Superior mesenteric arteriovenous fistulas (AVFs) are rare and are usually caused by previous bowel surgery or blunt abdominal trauma. Patients may be asymptomatic, have non-specific symptoms of abdominal pain, nausea and vomiting or present with symptoms of portal hypertension; some patients may present years after initial surgery or trauma. Traditionally, superior mesenteric AVFs are treated by surgical ligation. However, percutaneous endovascular treatment has become increasingly popular in recent years. Different options of endovascular treatment include coil embolisation, covered stent and vascular plugs. There is a risk of coil migration with coil embolisation and covered stents may cause abnormal vessel straightening. Vascular plugs allow the fistula to be treated with fewer devices and have minimal risk of migration. Newer devices such as microvascular plugs have the added advantage of being able to be delivered through microcatheters or diagnostic catheters. The smaller profile of the microvascular plug also allows it to navigate through tortuous vessels. We report a case of a 77-year-old patient presenting with recurrent abdominal ascites three years after small bowel resection. CT and angiogram demonstrated a superior mesenteric AVF, which was successfully treated with a combination of microvascular plug and coil. He remained relatively asymptomatic four months after treatment. A 77-year-old gentleman presented to gastroenterology outpatient clinic with two-month history of gradual onset of abdominal distension, abdominal pain and loss of appetite. He denied any jaundice, tea coloured urine, pruritus, swelling or weight loss. His past medical history included hepatitis B infection, small bowel resection three years ago secondary to small bowel ischaemia and hypertension. His drug history included spironolactone, entecavir, pantoprazole and neurobion. He was retired and did not smoke or drink. On examination, he had a midline laparotomy scar; his abdomen was soft and not tender but was distended with shifting dullness. He was not jaundiced and did not have hepatosplenomegaly. No abdominal bruit was detected. His blood results including liver function and albumin level were normal. He last underwent an abdominal ultrasound a year ago, which demonstrated liver parenchymal disease with small amount of abdominal ascites. He also had an oesophago-gastro-duodenoscopy earlier this year which demonstrated Grade 1 oesophageal varices and gastritis with erosions. As he was symptomatic from his ascites, he was admitted for abdominal paracentesis and 4L of ascites was drained. His ascitic fluid showed a normal white cell count with negative gram stain and culture. His symptoms improved after the abdominal paracentesis and he was discharged. However, a week later, he presented again with symptomatic ascites. Given the rapid re-accumulation of his ascites, he was admitted for further investigations and a contrast enhanced computed tomography (CT) was arranged.Contrast-enhanced CT abdomen showed a cirrhotic liver with gross ascites . In the ® Ansel guiding sheath  was first inserted via the right common femoral artery and angiogram of the SMA was performed via a 5 Fr 100 cm Simmons one catheter . A fistula between middle segment of the SMA and the SMV was confirmed with poor arterial supply to the distal branches of the SMA . Initial attempts at packing the fistula with a 6mmx20cm Interlock Fibered IDC Occlusion System  was unsuccessful due to the high flow fistula with repeated migration to the SMV; as the embolisation coil of the system was detachable, it was possible to retract the coil before its final replacement. The SMV was then accessed by a 4 Fr H1 catheter  and a MVP-7Q microvascular plug  was then deployed within the fistula. The fistula was then further occluded with two detachable Target 360 SOFT 7 mm x 20 cm and 8 mm x 30 cm coils  through a 1.7 Fr Excelsior XT-17 microcatheter   55 cm Flexorgan USA) .Patient was discharged three days after embolisation. At four-month follow-up, his symptoms of abdominal distension and pain have improved and was found to have mild ascites only on examination. His latest blood results also showed normal liver function.1 In our patient, the aetiology of the fistula is likely to be due to previous small bowel resection. In bowel resection, it is thought that a transfixation suture passing through the artery and vein simultaneously may result in the formation of the fistula.2 Another theory is after continuous ligation of an artery and a vein, a micro-abscess may form, which may result in the breakdown of the vessel walls forming a fistula between the two vessels.2Superior mesenteric arteriovenous fistulas (AVF) are uncommon and most reported cases are associated with previous bowel surgery or abdominal trauma such as gunshot wounds or blunt abdominal injury.3 The abnormal communication between the high pressure SMA and low pressure SMV allows blood to bypass the intestinal capillary bed resulting in portal hypertension with patients presenting with ascites or variceal bleeding. Mesenteric steal phenomenon may also occur due to the presence of the fistula.2,4 This phenomenon was observed in our patient; on the initial selective arteriogram, there was reduced blood flow to the distal branches of the SMA; after successful occlusion of the fistula, there was return of normal blood flow to these branches. Apart from features of portal hypertension, patients may also be asymptomatic, present with symptoms of abdominal pain, diarrhoea, nausea and vomiting and occasionally, features of right heart failure.5Patients with superior mesenteric AVF often have a delayed presentation which may take place up to fourteen years after bowel resection.6 However, as seen in our patient, abdominal bruits may not always be present. In patients with suspected superior mesenteric AVF, CT is often the first line of investigation; however, it may not always be possible to identify the precise location of the fistula and selective arteriography is required to determine the exact location of the fistula and the extent of mesenteric vessel involvement and also to guide further management.7As superior mesenteric AVFs are very rare, a high level of suspicion is required for its diagnosis. It has been suggested that in patients with oesophageal varices and a history of previous bowel surgery, the presence of an abdominal bruit should raise suspicions of this diagnosis.1,3,8 The objective of endovascular treatment is to obliterate the fistula without occluding the branches of SMA. One of the considerations when choosing appropriate embolisation method is the type of the fistula: iatrogenic fistulas are usually U type with no distal bowel supply whilst traumatic fistulas are typically H type with distal bowel supply.2,9 The options of endovascular treatment include coil embolisation, covered stent and vascular plugs. In coil embolisation, special considerations need to be paid to avoid inadvertent coil deployment and coil migration. Coils may embolise distally into the portal vein resulting in portal vein thrombosis or embolise to the distal SMA or back to the aorta leading to bowel infarction or lower limb ischaemia.10 These complications may be avoided by precise measurement of the diameter of the feeding artery and deployment of the coils using a microcatheter system.9 An inflated balloon catheter may also be placed proximal to the fistula to prevent coil embolisation.11 When covered stents are used, it is important that there is good expansion of the stent and adequate apposition to the vessel wall, in order to minimise the risk of stent thrombosis. If a balloon expandable stent is placed across a sharp bend, it may cause abnormal vessel straightening, vessel injury or stent deformation.10,12 To prevent stent thrombosis, patients are put on long term dual antiplatelet therapy. Amplatzer Vascular Plug (AVP) has also been used to occlude superior mesenteric AVF;5 unlike coil embolisation, it has minimal risk of migration even in high flow situations or short landing zones; it also allows occlusion of a larger vessel with a single device rather than multiple coils.13 However, it does require larger guiding catheters or delivery sheaths. The microvascular plug is a relatively new embolisation device; it allows rapid occlusion, can be re-sheathed and repositioned prior to its release; furthermore, it can be navigated into microcatheters and tortuous vessels. In our patient, initial attempts to occlude the fistula with detachable coils were unsuccessful due to repeated coil migration to the SMV secondary to the high flow fistula. With the aid of the microvascular plug, the blood flow of the fistula was reduced before the deployment of coils, allowing the successful obliteration of the fistula.Superior mesenteric AVFs may be managed by surgery or endovascular treatment. Given the recent advances in interventional radiology, endovascular treatment is often preferred especially in patients who have had previous abdominal surgeries as extensive adhesions may make surgical treatment more challenging.Superior mesenteric AVFs are rare high flow fistulas, which may be managed by surgery or by endovascular treatment.It is important to consider the anatomy and configuration of the fistula when choosing the type of endovascular treatment, for example, covered stents may lead to abnormal straightening of vessels in a U type fistula and there is a risk of coil migration with coil embolisation.Microvascular plugs are relatively new devices which can reduce the flow of the fistula even in tortuous vessels, allowing the fistula to be occluded by a single device or allow the deployment of coils without the risk of migration.


