Macrodactyly is a rare congenital disorder affecting the digits of hands and feet. It is often distressing for both parents and children. Surgical options range from soft tissue debulking with or without osteotomy and physeal arrest to simple or ray amputation. Although amputation is generally reserved for the severe progressive variant of macrodactyly and revision surgery, there is controversy regarding whether initial amputation or debulking is the best approach. We present a case of isolated macrodactyly of a minor toe, where debulking showed superior results. Macrodactyly is a non-hereditary congenital disorder of the limbs encountered rarely in clinical practice. It accounts for less than 1% of all extremity congenital anomalies .The term macrodactyly must be reserved for non-syndromic enlargement of digits that occurs singularly without associated limb hemihypertrophy and vascular anomalies, as seen in Proteus syndrome, neurofibromatosis, and other inherited syndromes ,3. Here,Treatment options can be broadly divided into a form of amputation and digit-preserving surgery by reduction, debulking, osteotomy, and/or physeal arrest (epiphysiodesis). Humphry (1892) first proposed amputation as a treatment option for macrodactyly, especially for cases that severely impede function. Tsuge (1967) proposed surgical preservation of the toe by shortening the digit while simultaneously maintaining both form and function. Although over the years there have been further advancements in debulking or shortening techniques, the results can be disappointing .A 12-year-old girl presented with enlargement of the fourth left toe since early childhood. The toe was gradually increasing in size over the last two years and the parents were mainly concerned about its appearance. She felt embarrassed about her left foot as it was an object of ridicule among her peers.On examination, there was a diffuse soft enlargement of the left fourth toe with the nail plate almost buried in the hypertrophied mass Figure . The toeX-ray of the affected toe showed no bony abnormality Figure . UltrasoSubsequent MRI scanning revealed a lobulated large subcutaneous homogeneous soft tissue mass of fat signal intensity with internal fibrous strands around the toe Figure . This waThe patient underwent the soft tissue debulking procedure under general anesthesia using a long dorsomedial incision to explore the medial neurovascular bundle, which was displaced by abnormal fat in the medial pulp. Removal of the skin and soft tissue was done preserving both the nerve and artery. The incision was extended laterally for further removal of abnormal fat. A physiological amount of normal-looking fat attached to the tip of the distal phalanx was retained to preserve form. Glabrous skin was trimmed adequately and the wound was closed directly without tension Figure .The postoperative course was uncomplicated with discharge from the hospital on the second postoperative day and regular follow-up in the outepatient clinic. She started walking on the day of discharge. There was a lateral deviation of the toe seen immediately postoperatively, which was corrected by a four-week-course of neighbor strapping of the third and fourth toes. The final appearance of the toe at three months was a normal anatomical appearance on the dorsum but with a slightly reduced pulp on the volar side Figure . The senThe diagnosis of macrodactyly should be solely applied to the presence of isolated enlargement of digit(s). The relative rarity of this condition and lack of a proper, standardized classification scheme has contributed to the paucity of long-term studies in the literature. An astute clinician needs to rule out other syndromic associations of macrodactyly such as Klippel-Trenaunay syndrome, Proteus syndrome, Parkes Weber syndrome, Maffucci syndrome and Ollier disease, hemihypertrophy, lymphangiomatosis, congenital lipofibromatosis, and neurofibromatosis ,3.Although the main indication for surgery in macrodactyly is cosmesis, improvement in function is relevant in more severe cases. There is controversy regarding debulking surgery versus amputation in the treatment of macrodactyly. This article aims to shed some light on this issue, but it is clear that in isolated, less severe forms like our case the debulking procedure is far better, whereas in the more extensive macrodactyly cases debulking can often produce a disappointing result.Preoperatively, there must be extensive counseling of the parents explaining the pearls and pitfalls of surgery and the overall suboptimal results that occur as a result of scarring, stiffness, and the possibility of regrowth necessitating subsequent amputation. Although the ideal time to operate is controversial, it depends on the type of macrodactyly; it is generally agreed that the progressive type should be operated earlier and likely requires further surgery. For other variants, if indicated, surgery should be performed before the child starts walking -7.Another universally accepted principle in the treatment of macrodactyly, the rapidly progressive and severe variant of disease, would be an amputation of the affected digit. The static and milder variants of macrodactyly are generally treated by watchful waiting. However, severe pain, deformity, and regrowth following surgery are relative indications for amputation ,6,7. HowFew surgical principles must be followed when planning a soft tissue debulking procedure: mid-lateral incision along the digits are preferred, when crossing creases extend as zigzag incisions onto the glabrous skin (to avoid scar contracture), nerve excision can be done as it limits nerve tissue-induced overgrowth, always debulk one side of a digit at a time with proper visualization and preservation of the digital artery, wait for at least three months to debulk the opposite half of the same digit, epiphysiodesis is recommended once the digit approaches the size of the same digit in the parent of the same sex, perform corrective osteotomy for angular deformity at the time of epiphysiodesis, and downsizing of the nail plate and bed is important to achieve a better cosmetic outcome -8.Downey et al. reported two cases of macrodactyly treated successfully with debulking combined with an island nail transfer (onycho-osteo-cutaneous flap) with good cosmesis. Kobraei et al. described reconstruction following nerve resection with nerve allograft and reported improved sensory outcomes ,10.Complications reported after surgery include wound dehiscence, infection, prolonged edema, ischemia of wound margins, sensory disturbances, recurrence/regrowth, scar contracture, joint stiffness, and keloid formation. Tolerton et al. have recommended methotrexate therapy to suppress keloid formation and to control recurrence after surgical revision for keloid ,8,11.The good result obtained in our case is because it was a less severe, non-progressive variant of macrodactyly where debulking surgery provides consistent and predictable outcomes. However, in the severe, progressive variant, the ideal choice is still a matter of debate. Some surgeons prefer amputation or shortening of the affected digit with/without free nail grafting. Tsuge procedure involves shortening and preservation of the nail unit as a pedicled nail flap done in two stages. Uemera et al. described shortening of the digit and nail preservation using a pedicled vascularized nail graft in a single stage. Hence, it would be prudent to note that the reconstruction of pain-free, mobile, and aesthetically pleasing appearance should be the goal in the treatment of foot macrodactyly .Macrodactyly is a difficult condition to treat because of its rarity in clinical practice and the overall suboptimal results of surgery. However, despite this, proper counseling for both parents and children, individualized surgical treatment, meticulous surgical planning and execution, and realistic expectations about treatment outcomes would ensure reasonably predictable outcomes with acceptable complication rates.


