Gastric duplication cysts are uncommon findings in adult patients. Accurate diagnosis of these cysts is difficult. Presenting symptoms are often non‐specific, and complications are rare. We report an uncommon case of a non‐communicating duplication cyst associated to a diverticula of the stomach in 38‐year‐old women. Gastric duplication cyst is a rare congenital disease; however, we should learn the keys to its diagnosis. Because of its possible malignant transformation, surgery should be considered regardless of the presence of symptoms. It is a rare congenital anomaly that accounts for 2–7% of all gastrointestinal duplications.2We report the case of a 38‐year‐old Nigerian woman who presented with a two‐month history of progressively increasing epigastric pain associated with loss of appetite. Personal and family medical history was unremarkable. She was not under any medication. No smoking or alcohol drinking habits were reported. On physical examination, there was no evidence of an abdominal mass. Blood tests revealed no abnormalities. The upper endoscopy exploration showed no obvious anomaly; in particular, mucosa appeared normal and no compression was found in the antro‐pyloric region.A CT scan with oral contrast material showed a 6‐cm homogeneous, non‐septated cystic mass with regular margins that could not be completely separated from the antro‐pyloric region of the stomach. The CT showed also a second cystic lesion of 7 cm contiguous to the first one. These two structures were non‐communicating with the stomach or with each other Figure . A 3D re® coagulating dissector. Afterward, we identified a second cystic mass of 6 × 7 cm residing in the lesser sac. It was densely adherent to the first one , without dysplasia. The first cavity had a thickened muscle tissue and corresponded to a non‐communicating duplication cyst. The second was sclerotic, devoid of muscular tissue and slightly inflamed arising from the first cavity and corresponding to a diverticulum Figure .The patient started oral intake on postoperative day 1 and was discharged on postoperative day 3 without any complications.3In this report, we present a unique association of a gastric duplication cyst (GDC) and a diverticulum of the stomach in 38‐year‐old women. This association has not been reported in the literature so far., GDC accounts for 2–7% of all gastrointestinal duplications.Duplications of the alimentary tract are rare and occur in 1 in 4500 births.By definition, gastric duplications have a well‐developed layer of smooth muscle and an epithelial lining. They are attached to the stomach sharing a common muscle wall and blood supply.Two types of duplications are described: tubular when they communicate with stomach lumen and cystic when the lumen is not contiguous with the stomach.These cysts are usually asymptomatic and are diagnosed incidentally. However, complications can occur, including infection, bleeding, rupture, or carcinoma arising in the cyst.GDC can mimic a pancreatic pseudocyst or sometimes a malignant pancreatic cystic tumor, in particular pancreatic mucinous.In the past, preoperative diagnosis of gastric duplications was quite rare, but CT scan along with endoscopic ultrasound has been proven to be effective in identifying GDCs.GDC has the potential for neoplastic transformation. The production of oncofetal antigens raises the problem of a precancerous condition.On the contrary, gastric diverticula can be classified into true diverticula comprising all gastrointestinal layers and false diverticula which comprise the mucosa and the submucosa.4GCDs are difficult to diagnose. Not only complications have been linked to this congenital anomaly, but also malignant transformation has been reported. Therefore, when unusual findings are encountered, we suggest that resection should be the first treatment option for gastric duplication cysts.5This report describes a unique association of a gastric duplication cyst and a diverticulum of the stomach in 38‐year‐old women. This association has not been reported in the literature so far. Two cystic lesions were found attached to the antro‐pyloric region. We performed a distal subtotal gastrectomy with a Billroth II reconstruction. The first cavity had a thickened muscle tissue and corresponded to a non‐communicating duplication cyst of the stomach. The second corresponded to a diverticulum arising from the first cyst. Histopathologic examination showed no signs of malignancy. However, the possibility of malignancy within these cysts should always be considered.None declared.Mohamed B.A and Abderrahmen M conceived the idea for the document and contributed to the writing and editing of the manuscript. Amine Z reviewed and edited the manuscript. Zied H reviewed and edited the manuscript. Rafik M reviewed the article before submission. All authors read and approved the final manuscript.Personal data have been respected.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


The proper management of a prolapsed rectal mass in a child or teenager is challenging. Given that the underlying etiology of a prolapsed rectal mass in this population is not always immediately clear, interdisciplinary assessment is often required. Juvenile polyps, more commonly presenting with bleeding than a prolapsed mass, can mimic the appearance of both hemorrhoids and the rectum itself - making a purely clinical diagnosis difficult. Presented here is a case of a prolapsed colorectal polyp in a teenage boy, who underwent manual reduction of the mass, followed by colonoscopy and endoscopic ligation. Further histological evaluation revealed it to be a juvenile retention polyp. Despite the rarity of polyp prolapse as a presenting symptom, this case underscores the importance of considering colonic polyps as the etiology of a prolapsed anorectal mass in a teenager. Occurring in about 1% of children, polyps are the leading cause of lower intestinal bleeding in children . Given tHowever, despite the difficulty in distinguishing the various subtypes of colorectal polyps grossly and clinically, juvenile retention polyps have low malignant potential. These polyps are classified as hamartomas and histologically contain dilated glands and lamina propria inflammation . A retroThe differential diagnosis for a prolapsed anorectal mass in children includes ileocecal intussusception, prolapsed rectal polyp, prolapsed rectal duplication cyst, prolapsed rectum, and hemorrhoids . Polyps Given the reported rarity of prolapse as a presenting sign in children with colorectal polyps, the next steps in the management of prolapsed colorectal polyps remain uncertain. Further, the gross appearance of a prolapsed colorectal polyp implicitly broadens the differential to include hemorrhoids, rectal prolapse, and more.A 13-year-old male patient presented to the emergency department (ED) with a prolapsed rectal mass. The patient noticed the mass while attempting a bowel movement, during which he noticed blood on the toilet paper, prompting him and his father to examine the area which contained a round, pink mass protruding from the rectum. A gross image of the mass is shown in Figure This patient’s history, aside from some constipation as an infant, contained no prior history of rectal prolapse, colorectal polyps, hematochezia, or melena. The patient also denied any abdominal pain, diarrhea, constipation, nausea, or vomiting. Further, the patient’s father was diagnosed with Crohn’s disease in his early 20s. Laboratory studies at three months of age showed reduced hemoglobin A1, indicating a possibility of β-thalassemia trait at the time, which was never confirmed at a later age. On presentation, this patient had a complete blood count (CBC) that showed a mild microcytic anemia. Given that the mass was noted to have a stalk, a rectal polyp was the leading diagnosis prior to any intervention; other diagnoses on the differential included hemorrhoid, rectal prolapse, and inflammatory bowel disease.Given the patient’s age, noncontributory history, and subtle presentation, determining the appropriate management for this patient presented a challenge in the initial hours of presentation to the ED. However, the polyp was successfully reduced back into the rectum in the ED prior to further intervention. The size of the polyp was likely to pose endoscopic ligation challenges to a gastroenterologist, which subsequently would have warranted recommending surgical resection by a general surgeon.3. Endoscopic ligation using a hot snare was performed to remove the polyp. Figures Colonoscopy was performed shortly after the mass had been reduced, following bowel prep. Pertinent negatives during the procedure included normal sphincter tone and no palpable rectal lesions. The location of the polyp was found to be in the sigmoid colon, solitary and semi-pedunculated in nature, and measuring 3.3 x 3.0 x 2.8 cmFinally, both the gross and histological features of the polyp confirmed the diagnosis as a juvenile retention polyp. Grossly, this polyp was round and pedunculated but lacked the characteristic long pedicles seen in adenomatous polyps. Histologic evaluation of the polyp displayed cystically dilated glands, with relatively equal amounts of glandular and stromal proliferation; this appearance contrasts with adenomatous polyps, which display predominantly glandular proliferation. Lastly, the lack of cellular atypia gave strong evidence that this polyp was indeed benign.Determining the etiology and appropriate management of a protruding anorectal mass in children can be challenging. As demonstrated by this case, history and physical exam may be insufficient to distinguish between varied conditions such as rectal prolapse, hemorrhoid, and prolapsed colorectal polyp in the child presenting with a mass protruding through the anus. Management for these three conditions differs, underscoring the importance of proper diagnosis.In this case, the absence of palpable rectal lesions and endoscopic localization of the polyp to the sigmoid colon confirmed the diagnosis of a polyp. Definitive diagnosis and treatment included reduction of the polyp back into the colon, followed by colonoscopy and polypectomy. The colonoscopy allowed for complete colon examination and confirmation of no other polyps or abnormalities.A spectrum of colorectal polyps exists, ranging from benign to pre-cancerous polyposis syndromes. These polyposis syndromes can be categorized into three broad classes relating to their histology or inheritance: inherited hamartomatous , inherited adenomatous , and noninherited  . These sOnce colonoscopy confirmed that this mass was indeed a prolapsed colorectal polyp, histologically differentiating between the many etiologies of colorectal polyps was equally important, as gross classification is likely insufficient.Elucidating the underlying etiology of a prolapsed rectal mass in a child can be challenging and effective treatment depends largely on doing so. Determining the proper course of action relies on interdisciplinary care. Juvenile retention polyps in children commonly present as hematochezia and, less commonly, anal prolapse. Most juvenile retention polyps exist in the rectosigmoid colon. Colonoscopy and polypectomy exist as the standard in removing juvenile retention polyps in children.


