Esophageal hyperplastic polyps (HPs) are a rare benign polypoidal growth most commonly resulting from gastroesophageal reflux disease (GERD). The lesion is asymptomatic in most patients unless large enough to cause luminal obstruction or gastrointestinal bleeding. The treatment of choice is endoscopic resection if it becomes symptomatic. Here, we report a case of a 51-year-old woman presenting with dyspeptic symptoms and upper gastrointestinal bleeding. An upper gastrointestinal endoscopy showed a large polyp with active oozing of blood at the gastroesophageal junction (GEJ), which was removed endoscopically after injecting adrenaline at its base. Histopathological analysis was suggestive of HPs. Hyperplastic polyps (HPs) of the esophagus or gastroesophageal junction (GEJ) are rare lesions with the exact prevalence being unknown. Generally benign esophageal lesions account for <1% of all esophageal tumors, and the majority are asymptomatic slow-growing tumors with a minimal malignant potential. Giant esophageal polyps are extremely rare and only account for 0.03% of cases of all esophageal lesions -4.The most common location of HPs in the upper gastrointestinal tract is the gastric antrum, and these are mostly small in size 1-2 cm) . In the -2 cm . IA 51-year-old female presented to the gastroenterology outpatient clinic with complaints of abdominal pain and exertional shortness of breath for one week. She had two episodes of melena the day before she presented to the clinic. The pain was in the epigastrium region, and it was burning in character, non-radiating, aggravated by meals, and relieved by taking antacids. She also reported occasional intermittent vomiting. On examination, she looked pale and was tachycardic with a pulse rate of 102 beats per minute. The abdomen was soft and non-tender with no visceromegaly. A digital rectal examination showed black-colored stools. She was admitted and managed with intravenous omeprazole, intravenous fluids, and packed red blood cell transfusions. A baseline workup was done, which showed a hemoglobin level of 8.3 gm/dl, a drop from 11.6 g/dl in just two months.Upper gastrointestinal endoscopy revealed a large polyp with its base located at the GEJ Fig. . During Histopathological examination showed dense acute and chronic inflammation with surface ulceration and inflamed granulation tissue along with proliferative reactive endothelial cells and fibroblasts Fig. . The dilThe patient was discharged on proton pump inhibitors and prokinetics. A surveillance endoscopy after two years showed a diminutive polyp at the same location (GEJ) Fig. , which wAlthough uncommon, a wide variety of pathologies can produce polypoidal lesions in the esophagus or at the GEJ. These include squamous papilloma, leiomyoma, Barrett’s esophagus-associated polypoid dysplasia, polypoid carcinoma, fundic gland polyps, and HPs . HP of tAnother study conducted on GEJ HPs by Abraham et al. reported a high association with gastroesophageal reflux disease (GERD) and Barrett’s esophagus, i.e., 48% and 15%, respectively . Other pHelicobacter pylori infection [On the extensive literature review, we found case reports previously published on GEJ polyps. One case report was of an inflammatory fibroid polyp in a five-year-old girl , anothernfection . To the Diagnosis of GEJ polyps can be easily missed in asymptomatic cases. Therefore, an upper gastrointestinal endoscopy should be performed in patients presenting with anemia or occult gastrointestinal bleeding to rule out HPs as a cause of upper gastrointestinal bleeding. Following resection of larger polyps, endoscopy surveillance is warranted to assess for the recurrence or development of neoplasia.


Retroperitoneal extrarenal Wilms tumor is a rare condition in children that can be easily misdiagnosed as other retroperitoneal malignancies unrelated to the renal origin. Computerized tomography scan plays a crucial role in diagnosing and distinguishing retroperitoneal malignancies. In this report, we present two cases of retroperitoneal extrarenal Wilms tumor in children who were admitted due to abdominal mass. Laboratory examination did not reveal any significant abnormality. However, a computerized tomography scan revealed a solid or cystic-solid mass in the retroperitoneum accompanied by a bone spur extending from the anterior edge of the vertebral body to the back of the mass, while the origin of the tumor remained unclear. By analyzing these two cases and reviewing previous studies on retroperitoneal extrarenal Wilms tumor in children, we summarized the clinical and imaging characteristics of this rare condition. We also found that the presence of a spinal deformity adjacent to the mass might indicate the possibility of a retroperitoneal extrarenal Wilms tumor. Extrarenal Wilms tumor (EWT) is a rare type of Wilms tumor (WT) in children and accounts for approximately 3% of WT . It is mCase 1 A 4-year-old female patient was admitted to the hospital after the discovery of an abdominal mass. There was no discomfort, and laboratory examination revealed no abnormalities; a computerized tomography (CT) scan revealed an oval mixed-density mass in the left middle and lower abdomen with a clear boundary. The dimensions of the mass measured on the image were approximately 51 mm in length, 39 mm in width, and 52 mm in height. The mass was primarily composed of fat density ( density , with a  density . The lef density . The patCase 2 A 3-year-old male patient was admitted to the hospital after the discovery of an abdominal mass. No discomfort was reported, and laboratory examination showed no apparent abnormality. A CT scan revealed the presence of a soft tissue mass with a clear boundary in the left retroperitoneum. The mass measured approximately 38 mm in length, 64 mm in width, and 44 mm in height in the image (he image . After the image . During he image . The finWT is a prevalent malignant tumor in children, comprising around 7% of all malignant tumors in this age group . EWT, onWe conducted a search for reports of retroperitoneal EWT that included detailed CT data or CT images between 1990 and 2022. Our search yielded a total of eight cases of retroperitoneal EWT in children, reported in previous works of literature. The proportion of male and female patients was similar, with six male patients and four female patients among the 10 cases. The age of the patients ranged from 8 days to 17 years, with a median age of 3 years. Notably, 80% of the cases were observed in children less than 5 years old. All 10 cases were unilateral, with most of the tumors located around the midline. There was no significant difference in the incidence of EWT between the left and right sides, which is consistent with previous literature.EWT primarily comprises germ tissue, epithelial cells, and interstitial components, with varying proportions of each component . The intThe most common CT findings of EWT are solid or cystic-solid masses, with round or oval shapes and some lobulated shapes. These masses are typically larger in size and may extend across the midline, compressing surrounding tissues and large blood vessels. Density may be uneven in the presence of fat or calcification within the mass . In CaseEWT is often associated with the urinary system and spinal deformities. For instance, retroperitoneal EWT frequently coexists with horseshoe kidneys. The coexistence of EWT and horseshoe kidneys was first reported by Moyson in 1961, and several related cases have been reported since then. According to literature statistics, approximately 7.6% of EWT cases are accompanied by horseshoe kidneys . FurtherIn summary, due to the limited understanding of EWT, radiologists may not be able to provide an accurate diagnosis before the operation. Therefore, surgical exploration and pathological analysis are necessary for a definitive diagnosis. Based on the cases reported and previous literature, it can be observed that retroperitoneal EWT in children typically appears as a solid or cystic-solid mass on CT images. These masses are often large in size, have a clear boundary, and may exhibit calcification or a fat shadow within the mass. Moreover, the presence of a horseshoe kidney or spinal deformity can also aid in the diagnosis of EWT.