Mucinous adenocarcinoma of the perianal region is an oncologic rarity posing a diagnostic and therapeutic dilemma for treating oncologists. This is due to the low number of reported cases, compounded by the lack of definitive therapeutic guidelines. It accounts for 2% to 3% of all gastrointestinal malignancies and is historically known to arise from chronic anal fistulas and ischiorectal or perianal abscesses. We hereby report an interesting case of perianal mucinous adenocarcinoma in a 66-year-old male initially treated for a horseshoe abscess with complex fistulae. He presented with a 6-month history of a discharging growth in perianal region and painful defecation associated with occasional blood mixed stools. An incisional biopsy from the ulcer revealed mucinous adenocarcinoma. Contrast-enhanced computed tomography (CT) scan and magnetic resonance imaging (MRI) scan showed a localized perianal growth which involves the internal and external sphincter as well as suspicious involvement in the posterior aspect of the levator ani/puborectalis sling, which was further confirmed with colonoscopy (see figures). With no preset treatment protocol for this rare entity, he was managed with an abdominoperineal resection (APR) and vertical rectus abdominis myocutaneous flap (VRAM) tissue reconstruction. He had a turbulent postoperative period including intestinal obstruction secondary to internal herniation of bowel resulting in flap failure. The subsequent perineal wound was managed conservatively with advanced wound care and has since completely healed. Mucinous cancer is a distinct form of colorectal cancer (CRC) found in 10–15% of patients with CRC. Mucinous cancer differs from adenocarcinoma in terms of clinical and histopathological characteristics. Mucinous cancer is a distinct form of colorectal cancer (CRC) found in 10–15% of patients with CRC. Mucinous cancer differs from adenocarcinoma in terms of clinical and histopathological characteristics . SurgeryThe aim of reporting this case is to highlight its rarity, clinicopathological characteristics, the treatment provided, management of postoperative sequelae with its final outcome and subsequent follow-up.W × CC) with high T2-w mucinous content—epicentre in lower anal canal with defect and involvement of the internal and external sphincter as well as suspicious involvement in the posterior aspect of the levator ani/puborectalis sling.A 66-year-old gentleman with underlying type II diabetes mellitus was initially treated under the colorectal team for his horseshoe abscess with complex fistula. We performed an examination under anaesthesia with endoanal ultrasound and drainage using modified Hanley procedure in October 2018 which histopathological examination (HPE) of biopsies taken showed adenocarcinoma with mucinous differentiation. We proceeded with a colonoscopy in November 2018 which showed grossly normal bowel mucosa but were unable to complete the scope procedure due to tight angle at hepatic flexure. CT TAP in December showed a perineal mass with minimal extension into left gluteal subcutaneous tissue with tiny lung nodule. MRI of the pelvis showed a large mass at the intergluteal cleft size 6.8 × 5.3 × 6.3 cm  tissue reconstruction was planned by the colorectal and plastic surgery teams. HPE from the operation confirmed the diagnosis of mucinous adenocarcinoma, well differentiated with no LN involvement .The colorectal team performed an abdominal perineal resection; the patient was placed in the Lloyd Davis position, and midline laparotomy was performed. Medial and lateral mobilisation of the sigmoid colon was performed followed with proximal mobilization up to splenic flexure and distally to the pelvic flood along with total mesorectal excision. Both inferior mesenteric artery and the vein were ligated in their origin. The sigmoid colon was divided with linear stapler and brought out as an end stoma at the left iliac fossa. Perineal incision was performed with R0 en bloc resection of the tumour along with coccygectomy .The plastic surgery team continued the operation with their VRAM flap procedure. The rectus abdominis muscle was palpated and marked; an incision was made along the area of interest. The right rectus abdominis muscle was dissected from posterior, lateral, and medial portions of the rectus sheath. Perforator vessels were ligated and divided. The deep inferior epigastric artery and vein were identified. The harvested rectus flap was rotated 180 degree on its deep inferior epigastric artery pedicle and tunnelled via intraperitoneal route into the pelvis. The flap was secured by a multilayered closure using absorbable and nonabsorbable sutures .Unfortunately, the patient developed intestinal obstruction during his recovery period in the intensive care unit a few days postoperatively. The dilated loops of bowel may have compressed the pedicle leading to the nonviability and subsequent loss of the VRAM flap. Exploratory laparotomy and adhesiolysis was performed by the colorectal team, and debridement of flap tissue was performed by the plastic surgery team. Once confirmed that the excision margins were clear, the perineal wound was managed with serial negative pressure wound therapy. Subsequently, his perineal wound successfully healed by granulation and secondary intention. The patient was discharged well from the hospital.The acceptable treatment of malignancy originating from a fistula-in-ano is APR of the rectum with wide local excision of the perineal lesions –6. This For our patient, we performed a combined surgery with the plastic surgery team, in which they had performed a perineal reconstruction to facilitate wound closure and healing. Vertical rectus abdominis musculocutaneous flap was used to close the perineal wound.Unfortunately, he developed intestinal obstruction on day 5 postoperatively, which we noticed from the ceased stoma output and distended abdomen. This intestinal obstruction causing abdominal distension is what we believe led to the compromise of the flap vascularity. CT scan of the abdomen showed that there was a transition zone between the distal small bowel and the terminal ileum . Our teaSome nonsurgical discussions are also worth mentioning such as the role of additional chemotherapy/radiotherapy. This topic has been debated widely. While there is evidence that chemoradiotherapy improves survival, some authors prefer not to add chemoradiotherapy arguing that the prognosis is good after surgery alone if treated early, and that follow-up is sufficient. Others advocate neoadjuvant chemo- and radiotherapy, noting that this increases the median survival for up to 3 years . For thiPreoperative CT scans of the thorax, abdomen, and pelvis show only local disease with no involvement of the lymph node and no distant metastasis. Although using other modalities such as MRI and endorectal ultrasound also may be considered in this case, these are proven better in tissue differentiation and to asses local invasion into surrounding however endorectal ultrasound was not performed for this patient because its not feasible for the patient.Mucinous adenocarcinoma (MAC) differs from adenocarcinoma (AC) in so far as it may have originated from the same genetic cause but instead of producing less mucus, produces far more. MAC is characterized by the formation of a tumour comprised of at least 50 percent mucin. Mucin is not mucus per se but rather the glycoprotein component of mucus and other bodily fluids . It is this mucinous component that many believe helps a tumour spread more aggressively as it sees beyond the walls of the tumour to the adjacent tissue . CommonlAs such, MAC has long been considered a more aggressive form of AC and to be far less receptive to treatment.Adenocarcinomas associated with fistula-in-ano are usually of the mucinous (colloid) histological type. Our patient had a well-differentiated histological grade, pT3NX which has a good prognosis but also poor sensitivity to chemotherapy or radiotherapy. Prognosis depends on the size of the tumour, presence of metastases, and the histological grade.The manifestation of a carcinoma in chronic fistula-in-ano is possibly due to chronic inflammation although the rarity of the condition precludes any definite assumption in regard to the etiologic relationship of the fistula and carcinoma . A rectaCarcinoma is rare complication of horseshoe abscess with complex fistula. It is debatable question that fistula leading to carcinoma or carcinoma leads to fistula formation. In this case, recurrent abscess with chronic fistula-in-ano with repeated perineal sepsis has led to the formation of mucinous adenocarcinoma. So any case of chronic fistula-in-ano and complex fistulas should be subjected for histopathological study before treating, and regular follow-ups are necessary for the operated cases of fistula-in-ano to rule out the conversion of fistula into malignancy. It is necessary, therefore, to evaluate the entire gastrointestinal tract by colonoscopy to rule out any possibility of transformation of malignant cell from proximal gastrointestinal cancer as there is possibility of deposition of malignant cell in the granulation tissue of fistula arising from more proximal cancer.In regard to squamous carcinoma which responds well to radiotherapy and chemotherapy, it is not applicable to our case as neoadjuvant therapy was debatable, with questionable sensitivity to a mucinous type of adenocarcinoma of perianal region, that is why the decision to proceed with the definite procedure of abdominal perineal resection with a VRAM flap as perineal reconstruction. In addition, due to the rarity of this tumor and the lack of sufficient patients for controlled trials, there is no consensus regarding diagnosis and treatment strategies.


Inguinal hernias are common among the population and usually contain part of the omentum or small bowel, however, other unusual contents have been reported. We report a case of a patient who presented for an incarcerated left inguinal hernia and was found to have an underlying perforated sigmoid cancer.An 87 years old man presented with typical signs of an incarcerated left inguinal area. During surgery, we dissected free a herniated hard inflammatory mass until it was found to be covering an underlying perforated sigmoid tumor. Inguinal hernia is a common condition affecting many individuals, and colorectal cancer is one of the rare contents reported inside these hernias. Due to the rarity of such a presentation, the surprise encounter during groin surgery may lead to suboptimal treatment. Perforated colorectal cancer, like in our case, may signify a more aggressive disease, and hence a correct diagnosis is crucial to improve outcomes. When underlying colon cancer is suspected during hernia surgeries, proper exploration and oncologic resection might be the optimal choice.Surgeons should keep the possibility of underlying colorectal cancer in mind when operating on inguinal hernias and opt for oncologic resection of the identified tumor along with proper lymph node dissection. In most cases, inguinal hernias are manually reducible and asymptomatic, however, a small percentage can present with incarceration . DiagnosSeveral uncommon findings have been reported in inguinal hernia sacs, including malignancies, which can be classified into saccular, intrasaccular, or extrasaccular depending on their location . ColorecWe present a case where a contained perforation of an undiagnosed sigmoid colon cancer led to the incarceration of the overlying omentum within a left inguinal hernia, revealing the underlying malignancy intraoperatively.This case was reported in line with the SCARE criteria 2An 87-year-old man with a non-significant medical history presented to the emergency department complaining of a painful left inguinal bulge that started one day before presentation. He denied any other complaints. Upon presentation, the patient had a temperature of 38.9 C (102.02 F) but was hemodynamically stable. On physical examination, he had a soft abdomen with an obvious left inguinal bulging that was not manually reducible, very tender to palpation, and had erythematous overlying skin.The patient was regarded as having an irreducible left inguinal hernia and routine labs were ordered. A CT scan showed a left fat-containing strangulated inguinal hernia with extensive fat stranding. The sigmoid colon showed focal wall thickening as it passed in proximity to the inguinal hernia  Label noDuring surgery, the abdominal wall aponeurosis was dissected until reaching the hernia. A hard protruding mass was palpated through a tight posterior wall defect with surrounding inflammatory discharge  Label noOne week later, pathology reported moderately differentiated infiltrating adenocarcinoma in the resected section of the sigmoid. The surgical margins were negative, however, 7 of the 15 excised lymph nodes were positive for metastasis. The wall of the resected sigmoid showed vascular emboli and signs consistent with perforation.The patient was referred to the oncology team for treatment planning. Outpatient imaging showed multiple metastatic liver lesions. Chemotherapy was started with the FOLFOX regimen for the first five months, however, the liver metastasis increased on repeat imaging, so he was switched to the FOLFIRI regimen, along with bevacizumab. During this period, and up to the time of writing of this report, the patient did not show any signs of clinical deterioration.3Groin hernia is a very common condition and constitutes the third leading gastrointestinal cause of outpatient visits , with a Neoplastic tumors found in hernias can be classified into three groups: saccular, intrasaccular, and extrasaccular. Saccular tumors are tumors originating from the sac itself such as mesotheliomas. Extrasaccular tumors are tumors present in proximity to the hernia sac, however, they are not contained within it. The last type, intrasaccular tumors, are tumors originating from adjacent tissue and are contained within the sac itself. The latter group most often originates from colorectal cancer .Colorectal cancer most commonly presents with abdominal pain, change in bowel habits, melena, and systemic manifestations of malignancy . HoweverIt is estimated that 3 %–10 % of patients with CRC present with perforation. This presentation is associated with more advanced disease and, therefore, any delay in diagnosis and management of the underlying malignancy might worsen the prognosis . More acIn our patient, we believe that an acute contained perforation of the sigmoid tumor developed one day before the presentation, leading to severe inflammation and further herniation of the overlying omentum anteriorly through the inguinal defect with subsequent incarceration due to the evolving inflammation and ischemia. To the best of our knowledge, perforated CRC causing an incarcerated inguinal hernia has only been reported in the English literature twice ,13, makiIn the case of colon cancer perforation, current literature emphasizes on giving priority to sepsis control, especially in unstable patients, where a damage control approach is recommended. Sigmoidectomy should be carried according to the oncological principles, with or without anastomosis and/or stoma formation . The cru4One of the unusual presentations of colorectal cancer is herniation through an inguinal defect. In our case, a contained perforation of an undiagnosed sigmoid cancer lead to inflammation of the overlying mesentery causing an incarcerated inguinal hernia. The presentation is rare, and surgeons should keep the possibility of malignancy in mind while operating on inguinal hernias to avoid suboptimal treatment and delay in diagnosis. When encountered, oncologic resection of the tumor along with at least 12 lymph node excision might be the best choice.This article has no conflict of interest with any parties.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The study type is exempt from ethical approval.Written informed consent was obtained from the patient for publication of this case report and accompanying images.Writing the paper: Hasan Sabra, Mersad Alimoradi.Data collection: Etienne El-Helou, Maysaloun Kharallah, Rawan Azaki.Supervision: Tony Kfoury.1Name of the registry: N/A.2Unique identifying number or registration ID: N/A.3Hyperlink to your specific registration (must be publicly accessible and will be checked): N/A.Dr. Tony Kfoury.Editorially reviewed, not externally peer-reviewed.


