A 30-year-old female presented to a rural hospital in Western Australia complaining of generalized abdominal pain and symptoms of partial bowel obstruction. Computed tomography (CT) showed a radiological ‘whirl’ sign, with images 4 years apart demonstrating interval progression. Given our patient’s past history with miliary tuberculosis, we performed a diagnostic laparotomy which confirmed omental torsion. We report a case of surgically and pathologically proven chronic secondary omental torsion presenting with partial bowel obstruction, and showcase rarely seen interval progression on CT. Omental torsion was first described in 1866 by Eitel , 3. OnceOur patient is a 30-year-old female who presented to a rural hospital in Western Australia with a 2-month history of recurring abdominal pain, nausea, and vomiting. On further history, she describes a clinical picture of intermittent bowel obstruction, going for days without flatus before self-resolution. This was associated with unintentional 4-kg weight loss and anorexia. On examination, she was vitally stable. She had a lower midline laparotomy scar with no abdominal distension and no palpable masses. Her abdomen was subjectively tender at the right upper and lower quadrants with no peritonism.Her past medical history was significant for miliary tuberculosis. At age of 19 years, she underwent a diagnostic lower midline laparotomy for drainage of pelvis abscess. Intra-operative findings revealed purulent peritonitis and abdominal tuberculosis. She subsequently completed anti-tubercular treatment in 2010. These were managed in Thimphu, Bhutan where our patient was originally from before her migration to Australia. She takes no regular medications and has no known drug allergies.On presentation, her blood work showed a neutrophilia of 8.38 (2–7.5) but was otherwise unremarkable with white cell count 10.7 (4–11), CRP 2.6 (<5) and lymphocyte 1.53 (1.2–4).On review of imaging, we noted a CT scan from 2019 which showed swirling and stranding of omentum/mesenteric fat inferior to hepatic flexure , with suspicion of internal herniation of the omental/mesenteric fat leading to infarction  and 3. MGiven the clinical findings of recurring abdominal pain, imaging suggesting small bowel obstruction with enteritis and the past history of miliary tuberculosis, the decision to proceed with diagnostic laparoscopy was made. On performing Hasson entry, we encountered extensive adhesions which necessitated conversion to laparotomy and prolonged adhesiolysis. We then found a large calcified inflammatory omental mass situated in the mid-abdomen, independent from the surrounding omentum. The mass appeared tethered to the ascending colon, obtaining its blood supply from the mesentry . It was Histopathology revealed omental tissue measuring 170 × 135 × 52 mm with extensive fat necrosis and focal vascular thrombosis causing ischemic necrosis with congestion and some hemorrhage –10, in kAt 1-month follow up, our patient reported complete resolution of symptoms.We believe that our patient may have had chronic secondary omental torsion dating prior to 2019. Her previous abdominal tuberculosis and pelvic abscess may have induced formation of chronic adhesions and triggered a bipolar torsion secondary to adhesions between the free omentum end and intra-abdominal structures . Due to the chronicity, the culprit omental mass obtained a secondary blood supply from the large bowel’s mesentry and detached from its original omentum, resulting in an independent omental mass adhering to surrounding bowel loops. The resulting bowel kinks contributed to her symptoms of abdominal pain and recurrent partial obstruction.Our case is highly unique in multiple aspects. First, our patient presented with atypical signs of secondary omental torsion. In addition to abdominal pain, she reported symptoms in keeping with recurrent partial bowel obstructions. In view of her past miliary tuberculosis, our initial differential diagnosis was an inflammatory phlegmon from potentially a recurrence of intra-abdominal tuberculosis, or encapsulating peritoneal sclerosis. Given her previous exploratory laparotomy, internal herniation from surgically created mesenteric windows was also considered.Second, omental torsion is rarely managed conservatively with surveillance imaging. Hence, it is rare that we have CT imaging showing the progression of omental torsion over 4 years, noting the markedly increased dimensions and characteristic mesenteric swirling.In conclusion, omental torsion is a rare cause of abdominal pain that requires a high index of suspicion due to the non-specific presentation. CT scan can serve as a valuable adjunct to decision making, but surgeons should have a low threshold in offering diagnostic laparoscopy for patients failing conservative management.


Segmental colitis associated with diverticulosis (SCAD) is a rare entity characterized by segmental circumferential colonic wall thickening involving the sigmoid and/or left colon in the presence of colonic diverticulosis. We present the case of a 57-year-old female with a past medical history of colonic diverticulosis who presented with chronic intermittent abdominal pain, non-bloody diarrhea, and hematochezia. Imaging revealed long-segment circumferential colonic wall thickening involving the sigmoid and distal descending colon with engorged vasa recta without significant inflammation around the colon or diverticula, consistent with SCAD. Colonoscopy showed diffuse mucosal edema and hyperemia of the descending and sigmoid colon with easy friability and erosions primarily affecting the inter-diverticular colonic mucosa. Pathology showed changes of chronic colitis including inflammation in the lamina propria, crypt distortion, and granuloma formation. Treatment with antibiotics and mesalamine was initiated with improvement in symptoms. This case highlights the importance of considering segmental colitis associated with diverticulosis in patients with chronic lower abdominal pain and diarrhea in the setting of colonic diverticulosis, and the need for a thorough workup including imaging, colonoscopy, and histopathology to differentiate it from other types of colitis. Colonic diverticulosis is a common condition that affects up to 65% of individuals over the age of 65 in the United States . Colonic3. A CT scan of the abdomen and pelvis was performed and showed a long segment of circumferential colonic wall thickening involving the sigmoid and distal descending colon in the region of colonic diverticulosis with engorged vasa recta and mild pericolonic inflammation not surrounding sigmoid diverticula suggestive of segmental sigmoid colitis rather than diverticulitis (Figure A 57-year-old White female presented to the emergency department with chronic intermittent abdominal pain, non-bloody diarrhea, and hematochezia. Her pain was mostly localized in the left lower quadrant and partly relieved by a bowel motion. There was no constitutional symptom or history of weight loss. She had a past medical history of hemorrhoids and colonic diverticulosis, with no significant past surgical history. Vital signs were within normal limits. On physical examination, the abdomen was soft and tender to deep palpation in the left lower quadrant. There was no rebound tenderness or guarding. The examination was otherwise unremarkable. Complete blood count showed normal hemoglobin at 13 g/dl and WBC 7200/mmPatients who have colonic diverticulosis may develop segmental colitis, which is most commonly found in the sigmoid colon . On imagTypically, SCAD involves the sigmoid colon with or without the left colon, where colonic diverticulosis is often present. On the other hand, ulcerative colitis typically involves the rectum and may extend continuously through the colon, while Crohn's disease can affect the terminal ileum and may involve locations beyond those associated with diverticulosis. In contrast, SCAD spares the rectum and right colon/terminal ileum. The differential diagnosis for SCAD also includes several conditions. Diverticulitis can have a similar clinical presentation to SCAD, but it usually presents acutely. On CT, acute diverticulitis is characterized by colonic wall thickening with pericolic inflammation centered around an inflamed diverticulum that is more severe than the degree of colonic wall thickening seen in SCAD. On colonoscopy, diverticulitis typically affects the diverticular orifices and the surrounding mucosa, while sparing the interdiverticular mucosa . InfectiSCAD should be considered in patients with chronic lower abdominal pain and diarrhea who have colonic diverticulosis. Imaging, colonoscopy, and histopathology are necessary to differentiate SCAD from other types of colitis. Treatment with antibiotics and mesalamine may be effective in improving symptoms.


The combination of placental mesenchymal dysplasia and hepatic mesenchymal hamartomas is an extremely rare finding. We present the case of a three-month-old female born at 35 weeks gestation with a history of placental mesenchymal dysplasia who presented with non-bilious, non-bloody emesis, and episodes of respiratory distress due to multiple enlarging abdominal cystic lesions. The patient’s presentation was unique due to both liver and adrenal solid and cystic lesions. After extensive imaging and multiple biopsies, expert interpretation of biopsy tissue revealed hepatic mesenchymal hamartoma within the liver and the adrenal gland. To our knowledge, this is one of the few documented cases of unresectable hepatic mesenchymal hamartomas with adrenal involvement successfully undergoing a whole liver transplant. Hamartomas are benign, local proliferations of disorganized tissue. Hepatic mesenchymal hamartomas (HMHs) are therefore a proliferation of mesenchymal liver tissue. They are not often associated with elevated alpha-fetoprotein (AFP) levels though there are case reports of HMH noting elevated AFP levels . AlthougWe present the case of a three-month-old girl born at 35 weeks with known hepatic masses/cysts and an adrenal cyst, brought to the emergency department by her mother due to four days of nonbilious, non-bloody emesis. The patient was undergoing a workup for hepatic lesions at an outside hospital. Prenatal sonograms showed maternal placental mesenchymal dysplasia and multiple abdominal cysts within the patient’s liver. The patient was delivered via cesarean section due to nonreassuring fetal heart rates, and the pregnancy was otherwise uncomplicated. Following the delivery, the patient’s liver cysts were followed closely. Interval sonograms revealed enlarging complex cysts and an enlarging adrenal lesion was also discovered. The patient was discharged with a follow-up ultrasound scheduled.Over the next two months, the patient frequently returned to the hospital and was admitted multiple times for an inability to feed and tachypnea. Extensive imaging, including CT scans, was performed to monitor the growth of the lesions Figures -3. A nasThe patient’s parents decided to relocate to be closer to family and an appointment with the oncologist resulted in an ultrasound and magnetic resonance imaging (MRI) evaluation. The ultrasound showed multiple, complex, predominantly cystic lesions within the abdomen, retroperitoneum, liver Figure , and lefFollowing the MRI, an ultrasound-guided biopsy of the left adrenal lesion was performed with a total of 10 core samples. The hospital pathologist interpreted the samples as myxoid adrenal cortical tumors with cellular architecture resembling adenoid cystic carcinoma. The cells were positive for MART1, CD56, synaptophysin, and inhibin. A focal positivity of calretinin was noted. Chromogranin, AFP, cytokeratin, MSA, CD45, and CD31 were negative. The cells were seen in a mucinous background and strongly positive for Alcian blue, but negative for S-100. Following this diagnosis, the oncology team requested a re-evaluation of the patient’s pathology reports, and tissue samples were subsequently sent to pathologists around the country for second opinions. Expert analysis from St. Judes returned a new diagnosis of mesenchymal hamartoma. The oncologic workup continued with the Tempus molecular testing assay  being negative (including testing for Beckwith-Wiedemann syndrome). The patient was then transferred to a sister facility out of state for liver transplantation evaluation, as her cysts were enlarging and affecting her ability to breathe. At the time of this writing, the patient received a cadaveric liver transplant with whole liver and duct-to-duct anastomosis. She experienced mild T-cell-mediated rejection successfully treated with steroids and is now gaining weight appropriately without other complications.Hepatic mesenchymal hamartomas (HMHs) are benign tumors classically characterized by primitive myxoid stroma with associated dilated bile ducts. It is currently believed that these lesions stem from an alteration of the 19q13 chromosome. These lesions have been associated with both Beckwith-Wiedemann syndrome and placental mesenchymal dysplasia in the literature . Most coThere are nine reported cases in the literature of combined placental mesenchymal dysplasia (PMD) and HMH and the combination of the two conditions is associated with a poorer prognosis of the fetus . Due to HMH can be a challenging diagnosis for several reasons, including its unclear etiology, varying levels of AFP, and in this case, adrenal involvement with an ambiguous first biopsy. The literature describes a report of HMH located exophytically and extending inferiorly into the pelvis, which may be confused with an ovarian cystic lesion . There hHepatic mesenchymal hamartomas (HMHs) are the second most common benign hepatic tumors after hemangiomas. They are rare in occurrence and while they have been described in the literature, due to their atypical presentation, they can create diagnostic challenges. As seen in this case, an adrenal cystic lesion presented a distractor for the clinicians. Ultimately, expert interpretation of the biopsy showed the adrenal involvement of HMH.


