As the use of contrast-enhanced ultrasound (CEUS) is still relatively novel but quickly expanding, we would like to present a series of clinical cases where CEUS was used in diagnostics of pediatric patients. The presented cases include kidney trauma, non-Hodgkin’s lymphoma with secondary liver deposits, renal cortical cysts, retropharyngeal abscess, necrotizing pancreatitis, and vesicoureteral reflux. The wide range of the presented cases demonstrates CEUS' multipurpose use, which, together with its other useful attributes, especially its favorable safety profile, makes it an excellent diagnostic tool. The use of contrast media with CT and MRI is widespread, with an estimated one-third to one-half of all investigations using it -3. On thCase 1: Kidney traumaAn 11-year-old girl got injured during a fall with a bike. A day later, she started to experience abdominal pain and nausea. She has had a fever (38°C) and a sore throat for a few days before the injury. The inflammatory markers were increased [C-reactive protein (CRP) 133 mg/L]. The physical exam found tenderness in the costovertebral angle and the left upper quadrant of the abdomen. A therapy with co-amoxiclav was started. The B-mode US examination showed a hyperechogenic change in the left kidney located between the upper and middle thirds of the kidney Figure . A subcaA day after admission, the patient's inflammatory parameters began to rise (CRP 187 mg/L), and microscopic hematuria was detected. Chest radiograph and urine culture tests ruled out respiratory and urinary tract infections, and the focus of possible infection was not found. Co-amoxiclav was replaced with ceftriaxone. A control CEUS examination showed a devascularization of the upper third of the kidney parenchyma, which was confirmed by the MRI of the abdomen. Approximately 40% of the kidney parenchyma was affected, and the increase in CRP was presumed to be due to the ischemia/necrosis of the damaged part of the kidney. The patient was followed clinically and with US until discharge.In this case, CEUS showed the extent of laceration a lot more clearly than B-mode and Doppler US. The approximate area of the injury was detectable by color Doppler, but CEUS demonstrated the lesion better and helped to evaluate the degree of organ injury Figure . Renal pIt is not always possible to have an image of the kidneys as clear as in our case as the view can often be distorted by the ribs. This is especially true for the more superior positioned left kidney.We agree with Miele et al., who think that CEUS in pediatric trauma could be used as first-line in mild blunt abdominal trauma, but not for major trauma or polytrauma where CT should be performed . AdditioCase 2: Non-Hodgkin’s lymphoma and secondary liver depositsA 13-year-old boy was admitted with a short history. Six days before the arrival, he noticed a painless, fast-growing mass on the right side of the neck. For the last two days, he was experiencing night-sweating, and he became febrile. He supposedly also lost some weight in the last week. On admission, he was in no distress and without any pain. Submandibularly a firm, immovable, painless mass, the size of 4 cm x 5 cm was palpable. The skin above the change showed no signs of inflammation. An enlarged lymph node was palpable in the axilla, measuring around 2 cm x 1 cm. There was no hepato- or splenomegaly. Blood count was within normal limits. Erythrocyte sedimentation rate was slightly increased. Biochemistry exams showed increased CRP, lactate dehydrogenase (LDH), ferritin, and urate. A chest radiograph did not show any masses or enlarged lymph nodes. The US of the neck showed a 3 cm x 3 cm x 4 cm hypoechogenic change with a slightly heterogenic content Figure . The useThe abdominal US discovered two hypoechogenic changes in the liver Figure . One meaWith the use of CEUS Figure , a pathoFine-needle aspiration of the neck lesion was performed. A cytological examination with immunophenotypization was suspected for a non-Hodgkin’s lymphoma CD10+. Differential diagnosis included a Burkitt lymphoma or a diffuse large B-cell lymphoma. Later, the histological examination confirmed Burkitt lymphoma. The boy was treated according to the protocol.In this case, CEUS excluded a cystic lesion of the neck, which was not possible using Doppler US alone. It also helped to evaluate the liver lesions as definitely pathological, most likely as metastases. Different lesions show different contrast filling patterns; however, in general, malignant lesions  fill with contrast already in the arterial phase and clear out faster than the surrounding parenchyma Videos -3.Case 3: Cortical cysts and subcapsular hematoma of the kidneysA 9-year-old boy had a bicycle accident and severely hit his left flank. Because of the abdominal pain and vomiting, internal organ injury was suspected. Abdominal US examination demonstrated a 3.5 cm x 3 cm hypoechogenic, possibly septated lesion in the lower pole of the kidney, as well as up to 15 mm thick layer of hypoechogenic material subcapsularly, probably a subcapsular hematoma. The following day US again showed the subcapsular hematoma, as well as three cortical cysts; two in the left kidney, measuring 4 cm and 8 mm, and one in the right kidney, measuring 12 mm. CEUS was performed for better delineation of the changes, and it showed homogenous parenchymal enhancement with a focal 8 mm large defect in the lower pole of parenchyma, through which the larger cyst communicated with the subcapsular fluid collection (most likely a mixture of hematoma and cystic fluid) Figure . It alsoThe boy was hemodynamically stable, without micro- or macrohematuria, and was thus treated conservatively. Follow-up was done using US.The CEUS helped us to delineate the parenchymal defect very well. It also showed a lack of active extravasation at the site of injury and the communication of the cyst with the subcapsular hematoma. Volume averaging used by CT can hide some thin septae, which may be seen with US and show enhancement with CEUS. As the evaluation of the malignant potential of the renal cysts is heavily influenced by the presence or absence of septae (Bosniak classification), CEUS can be very helpful in detecting early changes  Video 44.Case 4: Retropharyngeal abscessAn 8-month-old boy was treated for an abscessed lymph node of the neck, which was incised. Staphylococcus aureus was isolated, and he received the appropriate antibiotic therapy, after which he was asymptomatic and discharged home. His parents returned a month later after noticing the boy's tachypnea (40-50/min) and stridor. The physical exam revealed diffuse rales from the upper respiratory tract, without an obstructive component. Inflammatory parameters were elevated -- , but without neutrophilia or a left shift. He was afebrile. There was no palpable lymphadenopathy. Generally, the boy was lively and had a good appetite. Chest radiograph and abdominal US did not show signs of an infection. When searching for a possible focus of the infection an US examination of the neck revealed a partly cystic partly solid change, with the size of 4.5 cm x 3 cm x 5 cm to the left of the trachea Figure .After contrast application, the finding enhanced peripherally -- a 1 cm thick band of tissue became apparent Figure .An MRI of the neck was performed and it confirmed a retropharyngeal abscess, which was spreading downwards along the prevertebral muscle Figure .Due to poor access to the abscess for an incision , the ENT physicians decided for a conservative approach with a prolonged seven-week antibiotic treatment. The therapy led to a complete regression of the abscess and resolution of the breathing problems. The changes regressed quickly and were no longer visible with US; thus, MRI was used for the subsequent following. Due to two severe infections in such a short period, the immunological tests were done but were negative.In this case, the visualization of the neck was hindered because of the patient's constitution and short neck. Therefore, we were only able to obtain axial images of the neck region. Nevertheless, the US was useful in detecting the clinically unexpected lesion of the neck. CEUS helped to narrow down the diagnosis, but the final diagnosis was made by MRI, which then had to be used for follow-up due to the lesion becoming too small for visualization on the US Video .Case 5: Necrotizing pancreatitisA 3-year-old girl with many comorbidities (including Miller-Dieker syndrome and West syndrome) was admitted to the department because of problems with the passage of food through a percutaneous endoscopic gastrostomy (PEG) tube. The parents reported that any food given via PEG tube remained in the stomach until the next feeding attempt. She was also in pain. The US examination detected a paralytic ileus and free fluid in the abdomen. The inflammatory parameters and serum amylase and lipase were significantly increased . A CT scan showed an edematous pancreas, with an absence of focal opacification in the pancreatic tail, as well as inflamed peripancreatic fat, reactive mesenteric lymph nodes, and thickening of the adjacent stomach wall  and was fed parenterally. Antibiotic therapy was started. She was then followed with US, which showed a relatively clear image of the pancreas, but the injured area was poorly contrasted from the healthy parenchyma. With the use of CEUS, we managed to show a 14 mm perfusion defect in the tail of the pancreas Figure , so we cAfter the antibiotic therapy, the girl improved, but two days after therapy completion, the inflammatory parameters increased again. This time, the US showed a peripancreatic fluid collection, but CEUS showed no additional findings in the pancreatic parenchyma. The antibiotic treatment was repeated, and this time she recovered uneventfully. The peripancreatic fluid collection disappeared spontaneously over a two-week period. A few months after discharge, the patient had an additional subclinical flare-up of amylase and lipase, which normalized after being kept on NPO again. This time, magnetic resonance cholangiopancreatography (MRCP) was done but it showed no abnormalities in pancreatic duct, common bile duct, or gallbladder.The US was able to replace CT in this patient as the follow-up method because it was possible to visualize the pancreas very well in every examination. This was helped by the patient having a PEG tube, which allowed us to fill the stomach with fluid and remove any excess air. Usually, due to its retroperitoneal position, visualization of the pancreas can be very difficult. CEUS was useful in delineating the necrotic area of pancreatic parenchyma and was thus also useful in the follow-up of the patient Video .Case 6: Vesicoureteral refluxA pre-natal US examination of a baby girl showed hydronephrosis, megaureter, and expanded pyelo-ureteral connection of the right kidney. Postnatally it was clear that there was a duplicated collecting system with two ureters of the right kidney, dilatation of the upper pole, and dilatation of the second ureter, which drained into the bladder with ureterocele. Scintigraphy showed isotope buildup in the upper third of the kidney. Kidney function tests were within normal values. Prophylaxis with cefuroxime (1.25 mL in the evenings) against potential urinary tract infections (UTIs) was started. Contrast-enhanced voiding urosonography (ceVUS) showed evidence of fourth-degree vesicoureteral reflux (VUR) into the expanded ureter and the collecting system of the lower pole of the right kidney. Deflux surgery was performed (application of Vantris) and the ureterocele was incised, but not completely removed, as the surgeon felt it was too close to urethra and that complete removal might compromise the girl's continence. During the surgery, it was seen that the duplicated ureter drained either into the neck of the urinary bladder or into the proximal part of the urethra (where the ureterocele was). At the postsurgical examination, ceVUS showed third-degree reflux into the collecting system of the lower pole of the kidney. There was no reflux into the upper pole of the kidney. As the girl had a known duplication of the ureters on the right side, we performed cyclic ceVUS with two additional cycles and managed to show reflux also on the left side as well as duplication of at least part of the left ureter.The VUR is so far the only indication where US contrast is officially approved in the pediatric population in Europe, and its use is not off-label. A urinary catheter is inserted, and a contrast is injected. The kidneys, ureters, and bladder are then scanned sequentially before, during, and after voiding, and in case of VUR, a retrograde filling of the ureters and pyelon with microbubbles is observed. With a sensitivity and specificity of around 90%, ceVUS has been shown to be as efficient as voiding cystourethrography (VCUG) for the diagnosis of VUR. However, since with ceVUS, we avoid radiation exposure, it is seen as a preferable option when its use is possible. If the child is noncooperative, the intravesical pressure may rise and the contrast agent is destroyed quickly. Some children may also have problems with the postponed voiding phase. In these cases, VCUG may still have to be used -12 . The ofThe CEUS' main advantages are the avoidance of unnecessary radiation, anesthesia or restriction, as well as real-time demonstration of vascularization of pathological processes, and higher sensitivity in detecting vascularization [compared to contrast-enhanced CT (CECT) and contrast-enhanced magnetic resonance (CEMR)]. Additionally, the contrast agents used are proven to be at least as safe as the gadolinium-based contrasts and significantly safer than radiopaque contrasts . Due to Owing to the lack of radiation exposure, CEUS is extremely valuable for patient follow-up, as it allows us to perform frequent check-ups. In trauma patients, it cannot be used as a standalone diagnostic method for parenchymal injuries, as it is usually not sensitive enough  and can miss important details. However, it can be very useful for triage and guiding us in the right direction at the beginning of the investigations. All in all, though not without shortcomings, CEUS is an excellent tool in many cases, and its use will undoubtedly continue to grow.


