Colonic volvulus, where the colon twists around its mesentery, commonly occurs in the sigmoid and cecum. However, colonic volvulus of the splenic flexure is quite rare. Reported cases are limited but suggest that prolonged constipation in patients with either congenital anomalies, history of prior abdominal surgery, and or psychiatric history are described as common risk factors for large bowel volvulus. Here, we discuss a case of a 56-year-old man with a history of chronic constipation and no previous abdominal surgeries who presented to the emergency department with abdominal pain and distention. Further workup including a computed tomography imaging and decompressive via limited colonoscopy confirmed diagnosis of colonic volvulus of the splenic flexure. Surgical management of colonic volvulus is patient specific but invariably involves partial colectomy, as was performed in this case. Intestinal volvulus entails a portion of the gastrointestinal tract rotates along its mesentery. The affected portion of the bowel can therefore be at increased risk for arterial and/or venous occlusion, and bowel obstruction. A volvulus can occur in any portion of the colon, where it is not attached to the retroperitoneum . This isSFV can be categorized into both primary and secondary etiologies. Both comprise of hypermobility of the splenic flexure with torsion around its mesentery due to mobilization of the descending colon from retroperitoneal attachments, as opposed to the absence or laxity of phrenicocolic, gastrocolic and/or splenocolic ligaments .A 56-year-old male with history for chronic constipation, and no previous abdominal surgeries presented to the emergency department complaining of intermittent abdominal pain and distention. His vital signs were within normal limits. On examination, the abdomen was noted to be distended, tympanic, non-tender without guarding or rebound tenderness.Laboratory evaluation showed no significant leukocytosis and hemoglobin was also noted to be within normal limits.A computed tomography (CT) additionally revealed moderate distention of the transverse segment of colon , abnormaThe patient underwent a decompressive colonoscopy, a segment of volvulus was decompressed at the area of the splenic flexure and transverse colon. After endoscopic decompression, the colon was then prepped for elective surgical resection. The patient underwent an open left hemicolectomy, end to end colo-colonic anastomosis and intraoperative sigmoidoscopy. The twisted splenic flexure was noted to be redundant, medially displaced, with proximal dilation of the transverse colon and cecum noticed.Several thin adhesive bands were found, attaching the antimesenteric portion of the splenic flexure medially onto the colon mesentery. These adhesions were carefully taken down, restoring the splenic flexure to its normal position and the remainder of the bowel was thoroughly inspected prior to resection of the descending colon, no obvious masses or abnormalities were appreciated. Diet was slowly advanced with the return of bowel function. He was subsequently discharged to a skilled nursing facility for further recovery.Volvulus of the colon is the second most common cause of large bowel obstruction. The affected portion of bowel may become entirely or partially obstructed, and is at increased risk of ischemia . In mostSFV can be classified as primary or secondary etiologies. Primary SVF is associated with congenital anomalies, including absence or laxity of splenic ligaments, congenital bands and a wandering spleen. Secondary etiologies of SFV comprise two-thirds of SFV cases, and are caused due to underlying disruption of ligaments, mobilization of the splenic flexure or adhesions from prior surgeries .There are many risk factors associated with the development of SFV and they coincide with the primary and secondary etiologies. For individuals affected by a congenital anomaly, the main risk factor is chronic constipation, and others include Hirschprung’s disease, and cerebral palsy or myotonic dystrophy. In terms of the development of secondary SFV, the main predisposing cause is related to previous abdominal surgery involving the splenic flexure.Patients present with sudden onset of large bowel obstruction, abdominal pain, distention, constipation, nausea and vomiting . PhysicaThree important components that can assist in diagnosis include: patient’s history, examination findings and radiological findings, with CT having the highest sensitivity and specificity , 5.Plain abdominal X-ray typically reveals several characteristic features of SFV, including dilated large bowel loop with sudden termination at the splenic flexure , 2, 5. IThe management of a SFV is dependent on clinical factors, mainly revolving around the presence or absence of peritonitis and or hemodynamic instability. If peritoneal signs are present, emergency surgery is required . In the For high risk or elderly patients, there is a less invasive option known as colopexy.Splenic flexure volvulus is a very rare type of colonic volvulus usually seen in patients with chronic constipation or history of previous surgical mobilization. Identifying this disease process requires a high index of suspicion, as missed diagnosis can have detrimental consequences including bowel ischemia and perforation. Approach to managing this rare cause of colonic obstruction varies, depending on clinical presentation. Usual surgical intervention results in resection to decrease the risk of recurrence.


Scalp avulsion injuries are one of the life‐threatening traumatic injuries. Rapid management in the emergency department is vital to the successful rescue of an avulsed scalp. There are many replantation methods to treat scalp avulsion, so the best aesthetic and functional results are achieved. Skin grafting, free flaps, microvascular surgery, and hyperbaric oxygen are all suitable for reconstructive plans. We report a rare case of a scalp avulsion injury in a female due to an entanglement of a headscarf in a motorized machine resulting in defects and tissue loss of the hair‐bearing skin, nasal area, forehead, left ear, and bilateral eyelids and eyebrows. Preoperative management included early blood transfusion, intravenous fluids, and wound compression after rapid physical examination. Reconstructive surgery was performed using a full‐thickness skin graft and the outcomes were pristine. There are no clear guidelines to determine which reconstructive method is superior to another in each condition. Our case demonstrates that relatively primitive methods like skin grafting can give greater results if done with circumspection. Scalp ruptures are uncommon but serious. Severe traumatic injuries such as dog bites, high‐speed road collusions, or industrial accidents can damage hair‐bearing units and may result in an avulsion of the whole layers of the scalp.It is important to conduct a comprehensive examination of the body before starting treatment. Some injuries will be fatal if left untreated such as pleural effusion, pneumothorax, and intracranial hemorrhages. Hypovolemic shock may be seen in such injuries and must be detected and managed early by both blood and fluid administration.Avulsions of the scalp are painful and difficult to treat. The most successful and available therapeutic option is surgical replantation. However, failure of this process leads to undesirable results such as thermal wounds, infection, prolonged hospitalization period, and bad cosmetic outcomes.In this paper, we present a 10‐year‐old girl that had her scalp ruptured due to an electric bicycle accident. This avulsion extended to involve other structures. Such extensive injury with its management and outcome is a rare encounter in the literature.2A 10‐year‐old girl presented to the emergency department with a complete scalp avulsion as a result of an electric bicycle injury. Initial observation ,The main reason we went for full‐thickness graft is the lack of proper equipment at our hospital. Microvascular surgery, free flaps, or HBO2 therapy were all out of reach. Despite that, grafting appears to have great results when certain indications are considered.All authors have read and approved the manuscript. MBA served as lead in writing and reviewing the manuscript. SS, AH, AA, AN, BZ, and AE contributed to writing the manuscript.No conflict of interest exists in the submission of this manuscript.Ethical approval was given by the Aleppo University Hospital and the parent's patient has given their parental consent for this study.Written informed consent was obtained from the patient's parent for the publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal.