Endodontic microsurgery has yielded highly successful outcomes in preserving teeth with persistent or recurrent cases of periapical periodontitis that could not be successfully treated by nonsurgical endodontic approaches. To avoid complications in conditions in which periapical lesions invade anatomical structures such as the nasopalatine nerve tube and mandibular canal, selective curettage has been proposed as an alternative choice of complete curettage in surgery.The 8 cases reported herein had undergone root canal treatment and/or retreatment but still presented with symptoms, such as recurring sinus tracts and persistent dull pain. The radiographic examination indicated a large area of radiolucency that was associated with the tooth and had invaded adjacent critical anatomical structures. The patients opted for selective curettage via endodontic microsurgery, and the lesions were histologically confirmed as periapical cysts or granulomas. The follow-up results for one year or more indicated that the affected teeth were clinically asymptomatic and exhibited complete or incomplete healing radiographically.This case series provides clinical evidence for the feasibility of selective curettage in endodontic microsurgery, which can avoid complications caused by damage to the adjacent critical anatomical structures. Endodontic microsurgery (EMS) is a treatment option for teeth that have failed root canal treatment (RCT) or retreatment (ReRCT) and/or have severe anatomical variations . CurettaThe aim of this case series was to provide more clinical evidence for the feasibility of selective curettage  in EMS, We retrospectively evaluated the outcomes of 10 teeth from 10 patients who had received conservative endodontic microsurgery. The inclusion criterion was that the teeth had been previously treated before surgery, but the symptoms were persistent or recurrent. The radiographic examination indicated that the lesions were close to the critical structures, which posed a great challenge to complete curettage. Informed consent was obtained. Preoperative examinations  and cone-beam computed tomography ) were taken before EMS. All the patients denied a contributory and allergic history. Surgeries were performed by two experienced endodontists. The surgical procedures were performed under an endodontic microscope . Patients were given local anaesthesia ) with 4% articaine hydrochloride with epinephrine . Then, intrasulcular incisions were made and the full-thickness flap was elevated. After locating the root apex, an osteotomy was created, followed by root resection with a handpiece in the anterior area or an angled handpiece in the posterior area. Selective curettage, which removed approximately 40–70% of the lesions, was performed using a curette with sterile saline irrigation. The curetted tissues were immediately fixed with paraformaldehyde solution and then sent for histopathological examination. The resected root surface was stained with methylene blue and inspected carefully under high magnification. Retrograde preparation was performed with ultrasonic tips along the long axis of the tooth and retrograde filling with iRoot BP Plus . Guided tissue regeneration (GTR) with graft materials  and a bioactive membrane  was conducted for two cases with large lesions or through lesions , 6. The A 27-year-old woman presented in our department for gingival swelling in the maxillary right anterior area for 6 months. She had received RCT of tooth #8 several years previously and ReRCT 6 months prior because of swollen gingiva. Upon clinical examination, tooth #8 had a provisional crown with palpation tenderness, no cold response, and no percussion tenderness, and the probing depth was within the normal limits. PAR and CBCT revealed that tooth #8 had been previously treated with a large periapical radiolucency extending from tooth #7 to tooth #9; tooth #7 and #tooth 9 were responsive to cold and were within normal limits in sensitivity tests. Tooth #8 was diagnosed with periapical periodontitis, and EMS for tooth #8 was performed. Lesions around tooth #8 were thoroughly curetted, but those close to tooth #7, #9 and the nasal fossa were untouched. The pathological report indicated a periapical cyst. The patient remained asymptomatic after 66 months. The follow-up PAR showed complete healing, and CBCT indicated limited healing for the discontinuity of the cortical plate Fig. a-m.The patient was a 35-year-old woman whose chief complaint was swollen gums on the buccal side of the mandibular right first molar, recurrently for 1 year. Tooth #29 had undergone RCT in a local hospital 2 years prior. Tooth #29 had no cold response and no percussion or palpation tenderness. Periodontal probing was within normal limits. Tooth #30 had a sinus tract on the buccal side and responded normally to cold and electric pulp tests. PAR and CBCT revealed a previously treated root canal of tooth #29, and there was an 8 × 14 × 15 mm radiolucent area around the apical area of teeth #28, #29. The radiolucency penetrated through the apical area to the furcation area of tooth #30. Teeth #28 and #30 were both within normal limits for cold and electric pulp tests. Tooth #29 was diagnosed with periapical periodontitis and EMS for tooth #29 was planned. After flap elevation and osteotomy of tooth #29, selective curettage of 50% of the lesion was performed, leaving those adjacent to teeth #28 and #30. GTR was performed for tooth #29 and the furcation of tooth #30 to promote primary healing of the large bone defect. The pathological report indicated a periapical granuloma. Tooth #28 and tooth #30 were tested as vital pulp after 12 months, and PAR indicated incomplete healing of tooth #29  involving tooth #9 and tooth #10 as well as the nasopalatine nerve tube. Tooth #9 was diagnosed with periapical periodontitis. RCT was then performed for tooth #9, and regular follow-ups were advised for tooth #10 to assess its pulp vitality. Due to the persistent purulent drainage of tooth #9 in the following 3 months, EMS, as well as GTR, was recommended for the large through-and-through lesions in the apex. Lesions were selectively removed to preserve the nasopalatine nerve tube and vitalization of tooth #10. Histopathology examination reported a periapical cyst. At the 27-month follow-up, the patient did not report any clinical symptoms, and PAR indicated complete healing  are categorized as persistent intraradicular infection, extraradicular infection, foreign body reactions of exogenous materials, endogenous cholesterol crystals, true cysts and fibrous scar tissues –13. To pEMS obtained a high success rate in the present literature, which ranged from 69.3 to 93.3% in a meta-analysis of 10 clinical studies followed up for 2–13 years  with endThe aim of curettage in EMS is to remove diseased periapical tissues, foreign bodies or root fragments in the apex area, while the selective curettage means to selectively maintain the inflammatory tissues close to the mandibular canal, maxillary sinus or adjacent vital pulp teeth to protect anatomical structures and avoid complications. Fish histopathologically divided periapical periodontitis into 4 zones, namely, infected areas (zone 1 and zone 2), containing bacteria and bacterial toxins ans byproducts; and zone 3 and zone 4, which were filled with products of irritants and components of healing granulation tissues . It was Nesari put selective curettage into practice by removing approximately 50-70% of the granulomatous tissue in cases that had large through-and-through lesions, perforating into the nasal fossa, or in proximity to the mandibular canal . All theAccording to Carrillo et al, the prognosis of periapical lesions differs with size and pathological results, and large lesions and periapical cysts tend to have worse prognosis than others . Apical Recently, several cases with large periapical cystic lesions adjacent to critical anatomic structures were treated successfully with decompression and nonsurgical endodontic treatment , 36. TogThe histology of Nair’s study revealed that nearly two-thirds of the lumen was occupied by necrotic tissue, containing cells at different stages, and the narrow band of connective tissue surrounding and enclosing the cyst cavity was almost free of inflammation . BhaskarTaschieri et al reported a significantly higher success rate of GTR in penetrating lesions, but no significant difference was observed in cases that did not affect the buccal and lingual cortical bone , 40. It In the present study, GTR was applied in cases 2 and 3, which were both large periapical lesions (bone defects larger than 10 mm ). Case 2The healing assessment was based on Molven’s 2D criterion and Penn 3D CBCT criteria. For 2D examination, the lesion can only be visible when the periapical radiolucency reaches nearly 30–50% of bone mineral loss and lesions confined within the cancellous bone cannot be detected. A 2D lesion area addresses the mesiodistal and apicocoronal extent of the defect, while buccolingual directions on average have the largest extent of a periradicular defect, which may lead to misjudgment. As a three-dimensional imaging technology, CBCT can assess the extent and location of periapical lesions, the bone thickness and the proximity to anatomic structures such as the mandibular canal, nasopalatine nerve tube or adjacent vital teeth. In addition, CBCT can also be used to evaluate odontogenic versus nonodontogenic symptoms, and the good reproducibility and repeatability of CBCT allow us to precisely assess the stage of healing, which is difficult to discern in 2D examination. Treatment outcomes were categorized as complete healing, limited healing, uncertain healing and unsatisfactory healing . The absA limitation of our study was the fact that the age of the included patients was randomly selected (ranging from 21 to 36 years). According to the literature, most systematic reviews and meta-analyses have shown no statistically significant differences between patient age and the prognosis of endodontic microsurgery , 44, 45,In conclusion, this case series provided clinical supportive evidence for selective curettage in EMS. It can be considered an alternative strategy to avoid complications in cases of periapical granulomas or cysts involving critical anatomical structures. However, if the lesion shows uncertain or unsatisfactory healing at the 1-year follow-up and/or the symptoms persist, the patient must be informed of the possibility of resurgery; alternatively, if the biopsy indicates a result beyond periapical granuloma, cyst or fibrous connective tissue, a consultation with oral and maxillofacial surgery to determine the further treatment plan will be needed. Further studies and more cases are required to determine the outcome of this treatment approach.