An inguinal hernia involving the ureter is extremely rare and even rarer in patients with native kidneys. It can occur with or without obstructive uropathy and as such, a high index of suspicion should be held for patients with urinary symptoms and concurrent inguinal hernia. Additionally, iatrogenic ureter injury can occur if surgeons are unaware of ureteral involvement pre-operatively. We present a case of a patient with a known ureteroinguinal hernia who proceeded to have an elective hernia repair with ureteral protection. Ureteroinguinal hernias are an extremely rare phenomenon with less than 140 cases documented since 1880; most cases are identified intraoperatively . Risk faWe report on a symptomatic, native kidney patient who was diagnosed with a ureteroinguinal hernia preoperatively.A 76-year-old man was referred to the General Surgery clinic by our Urology colleagues with a left indirect ureteroinguinal hernia. Past medical history was significant for renal colic, atrial fibrillation, ischemic heart disease, permanent pacemaker, Ivor-Lewis oesophagectomy for Barrett’s oesophagus with high-grade dysplasia, open right inguinal hernia repair and open umbilical hernia repair.He was initially seen by our urology colleagues five months earlier, after being referred by his GP with LUTS. He reported a three-month history of occasional urgency, nocturia, weak flow and some terminal dribbling. Digital rectal examination (DRE) was insignificant with a benign prostate. An ultrasound of kidneys, ureter and bladder (USS KUB) showed a 48cc prostate with slight prominence of the left renal pelvis with no obstructing cause identified. He was subsequently commenced on Duodart  daily.On review two months later, he reported a few episodes of painless macroscopic haematuria and had a computed tomography intravenous pyelography (CT IVP) to exclude renal stone. This CT revealed that the distal aspect of the left ureter extended into the left inguinal canal within a left indirect inguinal hernia. The kidneys and renal tracts were otherwise unremarkable apart from simple-appearing renal cysts, with no stone disease or obstructive uropathy Figures , 1B. TheThe patient was consented to and underwent pre-operative insertion of a left ureteric stent and an open left tension-free inguinal hernia repair with Ultrapro mesh Figure . IntraopInguinal hernia repairs are one of the most common medical conditions encountered by general surgeons, with more than 20 million inguinal hernia repairs being undertaken worldwide . UreteraUreteroinguinal is classified as either paraperitoneal or extraperitoneal, based on the presence or absence of a hernial sac, respectively ,5,6. TheThe extraperitoneal hernia is not associated with a hernia sac and results from an embryological abnormality in which the ureteric bud separates late from the Wolffian duct as it descends to form the epididymis and testis -6. The uPreoperative diagnosis of ureteral hernia is optimal to avoid inadvertent ureteral injury; however, routine preoperative workup of inguinal hernia does not require any specific imaging. Signs that warrant further investigation include flank pain, dysuria, haematuria, acute urinary obstruction, double voiding requiring pressure to initiate or terminate voiding ,6. FurthHerniorrhaphy is indicated in all cases of ureteroinguinal hernias to prevent obstructive uropathy, incarceration or strangulation of the hernia and can be an open or laparoscopic procedure ,7,8. If Surgeons should be cautious when they encounter a hernia that contains fat that does not meet the characteristics of a cord lipoma and lacks the presence of a hernia sac. Careful dissection of fat from cord structures, and reduction to the retroperitoneum, rather than ligating and excising fat, should be performed to avoid iatrogenic ureteral injuries ,7. If unWhile ureteroinguinal hernias are rare, general surgeons need to be aware of these types of hernias so as to avoid intra-operative iatrogenic damage to the ureter which can have serious consequences. There should be an increased emphasis on preoperative diagnosis - a urological history should be taken in patients presenting with an inguinal hernia to guide further investigations. When ureteroinguinal hernia is identified preoperatively, a multidisciplinary approach between general surgery and urology should be undertaken to ensure the best outcome for the patient.


There were very few reports of Rosai–Dorfman disease in the thymus, which known as sinus histiocytosis with massive lymphadenopathy. It usually accompanied with other systemic symptoms such as fever, malaise, night sweats, or weight loss in the short term.Case presentationWe herein report a rare case of RDD of thymic origin and a review of the literature concerning the clinical and pathological features of this disease, which is often misdiagnosed as thymoma. The patient was underwent thymectomy to extirpate the lesion completely by video-assisted thoracic surgery.To the best of our knowledge, this is the fourth thymus occurring RDD case with proof via histology and IHC. Our findings suggest the difficulty of making a diagnosis before surgery and more cases will need to be reported in order to facilitate the preoperative diagnosis of such a rare tumor. Rosai–Dorfman disease (RDD) was first described by Rosai and Dorfman in 1969, accounting for 0.5% or less of all mediastinal tumors . We hereA 49-year-old woman was admitted to our hospital for assessment of anterior mediastinum nodule that was noticed on chest radiography during a routine health check. She had smoked one pack of cigarettes per day for the past 20 years and quit smoking for nine months. She denied the symptoms including the presence of chest pain, hoarseness, hemoptysis, cough and dyspnea. She had no risk factors for immunodeficiency disease or other infections. Physical examination shown normal breath sounds in both of chest fields. Laboratory findings were within normal limits. Her Pulmonary function tests and cardiovascular examination revealed normal performance. Plain and contrast-enhanced chest computed tomography (CT) Fig. a, b showHematoxylin and eosin (H&E) indicated a cross distribution of deeply and lightly stained lesions. The deeply stained zone was mainly composed of a large number of plasma cells and lymphocytes, and interspersed in a flake-like, lightly stained area like stripes. The giant pleomorphic tissue cells characterized by abundant cytoplasm, vacuoles, large nuclei, and irregular nucleus were distributed in the lightly stained area. In the cytoplasm of histiocytes, emperipolesis showed as some lymphocytes and a small number of plasma cells were phagocytized Fig. . ImmunohThe patient was discharged 2 days after the operation with no complication. She had been followed up for 3 months without evidence of recurrence.RDD disease, known as sinus histiocytosis with massive lymphadenopathy (SHML), is generally a rare benign disorder consisting of a proliferation of histiocytes. There were very few reports of RDD in the thymus –6. This Though the clinical presentation of RDD is variable, the most common place is painless bilateral cervical lymphadenopathy . It usuaIn Wu et al. report , the patThe radiologic diagnosis of RDD is often difficult because of the nonspecific imaging findings. Nodal involvement of RDD demonstrates massive bilateral cervical lymph node enlargement showing homogeneous enhancement on CT. MRI reveals homogeneous isointensity relative to the muscles on T1-wighted images and hyperintensity on T2-weighted images with homogenous enhancement. CT findings of extranodal RDD involving paranasal sinuses, nasal cavity, and larynx show homogeneously enhancing polypoid masses, mucosal thickening, or soft tissue opacification. In MRI images, paranasal sinus lesions may show marked T2 hypointensity. Affected sites typically show hypermetabolism of F-18 FDG on PET/CT. However, a solitary focus of increased activity in the thymus on an FDG PET/CT scan can be observed in a number of benign and malignant thymic conditions, including hyperplasia and thymoma.The pathologic feature of nodal RDD is the sinus expansion with large histiocytes . The hisThe differential diagnosis of the RDD was including the xanthogranulomatous family of diseases and Langerhans cell histiocytosis (LCH). The xanthogranulomatous family of diseases can show a wide variety of morphologic characteristics, including mononuclear cells that may be vacuolated, xanthomatous, spindle-shaped and display oncocytic changes . The hisThe standard treatments for RDD are still unknown. Spontaneous remission is observed and “wait and watch” approach is recommended , 6. OtheTo the best of our knowledge, this is the fourth thymus occurring RDD case with proof via histology and IHC. Our findings suggest the difficulty of making a diagnosis before surgery and more cases will need to be reported in order to facilitate the preoperative diagnosis of such a rare tumor.


Spindle cell tumor is very rare. Herein, we report a case of retroperitoneal spindle cell tumor in a 52-year-old female. The patient first presented with a complaint of persistent pain in the right upper abdomen. In the follow-up, a CT scan was performed and showed a retroperitoneal soft tissue density mass measuring 11 cm in diameter. Then, a subsequent operation was performed, and we completely removed the tumor and partially invaded lesions. The tumor was histologically diagnosed as a spindle cell tumor. Therefore, it is imperative for us to enhance the understanding of this seldom found tumor. Surgery remains the best option for treatment. Various types of human tumors can present as spindle cells, such as poorly differentiated epithelial-derived tumors, gastrointestinal stromal tumors, mesenchymal tumors, and neurogenic tumors , 2. SpinA 52-year-old female patient presented with a complaint of persistent pain of 1 month duration in the right upper abdomen. There was no history of previous abdominal trauma, bleeding, or family history of cancer. On clinical examination, there was slight tenderness in the right upper abdomen. Serum α-fetoprotein, carcinoembryonic antigen, carbohydrate antigen 125, and carbohydrate antigen 19-9 were normal. There was no obvious clinical history of malignancy. Enhanced upper abdominal computerized tomography (CT) showed a soft tissue density mass 11 cm in diameter . TherefoThe findings of intraoperative exploration revealed that the tumor was involved in the right hepatic artery, main portal vein, right portal vein, gallbladder, gastric antrum, duodenum, and head of pancreas. According to the results, we performed pancreaticoduodenectomy, perihilar hepatectomy, neoplasty of high bile duct, partial resection and repair of the main portal vein, partial resection and repair of the right portal vein, repair of the right hepatic artery, and reconstruction of the digestive tract . FinallyThe tumor was solitary and solid with an off-white cross-section . The actTo the best of our knowledge, soft tissue tumors usually occur in the limbs. Therefore, abdominal soft tissue tumors, especially retroperitoneal spindle cell tumors, are uncommon . RecentlDue to the diversity of pathological morphology, it was once named after inflammatory pseudotumor. A previous article has reported that the biological behavior of the tumor cells is inert, and is associated with distant metastasis, and that their prognosis is well . ClinicaThe management of retroperitoneal spindle cell tumors is complicated and based on their clinical biological behavior. In this case, CT is effective in detecting the soft tissue density mass located in enterocoelia, which was suspected of local lesion. The pathological results of pre-operative puncture are different from the post-operative results mainly not only because of its rarity but also plenty of neoplasms have overlapping cytomorphologic features. Complete surgery is the main treatment for intra-abdominal spindle cell tumors. If the tumor invades other organs in the abdominal cavity, extensive radical resection may be carried out . In our In conclusion, due to being a rare disease, much more studies on retroperitoneal spindle cell tumors are needed to enhance the management of this lesion. Complete resection is the gold standard for this kind of rare disease.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.HH prepared and wrote this article. ZD, HX, and LL were involved in managing the patient. ZC prepared the intraoperative pictures. CY revised the manuscript as well as acted as the corresponding author. ZH wrote and reviewed this manuscript. SZ and CY were the main surgeon. CS was involved directly in managing the patient. All authors contributed to the article and approved the submitted version.This research was financially supported by the funds from Science and Technology Planning Project of Guizhou Province, Science and Technology Cooperation Support of Guizhou Province [2021] General 080, Clinical Medical Research Center of Hepatobiliary Surgery of Guizhou Province, Science and Platform Talent of Guizhou Province [2017], Science and Technology Foundation of Health and Family Planning Commission of Guizhou Province [grant number: gzwkj2021-167], and Science and Technology Planning Project of Guizhou Province construction contract [2019].The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The “black esophagus” or “acute esophageal necrosis” is a very rare condition of the esophagus that is believed to have a multifactorial etiology and usually involves the distal esophagus. We present a case of a 66-year-old gentleman who presented with a history of retching followed by one episode of hematemesis two days after his left inguinal hernioplasty. His esophagogastroduodenoscopy showed diffuse ulceration and erosions throughout the esophagus, necrosis of the distal esophageal mucosa till the gastroesophageal junction, and a healed ulcer in the first part of the duodenum. He was managed with supportive care and discharged home in a stable condition. The “black esophagus” or “acute esophageal necrosis” is a very rare condition of the esophagus that is believed to have a multifactorial etiology and usually involves the distal esophagus . The mosHelicobacter pylori eradication therapy with an early follow-up and a plan of re-look EGD after a few weeks. His antiplatelet therapy was stopped until the follow-up.A 66-year-old male presented with a history of persistent retching followed by one episode of hematemesis two days after his left inguinal hernioplasty. He was a known case of hypertension, gastroesophageal reflux disease, and ischemic heart disease and was on dual antiplatelet therapy with a baseline ejection fraction of 45%. On arrival in the emergency room, he had tachycardia with a heart rate of 115 beats per minute but was maintaining his blood pressure and oxygen saturation. He was resuscitated with intravenous normal saline infusion, following which intravenous omeprazole infusion was started. His hemoglobin levels dropped from the baseline of 15.2 g/dL  to 11.3 g/dL. However, blood transfusion was not needed throughout the hospital stay as he maintained his hemoglobin and remained hemodynamically stable. After the initial resuscitation, we performed an esophagogastroduodenoscopy (EGD) that showed diffuse ulceration and erosions throughout the esophageal length, necrosis of the distal esophageal mucosa till the gastroesophageal junction (Figure The black esophagus is a rare clinical condition most commonly involving the distal part of the esophagus ,4. It isMultiple comorbidities can precipitate this condition. Diabetes mellitus is one of the common accentuating factors, and hyperglycemia is found in 90% of the patients presenting with esophageal necrosis . MalnutrAlthough perforation is rare, it is the most fatal acute complication of esophageal necrosis. If it occurs, esophagectomy is the surgical management . StrictuAcute esophageal necrosis is a rare condition that usually involves the distal esophagus. Its etiology is not clear yet but is suggested to be multifactorial. A “two-hit” model of mucosal injury due to reflux of gastric contents and decrease in esophageal blood supply has been proposed. Patients presenting with a critical condition have high mortality. The treatment is mostly cause-directed and supportive care.


