We report a case of large hemoperitoneum caused by a ruptured endometrioma in a 25-year-old Virgo woman. Hemoperitoneum caused by ruptured endometrioma is a rare entity. The diagnosis should be given consideration when a patient with known or suspected endometriosis presents with signs of intra-abdominal hemorrhage. Endometriosis is an estrogen-dependent benign disease affecting 2-10% of women of reproductive age and 50% of women with fertility problems. It causes a chronic inflammatory reaction, which results in fibrosis and adhesions . Many caWe hereby report a case of a 25-year-old Virgo woman with chronic symptoms of endometriosis, who presented with signs of intra-abdominal hemorrhage secondary to endometrioma rupture, with an aim to bring this severe, albeit rare, complication of endometriosis to the attention of clinicians.A 25-year-old Virgo woman presented to the emergency outpatient clinic of our department with acute-onset, lower abdominal pain for the past three hours and dizziness. The patient reported a history of chronic dysmenorrhea and polymenorrhea, managed with oral painkillers, with no further diagnostic workup having been undertaken. She was on day eight of her menstrual cycle.Her vital signs were stable . On physical examination, she was pale and displayed diffuse lower abdominal tenderness with guarding but no rigidity. There were no palpable abdominal masses. The patient did not consent to bimanual or rectal examination or transvaginal ultrasound.Laboratory tests revealed anemia with a serum hemoglobin level of 8.2 grams per deciliter (g/dL). The rest of her laboratory test results were normal (white blood cells (WBC) 10.100 cells per microliter, C-reactive protein (CRP) of 3 milligrams per liter), and a pregnancy test was negative. A transabdominal ultrasound showed a large pelvic mass and free intra-abdominal fluid. An emergency MRI scan of the lower abdomen and pelvis revealed the presence of a 10 x 10 centimeters adnexal mass, a "kissing ovaries" sign and free fluid, compatible with blood and blood clots, in the pelvic cavity. The uterus, fallopian tubes, and appendix appeared normal.The patient was admitted, and repeat hemoglobin, performed two hours after admission, was 7.5 g/dl, and two units of packed red blood cells were crossmatched and transfused. Six hours after admission, the patient developed hemodynamic instability , and an emergency decision for exploratory laparoscopy was made.Upon entering the abdominopelvic cavity, a large amount of fresh and clotted blood was present. After suctioning the blood (approximately 1700 milliliters), the entire abdominopelvic cavity was explored to identify the source of the bleeding. Bilateral endometriomas were present, and a rupture in the right ovarian cyst wall was recognized, causing hemoperitoneum and free "chocolate" fluid in the abdomen Figure , with biThe patient received two units of packed red blood cells intraoperatively and two additional units the next day. On discharge, hemoglobin was 10.5 g/dL. Her postoperative course was uneventful and histological analysis of the specimens confirmed the diagnosis of bilateral endometriomas.Patients with endometriosis present with a variety of symptoms. Endometriosis is usually suspected after evaluating clinical history, physical examination, and imaging studies (ultrasonography and/or magnetic resonance imaging). The gold standard for definitive diagnosis, however, remains visual inspection via laparoscopy and histopathological examination of biopsy specimens . SeveralIn our case, the patient had a history of chronic and cyclic dysmenorrhea and presented with acute lower abdominal pain and very low serum hemoglobin in consecutive blood tests. These findings set a strong suspicion for endometriosis-related intra-abdominal hemorrhage. Additionally, urgent imaging  revealed bilateral ovarian masses with endometriotic content, no other pelvic pathology, normal appendix, and the presence of free fluid in the abdominal cavity. Ectopic pregnancy was excluded by a negative pregnancy test. The gold standard diagnostic and therapeutic tool for this condition is laparoscopy, which allows suctioning of the free abdominal blood, "chocolate" fluid, and blood clots, visualization of the endometriotic cysts, recognition of the rupture and the spot of the active bleeding, resection of the cysts for histopathological diagnosis and control of the hemorrhage with electrocoagulation .Diagnosis of hemoperitoneum caused by ruptured endometrioma should be given consideration by clinicians when a patient with endometrioma presents with signs of intra-abdominal hemorrhage and after ruling out other possible diagnoses such as ectopic pregnancy, bleeding from the corpus luteum, and non-gynecological pathologies.


Congenital cystic and mediastinal neck masses include lymphangiomas, teratomas, neuroenteric cysts, thyroglossal duct cysts, branchial cleft cysts, vascular malformations and pulmonary hernias.A boy aged 9 years was referred for an assessment of a left asymptomatic cervical mass that grew steadily with no inflammation during about 1 year. The physical examination detected a mobile tumor of fibroelastic consistency on the anterior left neck, which was difficult to palpate.The mass did not hinder movements of the child. Ultrasound revealed a cystic mass with a possible diagnosis of a branchial cyst along the left jugulo-carotid chain with an inflammatory aspect; computed tomography showed a solid lesion in the left neck of unknown etiology, suggesting adenomegaly or a lymphoma. The mass extended towards the mediastinum. Left cervicotomy was undertaken for removal of the cervico-thoracic tumor; it had a benign appearance, glandular consistency, no necrotic areas, and extended into the anterior thorax . HistopaThe peak incidence of thymic cysts, in the first decade of life, may be explained by the fact that thymic residues are larger in the years before puberty. Although thymic cyst is not a frequent diagnosis, the abovementioned male patient in the first decade of life with a left cervical tumor falls within the common features of reports in the literature. It was a cyst lined with foreign body granulomas similar to cholesterol or keratin crystals, which are pathognomonic of thymic cysts;Left supraclavicular masses remind us of the abdominal lymphatic drainage, which was within normal limits. The choice was made to remove the tumor in the surgical theater under general anesthesia, applying perioperative measures pertaining to total tumor removal.Thymic cysts are a rare cause of neck masses, which should nevertheless be included in the differential diagnosis, especially in children.


Cavernous venous malformation is an uncommon entity that occurs in around 0.5% of the general population. Cerebellar cavernous venous malformation accounts for 1.2–11.8% of intracranial cavernous venous malformation cases. Patients are commonly asymptomatic until a hemorrhage occurs. In approximately 20% of the cases, cavernous venous malformation and developmental venous anomalies occur together, called mixed vascular malformation. Our case report reveals the imaging features of the mixed vascular malformation and highlights the appropriate imaging modality and sequence to detect the abnormalities.We report the case of a 15-year-old Malay male, a healthy young male who presented with dizziness, vomiting, and mild headache for 1 month. Computed tomography brain imaging at presentation revealed cerebellar hemorrhage with multiple cavernous venous malformation and coexisting developmental venous anomalies, which was then confirmed by magnetic resonance imaging. The patient was started on dexamethasone 4 mg four times a day, observed in the ward, and discharged well without neurological sequelae.A cavernous malformation with concurrent developmental venous anomalies requires accurate diagnosis. Our case report contributes to the literature on the imaging diagnosis of this disease, which is beneficial for current and future reference. Cerebral venous malformations (CVM), is also known as cavernomas or cavernous hemangiomas, are not uncommon cerebral vascular malformations. According to Zyck and Gould , this vaMost of the time, cavernoma is diagnosed incidentally. However, sometimes, patients may present with headaches, seizures, focal neurological deficits, or intracranial hemorrhages . In a reMultiple modalities are available to diagnose CVM. The advancement of noninvasive imaging technology has facilitated the diagnosis of vascular malformation . AnotherA 15-year-old Malay male presented with dizziness and vomiting for 1 month associated with a mild headache. He sought medical attention at general practitioners a few times for persistent symptoms. Otherwise, he denied limb weakness, imbalance gait, seizure, blurred vision, and tinnitus. He is a well-performing student with no history of substance use or previous trauma. On examination, the patient achieved the maximum Glasgow coma scale (GCS) score with no focal neurological deficit.This patient presented to a district hospital in October 2018 with a terrible headache. Urgent computed tomography (CT) of the brain showed cerebellar hemorrhage with perilesional edema  Hospital and admitted to this unit for further management. Magnetic resonance imaging (MRI) of the brain performed 4 days later showed features of acute hemorrhage Fig. . NumerouCavernous venous malformation (CVM) occurs in different age groups, ranging from pediatric to elderly, with no gender predominance . CVM occThe typical presentation of CVM is seizure, progressive neurological deficits, hemorrhage, and headache. As many as 21% of the patients are asymptomatic. Seizure is the most common clinical presentation in most studies, while hemorrhage occurs in 10–23%.Imaging findings in CVM depend on the blood degradation product present in the lesion. CT is essential for initial imaging to identify intracranial hemorrhage. However, CT findings for cavernoma are nonspecific. Multiple studies have shown low specificity of CT scan for CVM diagnosis . MeanwhiCT brain plain typically demonstrates hyperdense and, less commonly, mixed hyperdense and hypodense lesions. The additional findings include intralesional calcification, poor contrast enhancement, and minimal mass effect. A round-shaped, well-defined margin and slightly uneven high density and absence of surrounding edema may also be features that indicate cavernoma. However, these findings are nonspecific, leading to difficulty in differentiating cavernoma and other lesions such as partially calcified avascular low-grade glioma .MRI is a modality of choice to diagnose cavernous malformation. This malformation demonstrates a characteristic “popcorn” or “mulberry” appearance with a rim of signal loss due to hemosiderin or ferritin rim. Typical CVM is a mixed-signal lesion because it contains blood products from different ages. Usually, CVM does not demonstrate mass effect except for rapid growth or intramural hemorrhage. This is due to the nature of this lesion, which is a type of benign vascular hamartoma. MRI T2-weighted images (T2WI) are sensitive and specific in diagnosing cavernous malformation .et al., in 1998, suggested a gradient-echo sequence to diagnose cavernoma owing to its high sensitivity, demonstrating more significant signal loss in CVMs, particularly on GRE sequence, compared with conventional SE sequence [et al. [et al. [On T1-weighted images (T1WI), MRI demonstrates variable signal intensity based on the age of blood products. This reflects the slow flow, stagnation, or thrombosis of varying stages. In addition, a low fluid–fluid level may be evident. On gradient-echo (GRE) sequence, blooming artifacts are more apparent. This sequence is beneficial in detecting small lesions missed by the conventional spin-echo (SE) sequence . Labauge [et al.  and Lehn [et al.  support A cavernous malformation is a slow-flow lesion, rendering it challenging to detect using conventional digital subtraction angiography (DSA). CVM has therefore classically been defined as angiographically occult vascular malformations. However, in conjunction with flat-panel technology, recent technology has allowed the combination of cone-beam CT (CBCT) and DSA. This combination of technology has produced a high-resolution CT-like reconstruction of datasets obtained by conventional DSA. In a case report produced by Radvany in 2015, this recent technology documented a CVM and its associated DVA in three patients .Mixed vascular malformations is a terminology used to describe concurrent CVMs and DVAs. This condition is observed in 20% of cases (range 2–40%) . CT and et al. [In a study by Hon et al. , most paet al. .Symptomatic CVMs with hemorrhage, edema, mass effect, and epilepsy may warrant surgery. Surgical management is currently indicated in cases of conspicuous bleeding for patients with neurological symptoms and intractable epilepsy. Surgeons need to know the presence of associated DVAs, since incorrect cauterization of the collecting vein may cause venous infarction .A cavernous malformation with concurrent DVA is an uncommon condition requiring accurate diagnosis. The management depends on number and location of cavernoma and hemorrhagic cases. The treating surgeon must be aware of the associated CVM and DVA as management may differ.


