Enteric duplication cysts (EDCs) are rare congenital malformations formed during the embryonic development of the digestive tract. They are usually detected prenatally or in the first years of life. The size, location, type, mucosal pattern and presence of complications produce a varied clinical presentation and different imaging findings. Ultrasonography (US) is the most used imaging method for diagnosis. Magnetic resonance (MR) and computed tomography (CT) are less frequently used, but can be helpful in cases of difficult surgical approach. Conservative surgery is the treatment of choice. Pathology confirms the intestinal origin of the cyst, showing a layer of smooth muscle in the wall and an epithelial lining inside, resembling some part of the gastrointestinal tract (GT). We review the different forms of presentation of the EDCs, showing both the typical and atypical imaging findings with the different imaging techniques. We correlate the imaging findings with the surgical results and the final pathological features.EDCs are rare congenital anomalies from the digestive tract with uncertain pathogenesis.• More frequently, diagnosis is antenatal, with most EDCs occurring in the distal ileum.• Ultrasonography is the method of choice for diagnosis of EDCs.• Complicated EDCs can show atypical imaging findings.• Surgery is necessary to avoid complications.•  Enteric duplication cysts (EDCs) are rare congenital anomalies found anywhere along the gastrointestinal tract (GT) from the mouth to the rectum; most commonly in the ileum (33%), followed by the oesophagus (20%), colon 13%), jejunum (10%), stomach (7%) and duodenum (5%) 3%, jejun.The incidence is 1:4,500 births, found in 0.2% of all children, with a slight male predominance , 5–7.EDCs are believed to occur between the 4th and 8th weeks of embryonic development. Their aetiology is still unknown; several theories have been proposed to explain their pathophysiology, but no single hypothesis can justify all duplications, locations and associated anomalies. Split notochord theory is often postulated , 10.Associated anomalies such as spinal defects, cardiac or urinary malformations, are reported with an incidence rate of 16–26%. Other digestive anomalies are present in about 10% of cases. Therefore, once an EDC is found, a search for other anomalies is needed .EDCs must have three characteristics: an epithelial lining containing the mucosa of the alimentary tract, an envelope of smooth muscle, and the cyst must be closely attached to the GT by sharing a common wall Fig. . The mucStructurally, EDCs can be either cystic or tubular. Spherical cysts are the most common duplications (80%) and typically do not communicate with the adjacent lumen. Tubular duplication cysts (20%) run parallel to the GT, being communicated with it Fig.  4, 12, , 16. TheMultiple duplication cysts are rather uncommon (1–7%) , 16. TheAtypical EDC is a non-communicating isolated duplication cyst completely separated from the bowel with no communication or shared wall. A vascular insult could have led to the isolation. They are extremely rare , 20, espThe size, location, type, mucosal pattern and presence of complications produce different clinical presentations and several imaging findings of the EDCs. Ultrasonography (US) is the most used imaging method for diagnosis of abdominal EDCs. Magnetic resonance (MR) and computed tomography (CT) are utilised for oesophageal EDCs and for helping in difficult surgical approaches.We review the different forms of presentation of EDCs, showing both typical and atypical image findings with the different imaging techniques. We correlate the imaging findings with the surgical results and the final pathological features.The intrauterine presentation is increasing, mostly due to the improvement in prenatal screening US, routine second-trimester screening and improved imaging resolution. However, prenatal diagnosis of EDCs is often difficult, and US identifies only 20–30% of them, and sometimes they are discovered by chance Fig.  21, 22], 2221, 2The natural history of EDCs is quite variable. The clinical presentation or onset symptoms of these malformations range from infancy and early childhood to adulthood. Almost 70% of EDCs present symptoms within the first year of life and 85% in the second one , 10, 14.The signs and symptoms depend on the type and location of the duplication.Oral and oesophageal cysts may cause respiratory distress or dysphagia. Retrosternal pain, haemoptysis and infection can occur in case of large cysts with rapid growth Fig.  6, 23]., 23.6, 2Gastric and intestinal duplications may produce nausea, vomiting, abdominal distention or palpable abdominal mass Fig. . RecurreNonetheless, EDCs can sometimes be detected incidentally Fig. .Fig. 8A US is the imaging method of choice in the diagnosis of EDCs; only limited in the evaluation of oesophageal EDCs. Transoesophageal ultrasound might be useful but is not routinely used , 27.Classical findings of uncomplicated EDC include: presence of a cyst in relation to the gut with double-wall or muscular rim sign (gut signature sign), which is caused by inner hyperechoic mucosa and outer hypoechoic smooth muscle layer (muscularis propia) Figs.  and 7. HAs an EDC contains the same multi-layered wall architecture as the normal GT, the sign “five-layered cyst wall” is proposed. It corresponds to the innermost hyperechoic mucosa, hypoechoic muscularis mucosa, hyperechoic submucosa, hypoechoic muscularis propia and the outermost hyperechoic serosa. Identification of all five layers in a cyst is pathognomonic of EDC. However, this sign is difficult to demonstrate and needs expertise and high-resolution US (12–18 MHz) , 29, 30.An EDC shares wall with the adjacent GT. Therefore, the diagnosis is carried out if it is possible to demonstrate the “Y” sonographic configuration of the muscle layer caused by the splitting of the shared muscularis propria between the cyst and the adjacent loop. This sign is not described for other abdominal cysts and reflects one of the histological characteristics of the EDCs Fig.  29, 31], 3129, 3New US signs are described according to the characteristics of the EDCs:US is a dynamic study and allows to visualise the peristalsis of the cyst wall. It appears as a transient change of the shape and contour of the cyst because of a concentric contraction of the cyst wall Fig.  when theAlthough EDCs are frequently anechoic or hypoechoic, mucinous material or septations can be present without being complicated Fig.  27].Fig.Fig27].FComplicated EDCs rarely present the classic five layers or double-wall sign. Ectopic rest of pancreatic tissue can produce enzymatic destruction of the mucosa with inflammation, as well as loss of the wall layers showing a hyperaemic thick wall. In such cases, the “Y configuration” sign helps in establishing the correct diagnosis of EDC Fig.  3, 29, , 29, 30.In case of atypical or isolated EDC, the pseudokidney sign is described when there is a complete loss of typical wall layers because of severe congestion, thus producing a thick hypoechoic rim with a hyperechoic central layer .US prenatal diagnosis of EDCs includes the same signs as postnatal cyst: the double–wall sign and the presence of peristalsis. However, on the prenatal US, the “double wall” is not always seen or can be partial , 33, 34,CT is not typically performed for evaluation of EDCs due to radiation. CT may depict the location and extension of the cyst, as well as complications, the associated anomalies and anatomical relationship with surrounding structures. At CT, an EDC manifests as a cystic mass with a thin and slightly enhancing wall adjacent to the gastrointestinal wall. A high attenuation inside the cyst may be seen due to haemorrhage or proteinaceous material. A thick enhancing wall, air bubbles inside and cyst-surrounding inflammation may indicate an EDC complicated by infection Fig.  1, 11, , 15.Fig.Like CT, MR is not routinely used as a diagnostic method for EDCs, especially due to sedation requirement. On MR imaging, most duplications have low signal intensity on T1-weighed images and very high intensity on T2-weighted images Fig. . Both CTThe main considerations in the management of EDCs are: the condition of the patient, the location of the cyst, whether it involves one or more anatomic locations, whether its structure is cystic or tubular, and if it is communicated with the true intestinal lumen.With the widespread availability of antenatal diagnosis, EDCs are often diagnosed prenatally. The optimal time to perform the resection in children with antenatal diagnosis is not defined. These patients should undergo early investigation, followed by early resection even within the first 6 months of life , 37, 38.Treatment of asymptomatic EDCs remains controversial. The clinical behaviour of EDCs is unpredictable. EDCs tend to increase in size gradually and can cause symptoms and important complications that might be fatal, such as obstruction, massive bleeding or even a potential risk for malignant transformation in the adulthood , 17, 39.Early excision is associated with less morbidity and a shorter length of stay compared to excision in symptomatic patients. There are significant post-operative morbidities after resection of complicated EDCs, compared with its elective surgery. Cyst excision alone could be considered, but if there is a communication, sometimes a resection of the adjacent bowel is necessary. It is important to ensure that the cyst is entirely resected because recurrence or malignant changes may occur .Currently, minimally invasive surgery is becoming the elective approach, and most of the cysts can be resected successfully, either thoracoscopically or laparoscopically, as long as an exhaustive imaging diagnosis is available .EDCs are uncommon congenital abnormalities arising anywhere along the GT. Their clinical presentations vary according to the site of duplication; ileum appears as the most commonly involved. Nowadays, antenatal diagnosis is becoming more frequent. US is the method of choice to diagnose gastrointestinal EDCs. Although double-wall US sign in a cyst is the most typical for diagnosis of EDCs, the findings of the five layers sign or the “Y configuration” of the muscular layer are more specific features. Complicated cysts present atypical imaging findings. CT and MR imaging can be required in oesophageal or rectal EDCs for planning complicated surgical approach. Surgery is necessary because of the severe complications they can develop. The diagnosis is confirmed by histological examination.