Recent improvements in fetal therapies and perinatal care and the multidisciplinary involvement in fetal medicine have increased the demand for more accurate prenatal diagnosis. Fetal Magnetic Resonance Imaging (MRI) is a complementary imaging technique for the assessment of thoraco-abdominal anomalies for which Ultrasonography (US) is not conclusive. It is indicated in selected situations to precise the prognosis in diaphragmatic hernia, to characterise the nature and extension of a pulmonary malformation, to locate a bowel atresia or to better depict an abdominal cystic lesion or tumoural extension. It has become a mandatory complementary diagnostic tool and improves the management of the fetuses and newborns. Imaging modalities are essential in fetal medicine. The routine follow-up of fetuses is achieved by Ultrasonography (US), which is and remains the first level screening technique.Recent improvements in fetal therapies (fetoscopic surgery) and in perinatal care have increased the demand for more accurate prenatal diagnosis. Therefore, complementary imaging is mandatory in various clinical situations either to clarify an US diagnosis or to precise the anatomy and extension of a lesion. Fetal magnetic resonance imaging (fMRI) is performed in selected indications following US . Undoubt23In the following pages, we will precise in which fetal thoraco-abdominal anomalies MRI has an additional value in prenatal diagnosis.Congenital chest malformations range from small and asymptomatic entities to large space occupying masses that require immediate neonatal respiratory support and surgical treatment. Obviously, US enables a first detection of the lesion and pejorative signs when applicable. fMRI thanks to its multiplanar capacity, high anatomical definition and optimal tissue characterisation is a useful complementary imaging tool.CDH concerns one out of 4000 live births. US allows to establish the diagnosis but recent care advances  require more accurate information regarding the severity of the malformation. The prognosis of such a malformation when isolated relies on its side and location , time of discovery, precise content (position of the liver) and residual lung volume. In this context, fMRI is a good complementary tool that helps in better characterizing the anomaly . Thanks CLM include congenital cystic adenomatoid malformation, sequestration, bronchial atresia and bronchogenic cyst. It encompasses a large spectrum of lesions generated by airway obstruction in utero. The type of malformation depends on the timing of the obstruction, its level and severity. There is a considerable debate surrounding the classification of these lung lesions currently defined as congenital pulmonary airway malformations (CPAM) representing a wide continuum of lung anomalies. Additionally, the lesions are often mixed rendering the prenatal diagnosis difficult.CCAM is the most common congenital lung malformation and accounts for 30 to 40% of all congenital diseases. They correspond to abnormal cystic lung tissue connected to the bronchial tree. They are classified (Stocker’s classification) according to the size of the cysts. These lesions are easily diagnosed by US because of their typical hyperechoic pattern including cysts. The role of fMRI is first to evaluate their volume compared to the normal lung , second BPS is a developmental lung malformation that accounts for 6% of congenital thoracic lesions. It has a systemic arterial supply and is disconnected from the bronchial tree . The detBA sequence arises from interruption of the development of the airways and can occur at any level of the bronchial tree. It is hypothesized that BA results from an ischemic insult. On US, it appears like a non-specific hyperechogenic distended lung. fMRI may help in depicting the normal bronchovascular dichotomisation and the central branching mucocele appearing hypersignal on T2-weighted sequences. In cases affecting the upper lobes, an extrinsic compression can be better delineated by fMRI.BC is a distended blind bronchus resulting from abnormal budding of the ventral foregut. It is typically developed in the mediastinum (near the carina) less commonly it can develop in the lung parenchyma. It can be compressive on the mediastinum and airways leading to obstructive distal pulmonary distension. It usually appears like a mediastinal simple cyst. A differential diagnosis with other cystic lesions  has to me made for more complex lesions (haemorrhagic content). fMRI helps in depicting the lesion itself and the associated lung anomalies  due to bronchial compression.To summarize, in foetuses affected by CLM, fMRI may precise the diagnosis (according to their aspects and vascularisation), precise their extension and consequently differentiate between lesions that are more likely to cause fetal or neonatal distress requiring urgent surgical intervention. However, the overall rate of characterization is low because of a high percentage of mixed lesions and frequent non-specific imaging findings 12.Abdominal anomalies concern the digestive, the urinary or the genital tract and sometimes malformations involving both systems like in urogenital sinus or cloacal dysgenesis. Abdominal tumours are not rare during fetal life. Again, the role of fMRI is to better characterize these lesions and precise their extension and impact on the development of adjacent organs.EA results from an incomplete division of the foregut into the airways anteriorly and the digestive tract posteriorly. It is encountered in 1 out of 3500 live births. The sensitivity of prenatal diagnosis is still quite poor (40%). Various types are described and the most common type is the type III with a blind proximal pouch and a distal fistula between the airways and the distal esophagus leading to indirect signs . The visualisation of the blind proximal pouch, which is pathognomonic, may be difficult. fMRI, thanks to the high contrast resolution of T2-weighted sequences and dynamic acquisitions focused on the midline may help to establish the diagnosis by the visualisation of the distended proximal pouch when the fetus swallows and even to precise the length of the gap between the proximal and distal part of the oesophagus 14 which Digestive tract atresia occurs in 1 out of 4000 births, it is thought to result from ischemic insult . It appe17Pelvic cystic lesions are frequently encountered during fetal life. They may correspond to duplication cysts, ovarian cysts in female fetuses, ano-rectal malformations or genito-urinary sinus… and the list is not comprehensive. In cases depicted by US, fMRI may help for the differential diagnosis by a better characterisation of the cyst content and a better depiction of the digestive tract calibre and position .Abnormal progression of the uro-rectal septum leads to incomplete separation of the digestive from the uro-genital tracts. It occurs in 1 out of 2500 to 5000 live births. In some rare cases the urinary and genital tracts are both abnormal leading to various forms of urogenital sinus. In other situations, the malformation involves the digestive tract potentially leading to a simple ano-rectal malformation or a more complex cloacal dysgenesis. These anomalies must be differentiated because their prognosis is very different. fMRI is useful to clarify the anatomy of the malformation by differentiating the urinary from de digestive tract 21. fMRI Ovarian cysts are the most common pelvic cystic masses encountered in female fetuses. They occur in 1 out of 2600 pregnancies. These cysts classically appear in the third trimester in relation with the hormonal environment associated with the gestation. Most appear as a unilocular thin walled cystic structure with anechoic content. Generally, no complementary imaging is requested but complications like bleeding or torsion can occur in utero leading to an increased size and modified content. In such complex cases, fMRI may help for the characterization of the cyst thanks to specific signal of its haemorrhagic content Figure  23]..23].SCT is the most common location for teratoma in fetuses. The tumour arises from the anterior part of the coccyx and extends externally or inside the pelvis and abdomen. Most fetal teratomas are benign; consequently, their prognosis relies mainly on their intra pelvic/abdominal extension and spinal canal invasion . TherefoLM are composed of distended cystic lymphatic channels. They are mainly located in the cervico-facial and mediastinal regions but some can develop in the chest or abdomen. They appear as mainly cystic and septated masses. The cystic components appear anechoic but sometimes they display an echogenic content suggesting intracystic haemorrhage. These lesions typically infiltrate or displace the surrounding organs. Again, the main role of fMRI is to precise the extension of the lesion . In thorIn utero, a megabladder is defined in the second and third trimester as a bladder with a long axis on a midsagittal US scan of more than 30 and 50 mm respectively. Megabladders can be obstructive , secondary to reflux or dysplastic. The megabladder is an easy prenatal diagnosis but the etiology is sometimes difficult to establish in utero. fMRI may help in the visualisation of the urethra in case of thickened bladder wall with suspected urethral valve, it may also more easily than US exclude or confirm a microcolon in case of suspected megabladder, microcolon intestinal hypoperistalsis syndrome or cloacal dysgenesis (see above) . In casefMRI is a complementary imaging technique for the assessment of thoraco-abdominal anomalies for which US is not conclusive. It helps to determine the nature of a lesion, extension of tumours, or precise the anatomy in case of complex malformations. It is an important support to diagnosis and consequently to prognosis. Therefore, it allows a better depiction of malformations and anomalies with a better comprehension by the multidisciplinary staff. Consequently, it has become a mandatory complementary imaging technique in selected indications and improves the prenatal and neonatal management of the fetuses and newborns.