A 31-year-old primagravid female at 27 weeks gestation presented to the emergency room with three weeks of progressive blurring of vision associated with intermittent headaches. Ocular examination revealed diminished visual acuity, decreased color discrimination, and constricted confrontation visual fields; optic nerve appearance was however normal. Magnetic resonance imaging of the brain and orbits revealed a large tuberculum meningioma compressing the optic chiasm and prechiasmatic optic nerves, as well as a small sphenoid wing meningioma. Given the risk of permanent vision loss, the patient underwent emergent tumor resection. Near total resection of the masses was achieved and the patient had complete resolution of her vision post-operatively. She gave birth via Caesarean section at 39 weeks. This case report describes the clinical presentations of intracranial meningiomas and discusses the challenges this condition poses in management during pregnancy. Meningiomas remain the most common type of primary central nervous system tumor found in adults and can lead to a variety of clinical manifestations depending on factors such as size, location, and extent of brain invasion . OccasioA 31-year-old primagravid female at 27 weeks gestation presented to the emergency room with a three-week history of progressive, painless bilateral blurred vision associated with intermittent headaches. Her past medical history was unremarkable. Notably, the patient had no complications with her current pregnancy, or a history of cancer or thromboembolic disease. On initial presentation, visual acuity was diminished to 20/200 in both eyes. There was no afferent pupillary defect or restriction of extraocular movements. She could only identify 4/15 color plates of the right eye and 5/15 of the left eye. Confrontation visual fields were full on the right but constricted on the left. No overt optic disc edema was observed. Given the history of pregnancy and progressive vision loss, magnetic resonance imaging (MRI) of the brain and orbits was obtained. Imaging revealed a large extra-axial mass with cystic degeneration centered within the anterior cranial fossa over the tuberculum sella extending to the level of the olfactory groove, measuring 4.5 cm × 4.0 cm × 2.5 cm in size, with mass effect compressing the optic chiasm and pre-chiasmatic optic nerves . The lesDue to variance in size and location, meningiomas can vary in clinical presentation. In most cases, they present as slow-growing tumors and are often asymptomatic. When located in the sphenoid wing, these tumors can cause unilateral visual field and visual acuity loss . When lo


Gastric glomus tumors (GGTs) are rare gastrointestinal lesions originating from the neuromuscular arterial canal or vascular lumen which share many overlapping features with other stromal lesions. Despite most cases of GGTs being benign, there is a lack of reliable histological features predictive of tumor behavior. We present a case of a 42-year-old male who was determined to have a GGT via histological diagnosis and underwent surgical wedge resection. This case highlights the importance of establishing an accurate diagnosis and the various factors that must be taken into consideration to best determine malignant potential and management options. Gastric glomus tumors (GGTs) are rare gastrointestinal lesions originating from the neuromuscular arterial canal or vascular lumen . These lA 42-year-old male with hypertension and gastroesophageal reflux disease presented with a three-month history of intermittent sharp left upper quadrant pain and multiple episodes of non-bloody, non-bilious emesis. He had no fevers, chills, hematemesis, unintentional weight changes, jaundice, or changes in stool color and consistency. He was a non-smoker and did not have a history of illicit drug or alcohol use, recent travel history, or non-steroidal anti-inflammatory drug use. His only medications were amlodipine 5 mg and omeprazole 20 mg daily. He also had no previous abdominal surgeries, and there was no significant personal or family history of malignancy.3 soft tissue mass with central calcification and vascularity along the lesser curvature of the stomach. He was admitted to the hospital and underwent esophagogastroduodenoscopy (EGD) which demonstrated a 3 cm submucosal ulcerated mass at the incisura  of the abdomen showed a 3.2 x 2.7 x 3.1 cmFurther investigation with fine-needle aspiration (FNA) of the lesion demonstrated small, round, and uniform cells intermixed with capillary-sized vessels Figure . ImmunohAlthough EUS and FNA showed small, benign cells, there were concerning risk factors for malignancy including, the patient’s young age, symptomatic presentation, ulcerated lesion appearance, size of the lesion, and neovascularity . After dThe presence of GGTs accounts for only 1% of all gastric soft tissue tumors with a majority being benign and only a few malignant cases of unknown percentage were documented in the literature . CertainThis case demonstrates that GGTs pose two challenges: (1) differentiation given the significant overlap with more common stromal and mesenchymal tumors and (2) prediction of tumor behavior given the lack of reliable histological features. It is imperative to know the immunohistochemical staining associated with glomus tumors (positive for SMA and PLAP) in order to differentiate them from other submucosal tumors due to their overlapping histological appearance ,7. DespiThe management of subepithelial lesions is largely based on the penetrating mucosal levels Figure . For lesGGTs are rare gastrointestinal lesions that are predominately benign, however, share many significant overlapping features with other common stromal and mesenchymal lesions which cause challenges in prediction of tumor behavior given the lack of reliable histological features. Due to the rarity of glomus tumors and limited published knowledge, this case reflects the importance of establishing an accurate diagnosis. Factors such as age, symptoms, tumor size, neovascularity, gross appearance, degree of pleomorphism, Ki67 staining, and mitotic activity must be taken into consideration to best determine malignant potential and management options ranging from surveillance to endoscopic or surgical intervention.