Calcifying odontogenic cyst (COC) is a rare lesion of jawbone. It is classified among development cyst in the new WHO classification of tumors of the head and neck in 2017. It is a rare pathology, which is found more in the upper maxillae, with a predominance in women in the second or third decade. The diagnosis is based on the analysis of clinical, radiological and histological features.We report the case of a 17-year-old patient referred by his orthodontist following the fortuitous discovery of a mixed radiolucent/radiopaque image in the right jaw ranging from the tooth 11 to the tooth 16, for whom the clinical, radiological examination associated with fine needle aspiration cytology suggested a cystic lesion.Management initially consisted of decompression of the lesion and complete enucleation after nine months. Histopathological examination gave the diagnosis of calcifying odontogenic cyst. The follow-up showed favorable evolution. •Calcifying odontogenic cyst is a rare lesion of the jaws•Treatment is based on enucleation; in our case we opted for decompression which gave a good result which can be an alternative in large lesions•This case deserves better exposure in your journal. In 1971, the COC gained international recognition when the World Health Organization (WHO) Its classification is still subject to debate. It was classified in 1992 and 2005 by the WHO in odontogenic tumors. In its latest classification in 2017, COC was classified among the developmental cysts Below, we report a case of calcifying odontogenic cyst of the maxillary jaw in which decompression allowed the lesion to be reduced in size and its total enucleation after nine months. This case report has been reported in line with the SCARE Criteria 2A 17-year-old patient was referred by his orthodontist after the fortuitous discovery of mixed radiolucent-radiopaque images in the right anterior maxillary sector.His medical status was unremarkable, with no drug history and allergy.The extraoral examination was normal. There was no history of trauma, pain, paresthesia or lymphadenopathy.On intraoral examination, there was a slight swelling in the area extending from the tooth11 to the tooth16. The swelling was covered by a normal mucosa.On palpation, at the level of posterior maxillary alveolar process, the swelling was hard and painless. It became fluctuating and slightly tender in the anterior region. The cold tests carried out at all teeth of the lesion's area were positive.Digital panoramic radiograph revealed a mixed well-defined radiolucent-radiopaque image located in the area from the tooth 11 to the tooth 16 , with roUnder local anesthesia a cyst decompression was decided. The fine needle aspiration (FNA) of the contents of the lesion brought back a lemon-yellow liquid (3A). Incisional biopsy was performed and a decompression tube was placed B. Based Anatomopathological examination of the specimen gave the diagnosis of cemento-ossifying fibroma.9 months later, a reduction in the size of the lesion was observed and a second surgical intervention consisting of a total enucleation of the lesion was performed . The patHistopathological examination of entire lesion showed a cystic wall bordered by an odontogenic epithelium whose basal layer was made of cubocylindrical cells with ameloblastic differentiation. This aspect confirmed the diagnosis of calcifying odontogenic cyst.9 months later, the patient underwent an X-ray panoramic control which showed a beginning bone regeneration of the lesion area .Fig. 5Pa3First described in 1962 by Gorlin, COC is a rare lesion of jaw bone. It is defined as a cyst with an ameloblastoma-like epithelium containing calcifications and focal ghost cells. These cells are also present in dentinogenic ghost cell tumors In 1992, the World Health Organization (WHO) updated the classification of odontogenic tumors and modified COC's name into “calcifying cystic odontogenic tumor” (CCOT) because of their neoplastic behavior According to the study by Arruda et al., COC represents 1.3% of odontogenic cysts, with a distribution of 53% in women and 47% in men Swelling in the involved region is for the most common clinical sign noted in patients with COC. Smaller lesions are usually painless and discovered incidentally during routine radiographic evaluation. When located in the maxilla, patients may sometimes complain of nasal stiffness, epistaxis and headache Radiographically, COC generally appears as a unilocular lesion with a well-defined margin, and contains calcifications as in our case According to the study of Uchiyama and al, COCs was unilocular, borders were well defined and margins were regular. Root resorption was seen in seven of nine cases and teeth divergence in eight of nine. Impacted teeth were found in six of nine cases; An odontoma was found in one case The differential diagnosis of COC is made with all mixed lesions of the maxillae. It includes benign radiolucent lesions such as dentigerous cyst, adenomatoid odontogenic tumor, ameloblastic fibro-odontoma, and calcifying epithelial odontogenic tumor Classical histologic findings in COC are an odontogenic epithelium displaying keratinized ghost cells and calcification. Induction of dental hard tissues may be found in solid COC variants The recommended treatment for COC consists of enucleation with curettage, which means enucleation followed by removal of a 1- to 2-mm layer of bone around the periphery of the cystic cavity with a sharp curette or a bone bur. 4Calcified odontogenic cyst is an uncommon benign odontogenic lesion with a higher frequency in the upper maxilla. The treatment is most often conservative. Despite a rare risk of recurrence at 5 years, long term patient follow-up more to 10 years is recommended.Not required.No external funding.Dr MAINASSARA CHEKARAOU Samir designed the concept, analyzed and interpreted the findings, wrote and reviewed the final paper under the supervision of Prof CHAMI Bassima.Lamiae GAMRA made the lecture of the histological piece.Prof Mainassara SamirNot commissioned, externally peer-reviewed.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.The authors declare no conflict of interest.


Examinations of young children for suspicions of sexual abuse are challenging for the involved medical specialists because the consequences of the interpretation of the findings can be severe and dramatic. A broad knowledge of differential diagnoses including rare pathologies like urethral prolapse and failure of the midline fusion of the perineum, known as perineal groove, is essential in order to avoid unnecessary diagnostics and treatment, prejudgment, and to reduce patient family’s anxiety. We report two independent cases of girls aged 7 months and 5 years suffering from these rare pathologies, one presenting with painless lower genital tract bleeding, the other showing a lesion of the perineum as random finding during a neuropediatrician’s consultation. In both cases, the pathologies were initially misdiagnosed as injuries due to sexual assault, and judicial investigation procedures were initiated. In this paper, the characteristic symptoms and morphology of urethral prolapse and perineal groove are presented to enhance the awareness of these pathologies among forensic experts and help to establish the correct diagnosis. After an assumed sexual abuse, medical findings in pediatric gynecological exams are rare, and the proof is generally hard to bring. Even if the victim is examined immediately after the presumed assault, the prevalence of injuries is known to be low . In contThe mother of a 5-year-old girl of African origin (Gabon) noticed bloodstains in the girl’s panties Fig. , and susDuring the questioning by a police officer, the girl kept repeating that itching made her scratch her genitalia, without mentioning any other manipulation. The mother explained that her husband (the father of the girl), her 2-year-old sister and three brothers, among them two adolescent half-brothers, lived together in one household. The mother stated that the girl was under her supervision the whole day except for a period of 15–30 min when the girl was in the bathroom.Subsequently, the magistrate ordered a medicolegal opinion, and a further gynecological and a clinical forensic examination were initiated.At the time of the examination, the girl appeared neither physically compromised nor emotionally affected. The external genital organs were inspected in both supine and knee-chest position. At the vaginal entrance, prolapsed tissue of a doughnut-like form and livid coloration, easily bleeding on contact, could be observed Fig. . The hymMicrobiological diagnostics were negative for urogenital infections and sexually transmitted diseases. After a literature search, the suspected diagnosis of a urethral prolapse was made and confirmed by a specialist based on the pictures taken during the examination. The treatment was conservative, consisting of sitting baths and topical application of estrogen. The patient was seen for regular controls in pediatrics ambulatory care. After another period of bleeding in the first days, the response to the treatment was finally satisfactory. No complications, e.g., dysuria, pain, anemia, or urinary retention, occurred, and no further treatment was necessary.A 7-month-old girl of South European origin with a history of congenital macrocephaly and exophthalmia presented at the hospital for a medical specialist’s opinion and further examinations. At the general clinical examination, the physician detected a wet linear laceration of the perineum that had not been diagnosed before. The lesion did apparently not bother the child, who was under the care of both parents. The mother stated that she had not noticed this finding before and that there had never been a genital bleeding. Equivocal statements of the parents and an apparently difficult social setting further raised the suspicion, of a sexual abuse among the health-care professionals, and the case was reported to the prosecuting authorities. The magistrate in charge of the investigation ordered a medicolegal opinion and a clinical forensic examination was arranged.Ten days after the initial examination, the girl underwent an MRI under sedation for her underlying cerebral disease. The opportunity allowed for a gynecological and clinical forensic examination under optimal conditions. After separation of external labia in supine position, a wet unkeratinized perineal defect in extension of the internal labia with well-demarked raised margins was detected in the midline of the perineum Fig. . Apart fIn order to clarify whether the perineal defect was recent or known to be congenital, the police officer in charge of the investigation contacted the resident pediatrician, who had performed the routine check-ups of the girl. Unfortunately, the anogenital region had not been inspected in detail prior to the hospital admission and the age of the lesion remained unclear.The morphological appearance of the defect—absence of typical signs of injuries like an irregular configuration and hematoma/ecchymosis, and the lack of healing of the lesion between the first and the second examination (when compared to photographs that were taken during the first examination)—made it seem unlikely to be due to trauma. A literature search lead to the diagnosis of a congenital failed fusion of the perineum known as perineal groove. Given the good prognosis of this pathology and the fact that there were no symptoms and no complications, no special treatment was necessary. A genetic survey was initiated to rule out a possible genetic cause of the syndrome. The further treatment of the underlying disease and the follow-up are unknown.We report on two cases of young girls with no history of recent trauma presenting suspected vaginal bleeding and an apparent lesion of the perineum, respectively. Both findings were initially misdiagnosed as sequels of sexual violence, and led to police investigations. The underlying diseases, namely a urethral prolapse and a failure of the midline fusion of the perineum, are differential diagnoses of sexual abuse . HoweverAs the perineal groove is a congenital malformation that usually resolves spontaneously during the first two years of life , it is sUrethral prolapse almost exclusively affects girls, whereas perineal groove seems somewhat more likely to appear in males. To our knowledge, three cases in males have been published so far . A combiThus, a context of dysmorphic stigmata, as presented in the perineal groove case, allows for the physician to take into consideration a congenital malformation rather than an injury when confronted unexpectedly to such a rare genital condition. However, a literature review shows that such a context is rather uncommon in girls: most cases published did not show other external abnormalities, and only a minority of them was combined with internal congenital malformations like persistent ductus arteriosus , or co-eThe later the defect is discovered, the more likely it is to be mistaken for an injury. Samuk et al.  observedUrethral prolapse, in contrast, shows bleedings as most frequent symptom (86%), followed by a mass at the introitus (47%) and dysuria (32%) .Lower genital tract bleeding in a child is an alarming symptom for parents (or other caregivers), and usually leads to medical help being sought immediately. Adams et al.  classifiA comprehensive and meticulous gynecological and physical examination should usually reveal the respective lesion. For urethral prolapse, recognizing its origin from the external meatus of the urethra is essential to establish the diagnosis. However, the mass may be confounded as the vaginal entrance, since the protruding tissue frequently masks the normal anatomy of the external genital organs, resulting in a high rate of misdiagnoses. Detecting the vaginal entrance beside the prolapsed tissue may help determine the origin of the prolapse. In supine position, gentle posterior traction of the external labia can uncover the vaginal entrance. If the protruding tissue mass is voluminous, it is more likely to get to see the vaginal entrance in knee-chest position than in supine position. Putting a catheter through the center of the mass and drain urine can be necessary if there are voiding disorders, and may help to confirm the diagnosis.In order to differentiate perineal groove from traumatic lacerations of the perineum, it is essential to focus on the morphology of the lesion. The perineal groove extending in the midline from the posterior fourchette to the superior anal verge is equal in depth, clearly delimited with regular margins, and painless, whereas lacerations from trauma tend to be deep, bruised, and painful. Another particularity of the malformation is the absence of visible wound healing. Injuries heal rapidly, often ad integrum, within days to weeks, whereas the spontaneous epithelialization of a perineal groove usually takes at least several months, in some cases even years , 9, 13. Both the perineal groove and the urethral prolapse have in common that the diagnosis is made clinically and that the treatment can be conservative or expectant, respectively, except if there are complications or persistent complaints , 9, 14.In the literature , pelvic


The diagnosis of stercoral colon perforation, which is often difficult and delayed, must be known by all physicians who manage an increasingly older patient population.The stercoral perforation is a mortal condition. It affects elderly patients who have a long history of chronic and severe constipation as well as constitutes a surgical emergency whose prognosis, often grim, depends on the early diagnosis and treatment. We report the case of a stercoral colon perforation which occurred in an 89-year-old patient. The clinical symptomatology was that of an acute peritonitis evolving for four days. The diagnosis was only made intraoperatively and the surgical gesture was a resection of the involved left colon segment and Bouilly Volkmann colostomy. The consequences were unfortunately marked by a resistant septic shock resulting in the death of the patient on the 1 Stercoral perforation is a rare condition. It mainly affects older, weak and bedridden patients. The disease was first reported in 1894 . We repo3 and C-reactive protein level was 300 mg/L. The erect chest X-ray did not show a pneumoperitoneum or a hydro-aeric level. The abdominal computerized tomography (CT)   revealedphy (CT) . A diagnphy (CT)  showed gStercoral perforation is a complication of chronic constipation. It is a rare but dangerous disease with an estimated mortality rate ranging from 32 to 57% . The latet al. [On imaging, free air under the diaphragm appears, on chest X-ray, in only 30% of colonic perforations . The abdet al.  the diaget al. . Stercoret al. ,11. The et al. . Our surIn the elderly, chronic constipation should always be treated with dietary and pharmacological measures. When mismanaged, the biggest risk is to develop ulcers and stercoral perforations. A stercoral perforation diagnosis must be highly suspected in patients with a history of chronic constipation who present with acute abdominal pain. Early surgical intervention improves the prognosis, most often bleak.