A colonic perineurioma is often considered a benign cousin to a colonic polyp. However, in the submucosal type of perineurioma, it is important to rule out the malignant gastrointestinal stromal tumor (GIST). Alternatively, in the BRAF-positive serrated types of perineuriomas, surveillance is equivalent to intervals designated to serrated polyps due to a similar malignant potential. These versions serve as reminders that colonic perineuriomas are not to be disregarded. This case examines the epidemiology, classification, clinical features, diagnosis, treatment, and most importantly, the differential diagnoses of a colonic perineurioma. Heeding the malignant potential of its variants and possible differentials influences the course of treatment, recurrence, and surveillance which is vital for a gastroenterologist.A 35-year-old Caucasian female presented with sharp, non-radiating, epigastric abdominal pain associated with alternating constipation and diarrhea. A computed tomography (CT) scan demonstrated a thickened stomach wall and diverticulitis at the splenic flexure. Vital signs and labs were within normal limits. Colonoscopy showed a unusual looking polyp in the transverse colon Figure .Narrow band imaging (NBI) did not demonstrate typical vessel appearance or polyp pit pattern Figure . No otheColonic perineuriomas are rare benign mucosal lesions with a serrated or hyperplastic architecture composed of perineural cells. They are usually discovered incidentally during screening colonoscopies. With an incidence of 0.1% to 0.46%, they are found distal to the splenic flexure in the sigmoid colon and the rectum mostly as polyps and rarely as solitary masses. No clear pathogenesis has been found. These polyps are considered benign reactive processes; however, the serrated variant confers malignant potential from BRAF mutations resulting in fibroblast differentiation and proliferation [Mucosal perineuriomas are asymptomatic in comparison to the submucosal or intramural masses. Morphology alone can lead to strong suspicion of perineurioma, but the expression of at least two perineural markers, such as glucose transporter-1 (GLUT-1), Claudin-1, and epithelial membrane antigen (EMA), are generally required to confirm diagnosis . Even thDifferential diagnosis is dependent on the origin of the lesion: intramucosal or submucosal. Neurofibroma, ganglioneuroma, schwannoma, neuroma, Schwann cell hamartoma, benign epithelioid nerve sheath tumor, and leiomyoma of the muscularis mucosae should be considered for intramucosal colorectal perineuriomas. For submucosal perineuriomas, schwannomas and the only malignant differential, a gastrointestinal stromal tumor (GIST) must be excluded . ColorecA colonic perineurioma is considered a benign process. However, it is vital for gastroenterologists and patients to be aware of the malignant potential in BRAF-positive serrated variants and to rule out malignant differentials, such as GISTs, in submucosal perineuriomas.


Esophageal and gastric tumors are very lethal malignancies. Their most common histology is adenocarcinoma for more than 90% of all gastroesophageal tumors.Herein, we report a case of endoscopic submucosal dissection for gastroesophageal junction carcinoma, the first of its kind to be performed in the Kingdom of Saudi Arabia for a 72-year-old patient, who was found to have a gastroesophageal junction mass extending to the cardia. Complete excision was performed via endoscopic submucosal dissection. There were no complications in the postoperative period and the patient was discharged in good condition.Over time, the management of gastroesophageal junction carcinoma has evolved along with the surgical approach. Endoscopic submucosal dissection preserves the anatomical structures and not only leads to a better quality of life, but also decreases morbidity and mortality. The procedure shows favorable results for early-stage gastroesophageal junction carcinoma as a treatment option with excellent en bloc resection rates.Endoscopic submucosal dissection is an acceptable management for T1 gastroesophageal junction carcinoma Locally advanced unresectable and metastatic tumours are not curable. The goals of therapy include symptomatic palliation and survival prolongation, which can be most effectively achieved via systematic treatment. Carcinoma of the gastroesophageal junction (GEJ) is now classified as a separate entity with a distinct pathophysiological profile . Herein,2A 72-year-old healthy male presented with mild, intermittent, non-radiating, epigastric pain, that was associated with nausea and vomiting. Pain was exacerbated by food intake and relieved by fasting. The rest of the history was unremarkable. Physical examination findings were unremarkable with no evidence of palpable abdominal mass.PET-CT scan revealed a mass located in the GEJ extending to the cardia with heterogeneous thickening. The study also showed normal mediastinal structures with no evidence of lymphadenopathy or metastasis . EndoscoOn the 22nd of May, 2016, the patient underwent endoscopic submucosal dissection, the first of its kind to be performed in Saudi Arabia. There were no other lesions, suspicious masses or hiatal hernia. Dissection started from the proximal end and advanced deep within and below the mucosa. Then, parts of the mass were cut one by one using a circular cautery. The targeted tissues were retrieved carefully in the basket while maintaining adequate hemostasis. An intra-operative frozen section was sent to pathology that confirmed Gastric cancer intestinal type  and sati3In conclusion, endoscopic submucosal dissection is an acceptable management for T1 GEJ carcinoma. Further research is required for a consensus on criteria and management approach. The risks and benefits of minimally invasive approach with less morbidity and mortality versus possible long term complications have to attain an acceptable balance, and that requires a case-based review of the approach. With time, a standardization of the approach will aid physicians and surgeons to decide on the best modality and will simplify the decision-making process.4Esophageal and gastric malignancies are a major cause of cancer-related mortality with adenocarcinoma being the most common histology (> 90%) . Type IIThe distinction between an intestinal type GEJ adenocarcinoma of esophageal and gastric origin can be made through history, principally positive for GERD, and histological findings demonstrating esophageal adenocarcinoma. Biopsy samples from the gastric antrum and corpus presented with signs of atrophy, intestinal metaplasia and body predominant gastritis, indicate a gastric origin . In lineThe diagnostic workup for GEJ adenocarcinoma includes endoscopy, endoscopic ultrasound (EUS), and computed tomography (CT), with 80–90% accuracy to determine the exact tumor location and its spread to the upper mediastinal lymph nodes. For optimal nodal staging, EUS-guided FNA shows highest accuracy, yet it is not feasible in all cases due to technical difficulties. FDG-PET scans are gaining ground due to its diagnostic accuracy in detecting distant metastases . Since tOver time, the management has evolved from surgical resection alone, to the addition of adjuvant and neoadjuvant therapies for locally advanced disease, since perioperative chemotherapy has shown to improve survival. Similarly, surgical options have developed ranging from transthoracic esophagectomy to total gastrectomy with extended distal esophageal resection. Comparison of the various techniques involves assessment of oncologic efficacy, perioperative outcomes, survival, and quality of life. Hence, transthoracic esophagectomy with gastric tube formation has been accepted as the surgical standard for adenocarcinoma of the distal esophagus (GEJ type I). Classically, a proximal negative margin of a minimum of 5 cm is desirable .According to the US Gastric Cancer Collaborative data of 162 patients from seven USA centers (Siewert II and III cancers of the cardia or GE junction:67.6%), the proximal margin length was not associated with local recurrence or overall survival, but rather concluded that if esophagectomy is required, efforts to achieve a specific proximal margin should not be undertaken ,9. AlthoA systematic review and meta-analysis stated that ESD has been recognized as a preferred treatment for differentiated gastric adenocarcinoma without ulceration (T1a) with a diameter of ≤2 cm . AccordiNo conflicts of interest.No source of funding.As the report is case report a waiver was obtained from the Office of Research Affairs at KFSH.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 upon request.Abdullah AlShammari: design, writing and reviewing the study.Fatima Alam: searching the literature and data collection.Moahmmad Khan: writing and reviewing the article.Mohammed AbuRahma: design and review the article.Not applicable.Abdullah AlShammari.Not commissioned, peer reviewed.