Hydatid cysts, caused by Echinococcus granulosus, is an important health problem in endemic areas. The disease can localize most commonly in the liver and lungs. Primary pelvic involvement is a rare condition. In this case report, we aimed to present a 75-year-old male patient with a pelvic mass, which was diagnosed preoperatively as a hydatid cyst. Hydatid cyst disease is endemic to the Middle East, South America, East Africa, and the Mediterranean countries . Sheep, A 75-year-old Iraqi male presented to the surgery clinic with chronic abdominal and right inguinal pain. He did not have a history of any surgery or trauma and was taking amlodipine 10 mg for hypertension. On examination, the patient’s blood pressure was 135/95 mm Hg, heart rate was 62 bpm, and body temperature was 36.8°C. His abdominal examination did not reveal any signs of rigidity, rebound, or pulsatile mass. The laboratory examination findings were: leukocyte: 7300/mm3(4600-10200/mm3), c-reactive protein: 2.7mg/dL (0-5 mg/dL), potassium: 3.8 mmol/dL (3.5-5.1 mmol/dL), aspartate aminotransferase: 34U/L (5-34 U/L), and alanine aminotransferase: 205 U/L (0-55 U/L). Plain abdominal X-ray and ultrasonography did not reveal any abnormality. Intravenous contrast-enhanced computed tomography (CECT) scan revealed a calcified mass that was 60x52 mm in size and localized between the right internal iliac artery and urinary bladder (Figure Echinococcus granulosus is a parasite that causes hydatid cyst disease. This infection is usually observed in people who have close contact with dogs and sheep . The disSymptoms are non-specific but the main symptom is pelvic pain. Symptoms are related to pressure. Menstrual irregularity in females and infertility can be observed . On physSerological tests may be helpful in the diagnosis, but even they are not a 100% reliable . The disMebendazole or albendazole treatment is successful in the majority of the cases, but medical therapy should not be preferred as the primary treatment method except in cases where the patient is not suitable for the surgical approach or the cyst size is small or deeply located. Surgical treatment is the most effective method. A combination of preoperative drugs with surgery and postoperative medical therapy is the preferred regime . It has En bloc resection without rupture or spreading of the daughter cyst is the recommended treatment strategy . The useAlbendazole or mebendazole should be used in postoperative treatment. Albendazole given preoperatively in a dose of 10 mg/kg/day for one month kills most of the protoscoleces within the hepatic hydatid cyst. Ultrasonography and serological tests are useful in postoperative follow-ups .A primary pelvic hydatid cyst is rarely seen, and it should be considered in the differential diagnosis of pelvic masses, especially in those who live in or travel to endemic areas. In addition, the disease might not be diagnosed in the preoperative period despite all radiological and laboratory methods.


Cases of imperforate hymen with leaking hematosalpinx into the peritoneum are rare. We present a case of imperforate hymen mimicking acute appendicitis creating diagnostic challenges with a near miss diagnosis.A 12-year-old premenarchal female presented with severe pain that migrated from the epigastrium to the right lower quadrant. Physical examination revealed an ill-defined non-tender mass in the right lower quadrant on deep palpation, without signs of peritonitis. We made a diagnosis of an appendiceal mass and the patient underwent an appendectomy. We found approximately 200 mL of dark blood in the peritoneum and an inflamed appendix. After the appendectomy we noticed an engorged right fallopian tube leaking into the peritoneum and a bulky pelvic mass in the lower segment of the uterus. Perineal examination revealed a slightly bulging imperforate hymen. Hymenectomy was performed and 500 mL of viscous old blood was drained. On follow-up, the hymen was still open.Imperforate hymen commonly presents with cyclic abdominal pain and enlarging mass in premenarchal females, it is rare to present with hemoperitoneum and mimicking acute appendicitis.Although rare, imperforate hymen with retrograde menstruation that causes dilatation of the vagina and uterus  is an important consideration in the differential diagnosis of abdominal pain in premenarchal females with abdominal pain. It is easily diagnosed by physical examination. However, if patient or parents refuse genital exam evaluation, imaging studies can greatly help with diagnosis. Ultrasound will show an echogenic fluid accumulation in the vagina that can extend to uterus. Atypica2In March 2019, a 12-year-old premenarchal girl was referred to our hospital for the definitive management of acute appendicitis. She presented with a 5-day history of increasing abdominal pain. On admission to our hospital, the abdominal pain was located in the epigastrium and at the right lower quadrant (RLQ). The pain was gradual in onset and progressively worsened. The pain was severe, 8 on a scale of 1–10, sharp, constant but non-radiating. It was associated with constipation but not with anorexia, nausea or vomiting. The patient did not report any history of dysuria or any change in urinary frequency. She had unremarkable gynecological, birth and developmental history.On examination, the only abnormal sign was an ill-defined non-tender mass in the RLQ on deep palpation. The abdomen was not distended and without signs of peritonitis. A perineal physical examination was missed to be carried out by the attending surgeon and the admitting surgical resident. . Based on the clinical symptoms of RLQ pain, tender mass and the migratory nature of the abdominal pain, a differential diagnosis of an appendicitis was made. The patient was prepared for an appendectomy. Her lab work was within normal limits: Hb: 12.5 g/dL , WBC: 9400 cells/uL , Platelets: 319,0000 cells/uL . Since the patient’s presentation was classic for appendicitis, no imaging studies were needed. The patient was hydrated with intravenous (IV) normal saline and was started on broad-spectrum IV antibiotics (metronidazole and ciprofloxacin). Under general anesthesia, a RLQ incision over the McBurney point (located two thirds of the distance between the umbilicus and the inferior superior iliac spine) was made. On entering the peritoneum, an inflamed appearing appendicitis was noted. There was approximately 200 mL of dark blood in the peritoneum. We performed an appendectomy. Blood in the peritoneum was drained and the abdomen was thoroughly irrigated with warm saline solution. During the inspection of the bowel, we noted a ruptured, hemorrhagic right ovarian follicle and a bulky pelvic mass in the lower segment of the uterus. Under general anesthesia, a vaginal examination was conducted, and a slightly bulging imperforate hymen was identified A. A hyme3Although imperforate hymen is an anomaly usually diagnosed by a thorough history taking and a physical examination, the presentation mimicking acute appendicitis and a tender mass in the RLQ was atypical. The appendix was secondarily inflamed by the hemoperitoneum. The typical pathophysiology of an obstructed appendiceal lumen resulting in appendiceal dilation and inflammation leading to suppuration and gangrene was absent. This unique presentation led to the initial diagnosis of appendiceal mass with appendicitis leading to an appendectomy. This was a near miss diagnosis had the abdominal cavity not been carefully explored after appendicectomy. We however recognize that a thorough abdominal cavity exploration should have been done before appendicectomy. Nevertheless, this would not have changed surgical management. Typically, imperforate hymen presents with primary amenorrhea and a cyclic pattern of lower abdominal/pelvic pain ,8, with Summarized in The diagnosis of IH can be made from a physical examination alone. Nevertheless, due to non-specific presentations, patients are usually investigated for other causes of abdomen pain, resulting to expensive laboratory testing or radiographic evaluations. Observing the hymen and viewing into the vaginal vault are best accomplished by applying gentle labial traction with the patient in the supine frog-leg or knee-chest position. In the typical presentation of IH with a bulging mass at the vaginal introitus, the speculum examination is not indicated. Failure to do a perineal examination such as in our case, leads to delayed or missed diagnosis. However, if patient or parents refuse genital exam evaluation, imaging studies can greatly help with diagnosis. Ultrasound scan will show an echogenic fluid accumulation in the vagina that can extend to uterus. In low-resources setting like ours, however, imaging modalities may not be available ,10.Although the presentation may be non-specific, once diagnosed, the treatment of imperforate hymen is either hymen sparing hymenotomy or non-sparing hymenectomy . The standard surgical procedure is hymenectomy using cruciate, T, plus, or X shaped  incisions and removal of excess hymenal tissue . HoweverImportant and also actionable clinical implication of this case is improving accurate and timely diagnosis of imperforate hymen, particularly in those with atypical presentation. This calls for thorough genitourinary examination in girls of all ages from birth through the onset of menarche. Therefore, by performing examinations and by promptly diagnosing and treating imperforate hymen, we can prevent the incidence of obstructive symptoms and the associated complications due to delayed care.In conclusion, this case suggests that imperforate hymen can mimic acute appendicitis. Gynecological history taking and careful external genital and introitus examination should be recommended in premenarchal girls presenting with abdominal pain. Imaging or laboratory studies are usually not indicated for a classical presentation of imperforate hymen. However, if a patient or parent refuses genital examination, imaging studies can greatly help with diagnosis.No funding for this study.This article was approved by the ethics committee of the Eastern Regional Hospital, Koforidua, Ghana.Written informed consent was obtained from the patient’s parents as patient is minor, 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.Paddy Ssentongo: Concept and design of study, data collection, data interpretation and analysis, drafting, revision, approval of final manuscript.Foster Amponsah: Study design, performed surgery, data collection, revision, approval of final manuscript.Anna Ssentongo: Data Collection, revision, approval of final manuscript.Temitope Arkorful: Data collection, performed surgery, revision, approval of final manuscript.Seth Hansen-Garshong: Data collection, performed surgery, revision, approval of final manuscript.Richard Ofosu-Akromah: Data collection, performed surgery, revision, approval of final manuscript.John Oh: Data interpretation, manuscript revision and final approval.Not applicable to our manuscript.Foster Amponsah-Manu.Not commissioned, externally peer-reviewed.None declared. The authors have no financial, consultative, institutional, and other relationships that might lead to bias or conflict of interest.