Conjoined twining is one of the most fascinating and challenging situations which a pediatric surgeon may face in his career. Only few surgeons may have the opportunity to share in separation of such cases. In this report, we aim to share our experience with the successful separation of ventrally fused male conjoined twins . The case was thoroughly studied via preoperative cross-sectional imaging modalities (magnetic resonance imaging [MRI] and computed tomography [CT] angiography), complemented by data obtained from reviewing similar cases in the literature. A clear delineation of the complex anatomy was achieved preoperatively which proved to be well consistent with the operative findings. A detailed description of the operative procedure to divide/redistribute the shared abdominal/pelvic organs between both twins is provided. To the best of our knowledge, this is the first report to describe the detailed and unique internal anatomy of a common central phallus associating ischiopagus conjoined twins. The penis was centrally located in the perineum in between both twins with an open urethral plate. This common phallus had a peculiar configuration with four crura anchoring ischial bones of both twins together. Conjoined twining is one of the most fascinating and challenging situations which a pediatric surgeon may face in his career.In this report, we aim to share our experience with the successful separation of ventrally fused male conjoined twins  that were referred to our center from another country. The case was thoroughly studied via preoperative cross-sectional imaging modalities (magnetic resonance imaging [MRI] and computed tomography [CT] angiography), complemented by data obtained from reviewing similar cases in the literature.A case of omphaloischiopagus male conjoined twins was referred to our pediatric surgical center at the age of 3 months to prepare them for an elective separation. Both twins were looking healthy with a combined weight of 10 kg. They were ventrally joined through the abdomen starting from the xiphisternum down to the pelvis with a common perineum and a single central phallus. The common phallus was associated with an open urethral plate  with a single perineal orifice discharging both urine and stool. Each twin had two well-developed lower limbs (tetrapus ischiopagus).We started by building up a multidisciplinary team from different specialties required for achieving this mission. Principally, the team included pediatric surgeons/urologists, pediatricians, radiologists, anesthesiologists, plastic surgeons, and pediatric orthopaedics. Other specialties were consulted on demand. Our early concern was directed to check and maintain good nutritional status of the twins during the preparation phase, while required preoperative imaging were sequentially performed to disclose the unfamiliar and complex anatomy. Influenced by the novel coronavirus disease 2019 (COVID-19) pandemic, the preparation period was protracted for several months with a delayed separation at the age of 21 months. Several interdisciplinary meetings were held to plan for separation that included videoconference platform utilities. Detailed explanation of the procedure including vital and functional risks of the operation were fully explained to the mother; and informed consent was obtained.This included a battery of investigations starting by echocardiography to exclude cardiac anomalies. Pelviabdominal ultrasound was performed to assess the degree of hepatic fusion, the presence of separate biliary systems, the number and position of kidneys, and urinary bladders. Conventional gastrointestinal tract (GIT) contrast X-ray studies  were performed for each twin on separate days. Dynamic postcontrast CT studies (abdomen and pelvis) were also performed on two stages injecting intravenous (IV) contrast for each twin on separate days; an electronic three-dimensional (3D) model was reconstructed using Visible Patient program . PelviaTo avoid confusion, we had to define a standard position for imaging of the ventrally fused conjoined twins. The standard position was identified when the twins were resting on their sides such that the common umbilicus was facing upward. In such position, the twin on the right side in imaging films was identified as twin A while the other as twin B. In this resting position, the left side of twin A (marked by the presence of the spleen) was posterior , and thAs the fused area was large measuring 16-cm vertically and 9.0 cm transversely, it was decided to insert tissue expanders to facilitate soft tissue closure at the time of separation. Two single soft-based tissue expanders , 160 cc, rectangular in shape, and with dimensions of 8 cm × 4 cm × 5 cm, were placed subcutaneously with its longitudinal axis being parallel to the longitudinal axis of fusion. Placement was performed under general anesthesia on one lateral side of each of the conjoined twin 3-cm lateral to their line of fusion (midline) while resting on the iliac crest caudally and the last rib cephalically. The incision to insert each expander was remote and perpendicular to longitudinal axis of the dissected pocket . An intThe operation for separation of the conjoined twins lasted for approximately 15 hours. Four anesthesia teams were allocated: two for each child during morning and afternoon shifts. The procedure started by induction of anesthesia and insertion of central lines for both twins. Anesthesia was maintained using pressure controlled gentle ventilation with one minimal alveolar concentration (MAC) sevoflurane, 5 to 10 µg/kg fentanyl, and atracurium as needed. Hemodynamic parameters, serial arterial blood gases, hematocrit, and random blood sugar helped us to maintain good perfusion of different organs with minimal changes in respiratory and metabolic profiles. Tranexamic acid and blood products were used . Despite measures to reduce heat loss were instituted, temperature dropped to a lowest of 35.5 °C during the midthird of surgery with a corresponding lactate rise that was gradually reversed toward the end of surgery.The twins were positioned on their sides with the common umbilicus facing upward. A midline skin incision was made starting from their superior point of fusion opposite the xiphisternum and progressing downwards through umbilicus to reach the pubis (keeping the umbilicus to one of the conjoined twins). The incision was deepened through the layers of the abdominal wall equally dividing it between both twins. The incision was extended downwards disarticulating the abnormal cartilaginous pubic fusion between both twins (anterior side). Then, we started to divide/redistribute the shared abdominal/pelvic organs between both twins from above downwards in successive phases .Phase 1 was concerned with the liver . AlthouPhase 2 was concerned with the GIT. Two separate upper gastrointestinal tracts were found merging distally (at site of Meckel's diverticulum) into a single terminal ileum and colon. The separation was performed as shown inPhase 3 was concerned with the lower urinary tract . There Phase 4 was concerned with the genitalia . The coThe progress to complete separation went on by disarticulation of the posterior cartilaginous pubic fusion in-between, and by dividing the joined abdominal wall muscles and skin at the posterior side. Now the twins were completely separated , and twThe final phase of perineal reconstruction and abdominal closure was performed simultaneously in both twins by two sets of surgeons . For twin A, a colonic pull through was performed with reconstruction of a neoanus (without covering colostomy). Regarding twin B, a limited sagittal anorectoplasty was performed to separate the anorectum from the urethra and reposition the anus within the sphincteric muscle complex . A perineal urethrotomy was performed for each twin with indwelling urinary catheters. For each twin, anterior abdominal wall closure was facilitated by bilateral oblique innominate pelvic osteotomies and approximation of the pubic bones in the midline (like in exstrophy repair).Regarding pelvic osteotomies, the iliac apophysis was incised for 1 cm at and posterior to the anterior superior iliac spine (ASIS). Subperiosteal dissection of the medial aspect of the iliac wing was performed caudally to the triradiate cartilage and posteriorly to the sciatic notch. A nutrient vessel  was cauterized to minimize blood loss. Subperiosteal dissection of the lateral aspect of the iliac wing was then performed to the sciatic notch. The periosteum of the sciatic notch was then elevated to provide room for the Hohmann retractor. An oblique iliac bone osteotomy was performed using an oscillating saw. The osteotomy extended between a point as high as possible in the notch and another point in the iliac crest, 2-cm behind the anterior superior iliac spine. Internal and downward repositioning of the two front sections of the pelvis was performed and the diastasis was approximated, and the symphysis pubis temporarily held by a pointed bone reduction clamp. Non absorbable (Ethibond 5) transosseous sutures were then taken obtaining a diastasis width close to the normal value of 7 mm.Once the pelvis was reconstructed, expanders were retrieved and the abdominal wall was reconstructed in layers and closed without tension from below upward. A piece of prosthetic mesh (bioresorbable coated permanent mesh) was used to ensure a tension-free muscle closure on the midline upper abdominal wall closure in both twins. Fashioning and mobilizing the expanded skin flaps completed the closure. No intraperitoneal drains were left; however, subcutaneous drains were placed to avoid fluid collection under skin flaps. At the end of operation, both twins were immobilized in “Broomstick” cast to maintain knee extension with partial hip abduction. This was recommended by orthopaedic team to support their repair for pelvic diastasis.Both twins were extubated at the end of operation and were transferred to ICU. The postoperative recovery was uneventful. It was important to maintain adequate analgesia and antibiotic prophylaxis during the early postoperative period. On the postoperative day 5, enteral intake was resumed through nasogastric tube, and gradually progressed to full oral intake. The urinary catheters were also removed on the postoperative day 5, while the subcutaneous drains were removed 3 days later.The lower limb immobilization casts were removed after 6 weeks, and both twins started physiotherapy to help them to stand upright and walk for the first time. Both were passing well-formed stools three to four times per day; however, they were continuously dribbling urine. Follow-up ultrasound (2-month postoperative) showed normal kidneys without dilatation of the upper tract; however, both urinary bladders were empty.Surgical separation of conjoined twins is a unique experience that has been reported to be associated with high mortality.Ventral fusion is the most common type of conjoined twining with variable range of severity starting from the thorax above down to the pelvis.Reviewing similar cases in the literature, one can identify a common pattern for shared and fused organs despite the variation in severity. Starting by the GIT, omphaloischiopagus twins invariably have separate upper GITs merging distally to fuse at the site of