Myxoid liposarcoma (MLS) is a rare malignant soft-tissue neoplasm in which brain metastasis is still considered rare. We present a case of MLS brain metastasis and review of the literature.A 24-year-old male patient presented with headache, decreased level of consciousness and vomiting. He was treated for distal right thigh MLS 2-years ago. Imaging studies of the brain showed a left frontal intracranial mass. The patient underwent surgical resection followed by stereotactic radiosurgery. The histopathological study revealed metastatic myxoid/roundcell liposarcoma infiltrating the bone and peripheral margins.Treatment options for MLS usually includes surgical resection and adjuvant radiotherapy. A case-by-case based multidisciplinary approach is recommended for the management of similar cases. Soft-tissue sarcomas are rare malignant tumors and account for 0.7–1% of all adult malignant tumors ,3.Another distinctive feature of MLS is its tendency to local recurrence and metastasis to the surrounding soft tissues and the skeleton. In contrast to other LPS subtypes which metastasize foremost to the lungs . MLS metThe patient is a 24-year old male who was diagnosed with right distal thigh MLS in 2018. He had wide local excision with neo-adjuvant radiation (50 Gy/25 fractions).In February 2019, an MRI of the femur was obtained for restaging. The MRI did not show any signs of local tumor recurrence but was highly suspicious for an intramedullary enhancing osseous lesion involving the proximal right femur. A follow-up positron emission tomography (PET)/computed tomography (CT) was performed and revealed a mildly hypermetabolic intramedullary lesion within the proximal shaft of the right femur that was suspicious for malignancy.In May 2019 the patient was given 2 cycles of chemotherapy (ifosfamide and doxorubicin), and later in the same month, an MRI for the thigh showed further progression in the proximal right femoral osseous lesion.In June 2019, a biopsy was performed and was negative for any features of malignancy. Definitive radiotherapy (70 Gy/35 fractions) to the right femoral lesion was delivered to the patient by October 2019. The patient was then observed by regular follow up.In November 2020, the patient presented to the emergency department with a decreased level of consciousness, headache and vomiting. The patient also had a gross lesion in his forehead which he neglected for a while. CT scan was performed and showed a left frontoparietal mass measuring 6 × 5.4 cm with vasogenic edema. The patient was admitted and treated conservatively without any surgical interventions as he was COVID-19 positive with mild symptoms. Chest, abdominal and pelvic CT scans were done and were negative respectively.In December 2020, the patient was re-admitted with lethargy, drowsiness and decreased level of consciousness. Brain MRI showed a large contrast-enhancing left frontal intracranial mass with mass effect and uncal herniation . His GlaHistopathological analysis showed metastatic myxoid/round cell LPS. The tumor cells are negative for GFAP, S100, WT1, BCOR, SATB2, CD99 and cyclin D1.The tumor had infiltrated the skull bone and extended the peripheral margins . The casA follow-up staging CT scan showed a soft-tissue mass at the suprasternal notch related to manubrium sterni and an anterior peritoneal with involvement of linea alba metastatic deposit was found. Palliative external beam radiotherapy to the sternu was completed by January 2021.Four months later, follow-up brain MRI revealed a right occipital condyle lesion, mostly correlating with osseous metastasis. There was no evidence of recurrence at the surgical bed , and no The patient was observed by regular follow-up imaging. On his 6th month follow up, he was alive and all lesions were stable except the peritoneal lesion was slightly progressive. He was placed on single-agent dacarbazine.Soft-tissue sarcomas are rare malignant tumors, they account for 0.7–1% of all adult malignant tumors ,7.According to both the molecular and clinicopathologic dissimilarities, there are five subtypes of LPS acknowledged by the WHO in the latest update of LPS classification published in 2020: atypical lipomatous tumor also known as well-differentiated LPS, dedifferentiated LPS, MLS, pleomorphic LPS and myxoid pleomorphic LPS .MLS is the second most common type of LPS, as it roughly represents 20–30% of all LPS cases .There are multiple distinctive features of MLS including its clinical presentation, metastatic patterns, genomic and histopathological findings that help to segregate it from the other subtypes of LPS .MLS is painless, which leads to a large presenting tumor usually over 10 cm. It typically occurs in young adults and peaks between 30 and 50 years . MLS excUpon reviewing the literature, several studies reported the proclivity of MLS to present most commonly as slow growing, deep-seated in the soft tissues of the lower extremities, with two-thirds of the cases arising within the thighs.Moreover, another distinctive feature of MLS is its tendency to local recurrence and extra pulmonary metastasis such as the soft tissues and the skeleton, in contrast to other LPS subtypes which metastasize foremost to the lungs ,9,10.et al. reported that 13 out of 14 patients with distant metastasis had extrapulmonary lesions. The retroperitoneum and the spine were the most common sites, respectively [Several studies reported different percentages of distant metastasis; however, almost all studies reported MLS to have an unusual metastatic pattern. For example, Estourgie ectively . It is rectively .Our patient’s MLS first metastasized to the brain; however, there are only few cases published in the literature with brain as the first site of metastasis  Summarizet al. in 2018 with a summary of the previous literature [There are also some reported cases in which the brain was the primary origin of the patients LPS The last of them was reported by Watanabe terature .The management of LPS can differ according to the subtype, site presentation and whether it is a primary disease or if it is a recurrence with local or distant metastasis. It is suggested that the evaluation should be conducted by a multidisciplinary team.Surgery, radiotherapy and chemotherapy are usually included in the treatment plan in a varying extent . MLS havSome studies suggest that in patients with small or mildly symptomatic BMs, there can be a major advantage of gamma knife radiosurgery over surgery is that it is less invasive and not associated with significant recovery time so that systemic therapy can be administered sooner ,25.MLS must be considered for LPS patients who present with neurological manifestations early on. Early management can prevent further progression and improve the patient’s prognosis accordingly. A case-by-case based multidisciplinary approach is still recommended for the management of such patients to achieve the most favorable outcomes.MLS is a rare soft-tissue tumor that has a distinct presentation and metastatic pattern. It is usually treated with surgical resection followed by radiotherapy, and it tends to be located deep within the thigh. Very few reports have been published in the literature regarding metastatic LPS. Brain metastasis is rare and might be challenging, especially in cases of multiple cranial metastasis. Surgical resection with radiotherapy and adjuvant chemotherapy is the management option of choice; however, a case-by-case based multidisciplinary approach is recommended for the management of patients to achieve the most favorable outcomes.


