Idiopathic thrombocytopenic purpura (ITP) is the condition of having a low platelet count of unknown causes and is a poorly understood acquired hemorrhagic disease involving destruction of platelets in the reticuloendothelial system induced by antiplatelet antibodies. Patients with ITP can have traumatic intra-articular, intraosseous or soft tissue hemorrhage which may present as a rare intraosseous pseudotumor on medical imaging.9/L).A 30-year old male patient had complaint of pain in the right leg for 1 year. Laboratory test revealed a much lower platelet count (3–12 × 10Radiography and computed tomography showed expansive bone destruction in the distal segment of the right femur, and magnetic resonance imaging revealed heterogeneous signal intensity in the lesion. Lesion curettage and pathology showed an expansion cyst with a really thin cortical bone shell containing serum-like red liquid and some sediment-like deposit. Consequently, the diagnosis of a pseudotumor was confirmed.Lesion curettage and bone graft surgery were performed, and 8 units of platelet were transfused to the patient. Giant cell reaction was found on the shell of the lesion, but no tumor cell was found on pathological examination.9/L 5 days after operation, and the clotting time was normal. At 6 month follow-up after lesion curettage, the patient remained normal with no deterioration in the lesion site.The platelet count was 308 × 10The diagnosis of a pseudotumor of ITP relies mainly on imaging findings of the lesion and, in particular, knowledge of the underlying bleeding disorders. Radiologist and pathologist should be aware of the characteristics of this rare complication of ITP and other bleeding disorders like hemophilia in order to avoid misinterpretation of the lesion as a tumor or infection disease. Written informed consent was obtained from the patient for publication of the study and medical images.29/L to 12 × 109/L, and the normal reference is 100 × 109/L to 300 × 109/L) with normal clotting time.Patient has provided informed consent for publication of the case. A 30-year old male patient presented to the orthopedics department with complaint of pain in the right leg for 1 year, with the pain being intermittent, aggravated on activities and relieved after rest. The patient had a history of ITP 15 years ago when the patient had repeated epistaxis, skin purpura, and other hemorrhage symptoms, which did not respond to glucocorticoids. However, after vincristine therapy, these symptoms were resolved for a long time. Two years ago, the patient sprained his right knee, but X-ray examination found nothing abnormal. One year later, he felt pain in his right leg, but nothing abnormal was found on physical examination. Laboratory test revealed a normal red blood cells and white blood cell count, but a much lower platelet count (3 × 10Radiography of the right femur revealed an expansive, well-defined radiolucent lesion in the distal segment, with trabeculae inside and sclerotic margin Fig. . Transax9/L 5 days after operation, and the clotting time was normal. Giant cell reaction was found on the shell of the lesion, but no tumor cell was found on pathological examination (Fig. The patient was treated with lesion curettage and bone graft surgery Fig. . During Based on the clinical presentations, medical history, imaging and pathological findings, the final diagnosis was a pseudotumor. At 6 month follow-up, the patient remained normal with no deterioration in the lesion site.3Since Starker reported the first cases of hemophilia pseudotumor of bone in 1918,Aneurysmal bone cyst is a benign bone lesion of expansion, like intraosseous cavities containing blood without endothelial membrane.Bone necrosis secondary to increased intraosseous pressure was the key pathophysiologic factor in the formation of a hemorrhagic bone pseudotumor. Silber et alBone reaction caused by intraosseous hematoma is similar to giant cell reparative granuloma histologically. Indeed, a giant cell reparative granuloma of bone is a response to intraosseous hemorrhage.In our case, a correct diagnosis could not be reached based only on imaging presentations because similar imaging presentations could be found in cases with simple bone cyst, aneurysmal bone cyst, fibrous dysplasia, nonossifying fibroma, bone hemangioma, enchondroma, chondrosarcoma, and even chondroblastoma. The correct diagnosis was only made during open surgery with histopathological examination of the excised sample of the lesion. In curettage and bone graft surgery of the lesion, it was found to be an expansion cyst with a really thin cortical bone shell containing serum-like red liquid and some sediment-like deposit. Giant cell reaction was found on the shell of the lesion, but no tumor cell was found on pathological examination. A pseudotumor was diagnosed according to clinical presentations, medical history, imaging, and pathological findings.In conclusion, the diagnosis of a pseudotumor of ITP relies mainly on the imaging findings of the lesion and, in particular, knowledge of the underlying bleeding disorders. Radiologist and pathologist should be aware of the characteristics of this rare complication of ITP and other bleeding disorders like hemophilia in order to avoid misinterpretation of the lesion as a tumor or infection disease.Conceptualization: Wen-Juan Wu, Bu-Lang Gao.Data curation: Tao Sun, Shu-Man Han.Formal analysis: Wen-Juan Wu.Investigation: Tao Sun, Shu-Man Han.Methodology: Tao Sun, Shu-Man Han.Project administration: Tao Sun, Shu-Man Han.Resources: Wen-Juan Wu.Supervision: Shu-Man Han, Wen-Juan Wu.Validation: Bu-Lang Gao.Writing – original draft: Tao Sun.Writing – review & editing: Bu-Lang Gao.


Effusive-constrictive pericarditis (ECP) is a rare clinical entity resulting from accumulating pericardial fluid within a stiff, non-compliant pericardium. There are a number of etiologies for ECP, which include malignancy, radiation, post-surgical causes, infectious, and collagen disorders. Clinically, ECP often presents as right-sided heart failure, or in advanced cases, cardiac tamponade. Symptoms may persist despite treatment with pericardiocentesis, and may warrant consideration for pericardiectomy for more definitive management. Invasive hemodynamic evaluation with cardiac catheterization remains the gold standard for diagnosis of ECP; however, echocardiography can provide a definitive diagnosis with high sensitivity and specificity. Echocardiographic features suggestive of ECP include ventricular septal motion abnormalities, such as interdependence, accentuated longitudinal motion of the heart, and altered respirophasic ventricular filling. While these features have been well established and can lead to the diagnosis of ECP, they are rarely observed in clinical practice. We present a case of ECP in a 25-year-old active duty male with a history of chest wall myoepithelial carcinoma who clearly demonstrated such echocardiographic findings of ECP. Pericardial effusions are a commonly observed finding on echocardiographic evaluation. The effusions can vary in size from trivial, defined as <50 mL, to large, defined as >500 mL of fluid contained within the pericardial space. While the size of the pericardial effusion may provide clues as to its underlying etiology, it often correlates poorly with its hemodynamic effects on the heart. Clinical presentation and patient symptoms may vary widely and can include chest pain, dyspnea, and/or hemodynamic instability if cardiac tamponade is present. In general, most pericardial effusions can be monitored with serial imaging, and do not require drainage with pericardiocentesis, but in symptomatic patients with moderate to large pericardial effusions, or in those with findings of cardiac tamponade, pericardiocentesis can be a life-saving intervention. Immediate improvement in the patient’s symptoms and clinical condition is typically observed. Therefore, persistent symptoms following pericardiocentesis should raise suspicion for the presence of effusive-constrictive pericarditis (ECP).ECP is a rare clinical entity characterized by accumulating pericardial fluid within a stiff and non-compliant pericardium. Etiologies for ECP include malignancy-related conditions, radiation, post-surgical, infectious, or idiopathic -7. PrevaHerein, we report a case of an active duty soldier with a new pericardial effusion and clinical tamponade, who underwent pericardiocentesis and was found to have findings consistent with ECP on repeat echocardiographic evaluation.A 25-year-old non-smoking male with a history of chest wall myoepithelial carcinoma status post excision, chemotherapy, and radiation therapy with relapse in and progression of disease on pembrolizumab presents to the emergency department (ED) with 10 days of progressive dyspnea on exertion, palpitations, and 45-pound weight loss over the past three months. Initial evaluation consisted of a chest x-ray and CT of the chest with contrast, which revealed metastatic spread to the patient’s lungs including spread to the epicardium, and a new pericardial effusion Figures , 2.Diagnostic transthoracic echocardiogram was then performed, which showed a very large circumferential pericardial effusion, measuring up to 4 cm along the right ventricular free wall, with associated findings concerning for tamponade physiology Figure . Urgent fluoroscopic-guided pericardiocentesis was then performed, removing 590 mL of serosanguinous fluid. A pigtail catheter drain was left in place for residual effusion, and subsequent serial echocardiography was performed, revealing a persistent small-to-moderate sized pericardial effusion with continued respirophasic septal shifting, and annulus reversus on tissue Doppler imaging suggestive for ECP as the underlying cause for this clinical presentation Figures -5. Following the discovery of his ECP and the terminal nature of his malignancy, the patient wished to defer further procedures and definitive management for the ECP and was discharged to home hospice.The differential diagnosis for palpitations, dyspnea on exertion, and unintentional weight loss is extensive, and often best approached systematically for comprehensive evaluation. Cardiac etiologies to consider should include ischemia, valvular heart disease, heart failure, restrictive and dilated cardiomyopathies, myocarditis, arrhythmias, conduction disorders, pulmonary hypertension, primary or metastatic malignancy, and pericardial diseases, and to include but not limited to acute pericarditis, constrictive pericarditis, cardiac tamponade, and ECP. There are a plethora of non-cardiac causes, and further evaluation of pulmonary, infectious, gastrointestinal, oncologic, hematologic, and metabolic disorders should all be considered. Anchoring on alternative diagnoses without improvement in clinical condition may lead to deleterious outcomes and delay appropriate treatment. This case highlights the unique clinical and pathophysiologic features of ECP along with the importance of comprehensive echocardiography in the evaluation of ECP or other suspected pericardial conditions. With an overall reported prevalence ranging from 1% to 16% in patients presenting with pericarditis or cardiac tamponade, ECP remains a rarely encountered condition . InteresWhile ECP is well described in the literature, it is rarely observed given its low prevalence and complex pathophysiology. Establishing a diagnosis of ECP requires a thorough history and physical examination. In patients presenting with right heart failure, a history of cardiac surgery, tuberculosis, rheumatologic disorders, prior radiation therapy, and/or malignancy should heighten clinical suspicion for constrictive pericarditis, and further evaluation with transthoracic echocardiography should be performed. With concomitant features of acute effusive pericarditis, chronic constrictive pericarditis, and in severe cases, cardiac tamponade, identification of ECP by echocardiography requires a comprehensive study with two-dimensional imaging, M-mode, and Doppler echocardiography. Key features of constrictive pericarditis include respirophasic septal shifting, a septal “bounce” or “shudder” due to rapid early diastolic filling of the ventricles, and a plethoric inferior vena cava (IVC) on two-dimensional imaging. Because of lateral wall tethering in CP, “annulus reversus” may also be observed, in which tissue Doppler velocity of the lateral mitral annulus may be abnormally lower than the velocity of the medial mitral annulus ,2. In paOnce diagnosed, the treatment of ECP should focus on symptomatic improvement and overall quality of life. Initial treatment with diuretic therapy is often considered but is usually minimally effective at palliating symptoms. Historically, the definitive treatment of ECP was limited to pericardiectomy; however, recent studies have shown that ECP may be a transient process that may improve with medication targeted at treating the underlying inflammatory process with either non-steroidal anti-inflammatory agents, corticosteroids, and/or colchicine ,8. DespiECP is a rare clinical entity demonstrating pathophysiologic properties of constrictive pericarditis in the setting of a persistent pericardial effusion despite treatment with pericardiocentesis. While invasive hemodynamic evaluation by right heart catheterization remains the gold standard in establishing the diagnosis of ECP, non-invasive evaluation with a comprehensive echocardiographic study can often confirm the diagnosis in patients with high pre-test probability. Long-term prognosis of ECP remains unclear; however, with recent studies suggesting that ECP may be a transient condition, conservative treatment should be considered initially, reserving pericardiectomy for severe or refractory cases of ECP. Including ECP on the differential diagnosis of a patient with persistent pericardial effusion can save a patient from extra procedures and result in appropriate treatment sooner.