Meckel's diverticulum into common terminal ileum and colon.The bony pelvic deformity is also characteristic in ventrally fused ischiopagus.The lower urinary tract usually consists of two urinary bladders arranged in the middle zone of the common pelvic cavity.To the best of our knowledge, this is the first report to describe the detailed and unique internal anatomy of a common central phallus associating ischiopagus-conjoined twins. These details were well identified and documented preoperatively based on our previous experience using pelvic MRI to study other congenital anomaliesThe ability to provide soft tissue for reconstruction and coverage remains among the various challenges in successful separation of conjoined twins.Lastly, and not the least, challenge in conjoined twins is the ventral abdominal wall defect that results after separation. Posterior iliac osteotomies, besides the use of prosthetic mesh to bridge the muscle gap, are well-known techniques that proved to be very helpful in this respect. In our case, we believe that modifying the site of tissue expander application to be partly resting on the lateral abdominal wall muscles was of great help as well. This might have induced stretching of the abdominal wall muscles besides their well-known effect on the skin. This has been recognized by surgical teams during midline closure of the lower abdomen of both twins that went much easier than expected. Reviewing the literature, we could find similar techniques used in managing cases with large ventral hernias.A plan for long-term follow-up is essential. We may face limitations to follow cases operated from other countries. However, a stable way for communication should be established before they return home. The priority should be to monitor and protect the upper urinary tract. Next priority will be directed to achieve social continence. Faecal continence may be easier to manage through bowel management if necessary. Urinary continence will require more sophisticated procedures; most probably these twins will need management similar to those with incontinent epispadias. Lastly, the options and proper timing for genital reconstruction  should be discussed.


Newborns are considered obligate nasal breathers until the eighth week of life. Therefore, upper nasal obstruction in a newborn can present as a potentially life-threatening complication. Congenital nasal pyriform aperture stenosis (CNPAS) is a rare form of upper airway obstruction caused by a narrowing without occlusion in the most anterior opening of the bony nasal airways. According to the severity of this stenosis, early onset of respiratory symptoms can arise in the newborn.In this article, we present the case of a male term newborn with no prior relevant family history and uneventful gestation delivered in a eutocic manner with an adequate transition to the extra-uterine environment. On his first day of life, progressive respiratory distress, inability to breastfeed, and impossibility to make nasogastric probe progress through both sides of the nose were observed, leading the newborn to be admitted to a neonatal intensive care unit.During imagiological assessment with perinasal computerized tomography (CT) scan, an almost total occlusion of the pyriform aperture and a solitary median maxillary central incisor (SMMCI) were identified. Additional evaluation with brain magnetic nuclear resonance imaging (MRI) was unremarkable with no midline defects identified. Endocrine laboratory assessment was also normal.The newborn underwent pyriform aperture permeabilization surgery via a sublabial approach with bilateral nasal stent introduction, enabling total resolution of the initial respiratory symptoms. No incurrences were reported during the post-operatory follow-up period.With the present case report, the authors are trying to raise awareness for CNPAS not only as a rare cause of respiratory distress in the newborn but also as a clinical entity that can be associated with midline defects, which require further additional investigation and intervention. Upper nasal obstruction in the newborn can present as a potentially lethal complication as a newborn is considered an obligate nasal breather until the eighth week of life ,2. CongeStenosis of this anatomic region can produce symptoms, immediately after birth, such as apnea, cyclic cyanosis, difficulty feeding, and respiratory distress -3. In leCNPAS may not be initially diagnosed, and it can be mistaken with other more common causes of neonatal respiratory distress such as choanal atresia ,7. The dCNPAS can be either present as an isolated morphogenic variant or can be associated with solitary median maxillary central incisor (SMMCI) that has been recognized as a microform of holoprosencephaly ,9. Thus,The management of CNPAS depends upon the severity of the symptoms and the patient’s clinical evolution. While mild obstruction can be treated conservatively with intranasal corticoids or nasal decongestants for a few days, a moderate or severe obstruction will require surgical intervention .This case report aims to highlight the importance of a timely diagnosis to prevent severe respiratory complications and the deleterious clinical evolution of the patient while raising awareness for other possible findings that should prompt additional investigation.We present the case of a male term newborn with irrelevant family history and uneventful gestation who was delivered in an eutocic manner in a private hospital with an adequate transition to the extra-uterine environment.The first physical examination, immediately after birth, was unremarkable, and the neonate did not have any clear dysmorphic features. During initial breastfeeding, a clinical evident nasal obstruction without hypoxemia was first noted. Physical examination revealed the impossibility to make a nasogastric probe progress through both sides of the nose. The newborn was, immediately, transferred to the neonatal intensive care unit (NICU) of a central hospital with pediatrics and otorhinolaryngology support. He was breathing spontaneously upon admission, but during his first 24 hours of life, a sudden clinical deterioration with progressive respiratory distress and hypoxemia needing orotracheal intubation ventilatory support was soon noticed. Chest radiography and laboratory workup upon NICU admission were both normal.Further imaging study through a non-contrast CT scan of the paranasal sinuses confirmed the diagnosis of pyriform sinus hypoplasia Figure , and an A later MRI performed at six days of life excluded any associated central nervous system malformations. Analytical study with endocrine assessment was performed at this time and deemed normal. Given the radiological findings and their correlation with the physical examination findings of severe stenosis of the pyriform aperture, the newborn’s family accepted to proceed with surgical repair.On the seventh day of life, the newborn was submitted to pyriform aperture permeabilization surgery via sublabial approach with bone drilling and calibration Figure , followeThe patient is currently eight months old and under ambulatory follow-up with regular medical consults in pediatrics and otorhinolaryngology. Figure Upper airway obstruction in the newborn can lead to severe respiratory distress because newborns are considered obligate nasal breathers ,2. Due tCNPAS is a rare clinical entity that must be considered in the differential diagnosis of pathologies that cause bilateral nasal obstruction, such as atresia or choanal narrowing, nasal trauma , skull base malformations , nasal tumors , and nasal hypoplasia ,6,7.The pyriform aperture (bony inlet) is the narrowest part of the normal nasal airway; thus, any small changes in its cross-sectional area can result in a significant increase in the nasal airway’s resistance . Due to Two theories are currently adopted related to the pathogenesis of CNPAS ,5,7. TheIn our clinical case, the newborn was born without any immediate respiratory symptoms, and no craniofacial dysmorphism was observed upon physical examination. The CT scan was then performed because of the clinical deterioration that occurred in the first 24 hours of life. It showed severe pyriform sinus hypoplasia that was, furthermore, confirmed with flexible endoscopy showing almost full occlusion of the pyriform aperture. CT scan was not suggestive of a triangular hard palate. Henceforth, the bony overgrowth in the nasal process of the maxilla was assumed as the major etiological contributor to our patient’s CNPAS.During the diagnostic workup of CNPAS, CT imaging also revealed an SMMCI tooth. This finding is a part of a syndrome called SMMCI, which represents a spectrum of midline facial defects and other possible congenital anomalies -11. It hAccording to the international literature, the association of CNPAS with an SMMCI occurs in 40%-75% of CNPAS cases ,9. The pEndocrine abnormalities can be present in up to 40% of the cases with hypothalamic-pituitary axis (HPA) defects such as ectopic pituitary glands, hypothalamic agenesis, pituitary hypoplasia, or pituitary aplasia ,11,12. CThe lack of the previously mentioned hormones and factors can lead to short stature, neonatal hypoglycemia, compromised stress response, and abnormal growth and development . LaboratChromosomal abnormalities such as rings 18p-, 13p-, 3p+, 5q, and 7q- have also been described in international literature as being associated with CNPAS, either in its isolated form or associated with other clinical findings -11. In oOnce the diagnosis of CNPAS is established, conservative treatment involving the use of topical nasal decongestants, humidification, and lavage feeding is the initial line of management ,14. SurgIn our patient, who registered a fast clinical deterioration with the need for orotracheal intubation for mechanical ventilation, conservative management was not an option. After confirming the diagnosis, surgical intervention was necessary to correct the severe pyriform aperture stenosis, and it went without incurrences.In an international study by Pérez et al., where a series of 19 patients (ranging from 15 days of life and seven-year-old patients) underwent CNPAS surgery, 47.6% known syndrome association was reported . The autAccording to Gonik et al.'s systematic review, the overall success of surgery with a single intervention was 85.7% . In the CNPAS is a rare cause of nasal airway obstruction, which can mimic choanal atresia in a neonate. Early identification of CNPAS is crucial to define proper management . Recognition of the normal morphology of a neonate’s nasal cavity is essential to achieve a correct and prompt diagnosis. A whole pyriform aperture of width less than 11 mm in a CT scan confirms CNPAS in a full-term neonate.In the presence of an SMMCI, considered as a microform of holoprosencephaly, physicians should proceed with additional imagiological studies to access the additional midline defects. Endocrine laboratory assessment should be performed in patients with CNPAS associated with SMMCI to exclude hypopituitary deficiency with analytical repercussions that may require hormonal therapy. Conservative or surgical management will depend upon the dimension of the pyriform’s aperture described in the CT scan and the patient’s respiratory symptoms and clinical evolution.