Spontaneous urethral laceration in the female without associated external trauma is an exceedingly rare phenomenon. Most cases are related to childbirth or the presence of a concomitant pelvic fracture or penetrating injury. Herein, we present a novel case of spontaneous urethral laceration in a female which happened to occur during an acute flare of her previously diagnosed ulcerative colitis. The diagnosis of spontaneous urethral laceration is rare, and underlying etiology is often uncertain. Urethral injuries are commonly secondary to well-defined traumatic events such as blunt trauma, penetrating injuries, or iatrogenic injuries including traumatic instrumentation . The oveUlcerative colitis is a chronic inflammatory condition affecting mainly the large colon from the rectum ascending proximally. The common symptoms and side effects of UC are well known and described in the medical literature including pain, diarrhea, hematochezia, and increased risk of colon cancer . Of the MA is a 49-year-old Caucasian female with a past medical history pertinent for ulcerative colitis who presented to the emergency department of our tertiary care, rural Level I trauma center for evaluation of periurethral pain and dysuria. She reported that her pain started 2 weeks prior to presentation while she was seated on the toilet straining to void. Due to symptoms of her UC, she had been experiencing frequent diarrhea. While attempting to void, she experienced a sudden onset of excruciating lower pelvic pain. Her pain persisted, and she was subsequently evaluated at an outside ED later that evening. She was diagnosed with a suspected ulcerative colitis flare given her history. Her dysuria was diagnosed as a urinary tract infection, and she was treated with empiric antibiotics. Over the next 3 days, despite adherence to antibiotic therapy, her symptoms persisted. She then presented to her primary care physician who agreed with the outside ED findings. She was additionally treated for hemorrhoids and advised to continue her antibiotic course. The following day, she had a new onset of gross hematuria for which she was again evaluated at an outside ED. Ultimately, she was admitted to the outside facility for 11 days before being discharged with a urology follow-up. After another 5 days elapsed, she was seen by her gynecologist who expressed concern for hematoma vs. abscess vs. malignancy due to an ulcerated, ecchymotic mass near the urethra. The patient was then advised to be evaluated at a tertiary care facility.On presentation to our facility, she was found to be tachycardic with HR of 116, normotensive, normothermic, and nontachypneic with oxygen saturations of 98%. She denied any fever, chills, nausea, vomiting, or other abdominal signs or symptoms. A review of her medical history revealed depression and ulcerative colitis but no previous urological history. Her previous surgical history included cholecystectomy and an OB GYN history of cesarean delivery. She was a lifetime nonsmoker and denies heavy alcohol use or any other drug use. She is allergic to Macrobid. On genitourinary exam, an ecchymotic lesion was present circumferentially around the distal urethra with ulceration inferiorly transitioning into the anterior vaginal vault see .She reported that she had initially noticed this lesion shortly after her pain started 2 weeks prior to presenting at our facility. The rest of her physical examination was without abnormality. The initial impression was that this may be due to urethral prolapse, and the urology service was consulted. After attempted examination by urology in the ED, the decision was made to perform genitourinary exam under anesthesia and cystourethroscopy due to the patient's inability to tolerate physical examination at the bedside.The examination under anesthesia revealed a firm indurated ecchymotic circumferential area around the urethra suspicious for hematoma with thrombosed urethral prolapse on the differential. Rigid cystourethroscopy was performed and showed a 1.0-1.5 cm longitudinal laceration of the urethra at the 7 o'clock position which would be the likely etiology of the hematoma see . AdditioHer urine cultures from the operative intervention revealed Pseudomonas, and she was treated with culture-directed antibiotic therapy. A CT scan with and without contrast was ordered, and the patient was discharged with plans to follow up in the urology clinic in 2 weeks  was considered given the known association with GU ulceration (Hunner's Ulcers). IC is typically associated with pelvic pain and pressure with the frequent urge to urinate in the absence of positive culture results; it is a diagnosis of exclusion. The patient had positive urine results during the initial hospitalization (Pseudomonas aeruginosa) and developed drug-resistant Pseudomonas UTI 3 months postpresentation. She has been followed for 6 months since presentation and has experienced control of her GU symptoms with treatment of her GI disease, with relapse during her recurrent Pseudomonal UTI. Also, she underwent flexible sigmoidoscopy which revealed erythematous and friable colonic mucosa, and the biopsy revealed granulation tissue and inflammatory debris.Overall, the presence of a urethral laceration or complete disruption in a female without concomitant pelvic fracture is exceedingly rare. Literature review showed only 3 cases which were all associated with trauma despite the absence of a pelvic fracture with fall from standing causing a straddle injury and MVC being the underlying causes –8. Our cSpontaneous urethral lacerations in females, defined as a urethral laceration in the absence of a clear, traumatic inciting event, are exceedingly rare as they are typically the result of significant blunt trauma causing a pelvic fracture. Above, we present a unique case of female urethral laceration not only in the absence of pelvic fracture but also without any traumatic mechanism. Based on a review of the literature, such cases are extremely rare and we could not find previous reports. The patient was also experiencing an acute flare of ulcerative colitis, and any predisposition to urothelial injury from the resultant inflammatory state remains to be elucidated. The case highlights the need for awareness that urethral laceration is possible in the female population even in the absence of pelvic trauma.


Spinal intramedullary tuberculoma (IMTB) is a rare disease that accounts for 1 to 2/100,000 patients with tuberculosis [A 19-year-old male presenting with back pain and weakness of both lower limbs, which started in the left lower limb and subsequently involved the right lower limb for three months. He had sensory impairment below T6 and hypoesthesia. He complained of urine hesitancy and a feeling of incomplete voiding of urine. He was on anti-tubercular treatment (ATT) for last two months. MRI exhibited hypointense portion on T1-weighted images. T2-weighted image also showed hypointensity at T6, which suggested for intramedullary mass. Excisional biopsy was suggestive for tuberculoma.In TB-endemic country like in Indonesia, tuberculoma should be considered as a differential diagnosis for intramedullary SOL irrespective of age or presence of extra-cranial focus of TB. MRI is the optimal tool for evaluating and diagnosing IMTB at an early stage and useful in follow-up. However, IMTB imaging characteristics may vary with immune response of individual or the stage of the tuberculoma formation . The aimThis case was reported to emphasize that early surgical decompression is required as a delay might cause damage to the spinal cord. This case also provides some evidences based data, thus contributing to the future research studies and clinical practice. This ca2A 19-year-old male came to the hospital presented with back pain and weakness of both lower limbs of three months duration. It initially started in the left lower limb and subsequently involved the right lower limb. The patient also complained of urine hesitancy and a feeling of incomplete voiding of urine, but normal defecation. He came from primary health facility with acid-fast bacilli (AFB) smear-positive sputum. He was on anti-tubercular treatment for last two months with non-reactive HIV status, but there was no significant past medical history such as cough, night sweat, or decreased body weight. He denied any recent exposure from people who had tuberculosis.On examination, his mental functions and cranial nerve were normal. All of his reflexes are brisk and had a Babinsky sign for both of the lower limbs. Both of the upper limbs power were 5/5, whereas both of the lower limbs were 2/5. He had sensory impairment below T6 corresponding to vertebrae level and altered sensation with hypoesthesia. Laboratory findings revealed negative sputum examination for tuberculosis. Plain chest X-Ray, thoracolumbal, and lateral radiographs revealed normal finding . MagnetiSurgical resection was performed through posterior approach from T6 to T8 Level. Midline durotomy was perfomed and showed a thick mass intramedullary tumour at the vertebral level of thoracal VI, VII, and VIII . The patThe patient’s lower limbs power gradually improved throughout one month after the surgery. Clinically, there was an improvement in neurological deficits and bladder dysfunction, but he still had mild hesitancy while passing urine. The patient was able to ambulate independently and resume productive activities.3MacDonnell et al. reported lower extremity weakness, back pain, bowel and bladder dysfunction, and paraesthesia as clinical presentations, which resemble to the presentations of this case [The thoracic segment is the most common site of IMTB and hematogenous spread is usually the main etiology. Most cases of intramedullary tuberculomas are subacute and present with progressive symptoms suggestive of a compressive myelopathy . IMTB prhis case . The pathis case ,14.Chang et al. and Gupta et al. showed that typical MRI characteristics of IMTB are hypo or isointense to cord in T1-weighted sequence with only an indirect sign of focal cord expansion and heterogenous intensity on T2-weigted sequence with central hypointensity and peripheral hyperintensity, which is described as target sign [MRI is the optimal tool for evaluating and diagnosing IMTB at an early stage and useful in follow-up. However, MRI is sometimes non-specific and differentiation from malignant lesions is difficult, especially in the absence of TB in other body parts such as the lungs or lymph nodes. IMTB imaging characteristics may vary with immune response of individual or the stage of the tuberculoma formation. It means typical MRI signal characteristics may not be seen in all individuals . Chang eget sign ,16. Meanget sign .Tuberculoma should be considered in the differential diagnosis of all intramedullary space-occupying lesion (SOL) irrespective of age or presence of extra-cranial focus of tuberculosis in countries endemic to tuberculosis. These patients have been reported to respond well to anti-tuberculosis drug therapy with good functional recovery and most of the reported patients underwent surgery. The aim of the surgery is to decompress the spinal cord and to achieve improvement in neurological function. However, timely surgical decompression in selected cases provide good long-term outcomes and delayed surgery might be associated with worse outcomes. Mental or focal neurological changes during the follow-up must be examined ,5.4In TB-endemic country like in Indonesia, tuberculoma should be considered as a differential diagnosis for intramedullary SOL regardless of age or evidence of systemic TB. The best treatment of intramedullary tuberculoma is still a topic of debate. Both surgical and medical treatments have given good results in different case. This case was reported to emphasize that early surgical decompression is required as a delay might cause irreversible damage to the spinal cord, leaving permanent neurological sequelae. This case could provide some evidence based data, thus contributing to the future research studies and clinical practice.There are no conflicts of interest.This study was funded independently.This study was approved by the ethical board of Hasanuddin University of Makassar. Our patients has signed terms of consent to participate in the research of this original article. The institutional ethical committee has approved the publication of this original article.