Suture granuloma with hydronephrosis after abdominal surgery is extremely rare. We herein report a successfully treated case of suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery.A 63-year-old male underwent laparoscopic low anterior resection with covering ileostomy. Two months after primary operation, ileostomy closure was performed with two layered hand-sewn suture (Albert–Lembert method) using absorbable suture. In that operation, marginal blood vessels in the mesentery were ligated with silk suture. The patient had remained in remission with no evidence of tumor recurrence, however, 2 years and 5 months after primary surgery, a contrast-enhanced computed tomography (CT) scan showed a mass-forming lesion on the right external iliac artery (43 × 26 mm) and hydronephrosis. Positron emission tomography/computed tomography (PET/CT) showed a mass-forming lesion without high accumulation, which obstructed the right ureter. Recurrence could not be ruled out due to the rapid appearance of tumor and hydronephrosis in the short-term period. Thus, the patient underwent laparotomy. The tumor located in the mesentery near the anastomosis of ileostomy closure and it was strongly adherent to the retroperitoneum, which obstructed the right ureter. The adhesion between the tumor and ureter was carefully dissected and tumor resection with partial small bowel resection was then performed with preservation of the ureter using ureteral stents. Pathological examination of the tumor revealed fibrous proliferation of foreign body granuloma. In the resected tumor, sutures with foreign giant cells were found. Therefore, we diagnosed the tumor as silk suture granuloma, which was caused by the silk suture used to ligate blood vessels of the mesentery at the ileostomy closure. The patient remained well with no evidence of tumor recurrence as 5 years after the primary operation of rectal cancer.Suture granuloma is a rare surgery-related complication in the postoperative surveillance of patients with colorectal cancer. If suture granuloma mimicking local recurrence is a differential diagnosis, it would be important to consider to avoid unnecessary extended resection. Foreign body granuloma is a rare benign tumor, which is induced by medical materials several months or years after surgery . ParticuHydronephrosis is one of the suggestive of recurrence, which can be caused by lymph node metastasis or peritoneal recurrence in patients who underwent colorectal cancer surgery . It is vWe herein report a successfully treated case of suture granuloma with hydronephrosis by tumor resection.A 63-year-old male was admitted to undergo colonoscopy for the evaluation of blood feces. The patient underwent endoscopic resection for a type Isp polyp of the lower rectum. The pathological diagnosis examination revealed well-differentiated adenocarcinoma with submucosal layer 2500 µm) invasion and lymphatic infiltration ly1). The patients underwent laparoscopic low anterior resection with covering ileostomy as additional resection. The pathological examination of surgical specimen revealed there was no lymph node metastasis, resulting in pStage I. Two months after primary operation, ileostomy closure was performed with two layered hand-sewn suture (Albert–Lembert method) using absorbable suture. In that operation, marginal blood vessels in the mesentery were ligated with silk suture. After ileostomy closure, the patient had been followed by a contrast-enhanced computed tomography (CT) every 6 months and tumor marker every 3 months, and remained in remission with no evidence of tumor recurrence. However, 2 years and 5 months after the operation, CT showed a mass-forming lesion on the right external iliac artery (43 × 26 mm) (Fig. . The pat500 µm inSuture granulomas are caused by persistent foreign body reactions to suture material due to their antigenicity and/or presence of bacterial infection in the fibers of silk , 5. SilkAs to the granuloma after colorectal cancer surgery, seven case reports have been published in the English literature; details of the current case and the other seven cases are summarized in Table In colorectal cancer surgery, silk suture has been reported to develop surgical site infection more frequently compared to absorbable suture . In addiWe reported to our knowledge the case of suture granuloma with hydronephrosis caused by ileostomy closure after rectal cancer surgery.


Desmoplastic fibroma (DF) is a non-metastatic primary bone tumor that is extremely rare with local aggressive behavior. To the best of our knowledge, only few cases were published discussing this type of tumor and its management. This case report aimed to discuss a novel case as well as its management scheme. We present a case of a 36-year-old male with DF lesion involving the proximal tibial who underwent an extended curettage, triple type of adjuvant thereby, and internal fixation. Desmoplastic fibroma (DF) is a non‑metastatic primary bone tumor extremely rare, lytic with local aggressive behavior with a prevalence of 0.1-0.3% is the prevalence of this tumor among all bone neoplasms . DF may A 36-year-old male, otherwise healthy, presented to the clinic complaining of left knee pain for eight months, which has been increasing recently with no history of trauma or constitutional symptoms, no knee locking, and no significant past surgical or medical history. Upon examination, the patient had a normal gait and upon inspection, the patient had mild anteromedial proximal tibial swelling firm to palpation. The skin was intact with no discoloration or engorged veins. Upon palpation, he had mild anteromedial proximal tibial tenderness. Arch of range of motion was from zero degrees full extension up to 120 flexions, no locking or instability, and an intact distal neurovascular examination.X-ray was done which showed a mix of osteolytic osteosclerotic lesion involving the proximal tibial metaphysioepiphyseal with a narrow zone of transition, multiple lobulations, and cortical breakthrough. Differential diagnosis at the beginning included aggressive benign tumor, malignant bone tumor, which could not be ruled out completely. We started with giant cell tumor, chondromyxoid fibroma, and desmoplastic fibroma. The systemic staging was done for the patient that included x-rays for the whole tibia as well as MRI. MRI showed well-defined eccentric proximal tibial metaphyseal lesion medially measuring about 5x5.4x7.5 cm in anteroposterior diameter (AP), transverse, and intercommissural diameter (CC). It was heterogeneous low signal intensity on T1 with few areas of high signal foci anteriorly likely representing hemorrhage. Heterogeneous high signal intensity on T2 peripherally with central low signal intensity and small cyst posteriorly measuring about 2x2.21x2.6 cm AP, transverse, and CC diameter, respectively. Intense enhancement is appreciated, this lesion of narrow zone transition, with no aggressive periosteal reaction, and no chondroid matrix can be identified. Cortical breakthrough at the medial aspect was noted, no perilesional edema was seen. The above-described lesion at that time could have been chondromyxoid fibroma, a giant cell tumor with secondary ABC changes. Thus, further evaluation with guided biopsy was recommended  is a non‑metastatic primary bone tumor that is extremely rare in nature, lytic with local aggressive behavior . This paIn this case, due to the tumor type, size, site, aggressive behavior, possible effect over the surrounding structures, and its impact on the range of motion, extended curettage after exteriorization window was performed with three types of adjuvants. This technique helped us achieve complete resection of the tumor. The patient was pain-free after surgery, and he was able to perform a full range of motion after a six-week physical therapy program, all of which reduced the patient's bed-bound time and hospital stay. The patient was discharged on the second day that can be attributed to the type of the utilized technique.


Branchial cleft cysts are congenital anomalies which develop in utero, most commonly arising from the second branchial cleft. They are often asymptomatic lateral neck masses but can enlarge and become symptomatic in the setting of infection. The cystic cavity can form a potential space which can harbor infection and, in rare cases, malignant spread of primary tumors. Herein, we present a rare case of a 28-year-old male with an enlarging branchial cleft cyst of six months duration following an upper respiratory infection. Routine post-surgical histopathological examination of the excised mass revealed metastatic papillary thyroid carcinoma. To our knowledge, this case is one of five cases reported within the primary literature. This case draws attention to the occult nature of papillary thyroid carcinoma and the importance of routine histopathological examination of seemingly benign surgically excised lesions. Branchial cleft cysts are the most common congenital neck masses arising laterally . ApproxiA 28-year-old male was referred to the otolaryngology clinic for a mildly tender lateral neck mass that first appeared six months prior to presentation. The mass steadily grew in size. It was initially accompanied by mild sinus congestion without constitutional symptoms, dysphagia, dysphonia, shortness of breath, or any other unusual symptoms. Aside from a body mass index of 49, the patient had no pertinent medical history. He reported a 10-pack-year smoking history and social alcohol consumption limited to three to four beers weekly. His family history was significant for unspecified lung malignancy. Physical examination revealed a 5-cm cervical mass inferior to the mandible on the lateral neck. There was no stridor, the trachea was midline, and the thyroid was non-tender without palpable nodules. No other masses were appreciated on palpation of the neck. Contrast-enhanced computed tomography (CT) of the head and neck revealed a 6.5 cm x 4 cm cystic mass at level 3, consistent with a second branchial cleft cyst Figures , 1B.Fine needle aspiration of the cystic content was benign and without malignant cells. The branchial cleft cyst was surgically excised under general anesthesia without complications and the excised specimen was forwarded to pathology for further evaluation. Histopathological examination revealed a cystic component, delineated by squamous and ciliated respiratory epithelium, containing papillary structures with loose fibrovascular cores and hyperchromatic nuclei consistent with classic PTC Figures -2D.Immunohistochemical staining was cytokeratin 7 (CK 7) positive and thyroid transcription factor-1 (TTF-1) positive, commensurate with a diagnosis of metastatic PTC. Subsequent ultrasound of the thyroid revealed a 1.5-cm solid isoechoic nodule in the right lobe with characteristics correlating with a thyroid imaging reporting and data system (TI-RADS) 5 lesion. Fine need aspiration of the contents revealed thyroid follicle cells showing features suspicious for papillary carcinoma.The patient underwent a total thyroidectomy and was noted to have three separate foci of well-differentiated PTC in the right lobe with a small micro-carcinoma focus within the left lobe. Enlarged lymphadenopathy discovered in level 6 of the neck was identified as a site of metastases with extension outside of the lymph node into the soft tissue. Other foci were contained within the surgical margins. Following thyroidectomy, the patient was treated by a multi-disciplinary care team consisting of representatives from otolaryngology, endocrinology, and radiation oncology. At the patient’s six-week follow-up appointment, the patient had no particular neck complaints. The patient elected for aggressive radioactive iodine ablation and long-term thyroid suppression.Branchial cleft cysts are embryological remnants that fail to close in utero ,3. ThesePTCs are common thyroid tumors with metastatic potential. These tumors share an occult clinical picture consistent with asymptomatic congenital neck masses . Many inPTC metastasis within the confines of a branchial cleft cyst has been reported in the literature, albeit infrequently -14. A reFortunately, in this case, the patient sought care when the branchial cleft cyst became symptomatic following an upper respiratory illness. In the absence of symptoms, the patient would have been unlikely to seek medical treatment. This patient had limited financial resources and time away from work which hindered his ability to seek routine medical care. Further, the patient was morbidly obese with a body mass index of 49, thereby obfuscating thyroid testing and limiting detection even with routine thyroid physical examination . Taken tMetastatic dissemination of PTC within the confines of a second branchial cleft cyst is a rare finding with only four other cases previously documented in the literature. This case report serves to illustrate the importance of routine pathological examination of surgical specimens, even in those lesions of seemingly benign etiology. While PTC is amenable to treatment if identified early, harboring of a metastatic lesion within a benign congenital mass may lead to delayed treatment and reduced overall survival. More research is needed to discern the impact of socioeconomic status in concert with this unique clinical scenario.