Perineal hernia is a rare complication of rectal surgery. Different types of surgical approach have been described, but none of them have proven their superiority. Although there are many methods of closing the defect, we selected two cases to present from a series of five cases, in which the perineal hernia was successfully resolved surgically using only the perineal approach. The reconstruction of the perineal floor and closure of the defect were performed using a synthetic polypropylene mesh. The significance of this Technical Note article lies in the fact that we describe, step by step, a surgical technique for perineal hernia using just a perineal approach. Perineal hernia (PH) is defined as the protrusion of the intraabdominal viscera through a defect in the pelvic floor into the perineal space . AcquirePH generally occurs within the first two years after surgery, with a median interval of 10 months. It is most often accompanied by a bulging mass or pain associated with discomfort that worsens when standing or sitting. Skin erosion, urinary dysfunction, and bowel obstruction are among the complications that can accompany PH ,4.The treatment is surgical, but because of the lack of evidence and the existence of only a small number of studies on this topic due to the low incidence of PH, there is no consensus on optimal surgical management.Various surgical approaches have been described for repair, including perineal, abdominal, or a combination of the two, and abdominal procedures can be performed using either an open or laparoscopic approach ,5.In the next section, we describe a surgical technique used to resolve two cases of perineal hernia by using only a perineal approach.Over the course of the last three years, 5 patients were admitted with perineal hernia. In all cases, the surgical technique used is the one presented in this article. The 2 cases presented include intraoperative pictures and computed tomography (CT) scans performed within our service. In all cases, mesh repair, using the perineal approach, was taken into consideration. The study was approved by the Ethics Committee of the Regional Institute of Gastroenterology and Hepatology “O. Fodor”, Cluj-Napoca, Romania. All the patients have signed written consent.The first case was that of a 75-year-old woman with symptomatic PH after an abdominoperineal resection for rectal cancer. In 2019, the patient was diagnosed with T4bN0M0 inferior rectal cancer and underwent neoadjuvant chemoradiotherapy. Surgery consisted of an APR with a terminal sigmoidostomy, a total hysterectomy with a bilateral salpingo-oophorectomy, and a colpectomy. Eighteen months postoperatively, the patient presented with worsening bulge symptoms associated with discomfort, particularly while sitting. On physical examination, the patient had no fever and was hemodynamically stable. On inspection of the perineum, a large bulging mass, covered by skin, was observed, and the patient described pain during palpation .As the patient was symptomatic, surgery was indicated. A transperineal hernia repair was performed with the patient in the lithotomy position. After a vertical incision was made over the defect, the hernial sac was identified, containing viable small bowel content .The small bowel contents were reduced after opening the hernial sac .A dissection of the hernial sac was carefully performed, after which the excess was excised, and the sac was closed. A polypropylene mesh was then inserted across the defect (above the levator ani muscles) and anchored to the endopelvic fascia and adjacent muscular structures with 1.0 non-absorbable polypropylene sutures .Hemostasis was achieved, a subcutaneous surgical drain was placed, and the subcutaneous and skin tissues were closed. Postoperative recovery was uneventful, and the patient was discharged on postoperative day 5. No recurrence was observed during the last follow-up visit .The second case was a 57-year-old woman who presented to our clinic complaining of a perineal bulge and discomfort while sitting or walking. In 2020, she was diagnosed with inferior rectal adenocarcinoma (T4bN0M0) and underwent neoadjuvant chemoradiotherapy (nCRT), followed by surgery consisting of a laparoscopic APR with a terminal sigmoidostomy. Upon inspection of the perineum, a large perineal bulge was noted at the level of the postoperative scar .The hernia measured 10 × 15 cm and was covered with skin. It had an elastic consistency and was reducible, with no pain described during palpation. Further workup included laboratory tests and a thoracoabdominal and pelvic CT scan, which confirmed the presence of an extensive perineal hernia containing small bowel content. A perineal approach was chosen for repair, a vertical incision was made over the hernia, and the postoperative scar tissue was excised. Once the hernial sac was incised and opened, the small bowel content was reduced .After the dissection and excision of the excess hernial sac, the parietal peritoneum was mobilized up to the levator ani muscles and was then closed with simple interrupted sutures. The defect was then covered and closed with a tailored synthetic polypropylene mesh and fixed to the ischial tuberosity and sacral bone (on the levator ani muscles) using helical titanium tacks  and 2.0 non-absorbable polypropylene sutures .With the pelvic floor defect closed, the subcutaneous and skin tissues were closed, and a subcutaneous surgical drain was inserted. The immediate postoperative period was uneventful, and the patient was discharged on postoperative day 5. The one-and-a-half-year follow-up showed no signs of relapse  during tBoth surgeries were performed under general anesthesia, with the patient in the lithotomy position to maximize the field of view. The incision is made over the defect, taking some precautionary measures for the underlying tissues, especially for hernias in which the sac is thinner, in order not to injure the small bowel. Removal of the postoperative scar tissue is not mandatory, but we strongly recommend this because of the positive cosmetic effect. After the incision of the hernial sac, its contents must be adequately explored for their viability, and then reduced. Mobilization of the parietal peritoneum should be performed, especially in larger defects, to adequately close the hernial defect in order to avoid contact between the mesh and the small intestine. The excess sac should be removed, as it increases the risk of seromas. However, in cases of larger defects, it can be used as a reinforcement layer. Afterwards, the placement of the synthetic mesh should always be fixed below the levator ani muscles, as this allows for better closure of the defect, limiting the excess space for a possible recurrence. In order to further minimize the risk of recurrence, non-resorbable sutures should be placed. If the adjacent structures have a higher density (such as the pelvic floor), tacks should be preferred over sutures, as they offer better control. After the closure of the pelvic floor, subcutaneous sutures, as well as skin sutures, are applied. Subcutaneous drainage is mandatory, especially when the excess sac is not removed, to further minimize the risk of seromas.Postoperative recovery was uneventful, and the patient was discharged on postoperative day 6. No recurrence was observed during the last follow-up visit , showed that PH occurs significantly less often after mesh reconstruction than after primary closure. The BIOPEX study used an acellular non-crosslinked mesh derived from porcine dermis, sutured posteriorly either to the sacrum or the coccis or laterally to the remnant of the levator muscle; anteriorly, it was fixed to the transverse perineal muscles. The utilization of biological mesh for pelvic floor closures following an eAPR for rectal cancer in patients who had received preoperative radiotherapy showed no significant difference when compared to the group that underwent primary perineal wound closure at 30 days. Moreover, there were no notable variations in perineal wound healing or quality of life observed at other postoperative time intervals between the two randomization groups for up to 1 year after the surgery. Notably, the rate of freedom from perineal hernia at 1 year was significantly higher in the biological mesh group, reaching 87%, as opposed to the primary closure group, which had a rate of 73% . When coRegarding flap reconstructions, the use of pedicled muscle flaps, such as vertical rectus abdominis musculocutaneous (VRAM) flaps, offers successful healing, and seems to be the best flap reconstruction solution. The pedicled VRAM flap has found utility in various applications for challenging periabdominal wounds and is associated with fewer perineal complications compared to primary wound closures. Furthermore, it exhibits lower perineal morbidity and boasts excellent long-term survival outcomes, with success noted up to 10 years postoperatively. Additionally, it surpasses gracilis flap reconstruction in terms of complication rates. However, the applicability of the VRAM flap can be restricted by various factors such as patient positioning, previous abdominal surgeries, scarring, and the number of required ostomies. V-to-Y advancement flaps, in contrast, mitigate additional abdominal wall morbidity when compared to the VRAM flap, and provide a less bulky option for flap coverage. While local tissues can promote effective healing and deter perineal hernias, they are disadvantaged by their proximity to the radiated surgical field, potentially leading to increased wound healing complications. Another effective alternative described is the pedicled gracilis muscle flap, which offers a wide range of rotation without limiting postoperative mobility or ambulation. However, it may be inadequate for larger pelvic defects due to its size .Most commonly, symptomatic PH patients present with a bulging mass associated with pain or discomfort, which is worse in standing or sitting positions. The diagnosis is clinical, and CT or MRI can be performed during the oncological follow-up; however, the positioning of the patient may reduce hernia detection rates. The main complications of PH include skin erosion, urinary dysfunction, and bowel obstruction . Due to The abdominal approach provides better exposure and the ability to perform another procedure at the time of repair and perform a diagnostic exploration of the abdomen to assess oncological recurrence. Moreover, if patient selection is adequate, it seems that the abdominal approach has a smaller recurrence rate than the perineal approach. It is preferred if the reduction of the hernial sac content is difficult, given that dissection and control may be easier. When this approach is used, the patient should be positioned in the Lloyd-Davies position, and abdominal exploration is mandatory regardless of whether the approach is open or minimally invasive. All herniated organs, typically the small bowel and/or bladder, are carefully dissected out of the hernia sac. The hernia sac itself is excised to establish the anatomical boundaries of the defect, although it may be left in place if it is small or dissection is deemed risky. The urogenital organs, when present, are situated anteriorly, while the bony structures of the pelvic outlet, often with varying degrees of overlying pelvic floor musculature, constitute the posterolateral and remaining aspects of the hernial defect. Throughout this procedure, great care is taken to identify and protect the ureters, bladder, and prostate (or vagina) when applicable. If there is any available omentum left, it should be positioned over the mesh, and if feasible, the pelvic peritoneum should be closed to prevent the inclusion of the bowel. If mesh is used to cover the defect towards the posterior and lateral aspects, the sacral promontory and endopelvic fascia provide suitable locations for suture placement. Anteriorly, the pubic rami serve as anchor sites ,3,14.The abdominal approach can also be pursued laparoscopically, and in recent years, it has become increasingly popular, slowly replacing the open approach. When laparoscopy is preferred, the patient is positioned in the lithotomy position, and usually, four access ports are needed in order to achieve optimal work conditions. The mesh can be fixed in this case either by using surgical tacks or sutures, but a combination of the two can also be used. The mesh has to be fixed to the promontory or sacrum and to the pelvic side walls with a minimum of 1 cm overlap ,16. No sSimilarly, various techniques have been described to repair pelvic floor defects, including omentoplasty, synthetic or biological mesh repair, musculocutaneous rotation flaps, and free fascia lata flaps. Omentoplasty can be an excellent method due to its straightforward nature, but it might not always be accessible, adequate, or sturdy enough to effectively cover the defect. When a perineal hernia occurs following a sacrectomy, the posterior and caudal defect tends to be substantial, and the pelvic floor might be too lax for alternatives other than mesh reconstruction or tissue restitution securely anchored to the pelvic bone. Synthetic mesh repair is an excellent choice, but it raises concerns about the risk of fistula formation or the development of chronic mesh infections that might necessitate removal. It is also not advisable when the surgical site is contaminated. In cases involving complex or complicated hernias, such as those associated with abscesses or tumors, or when contamination occurs during surgery, myocutaneous flap reconstruction may be considered a more suitable option. Whether the flap consists of muscular tissue alone or requires myocutaneous transfer depends on the condition of the skin covering the hernia . The recThe best data on mesh choice shows that synthetic mesh is still likely to be the best option, and it is our choice for treating these cases as well; however, due to the small number of cases, further research is necessary to determine the best choice ,6,18.We reported two cases from a series of five with PH after APR for rectal cancer that were resolved using only a perineal approach, which in terms of recovery is better for the patients. The reconstruction of the perineal floor and closure of the defect were performed using a synthetic polypropylene mesh. The technique described can be used successfully.