Myxofibrosarcoma is a common soft tissue sarcoma of the extremities, which occurs very rarely in the thyroid gland.We report the case of a 61-year-old male who presented with a swelling of the left side of the neck and a newly emerged hoarseness. Ultrasound depicted a hypoechoic thyroid nodule with microcalcifications that was highly suspicious for malignancy. He underwent a left hemithyroidectomy. Histopathological examination and immunohistochemical studies revealed a myxofibrosarcoma of the thyroid gland.Myxofibrosarcoma of the thyroid gland is extremely rare. The diagnosis is based on histopathological features. Radical surgery achieving tumor-free resection margins remains the only chance for cure. However, the role of radiotherapy and/or chemotherapy is still under debate. Due to their high tendency for locoregional recurrence, a close follow-up after surgery is mandatory. Myxofibrosarcoma (MFS) is one of the most common malignant soft-tissue neoplasms in elderly patients and has a slight male predominance . MFS appA 61-year-old male presented at our emergency department with a swelling of the left side of the neck that increased over a period of 4–6 weeks and hoarseness. Clinical examination revealed a clearly visible enlarged, hard, and fixed left thyroid gland. Fiberoptic laryngoscopy was able to exclude primary neoplasia of the vocal cords, but confirmed paresis of the left vocal cord. Ultrasound displayed a thyroid gland with a total volume of 60 ml  as well as a large hypoechoic nodule with microcalcification and irregular margins in the left lobe measuring 40 × 39 × 52 mm, which was highly suspicious for a malignant thyroid tumor . In addition, a 3-mm measuring nodule in the medial right lung lobe and locoregional lymph node metastases were detected.Given the diagnosis of highly aggressive MFS and due to its untypical localization, F-18 fluorodeoxyglucose (FDG) positron emission tomography/computed tomography (PET/CT) scan was performed 2 weeks after the operation to find a primary localized elsewhere and to complete tumor staging. Unfortunately, PET/CT-scan excluded a primary somewhere else in the body but demonstrated local recurrence with a 9.6 × 7.1 × 9 cm left cervical tumor mass expanding from the esophagus to the carotid sheath that infiltrated the trachea, the front-edge of the lower cervical vertebrae and the higher thoracic vertebrae Fig. . In addiAfter discussing the case in our multidisciplinary tumor board, an urgent radiotherapy followed by chemotherapy with doxorubicin and ifosfamide was recommended. The patient was admitted to our department of radiation oncology to receive 70 Gy of radiation in fractions of 2 Gy five times a week in a time frame of 7 weeks. Between the radiation sessions, he twice developed dyspnea, supraglottic edema and inspiratory stridor and had to be admitted to the intensive care unit. Both times the symptoms were alleviated with corticosteroid therapy, tracheotomy was avoided, and the patient was able to continue its radiation treatment. Two months after surgery and after the first 30 Gy of radiation, a CT scan of the thorax demonstrated a tumor mass in the ventral upper thorax infiltrating the larynx, esophagus and left common carotid artery Fig. . UnfortuIn this report, we present a rare case of MFS of the thyroid gland. To our knowledge, only 4 cases of primary thyroid MFS have been reported in the literature so far –9. Only MFS represents approximately 5% of all soft tissue sarcomas . The terDiagnosis of MFS is based on microscopic characteristics, such as the presence of alternating hypocellular myxoid areas and hypercellular fibrous areas with curvilinear vessels , 3. AlthImportantly, radiological findings by imaging techniques such as CT scan and magnetic resonance imaging (MRI) may misdiagnose MFS. For example, in CT-scan low-grade MFS may be misinterpreted as a benign tumor and in MRI T2-weight signal MFS may appear as a cystic formation . MoreoveIrrespective of the grade, MFS shows with up to 61% a high tendency towards locoregional recurrences. Therefore, surgical resection with tumor-free margins, is the standard of care and remains the only chance for cure . AlthougHowever, the use of radiotherapy in MFS is still controversial. The existing case series, retrospective studies, and case reports regarding the use of radiotherapy in the treatment of MFS, mostly in an adjuvant setting, show conflicting results , 18, 19.The role of chemotherapy in the treatment of MFS remains unclear . Until tThe thyroid gland is a very uncommon localization for MFS and only a few cases have been reported in the literature during the past decades. Whereas imaging techniques may be helpful, the gold standard for diagnosis remains histopathology. Radical and wide surgical resection is still the cornerstone in the treatment of MFS and a close clinical follow-up combined with a CT-scan or MRI is mandatory. In addition, adjuvant radiotherapy may play a role in preventing locoregional recurrence. However, the existing data regarding radio- and chemotherapy are from retrospective studies and case series of low evidence. Accordingly, this elucidates the urgent need of multicentric and randomized controlled clinical trials that specifically focus on this aggressive tumor entity.


Function-preserving and Limb-sparing surgery are now the accepted gold standard of care for Extremity Soft Tissue Sarcoma (ESTS) with the goal of surgery for STS of extremities to obtain local tumor control and minimal morbidity. Limb-sparing surgery with post-operative radiotherapy for STS results in high survival rates and local control. Adjuvant radio chemotherapy might improve distant and local recurrence in high-risk patients. Hence, we aim to present how to achieve local tumor control and minimal morbidity for high grade ESTS by conducting limb-sparing surgery combined with appropriate reconstruction and radio chemotherapy.We present 2 cases with high grade sarcoma that underwent limb-sparing surgery with Latissimus Dorsi (LD) flap reconstructions. Wide excisions were completed with limb-sparing surgeries for both cases with free surgical margins and LD flap reconstructions. There was no post-operative complication. Follow up examination revealed normal function of the arm. The first patient was still in remission after 2-years follow up. The second patient got pulmonary metastasis after complete resection and adjuvant radiotherapy.Limb-sparing surgery with LD flap reconstruction is able to remove the tumor completely with negative margin for the primary objective. Secondary objectives are minimizing the morbidity, maximizing postoperative body functions, as well as achieving the best cosmetic value are also achieved. LD flap is commonly easy to harvest and able to give large tissue coverage for reconstruction after surgery.Limb sparing surgery followed by soft-tissue reconstruction and radio chemotherapy are suitable for increasing oncologic outcome, tumor control, and limb preservation. However, inhibitions towards local recurrence and distant metastases were not guaranteed. •Limb sparing surgery and radio chemotherapy maximize tumor control, oncologic outcome, and limb function•The latissimus dorsi flap is suitable for functional and large tissue coverage reconstruction of upper extremity after limb sparing surgery•Despite optimized local control treatment, local recurrence and distant metastases can still occur Initially, the mass size is identical to a marble. The growth of the lump was progressive and became irregular. At this point, the patient experienced pain associated with movement. He had no significant past medical history. Upon physical examination, the lump was immovable, tender, and firm on palpation with irregular surface and borders. The lump's size was10 × 10 × 10 cm and it was located 1 cm above cubiti. The skin temperature above the lump is warmer than the surrounding area. The lump surface is red and dark blue colored with a shiny surface. MRI is then done on the right upper extremity and resulted in a soft tissue tumor with necrotic tissue at ventral side of right distal humerus involving biceps brachial and brachialis muscle. There is no involvement of neurovascular on the tumor's area. Thorax X-ray and abdominal USG shows no distant metastasis. The tumor was staged as T2N0M0 based on the TNM classification , Fig. 2.Patient was admitted for wide excision surgery and reconstruction with Latissimus Dorsi (LD) Flap. Tumor borders were marked. Incision was made 2 cm lateral from tumor borders. Incision deepened through the fascia of biceps brachial muscle. Arteries, veins, median and radial nerve were identified and preserved. The tumor did not infiltrate neurovascular. Wide excision was done. Long and short head biceps brachial muscle, part of brachialis muscle, musculocutaneous nerve and cephalic venous were elevated. Frozen section was performed intra operatively to confirm the margins were negative. Incision was done according to design