Adhesions and external hernias are the two most common causes of small bowel obstruction. Perforation of organs within the abdomen or pelvis following manual vacuum aspiration is known to lead to an acute presentation.We report a case of a 33-year-old female with small bowel obstruction due to herniation of a loop of intestine through a uterine defect with symptoms starting 63 days following manual vacuum aspiration.Intra-abdominal or pelvic perforations usually present immediately which makes our case unique as the patient started having symptoms 63 days post manual vacuum aspiration. The most feared complication of prolonged small bowel obstruction is ischaemia which may lead to perforation.In our case, it is plausible that jejunum partially herniated into the uterine cavity shortly after manual vacuum aspiration, forming a jejunal plug, leading to the delayed onset of symptoms. This delay in onset of symptoms might have led to progressive massive dilatation of the small bowel and subsequent ischaemic necrosis.Detailed history taking is pertinent as bowel obstruction could still occur a prolonged period after manual vacuum aspiration. A double-contrast enhanced CT scan of the abdomen proves invaluable in the context of surgical planning and facilitating the collaboration of a multidisciplinary team, particularly when the underlying causes of bowel obstruction remain elusive upon initial presentation. •“The risk of uterine perforation as a complication of MVA is 0.06 to 0.36%.”•“2.4% incidence of SBO post hysterectomy.”•“She had a history of having had a MVA performed for an incomplete miscarriage 63 days prior to the start of her symptoms.”•“Contrast enhanced CT of the abdomen showed features of SBO with a transition point in the pelvis.”•“There was jejunal herniation into the uterine cavity”•“Intra-abdominal or pelvic perforations usually present immediately which makes our case unique as the patient started having symptoms 63 days post MVA.” The most common causes of SBO are adhesions due to previous abdominal surgery, followed by hernias. Rare causes include tumours, intussusception, gastrointestinal tuberculosis (GI TB)  and inteManual vacuum aspiration (MVA) is a safe surgical method of uterine evacuation for the removal of retained products of conception in a patient with an incomplete miscarriage. Fewer complications are reported for MVA compared to curettage. Although it is safe and effective, rare uterine perforations can occur and can be life-threatening, especially with intra-abdominal organ injury ,4,7,8.The risk of uterine perforation as a complication of MVA is 0.06 to 0.36 %. Close to 50 % of these are due to the suction cannula and mostly occurring at the fundus and anterior wall . Majorit2Retrospective report from the patient's file reported in line with the SCARE criteria .2.1Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.2.2Ethics approval for this study was granted by the Human Research Ethics Committee  at the third floor, Faculty of Health Sciences, Phillip Tobias Building, 29 Princess of Wales Terrace, Parktown, Johannesburg, South Africa, 2193. The clearance certificate number is M230457 and was granted on the 14th of July 2023.3A 33-year-old black-African female, G1P0M1 with no co-morbidities, presented to a level 2 hospital with a one-week history of obstipation, vomiting and abdominal distension associated with abdominal pain. The pain radiated to the umbilicus and suprapubic regions. She had a history of having had a MVA performed for an incomplete miscarriage, 63 day prior to the start of her symptoms. She had no previous history of abdominal surgery, and no external hernias were found. She was then referred to our facility, a level 3 hospital for further review and management.3− of 31.8 mmol/L , and her stoma losses were replaced. The stoma was then reversed 6 weeks after the surgery, and the patient was able to return to her usual activities.4To our knowledge and extensive literature search, jejunal herniation into the uterus has never been documented as a cause of bowel obstruction. Intra-abdominal or pelvic perforations usually present immediately which makes our case unique as the patient started having symptoms 63 days post MVA. Detailed history taking is pertinent and this diagnosis could still be considered after a prolonged period. This case also highlights the importance of radiological imaging in patients who present with features of SBO with no obvious cause.The common presenting symptoms of SBO are colicky abdominal pain and bilious vomiting. The dominance of either of the symptoms is dependent on whether the obstruction is proximal or distal ,2. On prGI TB predominantly manifests at the ileocecal junction but can potentially affect any segment of the GI Tract. Furthermore, GI TB has been associated with the development of bowel obstruction . Given tWhile small bowel herniation due to MVA associated uterine perforation has been described in the literature, usually these patients present in the acute setting ,7. The OPatients presenting with SBO without an obvious cause should undergo double contrast enhanced CT scan of the abdomen before they are taken to theatre for exploration or discharged . In this5Detailed history taking is pertinent as bowel obstruction could still occur a prolonged period after MVA. A double-contrast enhanced CT scan of the abdomen proves invaluable in the context of surgical planning and facilitating the collaboration of a multidisciplinary team, particularly when the underlying causes of bowel obstruction remain elusive upon initial presentation.Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Ethics approval has been obtained from: Human research ethics committee , University of the Witwatersrand. (Wits - HREC) Third floor, Faculaty of Health Sciences, Phillip Tobias Building, 29 Princess of Wales Terrace, Parktown, 2193.Clearance certificate number:M230457.No role of study sponsors.Muhammad Salman Idrees: Study concept and design, data collection, data interpretation and writing the paper.Alessandro Bellomo: Data interpretation and editing.Prof. Thifhelimbilu Luvhengo: Interpretation and editing.Muhammad Salman Idrees.This case report is not a first in man study.Nothing to declare.


Mandibular first molars, also called six-year molars as they appear at around six years of age, are the first permanent teeth to erupt in the oral cavity. They are the teeth most commonly affected by dental caries. Anatomically, the tooth presents with two roots and three canals. In very rare cases, presence of an extra root or a supernumerary root has been associated with the tooth. When this root is present lingual to the distal root, it is called radix entomolaris whereas when it is present buccal to the mesial root, it is called radix paramolaris. The presence of veiled canals is possible due to variation in the anatomy of the tooth. It is therefore necessary to locate, prepare and obturate these hidden canals in order to achieve success in endodontic treatment. Mandibular first molars are the first permanent teeth to erupt in the oral cavity; they are also the teeth most commonly affected by dental caries . They usA 13-year-old male patient came to the Department of Dentistry with a chief complaint of dull pain in the right lower back region of his jaw since three days. Both family and medical histories were non-contributory. The clinical examination revealed deep dentinal caries in relation to the right mandibular first permanent molar. The affected tooth was tender on vertical percussion but asymptomatic on palpation. Upon thermal pulp testing, the patient experienced intermittent mild pain that remained for 15-20 minutes after the removal of stimulus. Hence, the cause of the pain was chronic irreversible pulpitis of the affected tooth. Radiovisiography (RVG) revealed radiolucency involving enamel, dentine and pulp without periapical changes  till the F1 master file. Irrigation was done using 5.2% sodium hypochlorite. As the tooth was asymptomatic till a week later, the canals were dried with sterilized paper points and obturation was done using the protaper F1 gutta percha cone using lateral compaction technique. A radiograph was taken (Figure Glass ionomer cement restoration was placed to seal the access cavity and a porcelain-fused metal crown was placed. The patient was kept on a regular follow-up and was found asymptomatic on one, three and six months, post-operatively.The mandibular first permanent molar can present with varied anatomy. The detection of canals is important for successful treatment and satisfactory long-term prognosis. Radix paramolaris can present as a separate mature root or as a conical extension. It has been further classified as type A in which the cervical part is located on the mesial root complex, and type B in which the cervical part is located centrally between the mesial and the distal root complexes . The preAnatomical variations in tooth structures are a little uncustomary yet present. When treating a case with root canal therapy, acknowledgement of such variations becomes important. It is thus essential to locate, prepare and obturate these veiled canals in order to achieve success in endodontic treatment. The knowledge of such variations like radix entomolaris and radix paramolaris will help clinicians to prevent procedural errors.