A 9-year-old female spayed Brittany Spaniel presented for weakness and stumbling, and was diagnosed with severe hypoglycemia. An insulin to glucose ratio was not consistent with insulinoma as a cause for hypoglycemia. Diagnostic imaging  revealed a large left renal mass and a possible metastatic lesion in the right kidney. Glucagon therapy was initiated, but hypoglycemia was refractory to therapy. A left nephrectomy was performed and hypoglycemia subsequently resolved. Histopathology of the mass was consistent with nephroblastoma and immunohistochemistry for anti-insulin-like Growth Factor-2 (IGF-2) antibody revealed immunoreactivity in over 50% of the neoplastic cells. Chemotherapeutic treatment was initiated with a combined protocol of vincristine and doxorubicin. To the authors' knowledge, this is the first case report documenting the treatment of severe, refractory non-islet cell tumor-induced hypoglycemia in a dog, suspected to be secondary to an IGF-2 secreting nephroblastoma. Primary renal tumors are rare in dogs and constitute 0.6%−1.7% of all neoplasms, with the majority being renal cell carcinomas . NephrobParaneoplastic hypoglycemia is the hallmark of pancreatic beta-cell neuroendocrine tumors in dogs . Non-islEhrlichia canis, E. ewingii, Anaplasma phagocytophilum, A. platys, Dirofilaria immitis, and Borrelia burgdorferi. Abdominal radiographs revealed a mass effect in the region of the left kidney. On presentation to the referral hospital, physical examination revealed a grade II/VI systolic left apical murmur and a palpable mid-to-caudal abdominal mass.A nine-year-old, 17 kg, female spayed Brittany Spaniel was presented for an ~1-week history of disorientation, weakness, and stumbling. The dog had a prior history of degenerative mitral valve disease, and she had previously been treated for mammary carcinoma with initial diagnosis and surgical excision in 2018, as well as pulmonary adenocarcinoma with left radical mastectomy and right caudal lung lobectomy performed concurrently in 2020. There was no evidence of recurrence of either mammary nor pulmonary neoplasia based on screening abdominal ultrasound and thoracic radiographs performed at 3–6 month intervals following diagnosis and surgical excision. The dog was reportedly eating well, but was polydipsic and polyuric prior to presentation. No overt episodes of collapse or seizure activity were described by the owner. The patient's referring veterinarian had performed diagnostic testing 24 h prior to presentation that included a complete blood count (CBC), biochemical analysis, thyroid testing, urinalysis, vector-borne disease testing,The patient was neurologically appropriate, and the remainder of the physical examination was unremarkable.Point-of-care diagnostics at the time of presentation showed severe hypoglycemia , hyperlactatemia , and a base deficit . Abdominal ultrasonography was performed and revealed a large (10.9 cm × 6 cm × 6.2 cm) moderately vascularized, bilobed mass arising from the caudolateral aspect of the left kidney with differentials to include nephroblastoma, renal sarcoma, and renal carcinoma. The mass was mildly heterogeneous with hyperechoic retroperitoneal fat surrounding the mass. The left renal pelvis was dilated at 0.8 cm (reference range <2mm). The right kidney appeared progressively enlarged from the patient's previous ultrasonographic exam with decreased corticomedullary definition. The right renal cortex was hyperechoic and thick with mild dilation of the renal pelvis and diverticulum. Right ureteral dilation was not detected. These changes were not apparent on abdominal ultrasound performed 5 months prior. An ultrasound-guided fine needle aspirate of the left renal mass was performed, and cytology was consistent with carcinoma as characterized by round to cuboidal epithelial cells that had high nuclear to cytoplasmic ratios with small amounts of medium to dark blue cytoplasm and low numbers of discrete margined vacuoles. The nuclei within the cells were noted to be round to ovoid with nuclear crowding in clusters . An insuDuring hospitalization, the patient remained markedly hypoglycemic despite having a good appetite and frequent feedings. A glucagon continuous rate infusion [50 ng/kg IV bolus followed by 10 ng/kg/min IV (CRI)] was initiated on the second day of hospitalization. The dog's blood glucose improved to 9.88 mmol/L (reference range 3.61–6.22 mmol/L) but again fell several hours later and was too low to measure (< 1.1 mmol/L). The glucagon CRI was titrated upward to 12 ng/kg/min with mild improvement in blood glucose concentration . Overnight, the glucagon CRI continued to be titrated upward to a maximum rate of 40 ng/kg/min due to persistent hypoglycemia. During the periods of hypoglycemia, the patient exhibited generalized weakness, was quiet but responsive, and had no seizure activity.On the third day of hospitalization, thoracic and abdominal computed tomography (CT) was performed. A large, complex, multilobular mass arising from the left kidney was found . The masThe patient was premedicated with methadone (0.3 mg/kg IV) and dexmedetomidine (1 mcg/kg IV) and was then induced with propofol (2 mg/kg IV) and lidocaine (2 mg/kg IV) to effect. Following endotracheal intubation, the dog was maintained on gas anesthesia (1.5% isoflurane in oxygen). Lidocaine (30 mcg/kg/min titrated upward to 40 mcg/kg/min), dexmedetomidine (0.25 mcg/kg/h), and glucagon  CRIs were continued intraoperatively. A left nephrectomy was performed through a midline laparotomy to remove the large mass in the left kidney. The lesion in the cranial pole of the right kidney was palpable but was not sampled due to the risk of hemorrhage. After removal of the left kidney, the patient's blood glucose improved to 3.22 mmol/L (reference range 3.61–6.22 mmol/L). The glucagon CRI was weaned over several hours and discontinued when the patient became mildly hyperglycemic at 7.1 mmol/L (reference range 3.61–6.22 mmol/L) 3 h after surgery. The patient remained normoglycemic and was discharged 2 days following surgery.2 was noted with no evidence of lymphovascular invasion. Immunohistochemistry staining performed on the mass was positive for vimentin in the mesenchymal cells, cytokeratin AE1/AE3 in the epithelium, and WT-1 (Wilms' tumor gene). The histomorphologic features combined with the immunohistochemical results were most supportive of nephroblastoma. Immunohistochemistry for IGF-2 revealed that more than 50% of the neoplastic cells were immunoreactive with diffuse cytoplasmic granular staining  and doxorubicin (1 mg/kg IV) was initiated 13 days postoperatively with vincristine and doxorubicin being alternated every 2 weeks. Dactinomycin treatment was considered but not pursued due to cost and difficulty obtaining the chemotherapeutic agent. The dog has continued to do well clinically 6 months post-diagnosis of nephroblastoma, though the right renal lesion is visible on abdominal ultrasound interrogation (2.6 cm × 2.5 cm at largest cross-section). No recurrence of hypoglycemia was noted 6 months after surgery.A combination chemotherapy protocol with vincristine  and clinical stages (I-V) . These pThis case was unique for several reasons. The dog involved was a medium-sized breed, geriatric animal while historically, dogs diagnosed with nephroblastoma are young, large-breed dogs . In addiTo the best of our knowledge, this is the first case report detailing the treatment of severe, refractory hypoglycemia in a dog with a renal nephroblastoma that was able to be resolved with nephrectomy. This is also the first case report detailing IGF-2 expression in a canine renal nephroblastoma as the likely cause of hypoglycemia. Medical management was insufficient to control severe hypoglycemia in this dog, supporting the notion that surgical resection is the preferential treatment for patients with NICTH.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Ethical review and approval was not required for the animal study because this is a case report and no experimental procedures were performed. The owner consented to all diagnostics and treatment interventions performed.BL and EM managed this patient prior to and after surgery. AB performed the surgery. LT was the oncologist managing the patient's long-term care. PS drafted the initial manuscript. LR and RF provided histopathology images and legends. All authors critically reviewed the manuscript and provided revisions. All authors contributed to the manuscript's final revision and approved the submitted manuscript.


