined encompassed 15 patients aged 18 years or younger. However, 3 articles were not included in the study.Sphenochoanal polyps can be misdiagnosed as hypertrophied inferior turbinate, adenoid vegetation, pansinusitis, and nasal polyps.Isolated sphenoid sinus disease is an uncommon disease that affects 1%–2.7% of patients with diagnosis of paranasal sinus disease.Various pathological findings in the region, including vascular neoplasm, vascular malformations, and encephaloceles, can increase the risk of surgery in this region.Space-occupying lesions such as tumors and mucoceles are more likely to present with visual changes than with inflammatory disease.Radiological imaging with CT scanning of paranasal sinuses is regarded as the gold standard in the diagnosis of isolated sphenoid sinus disease.Partial or complete opacification may suggest lesions such as sinusitis which do not necessitate an MRI.In study by Nour et al. MRI was performed in patients with isolated sphenoid sinus pathology: in patients with CSF rhinorrhea to exclude the encephaloceles; in lesions with evident intracranial extension to determine the interface with the neighbouring structures; in lesions with hyperattenuated intrasinus signals to exclude fibroosseous conditions or rare osteoid/chondroid matrix-producing sinonasal sarcomas or meningiomas, and in patients presenting with visual disturbance to rule out any concomitant intracranial pathology.The average age of children presenting with sphenochoanal polyps was 12 years. As noted by Clement et al. an understanding the development of the sphenoid sinus is helpful in understanding the age of presentation for these children.Until the 1980s, the most widely used sphenoid approach was an external approach, through a Lynch incision and ethmoidectomy.The review shows, that 1 recurrence was noted in patient with sphenochoanal polyp, who was primarily diagnosed with antrochoanal polyp and underwent inadequate treatment not involving sphenoidotomy.Some authors reported spontaneous regression of small sphenochoanal polyps. Lim et al. described the regression of a sphenochoanal polyp in a 3-year-old child.A review showed that only 11 cases of sphenochoanal polyps in children have been described in the world literature in English.Sphenochoanal polyps should be kept in mind in the differential diagnosis of unilateral nasal cavity or paranasal sinuses masses. Misdiagnosis can result in recurrences in patients with sphenochoanal polyp, who can be mistakenly diagnosed with antrochoanal polyp and underwent inadequate treatment not involving sphenoidotomy and exact identification of the site of implantation.The symptoms of sphenochoanal polyps are nonspecific. Children most commonly present with nasal obstruction and discharge. Radiological imaging with CT scanning of paranasal sinuses is regarded as the gold standard in the diagnosis of isolated sphenoid sinus disease. When sphenoid opacification is present total eradication of the disease is mandatory. When the diagnosis is difficult or another pathology is considered, an MRI can be requested as a supplementary imaging modality. The endoscopic sinus surgery is now considered the “gold standard” — the first choice for primary treatment in children.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Not applicable – systematic review – ethical approval not required for the study.The authors declare no conflicts of interest.