Heterotopic pancreas (HP) is a relatively rare entity occurring in approximately 5% of the general population. It most commonly presents as an asymptomatic mass incidentally picked up on unrelated scans. HP most commonly occurs intra-abdominally, but has been known to occur in extra-abdominal sites such as the lung and brain. It is widely considered to bear little to no malignant potential. Difficulty and ambiguity in the diagnosis of HP commonly results in interventional dilemma and delay.We present a case of uncomplicated HP that was ultimately treated conservatively.A literature review is made of the typical workup in a patient with suspected HP, and the characteristic radiological and endoscopic findings commonly used for diagnosis of this rare condition. A succinct summary of management guidelines for HP is reviewed.HP is most commonly an incidental finding. Ambiguity surrounding its diagnosis commonly gives rise to interventional dilemma and delay. The gold standard for diagnosis remains that of EUS and FNA with histological confirmation. This report has been written in concordance with the SCARE criteria Agha et al. . It is present in approximately 5% of the general population.It is classified into 4 subtypes based on Gasper-Fuentes’ modification of Heinrich’s initial classification : Type I 2This case involves a 66-year-old gentleman with hypertension. He presented with elevated Cancer Antigen 19-9 levels of 128 μ/m incidentally detected on routine screening. Liver function test and other tumor markers  were within normal limits.Magnetic resonance cholangiopancreatogram (MRCP) revealed a lobulated, ill-defined endoluminal soft tissue mass measuring 1.7 × 2.0 cm abutting the lateral wall of the junction between the first (D1) and second (D2) part of the duodenum, but not invading into mucosa. Anatomical pancreatic tissue had no ductal dilatation, and was similar in appearance and consistency to the identified mass . DiffereGiven that this patient was asymptomatic with no malignant features seen on investigations, he was managed conservatively. He has since been followed-up in clinic once at an 8-month interval with a repeat CTAP showing a stable mass and no enlargement or invasion.3According to literature, HP is a rare occurrence found in 0.5–14% of all autopsies performed and 0.5% of all upper abdominal laparotomies ,4. The fPatients with HP commonly present with non-specific complaints such as abdominal pain, change in bowel habits, loss of appetite/weight, and anaemia. HP exceeding 1.5 cm in size commonlypresent with symptoms of gastric outlet obstruction. HP can undergo complications that conventionally occur in normal pancreatic tissue such as acute and chronic pancreatitis, pancreatic abscess and pancreatic pseudocyst formation. Malignant transformation of HP is a rare occurrence reported in only 0.7–1.8% of HPs in the current literature [Differentials for HP on radiological investigations (Computer tomography (CT) and MRCP) include other submucosal neoplasms of the gastrointestinal tract such as leiomyomas or gastrointestinal stromal tumors. Several radiological characteristics of HP have, however, been reported by Kim et al. to be independently significant (p < 0.05) for diagnosis of HP: typical location (pre-pyloric antrum or duodenum), endoluminal growth pattern, ill-defined borders, prominent enhancement of overlying mucosa and an LD/SD ratio of >1.4. Their study goes further to state that when two of these 5 criteria are used in combination, the sensitivity and specificity for diagnosing HP is 100% and 82.5% .On endoscopic ultrasound (EUS), features of ectopic pancreas include indistinct borders, lobulated margins, presence of anechoic duct-like structures, central umbilication, intramural growth pattern, and localization within two or more layers. Kim et al. reported that EUS features of HP that differentiate them significantly (p < 0.05) from mesenchymal tumors include: larger longest/shortest diameter ratio, antral location, mural growth pattern, third  layer disruption, irregular margins, and intermediate echogenicity . PreviouHistopathologically, the gross appearance of HP includes a characteristic central ductal orifice, pancreatic acini, ducts, islets of Langerhans, and intervening connective tissue.The management of HP is controversial and commonly delayed due to diagnostic dilemma. Reasons for surgical treatment depend on the presence of symptoms, management of complications, excluding malignancy or simply diagnostic uncertainty.4Even though reports of patients with HP presenting with massive bleeding gastrointestinal tract and even malignancy can be easily found in the literature to date, HP is still most commonly an incidental finding. Ambiguity surrounding its diagnosis commonly gives rise to interventional dilemma and delay. While there have been many guidelines and reports detailing the characteristic features of HP on a myriad of imaging modalities, the gold standard for diagnosis remains that of EUS and FNA with histological confirmation. This case report has been written in concordance with the SCARE criteria .Authors of this manuscript have no financial or personal relationships with other people or organizations that could inappropriately influence or bias our work.There was no financial funding or sponsors involved in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.Ethical approval has been exempted by the institution in which this manuscript was written and submitted from. 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. There is no ethical issue in this paper and all identifying names or identities have been omitted from the manuscript.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. There is no ethical issue in this paper and all identifying names or identities have been omitted from the manuscript. Ethical approval has been exempted by the institution as there are no patient identifiers or names included.This study does not involve human experimental subjects nor observational researchThe guarantor for this manuscript will be Dr. Brian Goh Kim Poh, the corresponding author.Not commissioned, externally peer-reviewed.


Gastric eosinophilic granuloma caused by parasitic infection is rare. It is often suspected to be a malignant disease and it is difficult to diagnose. We successfully diagnosed and removed a gastric eosinophilic granuloma using laparoscopic and endoscopic cooperative surgery (LECS).A 35-year-old woman visited our hospital because of epigastric pain. Upper gastrointestinal endoscopy revealed a 15 mm submucosal tumor (SMT) with changes in the folds, such as enlargement and convergence, located in the greater curvature of the lower gastric body. Computed tomography (CT) showed a dense, nonenhanced area of 15 mm at the same site. SMT was suspected, but undifferentiated cancer could not be excluded. We performed laparoscopic partial gastrectomy using LECS for resection biopsy.Histopathological examination showed an SMT 8 × 8 × 5 mm in size with an unclear boundary and necrosed insects at the core of the tumor. There was marked eosinophilic infiltration around the area. The diagnosis was gastric granuloma caused by parasitic infection.It is difficult to differentiate gastric eosinophilic granuloma caused by parasitic infection from malignant disease. In this case, LECS is considered a minimally invasive and useful procedure. Anisakis. This disease has been reported in Japan, Korea, the Netherlands, and western Europe, where raw fish is eaten. Gastric anisakiasis is divided into two types: the acute type (acute anisakiasis) and the chronic type (eosinophilic granuloma). The acute type, which develops sudden severe abdominal pain, is well known. The chronic type is relatively rare, accounting for 2~4% of anisakiasis cases. It is difficult to differentiate the chronic type of anisakiasis from malignant disease by endoscopy and imaging to achieve a definitive diagnosis before surgery. We performed laparoscopic and endoscopic cooperative surgery (LECS) for therapeutic diagnosis, which is considered a minimally invasive and useful procedure in this disease.Anisakiasis is a parasitic disease caused by the consumption of raw fish infected with 3/μL, eosinophils 3.8%. Upper gastrointestinal endoscopy revealed a 15 mm SMT with changes in the folds, such as enlargement and convergence, located in the greater curvature of the lower gastric body .We performed laparoscopic partial gastrectomy via LECS. The port arrangement was shifted to the foot side relative to the port arrangement in conventional gastrectomy because of severe gastroptosis. Five ports  were placed. The tumor location was confirmed in the greater curvature of the lower gastric body by endoscopy. The omentum around the tumor was minimally removed. A mucosal incision was made around the tumor with an adequate margin. The most anal side of the mucosal incision was endoscopically perforated. The rest of the specimen was circumferentially resected using laparoscopic coagulating shears Fig. . The speThe patient was discharged on the seventh postoperative day without complications. At the 6-month postoperative checkup, she had no complaints, such as bloating, pyrosis, and burp.Histopathological examination showed a yellowish white SMT 8 × 8 × 5 mm in size with an unclear boundary, and necrosed insects were found at the core of the tumor. There was marked eosinophilic infiltration around the area. The final diagnosis was gastric granuloma caused by parasitic infection Fig. .Fig. 4HIn our case, therapeutic diagnosis was less invasively performed by LECS for the granulomatous tumor which is difficult to differentiate as malignant tumor. The histopathological findings revealed that eosinophilic granuloma formation due to a chronic foreign body reaction. In this kind of chronic type, an EUS usually reveals a central hyperechoic area, which is a characteristic finding of Anisakis granuloma . It alsoHowever, these typical findings could not be confirmed in our case. Its endoscopic finding revealed a somewhat malignant tumor , metastatic gastric tumor) with ulcer formation and changes in the folds, such as enlargement, convergence, and erosion, on its top . Thus, wLECS is a surgical technique for SMT removal reported by Hiki et al. and a procedure that can minimize deformation and dysfunction by avoiding excessive resection of the stomach wall. However, when obvious ulcers are involved, it is necessary to prevent the spread of the tumor cells, and it may be better to consider the following methods that do not expose the tumor to the abdominal cavity: inverted LECS, nonexposed endoscopic wall inversion surgery (NEWS), and a combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) –7.We chose original LECS procedure and perforated gastric wall during resection of the tumor; however, we carefully paid attention not to spoil the gastric juice out from the stomach and to let the surface of the tumor touch to the abdominal cavity. The diagnosis was gastric granuloma caused by parasitic infection, excluding malignancy or typical SMT such as GIST and leiomyoma. LECS was a valid procedure for this case as a result.The patient did not eat raw fish 1 week before she visited at least. However, she usually eats raw fish. It is also important to keep in mind the gastric eosinophilic granuloma caused by parasitic infection, especially in regions where raw fish is eaten.LECS is a favorable less invasive candidate procedure for therapeutic diagnosis when we encounter the granuloma which is difficult to diagnose.


Transesophageal echocardiography (TEE) enables a more accurate visualization of left ventricular posterior aneurysms than transthoracic echocardiography due to the close proximity of the esophagus to the posterior ventricular wall. Therefore, TEE is essential for the accurate diagnosis of posterior aneurysm, particularly in urgent settings where preoperative assessments may be insufficient. However, once cardiac rupture occurs, it can cause catastrophic hemodynamic compromise. Transthoracic echocardiography (TTE) has a key role in the early diagnosis and prompt management of patients with cardiac rupture. Here, we describe the utility of intraoperative transesophageal echocardiography (TEE) in diagnosing a ruptured LV aneurysm that was missed on preoperative examination with TTE.2A 55‐year‐old patient with a past medical history of hypertension and type 2 diabetes mellitus was transferred to our institution with a sudden onset of chest pain. He had a medication history of metoprolol for hypertension. In the emergency room, he was pale and diaphoretic with a heart rate of 62 beats/min and a blood pressure of 76/48 mm Hg. He showed no difference in blood pressure among the limbs. Electrocardiography revealed a normal sinus rhythm with mild ST‐segment elevation in V1 and depression in V3‐V6 .%‐38%.3In our case, we diagnosed the patient as having a true LV aneurysm rather than a pseudoaneurysm on the basis that it clearly communicated with the LV and was continuous with the myocardial wall throughout. The most likely cause of LV aneurysm in this case was probably a previous asymptomatic myocardial infarction, which could be explained by the patient's history of diabetes mellitus.The posterolateral site of the aneurysm is also uncommon. Although TTE plays a useful role in the diagnosis of LV aneurysms,In summary, this case report showed that intraoperative TEE is useful for obtaining a correct diagnosis of ruptured LV aneurysm that is missed by preoperative TTE. By providing more accurate information when assessing posterior ventricular aneurysms, TEE is invaluable when intraoperatively developing surgical plans. This may particularly be true for cases in which there has been an insufficient preoperative assessment in urgent settings.None declared.TT: drafted the article and involved in approval of article. SS: involved in critical revision of article, approval of article, and data collection. Click here for additional data file. Click here for additional data file. Click here for additional data file. Click here for additional data file.