Synovial sarcoma is an uncommon soft tissue malignancy that mainly occurs near tendon sheath and bone joints. Primary intra-abdominal location is exceedingly rare and characterized by non-specific clinical signs.We report the case of a young female without medical history who presented with acute abdominopelvic pain. Ultrasound echography revealed a right mass measuring 7 cm in greater diameter cystic with solid areas, likely of ovarian origin. A coelioscopy with peritoneal biopsies was performed. Histological examination with immunohistochemistry concluded the diagnosis of GIST. The patient was referred to the surgery department and after laboratory routine analysis and computed tomography, the patient was proposed to surgical management. Per-operative findings revealed a mesenteric mass locally invading the greater omentum and the appendicular wall. Pathological examination with immunochemistry confirmed the diagnosis of mesenteric monophasic synovial sarcoma invading the appendicular wall with positive surgical margins. Chemotherapy was proposed with a good response. Our patient is free from disease 9 months later.We aimed through this case report to discuss mesenteric presentation monophasic SS, mimicking ovarian malignancy, emphasizing clinicopathological features and differential diagnoses. Synovial sarcoma (SS) is a rare and aggressive tumor, that represents up to 10% of all soft tissue malignancies . In contHere, we present a case of primary mesenteric monophasic SS, mimicking ovarian malignancy. Clinico-pathological features and differential diagnoses of this entity will be discussed.A 40-year-old female without past medical history presented to the gynecology department for acute abdominopelvic pain. Ultrasound echography revealed a right mass measuring 7 cm in greater diameter cystic with solid areas. A coelioscopy with peritoneal biopsies was performed. Histological examination of these samples showed a spindle cell proliferation with a dense vascular network. Nuclear atypia were scants and some mitotic figures were noticed. At immunohistochemistry, tumor cells showed focal positive staining with SMA, EMA, Cytokeratin AE⁄AE3, and DOG1. C-KIT, CD34, S100, Melan A, PAX8, p53, WT1, calretinin, mesothelin, and D2–40 were negative. The diagnosis of Gastrointestinal stromal tumor (GIST) was retained and the patient was referred to the surgery department for surgical management.A contrast-enhanced computed tomography (CT) Fig.  was perfThe right ureter and kidney were closely abutting the lesion, but there was no evidence of locoregional invasion into the adjacent viscera. There was no vascular invasion. Despite all these findings, the lesion was deemed resectable.After 2 weeks, a laparotomy was performed with the removal of the mesenteric mass, which was locally invading the greater omentum and the appendiceal wall. The resected mass was ill-defined, non-encapsulated, sized 19 × 17 cm, and weighed 1893 g. It was firm, fleshy with a white cut surface harboring hemorrhagic and mucoid areas. The mass was partially connected to the appendiceal wall and the greater omentum. Microscopically, the tumor was highly cellular and showed ovoid to spindle cells arranged in sheets and vague fascicles with hemangiopericytoma-like areas. Tumor cells display mild nuclear atypia and the mitotic rate was 18 mitoses⁄10 HPF. Mucoid regions exhibited hemorrhagic and mucinous changes in the setting of a hyaline–fibrous background. Immunochemistry revealed positive staining of the tumor cells for TLE1 and EMA .SS was first described in 1893 , 4. SS hThe most common clinical presentation is a painless mass. However, symptoms depend on the tumor size . HemorrhRadiologically, SS imaging findings are not specific . ComputeHistologically, there are three main subtypes: biphasic SS, monophasic SS, and poorly differentiated , 9. The The gold standard for SS diagnosis is molecular testing for SS18–SSX aberrations, the product of t   translocation, that can be detected by FISH or RT-PCR. Meanwhile, pathologists must know that sensitivity of SS18 break-apart FISH and RT-PCR is, respectively, 83% and 94% .The management of intra-abdominal SS consists of wide surgical resection of the tumor with regional lymphadenectomy , 13, 16.Mesenteric SS is an extremely rare form of intraabdominal SS. Clinically, even radiological findings are not specific and presentation may be misleading. The pathologic diagnosis is based on histologic features, immunochemistry staining, and ancillary molecular techniques. However, it remains challenging in a biopsy, especially with unusual immunophenotypes. Prognosis is poor and depend essentially on quality of surgical resection.


Malignant melanoma with gastric metastasis is extremely rare. We report a case of gastric metastasis caused by malignant melanoma of the lower limb.A 60-year-old woman was hospitalized for left plantar pain. The patient found a black maculopapular eruption on the left sole of her left foot, which caused pain when pressed, and the pain was aggravated by walking, so she went to our hospital for treatment. On the second day of admission, the lesion of the left foot was removed under local anesthesia, and the removed tissue was sent for pathological examination. Combined with immunohistochemistry, it was consistent with malignant melanoma. During hospitalization, the patient developed abdominal pain and asked for gastroscopy. Gastroscopy revealed two 0.5 cm × 0.6 cm spots that can be seen arising from the stomach mucosa which were slightly swollen, slightly black in the center, and without erosion, and no abnormality was found in the other parts. At the same time, a biopsy was taken under a gastroscope and pathology suggests malignant melanoma. The patient could not undergo subsequent treatment due to cost. The patient was followed up until February 2022 and was within the survival period.Malignant melanoma gastric metastasis is extremely rare. When a patient has a previous history of melanoma surgery, this needs to be considered when gastrointestinal symptoms are present, and regular endoscopic screening is recommended. Early surgical treatment and postoperative chemotherapy or combined targeted therapy may improve the prognosis of patients. Malignant melanoma (MM) is a common malignant tumor in the limbs, which is highly invasive, often occurs as metastatic cancer, and has a very poor prognosis . A studyA 60-year-old woman was admitted to our hospital with left plantar pain. The patient found a black maculopapular rash on the left foot with pressing pain, and the pain was aggravated by walking, so she was hospitalized for further treatment. On physical examination, the visible size of the black tumor on the left plantar was approximately 2 × 1 cm, with an outward expansive growth and tough texture, which cannot be pushed and does not touch the blood vessel Figure 1Because the patient has a strong desire to undergo operation, on the second day after admission, the lesion of the left foot was removed under local anesthesia, and the removed tissue was sent for pathological examination. The pathological findings showed that there were nests of abnormal cells in the epidermis and subcutaneous tissue, accompanied by pigmentation. The results of immunohistochemistry were as follows: PCK (−), HMB45 (+), S-100 (+), P53 (+), Ki-67 (+), CyclinD1 (+), Bcl-2 (+), and P16 (+). Combined with immunohistochemistry, it was consistent with MM. During hospitalization, the patient developed abdominal pain and asked for gastroscopy. Gastroscopy revealed two 0.5 cm × 0.6 cm spots that can be seen arising from the stomach mucosa which were slightly swollen, slightly black in the center, and without erosion, and no abnormality was found in the other parts Figure 2MM is clinically a common malignancy originating from the skin and mucosal tissues and is highly malignant . AlthougGenerally, patients with metastatic MM of the stomach have atypical clinical symptoms , includiFrom the perspective of pathological diagnosis, the diagnosis of gastric metastatic MM is extremely rare clinically, and it has various pathological microscopic manifestations, which are really challenging . For micIn patients with malignant melanoma, patients with metastasis are often in the late stage of the tumor, and the median survival time of patients with metastasis or recurrence is less than 10 months . At presMM gastric metastasis is extremely rare. When MM is considered for diagnosis, endoscopic screening should be recommended. Early surgical treatment, postoperative chemotherapy, or combined targeted therapy may improve the prognosis of patients with MM.The datasets presented in this study can be found in online repositories. The names of the repository/repositories and accession number(s) can be found in the article/supplementary material.The studies involving human participants were reviewed and approved by the Tongde Hospital of Zhejiang Province. The patients/participants provided their written informed consent to participate in this study. Written informed consent was obtained from the individual(s) for the publication of any potentially identifiable images or data included in this article.QH designed this study. FZ collected the information and images. QH wrote the manuscript. YS reviewed the manuscript. All authors contributed to the article and approved the submitted version.