Antrochoanal polyps  are considered to be the most common type of choanal polyps, making up ~4–6% of all nasal polyps in the general population and ~33% of nasal polyps in the paediatric age group. Patient’s suffering from ACP range between the ages of 5 and 80 years. Only 4% of the patients are children aged < than 10 years old. Overall there is a male predominance making up ~64% of the total number of patients. We report a case of an antrochoanal polyp in a 9-year-old girl who presented with complaints of unilateral nasal obstruction, snoring and obstructive sleep apnea. The patient underwent a computed tomography scan and was managed endoscopically for excision of the polyp, as a day case procedure. Antrochoanal polyps (ACP) are considered to be amongst the most common choanal polyps , 2. TheyA 9-year-old girl attended the outpatient Otolaryngology clinic at our hospital with complaints of unilateral nasal obstruction, snoring and obstructive sleep apnea (OSA). Her symptoms started 5-month prior to presentation and had been progressively getting worse. The girl was noticed by her parents to have increased somnolence and reduced attention during the day. Her general practitioner offered intranasal corticosteroids but with no benefit.Anterior rhinoscopy revealed hypertrophied inferior turbinates with allergic nasal mucosa and increased nasal secretions with no mass seen. There was no active pus discharge from the nose. On throat examination, a large red, strawberry shaped mass was seen hanging posteriorly in the oropharynx. Flexible nasal endoscopy (FNE) of the left nostril was done, revealing a large polyp extending from the middle meatus into the choana and a clear right airway. A computerized tomography (CT) scan was done  and 2 shAn endoscopic excision of left antrochoanal polyp in the day case unit was conducted the following week.Under general anaesthesia, a large congested mass was seen extending from the left maxillary antrum into the choana .Medialization of the middle turbinate was done followed by an uncinectomy. The cystic nasal component was removed using blakesley forceps and a middle meatal antrostomy was done The solid oral component of the antrochoanal polyp was large in size The patient was observed for 4-h postoperatively in the hospital with no active complaints. She was discharged on the same day on nasal decongestants, intranasal steroids and analgesia. She returned to the clinic 1-month postoperatively with significant improvement in breathing, quality of sleep and school performance. FNE showed a patent left airway with no recurrence of disease. The pathology of the polyp was reported to be of inflammatory nature suggestive of ACP.Nasal polyps are pedunculated, benign masses that arise secondary to chronically oedematous and inflamed nasal mucosa. They can be divided into two main types depending on their site of origin—either ethmoidal occurring in the middle meatus or choanal arising from the maxillary antrum , 4. The ACP arise from the maxillay antrum extending through the maxillary ostium, to the choana and may finally prolapse into the nasopharynx , 5. ThesThe pathophysiology of ACP has been unclear for many years with several theories hypothesized to explain its development. Amongst the most significant theories is that chronic inflammation and allergies are the main trigger. An associated inflammatory anatomical alteration at the level of the ostium and middle meatus results in a change in the pressure gradient within the maxillary sinus leading to protrusion of the polyp into the nasal cavity , 7.Clinical manifestations of ACP have varied amongst populations. The most common symptom is unilateral nasal obstruction , 6. SympNasal endoscopy and radiological assessment with a CT scan are gold standard for the diagnosis of ACP , 7, 8. ADiagnostic confirmation is by histopathology of the polyp, demonstrating pseudostratified ciliated epithelium which may contain oedematous and vascular stroma. It also demonstrates an infiltration of variable inflammatory cells. The scant presence of submucous glands and epithelial goblet cells is highly suggestive of choanal polyps , 7, 9.The treatment of ACP is primarily surgical with functional endoscopic sinus surgery (FESS) being the treatment of choice with shorter recovery time with minimal risks, especially in children , 8, 10. Thorough clinical assessment of patients who present with nasal obstruction can avoid unnecessary usage of medications and identifies patients who require surgical intervention. ACP can have significant impact on a child’s daily life and school performance, therefore, prompt diagnosis and treatment are required. With the drift towards endoscopic excision of ACP, surgical risks are minimised and hospital stays are shortened. Our case proves that it is safe to perform this surgery in a day case setting in carefully selected patients.None declared.


Primary anterior abdominal wall (AAW) abscess is a rare condition that can present clinically as an abdominal disorder and baffle even the most experienced clinicians. We discuss ultrasound, CT, and MRI features of a rare case of primary anterior abdominal wall abscess that was confirmed by histopathological findings. Primary anterior abdominal wall (AAW) abscess is a rare pathology owing to the limited vascularity of the AAW. Most cases of AAW abscesses described in the literature are secondary to intra-abdominal pathology -6. We coA 78-year-old man presented to the emergency department of our hospital with generalized abdominal pain for about one month. It was associated with abdominal swelling, gradually increasing in size. The pain was aggravated by movement and not related to food intake. He had one spike of fever two weeks ago before the presentation and admission to the hospital. He also had a history of chronic cough. He was constipated and tolerating an oral diet. He was hypertensive, diabetic, with a history of coronary artery disease, on oral medication (including anti-coagulants), and compliant with the treatment. No history of nausea, vomiting, or urinary symptoms was noted.On examination, his vital signs were as follows: temperature: 36.7 degrees Celsius, heart rate: 98/minute, respiratory rate: 18/minute, blood pressure: 116/58 mm Hg, oxygen saturation: 99%. On physical examination, he was conscious and oriented. There was a midline swelling on the abdomen, measuring around 15 x 10 cm with irregular margins. The swelling was fluctuant in nature, not fixed to the skin and adherent to abdominal muscles. There were skin colour changes with erythema and bruising. The swelling was minimally tender. No discharge from the swelling or any cutaneous scar was present. With contraction of the abdominal muscles, the swelling became fixed and more pronounced. There was no cough impulse (Fothergill’s sign). Basic laboratory tests were within normal limits. He was started on intravenous ampicillin/sulbactam, 1.5 g, four times daily for three days.Ultrasound of the abdomen was done which showed a mixed solid and cystic lesion with irregular margins in the deep anterior abdominal wall in the epigastrium in midline Figure . MinimalCT scan of the abdomen with contrast demonstrated an ill-defined complex lesion with a large central hypodense component of fluid attenuation and irregular thick enhancing wall in the AAW in midline in the epigastric region located a few centimeters above umbilicus Figure . It was MRI scan of abdomen showed a large well-defined lesion in the AAW in the supraumbilical region in the midline, which is iso to hyperintense on T1 and T2-weighted images Figure . On contWound culture result came as Streptococcus viridans, He was started on intravenous ceftriaxone, twice daily, for seven days. Ultrasound-guided aspiration of the midline AAW collection was done twice. Incision and drainage of the abscess cavity found a large pus cavity. Approximately 200 mL of foul-smelling greenish-colored pus was evacuated. Adjoining muscles were eroded and necrotic tissue was evident. Posterior rectus sheath was found to be intact. Histopathology demonstrated fragments of subcutaneous tissue of abscess cavity containing acute inflammatory infiltrate with abundant neutrophils and necrotic debris. The abscess cavity was surrounded by chronic inflammatory infiltrate Figure . HistopaPrimary abscess of the AAW is very uncommon owing to its hypo vascularity. The diagnosis is established by exclusion of intra-abdominal organ involvement. Secondary anterior abdominal abscesses following colon carcinoma, acute pancreatitis, spilled gall stones, jejunal diverticulitis, tubercular liver abscess, Chron’s disease, etc. have been reported in the literature -6. Only Clinical features of AAW abscess include high spiking fever, chills, tachycardia, tachypnoea, leucocytosis, localised abdominal pain, etc. Weiner et al. reported a case of primary AAW abscess and made a literature review of secondary abdominal wall abscesses in 1975. According to the study, inflammatory process may not show the classic symptoms of inflammation clinically when the abscess is deep in the fascial planes of the abdominal wall, making the diagnosis more difficult. There may be little tenderness even if the mass is apparent and palpable. They also found that fever might be present or absent, and leucocytosis of varying levels is common .Usually, AAW mass can be due to cellulitis (in diabetic patients) or hematoma . Since our patient was on anticoagulants, there is a possibility that the patient developed an AAW hematoma following a bout of cough and due to his co-existing diabetes mellitus, it got infected from a systemic source.The radiological examination of lesions of the abdominal wall helps to identify the nature of the disease. Palpation and other forms of physical examination frequently fail to specify the exact location and extent of a lesion. Forceful or repeated manipulation of abdominal wall masses should be avoided, if possible, as this might lead to rapid spread of the disease in case of malignant masses. The hallmark characteristics of an AAW abscess, such as mottled gas appearance and air fluid level, were earlier demonstrated using multiple X-ray views. X-ray was obtained tangentially to the lesion showing the soft tissue mass lateral to the preperitoneal fat line to determine if the lesion is most likely extraperitoneal. This exposed the patient to unnecessary radiation. Weiner et al. concluded that ultrasound B mode scanning was an accurate diagnostic test that was particularly useful in demonstrating disease of the anterior abdominal wall because it had no known adverse effects .Abdominal wall imaging using ultrasound can be used to locate lesions that are clinically assumed to be within the abdominal cavity. Further investigations using CT and MRI help to assess the extent, depth of involvement, and to rule out other causes of abdominal abscess. These imaging modalities for diagnosing and draining intra-abdominal abscesses have resulted in a significant decrease in mortality. The most common cause of death is multiple organ failure. The severity of the underlying cause, a delayed diagnosis, poor drainage, and undetected foci of infection in the peritoneal cavity or elsewhere are all linked to death.Panchagnula et al. presented a rare manifestation of colon cancer in a patient with AAW abscess. It demonstrated an abscess due to the perforation of a malignant mass, as well as bacteraemia and sepsis that followed. This article underlined the need for early detection and attribution of such an atypical finding to colorectal cancer as a differential diagnosis to prevent patient mortality due to sepsis in the hospital setting. If the abscess is accompanied by bowel symptoms, colonic carcinoma should be included in the differential diagnosis .Treatment of primary AAW abscess consists of surgical incision and drainage under antibiotic cover and bed rest. Our patient was given intravenous ceftriaxone, twice daily for seven days and the abscess cavity was incised and drained. He got symptomatically better, hence discharged home and advised to follow up in surgical outpatient.With a thorough understanding of the pathophysiology of AAW abscesses and a high clinical index of suspicion, earlier detection, and apt treatment is possible which ultimately leads to lower morbidity and mortality. Diagnostic imaging like ultrasound, CT, and MRI allow non-invasive examination of the AAW, complementing the clinical evaluation of the patient.