The abdominal wall is an extremely rare location for malignant peripheral nerve sheath tumors (MPNSTs). Besides presenting a rare location of MPNST, the peculiarity of our case lies in its association with Lynch syndrome, which is to our knowledge the first reported case of its kind.We present a case report of a 39-year-old male with a personal history of colonic cancer. Genetic counseling revealed Lynch syndrome with a heterozygous germline mutation in MLH1. Nine years after the right hemicolectomy, the patient presented with an asymptomatic lump in the abdominal wall. CT imaging showed a 3 cm mass in the aponeurosis of the right external oblique muscle. The patient underwent successful resection of the parietal tumor. Pathological examination revealed an MPNST. No additional treatment was warranted, and the patient exhibited no signs of relapse during the six months following the surgery.MPNSTs of the anterior abdominal wall are extremely rare and challenging. Some studies have investigated the presence of mismatch repair (MMR) deficiency in patients with sarcomas. Our case consolidates the hypothesis of an association between sarcomas and Lynch syndrome, which raises the question of the efficacy of immune checkpoint inhibitor therapy in these cases where treatment options remain limited.It is essential to have a deep understanding of the growth patterns of MPNSTs in the context of syndromes that predispose individuals to tumors, like Lynch syndrome. This knowledge is crucial for accurately predicting patient outcomes and developing appropriate plans for monitoring and treatment. •The abdominal wall is a rare location of MPNST.•First reported association of an MPNST with Lynch syndrome•Sarcomas could be a rare manifestation of mismatch repair deficiency. Malignant schwannomas are now called malignant peripheral nerve sheath tumors (MPNSTs) . The ter2We present a case report of a 39-year-old male with a family history fulfilling Amsterdam 2 criteria for clinical diagnosis of hereditary nonpolyposis colorectal cancer (Lynch syndrome) , and perIn 2013, an acute onset of pain in the right iliac fossa accompanied by fever led to a diagnosis of acute appendicitis and subsequent emergency surgery. An infected cecal mass was discovered during laparotomy, leading to a carcinologic right colectomy. Pathological examination revealed a colloid carcinoma of the colon, classified as pT3N0M0. The patient underwent six months of adjuvant chemotherapy (FOLFOX) and remained under close observation. After 18 months, hepatic metastasis in the second segment was detected during imaging, resulting in a second laparotomy and a left lateral sectionectomy. The patient received an additional six months of FOLFOX and showed no further signs of systemic illness. Due to his young age and his family history, a genetic counseling was conducted, revealing Lynch syndrome with a heterozygous germline mutation in MLH1.In 2022, nine years after the right hemicolectomy, the patient presented with an asymptomatic lump in the abdominal wall. Upon clinical examination, a hard three-centimeter mass was found in the right upper quadrant distant from the surgical scars, and CT imaging revealed a 3 cm mass in the aponeurosis of the right external oblique muscle with well-defined contours and spontaneous tissue density . This pr3Sporadic MPNSTs usually occur in patients with an age ranging from 30 to 50 years. When associated with neurofibromatosis type 1 (NF1), these tumors can manifest in younger patients ,7. FrequThe definitive confirmation of MPNST is based on the histologic examination. Macroscopically, tumors are usually larger than 5 cm with a white-gray firm to fleshy cut surface, necrotic areas, and hemorrhage. Histologically, the most specific features of MPNST are fascicles with alternating, marble-like cellularity, palisade/rosette-like arrangements, and asymmetric spindle cells . New stuLately, some studies have investigated the presence of mismatch repair (MMR) deficiency in patients with sarcomas. There are experimental (in mice), epidemiologic, histopathological, and molecular data for supporting the hypothesis that sarcomas could be a rare manifestation of MMR deficiency . In a moOn the other hand, some studies have investigated the link between MPNST and familial carcinologic history ,20. WhenIt's essential to delve deeper into the limitations in the existing published literature. MPNSTs may be underrepresented due to their rarity, which in turn restricts the depth of our current knowledge. This opens an intriguing opportunity to explore how we can expand our understanding of this entity. To address this gap, there's a potential avenue for enhancing the data landscape. This could involve the establishment of comprehensive data reporting mechanisms, allowing for the collection of information from a wider spectrum of cases. By pooling data from various sources, we could develop a more comprehensive and nuanced perspective on MPNSTs. the involvement of cancer registries could significantly amplify these efforts. Their role in systematically collecting and collating cancer-related data makes them a prime candidate for contributing to the understanding of rare entities like MPNSTs. Collaborating with cancer registries could bolster our insights by leveraging their expansive datasets.4MPNST is a rare entity. It is essential to have a deep understanding of the growth patterns of MPNSTs in the context of syndromes that predispose individuals to tumors, like the Lynch syndrome. This knowledge is crucial for accurately predicting patient outcomes and developing appropriate plans for monitoring and treatment.A written consent was obtained from the patient to publish this case report.Ethical approval was deemed unnecessary by our institutional ethical committee, as the paper is reporting a single case that emerged during normal practice.No funds, grants, or other support were received.Anis Hasnaoui: Conceptualization, Writing-Reviewing and Editing. Salma Kacem: writing-Original draft preparation. Imen Sassi: Data curation. Fakhreddine Ben Abdallah: Data curation. Sondes El Guesmi: Data curation, Investigation. All authors read and approved the final manuscript.Anis Hasnaoui.The authors declare that they have no competing interests.


Cholecystocutaneous fistula is a rare surgical entity caused by an abnormal connection between the gallbladder epithelium and the skin. These complex cases have historically required an open surgical approach and are difficult to manage. We present a rare case of a 65-year-old male patient, with chronic lithiasic cholecystitis and cholecystocutaneous fistula. The patient underwent a laparoscopic subtotal cholecystectomy, dissection of the fistula tract, and removal of the impacted stones from the abdominal wall. With appropriate expertize, a completely laparoscopic approach is acceptable and the technical challenges can be predicted and overcome through careful pre-operative planning. Cholecystocutaneous fistula (CCF) is an abnormal connection between the gallbladder epithelium and skin, first documented in the late 17th century . Its incA 65-year-old gentleman with a body mass index of 29.6 and medical history of Guillain–Barré syndrome, type 2 diabetes mellitus, hypertension, and chronic pain was referred to our outpatient clinic with intermittent upper abdominal pain. His surgical history included an open appendicectomy. He was wheelchair-bound outside his home and received weekly assistance from a carer. On examination he was anicteric. His abdomen was soft, but a mildly tender mass was palpable in the right upper quadrant. An initial computed tomography (CT) scan showed thickening of the gallbladder and a collection extending from the fundus and infiltrating the anterior abdominal wall . FurtherPost-drain removal, the patient was booked for elective laparoscopic cholecystectomy. An infraumbilical port was inserted to achieve pneumoperitoneum, and further ports were inserted based on ergonomics . InitialThe patient was transferred to the high dependency unit postoperatively. The subhepatic drain was monitored and noted to have a small amount of bilious output corresponding to a low volume bile leak from the gallbladder stump. This persisted; therefore, an endoscopic retrograde cholangiopancreatography with sphincterotomy and common bile duct stent placement was performed on post-operative Day 10. The patient was discharged on post-operative Day 14 with the subhepatic drain in situ and returned to the clinic two weeks later for its removal. Four years after the operation, the patient remains asymptomatic and the CCF is completely healed.Due to its rarity, there are no international guidelines for the management of CCF. However, it is standard practice to treat with antibiotics and drain any associated abdominal wall abscess . A systeEntering the abdomen necessitated pre-operative planning to locate a safe entry point devoid of visceral adhesions or fistulous tracts while maintaining ergonomic conditions. Our ports were inserted based on these principles. Port placement is important and should be placed at a sufficient distance from the gallbladder and fistula tract to allow adequate triangulation . A bimanDue to its adherence to the anterior abdominal wall, conventional traction of the gallbladder is a significant technical challenge. In our case, the gallbladder was separated from the anterior abdominal wall early and a fundus-first approach was performed. Otherwise, it may be difficult to achieve the critical view of safety because of the inability to retract an immobile gallbladder when attempting to expose the hepatocystic triangle. A fifth port was placed in the left iliac fossa to further assist with retraction. During dissection across the CCF, dilation of the internal opening should be considered. Furthermore, the external opening of the tract may also need to be dilated, but this was not necessary in our case due to adequate drainage through the internal opening.This case presented additional difficulties due to the presence of Guillain–Barré syndrome. Our patient required avoidance of non-depolarizing neuromuscular blockers and close control of his ventilatory capacity. Such patients should not be fully extubated until the respiratory and bulbar muscle reflexes have returned to normal, which may take some time . AutonomIn conclusion, CCF is a rare clinical entity and we have reported the first successful laparoscopic retrieval of gallstones migrating across the fistula tract. Our case demonstrates that laparoscopic cholecystectomy remains a safe option and that the technical challenges associated with it can be overcome with careful preoperative planning.


Diathermy-induced explosions in the gastrointestinal tract can occur during laparotomy and can be fatal. Hydrogen and methane are the most common flammable gases that are produced in the gastrointestinal tract. A 35-year-old male was referred to a tertiary hospital with abdominal pain after being assaulted and stabbed in the abdomen. He presented with a 2-cm wound in the midline below the xiphoid process and with an omentum protruding through the wound. Explorative laparotomy was done to repair the jejunal perforation, but a gastric blast occurred, making more than half of the gastric pouch non-viable. The operation was converted to a near-total gastrectomy with Roux-en-Y gastrojejunostomy. During open abdominal surgery, fires and explosions can occur. Precautions should be taken during open abdominal surgery to reduce the risk of explosions, such as allowing combustible gases to exit the cavity before using diathermy.  Most of these explosions have occurred in the colon and rectum during endoscopy, but explosions have also occurred during colostomy , and a sur there . The expethane CH are prod2 through the scope [Various measures have been proposed to reduce the risk of explosion during electrosurgical procedures in the large bowel: the infusion of COhe scope , 5, the he scope  and oralhe scope  in the phe scope . WhetherA 35-year-old male referral from a peripheral health center presented with abdominal pain for 1 day. He was assaulted by group of unknown people while riding his motorcycle on his way back home and sustained a penetrating abdominal injury, whereby he was stabbed in the abdomen and around the upper arm. The patient reports loss of consciousness following the event for an undetermined period of time until he found himself awake at the hospital, stained with blood and weak; he had no vomiting, no blood in his urine, no consumption of intoxicants before driving, no medical history of epilepsy and he was able to use all of his four limbs.The patient’s last meal was ~4 hours before the occurrence of the event. He was referred to the tertiary hospital, where a formal abdominal ultrasound was done upon arrival at the emergency department and revealed significant fluid collection in both the splenorenal and hepatorenal recesses.Upon general examination, he was pale with normal vital signs. On abdominal examination, patient had muscle guarding, 2-cm wound in the midline ~10 cm below the xiphoid process, gushing out air with every respiratory cycle, not actively oozing blood; omentum can be seen protruding through the wound with generalized abdominal tenderness on superficial and deep palpation and distant bowel sounds. Other systems were normal except for the musculoskeletal system, which had two superficial lacerations of ~1 cm each around the left deltoid muscle. We had the impression of a peritoneal violation and visceral injury, hence planned for explorative laparotomy.His lab results were normal, and the patient was reviewed by the anesthesia team and was cleared for surgery. Upon explorative laparotomy, a penetrating wound crossing all the abdominal wall layers and violating the peritoneal space was revealed: hemo-peritoneum with small bowel contents in the peritoneal cavity mixed with food particles; omental laceration below its attachments to the transverse colon; mesenteric laceration with mesenteric border jejunal perforation with normal liver, spleen and other viscera. What was done was peritoneal lavage with warm normal saline, resection of the jejunal perforation site and end-to-end primary anastomosis intraoperatively. Upon small bowel resection, gastric blast occurred due to the gas–diathermy reaction, making more than half of the gastric pouch burnt and non-viable. The operation was converted to a near-total gastrectomy with Roux-en-Y gastrojejunostomy, as shown  in the iFires and explosions have occurred in the operating theater for many years. Flammable inhalation anesthetic agents were responsible for many incidents in the past, but these are no longer available in many countries. Other causes of fires and explosions still exist in the operating theater and, from time to time, result in serious and occasionally fatal injuries. Flammable gases are produced at all levels of the gastrointestinal tract. Hydrogen and methane are the most common flammable gases produced in the bowel. The proportions will vary with diet, digestion and metabolism . The larBowel preparation of the colon with mannitol or lactulose is associated with an increase in combustible gas, resulting in explosions during colonic resection caused by electrosurgery . Oxygen The explosive range of hydrogen is 4–72% and that of methane is 5–15% [Rarely, during open abdominal surgery, do fires and explosions occur in the operating room. When they do happen, they have the potential to seriously endanger patients, hurt employees, damage theaters and equipment structurally . To limit the danger of electrosurgery-induced ignition, precautions should be taken during laparotomy.