Esophagogastric junction tumors are a challenging pathology for surgeons and the best treatment depends on an adequate initial localization and stadification. Approximately half of patients relapse after curative surgery during the first two years. Surgical resection could increase the survival of these patients, but the esophageal reconstruction is a surgical challenge for which there are multiple reconstruction techniques described with different organs.In this report, we present the case of a patient with an esophagogastric junction tumor treated initially with total gastrectomy and esophageal margin. The patient presented an anastomotic recurrence that was taken to surgical resection, but a second recurrence required a residual esophagectomy with ileocolonic reconstruction, to achieve adequate oncologic treatment. Despite multiple therapeutic modalities, esophagogastric junction (EGJ) tumors have a poor prognosis, with a five-year survival rate of 8% in 1973 and an increase to 17% in 2008, due to the introduction of neoadjuvant chemoradiotherapy [Recurrence of these tumors after surgical resection with curative intent is around 40% and many occur in the first two years. Surgical rescue is still controversial, as some studies show the limited role of surgery, while others report increased survival of patients undergoing surgical rescue .There are several reconstruction alternatives after esophagectomy when the stomach is not available, and the decision is made based on the replacement organ, its length, and its vasculature . The gasA 55-year-old man with a relevant history of back injury from a multiple-load firearm projectile consulted the Instituto Nacional de Cancerología (INC) in November 2015 with a three-month history of dysphagia, vomiting and 20 kilograms (kg) of weight loss. Studies were performed, and upper gastrointestinal endoscopy (UGIE) showed a tumor lesion in the EGJ with obstruction, which compromised the entire esophageal circumference from 39 to 44 cm. In this endoscopic study, the Z line was compromised by a tumor, not allowing an adequate definition of its localization. It was deduced that it could be 41 cm from the dental arch, with no findings of compromise in the fundus or gastric body, and was classified as a Siewert type II. Pathology reports indicated a well-differentiated adenocarcinoma . In March 2016, restaging was carried out, which showed infiltration of the fundus and minor curvature of the gastric body. Surgery was opted for, a total trans-abdominal gastrectomy plus distal esophagectomy with modified D2 drainage. Surgical pathology reported a well-differentiated intestinal-type adenocarcinoma with poor response to neoadjuvant therapy, positive proximal resection margin for adenocarcinoma, but a negative esophageal donut, and four of 18 lymph node-positive metastases. Pathological staging was ypT3ypN2 for stage IIIA according to TNM 8th ed. After surgical resection, the patient received chemotherapy with cisplatin plus capecitabine (ARTIST) without radiotherapy. During follow-up, elevation of the carcinoembryonic antigen (CEA) was documented, and in a new UGIE in April 2017 a 3-mm nodule was identified in the esophageal-jejunal anastomosis whose pathology result was positive for adenocarcinoma recurrence. A positron emission tomography (PET-CT) was performed, which reported hypermetabolism at the esophagus-jejunal junction with an SUV max of 3.7  for six cycles, which was received without complications. Currently, the patient has no evidence of new relapses.The incidence of EGJ carcinoma has increased significantly since 1970 in the United States, and similar increases have been reported in Sweden, Canada, and Great Britain . DespiteThe endoscopic study is the fundamental pillar to define the best treatment for patients with EGJ lesions since defining the exact location predicts patterns of lymph node metastasis . In thisEsophagectomy is indicated in the treatment of EGJ type I tumors using a thoracic and abdominal approach, while gastrectomy and lymphadenectomy with an abdominal or transhiatal approach are sufficient for type III tumors . But forEsophageal involvement greater than 25 mm is a significant preoperative predictor of recurrence, with significantly lower disease-free and overall survival rates compared to those with involvement ≤25 mm (p < 0.001) . The neeLymph node involvement in all oncological pathologies, as well as in EGJ tumors, is a prognostic factor for overall recurrence and survival rates. These tumors have the particularity that lymphatic drainage pathways include both the abdomen and the mediastinum . In radiPositive margins in oncological surgeries for EGJ tumors are presented in up to 35% of cases mainly due to the proximal resection margin, but this incidence lowers to 0% if they are resected more than 6 cm. Subsequent studies have failed to demonstrate an association between proximal margin length and recurrences .EGJ tumor recurrence can occur in 20% to 50% of cases, usually in the first two years of surgery for the primary tumor . There iIn the described case, the patient presented two recurrences. In the first one, the previous anastomosis was resected via transhiatal and a new esophageal-jejunal anastomosis was performed, but in the second recurrence greater esophageal involvement was evidenced, so it was decided to perform an esophagectomy using the right colon and the distal ileum for reconstruction.Patients with recurrences have a median survival of 22 months and surgical resection has improved survival in some series, but not in others . In a seTraditionally, the stomach has been the first choice to replace the esophagus due to the rich submucosal vasculature, easy mobilization, and the need for just one anastomosis . In our There are other alternatives for cases where the stomach cannot be used. In the case of our patient, during the resection of the first local recurrence, the distal esophagus had to be replaced with the jejunum. This organ can also be used as an interposition between the esophagus and the stomach as a free flap and has the advantages that it is an abundant organ, does not require preparation, is usually disease-free, has a diameter similar to the esophagus, has intrinsic peristalsis, and in general, its length does not change over time .During the second recurrence of adenocarcinoma in esophageal anastomosis with the jejunum, the colon was used to replace the esophagus. The left colon is easy to mobilize and adequate irrigation is provided by the left colic and middle colic veins. Furthermore, mucus production functions as an antireflux barrier, and the isoperistaltic mechanism helps transit of food bolus; however, extensive mobilization and three anastomoses are required, which could increase morbidity .The right colon that was used in reconstruction has a thinner wall when compared to the left colon, is more voluminous, and peristalsis is slower. Its main disadvantage is the absence of a marginal artery in a third of cases, making it necessary to preserve the arterial arches of the ileocecal area, obtaining a long ileum segment (up to 20 cm) and thus ensuring suitable blood flow and length to replace the thoracic and cervical esophagus . In our A case series published in 2012 in which esophageal reconstruction with ileocolic interposition was performed with six patients did not report mortality at 30 days, one patient died of pneumonia within 90 days, and there were no anastomotic leaks or graft necrosis .Finally, it was decided to do a hybrid technique with thoracoscopy and laparotomy because we wanted to give the patient the opportunity to have the advantages of minimally invasive surgery . Since tThere are multiple consequences of an inadequate classification of esophagogastric junction tumors. Mainly, it involves the erroneous choice of surgical approach, and the oncologic treatment, such as the temporal relationship between chemotherapy, radiotherapy, and surgery that depends on a clear topographic understanding and accurate classification of these tumors. Perioperative chemotherapy is the choice for Siewert III tumors and neoadjuvant chemoradiation therapy, such as CROSS, is the choice in Siewert I and II tumors. Finally, adequate initial decisions could reduce the risk of relapse, which could lead to increased morbidity and mortality, and thus avoid the need for complex esophageal reconstructions such as in the reported case. Surgical resection should always be considered in patients with isolated local recurrences since it improves overall survival rates. Gastrointestinal and oncological surgeons should be familiar with the different techniques to treat recurrent EGJ cancer so they can handle complex cases such as the patient described in this case report, in which it was finally necessary to use the right colon and distal ileum for esophageal reconstruction.