Non-Hodgkin lymphoma affecting the brain, eyes, and cerebrospinal fluid without systemic spread is known as primary central nervous system lymphoma (PCNSL). While intracerebroventricular PCNSL is commonly found in the lateral ventricles and the third and fourth ventricles, the occurrence of PCNSL originating from the septum pellucidum is extremely rare.Two patients presented with recent memory loss and high cranial pressure.Magnetic resonance imaging revealed a clear enhancing lesion in the septum pellucidum region. Pathological examination confirmed that both cases were primary large B-cell lymphoma GCB  subtypes located in an “immune-privileged” area.Both patients underwent total tumor resection, and the procedures were successfully completed without surgical complications.Over a 1-year period, treatment included four cycles of high-dose methotrexate combined with temozolomide. During the follow-up period (19–23 months), no recurrence of the lymphoma was observed.In cases of PCNSL in the septum pellucidum, it is crucial to consider it as a potential differential diagnosis for intraventricular tumors. Surgical interventions should focus on maximizing tumor resection while ensuring the protection of critical structures like the fornix and peripheral neural components. The role of surgery compared to biopsy, as well as the long-term complications, necessitates extended follow-up. Additionally, an individualized treatment approach, considering factors such as age, Karnofsky performance score, and organ function assessment, can lead to positive outcomes. Contrast-enhanced brain magnetic resonance imaging (MRI) is recommended for diagnosis of this condition. Lesions usually appear as homogenously enhanced masses on imaging. Stereotactic biopsy is commonly performed to obtain biopsy material for histological analysis, which is the gold standard for the diagnosis of PCNSL. Understanding of the molecular mechanism underlying the pathogenesis of diffuse large B-cell lymphoma (DLBCL) has been improved through recent advances in molecular genetics. Several pathogenetic mechanisms have been shown to be involved in PCNSL, namely mutations in specific genes  as well as dysregulation in the nuclear factor kappa B (NF-kB), JAK/STAT, Toll-like receptor and B-cell receptor signaling pathways.An aggressive non-Hodgkin lymphoma that affects only the central nervous system, such as the brain, eyes, and cerebrospinal fluid, is termed primary central nervous system lymphoma (PCNSL), which accounts for 4% to 6% of all extranodal lymphomas, as well as for 4% of newly diagnosed malignant brain tumors. Normally, PCNSL starts during the sixth or seventh decade of life, but it can begin earlier in immunocompromised patients. DLBCL accounts for about 90% of PCNSL cases, while T-cell lymphomas, poorly characterized low-grade lymphomas, and Burkitt lymphomas make up the remainder of cases. Immunocompetent and immunocompromised patients can be affected by PCNSL. Congenital and acquired immunosuppression are risk factors for PCNSL. In addition to immunodeficiency, other risk factors are associated with PCNSL that have not been well characterized. Immunocompetent versus immunodeficient individuals exhibit different patterns of PCNSL.,11 It has been reported recently that the PCNSL incidence has steadily increased, especially in elderly patients over 65 years of age, who represent the majority of immunocompetent PCNSL cases.,13 Moreover, PCNSL was identified as an independent poor prognostic factor based on age. Furthermore, elderly patients are more likely to suffer from iatrogenic toxicity than younger ones; therefore, elderly patients are a unique and vulnerable group of patients in need of treatment. A patient over 60 years of age is still at risk of poor outcomes, with 1-year progression-free survival rates reported to be 40% and median overall survival (OS) in the range of 8 to 43 months in elderly patients receiving multi-drug regimens, which included high-dose methotrexate (HD-MTX).–21Males are more likely to be diagnosed with PCNSL, and the median age at diagnosis is 60 years. In patients with PCNSL, the white matter of the brain around the supratentorial midline is usually affected, including the thalamus/basal ganglia area, corpus callosum, paraventricular, cerebellum, brainstem and spinal cord. In most cases, lesions are located near either the ependyma or the pia,,24 and periventricular white matter involvement is common. Intracerebroventricular PCNSL is mainly located in the lateral ventricles and the third and fourth ventricles.,27 In 2013, Cheatle et al reported a case of PCNSL originating from the septum pellucidum in a young woman. Isolated PCNSL in the septum pellucidum has been rarely reported in immunocompetent elderly patients. In the present study, we describe 2 cases of intraventricular PCNSL in immunocompetent elderly patients.In immunocompetent individuals, PCNSL typically presents as a solitary, uniformly enhanced mass, although multiple lesions are seen in 20% to 40% of cases.A 65-year-old woman presented with a 1-month history of memory loss. She had no special history, personal history, or family history. She underwent a thorough clinical examination. Her preoperative Karnofsky performance score (KPS) was 70. On fundoscopy, no changes were observed in the optic disk or retina, and a slit-lamp examination revealed no abnormal findings. The patient showed significant recent memory loss on physical examination of cortical function . The remainder of the physical examination findings were negative. The results of a routine hematological examination were normal. All pituitary hormone levels were normal. Tumor marker levels remained within normal laboratory ranges. Immunological examination for HIV was negative. No suspicious lesions were found on chest/abdomen/pelvic enhanced computed tomography (CT) scans. A 3.4 × 2.6 × 2.7 cm lesion with a low signal in T1-weighted imaging (T1WI) and isosignal in T2WI was seen in the septum pellucidum region on head MRI, and the lesion was significantly enhanced after enhancement . The postoperative KPS score was 90. No complications occurred in the postoperative period. Postoperative enhanced MRI revealed disappearance of the tumor  combined with temozolomide  were given after 2 weeks for 1 year. No radiotherapy was given. At the 23-month follow-up, no evidence of malignancy was found, and positron emission tomography (PET)/CT did not reveal hypermetabolic areas  for 4 cycles + TMZ  was given after 3 weeks for 1 year. No radiotherapy was used. After 19 months of follow-up, there was no evidence of malignancy, and no hypermetabolic foci were detected by positron emission tomography/computed tomography  uptake on positron emission tomography/computed tomography.–37 The MRI-based differential diagnoses of PCNSL in the septum pellucidum region and other CNS tumors in this region are presented in Supplementary table, http://links.lww.com/MD/K693.On imaging, tumors in the septum pellucidum may have one of the following presentations: a tumor is located on one side or occupies the entire septum pellucidum, with clear borders and rare peritumoral edema; a tumor is at an acute angle to the septum pellucidum when it is small and at an obtuse angle when it is large; the septum pellucidum is deviated and a tumor is growing around the Monro foramen area or towards the third ventricle, resulting in unilateral or bilateral ventricular dilatation; or a tumor is growing into other parts of the ventricles and causing compressive edema on the surrounding brain parenchyma. However, PCNSL in the septum pellucidum has unique MRI characteristics of low or equal signal on T1WI, equal or high signal on T2WI, obvious uniform enhancement after enhancement, a high signal in diffusion-weighted imaging, a low signal in the ADC map, a lack of intra-tumor veins and neovascularization in susceptibility weighted imaging, an elevated lipid peak and elevated Cho/N-acetylaspartate ratio on MRS, and high The non-GCB subtype is more likely to occur around the lateral ventricles, and the GCB subtype is more likely to occur in the midline/center and has a better prognosis. Genetic testing usually reveals mutations in MYD88, CD79B, TP53, CCND3, BTG2, PIM1 and other genes. In the present report, both patients presented with memory loss and high cranial pressure, and the MRI and pathological manifestations were consistent with the features reported in the literature. Genetic detection of TP53, PIM1 and MYD88 mutations then further clarified the diagnosis.PCNSL is 95% activated B-cell-like DLBCL, with a few GCB subtypes. as seen in the initial presentations of our patients. More than half of patients with PCNSL suffer from disturbances in the cerebral hemispheres and basal ganglia.,43 T1WI of lymphoma lesions in the CNS commonly show hypointense lesions, and these lesions are iso- to hyperintense on T2WI. Lesions in the brain are generally well-defined and well-separated from the surrounding brain parenchyma, with minimal peritumoral edema. Corticosteroid are believed to greatly influence imaging findings if they lead to shrinkage or disappearance of a tumor, thereby limiting the imaging findings and confounding biopsy results. Thus, imaging and biopsy collection must be performed before steroids are administered. In some cases of PCNSL, a lesion with a diffuse border can be seen, even without the formation of a distinct mass, mimicking a malignant glioma. Histopathology in such cases revealed that the tumor cells invade the neural parenchyma in small clusters or single cells with angiocentric accentuation. Chest, abdomen, and pelvic screening examinations are also needed to confirm that secondary lymphoma is not present.,46,47 In cases of suspected PCNSL, further diagnostic evaluation is essential, including slit-lamp evaluation to detect involvement of the intraocular tissues, which reportedly occurs in about 20% of PCNSL cases.Clinical diagnosis of PCNSL is based on relevant clinical features, radiological findings, and tissue biopsy results. The symptoms of PCNSL are nonspecific, but cognitive decline and gait disturbance are the most common presentations,,49–53 In recent years, numerous studies have reassessed the role of surgery in PCNSL treatment,,54–57 arguing that the earlier studies were small-sample, single-center, retrospective stud done in the absence of standard chemotherapy. Cloney et al concluded that surgical resection of PCNSL was safe for selected patients and had complication rates comparable to other intracranial tumors, with a meta-analysis showing no difference in complications between patients who underwent surgical resection and those who underwent biopsy. However, meta-analysis of more than 1000 patients with PCNSL showed a significantly lower risk of death and disease progression in patients who underwent resection compared to those who underwent biopsy only.Previous research has reported a number of specific characteristics of PCNSL, including infiltrative growth, location in deep or functional areas of the brain, a propensity for cerebrospinal fluid and meningeal dissemination, and sensitivity to radiotherapy and chemotherapy. Many previous studies concluded that surgical treatment is associated with a high risk of complications, minimal clinical benefit, and delayed chemotherapy, and thus, the current literature mostly recommends surgery only in cases with brain herniation causing elevated intracranial pressure. In several studies, surgical excision combined with chemotherapy led to better outcomes than chemotherapy alone, suggesting that multimodal treatment may be more beneficial. Notably, the extent of tumor resection was positively correlated with survival, with a median survival superior to stereotactic brain biopsy and postoperative complications similar to those observed for other