A 9-year-old boy with a 16 cm chest wall mass, presenting with progressive cough and exertional dyspnea, was finally diagnosed with Ewing sarcoma of the rib. Such massive tumors usually present with metastasis and carry a bad prognosis. Fortunately, we present here a successful treatment approach for Ewing sarcoma of the ribs, defeating the overwhelming obstacles commonly faced in chest wall tumors. Delays in diagnosis, misdiagnosis, difficulty with general anesthesia, opportunistic infections, disruptions in chemotherapy delivery, and debilitating chest wall deformities are all potential challenges that could complicate the course of treatment. Ewing sarcoma is the second most common primary bone malignancy in children and adolescents. Rib Ewing sarcoma accounts for 13.4% of the total cases. Approximately 20–25% of patients present with metastases at diagnosis and are often resistant to intensive therapy [A 9-year-old male presented to the emergency department with a 10-day history of progressive dry cough, chest pain, fatigue, and exertional dyspnea. Symptoms started one month prior to presentation when the patient suffered progressively exacerbating chest pain and cough, which became more prominent in the supine position. The symptoms have been severely aggravated in the last 10 days. Otherwise, the patient denied any change in appetite, fever, weight loss, headache, gastrointestinal symptoms, or urinary problems.Prior to his presentation to the emergency department at our institution, he was seen in another hospital where a chest X-ray showed an abnormal consolidation and pleural effusion in the right hemithorax. On presentation, he was afebrile (temperature 37.8°C), tachycardic (heart rate of 112 beats per minute), normotensive (126/76 mmHg), slightly tachypneic (respiratory rate of 27 breath/min), and saturating at 100% on room air.The physical exam was remarkable for the use of accessory muscles for breathing and decreased breath sounds on the right upper, middle, and lower fields. In addition, a palpable mass measuring around 3 cm in diameter was noted on the anterior right chest, associated with right-sided axillary lymphadenopathy. No other pertinent positives were detected.A CT chest with contrast was performed Figures  which shBased on the history, physical exam, and imaging results, the patient was admitted and a PET scan was performed . It reveThereafter, the decision was made to perform a CT-guided biopsy. The procedure was carried out under sedation, and 5 fragments of soft tissue measuring in aggregate 0.7 × 0.5 × 0.2 cm were submitted to the pathology lab.Histopathology revealed a small-blue-round cell tumor. Immunostaining was remarkable for positive synaptophysin, CD99, and FLI-1. The PAS and PASD stains highlighted the cytoplasmic glycogen. CKAE1/3, chromogranin, desmin, S100, MYOD1, Myogenin, CD45, and TdT were all negative. The pathology result was consistent with Ewing sarcoma. Accordingly, he was diagnosed with Ewing sarcoma of the chest wall, with staging of local disease.A solid tumor panel by molecular testing of RT-PCR was also taken, but the results could not be obtained urgently as they were not locally available and had to be sent to another country.Initially, the patient was planned for bilateral bone marrow aspirate and biopsy, and the insertion of a central line (Polysite). However, they could not be carried out due to the difficulty of general anesthesia at that time. Instead, central access was secured through a peripherally inserted central catheter (PICC) to start chemotherapy after obtaining a baseline echocardiogram. The patient was initiated on CHILDREN'S ONCOLOGY GROUP protocol AEWS0031, which consists of a total of 43 weeks of treatment. Chemotherapy consists of 14 cycles of chemotherapy: 6 cycles of induction, followed by 8 cycles of consolidation after local control through surgical excision or radiotherapy. Each cycle is over 14 days in length with an alternation between vincristine/cyclophosphamide/doxorubicin/GCSF (VDC) and ifosfamide/etoposide/GCSF (IE).Prevotella bivia. The patient was treated with meropenem, vancomycin, and amikacin for a total of 14 days. The patient also developed severe dermatitis over the site of the PICC line, which required line removal and treatment with clobetasol . The patient had to receive his second cycle of chemotherapy IE through a peripheral line.The treatment course was complicated by a perianal abscess after cycle 1 of VDC, managed by drainage. The culture remained negative, but 16S from abscess fluid disclosed After completion of the second cycle, the solid tumor panel resulted from molecular testing of RT-PCR confirmed the diagnosis. The patient's tissue cell lysate was positive for t  EWS/FLI-1/ERG fusion transcript.x AP x TR) decreased to a size of 6.5 × 8.9 × 4.1 cm in its maximum dimensions.A CT chest was obtained after the second cycle of chemotherapy, which showed a significant decrease  in the size of the enhancing pleural mass in the right hemithorax, with resolution of its mass effect on the adjacent cardio-mediastinal structures. The mass that was previously measuring 16 × 14 × 11 cm  inserted under general anesthesia. A bone marrow biopsy and aspirate were obtained and were negative for metastatic disease.The patient continued to receive the planned 6 cycles of induction chemotherapy, then local control by surgical resection was decided. The surgery involved the resection of part of the 5th rib, total resection of the 6th rib, right lower lobe wedge resection, and partial resection of the right middle lobe. In addition, two other pulmonary nodules were detected in the right middle lobe and were removed. Segmental lung resection had to be performed on the stuck right lower lobe, with pleurectomy as an en bloc with the whole specimen . No compOn gross examination, the tumor was exophytic in nature, going intrathoracically and definitely infiltrating the major fissure between the right middle lobe and right lower lobe and also stuck to the diaphragm. The tumor pathology revealed fibrosis and granulation tissue, which was consistent with the treatment effect. No viable residual tumor tissue was identified in the specimen or the lymph nodes.As the patient had an R0 resection with a complete response, and as per the recommendations, there was no indication for adjuvant radiotherapy. However, since he initially had a large lesion, with suspicious pleura involvement that was not sampled, and due to its location involving the chest wall, radiation therapy was opted for.The patient was started on radiotherapy 2 weeks following surgery and after securing proper healing of the chest wall scar. The patient received radiation for the whole involved lung with 15 Gy for 10 sessions, followed by a boost to the surgical bed to a dose of 50.4 in 1.8 Gy per fraction.The patient later continued his chemotherapy plan for a total of 43 weeks (14 cycles of chemotherapy).The CT chest and PET scan at the end of treatment confirmed complete remission. Currently, the patient has been in remission for more than one year without a relapse. The patient is being regularly followed up with an imaging evaluation every 3-4 months.Ewing sarcoma is the most common malignant chest wall tumor in children and adolescents. Indeed, more than 50% of the chest wall tumors are chondrosarcoma and Ewing sarcoma . ClinicaThe diagnosis of Ewing sarcoma among the chest wall tumors remains a challenging task. In addition, the dilemma of initiating the proper treatment can be time-consuming. Pleurisy, rib fracture, or muscle strain are the most common misdiagnosis of rib Ewing sarcoma . MisdiagInitiating chemotherapy before approaching local control with surgery or radiation is advisable. Indeed, delaying surgery is found to be correlated with higher rates of successful complete resection of the Ewing sarcoma . The decSeveral factors might complicate the course of treatment. Chemotherapy resistance is a major obstacle and is usually encountered with large tumors or in specific patients profiles . MoreoveA surgical approach with thoracoscopic guidance is another modality to avoid a lateral thoracotomy, thereby enhancing postoperative recovery and reducing pain. Resection of the anterior or lateral chest wall with more than 3 ribs is considered a critical choice as it might lead to a flail chest deformity and acute respiratory failure .In this case, the persistence of chest pain and the large mass were alarming signs, which were overlooked initially. Fortunately, he only exhibited localized disease without metastasis at presentation. A high index of suspicion and the prompt initiation of chemotherapy have been key aspects of his prognosis. Chest wall tumors commonly encounter difficulties in keeping the patient under general anesthesia and securing central access. Delivering chemotherapy through a peripherally inserted intravenous line was used to avoid delays. Abating the tumor size with chemotherapy cycles separated by 14 rather than 21 days hastened the reduction of the tumor size and facilitated R0 resection with fewer debilitating surgical consequences.