The Central giant cell granuloma (CGCG) is a non-odontogenic, osteolytic lesion of unknown aetiology, which affects the craniofacial region, particularly the anterior mandible. The age group commonly affected is below 30 years, with a distinct female predilection. Histopathological analyses show fibro cellular stroma consisting of evenly distributed multinucleated giant cells, multiple foci of haemorrhage, and focal areas of spicules of newly formed bone. Depending upon the extent, behaviour, and characteristics management varies from non-surgical to surgical approaches. Since CGCG is associated with a higher rate of recurrence, excision by curettage with the removal of peripheral bone margins is the gold standard and radical surgical intervention in aggressive lesions is associated with low recurrences. Reconstruction of the resulting surgical defect is extremely important to restore aesthetics and function. This case report reviews presentation along with currently used therapies for CGCG while describing an uncommon case of locally aggressive CGCG occurring in a 50-year-old female involving the posterior mandibular region, successfully managed with marginal mandibulectomy, curettage and reconstructed with submental island flap with no recurrence during follow up. The central giant cell granuloma (CGCG) is a non-odontogenic, osteolytic lesion of unknown aetiology, which affects the craniofacial region, particularly the anterior mandible. It is histologically benign, although locally proliferative and destructive from osteoclastic activity . It was A 50 years old female patient reported to our department in December 2019 and presented with intraoral swelling at the left mandible for six months Figure -3D. CGCGConsidering the aggressive nature of the lesion as well as the patient’s age, the treatment plan included surgical excision and reconstruction using a submental island flap, under general anaesthesia (GA). Surgical Procedure: A combination of extraoral and intraoral approach was used to excise the lesion completely. Extended marginal mandibulectomy and bone debridement were done to obtain adequate safety margins Figures , 5B. ForThe CGCG has two major cell types in its highly cellular fibroblastic stroma: Spindle-shaped cells and MNGC. Out of these two cell types the spindle-shaped cells contribute to tumour proliferation. Even though precise aetiology is unclear, it has been hypothesized that due to some epigenetic events the spindle-shaped cells gets transformed into tumour cells. These tumour cells later release cytokines which mediate the recruitment of monocytes from blood and transform them into osteoclast-like cells (MNGC). MNGC then cause bone resorption and local proliferation of lesion . VariousNon-surgical therapy using pharmacological agents have been reported in the literature by various authors: Jacoway et al. first proposed intralesional steroid injections for CGCG . The hypSurgical therapy is the gold standard for the treatment of CGCG. The most commonly used intervention is curettage. It can range from a simple curettage to resection. Additionally, combination with cryosurgery and peripheral ostectomy helps to reduce the rate of recurrence. The lowest recurrence has been reported with en bloc surgical resection with a 5-mm margin . SubsequCGCG in its aggressive form can cause extensive bony destruction thereby leading to cosmetic deformities as well as functional impairments; therefore, elimination of such lesions with adequate safety margins is of paramount importance in order to prevent any future chances of recurrence. In our case, we saw a similar presentation of an aggressive lesion at an uncommon age involving the posterior mandibular region. Considering the nature of the lesion along with patient age, we managed the case in an evidence-based manner by extended marginal mandibulectomy and bone debridement. Since such a procedure leaves a weakened bone as well as a large defect, we used a titanium plate to strengthen the mandible and a submental island flap to reconstruct the large surgical defect. The outcome was satisfactory with no recurrence after one year.


Mixed germ cell tumor (MGCT) mainly occurs in young women’s ovaries and men’s testicles and rarely occurs outside the gonad. Fewer than 10 cases of mediastinal MGCT are available in PubMed, Embase, and other databases in English, while mediastinal MGCT with three pathological components, such as yolk sac tumor, immature teratoma, and embryonal carcinoma, has not been reported previously. A 12-year-old male sought medical attention for chest discomfort and underwent a computed tomography (CT) scan. A large soft tissue mass occupying most of the left thoracic cavity and mediastinum was detected. A CT-guided biopsy was performed, and an MGCT was diagnosed with pathological components, including yolk sac tumor, immature teratoma, and a small amount of embryonal carcinoma. Due to the large size of the tumor, the patient was treated with an EP regimen (etoposide + cisplatin) and paclitaxel + ifosfamide + cisplatin interstitial chemotherapy. The patient was followed up for 6 months and was alive with the disease. To the best of our knowledge, this is the 10th patient with MGCT in the mediastinum. The incidence of mediastinal MGCT is low, but it should still be considered one of the differential diagnoses of isolated pleural fibroma and neurogenic tumors. It has a low degree of differentiation, and the most common combination is astrocytoma and yolk sac tumor (YST), derived from primitive germ cells of embryonic gonads ,2. Furth22.1−9/L; red blood cell (RBC): 2.79 × 10−12/L; Hb: 68 g/L; PLT: 123 × 10−9/L), considering the possibility of bone marrow suppression after chemotherapy; thus, patients were given an infusion of RBCs to correct anemia and recombinant human granulocyte colony-stimulating factor to stimulate bone marrow hematopoiesis, and temporarily chemotherapy was stopped. On day 11, after the suspension of chemotherapy, the patient’s mental appearance improved compared to before, and the blood test showed that the blood routine recovered . Then, he started to continue the treatment according to the chemotherapy regimen of EP regimen (etoposide + cisplatin) and paclitaxel + ifosfamide + cisplatin + bleomycin chemotherapy regimen. During the treatment period, the patient’s blood routine was monitored at an average of 2 weeks to observe the patient’s tolerance to the chemical regimen, body temperature, and mental outlook and perform a full physical examination if necessary. After 4 months of treatment with the aforementioned chemotherapy regimen for six cycles, the patient underwent a whole-body PET/CT examination to evaluate the treatment effect. PET/CT showed that the tumor volume was not significantly reduced compared to before treatment  number and hemoglobin (Hb) level increased, and platelet (PLT), albumin, serum calcium, and phosphorus values decreased, while the remaining laboratory indicators were not abnormal. Tumor marker detection showed that neuron-specific enolase, carbohydrate antigen 199 (CA-199), 125 (CA-125), and alpha-fetoprotein (AFP) were significantly increased, and the results of the above laboratory tests and tumor markers are presented in reatment , but no Informed consent: Both oral and written informed consent from the patient and his parents to make the patient’s details public were obtained.Ethical approval: The research related to human use follows the principles of the Helsinki Declaration and has been approved by the Ethics Committee of the Affiliated Hospital of Zunyi Medical University.2.2PubMed and Web of Science databases were searched, and English case reports and case series on mediastinal MGCT published before August 1, 2020, were retrieved. The following keywords  AND (Mixed germ cell tumor OR MGCT OR mixed GCT) were used for retrieval. A total of eight full-text articles, including nine patients with mediastinal MGCT, were retrieved for the analysis. The first author and references for each case, as well as the patient’s age, gender, maximum tumor diameter, symptoms, CT image characteristics, follow-up results, and treatment, are presented in Finally, only eight full-text articles of mediastinal MGCT patients were retrieved from the literature, indicating that MGCT is not common in mediastinum ,12. All 3in vitro germ cells or the failure of the original germ cells to complete the normal migration from the urogenital ridge to the gonad ridge during embryonic development [The mediastinal MGCT might be related to the abnormal migration and malignant transformation of the primordial germ cells during embryogenesis, resulting in the production of elopment . The extelopment ,14. The elopment . A revieelopment . The clielopment  reportedelopment .Based on the aforementioned characteristics, mediastinal MGCT needs to be differentiated from mediastinal teratoma, isolated fibroma, neurogenic tumor, lymphoma, and metastatic tumors. The CT manifestations of teratomas are well-defined cystic solid masses. Mature teratomas may be easily diagnosed due to their inclusion of mixed densities of adipose tissue, calcification, and bone. A solitary fibroma is usually manifested as a soft tissue mass with uniform density, but when the tumor is large, cystic degeneration and necrosis may occur, presenting an uneven density. In addition, the CE–CT showed obvious enhancement of lesions, and enhanced tumor vascular shadows were relatively specific. Neurogenic tumors appeared as a round or spindle-shaped soft tissue mass in the mediastinal thoracic cavity. Various pathological types may have different imaging findings, the density of benign lesions is relatively uniform, the malignant lesions are low-density cystic necrosis and/or high-density calcification lesions, and the lesions exhibit heterogeneous enhancement on CE–CT. Mediastinal lymphoma manifests as an irregular soft tissue mass in the mediastinum on CT, and multiple enlarged lymph nodes can be seen in the lesion with uniform density but with rare necrosis and calcification. The lesion surrounds the growth of large blood vessels and shows mild to moderate enhancement on CE–CT. Metastatic tumors, with a history of primary tumors, are mostly multiple foci, necrosis is common, and uneven enhancement on CE–CT could be identified on PET/CT.Strikingly, like most tumors, histopathological examination is crucial for the accurate diagnosis of MGCT, but the disadvantage of preoperative biopsy is that only a little tissue was obtained, which might lead to missed or incomplete diagnosis of tumor histopathological components ,17. HoweComplete surgical resection of tumor tissue is a key factor in the prognosis of mediastinal MGCT. However, the majority of the patients have lost the opportunity of surgical treatment due to large tumor volume, the embedding of large peripheral vessels, and distant metastasis at the time of diagnosis. In these patients, chemotherapy regimens of EP (etoposide plus cisplatin) and paclitaxel plus ifosfamide plus cisplatin are administered. Almost half (4/9) of our patients received chemotherapy alone, and even after surgery, some patients ,8 died o4In a nutshell, mediastinal MGCT has a low incidence rate and some difficulties in diagnosis. A large soft tissue mass was detected in the mediastinum with low-density necrosis and high-density calcification. The contrast agent dynamic enhanced scan showed mild and moderate progressive enhancement with a specific value for the diagnosis of mediastinal MGCT. MGCT has a high degree of malignancy and poor prognosis. Therefore, an in-depth understanding of the clinical and imaging knowledge of this disease is the key to early diagnosis, early intervention treatment, and improvement of prognosis.MGCTmixed germ cell tumorMIPmaximum intensity projectionCTcomputed tomographyFDGfluorodeoxyglucosePET/CTpositron emission tomography/computed tomography