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.Karya Triko Biakto: Conceptualization, Methodology, Supervision, Data curation, Formal analysis, Validation, Resources, Funding acquisition, Project administration. Jainal Arifin: Conceptualization, Supervision, Formal analysis, Validation. Gerald Wonggokusuma: Conceptualization, Supervision, Formal analysis, Supervision, Validation, Writing - Original Draft, Writing - Review & Editing, Visualization. Carlo Micelli: Conceptualization, Software, Data curation, Formal analysis, Investigation, Validation, Writing - Original Draft, Writing - Review & Editing, Visualization.No.Gerald WonggokusumaNot commissioned, externally peer-reviewed


Mycobacterium marseillense is a rare, atypical mycobacteria that has been reported to cause pulmonary and cutaneous infections; however, no previous reports of this pathogen causing tenosynovitis exist. This case reports a 73-year-old male renal transplant recipient who presented with chronic extensor tenosynovitis of the right hand caused by M marseillense. The patient was treated with radical extensor tenosynovectomy and 6 months of antibiotic treatment. A review of literature on tenosynovitis caused by atypical mycobacteria was performed. The patient successfully responded to treatment with no complications or recurrence of infection at the 18-month follow-up. Tenosynovitis of the hand caused by atypical mycobacteria is rare. A high index of suspicion is required to prevent a delay in diagnosis, particularly in immunocompromised individuals.Renal transplant recipients are at an increased risk of atypical nontuberculous mycobacterial (NTM) infections. Infections caused by NTM are uncommon in the general population, rarely occurring in immunocompetent individuals. NTM infections are an uncommon cause of tenosynovitis.  The most observed species causing NTM infections in renal transplant recipients are Mycobacterium chelonae and Mycobacterium kansasii.4 Recently, Mycobacterium marseillense has been reported as the cause of pulmonary and cutaneous infections; however, there have been no previous reports of this pathogen causing tenosynovitis.Immunocompromised patients including renal transplant recipients are at an increased risk of atypical nontuberculous mycobacterial (NTM) infections. Nontuberculous mycobacteria (NTM) are omnipresent environmental organisms, consisting of over 150 distinct species, found in soil, water, and other reservoirs.This case reports a 73-year-old man with a history of polycystic kidney disease after deceased donor kidney transplantation on tacrolimus, mycophenolic acid, and prednisone who presented to the office with a 1-year history of a progressively enlarging painless right dorsal wrist mass. He first noticed the mass a few weeks after his kidney transplant. He denied pain, weakness, or paresthesia in his right hand and wrist. His primary concern included the dorsal, painless mass. Examination revealed a soft-tissue mass 5 × 7 cm in size overlying the fourth dorsal compartment. The mass was soft, mobile, and nonpulsatile. The mass moved with flexion and extension of the digits. No neurovascular deficits were appreciated. MRI of the wrist demonstrated innumerable rice bodies within the fourth dorsal compartment with distension of the tendon sheath and a partial rupture of the extensor digitorum communis (EDC) tendon to the index finger  as previously seen on the MRI was identified and was treated with débridement alone. He tolerated the procedure well with no immediate complications and was discharged on the same day.M marseillense after 10 days with susceptibility to all tested antibiotics . Aerobic, anaerobic, and fungal cultures yielded no growth after 3 days per our institutional protocol.Histological examination of the specimen revealed synovial hyperplasia and numerous palisading granulomas with focal necrosis. Grocott methenamine silver and acid-fast bacilli (AFB) stains were performed and were negative for microorganisms. This pattern was suggestive of necrotizing granulomatous tenosynovitis. AFB culture yielded M marseillense, the infectious disease service recommended treatment with azithromycin 500 mg daily, rifabutin 300 mg daily, and ethambutol 400 mg daily to be taken for 6 months. At the 3-, 6-, 10-, and 18-month follow-ups, the incision was well-healed with no recurrence of mass (Figure Because the culture yielded s Figure . He toleM marseillense. Among renal transplant patients, the reported incidence of NTM infections is between 0.16% and 0.38%.5 Atypical NTM infections in immunocompetent patients are uncommon, and when they occur, 90% of cases commonly affect the lungs, making NTM tenosynovitis an even rarer occurrence.6 These infections often occur because of previous trauma, surgery, corticosteroid injections, or nonapparent inoculation from contaminated sources. The most commonly reported site for NTM tenosynovitis is the fourth dorsal extensor compartment because of the highest risk of penetrating injury to this area in the hand and wrist.6-8 Previous case reports demonstrate favorable outcomes with no recurrence with adequate débridement and tenosynovectomy.6-8 In the case of our patient, no report of previous trauma or penetrating injury to the hand as a potential source for inoculation was observed. A variety of fast- and slow-growing NTM species have been isolated as causes of tenosynovitis, including M chelonae, Mycobacterium malmoense, Mycobacterium abscessus and more commonly, Mycobacterium marinum and M kansasii.6-12M marseillense is a more recent discovery that until now has been described as causing infections with pulmonary, lymphatic, and cutaneous involvement.13-21To our knowledge, this is the first reported case of tenosynovitis caused by Mycobacterium marseillense was first described in 2009 as a new species belonging to the Mycobacterium avium complex phylogenetic group, originally isolated from respiratory specimens. It is a small, slow-growing, acid-fast, gram-positive bacilli showing close similarity to Mycobacterium chimaera and Mycobacterium intracellulare.16 Although NTM infections are generally uncommon in immunocompetent patients, there have been multiple reported cases of M marseillense occurring in immunocompromised patients. Therefore, one should include M marseillense in the differential diagnosis in treating individuals presenting with a slowly growing mass in the hand of an immunocompromised patient.M marseillense is slow-growing and painless, the time from onset to diagnosis can be anywhere from 6 months to 1 year. This delay in diagnosis and treatment can ultimately lead to tendinous disruption and bony involvement resulting in other complications. As noted in our patient, a partial tear of the EDC to the index finger was reported on the MRI and confirmed intraoperatively. The absence of clinical signs such as pain, fever, and erythema along with negative inflammatory markers such as a normal erythrocyte sedimentation rate and C-reactive protein make the diagnosis of M marseillense challenging.17 MRI can be helpful for diagnosis as well, showing synovial thickening around the tendons and fluid within the tendon sheaths. Rice bodies, seen on MRI or on gross intraoperative inspection may be suggestive but not pathognomonic for M marseillense as rice bodies can also be seen in other inflammatory conditions such as rheumatoid arthritis and seronegative inflammatory arthritis.18 Perioperatively, AFB cultures are essential for the diagnosis of M marseillense. Although AFB stains may be useful for immediate diagnosis of an NTM infection with >95% positive predictive value, it has been shown to have a 20% to 90% sensitivity depending on mycobacterial burden.19 Thus, current guidelines recommend continuing AFB cultures for 18 to 24 days to confirm negative growth after a negative AFB stain.20 Based on this case report, the authors propose consideration for tenosynovectomy and multidrug antimycobaterial therapy in the treatment of M marseillense in the hand and wrist.Clinical awareness of this entity is essential for diagnosis of atypical NTM tenosynovitis. Because M marseillense infection causing tenosynovitis in an immunocompromised patient. Diagnosis of tenosynovitis can be difficult because often no physical signs of acute or chronic infections exist, and erythrocyte sedimentation rate and C-reactive protein levels are typically normal. A high index of suspicion is required to prevent a delay in diagnosis and treatment, particularly in immunocompromised individuals.Tenosynovitis of the hand caused by atypical mycobacteria is rare. To our knowledge, this is the first reported case of