and deepened to fascia of latissimus dorsi muscle. Latissimus dorsi muscle was elevated while preserving arteries, veins and thoracodorsalis nerve. Flap was put into the defect area. Distal part of latissimus dorsi was sutured to biceps brachii tendon. Medial part was sutured to long and short head of biceps brachii muscle. Surgical wound was sutured layer by layer .Fig. 3LiThe histopathological examination revealed an undifferentiated high grade pleomorphic sarcoma with negative surgical margins (R0) .Fig. 4 with a dosage of 66 Gy in 33 fractions and chemotherapy with Ifosfamid, Doxorubicin and Mesna. The patient was in remission state during follow up that is done 2 years later, concluding there was no case of recurrence.3A 40-year-old man was referred to our hospital with a complaint of a lump in the upper right arm in the last 2 months. Previously, there was a lump excised 5 months ago, with anatomical pathology result of high-grade sarcoma suspect myxofibrosarcoma, rhabdomyosarcoma and hyposarcoma. The lump reappeared 3 months after the first excision. It quickly enlarged with associated intermittent pain. Patient had a history of pulmonary TB but never completed any tuberculosis treatment.Upon general physical examination, the tumor was located in the right upper arm with the size of 4 × 5 × 4 cm, hard, fixed to muscle, with scars seen from the previous excision. There were no lumps in the regional lymph nodes. Based on non-contrast MRI, a suspected malignant soft tissue of 3.8 × 4.2 × 6 cm in the subcutis lateral to the 1/3 middle of the humeral region is found. There was a possibility of muscle infiltration to the biceps brachii muscle. No neurovascular or humeral bone involvement was seen. Based on PET SCAN, no metastases were found. A chest X-ray revealed an infiltration in the right upper lung field and the IFN-Gamma Release Assay (IGRA) resulted positive for TB infection. The patient was diagnosed with sarcoma of the right humerus T2N0M0 and pulmonary TB. The patient was given pulmonary TB treatment for 8 months.The patient underwent wide excision and latissimus dorsi (LD) flap reconstruction. An elliptical incision was made on the excision surgical site of ±2 cm. Incision was deepened through the fascia of biceps brachial muscle. The artery, vein, and radial nerve are identified and preserved. The tumor did not infiltrate the neurovascular system. Tumor with segmental biceps muscle removed. Intraoperative frozen section showing negative surgical margins. The donor was taken from latissimus dorsi muscle. The flap was transferred to the defect area. Surgical wounds were closed layer by layer. The mass was sent to pathological examination. The result showed high grade myxofibrosarcoma with a complete excision of the tumor (R0) , Fig. 7.Patient was discharged on the seventh post-operative day. No postoperative complication was noticed. Follow up examination revealed normal movement and function of the arm. He recovered a full strength and range of motion of the elbow. The patient was given post-operative radiotherapy with a total dose of 68Gy. The post-radiotherapy MRI of the right humerus with contrast resulted in neither pathological lesions nor enhancement in the soft tissues of the right brachii region. An inhomogeneous mass appeared in the lower right lung suggestive of pulmonary metastases. Then, a chest X-ray showed a large nodule in the right lateral hemithorax, and an MRI showed a thick- walled cystic mass in the right hemithorax lateral costal pleura, suggesting a loculated pleural metastasis. Fibrosis accompanied by cystic bronchiectasis in segments 1–2 of the right lung and fibrosis in segments 2–6 of the left. The patient underwent a right lung mass biopsy and FNAB. The biopsy result showed metastasis of malignant tumor with feature similar to that of the tumor in the humerus . The FNAB also contained malignant tumor cells that could originate from a sarcoma.The patient developed into pulmonary metastasis seven months after complete resection. He was consulted to a thoracic and vascular surgeon for consideration of pulmonary metastatectomy. However, there was no operative procedure from the thoracic and vascular surgery department. A chemotherapy was scheduled due to its inoperability for pulmonary metastatectomy. Unfortunately, the patient was lost to follow-up.4We reported 2 cases with undifferentiated high grade pleomorphic sarcoma and high-grade myxofibrosarcoma which underwent limb-sparing surgery with LD Flap reconstruction. Both cases were high grade sarcoma treated with surgery and adjuvant radiotherapy. However, they have different outcomes. STS is a rare malignant mesenchyme-derived tumor which usually involves extremities. Previously, the surgical therapy of ESTS commonly is an amputation We performed limb sparing surgery for both cases referencing the gold standard care for ESTS. Based on the imaging, the tumors were resectable with oncologically safe margins, no involvement of neurovascular and safely operated to improve quality of both patient's life. There were no regional and distant metastases. The objective to preserve a limb and its function after surgery might need complex soft-tissue & neurovascular reconstruction. This might require rotational fasciocutaneous or myocutaneous flap, full-thickness skin graft, free flap, split-thickness skin graft, pedicled muscle flap, nerve interposition, and vascular graft Integration of multidisciplinary approach involving surgery with neoadjuvant or adjuvant radiation therapy (RT) and/or chemotherapy is able to provide local control in approximately 90 % of cases and result in significant enhancement on disease-free survival Adjuvant and neoadjuvant chemotherapy are still subject to controversies for the treatment of STS, except Ewing sarcoma and rhabdomyosarcoma Instead of optimal local treatment and local control, 20 % - 30 % of STS develop metastases. The overall 5-year survival of metastatic STS patients has not improved in the last decades A retrospective study examined 94 patients with intermediate or high- grade localized ESTS got radical resection and RT. 32 % of them experienced recurrence after 60 months median of follow up 5Limb sparing surgery followed by soft-tissue reconstruction and radio chemotherapy is suitable for maximizing tumor control, oncologic outcome, and limb function for soft tissue sarcoma. Moreover, an inhibition towards local recurrence and distant metastases were not guaranteed.None declared.The authors declare no conflict of interests.


Ascaris lumbricoides is a fairly common intestinal nematode affecting children worldwide, leading to major medical and surgical complications. Although most of the cases are asymptomatic, heavy infestation causes various acute abdominal complications. Ascaris-induced intestinal intussusception is one of the rare presentations.Ascaris lumbricoides infestation presenting with ileocolic intussusception. The patient presented to the emergency unit with colicky abdominal pain, vomiting, and constipation for two days. He was sick-looking and dehydrated. Further examination revealed diffuse abdominal distension with tenderness, guarding, and palpable mass in the right lower quadrant. Ultrasonography showed long-segment ileocolic intussusception with several worms in the intestinal lumen and adjacent mesenteric lymphadenopathy. An exploratory laparotomy was performed, which revealed ileocolic intussusception. The telescopic loop of the ileum was found to be gangrenous and was resected, and a loop ileostomy was performed. The patient was discharged on the seventh day postoperatively without any complications.We report a case of a 13-year-old boy with Ascaris in cases presenting with acute gastrointestinal complications. Early diagnosis and prompt surgical intervention can prevent bowel ischemia/gangrene and significantly reduce morbidity and mortality associated with such cases.Physicians in tropical and subtropical countries should consider this condition in the differential diagnosis when they encounter similar presentations in their clinical practice. Sonography is a non-invasive, easy-to-use, and widely available imaging modality that can be employed to diagnose entrapped  Ascaris lumbricoides (roundworm), affecting as many as 1.5 billion people worldwide; it is a significant cause of morbidity and mortality in various parts of the world [Ascariasis is an intestinal nematode caused by he world -3. The mhe world .Ascaris lumbricoides in the intestinal lumen.While most of the infected children remain asymptomatic, a heavy parasitic infestation may lead to grave complications such as intestinal obstruction, volvulus, intussusception, and migration to other organs such as the biliary tract . Most chAscaris lumbricoides in the intestinal lumen.This report documents a case of intussusception in a 13-year-old boy due to entrapped A 13-year-old boy was brought to the emergency unit of the JN Medical College, Aligarh due to colicky abdominal