We describe 3 cases of omental lipoma of whom 2 presented with symptomatic haemorrhage. Notably the haemorrhage in the 2 reported cases was from foregut arteries. Thorough knowledge of anatomy and embryology is critical in identifying the source of haemorrhage and differentiating this condition from other common causes of mesenteric haemorrhage. To the best of our knowledge, this is the first case series reporting this uncommon cause for abdominal haemorrhage. The successful management of this condition using superselective embolization is discussed. Clinicians need to exercise diligence and caution in omental lipomas presenting with spontaneous haemorrhage and this notion is exemplified in our reported cases. Omental lipoma is a benign tumor of mature adipose tissue . SpontanA 50-year-old gentleman with hypertension, cholelithiasis, and previous left ureteric calculus had an episode of syncope and lower abdominal pain. On examination, he was tachycardic at 137 beats per minute and hypotensive at 68/53 mmHg. The patient was given intravenous 0.5 mg of adrenaline and started on a noradrenaline infusion during resuscitation. Ultrasound scan done in the Accident and Emergency Department showed a large amount of intra-abdominal free fluid.A CT mesenteric angiogram showed a large volume hemoperitoneum and active contrast extravasation in the region of the greater omentum Figures . The souA catheter angiogram was performed with a view to identify and embolize the bleeding vessel. Angiogram performed from the splenic artery confirmed the presence of an active haemorrhage from an aberrant artery which extended from the splenic hilum down to the right iliac fossa . The artThe CT scans were reviewed again in view of the abnormal vasculature in the right iliac fossa. It was noted that there actually was a large lipomatous lesion in the right iliac fossa. It had grown slightly in between the CT scans and was causing displacement of the small bowel loops. A MRI confirmed the presence of a fatty lesion with several abnormal internal vessels.Image guided biopsy of the lesion was performed. Pathological specimen of the fat-containing mass demonstrated lipomatous tissue with focal fibrosis and old haemorrhage . There wA 57 year old gentleman with history of Child's C liver cirrhosis complicated by oesophageal varices and prior variceal bleed, alcohol dependence and multiple cardiovascular risk factors presented to our Emergency Department with abdominal pain and distension. A bedside abdominal tap revealed frank blood. He was hypotensive at presentation and his haemoglobin level dropped from a baseline of 10.5g/dL to 6.4g/dL. The coagulation factors were significantly deranged due to liver dysfunction.A CT mesenteric angiogram was performed. It showed a 3.3 x 1.9cm haematoma in the sigmoid mesentery with a focus of contrast extravasation in the arterial phase that showed progressive pooling in the portal venous and delayed phases . SubsequA repeat CT mesenteric angiogram performed 2 days later showed no contrast extravasation in the region of the haematoma. There were no further episodes of bleeding during this admission.A 71-year-old gentleman with multiple cardiovascular risk factors, known pancolonic diverticular disease and antral gastritis, was referred to our surgical service for per rectal bleeding. On examination, the patient was found to be pale, hypotensive (BP 80/50), and tachycardic (HR 108). Digital rectal examination revealed some stale melaena, although the patient reported passing moderate amounts of bright red blood in his stools intermittently.His haemoglobin levels were 6.0g/dl on admission. He underwent fluid resuscitation and 4 units of packed red blood cell transfusion. Emergent esophagogastroduodenoscopy (OGD) and colonoscopy was performed which revealed areas of gastritis and pan diverticular disease but otherwise no sites of active ulcer or diverticular bleed.A CT mesenteric angiogram was performed which showed no active contrast extravasation in the arterial and portal venous phases. Dense material was noted within the ileum, probably from prior haemorrhage. There was an incidental finding of a fat-containing mass in the pelvis displacing the adjacent bowel loops . There aWe have described 3 cases of omental lipoma of whom 2 patients demonstrated acute intra-abdominal haemorrhage treated successfully by transarterial embolization. To our knowledge, there have been no previous reports of haemorrhage from omental lipoma in English literature.Regardless of the location of the intra-abdominal lipomatous lesions, the arterial supply was from an aberrant branch arising from left gastro-epiploic artery close to the splenic hilum, which implies foregut embryological origin of these rare lesions Figures . AnatomiIn the first case the source of the haemorrhage was unclear. Review of images did not reveal bleeding from the superior mesenteric artery. Review of previous CT performed 2 years ago, revealed an abnormal corkscrew vessel arising from the splenic hilum supplying a lipomatous lesion in the right iliac fossa.In the second case, haematoma was seen in the region of the sigmoid mesentery, suggestive of a bleed from the inferior mesenteric artery. However, there was no active contrast extravasation during selective catheterization of the superior mesenteric and inferior mesenteric arteries. Selective cannulation of celiac axis demonstrated an aberrant vessel arising from the splenic hilum and coursing obliquely to the right lower abdomen in the region of the haematoma. The aberrant vessel was successfully embolized.In the third case, no active contrast extravasation was seen in the arterial and portal venous phases. There was a large fat-containing mass in the pelvis resulting in mass effect. Once again there appeared to be similar pattern of aberrant branch arising from the splenic hilum supplying the mass.The lipomatous lesions can easily be mistaken for normal mesenteric or omental fat. Careful examination can reveal mass effect such as displacement of bowel loops which was seen in our series . AngiomyA lipoma usually appears as a variably echogenic mass on ultrasound and may be encapsulated . A liposWhile ultrasound allows for characterisation of a fat-containing mass, its anatomical location is best determined by CT or MRI . On CT, MRI is highly sensitive in characterizing typical features associated with well differentiated liposarcoma and highly specific in diagnosing simple lipoma . With MRA lipoma cannot be distinguished from an angiomyolipoma on CT and MRI, as the latter will also display imaging features of macroscopic fat and rarely calcification. Histological differentiation is required . Lack ofPathological specimen of the fat-containing mass in the first patient displayed lipomatous tissue with focal fibrosis and old haemorrhage. Pathology report noted that there was no evidence of high grade sarcoma. Immunostains for CD31 and CD34 were negative for abnormal vascular proliferation, thereby ruling out angiomyolipoma.Definitive management of a symptomatic lipoma includes surgical resection . There iAn omental lipoma is a rare benign tumour. In this case series, we have described 3 patients with omental lipomas, of whom two patients presented with active haemorrhage. Thorough knowledge of anatomy and embryology, as well as previous imaging, can aid diagnosis. Superselective transarterial embolization is safe, minimally invasive, and effective and hence should be offered as the first line treatment approach in the management of bleeding omental lipoma.


However, the lesion progressed fastly showing an evident growth, so it was decided that an intraoral biopsy should be performed. The diagnosis was sinonasal ENKLs. This case is an example that the rare T-cell lymphoma can mimic an odontogenic lesion, thus puzzling the clinician. Fortunately, the rapid growth of the lesion prompted the correct diagnosis and early treatment.Extranodal natural killer/T-cell lymphoma (ENKL) is an aggressive and infrequent malignant neoplasm. Early sinonasal ENKL clinical symptomatology is often not specific which can mimic several clinical odontogenic processes such as dentoalveolar abscesses. A 41-year-old female was referred to our institution due to facial pain with skin rash, fever, and intraoral swelling in the left side of the maxillary region. Computed tomography (CT) revealed a soft tissue hypodense area in the left side with bone discontinuity in anterior and lateral maxillary sinuses. Initial laboratorial tests showed no alterations on hemogram, coagulation profile, and immune phenotype (CD3 Extranodal natural killer/T-cell lymphoma (ENKL) is an infrequent malignant neoplasm  that ariSinonasal ENKL presents as a highly aggressive neoplasm , which iDue to the anatomical proximity with oral cavity and paranasal sinuses, ENKL can affect intraoral elements, which can mimic several clinical odontogenic origin entities, including inflammatory and infectious diseases, such as dentoalveolar abscesses .Accordingly, the objective of this report is to describe the main clinical, radiographic, and histologic characteristics of a sinonasal ENKL case in the maxillary sinuses, first diagnosed as an odontogenic abscess due to its early clinical features. Furthermore, the aggressive lesion development is also illustrated in tomographic examinations performed in different short time interval moments.A 41-year-old Caucasian woman noticed left cheek swelling and pain in corresponding upper premolars and molars and attended to a consultation in the Oral and Maxillofacial service at Hospital Municipal do Campo Limpo . Her medical history revealed a previously ischemic cerebrovascular accident and continuous use of anticoagulants but no other past disease.Extraoral examination showed no lymphadenopathy or paresthesia but an evident swelling in the left cheek  with a hDespite of accomplishing imaging examinations as requested in the first consultation, the patient only came back to the Oral and Maxillofacial service after three weeks, when she felt paresthesia and severe pain in her left face. +/CD4+) examinations, as well as blood tests for hormones, especially the parathyroid hormone.No alterations were verified in the patient hemogram, coagulation tests, and immune phenotype  was used for MCT imaging. Acquisition imaging parameters were 0.5 mm slice thickness, 1.0 mm nus wall  orbital nus wall .The second consultation MCT axial slices revealed that the soft tissue hypodense area in the left side increased in size, with greater nasal cavity involvement and bone destruction than At this point, the main diagnostic hypothesis was osteosarcoma, sinonasal diffuse large B-cell lymphoma, parathyroid brown tumor, and extranodal malignant lymphoma, particularly maxillary ENKL. The hypothesis of dentoalveolar abscess was disregarded: floating tumefaction might be coincidentally previously present due to the periodontal disease severe status.A biopsy was taken from the lesion  and sent to the hospital's pathology department. The histopathological examination with hematoxylin and eosin (H&E) showed a diffuse proliferation of small to medium-sized atypical lymphocytes with areas showing an angiocentric pattern effacing the normal architecture of the oral mucosa. Mild epithelium tropism and espongiosis were observed Figures . Focal aBefore the diagnostic definition, the patient was treated with one cycle of CHOP . Once the diagnosis was established, the AspaMetDex  regimen was started, but no response was observed after two cycles of chemotherapy; on the contrary, the lesion became larger, and the acute inflammatory signs turned more evident. Facing this, the DICE  regimen and local radiotherapy (30 Gy) were started. After two cycles, the lesion presented a significant reduction, but her general condition deteriorated and was associated with mucositis and persistent neutropenia. Before even starting another cycle, five months after the diagnosis, the patient passed away.Although malignant lymphomas are also considered opportunistic neoplasms as they usually affect immunocompromised patients , in the Sinonasal ENKL is an aggressive and speedy evolution lesion . Our casImaging features in MCT often shows infiltrative or permeative bony discontinuity, with different destruction degrees ; in our The differential diagnosis should include malignant maxillary tumors, such as sinonanasal undifferentiated and nasopharyngeal carcinoma , or otheOutcomes for sinonasal malignancies, enclosing ENKL, have improved recently ; nonetheOverall, paranasal sinus malignant lymphomas usually present nonspecific early clinical symptomatology , 12. Thein situ hybridization for EBER, since immunostaining for LMP1 is frequently negative [Notwithstanding, considering the aforementioned nonspecific signals and symptoms, the final diagnosis of the sinonasal ENKLs is achieved by histological and immunohistochemical evaluations , 6. The negative .Treatment for ENKL is mainly dependent on the disease stage at the diagnosis and, although controversial , the hisIn conclusion, sinonasal ENKL is an infrequent aggressive disease that can resemble to odontogenic origin diseases, which can delay the diagnosis. Imaging examinations are essential to guide diagnostic hypotheses; however, histological and immunohistochemical examinations are essential in the diagnosis process. The speedy neoplasm progress of this malignant disease was illustrated in this report by the CT examinations performed in distinct moments, with short time interval.