Glioblastoma with primitive neuronal component should be considered as a differential diagnosis of infratentorial tumors. Glioblastoma with primitive neuronal component should be considered as a differential diagnosis of infratentorial tumors. The most common location of this tumor is the temporal lobe. There are few cases of infratentorial GBM‐PNC reported. We reported a patient with cerebellar GBM‐PNC, a very rare location of this tumor.Glioblastoma multiform (GBM) is the most frequent malignant astrocytoma presented mostly among adults. Although radiation therapy and chemotherapy are used as standard treatments, most of the GBMs are resistant to treatment and have a poor prognosis.Glioblastoma with primitive neuronal component is an aggressive tumor with a short survival rate because of the invasion and metastases to the surrounding tissues and entire neuroaxis.2A 71‐year‐old man presented with progressive true vertigo, nausea, and vomiting. Brain computed tomography revealed a circumscribed intraaxial hemorrhagic mass in the center of the right cerebellar hemisphere Figure  and 3. AVascular glomeruloid formation and perivascular pseudorosettes were also detected in PNET area. Immunostains showed that the tumor was immunopositive for Synaptophysin in PNET components and GFAP positive in glioblastoma areas. CD20, LCA, CK, and TTF1 were negative. The tumor was diagnosed as GBM‐PNC Figure .3Glioblastoma with primitive neuronal component is a very rare tumor accounting for 0.5% of all GBMs, being more common among adults. However, some cases have been reported in children aged 12 and 17 years. Moreover, Perry et alAlthough the prognosis of GBM‐PNC is poor, long‐term survival is variable. In the study on 53 cases of GBM‐PNC, the median survival rate was 9.1 months from the first diagnosis and ranged from less than a month to 33 years.Histologically, The GBM‐PNC consists of two components. The glial component consists of astrocytes with abundant eosinophilic cytoplasm and large vesicular nuclei, mitosis, necrosis, and microvascular proliferation on the fibrillary background. The hypercellular area of small cells with a narrow cytoplasm, hyperchromic nuclei, pseudorosettes forming, and a multifocal distribution is the histologic features of the PNC.Glioblastoma with oligodendroglial differentiation (4%‐20% of GBMs) composed of foci with clear cytoplasm, round nuclei, branched capillary vessels, and calcification. The presence of oligodendroglial component associated with co‐deletion of chromosome 1p and 19q appears to be an important prognostic factor.The diagnosis of GBM‐PNC is confirmed using immunohistochemistry. The glial component of the tumor is usually positive for GFAP, S100, OLIG2, and vimentin, while the PNC always expressed the synaptophysin and is negative for glial markers. CD56 is reported as a positive marker in both components.The metastasis is not common among patients with GBM tumor, and it accounts for <2% of the GBMs. The spinal metastasis is very rare in GBMs. However, GBM‐PNC has a high tendency to spinal metastasis and cerebrospinal fluid dissemination.Temozolomide is the treatment of GBM, while platinum‐based chemotherapy is effective on PNETs. However, the treatment of GBM‐PNC is still a challenge due to few available data on therapeutic approaches. However, in a review of the literature on GBM‐PNC treatment, Prelaj et alThe tumor is most likely diagnosed using imaging in a patient with symptoms of CNS involvement. Reports on radiologic features of GBM‐PNC are very rare. Ali et al studied on radiologic features of GBM‐PNC tumors in nine patients and compared them with conventional GBM. They found a reduced Apparent Diffusion Coefficient (ADC) in GBM‐PNC tumors compared to conventional GBM, suggesting that significantly reduced diffusion of a tumor on MRI should be considered as a diagnostic radiologic feature of GBM‐PNC.The most frequent location of GBM‐PNC is the temporal lobe occurring in 52% of cases.There are multiple cases of GBM‐PNC reported in the literature.In our case, a GBM‐PNC was observed with MRI features similar to previously reported tumors, but at a rare location. This report suggests that although infratentorial GBM‐PNC tumors are rare, they should be considered as a differential diagnosis in any infratentorial tumor.None declared.AS, SE, PM, FS, MA: contributed in data gathering, writing the manuscript, and all read the final version of the manuscript and approved that.


Treatment of a large chronic prepatellar bursitis can be difficult to manage surgically because of a high rate of local complications and a significant chance of recurrence. We present a 2-stage technique using negative pressure dressings which produced a good outcome with no recurrence at one year after surgery. Inflammation of the prepatellar bursa is a common condition, especially in males. It is typically caused by repetitive injury and often seen in patients whose occupation involves kneeling. It is referred to by various eponymous names such as clergyman's knee and housemaid's knee. Acute inflammation can settle with the well-established nonoperative treatment algorithm of rest, ice, activity limitation, and anti-inflammatories .Inflammation can however become chronic with the swelling becoming large and problematic. Surgical intervention is reserved for severe refractory cases. Open and endoscopic bursectomy procedures have been described –4. Most Surgical excision can place the skin overlying the knee at risk of vascular compromise as the anterior wall of the bursa is usually adherent to the skin. One way to reduce this risk is to excise posterior wall only but risk of recurrence still remains .We present a successful 2-stage open technique using negative pressure dressings for a large chronic prepatellar bursitis.A 62-year-old joiner presented with 2-year history of a painless swelling over his right knee. It was occasionally tender to kneel on; however, it was the large size of the lesion that was his main problem . It was A MRI scan  revealedA well-circumscribed lesion was excised along with an ellipse of the skin . A vacuuThe nylon sutures were removed at 2 weeks and he returned to work 1 week after this. He was advised not to kneel for four weeks. Histological examination confirmed a benign chronic inflammatory bursitis. He was reviewed at 1 year following his operation. His wound has healed without any complications . He did Surgical management is reserved for refractory cases of prepatellar and olecranon bursae. Both open and endoscopic treatments had been described. Skin compromise is a devastating complication following surgical excision , 11, 12.Negative pressure wound therapy (NPWT) has transformed management of complex wounds with its efficacy being proven extensively in the literature –15. It hWe therefore recommend a 2-stage open surgical technique using negative pressure dressings to treat a large chronic prepatellar bursitis.


An 11-year-old boy presenting with sudden onset double vision, headache and neck pain was found to have left lateral rectus palsy, papilledema and neck rigidity. An initial diagnosis of benign intracranial hypertension was considered. However, magnetic resonance imaging (MRI) of the brain surprisingly discovered the pineal gland cyst. He underwent Krause´s procedure for the excision biopsy of the cyst. Histopathological examination confirmed epidermoid cyst. Postoperatively, he had transient ataxia and upgaze palsy but recovered well. He was asymptomatic during the first and third-month follow-ups. The case highlights the unusual presentation of a rare intracranial tumor, pineal epidermoid cyst. Neuroimaging and timely surgery lead to a good outcome. Epidermoid cysts are a group of slow growing intracranial tumors representing approximately 1% of all central nervous system tumors. Furthermore, pineal location of epidermoid cyst is extremely rare . Headach2. His vital signs were normal. Central nervous system examination revealed normal higher mental functions, grade 3 papilledema bilaterally, left lateral rectus palsy, nystagmus on left lateral gaze and neck stiffness. Other cranial nerves, motor and sensory system were normal. There were no cerebellar signs and the gait was normal. He was admitted in the intensive care unit for further evaluation and monitoring. An initial diagnosis of benign intracranial hypertension was considered and he was started on anti- cerebral edema measures pending neuroimaging.An eleven year old boy from rural South India was referred to our centre by an ophthalmologist for sudden onset diplopia. The diplopia was particularly complained when looking towards the left side. He also complained blurring of vision and frequent eye blinking in both eyes. There was no headache, vomiting, speech disturbance, seizures or weakness of limbs. There was history of trivial trauma to head while playing in the school, three weeks ago. There was no external injury. He developed some restriction of neck movements following the incident which improved subsequently. His birth history and developmental history were unremarkable. His immunization was appropriate for age. On examination, he weighed 32.6 kilograms. His height was 139cm, head circumference, 52cm and body mass index was 17.1kg/mHis complete blood count, electrolytes, renal and hepatic function tests were normal. Magnetic resonance imaging of the brain revealed a well-defined lesion measuring 1.6cm x 1.5cm x 1.6cm in the pineal region. The pineal gland was not visualized separately. The lesion was hyper intense on T1 and T2 weighted images  with no Epidermoid cysts represent misplaced ectodermal cells during division of neurectoderm around third to fourth week of life. Epidermoid cysts are rare forms of intracranial tumors. These cysts grow slowly, but attain relatively large size and have a tendency to invade the local tissues . The comMRI is the investigation of choice for evaluation of pineal gland tumors, which can differentiate epidermoid cyst from other intra axial tumors. MRI of cyst shows hyperintensities on T1 and T2 with no post contrast enhancement with intense diffusion restriction . These fIntracranial epidermoid cysts are quite rare and grow slowly. They usually present with features of raised intracranial pressure. The diplopia and unilateral lateral rectus palsy, the unique presentation in the present case, initially led us to think of benign intracranial hypertension. However, MRI brain scan detected the exact location of the pineal cyst. Though challenging, surgical resection of the cyst by an expert could lead to fairly good results.