Synovial sarcomas (SS) are malignant tumors rarely arising in the head and neck region. In most of these cases, the tumor arises in the cervical or hypopharyngeal region, and extremely rarely in the oropharynx.Herein, we report the case of a 22-year-old male oropharyngeal SS patient presented with breathing difficulty and dysphagia. The management plan included an emergency tracheostomy, followed shortly by transcervical resection of the oropharyngeal sarcoma tumor, the pectoralis major myocutaneous flap was used for pharyngeal reconstruction, followed by adjuvant radiotherapy resulting in more than 5 years disease-free survival.SS arising in the oropharynx are extremely rare. Transcervical resection coupled with adjuvant radiotherapy warrants enhanced locoregional control in advanced oropharyngeal cases. Synovial sarcomas rarely arise in the head and neck region, specifically in the oropharynx. We report a case of an oropharyngeal synovial sarcoma patient that was presented with breathing difficulty and dysphagia. The patient underwent tracheostomy followed shortly by resection of the oropharyngeal sarcoma tumor, pectoralis major myocutaneous flap was used for pharyngeal reconstruction followed by adjuvant radiotherapy resulting in more than 5 years disease-free survival which confirms the effectiveness of such modalities in permitting locoregional control. Synovial Sarcoma (SS) is a rare malignant tumor commonly occurring in younger adults that accounts for almost 5–10% of soft tissue sarcomas . ApproxiHere, we describe a rare case of surgically treated left oropharyngeal SS being the first reported in the middle east region. Clinical presentation, imaging, surgical approach and histologic features of the tumor are outlined in this report in compliance with the CARE guidelines .A previously healthy 22-year-old male, engineering student was referred to our cancer center with progressive breathing difficulties, dysphagia and weight loss. The patient never smoked and has no family history of malignancies. On initial assessment, the patient was found to have a large left oropharyngeal mass that markedly compromised the airway. Once the airway was secured by tracheostomy performed under local anesthesia, a thorough exam of the pharynx revealed a large left oropharyngeal tumor that extended from the left lower pole of the palatine tonsil down to the hypopharynx inferiorly. Biopsy confirmed the diagnosis of SS.Histologic features included monophasic mesenchymal proliferation composed mainly of uniform spindle cells consistent with SS. Tumor cells were positive for CD99, BCL-2, TLE-1, CD56, Nestin and SS18 rearrangement was identified  & 2. DueImaging included neck MRI and PET CT scans. A large left oropharyngeal tumor extending from the lower end of the left palatine tonsil to the junction with the hypopharynx. No regional lymph nodes or distant metastasis were identified, After discussing the case in our multidisciplinary team meeting, surgical resection was advised. A transcervical approach to the left oropharynx was performed. The procedure involved a transverse cervical incision raising subplatysmal flaps. The intermediate tendon of the digastric muscle was identified and divided. The hypoglossal nerve was mobilized and preserved. Left wide pharyngotomy provided great access to the tumor. This enabled good resection with margins kept under direct vision throughout the procedure. Left palatine tonsil and left half of hyoid bone were included in the resected specimen and found later to be infiltrated by malignant sarcoma cells.At the end of the tumor resection, it was concluded that the residual pharyngeal mucosa was not sufficient for primary closure and therefore skin in the form of pectoralis major myocutaneous flap was used to reconstruct the defect. Nasogastric tube feeding used for one week until a gastrografin study showed no leak from the pharynx. Oral feeding gradually resumed with the help of the speech and language therapy team. The patient was discharged home on day 14 postoperatively. Our multidisciplinary team recommended adjuvant radiotherapy (RT), as the pathology of the specimen showed a positive margin near the hyoid bone area.RT was started 5 weeks after surgery. The intensity modulated RT technique was used to deliver 66 Gy over 33 fractions. The high risk clinical target volume (CTV66) was generated by expanding the resected primary gross tumor volume on fused preoperative staging CT scan with a 15 mm margin in superior-inferior direction and 10 mm margin in all other directions, with exclusion of any tissues not at risk for microscopic spread . The low risk CTV56 was generated by expanding the resected gross tumor volume on fused preoperative staging CT scan with a 35 mm superior inferior direction and 15 mm margin in all other directions, including surgical flap, scar and postoperative changes and excluding any tissue not at risk for microscopic disease. No elective RT to the neck nodes was administered. To create planning target volumes (PTVs), CTVs were given a uniform set up margin of 5 mm. The PTV66 and PTV56 volumes were 462 and 950cc, respectively. Target volume coverage and dose constraints for organs at risk were achieved. The treatment was guided by daily bone match cone beam CT image guidance and was well tolerated by the patient.The tracheostomy tube was removed after the conclusion of RT. Interestingly fiberoptic laryngoscopy has shown metaplasia of the skin used in reconstructing the pharyngeal defect to mucosa like appearance after the first year. Regular follow-up by clinical examination and imaging has not shown any local recurrence or distant metastasis over 5 years of follow-up .SS is a high-grade aggressive sarcoma that rarely arises in the head and neck region . It is mPharyngeal SS can be asymptomatic until attaining a large enough size to cause mass effects on surrounding structures leading to serious symptoms like breathing difficulties and dysphagia. In our case, the diagnosis was delayed as the patient only presented after breathing difficulties and dysphagia occurred. CT or MRI remain the primary cross-sectional imaging technique of choice to assess the size of the tumor and regional lymph nodes involvement prior to planning surgical resection. In regards to the histological type, previous studies have shown no significant difference in clinical outcomes between the biphasic and monophasic variants .Adequate surgical resection remains the best treatment option. This can be challenging to achieve in the complex anatomy of the head and neck region. Inadequate transoral wide local excision is followed by high recurrence rates . In thisHead and neck surgeons familiar with the transcervical approach to tongue base tumors will have no difficulty in applying this knowledge to such cases. Other minimally invasive procedures such as the transoral robotic approach have been used and showed favorable outcomes in experienced hands in less advanced tumors . In the The role of radiotherapy with or without chemotherapy remains unclear as previous literature on this topic is scarce. However, some studies have recommended using adjuvant radiotherapy in certain unfavorable pathological features, these include positive margins and larger tumor size as in our case . AlthougSS of the oropharynx is extremely rare. Most pharyngeal SS tend to affect the hypopharynx. Only a few cases are reported in the literature describing the oropharyngeal location. Complete surgical resection is the treatment of choice. We found that using the transcervical approach improves the adequacy of the surgical resection and provides better locoregional control. Adjuvant radiotherapy is recommended in advanced cases or in unfavorable pathological outcomes. This treatment plan was effective in our case resulting in 5 years disease-free survival.Synovial sarcomas arising in the oropharynx are extremely rare. The management of such cases is poorly discussed in the literature.Complete transcervical resection is the treatment of choice as it provides direct visualization of surgical resection margins enabling for better locoregional control.Adjuvant radiotherapy is recommended in advanced cases or in unfavorable pathological outcomes.


The discovery of a mediastinal mass presents a wide array of differential diagnoses which largely depends on the boundaries of the mass and its contents. Both computed tomography (CT) and magnetic resonance imaging (MRI) of the chest can determine radiologic compartmentalization to aid in diagnosis. Tissue biopsy for pathology, however, is necessary for final diagnosis. The establishment of a diagnosis should not be delayed, as mediastinal mass may be due to serious causes such as malignancy or infection. Here, we present a rare case of a 72-year-old male with a mediastinal mass that formed as a complication of traumatic esophageal perforation during cardiac arrest. Pathology revealed foreign plant material with granuloma formation secondary to food residue as the etiology of the mass. Diagnosis of a mediastinal mass can present a challenging feat. Thymoma, teratoma, thyroid goiter, and lymphoma are common causes; however, the differential diagnosis is quite broad . DetermiDespite being relatively uncommon, esophageal perforation carries high morbidity and mortality that can reach up to 40% . The symA 72-year-old male with a past medical history significant for hypertension, gastroesophageal reflux disease, and nutcracker esophagus presented to the emergency department (ED) with a chief complaint of chest pain. He had a recent history of cardiac arrest post a choking episode two months earlier. He underwent chest CT at that time, which showed pneumomediastinum and pneumothorax with left lobar pneumonia and left-sided pleural effusion. He underwent thoracotomy and laparotomy with the repair of lower esophageal rupture. The empyema was drained, and food material was recovered from both the mediastinum and pleural cavity during surgery. A gastrostomy tube was placed for nutrition. He was treated with multiple courses of intravenous antibiotics. He recovered well and was discharged to a rehabilitation facility.Two months later, the patient returned to the ED with chest pain. He described the pain as sharp and pleuritic, located at the left posterior chest wall with local tenderness to palpation. He denied fever, chills, shortness of breath, cough, weight loss, or night sweats. Physical examination was remarkable for tenderness at the left lower posterior chest. His incision site was well-healed. He was afebrile and hemodynamically stable. Initial laboratory studies did not reveal any abnormalities. He underwent a chest CT without contrast that showed left lateral mildly displaced subacute fifth through ninth rib fractures, as well as an unexpected new soft tissue mass in the anterior mediastinum measuring 2.2 x 1.7 x 4.5 cm as shown in Figures Candida albicans. Gross examination of the aspirate showed partially necrotic plant material associated with reactive fibrous tissue with infiltrates of chronic inflammatory cells. Pathology showed extensive necrosis with chronic inflammation, giant cells, and plant foreign material with a granulomatous reaction that represented food residues (Figures Initially, the patient was treated with broad-spectrum antibiotics. He did not improve; therefore, a CT-guided aspiration of the mass was performed. No significant lymphoid immunophenotypic abnormalities appeared on flow cytometry. The sample was predominantly granulocytic cells with very few lymphocytes detected. Cultures grew  Figures , 3. Groc Figures . The patEsophageal perforation is a fatal condition if not diagnosed in a timely manner. It carries high morbidity and mortality. With iatrogenic perforation secondary to endoscopy and luminal narrowing being the most common, other etiologies also include spontaneous trauma and caustic substance ingestion ,4. AlthoThe most common cause of death in patients with esophageal rupture is sepsis leading to multiorgan failure; the most frequently reported complications include persistent leak, fistula formation, mediastinitis, empyema, esophageal stricture, pneumonia, abscess, mediastinitis, and sepsis -11. No dIt is highly unusual for food to travel to the anterior mediastinum rather than remain close to the esophagus. This is thought to be due to chronic inflammation and organization leading to anterior migration of the granuloma or less likely secondary to food escaping during surgery to the anterior part of the chest. Upon a review of medical literature, reported esophageal repair complications included persistent leakage, prolonged mechanical ventilation, pneumonia, arrhythmia, status asthmaticus, and empyema . MediastThis case represents a novel etiology of anterior mediastinal mass as well as an unusual presentation of delayed complications of esophageal perforation. The plant foreign material originated from food that escaped from the perforated esophagus either during cardiac arrest or during the surgical esophageal repair. It is not well understood if the granuloma migrated or originated in the anterior mediastinum. Health care providers should always consider the less common causes of mediastinal masses, especially if patients do not improve with treatment. Thorough patient history is essential, as recent esophageal intervention can be a key factor in the differential diagnosis of mediastinal mass.