Gastrointestinal (GI) involvement in hepatocellular carcinoma (HCC) is uncommon. In particular, HCC with duodenal invasion is known to be a rare condition. In such cases, surgical indication has been generally negative except in few reported cases. To our knowledge, this report describes the first case of HCC with duodenal invasion, resected by hepatectomy accompanied by pancreas-preserving partial duodenectomy (HPPD) following multimodal therapies including systemic sorafenib administration.A 65-year-old man had been repeatedly treated for multiple HCCs by transarterial chemoembolization (TACE) and sorafenib. However, the main tumor formerly ruptured began to involve his duodenum, causing GI bleeding. The collateral vessels from the pancreatic and omental branches entered the tumor and nullified the transarterial hemostatic embolization. Hence, HPPD was performed to preserve the major Vater papilla. Histopathological examination revealed poorly-to -moderately differentiated HCC cells invading the duodenum.HPPD treatment successfully removed HCC with duodenal invasion achieving viable tumor clearance status (R0). We underline the importance of achieving viable tumor clearance status at any time during the treatment course of patients with advanced HCC as this approach may be the only approach to enable HCC patients with duodenal invasion to resume a healthy life. There hIn this case report, we performed surgery on a patient with multiple HCCs, one of which involved the duodenum. The onset of disease was marked by the rupture of the main tumor in segment 5 which had been initially controlled by repetitive TACE along with 3 other lesions which were subsequently detected around the main tumor. While the other lesions were kept under control by TACE, the lesion in segment 5 proved to be resistant to TACE and chemotherapy, gradually developing and invading the duodenum, inducing gastrointestinal (GI) bleeding. The transarterial hemostatic embolization was disturbed due to the presence of collateral vessels. Hence, the liver tumor involving the duodenum was removed en bloc by hepatectomy accompanied by pancreas-preserving partial duodenectomy (HPPD). After 36 months from the surgery, the patient is still alive with no viable lesion, living a disease-controlled life.The reference therapeutic guideline for the treatment of HCC in Japan is the Japanese Society of Hepatology (JSH) HCC Guidelines 2017. These guidelines provide an algorithm for HCC treatment . The alg2A 65-year-old male positive for hepatitis C virus antibody had been treated for HCCs in the liver segments 5, 6, 7, 8 in our hospital since October 2014. The patient was initially treated for the ruptured HCC in the segment 5 with TACE, while subsequent examinations detected other HCCs in segments 6, 7 and 8 which were similarly treated by 2nd line TACE, following the Japanese HCC therapeutic guidelines. After the treatment, the tumors in segments 6 and 7 were well controlled, while the pre-ruptured tumor in segment 5 and the lesion in segment 8 still remained viable. Hence, a 3rd line TACE was performed after 6 months: while the segment 8 tumor were well embolized after the treatment, the segment 5 tumor could not be embolized completely. Subsequently, it continued to gradually develop, as the caudal side of this tumor was perfused by the gastroepiploic artery, due to the ruptured tumor progression into the greater omentum. The collateral vessels from the omental branch into the tumor disturbed further TACE, as we suspected it could induce ischemia in the GI tract. Hence, the chemotherapeutical sorafenib was selected and administered repeatedly .Fig. 1ThSince this pre-ruptured tumor began and continued to involve the duodenum in the next six months, causing anemia and malnutrition, even further administration of sorafenib became difficult. At this point, the patient was referred to our surgical department for the first time. His critical situation compelled us to consider a surgical intervention.A pre-operative examination by CT revealed a massive HCC in segment 5 of 6.5 cm in diameter, protruding from the liver and penetrating the duodenal wall a, while During surgery, we found that the ruptured HCC in segment 5 further developed to became about 10 cm in diameter, involving the duodenal wall, fortunately without any macroscopic peritoneal dissemination. This corresponded to a grade evaluation of S2 (invasion to other organs) and P0  according to the General Rules for the Clinical and Pathological Study of Primary Liver Cancer 2019 by Liver Cancer Study Group of Japan . We starPost-operative course was uneventful except for a wound infection. He was discharged on the 45th postoperative day. Tumor markers were found to be in the normal range within three months after the surgery. Pathological examination was compatible with the pre-operative findings and revealed poorly-to-moderately differentiated HCC cells directly invading the duodenal wall and extending inside the duodenal lumen . ApproxiAfter this surgery, the lesion in segment 8 remained stable. However, it was radio-frequency ablated twice as a preventive measure. Three years after the surgery the patient is still alive and leads a disease-controlled life.3Extrahepatic metastases of HCC have been reported mainly in the lung and in the lymph nodes, while GI tract involvement in HCC is uncommon . Its freThe first case of direct duodenal involvement in HCC was reported by Humbert et al. and caused upper GI bleeding . EndoscoSurgical resection of HCC invading the duodenum has been rarely performed due to patient’s ill condition and due to surgical stress involving the necessity of maximal invasive HPD. Ja-Der Liang et al. reported 21 cases of HCC involving the duodenum following its invasion or due to the development of metastasis . Among tKato et al. presented surgical cases of HCC with GI tract involvement in their review paper . AccordiSorafenib is a chemotherapeutical drug principally indicated for the treatment of patients with HCC without surgical indication, in agreement with the Japanese guidelines for HCC . The resIn this case report we present the possibility of a resection of the duodenal invasion of HCC by performing the HPPD procedure, which will surely relieve the surgical stress compared to the HPD procedure. Although the liver function in our patient allowed additional anatomical hepatectomy including right hemi-lobectomy, we chose to perform a partial liver resection to avoid a major HPD, since concomitant pancreaticoduodenectomy would have been required if we would have failed to preserve the major papilla near the tumor during the operation. Although we defined the resection corresponded to grade R0, our evaluation may be incorrect in precise as the tumor had previously ruptured and we suspected that remaining liver lesions could still be present. In support to our grade, however, during pre-operative CT and surgery we did not found any dissemination or other viable lesions. In conclusion, our available data demonstrate that the procedure achieved grade equivalent to R0 . This result was achieved with minor surgical stress in comparison to major HPD resection.Although the patient positively underwent additional radiofrequency ablation of segment 8 lesion twice after the surgery, this multimodal approach has further enabled him to live with no viable lesion to date for three years. Resection of the tumor even in oncological emergency might have helped him achieving a better prognosis in comparison to obstructed sorafenib administration that meant best supportive care.4We report a case of HCC with duodenal invasion successfully resected by HPPD following pre-treatment with repeated TACE and sorafenib administration. This result underlines the possibility of achieving a R0 (no viable tumor remaining) status at any time during treatment of patients with advanced HCC since this status may be the only way to enable patients with life-threatening disorders to resume a healthy life.None.None.Ethical approval was not required for this case.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.TI, AY, and TH performed the operation.AM managed the follow-up after operation.TI and TH wrote the manuscript.TO and RD revised the manuscript.All authors read and approved the final manuscript.I have nothing to declare in this category.The guarantors of this study are TH and RD.Not commissioned, externally peer-reviewed.


Ruptured pseudoaneurysms are a rare complication of gastrectomy, but when they do develop, they are often fatal. We presented herein the first report of a case of pseudoaneurysm arising from the right inferior phrenic artery (RIPA) after a laparoscopic gastrectomy.A 61-year-old male patient underwent a laparoscopic distal gastrectomy and D1+ lymph node dissection with Roux-en-Y reconstruction for early gastric cancer. He was discharged on postoperative day (POD) 9 without any complications, such as anastomotic or pancreatic leakage. On POD 19, he was referred to the emergency room for upper abdominal pain. Enhanced abdominal computed tomography revealed a 60 × 70 mm hematoma, indicating intra-abdominal bleeding and a 10-mm pseudoaneurysm in the RIPA. Selective digital subtraction angiography confirmed the presence of a pseudoaneurysm in the RIPA, which was embolized using multiple microcoils. Thereafter, no clinical signs were observed, and the patient was discharged from the hospital 15 days after angiography without any recurrence of bleeding. We hypothesized that the cause of the pseudoaneurysm was mechanical vascular injury due to the thermal spread of the ultrasonically activated devices (USADs) during lymphatic node dissection.Given the thermal spread of USADs, safe and appropriate lymph node dissection based on precise anatomical knowledge is crucial to preventing postoperative pseudoaneurysms. Pseudoaneurysms result from the partial to complete disruption of the vascular wall and ultimately lead to hemorrhage contained by the adventitia of the vessel wall or the perivascular soft tissues . Inferio3/μL, red blood cell count of 396 × 104/μL, and hemoglobin 11.2 g/dL. Enhanced abdominal CT revealed a hematoma 60 × 70 mm in diameter, indicating intra-abdominal bleeding, and a 10-mm pseudoaneurysm in the RIPA  9 without any complications, such as anastomotic or pancreatic leakage. On POD 19, he was referred to the emergency room for upper abdominal pain. Guarding and rebound tenderness were denied. Serum biochemistry showed a white blood cell count of 16.2 × 10Iatrogenic pseudoaneurysms can develop as a result of (a) mechanical vascular injury during the dissection or removal of lymph nodes and connective tissue due to a malignancy; (b) the digestion of the arterial vessels resulting from a pancreatic, biliary, or enteric fistula; or (c) local sepsis . PseudoaIn the present case, the RIPA pseudoaneurysm developed after a laparoscopic distal gastrectomy for gastric cancer. IPA pseudoaneurysms are very rare, with only nine cases (including our case) thus far reported Table  6–13]. –13. 6–13In laparoscopic surgery, ultrasonically activated devices (USADs) are widely used for cutting, and when using USADs, precautions must be taken against lateral thermal damage to surrounding tissues that could lead to inadvertent trauma to the adjacent organs, including vessels . When weWe reported a case of RIPA pseudoaneurysm following a laparoscopic distal gastrectomy. Given the thermal spread of USADs, safe and appropriate lymph node dissection based on precise anatomical knowledge is important to prevent postoperative pseudoaneurysms.