intracranial tumors.,60–64 In terms of the specific extent of excision, more extensive resection was associated with better survival. Rae et al and Ouyang et al reported that craniotomy improves the survival rate of PCNSL patients more than biopsy. A single-center study of 167 PCNSL cases showed that the benefit was more pronounced in those who underwent complete tumor resection. A study of 4812 PCNSL cases from the SEER database in the United States showed that complete or partial resection of the tumor improved the prognosis and survival time of patients. Mario et al reported good results for neuroendoscopic resection of intracerebroventricular PCNSL treatment. Patients with PCNSL who received adjuvant radiation therapy (RT) after surgery had a significant survival advantage, according to Kinslow et al. Thus, numerous variables affect the decision regarding whether surgery can benefit a patient with PCNSL. It may be reasonable to consider surgery for patients with a large primary lesion causing a prominent tumor burden in order to improve the patient quality of life. Several factors must be considered in the clinical decision to pursue a debulking surgical procedure, such as the patient age, performance status, and deep brain structure involvement. Surgical intervention may not be an option when tumors are diffuse and affect multiple neurologic structures.The application of modern precision microsurgery techniques and equipment  allows for total tumor resection with maximum protection of neurological function. Therefore, at this time, the advantages of surgery have become progressively more pronounced. Surgery can quickly relieve tumor compression, improve symptoms, clarify pathological diagnosis and shorten the course of chemotherapy. Gross resection of the complete tumor via surgery is an independent prognostic factor for long-term survival.For PCNSL in the hyaloid septal area, preoperative assessment should be adequate, and the frontal cortex, sulcus, and corpus callosum-callosal interspace approaches should be taken according to the location of the tumor and the experience of the operator. Intraoperative accurate judgement and protection of the fornix and peripheral neural structures are the difficulty and key to success of the surgery. We propose that the following points should be given attention during surgery: the fornix embedded in the corpus callosum is a possible site of fornix injury during surgery; the depth of downward separation should be carefully observed when separating the septum lucidum/interseptal space; the fornix should be separated bilaterally through the posterior inferior part of the septum lucidum; and when separating the septum lucidum and the fornix posteriorly, care must be taken to avoid injury of the fornix columns anteriorly to the anterior part of the interventricular foramen. For the 2 patients described in this report, the morphology and position of the fornix and its surrounding structures were altered by the tumor, and the sulcus-lateral ventricle-interventricular foramen approach was used after adequate preoperative assessment by MRI in coronal and sagittal positions, which proved to be suitable for these cases. The operating space and surgical freedom within the lateral ventricle were good. The tumor was clearly delineated from the ventricular wall and mildly adhered to the corpus callosum, and the interventricular foramen was not completely obstructed. The tumor was isolated and completely resected in accordance with the authors’ experience as described above, which effectively preserved the fornix and the peripheral neurovascular structures and avoided the risk of hydrocephalus and metastasis of tumor after implantation of the palliative V-P shunt. Significant improvement in the patients’ symptoms was observed postoperatively without complications.,72 Both cases in this report were treated with HD-MTX combined with TMZ , and no RT was administered.No tumor recurrence was seen at 19–23 months of follow-up. In the future, with the use of new targeted inhibitors , immune checkpoint inhibitors (targeting programmed death receptor-1), immunomodulators and extensive research on chimeric antigen receptor (CAR)-T cell therapy, the prognosis of patients will surely be further improved.There is no standard drug treatment for PCNSL, and HD-MTX–based combination chemotherapy is currently preferred. When combined with TMZ, significantly improved progression-free survival and OS are observed. TMZ readily crosses the blood–brain barrier.Overall, primary CNS lymphomas are underdiagnosed in immunocompetent individuals due to their low incidence and nonspecific symptoms. Primary CNS lymphoma in the septum pellucidum region in the elderly with normal immune function is rare. The 2 patients in our current report were presented with memory loss and increased cranial pressure as the first symptoms, which need to be differentiated by neuroimaging from intracerebroventricular central neuroblastoma and others. The tumor was completely removed using a precise microsurgical technique, and it was clear intraoperatively that the tumor originated in the hyaline septum. The fornix column and corpus callosum were well protected during the surgery, and patients with postoperative memory loss recovered to varying degrees without cognitive or mental impairment. The postoperative treatment plan, HD-MTX combined with TMZ, which is economical, has good blood-brain barrier permeability and low neurotoxicity, has achieved good results. Memory, emotion, and mental disorders in septum pellucidum may be caused by the degeneration of the surrounding structures . Intraoperative identification and protection of the fornix and peripheral neural structures are difficult but critical to the success of the surgery due to the disruption and displacement of normal anatomical structures by the tumor. The follow-up time for the 2 presented cases was short. Longer follow-up is needed to confirm whether surgical resection of the tumor and administration of combination treatments can improve the prognosis and survival time as compared to biopsy alone, and whether potential complications such as cognitive deficits will occur in the distant future. The results of this study are summarized in the following table.https://www.medjaden.com/show-790.html) for English language editing and review services.The authors would like to thank Medjaden Bioscience Limited (Formal analysis: Xu Yan, Kun Xue.Writing – original draft: Liuzhe Lu, Xuechao Dong.Writing – review & editing: Dawei Chen.


Uterine rupture is a life-threatening peripartum complication. Spontaneous uterine rupture in early pregnancy is very rare. The diagnosis of uterine rupture should be considered when a pregnant patient presents with an acute abdomen because its clinical signs in early pregnancy are non-specific and the differentiation with other acute abdominal emergencies is challenging. Here, we present a case of acute abdominal pain. The patient was a 14-week pregnant 39-year-old female  with a history of two lower-segment cesarean sections. Our preoperative diagnosis was either heterotopic pregnancy or acute abdomen. Emergency laparotomy confirmed the presence of a spontaneous uterine rupture. The rupture of a pregnant uterus is a life-threatening complication in obstetric practice with high maternal and fetal mortality. Uterine rupture (UR) can be complicated by hypovolemic shock, bladder injury, need for hysterectomy, and maternal death .Early pregnancy UR is rare with several reported cases, but the actual rate of incidence is unclear in the current literature . The risThe classic symptoms described for third-trimester UR include acute-onset abdominal pain, vaginal bleeding, and non-reassuring fetal heart rate tracing. Unfortunately, these symptoms may not be present, especially with UR in early pregnancy .Here, we describe the importance of including UR in the differential diagnosis of severe abdominal pain in early pregnancy by reporting a case of massive hemoperitoneum in a 14-week pregnant female due to spontaneous UR that was discovered during laparotomy.A 39-year-old pregnant female  with a gestational age of 14 weeks  presented to our emergency department with a history of acute, severe lower abdominal pain for 12 hours and vomiting three times. She had a history of two previous lower-segment cesarean sections (CSs), with the last one a year ago. There was no history of other uterine surgeries or procedures. She denied any history of trauma. She was on regular antenatal care at another healthcare facility.On physical examination, the patient was conscious, oriented, and pale, and her limbs were cold and clammy. Her heart rate was 99 beats/minute, and her blood pressure was 100/70 mmHg. Abdominal examination revealed distension, guarding, and generalized tenderness with rebound tenderness all over the patient’s abdomen. The patient denied any vaginal bleeding, and per vagina examination was unremarkable. She was resuscitated, stabilized, and given analgesics. Urgent ultrasonography showed marked free fluid throughout the abdomen and pelvis (Figure An intrauterine single viable fetus corresponding to 14 weeks and three days gestation and a hematoma were seen surrounding the bulky gravid uterus Figure .9/L, respectively. The coagulation profile was normal. The patient was urgently referred to obstetrics and gynecology for the suspected rupture of a heterotopic pregnancy. The risk of abortion was explained, and signed consent was obtained. Exploration laparotomy was done under general anesthesia with the appropriate premeditations. It showed the complete rupture of the anterior wall of the uterus, extending from the fundus to the isthmus with a defect of approximately 6 cm. The fetus and placenta were found in the uterine cavity. However, a primary ultrasound scan showed an anteriorly placed placenta with a small underlying hypoechoic area of retroplacental separation. The defect was repaired with Vicryl-1 in three layers. The abdominal cavity was washed with normal saline. The ovaries and tubes were unremarkable, no tubal ligation was done, and the urinary bladder was intact. The estimated blood loss was nearly 1.8 L. Pregnancy was terminated, and the patient received three units of blood in the operation theater. There were no postoperative complications and the patient recovered well. She stayed for three days in the hospital and was charged with outpatient clinic follow-up. The four-week follow-up was satisfactory.The ovaries were hardly differentiated from a sizable pelvic hematoma. As the patient started to show signs of shock, she was given blood and blood products. Laboratory investigations showed hemoglobin and platelet levels of 8.5 g/dL and 258 × 10Spontaneous UR in early pregnancy is a rare but serious obstetric complication, especially if associated with a wrong or late diagnosis. Several cases have been reported in the literature ,7-11. ThThe early diagnosis of UR is difficult because typical clinical manifestations include abdominal pain, fetal heart irregularities, and vaginal bleeding . These aUltrasonography can be helpful. Finding an abnormality in the uterine wall, a hematoma next to a hysterotomy scar, free fluid in the peritoneum, anhydramnios, or fetal parts outside the uterus are findings supportive of UR diagnosis. However, the diagnosis is often confirmed when hemoperitoneum and fetal parts are identified outside the uterus during laparotomy . Our patUR should be considered in any pregnant woman with free fluid in the abdomen or hemoperitoneum, even when there are no identifiable risk factors in the obstetric history. Complete rupture of the uterus from the fundus to the isthmus can be encountered. Although UR in early pregnancy is rare, it must be kept in mind because early diagnosis and intervention can save the mother’s life.