Gastric volvulus (GV) is defined as a rotation of the stomach along its short or long axis leading to variable degrees of gastric outlet obstruction. Rotation of the stomach >180° may cause closed loop obstruction and possible strangulation, which often causes acute abdominal pain. Strangulation and gangrene of the twisted stomach sometimes occurs, which demands immediate surgical intervention. We report a case of acute gastric volvulus due to a gastrointestinal stromal tumor (GIST), with multiple recurrences, that eventually required emergency gastrectomy.A 71-year-old woman with a history of recurrent epigastric pain, nausea, and anorexia was diagnosed to have a 70-mm sized submucosal tumor (SMT) in the lesser curvature of the stomach. An elective gastrectomy was planned; however, before the procedure, she visited the emergency room with acute recurrent epigastric pain associated with postural variations. Computed tomography (CT) revealed a GV and the tumor had shifted to the greater curvature. An emergency gastrectomy was performed. The postoperative course was uneventful and pathological examination revealed features consistent with that of GIST.GV with GIST has rarely been reported and risk factors such as size or localization are unknown. In this case, GV was probably caused by GIST of the stomach, which was large and heavy enough to rotate the gastric body around the mesenteroaxis.Surgical intervention without delay should be planned in similar scenarios accounting for the risk of GV in GIST. Rotation of the stomach >180° may cause closed loop obstruction and possible strangulation which often causes acute abdominal pain. Strangulation and gangrene of the twisted stomach sometimes occurs, which demands immediate surgical intervention .2A 71-year-old woman, who had previously been diagnosed with a 45-mm sized tumor a year ago, visited her local primary doctor with complaints of recurrent episodes of epigastric pain, nausea, and anorexia. On upper gastric endoscopy, a 70-mm submucosal tumor (SMT) was found at the gastric angle a and b. She had a past medical history of hypertension, herpes zoster, delivery by cesarean section, gastritis, and cholelithiasis. We had planned to perform an elective gastrectomy, but while awaiting the surgery, she came to our hospital with complaints of sudden abdominal pain. A computed tomography (CT) showed that her stomach had twisted organoaxially and the SMT had moved to the side of greater curvature a and b.FLaboratory tests were within the normal ranges. She was admitted to our hospital and kept in the right lateral decubitus position, which relieved her pain. Abdominal magnetic resonance imaging (MRI) on the following day, which had been already planned to examine the characteristics of the tumor, showed that the tumor had returned to its original position a and b.FDuring the course of rescheduling the elective gastrectomy, her abdominal pain and nausea recurred throughout the day, especially when she changed her body posture. We attributed the recurrent pain to the occurrence of recurrent GV and decided to perform an emergent gastrectomy on the same day. Via a median incision, we found a tumor at the lesser curvature of stomach, which was resected along a line 2 cm away from the tumor with an electric scalpel and a harmonic scalpel and was sutured with an absorbable thread in the direction of the long axis. The operation time was 137 min and the blood loss was 104 ml. The tumor size was 90 × 73 mm and the weight was 224.5 g a.Fig. 4HThe patient had an uneventful recovery and was discharged on the 14th postoperative day. The histopathological findings of the tumor specimen showed long spindle-shaped cells lined in a bundle with randomized complex arrangement and growth, in a storiform pattern b. There 3GV occurs due to torsion of the stomach beyond its physiological range and causes obstruction to the passage of food . The patAlthough some cases of GV with gastric cancer have been reported, GV with GIST have rarely been reported. We searched PubMed using the keywords “gastric volvulus” and “gastrointestinal stromal tumor.” Only one case was reported and the risk of GV based on the tumor size and position was unknown . In our Tanner suggested methods of surgical repair for GV. These included diaphragmatic hernia repair, simple gastrectomy, gastropexy and gastrocolic ligament repair (Tanner’s procedure), gastrectomy, gastrojejunostomy, fundoantral gastrostomy (Opolzer’s procedure), and repair of the diaphragm .Insertion of a nasogastric tube and endoscopic reduction are sometimes effective as GV treatment, especially for the mesenteroaxial type which has no closure of the cardiac orifice . Percuta4A GIST might cause GV and surgical intervention should be considered to prevent GV. Recurrence of GV can occur; therefore, immediate surgical intervention should be planned as soon as practicable if the case has a surgical indication oncologically.None of the authors has any conflict of interest to declare.This report did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.Ethical approval has been exempted by our institution.Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available and can be reproduced whenever needed.RM performed the operation and perioperative management of the patient. RM also acquired and interpreted the data and drafted the manuscript. YK, CI, SK, TT, HK, YT, TH, TY, and KI participated in the operation, perioperative management of the patient, and revision of the manuscript. KO reviewed pathological findings. All authors read and approved the final manuscript.Not applicable.Ryohei Murata.Not commissioned, externally peer-reviewed.


Epidermoid cysts (ECs) are benign lesions that can be encountered throughout the body, but with a low incidence in the head and neck (1.6 to 7%). In oral cavity, the most common affected site is floor of the mouth, but tonsillar location remains extremely rare (less than 0.01%). Here we present an epidermoid cyst of the right palatine tonsil which was incidentally detected in a patient who consulted for a chronic headache. Epidermoid cysts (ECs), also named epidermal, epithelial, keratinous, sebaceous, or infundibular cysts are benign lesions developing from abnormal epithelial components of ectodermal tissue formed during the fetal period , or implanted epithelium arising after surgery or trauma (acquired cysts) . They arA 28-year-old female with no pathological history, consulted for chronic headache without a history of recurrent tonsillitis. On physical examination the palatine tonsils were hypertrophied and symetric, the throat isthmus was symmetrical. There were no palpable neck masses or other findings on head and neck examination. An injected cerebral computed tomography performed, showed cystic formation of the right palatine tonsil which enhanced in peripheral with a center of fluid density . The patEpidermoid cysts are defined as benign lesions that are histologically characterized by cystic spaces lined by squamous epithelium . Among tThese cysts can be associated with certain hereditary syndromes like Gardner syndrome caused by mutations in the adenomatous polyposis coli gene, or in Lowe syndrome, an X-chromosomal oculo-cerebral-renal disorder caused by mutations of the OCLR1-gene  . In oralDiagnosis is based on imaging and can be aided by fine needle aspiration in case of symptomatic tonsillar mass, followed by excision biopsy. Imaging studies can provide some diag¬nostic information about epidermoid cyst. On CT scan, epidermoid cyst should appear as a well-circumscribed, low-density, unilocular mass. Typically, it is predominantly fluid-attenuated. On magnetic resonance imaging, the appearance of EC is variable according to their fluid contents and protein density. Often, they exhibit a low signal intensity with T1 sequences and a high signal intensity with T2 sequences ,12. TreaThe importance of this rare case report is to highlight the rarity of intratonsillar EC presented as an incidental finding in our case and the need for histopathological examination to differentiate it from the tonsillar neoplasia due to similar appearance.The authors declare no competing interests.


The lipoma of the oral cavity is a relatively rare pathology, characterized by overgrowth of the mature adipocytes. Buccal fat pad lipomas usually interfere with the esthetics and the function of the face.A sixteen-year-old patient reported slow-growing swelling, which started two years ago. Clinical examination revealed two bilateral masses in the soft tissue. MRI imaging revealed a characteristic image of bilateral lipomas connected to the buccal fat pad. Surgical removal was conducted and the histology report confirmed our clinical diagnosis of common lipoma.The lipoma of the buccal fat pad is a benign neoplasm of the adipose tissue. It should be removed when functional or esthetic problems occur and emphasis should be put on the correct surgical technique.The bilateral buccal fat pad lipoma is an extremely rare condition of the oral cavity. Surgical removal with intraoral approach is the preferable treatment, together with intense care of the anatomical structures of the buccal space. Key words:Buccal space lipoma, oral cavity, buccal space, bilateral, buccal fat pad lipoma. The lipoma is a benign mesenchymal neoplasm composed of mature adipocytes and usually surrounded by a fibrous capsule . AnatomiIn the oral cavity, the lipoma is quite unusual, representing only 1-4% of benign tumors . HistoloA 16-year old female patient came at the university clinic, reporting bilateral swelling of the cheeks, especially on the right side. The patient had noticed that the swelling had started two years ago with no signs of pain, slowly growing and causing asymmetry of the face. The general medical history of the patient does not contain any condition.Clinical examination revealed a bilateral, soft, mobile and painless mass into the soft tissue. The mass on the right side was much larger, thus causing asymmetry Fig. A.Imaging with MRI scan showed two round-shaped, finely encapsulated masses of adipose tissue connected to the buccal fat pad Fig. B. These Surgery was conducted with the intraoral approach under general anesthesia, first on the right and subsequently on the left side, following the same procedure.A relatively transverse incision was performed with a no. 15 blade through the buccal mucosa, extending from the external oblique ridge halfway up the mandibular ramus posteriorly, to approximately 5mm under the papilla of the parotid duct anteriorly, in order to recognize and protect the Stensen’s duct. A secondary incision to the buccinator muscle granted access to the lipoma. The masseter muscle, the surrounding vessels and the parotid duct were identified and protected as well. The lipoma was carefully detached from the surrounding tissues and was removed, including the well-attached larger front part of the buccal fat pad Figs. A,3A. ThoThe patient was hospitalized and monitored for two days and then discharged in good general condition. Post-surgery instructions were given. Post-traumatic swelling and edema entirely disappeared two weeks after surgery Fig. B.Histological examination of the removed masses confirmed the typical image of common lipoma.The buccal fat pad has plenty of functional and aesthetic roles . In the The buccal fat pad lipoma is a rare, usually asymptomatic mass that causes swelling of the buccal area. To the best of our knowledge a bilateral buccal fat pad lipoma has never been reported in the literature. Surgical attention is needed in order to secure the buccinator branch of the facial nerve, the vessels and the parotic duct in the area. Intraoral approach grants adequate access in order to remove a benign mass like lipoma and it is not necessary to adopt an extraoral approach.