Collection of oocytes becomes challenging in some scenarios, like the possibility of an ovarian cancer, the “ex-vivo follicular aspiration for oocyte retrieval was performed on the specimen, using a standard ultrasound-guided procedure to ease and improve the process. All the follicles were aspirated and 5 metaphase II oocytes were obtained.In the present case report, the case of a patient with an adnexal mass suspected to be a recurrent teratoma was described who referred to our Assisted Reproduction Unit in Hospital Quironsalud Malaga for FP counseling. After controlled ovarian hyperstimulation, followed by laparoscopic abdominal examination and oophorectomy, an ex-vivo ovarian aspiration of mature oocytes for FP using standard ultrasound guidance. Although this ultrasound guidance is not completely necessary, as other authors demonstrated previously, such a procedure permitted an easy and complete harvest of oocytes in a rare tumor with bizarre cystic formations, which made follicle recognition very difficult.This is to our knowledge, the first communication describing the  Deciding whether following a more or less conservative approach having into account the aforementioned risks, the frequent bilateralism as well as a frequent incidence in young patients with fertility desire, is a challenging situation for a clinician.Ovarian teratomata are the most frequent benign ovarian masses in the reproductive years, and they are bilateral in 10–15% of cases , 7. Tranex-vivo retrieval of mature oocyte for FP during a laparotomy, aspirating ovarian follicles with a needle in a patient with a recurrent borderline ovarian tumor, as a method to avoid tumor upstaging after spillage of its content as a consequence of its puncture. The procedure had precedents, but was performed on unstimulated ovaries and followed by IVM of the oocytes  that diagnosed a “probable mucinous cystadenoma” in the right ovary without visible extraovarian extension.The choice of an oophorectomy was selected because ultrasound and MRI determined a very complex mass, with rapid growth, difficult to characterize as clearly benign, and without a significant healthy portion of the ovary to be observed in the future. Tumor markers  were in the normal range. Being a teratoma, the most probable type of tumor considering her antecedents, neither the ultrasound nor the MRI, could absolutely confirm the diagnosis, and the disposition of the tumor did not permit to think that a conservative surgery was possible since no “normal” areas of the ovary could be distinguished.After a thorough discussion about all medical and personal factors , the patient accepted laparoscopic surgery involving oophorectomy and other possible actions derived from the surgical examination of her abdomen.ex-vivo follicular aspiration was offered to the patient, after extensive information and explanation of the procedure, possibilities and risks. The aim of the extracorporeal follicular aspiration was to ease the aspiration of the follicles in such an atypical ovary and to avoid spillage of uncertain tumoral content in the abdominal cavity. Patient was informed about all the aspects of oocyte cryopreservation and blood test was performed to assess infectious status  and other clinical and preoperative parameters. Tests to determine anti-müllerian hormone levels and a thyroid profile were also performed. Written consent for fertility preservation was obtained according to our Institutional Review Board.A proposal for oocyte cryopreservation, following ovarian stimulation and kg/m2, and an intention to obtain as many oocytes as possible, after obtaining written consent for all the procedures, and the patient being coincidentally in the fourth day of her cycle, an injection of chorifollitropin alpha 150 mg  was indicated, adding a daily injection of 0.25 mg of ganirelix  from the 6th day of stimulation. On the seventh day after the injection, some apparently new follicles could be distinguished from the other cysts with difficulty; comparing with previous images, three to four probable follicles were seen, with 13–15 mm in diameter. On this day, hormonal levels were: estradiol 906 ng/ml, progesterone 0.86 ng/ml, and LH 1.12 ng/ml. Anti-müllerian hormone levels were received this day, with a value of 1.1 ng/ml.An ultrasound estimation of her ovarian reserve through antral follicle count (AFC) was not feasible due to the characteristics of the ovary, already full of follicle-like formations. With a BMI of 21, 48 mcg of recombinant HCG  was subcutaneously injected. The election of the moment for the trigger was based more on our clinic′s average length of antagonist protocol cycles (9 days of stimulation) than in the diameter of the follicles, since distinguishing growing follicles from tumor cysts images was somehow difficult. Thus, a new hormonal determination was considered unnecessary.On the 8th and 9th day, 200 units of r-FSH  were added to the ganirelix injection and, finally, on the 10th day, a dose of 250 hr after the HCG injection. Laparoscopy under general anesthesia started on time. Absence of ascitis or lesions in the peritoneum and abdominal organs surfaces could be observed. The left fallopian tube was absent but a small piece of ovarian albuginea, 5 mm in diameter, could be distinguished in the left uteroovarian ligament, with no identifiable follicular structures. No adhesions were noted in the abdominal cavity or pouch of Douglas. The right ovary was free of adhesions, easily movable, presented a lightly irregular but smooth surface and some protruyent amber-translucid cystic formations could be distinguished among some sclerotic and opaque-greysh areas. The right fallopian tube looked normal. A subserous pediculated fibroid of 25 mm in the posterior wall of the uterus, close to the uteroovarian right ligament, was easily removed. The patient presented a 6 cm scar from the previous oophorectomy in right lower quadrant area which was considered enough for a safe extraction to avoid spillage of ovarian content and rupture of the follicles. Thus, after lavage of peritoneal cavity with saline serum and collection for cytologic evaluation, oophorectomy was performed carefully without any rupture. The specimen was placed in a bag and extracted through the right lower quadrant incision without other difficulty than a little extension of its length to facilitate the extraction. Then, the specimen was taken to the assisted reproduction laboratory, contiguous to the operating room where the surgery was completed. No other suspicious or metastatic lesions were observed in the abdominal cavity. The transport of the bag was made in a stainless steel recipient 30×10 cm, partially filled with 500 ml of NaCl 0.9% at 37°C.Surgical intervention was scheduled to start 35 cm in diameter, was placed minutes after the operative section of vascular pedicles, in another stainless steel recipient 30×10 cm, partially filled with warm saline and Sydney IVF Gamete Buffer   .cm, Cook Medical) was used as in normal routine vaginal procedures. The image obtained was very satisfactory, and a specular image of the specimen was formed due to the rebound of ultrasound in the bottom of the steel recipient. The aspiration at a negative pressure of 150 mm Hg with a follicle aspirator  resulted in traditional vaginal retrievals, and was started on those follicles which ultrasound echogenicity and size resembled most as normally observed ones in conventional IVF procedures  at 37°C and taken under the laminar flow chamber for microscopic analysis. During the aspiration, if a non clear fluid was obtained, the aspiration system was rinsed with media for the system to be clean for the next cavity to be aspirated, in order to avoid any damage on the oocyte that could be produced by any fluid different than the follicular one such as blood, mucus, sebum, etc. Eighteen cavities  were aspirated in total, filling 6 and a half tubes, and two of them in which content was clearly not serous fluid, were ignored. The first 7 cavities were aspirated, 3 tubes filled and they contained 5 cumulusoocyte complexes, while the other one was found in a fifth tube filled with mixed serous and bloody material. The fourth, sixth and seventh tubes did not contain any oocyte. During the filling of the fourth tube, a yellow dense fluid appeared in small amount, so the system was rinsed to continue with the fifth tube. The aspiration procedure was completed in 9 min.With the help of an assistant carefully holding the ovary, in a sterile way with latex and powder free gloves, follicle aspiration was performed with ultrasound guidance  using the vaginal probe as normally done in conventional oocyte retrievals, covered with a latex free sterile cover and equipped with a plastic disposable guide . For theocedures . The obtmin, embryologists proceeded to denudation with hyaluronidase 80 U/ml (SAGE IVF Inc). Five metaphase II oocytes and one metaphase I were characterized. All mature oocytes were vitrified using Cryotop (Kitazato) and the method described by Kuwayama  with cytologic study of peritoneal fluid negative for malignancy. Thyroid function profile tests from blood samples obtained on the day of the surgery  were performed after knowing the pathologist′s report, and the results were completely normal.Fortunately, the majority of ovarian masses in premenopausal women are benign. Decisions in the management of ovarian tumors are greatly influenced by the age and reproductive profile of the patient since it is desirable to preserve as much as possible their endocrine and reproductive performance.In the present case, the clinical evolution, age, negative tumor markers and a history of oophorectomy due to a mature teratoma, suggested the possibility of a new teratoma arising in the contralateral ovary, something that occurs in 10–15% of all cases . UnfortuPure struma ovarii is a rare tumor, comprising 3% of all ovarian teratomata . In the Laparoscopic approach is the preferred way of surgical removal of presumable benign ovarian masses. It is generally recommended to do it through the umbilical port  causing Preservation of gametes is, when possible, the FP method of choice instead of cryopreservation of ovarian tissue. It is not known whether a recurrence of germinative cells tumor when using cryopreserved oocytes from an affected ovary is possible. In a review including 12 patients previously treated by malignant ovarian cell tumors  who recein vitro maturation (IVM) of immature oocytes is a technique that has shown satisfactory results  levels could have helped for estimation but the patient was on her fourth day of the cycle so the procedure started without AMH results. On the other side, as the cycle was not planned for fertilization and transfer, and the risk of hyperstimulation syndrome was virtually eliminated, a 150 sponders  and withhr later, thus surgeons had time to perform the oophorectomy around 36 hr after to maximize the chances of obtaining mature eggs with a minimal risk of spontaneous ovulation.The moment of the trigger was chosen according to the average of days at which this trigger occurred in our clinic since follicle measurements were not possible. The surgery was planned to start 35 When surgical integrity of the ovary is preferable, “in pelvis” oocyte retrieval by means of traditional transvaginal follicular aspiration must not be the first choice. In cases where a teratoma is suspected but there is a clearly normal proportion of the ovary where follicles can develop and be aspirated , the risex-vivo retrieval of mature oocytes obtained from ovaries previously stimulated with gonadotropins and extirpated through laparotomy. In our case, after the laparoscopic observation of the absence of suspicious lesions in the abdominal cavity, extraction of the ovary using an endobag was decided. Bocca (Fatemi et al.  were thed. Bocca  describeex-vivo oocyte retrieval reviewed in the literature, time of ischemia, from the oophorectomy to oocyte collection, is described in terms of less than half an hour, but not much importance is given to this issue. In animal experiences, immature oocytes can survive and be in vitro matured after being retrieved several hours after death (min from the moment of the oophorectomy to the deposit of the oocytes under the embryologist′s microscope, timing may be considered as perfectly adequate.In the cases of er death . In someer death . ConsideAccording to the images observed during the ultrasound diagnosis and during the monitoring of the ovarian stimulation, a presumable difficult aspiration of the follicles was foreseen, and our team thought that it was possible to ease and improve the oocyte retrieval described by Fatemi et al.  using ulConsidering all the aspects of the case, the patient, who was a candidate for egg donation after losing her ovaries, has been able to theoretically preserve certain capacity to achieve at least one live birth with her own eggs, with an estimated probability of around 41%, considering a chance of 8.2% of live birth per cryopreserved oocyte at her age .ex-vivo aspiration using standard ultrasound guidance, of mature oocytes for fertility preservation during a laparoscopic oophorectomy of specimen after stimulation with gonadotropins. Although this ultrasound guidance is not completely necessary, as other authors demonstrated previously, such a procedure permitted an easy and complete harvest of oocytes in a rare tumor with bizarre cystic formations which made follicle recognition very difficult.This is, to our knowledge, the first communication describing the