The presence of intra-abdominal calcification in the pediatric population can be due to a wide range of conditions. Calcification in the abdomen can be seen in normal or abnormal anatomical structures. In some patients, abnormal calcification points towards the pathology; whereas in others, calcification itself is the pathology. After a thorough history and clinical examination, point-of-care ultrasound (POCUS) would complement the assessment of acute abdominal pain, based on the list of differentials generated as per the abdominal region. The main objective of this article is to review commonly encountered causes of intra-abdominal calcifications in the pediatric population and help in clinical decision-making in a Pediatric Emergency Department.We describe a series of pediatric patients who presented to the Pediatric Emergency Department with acute abdominal pain, in whom point-of-care ultrasound helped expedite the diagnosis by identifying varying types of calcification and associated sonological findings. For children who present to the Pediatric Emergency Department with significant abdominal pain, a rapid distinction between emergencies and non-emergencies is vital to decrease morbidity and mortality.In a child presenting to the Pediatric Emergency Department with abdominal pain, POCUS and the findings of calcifications can narrow or expand the differential diagnosis when integrated with history and physical exam, to a specific anatomic structure. Integrating these findings with additional sonological findings of an underlying pathology might raise sufficient concerns in the emergency physicians to warrant further investigations for the patient in the form of a formal radiological ultrasound and assist in the patient's early disposition. The use of POCUS might also help to categorize the type of calcification to one of the four main categories of intra-abdominal calcifications, namely concretions, conduit wall calcification, cyst wall calcification, and solid mass-type calcification. POCUS used thoughtfully can give a diagnosis and expand differential diagnosis, reduce cognitive bias, and reduce physician mental load. By integrating the use of POCUS with the history and clinical findings, it will be possible to expedite the management in children who present to the Pediatric Emergency Department with acute abdominal pain. The presence of intra-abdominal calcification in the pediatric population can be due to a wide range of conditions. Calcification in the abdomen can be seen in normal or abnormal anatomical structures. In some patients, abnormal calcification points towards the pathology; whereas in others, calcification itself is the pathology . The preIntraabdominal calcifications in children can occur due to a broad spectrum of conditions ranging from benign causes to adverse conditions like malignancy. These can be broadly divided into concretions, conduit calcifications, cystic calcifications, and solid mass calcifications . ConcretIntra-abdominal calcification is detected on the ultrasound by the presence of a hyperechoic area in the abdominal organs. Calcium obstructs ultrasound more than any natural substance and results in the formation of an area of sonological opacity  called the posterior acoustic shadowing . Once thPoint-of-care ultrasound (POCUS) of the abdomen performed by emergency physicians is increasingly being used to evaluate clinical manifestations and to facilitate accurate diagnoses in the emergency departments –6. For cA 10-year-old boy was brought to the PED with fever for four days with associated poor appetite and abdominal pain for three days. He had tenderness and guarding in the right iliac fossa. The patient was clinically suspected of having acute appendicitis.A POCUS examination of the abdomen was performed using a curvilinear transducer (2–5 MHz), which showed a distended appendix (16 mm in diameter) with wall thickening  and showed hyperechoic areas in the gall bladder with well-defined posterior acoustic shadowing , which showed hyperechoic areas in the gall bladder, which appeared as low-amplitude homogeneous echoes layering on the posterior wall of the gall bladder with no posterior acoustic shadowing suggestive of gall bladder sludge Fig.  and assoA 16-year-old boy presented to the PED with severe abdominal pain for the past six hours, radiating from the left lower abdomen to the groin area. Examination of the abdomen revealed tenderness in the left lumbar area with no guarding.A POCUS examination of the abdomen performed using a curvilinear transducer (2–5 MHz), showed a hyperechoic area in the renal pelvis with pelvicalyceal dilatation Fig. . A comprA 2-year-old boy with underlying complex congenital cyanotic heart disease was brought into the PED with fever, abdominal pain, multiple episodes of non-bilious vomiting, and diarrhea for 3 days. His cardiac examination revealed a continuous murmur over the right upper sternal border. The room air oxygen saturation was 84%. The abdomen was distended and non-tender.A POCUS examination of the abdomen was performed using a curvilinear probe 2–5 MHz) to evaluate the abdominal distension and revealed no free fluid in the abdomen and no abnormally distended bowel loops. The renal POCUS showed calcification of the renal medulla in bilateral kidneys, appearing as hyperechoic areas in the renal pyramids with coarse echotexture, suggestive of suspected nephrocalcinosis , and showed a heterogenous pancreas with parenchymal calcification, cystic areas, and ductal calculus Fig. a. Dense POCUS examination of the abdomen performed by emergency physicians is increasingly being used to evaluate clinical manifestations and to facilitate accurate diagnoses in the emergency departments due to accessibility and portability of ultrasound machines –6. The aAbdominal POCUS is performed with the patient laying in the supine position. A low-frequency transducer is used to scan for focused findings  . A high-POCUS is a valuable assessment tool for abdominal pain. The finding of different types of calcifications on POCUS can narrow down the differential diagnosis. When using POCUS to assess right lower quadrant pain, thoroughly interrogate for sonological features of acute appendicitis , 17. ThePOCUS of the hepato-biliary system is done to detect gallstones and evidence of biliary obstruction or inflammation . UltrasoPOCUS can be a useful adjunct in the assessment of the kidneys and urinary tract for the presence of hydronephrosis, calculi, cysts, and abscesses . UrolithNephrocalcinosis, which is the calcification of renal parenchyma, is seen as secondary to hyperparathyroidism, renal tubular acidosis, and medullary sponge kidney . UltrasoBedside ultrasound for assessment of the pancreas, and its pathology is out of the scope of PEM POCUS as currently described in the literature . HoweverIn addition to the above causes of intra-abdominal calcifications, neuroblastoma, calcified lymph nodes, an ovarian dermoid, peri-portal calcified lymph node, fecalith, and calcified granulomas in the spleen will appear as a hyperechoic area on the POCUS imaging of the abdomen . By corrThere could be numerous pitfalls while performing POCUS abdomen in PED. The presence of abdominal pain might make the child uncooperative for the abdominal POCUS examination. Similarly, intestinal gas and fecal matter might obscure the underlying structures . CalcifiIn a child presenting to the Pediatric Emergency Department with abdominal pain, POCUS and the findings of calcifications can narrow or expand the differential diagnosis when integrated with history and physical exam, to a specific anatomic structure. Integrating these findings with additional sonological findings of an underlying pathology might raise sufficient concerns in the emergency physicians to warrant further investigations for the patient in the form of a formal radiological ultrasound and assist in the patient's early disposition. The use of POCUS might also help to categorize the type of calcification to one of the four main categories of intra-abdominal calcifications, namely concretions, conduit wall calcification, cyst wall calcification, and solid mass-type calcification. POCUS used thoughtfully can give a diagnosis and expand differential diagnosis, reduce cognitive bias, and reduce physician mental load. By integrating the use of POCUS with the history and clinical findings, it will be possible to expedite the management in children who present to the Pediatric Emergency Department with acute abdominal pain.


Background. Resplenectomy is most commonly done for the treatment of recurrent idiopathic thrombocytopenic purpura (ITP) refractory to medical management due to the regrowth of a missed accessory spleen. Case Report. A 66-year-old male had undergone open splenectomy for traumatic rupture 40 years ago. He presented with a leiomyosarcoma of his leg, which was surgically removed. When he developed metastatic disease, chemotherapy was started. He developed left upper quadrant pain, and on CT scan, a 5 cm mass compatible with a sarcoma was found between the tail of the pancreas and the left adrenal gland. During laparoscopy, dense adhesion of the omentum to the abdominal wall and the stomach from his previous splenectomy was divided. The lesser sac was opened through the gastrocolic ligament, and the splenic flexure was taken down. Superior and dorsal to the tail of the pancreas next to the left adrenal gland, the mass was identified and carefully dissected out. The vascular pedicle, which originated from a side branch of the splenic vessels at the tail of the pancreas, was stapled. The gastric fundus showed multiple nodules, and therefore, a modified sleeve gastrectomy was done; also, a 2 cm nodule in segment 5 of the liver and an omental nodule were removed. The tumors and gastrectomy specimen were placed in an endobag and removed through a periumbilical mini-incision. The patient recovered without any complications from the procedure and his LUQ pain resolved. Pathology revealed no sarcoma metastases but accessory spleens in all specimens. Discussion. Splenosis with multiple implants within the abdomen after splenectomy for trauma is a rare condition. In our patient, this seems to have been triggered by chemotherapy for his sarcoma resulting in extramedullary hemopoiesis. Laparoscopic removal of accessory spleens can be safely done. Overall rates of splenectomy have recently declined due to the development of medical therapies for many disorders, embolization of the splenic artery for some disorders , and nonoperative management of traumatic splenic laceration , 2. LapaIn traumatic splenectomy, the presence of splenules is of benefit and some surgeons implant splenic tissue into the omentum during splenectomy. In case of shattered spleen, splenic tissue dispersed within the abdomen may find access to vascularity and regrow by time. Such regrown spleens may become symptomatic causing pain, bowel obstruction, or hemorrhage –11. CT sSignificant advances in chemotherapy for sarcomas have recently been made . One of A 66-year-old male had undergone open splenectomy for abdominal blunt trauma 40 years ago. He was well and asymptomatic for almost four decades when he developed a leiomyosarcoma on his leg. This was surgically removed, and he also received radiation to the tumor region. Few months later, metastatic disease was diagnosed and he was started on chemotherapy. Imaging at this time revealed no evidence for intra-abdominal seeds. Chemotherapy with docetaxel/gemcitabine, pazopanib, eribulin, temozolomide, and doxorubicin/olaratumab was initiated, and the patient tolerated the agents well for several months when he started to complain of left upper quadrant (LUQ) pain. On CT scan, a 5 cm mass was found close to the tail of the pancreas and the left adrenal gland Figures . This waIn the OR, the patient was placed supine. A 5 mm Fios first entry port in the LUQ was used to establish pneumoperitoneum; another 5 mm port was placed in the epigastrium and a 10-12 mm trocar above the umbilicus using his old laparotomy scar. Dense adhesion of the omentum in the LUQ to the abdominal wall and the stomach was divided. Several nodules were found in the omentum, and another nodule was found in segment 5 of the liver , and it The patient recovered well from the procedure without any complications and was discharged on day 3. The LUQ pain had resolved. Pathology revealed splenic tissue in all four specimens and no evidence for leiomyosarcoma metastases Figures . The patWe present a patient with metastatic leiomyosarcoma with a new painful mass in the LUQ. On laparoscopy, multiple additional intra-abdominal lesions were found, and it was assumed that diffuse spread of the malignancy was present. To our surprise, on pathology, the masses did not reveal metastatic leiomyosarcoma but accessory spleens reflecting a diagnosis of splenosis.On a CT scan one year earlier, this condition was not present, and the LUQ nodule developed and became symptomatic only after chemotherapy including pazopanib had been initiated. The agent is used to treat various types of malignancies and has shown promising features in the treatment of soft tissue sarcoma including metastatic leiomyosarcoma , but alsSuch a condition had not been taken in consideration by our team, and we assumed metastatic leiomyosarcoma when the patient presented with LUQ pain and the lesion was found on CT scan. If an accessory spleen had been considered, a liver/spleen scan may have been beneficial prior to surgery . SurgicaRegrowth of splenic tissue causing problems is most commonly associated with recurrent ITP, and most patients are asymptomatic except for their thrombocytopenia . SplenosLaparoscopy should be the preferred approach to explore pathologies in the left upper quadrant even in patients with a history of open splenectomy. The case also emphasizes that resplenectomy can be safely done using the laparoscopic approach. It should be noted that some chemotherapies and administration of hematopoietic growth factors may trigger hypertrophy of splenic tissue spilled within the abdomen as well as growth of accessory spleens. This pathology should be considered, and special imaging such as technetium-99m (Tc-99m) sulfur colloid scintigraphy or Tc-99m heat-damaged red blood cell scintigraphy may be advisable in similar cases . These t


Penile urethral stones are very and constitutes less than 1% of the urinary tract stones and commoner in males. They are either primary or secondary. The clinical diagnosis require high index of suspicion.A 30-year-old male was complaining of penile pain, weak urinary stream and dribbling at the end of micturition for 2 months, later on he developed severe dysuria and a tender nodule over the dorsal penile surface. An attempted urethral catheterization was failed. There was no history of urethral trauma or instrumentation. Examination of genitalia revealed a normal meatus with a fistula at dorsal mid penile shaft and the urine were coming out from that opening with surrounding redness and edema with palpable firm nodule in the penile shaft. A pelvic x-ray revealed a mid-urethral radiopaque shadow, cystoscopy revealed an impacted stone in mid-bulbar urethra, attempts of stone extraction was failed. An open ventral urethral incision was made and the stone was removed, dorsal fistulectomy and repair was performed. Foley's catheter was placed and removed later after 21 days. The patient had uneventful postoperative period and the follow up was done up to 6 months with no postoperative complications.The clinical diagnosis of penile urethral stones require high index of suspicion. Management options are variable depending on impaction site, the size, and associated urethral pathologies. The fistula tract require excised and repair. Most ureteral stones are located in the posterior urethra and they are small in size, giant stones are very rare. They can be diagnosed in both pediatric and adult patients. It is commoner in males while in females it is exceedingly rare due to shorter urethra .Primary or called native urethral stones are very rare and arise de novo in the urethra, they are small in size and multiple and usually occur in patients with urethral strictures, diverticulum, infection, hypospadias, and meatal stenosis and are mostly struvite type (magnesium ammonium phosphate), but may be calcium phosphate or calcium carbonate. Secondary urethral stones are commoner than the primary ones and they usually migrate from the upper urinary tract, they are larger than the primary stones and mostly are made from calcium oxalate ,4,5.Patients usually present with dysuria, frequency, acute retention of urine, penile pain, perineal pain, hematuria, dribbling, urinary incontinence, pain during ejaculation, and painful coitus. Rarely patients may present with urethro-cutaneous fistula like the presentation in our case. Acquired fistulas are usually caused by trauma, tumors, impacted stones or foreign bodies in the urethra ,7.The clinical diagnosis require high index of suspicion, investigations are required to detect other associated stones in the upper urinary tract and other pathologies. Ultrasound is helpful to detect the site of impaction, number of stones in the lower and upper tract, and abnormalities in other parts of the urinary tract like hydronephrosis, infection, or renal stones. Plain X-rays may detect opacifications, their site and the size when the stones are radio-opaque. CT-scan and magnetic resonance imaging yield additional anatomical information and more details about the upper urinary tract that are essential for the diagnosis and to determine the management plan ,8.The management options of urethral stones are variable and depend largely on many factors like the location of stone impaction, the size of the stone, and the presence or absence of any associated urethral pathologies. Retrograde manipulation of the stones back into the urinary bladder may be suitable in some patients with small urethral stones, this is followed by litholapaxy or lithotripsy. Anterior urethral stones may be extracted by means of endoscopic removal or by ventral meatotomy when the stone is impacted in the distal shaft of penis .The work of this report case has been reported in line with the SCARE 2020 criteria .2A 30-year-old male presented to emergency hospital complaining of penile pain, weak urinary stream and dribbling at the end of micturition for 2 months duration. The pain was constant pain and aggravated with movement, urination, and sexual intercourse and relieved by rest. The color of the urine was normal during this period.In the last 2 weeks the patient developed severe dysuria along with development of a tender nodule over the dorsal surface of the penis. The patient visited the emergency department. An attempted urethral catheterization was failed at that time.There was no history of urethral trauma or urethral instrumentation. The past medical and surgical histories were negative, and the drug history were negative.The family history for any relevant genetic information and psychosocial history was negative.2.1The general examination was unremarkable. Examination of the genitalia revealed a normal urethral meatus but there was a fistula at dorsal mid penile shaft and the urine were coming out from that opening, there was surrounding redness and edema with palpable firm nodule in the penile shaft .Fig. 1Sh2.2The patient was then sent for investigations, the renal function was normal with normal complete blood count. The urinalysis showed full pus cells and red blood cells in urine. Ultrasonography of abdomen revealed normal bladder wall with normal ureters, no stones and no hydronephrosis. A pelvic x-ray revealed a mid-urethral radiopaque shadow .Fig. 2Pe2.3The patient underwent an emergency cystoscopy which revealed an impacted stone in mid bulbar urethra, attempts of stone extraction was failed, then decision was made to remove the stone by the open procedure  & 4.Fig.An open urethral incision was made at ventral surface of the penis and then removal of the stone was done along with dorsal fistulectomy and repair was performed. The patients received broad spectrum antibiotics parentally. Foley's catheter was placed and removed later after 21 days .Fig. 5An2.4The patient had uneventful postoperative period and the follow up was done up to 6 months with no postoperative complications. The patients was informed to visit the hospital if he develop any urinary symptoms like difficulty in urination, dysuria, poor stream, and difficult in initiating the urination.3Secondary or migrated urethral stones are commoner than the primary ones. Impacted urethral stones causing urethro-cutaneous fistula is an extremely rare clinical presentation and only few cases are reported in literature ,5.Primary stones don’t cause acute symptoms in the majority of patients due to their gradual and slow development, while secondary stones usually cause acute symptoms in most patients. Impacted stones in the urethra may predispose to infection and abscess formation, they may become impacted in the anterior or posterior urethra. The detailed management plan must be addressed before the start of the management .It is very important to exclude other associated pathologies that may coexist with urethral stones such as diverticula and strictures. The composition of the stones varies according to the geographical region, in the industrialized societies calcium oxalate stones or cysteine stones are predominant while in the developing countries they are mostly struvite stones or uric acid stones ,13.Urethral stones may be easily pushed back to the urinary bladder and then may be managed accordingly either by the endoscopic technique or by open cystolithotomy. Stones which are impacted in the anterior urethra may be pushed outside by gentle antegrade manual milking after generous lubrication of the urethral lumen using xylocaine gel. Sometimes and when the facilities are available stones may be managed using extra-corporeal shock wave lithotripsy, cysto-lithotripsy, electrohydraulic endourethral lithotripsy is also quite effective and less traumatic, and Holmium laser lithotripsy ,14.The fistula tract must be removed with debridement of the infected and gangrenous tissues, drainage of associated pus collections, in some patients when the amount of tissue destruction is large, flap reconstruction may be required .Follow up is recommended because some patients may develop stricture at the site of stone impaction especially when the management is delayed and there is associated infection. Strictures are best managed by urethrotomies or urethroplasties ,15.I had severe pain and had fear when the urine was coming out from the opening in the penis, I was reassured that it is a stone impacted there. After surgery I feel quite better and living my normal life back.The authors report no declarations of interest.None.Ethical approval has been exempted by my institution for reporting this case.An informed written consent was taken from the family for reporting the case and the accompanying images.Dr Shakir Saleem Jabali and Dr Ayad Ahmad Mohammed contributed to the concept of reporting the case and the patient data recording.Drafting the work, design, and revision done by Dr Ayad Ahmad Mohammed.Final approval of the work to be published was done by Dr Ayad Ahmad Mohammed and Dr Shakir Saleem Jabali.Not applicable.Dr Ayad Ahmad Mohammed is guarantor for the work.Not commissioned, externally peer-reviewed.