We report a case of a 2-day-old neonate with bilious vomiting and abdominal distension. A small bowel obstruction with ileal perforation due to a misplaced clamping of the umbilical cord was apparent before laparotomy. This complication was a sequala after clamping the cord too close to the abdominal wall in a case where there was a hernia into the cord with intestinal content. A herniation of abdominal contents due to an omphalocele minor or a hernia must be taken into consideration during the inspection of the umbilical cord before clamping. Abdominal wall defects are rare congenital entities that can lead to an evisceration of intraabdominal organs. Omphalocele is an embryopathy of the midline abdominal wall. The umbilical cord inserts on the hernial sac surface. The intestine, liver, spleen, bladder or gonads can prolapse into the hernial sac . The herHowever, mild forms of omphalocele can also present together persistent omphaloenteric duct (POD) . In embrDirectly after birth, a diagnosis of herniation of the intestine due to a small omphalocele or a hernia into the cord may sometimes be overlooked when there is not a careful inspection of the umbilicus. In such circumstances, cord clamping can result in accidental injury to the intestines –7.We present a case of a 2-day-old female neonate whose hernia into the umbilical cord was not recognized, and the prolapsed ileum was clamped. Due to its rarity, we want to highlight and emphasize this complication of cord clamping to prevent this type of injury at the time of birth.Literature research was undertaken to identify similar cases with special regard to the outcome  and a high PCT (16.0 ng/dl). An ultrasound examination showed umbilical vessels and intestinal loops lying within the area of the umbilical clamp. IV fluids and antibiotics were initiated, and the patient was prepared for an emergency laparotomy. Intraoperatively, a loop of small bowel (ileum) that was herniated through the umbilicus was pinched off by the applied umbilical clamp and was necrotic . A resecAbdominal wall defects such as omphalocele or hernia into the cord are characterized by an abnormality of the umbilical ring , which affects boys and girls almost equally. The sizes of omphaloceles vary considerably. Jones classified omphaloceles into defects with a diameter smaller than 2.5 cm, defects with a diameter of 2.5–5 cm and those with a diameter larger than 5 cm . Asabe eAltogether with our case reported here, there have been 31 reported cases of ligated hernias of the umbilical cord in the literature. A small omphalocele, a hernia into the cord, and a POD were not recognized postnatally, which resulted in the clamping or ligating herniated intestinal loops. Patients mostly had a suspected, broad-based umbilicus or presented with symptoms of abdominal distention and bilious vomiting, which are similar to the symptoms in our patient. In all cases, surgery with immediate laparotomy and exploration was the treatment of choice. Twenty patients survived 74%), and in 3 cases (7%), the outcome was not mentioned. Fatal outcomes were reported in seven cases (17%); all but one of the cases were fatal before 1963 4%, and i, 23, 24.The careful inspection of the umbilical cord of every newborn before clamping or ligation is essential. Obstetricians, pediatricians and nurses who clamp, manipulate, or shorten the cord should be cognizant of an abdominal wall defect with herniation of the intestine into the cord. We emphasize that in small omphaloceles or hernias into the cord, the diagnosis is not always immediately obvious. Therefore, the umbilical cord should be routinely clamped at least 5 cm from the abdominal wall to prevent any possibility of iatrogenic damage to the bowel.DK drafted the manuscript. A-KS contributed to drafting and writing of the manuscript. AS contributed to drafting and writing. UR supervised and controlled the manuscript. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Neuroblastoma (NB) is a malignant neoplasm accounting for 7.5% of malignancy in children. It can originate anywhere along the sympathetic chain with the adrenal medulla being the most common site in 35% of cases. The initial presentation of orbital metastasis is very unusual that accounts for only 8% of all NB cases. We report a rare case of a 16-month-old girl who initially presented with bilateral rapidly progressive ocular proptosis for two weeks. CT scan of the brain and orbits revealed bilateral heterogeneous lateral orbital lesions, and CT scan of the abdomen and pelvis revealed huge heterogeneous right adrenal lesions. Histopathology of the abdominal mass confirmed the diagnosis of stage IV NB with orbital metastasis and the patient was started on an aggressive chemotherapy regimen. Ophthalmologists have a vital role in the diagnosis of NB which should be considered in the differential diagnosis of any rapidly progressive proptosis in young children. Early investigation and systemic workup should be made immediately, as it is a potentially life-threatening malignant tumor that requires aggressive management. Neuroblastoma (NB) is a malignant tumor of early childhood that accounts for 7.5% of all cancers in children younger than 15 years of age and is responsible for 15% of tumor-related deaths in children . ApproxiNeuroblastoma commonly metastasizes to bone (60%), regional lymph nodes 45%), orbit (20%), liver (15%), brain (14%), and lungs (10%) [5%, orbitA 16-month-old girl presented to the emergency room with a history of sudden bilateral progressive proptosis for a duration of 15 days. It was associated with decreased activity, reduced oral intake, and weight loss that were noticed by her mother. She was previously healthy with an unremarkable past medical history. There was no history of recent illness, allergies, or trauma. A family history of similar medical conditions was negative. Examination of the eyes showed bilateral severe non-axial, non-pulsatile proptosis that is more prominent in the right eye and was associated with conjunctival prolapse, chemosis, and subconjunctival hemorrhage  as well as supportive treatment.Ophthalmic involvement occurs in due course of NB in 50% of cases . However Neuroblastoma represents the second most common orbital tumor in children after rhabdomyosarcoma (RMS). In the present case, the differential diagnosis included NB, RMS, lymphoma, and retinoblastoma (RB). RB was excluded as the fundus examination showed a flat normal retina. Meanwhile, orbital lymphoma is usually present with insidious slowly progressive proptosis which is mostly unilateral with a rare incidence in children as the typical age of presentation is between 50 and 70 years . TherefoTreatment of the primary disease is based on the Children’s Oncology Group Neuroblastoma Risk Group Assignment Schema of low, intermediate, or high . As orbiProptosis in children can be the only manifestation of metastatic orbital NB, especially with rapid progression. Early investigation and systemic work-up should be made immediately, as the metastatic disease is potentially life-threatening that requires aggressive management. The role of the ophthalmologist in these patients depends on the severity of the condition and varies from supportive treatments to active intervention and management of ophthalmic complications in addition to the vital rule in diagnosis and staging as well as assessing response to treatment and long-term follow up.


Desmoid fibromatosis (DF) involving the gastrointestinal tract is extremely rare. Its intramural location and occasional expansile growth pattern within the bowel wall may mimic a gastrointestinal stromal tumor (GIST). Due to the different disease behaviors and management, it is important to make a correct diagnosis before further treatment. We present an extremely rare case of a gastric DF that on imaging appeared as a discrete intramural mass mimicking a GIST and that was preoperatively correctly diagnosed as a DF based on its cytomorphologic, immunohistochemical, and molecular profiles.. These results excluded a GIST and confirmed the diagnosis of a gastric DF.The patient is a 71-year-old female who presented with dysphagia and unintentional weight loss. A mass was identified at the gastric fundus. Endoscopic ultrasound-guided fine-needle aspirate (FNA) and biopsy (FNB) were performed. The FNA showed a few small aggregates of cytologically bland spindle-shaped cells with elongated nuclei. The FNB yielded small fragments of tissue composed of bland spindle cells demonstrating nuclear and cytoplasmic immunostain for β-catenin and focal stain for smooth muscle actin (SMA) and desmin. CD117, DOG1, CD34, caldesmon, S100, cytokeratin AE1/AE3, signal transducer and activator of transcription 6 (STAT6), MUC4, progesterone receptor (PR), and anaplastic lymphoma kinase (ALK) were negative, and MIB-1 showed a very low proliferation activity index. Molecular studies performed by targeted next-generation sequencing showed activating mutations in CTNNB1Although it is very rare, DF must be included in the differential diagnosis of discrete intramural gastric spindle cell lesions. A definitive diagnosis can be made preoperatively if enough lesional material is available for appropriate immunohistochemical and molecular studies. Desmoid fibromatosis (DF), also known as desmoid tumor and aggressive fibromatosis, is a locally aggressive non-metastasizing myofibroblastic neoplasm with an infiltrative growth pattern and propensity for local recurrence . The mosA 71-year-old female presented with dysphagia, intermittent left upper abdominal pain, and unintentional weight loss of approximately seven lbs during the last four months. Her past medical history was significant for Barrett’s esophagus, laparoscopic left salpingo-oophorectomy for an ovarian cystadenoma, and repair of aortic stenosis with aortic valve replacement. Physical examination revealed left upper abdominal tenderness on deep palpation. An abdominal CT scan with contrast demonstrated an 8.5 x 6.0 x 5.5 cm solid, well-marginated mass along the fundus of the stomach, extending to the gastroesophageal junction with inhomogeneous contrast enhancement, and it was thought to be most consistent with a GIST. Upper gastrointestinal endoscopy showed a large subepithelial gastric lesion with no bleeding or ulceration of the mucosa located in the cardia/fundus of the stomach Figure . EndoscoFine needle aspiration (FNA) and biopsy (FNB) were performed. The FNA showed very scant cellularity with a few small aggregates of cytologically bland spindle-shaped cells with elongated nuclei in a myxoid background. The FNB yielded small fragments of tissue composed of bland spindle cells in a fibro-myxoid stromal background containing small elongated blood vessels, and no mitosis or necrosis was identified Figure . The difThe patient underwent a proximal gastrectomy for curative treatment. A well-demarcated bulging intramural ovoidal mass measuring 9.2 cm x 7.5 cm x 5.5 cm abutting the serosa was removed with negative resection margins. On gross examination, the gastric mucosa was freely movable and flattened without bleeding or ulcerations. The cut surface of the mass showed an ovoid lesion with discrete contours and heterogeneous, tan-white fibrous central areas alternating with more myxoid peripheral areas. No gross evidence of infiltration into the adjacent structures was identified Figure .Microscopically, the cellularity of the lesion was quite heterogeneous, with sections taken from the central portion of the tumor, demonstrating uniform, cytologically bland, spindle cells with long sweeping fascicles in a fibrotic background alternating with more cellular areas showing a storiform pattern. Sections from the peripheral areas were instead less cellular and demonstrated a more myxoid stromal background in which irregular stag-horn thin-walled blood vessels could be identified.Despite extensive sampling of the lesion, only two foci of early infiltration (5% of the lesion) into the subserosal gastro-epiploic fat were identified Figure . A finalGastric DF presenting as a discrete intramural mass with an expansile growth pattern mimicking a GIST is extremely rare ,4. HowevSearching the literature, we found nine cases of primary gastric DF Table  3-10]. -10. 3-10Macroscopically, gastric DFs appear as large masses preferentially located either at the gastroesophageal junction or near the antrum. The cut surface shows a whorled, firm, tan-gray fibrous parenchyma without hemorrhage, necrosis, or cyst formation. They originate from the muscle layer and usually infiltrate all layers of the stomach with occasional ulceration of the mucosa or extension into the adjacent organs. However, occasionally, as in our case, DF may present as a well-circumscribed mass resembling a gastric GIST.Microscopically gastric DFs consist of long sweeping fascicles of a slender spindle or stellate cells with tapering ovoid nuclei and inconspicuous or small nucleoli. No nuclear hyperchromasia or cytological atypia is usually identified. The vasculature is variably prominent, composed of thick blood vessels or thin, delicate blood vessels with a stag-horn pattern. Although in some cases the gross appearance of gastric DFs may appear circumscribed, microscopically, usually they show an infiltrating pattern of growth within the adjacent gastric muscle layer, into the serous layer, adjacent gastro-epiploic fat, and sometimes into the overlying mucosa. In this regard, our case is unique due to its near-total macroscopic and microscopic expansile growth pattern characterized by a spindle cells proliferation pushing aside the adjacent structures. In fact, the gastric mucosa, submucosa, and muscularis propria were not infiltrated by the neoplastic cells, and a thin layer of dense collagenous tissue was identified between the tumor and the adjacent muscularis propria. Although the great majority of our tumor showed pushing borders, two foci in which the spindle cells showed early infiltration into the adjacent serosal gastro-epiploic fat Figure .The immunohistochemistry profile of DF is characterized by diffuse nuclear labeling for β-catenin and variable positivity for desmin and SMA. Dysregulation of the WNT/beta-catenin signaling pathway is identified in all tumors, and it is due either to somatic activating mutations in the CTNNB1 gene or germline inactivating mutations in the adenomatous polyposis coli (APC) gene . AbnormaThe clinical behavior of DF is unpredictable, with the sporadic type DF reportedly having a relatively better prognosis than those associated with FAP. The mortality rate for all cases with intra-abdominal fibromatosis is approximately 30%, and spontaneous regression has been reported in abdominal wall lesions but rarely in intra-abdominal sites. Recurrence is usually associated with young age and larger tumor size ,2,12. ThThe main differential diagnosis should be made with GIST, inflammatory myofibroblastic tumor, inflammatory fibroid polyp, leiomyoma, schwannoma, solitary fibrous tumor, and plexiform fibromyxoma.In summary, the value of this short report is to raise awareness among surgeons and pathologists that, although rare, primary gastric DF should be included in the differential diagnosis of gastric intramural spindle cells mesenchymal neoplasms to avoid a misdiagnosis of a GIST or other spindle cell lesions.