The authors have declared no conflicting interests.All procedures adopted in the present study were in respect to the ethical standards in the World Medical Association Declaration of Helsinki. The subject gave his written informed consent to publish the present case (including publication of the image).Dear Editor,Eosinophilic angiocentric fibrosis (EAF) is a rare, idiopathic fibroinflammatory disease usually involving upper airways, nasal cavity, paranasal sinuses, and rarely the orbit. The most common presentation is a nasal mass with prolonged obstructive symptoms.Herein we report the case of a 46‐year‐old man showing a destructive lesion of upper lip, nasal cavity, and cleft palate. His medical history was positive for chronic cocaine abuse and plaque psoriasis not controlled by topical treatment. At the first examination, the patient showed an exuding‐destructive lesion involving upper‐lip, the nasal‐choanae and hard‐palate, with local edema and speech impairment Figure . PatientAlthough in literature several cases of EAF have been described,


Postoperative hematoma and seroma, foreign body reaction, infection, mesh rejection, and fistula formation are the complications associated with the use of surgical mesh. Mesh migration is a rare but serious and challenging complication after hernia repair. When this happens, infection, abscess, fistula, and bowel obstruction are the most common sequelae.Our patient was a 62-year-old woman with a history of appendectomy 30 years ago and then underwent 3 incisional hernia repair surgeries which the last one was 5 years ago using laparoscopic IPOM. The patient was nominated for surgery with a diagnosis of recurrent incisional hernia. The patient underwent laparotomy and after enterolysis, a small bowel loop was seen that adhered to McBurney's region, which was released. There was a mass inside the small bowel. Resection and anastomosis of the involved intestine were performed. After enterotomy, it was determined that this mass was the mesh used in the previous surgery. Mesh migration is a rare consequence of incisional hernia repair with a prosthetic mesh. It can happen years after a hernia repair and it is additionally crucial to consider as a differential diagnosis in all patients who show unusual symptoms or abdominal pain. The most common complication of abdominal surgery is an incisional hernia, which affects approximately 10-15% of patients. The recurrence rate after the anatomic repair is almost 20-45 %. Prosthetic surgery has dramatically reduced the recurrence rate from 50% to 10%–20% . Using sThe patient was a 62-year-old woman referred to the General Surgery Department due to the protrusion and bulging on the appendectomy incision. She had a history of appendectomy 30 years ago and then underwent 3 incisional hernia repair surgeries in which the last one was 5 years ago using laparoscopic IPOM.Over the years, the patient has had no symptoms and signs of bowel obstruction and has only complained of chronic intermittent abdominal pain. On physical examination, there was only one bulging on the McBurney incision. All lab tests were unremarkable. CT scan of the abdomen and pelvis confirmed incisional hernia. The patient was nominated for surgery and underwent laparotomy after general anesthesia. After enterolysis and intestinal adhesions removal, a small bowel loop that adhered to McBurney's region was released. There was a mass inside the small intestine. In the surrounding area, there was no sign of an abscess, fistula, or sinus formation. Resection and anastomosis of the involved intestine were performed. After enterotomy, it was determined that this mass was the mesh used in the previous surgery . The patWhile the incidence of recurrence of incisional hernias after the simple sutured repair is more than 60%, applying mesh reduced the recurrence rate to around 30%. Mesh repair is especially crucial for incisional hernias more than 4 cm in diameter because the risk of bigger hernia recurrence is likely related to the tension imposed on the repair .Theodor Billroth proposed in 1890 that using a prosthetic material to close the hernia defect was the best technique to repair hernias. Surgeons now believe that using a prosthetic mesh to repair hernias is the best option. Composite meshes are divided into two types: absorbable and permanent (non-absorbable). Absorbable composite meshes which must be hydrated before use, are not modifiable and can affect the success of tissue ingrowth which is ideal to minimize probable complications. Permanent composite meshes can be customized to fit a variety of applications and have less visceral adhesions and problems. Even though surgical meshes reduce recurrence rates, they have side effects such as infection, adhesion, and bowel obstruction .The cause of mesh migration is not yet known. A primary mechanical migration and a secondary migration are two separate mechanisms that have been proposed. One reason for mesh migration in adjacent anatomical areas might be an insufficient fixation on the fascia or improper stabilization by external forces. Later on, the mesh may dissolve into the surrounding tissue. Secondary migration may also occur through trans-anatomical planes as a result of the foreign body reaction ,5. AnothThe first case of mesh migration after incisional hernia surgery was described by Herrera et al. Both composite and no absorbable mesh migrations have been reported in the literature, but it is invariably linked with clinical signs and symptoms such as abscess formation, enterocutaneous fistula formation, or intestinal obstruction . The uniNot only complications following mesh contamination depend on traits of mesh-like material, pore size, filament structure, and coating, but also a surgical method like the plane of mesh placement, sort of fixation, tissue handling must be considered. Patient bad dietary habits and concurrent enterotomy along with mesh used during hernia repair also can accelerate the mesh contamination possibility , 7.Suture fixation is 93% less likely to have complications, but this is not statistically significant. It has been advised that suture fixation might also additionally increase the hazard of post-operative pain, wound contamination, and operating time. Also, regular utilization of absorbable tack quotes decreased post-operative pain and seroma formation . One of Radiologists, who are usually concerned at the beginning and throughout a patient's hospital stay, ought to be suspicious of findings suggesting migrated mesh. Surgical staples in unusual locations as well as abnormal configurations ought to be investigated immediately via CT to gauge for mesh-related pathology, and notably intra-luminal migration. Many synthetic and biologic meshes are difficult to see on CT. Therefore, secondary findings of mesh migration such as mural inflammation, abnormal bowel course or contour, an unusual appearance of bowel contents, as well as, ectopic staples should prompt radiologists to consider intraluminal migration . AlthougIn conclusion mesh migration is a rare consequence of incisional hernia repair with a prosthetic mesh. It can happen years after a hernia repair and it is additionally crucial to consider as a differential diagnosis in all patients who show unusual symptoms or abdominal pain. The results of mesh migration are serious and may require surgical intervention. For these reasons, we suggest surgeons include mesh migration and its potential complications during the consent process.


Here, we report on a patient with a multilocal recurrent atypical meningioma, in which 68Ga-DOTATATE PET was considerably helpful for treatment guidance and decision-making.Currently, contrast-enhanced MRI is the method of choice for treatment planning and follow-up in patients with meningioma. However, positron emission tomography (PET) imaging of somatostatin receptor subtype 2 (SSTR2) expression using  SSTRDOTATATE . PositroDOTATATE . In prevDOTATATE –16. ThesDOTATATE , 17.68Ga-DOTATATE PET was considerably helpful for treatment guidance and decision-making.Here, we report on a case of a patient with a complex multimodally treated recurrent atypical meningioma in which A 63-year-old man presented with progressive mental alterations and mild left-sided hemiparesis. MRI revealed a large (5.5 cm × 7.0 cm) contrast-enhancing lesion in the right frontal lobe with attachment to the dura, suggestive of a meningioma, with a distinctive perifocal edema and midline shift of 11 mm Figure 1Two days after surgery, revision surgery due to a space-occupying subdural hematoma and, in the further course, a second revision surgery with removal of the bone flap for postoperative infection were necessary. The patient recovered well and was discharged with a mild left-sided hemiparesis for rehabilitation. The neuropathological analysis demonstrated an atypical meningioma WHO grade 2 according to the fifth edition of the WHO Classification of Tumors of the Central Nervous System (CNS) published in 2021. After implantation of an autologous cranioplasty 3 months later, the patient was followed up with MRI scans every 6 months according to the current guidelines .68Ga-DOTATATE PET scan was performed, showing increased tracer uptake in the right temporopolar region and in the right frontal area of the lesion previously treated with SRS. In contrast to MRI, 68Ga-DOTATATE PET revealed an additional distant small dural and intraosseous right frontopolar lesion   and remained stable in the following scans. Forty-eight months after initial diagnosis, follow-up MRI showed a new contrast-enhancing right temporopolar lesion, suggestive of a distant meningioma relapse. To exclude further lesions, a r lesion Figure 268Ga-DOTATATE PET after 12 months in accordance with the MRI showed a favorable treatment response without any tracer uptake.The patient tolerated the surgery and radiation procedures well without further neurological and cognitive impairment. In the follow-up MRI scans every 6 months, the irradiated frontopolar lesion was stable. There was no evidence of tumor recurrence. A follow-up 68Ga-DOTATATE PET shows higher sensitivity and improved delineation of meningiomas, especially for those located at the skull base, adjacent to the falx cerebri, and tumors with bony infiltration, compared to conventional MRI  and 3  meningiomas are particularly difficult to treat . They teonal MRI . Accordir growth , 24. Thu68Ga-DOTATATE uptake on PET. However, there was no difference in the immunohistochemical grade of SSTR2 expression in tumor samples at initial diagnosis and in recurrent tumors. In that study, a threshold of 2.3 for the maximum standardized uptake value (SUVmax) was able to discriminate between tumor and non-tumor tissue . Three of the analyzed recurrent tumors were previously irradiated. Nevertheless, no information was provided about the SUVmax in these cases  in the PET scan 19 months after radiation, even though no difference in the SSTR2 expression was detectable by immunohistochemical analysis.Regarding the quantitative correlation of SSTR2 expression and PET tracer uptake, Rachinger et al.  analyzedse cases . In our 68Ga-DOTATATE PET 12 months after revision surgery and fractionated radiotherapy of the resection cavity and frontopolar lesion revealed no further tracer uptake in the irradiated areas. A possible reason may be the differences in the delivered radiation dose (16 Gy vs. 59.6 Gy), resulting in a lower biological equivalent dose of approximately 41.6 Gy for radiosurgery compared to approximately 79.3 Gy for fractionated radiotherapy. Up to now, there are no data in the literature on changes in SSTR2 expression grade and SUVmax in 68Ga-DOTATATE PET after fractional radiotherapy or radiosurgery. This will be a challenge for the near future.Interestingly, the follow-up 68Ga-DOTATATE PET is of considerable value for treatment decision-making in patients with recurrent and atypical meningiomas, especially with bony involvement, which have a high risk of recurrence. More data need to be collected regarding the correlation of SSTR2 expression and tracer uptake in previously irradiated tumors, which would allow more insight in radiation biology.The present case report suggests that The original contributions presented in the study are included in the article/supplementary material. Further inquiries can be directed to the corresponding author.