Appendiceal diverticulitis (AD) represents a rare cause of acute abdomen. Diagnosis of AD is a challenge because of its rarity and resemblance to other ileocecal diseases like as cecal diverticulitis (CD) and acute appendicitis (AA). Preoperative imaging can be useful to aid diagnosis. Surgery represents the correct treatment of AD.A 48-year-old Caucasian male presented to the Emergency Department with a two-day history of right lower quadrant (RLQ) abdominal pain and fever. Physical examination revealed RLQ abdominal pain and rebound tenderness with muscle guarding. Laboratory tests reported high levels of C-reactive protein and neutrophilic leukocytosis. Abdominal computed tomography(CT) scan showed findings of AA and a thin-walled 5 mm appendiceal diverticulum. The patient underwent laparoscopic appendectomy. The postoperative course was uneventful, the patient was discharged on the 5th postoperative day in a stable condition. Gross anatomy confirmed the presence of appendiceal diverticulum in the distal appendix on the mesenteric border. Histopathological examination revealed an inflamed and perforated appendiceal pseudo-diverticulum with surrounding AA and peri-appendicitis.Appendiceal diverticulosis is an uncommon entity, classified as congenital or acquired based on the number of appendiceal layers herniating through the normal wall. Two thirds of diverticula will develop acute or chronic diverticulitis that can lead to several complications some of which can be life-threatening.AD is a rare surgical emergency and represents often an overlooked diagnosis. Early diagnosis and treatment are crucial for reducing morbidity and mortality Appendectomy represents a safe and appropriate treatment of AD. •Appendiceal diverticulitis (AD) represents a rare cause of acute abdomen.•Diagnosis of AD is a challenge because of its rarity and resemblance to other ileocecal diseases.•Preoperative imaging can be useful to aid diagnosis.•Surgery represents the correct treatment of AD. Appendiceal diverticula are classically divided into acquired and congenital types: the majority are acquired with an incidence of 0.004–2.1 % from appendicectomy studies and of 0.20–0.66 % from autopsy studies . A rare 23/μL). The patient was managed with fluids, intravenous broad-spectrum antibiotics, antipyretic drugs and bowel rest. The patient, after a non diagnostic abdominal ultrasonography (US) due to the presence of large amounts of intestinal gas, was evaluated by abdominal computed tomography (CT) scan which revealed findings of AA like as the presence of a dilated appendix with thickened walls, a peri-appendiceal fat stranding and a pericecal fluid collection; a thin-walled 5 mm appendiceal diverticulum was also noted  abdominal pain and fever (38 °C); he had no nausea and vomiting, others vital signs were normal. The patient referred habit on smoking but denied alcohol consumption; his past and familial medical histories were normal. He was employed by profession, married and of medium socio-economic status. Physical examination revealed mild abdominal distention, RLQ abdominal pain with obvious muscle guarding and rebound tenderness, hypoactive bowel sound. Laboratory tests reported high levels of C-reactive protein (45.5 mg/L) and neutrophilic leukocytosis  are true diverticula because they contain all the layers of the appendiceal wall and tend to be single and located at the antimesenteric margin of the appendix. Acquired diverticula (the most common type) are pseudodiverticula  because only the mucosa, submucosa and serosa are the components of the diverticulum wall without the muscle layer ,6; they 4AD is a rare surgical emergency and represents often an overlooked diagnosis. The differential diagnosis of AD in patients presenting with signs and symptoms of AA is important as AD is associated with a higher risk of perforation and mortality in contrast to AA and it has also an increased risk of appendiceal neoplasms. Appendectomy represents a safe and appropriate treatment for symptomatic and complicated AD.Ethical approval has been exempted by our institution because this is a case report and no new studies or new techniques were carried out.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Giuseppe Evola: Drafting the manuscript, literature research.Giovambattista Caruso: Drafting the manuscript, literature research.Elia Pulvirenti: Operated on the patient, drafting the manuscript.Maria D'Angelo: Drafting the manuscript, literature research.Martina Reina: Drafting the manuscript, literature research.Giuseppe Angelo Reina: Operated on the patient, revising the manuscript.The guarantor for this case report is Giuseppe Evola.The guarantor for this case report is Giuseppe Evola.Written informed consent was obtained from the patient, for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Not applicable.Not commissioned, externally peer-reviewed. The journal has a double anonymised peer review process.The authors have no conflict of interest to declare.


Orbital pseudotumor is a rare condition characterized by an idiopathic inflammatory process of the orbit with a polymorphous lymphoid infiltrate. It is misdiagnosed as orbital cellulitis or orbital mass with conjunctivitis in children. Orbital pseudotumor is a rare condition characterized by an idiopathic inflammatory process of the orbit with a polymorphous lymphoid infiltrate. It is misdiagnosed as orbital cellulitis or orbital mass with conjunctivitis in children. It is misdiagnosed as orbital cellulitis or orbital mass with conjunctivitis in children. This study presents two pseudotumor cases among two boys presented with intermittent headache.Orbital pseudotumor is a clinical condition that is an idiopathic inflammatory process of the orbit that is marked by an infiltrate of different kinds of lymphocytes.22.1A 13‐year‐old healthy boy, presented with a one‐week history of left upper eyelid swelling. His ophthalmological examination, apart from eyelid swelling causing mechanical ptosis, was normal. His eyelid swelling was switching from left to right. He had been complaining of intermittent migraine headaches for a year and had received no treatment. All routine blood investigations were within normal limits. The contrast‐enhanced CT scan of the patient is shown in Figure 2.2A nine‐year‐old healthy boy with a history of intermittent headache for 2 years presented to our emergency department with a one‐week history of increased pressure intensity (9/10), feeling retro‐orbital pressure, and left eye droopiness. On follow‐up, he was found to have left eye episcleritis. His headache was primarily left temporal, but shifting in location, and was associated with photophobia and phonophobia. It was pulsatile and was relieved by sleeping and acetaminophen. His ophthalmological and neurological examinations were normal. In the second case, investigations included routine lumbar puncture with opening pressure, lactic acid, ammonia, amino acids, complements, thyroid antibodies, erythrocyte sedimentation rate, myelin oligodendrocyte glycoprotein, aquaporin antibodies, oligoclonal bands, the IgG index, HLA B51, von Willebrand factor, and NMDA receptor antibodies, all within normal limits. Riboflavin 200 mg taken orally once daily controls his headache very well. Contrast‐enhanced axial MR images of the patient are shown in Figure 3Orbital pseudotumor was first highlighted by Birch Hirschfield in 1905. Although in most cases it is idiopathic, reports suggest that unknown microbes, minor injuries, and long‐term irritation are the major risk factors for the progression of the condition.Palpable mass, decreased ocular motility, eyelid swelling, pain, proptosis, and increased intraocular pressure are all common ophthalmic clinical findings.In the present case series, a contrast‐enhanced CT scan displays a diffusely enlarged left superior rectus muscle with intense homogenous enhancement and enhancement of its tendineous insertion Figure , which iIn the present case series, another child presented with episcleritis and retro‐orbital pressure. In cases of orbital pseudotumor, inflammatory cellular infiltrates have been demonstrated within involved muscles, sclera, and episclera, as well as in the intraorbital connective tissue, forming focal tissue masses. Myositic, tumefactive, episcleritic, and infiltrative (diffuse) forms have been described both alone and in combination. Isolated scleral inflammation, as seen in our patients, characterized by thickening and enhancement of the sclerouveal rim, probably represents a type of orbital pseudotumor.Bernardino et al., reviewed 350 normal patients and patients with orbital pseudotumor.Sclerouveal rim thickening on CT and scleral inflammation need not always be scleritic or caused by a pseudotumor. Thick CT sections through the globe may result in volume averaging of the sclerouveal rim and the scleral surface of the globe, which are parallel to the plane of the section. This causes an apparent thickening of the sclerouveal rim in a normal patient. Inflammatory changes after trauma  and after surgery exhibit similar CT findings.An earlier research described a case of unilateral orbital myositis of new onset after COVID‐19 without a severe course, in which the patient received topical therapy with a preliminary diagnosis of conjunctivitis, but no improvement was seen.Oral systemic corticosteroids are the preferred treatment for orbital pseudotumors. A rapid response to steroids is also considered diagnostic. Prednisone doses of 1–1.5 mg/kg per day in children lead to resolution of pain and proptosis within 24–48 h. When the amount of collagenous connective tissue increases, as seen in more chronic forms of orbital pseudotumor, the sensitivity to corticosteroids decreases. Low‐dose radiotherapy can be indicated when corticosteroids fail or are medically contraindicated, or for recurrences when the patient is already receiving corticosteroid therapy.4Orbital pseudotumor is a rare inflammatory condition that occasionally presents as a chronic condition in children. It is often misdiagnosed as orbital cellulitis or an orbital mass with conjunctivitis. Because this disorder affects vision, it is crucial to diagnose and treat it promptly.Mohammed Almuqbil: Conceptualization; data curation; formal analysis; funding acquisition; investigation; methodology; project administration; resources; software; supervision; validation; visualization; writing – original draft; writing – review and editing.No fund was received for this study.The author declares no conflict of interest.Written informed consent was obtained from the patient's next of kin to publish this report in accordance with the journal's patient consent policy.