Schwannomas of the descending loop of the hypoglossal nerve are very rare. Existing literature of the schwannoma of the descending loop of the hypoglossal nerve is limited to two previously reported case. They are slow-growing tumors that may masquerade a carotid body tumor. We herein described a rare case of schwannoma of the descending loop of the hypoglossal nerve in the s right latero-cervical region with diagnostic imaging and histopathological findings. A 37-years-old woman has had a palpable firm, mobile mass in the right latero-cervical region, of imaging, MR images showed homogeneous hypointensity on T1-weighted imaging (T1-WI), heterogeneous hyperintensity on T2-WI, and heterogeneous enhancement on contrast-enhanced T1-WI. Diagnostic imaging using computed tomography (CT) and magnetic resonance imaging (MRI) was suspected of Chemodectoma or neurogenic tumor. At operation, a 4 cm mass arising from the descending loop of the hypoglossal nerve of was resected en bloc with the loop itself; Final diagnosis was confirmed on the basis of histopathological finding and intraoperative findings. Postoperative course was uneventful and the patient is free from disease recurrence at tree-year follow-up. En bloc resection remains the real curative treatment of Schwannomas, ensuring unlimited freedom from disease, although causing functional impairment which may be significant. Nonetheless recurrence should be prevented as, besides requiring reintervention, it may harbor a malignant evolution towards sarcoma. Schwannomas of the descending loop of the hypoglossal nerve may masquerade a chemodectoma of the carotid bifurcation and can be curatively resected without any functional impairment. This case confirmed the differential diagnosis on the basis of the intraoperative finding that the tumor was continuous with the hypoglossal nerve. Approely rare , 10, 11.A 37-year-old woman was referred for a non-tender, laterocervical mass enlarging within a month, without pain, dysphagia, dysarthria or any other symptom. At physical examination revealed a palpable firm, freely mobile mass measuring about 4 cm diameter, was not pulsating. Overlying skin was normal and no deviation, fasciculation or hemiatrophy of the tongue upon protrusion was observed. No lymph nodes were palpable. At cervical ultrasound examination (US), it appeared solid, heterogeneous and located between the internal (ICA) and external (ECA) carotid arteries, with normal flow velocities in both of them. Non-contrast CT revealed a well-circumscribed spherical 4,8x3,8x3,2 cm mass with heterogeneous density in the right laterocervical region. Contrast-enhanced CT demonstrated inhomogeneous weak enhancement, and intratumoral blood vessels were strong enhancement. No evidence of cystic or necrotic degeneration was present in the CT . One weeth and 10th cranial nerves. Hypoglossal nerve schwannoma is rare, since this nerve is purely motor. Schwannomas of the vagus and hypoglossal nerve are known to potentially masquerade a tumor of the carotid body at preoperative imaging, due to the close situation of these structures [Schwannomas are benign tumors. They usually develop from the sensory component of cranial nerves, most commonly from 8ructures -16. Howeructures , which cructures . As for ructures , given tructures , 18-20. Extra cranial hypoglossal schwannoma is very rare and few cases have been described in the literature. Existing literature of the schwannoma of the descending loop of the hypoglossal nerve is limited to two previously reported case, and this report adds that prompt resection of even small masses involving the carotid bifurcation is always indicated in order to obtain the maximum possibilities of a durable cure, limiting at maximum functional impairment. Despite the rarity of schwannomas, this condition should be considered in differential diagnoses for masses localised in the neck.


Echinococcus granulosus and still widely endemic in Tunisia especially in rural areas where the sheep-dog cycle is dominant. It is an important public health problem in the pediatric age group causing significant morbidity and mortality. We report a case of primary hydatid cyst of the small intestine in a child and we want to highlight the difficulty that we meet in the diagnosis despite the contribution of imaging.Hydatid disease or hydatidosis is a worldwide zoonosis disease caused by the tapeworm of  Cystic echinococcosis is a widespread zoonotic parasitic disease especially in Tunisia which is one of the most endemic countries in the Mediterranean areas . In rura3 with a differential of 67% neutrophils, 29% lymphocytes, and 3% monocytes. The C-reactive protein concentration and erythrocyte sedimentation rate were 59mg/l and 110mm/h respectively. The hydatid serology (ELISA technique) was negative. A chest X-ray and an abdominal plain radiography showed no pathological appearance. Abdominal ultrasonography (USG) revealed a large septate cystic mass in the right iliac fossa with no free fluid in the peritoneal cavity. Liver and spleen were normal. Contrast enhanced computed tomography of the abdomen detected the cystic mass located in the hypogastria and the right iliac fossa measuring 8,5 X 8 X 4,5cm with water density and having well defined borders. This mass was unilocular with internal septa and shows post contrast enhancement of the cyst wall (A 7-year-old boy originated from the governorate of Zaghouan presented to our emergency with lower abdominal pain, vomiting since three days without fever. The patient medical history was unrevealing with no history of trauma. Abdominal examination revealed a tender mobile mass in the hypogastrium reaching up to the umbilicus. The rest of his physical examination was unremarkable. Laboratory investigation showed haemoglobin of 11,5g/dl, total leucocyte count was 10,100/mmyst wall . ConsideDuring diagnostic laparoscopy a large hypogastric mass filling the lower abdomen obscuring the view with dense adhesions was noticed, however the appendix was located in the sub-hepatic region with no pathologic signs. Conversion was needed due to dense omental adhesions, to severe tissue inflammation around the mass and to intraoperative technical difficulty. On laparotomy, after releasing adhesions, intraoperative findings showed a fibrous whitish mass mainly arising from the small intestine, closely adherent to the adjacent loop . A smallEchinococcus granulosus remains a public health problem through-out the world despite the deployed prevention programs. Life cycle of E. granulosus involves usually dogs as definitive host and sheeps as an intermediate one. Humans are accidental intermediate hosts infected through ingestion of water or food contaminated with dog faeces or through direct contact with animal hair that retain eggs on their coat [Hydatid disease caused by eir coat . Gastriceir coat , peritoneir coat -6. This The mechanism of infestation remains not clear. Some authors suggested that a small primary hydatid cyst of the liver may rupture and then undergo spontaneous resolution, while their content gets seeded into the abdomen . AsymptoThe goal of the surgery is to remove the cyst without any spillage. It is very important that a correct preoperative diagnosis is made since all precautions must be taken to prevent dissemination. In fact, prophylactic measures such as irrigation with scolicidal solution, protecting the field of surgery by towel soaked with hypertonic saline and albendazole systemic chemotherapy are strongly recommended. In our case through a pfannenstiel incision, the whole cyst was enucleated without any spillage than a segmental resection of the pathologic intestine was performed. Histopathological examination is the final confirmatory diagnosis tool for the identification of the causative agents. A definitive diagnosis of hydatid cyst is confirmed by identification of protoscolices, refractile hooks or fragments of laminated membrane. The cyst can be fertile or sterile like it was in our case. The exact time required for development of protoscoleces within cysts in the human host is not known, but a proportion of cysts does not produce protoscoleces and remain sterile . HydatidThe involvement of small intestine especially as a primary localization of hydatid cyst is a rare finding. Hydatid cyst should always be considered in the differential diagnosis of all intraabdominal cystic mass especially among children who live in endemic areas. This case establishes that hydatid cyst can be found in all parts of the body and this should always be taken into account in the differential diagnosis of cystic lesions.


Case Presentation. A 25-year-old woman with stable metastatic NET of the pancreas G2 T4N1M1  already underwent several pharmaceutical therapies. Due to the young age, the G2 characteristic, and the stable liver disease, the decision for debulking was made. Based on a 3D CT scan, an embolization was successfully performed directly prior to a pylorus-preserving pancreatic head resection, advanced interaortocaval lymph node dissection, and an atypical liver resection within segment VI. Histological workup revealed a stage pT3, G2, pN1 (29/34), pM1c (hepatic and extrahepatic), L1, V0, Pn0 with complete surgical resection of the primary tumor (180 mm). The excision of the liver segment V showed a completely resected metastasis.  Neuroendocrine tumors (NETs) are a rare entity and are most commonly found in the gastroenteropancreatic tract. The clinical outcome depends on the potential resectability, grade, and stage. Here, we report a case of a tumor debulking in a metastatic NET of the pancreas. A 25-year-old woman with stable metastatic NET of the pancreas G2 T4N1M1  already underwent several therapies.  In this patient, extensive surgery of a pancreatic NET with the aim of a prolonged progression-free survival was performed. Close cooperation between different disciplines is absolutely mandatory. Modern imaging allowed a precise therapy plan to be worked out. Neuroendocrine tumors (NETs) are rare tumors with a relative incidence of 2% of all neoplasms and are most commonly found in the gastroenteropancreatic tract . The absFuture disease progression can be predicted by the following factors: proliferative index Ki67, extension of liver metastases, and presence of distant extra-abdominal lesions .In March 2014, computed tomography (CT) imaging and liver biopsy of a 25-year-old female patient revealed an intermediate grade (G2) NET of the pancreas involving the duodenum . The tumAt that time, in view of the extensive metastatic spread, let alone the expected extent of surgery for the primary tumor, both the patient and the medical team rejected surgery and in the following years the patient received chemotherapy, peptide receptor radionuclide therapy (PRRT), and since August 2017 lanreotide injections.In December 2018, the hepatic metastases showed reduced volume by 21%, but the primary tumor had increased by 18% on its largest axis, and furthermore, the patient started to report intermittent symptoms of gastric obstruction. The extra-abdominal metastases were stable. Hepatic biopsy at that time revealed that the metastases were G1, potentially explaining the differential response to the primary tumor, which was G2. Restarting chemotherapy with capecitabine/temozolomide was proposed, but the patient was hesitant and asked for a second and third opinion. A second university hospital and tertiary referral center for NET considered the finding to be inoperable because of a suspected invasion of the mesenteric vessel axis and also proposed capecitabine/temozolomide.In March 2019, the patient was seen in our institution. Based on a repeated somatostatin receptor positron emission tomography-computed tomography (PET-CT) scans, the extrahepatic primary and lymphonodal tumor formation was progressive while the liver metastases remained stable under the therapies mentioned above . Due to As part of the operation planning, a CT scan in order to three-dimensionally present the vascular supply of the main tumor formation was performed . Based ost postoperative day.The embolization was successfully performed directly prior to a pylorus-preserving pancreatic head resection, advanced interaortocaval lymph node dissection, and an atypical liver resection within segment VI Figures –9. Postoth edition 2017 was pT3, G2, pN1 (29/34), cM1c (hepatic and extrahepatic), L1, V0, Pn0 with complete surgical resection of the primary tumor [Histological workup revealed a moderately differentiated neuroendocrine tumor of the pancreas with a maximum tumor diameter of 180 mm. The mean Ki67 proliferation rate of the primary tumor was 9%, whereas the lymph node metastasis showed 15%. TNM classification according to the 8NETs are rare tumors with a relative incidence of 2% of all neoplasms and are most commonly found in the gastroenteropancreatic tract . The absFuture disease progression can be predicted by the following factors: proliferative index Ki67, extension of liver metastases, and presence of distant extra-abdominal lesions . In our At the interdisciplinary tumor board, it was decided to control the patient for disease progression by means of a gallium-68-DOTATATE PET/CT six months after surgery. Treatment with somatostatin receptor analog (lanreotide) was continued until two weeks before gallium-68-DOTATATE PET/CT, which showed a stable course, in particular of the two known cervical and thoracic (right hilum) lymph node metastases. A robotic resection of the cervical and thoracic lymph nodes is planned. The liver metastases are as well currently stable under lanreotide therapy and might remain stable for a long time period due to the low grade. In the case of progression, nowadays, there are numerous options to treat even multiple liver metastases. The handling should be performed multimodal, for example, systemic treatment, by selective internal radiation therapy (SIRT), radiofrequency ablation, bland embolization, chemotherapy, or a combination of several techniques.Panzuto et al. described in their work the risk score for tumor progression. With 15% Ki67, 25–50% liver involvement, and extra-abdominal metastases, our patient would be placed in the high-risk group with a median progression-free survival (PFS) of 12 months . In the Close cooperation between different disciplines and open discussion beyond hospital borders are absolutely mandatory. Modern imaging including somatostatin receptor PET/CT and CT angiography with 3D reconstructions allows to create precise therapy plans. The large tumor debulking of the primary tumor allows therefore, in subsequent steps, to remove the cervical and thoracic metastases. This individual approach does not obtain a situation of absence of disease but limits the spread to the liver with all therapeutic options mentioned above, including liver transplantation in the future as a possibility in the absence of extrahepatic metastases.