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.Data acquisition: A-KM, RG, AB, AA, DR. Writing of manuscript drafts: AM, NG, RG, MR, DR. All authors contributed to the article and approved the submitted version.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.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Intramedullary spinal cord metastasis (ISCM) of malignant tumors rarely happens. To the best of our knowledge, only five cases of ISCM from esophageal cancer have been reported in literature. We here report the sixth descripted case of ISCM from esophageal cancer.A 68-year-old male presented with weakness of right limbs and localized neck pain two years after diagnosed esophageal squamous cell carcinoma. The gadolinium enhanced Magnetic resonance imaging (MRI) of cervical spine showed a mixed-intense intramedullary tumor with typical more intense thin rim of peripheral enhancement in C4-C5. The patient died fifteen days after diagnosis of irreversible respiratory and circulatory failures. An autopsy was refused by his family.This case highlights the importance of gadolinium enhanced MRI for diagnosis in ISCM. We believe that early diagnosis and surgery for selected patients shows helpfulness to save their neurologic function and improve quality of life.The online version contains supplementary material available at 10.1186/s12883-023-03147-0. Intramedullary spinal cord metastases (ISCMs) have very low incidence of only 8,5% among central nervous system metastases and nearly 3.5% of all spinal metastases –3. They A 68-year-old male presented localized pain of neck and ingravescent weakness in his right limbs for weeks in October 2019. This patient was diagnosed with esophageal squamous cell carcinoma in November 2017 by upper gastrointestinal endoscopy and received concurrent radiotherapy and chemotherapy for 34 times until March 2018. Paclitaxel and carboplatin were planned to be used. Between May 2018 and August 2019, the reexamination showed pulmonary and hepatic metastases. He underwent two times of docetaxel and six times of 5-fluorouracil and cisplatin accompany with 15 times of lung radiotherapy.Motor power of right upper limb is grade III, and grade II of right lower limb according to the British Medical Council grading system. The shallow sensation of the right side was weaker with no accurate sensory level. His bilateral patellar and ankle clonus and Babinski sign were positive. The power of his left limbs was nearly normal.On day 2 of admission, the patient had difficulty urinating, numbness in the perineal area. Dyspnea was observed on that night. He was transferred to ICU for monitoring and life supports.Between day 2 and day 5, respiratory rate and blood pressure fluctuations prevented the transfer to an MRI unit.On day 5, his vital signs were stable but neurologic function worsened. Reexamination demonstrated the motion of right lower limb was lost at grade I and grade III of the left. His shallow sensation decreased below the T6 level on the left and below T10 level on the right. Blood tests, head MRI and regular cervical spine MRI were completed. No sign of infection was observed. The CEA (carcinoembryonic antigen) level was 6.92ng/ml ; and the NSE (neuron specific enolase) level was 32.4ng/ml . Head MRI indicated metastases in the left temporal lobe and the right parietal lobe, but respective locations had no connection with any of the neurologic deficits. T2-weight imaging of the cervical spine demonstrated a hypo-isointense area in C4-5 with fusiform high intense of the surrounding spinal cord  examination and an enhanced cervical MRI was performed. There was no obvious abnormality in CSF examination, except for the mild elevation of glucose  and protein . However, a 26 mm*10mm*15mm intramedullary patchy intense tumor was found in C4-5 levels, surrounded by a more intense thin rim of peripheral enhancement in post-gadolinium T1 weighted MR images , and she was the only patient diagnosed within thoracic segment. The onset showed up variedly between 1 month to 2 years after primary cancer diagnosis. All the patients had enhanced-MRI examination and 80% of the patients(n = 4) were diagnosed based on the imaging. Brain metastasis appeared in 60% of the patients. Paralysis was observed in all patients, while most patients also suffered from urinating issues. Respiratory failure happened in two patients. Two patients underwent surgical resections and both had improvement in neurological function after surgery. Four patients that received radiotherapy and had follow-up records ended up dead within 3 months.Intramedullary spinal cord metastases (ISCMs) are uncommonly observed. It is estimated at autopsy of 0.9–2.1% in patients with cancer , 11. TheThree different routes of dissemination were hypothesized: hematogenous spread, meningeal carcinomatosis, and direct invasion. The most accepted is hematogenous spread which can explain why the metastasis may occur at any level of the spinal cord. Patients with ISCMs usually have a high rate of lung and intracranial metastases . This thWeakness is the most common clinical symptom of ISCMs, while localized pain in back or neck, extremity pain, sensory loss, urinary incontinence, and Brown-Sequard syndrome are the other developments, 12, 13.The diagnosis of ISCMs mainly depends on the patient’s previous history and imaging findings. Gadolinium enhanced MR imaging is considered to be the most sensitive method to diagnose ISCM. Rykken et al. reported 2 enhancement features on MR imaging: a more intense thin rim of peripheral enhancement around an enhancing lesion (rim sign) and an ill-defined flame shaped region of enhancement at the superior/inferior margins (flame sign) . It stroFDG-PET scan is considered to be useful in showing metabolic activities , 13. AltThe presence of ISCM usually indicates high malignancy and poor prognosis. According to Goyal et al., the median survival of patients with ISCM was only 3.6 months. Age, sex, type of primary malignancy and the presence of brain or other systemic metastases did not influence survival , 18. SciIn conclusion, ISCM is an infrequent, deteriorating complication of malignancy. Early gadolinium enhanced MR imaging is particularly valuable for diagnosis of ISCM. Surgery seems to be helpful to save neurologic function and improve quality of life.Additional file 1.


Sigmoid volvulus and small bowel obstruction are typically thought to be separate clinical pathologies with distinct clinical features, diagnostic criteria, and treatment strategies. We present a rare case of simultaneous sigmoid volvulus and small bowel obstruction. To our knowledge, this is the first such case in literature and presented a unique set of challenges in regard to treatment and management. This case discusses a different approach to the surgical management of sigmoid volvulus and small bowel obstruction, which is markedly different from the expected and traditional surgical management of isolated sigmoid volvulus and small bowel obstruction. Sigmoid volvulusSigmoid volvulus occurs when the sigmoid colon twists on itself, which can lead to large bowel obstruction and sigmoid colon ischemia . ObstrucDiagnostically, sigmoid volvulus can be identified by a classical “coffee-bean” sign on a plain abdominal X-ray . Other iTreatment of sigmoid volvulus is often achieved by flexible sigmoidoscopy detorsion, a Hartmann’s procedure, or resection with primary anastomosis, based on surgeon preference and clinical eligibility.In patients who are hemodynamically stable and at high risk for surgical complications, sigmoid volvulus can be treated with flexible sigmoidoscopy; however, a study conducted by Ballantyne et al. demonstrated a 50% recurrence in sigmoid volvulus following flexible sigmoidoscopy detorsion [In patients with signs of peritonitis or perforation, detorsion of the volvulus can lead to reperfusion injury . ConsequSmall bowel obstructionSmall bowel obstruction (SBO) is a common surgical emergency that can be caused by a multitude of etiologies. The most common cause of SBO in developed countries is intra-abdominal adhesions. Other common etiologies include incarcerated hernias, malignancy, inflammatory bowel disease, stool impaction, foreign bodies, and volvulus.Diagnostically, the hallmark of a SBO is dilation of the small bowel, proximal to the site of obstruction, with decompression of the distal bowel with plain radiograph and/or CT imaging of the abdomen . The extInitial management of SBO includes fluid resuscitation, pain control, antibiotics, and nasogastric (NG) decompression . In someAn 81-year-old black male with a past medical history of seizures, hypertension, asthma, unspecified psychiatric disorder, and dementia presented to the Emergency Department at Larkin Community Hospital in Miami, Florida via ambulance for abdominal pain, diarrhea, and vomiting.He is a resident of an assisted living facility (ALF). He reports his symptoms started earlier the same day and rated the abdominal pain a six out of 10. He had approximately three episodes of non-bloody diarrhea but denied having any fever, cough, shortness of breath, chest pain, heart palpitations, or urinary symptoms. Physical examination was notable for abdominal distension, tenderness to deep palpation, and hypoactive bowel sounds with auscultation. There was no hepatomegaly or splenomegaly noted. Additionally, the CT scan of the abdomen revealed a possible bowel obstruction and a sigmoid volvulus.A small bowel series was performed and revealed delayed transit of contrast through the small bowel and dilated loops of the large bowel without enteric contrast, which was concerning for obstruction. Plain radiographs of the upper and lower abdomen prior to the administration of oral contrast can be seen in Figure At the 1 minute mark Figure , opacifiAt the four-hour mark, enteric contrast is noted within the mid to distal small bowel Figure , with diThe patient was subsequently diagnosed in the emergency department with small bowel obstruction (SBO) and lactic acidemia Table . He was The following morning, he continued to have abdominal distention and a high NG tube output. An emergent exploratory laparotomy was scheduled for lysis of adhesions and possible bowel resection.Physical examGeneral: The patient was awake and alert, with no apparent distress.Cardiovascular: S1 and S2 heart sound present, regular rate and rhythm, with no palpable heaves, thrills, or lifts. Pulses were normal, and the blood pressure did not differ substantially between the two arms or between the two legs. No notable edema. No jugular vein distension.Respiratory: Lungs were clear to auscultation, bilaterally, with bilateral symmetric chest expansion. No Ronchi, rales, or wheezing. No use of accessory muscles, no grunting, no evidence of nasal flaring, no paradoxical movements, no prolonged exhalations or shallow respirations, no