Liver hemangiomas are benign liver lesions that require surgical excision when large and symptomatic. Often, these tumors are removed through large anatomical resections which sacrifice more liver parenchyma than needed. Tumor enucleation, which takes advantage of a digitoclasia-like technique along the plane between the tumor pseudo-capsule and liver parenchyma, poses challenges when performed laparoscopically. We propose a parenchymal sparing, minimally invasive, robotic-assisted technique to remove liver hemangiomas.Three male patients with symptomatic hemangiomas were treated in our center between 2015 and 2018. The lesions were located in segment II, III and segment IV-V respectively. Robotic-assisted hemangioma enucleation was accomplished successfully in all three patients. The procedures were performed with a parenchyma-sparing intent and a formal segmentectomy was not required. There were no conversions to open surgery.The robotic platform provides a powerful tool in the enucleation of liver hemangiomas. The enhanced vision and the superior suturing ability allow to develop safely the plane between the tumor pseudo-capsule and the liver parenchyma, with outstanding selective control of all the vascular supply and drainage encountered during the dissection. Furthermore, precision of the hilar dissection allows selective lobar or sectorial arterial control which helps minimize intraoperative bleeding.In our experience, robot-assisted enucleation of liver hemangiomas offers low morbidity, fast recovery, excellent cosmetic results, and it could become a therapeutic option when the location of the hemangioma allows this approach. Exploratory laparoscopy and intraoperative ultrasound are performed for lesion localization and port placement strategy. The configuration is shown in The key aspect of this technique is to selectively control the arterial inflow to the lesion. Arterial clamping usually is done at lobar level in the hilum.Keeping a low central venous pressure during the parenchymal transection is advised, as it facilitates bleeding control.Mass enucleation represents the most challenging part of the procedure. The identification of a plane between the hemangioma’s pseudo-capsule and the liver parenchyma is almost invariably possible. When hemangiomas arise from the liver surface, the surgical plane is of relatively easy identification. Hemangiomas located deep into the liver require dissection of normal parenchyma prior to enucleation. This poses greater challenges to the surgeon in terms of resection margin adequacy and sparing of the parenchyma. Once the correct plane is identified, small connecting veins are found between the hemangioma and normal liver tissue. These can be coagulated with bipolar forceps or suture ligated with 4-0 or 5-0 Prolene.Following enucleation, the arterial bulldog clamp is removed and the central venous pressure is increased to test and further secure the hemostasis. Fibrin glue is applied to the surface of the liver. A Jackson-Pratt drain is left by the enucleation site and the specimen is retrieved enlarging one of the port sites or a Pfannenstiel incision depending on size.4A 42-year-old man was seen in our outpatient department complaining of moderate left upper quadrant abdominal pain. He was known to have a liver hemangioma diagnosed 1.5 years prior. Double helical CT scan revealed an 8.2 x 5.8 cm  vascular5A 44-year-old man presented to our clinic with long-standing left-upper quadrant pain. CT scan revealed a 3.9 x 3.5 cm segment III hemangioma . Positio6A 62-year-old man with a known diagnosis of liver hemangioma, presented to our outpatient department with right-upper quadrant pain. CT scan imaging showed a 9.1 × 7 x 2.2 cm mass occupying segments IVa and V. Prior to surgery, the patient underwent selective arterial embolization in the attempt to decrease the size of the lesion. Trocar placement was similar to the one showed in 7Liver hemangiomas are usually managed expectantly with serial imaging follow-ups . SurgicaSurgery for these lesions is challenged by the high risk of bleeding, which discourages many surgeons from performing these resections in a minimally invasive fashion . Based oIn the open approach, a delicate detachment of the tumor from the pseudo-capsule can be done digitally, proceeding with blunt movements. As the dissection proceeds, tumor feeding and draining vessels are ligated as they are encountered. This technique based on tactile feedback cannot be replicated in minimally invasive surgery. Texture, consistency, and pulsatility of the tumor cannot be appreciated on the robotic platform. Nevertheless, the high-quality imaging provided by the camera system allows developing a “virtual haptic feedback”. Magnified visualization of minimal changes resulting from the interaction of the instruments with the tissues, enables the surgeon to “virtually feel” the tissue resistance. This in some way replaces the lack of tactile feedback. Such ‘sixth sense’ for tissue consistency, however, is developed after a significant experience at the console.To our knowledge, this is the first report of robotic liver hemangioma enucleation. The microsurgical abilities of the robot allow a delicate dissection with an accurate detachment of the tumor from its pseudo-capsule. Selective suturing of small vascular branches connected to the tumor is possible with the robotic platform, replicating the enucleation performed in open surgery but in a minimally invasive fashion. Furthermore, ICG allows the recognition of vascular patterns and anomalies intraoperatively ,14.8Robotic-assisted surgical enucleation of liver hemangiomas is safe and feasible. Further studies involving more patients are needed to expand the application of robotic surgery for these procedures.Pier Cristoforo Giulianotti has a consultant agreement with Covidien Medtronic and Ethicon Endosurgery, and he also has an institutional agreement (University of Illinois at Chicago) for training with Intuitive. Roberto Bustos, Valentina Valle, Gabriela Aguiluz, Yevhen Pavelko, and Eduardo Fernandes have no conflicts of interest or financial ties to disclose.This research was not conducted with any specific grants from funding agencies in the public, commercial, or not-for-profit sectors.This study has been approved by the Institutional Review Board at our institution.Written informed consent was obtained from the patients for publication.PCG: data analysis and interpretation, writing and revision.RB: study design, data collection, and writing.VV, GA, YP: collection and assembly of data.EF: writing and revision.Study registered with Research Registry UIN researchregistry4777.Pier Cristoforo Giulianotti.Roberto Bustos.Eduardo Fernandes.Not commissioned, externally peer-reviewed.


Internal hernias involve herniation of viscera into an abdominal compartment through a defect in the mesentery or peritoneum. Herniation may occur through normal anatomic structures or through pathologic defects secondary to congenital abnormality, inflammation, trauma, or surgery. Patients with an internal hernia most commonly present with acute bowel obstruction. While internal hernia is an uncommon cause of bowel obstruction, making up approximately 0.2-0.9% of cases , the incidence is increasing due to greater use of techniques such as Roux-en-Y for liver transplant and gastric bypass. There are multiple types of internal hernia, including paraduodenal, Foramen of Winslow, sigmoid mesocolon, pericecal, transmesenteric, transomental, supravesical, and pelvic. We present a case in which a transverse colon epiploic appendage adhesion to the ascending colon mesentery resulted in a closed loop obstruction mimicking a pericecal internal hernia. Radiologists should be aware of the imaging findings of closed loop obstruction related to internal hernia and maintain a high index of suspicion in patients with history of prior abdominal surgery presenting with bowel obstruction. It is useful for radiologists to understand that adhesions may result in internal hernias, which mimic the classically described categories. Internal hernias involve herniation of viscera into an abdominal compartment through a defect in the mesentery or peritoneum. Herniation may occur through normal anatomic structures or through pathologic defects secondary to congenital abnormality, inflammation, trauma, or surgery. Patients with an internal hernia most commonly present with acute bowel obstruction. While internal hernia is an uncommon cause of bowel obstruction, making up approximately 0.2-0.9% of cases , the incThere are multiple types of internal hernia, including paraduodenal, Foramen of Winslow, sigmoid mesocolon, pericecal, transmesenteric, transomental, supravesical, and pelvic. We present a case in which a transverse colon epiploic appendage adhesion to the ascending colon mesentery resulted in a closed loop obstruction mimicking a pericecal internal hernia.A 58-year-old female presented to the emergency department with intermittent, crampy right-sided abdominal pain, nausea, and vomiting, which began approximately 18 hours previously. Her past medical history was significant for hypertension and her surgical history included a thyroidectomy for treatment of thyroid cancer and a Caesarean section. A contrast enhanced CT abdomen and pelvis was obtained, demonstrating multiple fluid-filled, dilated small bowel loops in the right abdomen, which were predominantly anterolateral to the ascending colon and cecum . In addiAfter resection, the patient's small bowel was left in discontinuity and an abdominal wound-vac was placed. The following day, the patient returned to the operating room, at which time the terminal ileum was also found to be nonviable. An ileocecectomy with enterocolonic anastomosis was performed.The patient had a complicated postoperative course, but was ultimately discharged approximately two weeks after the initial surgery.Based on the imaging findings in this case, this internal hernia was thought to represent a pericecal hernia. Pericecal hernias make up approximately 0.1-6.6% of internal hernias . There aClinical manifestations include paroxysmal epigastric discomfort, abdominal distention, colicky periumbilical pain, and nausea and vomiting with meals . To diag