Recent advances in chemotherapy and chemoradiotherapy allow performance of conversion surgery by improving tumor shrinkage in select patients with initially unresectable locally advanced pancreatic cancer (LAPC), thereby providing curative potential. The number of conversion surgeries requiring arterial reconstruction for select patients with initially unresectable LAPC following favorable responses is expected to increase, so providing effective options for safe arterial reconstruction is critical.Herein we report a case of successful conversion surgery for initially unresectable LAPC with splenic artery transposition for hepatic arterial reconstruction after gemcitabine/nab-paclitaxel (GnP). A 71-year-old woman was referred to our hospital for evaluation of a pancreatic head mass after developing diabetes. She was diagnosed with unresectable LAPC, which was in wide contact with the common hepatic artery (CHA), proper hepatic artery (PHA), and splenic artery (SA). She received GnP, and after 6 cycles, durations of disease control and normalization of serum carbohydrate antigen 19-9 (CA19-9) exceeded 7 months. She underwent radical subtotal stomach-preserving pancreaticoduodenectomy with CHA-PHA and portal vein (PV) resection (SA-right hepatic artery anastomosis/PV-superior mesenteric vein direct end-to-end anastomosis). Histopathological examination revealed R0 resection with a histological response of Evans grade IIB. No signs of tumor recurrence have been observed for 14 months postoperatively.No consensus has been reached regarding the optimal treatment regimen, duration, or criteria for conversion surgery in patients with LAPC, especially in cases requiring arterial resection. SA transposition for hepatic arterial reconstruction is generally very consistent, easily accessible, and offers adequate length and diameter for successful arterial anastomosis.Even for a SA initially in contact with the tumor, SA transposition for hepatic artery reconstruction is a safe and effective option when tumor contact disappears due to chemotherapy. Reportedly, 30–40% of all PC patients present with unresectable locally advanced PC (LAPC) with involvement of nearby vasculature, such as the hepatic, celiac, and superior mesenteric arteries . Recent 2A 71-year-old woman was referred to our hospital for evaluation of a pancreatic head lesion that had been identified incidentally on abdominal ultrasonography after she had developed diabetes. She had hypertension and underwent an appendectomy when she was 30 years of age. She was taking an oral diabetic agent and an anti-hypertensive drug. There was no family history of pancreatic cancer or genetic disorders. The results of the physical examination were unremarkable. Laboratory analyses revealed high levels of hemoglobin A1c (7.5%) and tumor markers, including carbohydrate antigen 19-9 (CA19-9) (228.2 U/mL) and Span-1 (43.0 U/mL). Enhanced multidetector-row computed tomography (CT) revealed a 29-mm hypovascular tumor in the pancreatic head, in wide contact with the common hepatic artery (CHA), proper hepatic artery (PHA), and splenic artery (SA) a,d. Endo2; nab-paclitaxel 260 mg/m2) on days 1, 8, and 15 of 28-day cycles. After 2 cycles of induction GnP, serum CA19-9 levels quickly normalized (27.6 U/mL) and remained within the normal range. After 6 cycles, the primary tumor had decreased to 10 mm in diameter, and tumor contact with the SA finally disappeared, but tumor contacts with the CHA and PHA were still observed  was smaller than the right hepatic artery (RHA), and intraoperative ultrasonography confirmed RHA-only blood flow was sufficient to cover the bilateral lobes of the liver. Finally, we performed radical subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) with combined CHA-PHA and superior mesenteric vein (SMV)/splenic vein (SV) resection -SMV direct end-to-end anastomosis) , and GroThe excised specimen showed a solid tumor in the pancreatic head, and unclear boundaries with the CHA and PV , Fig. 4.After surgical treatment, the patient developed liver infarction which was categorized as Grade II in accordance with the Clavien-Dindo classification, in the lateral segment on postoperative day 33. Contrast-enhanced CT showed maintained blood flow in the reconstructed hepatic artery and PV, with no stenosis or occlusion, and improvement was achieved with conservative treatment. The patient was discharged on postoperative day 42, after having received adjuvant chemotherapy with S-1 for 6 months. There were no severe adverse events during adjuvant chemotherapy. The patient had follow-up blood testing and CT scans, and no signs of tumor recurrence have been observed as of 14 months postoperatively.3R0 resection is the only the curative treatment for PC, and can achieve prolonged survival. In recent years, surgery alone has been considered insufficient, and multidisciplinary treatments combining surgical resection and chemotherapy or chemoradiotherapy have been applied to improve prognosis ,7. AdvanWith respect to optimal preoperative treatment regimens, recent studies comparing FOLFIRINOX and GnP reported that both regimens represent viable options ,10, but For R0 resection, concomitant vascular resection and reconstruction are often necessary during conversion surgery for LAPC, due to widespread tumor invasion. PV and/or SMV resection has generally been considered to be justified in recent studies from several high-volume centers . In contAlthough few reports have described patients who underwent PD with combined arterial resection for PC, Bachellier et al. analyzed patients who underwent arterial resection with concomitant pancreatectomy including PD, and reported an acceptable overall mortality rate of 5.1% and median overall survival of 13.7 months . Althoug4Further studies are necessary to evaluate and determine the optimal treatment regimen, duration, and criteria for conversion surgery and resection, especially for cases requiring arterial resection. Even for a SA initially in contact with the tumor, SA transposition for hepatic artery reconstruction is a safe and effective option when tumor contact disappears due to chemotherapy.The authors declare that they have no competing interests.This report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.This study is exempt from ethical approval in our institution.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.HI (Expert hepatobiliary-pancreatic surgeon certified by the Japanese Society of Hepatobiliary Pancreatic Surgery) and HT performed the surgery on this patient. IH, HT, KM, and TH managed the postoperative course of the patient. HT and HI wrote the manuscript. All authors have read and approved the final manuscript.http://www.researchregistry.com.Our case report is not first-in-man. Therefore, in accordance with the Guidance of Research Registry, we did not register our case report at Hideharu Tanaka (Corresponding author and Guarantor).Not commissioned, externally peer-reviewed.Not applicable.


Diathermy is extensively used in patients for intracardiac device implant and extraction. While diathermy helps with adequate hemostasis, it may rarely be associated with fatal dysrhythmias. We report a case of diathermy-induced ventricular fibrillation during device extraction. The case highlights the importance and supports the involvement of a defibrillation facility during pacemaker revisions requiring diathermy. Surgical diathermy involves the use of a high-frequency electric current in the cutting and coagulation of body tissue. In cardiology, monopolar diathermy is extensively deployed in patients to support permanent pacemaker (PPM) implantation and extraction. While diathermy helps with adequate hemostasis and reduces bleeding complications, it may rarely be associated with fatal dysrhythmias. We report a case of diathermy-induced ventricular fibrillation (VF) during device extraction.. The patient subsequently tolerated the remainder of the procedure very well and experienced an uncomplicated device extraction.A 44-year-old man was transferred from his local hospital to undergo pacemaker extraction following the emergence of an infection in the pacemaker system. He had received a Sensia SEDRO1 dual-chamber PPM  25 years ago that was implanted for sinus node dysfunction and syncope. He had no other significant comorbidities but showed evidence of a pacemaker pocket infection with device erosion. His blood cultures were negative and he was systemically well with stable hemodynamics and without the need for any inotropic support. A preprocedure transesophageal echocardiogram confirmed a structurally normal heart. A pacemaker check revealed an underlying sinus rhythm at 70 bpm. Based on the above, he had a class 1 indication for device extraction and the procedure was performed under sedation. Prior to extraction, his pacemaker was programmed to VVI, bipolar mode, defibrillation pads were connected, and continuous rhythm and hemodynamic monitoring were performed. Using an electrosurgery generator  for monopolar diathermy, an incision was made over the pacemaker pocket in an attempt to extract the generator. The pacing wires were not exposed at this point and were located beneath the pacemaker generator without no contact with the diathermy blade. During diathermy, VF was noted, with loss of cardiac output. The patient was immediately cardioverted to sinus rhythm successfully with a single 150-joule direct-current shock 1 As a result, in addition to the ongoing increase in device implantation rates, there is also a growing need for device replacements either due to battery depletion or, rarely, device infections.2 Diathermy is extensively used and is very effective in maintaining good hemostasis in patients who are on anticoagulation or antiplatelet therapy. It is well-recognized that the use of diathermy can cause interference, resulting in pacing inhibition and asystole in patients who are pacing-dependent. However, the occurrence of ventricular arrhythmia is rare and the mechanism behind it in this context remains unclear, particularly in patients with a structurally normal heart.The rate of PPM implantation and its prevalence continue to rise with the expanding aging population worldwide.3 In this context, the interference caused by diathermy can lead to potentially life-threatening arrhythmias. A rare case of diathermy-induced VF was previously reported as a result of an insulation defect in the high-voltage lead at the level of the pectoral muscles.4 In our case, a possible explanation for the VF could be due to the close proximity between the diathermy blade and the PPM generator. Diathermy usage in patients with either a pacemaker or an ICD can result in electrical interference that may initiate inappropriate shock, inhibition, reprograming, or damage to the device.7 Preventative strategies include programing the PPM to asynchronous VOO or DOO mode , application of a magnet over the device, disabling of the ICD therapy, the use of short bursts if monopolar diathermy is unavoidable, placement of the dispersive electrode in a position as far as possible from the cardiac device, and electrocardiogram monitoring for PPM in the case of inhibition.Electromagnetic devices, such as PPMs and implantable cardioverter-defibrillators (ICDs), have been reported to interfere with electrosurgical devices.In addition to adhering to the general safety principles of diathermy, the present case also highlights the importance of involving a defibrillation facility, which should be readily available when necessary, and supports the standard practice of using defibrillation pads as a safety net in all patients who require diathermy.