pursed lip breathing, no costal retractions, and no tachypnea.Abdominal/GI: Surgical scar present approximately 10cm, midline. Physical examination was notable for abdominal distension, tenderness to deep palpation, and hypoactive bowel sounds with auscultation. There was no hepatomegaly or splenomegaly noted. Differential diagnosisThe diagnosis of small bowel obstruction, secondary to abdominal adhesions, was high on the list of differential diagnoses based on the clinical presentation and previous abdominal scar; however, several aspects of the patient’s past medical history and clinical presentation still provided a few other diagnoses to consider. Factors that were considered for other diagnoses are listed below Table . NonethePreoperative diagnosisSimultaneous small bowel obstruction, secondary to abdominal adhesions with sigmoid volvulusDiscussion of preoperative managementIn regards to the patient’s SBO, his persistent signs and symptoms, despite adequate intravenous fluids, antibiotics, and adequate pain control, warranted continued consideration for surgical management. Ultimately, the high NG tube output of approximately 1,000mL of bowel contents was one of the final factors that indicated surgical management of his SBO. The plan was to perform a small bowel resection with primary anastomosis.In regards to his sigmoid volvulus, the signs of peritonitis associated with sigmoid volvulus and lactic acidosis indicated the likely surgical procedure for this patient to be Hartmann’s procedure.After consent was obtained for exploratory laparotomy with lysis of adhesions and possible bowel resection and colostomy, he was kept NPO, and a type and screen were performed. Preoperative antibiotics were administered in the form of 1 gram of intravenous Rocephin. Due to his presentation and urgency for surgical management, preoperative oral laxatives for bowel preparation were not achieved.Discussion of surgical managementUpon exploration, the patient was confirmed to have evidence of both small and large bowel obstruction, as well as sigmoid volvulus. Extensive adhesions, a small bowel stricture, and two abdominal foreign bodies were also found. During the operation, dissection of the adhesions occupied approximately 66% of the total operative time.Sigmoid VolvulusFollowing adhesion dissection, the sigmoid colon was found to be volvulus around the inferior mesenteric artery, torsed twice. After the detorsion of the sigmoid volvulus, it was tested for viability. Although there was significant enlargement and dilation of the proximal and distal segments of the sigmoid colon to the volvulus, there was no evidence of colonic ischemia, perforation, or gangrene necrosis. There was also no sign of stricture or tumor distally at the rectum or proximal to the volvulus. The sigmoid volvulus was resolved, and a sigmoidectomy with primary side-to-side and functional end-to-end anastomosis was performed. The mesentery was layered on top of the anastomosis to improve healing.Following the resolution of the sigmoid volvulus and subsequent sigmoidectomy, we ran the bowel for other pathologies. While running the bowel, we encountered multiple areas of adhesions, which were carefully lysed with a combination of blunt dissection, finger dissection, and sharp dissection using Bovie, Metzenbaum scissors, and the Harmonic scalpel. Upon reaching the ileum, we found evidence of a previous anastomosis, approximately 10 cm in length, which was created in an antiperistaltic fashion. We also discovered a stricture and two blind ending loops at this location.Small Bowel ObstructionWhile observing the peristalsis of the succus when running the bowel, we found an area of stricture at the distal jejunum and ileum, along with difficulty for the succus to pass through distally into the cecum and ascending colon. This stricture, which was caused primarily by the antiperistaltic segment, was noted to be the cause of the SBO, and we also identified two small perforations in the jejunum. We decided it was in his best interest to resect this portion of the small bowel. We started the bowel resection at the previous ileal anastomosis. Small bowel resection was performed with primary side-to-side, and functional end-to-end anastomosis was performed. The mesentery was then approximated and sutured to avoid internal herniation.Abdominal AdhesionsWe then turned our attention to the adhesions of the abdominal wall. Upon debridement of the abdominal wall, we discovered two foreign bodies that were hard and topically ossified. The foreign bodies were resected and sent to pathology.ClosingWe confirmed, through manual palpation, placement of the NG tube in the stomach. We placed a Jackson-Pratt (JP) drain in the pelvis to protect the sigmoid anastomosis. After adequate irrigation of the abdomen and confirmation that there was no bleeding, the abdominal fascia was closed. The subcutaneous tissue was irrigated, and the skin was closed with staples. The abdomen was cleaned and sterile dressings and an abdominal binder were applied.Postoperative diagnosesFollowing completion of the surgery, the patient's final diagnoses included: an acute abdomen, complete small and large bowel obstruction, sigmoid volvulus, extensive adhesions, small-bowel stricture, and removal of two abdominal foreign bodies.Challenges to this caseBowel PreparationTypically, the common practices for bowel preparation include oral laxatives, preoperative oral antibiotics, and intravenous antibiotic prophylaxis. Due to the patient’s acute presentation, we were unable to perform adequate bowel preparation for surgery. Although preoperative antibiotics were given, we were unable to administer any laxatives to evacuate the bowel in preparation for surgery.In a retrospective study conducted by Shahmoradi et. al, researchers concluded there was no significant difference in mortality, anastomosis leakage, prolonged ileus, bleeding, surgical site infection, or fascial dehiscence in an unprepped bowel between a Hartmann’s procedure and primary anastomosis . ConsequSmall Bowel Obstruction (SBO)Small bowel obstructions are commonly caused by scar tissue or adhesions, hernias, or cancer. During the procedure, we discovered evidence of previous abdominal surgery and anastomosis while running the bowel. Specifically, we identified an antiperistaltic segment of the bowel at the distal jejunum and ileum where the previous anastomosis had been performed. We believed this to be the most likely cause of SBO. However, we were unable to rule out other possible causes of SBO, such as adhesions or even the sigmoid volvulus.Since this is the first case in the literature of a patient with simultaneous small bowel obstruction and sigmoid volvulus, although we highly suspect the antiperistaltic segment to be the primary cause of SBO, it is still worth noting that the SBO could have been caused by either the antiperistaltic segment and the sigmoid volvulus, or both simultaneously.Before surgery, we attempted to conservatively manage his SBO, which involved NG tube placement. NG tube placement allows for the small bowel to rest, return to normal size, and hopefully resolve any obstructions that may be caused by adhesions from the previous surgery . HoweverTraditionally, surgical management of small bowel obstruction, secondary to adhesions, involves lysis of abdominal adhesions . While tHowever, a study conducted by Murrell and Stamos discovered that a takedown of a leaking anastomosis can likely result in a permanent ostomy for many patients . With thWhen discussing what would be best for this patient and considering his postoperative implications, we decided to forego resection followed by end ileostomy and performed a small bowel resection followed by primary anastomosis instead. Given his past medical history of seizures, unspecified psychiatric disorders, dementia, and residence in an ALF, we concluded that the management of an ileostomy bag would be too cumbersome for both the patient and the ALF staff. It would also diminish his quality of life. Additionally, given his history, an ileostomy bag places him at higher risk of complications associated with the care of the stoma and ileostomy bag maintenance, such as infection, stoma stricture, bleeding, and general hygiene. For these reasons, we decided bowel resection followed by primary anastomosis would be most beneficial, while also maximizing his quality of life.In deciding to perform another resection and primary anastomosis, we posed the risk of an anastomotic leak, mesenteric entrapment, and anastomotic stricture, to name a few . In all Sigmoid VolvulusWhen discussing the surgical management for his sigmoid volvulus, Hartmann's Procedure is indicated in the presence of hemodynamic instability, coagulopathy, acidosis, or hypothermia. Given his presentation of persistent abdominal pain and evidence of significant bowel obstruction and lactic acidemia, traditional surgical management of the sigmoid volvulus via Hartmann’s procedure was warranted. However, for the same implications and consequences mentioned previously when discussing surgical management of his SBO through end ileostomy, we discussed the benefits and consequences of performing a primary anastomosis versus Hartmann’s procedure for his sigmoid volvulus. When evaluating functionality and quality of life, we wanted to explore the option of performing a primary anastomosis in the management of his sigmoid volvulus.A prospective randomized study by Sasaki et al. discovered improved healing in patients who underwent a primary anastomosis between two healthy segments of the bowel compared to resection followed by end-colostomy formation . In evalGiven the studies mentioned and the overall outcome of our patient, we feel confident and comfortable in our decision to repair both the SBO and sigmoid volvulus, with resection and primary anastomosis, as opposed to the traditional resection and end ileostomy and colostomy, respectively. During his outpatient follow-up appointment, he returned to baseline mentation and function and was without pain, discomfort, or any other clinical manifestations of his initial diagnosis.Prolonged IleusThis patient’s postoperative course was complicated by a prolonged postoperative ileus (POI) that lasted approximately 17 days. When determining the cause of the POI, we considered a multitude of possible etiologies for which the criteria by which we were able to rule out some causes are listed in Table Traditional treatment of POI often involves a multimodal approach. For example, Basse et al. discovered a multimodal approach involving epidural analgesia, early oral nutrition and mobilization, cisapride, a gastrokinetic agent, and laxative treatment with magnesia to be effective within 48 hours of colonic resection . Other mHis POI was thought to have resolved after having one bowel movement approximately one week into his postoperative recovery; however, the following day, he presented with nausea, vomiting, tachycardia, and abdominal distension. A kidney, ureter, and bladder (KUB) plain radiograph was ordered, and re-demonstrated signs of ileus without perforation Figure . Given tIn determining whether another operation was warranted to search for another cause of prolonged ileus, we placed an NG tube with suction. We immediately retrieved approximately 1,000 mL of gastric fluid. Under suspicion of another possible obstruction or failed anastomosis from the initial surgery, we order a CT scan of the abdomen with contrast. Fortunately, the CT scan of the abdomen demonstrated contrast passing through the entire small and large bowel until the descending colon, thus excluding