The majority of spinal nerve sheath tumors are within the intradural/extramedullary compartment. A subset of these tumors develop extraforaminal components that gradually expand into potential spaces. Herein, the authors provide a 2D video demonstrating the technical nuances concerning resection of cervical dumbbell schwannomas with extraspinal extension. Although nerve sheath tumors with large extraforaminal extension are often associated with complications and pose unique challenges to surgeons, circumferential exposure with intradural exploration allows for gross-total resection and nerve root preservation, without need for adjuvant treatments. The use of intraoperative ultrasound, neurophysiological monitoring, Doppler imaging, and meticulous surgical techniques aided to circumvent complications. This operative video will illustrate the technical nuances for resection of a cervical dumbbell schwannoma. The patient is a 23-year-old female presenting with progressive gait imbalance and left hand and triceps weakness.1 Preoperative CAT scan reveals associated bony remodeling.2Preoperative MRI scan reveals a homogeneously enhancing lesion causing severe spinal cord compression emanating into the left-sided C8 neuroforamen.The surgical plan is as follows.3 We then brought in the ultrasound to confirm that there was, in fact, an intradural component of the tumor.4 Once this was confirmed, we performed a midline durotomy using an 11 blade. 5-0 Nurolon dural tack-ups were then utilized. Neuromonitoring then confirmed that there were no motor branches entering the tumor.6 Because these were felt to be dorsal sensory branches, they were cauterized and divided. Here, we can clearly see the motor root of C8 on the left side. We then closed the inner durotomy on the lateral side with 5-0 Nurolons and 6-0 Prolenes. After the lateral durotomy was closed, we then paid our attention to closure of the midline durotomy using 5-0 Nurolons.After performing standard subperiosteal dissection, we placed lateral mass screws at C4, C5, and C6. We then performed freehand thoracic pedicle screws using the funnel technique. Here, we drill the outer cortex of the pedicle, followed by gear shift, then subsequently freehand screw placement. After the thoracic pedicle screws were placed, we then performed an en bloc laminectomy at C6, C7, and T1. We then performed a complete facetectomy on the left at C7/T1 for exposure of the extradural component of the tumor. We also performed an inferior facetectomy on the left at C6/7. This aided mobilization and exposure of the C7 nerve root. We then cauterized the capsule of the tumor for further mobilization and shrinkage. Here, the C7 nerve root can clearly be seen.7 Interconnecting rods were then placed and final locked.We then brought our attention back to the extradural component of the tumor. It was much easier to mobilize now that the intradural component had been resected. We subsequently performed further cauterization of the capsule for mobilization. We can start to see the scalloped C7 vertebral body here. We then performed internal debulking of the tumor to aid in further mobilization. The ventral and lateral components of the tumor were carefully dissected. The remaining attachments were then cut. Final tumor delivery can be seen here. We then brought a Doppler in to confirm pulsatile flow of the left side of vertebral artery.Postoperative imaging reveals a gross-total resection of the tumor. Hardware position was confirmed with a postoperative CAT scan. Adequate sagittal and coronal cervical balance can be appreciated.The patient had an uneventful postoperative course. She was eventually discharged to inpatient acute rehabilitation for 1 week. At 2-year follow-up, she has continued motor strength improvement in her left upper extremity and lower extremity with resolution of her myelopathic symptoms.We sincerely thank Xian M. Boles, 3D Medical Illustrator at the University of North Carolina Department of Neurosurgery, for the exquisite and skillful rendition of our case.The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this publication.Primary surgeon: Wilkinson, Galgano. Editing and drafting the video and abstract: all authors. Critically revising the work: all authors. Reviewed submitted version of the work: all authors. Approved the final version of the work on behalf of all authors: Ojukwu. Supervision: Galgano.Supplemental Fig. 1The necessary patient informed consent was obtained in this study.


Posterior communicating aneurysm (PCOM) commonly presents with ptosis of the eye. This is so also with space occupying lesion compressing the oculomotor nerve. It is quite uncommon for a patient to have both lesions at the same anatomical space concurrently causing ptosis. If undiagnosed before surgical intervention, surgical complications from such a complex neurosurgical problem can be extremely devastating. We share our recent experience with confusing clinical presentation and subsequent treatment of a sellar brain mass co-existing with a left posterior communicating artery aneurysm at the same location in a 48 years old woman who was successfully managed with left pterional craniotomy and clipping of the PCOM aneurysm followed by gross total excision of the lesion. She improved with full resolution of left ptosis within 2 months. The histology revealed WHO Grade 1 psammomatous meningioma. Although similar sorts of pathologies occurring together have been described in the literature, this unique experience underscores the importance of thoroughly evaluating neurosurgical cases clinically irrespective of findings from radiologic investigations in order to prevent unexpected intra-operative disasters and embarrassment. Moreso, this is important particularly in Africa where advanced investigations to easily identify such complex pathologies are not readily available. PCOM aneurysm is well known to be a common cause of ptosis. This clinical manifestation is also classical with any space occupying lesion compressing the oculomotor nerve. It is quite uncommon for a patient to have combination of both lesions at the same time causing ptosis. Although quite rare, neurovascular lesions could co-exist with brain tumours such as meningioma 29.3-44%), glioma 27.5-38%), pituitary adenoma 11-20.6%), lymphoma, craniopharyngioma, chordoma, epidermoid tumor, dermoid tumour, as well as choroid plexus adenoma [1-20.6%, 9.3-44%, .5-38%, pPatient information: a 48-year-old woman was referred to the facility for a transsphenoidal sellar tumor removal. She was a known hypertensive patient who presented on account of sudden onset of headache with complete left ptosis and diplopia. Her medical, family and other relevant history were not remarkable.Clinical findings: her vital signs were within limits. Clinical examination revealed left oculomotor nerve palsy with ophthalmoplegia. Otherwise, she was fully conscious with no other cranial nerve deficits. Motor and sensory examination revealed no remarkable findings.Diagnostic assessment: brain magnetic resonance imaging (MRI) done prior to presentation showed a sellar space-occupying lesion with homogenous contrast enhancement and a hypointense periphery (eriphery  A,B,C. Heriphery  A,B. EndTherapeutic interventions: she was offered left pterional craniotomy and clipping of the aneurysm (aneurysm  A,B,C foFollow-up and outcome: the histology revealed WHO Grade 1 psammamatous meningioma. Her ptosis completely resolved and she made full recovery.Informed consent: the patient consented to the procedure.This is a clear illustration of the importance of thoroughly evaluating available neuroimaging for each neurosurgical case with the clinical presentation for that case in perspective. In present-day medical practice, there appears to be an increasing over-dependence on imaging among other investigative modalities and less attention to clinical details in arriving at a diagnosis. Although her brain MRI scan revealed a sellar mass, the suddenness of her symptoms is not typically characteristic of brain tumours. Symptoms from brain neoplasm are generally known to be gradually or rapidly progressive depending on the level of aggressiveness while vascular problems are commonly sudden in clinical manifestation. Second, homogenous contrast enhancement and a hypointense periphery  A are noOf the brain tumours associated with cerebral aneurysms in neurosurgical practice, meningiomas are the commonest . SeveralVarious intracranial brain pathologies occurring together have been described in the literature -7. Howev


Developmental cysts are the most common retrorectal area cysts observed in adults. Tailgut cysts tend to be multicystic, and their lining epithelium may display the characteristics of columnar, musin-secreting columnar, ciliated, transitional or squamous epithelia. While the large majority of cysts tend to be benign, several malignant cases have been reported, with adenocarcinoma and carcinoid tumors constituting the more common types of malignant tailgut cysts. A 55-year-old female patient presented to our hospital with complaints of swelling in the gluteal region. Following morphological, histomorphological and immunohistochemical evaluations, a diagnosis of a moderately differentiated adenocarcinoma arising from a tailgut cyst was made. Tailgut cysts are infrequent diseases but adenocarcinoma arising from a tailgut cyst is extremely rare. In rare cases, developmental cysts may undergo malignant transformation that warrants an accurate morphological and histomorphological assessment, as well as numerous samplings, for an accurate diagnosis. The retrorectal or presacral area is defined as the region delimited anteriorly by the rectum; posteriorly by the sacrum; superiorly by the peritoneal reflection; inferiorly by the levators ani and coccygeus muscles; and laterally by the ureters and the iliac arteries . Masses A 55-year-old female patient presented to the General Surgery Outpatient Clinic of the Istanbul University Cerrahpaşa Medical Faculty with complaints of a swelling in the right gluteal area which, while being present since childhood, had gradually started to grow in the past six months. The physical examination of the patient revealed a soft and smooth-surfaced lesion in the right gluteal area that exhibited growth towards the lumen, displacing the vaginal wall on the front side and the anal canal. The patient’s Ca 19-9 value was 204, while other blood chemistry and hemogram results were normal. Magnetic resonance imaging (MRI) revealed a cystic mass lesion 21x16x15 cm in size in the right gluteal region that displaced the anal canal and the distal two-thirds of the vagina, while also deviating the rectum to the left. The lesion had no association with the uterus or adnexa. Medially, the mass reached the external anal sphincter and mesorectum, while reaching the right lateral wall of the vagina and mesorectum superiomedially, and the posterior part of the ischiorectal ramus laterally. The mass was excised as a uniblock through the aspiration of the contained fluids .A 26x11 cm mass of tissue was clearly observed on macroscopic examination and was surrounded by areas of fat tissue and characterized by a brown-colored membrane with a speckled appearance that had a wall thickness that varied between 0.5 and 1.5 cm. There was no multiocularity in the cyst sections. Nearly 50 percent of the cysts’ inner area was constituted of yellow-orange colored areas of 0.1 to 0.2 cm with irregular boundaries, as well as a rough and granular surface.Histopathological examination revealed the inner surface of the cyst to be lined with non-keratinized multi-layered squamous epithelial, columnar epithelial and transitional epithelial cells, while the wall of the cyst contained connective tissue, vascular structures and slight mononuclear inflammatory cell infiltration .The cyst wall was found to have a moderately differentiated infiltrative-type adenocarcinoma with a tubular pattern, and the tumor showed full-level invasion over the entire cyst wall .The tumor exhibited approximately 10 percent necrosis; stromal reaction was apparent, and the walls adjacent to the tumor and the inner surfaces also exhibited xanthogranulomatous reactions. Immunohistochemical (IHC) tests revealed 100 and 90 percent of the tumor cells to be CDX2 and CK20 positive, respectively, while a moderately high level of tumor cells showed CK7 positivity .Based on these findings, the case was diagnosed as a moderately differentiated adenocarcinoma arising from a tailgut cyst.Tailgut cysts normally develop in the eighth week of embryological life from the remains of hindgut involution. While the majority of tailgut cysts occur in the retrorectal area, they may also appear in the anterior rectal, perianal, perirenal and posterior sacral regions.The lining epithelium of these multicystic lesions may have the characteristics of columnar, musin-secreting columnar, ciliated, transitional and squamous epithelia, with walls of smooth muscle clusters, constituted of fibrous tissue, fat tissue and disorganized bands. No myenteric neural plexus has been identified to date in such cysts. They can be accompanied by granulomatous reactions, which are often associated with an inflammatory infiltrate constituted of mononuclear cells, and more rarely with foreign body-type giant cells . The majority of cases are in the adult age group, although several cases in childhood or infancy have also been reported. Their distinction from other retrorectal cysts is difficult through imaging methods. In contrast to epidermal and rectal duplication cysts, which tend to be unilocular, tailgut cysts exhibit a multilocular appearance on radiological imaging, and thin calcification has also been observed on their walls in rare instances. A definite diagnosis requires histopathological assessment.Epidermoid cysts, another type of cyst, have lining epithelia with squamous characteristics. In the presence of skin adnexa on the cyst wall, they are defined as dermoid cysts, and this tends to be their most important histologically distinguishing feature. The cyst walls contain no smooth muscles ,4,5, andWhile the large majority of developmental cysts tend to be benign, several malignant cases have also been reported. Adenocarcinoma and carcinoid tumors constitute the more common types of malignant tailgut cysts, although cases of neuroendocrine carcinoma, adenosquamous carcinoma, squamous cell carcinoma, endometroid carcinoma and sarcoma have also been reported ,5,7–9.Based on the strong p53 and Ki-67 positivity and p21 negativity observed in the dysplastic epithelia of two cases with adenocarcinoma arising from the tailgut, it has been suggested that their sequence of dysplasia and carcinoma follows a similar pattern to that of colon adenocarcinoma .In conclusion, the origin and classification of tailgut cysts continue to be a matter of debate. To date, malignant transformations have been reported in 32 tailgut cysts in the literature, and most of these cases were adenocarcinoma or neuroendocrine tumors, while a few rare cases were carcinoid tumors. Following macroscopic and microscopic examination, we identified a moderately differentiated adenocarcinoma arising from the tailgut, leading us to believe that the accurate identification of areas of malignant changes in these lesions requires a detailed macroscopic examination along with numerous samplings.