Congenital mesoblastic nephromas are rare renal tumours that are encountered in paediatric age group. A term female neonate at the end of first week of life presented with bilateral lower limb swelling. On radiological evaluation, ultrasonography revealed an intra-abdominal mass which was managed with radical nephroureterectomy. Histopathological examination confirmed a diagnosis of congenital mesoblastic nephroma of mixed subtype. Among neonates, congenital mesoblastic nephroma (CMN), is more common.2 CMN can be associated with antenatal complications such as polyhydramnios, preterm labour and premature delivery.3 It is often recognized in the newborn who presents with an abdominal mass. Radical nephrectomy is the treatment of choice with adjuvant chemotherapy recommended for the more aggressive cellular or mixed variants.4 We report a rare case of congenital mesoblastic nephroma in a term neonate born via normal vaginal delivery.Wilm's tumour accounts for approximately 90% of paediatric renal tumours and is the most common renal neoplasm in children between one to four years of age.A term female neonate at ten days of her life was taken to a peripheral health facility with complaints of bilateral swelling of lower limbs. She weighed 2500 g at birth and was reported to have cried immediately after birth. During the antenatal period, the mother had regular antenatal checkups and had an uneventful pregnancy.At the health centre, ultrasonography of lower limbs showed findings suggestive of cellulitis and abdominal ultrasonography showed a large exophytic mass measuring 57x54 mm in the upper pole of the right kidney. She was then referred to a tertiary care centre for further management.Computed Tomography (CT) scan of the chest and abdomen was done which revealed a heterogeneously enhancing, well defined soft tissue density space occupying lesion in the right abdominal cavity arising from the right kidney, extending from the subhepatic region to the pelvic brim. The tumour was seen crossing the midline and displacing the bowel loops towards the left abdominal cavity. Areas of calcification were not noted. Findings from bilateral lung and mediastinum were normal.With these findings, a provisional diagnosis of Wilm's tumour was made and oncology consultation was done following which she was planned for a radical nephrectomy. Preoperative blood investigations including liver, renal function tests and complete blood counts were all normal. She underwent radical right nephroureterectomy, the mass was resected as a whole and sent to the Department of Pathology at another tertiary care centre for histopathological examination.On gross examination, the right kidney measured 11x10x9 cm which showed a mass measuring 8x8x7 cm which extended from the upper up to the lower pole of the kidney. On the cut section, the mass was solid, grey white with focal cystic areas. The right ureter, measuring 3.5x0.5x0.5 cm was sent in a separate container and was grossly unremarkable .On microscopic examination, the tumour was arranged predominantly in sheets and consisted of highly cellular areas with densely packed tumour cells as well as focal areas showing interlacing fascicles of tumour cells .Mitotic figures were 5/10 high-power field (HPF). Tumour was limited to the kidney with intact overlying renal capsule and hilar vessels as well as the ureter were free of tumour. Focally, small area of normal renal parenchyma showing glomeruli and tubules was also seen, adjacent to the tumor .Tumour cells had a scant amount of eosinophilic cytoplasm with oval to spindled vesicular nuclei and inconspicuous to small prominent nucleoli in some of the cells .A diagnosis of congenital mesoblastic nephroma, mixed subtype was made. She was discharged seven days post-surgery with stable vitals. Follow up at the paediatric surgical outpatient department was advised, with a plan to start adjuvant chemotherapy with actinomycin D and vincristine on follow up.One year post surgery, the child is doing well with no signs of recurrence on follow up ultrasonography. However, as the condition of the child has improved and the parents are happy about the progress, after discussion with the treating clinicians, they decided to skip chemotherapeutic treatment.5 It is the most common congenital renal tumour.2 Around 90% cases are diagnosed within the first year of life.5 Neonates most commonly present with an intraabdominal mass.2 Antenatal complications such as polyhydramnios, preterm labour and premature delivery may also be associated in around 71% cases.3 Paraneoplastic syndromes including hypertension and hypercalcemia, though uncommon, have also been reported.2 Increased renin synthesis by the tumor cells is thought to be the cause of hypertension whereas secretion of parathormone like proteins is responsible for hypercalcemia.2CMN is an uncommon mesenchymal neoplasm that represents 2-4% of all paediatric renal tumors.Due to routine use of ultrasonography, most cases are picked up during the antenatal period and the management plan initiated accordingly. In our case, tumour was diagnosed during the postnatal period when the child presented with lower limb swelling and ultrasonographic investigation for the same incidentally revealed a right sided renal mass.6 Cellular variant in contrast appear heterogeneously enhancing with fluid filled spaces representing haemorrhage, necrosis and cystic changes.6Congenital mesoblastic nephroma are low grade fibroblastic neoplasms that arise from the infantile renal sinus. These are more common than Wilm's tumor during the neonatal period however the two entities may not be distinguishable radiologically. On imaging, cases of classic CMN appear as homogeneous solid mass with "ring" sign of concentric hypoechoic and hyperechoic rims surrounding the tumour.5 The classic variant accounts for 24% of the cases and the mixed subtype is least common, accounting for 10% cases.7 Morphologically, tumours in classic CMN resemble infantile myofibromatosis and are composed of fascicles of fibroblastic cells with tapered nuclei, eosinophilic cytoplasm and a low mitotic activity.8On macroscopic examination, classic CMN exhibit a solid firm grey white tumour with whorled appearance in contrast to the cellular variants in which the mass is soft, cystic with areas of haemorrhage and necrosis. Among the three histological variants of CMN, cellular variant is most common, representing 66% of cases.8 Tumour cells arranged in ill formed fascicles give rise to sheet-like pattern of tumour cells. Tumour cells are plump, ovoid, with vesicular nuclei and moderate amount of cytoplasm. Mitotic activity is usually high and areas of necrosis and haemorrhage may be seen.8 Mixed CMN demonstrates features of both cellular as well as classic CMNs. In keeping with this, our case also showed tumour cells composed of dense areas of ovoid shaped cells in addition to spindle shaped cells arranged in fascicles. Tumour cells in CMN are positive for vimentin, desmin and actin but negative for CD34 and epithelial markers, however diagnosis is primarily based on morphology.9In contrast, cellular variant of CMN morphologically has a greater cellularity and resembles infantile fibrosarcoma.10Recent genetic studies have shown differences between classic and cellular variants of CMN. The cellular variant shows a translocation   with formation of ETV6-NTRK3 gene which is not seen in the cellular variant.11 Chances of recurrence are higher in patients are older than 3 months of age with the cellular variant of CMN.4 Recurrences are also common when surgical margins are positive or if there has been an intraoperative tumour rupture.4 All of these cases as well as cases of relapse are eligible to receive adjuvant chemotherapy.4 Combinations of vincristine, cyclophosphamide and doxorubincin (VCD), vincristine, doxorubicin and actinomycin D (VDA) have been successfully used. 4The treatment of choice for CMN is radical nephrectomy. Nephrectomy alone is usually sufficient and only around 5% patients develop recurrence that is mainly related to the completeness of tumour resection.2 Neuroblastomas can also be a differential diagnosis for congenital tumours and may invade the kidney or rarely even arise from the renal parenchyma. In cases of CMN, rarity of this tumour and unfamiliarity with cases can pose a diagnostic difficulty. Radiological features and morphological findings must be used synergistically to reach a diagnosis and the pathologist must always keep in mind the possibility of CMN in case of a renal tumour in neonates.The differential diagnosis for renal tumours in paediatric population commonly include Wilm's tumour, congenital mesoblastic nephroma, clear cell sarcoma of kidney (CSSK), ossifying renal tumour of kidney (ORTI) and malignant rhabdoid tumour.CMN are the most common congenital renal neoplasms which are mostly diagnosed in the first year of life. These are low grade neoplasms that carry excellent prognosis with radical nephrectomy. Surgical management is adequate for classic variants however adjuvant chemotherapy is recommended for the more aggressive cellular and mixed variant of CMN.


The aim of this study was to introduce a patient with mucinous nonneoplastic cyst (MNNC) at an unusual age. MNNCs of the pancreas are uncommon primary tumors, which affect middle-aged women in their fifth decade of life and have significant malignant potential. Therefore, it is important to accurately diagnose and remove them. This case is a 28-year-old woman patient who presented with a pain in the right and upper abdomen from 3 months ago and worsened at night. A cystic lesion was observed near the upper bridge of the left kidney in abdominal ultrasonography. Contrast-enhanced abdominal computed tomography (CT) scan showed a cystic lesion in the trunk and umbilical cord of the pancreas. The patient underwent surgery and the mass was removed and the MNNC was diagnosed. Approximately 10% of cystic lesions of the pancreas are cystic neoplasms that make up 1% of all pancreatic tumors . MCN areThe patient was a 28-year-old woman with complaints of a pain in her upper left abdomen, which she had referred on 22 October 2019. The pain in the patient had started 3 months earlier. The pattern of pain was that the pain was consistently low, but worsened at night. The patient had no symptoms of nausea and vomiting, no weight loss, no fever, no icterus, no history of surgery, no special medication, but antacid therapy had been used for her for about a month, but the pain had not changed. Her family background was negative. The patient’s vital signs and abdominal examination were normal .On ultrasound, the size, echogenicity, and parenchyma of the liver were normal, the bile ducts within and outside the liver were not dilated. Diameters of the port, bile ducts, and gallbladder were normal. The spleen and pancreas had normal size. And the pancreatic ducts were not dilated. A 61 × 50 mm cystic lesion with internal septa was observed adjacent to the upper bridge of the left kidney. The patient’s abdominal CT showed a clear thin-walled cystic lesion containing septa in the spleen with a size of 50 × 61 × 48 mm .The patient had a surgical consultation and underwent an abdominal surgery on the day of admission. The abdominal wall was opened by the right subcostal method and distal pancreatectomy was performed by preserving the spleen . The masThe patient was a young woman with nonspecific gastrointestinal symptoms who was diagnosed with MCN after diagnostic procedures. The table below shows the characteristics of patients in previous studies .Women account for 98% of MCN cases and are mainly affected in the fifth decade of life  .Clinical appearances are nonspecific and 62% of patients have abdominal pain, 11% weight loss . Large cystic pancreatic neoplasms of the mucosa can put pressure on the surrounding organs and structures, leading to abdominal pain and a feeling of fullness, but in general, many patients are asymptomatic and the lesions are accidentally seen on imaging . The patMRI has a higher diagnostic accuracy than CT scans in this cyst (19.9 vs. 1.2%). MRI also more accurately defines the association of the pancreatic duct with the lesion and can distinguish cyst-like from IPMN. MRI also improves cyst content in T1 and T2, which is its most important advantage over CT scan . Any panRisk factors for malignancy are large lesions, with nodules or masses, calcification, walls >2 cm in thickness, presence of septa, and high patient’s age . MucinouIn 2010, the International Association of Pancreatology recommended the removal of all MCNs for the following reasons: the lack of specificity of diagnostic tests and biopsy specimens, the risk of malignant transformation of 6–27%, the impossibility of distinguishing non-invasive lesions from invasive lesions, and good results of a complete surgery. The association also recommends laparoscopic resection, parenchymal resection, and distal pancreatic resection for lesions <4 cm without mural nodules . The sur