Primary epididymal tumors are rare. Adenomatoid tumors comprise 30% of paratesticular tumors. They are benign neoplasms originating from mesothelial cells. On the other hand, leiomyomas, originating from smooth muscle cells, are less common in paratesticular region. Leiomyoadenomatoid tumor is a benign tumor which combines the morphologic features of adenomatoid tumor and leiomyoma. To the best of knowledge, only two cases of leiomyoadenomatoid tumor in the paratesticular location have been reported in the literature. We document another such case. Tumors of the epididymis are rare and most are benign. Adenomatoid tumor is the most common tumor of the epididymis. It is a benign neoplasm that can also occur in other organs such as the uterus and fallopian tubes in female genital tract.A previously healthy 33-year-old male patient presented with left painless scrotal swelling for the past 2 years, which increased in size slightly in the past year. He had no other symptoms. Physical examination showed scrotal hard round nodule measuring around 15 mm. Routine laboratory tests including complete blood count, blood biochemistry, and urinalysis were within normal limits. Scrotal ultrasonography revealed a well-defined heterogeneous predominantly hypoechoic lesion in the left epididymis measuring 14 × 12 mm with internal vascularity. Scrotal MRI showed left extra-testicular solid mass in relation to the epididymis tail measuring 13 × 13 mm with very low T2 signal intensity .Fig. 1ScSubsequently, left scrotal exploration revealed a mass noticed related to the lower pole of the testis, likely from epididymis tail. Tunica eversion was done, and the mass was dissected from surroundings. The patient's postoperative course was uneventful. On gross examination, the specimen consisted of 13 × 13 mm tan brown firm encapsulated mass. Cut surfaces were firm, white and homogenous.Microscopically, the tumor was well-defined, composed of two components; the first predominant component comprised fascicles of spindle smooth muscle proliferation, intermingled with a second component composed of gland-like spaces lined by flat to cuboidal cells having round nuclei and conspicuous nucleoli . No nuclImmunohistochemical studies showed fascicles of spindle smooth muscle cells stained by Caldesmon and Smooth Muscle Actin (SMA). The gland-like component showed reactivity for Calretinin, Cytokeratin 7, Cytokeratin AE1/AE3 and Podoplanin, but stained negative for Cytokeratin 5/6. The two components observed; mesothelial and muscular, lead to the diagnosis of a leiomyoadenomatoid tumor.Leiomyoadenomatoid tumor is an extremely rare benign neoplasm of the epididymis that have biphasic pattern: an adenomatoid component intermixed with fascicles of smooth muscle cells. There is no agreement on the pathogenesis of this exceedingly rare entity.It is essential to mention that an exuberant growth of smooth muscle component can sometimes obscure the adenomatoid epithelial-like component, which may result in misdiagnosis of malignant tumor infiltrating a smooth muscle bundles.,This entity has also been described to occur in the female genital tract, most commonly arising from the uterus. To our knowledge, our case is the third documented epidydimal leiomyoadenomatoid tumor .4,5 The Leiomyoadenomatoid tumor is a very rare benign neoplasm of the epididymis that is characterized by having two components; adenomatoid and smooth muscle. We are presenting the third case of epididymal leiomyoadenomatoid tumor to familiarize clinicians and pathologists about this exceedingly rare entity.The authors declared no potential conflicts of interest.


A lipoma is a benign tumor, where the parenchyma is composed of adipose tissue. Lipomas comprise 0.1%–5% of all benign tumors in the oral cavity. A 43-year-old man, with a known masticatory disorder, visited the Department of Oral Surgery at our hospital because of a facial swelling. The swelling, which had worsened over 15 years, was not painful, but the patient had discomfort while eating and talking. A detailed examination revealed a smooth, elastic, soft, circular, and yellowish pink pedunculated tumor-like lesion, with a diameter of approximately 40 mm, on the right buccal mucosa. An oval-shaped neoplastic lesion with a well-defined border of 40 mm × 20 mm was noted on MRI. Based on these results, the lesion was characterized as being a benign lipoma. The tumor was resected under local anesthesia. The pedunculated tumor was excised with an electric knife, and the wound was sutured. No trismus or paresthesia was noted on the postoperative follow-up. A lipoma is a benign tumor, where the parenchyma is composed of adipose tissue. Lipomas often occur subcutaneously and present as tender, yellow masses under the submucosa. They commonly occur on the back, neck, thighs, and face, specifically the oral region. Lipomas comprise 0.1%–5% of all benign tumors in the oral cavity . The mosA 43-year-old man, with a known masticatory disorder in the oral phase and speech disorder, presented to the Department of Oral Surgery at Hironokogen Hospital due to facial swelling. The swelling, which had worsened over the course of 15 years, was not painful. The patient however experienced discomfort while eating and talking. A detailed examination revealed the presence of a smooth, elastic, soft, circular, and pedunculated tumor-like lesion, with a diameter of approximately 40 mm, on the right buccal mucosa. This resulted in swelling of the right cheek without any facial nerve palsy . We consLipomas are one of the most common types of benign, soft tissue tumors. Lipoma growth is slow, causing long periods of abnormality before diagnosis. The tumor was very large, pedunculated, and mobile; it was difficult to chew. Despite a masticatory and speech disorder, the patient described in this case report had lived with the lipoma for more than 15 years before diagnosis. The average period of noticing the presence of a lipoma to when they first seek treatment is 2 years . FactorsAn extremely large lipoma (40 mm × 20 mm) was successfully excised from the buccal mucosa of a patient 15 years after initial presentation.


Gastric duplication cysts (GDCs) are a relatively rare congenital anomalies and are mostly diagnosed in the early years of life. Herein, we report a very rare surgical case of adenocarcinoma arising from a GDC with lymph node metastasis. A 78-year-old woman was referred to our hospital because of elevated serum levels of cancer antigen (CA) 19-9. Endoscopic ultrasound, contrast fistulography, and computed tomography showed a cystic lesion communicating with the lesser curvature of the stomach. The serum levels of CA 19-9 were high, and fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) imaging demonstrated a slightly enlarged lymph node with high FDG uptake after four months. The size of the cyst was unchanged. It was diagnosed as a GDC. The enlarged lymph node was highly likely to be malignant. Hence, we performed a distal gastrectomy involving the origin of entry and whole body of the GDC with en bloc regional lymphadenectomy. The postoperative pathology was consistent with GDC with moderately differentiated adenocarcinoma and lymph node metastasis. Adjuvant chemotherapy with tegafur-gimeracil-oteracil potassium (S-1) was administered for 12 months. At present, the patient is alive, with no recurrence of the lesion even four years after the operation. GDCs in adults are rare and may predispose to malignancy. Early diagnosis and prompt surgical intervention are important for favorable outcomes. Gastric duplication cysts (GDCs) are relatively rare congenital anomalies that are mostly diagnosed in the early years of life. It is usually diagnosed before age 12. GDCs in adults are generally detected incidentally. This incidental detection is also because most cases are asymptomatic though in some cases, a symptomatic obstruction may occur. One-third of GDCs are associated with other developmental anomalies such as GDCs at other locations and duodenal diverticula . An estaHelicobacter pylori infection by a stool antigen test and subsequently underwent eradication therapy just before her visit to our hospital and it was successful. All laboratory test results were normal except the CA 19-9 concentration, which was 186.9 U/mL . The patient underwent serial diagnostic imaging examinations of the alimentary system. Upper gastrointestinal endoscopy revealed a small orifice in the lesser curvature of the lower body of the stomach  19-9 by medical check including cancer screening with no significant clinical symptoms. She had a history of hypertension, but she had no other significant past history nor family history of malignancy. She was diagnosed with a h Figure . Suctionh Figure , 1C. In h Figure . It was normal, <7 U/mL. Th Figure . The finThis report reveals that GDCs in adults are rare and may predispose to malignancy. Early diagnosis and prompt surgical intervention are important for favorable outcomes. The term ‘alimentary tract duplication’ was used by Ladd to describe congenital malformations that involve the mesenteric side of the associated alimentary tract and share a common blood supply with the native bowel . AlimentGDCs are classified as either cystic or tubular depending on their communication and contiguity with the stomach. More than 80% of gastric duplications are cystic and do not communicate with the gastric lumen. The remaining 20% comprise tubular GDCs, which are contiguous with the stomach and communicate to a certain extent with its lumen . DuplicaHelicobacter pylori infection is considered to be the cause of malignant transformation. However, almost all adenocarcinomas arising from GDCs are cystic, without communication with the gastric lumen. This case is the first report of adenocarcinoma originating from a GDC and communicating with the lesser curvature of the stomach. The patient was diagnosed with a Helicobacter pylori infection by a stool antigen test and subsequently underwent eradication therapy. Helicobacter pylori-induced gastritis may have led to gastric cancer in this case. Up to 10% of GDCs may contain ectopic pancreatic tissue, which may lead to pancreatitis that mimics a pancreatic pseudocyst. However, malignant transformation of heterotopic pancreatic tissue is extremely rare. Persistent irritation together with an increase in the intracystic pressure and oxygen deficiency may cause chronic inflammation, repeated apoptosis, and regeneration of the epithelium, which may ultimately lead to malignant transformation within the GDC [Adenocarcinoma arising from a GDC is extremely rare with only 16 cases reported in the literature (Table  the GDC . In thisGastritis cystica profunda (GCP) is one of the most important differential diagnoses. GCP usually develops in the stomach after gastrectomy and is considered to be a precancerous lesion associated with Epstein-Barr virus infection. Adenocarcinoma rarely arises from GCP in the unoperated stomach. The difference between adenocarcinoma arising from a GDC and that arising from GCP is the presence of a smooth muscle coat surrounding the lesion in case of the former . A gastrThis is the only case in which the long-term prognosis over a four-year-period has been reported after surgery for gastric cancer with lymph node metastasis arising from a GDC. In most cases, tumors without communication with the gastric lumen grow asymptomatically. By the time symptoms appear, such tumors have already invaded the surrounding organs or metastasized. Although the diagnosis of malignancy originating from a GDC is difficult, once a GDC is detected, even if it is asymptomatic, it should be removed, considering its potential for malignancy. We should be careful not to rupture the cyst wall as this will result in peritoneal carcinomatosis.In conclusion, GDCs are rare and usually present as benign lesions but may predispose to malignancy and other complications in adults. GDCs should be considered in the differentiation of cystic masses of the gastrointestinal tract. Once detected, prompt surgical intervention is important for optimal outcomes.