Cholesteatoma is a common occurrence in the middle ear, whereas cholesteatoma of the external auditory canal (EAC) is a rare condition. We report an unusual presentation of the cholesteatoma in the EAC.We report a case of a 67-year-old male presented to the ENT casualty with a longstanding history of left sided squeaky type sound, aggravated whenever he talks or eats. He subsequently had a Computed Tomography (CT) scan of the left petrous bone which identified a left-sided EAC cholesteatoma. Clinical symptoms of EAC cholesteatoma are non-specific, and hence we recommend considering cholesteatoma when patients present with abnormal EAC symptoms and intact tympanic membrane.His cranial nerves examination was normal, and the tympanic membrane was intact. His blood count and infective marker were normal. The CT scan of the brain showed a lesion in the left external auditory canal close to the tympanic membrane. The lesion was in contact with the anterior inferior canal wall which had features suggesting bony erosion. Gas bubble seen in the posterior part of the TMJ was in relation to bony erosion of the EAC.The cholesteatoma of the EAC is very rare. CT scan can provide detailed information about the extent of external ear canal cholesteatoma, which can be used to identify complications of the disease, in addition to differentiating the external ear canal from the middle ear cholesteatoma. Early recognition of cholesteatoma and prompt treatment is essential to prevent catastrophic complications. •A cholesteatoma originating in the external auditory canal is a rare finding.•Cholesteatoma can present with atypic symptoms such as temporomandibular joint disorders. The aetThis case report has been reported in line with the SCARE criteria .2A 67-year-old man presented with a left sided audible high-pitched sound on TMJ movements. At the presentation he did not have any TMJ dysfunction, trismus, headache or preauricular swelling. He did not complain of hearing loss, or any symptoms of facial palsy. He complained of longstanding unbearable headache, otalgia, and localised TMJ pain which lasted 6 weeks prior to his initial presentation. He did not have a significant past medical history and was not taking any regular medication. There was no significant family history.On examination of the left ear canal, a gas bubble was visible in the distal portion of the EAC which deflated when speaking, producing the audible squeaky sound. There was a small mass just anterior to the tympanic membrane, however, the tympanic membrane was intact. There was no obvious keratinized growth in the attic of the tympanic membrane. His pure tone audiogram was normal. He had CT of temporal bone . which sHe has started on conservative medical therapy with regular cleaning and debridement of the keratin debris. If the conservative medical management fails to prevent progression of his disease, he will be offered more definitive management, surgery. The surgery involves bony meatoplasty via a postauricular approach for more adequate debridement, canalplasty, and often split-thickness skin grafting to cover the canal defect.3The European Academy of Otology and Neurotology and Japan Otological Society (EAONO/JOS) defined a cholesteatoma as a mass formed by the keratinising squamous epithelium in the tympanic cavity and/or mastoid and subepithelial connective tissue and by the progressive accumulation of keratin debris with or without a surrounding inflammatory reaction. Cholesteatoma is classified into acquired, congenital, and unclassifiable (cholesteatoma whose origin cannot be accurately determined) .Although there has been much debate about the definition and aetiology of cholesteatoma, it is commonly accepted to consider congenital cholesteatoma as an epidermoid cyst behind an intact tympanic membrane, which arises from congenital remnants of keratinising squamous epithelium in the temporal bone ,6. It is[14]. In this case, the external ear canal cholesteatoma moves anteriorly and invades anterior bones in the ear canal including the TMJ. The destruction of the anterior bone in the ear canal is visible in the CT scan image. For patients with a high jugular bulb, the development of external ear canal cholesteatoma can easily lead to the jugular bulb exposure[14]. If the external ear canal cholesteatoma invades the middle ear, it will cause the same damages as middle ear cholesteatoma does, such as the destruction of facial nerve canal, labyrinth bone, sigmoid sinus and skull base.External ear canal cholesteatoma develops due to the accumulation of squamous keratinized material in the external ear canal. The expansion of external ear canal cholesteatoma leads to the formation of periostitis and sequestrum with inflammatory stimuli of lysosomal enzymes, collagenase, prostaglandins as well as the swelling pressure . HoweverA detailed otological assessment is required to diagnose cholesteatoma, coupled with a full audiometric evaluation and imaging (MRI or CT scan) . The useTreatment of cholesteatoma is dependent on the severity of the disease process ,11. Cons4EAC cholesteatomas are a rare entity and insidious in nature. It can present with a myriad of clinical manifestations and should be suspected in all patients with unexplained otological and TMJ related signs and symptoms. Temporal bone CT scan can aid the diagnosis and also differentiate the external ear canal from the middle ear cholesteatoma. The late-stage presentations of the disease are very common.N/A.Consent taken from the patient.None.Dr Fatemeh Salimi study concept and design, or interpretation, writing the paper.Dr Dema Motter data collection, data analysis.Dr Zahra Salimi contributed to the paper writing.1. Name of the registry:2. Unique Identifying number or registration ID:3. Hyperlink to your specific registration (must be publicly accessible and will be checked):Has been obtained, verbally at the initiation of the case report as well as a signed consent form.Fatemeh Salimi.Written informed consent was obtained from the patient's parents for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.Not commissioned, externally peer reviewed.None.