Chronic subdural haematoma is a common neurological condition especially among the elderly population. Its presentation can be unspecific but often attributed to pressure, cortical irritation, and/or vascular compromise. In the patients’ cohort presented below, we have a series of cases where clinical history and examination did not result in an initial clinical diagnosis or suspicion of chronic subdural haematoma, with the diagnosis made only after brain imaging. We reviewed the literature regarding the aetiopathogenesis and clinical features of our patient cohort, which included a young woman with isolated right ptosis and pupillary dilatation, an elderly man with paraplegia, another elderly man with isolated right foot drop, and a young military man with no history of trauma. Our series re-emphasizes the sometimes non-specific and varied clinical presentation of chronic subdural haematoma. We reiterate the need for early brain imaging in patients who present with neurological disorder. Chronic subdural haematoma (CSDH) is a common neurological condition especially among the elderly population . The aetThe initial trauma may be so mild, especially in the elderly, that they may go unrecognized. The haematoma that forms may progress insidiously over a period during which the patient may be asymptomatic. With the initial formation of acute SDH, an inflammatory process begins which leads to the development of a fibrous membrane along the internal and external layers of the clot. With the passage of time, this new membrane undergoes reorganization several weeks after injury .Inflammatory response results in the expansion of the haematoma and perpetuation of the pathological process , 6. Thiset al. and Kawakami et al. [In addition to the inflammatory response, abnormal angiogenesis contributes to increased clot volume through persistent micro-haemorrhages and rebleeding, thus creating a vicious cycle of inflammation and haemorrhage. Activation of the coagulation mechanism and attendant hyperfibrinolysis results in a local coagulopathy within the haematoma cavity. This has been demonstrated by Shim i et al. , 11.The symptom-complex of CSDH is either from direct physical compression of an anatomic area of the brain or an indirect effect from compromise of a particular vascular territory , 13. TheA 42-year-old woman presented to the outpatient clinic with a 2-week history of headaches and 3-day history of drooping of the right eye and inability to open the eye. She had been involved in a passenger road traffic accident 3 weeks prior. At presentation she was fully conscious, and oriented in time, place, and person. However, she had a recent onset painless drooping of the right eyelid . Her visBrain CT scan done revealed a right fronto-temporal CSDH causing uncal compression and midline shift as well as partial effacement of the ipsilateral lateral ventricle .She underwent a right frontal and parietal burr hole drainage of the haematoma under local anaesthesia and sedation. Her post-operative course was satisfactory, and she was discharged on the 4th day post-surgery. She had complete resolution of her symptoms in 2 weeks .A 72-year-old man who was admitted by the orthopaedic team on account of progressive lower extremity weakness of 3 weeks duration that culminated in his inability to ambulate independently. He had no other neurologic symptoms. He denied history of prior trauma. Although he was a known hypertensive, he had not been on antiplatelets. His neurologic examination revealed a fully conscious elderly man who was awake, alert, well oriented in time, place, and person. Other neurologic examination findings were normal except for grade 2 power in both lower limbs. His deep tendon reflexes were normal in all extremities. Sensory function was intact.Prior to this, he had been managed for low back pain and lumbar spondylosis. Spine MRI done prior to neurosurgery consultation did not explain the lower extremity motor weakness. Brain CT done revealed bilateral fronto-parietal CSDH . He was A 78-year-old man with a 1-week history of headaches and dragging of the left foot. He had fallen in the bathroom 6 weeks prior to presentation. He had no other symptoms. Examination was unremarkable except for a left-sided foot drop with increased ankle jerk reflex. Brain CT done revealed a right-sided fronto-parieto-temporal CSDH  and 4. HA 40-year-old military man who presented with a 1-week history of severe generalized headaches that was unresponsive to analgesics. He had two episodes of non-projectile vomiting before presentation. There were no other symptoms. He denied any history of trauma. He was not on any anticoagulants and had been otherwise healthy. Neurologic exam was normal. Brain CT scan done showed a right-sided fronto-parietal CSDH . With thSymptoms and signs of CSDH are notoriously unspecific. This has led to CSDH being reported in neurological literature as a ‘great mimic of neurological disorders’ . ClinicaIsolated third nerve palsy is extremely rare, with only ~16 cases reported in literature [Another unusual presentation was paraparesis in a 72-year-old man. With a long-standing history of low back pain and lumbar spondylosis, an initial diagnosis of degenerative spine disease was considered. However, with an unremarkable spine MRI, a brain CT was done and it revealed a bilateral CSDH with extension into the anterior inter-hemispheric fissure. We postulated that the bilateral motor involvement of the lower extremity could be from two possibilities.The first possibility was a direct compression of the lower limb motor strip against the falx cerebri from the bilateral subdural collection like what is seen in a parasagittal meningioma .et al. [Second, subfalcine herniation could result in the compression of the branches of the anterior cerebral artery with resultant ischaemia of the medial surfaces of the frontal lobes, which bears the motor homunculus of the lower extremities. Koyama et al.  demonstret al. [While few reports of bilateral lower extremity weakness have been reported with CSDH, unilateral foot drop is extremely rare. Two previous cases of isolated foot drop from CSDH have been reported, Sengupta et al.  and Weiset al. . Direct In another unusual case, we review a rare case of a ‘roller-coaster’ phenomenon presenting with CSDH. Interestingly, extensive literature search did not yield any report of CSDH occurring with bumpy road rides in a young fit adult. Instead, few reports of CSDH occurring from acceleration-deceleration-type phenomenon have been reported in literature.Scranton and colleagues described a case of symptomatic bilateral SDH associated with riding a centrifugal motion simulator in a previously healthy 55-year-old male . The suset al. reported roller coaster headaches and subacute SDH in an otherwise healthy 45-year-old female with no other medical problems [Williams problems . The patRotational acceleration-deceleration forces have been found to cause very rapid deformations in the brain parenchyma as well as brain vasculature. These forces are measured in G, where 1G is the acceleration experienced by a free-falling object near the surface of the earth or 9.81 m/s2 or 32.2 ft/s. The magnitude, rate of change, and duration of G forces at play are important determinants of injury , 23.et al. [The report of CSDH following eccentric exercise using vibrating belts by Park et al.  supportsThe effect of these G forces alone does not tell the whole story. An important finding is that individual brain deformation differs significantly, and this may be the reason for the differences in injury susceptibility among different people . Even thThis series of uncommon presentations of a common neurosurgical disease re-emphasizes the non-specific features of CSDH especially in the older population. All four of the patients did not have CSDH as their initial diagnosis. However, on imaging the diagnosis of CSDH was made, underscoring the value of routine early brain imaging in patients who present with florid neurological symptoms and signs such as the patient cohort in this series.


Gallstone ileus is a rare condition. It accounts for approximately 1% of small bowel obstruction and is more prevalent in the elderly population. It is usually present in relatively comorbid patients posing further operative challenges. The following report investigates the management of two large gallstones resulting in two different points of obstruction. Is double trouble doubly hard to manage? Mr. X, a New Zealand European 82-year-old male with a background of a previous transient ischaemic attack, hypertension, and osteoarthritis, presented with two months of abdominal bloating, constipation, and generalised abdominal pain. There was no prior history of cholecystitis or known cholelithiasis. He describes intermittent bouts of large-volume vomiting and progressive abdominal distension. He presented two months prior with a similar episode which was deemed to be secondary to an incarcerated umbilical hernia for which he underwent primary repair under general anaesthesia (GA). Of note, the umbilical hernia was found to contain an incarcerated omentum only with no bowel involvement, and the compromised omentum was resected.On examination, the patient was noted to have a markedly distended abdomen which was generally tender but not peritonitic. His white cell count and c-reactive protein were both slightly raised above normal at 16 and 9, respectively, and his liver functions were normal. Other investigations included a chest X-ray and a CT abdomen-pelvis . A 2 cm Mr. X proceeded for laparotomy and enterotomy after the insertion of a nasogastric tube and intravenous line. A midline laparotomy was performed. A large calibre small bowel was identified. A large gallstone was initially encountered in the jejunum on inspection; however, the small bowel appeared to be very dilated distal to this as well. On further inspection, a second stone was also identified (as reported on the imaging) in the distal ileum . The smaPostoperatively, the patient's diet slowly progressed from sips to free oral fluids as we presumed he would have a prolonged ileus given the chronicity and double stone presentation. However, he was passing flatus by day 3 and progressed well to a normal diet by day 4. He was discharged home on day 7 postadmission and is currently at home awaiting outpatient follow-up to discuss a cholecystectomy; however, given his age, it is unlikely we will go forward with this –10.Gallstone ileus is usually caused by obstruction at the distal ileum and is classically seen in elderly female patients , 6, 11. In this scenario, regarding an elderly gentleman, there was obstruction at both the ileum and the jejunum. Whether his initial presentation of incarcerated umbilical hernia was also perpetuated by the presence of these stones is uncertain, as there was no imaging performed at this point .In this patient's case, the mechanism of gallstone ileus appears to be originally caused by a bout of cholecystitis, as expected as the root cause of all gallstone ileus cases. However, it appears that the subsequent pericholecystic inflammation and resultant adhesions around the biliary systems and bowel that were in close proximity have led to two stones being passed through these adhesions , 13.It would be feasible to assume the second stone was held up at the jejunum, resulting in thickening and stenosis secondary to the hold-up created by the first stone obstructing the distal ileum.While this presentation was unusual, we can suffice to say the patient made a remarkable recovery given his presentation and having had two GAs within close proximity.


Pseudo broad ligament fibroids originate in the uterus but grow into the broad ligament while retaining their attachment to the uterus. We report a case of a right-sided pseudo broad ligament fibroid mimicking an adnexal mass in a 40-year-old woman presenting with dysmenorrhoea and heavy menstrual bleeding. She had a uterine mass corresponding to an 18-week pregnant uterus size, which clinically and radiologically posed a diagnostic dilemma between an ovarian cyst, a bicornuate uterus with multiple fibroids, and a broad ligament fibroid. She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy, which revealed a pseudo broad ligament fibroid of 12x10x6 centimeters, weighing 1.2 kg. The histopathology report confirmed the diagnosis of a leiomyoma with normal ovaries. Fibroids in the broad ligament, though rare, occurring in less than 1% of all fibroids, are the most common extrauterine leiomyomas [A 40-year-old female, para one, with a previous cesarean section, non-tubectomized, presented with complaints of heavy menstrual bleeding and dysmenorrhoea for one year. There were neither disturbances in her bowel and bladder habits nor a history of weight loss. There were no associated comorbidities and no history of ovarian or breast cancers in the family. On general examination, she had a BMI of 21 kg/m2 and mild pallor. Her pulse was 88 beats per minute, regular and with good volume, and her blood pressure was 118/80 mmHg in her left arm in the supine position. Her abdominal examination revealed a mass in the hypogastrium corresponding to an 18-week-old uterus. It was palpable more on the left side within the hypogastric region. However, its lower margin was not palpable. Another mass corresponding to an 18-week-old uterus was palpated on the right, adjacent to the above mass. This mass was firm and regular, with a positive groove sign . The lower extent of the mass was difficult to ascertain. On per-speculum examination, a single cervix was seen. The cervix and vagina were unremarkable. Per vaginal examination, an anteverted, 18-week-size uterus was revealed that was separate from the mass. The mass was smooth and firm and occupied the posterior fornix. Bilateral fornices were full but non-tender. We suspected a fibroid or an adnexal mass.Her routine investigations were within normal limits. Her cancer antigen (CA) 125 levels were 6.8 U/ml . Preliminary ultrasonography of the abdomen revealed a suspected bicornuate uterus with a bulky right horn. However, the opinion of a senior radiologist after repeating detailed ultrasonography revealed a bulky uterus with a submucosal fibroid measuring 3x3 cm and an adnexal mass measuring 10x8 cm, most likely a subserosal or broad ligament fibroid. Computerized tomography (CT) in Figure A well-defined heterogeneously enhancing soft tissue density lesion was noted in the right adnexa measuring 11x10x10 cm, which was seen separately from the ovary. The mass derived its blood supply from the internal iliac artery and caused the displacement of the pelvic organs. The CT was suggestive of a broad ligament fibroid. The patient was worked up for laparotomy with a total abdominal hysterectomy.The patient underwent a laparotomy under spinal anesthesia. Figure The right fallopian tube was pulled over the fibroid. A loop of the small intestine was adhered to the fibroid by thin adhesion, likely suggesting a parasitic blood supply. The left-sided round ligament was stretched, and the uterus was deviated to the left. The uterus was eight to 10 weeks in size and was unremarkable. The ureteric course was determined to be lateral to the fibroid, suggesting its uterine origin.She underwent a total abdominal hysterectomy with bilateral salpingo-oophorectomy by the routine method as seen in Figure The patient had an uneventful recovery in the postoperative period. The histopathology report showed a leiomyoma with hyaline degeneration, as seen in Figure Fibroids, the most common neoplastic growth in the uterus, may occur at extrauterine sites, the broad ligament being the most common site. Broad ligament fibroids (FIGO 8) are either true, i.e., primary, or false, which is secondary. True broad ligament fibroids arise from the smooth muscle tissue in the broad ligament. False broad ligament fibroids originate in the uterus but grow into the broad ligament while retaining their attachment to the uterus. The ureter and uterine artery run laterally to the fibroid, which may coexist with uterine fibroids .A broad ligament fibroid may cause compression symptoms like urinary and bowel dysfunction, depending on the organ being compressed. When coexisting with intramural or submucosal fibroids, they may cause menstrual symptoms , as was Large, broad ligament leiomyomas often displace adjacent organs and distort pelvic anatomy, increasing the risk of injury to the ureters and adjoining structures . Its locBroad ligament fibroids pose a diagnostic challenge for both the gynecologist and the radiologist. An ultrasound may not suffice to differentiate these from ovarian masses, and other aids like an MRI or CT scan would be required. Concurrent uterine fibroids may be present, causing menstrual symptoms along with pressure symptoms. The surgical approach must be kept in mind to avoid injury to the ureters and surrounding structures due to distorted anatomy. Preoperative ureteric stenting can be considered to avoid injury to the ureters in cases of large and unusual fibroids. Our case highlights the need to keep in mind the various differential diagnoses while dealing with suspected adnexal masses, the diagnostic challenges faced, and the surgical approach required to reduce injuries while operating on broad ligament fibroids.


Intestinal obstruction is a common surgical emergency encountered almost in every casualty. Though adhesions, hernias and malignancies are the common causes of obstruction, various articles describe unusual causes of intestinal obstruction which needs timely surgical interventions to prevent morbidity and mortality.In this case report we present the history of a 50 year old sub-fertile woman who presented with features of intestinal obstruction and confirmed radiologically with both plain x-ray and computed tomography. After conservative management and as the imaging didn't show the cause of obstruction, exploratory laparotomy was performed. There we found have encircling of left fallopian tube around mid-ileum with gangrenous part. Left salphingectomy and bowel resection with side-to-side anastomosis resulted in a favorable outcome.Intestinal obstruction can compromise blood flow to bowel loops leading to gangrene, perforation and death.Awareness, early recognition and timely intervention in intestinal obstruction is mandatory to prevent poor outcomes, especially in cases of unknown cause and not responding to conservative management. The real surgical challenge is not the decision whether to perform surgery, but the decision when and how to perform it. •Intestinal obstruction is a common surgical emergency encountered almost in every casualty.•Though adhesions, hernias and malignancies are the common causes of obstruction, various articles describe unusual causes of intestinal obstruction that needs timely surgical interventions to prevent morbidity and mortality.•Intestinal obstruction can compromise blood flow to bowel loops leading to gangrene, perforation and death.•Awareness, early recognition and timely intervention in intestinal obstruction is mandatory to prevent poor outcomes, especially in cases of unknown cause and not responding to conservative management. Around 20 % of cases with acute abdominal pain are due to intestinal obstruction, mostly small bowel ,2. Most 2A 50 year old sub fertile female presented with history of sudden onset of generalized colicky pain of 1 day duration. It was associated with repeated bouts of non-bilious vomiting and not passing flatus. She didn't have abdominal distension or fever. In the past she was investigated for subfertility and underwent laparoscopic fimbrial cystectomy of the left fallopian tube. She also had undergone open appendicectomy in the past. No other significant past medical history.On examination she was haemodynamically stable, abdomen was soft with no palpable masses and bowel sounds were sluggish. Digital rectal examination was unremarkable. Her urine HCG (human chorionic gonadotropin) dipstick test was negative. She was investigated in view of intestinal obstruction. Supine x ray of abdomen showed dilated small bowel loops, erect chest x ray was normal and ultrasound sonography shows free fluid in the abdomen with features of small bowel obstruction. After 48 h of conservative management, no improvement in bowel sounds and bowel opening. Contrast Enhanced Computed Tomography (CECT) showed features of small bowel obstruction with the transition point in the mid ileum and cause for obstruction not identified. As the imaging done failed to show the cause of obstruction, it was decided to proceed with explorative laparotomy , Fig. 2.Lower midline incision was made and peritoneum was entered. Moderate amount of blood-stained free fluid was found in the cavity. There were no evidences of adhesions that may have caused this obstruction. Impending gangrenous bowel loops were identified and the gangrenous part was encircled by the left fallopian tube. Free end of the fallopian tube strongly adhered to the ovary and broad ligament. In order to release the small bowel without spillage left side salphingectomy has to be done. So, on table consultation was taken from the gynecologist for the salphingectomy. Viability of the bowel loops was tested. Nearly 2 ft of unviable small bowel loop identified and was resected with its mesentery close to the loops. Side to side anastomosis was done using linear staplers. Mesentery defect was closed with absorbable suture material. Her post-operative period was unremarkable, oral intake started on the day 3 with clear fluids and gradually to her normal diet. She was post operatively followed up with duration of 2 weeks, 2 month and 6 month time period to assess her nutritional status, bowel habit and to exclude other features of short bowel syndrome.3Intestinal obstruction is one of the common emergency encountered in surgical field, accounting for nearly 20 % of admissions presenting with acute abdominal pain. In intestinal obstruction more than 75 % are due to small bowel obstruction. Post surgical adhesions are the leading cause of small bowel obstruction while hernias and strictures are next in the list. Colorectal cancer is the leading cause of large bowel obstruction. ,4Cardinal features of obstruction are abdominal pain, vomitting, absolute constipation and abdominal distension. Small bowel obstruction diagnosis is mainly based on a clinical examination and by confirmatory radiological examinations such as plain X ray of the abdominal cavity or computer tomography. Plain supine abdominal x-rays are diagnose small or large intestinal obstruction based on the transverse bands across the bowel and differentiating level of obstruction by small bowel loops located centrally where as large bowel seen peripherally. Erect chest x ray to be done in abdominal tenderness to exclude perforation. Sri Lanka is developing nations and resources are very limited. Though CT is available immediate access is limited; so x-ray was used as a first line investigation.Contrast enhanced CT important with regard to precise detection of causes of obstruction (other than postoperative adhesions or strangulation) and can be used to differentiate between patients requiring surgeries and patients who can be managed conservatively . EntericIn initial management of intestinal obstruction fluid resuscitation and electrolyte replacement with that decompression of proximal bowel by nasogastric tube placement .Cause for the small bowel obstruction mostly determines the mode of treatment. Period of conservative management can be continued for 48 to 72 h in that majority of cases will resolve . But litA case of intestinal obstruction caused by encircling fallopian tube which is very much similar to our case. In the above case a loop of ileum was encircled by right fallopian tube. Right side salpingo oophorectomy was done to release the bowel loop .Another case where a defect in the broad ligament and fallopian tube acting as a band around the bowel and causing obstruction . In a caLaparoscopy can be used as a final diagnostic tool to look for the disease and to determine further surgical management whether to continue with laparoscopically or laparoscopic-assisted open approach. In our case, exploratory laparotomy was performed but it would be better with a laparoscopic-assisted open approach. Initially, gastrointestinal obstruction is self-contraindication for laparoscopy, with time change to relative contraindication. Now, the absolute contraindication for laparoscopy in a patient with small bowel obstruction is haemodynamic instability and cardiopulmonary impairment . Relativ4This case highlights the importance of clinical judgement to decide on operative management in small bowel obstruction of unknown etiology not responding to conservative management.Written informed consent was obtained from patient. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethical approval is waived by the Ethical Review Committee of Teaching Hospital, Jaffna, Sri Lanka.No funding was provided.Study concept – V. Niroshan, S.T. Sarma.Data collection – V.Niroshan, S. Theivaagar, P. Abiharan.Interpretation - V. Niroshan, S.T. Sarma, S. Theivaagar.Manuscript preparing - V. Niroshan, S.T. Sarma, P. Abiharan.V. Niroshan.N/A.The authors have no competing interests.