The gastrostomy is one of the most common procedures performed in general surgery. Although a simple procedure, it is not exempted from potential complications, specifically portal venous gas and intestinal pneumatosis being some of the ones with higher rates of mortality. The following case report presents a pneumoperitoneum due to extensive pneumatosis from esophageal, gastric, intestinal and portal gas. These rare complications were managed medically without undergoing emergency surgical intervention.A 19-year-old male patient, with previous history of cerebral palsy, chronic malnutrition and severe physical deconditioning, required a nutritional access. Due to co-existing pathologies, an open gastrostomy was chosen as the best intervention, which was performed without complications. On the tenth postoperative day, patient presents abdominal pain and diarrhea; laboratory results were within normal limits, and the abdominal computed tomography scan reported extensive pneumatosis compromising esophagus, stomach, small intestine, part of the colon, pneumoperitoneum and gas in the portal venous system. Medical management was carried out with an adequate recovery.Intestinal pneumatosis and portal venous gas are rare and potentially lethal complications. Surgical intervention as well as severe malnutrition impairs carbohydrate digestion and promotes bacterial fermentation forming large volumes of gas and dissection of the intestinal mucosal wall, causing the intestinal pneumatosis evidenced in this case report.This case report presents a rare open gastrostomy complication, as well as a differential diagnosis to pneumoperitoneum. Additionally, the medical management poses a successful alternative to an emergency surgical intervention. Potentially, common gastric complications include: obstruction, tube displacement, bleeding and perforation. Meanwhile, portal venous gas and intestinal pneumatosis are rare complications. Pneumatosis as a complication was reported for the first time by the University of Michigan group in 1983 . In the 2A 19-year-old male patient, with body mass index (BMI) of 8.45 kg/m  and prevTen days after surgery, patient in-hospital presented diffuse abdominal pain and multiple diarrheic episodes, of insidious origin, referring it began two days after surgical procedure and gradually increased its intensity. Laboratory results were within normal limits, and the abdominal computed tomography (CT) scan revealed extensive pneumatosis from esophagus, stomach, small intestine and partial colon. Additionally, moderate pneumoperitoneum and gas in the venous portal system were also reported , Fig. 2.3The following case reports a pneumoperitoneum, as a rare complication of open gastrostomy procedure, usually associated with a rupture of the digestive tract (90%) . The ideIntestinal pneumatosis and portal venous gas are rare and potentially lethal complications. Pneumatosis normally occurs in the small intestine  and rareThe etiologies can be either benign or potentially lethal. Although their pathophysiology is not clear, several theories have been proposed Considering the patient in this case report was in an early postoperative state from the gastrostomy, theory four stemming from the surgical context  could exClinically, some patients are asymptomatic while others present severe symptoms of abdominal pain and diarrhea (53%)  followedThe treatment protocol has varied in the last years from a medical approach to an early surgical intervention. Treatment is often not warranted in asymptomatic patients as they resolve spontaneously . Symptom4Pneumoperitoneum is a potentially rare complication of open gastrostomy, which can be treated medically as done in this case report. Nevertheless, potentially lethal conditions such as mesenteric ischemia, intestinal necrosis and intestinal obstruction have to be excluded first and treated accordingly, considering pneumoperitoneum as a differential diagnosis. A complete evaluation of the patient and a close follow-up using an established algorithm can prevent surgical interventions in benign cases of intestinal pneumatosis, as well as optimize the surgical intervention for those who require it early.The authors declare they have no conflicts of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The Ethical and Research Committee of the Fundación Cardioinfantil – IC and the General Surgery Research Group at the Fundación Cardioinfantil – IC.Written consent was obtained from the patient for publication of this report. Any details identifying the individuals to the clinical history and images associated were eliminated as to remain anonymous.Perez Rivera CJ, González-Orozco A, and Caicedo I designed the report, analyzed the data, and wrote the paper. Ramirez NA, Cabrera P collected patient’s data and were the perioperative attending physicians.N/A.Perez Rivera Carlos Jose.Not commissioned, externally peer-reviewed.


Peliosis hepatis (PH), which is characterized by blood-filled cavities in the liver, is a rare disease. Its diagnosis depends on postoperative pathological examinations and immunohistochemistry.A 44-year-old female complained of right-middle upper abdominal pain and distension for 1 month, with occasional vomiting and fever.Because of the similar imaging features, the patient was initially misdiagnosed as cystic echinococcosis (CE). The immunoassay of echinococcosis was negative. Irregular hepatectomy was performed. Eventually, the patient was diagnosed with PH based on postoperative histopathology and immunohistochemistry.The patient underwent hepatectomy. Then, the cystic lesion was collected for intraoperative pathological examination. Thus, the blood liquid was extracted from the cystic lesion. Pringle maneuver was administered to prevent bleeding, and then the whole cystic lesion was removed.She recovered smoothly and there was no relapse occurred during 6 months’ follow-up.It is difficult to differentiate PH from CE and other hepatic diseases due to the lack of special imaging features. Pathological examinations and immunohistochemistry can provide a confirmed diagnosis of PH. It is usually difficult to differentiate PH from other hepatic diseases at initial diagnostic stage. Herein, we reported a case of PH in a 44-year-old female who was initially misdiagnosed as cystic echinococcosis (CE) in another hospital because of the similar imaging features between the 2 diseases. She was finally diagnosed with PH according to the postoperative pathological examination and immunohistochemistry in our hospital.Peliosis hepatis (PH), of which pathogenesis is unknown, is a rare benign lesion of the liver and characterized by the blood-filled cavities in liver.29/L ; hemoglobin, 81 g/L ; hematocrit, 26.1% ; neutrophil granulocyte percentage, 73.2% ; total bilirubin, 41.9 μmol/L ; direct bilirubin, 17.6 μmol/L ; indirect bilirubin, 24.3 μmol/L ; prothrombin time, 12.9 seconds ; plasm D-Dimer, 63.8 μg/mL ; fibrinogen degradation product, 113.4 μg/mL . Besides, tumor markers such as α-fetoprotein, carcinoembryonic antigen and carbohydrate antigen 19-9 were in normal ranges. Serologic tests for complement C3/C4, kidney function, humoral immune antibody spectrum, hepatitis A/B/C and human immunodeficiency virus showed negative. Serum enzyme-linked immunosorbent assay for echinococcosis showed negative. Electrocardiography and gastroscopy showed no evident abnormalities. This patient had no history of living in echinococcosis endemic areas, eating raw beef and exposing to toxic agents or immunosuppressive drugs. According to the imaging features, she was initially diagnosed with CE, but the clinical manifestations should be taken into account in the clinical diagnosis as proposed by the radiologists.This study was approved by the Ethics Committee of Chengdu Second People's Hospital. A 44-year-old female was referred to our hospital because of complaint of right-middle upper abdominal pain and distension for 1 month, with occasional vomiting and fever. Enhanced computed tomography (CT) showed a huge cystic lesion sized 13.5 × 12 cm in the right lobe of the liver, and ascus and hemorrhage were observed in the lesion  and weaker signals on T2WI (T2 weighted imaging) than those of its inner cystic lesions, and the cyst wall had consistently low signals. Nonetheless, PH usually shows centrifugal enhancement in venous phase and centripetal enhancement in the arterial phase on CT. Because of intracavity hemorrhage, PH shows the lesion with different signals in MRI images. Previous literature had reported that PH had long T1WI and short T2WI signal in the hemorrhagic cystic lesion in the subacute phase, and long T1WI and T2WI signal in chronic hemorrhage phase. The remote and recurrent hemorrhage may display fluid interface. We reviewed all the imaging features of this patient. MRI of this patient showed a lesion in the right liver, sized approximately 13.5 × 12 cm with hemorrhage and fluid in it, and long T1WI and T2WI signals were observed in the lesion. PH and echinococcosis have a similar specific imaging feature of multiple inner small cysts in the large cyst. Therefore, the PH mimicking CE has not been reported in previous literature.Although the patient was diagnosed as CE by radiologists, she had no history of living in epidemic areas, eating raw beef, and exposing to toxic agents and immunosuppressants. Thus, the specific mechanism for the pathogenesis of PH was unknown. In the diagnosis of CE, CT, and MRI play a significant role and they can display the cystic size, location, and relations to adjacent organs. In a previous report of CE, CT showed a large cystic lesion containing smaller round shaped cystic lesions with a lower density inner substance than in the large cystic lesion.In this case, the patient had no previous medical history. Though the serologic tests for echinococcosis showed negative, the imaging features of PH mimicking CE made diagnosis difficult. Therefore, pathological examination and immunohistochemistry could definitely diagnose PH. In addition, PH should be differentiated from other hepatic diseases such as hepatic adenoma, hemangioma, focal nodular hyperplasia, and hepatic abscess. and hepatic failure. The preoperative liver function (Child-Pugh grade A) of this patient was evaluated after surgery, and results showed normal. Then, a precise hepatectomy was performed to ensure that the liver tissues could be reserved as more as possible to prevent postoperative hepatic failure. Echinococcosis requires surgical treatment and long-term medication to avoid recurrence. Compared to echinococcosis, patients in previous literature reports were followed up with no recurrence after surgical resection and could live for long term survival. And the patient was no relapse occurred during 6 months’ follow-up.In this patient, the moderate anemia might be caused by hemorrhage in the lesion. Surgery is the most effective treatment for the prevention of massive hemorrhage caused by lesion rupture,Conceptualization: JinHeng Liu, YanTin Wang, Xubao Liu.Data curation: JinHeng Liu, YanTin Wang, SiNeng Yin, NengWen Ke.Formal analysis: JinHeng Liu.Funding acquisition: Xubao Liu.Investigation: JinHeng Liu, YanTin Wang.Methodology: JinHeng Liu, SiNeng Yin.Resources: SiNeng Yin, NengWen Ke.Visualization: Xubao Liu.Writing – original draft: JinHeng Liu, YanTin Wang.Writing – review and editing: Xubao Liu.