Paraganglioma is rare in children and most pheochromocytomas originate in the adrenal gland.The clinical characteristics, diagnosis, and managements in a 9-year-old boy who presented with vomiting and occasional headache with a blood pressure of 210/170 mm Hg was retrospectively reviewed. CT scan of the chest revealed a 7 × 5-cm-sized soft tissue mass in the left paraspinal area. Biochemical reports revealed elevated levels of serum norepinephrine, urine norepinephrine, urine dopamine, and serum neuron specific enolase.The immunohistochemical studies suggested that the tumor was a paraganglioma of the posterior mediastinum.The patient underwent mass resection with thoracotomy. Before operation, the patient was prepared by orally administering captopril, propranolol hydrochloride, and phenoxybenzamine. Body fluid volume was also prepared by vein and mouth in 3 days.The patient was followed up postoperatively for 1 year without recurrence.We should be highly vigilant the pediatric tumor of the posterior mediastinum with vomiting and headache as the first clinical manifestation. Here, we report a rare case of a paraganglioma of the posterior mediastinum in a 9-year-old boy.Pheochromocytomas and paragangliomas, which arise from chromaffin cells of the adrenal medulla and extra-adrenal paraganglia, respectively, are uncommon. Approximately 95% of catecholamine-secreting tumors are located in the abdomen and pelvis.2The patient's parents provided informed consent for the publication of his clinical and radiological data. This case report was approved by Medical Ethical Committee of West China Hospital, Sichuan University.3A 9-year-old boy presented to a local hospital with vomiting and occasional headache with a blood pressure of 210/170 mm Hg. No obvious diseases were observed on digestive endoscopy and abdominal computed tomography (CT) scan, and no remarkable improvement by medicine treatment. CT scan of the chest revealed a 7 × 5-cm-sized soft tissue mass in the left paraspinal area from T3 to T7 with destruction of the adjacent thoracic vertebra and ribs (Fig. Thoracotomy was performed through the left fifth intercostal space. Intraoperatively, several membranous and fascicular adhesions existed in the thoracic cavity. The irregular ovoid mass measured 8 × 7 × 5 cm. The tumor originated from the nerve root and adhered to the surrounding tissue. It invaded the spine and chest wall. The mass was tough and rich in blood supply. There were intraoperative changes in the patient's blood pressure, which ranged from 85/50 mm Hg to 180/130 mm Hg. During the resection, the surgeon closely communicated with the anesthesiologist to decide the operative process. Histological studies demonstrated that the mass was a tumor Fig. . Immunoh4 Except the presenting symptoms, the catecholamines in the blood and metabolites in the urine are always elevated. Radiological tests are helpful to determine the tumor location. It is important to distinguish from the other tumors before operation. Furthermore, α-adrenergic or/and β-adrenergic blockade, which are considered to decrease the risk of cardiac dysrhythmia accompanied with pheochromocytoma during the surgery, are used to maintain normal blood pressure normal.,5 Meanwhile, patients with pheochromocytoma usually have low blood volume and it is necessary to counteract hypovolemia after removing the tumor due to sudden decrease in serum catecholamine levels. Our patient presented the same symptoms such as vomiting, headache, and hypertension, as those previously reported in the literature. Preoperative biochemical studies revealed that serum and urine norepinephrine were elevated and serum and urine epinephrine were within the normal range. The results suggested that the tumor mainly produced norepinephrine. Postoperatively, serum norepinephrine continued to decline. However, serum epinephrine increased on postoperative day 2 and then was within the normal range, which may be due to the intraoperative extrusion of the tumor. To maintain stable intraoperative blood pressure, blood volume was prepared for physiological need of sodium solution intravenously and orally on preoperative day 3.Patients with paragangliomas often present with symptoms secondary to catecholamine excess. The common symptoms are headache, palpitations, sweating, nausea, vomiting, and weight loss. Hypertension is observed in 70% to 90% of children with pheochromocytoma. reviewed the surgery and perioperative care required for patients with pheochromocytoma and paraganglioma. Surgical resection for paraganglioma was regarded as the gold standard of treatment options. Intravenous midazolam and propofol were used as anesthesia. Tsirlin et al suggested that fentanyl, ketamine, and morphine should be avoided because they may stimulate catecholamine release. Intraoperatively, tumor vessels were first managed to prevent catecholamine entering the vascular structure. Meanwhile, it was necessary to closely communicate with the anesthesiologist to control hemodynamics. Once the blood pressure was elevated, the operation was suspended. Vasopressin was used for hemodynamic resuscitation to control acute catecholamine deficiency after tumor removal.Renard et al Owing to the relative rarity of the tumor, chemotherapy for children was absent and unsatisfactory. In our patient, preoperative CT of the chest and abdomen suggested no other problems besides the mass in the posterior mediastinum. Meanwhile, surgical resection was complete. Postoperatively, the symptoms of vomiting and headache disappeared. The patient's blood pressure remained normal without the use of hypotensors. Biochemical test results revealed that serum and urine norepinephrine and epinephrine levels returned to normal. Our patient decided to undergo long-time follow-up without chemotherapy. During the follow-up, monitoring the patient's symptoms and blood pressure was important. CT of the chest and biochemical studies are essential 3 months, 1 year, and then each year postoperatively.The tumor was excised for histological and immunohistochemical examinations. The accurate diagnosis of paraganglioma could be based on immunohistochemical staining of syn, cgA, Ki-67, S100, and PCK. However, the definition of malignancy in paraganglioma was based on not only histological and immunohistochemical characteristics but also the presence of metastasis and the size of the tumor.5The experience of treating pediatric paraganglioma of the posterior mediastinum is insufficient. Our treatment was based on some case reports and experience with adults. Our patient was rehabilitated and discharged using a series of perioperative managements. However, pathological diagnosis could not provide benign or malignant diagnosis, and long-term follow-up is still needed.Conceptualization: Chang Xu.Data curation: Gang Yang, Weiya Wang.Formal analysis: Gang Yang.Writing – original draft: Miao Yuan.Writing – review & editing: Chang Xu, Weiya Wang.


Mixed neuroendocrine-non-neuroendocrine tumors (MINEN) of the gallbladder are extremely rare; indeed, the English expert literature reports a mere handful of case reports and case series on this topic. According to the WHO classification of 2010, MINEN are considered to be tumors consisting of two major components, neuroendocrine and non-neuroendocrine, each of which hosts at least 30% of the total cellular population. To date, the etiology and pathogenesis of MINEN have not been precisely determined and the non-specific symptoms generally result in late diagnosis  and contribute to the generally poor prognosis. As far as the management of the disease is concerned, radical surgery plays a crucial role; however, the significance of surgical debulking and biological therapy applying somatostatin analogues has not yet been determined.A 56-year-old female was referred to our department for a rapidly progressing tumor in the subhepatic area along with the infiltration of S5 and S6 liver segments. With regard to preoperative findings, the tumor appeared as operable, although, during the surgery, an extensive involvement of the hepatoduodenal ligament by the tumor through the lymph nodes was revealed. Due to acute perioperative bleeding from the necrotic tumor, we decided to perform modified resection. Histologically, the tumor was confirmed as MINEN of gallbladder, where the neuroendocrine component was dominant over the non-neuroendocrine component. Six weeks after the discharge, the patient underwent a follow-up CT revealing large recurrence of the disease. Thereafter, the patient was started on systemic therapy with etoposide and carboplatin in combination with somatostatin analogues. Thirteen months after the surgery, the patient is in good clinical condition, and while a recently performed PET/MRI scan revealed a hepatic lesion and hilar lymphadenopathy in full regression, there was a spread of small peritoneal and pleural metastases. The patient remains in the follow-up care.The occurrence of mixed neuroendocrine-non-neuroendocrine neoplasms is extremely rare. Radical surgery remains the only potentially effective approach to the cure of this disease. The role of biological therapy and debulking in the management of the disease has not yet been precisely defined. In our experience, both of these methods have the potential to positively influence overall survival rates and the postoperational quality of life of patients. WHO Classification of Tumors of the Digestive System is based on NET assessment using morphological criteria and proliferative activity of tumor cells . –22. 6–22A 56-year-old female was referred to our department from another facility in the patient’s area for a rapidly progressing tumor in the gallbladder and liver area. The patient reported several-month right upper quadrant pain and 4-kg weight loss over the past year. There was no laboratory sign of obstructive jaundice at the day of admission. Preoperative CT and MR scan Figs. . The couMalignant tumors of the gallbladder are uncommon findings, accounting for about 0.5% of all malignancies . DespiteRecently, increasing importance is assigned to multipotent, progenitor cells persisting in the biliary tree, where they fulfill their role in regenerative processes . These c18FDG, an indicator of increased glucose metabolism. A correctly indicated examination provides the specificity and sensitivity of almost 90–100% [MINEN, as well as other gallbladder tumors, do not have specific symptoms. The most common symptoms of the disease include non-specific abdominal pain, weight loss, anorexia, and obstructive jaundice (which is a sign of advanced disease). The basic imaging technique is computed tomography with intravenous administration of contrast agent. This examination is sometimes preceded by ultrasound of the abdominal compartment because of its affordability and non-invasive nature. Generally, gallbladder tumors initially have an appearance of polyps or local wall thickening and are often an incidental finding. Depending on the extent, advanced carcinoma may take the form of an intraluminal expansion of the gallbladder, diffuse thickening of the wall or a mass essentially replacing the gallbladder and further infiltrating the adjacent liver parenchyma. Findings from imaging techniques are dependent on many factors . Smaller tumors are more homogenous, and the homogeneity decreases with increasing size, predominantly due to regressive changes. A separate chapter is the use of methods of nuclear medicine, such as SPECT, PET/CT, or PET/MRI. The most frequently used radiopharmaceutical is  90–100% –36. The  90–100% . FDG is  90–100% .The only potentially curative method is radical surgery achieving R0 resection. To date, there has been no consensus about the extent of the resection procedure. The selected type of surgery varies from simple cholecystectomy up to major hepatic resection. The type and extent of the resection procedure should reflect the stage of the disease. The standard procedure in early-stage disease is cholecystectomy, with lymphadenectomy of the lymph nodes of the hepatoduodenal ligament and en bloc resection of the hepatic parenchyma surrounding the gallbladder bed. In a locally advanced disease, hepatectomy is recommended. Systemic therapy can be used in the neoadjuvant and adjuvant setting . BiologiMixed neuroendocrine-non-neuroendocrine tumors localized in the biliary tract are extremely rare. This type of lesions can occur in any organ that has an embryonic origin from the primitive gut. The origin of these malignancies is still not fully understood. These tumors do not have specific symptoms, and this is the main reason they are often diagnosed in late stages of the disease. Spiral CT scanning is the method of choice for diagnosis and staging of the disease. The primary treatment modality should be radical surgery. Systemic chemotherapy, optimally combined with biological therapy with somatostatin analogues, has an indispensable role in the therapeutic algorithm.