We report the case of a 44-year-old gentleman who underwent coarctation repair at the age of 7 years. He was lost to follow-up and represented. Computed tomography scan demonstrated a 9.8-cm diameter aortic aneurysm involving the distal aortic arch and proximal descending aorta. Open surgery was performed to repair the aneurysm. The patient made an unremarkable recovery. He was followed up 12 weeks later, and significant improvement in preoperative symptoms was observed. This case demonstrates the importance of long-term follow-up. We report the case of a 44-year-old gentleman who underwent coarctation of aorta (CoA) repair at the age of 7 years with the Dacron patch technique and was subsequently lost to follow-up.The patient presented with hoarse voice, gastric reflux, and chronic cough over the prior 12 months. Historical notes were unavailable for review.A chest X-ray showed evidence of a widened upper mediastinum with smooth contours . This tOn CT imaging, the left vocal cord looked intact and was in paramedian position, therefore suggestive of left recurrent laryngeal nerve palsy resulting from extrinsic compression.Echocardiogram confirmed a mildly dilated ascending aorta, tricuspid aortic valve, and mild aortic regurgitation with preserved heart function.A left posterior–lateral thoracotomy was performed with deep hypothermic circulatory arrest. The aneurysmal mass, measuring over 10 cm in diameter, was dissected, excised, and replaced using size 28-mm Dacron tube graft with a single side arm which was anastomosed to the left subclavian artery. A split arterial line was used to continue upper and lower body circulation, while the distal aneurysm was being repaired. A direct left ventricular vent was used. Time of cardiopulmonary bypass was 165 minutes and deep hypothermic circulatory arrest (20°C) was 24 minutes. The patient made an unremarkable recovery and was discharged home 12 days later. When he was reviewed in the clinic 12 weeks postoperatively, both hoarseness and chronic cough had improved. Flexible nasendoscopy revealed a left vocal cord palsy which was most likely due to the original compression of the recurrent laryngeal nerves. Repeat CT scan confirmed successful repair. . The paCoA is a congenital heart defect which accounts for 5 to 8% of all defects with 80% of these cases being male. Different surgical approaches to repair CoA can be utilized usually during childhood. These include end-to-end resection, patch repair, interposition grafts, and subclavian flap arterioplasty. Endovascular approaches are becoming an increasingly available option in appropriate cases.Aneurysm formation is a recognized late complication of CoA repair and has been described after all types of intervention. Dacron patch repairs are associated with the highest incidence of postoperative aneurysm formation ranging between 33 and 51%.The most reported presentation of post-CoA aneurysm repair is shortness of breath or back pain. Alternatively, it is detected during regular follow-up. Unlike previously reported literature, in this case, the main presentation was hoarseness as a result of external nerve compression. The size of 10 cm reached by the aneurysm has surely played a role in this patient's presentation. Importantly, to our knowledge, this is the largest post-CoA repair aneurysm described in the literature, with other authors reporting maximum diameters up to 60 mm.Despite the progressively increasing use of endovascular approaches for postrepair complication of CoA, mainly for pseudoaneurysm, the vicinity to the subclavian artery and the size of the aneurysm made percutaneous stenting not a suitable option. As noted by others, while endovascular approaches could be a valid alternative in the cases of re-CoA, large-sized postrepair aneurysms are less amenable to be treated percutaneously.Despite recommendations in the most recent guidelines,The clinical relevance of this life-threatening condition should be carefully considered in the management of congenital heart disease patients, and this case strengthens the importance of a regular follow-up of these subjects. Ideally, patients should be registered with specialist services to ensure expert, life-long follow-up. Continuous lifelong surveillance is, therefore, mandatory, and cardiac magnetic resonance imaging


Melanocytic origin neoplasms are most common in older and gray horses, but their nature may differ from those of non-gray horses. In this case report, we describe the repeated excision of a hoof lesion, which was initially diagnosed as a keratoma with melanocytic grains, and evolved over time into an anaplastic malignant melanoma.Melanomas in horses are most often associated with gray, older horses with an average age of over 16 years. Anaplastic malignant melanoma, however, can very rarely affect non-gray horses. Herein, we report a case of a 16-year-old Wielkopolski gelding with a chronic lameness caused by a mass in the hoof. The first resection of the lesion and histopathological examination confirmed the presence of a keratoma. The regrown mass and persistent lameness resulted in another mass resection. The second histopathological examination result suggested a neoplastic growth of melanocytic origin with a low histological malignancy. Less than 2 years after the first resection, the horse returned to the clinic with deformation of the hoof capsule and severe lameness. The result of the third histopathological examination indicated low-differentiated malignant neoplasm. The result of the immunohistochemically test indicates a tumor of melanocytic origin with high malignancy. Neoplasms are relatively rare in horses and amount to about 3% of the problems reported in veterinary practice . It is eA 16-year old Wielkopolski (Polish