Intestinal obstruction due to internal herniation of the bowel is a rare clinical entity which is often overlooked in the differential diagnosis of patients with abdominal pain who have no previous history of abdominal surgery. Several sites of bowel internal herniation have been described, amongst which internal herniation through the foramen of Winslow accounts for about 8% of cases. These patients present with nonspecific abdominal pain associated with symptoms of gastroesophageal reflux disease, and hence the diagnosis is often overlooked. The usual symptoms of intestinal obstruction can be delayed, which results in a delay in diagnosis and gangrene of the herniated bowel segment. Abdominal radiographs and computed tomography are helpful in the diagnosis. Open reduction is the management of choice; however, laparoscopic reduction has also been attempted, with good results.We report a case of a middle-aged Sri Lankan man who presented with features of gastroesophageal reflux disease, developed features of intestinal obstruction and was found to have a gangrenous small bowel loop which had herniated through the foramen of Winslow. Following needle aspiration and reduction of the herniated small bowel loop, the gangrenous part of the small bowel was resected and an ileoileal anastomosis performed. The large foramen of Winslow was partially closed with interrupted stitches. The patient made an uneventful recovery.Since delayed diagnosis of bowel obstruction is detrimental, it is of utmost importance to diagnose it early. Because internal herniation of the small bowel through the foramen of Winslow presents with nonspecific symptoms including features of gastroesophageal reflux disease, as documented in several cases worldwide and also presented by our patient, there should be a high degree of suspicion of internal herniation of the bowel causing bowel obstruction and low threshold for extensive investigation of patients presenting with symptoms of gastroesophageal reflux disease which does not resolve with usual medication. Internal hernias are a rare clinical entity, accounting for 0.2–0.9% of all hernias. The incidence of intestinal obstruction due to internal herniation of the bowel is 0.6–5.8% . Interna3/l and C-reactive protein 139 mg/l), and abdominal X-ray revealed dilated small bowel loops. Ultrasound scan of the abdomen was normal. Urgent contrast-enhanced computed tomography revealed dilated small bowel loops without an obvious cause of obstruction. The patient underwent emergency exploratory laparotomy and was found to have a gangrenous mid-ileal bowel loop herniating through a tight foramen of Winslow (Fig. A healthy 52-year-old Sri Lankan man with no previous medical or surgical history presented with epigastric pain associated with several episodes of bilious vomiting for 1 day. Bowel functions were normal. He was afebrile, there was mild epigastric tenderness, and the digital rectal examination was normal. He was initially treated with analgesics, prokinetics and proton pump inhibitors. His symptoms worsened, and on the third day he complained of abdominal distention and persistent vomiting. Increasing epigastric tenderness with gaseous abdominal distention was noted, and he had not had bowel movement since admission. He was hemodynamically stable but had elevated inflammatory markers (white blood cell count 17 × 10Internal hernias are a rare clinical entity, accounting for 0.2–0.9% of all cases of intestinal obstruction, amongst which herniation through the foramen of Winslow is very rare, constituting only 8% of internal hernias . The smaAs internal herniation through the foramen of Winslow often presents with nonspecific symptoms such as epigastric pain, regurgitation, nausea and vomiting, differential diagnoses range from gastrointestinal to pancreatic or gallbladder pathology . The reaThe diagnosis is made either preoperatively or intraoperatively. The presence of a circumscribed collection of bowel gas with air fluid levels high up in the left upper abdomen and displacement of the gastric air bubble to the left in plain abdominal radiographs is suggestive of herniation of the small bowel through the foramen of Winslow , 9. CompManagement involves reduction of the hernia either laparoscopically or by a laparotomy before the bowel becomes gangrenous . Gentle Delayed diagnosis of small bowel obstruction results in serious complications including perforation, gross peritoneal contamination, sepsis and death. As our patient was diagnosed on the third day following hospital admission, he had a gangrenous bowel segment which had to be resected. The primary reason for the delay in diagnosis was that the patient complained of an epigastric pain with regurgitation which we attributed to gastroesophageal reflux disease. In retrospect, the symptoms were likely brought about by compression of the stomach by the congested, oedematous herniated small bowel loop. Hence suspicion of a sinister pathology is important in a patient who presents with unresolving epigastric pain suggestive of gastroesophageal reflux disease even in the absence of other symptoms, and highlights the importance of early computed tomography followed by early surgical intervention to prevent further complications.At the 1-month review of the patient, he is thankful for the treatments he received from the admission until the discharge and not worried about the delayed diagnosis given the complexity of his presentation. However, being a manual worker is he worried about not being able to carry out his occupation to the fullest of ability yet, and he attributes it to the mild pain he experiences at the surgical site from time to time.


The basis of retinal detachment repair is sealing the retinal breaks. In order to seal the retinal breaks, chorioretinal adhesion around these lesions has to be achieved. Laser retinopexy is not immediate thus necessitates the use of a temporal endotamponade to maintain both tissues in apposition. We propose the use of a patch of lyophilized human amniotic membrane (LAMPatch) in order to occlude the retinal tear effectively until the chorioretinal adhesion is settled, overcoming the risks and limitations of the current tamponades.23-gauge vitrectomy was performed on eyes with primary retinal detachment with single retinal breaks of less than one-hour extension. A LAMPatch was deployed over the retinal breaks after retina was repositioned with perfluorocarbon. Neither gas nor silicon oil were injected.Six eyes of six patients with total or partial retinal detachment were included. Retinas remained reattached in all cases until the end on follow-up . Best-corrected visual acuity at 1-week postop was between 20/30 and 20/100. Neither elevations of intraocular pressure, cataracts nor signs of inflammation were registered during follow-up. No second surgeries were needed.This technique has proven to be safe and effective in this small case series. No intraocular pressure rise, inflammation or cataracts were registered until last follow-up visit. The basis of retinal detachment (RD) repair was established by Jules Gonin 100 years ago and it is still up to date: sealing the retinal break .In order to seal the retinal breaks, chorioretinal adhesion around these lesions has to be achieved. Laser retinopexy is the preferred technique, nevertheless its effect is not immediate , thus neHuman amniotic membrane (HAM) has been reported to be safe for intraocular use; moreover, as Rizzo et al. described, it appears to promote retinal healing –8. LyophWe propose the use of a patch of lyophilized HAM (LAMPatch) over the retinal tear as a localized temporary tamponading agent in replacement of currently used tamponades, in order to occlude the retinal tear effectively until the chorioretinal adhesion is settled, overcoming the risks and limitations of the current tamponades.This is a consecutive, single-center case series of six eyes of six patients with primary RD treated by a single surgeon with pars plana 23-gauge vitrectomy with the Constellation System . Inclusion criteria were: eyes with primary RD, single retinal breaks of less than one hour extension and minimal to no signs of vitreoretinal proliferation. Patients with previous retinal surgeries were excluded. Three cases had superior breaks, and three cases had inferior breaks. Surgical repair took place between November 2019 and June 2020. Written informed consent for participation was obtained from all patients. The study was in compliance with the Declaration of Helsinki. An independent ethical committee approved this study in accordance with the Helsinki declaration.Preoperatively, an ophthalmic history and a complete ophthalmic examination including refraction with assessment of best-corrected visual acuity (BCVA) Goldmann applanation tonometry and a fundus dilated ophthalmic examination was performed.HAMs were obtained from Amnios, Inc,  where HAM is harvested from human placentas following standardized procedures. A sample of HAM is previously collected to perform Protein Chain Reaction (PCR) for HIV, Hepatitis B, Hepatitis C, Brucellosis, Toxoplasmosis, CMV, Syphilis and Chagas before dispensation. Once the procedure of cleansing and dissecting of the HAM is finished, fragments of different sizes are loaded into sterile Petri dishes, wich are placed in a freezer at −80 ℃ for 2 h. Then, the freezed plates are stored in the freeze-dryer shelves under a determined vacuum . The final products are exposed to gamma radiation (15–20kgray) for sterilization. .M.S. performed all surgical procedures with the Alcon Constellation system  as follows: A retrobulbar block was performed followed by placement of three 23-gauge trocars. A complete vitrectomy including a meticulous peripheral vitreous shave was performed. Retina was repositioned with either liquid perfluorocarbon or air ensuring that the borders of the lesions were completely attached and no subretinal fluid was left. Laser photocoagulation was applied around the retinal breaks. Perflurocarbon–liquid–air exchange was performed. Once the eye was full of air, tailored pieces of lyophilized HAM between 3 to 6 mm in diameter Fig.  were intImmediately after surgery, no head-positioning instructions were recommended. Patients were placed on prednisolone acetate 1% and moxifloxacin 0.5% four times daily. All patients were examined postoperatively at the first postoperative day and then at 1-week; the following visits were scheduled on a monthly basis. Mean follow-up was 3.5 months (2–7 months). The postoperative evaluations included measurement of the BCVA and intraocular pressure (IOP), biomicroscopy and dilated fundus examination.Six eyes of six patients with total or partial RD were included Table .Table 1PRetinas remained reattached in all cases from 1-day to the end of follow-up. All LAMPatches stayed completely adhered to the retinal surface covering the break at the 1-week postoperative visit. In one case the LAMPatch was not in place in the vitreous cavity after a comprehensive fundoscopy. Patient did no referred symptoms at the 1-month postoperative visit (Patient 2). Neither was found in the vitreous cavity after a comprehensive fundoscopy. Patient did not refer any symptoms. In another case (Patient 6) the LAMPatch was found partially detached from its borders at the 5-month postoperative visit Fig. . The othVitrectomy has become the preferred surgical technique for addressing RD. Technological advances regarding vitrectomy and visualization systems have improved overwhelmingly in the last decades, allowing the procedure to be faster, safer and more comfortable for patients. Notwithstanding, vitrectomy for RD repair still has unwanted side effects due to the use of tamponades. Intraocular silicon oil and/or expansive gases may produce, even when they are no longer inside the eye, visual impairment, cataracts and glaucoma , 5. As tWe believe that there is room for a different strategy to achieve the same results: to occlude the break and keep retina in position until retinopexy is consolidated, without the side effects caused by current endotamponades. Other papers have been published adressing this issue using a fibrin glue plug, reporting similar benefits , 11. We We propose the use of a thin layer of lyophilized amniotic membrane as a patch (LAMPatch) to temporary block the retinal breaks until a firm laser retinopexy is achieved, avoiding the use of endotamponades like gas or silicon oil. It is critical to understand that this technique does not replace laser retinopexy, conversely, it buys time until strong retinopexy is attained, generally 24 hs postop .HAM has already been used in retinal surgery with good tolerance ; neverthIn the present series of six cases, LAMPatch technique showed efficacy both in superior and inferior breaks. This technique has proven to be safe and effective in this small case series. An advantage of avoiding the use of endotamponades like gas or silicon oil was that the visual axis was not impaired and visual recovery started earlier. No IOP rise, inflammation or cataracts were registered until last follow-up visit. The limitations of this case series were the short follow-up and the small number of cases.We propose to consider the use of the LAMPatch technique as an alternative approach for the treament of selected cases of RD.