Colorectal cancer (CRC) is the third most diagnosed malignancy in the Western world. Routine staging of CRC often identifies incidental lesions on cross-sectional imaging. Appropriate treatment is dependent on a correct histological diagnosis. Pancreatic Ductal Adenocarcinoma (PDAC) is a rarer and often devastating diagnosis for which the treatment pathway differs significantly to CRC. We report two rare cases: the first recorded case of PDAC with synchronous rectal metastasis and a case of an acute presentation with large bowel obstruction from synchronous colonic metastasis. Both cases presented a significant diagnostic challenge. The management of both cases would have been altered had the histological diagnosis been known prior to surgery. Clinicians treating CRC should be wary of incidental lesions on staging investigations as they rarely represent an occult extra-intestinal primary malignancy. Immunohistochemistry plays an important role in ascertaining the origin of gastrointestinal malignancy. Colorectal tumours are common and usually due to neoplastic transformation at various stages of the adenoma-carcinoma pathway . ColorecAn 82-year-old man with no significant medical history presented with progressive change in bowel habit and abdominal pain for 2 months. Colonoscopy 1 year prior had only revealed diverticulosis but on rectal examination at re-presentation a firm mass was palpable within the rectum. Colonoscopy was repeated and revealed an ulcerated non-obstructing low-rectal mass 3 cm in size . BiopsieRoutine staging for rectal cancer was performed. Magnetic resonance imaging (MRI) of the pelvis revealed an anterior rectal mass 7–8 cm from the anal verge with invasion into the seminal vesicles and at least three lymph nodes suspicious for metastases (cT4aN2). Computed tomography (CT) chest, abdomen and pelvis revealed enlarged nodes along the inferior mesenteric artery chain, but no definite metastatic disease was reported . A 1.4 cMultidisciplinary team (MDT) discussion involving a pancreatic surgeon deemed a primary rectal adenocarcinoma with either incidental primary malignant or metastatic lesion in the distal pancreas as the likely diagnoses. Treatment recommended was neoadjuvant long-course chemoradiotherapy for the rectal tumour followed by rectal resection and distal pancreatectomy. Following neoadjuvant therapy restaging showed a slight reduction in size of pancreatic tumour from 14 to 12.6 mm and was again reported as consistent with a metastasis from a primary rectal malignancy. A laparoscopic ultra-low Hartmann’s procedure  combined with distal pancreatectomy and splenectomy was performed.Histopathology revealed a well to moderately differentiated, 18 mm PDAC in the pancreatic tail with lymphovascular and perineural invasion. The rectal specimen revealed a 32 mm mass in the anterior rectum and microscopically demonstrated grossly intact colorectal mucosa with extensive infiltration by adenocarcinoma from the sub-serosal aspect. The tumour in the submucosa and underlying structures of rectum showed immunoreactivity for CK7 while CK20 and CDX2 were negative; however, the overlying rectal mucosa showed reactivity to CK20 and CDX2 but was negative for CK7 .A 71-year-old man with a background of cardiac disease and obstructive sleep apnoea presented to the emergency department with symptoms of large bowel obstruction. Urgent CT abdomen and pelvis revealed short segment hepatic flexure thickening and stranding with evidence of obstruction at this point. An additional soft tissue mass in the tail of the pancreas encasing the splenic vasculature was reported as suspicious for metastatic disease from a primary colonic malignancy or a synchronous primary pancreatic malignancy . Serum CDue to the presence of large bowel obstruction, the patient proceeded to an urgent laparotomy. Operative findings were of a hard sclerotic mass within the pancreatic tail involving the splenic hilum. A further cicatrizing tumour was identified at the hepatic flexure with obstruction of the ascending colon. A right hemicolectomy and distal pancreatectomy with en-bloc splenectomy was performed.Histopathology of the pancreatic resection revealed a 45 mm moderately differentiated PDAC with lymphovascular and perineural invasion. The colonic specimen revealed infiltration of metastatic PDAC from the serosal aspect into the muscularis and submucosa with focal areas infiltrating into mucosa. One of 18 mesocolic lymph nodes resected contained PDAC. Immunostaining of both tumours was positive for CK7 and negative for CK20.We report two cases of PDAC with synchronous colorectal metastases from the same institution within a 4-month period. In both instances a presumptive diagnosis of CRC with either distant metastasis to the pancreas or incidental pancreatic tumour was made, and treatment proceeded according to that recommended for CRC. If the true diagnosis was known the management of both cases could have differed significantly.CRC is common and in a patient with lower gastrointestinal symptoms, imaging and/or histology suggestive of a primary CRC this is likely to be the presumed diagnosis, even in an MDT setting with numerous CRC specialists and a pancreatic surgeon. Pancreatic lesions are metastases in only 0.5–3% of cases  and pancMetastasis of PDAC to the colon and rectum is extremely rare but may become more common with increasing incidence of PDAC. We describe the first reported case of PDAC with synchronous rectal metastasis, which was also occult. There is a single previous case report of PDAC metastasizing to the rectum , but thiThe rarity of colorectal metastasis from PDAC and lack of discerning imaging characteristics means radiological reporting is unlikely to suggest a pancreatic primary as the most likely diagnosis. Colonoscopy and biopsy should be performed when possible; the endoscopic appearance may not appear typical of a mucosal lesion such as CRC . In caseAlong with the morphological histopathological features, immunohistochemistry strongly supported the diagnosis of PDAC metastasis following resection in both cases. Immunostaining was not performed on the diagnostic biopsy in Case A which showed tubular adenoma with a focus of high grade dysplasia; if only superficial rectal mucosal biopsies were obtained it may still have stained as for a CRC primary with immunohistochemistry. Histological diagnosis was not available preoperatively for Case B. Cytokeratin’s are intermediate filament proteins found in the intracytoplasmic skeleton of epithelial cells and are useful markers for epithelial malignant proliferations , CK7 immCase A showed mildly elevated serum CA19-9 and normal serum CEA levels. Two other case reports showed this trend, one being a synchronous metastasis  and the In conclusion, we report two rare cases of synchronous colorectal metastasis from PDAC in which the diagnosis was not known until after combined colorectal and pancreatic resection. The management of both cases, but case A  in particular, would have been significantly altered had the histological diagnosis been known prior to treatment. Immunohistochemistry is an important tool in determining the primary origin of a gastrointestinal malignancy and should be performed on pre-treatment biopsy where there is clinical possibility of an alternative primary site; this is particularly critical for rectal tumours where neoadjuvant therapy may be recommended.