Dienogest (DNG) is considered to be effective against ovarian endometrioma (OMA). We report a rare case of OMA transformation to ovarian cancer during long-term endometriosis treatment with a periodic administration of a gonadotropin-releasing hormone agonist (Gn-RH agonist) and DNG. The patient was a 41-year-old Japanese woman. OMA and adenomyosis of the uterus were revealed via computed tomography. Consequently, she underwent conservative treatment without undergoing surgery because her overall status was poor. She received cyclic therapy (Gn-RH agonist and DNG) for approximately eight years. However, she reported lumbago and underwent close medical examination at our hospital after about eight years of treatment. Under the suspicion of malignant transformation, she underwent surgery. The pathological diagnosis was clear cell carcinoma of the right ovary (stage 2B). After surgery, she received six courses of chemotherapy . No evidence of disease was observed after chemotherapy. Our findings suggest that malignant transformation of OMA can occur during DNG treatment. Since the delayed detection of ovarian cancer greatly affects the prognosis, women older than 40 with OMA are encouraged to undergo regular check-ups every few months. Currently, Japanese women are marrying later in life, which greatly increases the number of menstruations and the risk of endometriosis . Treatme2) visited our department due to severe vomiting. Although hyperglycemia and hypertension had been identified upon screening at her workplace, she neglected these findings. She underwent medical examination for the vomiting at a local clinic; however, because her condition did not improve, she was referred to our emergency medical center. She had a history of appendicitis at 20 years of age, and she had undergone bilateral ovarian cystectomy for OMA at 28 years of age. She did not have any additional relevant medical or family history.A 41-year-old Japanese woman : 13.7%; and brain natriuretic peptide level: 922.8 pg/mL. Moreover, her tumor marker findings included cancer antigen (CA) 125 level of 636.0 U/mL and CA19-9 level of 610.0 U/mL. Furthermore, her blood gas analysis findings were pH, 7.490; pCO2, 34.0 mmHg; and pO2, 64.9 mmHg. Chest radiography indicated a cardiothoracic ratio of ≤ 50% and a small pleural effusion. T1- and T2-weighted magnetic resonance images (MRI) revealed high-intensity signals in two ovarian tumors (tumor size: right < left) and masses with a maximum diameter of 59 mm in the left ovary  was continued alternately for approximately eight years as endometriosis treatment. Moreover, regular medical examination for tumor markers and ultrasonography was performed every three months.After approximately seven years of treatment, MRI findings revealed high-intensity signals in two ovarian tumors with a diameter of 35 mm or less, and the tumor size indicated a partial response . MoreoveHowever, she reported lumbago and underwent careful medical examination at our hospital after approximately eight years of treatment. Malignant transformation of the right ovarian tumor was suspected on ultrasonography (tumor enlargement and a solid mass). MRI findings revealed a mass with a maximum diameter of 114 mm in the right ovary. The solid part of the mass exhibited a low-intensity signal . PET/CT 2; carboplatin, AUC 5). After chemotherapy, PET/CT did not show abnormal uptake. Currently, she exhibits no evidence of disease after chemotherapy.Following surgery, she received six courses of conventional TC  , type 1 The factors associated with the differential diagnosis of OMA and ovarian cancer include age, size of the ovarian cyst, tumor marker levels, and diagnostic imaging findings . The risk of malignant transformation of OMA increases with age over 40 years and a maximum tumor diameter of 6 cm . Serum CIn conclusion, the malignant transformation of OMA is rare during DNG treatment. Since diabetes in women with endometriosis might be associated with ovarian malignant transformation, it should be carefully assessed and treated. Moreover, because a delay in the detection of ovarian cancer greatly affects prognosis, women older than 40 with OMA are encouraged undergo regular check-ups every few months.


Introduction: Carotid body tumors also known as parganglioma or chemodactomas are one of the rare tumors of head and neck which present as slow growing masses in the neck region. We present a case of 40 years female with painless slow growing mass over left side of her neck for 6 months. Diagnosis was made on basis of clinical history, examination and radiological findings. Tumor was graded as Shamblin grade II. She was managed with excision of the tumor without preoperative embolisation. Intraoperative and postoperative periods were uneventful.2 over left anterior triangle for 6 months with no history of dysphagia, odynophagia, change in voice, shortness of breath, palpitations, tremors or syncopal attacks. She underwent USG neck and CT angiogram. Based upon the radiological and clinical findings, she was diagnosed asCarotid body tumor. She was managed with excision of the tumor without preembolisation. Her diagnosis was confirmed with histopathology.Case presentation: A forty years female presented with left sided painless neck swelling∼5 × 4 cmConclusion: Carotid body tumours are rare entities of head and neck region. They are mostly benign in nature. Though mostly bening, increasing size might result in grave complications. Thus, the recommended treatment for carotid body tumors is early excision with or without pre-embolisation. In our case preembolisation was not performed. Though some studies have suggested the use of preoperative embolisation in large sized tumors, more studies are yet required to justify the choice of preembolisation despite the dreaded complications. These are rare paraganglionic tumors commonly found in head and neck. The term paraganglion was coined by Kohn. Clinical presentation of the tumor is an asymptomatic slow growing mass in neck. However, they can produce symptoms due to pressure and local invasion of the surrounding tissue. Most commonly involved are hypoglossal nerve, glossopharyngeal nerve, vagus nerve and sympathetic chain .Originally derived from neural crest cells, common site of presentation is the carotid bifurcation. Histologically Carotid body is composed of two types of cells, type I paraganglionic cell also known as chief cell and type II supporting cell also known as sustentacular cell. The characteristic pattern of these tumors are arrangement of type I cells in a pseudoalveolar pattern also known as Zellballen  with finely granular eosinophilic cytoplasm and small oval nuclei. Type II cells have chemoreceptor activity.They have close resemblance with branchial cysts, tuberculous lymphadenitis, lymphomas, salivary gland tumours, carotid artery aneurysm, metastatic carcinoma or lateral neck masses and thus should be differentiated. But slow growing isolated firm mass in left lateral side of neck with pulsatile nature on palpation makes it easier to delineate it from conditions described above. Clinical history, examination and radiological diagnosis are the keystones to diagnosis and management. Ultrasonogram, CT, MRI are useful radiological tools in diagnosis. Yet Angiography is essential to study about the vascular anatomy . Treatme22 over left anterior triangle region over upper third of anterior border of SCM lateral to hyoid bone. It was non tender, firm with ill defined margins. Surface was smooth and it was pulsatile in nature. Mass was mobile sideways but not vertical (Fonataine’s sign). Fluctuation was absent. There was an absence of carotid bruit. Mass was not bimanually palpable. Mouth opening was adequate, secretions from both the parotid ducts were normal and facial nerve function was intact on both the sides. With the clinical history and findings above she was posed the diagnosis of left carotid body tumor. She underwent USG neck which showed a highly vascular hypoechoeic mass measuring around 3.5 × 3.1 cm2 at carotid bifurcation splaying left Internal Carotid Artery and External Carotid Artery. She was then planned for CT angiogram . Dissection was done along the subadventitial plane. There was a major feeder vessel from External Carotid Artery which was ligated along with small vascular branches around the tumor. Internal Carotid Artery and External Carotid Artery both were preserved. Blood loss was minimal with no injury to adjacent vascular structures. The excised mass was sent for histopathological examination. Postoperative period was uneventful. She was discharged on 7th postoperative day and was followed up after 3 months and showed no signs of recurrence or complications.A forty years female presented with left sided painless neck swelling for 6 months. The swelling was gradually progressive with no aggravating or relieving factors. There was no history of dysphagia, odynophagia or change in voice. She didn’t give any history of shortness of breath, palpitations, tremors or syncopal attacks. There was no history of fever, weight loss or loss of appetite. She denied any history of similar swelling elsewhere in body. There was no history of similar swelling in any family members. On General physical and systemic examination, no abnormality was detected. On examination of the swelling, there was a single globular swelling ∼5 × 4cmngiogram a–c whichThe final histopathological reports of the mass revealed Zellballen, alveolar pattern of cells with hyperchromatic nuclei and vascular proliferation in between the cells. Atypical cells were not seen . The fea3The case we have presented represents one of the rare entities accounting for 0.06% of head and neck tumors, out of which less than 10% are malignant. Familial accounts for 10% while 31.8% of the familial type are bilateral. Only 6% of the sporadic form are multicentric ,5.Mechanisms of Carotid Body tumour is not clear. Hypoxia and genetic factors are considered to be involved in its pathogenesis. According to some studies, disease-induced low partial pressure of the oxygen in the blood and chronic continuous hypoxia in high altitudes (above 1500 m) and chronic intermittent hypoxia due to sleep apnea syndrome could be the stimulus for the hyperplasia and hypertrophy of the carotid glands. Genetic-type amounts to approximately 35%. In individuals with genetic susceptibility, experience of chronic hypoxia might lead to development of tumor at an early age. However family history is not the only governing factor . In our Carotid Body Tumor has been classified by Shamblin Research group into type I , type II  and type III (wrapped type). As the grading goes higher the chances of complications rise. Cranial nerves, Cervical great vessels are at higher risk of injury pre and postoperatively. According to the grading above, it was Shamblin Grade II in our case with no signs of complications.Recent vascular imaging techniques have also made it easier for better preoperative assessment and planning during surgery . The diaDigital Subtraction Angiography (DSA) is the gold standard for diagnosis. However Color Doppler is also done. But DSA is not helpful for information regarding Cranial blood circulation.CT-scan can delineate the relation of tumour with surrounding structures .Definitive management of carotid body tumor is early surgical excision which is equally important to reduce risk of malignancy and perioperative complications. First surgical excision was attempted in 1880 by Reigner but it resulted in postoperative mortality. Maydel in 1886 performed similar procedure and fortunately the patient survived. However hemiplegia and aphasia were the complications. First successful excision was done by Scudder in 1903 .For small tumors excision is simple but for larger tumors and those encasing the arteries, some studies have suggested that division and ligation of External Carotid Artery might be helpful and safe approach for complete excision of the tumors where as ligation of Internal Carotid Artery must be avoided as far as possible to avoid grave complications like stroke. Intraluminal vascular shunts and grafts is used in cases where the vessel intima is damaged .In our case we performed early excision of the tumor without pre embolisation. Preoperative embolisation of the tumor was initially suggested for large tumors with the purpose of reducing blood loss and intraoperative complications but studies now have reported that there is no difference in estimated blood loss, cranial nerve injury, stroke and length of hospital stay .4Early surgical excision of carotid body tumour is the treatment of choice which can be done without preembolisation. However preembolisation is still a matter of controversy. Thus more studies need to be done comparing the outcomes of surgeries with and without pre-embolisation. This case has been reported according to SCARE criteria .No conflict of interest.No sources of funding.As this is a case report ethical approval has been exempted and written informed consent has been taken from the patient.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 as required.Dr.Sudha Shahi- Study concept and design, data collection, literature search, writing paper, final decision to publish.Dr. Anupam Raj Upadhyay- Literature search, final decision to publish.Dr. Anuj Devkota- Literature search, final decision to publish.Dr. Tridip Pantha- Supervised the writing of the manuscript, final decision to publish.Dr. Dipendra Gautam- Supervised the writing of the manuscript, final decision to publish.Dr. Dhundi Raj Paudel- Supervised the writing of the manuscript, final decision to publish.Is a case report.Dr. Sudha ShahiNot commissioned, externally peer reviewed.