The management of precancerous colonic lesions has radically changed with the progress in endoscopy, especially therapeutic endoscopy. Large or suspected polyps were formerly managed surgically. Endoscopic submucosal dissection has completely changed the management of this kind of lesion, exposing patients to fewer postoperative complications.We report the case of a 76-year-old women with a history of ileocecal resection with ileocolic anastomosis for benign cecal tumor. A few years later, she presented with chronic abdominal pain, clinically significant weight loss, and recurrent digestive bleeding requiring hospitalization for repeated transfusionsUnfortunately, symptoms did not improve with medical treatment. A second colonoscopy was performed a few months later  and revVideo 1 Chronic ileal ischemia following cecal resection with ileocolic anastomosis for huge polyp.This is the first reported description of chronic ischemic ileitis after resection of a noncancerous colonic lesion. It illustrates the importance of endoscopic management of precancerous lesions by endoscopic submucosal dissection, thus avoiding more invasive management and allowing organ preservation.Endoscopy_UCTN_Code_CCL_1AD_2AF


The patient exhibited superomedial scapula angle osteochondroma with winging, a rare manifestation of scapular osteochondroma. The patient had a slow-growing mass on the left scapula for several years. Physical examination revealed a visible deformity with significant winging of the scapula. Imaging studies demonstrated a large osteochondroma arising from the superomedial angle of the left scapula, with a bony stalk. (3) Results: Surgical excision was performed, and histopathological analysis confirmed the diagnosis of osteochondroma. Following the surgery, the patient experienced a significant improvement in scapular winging. A comprehensive literature review revealed only a limited number of reported cases of scapular osteochondroma with winging, underscoring the significance of this case report as a valuable addition to the existing literature. The diagnosis of scapular osteochondroma should be considered in the differential diagnosis of patients presenting with a scapular mass, particularly when associated with winging. Surgical excision is the recommended treatment, and complete excision is crucial to prevent recurrence. (4) Conclusions: This case report highlights a rare presentation of scapular osteochondroma with winging and emphasizes the importance of considering this diagnosis in patients with scapular masses accompanied by winging. The successful surgical intervention in our case resulted in significant improvement. Clinicians should be aware of this entity and consider prompt surgical intervention for complete excision, ensuring optimal patient outcomes and preventing recurrence. Further research and additional case reports are necessary to enhance our understanding of scapular osteochondroma and its varied clinical presentations. Furthermore, comprehensive studies involving larger patient cohorts are necessary to explore the full spectrum of clinical presentations of scapular osteochondromas. By documenting and analyzing a wider range of cases, including variations in tumor location, size, and associated symptoms, researchers can identify patterns and establish more accurate diagnostic criteria. This will facilitate early detection and appropriate management of scapular osteochondromas, ultimately improving patient outcomes. Scapular winging is a distinct condition characterized by the abnormal protrusion of the scapula from the back, giving it a noticeable “wing-like” appearance . This poOsteochondromas are benign bone tumors that have the potential to develop in any bone. However, they are most frequently encountered in the long bones of the arms and legs. Osteochondromas originating in the scapula are considered rare, and those specifically located in the superomedial angle of the scapula are even rarer. These superomedial scapular angle osteochondromas present unique challenges in terms of diagnosis and management. Understanding the clinical presentation, diagnostic approaches, treatment options, and outcomes associated with this rare manifestation is crucial for providing appropriate care to affected patients .Superomedial scapular angle osteochondroma with winging is a rare condition, with an estimated prevalence of 0.003% to 0.02%. This means that it is estimated that there are only 3 to 20 people in every 100,000 people who have this condition. The condition is more common in females than males, with a female-to-male ratio of 2:1 .This article aims to present a noteworthy case of superomedial scapular angle osteochondroma associated with scapular winging in a young female patient. By analyzing this case, we aim to shed light on the clinical characteristics and management strategies specific to this rare condition. Furthermore, a comprehensive review of the existing literature on scapular osteochondromas and associated winging will be conducted to further enhance our understanding of this unique manifestation.Through an in-depth examination of the presented case and a thorough review of the literature, we hope to contribute valuable insights into the clinical features, diagnostic modalities, treatment options, and prognostic considerations associated with superomedial scapular angle osteochondroma with winging. This information will not only enhance our knowledge of this rare condition but also assist healthcare professionals in making informed decisions regarding diagnosis and management.Scapular winging caused by osteochondromas is a rare manifestation that can significantly impact a patient’s quality of life. While nerve injuries are the most common cause of scapular winging, bony abnormalities such as osteochondromas can also contribute to its development. The occurrence of osteochondromas in the scapula, particularly in the superomedial angle, is considered rare . This arThe rarity of this case highlights the need for a comprehensive literature review to identify and analyze previously reported instances of scapular osteochondromas with associated winging. By consolidating the available information, healthcare professionals can gain valuable insights into the diagnosis, management, and treatment outcomes of this unique presentation. This case report not only adds to the existing literature but also emphasizes the importance of considering scapular osteochondromas in the differential diagnosis of patients presenting with scapular masses, particularly when scapular winging is observed.Osteochondromas, benign osseous tumors arising from growth plates, predominantly manifest in long bones, and when affecting the scapula, may induce complications such as winging given their proximity to nerves and soft tissues. Radiologically, they are characterized via:-Exostosis: Evident as a distinct bony projection from the scapular cortical bone, typically orienting away from the closest joint;-Bone continuity: Osteochondroma cortical bone is in seamless continuity with the host scapular bone, as is the marrow space;-Skeletal alteration: Osteochondroma may precipitate visible scapular deformity.X-ray:-Cartilaginous cap: Osteochondromas characteristically bear a cartilaginous cap, observable on MRI as a high-intensity signal on T2-weighted images; a cap exceeding 1–2 cm thickness in adults could indicate a rare malignant transformation;-Bone marrow continuity: MRI echoes X-ray findings of osteochondroma and host marrow continuity;-Soft tissue implication: MRI can offer intricate details on the osteochondroma’s influence on surrounding soft tissues, inclusive of muscles, nerves, and vessels.MRI:These are typical findings; however, variations exist, and diagnosis should align with clinical history and presentation.In conclusions, scapular winging is a distinct condition characterized by the protrusion of the scapula, primarily caused by muscle weakness or paralysis. While nerve injuries are the most common etiology, bony abnormalities such as osteochondromas can also contribute to this condition. Superomedial scapular angle osteochondromas are rare occurrences, further underscoring the significance of this case report. By reviewing the literature and sharing this unique case, we contribute to the understanding and awareness of scapular osteochondromas with associated winging.A 24-year-old female presented to our clinic with a six-month history of pain and swelling in her right shoulder. The patient presented with a protrusion of the left scapula, emanating from the dorsal region, leading to significant discomfort. On physical examination, we noted a prominent left scapula that was winging from the back. There was also a palpable, firm mass in the superomedial angle of the left scapula. Imaging revealed a bony mass in the superomedial angle of the left scapula consistent with an osteochondroma .CT showed that the mass was attached to the scapula and had caused erosion of the scapular bone .The patient underwent surgical excision of the osteochondroma, and her symptoms improved postoperatively. Follow-up radiographs at 1, 3, 6, and 12 months showed no evidence of recurrence. At present, the patient’s follow-up is conducted every 6 months, accompanied by regular radiological investigations.The management and treatment of scapular winging with osteochondromas depend on the severity of the symptoms and the size and location of the osteochondroma. In asymptomatic cases, observation may be appropriate, with regular monitoring to detect any changes in the size or symptoms of the osteochondroma.However, in cases where the osteochondroma is causing significant pain, weakness, or functional limitations, surgical excision is the treatment of choice. The goal of surgery is to remove the osteochondroma and any associated bone or soft tissue that may be contributing to the scapular winging. In some cases, the scapula may need to be stabilized or repositioned during surgery to prevent recurrence of the scapular winging.There are several surgical approaches to the excision of scapular osteochondromas, including open or arthroscopic approaches. The choice of approach depends on the size and location of the osteochondroma, as well as the surgeon’s preference and expertise.A 5 cm longitudinal incision, 0.5 cm medial to the medial border of the right scapula, centered on the superomedial angle. Following skin incision and dissection of the fat tissue, a split of the rhomboid fibers was performed, revealing the base of the tumoral mass .Carefully, peritumoral dissection was continued up to the tip of the scapula, palpating the contour of the second rib which was in contact with the tumor.Resection of the base of the tumor was performed with an oscillating saw followed by detachment and removal of the osteochondroma.Carefully, bleeding control was assured together with excision of the bursal peritumoral tissue .Closure with interrupted sutures of the subcutaneous tissue and intradermic suture with performed at the end of the procedure.The sutures were removed at 14 days postop.After surgical excision, patients may need to undergo physical therapy to restore strength and range of motion to the shoulder and scapula. They may also need to wear a brace or sling for several weeks to support the shoulder and allow for proper healing.The histopathological examination performed on the surgically removed tissue sample shows us that the existing tumor mass is an osteochondroma .Histopathological Examination ReportLaboratory sample registration number: 17915/23.Specimen analyzed: Tumor formation in the right shoulder blade.Macroscopic Description:2. The specimens were processed after prior decalcification.The specimen consists of a bone fragment with a polypoid excrescence measuring 3.5 cm in maximum diameter, along with a separate fragment measuring 1.5 × 0.8 cmMicroscopic Description:Microscopic examination of the sections reveals trabecular bone tissue with hematogenous marrow. The bone tissue shows benign tumor proliferation, which is covered by a thin layer of perichondrium. A subjacent cartilaginous cap is present, composed of chondrocytes arranged in columns. These chondrocytes exhibit minimal atypia and increased cellularity towards the depth of the lesion. Endochondral ossification is observed, with the