The epidemiological profile of adenomyosis has drastically changed in recent years due to advancements in imaging techniques. Even though adenomyosis is not uncommon in women of childbearing age, we present an intriguing case of a 30-year-old woman with long-standing progressive dysmenorrhea and infertility who had a posterior wall exophytic adenomyomatous polyp with full-thickness pseudo-invasion out of the uterine serosa into the right ovarian endometriotic cyst, mimicking malignancy. After surgical excision, the patient spontaneously conceived and delivered a live-term baby, soon after which she experienced an early recurrence. Clinicians must be aware of the distinctive features of different subtypes of adenomyosis to plan treatment and avoid invasive surgery. Adenomyosis represents the benign invasion of the endometrial glands and stroma into the myometrium . BecauseA 30-year-old Indian woman, nulligravida, married for one year, anxious to conceive, presented with long-standing, progressive, and severe dysmenorrhea, lasting up to five days of menses, not relieved with medical management. She had regular menstrual cycles with moderate flow. There was no history of chronic pelvic pain, dyspareunia, bowel, or bladder symptoms. Four years ago, she underwent a laparoscopic cystectomy for a symptomatic left ovarian endometriotic cyst measuring 11.1 x 7.8 x 8.8 cm.A bimanual pelvic examination was done, which suggested a retroverted uterus corresponding to 8-10 weeks of gravid uterus size, with posterior and right forniceal fullness, fixed to the uterus, and non-tender. No nodularity was felt in the pouch of Douglas (POD) and uterosacral ligaments. 2D and 3D TVUS was performed, which suggested a retroverted bulky uterus measuring 11.0 x 5.0 x 8.3 cm with a focal ill-defined cystic heterogenous intra-myometrial lesion measuring 5.2 x 4.1 cm in the posterior uterine wall, penetrating the serosa -125 level was 249.50 U/mL, serum lactase dehydrogenase (LDH) was 176 U/L (reference range: 208-378 U/L), and anti-mullerian hormone (AMH) was 4.06 ng/mL. A presumptive diagnosis of extrinsic adenomyoma was made. The differential diagnosis was cystic degeneration of the fibroid, ovarian carcinoma, or uterine leiomyosarcoma.Given the concerning imaging features, the patient underwent laparotomy. Intraoperatively, the uterus was pushed anteriorly by a large right endometriotic cyst adherent to the posterior wall of the uterus and the rectosigmoid. After adhesiolysis and right endometriotic cystectomy, a polypoid soft lesion with intra-mural extension breaching through the right posterolateral uterine serosa was noted Figure . The samPost-surgery, the patient was advised periodic follow-up and assisted reproduction, given the increased risk of recurrence of adenomyoma and endometriosis, even though she had a higher EFI score. She was given one dose of leuprolide acetate 11.25 mg depot and advised to continue dienogest 2 mg tablets until she was ready to plan pregnancy.The patient was lost to follow-up post-surgery. Two years later, she again reported to our clinic with complaints of severe dysmenorrhea. She stopped taking dienogest tablets and conceived spontaneously five months after the surgery. She delivered a live-term male baby weighing 2.8 kg through an elective lower-segment cesarean section six months ago. The antenatal, intrapartum, and postnatal periods were said to be uneventful.TVUS followed by MRI pelvis was done, which was suggestive of a larger well-circumscribed multiloculated T2 hypointense mass at the same site, showing multiple fluid-fluid levels and areas of gradient recalled echo blooming, measuring 7.8 x 5.7 x 5.6 cm, suggestive of cystic adenomyoma, again with the posterior serosal breach, abutting the right endometriotic cyst, measuring 4.8 x 5.5 x 5.0 cm Figure , 2D. TheThe patient was advised total hysterectomy with bilateral endometriotic cystectomy because of the sizeable exophytic adenomyoma, recurrent endometriosis, and persistent severe pain. Since the patient insisted, we planned a fertility-preserving surgery. Extensive rectosigmoid adhesions were noted during laparotomy, and the same was released. Bilateral ovarian endometriotic cysts were excised. Chocolate-brown colored fluid drained from the exophytic cystic adenomyotic growth Figure . It was Histopathology was once again consistent with adenomyoma. The patient was counseled for strict periodical follow-up and started on dienogest tablets (2 mg once daily) for six months. She was asymptomatic in the follow-up period, and we planned to continue long-term hormonal treatment until the patient plans for the subsequent pregnancy.To the best of our knowledge, this is the first case of a pseudo-invasive posterior wall subserosal adenomyomatous polyp documented in the literature. Adenomyosis is a heterogenous condition that may manifest in various forms. There have been reports of adenomyomatous endometrial polyps in the literature, and it is essential to note that the risk of endometrial cancer is 16% with atypical endometrial polypoid adenomyoma . In 1991Kishi et al.  threw liExtrinsic adenomyosis was found to be frequent in the posterior wall of the uterus (96.1%), closely associated with pelvic endometriosis with POD obliteration (96.1%) and ovarian endometrioma (66.7%). In 72.5% of extrinsic adenomyosis, a teardrop deformity of the rectum, in which the rectum is dragged up toward the uterus instead of the usual round shape, was observed during MRI. Marcellin et al. also reinforced that 56.5% of deep infiltrating endometriosis (DIE) patients had focal adenomyosis of the outer myometrium diagnosed by pre-operative MRI . Their cThus, it is hypothesized that pelvic endometriosis initially forms utero-rectal adhesion, resulting in the obliteration of POD, and then invades the rectum posteriorly and disrupts the uterine serosa anteriorly. This "outside-to-inside invasion"  from an The presence of endometrioma poses a difficulty in counting the antral follicles by TVUS , as theyFertility-preserving excision of focal adenomyosis can be done with either laparoscopy or laparotomy. Both of which have specific advantages and disadvantages. During surgery, the distinction between adenomyoma and healthy myometrium can be better done by palpation, facilitating complete excision. Given the concerning imaging findings, laparotomy was performed in this case. The aim was to thoroughly resect the lesions to prevent recurrence and meticulously reconstruct the uterine defect, which is more critical to avoid uterine rupture during subsequent pregnancy. Even though laparoscopy is associated with fewer postoperative complications, including pain, and shorter hospital stay, it also involves the risk of upstaging of malignancy if present, incomplete adenomyoma excision, inadequate reconstruction of the uterine wall, concerned use of the morcellator for retrieval of the specimen, and higher risk of uterine rupture during pregnancy when compared to laparotomy. The factors attributing to uterine rupture are the method of removing adenomyosis , extent of resection, resultant myometrial defect and its proper reconstruction, postoperative complications, the interval between the surgery and pregnancy, and skill of the surgeon. The risk of uterine rupture during pregnancy following adenomyomectomy is more than 1.0% compared to 0.26% post-myomectomy . Hence, For secondary prevention, we counseled the patient for regular follow-up and the need for long-term hormonal treatment. While choosing the medical treatment for endometriosis, a pragmatic approach must be followed considering the efficacy, side effects, tolerability, adherence to the treatment, costs, and women's preferences. Continuous oral low-dose monophasic estrogen-progestin hormonal contraception, progestogens like depot medroxyprogesterone acetate, medroxyprogesterone acetate, norethisterone acetate, desogestrel, and dienogest, or levonorgestrel-releasing intrauterine system can be recommended. The unfavorable side effect profile limited the long-term use of GnRH agonists and oral antagonists .This patient had an exophytic adenomyomatous polyp, which progressed to a cystic adenomyoma despite the primary surgery and amenorrhea induced by pregnancy and lactation. Both are rare manifestations of adenomyosis. Hence, the distinctive imaging features and various MRI-based subtypes of adenomyosis ,12, whicThe presence of an exophytic pseudo-invasive subserosal adenomyomatous polyp protruding into the ovarian endometrioma is a relatively rare condition. These lesions may mimic cystic degeneration of fibroid, leiomyosarcoma, and ovarian malignancy, borderline ovarian tumors. It highlights that pelvic endometriosis may be the precursor for extrinsic adenomyosis, and their co-existence represents a significant decisive point in integrating the diagnostic strategy and treatment planning. Clinicians must be aware of the distinct features of relatively new MRI-based subtypes of adenomyosis to avoid overdiagnosis and invasive treatment. Shared decision-making, proper pre-operative consent, adequate information to the patient and physician during the pregnancy succeeding adenomyomectomy, and long-term medical management are crucial.