Surgical resection of spinal cord hemangioblastomas remains a challenging endeavor: the neurosurgeon’s aim to reach total tumor resections directly endangers their aim to minimize post-operative neurological deficits. The currently available tools to guide the neurosurgeon’s intra-operative decision-making consist mostly of pre-operative imaging techniques such as MRI or MRA, which cannot cater to intra-operative changes in field of view. For a while now, spinal cord surgeons have adopted ultrasound and its submodalities such as Doppler and CEUS as intra-operative techniques, given their many benefits such as real-time feedback, mobility and ease of use. However, for highly vascularized lesions such as hemangioblastomas, which contain up to capillary-level microvasculature, having access to higher-resolution intra-operative vascular imaging could potentially be highly beneficial. µDoppler-imaging is a new imaging modality especially fit for high-resolution hemodynamic imaging. Over the last decade, µDoppler-imaging has emerged as a high-resolution, contrast-free sonography-based technique which relies on High-Frame-Rate (HFR)-ultrasound and subsequent Doppler processing. In contrast to conventional millimeter-scale (Doppler) ultrasound, the µDoppler technique has a higher sensitivity to detect slow flow in the entire field-of-view which allows for unprecedented visualization of blood flow down to sub-millimeter resolution. In contrast to CEUS, µDoppler is able to image high-resolution details continuously, without being contrast bolus-dependent. Previously, our team has demonstrated the use of this technique in the context of functional brain mapping during awake brain tumor resections and surgical resections of cerebral arteriovenous malformations (AVM). However, the application of µDoppler-imaging in the context of the spinal cord has remained restricted to a handful of mostly pre-clinical animal studies. Here we describe the first application of µDoppler-imaging in the case of a patient with two thoracic spinal hemangioblastomas. We demonstrate how µDoppler is able to identify intra-operatively and with high-resolution, hemodynamic features of the lesion. In contrast to pre-operative MRA, µDoppler could identify intralesional vascular details, in real-time during the surgical procedure. Additionally, we show highly detailed post-resection images of physiological human spinal cord anatomy. Finally, we discuss the necessary future steps to push µDoppler to reach actual clinical maturity. Although literature shows that IONM can significantly improve the prevention of neurological damage during surgery , there iIntra-operatively, ultrasound and its submodalities ) have become a more common practice during spinal procedures given their many benefits including ease of use of the techniques, mobility, and availability of real-time feedback during surgical resection –27. For Over the last decade, µDoppler-imaging has emerged as a new, high-resolution, contrast-free sonography-based technique which relies on High-Frame-Rate (HFR)-ultrasound and subsequent Doppler processing. In contrast to conventional millimeter-scale (Doppler) ultrasound , the µDoLike many other developments in Neurosurgery, the focus of µDoppler-imaging so far has primarily been on cerebral pathology, with only a handful of animal –36 and iHere we describe the first application of µDoppler-imaging in the case of a patient with hemangioblastomas located in the thoracic spinal cord. We demonstrate how µDoppler is able to identify intra-operatively and with high-resolution, key anatomical and hemodynamic features of the lesion. In contrast to pre-operative MRA, µDoppler could identify intralesional hemodynamic details, in real-time during the surgical procedure. Additionally, we show post-resection µDoppler-images of physiological human spinal cord anatomy. Finally, we discuss the necessary future steps to push µDoppler reach actual clinical maturity.2.2.1.The patient is a female in her 60's with an extensive prior history of hypertension and recurrent spinal hemangioblastomas, for which she had three prior surgical procedures: two procedures to remove intramedullary hemangioblastomas in the lumbar region  and one procedure to remove a high cervical, intramedullary hemangioblastoma . This su2.2.Pre-operative imaging (MRI/MRA) confirmed the presence of multiple intradural hemangioblastomas. The largest (lesion 1) appeared to be both intra- and extramedullary and was located at Th10-Th11 on the right posterior side of the myelum .3.3.1.CompactDAQ module (NI 9250) at 500 Hz and stored for post-processing purposes.High-frame-rate (HFR)-acquisitions were performed using our experimental research system  interfaced with a L8-18I-D linear array  or a 9l-D linear array . Acoustic safety measurements were performed in collaboration with our department of Medical Technology prior to obtaining medical ethical approval to perform this study. For all scans we acquired continuous angled plane wave acquisition  with a PRF ranging from 667 to 800 Hz depending on the imaging depth and transducer. The average ensemble size (number of frames used to compute one Power Doppler Image (PDI)) was set at 200 angle-compounded frames from which the live PDIs were computed, providing a live Doppler FR ranging between 3 and 4 Hz. The PDIs as well as the raw, angle compounded beamformed frames were stored to a fast PCIe SSD hard disk for offline processing purposes. Parallel to our HFR-acquisitions, patient's vital signs  were recorded using a National Instruments’ To make our PDIs trackable in the OR, we integrated our transducers into Brainlab neuronavigation software by attaching the conventional optical tracking geometry to the transducer casing using custom-made 3D-printed attachments. An overhead camera recorded the surgical field as the surgeon performed µDoppler-acquisitions and removed the tumor. Through integration of our custom CUBE-cart in the OR-system, our live PDIs were displayed in real-time on the OR-screens .3.2.Trimano, Gettinge) with a transducer-holder (lesion 1) revealed to have both an intramedullary and extramedullary component. The caudal lesion (lesion 2) revealed to be only extramedullary. Finally, the post-resection µDoppler-acquisitions were performed, again both hand-held and using the intra-operative surgical arm. The total intra-operative acquisition time of the µDoppler-data was around 30 min.Our experimental image acquisitions were integrated into the conventional surgical workflow, with an acquisition session both pre- and post-resection. First, the patient was placed in prone position and head-fixated in the Mayfield. A medial incision was made at the level of T9-T11, before stripping paraspinal muscles from the spinous processes and inserting a wound distractor. A laminectomy was performed from T9-T11, revealing the dura surrounding the spinal cord. The pre-resection HFR-acquisitions were performed prior to durotomy. First, hand-held 2D-images were made along a continuous trajectory spanning the full axial and sagittal length of the exposed myelum  for orier-holder . In sagir-holder . Both tu3.3.20% cut-off percentage) over each ensemble and mapped onto a 100 µm grid using zero-padding in the frequency domain. The ensemble size was kept similar to the one used in acquisition (ne = 200). Given the significant, mostly in-plane motion due to the patient's breathing, single PDIs at the end of the inhale or exhale were manually selected from each dataset to ensure presentation of the most stable images.In offline processing, PDIs were computed using an adaptive SVD clutter filter (Color Doppler Images (CDIs) were computed by taking the mean of the difference of the instantaneous phase signal for all frames in one ensemble as described by Kasai et al. . All ini4.4.1.yellow asterix) hemangioblastoma, again revealing µDoppler's ability to detect microvascular details. 2D-µDoppler was able to identify an intricate microvascular network inside both hemangioblastoma foci  None of 4.2.4.3.4.4.Directly post-operatively, neurological examination showed similar motor scores for the right leg as were seen pre-operatively. The patient underwent an intensive rehabilitation programme and was seen for regular check-ups with MRI-scans every 6 months. One year after surgery, walking and standing had subjectively improved based on patient report, without significant change on the MRC-scale for both legs. The patient expressed to be satisfied with the surgical outcomes. The one-year MRI showed a slight growth of tissue in the thoracic surgical region, which now warrants more close monitoring with more regular MRI-scans (every 3 months).5.To the best of knowledge, this work presents the first µDoppler-images of human spinal hemangioblastomas. We show how µDoppler has the ability to detect intricate, intralesional microvasculature, which is otherwise not available pre- or intra-operatively with the currently available clinical techniques such MRI, MRA or conventional ultrasound. Having access to a real-time, high-resolution technique which can visualize hemodynamics in particular, could be valuable to support the neurosurgeon in their balancing act between removing too much or too little of the hemangioblastoma intra-operatively. The hope is that by having access to demarcating microvascular details as we show here  , 42. ThrThis case report marks the first application of µDoppler-imaging in the case of a patient with two thoracic spinal hemangioblastomas. We demonstrate how µDoppler is able to identify intra-operatively and with high-resolution, hemodynamic features of the lesion. In contrast to pre-operative MRA, µDoppler could identify intralesional vascular details in real-time during the surgical procedure, without the need for a contrast-agent. Additionally, our technique was able to capture highly detailed post-resection images of physiological human spinal cord anatomy. Although immediate surgical impact could not be achieved in this single case report, we hope this demonstration will add to scientific awareness of the availability of µDoppler-imaging, as well as the quality of its images when applied to new contexts such as hemangioblastoma.