formation of bone trabeculae at the base of the lesion.The separate fragment consists of a few bone trabeculae along with conjunctive-vascular and adipose tissue. The resection margin shows healthy tissue.Histopathological Diagnosis:Based on histological appearance, the diagnosis corresponds to an osteochondroma (exostosis).Informed Consent:In accordance with ethical guidelines, informed consent was obtained from the patient for the purpose of this case study and subsequent publication. Care was taken to ensure that the patient understood the nature of the case report, its potential benefits, and possible implications.Privacy and Anonymity:To protect the patient’s privacy, all identifying information has been removed or altered in the case report and any accompanying images. The patient’s anonymity has been preserved to the fullest extent.We affirm that the ethical guidelines were thoroughly followed while preparing this case report and literature review, keeping the welfare of the patient and the integrity of the scientific community in mind.During the six-month follow-up, the patient reported remarkable improvement in her shoulder pain and weakness. She stated that the symptoms had completely resolved, indicating a successful outcome of the surgical intervention. Upon examination, no scapular winging was observed, indicating the restoration of normal scapular positioning. Imaging studies conducted at the follow-up visit confirmed the complete excision of the osteochondroma, affirming the efficacy of the surgical procedure.The patient’s post-operative recovery involved a two-week period of immobilization in an elbow sling. This approach allowed for the passive range of motion of the shoulder joint while ensuring the necessary protection and support. The patient’s progress was carefully monitored by a physical therapist throughout this immobilization period. Following the immobilization phase, a tailored rehabilitation program was initiated, focusing on active assisted range of motion (AAROM) and active range of motion (AROM) exercises. These exercises were performed under the supervision and guidance of the physical therapist.The rehabilitation program aimed to gradually restore the patient’s shoulder function, strength, and mobility. The physical therapist closely monitored the patient’s progress, adjusting the exercises and intensity as needed. The program emphasized a gradual increase in shoulder movements and resistance exercises to improve muscle strength and stability. This approach ensured a safe and effective recovery process, minimizing the risk of complications and promoting optimal healing.The patient’s commitment to the rehabilitation program, coupled with the expertise of the physical therapist, contributed to her successful recovery. As a result, the patient regained the ability to engage in her usual activities without any restrictions. She expressed high satisfaction with the outcome of the surgery, indicating her contentment with the resolution of her symptoms and the restoration of her shoulder function.The rarity of scapular winging associated with osteochondromas, particularly in the superomedial angle of the scapula, underscores the need for increased awareness and understanding of this condition. The erosion of scapular bone caused by osteochondromas in this specific location can lead to a range of debilitating symptoms, including pain, weakness, and functional limitations .The impact on a patient’s quality of life can be significant, as these symptoms can interfere with daily activities and restrict participation in sports or physical exercises. Therefore, early diagnosis and appropriate management are crucial to address these challenges and improve patient outcomes.Scapular winging associated with osteochondromas is an exceptionally rare condition, and its occurrence in the superomedial angle of the scapula is even rarer. Osteochondromas in this specific location can lead to erosion of the scapular bone, resulting in notable symptoms such as pain, weakness, and functional limitations. Therefore, surgical excision is considered the preferred treatment approach for symptomatic osteochondromas in this context. However, in cases where the osteochondroma is asymptomatic, observation may be a suitable management option .The manifestation of scapular winging with osteochondromas can significantly impact the patient’s quality of life. The associated pain, weakness, and functional restrictions can hinder daily activities and limit participation in sports or physical exercises. Thus, timely diagnosis and appropriate management are crucial to address these debilitating symptoms .Surgical excision remains the treatment of choice for symptomatic cases of scapular osteochondromas. The selection of the surgical approach depends on factors such as the size and precise location of the osteochondroma. During the surgical procedure, it is imperative to meticulously dissect any adherent muscle or soft tissue to ensure complete removal of the osteochondroma, minimizing the risk of recurrence.Postoperative rehabilitation plays a critical role in restoring shoulder and scapula function. A comprehensive physical therapy program is typically implemented to facilitate a gradual recovery and regain optimal range of motion and strength. The program may involve active-assisted and active range of motion exercises, guided by a physical therapist. Close follow-up is necessary to monitor the patient’s progress, assess the effectiveness of the treatment, and identify any potential signs of recurrence .In the presented case, the patient experienced a successful outcome following surgical excision of the scapular osteochondroma. The complete resolution of symptoms and restoration of normal function, as reported by the patient, highlights the effectiveness of the chosen treatment approach. The patient’s ability to return to her usual activities without any restrictions and her high satisfaction with the surgical outcome further underscore the importance of early diagnosis and appropriate management of scapular winging associated with osteochondromas.The clinical implications emanating from the presentation of this case study possess a dual significance. First, the case underscores the necessity of contemplating osteochondromas as a plausible etiology of scapular winging, with particular emphasis on the younger patient demographic wherein the incidence of osteochondromas is more prevalent. Second, the case delineates the pertinence of surgical intervention in instances where osteochondromas engender substantial symptomatic manifestations.(1)In the clinical evaluation of scapular winging, particularly in younger patients, osteochondromas ought to be acknowledged as a potential causative factor;(2)Osteochondromas engendering pronounced symptomatic repercussions may necessitate surgical intervention;(3)The determination of a therapeutic approach to manage an osteochondroma should be individualized, taking into consideration various factors such as the severity of symptomatology, the dimensions and anatomical position of the tumor, and the patient’s age and degree of physical activity.The salient points to be extracted from this case presentation encompass the following:Scapular winging associated with osteochondromas is an infrequent yet impactful condition.Optimal management entails surgical excision for symptomatic cases, while asymptomatic ones may warrant observation. Adherence to meticulous surgical approaches, postoperative physical therapy, and regular patient monitoring forms a holistic treatment plan.Osteochondromas, including those occurring at the superomedial angle of the scapula, often present in a similar way across patients. These benign bone tumors typically develop during childhood or adolescence and can lead to skeletal deformities or complications related to surrounding soft tissue structures . The cliHowever, clinical presentations are generally similar across genders. It is worth mentioning that while the location of the osteochondroma on the superomedial angle of the scapula might be less common, the presentation and complications such as scapular winging can be seen in both genders .The outcomes for patients with osteochondromas are generally good, with surgical excision often resolving symptoms. Young patients, in particular, tend to recover well and regain normal function, especially when the osteochondroma has been causing mechanical symptoms.However, differences in outcomes can arise due to a variety of factors. For instance, the precise location and size of the tumor, the patient’s overall health and age, and the presence of any complications such as malignant transformation, which is rare but can occur.The case of a young female patient with an osteochondroma at the superomedial scapula angle could therefore present similarities in clinical presentation to other cases of osteochondromas but may also have unique aspects due to the specific location of the tumor and the patient’s gender and age. The outcome for this patient is likely to be positive following surgical intervention, consistent with the general prognosis for osteochondromas.The case accentuates the merit of prompt intervention, demonstrating substantial potential for symptomatic and functional improvements. Greater research and case documentation are vital to enriching our grasp of this condition, thereby refining diagnosis, treatment protocols, and overall patient care.Osteochondromas occurring in the scapula are considered rare, and those specifically located in the superomedial angle of the scapula are even rarer. When present, these osteochondromas can give rise to various symptoms including scapular winging, weakness, and pain. The management of symptomatic cases typically involves surgical excision, which is considered the treatment of choice. However, due to the limited number of reported cases and the rarity of this condition, further research is needed to enhance our understanding of its pathophysiology and to establish optimal management strategies.Scapular winging with osteochondromas is an uncommon condition that can significantly impact the affected individuals. The associated pain, weakness, and functional limitations can hinder daily activities and impair overall quality of life. In some cases, osteochondromas in the scapula may not cause any symptoms and can be managed through observation, while in symptomatic cases, surgical intervention is recommended.The primary objective of surgical treatment is the complete removal of the osteochondroma along with any associated bone or soft tissue. This approach aims to alleviate symptoms, restore normal scapular and shoulder function, and prevent potential complications or recurrence. Postoperative physical therapy is often necessary to facilitate rehabilitation and optimize the recovery of shoulder and scapula function. Physical therapists work closely with patients to develop individualized rehabilitation programs that may include exercises to improve range of motion, strength, and functional abilities.Despite the available literature on scapular winging with osteochondromas being limited, further research is essential to improve our knowledge and understanding of this rare condition. Areas of investigation may include the underlying pathophysiological mechanisms, risk factors, optimal surgical techniques, long-term outcomes, and potential complications. Collaborative efforts among researchers, clinicians, and experts in the field are necessary in order to gather more data, conduct comprehensive studies, and establish evidence-based guidelines for the management and treatment of scapular winging associated with osteochondromas.In summary, osteochondromas occurring in the scapula, particularly in the superomedial angle, are rare. They can result in scapular winging, weakness, and pain, and surgical excision is generally recommended for symptomatic cases. However, due to the limited number of reported cases, further research is warranted to improve our understanding of the pathophysiology and optimal management strategies for this rare condition. By advancing our knowledge in this field, we can ultimately enhance patient care, optimize treatment outcomes, and improve the quality of life of individuals affected by scapular winging with osteochondromas.