pain, vomiting, and constipation for two days. Further history revealed four to five episodes of intermittent abdominal pain in the past six months. He had a history of pica and was not thriving well. Furthermore, he belonged to a farming family with an extremely low socioeconomic status.3, neutrophils: 75%, eosinophils: 10%; the patient's platelet count was normal, with normal renal parameters and liver enzymes. Multiple air-fluid levels were detected on the erect abdominal radiograph, indicating intestinal obstruction.On physical examination, he was sick-looking and moderately dehydrated with a temperature of 38 °C, pulse rate of 100 per minute, respiratory rate of 25 per minute, and BP of 110/70 mmHg. Abdominal examination revealed diffuse distension with tenderness, guarding, and palpable mass in the right lower quadrant of the abdomen. Routine investigations at the emergency unit revealed the following findings - hemoglobin (Hb): 8.8 g/dl, WBC count: 14000/mmHigh-resolution sonography on the transverse plane of the abdomen, via a linear transducer placed in the right iliac fossa region, showed a swirled pattern of alternating hyperechogenicity and hypoechogenicity. This gave the classical “target” appearance representing the alternating layers of mucosa, muscularis, and serosa. These findings were consistent with intussusception, with the inner bowel  were initiated. An urgent laparotomy was planned at this time. Laparotomy revealed ileocolic intussusception. Figure y Figure .Histopathological examination of the resected bowel segment revealed a varying degree of congestion, edema, and coagulative and hemorrhagic necrosis. Albendazole (400 mg OD for three days) was started. The rest of the worms subsequently came out from the stoma loop. The patient's condition improved significantly in the postoperative period and he was discharged on the seventh postoperative day, with the advice to undergo anastomosis and closure of ileostomy at a later stage. Deworming was done for the patient's family members who screened positive for ascariasis.Ascaris lumbricoides infestations are asymptomatic. However, individuals with heavy worm infestation are likely to develop a wide spectrum of acute abdominal complications such as intestinal obstruction, biliary obstruction, cholangiohepatitis, pancreatitis, liver abscess, and acute appendicitis [Ascariasis is one of the most prevalent nematode infestations, especially in tropical and subtropical regions where unhygienic disposal of human excreta is common, and it is transmitted via the fecal-oral route . Repeatendicitis . The othndicitis .Ascaris-related intestinal obstruction is an acute problem in the developing world, with an incidence of 9.2 cases per 100,000 persons [Ascaris-related intestinal obstruction due to the smaller size of the bowel lumen and often an increased parasitic load [Ascaris worms in the intestinal lumen at the ileocecal valve can cause intestinal obstruction [Ascaris worms acts as a fixed point leading to intussusception or volvulus [Ascaris, however, is very uncommon.tic load . A host truction . If the volvulus . Most cavolvulus . IntestiAscaris lumbricoides infestation and associated complications have been described in the literature [The histopathological study of the resected bowel segment in our case exhibited edema, congestion, and coagulative and hemorrhagic necrosis indicative of combined ischemia and venous outflow obstruction due to strangulation induced by intussusception. Plain radiographs, barium examinations, ultrasonography, and CT scan findings of terature ,12.Ascaris mass in the intestinal lumen. The appearance of Ascaris as a long echogenic structure  with or without a central anechoic tube and mostly without acoustic shadowing on ultrasound has been reported in various studies in the literature [The role of ultrasonography is of key importance in the early diagnosis of terature -14. Variterature ,14,15.The management of uncomplicated ascariasis is usually conservative and involves anti-parasitic drugs such as albendazole, mebendazole, or pyrantel pamoate. Partial intestinal obstruction due to ascariasis may resolve spontaneously with bowel rest, nasogastric decompression, anthelminthic treatment, and fluid-electrolyte replacement . In moreA high index of suspicion, early diagnosis, and prompt intervention can prevent bowel ischemia/gangrene and significantly reduce morbidity and mortality associated with such cases. Primary prevention of ascariasis involves maintaining proper hygiene and sanitation practices, and periodic deworming on detection of ova/cysts on microscopic stool analysis .Ascaris worms in the intestinal lumen. Information/guidelines to raise awareness about ascariasis and its preventive measures should be included in all health education programs and should be communicated to school children and their parents/caregivers to prevent the risk of infection.Acute intestinal obstruction is one of the major causes of morbidity and mortality in children in developing countries. Intestinal intussusception requires early diagnosis, as it usually constitutes a strangulation/obstruction type of intestinal obstruction that quickly leads to bowel ischemia and gangrene and can cause high mortality. Ultrasonography is a very useful diagnostic tool for the early detection of these complications and for localizing balls of


Glomus tumors are infrequent benign tumors that originate from the glomus body and can be found anywhere in the body including the gastrointestinal tract. It is rare that gastric glomus tumors present with life‐threatening upper GI bleeding. Diagnosis of gastric glomus tumors poses a challenge due to overlapping endoscopic and endosonographic features with other gastric subepithelial lesions, and the final diagnosis may not be clear until after surgical resection and pathological examination. We report the case of a 61‐year‐old patient who presented with massive upper GI bleeding secondary to an ulcerated gastric glomus tumor that was eventually treated with surgical wedge resection of the tumor. Although very rare, it is possible that gastric glomus tumors present with life‐threatening GI bleeding. It should be considered in the differential diagnosis of gastric subepithelial lesions, and the final diagnosis may not be clear until after surgical resection and pathological examination. The significant aspects of his medical history were as follows: type 2 diabetes mellitus, hypertension, end‐stage renal disease on regular hemodialysis, coronary artery disease, and rectal cancer status post‐abdominoperineal resection with permanent colostomy.He was referred to the endoscopy unit by his oncologist for a workup of iron deficiency anemia, with a history of passing dark stools intermittently for the past few weeks.On clinical examination, the patient was hemodynamically stable. There was pallor with a normal abdominal examination. There was no evidence of melena at the time of examination. Laboratory tests revealed: hemoglobin = 6.4 g/dl, platelet count = 357,000/μl, INR = 1, urea = 23.5 mmol/L, and creatinine = 342 μmol/L. Liver function test results were normal.Esophagogastroduodenoscopy (EGD) revealed an approximately 3 cm subepithelial lesion in the antrum with a clean‐based ulcer in the center. There was no evidence of altered or fresh blood in the stomach. A colonoscopy was performed through the colostomy and was normal  was conducted and revealed a hyperechoic antral lesion originating from the second and third layer. The EUS findings were suggestive of lipoma .In CT scans, GGTs appear as well‐circumscribed subepithelial masses that have strong arterial phase enhancement, a progressive filled‐in enhanced pattern, and prolonged enhancement during multiphasic scans. Unfortunately, CT imaging cannot differentiate between GGTs and other mesenchymal tumors.14The treatment of choice for GGT is surgery with negative margins, which may include resection of the tumor, subtotal gastrectomy, or wedge resection.4In this case report, GGT was initially misdiagnosed as a lipoma and later presented with a life‐threatening GI bleed that was ultimately treated with surgical resection of the tumor. GGT is a rare disease with limited published knowledge, and there are no definitive guidelines for diagnosis and treatment. To date, the course of GGT management has been left to the physician's discretion.Ahmad Ayash and Nasrein Elkomy reviewed the literature, drafted and edited the manuscript, and approved the final manuscript. Muneera Jassim Al‐Mohannadi, Saad Rashid Al‐Kaabi, and Mahir Petkar reviewed the literature and edited and approved the final manuscript. The manuscript was prepared according to ICJME guidelines and CARE guidelines for reporting case reports.The authors declare that they have no conflicts of interest.The case report was approved (MRC‐04‐21‐641) by the IRB and Medical Research Centre of Hamad Medical Corporation, Doha, Qatar.Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.