Out of those, Dermatofibrosarcoma protuberans (DFSP) of the breast is extremely rare, especially in men with only six cases, including this case, reported so far. We report a case of recurrent DFSP in a 35-year-old male after a latency of 8 years in the region of previous surgical scar. It was managed by a wide local excision followed by reconstruction using latissimus dorsi flap. It is important to carefully manage recurrent cases because the post-operative margin status is an important determinant of recurrence, and therefore, requires vigilant resection of the tumour without causing extensive morbidity to the patient.Soft tissue tumours represent 0.2%–1% of all breast malignancies. [Al Tarakji M, Toro A, and Di Carlo I,  Dermatofibrosarcoma protuberans (DFSP) is a rare soft tissue tumour with an incidence rate of 4.2–4.5 cases per million persons per year and local recurrence rates up to 60% . In thisA 35-year-old male from Central India presented to the Surgical Outpatient Department with a gradually increasing nodule of 5 cm in the right mammary region. It was not associated with any pain, ulceration or discharge. He had a similar complaint in the same location 8 years ago and was diagnosed with biopsy-proven DFSP and was surgically treated for the same. He did not have the records of his previous surgery, but he had the histopathology report, which stated the diagnosis of DFSP with histologically negative margin status. According to the history given by the patient, he did well after the surgery and was disease free until he noticed this nodule few months ago. There was no history of radiotherapy and/or chemotherapy. He did not have any other co-morbidities. There was no family history of breast, colon or skin cancer.He had a normal body mass index and his vital parameters and systemic examination was within normal limits. On examination, a 4 × 5-cm firm reddish-pink nodule, fixed with the overlying skin and restricted mobility, was present 2-cm lateral to the right nipple-areola complex extending up to the anterior axillary line . Since iHis complete blood count, liver function test and kidney function test were within normal limits. A chest radiograph and contrast-enhanced computed tomography (CT) scan were performed to evaluate local extension and metastasis, which were absent. Fine-needle aspiration cytology of the nodule revealed spindle cells. After a careful history, examination and diagnostic workup, a preoperative diagnosis of recurrent DFSP was made. Keeping the aggressive nature of the recurrent tumour and future reconstruction in mind, a wide local excision (WLE) with pedicled latissimus dorsi (LD) flap was planned, after consultation with the Plastic Surgery Department.An elliptical incision was made around the tumour, taking 2.5-cm margin including the previous surgical scar and right nipple-areola complex due to its proximity. The tumour was excised, taking a 2.5-cm circumferential margin, including the surrounding breast tissue and extending up to the pectoralis major fascia. On assessing the tumour grossly, it was felt that it was reaching up to deep margin. Therefore, an intra-operative decision was taken to do a cavitary shave of the deep margin including 1 cm of pectoralis major muscle. The LD flap was raised and placed over the defect  and 3. TThe wide local specimen measured 12 × 9 × 3 cm with nipple-areola complex at the edge of the skin flap. On serial sectioning, a grey-white tumour measuring 5 × 4 × 3 cm was identified. Histopathology of the tumour showed a spindle cell tumour with myxoid changes and areas of necrosis and low mitotic count (1–2/hpf) . The cirThe post-operative period was uneventful with good functional results. The patient was then referred to the Medical Oncology Department for consideration of imatinib therapy and/or radiotherapy. There were no signs of recurrence at 6 months follow-up.DFSP is an uncommon, low-grade sarcoma of dermal fibroblast origin with an incidence rate of 4.2–4.5 cases per million persons per year .t between chromosomes 17 and 22, which is thought to be a key in the tumour’s pathogenesis. The chromosomal translocation leads to the fusion of platelet-derived growth factor (PDGF) beta polypeptide gene and collagen type 1A1 gene, resulting in the overproduction of PDGF and eventually cellular proliferation and tumour formation. This chromosomal translocation is present in over 90% of DFSP and can be detected either by fluorescence in situ hybridisation (FISH) on interphase nuclei and/or by multiplex reverse transcription-polymerase chain reaction (RT-PCR) [DFSP has been reported to arise in areas with a history of prior trauma, including tattoos, vaccination sites, burn scars, surgical scars and radiation treatment. The exact mechanism in which trauma may predispose for development of DFSP is unknown, but it seems intuitive that chronic inflammation and stimulation of the immune system at a local level may trigger the immunopathologic changes that could lead to the malignant transformation of dermal cells . Studies(RT-PCR) . Other c(RT-PCR) . This pa(RT-PCR) .The early clinical symptoms of DFSP are non-specific, making diagnosis difficult and leading to a high incidence of misdiagnosis . The mosPathological and immunohistochemical examinations are currently the gold standard for diagnosing DFSP . MicroscThe role of radiological imaging is limited in the management of DFSP. Most patients undergo excision and biopsy of the mass without the need for CT or magnetic resonance imaging (MRI) due to its superficial location . On CT, The treatment of DFSP is primarily surgical. The size and location of the tumour and cosmetic issues will dictate the most appropriate surgical procedure. Modified Mohs surgery and traditional WLE, typically with 2–4-cm margins to investing fascia that are subsequently verified to be clear through the traditional pathologic examination, are all methods to achieve complete histologic assessment . HoweverMargin status is important in the surgical management of DFSP as it determines further treatment and prognosis. Disease-free survival after treatment for DFSP is strongly predicted by tumour depth in the primary setting and margin status in recurrent tumours . HoweverRadiation therapy, if not given previously, or imatinib mesylate should be considered if this is not possible, or if additional resection would lead to unacceptable functional or cosmetic outcomes. Imatinib mesylate, a protein tyrosine kinase inhibitor, has been approved by the FDA for the treatment of un-resectable, recurrent and/or metastatic DFSP in adult patients as it inhibits overactivity of PDGF receptor in these tumour cells . BecauseIn a prospective study of 244 patients , the medIn conclusion, DFSP is an uncommon, low-grade sarcoma of dermal fibroblast origin with a high local recurrence rate. Diagnosis is established by histology and immunohistochemistry. Treatment of DFSP is primarily surgical—Modified Mohs surgery or traditional WLE. The size and location of the tumour, and cosmetic issues, will dictate the most appropriate surgical procedure. The disease-free period in DFSP is strongly predicted by margin status in recurrent tumours; therefore, every effort should be made to achieve histologically free margins. Recurrences can occur after a long latent period, like 8 years in the present case. The current case emphasises the importance of follow-up in DFSP cases, as well as advocating long duration self-surveillance of surgical scars by patients.The authors have no conflicts of interest to declare.The authors have received no funding for this work.DKD was responsible for data acquisition and contributed to the design and editing of the manuscript. NW wrote the manuscript and contributed to the design and editing. SP critically reviewed the final draft.


The diagnosis and treatment of Superior Labrum Anterior to Posterior (SLAP) tears have been evolving and controversial. The lack of clear diagnostic criteria on physical examination, Magnetic Resonance Imaging (MRI), and arthroscopic evaluation clouds the issue. The high rate of MRI diagnosed SLAP lesions in the asymptomatic population of athletes and non-athletes warrants consideration when planning treatment for those with shoulder pain.To provide information on the evaluation, diagnosis and management of SLAP tears in athletes.The results of a structured non-operative rehabilitation program are discussed and compared to traditional surgical techniques. The evolution of the author’s treatment algorithm is presented. Results: The successful return to overhand throwing is more common with non-operative treatment than with surgical.A rehabilitation program focused on stretching the posterior capsule and correcting scapular posture is more successful than surgery for most throwers with SLAP lesions. The location of the long head of the bicep origin has variability as well and can range from anterior to central to posterior locations along the superior rim of the glenoid . The rolThere is increasing evidence that superior labral “Tears”, like meniscal cleavage planes, are frequently present on MRI in asymptomatic overhand throwers. In fact, in the experienced thrower, these “Tears” are now considered adaptive changes by the majority of Major League Baseball team physicians . HoweverSimilarly, Schwartzberg has shown that MRI documented SLAP lesions is present in 55-72% of the asymptomatic middle age population . Outlet etc.) [It is important to realize that not all SLAP lesions require surgery, and for those that do, not all patients benefit from the same surgery. The key is to determine whether the labrum is solely responsible for the patient’s symptoms and whether restoring the attachment of the labrum and biceps root to the glenoid will be helpful. In the older patient with or without rotator cuff repair, the repair of the SLAP is associated with inferior results in comparison to intentional neglect or performing a bicep tenodesis/tenotomy in regards to stiffness, persistent pain and need for revision. A number of authors report good results in athletes, including those with moderate overhead usage  . Howeveretc.) , 17-19.The best treatment for Type 2 SLAP tears in the overhead athlete is now more controversial than in the past when the surgical repair was routinely performed. While repair of Type 2 SLAP lesions was 9.4% of all applicants’ shoulder procedures performed by ABOS Part 2 candidates from 2003 to 2008 , 21, 22.2We evaluated the injury history of 1750 high level collegiate and high school baseball players eligible for the Major League Baseball draft over a three-year period. Fifty-two pitchers were signed, including free agents. Every pitcher underwent an in-person evaluation and MRI scan of the shoulder at intake. The MRI evidence of labral lesions and rotator cuff pathology was assessed. The pre-signing history and subsequent injury history for all players were documented.3Of the 1750 players  with reviewed available pre-draft histories, a history of MRI documented SLAP lesion was found in 17%. Not all MRI had been done for shoulder pain, some had been done as screening. Those that returned to play with sufficient proficiency were considered for the draft. The rate of injury following matriculation as a professional baseball pitcher (N=52) in our organization was followed. In three years of professional baseball, 1 player (1.9%) required surgery for a failed previously repaired SLAP lesion and none for a new injury.4The assessment of shoulder injuries in athletes and the general population is challenging particularly in the overhead throwing athlete. Reliance on MRI scans will over-diagnose labral pathology and lead to excessive or unnecessary treatment. Clinical evaluation is of critical importance to accurately diagnose and successfully treat shoulder injuries while avoiding unnecessary or potentially harmful surgery. The above pre-draft assessments should not be construed as a reliable prevalence statistic since the MRI was done for a variety of reasons including injuries in other sports, screening by concerned parents/agents, and was self-reported by players hoping to be drafted. However, the rate of shoulder surgeries for SLAP