The management of concomitant complications after OAGB is challenging. We aim to show the surgical management of two concomitant complications after one anastomosis gastric bypass: internal hernia and anastomotic ulcer perforation.2, respectively. Clinical examination showed generalized peritonitis, computed tomography showed pneumoperitoneum, diffuse peritoneal effusion, and rotation of the superior mesenteric vessels indicative of an internal hernia.We present the case of a 32-year-old woman with BMI of 51 kg/m2, who underwent OAGB. Three years later, she presented with intense and brutal epigastric pain. She was a heavy smoker. Her weight and BMI were 75 kg and 26 kg/mA generalized biliary peritonitis secondary to a perforated ulcer on the gastrojejunal anastomosis and internal hernia of the common loop into a large Petersen orifice were diagnosed. The internal hernia was reduced, and a perforation of the posterior surface of the gastrojejunal anastomosis was identified. Surgical treatment consisted in the placement of a Kehr’s drain into the perforation, closure of the Petersen orifice, and lavage-drainage of the peritoneal cavity. The postoperative course was uneventful, and she was discharged on postoperative day 12. The Kehr’s drain was removed 1 month after discharge.The combination of two different complications after OAGB can make the pre- and intra-operative judgment difficult and hamper the therapeutic approach. The initial reduction of the internal hernia made it possible to reduce the pressure in the surgical assembly and facilitated the treatment of the anastomotic perforation.The online version contains supplementary material available at 10.1007/s11695-023-06562-x. The one anastomosis gastric bypass (OAGB) is a well-established bariatric procedure, with some theoretical advantages over the Roux-en-Y gastric bypass such as a lower rate of anastomotic ulcers and internal hernias . Our terWe present the case of 32 years old patient who underwent OAGB with a 150 cm biliary loop in 2014 for morbid obesity, with a BMI of 51 kg/m2. She was a heavy smoker. Three years after the initial procedure, she presented with intense and brutal epigastric pain. Her weight and BMI were 75 kg and 26 kg/m2, respectively. Clinical examination showed generalized peritonitis, computed tomography showed pneumoperitoneum, diffuse peritoneal effusion, and rotation of the superior mesenteric vessels indicative of an internal hernia. Urgent laparoscopy was performed. No endoscopic option was possible due to the peritonitis.A generalized biliary peritonitis secondary to a perforated ulcer on the “anterior surface” of the gastrojejunal anastomosis and internal hernia of the common loop into a large Petersen orifice were diagnosed. A careful and relatively easy reduction of the common loop from the cecum was performed. The OAGB was de-rotated by 180°, the perforation of the “anterior surface” was in fact a perforation of the posterior surface of the gastrojejunal anastomosis. Surgical treatment consisted in the placement of a Kehr’s drain in the perforation, closure of the Petersen orifice, and lavage-drainage of the peritoneal cavity. The postoperative course was uneventful and she was discharged on postoperative day 12. After CT scan control with oral contrast administration, the patient eats quickly with the T-tube in place, first soft food then solid.The Kehr’s drain was removed 1 month after discharge.The initial therapeutic tactic aimed to restore the normal anatomy of the bypass, first reducing the internal hernia before treating the ulcer perforation. The internal hernia can be asymptomatic because the opening of the Petersen defect is broad. In our experience, the rate of internal hernias requiring surgery is 3% after OAGB , 2, 4.This latex drain causes inflammation and scar tissue formation. The Kehr’s drain was retired one month later with an excellent clinical outcome.The combination of two different complications after OAGB can make the therapeutic approach challenging. The initial reduction of the internal hernia made it possible to reduce the pressure in the surgical assembly and facilitated the treatment of the anastomotic perforation.Supplementary file1 (MP4 169328 KB)Below is the link to the electronic supplementary material.


Superior lumbar hernias are extremely rare, and surgical repair is essential for their treatment. However, the direct observation of the hernial orifice is frequently difficult because the hernia disappears in prone or lateral positions, which is an issue when using the open approach. Therefore, using anatomical landmarks to detect the hernial orifice on preoperative CT scans may be useful for correct identification and visualization. Here, we report two cases of superior lumbar hernias successfully treated using the abovementioned method. Lumbar hernias (LHs) are extremely rare hernias where abdominal contents protrude through a defect in the dorsal abdominal wall, of which approximately 300 cases have been reported to date . SuperioSurgical repair is the most effective treatment for LHs . HoweverIn this case report, we describe two cases of SLHs that underwent open-approach repair using anatomical landmarks to identify the hernial orifice with the assistance of preoperative imaging. Furthermore, we aimed to help develop surgical strategies to overcome the difficulties associated with this type of hernia.Case oneAn 80-year-old male patient with a history of myocardial infarction, idiopathic thrombocytopenic purpura, and laparoscopic cholecystectomy was referred to our hospital. He reported the presence of a protruding mass in the right lumbar area for one week without any preceding episode of trauma. On physical examination, a soft mass measuring 40 × 40 mm and protruding in the standing and sitting positions was observed at the right costovertebral angle. However, the protrusion disappeared in the prone and lateral positions Figure .Ultrasonography revealed a retroperitoneal adipose tissue mass. CT and MRI showed a right SLH. The patient underwent a hernioplasty for the right SLH. The hernial orifice, oriented in relation to the right 12th rib and processus spinosus of the third lumbar vertebrae, was preoperatively marked according to the CT scan for correct detection Figure . The patCase twoA 90-year-old female patient with a medical history of cerebral infarction and a hiatal hernia, although generally self-reliant, presented with a protruding mass in the left lumbar region. Physical examination revealed a round and soft protruding mass beneath the 12th rib of the left upper flank area. The mass easily reduced and protruded while sitting. However, the mass disappeared in the prone and lateral positions Figure . UltrasoConsidering the potential risk of strangulation, the patient underwent a hernioplasty. The hernial orifice, oriented in relation to the left 12th rib and left processus transversus of the third lumbar vertebrae, was marked preoperatively according to the CT scan for correct detection. An open hernioplasty was performed with the patient in the right lateral position via a 4-cm skin incision. A 2.5-cm hernial orifice was identified, and the hernial sac was dissected and ligated. A 10.2-cm diameter Bard® Modified Kugel® Hernia Patch Direct sub-lay mesh was placed into the retroperitoneal space, and the strap was fixed to the hernial orifice with a 3-0 braided absorbable suture Figure . The patA significant clinical issue in repairing SLHs is correctly identifying and visualizing the hernial orifice. Generally, the patient is positioned in the prone or lateral position during LH repair . In caseLaparoscopic hernioplasties using a mesh that enables easy visualization of the hernial orifice have recently been reported . HoweverTension-free mesh hernioplasty using an open approach based on radiographic hernial orifice identification is a simple and feasible technique for treating SLH. SLH is an extremely rare condition. Therefore, our report may be helpful to surgeons treating SLHs.Furthermore, the small incision directly above the hernial orifice is effective, with minimal tissue dissection necessary, and ensures the exact placement of the mesh. Nevertheless, further studies are required to validate the efficacy and superiority of these findings.


Midgut volvulus is a rare incidence in adults, especially in octogenarians. More unlikely is to find a midgut volvulus without necrosis or the need to do bowel resection when the volvulus is found within an internal hernia due to a mesenteric defect. No case has been reported with our unusual presentation, making it a rare and challenging discovery. We describe the case of an 83-year-old male who presented with nonspecific symptoms and was found to have a midgut volvulus with an internal hernia through a mesenteric defect, which had a successful recovery at the end. Midgut volvulus is a torsion of the small bowel that, upon diagnosis, is a surgical emergency due to vascular compromise of the abdominal area. Midgut volvulus is mostly found in infants due to congenital gut malrotation during embryogenesis . BecauseIn this case report, we discuss an elderly male patient with an unusual midgut volvulus at the age of 83 years who presented with nonspecific symptoms, and imaging results showed small bowel volatilization around the superior mesenteric artery (SMA) due to internal herniation secondary to a mesenteric defect, which, with a lot of difficulties, we managed to retrieve the patient's baseline functioning within three weeks postoperatively. Thus, a high index of suspicion and a prompt surgical exploration for its correction are essential.The patient was an 83-year-old Hispanic male with a past medical history of hypertensive disorder, pulmonary fibrosis, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease (GERD), and psychotic disorder. Past surgical history consisted of bilateral hip arthroplasties. The patient presented to the Emergency Department from an Assisted Living Facility (ALF) due to respiratory distress. The patient was a poor historian and denied any symptoms or findings. He was given solumedrol IV (corticosteroid) and bronchodilator therapy, where his respiratory distress improved. Upon evaluation by the internal medicine service, the patient was admitted for further observation. During his progression in observation, the patient was found to have gradual distension of his abdomen as well as associated abdominal discomfort. The primary team initiated the placement of a nasogastric tube (NGT) and computed tomography (CT) scan to rule out any intra-abdominal pathology. General surgery was consulted immediately after the findings of a significantly severely distended stomach as well as a fluid-filled distal esophagus with a distended duodenum in the proximal portion of the jejunum with the collapse of the remainder of a small bowel and concern for twisting of the superior mesenteric vessel and the mesentery showing some fat stranding and concern of midgut volvulus Figures -2.Upon evaluation by the surgical team, the patient was found with abdominal distension and discomfort. Surgical intervention was discussed for the need for an exploratory laparotomy. The proxy signed informed consent.We initiated our procedure by performing a midline laparotomy incision. We initially noted a significant decompressed small bowel. We initiated proximally at the ligament of Treitz to run the bowel upon our meticulous approach for the running of the small bowel of the jejunum, where we noticed that a large internal herniation of the majority of the small bowel went through a mesenteric defect. The terminal ileum was surrounded by dense adhesions at the root of the mesentery of the small bowel, in the area of herniation. Additionally, the small bowel was rotated greater than 180° around the engorged superior mesenteric pedicle Figure . We alsoThere were adhesions at the root of the small bowel, tightly encasing and involving the adjacent small bowel mesentery. By meticulous dissection, we freed the terminal ileum and the ileal segment from the surrounding mesenteric adhesions, and a defect was then clearly visualized. The reduction of the internal herniation and volvulization of the small bowel was performed carefully until the entirety of the bowel was devolvulized. The mesenteric defect was then approximated using 3-0 Vicryl stitches in a continuous running suture. We reexamined and ran the small bowel to ensure appropriate anatomical placement.We began the procedure at the level of the ligament of Treitz, taking a meticulous approach to trace the small bowel down to the terminal ileum. During this examination, we ensured that no additional mesenteric defects were identified. However, further examination of the small bowel raised concerns regarding its perfusion. As a result, a decision was made to perform a small bowel resection of approximately 10 cm using a linear GIA stapler. Subsequently, an end-to-end stapled anastomosis was created. The patient had no perioperative complications. The patient remained intubated and was taken to the intensive care unit (ICU) for postoperative care. Six days after the procedure was done, a small bowel series demonstrated normal course and transit contrast material through the small and large bowel loops with no evidence of small bowel obstructions. During the patient's stay at the ICU, several attempts were made to start the patient on oral feedings. The patient failed his first barium swallow test. After 48 hours, the test was repeated, and this time he successfully passed. After 20 days, the patient was transferred to the medicine floor, where the trickle feedings started, and he was later discharged to a nursing home for long-term care.whirl sign, which is a hallmark of midgut volvulus. The whirl sign denotes the pattern of the mesentery, and SMV is rotated clockwise around the SMA [Midgut volvulus is more commonly presented in infants and children but rarely in adults. It is roughly estimated that the incidence of this disease in adults is 0.2% to 0.5%, which decreases with age. Clinical presentations of midgut volvulus in adults are rare. Some adults may be asymptomatic, which may lower the incidence rate of the disease. It has been documented in previous cases that the disease can present with recurrent pain, intermittent obstruction, and malabsorption over months to years . These s the SMA ,5. CasesA small bowel volvulus can be primary (rare) or secondary to many other factors . Predisposing conditions include malrotation (failure of the bowel to undergo counterclockwise rotation during embryogenesis), congenital bands, postoperative adhesions, tumors, intussusception, or internal hernia ,6. ShettSome physical examination findings of a patient with advanced midgut volvulus are concerning and suggest major complications. Coste et al. stated that signs of peritonitis may be suggestive of intestinal ischemia with edema and erythema of the abdominal wall. The most prevalent symptom in older children and adults is the abrupt onset of abdominal pain. The abdominal pain can last hours to days or can be chronic intermittent pain for weeks, months, or years. Other symptoms include chronic diarrhea, intermittent vomiting, malabsorption, and failure to thrive. If the patient is found to have a necrotic bowel, it can be conservatively resected to ensure adequate length for feeding and preventing short gut syndrome. Delaying the diagnosis of midgut volvulus can lead to serious consequences such as short gut syndrome requiring intestinal transplantation or death . A surgical Ladd's procedure is the surgical intervention used in cases like this. This procedure consists of four parts: detorsion of any midgut volvulus in the counterclockwise direction; division of Ladd's bands overlying the duodenum, relieving the source of intermittent obstruction; mobilization of the duodenum to widen the narrowed small bowel mesentery; and division of adhesions around the SMA to prevent further volvulus. In cases where there is malfixation and the small bowel is normally located, currently, there are no identified surgical means to prevent midgut volvulus. There is a high risk of these patients developing complications, such as bowel obstruction, in the future . AccordiTo date, we could not find a case presenting a mesenteric defect with internal herniation and small bowel volvulization around the SMA without signs of necrosis. This is the first reported case of its kind, involving an octogenarian male who presented to the emergency department with nonspecific symptoms and survived the extent of the surgical procedure without complications. A possible cause could have been the mesenteric defect found in the operating room, where there were findings of internal herniation. This case shows the importance of advanced imaging technology such as CT scans for proper diagnosis and treatment. The procedure of choice for midgut volvulus will be Ladd's procedure, where the procedure reduces symptoms and helps prevent further development of this disease. Furthermore, the importance of documenting these types of cases is to show that they do occur in adult patients and it is important to diagnose and treat them appropriately. We aim to ensure that physicians recognize this rare presentation and decrease the morbidity and mortality in adults with midgut volvulus.