In extreme preterm infants, massive congenital sacrococcygeal teratomas with great hemodynamic commitment may be a situation for limitation of care. In extreme preterm infants, massive congenital sacrococcygeal teratomas with great hemodynamic commitment may be a situation for limitation of care. She presented a rapid worsening course with hypovolemic shock, acidosis, and death. This case highlights the hemodynamic effects of large congenital teratomas with vascular components as a major cause of death.Congenital sacrococcygeal teratomas (SCT) are germinal cell neoplasms derived from the misdifferentiation of the primitive streak during embryonic development.2A female preterm infant was born to a 26‐year‐old healthy primigravida mother and a 30‐year‐old nonconsanguineous father. The first trimester was of low risk, and pregnancy was uneventful until 19 weeks, when the obstetric ultrasound revealed a sacrococcygeal mass with internal and external component (with 34 × 28 mm) suggestive of teratoma, why she was referred to our center. The amniocentesis showed a normal array comparative genomic hybridization (aCGH), and the echocardiogram was normal. An MRI was performed at 22 weeks gestation, which revealed a sacrococcygeal mass (60 × 70 × 57 mm) with mixt characteristics, predominantly solid, with the biggest cyst measuring 40mm, without invasion or compression of the pelvic structures or coccyx, Altman type 2. The subsequent ultrasounds revealed a fast growth rate of the tumor (80 × 60 mm) associated with profuse vascularization. The pediatric surgery team was informed. Until delivery, there were no other incidents.2 1.00), and intravenous adrenaline, with recovery of cardiac frequency after 6 minutes of resuscitation maneuvers. A single dose of surfactant was administered at the first hour of life.Labor was spontaneous, and she was delivered vaginally at 26 weeks and 6 days of gestation, after a full cycle of antenatal steroids. The presentation was cephalic, and the birth weight was 1300 g. The Apgar score was 0, 0, and 5 at 1, 5, and 10 minutes, respectively. The parents expressed a desire for investment to be made in the child. For resuscitation, she needed ventilation with positive pressure, oxygen . She was pale with increased capillary filling time and was presented with a reddish mass at the sacrococcygeal area measuring 14 × 7 × 4 cm, 750 g of estimated weight, with visible active bleeding . The cranial ultrasound revealed signs of subependimary hemorrhage and periventricular hyperecogenicity.The patient, then, received substantial doses of adrenaline and was volumized several times with saline and glucose solutions, followed by transfusion of red blood cells (up to 30 mL/Kg), fresh‐frozen plasma (10 mL/Kg), and platelets (10 mL/Kg). Despite the efforts, the post‐transfusion hemoglobin level remained low, 5.8 g/dL. Also, she started ampicillin, gentamicin, and a perfusion of intravenous sodium bicarbonate, due to severe metabolic acidosis  which have a better prognosis and survival, immature teratomas  and malignant teratomas (very uncommon in infants).As a consequence of the rapidly clinical worsening, the surgical options and adverse intraoperatory outcomes are scarce. Hence, patient characteristics, tumor morphology, and exsanguinating hemorrhage are important causes of early neonatal death.The differential diagnoses include myelomeningocele, lipoma, and the dermoid cyst, but also malignant tumors such as sarcoma of Ewing/PNET, neuroblastoma, and myosarcoma. The probability diagnosis is established on the basis of imaging detection of the tumor, ultrasound, and MRI, and in the finding of high levels tumor markers, such as alpha‐fetoprotein (AFP) and human gonadotrophic hormone (B‐HCG). High levels of AFP may indicate malignancy; unfortunately in the neonatal period, these values are usually high and only reach normal values about 9 months of age. The levels of these tumor markers were not evaluated in this reported case. The definitive diagnosis is established after anatomopathological analysis.In this case, we focus on two main mechanisms related for a bad prognosis for this tumor, the mass effect, and the rich vascular component. Although early preterm births themselves may not be the major cause of death in patients with SCTs, the large dimensions might be a likely cause of preterm deliveryLikewise, and most importantly, the rich vascular component of the tumor—which can justify the severe anemia, hypovolemia, and high‐output cardiac failureHigh‐output cardiac failure is a less common form of heart failure and results from the heart's inability to provide sufficient blood for the body's demand, either secondary to diffuse arteriolar dilation or possible bypass of the arterioles and capillary beds that can occur in vascular tumors. The problem lies with an increase in the body's demand for perfusion that the heart is not able to provide, even with a normal cardiac function.Finally, this adverse cardiovascular status prevented a safe and effective surgical resection, as the poor hemodynamic condition constitutes a great surgical risk.Teratomas are the most common neoplasm in neonates, but not commonly found in literature. This report highlights a rare but extremely challenging presentation in neonatology and surgery. Such cases are important for clinicians to be aware of in order to appropriately counsel future families in the antenatal period. This might also allow for decisions about limitations of care in the immediate postnatal period to be made. In this particular case, the clinical state of the baby after delivery, the degree of resuscitation required, the biochemical parameters following resuscitation, in addition to the known poor prognostic patient and tumor factors, make the futility of treatment obvious in retrospect.There is a great difficulty on making withdrawal of care decisions in high pressure environments, especially when parents want investment, but the extreme prematurity, the aggressive resuscitation, the dimensions of the tumor, and the precarious hemodynamic and general condition of the patient may be useful to help with this decision.4Summarizing, this case emphasizes that SCT’s dimensions and its vascular components are the major determining hemodynamic changes that are crucial for the prognosis of these patients. Accordingly, the prenatal diagnosis and precise classification of the neoplasm would help the proper counseling in the antenatal period and the approach after delivery. A multidisciplinary involvement during pregnancy, including pediatric surgery, and a multidisciplinary approach after birth is of the utmost importance in clinical situations such as that reported in this clinical case.The authors have no conflict of interest or any financial support to declare. This manuscript has not been submitted or published elsewhere. Data sharing is not applicable to this article as no new data were created or analyzed in this study. All authors consciously assure that, for this manuscript, all the previous statements correspond to the truth.PM‐S: designed the study case and wrote the draft of the manuscript. All other authors: have contributed to data collection and manuscript review. All authors: have approved the final version of the manuscript.