Postoperative ileus (POI) occurs after gastrointestinal and other intra-abdominal surgeries, and its incidence rate is reported to range between 10 and 30% following major abdominal surgery. Should ileus remain for several days or if symptoms worsen despite management, further investigation is warranted to consider other diagnoses such as small bowel obstruction (SBO), intra-abdominal abscess, or perforation. The etiology of postoperative obstructive symptoms can evolve during the postoperative course and many possible factors contribute to postoperative gastrointestinal dysfunction. Prolonged POI may be a risk factor for hernia incarceration. We describe the case of a 72-year-old male with a history of perforated diverticulitis and Hartmann procedure status post-colostomy takedown complicated by prolonged POI for six days. Clinical workup revealed incarcerated inguinal hernia, which was treated with urgent inguinal hernia repair. Follow-up revealed resolution of gastrointestinal dysfunction within 48 hours of hernia repair. Prolonged postoperative ileus (POI) occurs after gastrointestinal and other types of surgery. POI is characterized by bowel dysfunction and decreased motility, resulting in the ineffective passage of intestinal contents. Symptomatically, patients may present with abdominal distension, decreased or absent bowel sounds, constipation, and inability to advance oral intake . The exaEvaluation of an ileus should exclude other diagnoses such as small bowel obstruction (SBO), intra-abdominal abscess, or perforation, making ileus a diagnosis of exclusion. Prolonged ileus, defined as signs and symptoms of ileus on POD four or after , continuIncarcerated inguinal hernia in the setting of POI is rare, with only a handful of reported cases in the literature . We repoA 72-year-old male presented to the colorectal team for Hartmann’s procedure reversal (colostomy takedown). He had a past medical history of perforated diverticulitis status post (s/p) open Hartmann procedure 12 months ago resulting in the current colostomy. Patient imaging on chart review revealed a six-month history of moderate-sized right inguinal hernia containing a loop of non-obstructed small bowel as seen in Figure Prior to the colostomy takedown, the patient had reported multiple, daily, soft stool outputs out of the colostomy bag. Before the colon resection in 2021, the patient’s bowel habits had included daily firm bowel movements with minimal straining. He denied any known history of hernias past or present. Past medical history was significant for diverticulitis, dyslipidemia, pulmonary emphysema, kidney stones, chronic rhinitis, and schizophrenia. Past surgical history was significant for colon resection for perforated diverticulitis with colostomy in 2021. Recent medication changes were limited to recent surgery and hospital admission. Family history was noncontributory. He had no known allergies.Robotic-assisted laparoscopic reversal of Hartmann’s procedure and lysis of adhesions was performed. Intraoperative findings involved a right inguinal hernia with a loop of small bowel that was reduced during surgery. Postoperatively, the patient was advanced to clear liquids on POD zero. Oral intake caused significant nausea and vomiting, and the patient was made nothing by mouth (NPO) on POD one, which alleviated nausea. An abdominal X-ray was performed, which showed significant mild gaseous distention of several loops of the small and large bowel, nonspecific in the postoperative setting with no evidence for high-grade intestinal obstruction or large pneumoperitoneum as seen in Figure The patient continued passing flatus and burping but had no bowel movements. POD three through four, he was advanced to clear liquids and then a full liquid diet. On POD five, he had an irregular dark bowel movement thought to be from recent surgical anastomosis and was advanced to a low-fiber diet. On POD six, he developed nausea, and bilious vomiting, and continued to produce dark bloody stool with ongoing significant abdominal pain. His diet was changed back to NPO. The patient refused nasogastric (NG) tube insertion at this time.Physical examThe patient’s vitals on POD six s/p colostomy takedown were as follows: temperature of 36.9 °C, blood pressure of 138/75 mmHg, heart rate of 84 bpm, respiratory rate of 16, and pulse oximetry of 98% on room air. The physical exam showed a 72.57 kg male resting in bed in mild distress. The patient reported nausea and two episodes of emesis. He had bilaterally palpable carotid, radial, femoral, and posterior tibial pulses. Auscultation failed to appreciate any carotid bruits. Chest sounds revealed bilaterally clear breath sounds with no crackles, wheezes, or rales. His abdomen was mild to moderately distended and firm and tender to palpation in the left lower quadrant with normoactive bowel sounds. Inspection and palpation failed to appreciate any abdominal masses. A right inguinal hernia was appreciated upon visual inspection and palpation. The hernia was not able to be reduced. His abdomen revealed prior surgical incisions from the recent colostomy takedown.Diagnostic studies/clinical decision-making9/L, hemoglobin of 14.2 mg/dL, platelet count of 322,000, and glucose of 153 mg/dL.Recent blood tests showed no leukocytosis and no electrolyte abnormalities involving potassium, calcium, or magnesium. He was found to have a white blood cell count of 9.4 x 10CT imaging of the abdomen and pelvis with contrast was ordered to rule out an anastomotic leak, abscess, or SBO. Imaging findings suggested incarceration of a known right inguinal hernia containing small bowel, with associated upstream small bowel dilation and gas fluid levels, suggesting SBO as seen in Figure Several attempts were made to manually reduce the hernia, even by sedating the patient and positioning him in Trendelenburg. However, all attempts were unsuccessful. He had inguinal pain and tenderness on examination with persisting signs of SBO. Urgent operation for right inguinal hernia repair with relief of obstruction and possible small bowel resection was recommended with NG tube placement.TreatmentThe usual treatment approach for SBO caused by incarcerated hernia is urgent operation as it is significantly associated with risk for strangulation . The patFollow-upOn POD two, abdominal X-ray findings reflected improving SBO and the NG tube was removed. He was evaluated and found to have no nausea or vomiting, and a soft, non-tender, non-distended abdomen on physician exam. The patient’s diet was advanced. He had a return of bowel function, thereby demonstrating the resolution of bowel obstruction, and was discharged home.We described a case of a 72-year-old male presenting with nausea, vomiting, diet intolerance, distended tender abdomen, and bloody stools in the postoperative setting of a colostomy takedown initially suspected to be prolonged POI. While this clinical picture can be explained by several possible pathologies, it was eventually found to be EPSBO due to incarcerated hernia.EPSBO may present with an initial return of bowel function and initiation of oral intake with subsequent nausea, vomiting, abdominal distention, and pain, as in this case. Compared to this, a postoperative patient presenting with an ileus usually lacks the return of bowel function or advancement of oral intake . IntenseExplanations for the progression of this case involve two theories. The existing hernia may have presented with intermittent SBO and corresponding symptoms of abdominal distension, nausea, vomiting, and abdominal pain that may have mimicked symptoms of POI. Alternatively, symptoms from existing ileus, such as vomiting, may have escalated the hernia from asymptomatic to incarcerated. In the event of increased intra-abdominal pressure, hernia contents can be forced into the point of weakness in the abdominal wall and unable to be reduced . Intra-aManagement of asymptomatic hernias prior to major abdominal surgeries that pose a significant risk of POI may decrease the need for surgical interventions for postoperative hernia incarceration . ConsideAn alternative approach is concurrent stoma closure and hernia repair compared to a staged procedure. In theory, this approach would reduce net recovery times and eliminate the need for two separate major abdominal surgeries compared to a single surgery. According to Oma et al., synchronous repair of the hernia and colostomy reversal led to a longer hospital stay and increased risk of reoperation for hernia recurrence compared with incisional hernia repair only . RudnickThis case also highlights that many patients with inguinal hernias are asymptomatic, as this patient denied a history or current complaint of groin bulge or tenderness. A detailed history and physical exam supplemented by CT imaging are vital in identifying the site of obstruction. Imaging five months prior had documented his right inguinal hernia, which further proved to be significant as a means of comparison to current imaging and presentation. Incarcerated hernias pose a concern for strangulation, posing significant morbidity and adverse outcomes, and should be managed with emergency surgical repair . DistingPhysicians should be cognizant that the etiology of postoperative obstruction can change during the postoperative course. As for this case, we theorize that the patient may have initially presented with uncomplicated POI due to inevitable pathophysiological factors related to abdominal surgery. However, the condition eventually evolved into mechanical obstruction, altering the course of management significantly. In most patients with prolonged POI, reliable baseline tests, and routine imaging are useful in narrowing down the differential and ruling out an underlying cause of mechanical obstruction.


We present a unique case of bowel obstruction with a hiatus hernia causing atypical chest pain with dynamic ST-segment elevation in a regional Australian emergency department. The ST elevation only resolved after nasogastric decompression of the bowel obstruction. Early thrombolysis of presumed myocardial infarction led to upper gastrointestinal tract bleeding that could have been avoided with timely diagnosis. An extensive review of literature, in addition to our case report, suggests bowel obstruction is a differential diagnosis for patients who have inferior pattern ST elevation but normal troponin presenting with atypical chest pain, nausea, vomiting and previous abdominal surgery. Acute mechanical bowel obstruction is a common surgical emergency, accounting for 20% of emergency surgical operations for abdominal pain . RecogniA 78-year-old female presented at 4 am to a regional Australian Hospital with 12 h of severe retrosternal chest pain, associated with diaphoresis, nausea and four episodes of bilious emesis. Her 12-lead electrocardiogram (ECG) met ST-segment elevation myocardial infarction (STEMI) criteria with STE in leads II, III and aVF . Her bacHer initial biochemistry, including high-sensitivity troponin, was within normal limits. A transthoracic echocardiogram showed normal ejection fraction and no segmental wall motion abnormality. She underwent coronary artery catheterization for persistent ST-elevation after thrombolysis, which found only mild non-obstructive coronary artery disease. Due to persisting pain, a computerized tomography (CT) aortogram was performed, demonstrating a significantly dilated stomach, a hiatus hernia and small bowel loops with a transition point suggestive of small bowel obstruction as shown in Two days later, packed red blood cell transfusions were required for declining haemoglobin to 72 g/L. A CT mesenteric angiogram revealed resolution of the bowel obstruction but active bleeding of a Mallory-Weiss tear in the lower third of the oesophagus, managed with gastroscopy. She recovered well and was discharged home 8 days later. Informed consent to publish form has been obtained and is held by the treating institution as per the local ethics committee guidelines.Bowel obstruction is one of the most common pathologies in general surgery. Diagnosing and treating this in a timely manner are critical due to consequences such as bowel ischemia, aspiration and sepsis . We presIn each case, including ours, there is atypical chest pain or sometimes abdominal pain accompanied by inferior STE and normal troponin markers. Nearly all patients described as having this phenomena had previous abdominal surgery and hence a risk factor for bowel obstruction with associated symptoms of nausea and vomiting. Variably, inferior wall hypokinesis is demonstrated, likely due to the mechanical restriction of systolic expansion . CardiacUnique to our case is the regional Australian location of our hospital. Without immediate access to the cardiac catheterization lab, our patient required thrombolysis of her presumed STEMI rather than a percutaneous coronary intervention. Thrombolysis had several implications in this patient who had a bowel obstruction. About 11.4% of patients after thrombolysis require a transfusion, with the most common site for spontaneous bleeding being gastrointestinal, as observed in our patient who had a Mallory-Weiss tear . Our patSmall bowel obstruction with gastric distension is a very rare but important cause of STE in a patient with prior abdominal surgery presenting with atypical troponin-negative chest pain. Awareness of such cases can lead to earlier delivery of more appropriate care and highlights the primacy of taking a thorough history of presenting illness in presentations of general surgical pathology.