Bronchial schwannomas are rare tumors that arise from Schwann cells and account for a very small percentage of primary lung tumors. This case report describes a rare incidental finding of a bronchial schwannoma discovered in the left lower lobe secondary carina via bronchoscopy in a 71-year-old female who presented with minimal symptoms. Schwannomas are benign tumors arising from the Schwann cells of the peripheral nervous system. Schwannomas are most commonly found in the upper limbs, the head, the trunk, and the flexor surfaces of the lower extremities . SchwannA 71-year-old Caucasian female with a past medical history of COPD, hyperlipidemia, peripheral vascular disease, and syndrome of inappropriate antidiuretic hormone was referred to pulmonology for evaluation of an abnormal CT chest that had identified left mainstem endobronchial debris versus tumor. At the time of pulmonology evaluation, the patient was mostly asymptomatic, presenting with only a chronic smoker’s cough with occasional phlegm production. Given that this patient had a history of one pack of cigarettes every day for 50 years, a repeat CT chest was obtained which showed a persistent left mainstem endobronchial lesion as shown in Figure Histologic examination revealed well-defined submucosal, bland spindle cell proliferation with cells arranged in vague fascicles and demonstrating tapered nuclei with focal palisading and eosinophilic cytoplasm as shown in Figure Schwannomas have been documented to occur throughout the body, including the head, neck, trunk, and extremities . The tumSchwannomas presenting in the bronchial tree are typically diagnosed in adults and may remain asymptomatic until they have grown to a significant size . In someHistopathological examination is essential for the definitive diagnosis of bronchial schwannomas. Microscopically, these tumors are characterized by spindle cells arranged in fascicles, with nuclear palisading. Additionally, positive staining for S-100 protein helps to support the diagnosis .Bronchial schwannomas are best treated with surgical resection, which offers a favorable prognosis and low risk of recurrence . In caseBronchial schwannoma should be considered as a possible differential diagnosis of pulmonary masses, even in asymptomatic patients. Small bronchial schwannomas may not be detected through non-invasive imaging and patients may not exhibit symptoms until the tumor has grown to a significant size. The prognosis for benign tumors is excellent, with complete surgical resection as the preferred treatment option.


Surgical clip migration post-laparoscopic cholecystectomy is a rare but important complication to consider in patients presenting with biliary obstruction. Titanium surgical clips are widely used in laparoscopic surgery to ligate vessels and ducts and are particularly important in laparoscopic cholecystectomy to ligate the cystic duct. More common complications associated with clips involve dislodgement, however, there are reported cases of migration into visceral structures causing an obstruction. We describe a case that demonstrated an acute migration of surgical clips into the common bile duct (CBD) within a three-week period, which occurred 32 years after laparoscopic cholecystectomy, likely attributed to erosion. On the patient's first presentation, she had acute pancreatitis with a CT demonstrating clips in the correct position. Three weeks later, the patient presented a second time with acute cholangitis and the repeat CT demonstrated the clips in the CBD. We hypothesize that the erosion of the bile duct is due to the pressure effects from either intra-abdominal organ movements or subtle clip movements, and eventually, persistent erosion leading to intra-ductal migration of the clips with the passage of the clips along the path of least resistance into the CBD, resulting in biliary obstruction. Management included standard treatment for biliary obstruction with intravenous broad-spectrum antibiotics and endoscopic retrograde cholangiopancreatography with excellent outcomes. Surgical clip migration after laparoscopic cholecystectomy is a rare complication. The first laparoscopic cholecystectomy was performed in 1985 by German surgeon Dr. Erich Mühe in Böblingen, Germany [A 70-year-old woman presented to a metropolitan tertiary hospital with acute pancreatitis. This was in the background of a laparoscopic cholecystectomy performed 32 years ago for cholecystitis. She was otherwise well, with no significant past medical history, and reported no alcohol intake. She presented with a two-day history of epigastric pain and vomiting. Biochemical results demonstrated obstructive liver enzymes, with a bilirubin of 151 µmol/L and serum lipase level greater than 1000 U/L. She was investigated with an ultrasound abdomen, computed tomography (CT) abdomen and pelvis, and magnetic resonance cholangiopancreatography (MRCP), all of which did not show choledocholithiasis or cholelithiasis, with a normal biliary system. Of note, the CT also confirmed the previous cholecystectomy with a surgical clip in the expected position  400, alkaline phosphatase (ALP) 260), hyperbilirubinemia (90 µmol/L)), and an elevated serum lipase level of 6500 U/L. She was also bacteremic. Blood cultures were positive for Streptococcus mutans. Another CT abdomen and pelvis was performed, and this demonstrated surgical clips that were placed during the cholecystectomy had displaced, eroded, and migrated into the distal CBD with resultant proximal extrahepatic and intrahepatic duct dilatation  was performed. Purulent bile, two stones, and three clips were found within the CBD Figure . A sphinThe patient was followed up in the outpatient clinic four months after her second admission. She had been able to return to her baseline function and activities of daily living, with no further reported episodes of abdominal pain.Surgical clip migration after laparoscopic cholecystectomy was first reported in 1992 . The mosThe causes of clip migration remain unclear. One hypothesis suggests that the erosion of the bile duct is due to the pressure effects from either intra-abdominal organ movements or subtle clip movement. Eventually, persistent erosion leads to intra-ductal migration of the clips with the passage of the clips along the path of least resistance . Once inIn this case, we postulate that the clip may have eroded over time, leading to the formation of stones within the cystic duct. The patient’s first presentation was potentially due to the passage of microlithiasis or radiologically translucent stones causing pancreatitis. The local inflammation and pressure effects may have resulted in an impetus for further clip erosion. The second presentation is attributable to the passage of the clips. Biliary obstruction and dislodgement of clips at the distal CBD would have caused pancreatic duct irritation, acute pancreatitis, and subsequent acute cholangitis. Based on the intervals of the scans, we can infer that the displacement of clips occurred within a three-week period.Management of this case was based on the principles of management of acute pancreatitis and acute cholangitis. In the first presentation, as there was no radiological evidence of biliary obstruction and an improvement of biochemical findings of obstructive liver enzymes, it was appropriate to manage expectantly. The second presentation required more involved management of cholangitis and intervention with ERCP, as is routine with obstructive jaundice secondary to choledocholithiasis.ERCP was useful in this case for clearance of the CBD and should be considered in the first instance. If initial attempts are not possible for clearance, a biliary stent should be considered for source control of sepsis. A repeat ERCP could be performed at a later stage for clearance of the CBD once oedema from pancreatitis has settled. Other options such as operative or percutaneous approaches should be reserved for settings where endoscopic approaches are not feasible or there are clinical contraindications against endoscopic approaches.This case highlights the need for consideration of the rare yet important differential of migrated surgical clips as the cause of biliary obstruction at any timeframe after laparoscopic cholecystectomy. It is suggested that retained foreign bodies, such as surgical clips, can erode and migrate through intra-abdominal tissues due to inflammatory reactions of tissues against the foreign body. Management is no different from any other routine presentation of biliary obstruction and cholangitis with an ERCP.