Acute presentations of paediatric tracheal deviation secondary to neck masses are rare. The differentials are broad and the child may be compromised. Stabilising and resuscitating the child are the primary aims.This case describes a six-year-old boy with a history of neurodevelopmental delay and progressive dysphagia, presenting with an acute history of soft food bolus impaction, significant tracheal deviation and a firm neck lump. We discuss the diagnostic difficulties of the presentation, the work-up and the management of this rare case in the setting of a university hospital in the United Kingdom, with no paediatric intensive care on site. Lateral deviation of the trachea may be a normal finding on a paediatric chest X-ray, but it could well represent an airway emergency. This requires a rapid diagnosis to establish a surgical or medical treatment plan. Differential diagnosis of pathological tracheal deviation includes tension pneumothorax, upper lobe lung collapse and cervical or mediastinal masses. Acute presentations of paediatric tracheal deviation secondary to neck masses are rare. The differentials are broad and the child may be compromised. Stabilising and resuscitating the child are the primary aims .This case describes a six-year-old boy with a history of neurodevelopmental delay and progressive dysphagia, presenting with an acute soft food bolus impaction, significant tracheal deviation and a firm neck lump.A six-year-old boy was brought to our emergency department (ED) by his mother. He had absolute dysphagia since eating meatballs earlier that day. His past medical history included birth at 25 weeks gestation with subsequent neurodevelopmental delay and associated dysphagia; the patient was normally on a pureed diet.On arrival, his pulse rate was 82 beats/minute, blood pressure was 125/90 mmHg and respiratory rate was 16/minute. A chest X-ray (CXR) was performed . There were no associated superficial skin changes. The child had intermittent respiratory distress and lots of secretions, but no stridor. Admission blood tests were normal and the CXR demonstrated superior mediastinal widening with significant tracheal deviation to the right. There were no radio-opaque foreign bodies, lung changes or signs of perforation Figure .After discussion and consent with the child’s mother, he was taken to theatre for intubation, ventilation, removal of a suspected food bolus and subsequent transfer for computed tomography (CT) to further investigate the superior mediastinal mass. He was gas-induced with sevoflurane and kept spontaneously breathing throughout. The child was intubated using a Macintosh laryngoscope and a size 5 endotracheal tube (ETT), mounted over a flexible bronchoscope. The laryngeal inlet was displaced and rotated to the right. No foreign body was found in the airway down to the carina. There were copious secretions with food particles in his upper aerodigestive tract. A rigid oesophagoscopy was performed, identifying impacted meatballs at 15 cm from the incisors. These were mobilised distally to 25 cm from the incisors, after significant debulking with graspers and attempted retrieval using graspers, forceps and a Dormia basket. In view of the distance of the food bolus and our equipment available, the remaining meatball was left in situ. The oesophageal mucosa was intact on inspection and the dentition unchanged but noted to be poor, with multiple missing teeth. No abnormality was noted in the oesophagus. Interestingly, the trachea was central and the neck lump absent on examination after the oesophagoscopy, which raised the suspicion that the clinical findings were related to the soft food bolus.A CT scan of the neck and chest with contrast was performed following tracheo-oesophagoscopy, confirming these suspicions. The neck was normal with no masses or signs of perforation Figure . HoweverThe child was transferred to the local tertiary hospital paediatric intensive care for ongoing ventilatory support and further investigations. The child was extubated the subsequent day, treated for aspiration pneumonia with a course of antibiotics, had a period of nasogastric (NG) feeding and no abnormalities were found on flexible oesophagogastroscopy performed four weeks later. A repeat CXR prior to discharge showed a midline trachea and resolution of the widened superior mediastinum Figure . A feediNeck lumps causing significant tracheal deviation are very rare in children. The tracheal deviation is caused by extraluminal pressure effects. The underlying pathology originates from structures within the neck, mediastinum or hemithoraces. It may also be a normal variant in children up to five years of age when the trachea is more flexible . This cao endoscope. Once the airway was secured and the child was ventilating well, we proceeded to manage the soft food bolus, being careful in view of a history and examination findings suggestive of a potential structural underlying cause. A variety of techniques can be used for soft food boluses, broadly classified into pushing or extraction techniques [Initial management decisions and safe transfer to theatre relied on clear communication to the parent and amongst the multidisciplinary team: anaesthetist, otolaryngologist, paediatric emergency team and theatre team. By mounting an age-appropriate ETT over a flexible bronchoscope, the airway was examined whilst intubating the child. Alternative methods include using a ventilating bronchoscope or a laryngoscope (e.g. Lindholm), with an ETT mounted on a rigid 0chniques .Our differential diagnoses included oesophageal masses, thyroid masses, thymus masses, lymphoma and vascular abnormalities. The CT with contrast was performed to exclude these. Reassuringly, the cause of the lump and tracheal deviation was the meatball food bolus, as demonstrated with post-oesophagoscopy examination and imaging Figures , 3. ThisSoft food bolus impaction can present with a neck lump and tracheal deviation in children. The child may be compromised and may have risk factors for developing soft food bolus impaction. Simultaneous assessment and resuscitation is the primary focus in an unwell child. Prompt exclusion of life-threatening differential diagnosis is paramount in a deteriorating child with tracheal deviation and a neck lump. Patient safety is the primary concern and transfer to an appropriate centre, if the patient is stable enough, should be considered. Once the airway is secured and the patient is stabilised, pushing and extraction techniques are implemented through oesophagoscopy to dislodge impacted food boluses. Further investigations including cross-sectional imaging of the neck and thorax and endoscopy may be required to exclude underlying causes. Dysphagia is a common symptom in children with neurodevelopmental delay and is best managed by the multidisciplinary team, with input from the paediatric doctors, speech and language therapy team and dietitian team.


It is important to objectively grasp the current status of automated electrocardiogram (ECG) diagnosis. This report aimed to analyze and evaluate ECG records that our members have encountered as an inappropriate diagnosis in real‐world clinical practices. Thus the results of automated diagnosis obtained by a computer‐equipped electrocardiograph have been widely applied in clinical medicine and preventive medicine. As a result of its wide range of utility and application, the results of automated ECG diagnosis are shared and utilized in medical practice in various situations by cardiologists, specialized medical staff, practitioners in other fields, and paramedical personnel. Therefore, while automated ECG diagnosis requires high accuracy, there are in fact many problems and issues still to be resolved.In order to achieve this, it is necessary to further improve the accuracy of automatic ECG interpretation, such as by utilizing artificial intelligence (AI) with an appropriate method.As a first step, it is important to objectively grasp the current status of automated ECG diagnosis.Thus this report aimed to analyze and evaluate ECG records that our members have encountered as an inappropriate diagnosis in real‐world clinical practices. We suppose that there are no substantial differences between the automated ECG device employed in this study manufactured by Fukuda Denshi Co. Ltd. , Nihon Kohden Corporation , Suzukenn Co. Ltd.  and those widely used in other countries in the automatic measurement algorithm for P, Q, R, S, T waves, and in the criteria for ECG diagnosis. However, a careful check of automatic measurement algorithm and diagnostic criteria in the individual device is required in extrapolating the present results to other devices used in other countries.2Xerox copies or electronic records of ECG data that have been judged to have an inappropriate automated diagnosis were collected. The collection period was approximately 6 months from spring to autumn 2018. The approval of the ethics committee or the equivalent organization for each member's facility was obtained in advance of the collection.A total of 1524 de‐identified ECGs were collected from 12 task force members. As shown in Table 3The 1524 collected ECG records were classified into the following six categories of inappropriate diagnosis.3.1When developing computer algorithms for automated ECG interpretation, it is possible that diagnostic criteria are sometimes a little broad because of the concern that a lack of important diagnosis may cause serious clinical problems. For example, ST level elevation because of early repolarization in young people may be a normal variant, but there are many cases where “acute myocardial infarction” is displayed as a result of the automated diagnosis. In cases where there is poor R wave progression in V1, V2, there are many examples where a diagnosis of “anterior or anteroseptal myocardial infarction” has been made because of misreading as a Q wave or QS pattern.A typical example is shown in Figure 3.2In view of the characteristics of the conventional algorithm of automated diagnosis described above, the occurrence of inappropriate diagnosis because of “under‐diagnosis” is infrequent compared with “over‐diagnosis.” However, an under‐diagnosis may cause serious problems in the clinical setting, if important abnormalities that require quick and appropriate action are missed.We have encountered several cases of atrial fibrillation that have been left untreated for many years because of diagnosis as a “normal sinus rhythm” because of low amplitude f‐wave and a relatively small irregularity in RR intervals. An example is shown in Figure 3.3Essentially, automated diagnosis is based on results of precise measurements of P, Q, R, S, T wave including each onset points, offset points, PQ, QRS, and QT intervals. If the values of these parameters are inaccurate, the final diagnosis of the ECG becomes unreliable.In particular, inaccurate measurements occur frequently at the onset of P wave and the offset of T wave because of their lenient waveforms, resulting in an inappropriate diagnosis such as “prolonged PQ (PR) interval” or “prolonged QT interval.”In addition, it is still controversial as to which leads or how many beats should be used for automatic measurements. Primary discriminant function, probabilistic logics including Bayes' theory and bifurcation theory have been proposed as mathematical approaches for measurements of ECG parameters.3.4The final diagnosis is made by combining the measured data of each waveform and interval. However, it is impossible to make an appropriate diagnosis if there is an inadequacy in the algorithm for each diagnostic process.For example, although the diagnosis of “complete atrio‐ventricular (AV) block” is made by combining information including accurate detection of P waves and QRS complexes, accurate measurement of PP and RR intervals and the confirmation of AV dissociation showing no fixed relations between P waves and QRS complexes. Furthermore, marked bradycardia with a heart rate that is less than 50/min may appear with completely regular RR intervals. However, the diagnosis of complete AV block is often missed as AV dissociation findings are not recognized. Unfortunately, many detailed algorithms for automated diagnosis including complete AV block have not been disclosed.An example is shown in Figure 3.5A detailed suggestion for terminology used in the diagnosis or abnormal ECG findings has been published in the first report of consensus documents.For example, if a slight ST‐T abnormality was observed in leads V1 or V2, “Brugada syndrome suspected” may appear as a name in automated diagnosis. As “there is a risk of sudden death” for this condition, it may result in a request for immediate consultation with a specialist, even though it was unnecessary. Furthermore, a similar ECG finding may often be described as “RSR′ pattern,” “incomplete right bundle branch block,” etc Therefore, reliable algorithms are needed for discrimination, together with explanations on their clinical significance.3.6Electrocardiogram findings with low clinical significance or unclear definition including RSR′ pattern, S1S2S3 pattern, slight axis deviation, clockwise rotation or counterclockwise rotation, etc were sometimes emphasized at medical checkup, and “attention required” or “re‐examination required” were frequently instructed.4With regard to the frequency of inappropriate automated diagnosis in clinical practice, large‐scale reliable results have not been reported until now.The reported frequency of inappropriate diagnosis differs depending on the type of institution to which the examiners belong to, that is, an institution for medical examination, a general hospital, a university hospital, or a special hospital for cardiovascular diseases. In fact, there was a huge bias by our members who submitted actual examples of inappropriate diagnosis as shown in Table Therefore, in order to estimate the approximate frequency of inappropriate automated diagnosis in the general population, consecutive 50 000 over‐read ECGs at medical checkup were investigated. Subsequently, 1108 cases were extracted as inappropriate diagnosis. The frequency of inappropriate automated diagnosis in the population was about 2.2% (1108 out of 50 000 cases), conversely, in nearly 98% of cases the automated diagnosis had been appropriate.Figure The highest frequency was “over‐diagnosis of myocardial infarction” (29.3%). In contrast, “ST‐T changes” where ischemic heart disease could not be excluded were overlooked (13.6%). It is necessary to evaluate the ST‐T changes more accurately from the standpoint of medical examination.Over‐diagnosis of left anterior hemiblock or left posterior hemiblock against slight axis deviations, and over‐diagnosis of ventricular premature contractions against supraventricular premature contractions with aberrant ventricular conduction also appeared frequently, although their clinical significance may not be important. These were thought to be because of inaccurate measurements and inadequate algorithms for the diagnosis. However, misdiagnosis of atrial fibrillation, overlooking of pacing spikes, and misdiagnosis of AV block in the medical examination must be avoided because it is likely to require a thorough checkup at a specialized cardiology institution. Fortunately, these did not appear frequently.An accurate diagnosis of atrial fibrillation is increasingly important because of recent improvements in ablation therapy performance and the introduction of newly developed direct oral anticoagulants. Accordingly, a major revision of treatment guideline in Japan has been made in recent years.5Inappropriate ECG diagnosis can be caused by poor recognition of waveforms as well as several other factors.Table In particular, “recognition of P waves” was a primary factor greatly affecting diagnostic accuracy. The P wave is small, lenient, and sometimes flat. Furthermore, it may become negative or sharpened depending on various conditions.Accurate recognition of P waves is sometimes difficult even for experts and automatic diagnosis would require a fairly high level of advanced technology. However, in order to further improve the accuracy of automatic ECG diagnosis, it is essential to further improve P wave recognition. Conventional approaches for improving the measurement accuracy of ECG signals have been introduced. Application of AIs with an appropriate method including deep neural network, etc, may result in a breakthrough for further improvements.It should be noted that studies using AI is progressing in individual applications, such as the evaluation of ischemic heart disease severity or the risk of atrial fibrillation development from the ECG findings.6Although the accuracy of automated ECG interpretation currently used in Japan and overseas is high, inappropriate diagnosis or ambiguous notations in actual clinical practice is not uncommon. However, there have been very few studies that have clarified the actual situation of inappropriate diagnosis. Inappropriate diagnosis or misdiagnosis leads to unneeded re‐examinations or unnecessary consultations with a specialist. In contrast, adequate and essential treatment may not be received as serious abnormal findings may have been overlooked. Further improvement in the accuracy of automated diagnosis is an urgent need.All authors declare no conflict of interests to this article.Masayasu Hiraoka, Takao Katoh, Naohiko Takahashi, Eiichi Watanabe, Takanori Ikeda, Yuji Kasamaki, Naokata Sumitomo, Masaaki Yashima, Norihiro Ueda, Hiroshi Morita.Yoshifusa Aizawa, Hiroshi Inoue, Toru Oe, Noboru Okamoto, Satoshi Ogawa, Ken Okumura, Itsuo Kodama, Kaoru Sugi, Teruhisa Tanabe, Kazunobu Yamauchi.Takashi Ashihara, Ritsuko Kono, Yoshinori Kobayashi, Tsuyoshi Shiga, Wataru Shimizu, Masaomi Chinushi, Mikiko Nakagawa, Kenji Nakai, Makoto Hirai, Kazutaka Aonuma, Shiro Kamakura, Yoichi Kobayashi, Shingo Sasaki, Ken Kato, Akiko Chishaki, Ayano Minoura, Yuji Murakawa, Akira Yamashina, Shigeyuki Watanabe, Naomi Izumida, Takashi Wada, Yoshiko Furukawa, Daiya Ushinohama, Hitoshi Horigome, Tsuyoshi Yamauchi, Takuya Ishiguro, Takashi Kaiami, Yusuke Kagamihara, Jiro Suto, Eiji Yamaguchi, Tatsuya Yoneyama.