lesions is indicative of the relatively low probability of operative intervention being required if proper diagnosis and non-surgical treatment are rendered.4.14.1.1In our population of professional overhead throwers, complaints of shoulder pain are investigated with a thorough history and physical exam. As we expect an MRI to demonstrate labral changes regardless of the cause of the player’s pain, MRIs are reserved for recalcitrant cases. Key aspects of the patient’s history are the locations of pain and the provocative phase or phases of pitching. Appreciating the stress on anatomic structures during the phases of pitching facilitates the diagnosis. In our experience, posterior pain with late cocking usually indicates a posterior superior labral tear or hypertrophy with or without undersurface tearing of the infraspinatus-supraspinatus junction. This is commonly referred to as “internal impingement” and is often caused by a flap of tissue  being trapped in the cocked position. Posterior pain during release or follow through is most commonly indicative of an eccentric failure of the posterior rotator cuff. Anterior pain during cocking is typically associated with some degree of dynamic anterior instability which can be multifactorial . Anterior pain with “finishing” the throw or terminal stage of follow-through can indicate mechanical impingement of the bicep or lesser tuberosity on the coracoid. These must all be questioned during the history, correlated with a provocative physical exam and critically evaluated with imaging, especially the MRI.1). The deceleration sign is positive when the eccentric contraction of the humeral decelerators is painful in the follow through position. This is tested by placing the patient in the follow through position of throwing and applying downward pressure to the wrist while the patient resists the applied force. Posterior pain is suggestive of inflammation and eccentric failure of the posterior rotator cuff . Scapula Dyskinesia and scapular posture can be assessed by inspecting scapular kinesis from behind with the patient moving his arm through all planes including internal and external rotation in the 90-degree abduction position. Thorough evaluation of winging, relative protrusion, and fluid movements of glenohumeral motion with relation to scapulothoracic motion. Hitches, sudden jump/catches, or pain should be assessed with shoulder flexion. Tightness of the posterior capsule is assessed with the patient supine and the examiner immobilizing the scapula against the table. The examiner pushes the humerus across the chest while stabilizing the lateral border of the scapula and keeping the forearm in neutral rotation to prevent coupled external rotation. The shoulder will externally rotate as the arm is pushed into adduction as the posterior-inferior capsule comes under tension. This must be resisted by the examiner in order to obtain accurate and reproducible results. A tight capsule will prevent the elbow from passing through the midsagittal plane, while a flexible capsule will allow movement almost to the midline. Reproduction of pain with the supine cross body test is indicative of posterior capsule tightness as the pain generator .On physical exam, special attention to labral signs is helpful, with the O’Brien sign and Jobe Relocation test. Less commonly performed tests can be helpful in the throwing population such as the “Internal Impingement Sign” which is positive when posterior pain is reproduced by exaggerating the cocked position, especially with horizontal extension in the 90 degrees abducted position. Reproducing the patient’s localized pain in the posterior joint line during this maneuver indicates mechanical entrapment of posterosuperior labrum, rotator cuff tissue or both. This maneuver is similar to performing apprehension testing in the standing position but with increased horizontal extension. The patient must not only identify if this position is painful or uncomfortable, but specifically where the discomfort is located as well as the character of the pain (pinching/catching versus pain or apprehension) , posterior capsule inflammation, adhesive capsulitis, subacromial/subcoracoid bursitis, bicep tendonitis and rotator cuff tendonitis. In addition. multiple varieties of mechanical impingements  may cause pain. The patient’s activities, location of pain, age, and degree of impairment are all helpful clues to an adequate differential diagnosis.We have found that the physical exam is the most helpful way to differentiate and attain the correct diagnosis. The most helpful findings on history and physical exam to differentiate between the pain of SLAP origin versus rotator cuff functional failure are location of pain during the phase of throwing and provocative signs on exam, especially after throwing. The local anesthetic injection can be helpful to confirm a subacromial source of symptoms. However, an intra-articular injection may prompt a relief of pain but does not differentiate between mechanical entrapment of tissue, capsulitis, bicep tendonitis, dynamic instability due to cuff failure, or instability due to SLAP lesion as the source of that pain.1. Although they are not universal, they provide a reliable rationale for treatment programs. Note that in all cases, the presence of an MRI documented Type 2 SLAP is expected but often irrelevant.We have a full-size pitching lane in our contiguous physical therapy clinic which allows examination immediately after throwing. The most common combination of history and examination findings indicating the root cause of symptoms is demonstrated in Table 4.34.3.1Our data has demonstrated that surgical treatment of SLAP lesions in throwers has a significantly lower success rate compared to directed rehabilitation that prioritizes the posterior capsule flexibility and scapula positioning. Up to 85% of patients with isolated SLAP tears treated with non-operative management have done well. While many authors have reported good results with surgical repair , 28-30, The role of posterior capsule and posterior rotator cuff tightness in the painful thrower’s shoulder has been well described -33. ThisPatients participating in an internal rotation stretching program have found stretching with their hand behind the back similar to the “Towel Stretch” commonly performed during post-surgical rehabilitation. We do not recommend this stretch or motion for throwers as it promotes a forward rotated and protracted scapular position which increases stress of the anterior-superior capsule.Scapular malposition of anterior tilt, protraction and upward rotation is commonly seen in overhead athletes . ScapulaIn throwers with scapular dyskinesia, a simple in-office demonstration can convince the patient that scapula posture control is important for success with non-operative management. This can be demonstrated by starting the patient in their baseline standing position and bringing the arm into a maximally cocked position while holding the scapula in the protracted posture causing the patient to feel the significant strain on their elbow and shoulder. The patient is then later instructed to “Set” their scapula with retraction which allows them to bring their arm further into a cocked position with ease and a lack of discomfort. With the scapula retracted, the shoulder and elbow experience significantly less strain which is immediately apparent to the patient. This demonstration often fosters greater patient commitment towards non-operative management and deters those who may have been biased toward surgical intervention for their observed MRI findings rather than their actual functional pathology.Rehabilitation is best performed by a physical therapist or certified athletic trainer well-versed in these concepts and baseball throwing mechanics. Assessment of mechanics by a qualified professional is critical to confirm that the player maintains adequate scapular posture while throwing. Having a throwing lane in the therapy clinic is also helpful for observation and analysis of pitching mechanics.et al demonstrated that overhead athletes with stable Type II SLAP lesions and concomitant PASTA lesions did well with debridement of the posterosuperior labrum and PASTA lesion. For overhead athletes with extensive detachment of the anterior and posterior portion of the labrum, the anterior superior labrum was repaired while the posterosuperior labrum was debrided. Meantime and return rate to play were similar between the debridement only group and the repair group [et al followed 13 overhead athletes with SLAP repairs for 28 months and found that only 4 were able to return to prior levels at 11 months, while 1 never did [et al demonstrated that all eight of their pitchers that lost greater than 10 degrees of external rotation at 90 degrees of shoulder abduction were unable to return to throwing [Although posterior stretching has been demonstrated to be successful in 66.7 to 90% of athletes , in the ir group , 45. Debir group . For their group . Yung etever did . In a syever did . Many otever did , 50. Wheever did  which coever did . In 2011throwing . Due to throwing . With thOnce the labrum has healed, the principles applied during the non-operative program are again applied postoperatively. During the early post-operative phase, scapular posture is again reinforced and early passive external rotation in the scapular plane is instituted to avoid the critical loss of external rotation. Closed chain cuff exercises using “Ball on the Wall” or Dynamic Stabilization and Strengthening (DS2) platforms are safe and effective modalities to initiate early rotator cuff and scapula stabilization and strengthening.4.3.2Non-operative management is the standard for non-throwers as well. Focus on rotator cuff strengthening, scapular kinetics, and capsule flexibility is paramount to recovery. Determining the cause or etiology of the onset of symptoms either through the history or a physical exam can guide the target of the therapy. The physician, physical therapist, or athletic trainer must be cautious with increased or new activities as they can result in painful inflammation that impairs rotator cuff strength resulting in dynamic instability. If overuse induced inflammation is the primary cause of symptoms, anti-inflammatory modalities, medication such as non-steroidal anti-inflammatories or even steroids, and treatment as simple as cryotherapy geared to controlling inflammation are initiated followed by strengthening and training of scapular rhythm. Trauma such as a fall or motor vehicle accident can result in dysfunction of the rotator cuff resulting in a similar cascade, however, treatment should focus more on cuff strength and scapula kinetics in the early phase.etc.) in the shoulder and that a concerted non-operative protocol with focus on scapular posture, strengthening and stretching with a well-qualified physical therapist or trainer has a high likelihood of success prior to considering any surgical intervention. If an adequate attempt at non-operative management fails (as defined by improvement in posterior capsule tightness and scapula posture), surgical intervention must be carefully weighed with care, with an understanding that the prior level of performance in overhead athletes may not be achieved. Combining tenodesis with SLAP repair in throwers is not advised due to the expected loss of external rotation as well as the creation of a stress riser in the proximal humerus. In the non-throwing athlete, pain relief is usually substantial and the risks acceptable. In the non-athlete with tenodesis without SLAP repair, pain relief is significant with few complications.In most cases, an MRI diagnosis of a SLAP lesion is an incidental finding which can cause significant concern in patients leading to unnecessary and sometimes harmful surgical intervention. In order to avoid patient anxiety and overtreatment, it is important to educate patients about the prevalence of asymptomatic SLAP lesions in the general population before an MRI is performed. Once diagnosed, it is highly recommended that the patient understands that the labrum is only one of a number of issues (posterior capsule, scapula dyskinesia,