a complete bowel obstruction and/or failed anastomosis as the cause of prolonged ileus.At this time, we diagnosed him with prolonged postoperative ileus and multifactorial gastroparesis, secondary to multiple antipsychotic medications. We requested a psychiatry consultation to discuss psychiatric medications possibly interfering with bowel movements. Upon further investigation, we suspected multifactorial gastroparesis, likely caused by the long history of antipsychotic medication use, as the primary culprit for the POI.Following adequate medication reconciliation by psychiatry, we elected to try another trial of metoclopramide to stimulate gastrointestinal activity, along with the addition of oral Erythromycin in an attempt to resolve the POI. A common side effect of erythromycin is an increase in the number and force of gastric contractions . For thiGiven the patient’s history of failed anastomosis and previous abdominal surgery, we strongly considered reoperation once the prolonged ileus was considered pathological, not physiological. However, we also wanted to provide him a little more time for his ileus to resolve than typically indicated. Given his past surgical history we considered the fact that his POI may take slightly longer to resolve in comparison to a virgin abdomen without a surgical history. Additionally, given the initial bowel movement he had approximately one week after surgery, we were not eager to take him back into surgery. We decided to remain as conservative as possible to try and give the anastomosis the opportunity to function.We decided to continue a multimodal approach as recommended by Basse et al. Although we did not follow a specific regimen, we incorporated a multimodal approach which included metoclopramide, erythromycin, and early oral feeding and mobilization, along with adequate medication reconciliation given our suspicion for multifactorial gastroparesis. We ultimately hoped to delay and avoid operating on him again to resolve the POI.After approximately 20 days following surgery, the patient had four total bowel movements within 24 hours. We advanced his diet from clear liquids to a soft diet, which he tolerated well. We considered the POI was resolved and continued to monitor his progression. While we are still unclear about the exact etiology of his POI, we suspect the prolonged POI was more a result of multifactorial gastroparesis, secondary to chronic antipsychotic medication use, instead of the surgical procedure itself. Fortunately, our medical and surgical decision not to reoperate was appropriate as the POI eventually resolved with conservative management, without any potentially fatal events.He was discharged the following day and instructed to follow-up in two weeks. He was seen by Dr. Masri for his two-week follow-up appointment at the outpatient clinic. He was doing fine, having normal bowel movements, and tolerating his diet well. At this time, we signed off on the patient, determined the SBO, sigmoid volvulus, and postoperative ileus to be resolved, and will see him as needed moving forward.To our knowledge, this is the first case in literature of a simultaneous small bowel obstruction and sigmoid volvulus. One particular question we considered was if the sigmoid volvulus could have been the cause of the small bowel obstruction. Unfortunately, we were unable to answer this question. Additionally, all clinical indications pointed towards a small bowel resection with end ileostomy and colonic resection with end colostomy for the small bowel obstruction and sigmoid volvulus, respectively. While this was part of our surgical plan, when considering the patient’s medical and psychiatric history, living situation, and quality of life, we decided to pursue a more cavalier approach and attempt a small bowel resection with primary anastomosis and colon resection with primary anastomosis instead. One consequence or complication we were prepared to face was the need to operate on him again due to failed anastomoses, which would have ended with the end of the ileostomy and colostomy as surgically indicated. This was a risk we were prepared to take. We decided that if our plan to perform resection with primary anastomosis was successful, we would be happy with our surgical decision. On the other hand, if the surgical attempt for resection and primary anastomosis failed and warranted another procedure only to end with an end ileostomy and colostomy, we were still content with the attempt we would have taken to try to maximize his quality of life. Fortunately, our surgical decision was successful in the end, as he tolerated the resection and primary anastomosis well and, as far as we know, has not experienced any adverse side effects or complications from our surgical management. Despite the patient’s previous surgeries or not, the decision to perform the surgical procedure that will maximize, his quality of life with limited or reduced risks should always be considered. Regardless of the clinical or surgical indications, an experienced surgeon ought to exercise their professional judgment to take an alternative approach as long as the patient's best interest is in mind and the approach is safe for the patient as well. Additionally, despite the surgical aspects of this case, other medical and psychiatric diagnoses should always be considered when possible and appropriate. It cannot be definitively concluded whether or not his history of chronic antipsychotic medications was the etiology for prolonged postoperative ileus and multifactorial gastroparesis; however, given the resolution of the POI shortly after psychiatric medication reconciliation was performed, we highly suspect this to have played a role in his prolonged POI.


The presence of a supernumerary tooth is one of the most common dental anomalies, and surgical treatment is often required to address this anomaly. Moreover, it may lead to malocclusion, and long-term follow-up is important to monitor its status. A 4-year-and-11-month-old boy was referred to our hospital for dental caries treatment. At 5 years and 5 months of age, a radiographic examination showed a supernumerary tooth (first supernumerary tooth) near the permanent maxillary left central incisor, and it was extracted 6 months later. Eighteen months after the extraction of the first supernumerary tooth, a new supernumerary tooth (second supernumerary tooth) was detected in the same region, which was extracted when the patient was aged seven years and seven months. Seven months later, another supernumerary tooth (third supernumerary tooth) was detected and extracted immediately. However, the permanent maxillary left central incisor did not erupt spontaneously even after 6 months. Therefore, surgical exposure was performed, and the central incisor erupted into the oral cavity. This report describes our experience with this patient with three metachronous supernumerary teeth and their management until the eruption of the permanent tooth. This report highlights the importance of long-term follow-up after supernumerary tooth extraction until the permanent teeth in that region have erupted completely. According to Das et al., 2012), the presence of supernumerary teeth in the long term may prevent the spontaneous eruption of adjacent permanent teeth 2, the pr, with onWe previously reported a case of the development of a new supernumerary tooth after the extraction of a previous supernumerary tooth in the same region . HoweverA 4-year-and-11-month-old Japanese boy with an intellectual disability was referred to the Pediatric Dentistry Clinic of Hiroshima University Hospital with the chief complaint of dental caries. He had been receiving dental checkups and treatment from a general practitioner since the age of 2. However, the dental caries was advancing rapidly, and he was referred to the hospital for caries management. With regard to the medical history, the patient was diagnosed with autism spectrum disorder and exhibited an intellectual delay of about a year. The medical and family histories were otherwise unremarkable, except for the presence of certain allergies.At 5 years and 5 months of age, a supplemental supernumerary tooth (first supernumerary tooth) was detected near the permanent maxillary left central incisor A. This sA small radiolucency was observed near the crown of the maxillary left central incisor in the dental X-ray image taken during the first extraction. The dental X-ray images at 6 years and 3 months and 7 years and 5 months showed a progressive growth of this structure A,B, whicBy the time the patient was aged 8 years and 2 months, the permanent maxillary left central incisor had not erupted in the oral cavity A. A periOrthodontic treatment was considered after the extraction of the third supernumerary tooth; however, the patient was uncooperative because of his intellectual disability. At 8 years and 9 months of age, a periapical radiograph revealed no change in the location of the permanent maxillary left central incisor A,B. ThusFollowing surgical exposure, the incisor gradually erupted in the oral cavity . At 9 yeTo the best of our knowledge, this is the first report of a case in which a third supernumerary tooth occurred after the extraction of the second supernumerary tooth. The treatment progression of the patient is shown in Yamashita et al., (1981) reported the formation of a root-like calcified tissue after the extraction of an immature permanent tooth , and theAccording to a report by Primosch et al., 1981), the treatment plan for embedded supernumerary teeth in the maxillary anterior region that cannot erupt is generally divided into an immediate and a delayed surgical approach . Russell1, the trRussell and Folwarczna 2003) and Primosch 1981) reported that genetic factors have been implicated as one of the etiologies of supernumerary teeth 003 and P. Accordi81 reportThe Japanese Society of Pediatric Dentistry has reported the eruption time of the permanent maxillary central incisors in Japanese males as 7.20 ± 0.67 years, which is considerably less than the age of the patient in this report . TherefoAn intraoral photograph at the age of 9 years and 7 months showed a mesial inclination of the permanent maxillary left central incisor and a space shortage for the maxillary incisors. Accordingly, orthodontic treatment such as a lateral expansion of the maxillary dental arch is required. We consider the treatment according to the wishes of the patient and parents. The goal of supernumerary tooth treatment is not only the extraction of the supernumerary tooth but also a proper eruption of the permanent tooth. Therefore, it is important to establish a long-term treatment plan, including orthodontic treatment.This study had certain limitations. First, we previously reported the patient’s status until the extraction of his second supernumerary tooth . Second,We encountered a rare case of a third supernumerary tooth occurring in the same region after the extraction of the previous two supernumerary teeth. Multiple supernumerary teeth have been reported in a single patient; however, no report has documented the detection of three supernumerary teeth metachronously in the same region. In this case, the permanent maxillary left central incisor had not erupted spontaneously after the extraction of the third supernumerary tooth, and, eventually, surgical exposure was required. This report reconfirms that long-term follow-up is necessary and the need for a surgical approach, such as surgical exposure, should be considered if the permanent teeth are unable to erupt spontaneously after the extraction of the supernumerary tooth.