First operated by Claudius Amyand in 1735. Amyand’s hernia is a rare presentation and accounts for only 1% of all inguinal hernias. Amyand’s hernia is described when the appendix is trapped within an inguinal hernia. In most cases, Amyand’s hernia is an incidental finding intra-operatively due to variable clinical manifestations, and features. Amyand’s hernia has variable theories explaining its pathophysiology besides having multiple proposed surgical approaches either via laparoscopic or open repair and with the latter being in a debate of pro and against mesh repair. We present a case of a sliding Amyand’s hernia in which the vermiform appendix and part of the cecum were adherents to the wall of a right inguinal hernial sac. Amyand’s hernia is a rare form of inguinal hernias and its presentation is widely variable. However, in most cases, it is non-complicated and is found as an incidental intraoperative finding. Many studies debate among different diagnostic and management approaches to serve a better outcome with fewer operative complications. Hernia is a protrusion of an organ or its fascia through the wall of a containing cavity . When anA 47-year-old male patient presented to our outpatient clinic complaining of 4 years duration of right groin swelling. No associated comorbidities were found. On examination inspection of the swelling, it was about 5 × 7 cm, oval in shape, soft inconsistency, with well-defined edges and smooth surface and gives an expansible impulse on coughing. On scrotal neck test, it was inguinoscrotal (funicular type). The hernia was completely reducible with no signs of obstruction or strangulation. The patient was scheduled for open hernia repair.Routine pre-operative laboratory workup was done including TLC, ESR and CRP showed no abnormalities. Intra-operatively, the hernial sac was identified and dissected from the spermatic cord down to the internal ring; upon opening the hernia sac, a vermiform appendix with its mesoappendix and part of the cecum were completely adherent to the wall of the sac The post-operative course was uneventful and the patient was discharged from the hospital on next day. Follow-up examinations and imaging showed no complications.et al. suggested that appendicitis in such cases could be due to extraluminal compression rather than intraluminal obstruction; several theories on the pathophysiology of this rare disorder have been reported however an exact cause is still unclear [Claudius Amyand was the first to operate and report a case of inguinal hernia harboring a vermiform appendix in 1735 . Most ofLosanoff and Basson classify the Amyand’s hernia into four types according to the condition of the vermiform appendix; Type 1: Normal appendix within inguinal hernia; Type 2: Acute appendicitis within inguinal hernia with no abdominal sepsis; Type 3: Acute appendicitis within the inguinal hernia, abdominal wall or peritoneal sepsis; Type 4: Acute appendicitis within an inguinal hernia, related or unrelated abdominal pathology . Rikki mImaging studies are seldom requested to diagnose inguinal hernias and diagnosis depends primarily on clinical examination especially in completely reducible uncomplicated cases. Ultrasound can detect vermiform appendix within the hernia sac . Computeet al. recommended that the presence of appendicitis and hence appendectomy should not limit the use of mesh in the repair and the best management option should be according to surgical preference [et al. and Vermillion et al. were the first to use laparoscopy in Amyand’s hernia management reporting low septic environment, better outcomes and better recovery [While many authors do not recommend mesh repair in cases where there is acute appendicitis and appendectomy is needed to be performed, others see that it is safe and it could reduce the rate of recurrence of inguinal hernia even in the presence of a septic environment . Ivashcheference . Laparosrecovery , 14. TheIn our case, the appendix and part of the cecum were adherents to the hernia sac wall. The appendix was not inflamed—type1—therefore not requiring appendectomy. Mesh repair was done without evidence of recurrence of hernia at 1-year follow-up. Green and Gutwein reported the only similar case to ours: a type 1 Amyand’s hernia to which herniotomy with hernioplasty was performed without the need of appendectomy . On the Amyand’s hernia is a rare entity and its presentation differs from case to case. The diagnosis is very difficult owed due to the uncomplicated presentations which are mostly seen in these patients. Management modalities are debatable and provide many plausible and rationally accepted pros and cons that steer the approach toward one surgical modality versus the other. However, in our opinion, open repair with mesh without the need for an appendectomy should be the definitive strategy in absence of inflammation, sepsis, provided by a clean intra-operative environment and skilled surgical expertise.


Lipomas are relatively rare in the head and neck, and sialolipoma was described as an entity about 20 years ago as lipoma that entraps salivary gland tissue. Less than 10 cases have been described in the floor of the mouth not related to the major salivary glands. Here, we report a case of sialolipoma affecting the floor of the mouth in a 47-year-old patient and reviewed the clinical, histologic, and immunohistochemical characteristics of the lesion. Lipomas of the oral cavity are relatively very rare lesions, unlike their counterparts in the trunk and extremities where they constitute the most common mesenchymal tumor. Based on many reports, lipomas constitute between 1% and 5% of all benign oral lesions , 3. A leA 47-year-old Saudi male presented at the Oral and Maxillofacial Surgery Clinic of the University Dental Hospital at King Saud University Medical City (KSUMC) for assessment of swelling of the floor of the mouth reportedly of more than 3-year duration. The swelling was noted as a slow-growing, painless mass which caused the patient minimal discomfort and slight interference with speech, mastication, and movement of the tongue. The patient reported neither a history of trauma to the floor of the mouth nor that of intense pain while eating. The medical and family histories were noncontributory, and the patient was generally in good health.Oral examination revealed the presence of a circumscribed, soft mass located on the left side of the oral cavity that was beside the tongue. The overlying mucosa was intact and appeared normal Figures . In its Imaging studies by CT scan and MRI showed an irregular mass in the area of the genioglossus muscle extending from the base of the tongue to the skin overlying the mylohyoid muscle with a density similar to the adjacent subcutaneous fat . A hypoiThe patient underwent surgical treatment under general anesthesia, and the lesion was excised through an intraoral approach. The specimen was formed of lobulated spherical masses, yellowish to pale pinkish in color, and measured 3.5 × 4.7 × 1.5 cm in its greatest dimension Figures . The masHistological examination showed an encapsulated lobulated tumor comprising mostly mature adipocytes. The lobules were separated by fibrovascular connective tissue septae in places. There were entrapped salivary gland acini and ducts scattered within the tumor mass Figures . The adiThe patient was followed up for more than 5 years, and there was no evidence of disease or recurrence.Sialolipoma was first described and reported as a series of 7 new cases in 2001 . A subseThis report is that of a 47-year-old male patient with floor of the mouth sialolipoma, which coupled with its relatively large size is unusual for this specific entity. However, this is not a particularly rare finding in sialolipoma of other intraoral sites . In geneUltrasound examination would be the first choice among imaging investigations; however, lipomas may have a wide range of sonographic appearances . The CT Citing additional evidence from immunohistochemistry and ultrastructural studies, Nagao et al.  proposedThe treatment of choice is complete surgical removal as for all lipomas. In the present case in which the tumor arose in relation to minor salivary gland tissue in the floor of the mouth, there is no justification for removing the sublingual salivary gland as long as there is no proof that the tumor originates from the latter or found to be related to it during surgery. In the present case, the tumor shelled out without any adherence to the sublingual gland. Reported cases in the literature have shown no recurrence throughout the period of follow-up ranging from 7 to 91 months , 9, 10. This report underlines that lipomas should be included in the differential diagnosis of asymptomatic, soft, mobile lesions of the floor of the mouth and that sialolipoma of the minor salivary glands could be the diagnosis found in microscopy after differentiation from relatively similar lesions such as lipoadenoma, lipomatosis, and pleomorphic adenoma with extensive lipomatosis. It may be more common than presently diagnosed as it is easy to overlook the presence of small scattered salivary gland elements. In addition, patients may be males younger than 60 years old.