Colonic atresia is a rare cause of congenital low-type intestinal obstruction in the neonatal age group and may present as a surgical emergency if not diagnosed early. Clinically, it can pose a diagnostic dilemma for Hirschsprung disease, which involves a different treatment strategy. Therefore, an early and accurate diagnosis is paramount from a management and prognosis perspective. The contrast enema plays a crucial role in the diagnosis of the disease. The "Windsock or Cobra head sign" on the contrast enema, typically seen only in type 1 colonic atresia, can help radiologists and surgeons identify this disease. We report a case of a two-day-old neonate, including a clinical feature of low-grade intestinal obstruction with distinctive imaging signs of type 1 colonic atresia, which can help make a definitive diagnosis. Most low-type intestinal obstructions are congenital in the neonatal age group and may present a surgical emergency. The incidence of neonatal intestinal obstruction is one in every 2000 live births . CongeniA two-day-old baby boy, born with normal-term vaginal delivery, was referred to pediatric emergency with complaints of progressive abdominal distention and absent passage of stool since birth. A detailed history revealed worsening symptoms after feeding. Birth history did not reveal any significance. Initially, her vitals were within the normal range, but then she developed mild respiratory distress and appeared mottled and dehydrated after episodes of vomiting. On examination, the abdomen appeared distended with visible peristalsis. The rectal examination revealed no meconium stain, but the anal opening arose at the usual site. The laboratory parameters appeared within normal limits.A diagnosis of neonatal intestinal obstruction with a provisional diagnosis of Hirschsprung's disease (HD) was considered. The abdominal radiograph revealed dilated gas-filled bowel loops in the abdominal cavity with a paucity of gas shadow in the rectal region Figures , 1B, witFor further evaluation, rectal contrast enema performed under fluoroscopy guidance, and an appropriately diluted water-soluble contrast enema was injected rectally. It showed a small-caliber rectum and sigmoid colon (microcolon) with a preserved rectosigmoid ratio of 2:1. A round, contrast-filled, blind-ended pouch-like structure was depicted distally at the junction of the sigmoid along with a descending colon with no flow of contrast into the proximal colon Figures , 2B. ThiOutcome and follow-upNeonate underwent surgery due to worsening symptoms; imaging findings corroborated intraoperative findings. Open laparotomy revealed an intraluminal thin mucosal web in the sigmoid colon, bulging into an adjacent dilated descending colon, with the expulsion of meconium after the incision of the web. These findings confirmed the diagnosis of type 1 colonic atresia Figures , 3B. TheCongenital colonic atresia is among the rare causes of low-type intestinal obstruction, accounting for 1.8%-5% of all intestinal atresias, with an increased preponderance in males . Unlike Several theories were proposed to explain the etiopathogenesis of colonic atresia (CA). The most accepted one was an early intrauterine vascular insult caused by extrinsic compression of bowel obstruction  leading into aseptic necrosis and resorption ,4. The oAn association between colonic atresia and HD is reported in 2% of patients . Hence, Clinically, newborns with colonic atresia generally present features of a low type of intestinal obstruction. Unlike another type of intestinal obstruction, the bauhin valve presents as a closed bowel loop obstruction. Hence, the onset of abdominal distention and vomiting is usually delayed ,9.Imaging plays a primary role in making a definitive diagnosis, excluding the close mimickers, and can be a guiding light for surgeons with regard to prognosis and management . A plainBased on the revised classification of Martin et al.  and GrosThe management of colonic atresia includes early surgery to prevent morbidity and mortality. The repair included a primary or step-by-step anastomosis. The choice of surgical procedure depends on the location of the atresia. The preferred surgery for the proximal type of colonic atresia is resection and primary anastomosis. Colo-colic anastomosis with covering ileostomy is preferred in the distal or left-sided type of CA, as done in our case. Early perinatal diagnosis and individualized operation are the key steps in managing colonic atresia ,12-14.Congenital colonic atresia is a rare form of low bowel obstruction in neonates with a slight male preponderance and may present a diagnostic dilemma clinically for Hirschsprung disease. Neonatal survival depends on early, accurate diagnosis and timely treatment. The contrast enema plays an important role in making the final diagnosis. The characteristic "windsock or cobra head sign" on the contrast enema can be a clue for radiologists and pediatric surgeons to make an early and accurate diagnosis of type 1 colon atresia. In 2% of the population, type 1 colon atresia is associated with HD; therefore, a rectal biopsy must be recommended before surgery in all cases.


Hydatid cysts are most frequently located in the liver and lungs and very rarely can be found in the pericardium. Diagnosis and treatment are quite challenging, as the disease can present itself in many forms depending to the location and the complications that it might cause.A 22-year-old man presented to our hospital with ongoing dry cough for more than 1 month prior to admission. Other symptoms included chest pain, fatigue, low grade fever, and night sweats, which have worsened in the past 2 weeks. Physical examination revealed normal respiratory and heart function. Chest X-ray demonstrated mediastinal enlargement and left pleural effusion. Contrast-enhanced computed tomography images showed a walled cystic mass lesion measuring up to 56 × 50 mm in close proximity to the upper left atrium, ascending aorta and pulmonary artery, potentially localized in the pericardium, with a 10 mm endoatrial filling defect, findings were compatible with hydatid cyst, left pleural effusion and peripheral pulmonary upper left lobe consolidation. Cardiac involvement was excluded on magnetic resonance imaging and trans-esophageal ultrasound. The patient underwent fine needle aspiration of the affected lung and thoracocentesis. No malignancy was found, meanwhile the biopsy confirmed the presence of pulmonary infarction. In view of the imaging findings were highly suspicious of a hydatid cyst, we performed a test of antibody titers that was negative. The patient underwent left anterolateral thoracotomy, and after the opening of the pericardium, a cystic mass of 5 cm in diameter was found next to the left atrium and in close proximity with the left pulmonary veins. The content of the cyst was completely removed after the surgical area was isolated with gauze impregnated with hypertonic solution (NaCl 10%). The mass resulted to be an echinococcal cyst with multiple daughter cysts within it that did not penetrate/involve (perforate) the cardiac wall.Pericardial echinococcosis is a very rare pathology in which a high expertise multidisciplinary approach is required. The compression mass effect caused by the cyst can lead to complications, such as in our case where the pulmonary vein was compressed, leading to pulmonary infarction. The value of radiology studies and transoesophageal ultrasound are very important in the diagnosis. Surgery in these cases is always recommended, but preferred surgical approach is questionable. In cases such as ours, we recommend anterolateral thoracotomy. Hydatid cysts are most frequently located in the liver and lungs and very rarely can be found in the pericardium . DiagnosA 22-year-old man presented to our hospital with ongoing dry cough for more than 1 month prior to admission. Other symptoms included chest pain, fatigue, low grade fever, and night sweats, which have worsened in the past 2 weeks. Physical examination revealed normal respiratory and heart function. Chest X-ray demonstrated mediastinal enlargement and left pleural effusion.CECT images showed a walled cystic mass lesion measuring up to 56 × 50 mm in close proximity to the upper left atrium, ascending aorta and pulmonary artery, potentially localized in the pericardium, with a 10 mm endoatrial filling defect, findings were compatible with hydatid cyst, left pleural effusion and peripheral pulmonary upper left lobe consolidation . The cystic mass found was an echinococcal cyst with several daughter cysts measuring up to 10 mm within it. After removal of the daughter cysts and a partial resection of the pericyst, no involvement/penetration of the heart wall was found Fig. . The remEchinococcus granulosus [Hydatid disease/Echinococcus cyst is a parasitic disease caused by an infection with the larvae of the tapeworm anulosus . The mosanulosus –7. Pericanulosus –5.Patients with pericardial hydatid cysts may remain asymptomatic until echinococcal cysts cause pressure mass effects on surrounding structures. Presenting symptoms of uncomplicated pericardial hydatid cysts include chest pain due to stretching of the pericardium and/or compression of coronary vessels and dyspnea –5.The diagnosis of hydatidosis is based on immunodiagnostic methods along with radiological and ultrasound examinations –8.In our case, the antibody titer test was negative. False negative results in human hydatidosis may range from 3 to 5% of hydatid patients up to 35–40% in hyperendemic areas, as in the case of our country .Although pericardial hydatid cysts can be detected by transthoracic echocardiography, cross-sectional imaging studies such as computed tomography (CT) and/or MRI are usually necessary to identify before the surgery the cardiac anatomy, disease location and cyst size –7.CT is a better imaging technique for revealing small calcifications, which may be a helpful imaging finding in the diagnosis of a hydatid cyst. Our case had no calcifications and no other cysts in the liver or in the other structures. The relationship of hydatid cysts with surrounding structures can be seen by MRI –4. HydatTreatment of pericardial hydatid cysts can be accomplished with surgical excision of the cystic lesion. Medical treatment  is complimentary for disseminated cases and for prophylaxis –7.Research has shown that 73–75% of patients respond to medical management to some extent, but the reported cure rates are only 25–30%, and this strategy is a long and tedious process involving considerable risks .In our case, considering the rare position of the cyst (retrocardiac) and the fact that the cyst did not enter the intracardiac site, the surgery was performed through left anterolateral thoracotomy by thoracic surgeons after 7 days of premedication with albendazole. It was necessary to release the Botalli duct after opening the pericardium to better expose the cystic lesion and all the structures adjacent to it. The surgery was performed in cardiac operation suite/room theatre with the availability of cardiac surgeons for any intraoperative complications.There are a lot of cardiac surgeons that would prefer to perform the surgery in cases like that through the sternotomy, but in our case the cardiac surgeons were not familiar with the surgery in the area that the cystic mass was localized.Regarding the premedication with albendazole prior to surgery there have been recent studies that emphasise the role of albendazole in cases of rupture of large cysts of the lungs . In our Pericardial echinococcosis is a very rare pathology in which a high expertise multidisciplinary approach is required. The mass effect caused by the cyst can lead to complications, such as in our case where the pulmonary vein was compressed, causing a pulmonary infarction. The values of radiology and transesophageal ultrasound are very important in the diagnosis. Surgery in these cases is always recommended, but still the surgical approach is questionable. In cases such as ours, we recommend anterolateral thoracotomy.