A 35-year-old woman with a history of polyacrylamide hydrogel filler injection was referred with a fluctuating facial abscess after decayed tooth extraction. MRI imaging confirmed the diagnosis of an abscess. After appropriate treatment, the patient healed with a little hyperpigmentation and deformity in the zygomaticotemporal area. Although polyacrylamide hydrogel filler injection is considered non-toxic, non-immunogenic, and biocompatible; as a permanent material, physicians should be aware of the risk of its late complications such as late infections. In addition to antiseptic measures, antibiotic prophylaxis may be necessary before the procedures which have a risk of bacteremia and close to the permanent filler location. The complication rate of filler injections can be as high as 18% -3. In thA 35-year-old non-smoker, healthcare worker woman was admitted to the emergency department with a high fever, facial swelling, and difficulty in swallowing a day after decayed tooth extraction. There was no previous facial surgery or intervention history except for an injection of a facial filler five years ago. On the physical examination, prominent swelling and hyperemia were present on the left side of the face, buccal area, and the oropharynx. The laboratory findings showed a mild increase in acute phase reactants. The patient was hospitalized by the Department of Infectious Diseases and given parenteral antibiotherapy of ampicillin/sulbactam and ciprofloxacin.During her hospitalization, the prominent edema on her face gradually regressed and a localized, fluctuating abscess causing circulation impairment of the skin above appeared on the fifth day Figure . MRIs ofWith the detailed history, it was understood that she had PAAG filler injection over her bilateral cheek bone and temporal areas five years ago. During the follow-ups, there was no bacterial growth on the culture. After the treatment, the patient healed with some hyperpigmentation and deformity on the zygomatic area.Among a wide variety of fillers, PAAG fillers are relatively new generation permanent fillers that are presented to the market as non-toxic, non-immunogenic, non-embryotoxic and biocompatible products. They have been in use for more than 25 years and got Conformité Européenne (CE) certification in 2001 . It is composed of 2.5% polymer of acrylamide monomer and 97.5% non-pyrogenic water and is a jellylike colorless substance .Late infections of the PAAG filler material are rare compared to the other complications and they are usually caused by repeated injections to the previously treated sites or an accidental puncture of the injected site during supplement injections such as botulinum toxin, filler, or lipolysis . In factUnlike up-to-date literature, the starter of the infection in our case was a decayed and infected tooth extraction. Soon after extraction, a local infection caused an abscess formation in or around the PAAG filler. Systemic or local bacteremia during extraction of the infected tooth might have caused new colonization around or inside the filler or might have activated the dormant bacteria somehow which might have been colonized in the filler previously. The PAAG fillers do not incorporate with the living tissue but they are reported to be surrounded by a thin interlayer of connective tissue and elastic fibers , thus thThe uniqueness of this case is that it is the first filler infection reported after a surgical intervention to our knowledge. Any local procedure carrying a risk of bacteraemia may cause an inoculation of bacteria to the filler material or activate the dormant bacteria residing in the filler. Thereby, patients who have permanent fillers may need to use prophylactic antibiotics before surgical procedures which carry a risk of local or systemic bacteraemia.


Select spinal tumors can be treated with en bloc spondylectomy (EBS) but the surgical complexity and relatively low frequency of eligible tumors render EBS an uncommon procedure. The expanded surgical access encompasses acceptance of relatively high morbidity as a trade-off against improved oncological results and survival. EBS durations can be long with dynamic changes affecting the risk-benefit ratio as the surgery proceeds. We present a series of cases where we have elected to “abandon” EBS due to adverse findings or rising intraoperative risk along with our lessons learned. A search of our surgical database for all “en bloc” spinal tumor procedures over a three-year period was performed and 27 operations were identified. Of these, four were abandoned. Two of the four surgeries were halted owing to adverse anatomical findings. One involved significant tumor growth from the interval imaging bringing into question disease control and the other displayed tumor adherence to the lung requiring significant dissection. The further two cases incurred significant blood loss and associated physiological complications of end-organ dysfunction. Pre-operative embolization (POE), anesthetic monitoring, controlled hypotension, volume replacement, and transfusion optimize our chance of achieving the surgical plan. However, cardiovascular instability must be managed promptly and early warning signs of end-organ injury  should not be overlooked. In some situations abandoning the procedure may be in the best interests of the patient. Although en bloc spondylectomy (EBS) is a recognized treatment for certain spinal tumors including primary malignant bone tumors, aggressive benign tumors, and occasionally solitary metastatic tumors, the surgical complexity and relatively low frequency of tumors eligible, prevent this from being a routine technique. En-bloc surgery requires the removal of the entirety of a tumor without violation of its capsule. This concept is familiar to oncological surgery and has been widely accepted to reduce local tumor recurrence and lengthen survival -4. EBS, initially described by Stener , Roy-CamThe planning of an en bloc excision may indeed involve the necessary sacrifice of adjacent structures, e.g division of nerve roots, and encompasses acceptance of a degree of morbidity as a trade-off against improved oncological result and survival. We find that going into surgery with this prior calculation can motivate us as surgeons to complete the planned task. We must however be wary of situational changes, not uncommon in long complex surgical procedures, which can alter the risk-benefit balance making our original surgical aims no longer justified. There is a relative paucity of data describing intraoperative decision-making across all surgical specialties, with rare surgical procedures such as EBS being no exception. The aim of this paper is to present a case series where the decision was made to “abandon” or halt spinal tumor EBS along with the associated learning points.This case series was approved by an internal board review. The surgical database was searched for all spinal tumor procedures labeled as “en-bloc”. Between January 2019 and April 2022 27 EBS cases were identified. A case notes review was performed and of these 27 operations four (15%) were “abandoned”. Our definition of abandoned in this instance was the unplanned halting of the surgical procedure, once commenced, secondary to adverse intraoperative events or findings. Operative techniqueAs there is considerable variation in the surgical technique needed for EBS depending on the spinal level and tumor morphology we cannot report a standard surgical approach and technique for this case series. Surgical planning was made following a multidisciplinary team (MDT) discussion involving radiologists, surgeons, clinical and radiation oncologists as well as histopathologists for all patients. Anterior, posterior, or combined surgical approaches were used as appropriate following the principles of blunt anterior vertebral body dissection, ligation of radicular arteries, circumferential decompression of the spinal cord, and atraumatic handling of the spinal cord as described by Tomita et al. . VasculaAnesthetic considerationsAll patients were seen in the pre-operative assessment clinic by a consultant anesthetist for review and optimization of medical co-morbidity. Intensive care unit (ITU) beds were booked for the post-operative period as standard. Routine pre-op bloods included the cross-matching of four units of blood. Central line access and arterial line monitoring were employed, along with double lumen endotracheal (ET) intubation if deflation of a lung was required. Intraoperative cell salvage was used for as long as possible depending on the requirement for thrombin-based hemostatic agents. We used relative hypotension to control blood loss during surgery (80-100mmHg systolic pressures). Along with typical anesthetic monitoring, particular attention was paid to urine output and serum lactate measurements to monitor end-organ function. Blood gas Haemoglobin (Hb) levels and thromboelastography (TEG) were used for real-time hemorrhage and clotting assessment. Case one: 27-year-old male biopsy-proven giant cell tumor (GCT)Case one presented with several months of left-sided chest well pain. Subsequent imaging showed a lytic tumor at T6/7 growing against the left lung (6.3 x 6.5 x 6.4 cm). He was initially treated with Denosumab therapy within one month of diagnosis. After initial growth (to 8.8 x 8.5 x 9.7 cm) the tumor became stable but growth commenced again after one year. At this time T6 and T7 were involved with extraspinal extension from T5-T8 Figure . FollowiA two-staged operation (posterior-anterior approach) was planned as a single sitting. Stage one included an instrumented fusion of T3-T10, T5, and T8 laminectomy followed by T6 and T7 left hemilaminectomy, costotransversectomy, and pediculectomy. Right-sided paravertebral dissection was performed down to the aorta. On the left side, the lung was strongly adherent to the tumor. Osteotomies and discotomies were made to release the left lateral aspect of T5 and T8 vertebral bodies along with the complete T6 and T7 vertebrae.The planned stage two thoracotomy access to the left chest was postponed owing to the adherent lung, long operative time (8 hours), and developing deranged acid-base balance .On waking the patient was found to have anterior cord syndrome with flaccid paralysis of the lower limbs thought to be secondary to hypoperfusion.A left-sided thoracotomy was performed after three days, with cardiothoracic surgeon assistance concluding that lobectomy would be required to facilitate EBS. Significant desaturation (35%) and decreased cardiac output occurred on deflating the left lung. Repeated repositioning of the double-lumen ET tube failed to improve the parameters. The decision was made to abandon surgery and return to ITU. Consolidation was seen on the chest x-ray and treatment for hospital-acquired pneumonia was commenced. At two weeks we considered converting our plan to intralesional debulking but he was able to tolerate single lung ventilation and the lobectomy was completed with the delivery of specimen en bloc. Anterior reconstruction was performed with a cage and autologous rib graft. He made a good respiratory recovery and improved neurologically, being able to mobilize with the aid of two crutches.Case two: 63-year-old female with T5 thyroid metastasisCase two, an asthmatic and long-standing type two diabetic presented with 18 months of thoracic pain radiating to the right chest wall, burning thigh pain, and proximal lower limb weakness. Her background included right hemithyroidectomy 20 years ago for benign disease, three years of left thyroid swelling, and completed thyroidectomy six months previously. Staging demonstrated PT3 papillary thyroid carcinoma with T5  and the right T5 nerve root ligated along with small segmental vessels. Left hemilaminectomy of T4, T5, and left facetectomy of T4/5, T5/6 were completed. The right T4 pars were divided to leave the right T4/5 facet (with tumor involvement) intact. Osteotomies just above the T4/5 disc and below the T5/6 disc were commenced, with just the anterior-most bone remaining, when a significant drop in blood pressure (BP) and tachycardia occurred. Her Hb was stable and BP improved with fluids, however on the basis of rising lactate  and relative anuria for the last hour we felt the completion of osteotomies could risk further bleeding and left her vulnerable to further deterioration. Hemostasis was achieved and the wound closed. 