Uterine leiomyomas (fibroids) are the most common tumor of the reproductive system in women between menarche and menopause. Uterine lipoleiomyomas are a rare variant of leiomyoma, consisting of smooth muscle cells admixed with adipocytes.Herein is the case of a 70-year-old female who presented with acute pelvic pain and a palpable pelvic mass. A computed tomography scan of her abdomen and pelvis demonstrated a large, circumscribed, fat and soft tissue density, uterine mass suggestive of a lipoleiomyoma. Histopathology examination of the resected specimen after total abdominal hysterectomy confirmed a mature lipoleiomyoma. Uterine lipoleiomyoma (LLM) is a rare variant of leiomyoma occurring with a frequency between 0.03% and 0.2% and predominantly found in an intramural location -3. It isA 70-year-old, gravida 4 para 4, previously well postmenopausal woman, presented to her gynaecologist with sudden onset pelvic pain. There was no history of acute vaginal bleeding, dysuria or hematuria. Her last menstrual period was at age 50. Past surgical history included abdominoplasty. On abdominopelvic examination, there was a 12/40 midline pelvic mass. Pelvic ultrasonography revealed a 8-cm markedly hyperechoic pelvic mass, likely of uterine origin, and no ascites  scan of her abdomen and pelvis was subsequently done and demonstrated a large, circumscribed, fat and soft tissue density, uterine mass measuring 8.9 x 7.6 x 8.5 cm, abutting the left pelvic side wall, subjacent small bowel loops, left lateral border of the recto-sigmoid colon and posterior wall of the urinary bladder Figures -4. The uGross pathology after total abdominal hysterectomy (TAH) and omental biopsy showed a uterine mass measuring 11.0 x 9.0 x 8.0 cm, with normal adnexa and fallopian tubes Figure . Cut secLLM is a rare variant of leiomyoma, with two main theories of origin suggested viz a multipotential Mullerian cell origin and adipose metamorphosis of uterine smooth muscle cells . LLM mayLLM is generally asymptomatic, but can present with a range of clinical symptoms such as acute pain, abnormal vaginal bleeding, infertility, and pressure on the urinary bladder and/or rectum. Radiological imaging is crucial in detecting LLM. Ultrasonography demonstrates a markedly hyperechoic pelvic mass while CT scans show a solid mass arising from the uterus with areas of fat and soft tissue density. MRI is a useful technique, showing areas of high signal intensity on T1-weighted images which lose signal on fat suppressed sequences .LLMs only require treatment if symptomatic. It is crucial however to differentiate LLM from other diagnoses which may require a different management approach and possible surgical intervention. Among the differential diagnoses, LLM is most commonly misdiagnosed preoperatively as a mature ovarian teratoma . Other dThe pre-operative differentiation of benign variants, such as leiomyomas and LLM, from malignant tumours such as leiomyosarcoma (LMS) is challenging. While malignancy in fibroids tends to be rare, it is of great clinical importance as benign tumours may be treated conservatively or with minimally invasive techniques, which are not appropriate in the setting of malignancy. This is further complicated by the existence of intermediate variants  or more aggressive histologic subtypes of LMS. Some studies have looked at different features on MRI  and other imaging modalities . AnotherUterine LLM is an uncommon benign uterine tumor that occurs primarily in postmenopausal females and consists of smooth muscle cells admixed with a significant amount of lipocytes. Imaging plays a pivotal role in the preoperative characterization and localization of the mass, demonstrating its adipocyte-rich consistency. Symptomatic patients with uterine LLM are generally managed with surgery. Histopathological analysis of the resected specimen confirms the presence of fibrotic tissue and mature adipocytes, and also excludes other important differentials, including liposarcoma.


Porencephalic cyst is a rare entity affecting the central nervous system, whose etiopathogenesis has not yet been clearly defined. It is a cavity within the cerebral hemisphereFrom an epidemiological point of view, porencephalic cysts are described in newborns with an estimated incidence of 3.5 per 100,000 live births,,,The symptoms that characterize porencephaly are numerousFor the diagnosis of porencephaly, the electroencephalogram may help but the findings are not specific, and radiological techniques are necessary. A cerebral CT scan shows a hypodense intracranial cyst, with a well-defined border and central attenuation due to the cerebrospinal fluid. Mass effect on the adjacent parenchyma is not usually observed, but very large cysts can cause it locally. Brain MRI shows a well-defined, white matter-coated brain cyst with or without gliosis, with the cerebrospinal fluid signal. Fetal MRI is also helpful to differentiate this entity from extra-axial lesions such as arachnoid cysts but also rare tumors.Upon dissection of the brain (weight 1214 g [mean reference range 1366 g]), a slight asymmetry of the cerebral hemispheres was noted, with a prevalence of the left one. The leptomeninges were smooth and shiny, with no focal alterations; the vessels were marked dilated and congested. At serial coronal sections, a large cavitated formation was present in the white matter of the entire left cerebral hemisphere, in the superolateral position to the ventricle. It extended from the middle third of the frontal lobe to the middle third of the occipital lobe, reaching a maximum diameter of 2.5 cm in the left temporal area. In addition, the occipital lobe of the left cerebral hemisphere showed an abnormal supernumerary convolution. In At the end of the autopsy, the cause of death was identified in acute circulatory failure in a subject suffering from severe coronary artery disease and porencephaly. Therefore, the finding of the porencephalic cyst was incidental, and the origin of this disease was likely attributed to a congenital cause. Indeed, the man had always had good health, except only for recurrent episodes of mild headache.postmortem and the histopathological analysis confirmed the porencephalic nature of the large cerebral cavitated defect.We deemed this finding of interest both for the rarity of the detected cerebral anomaly and for the man’s survival until adulthood in the absence of severe symptoms. Indeed, the first diagnosis occurred only


An H-section steel bar that had been set against the wall fell and hit the abdomen and then both legs of a 33-year-old Chinese man. As his vital signs were stable and his chief complaint was leg pain, he was transferred to a local medical facility. After the confirmation of gross hematuria by an indwelling a bladder catheter there, he was transported to our hospital. On arrival, his vital signs were stable. His main complaint was foot pain. He had a scabbing injury at the scrotum and bilateral foot joint deformity. Whole-body computed tomography (CT) from head to toe revealed trabecular formation in the bladder and slight fluid collection in the rectovesical pouch, as well as bilateral fracture-dislocations at the ankles. The urinary tract injury and the fluid collection in the rectovesical pouch were managed conservatively, and the lower limbs were treated tentatively. Follow-up CT on day 3 revealed multiple free air pockets in the intra-abdominal cavity, which was considered to indicate perforation of the duodenal ulcer and treated conservatively. However, he showed abdominal pain on day 7, and repeated CT revealed increased fluid in the intra-abdominal cavity. Urgent laparoscopy showed intact bowels and perforation of the bladder that was closed by suturing. He ultimately obtained a survival outcome. This is the first case of transient trabecular formation in the bladder and delayed free air due to traumatic intraperitoneal bladder rupture. This unique case adds another radiological finding to the list of documented etiologies of traumatic bladder perforation. Bladder rupture, a relatively rare condition, is most commonly due to abdominal and/or pelvic trauma, but it may be spontaneous or iatrogenic in association with surgical or endoscopic procedures -3. BladdWe herein report a case of free air due to traumatic intraperitoneal bladder rupture initially treated as duodenal perforation.An H-section steel bar that had been set against the wall fell and hit the abdomen and then both legs of a 33-year-old Chinese man. He was unable to stand due to his leg injuries and was transferred to a local medical facility. His vital signs were stable and his chief complaint was leg pain. After the confirmation of gross hematuria by indwelling a bladder catheter, he was transported to our hospital because there were no urologists at the local medical facility. He had no specific past or family history.4/μL, prothrombin time of 12.4 (11.7) seconds, activated partial thromboplastin time of 26.2 (26.7) seconds, fibrinogen of 185 mg/dL, and fibrin degradation product of 29.1 μg/mL. Whole-body CT from head to toe revealed trabecular formation in the bladder and slight fluid collection in the rectovesical pouch , respiratory rate of 20 breaths per minute, and percutaneous saturation of oxygen under room air of 97%. His main complaint was foot pain. He had a scabbing injury at the scrotum without abdominal signs and bilateral foot joint deformity. The results of a biochemical analysis of the blood were as follows: total protein of 6.2 g/dL, albumin of 4.0 g/dL, total bilirubin of 1.2 mg/dL, aspartate aminotransferase of 48 IU/L, alanine aminotransferase of 17 IU/L, lactate dehydrogenase of 294 IU, creatine phosphokinase of 2,374 IU/L, glucose of 110 mg/dL, HbA1C of 5.5%, blood urea nitrogen of 27.1 mg/dL, creatinine of 1.63 mg/dL, uremic acid of 6.5 mg/dL, sodium of 140 mEq/L, potassium of 4.2 mEq/L, calcium of 8.7 mg/dL, C-reactive protein of 0.02 mg/dL, white blood cell count of 23,600/μL, hemoglobin of 14.0 g/dL, platelet of 22.5×10Initially, he received a diagnosis of urinary tract injury and fracture-dislocations of the bilateral lower limbs.The urinary tract injury and fluid collection in the rectovesical pouch were managed conservatively with fasting based on the urologists’ decision without further examination, and the lower limbs were treated by external fixation and pinning. Ultrasound on day 2 also indicated trabecular formation in the bladder (Figure Follow-up CT on day 3 revealed multiple free air pockets in the intra-abdominal cavity and the disappearance of the fluid collection and trabecular formation in the bladder (Figure He underwent emergency gastroscopy, resulting in the discovery of a duodenal ulcer at the bulbus, and therefore the free air was considered to indicate perforation of the duodenal ulcer and was treated conservatively with fasting.However, he experienced abdominal pain on day 7 with peritoneal stimulation signs, and immediate CT revealed increased fluid in the intra-abdominal cavity. He underwent urgent laparoscopy, which showed intact bowels and perforation of the bladder, which was closed by suturing. From day 8, he started to drink and eat. On day 12, his lower limbs underwent internal fixation. He was then transported to another medical facility for rehabilitation.To our knowledge, this is the first case to show traumatic transient trabecular formation in the bladder. Initially, we thought this was a congenital abnormality or tumor because the trabecular formation did not move, even with the application of pressure during an ultrasound examination ,7. The mThe bladder rupture in the present case was initially missed, though urologists were consulted. The present case did not have pelvic fracture, which is a common cause of blunt traumatic bladder rupture, and the main complaint was foot pain; however, an indwelling bladder catheter revealed gross hematuria, and fluid collection was noted in the rectovesical pouch on initial CT. In addition, our patient showed azotemia and increasing serum creatinine levels. Ascites and increasing serum creatinine levels are often noted in patients with acute kidney injury. However, these findings are also observed in patients with intraperitoneal urinary leakage . Again, This case showed delayed free air, and the free air was initially considered to indicate perforation of a duodenal ulcer. Free air induced by traumatic bladder perforation is an extremely rare finding, and previous reports have also initially treated such cases as bowel perforation ,5. HowevThis was a case of transient trabecular formation in the bladder and delayed free air due to traumatic intraperitoneal bladder rupture. This unique case adds another radiological finding to the list of documented etiologies of traumatic bladder perforation.