Hepatic small vessel neoplasm (HSVN) is a rare vascular hepatic lesion that is usually an asymptomatic incidental finding. Here we present a case of a 66-year-old male with HSVN who was discovered to have a lesion presenting as a small nodule in an explanted liver. HSVN is a recently described hepatic vascular lesion that has been previously underdiagnosed. It has an uncertain long-term malignant potential, so close follow-up is recommended. Hepatic vascular tumors demonstrate a range of appearances, from benign cavernous hemangioma to malignant angiosarcoma, the most common primary sarcoma of the liver. The differentiation between these two vascular lesions can usually be performed on routine morphology; however, recently, a few vascular lesions have been reported with features of both categories. The hepatic small vessel neoplasm (HSVN) was first described by Gill et al.  in 2016;Our case is a 66-year-old male with a clinical history of alcoholic cirrhosis, diabetes mellitus, hypertension, coronary artery disease, and end-stage renal disease. Before the hepatic explantation, the MRI and CT scans showed no suspicious liver lesions besides cirrhosis.The patient underwent native liver hepatectomy for a liver transplant. A gross examination of the explanted liver showed one small tan-brown nodule measuring 0.7 cm in the greatest dimension in a background of cirrhotic nodules. No other suspicious lesions were identified.Histologic examination showed vascular lesion, and immunohistochemical stain for CD34 highlights the vessels Figures . The lesThe immunohistochemical stain for p53 was wild type. The Ki-67 is about 3% , higher 2, and the size range is between 1 cm and 15.9 cm as reported by Walcott-Sapp et al. [Since 2016 when HSVN was first described . This lep et al. . In all The immunohistochemical stains for vascular markers CD34, CD31, and FLI-1 are uniformly positive in HSVN . The proThe differential diagnosis of HSVN includes cavernous hemangioma, anastomosing hemangioma, epithelioid hemangioendothelioma, and angiosarcoma. Among these vascular lesions, the histologic features of anastomosing hemangioma can be very similar to HSVN. Although most cases of anastomosing hemangioma are reported in the retroperitoneum, kidney, and ovary , it has The distinction between these two entities is that the anastomosing hemangioma is well demarcated without liver infiltration. In addition, anastomosing hemangiomas usually have areas similar to cavernous hemangiomas, but this histologic finding is never reported in HSVN .Molecular studies performed on HSVN cases have shown the presence of GNAQ and GNA14 mutations. These have not been reported in cavernous hemangioma or angiosarcomas , 9.The rarity of this neoplasm means it has likely been underdiagnosed in the past. HSVN should enter the differential diagnosis of the pathologist whenever a hepatic vascular lesion is encountered, particularly if it has an infiltrative margin. The diagnosis of HSVN can then be confirmed or ruled out using the immunohistochemical stains discussed above. Although there have been no reported cases with recurrence or metastasis, the course of the disease is not well understood, so close follow-up is recommended , 10. If We report a case of HSVN incidentally found in an explant liver; the lesion was not seen in radiographic images prior to the surgery. The awareness of this neoplasm is necessary to make an accurate diagnosis and differentiate it from other liver lesions especially angiosarcoma. As the number of reported patients is low and there are not enough data about the long-term prognosis, resection and close follow-up are recommended.


Olfactory neuroblastoma is a rare, undifferentiated carcinoma of the nasal cavity. It is an extremely rare malignancy, usually occurring in the sixth decade of life with no known underlying cause. In this case report, we present a 71-year-old male with an enlarging facial mass near the right medial nasal bridge, initially diagnosed as undifferentiated carcinoma on biopsy and later confirmed as olfactory neuroblastoma eroding into the anterior skull base. Our patient presented with the signs and symptoms of epiphora, epistaxis, intermittent headaches, anosmia, and an enlarging facial mass. The treatment modalities include surgery, radiation therapy, and chemotherapy. The purpose of this case report is to highlight the importance of chemotherapy and adjuvant radiotherapy for treatment without the need for surgery. Further studies need to be done to divulge the risk factors for olfactory neuroblastoma and to implore new chemotherapeutic treatment modalities that minimize long-term mortality and morbidity. Olfactory neuroblastoma, also referred to as esthesioneuroblastoma, is a rare malignant tumor of neuroectodermal origin. Berger and Richard first described olfactory neuroblastoma in 1924 . The cliThese lesions can be easily missed because the presenting symptoms mimic those of benign tumors of the nose. The most common symptoms are unilateral nasal obstruction (70%) and epistaxis 50%). Other symptoms include headaches, pain, excessive lacrimation, rhinorrhea, anosmia, and vision changes. Olfactory neuroblastoma originates from the olfactory epithelium; however, olfactory neuroblastoma rarely causes anosmia (5%) [0%. OtherIt is challenging for characterization and treatment due to its rare incidence. There are three modalities used to treat olfactory neuroblastoma: surgery, external beam radiation, and chemotherapy. The optimal treatment regimens are still under investigation. Often, a combination of these three modalities is used, namely surgical resection with postoperative irradiation, for all but a small number of tumors ,7. ChemoA 71-year-old male patient presented to our clinic in April 2015 with the chief complaint of a progressively enlarging bump over the right medial nasal bridge. He had been experiencing right eye epiphora, epistaxis, anosmia, and intermittent headaches for the past month, as shown in Figures Further imaging investigations, including computed tomography (CT) and magnetic resonance imaging (MRI) scans, revealed a sizeable ethmoidal mass eroded into the medial aspect of the right orbital contents. Notably, it had not invaded the orbital fat, and the integrity of the medial rectus muscle remained unaffected. The imaging also indicated tumor erosion into the anterior skull base, resulting in a mass effect on the brain with a displacement of approximately 15 mm. No spread to the cervical lymph nodes was observed. A positron emission tomography (PET) scan was performed, which demonstrated a right sinonasal mass measuring 5.6 x 5.0 cm with a maximum standardized uptake value (SUV) of 12.8. The tumor infiltrated the right nasal cavity, anterior nasal tissue, right medial orbit, ethmoid air cells, and frontal ethmoidal regions.Considering the extent of the disease and its rapid progression, surgical intervention was deemed unsuitable for the patient. Therefore, a treatment plan involving systemic therapy was initiated. The patient received four cycles of cisplatin plus etoposide, administered over a period of two months (May and June 2015). This was followed by adjuvant radiotherapy. A follow-up MRI conducted after two months of treatment revealed a significant reduction in tumor size, predominantly within the ethmoidal air cells. However, there were concerns regarding the residual disease, as dural enhancement overlaying the frontal lobe and a small area of intracranial tissue at the level of the right ethmoid recess were detected. Subsequent MRI scans performed at six-month intervals over two years demonstrated a progressive decrease in tumor burden. Finally, the MRI conducted in January 2018 showed complete remission of the disease with no evidence of recurrence.The patient's olfactory neuroblastoma responded well to the treatment regimen, which involved four cycles of cisplatin plus etoposide followed by adjuvant radiotherapy. The imaging findings indicated a significant reduction in tumor size, ultimately leading to complete remission by January 2018, with no signs of disease recurrence. Overall, this case highlights the successful management of olfactory neuroblastoma using a combination of chemotherapy and adjuvant radiotherapy, which proved effective in achieving complete remission without surgical intervention.Olfactory neuroblastoma (ONB) is a rare malignant neoplasm of the nasal cavity, accounting for approximately 3% of the malignancies of the sinonasal cavity . AlthougIn terms of staging, a CT scan helps in determining bone erosions, but an MRI is best for determining the extent and delineation of the tumor. Taking this forward in 1976, Kadish et al. developed a system of staging based on the neuroradiological findings and clinical evaluation, categorizing the tumors into three stages . Stage AIn 1988, Hyam et al. suggested another four-tiered system of staging based on histopathological features and biological factors , accordiDue to its rarity and anatomic location, there is no set of guidelines in place regarding the ideal treatment course for olfactory neuroblastoma. The most commonly used modalities include surgical resection , radiation therapy, and chemotherapy. For small localized lesions, surgery is enough as a single modality, whereas multiple modalities are used to tackle advanced diseases . SurgicaIn cases of advanced metastatic disease or when there is a medical contraindication to surgery, radiotherapy alone or with adjuvant chemotherapy is used. Usually, platinum-based regimens are used in the treatment of ONB, but the indication of their use and the choice of the best drug are still issues of debate. The most commonly used regimen includes cisplatin plus etoposide given for four cycles . There iAs opposed to the prior belief that surgery is the best and first modality for the treatment of olfactory neuroblastomas, this case report of a patient with advanced disease (Kadish stage C) achieving a cure with chemo-radiotherapy alone definitely opens up new horizons in the management of this malignancy. It would be interesting to see the effects of this approach in more patients so that enough data can be gathered and the validity of this treatment can be tested.