3000ml crystalloid, three units packed red cells and 500ml cell salvage were given and the patient was moved to ITU sedated.Overnight, acidosis worsened and the following day the decision was made to wake up rather than return to surgery. Episodes of hypotension, desaturation, and supraventricular tachycardia were treated in ITU over the next four days prior to ward discharge. Return to the theatre was conducted at one week for posterior wound reopening, completion of osteotomies, and anterior soft tissue divisions. Unfortunately, fracture of the very friable tumor resulted in removal as three segments rather than en bloc. Reconstruction was completed with an expandable cage and rods. Our patient remained in ITU for two days, had a chest drain for five days, and was discharged after 10 days of mobilizing with a frame. Case three: 61-year-old female with malignant peripheral nerve sheath tumor (MPNST)Case three had a previous history of left S1 MPNST with intralesional debulking and biopsy performed at another institution. Imaging demonstrated a heterogenous solid/cystic enhancing left sacral mass of 4 x 4.8 x 5.2cm Figure . Given tThe second stage was commenced prone with muscle strip for exposure of the sacrum, left alar, and SI joint superiorly and left sciatic notch inferiorly. L5 and S1 laminectomy was completed and posterior dura opened. The left S1 and S2 nerve roots were identified and divided intradurally before the anterior dura was opened. At this stage, ongoing significant bleeding was noted. Following a hemostatic pause to evaluate, the developing scenario was hemodynamic instability and anuria, likely secondary to blood loss, deranged clotting, and renal hypoperfusion . Massive blood loss transfusion protocol was followed but a unanimous decision to defer further osteotomies to another time was made. Hemostasis with hemostatic products was achieved and the wound closed. We estimated 5000 ml of blood loss in total. The patient went to ITU for correction of TEG-based clotting with cryoprecipitate and platelets, Hb correction with packed red cells, and hemofiltration. After five days in ITU renal function improved but low platelet count and albumin led the focus to change from when to return, to whether to return for the completion of EBS. A decision was made not to proceed. She did return to the theatre after six days for laparotomy, washout, and removal of swabs left intentionally for hemostasis, washout of the sacral wound, and further dural repair. Her 24-day ITU stay was further complicated by flash pulmonary edema, anemia, renal failure, S. epidermidis bacteremia and extended-spectrum beta-lactamase (ESBL) wound infection. On discharge three weeks later she was mobile around the room independently and using a handrail for stairs. Further elected treatment was with radiotherapy. Case four: 26-year-old female with T8 OsteosarcomaCase four had a background of adolescent idiopathic scoliosis and posterior stabilization aged 16. Subsequently, she presented one year ago with acute paraplegia of grade B on the American Spinal Cord Injury Association (ASIA) impairment scale and was diagnosed with T8 osteosarcoma and lung metastases. She was treated with emergency posterior decompression and post-operative chemotherapy at another unit. Thoracoscopic resection of pulmonary metastases demonstrated histological good response with 100% necrosis following chemotherapy. Following the MDT discussion, given this good response, the initial consideration was radical resection with the sacrifice of the cord. However, upon clinical review, she had preservation of protective sensation in the legs and a recent recovery of movement in her toes. A cord-saving en bloc excision, to aim to preserve her residual function and provide optimal local control of her spinal disease, was elected.Her MRI four weeks prior to surgery demonstrated signal change within T8 and superior T9 likely to represent residual tumor, with a small right paraspinal extraosseous component. Owing to the artifact around the metalwork on MRI images we present CT imaging Figure . CombineA left-sided thoracotomy with fifth rib osteotomy (retaining vascular pedicle for use as strut graft), was performed followed by left lung deflation, the opening of pleura, and mobilization of the aorta. The intraoperative appearance was of significant extraosseous growth T7-T9, including the plane between the aorta and esophagus. The degree of progression from the scan one month previously suggested aggressive tumor behavior. Frozen section histology taken from a small tumor breach showed a high-grade pleomorphic tumor. A discussion was held with oncology regarding tumor progression, reservation about prognosis, and the validity of performing the second stage as operative recovery time would be significant with limited oncological benefit. A decision was made to abort the procedure. The thoracotomy was closed with a chest drain. CT staging was repeated showing an increase in the size of a right lower lobe pulmonary metastasis hence the disease was not controlled as previously thought. She was discharged from ITU after five days and went home after a further two days with the ability to transfer and mobilize in a wheelchair as per pre-op. Follow-up was planned with further chemotherapy. Case selection and planningCareful patient selection is essential prior to EBS. Given that the aim of EBS is often for local disease control rather than curative purposes the systemic disease burden has a great effect on long-term outcomes. In case four we found unfavorable intraoperative disease with progression from our imaging four weeks prior. We should be wary when operative justification rests on systemic staging suggesting disease remission. Our current routine is to perform an up-to-date whole spine MRI scan 24-48 hours prior to the operation which minimizes the risk of omitting the asymptomatic tumor growth during the time between the clinic review and surgery. In rare cases, it can also reveal further spinal lesions which would have a major impact on surgical planning.In addition to the spinal surgery and anesthetic team complicated combined approaches often require the presence of specialist assistance . Relevant specialist and oncologist opinions may be sought as appropriate.Blood lossTwo of our four cases suffered deterioration from effects of hemorrhage and hypotension. On both occasions, the deterioration coincided with making partial osteotomies, a generally accepted crux point in bleeding for EBS. One of the major concerns with EBS is the accepted high volume hemorrhage and associated risks. Most of the adverse intraoperative events are either directly or indirectly related to blood loss. Most of our management strategies are aimed at minimizing, and compensating for, hemorrhages. Vertebrae have copious blood supply potentially increased further with adjacent tumor involvement. Non-compressible vascular channels in the cancellous bone can make bleeding difficult to control. Given the aim of EBS is not to breach the tumor capsule there is some advantage gained by reducing blood loss from vascular tumor types that would be readily encountered with intralesional surgery. Generally, however, this advantage is offset by bleeding from increased complexity, dissection, and operative length. Spinal tumor surgery variables influencing blood loss include histology, epidural spinal cord compression, tumor location, and body mass index (BMI), as also surgical strategy and procedure length . HypervaThe vascularity of tumors varies  and althWe normally choose to run relative hypotension of 80-100mmHg systolic pressure as a balance between reducing bleeding and maintaining adequate tissue perfusion to minimize end-organ injury. Faced with hemorrhage at our unit we are guided by volume replacement in the first instance to maintain cardiovascular stability, whilst monitoring Hb on blood gas samples to guide the use of allogenic transfusion or cell salvage replacement (target Hb > 80g/L). A further complication of coagulopathy can occur with red cell replacement and when larger transfusion protocols are initiated (> 4 units) often platelets and clotting factors need to be considered. TEG can be very useful to determine real-time clotting status. We also consider the use of IV tranexamic acid, which has been shown to reduce gross blood loss  and tranAnesthetic timeIt is widely accepted that certain complication rates increase with longer operative times. Infections for example increase significantly after two hours duration. Cheng et al.  find thaStaging surgeryOur current elective planning for EBS follows MDT discussion and identification of appropriate cases. However, we do not currently have a formal assessment system for assessing risk and operative time. Factors we take into account are tumour type, spinal location, approach (posterior vs anterior vs combined), comorbidity and number of vertebrae affected. Mirza et al score spinal surgery “invasiveness” determining the effect of surgical extent on blood loss and operative time , howeverLogic dictates that a single-stage procedure be performed in one sitting where staging based on a need for repositioning in combined approach cases may indicate a natural break. However one significant barrier to performing an elective two stage plan on separate days is the logistical difficulty faced by obtaining theatre space, in conjunction with ITU capacity, on two days relatively adjacent in time. Another issue with a planned surgical gap is the concept of anaesthetic window. The majority of post-op complications occur on days one-three and the sequelae may persist for longer ,30 rendeOptimal setup and flexible approach to the surgical plan based on the intraoperative findings and feedback do play a major role in achieving favorable outcomes in spinal en bloc procedures. Careful physiological monitoring allows the identification of situations in which abandoning the resection works in the best interest of the patient. Sometimes we must abandon our best-laid plans but in certain cases, it is possible to recommence the procedure once the deranged patient’s physiology has been optimized.