warmblood), chestnut gelding, weighing 450 kg, was referred to the Equine Clinic of the Warsaw University of Life Sciences for an orthopedic consultation due to lameness, which had been gradually increasing over the prior two months. Observation of the horse in motion revealed supporting limb lameness of the right front limb, rated at 4 points on a 5-point scale (according to the AAEP Grading System). A close visual examination showed the presence of a purulent fistula in the area of the coronary band and deformation of the anterior wall of the hoof capsule . PalpatiPartial hoof resection was chosen as the best surgical approach. In order to soften the hoof capsule and ensure aseptic conditions, a wet dressing with 1% povidone iodine was applied the day before the procedure. The procedure was performed under general anesthesia. Low 4-point block was performed with bupivacaine HCl 0.5% . The keratoma was exposed by removing the hoof wall, for which a cast saw was used by making 2 parallel cuts on both sides of the expected keratoma. The third cut line ran above the defect, and the fourth cut was in sole on the border of the white line. A section of the hoof wall was separated and lifted using forceps. The keratoma with a margin of healthy tissue was removed with a laurel knife . AffecteThe fragment collected during the operation was sent for histopathological examination. In the obtained results, the diagnosis indicated keratoma. The collected sample also showed the presence of numerous melanocytes, filled with melanin grains, showing no signs of cellular atypia or signs of proliferation . A pressThe horse returned to the clinic with grade 3 lameness 341 days after surgery. Upon arrival, a fistula opening was found near to the edge of the anterior sole, as well as the midline of coronary band. Above the coronary band a clear, painful deformation was also found. A fragment of the anterior wall was resected down to the corium. From the clinical picture it could be concluded that the coffin bone was atrophied. Exposed tissues, especially around the coronary band were pigmented. A fragment was taken for histopathological examination a second time. Within the examined tissues, especially in the wall’s horn tubules, large clusters of spindle-shaped cells filled with melanin grains obscuring the cell nuclei were present. These cells showed a low degree of anisocytosis and anisokaryosis, and mitotic figures were not found. The histopathological examination result suggested a neoplastic growth of melanocytic origin with a low histological malignancy. The therapy and the bandages used were analogous to those described after the first treatment. The horse returned home after 5 days.2). Several dark brown melanin granules were visible in the cytoplasm of the majority of neoplastic cells  and the suffering of the animal, the owners decided to euthanize the horse 880 days after the first treatment. No metastases were found during the post-mortem examination. Post-mortem radiographic examination  and compThe appearance of any abnormal mass of cells in the hoof, causing pressure on the coffin bone, is manifested by severe lameness (AAEP grade 3–4) regardless of the type of cells . The mosKeratomas should be differentiated from even less common neoplasms. Due to the localization of the changes, the clinical symptoms are the same and result from the pressure of the mass on the distal phalanx. So far, squamous cell carcinomas ,10,11, mIn our case, a histopathological examination of the primary lesion was performed and confirmed the presence of a keratoma. Numerous melanocytic cells were also present in the histological specimen, but these showed no signs of cellular atypia and proliferation. Due to the typical appearance of the keratoma, the fact that melanocytes may be present in the keratoma, no malignant features were found, and the rarity of melanocytic neoplasms in the horse’s hoof, the diagnosis of keratoma was made. Taking into account the later microscopic appearance of this lesion, it cannot be ruled out that from the beginning it was a melanocytic neoplastic hyperplasia without any signs of histological malignancy, which progressed to melanoma. Although at the time of the initial diagnosis, there was no basis for the diagnosis of a neoplasia of melanocytic origin, based on this case, in keratoma diagnosis with numerous melanocytes, the possibility of melanocytic neoplastic hyperplasia should be considered, despite the lack of malignancy.In the previously described cases of other neoplastic growths, which in the initial stage were considered to be keratomas, one of the common features was lameness that persisted for a long time after removal of the mass . The desMelanomas are neoplasms that are uncommon in non-gray horses. They occur occasionally in the horse’s foot. However, it is known from the available data that the melanomas that appear in the foot of equines are invasive. Although some authors use the classification of benign and malignant for melanocytic neoplasms in horses , as earlAn analogous type of neoplasm found in humans is nail apparatus melanoma (NAM). It is a rare subtype of melanoma, more commonly found in Asians  and AfriAlthough the conservative surgery provides a good option in human  and remoDue to the fact that the clinical symptoms related to the presence of any mass within the horse’s hoof capsule are the same, regardless of the origin and nature of this mass, one should always be aware of neoplastic growths other than keratomas. The rare case described by us confirms the current thinking that any melanocytic-origin tumors should be treated as malignant, especially when they occur in non-gray horses. Additionally, there are still no effective treatments for such lesions in horses.