Gastric subepithelial lesions are common. However, their diagnosis and management can pose a challenge. Herein, we present the case of a 49-year-old man who was incidentally discovered to have a gastric subepithelial lesion that increased in size during follow-up. Submucosal tunneling endoscopic resection was performed, and the tumor was successfully removed en bloc. The pathological and immunohistochemical findings were consistent with a gastric globus tumor. Although rare, glomus tumors should be considered when gastric subepithelial lesions are discovered. Resection with an endoscopic technique can be used to preserve the stomach and can be considered an alternative to surgical removal. However, such procedures should only be performed by experienced therapeutic endoscopists. Gastric subepithelial lesions (SELs) are fairly common and have been reported to have a prevalence of 0.76–1.7% among the general population . The iniAccording to the American Society of Gastrointestinal Endoscopy and European Society of Gastrointestinal Endoscopy guidelines, endoscopic ultrasound (EUS) is the most accurate imaging test for evaluating SELs and should be used to evaluate such lesions ,5. HowevHerein, we present a case of asymptomatic SEL that increased in size over the follow-up. After a discussion with the patient, the lesion was successfully removed through submucosal tunneling endoscopic resection (STER). The pathologic report revealed the lesion to be a glomus tumor.2 originating from the fourth echo layer, or the muscularis propria layer  after submucosal injection of a glycerol solution. A tunnel was created using the submucosal dissection technique c. The tuHistological study further revealed that the tumor comprised branching capillary vessels surrounded by collars of uniform tumor cells a. The roA glomus tumor is a mesenchymal neoplasm that can be found anywhere throughout the body. Such tumors are rarely reported in the stomach . When a The first involves accurately diagnosing the tumor. Glomus tumors usually originate from the third or fourth echo layer and are mostly discovered in the antrum. Such tumors can appear hypoechoic or hyperechoic on EUS, with hypervascularity and internal echo patterns indicating calcification ,7. HowevThe management of SELs depends on precise diagnosis. Despite being the current best tool to characterize SEL, EUS alone is not able to distinguish among all the different types of SEL. For SELs with an unknown diagnosis, the most concerning diagnosis is GIST. The management of SELs with an unknown diagnosis in the different society guidelines generally reflects its policy regarding the management of GIST.In In our case, the gastric SEL was <20mm on initial presentation, originating from the muscularis propria layer but without high-risk features. Tissue acquisition or active surveillance were both feasible options. As the tumor size gradually increased over time, tissue acquisition to confirm the diagnosis or diagnostic resection were both acceptable management techniques. As there are still many controversies regarding the management of small gastric SELs, the decision depends on the availability of local resources, the endoscopist’s experience, and the patient’s preference.Even if tissue acquisition was performed in our case, the correct diagnosis might not have been made. In a recent review, 46 cases of gastric glomus tumor were reported in the literature between 2010 and 2019, and only 19 of them had a preoperative diagnosis. Among the patients who underwent endoscopic ultrasound-guided fine-needle aspiration to determine the pathology, a diagnosis was correctly given in only 8 out of 13 cases .The second challenge related to management involves the uncertainty of the pathological nature of glomus tumors. Glomus tumors are typically benign, and the guidelines released by the European Society of Gastrointestinal Endoscopy in 2022 indicate that no surveillance is required if the diagnosis is clear because only anecdotal evidence supports that a risk of malignancy or complications is present . HoweverCriteria were proposed for defining malignancy in glomus tumors originating from soft tissues . In addiBecause glomus tumors are potentially malignant, if removal is planned, a local operation for complete resection is typically recommended, and such operations are indeed performed in most cases in the literature . HoweverRegardless of which endoscopic technique is considered, procedures should always be performed by an endoscopist skilled in advanced tissue resection techniques, as suggested by the American Gastroenterological Association .Gastric globus tumors are a rare form of gastric subepithelial lesion. With the current case, we demonstrated the possible challenges in the clinical scenario, including the difficulties in correctly diagnosing such lesions, the timing of tissue acquisition, and the uncertainty of the pathological nature. If the removal of gastric globus tumors is planned, previously it was mainly performed by local operation, with some reports using ESD. We showed that STER may have some potential advantages over ESD and can be an alternative. Compared to an operation, resection with an endoscopic technique can better preserve the stomach, but should always be performed by an experienced endoscopist.


Bilobed testis is an extremely rare congenital malformation, and even rarer on the right side. Only 7 cases have been reported in the literature. We describe the case of a 9-year-old boy with a right bilobed testicle confirmed on ultrasound and discovered incidentally as a mass on physical examination. The aim of our work is to consider the bilobed testicle as a differential diagnosis of a testicular mass despite its rarity and to show the importance of ultrasound and MRI for its definitive diagnosis to avoid unnecessary surgery. Bilobed testis is an extremely rare congenital malformation in children, more common on the left side We describe here a case of right bilobed testis in a 9-year-old boy confirmed by scrotal ultrasound.A 9-year-old boy with no particular personal or family history was referred to the department of pediatric surgery and radiology for a right scrotal painless mass, not increasing in volume, with no inflammatory signs. It has appeared 2 years prior to his admission.The clinical examination revealed a round, painless, mobile mass, well-limited, in the upper pole of the right testicle. The rest of the physical examination didn't reveal anything particular.Faced with this clinical picture, a scrotal ultrasound was performed revealing a hypoechoic mass attached to the upper pole of the right testicle with normal vascularization shown in the Doppler ultrasonography measuring 10 × 6.5 × 5 millimeters. The mass had a similar size and echotexture with normal adjacent testis . The lefBecause of the echogenicity corresponding to a testicular structure and the absence of complications such as testicular torsion, the diagnosis of bilobed testicle was retained.Conservative treatment was indicated with quarterly ultrasound monitoring of the patient.Bilobed testis is an extremely rare testicular malformation According to previous studies the bilobed testicle is considered a benign entity, however a debate still persists over the risk of torsion and malignancy on bilobed testicle cases Historically, the definitive diagnosis of polyorchidism was made by surgical exploration, nowadays ultrasound and MRI are sufficient to diagnose polyorchidism including bilobed testicle.The management of polyorchidism still remains controversial As mentioned above in the case report, in our experience, given the absence of complications, surgical exploration was not necessary.Written and informant consent for publication of the case was obtained from the patient.


Intestinal volvulus is defined as a twisting of the bowel on its mesentery. It itself is a rare occurrence, with documented incidence of 1% as the cause of all small bowel obstruction, with further 0.82% of them being associated with intestinal malrotation. The classical radiographic feature described in literatures is the whirlpool sign. We herein report a rare presentation of congenital malrotation causing a small bowel obstruction in a 43-year-old man. The patient presented with acute abdominal pain and underwent an emergency laparotomy and resection of small and large bowel , with an estimated 2.6 m of viable small bowel left. The patient had a prolonged recovery complicated by another relook operation, superior mesenteric vein thrombus and a high-output stoma with subsequent electrolyte derangements and acute kidney injury. He was discharged on Day 26 and had been seen in the outpatient department with good functionality. Intestinal volvulus is a rare but life-threatening condition that is defined as a twisting of the bowel on its mesentery resulting in a bowel obstruction. It requires timely diagnosis and urgent management due to its obstructive pathophysiology resulting in possible bowel infarction, perforation and sepsis. Small bowel volvulus is thought to be more common in the paediatric population due to the higher incidence of congenital associations  , 2. It iThis case highlights the rarity of these diseases and the importance of having them as part of the differential diagnosis for all patients with small bowel obstruction. It also highlights the classical clinical and radiological findings of small bowel volvulus, as well as the morbidities associated with it.A 43-year-old man presented with acute abdominal pain, nausea and vomiting in the context of not opening his bowels for 10 days. Otherwise, he was a fit and healthy gentleman with no previous abdominal surgeries. He was a light-smoker and did not consume any alcohol or illicit drugs. On presentation, the patient was unwell with diaphoresis and had a rigid abdomen with global peritonism. Rectal examination revealed no blood or mass. Blood tests showed a raised white cell count (27.8/L), borderline elevation of lactate (2.9 mmol/L) and normal C-reactive protein (< 2.0 mg/L). Computed tomography (CT) demonstrated small bowel obstruction with multiple dilated loops with twirling of the mesenteric vessels in central abdomen, as well as moderate ascites .The patient underwent an emergency laparotomy and resection of small and large bowel. He was found to have malrotation of the small bowel around its mesentery with associated haemoperitoneum. Given intra-op finding of non-viable intestine, a total of 3 m of intestine  was resected with primary anastomosis. An estimated 2.6 m of viable small bowel was left.He was admitted to intensive care unit (ICU) post-operation given ongoing shocked state requiring two vasopressor agents. Day 2 post-operation, the patient was found to have small bowel herniating through his vacuum-assisted closure dressing, necessitating a re-look laparotomy. Given the ongoing shocked state, the decision was made to form an end-ileostomy and mucus fistula from transverse colon. The patient’s fascia was subsequently closed.His admission was further complicated by acute kidney injury (AKI) secondary to high nasogastric + stoma outputs (6.6 L/day at peak) requiring aggressive fluid replacement and Loperamide + Metamucil. This was likely contributed by the relatively proximal nature of the stoma. Repeat CT also showed a thrombus within the left-sided branches of the superior mesenteric vein continuing into the vein proper , which wSmall intestine, or midgut, volvulus itself is a rare occurrence, especially in the adult population, with documented incidence of 1% as the cause of all patients presenting with small bowel obstruction. Further 0.82% of these patients were found to have associated intestinal malrotation as well [This patient presented with clinically suspicious symptoms and an acute surgical abdomen, all of which were highly suggestive of an acute bowel obstruction. Patients with small bowel volvulus are more likely to present acutely with bowel ischaemia and peritonitis . This waThis case also highlights the interpretation of the relevant investigations in the work-up of such patients. On admission, the patient’s lactate level (2.9 mmol/L) did not really correlate with his clinical status nor intraoperative findings. Although increased lactate is associated with strangulated bowel, the level can lag by 8 h . In termIn terms of management of small bowel volvulus, 65.2% of patients require some form of surgical intervention . HoweverThis case also highlights the various morbidities and complications associated with the disease and its surgical interventions. Mesenteric venous thrombosis is a rare but reported complication after abdominal surgery, usually in the superior mesenteric vein, accounting for 1 in 1000 emergency surgical laparotomies for acute abdomen . Malnutr