The gastrointestinal tract is one of the most common sites for extranodal Burkitt lymphomas (BLs), but an appendiceal BL is extremely rare. We describe a case of appendiceal BL presenting with acute appendicitis and acute kidney injury. A 15-year-old obese male presented to the emergency department with fever and right-sided abdominal pain. WBC count was slightly increased, and a CT scan of the abdomen showed features of ruptured appendicitis and peritonitis. The patient was placed on antibiotics, and an interval appendectomy was planned. The patient developed a worsening acute kidney injury one day later, requiring a laparoscopic appendectomy. Gross examination of the appendix revealed a dilated, firm, sausage-like appendix with a hemorrhagic serosa and a firm mesoappendix. Microscopic examination of the appendix showed a dense diffuse infiltration of monomorphic medium-sized atypical lymphoid cells with round nuclei, dispersed chromatin, and small nucleoli. Few scattered macrophages created a vague "starry sky" appearance. Many mitotic figures were seen. The lesion also involved the mesoappendix. Immunohistochemical analysis showed that the lymphoma expressed CD10, CD20, and BCL6 but was negative for CD34, BCL2, and TdT. Later, the fluorescence in situ hybridization (FISH) analysis detected an IGH-MYC  fusion. A final diagnosis of appendicular Burkitt lymphoma was made. Two weeks later, a bone marrow biopsy performed for staging showed involvement of bone marrow by BL. The patient lost follow-up after that due to the transfer of care to another hospital. Burkitt lymphoma (BL) is an aggressive B-cell lymphoma first described in 1958 by Dennis Burkitt as sarcoma afflicting the jaws of African children . BL is pAlthough BL is considered a nodal lymphoma, it most commonly presents as an extranodal disease. The gastrointestinal tract and head and neck are the most prevalent sites for extranodal BL. Bone marrow, genitourinary tract, central nervous system, and liver are less common sites. Current therapies allow for long-term survival in most patients and even cures in some cases of BL. Poor prognostic indicators include age >40 years, Eastern Cooperative Oncology Group (ECOG) performance status ≥2, serum lactate dehydrogenase (LDH) >3X upper limit of normal, bone marrow and central nervous system involvement, and a delay in diagnosis .Appendiceal Burkitt’s lymphoma is extremely rare; we found <20 reports published to date. This paper presents a rare case of BL of the appendix diagnosed in a child with an unusual presentation of acute appendicitis and acute kidney injury.A 15-year-old obese male presented to the emergency department with right-sided abdominal pain, constipation, tenesmus, dysuria, nausea, and vomiting for one week. He had no history of fever, hematuria, blood in stool, weight loss, penile discharge, or kidney stones. Physical examination showed a diaphoretic morbidly obese male (BMI: 40.19 kg/m²) with tenderness on the right side of the abdomen. No guarding or rigidity was noted. Bowel sounds were normal. Laboratory investigations are shown in Table An abdominal computed tomography (CT) scan showed extensive inflammatory stranding/phlegmon in the lower abdomen and pelvis, centered at the right lower quadrant. A thick-walled fluid collection (4.7 x 4.9 cm) in the pelvis concerning for ruptured appendicitis was noted Figure . PeritonA day later, the patient developed a worsening acute kidney injury (serum creatinine raised to 2.86 mg/dL (N: 0.2-0.7 mg/dL)). He underwent cystoscopy with bilateral retrograde pyelogram ureteral stent placement. Creatinine improved slightly following the procedure. A decision was made to take the patient to the operation theater for a laparoscopic appendectomy and to perform a kidney biopsy due to suspicion of acute interstitial nephritis as a cause of acute renal failure.During surgery, the appendix was significantly inflamed with phlegmon formation. No macroscopic perforation or necrosis was noted. Inspection of the terminal ileum revealed significant dilation and inflammation with creeping fat. Gross examination of the specimen showed a dilated, firm sausage-like appendix measuring 9.5 x 0.8 x 0.7 cm with a hemorrhagic serosal surface and an attached firm mesoappendix (6.2 x 2.0 x 2.1 cm). A cross-section of the specimen did not reveal any definitive mass in the appendiceal lumen. Microscopic examination, as shown in Figure Flow cytometry was not performed on the appendix, as the specimen was received in formalin. Two weeks later, a bone marrow biopsy performed for staging showed atypical lymphoid cells comprising approximately 30% of the marrow area. Flow cytometry performed on bone marrow showed a CD10+ B-cell lymphoma with kappa light chain restriction. Overall findings, including immunohistochemical analysis, were consistent with the involvement of lymphoma. Later, FISH analysis performed on the appendix detected an immunoglobulin heavy-chain (IGH)-MYC  fusion and loss of BCL2. A final diagnosis of appendicular Burkitt lymphoma was made. Hematology/Oncology was consulted to initiate chemotherapy, but the patient lost follow-up due to the transfer of care to a hospital near the family's residence.Gastrointestinal (GI) lymphomas account for 4-20% of non-Hodgkin's lymphomas and 30-45% of extranodal lymphomas .Acute appendicitis is a characteristic of most appendicular tumors, including lymphomas ,8. PatieThere are no classical imaging features of appendiceal lymphomas. Diffuse enlargement of the appendix with thickening of its wall and periappendiceal tissue can be seen on imaging, representing a direct serosal extension of lymphomatous cells or a related inflammatory process. The diameter and size of the lymphomatous appendix on CT scan are usually >3 cm, which is larger than the expected size of non-tumor appendicitis -12. HoweOur case was unusual in that it presented with acute appendicitis and acute renal failure mimicking acute interstitial nephritis. Besides, our patient was kept on antibiotics for a week to treat appendicitis conservatively, increasing the chances of a poor outcome due to a delay in diagnosis of Burkitt lymphoma. In addition to bone marrow and CNS involvement, poor prognostic indicators of BL include a delayed diagnosis.We want to highlight that the risk associated with delayed lymphoma diagnosis must be considered when examining the risks and benefits of operative versus nonoperative management of acute appendicitis. Moreover, we want to reiterate that all appendectomy specimens should undergo a histological evaluation to avoid missing potential deadly diseases.Primary Burkitt lymphoma of the appendix is extremely rare. Appendicitis is one of the most frequent presentations of primary appendiceal lymphoma. Therefore, all appendectomies must undergo a histopathological examination. When comparing the risks and benefits of operative versus nonoperative management of acute appendicitis, it is important to consider the potential risk of late diagnosis of lymphoma in patients with appendicitis undergoing conservative management.