Undifferentiated nasopharyngeal cancer of the cavum (UCNT) is the most frequent neoplasm of the nasopharynx, having a close relationship with exposure to Epstein-Barr virus. It has a high potential for locoregional or distant invasion which are the cause of some treatment failures. The extension to the maxillary sinus is rarely described. We report here the case of a 38-year-old patient with headaches associated with epistaxis, left otalgia and facial pain. Examination by anterior rhinoscopy objectively revealed a polylobed ulcerating mass. Otoscopic examination revealed a left seromucous otitis media. Computed tomography showed a voluminous tumour process in the infra temporal fossa and nasopharynx with significant locoregional extension particularly in the maxillary sinus. Pathological examination revealed an UCNT of the cavum and the patient was classified as T4N2M0. The patient received chemoradiotherapy, with wide irradiation of the cervical lymph node areas. The deep localization of the cancer of the cavum, which is difficult to examine, requires a diagnostic and extension work-up, both endoscopic and radiological, which is an important step in the diagnostic and therapeutic management. Carcinomas of the cavum, in particular undifferentiated, are the most frequent tumours of the nasopharynx . They haA young patient of 38 years of age who smokes, presented at the otolaryngology consultation for headaches associated with epistaxis, left otalgia and facial pain. The clinical examination revealed a nasopharyngeal polylobal ulcerated mass with left seromucous otitis. A cervicofacial computed tomography (CT) showed a large tumour process in the left infra temporal fossa, poorly limited, hypodense, enhancing after injection and measuring approximately 62x50mm. It extends anteriorly to the left maxillary sinus with lysis of its walls and internally the pterygoid region, the nasal fossae, the posterior ethmoid cells and the homolateral choana . LateralThe UCNT is particular among other head and neck neoplasms considering its epidemiology, histopathology and treatment ,5. Its gth edition. This invasion is an independent negative prognostic factor for UCNT.Maxillary sinus invasion in patients with UCNT is relatively uncommon. This invasion is defined as T3 disease according to AJCC staging system 8


Backgroud: Presacral tumors are rare space occupying lesions that arise in the presacral space. The incidence of presacral tumor has been reported to be 1 in 40,000 to 63,000 patients. An even rarer occurrence is the transformation of a presacral tumor into a squamous cell carcinoma (SCC).Case Summary: A 61 years old man was referred to our hospital for a palpable mass near anus and appeared repeatedly in last 10 years. The patient previously underwent two surgeries at another hospital. A posterior approach was implemented in the first two surgeries, and the diagnosis was benign presacral epidermoid cyst. Two months before his admission to our department in 2017, the patient complained of a mass measuring ~2 cm around his anus. Physical examination revealed a 2 cm mass at the 12 o'clock direction in chest-knee position. A digital rectal examination indicated a rubbery lesion located in the presacral space. The Pre-operative pelvic magnetic resonance imaging (MRI) confirmed the presence of a 6.8 cm * 5.2 cm * 7.3 cm mass located at the presacral space. In contrast phase, the center of the lesion exhibited homogenous density without enhancement. The mass was then excised via posterior para-sacral approach with pathological report showing a benign epidermoid cyst after operation. The patient was discharged with full recovery without fecal incontinence. Fifteen months after being discharged from our hospital, the patient discovered a recurrence at the original site of where the mass previously appeared. Unlike the previous instance, the mass was accompanied with swelling, pain, and localized increased skin temperature. Pelvic MRI showed a 3.2 cm * 7.2 cm * 5.8 cm located at the same place, with no enhance in the core of mass. However, a speckled enhancement was observed on the margin of the lesion. The lesion was completely resected using the same procedure as before with a pathological diagnosis of SCC. The patient underwent chemoradiation therapy and remained disease free for more than 1 year.Conclusion: Although very rare, benign cyst from presacral space can become malignant transformation. This highlights the importance of pre-operative diagnostic tests and evaluation to correctly identify the source of the primary cancer, which is crucial prior to starting adjuvant therapy. Presacral epidermoid cyst is considered a congenital lesion which originates from an embryologic error. They rarely become malignant transformation. In this case, we resected the tumor by posterior approach and confirmed the diagnosis of benign epidermoid cyst in the patient's third operation. The patient came back 15 months later for recurrence of the retrorectal tumor, and finally diagnosed as SCC, which was an unexpected finding. The case highlights the important of pre-operative evaluation. The malignant transformation of presacral epidermoid cyst could happen after frequent relapses.In the fields of colorectal surgery, the diagnosis and discovery of retrorectal tumor in patients rarely pose much of a concern to the patients' prognosis. Tumors arising at presacral space are classified into five types : congeniA 61 years old man who was referred to our hospital complained of a palpable mass around the anus and appeared repeatedly in last 10 years.The patient discovered the mass around his anus by himself 10 years ago. He underwent two major surgeries for resection of the mass by posterior approach. A palpable lesion appeared 2 months ago prior to admission into our hospital.The patient was diagnosed with hypertension and took single dose of calcium channel blockers daily. His blood pressure was under control and well-managed.A 2 cm mass was observed at the 12 o'clock direction in chest-knee position. Digital rectal examination determined the presence of a rubbery lesion located in presacral space. The mass was smooth and firm, and no nodule was felt on the surface. The mass was tender and the local skin temperature was slightly elevated.Cell blood count revealed mild anemia with a hemoglobin count of 122 g/L along with normal white blood cell and platelet count. The blood biochemistries, hematological tumor markers, prothrombin, and partial thromboplastin were normal. Electrocardiogram, chest computed tomography, echocardiography and pulmonary function tests were also normal.Before the first surgery in our hospital, pre-operative pelvic magnetic resonance imaging (MRI) with intravenous Gadolinium highlighted a 6.8 cm * 5.2 cm * 7.3 cm mass located at presacral space. In contrast phase, the center of the lesion showed homogenous density and without enhancement  and adjuvant chemotherapy were implemented. The chemotherapy regimen of gemcitabine plus cis-platinum was given, which is standard protocol for lung SCC . The BEPAlthough it is very rare, benign cyst from the presacral space can become malignant transformation. This case highlights the importance of pre-operative diagnostic tests and evaluation to correctly identify the source of the primary cancer, which is crucial prior to starting adjuvant therapy.All datasets generated for this study are included in the article/supplementary material.The studies involving human participants were reviewed and approved by ethics committee of Shanghai Tenth People's Hospital Affiliated to Tongji University. 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.XW reviewed the literature and drafted the manuscript. LY performed the surgeries and made important revisions to the manuscript. CC contributed to drafting the manuscript. XW, MY, XY, HC, and CC assisted during the surgeries. All authors have approved the submission of this manuscript.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Jejunal diverticula are a rare subtype of false diverticula found in the gastrointestinal tract. When present, they are usually multiple, in the proximal jejunum and asymptomatic. Rarely, they can cause acute complications that can develop into an acute abdomen requiring surgical intervention. We present the rare manifestation of a single jejunal diverticulum causing midgut volvulus and bowel ischemia. Early surgical intervention with small bowel derotation allowed complete recovery.Data regarding the case, operative intervention, and patient follow-up was prospectively accumulated with permission of the patient at an academic institution. All patient identifiers were removed. All research steps were performed under guidance outlined in the SCARE criteria.We present the case of a 78-year-old man who presented to our institution with an acute abdomen. CT imaging demonstrated a whirlpool sign without an obvious lead point. The patient was without prior surgical intervention. Urgent exploratory laparotomy revealed a midgut volvulus with associated bowel ischemia and impending infarction secondary to adhesive disease from a large single jejunal diverticulum. Derotation resulted in gradual recovery of bowel vascularity. Resection of the portion of the jejunum containing the diverticulum resulted in full clinical recovery of the patient.Complications of jejunal diverticula, although rare, should be considered as part of the differential diagnosis of an acute abdomen of unknown etiology. Urgent surgical intervention was required to avoid a potential catastrophic outcome. The outpouchings of the gastrointestinal tract may be true diverticuli that involve all layers of the bowel wall. The most common true diverticulum is a Meckel’s diverticulum present in approximately 2% of the population and usually found in the ileum . AlternaDifferent locations in the GI tract predispose to true and false diverticuli. Diverticuli are common in the esophagus but are much less common in the stomach ,6. They Jejunal diverticuli are uncommon and when they do exist are usually asymptomatic ,12. The 2www.researchregistry.com website with UIN 5776.Data on this patient was prospectively accumulated at an academic institution. This research work has been reported in line with the SCARE criteria . This st3A previously well 78-year-old male in the mid-morning of April 5, 2020 developed increasing abdominal pain. The pain was steadily increasing over 6 h which prompted urgent travel to an emergency room. The pain was treated with intravenous morphine. A CT with intravenous contrast was performed. It showed a “whirling” of the small bowel mesentery with edematous changes concerning for volvulus . A CT wiThe patient’s vital signs were stable, yet due to unrelenting pain, he was taken urgently to the operating room for exploratory laparotomy. Upon opening the abdomen, the small bowel was profoundly discolored from venous congestion. The bowel was twisted on its mesentery causing obstruction of venous outflow. There was marked fibrin deposition throughout the abdomen with a large amount of inflammatory exudate. A large solitary jejunal diverticulum measuring approximately 5 cm in length was evident approximately 45 cm from the duodenojejunal junction. The apex of the diverticulum was adherent to the abdominal wall. Pictures of the solitary jejunal diverticulum in-situ were taken . The divAfter derotation of the bowel, the abdomen was copiously irrigated with warm saline. Impending infarction resolved after approximately twenty minutes. The normal color returned to the small bowel and fully restored after forty minutes. A generous resection of the diverticulum including an approximate 30 cm segment of the jejunum was performed . A staplThe patient recovered from surgery without incident. He was maintained on nasogastric suctioning for 72 h initially with a large volume of bile-stained contents from the stomach. As the volume of nasogastric suctioning reduced, the tube was removed. The patient gradually resumed sufficient gastrointestinal function to be discharged from the hospital on his sixth postoperative day. Normal alimentation occurred after approximately eight weeks.Pathologic examination of the specimen determined that the normal muscular coating of the bowel was absent in the area of the diverticulum. This confirmed that this was a false diverticulum where mucosa and submucosa were present in the outpouching in the absence of a surrounding layer of smooth muscle .Fig. 4 patients does not meet the DHHS definition of research (45 CFR 46.102(d)(pre-2018)/45 CFR 46.102(l)(1/19/2017)) or the FDA definition of clinical investigation (21 CFR 46.102(c)) and therefore are not subject to IRB review requirements and do not require IRB approval.This case report is of 1 patient.Written and signed consent was obtained from the patient.Paul H. Sugarbaker: study concept or design, data collection, data analysis or interpretation, writing the paper.Aradhya Nigam: data collection, data analysis or interpretation, writing the paper.Faye F. Gao: study concept or design, data collection, data analysis or interpretation, writing the paper.Mark A. Steves: data collection, data analysis or interpretation.www.researchregistry.com website with UIN 5776.This study was registered as a case report on the Paul H. Sugarbaker, MD.Not commissioned, externally peer-reviewed.