Esophageal stent placement is commonly indicated for the management of inoperable esophageal malignancies, benign strictures, and esophageal perforations including Boerhaave’s syndrome. We present a case of a 74-year-old female, who presented with small bowel obstruction secondary to a migrated esophageal stent, which was placed 20 weeks previously for Boerhaave’s syndrome. She was surgically managed with laparotomy and retrieval of the fractured stent with local resection of the small bowel, followed by primary anastomosis. Endoscopic esophageal stent placement has a wide range of utility, ranging from use for benign strictures to esophageal perforations, to fistulas and for palliative therapy of esophageal cancer ,2. ThereA 74-year-old female presented to our medical center with a two-week history of lower abdominal pain and nausea. On examination, there was tenderness in the lower abdomen with guarding. Her past medical history included total abdominal hysterectomy with bilateral salpingo-oophorectomy, vaginal prolapse, bilateral mastectomy for breast cancer, and thyroidectomy.She had a background history of Boerhaave’s syndrome with a distal ruptured esophagus 20 weeks prior. At that time, she was thought to have first presented with partial left pneumothorax and pneumomediastinum, which was managed with chest drain insertion. A delayed diagnosis of a distal ruptured esophagus lead her to being treated conservatively at that time with an endoscopically inserted self-expanding covered stent (full covered type) 18 × 150 mm in diameter at the distal esophagus. Correct placement of the stent in the distal esophagus is demonstrated on the chest radiograph , neutrophils of 9.2 × 109/L , and hemoglobin of 13.4 g/dL . The chest radiograph revealed that the esophageal stent was no longer located in the mediastinum , white blood cell (WBC) of 11 × 10A plain film of the abdomen was performed to investigate the possible location of the stent and revealed its location superimposed over the pelvic inlet Figure .Computed tomography (CT) showed that the stomach was distended with fluid, as well as the proximal small bowel. The bowel distention was demonstrated as far as the stent, which was located in the jejunum Figure .She was managed with intravenous antimicrobials, nasogastric tube insertion, and intravenous fluid hydration. To assess if the stent may pass spontaneously, interval plain abdominal radiographs were performed on day 1 and day 3 post-admission.With the lack of progression of the stent, she was planned for operative retrieval four days into admission. Laparoscopy was initially performed, but due to difficulty locating the stent, there was conversion to a midline laparotomy. Manual running of the small bowel located the stent within the distal jejunum.Enterotomy was performed with retrieval of the stent, which was found to be incompletely fractured Figure .Resection of the involved small bowel was performed, followed by side-by-side stapler anastomosis using NTLC75  and oversewn with 3-0 polydioxanone suture (PDS) . She was nil by mouth for 48 hours postoperatively with the nasogastric tube being removed at this time. Oral diet was initiated successfully three days postoperatively. She was well for discharge 10 days after surgery without any complications.Esophageal stenting represents an important tool for the nonoperative management of esophageal pathologies including inoperable esophageal malignancies, benign strictures, and esophageal leakage ,7. BoerhIn this case, elective stent retrieval was attempted, and the stent was visualized on endoscopy but aborted due to difficulty in removing at endoscopy. The patient remained asymptomatic until 15 weeks after the trial of removal at endoscopy, where she presented here with small bowel obstruction secondary to the stent migrating and impacting the jejunum. Nonoperative management was attempted with serial abdominal radiograph imaging to assess for spontaneous passage of the stent, but with failure of spontaneous passage of the stent, operative surgery was performed. Stent migration requiring operative management is an uncommon occurrence with surgical methods involving laparotomy incision, enterotomy to retrieve the stent, local resection of the affected bowel, and primary anastomosis . There aApplications for endoscopic stenting remain an important nonoperative management option for both malignant and benign conditions of the esophagus. We present a case of small bowel obstruction secondary to esophageal stent migration, which was inserted for conservative management of Boerhaave’s syndrome. When possible, esophageal stents should be retrieved due to the complications associated locally and when migration occurs. Although surgical intervention is not commonly required, it is indicated when there is a risk of obstruction and perforation. We have demonstrated that this may be successfully managed with open retrieval of the stent, local bowel resection, and primary anastomosis.