The ossicular chain function is well known since mid-19th century. Its presence promotes a sound amplification of about 30 dB. Therefore, one can expect its interruption results in air-bone gap of about 30 dB or more. This discontinuity, represented mainly by erosion of the incus, is commonly encountered in chronic otitis media or, more rarely, in middle ear trauma, either as a consequence of the disease itself or produced by surgical procedures. In many instances, in order to improve or preserve hearing, ossicular reconstruction is part of the treatment, performed using implants of different kinds, usually rigid, to assure an efficient transmission of acoustic energy from the tympanic membrane (TM) to the oval window. However, some cases challenge the common sense about the physiology of the tympano-ossicular unit. The authors present seven patients with ossicular interruption, which, surprisingly, didn’t require a surgical reconstruction to reach a quite good (sometimes excellent) functional result, and further propose an explanation based on acoustic physics knowledge for such cases.In all patients, the ossicular defect was type A of Austin.Nine-year-old boy, left cholesteatoma, normal hearing. Malleus head and incus removed. Functional reconstruction postponed. Postoperative audiogram: completely closed gap . During 29-Year-old man, left attic cholesteatoma, bilateral mixed hearing loss. Incus and malleus head sacrificed. No reconstruction performed. Postoperative audiogram with a mean gap of about 21 dB. During the revision, no residual disease noted. A fibrous adhesion was seen between the TM and the stapes head. Adhesion removed and replaced by cortical bone autograft. Final mean gap: 35 dB.22-Year-old woman; 30 days history of horse fall followed by immediate facial asymmetry. House-Brackmann grade VI left facial paralysis. Audiogram: about 6 dB gap . Transma35-Year-old man, right cholesteatoma, slight conductive hearing loss. Malleus head and incus removed. No reconstruction performed. Postoperative mean gap: 20 dB. On second look, again a fibrous bridge found to connect the malleus handle to the stapes. It was removed and a hydroxy-apatite prosthesis was interposed. Final audiogram: no change on mean air-bone gap.33-Year-old man, right cholesteatoma, normal auditory thresholds. Incus removed. No reconstruction performed. Postoperative gap of only 15 dB. On revision surgery, a thin filiform fibrous adhesion linked the stapes to the malleus . Adhesio23-Year-old man, left cholesteatoma, bilateral normal hearing. Malleus head removed. Incus partially removed, with a small segment of the long process left attached to the stapes due to an extremely fixed incudostapedial joint. Postoperative audiogram: almost no gap . High fr31-Year-old male, right attical cholesteatoma, mixed hearing loss, mean gap of 21 dB. Complete absence of the incus noticed. Only a connective tissue cord from the malleus handle to stapes head, left in place. No postoperative audiogram.These cases are testimonies of the surprising capacity of the human body to adapt to adverse conditions, with the healing process serving not only to restore the anatomy of an organ or tissue, but also its function. Of course, in most cases, these possibilities cannot be completely reached, but one must be aware to this potential and not be excessively attached to the routine of the surgical technique. The absence of the incus, in a simplistic analysis, could not allow a good sound conduction from the TM to the oval window, unless there was a tympanic retraction over the stapes head, setting up a myringostapediopexy. However, in none of these cases, did we identify any tympanic retraction that could be responsible for the sound transmission to the stapes. It seems clear that, in each one of these patients, the fibrous bridge was the only sound wave conductor. All cases, particularly 1, 3, 5 and 6, achieved functional results that are surprising even when compared with the best series of conventional ossicular reconstruction.How can we explain such good results? Cases 3 and 5 may help us to elucidate the enigma. On them, we mobilized the malleus and observed the effect of this on the stapes or the round window. As could be expected, when the malleus was medialized, there was no movement of those structures because the fibrous bridge, being soft and flexible, deformed without causing any effect on the stapes. However, the lateral traction caused a clear response.In a normal situation, the TM, stimulated by sound, produces vibratory movements that start with a medialization correspondent to the compression phase of the wave, followed by a return passing through the neutral position, until it reaches a lateral situation (rarefaction phase). These movements repeat continuously while the stimulus lasts. The ossicles follow this movement, with the footplate moving into and out of the vestibule successively. To explain the reported cases, we propose a model which, although not perfect, seems to be sufficient to generate a near normal cochlear stimulus. According to this model, the cycle previously described suffers an amputation of the phase that corresponds to the entrance of the stapes into the vestibule. When the TM medializes, the fibrous bridge deforms and the stapes remains stable. However, when the TM is displaced outwards, the bridge pulls the stapes . Further®, which he filled with a tape of fascia, so to create and maintain, in a long-term basis, a fibrous columella between the footplate and the TM. The author reported a mean gap of 20 dB or less in 40% of cases. Obviously many latter series reported better results employing several implants,We can find, in the past, evidences of the existence of this effect. Sheehy,Of course we are not suggesting that we abandon the ossicular reconstructions. But we must be mindful of the real possibility of this kind of situation and do not ever underestimate the power of these fibrous bridges in maintaining a good sound conduction. And we strongly recommend the preservation of these adhesions in cases where the air-bone gap does not reach 25 dB.A fibrous bridge can adequately transmit sound to the stapes, resulting in a near normal auditory function. In such cases ossicular reconstruction may be unnecessary.The authors declare no conflicts of interest.


This case report describes the clinical presentation, magnetic resonance imaging (MRI) as well as the histopathological findings in an elderly cat with an intracranial cholesterol granuloma.An 11.5-year-old, male neutered cat was presented at the emergency service with deteriorating behavioral changes including aggression, and progressive generalized ataxia. Magnetic resonance imaging (MRI) of the brain revealed a large, well demarcated, inhomogeneous and contrast enhancing mass in the lateral ventricles with marked mass effect. Due to a poor clinical prognosis, the cat was euthanized. Histological examination identified the mass as a bilateral cholesterol granuloma in the choroid plexus of the lateral ventricles.Although plexus cholesterol granulomas are rarely seen in cats, they should be considered as a differential diagnosis in elderly patients with neurological signs such as behavioral changes. Diagnosis of an intracranial mass in adult cats is frequently considered to be a neoplasia . EspeciaDespite the misnomer, cholesteatomas cannot be considered a neoplastic lesion. The term “Cholesterol granuloma” represents a significantly better description of the lesion. The pathogenesis of cholesterol granulomas development is only partly understood. According to previous publications, cholesterol granulomas arise secondary to repeated hemorrhage or chronic inflammation, leading to a deposition of cholesterol crystals with subsequent granulomatous inflammation foreign body reaction , 8. In hfalx cerebri [Cholesterol granulomas in cats and dogs most frequently occur in the middle ear because of chronic inflammation –22. Intr cerebri , 12. In  cerebri . The preAn 11.5-year-old, male neutered European Short Hair Cat, was presented at the emergency service of the Clinic for Small Animals  due to behavioral changes , generalized ataxia and sneezing. For approximately 3 months, the cat was sneezing and for seven days prior to presentation treated for otitis externa with amoxicillin/clavulanic acid by the referring veterinary surgeon. The clinical signs deteriorated further. The referring veterinary surgeon performed then a dental restoration with the suspicion of inflamed and painful teeth as the cause for the clinical signs. The cat became more aggressive, showed episodes of ‘running fits’, uncoordinated scratching and generalized ataxia. The cat also started to urinate and defecate outside the cat´s litter box, was falling into the feeding dish, developed difficulties while jumping and finally showed compulsive pacing. Otherwise, the cat was regularly vaccinated and dewormed, kept as an indoor-cat and received a commercial diet.During the physical and neurological examination, the cat was highly aggressive and defensive but otherwise alert. Pulse (144 beats per min), respiration (36 breaths per min), body temperature (37.9 °C), and other physical findings were considered normal. Because of hiding and avoiding walking, it was not possible to investigate whether ataxia or paresis were present. Otherwise, the neurological examination was unremarkable. Based on the history and the results of the clinical examination a forebrain lesion was suspected. Hematology, biochemistry, electrolytes, and thyroxine levels taken at the referring veterinary surgeon were unremarkable. Based on previous results, MRI was recommended for further diagnostic examination. MRI of the brain was performed with a 3 Tesla MRI unit . MRI sequences included: T2-weighted images in transverse (tra) and sagittal (sag) plane, tra FLAIR (Fluid-attenuated inversion recovery), tra GRASE (Gradient and Spin echo), dorsal (dor) SPAIR  as well as a tra, sag and dor T1-weighted pre- and post-contrast (Gadoteric acid/Gadoterate meglumine). Previously, the cat was anesthetized and placed in sternal recumbency for image acquisition. General anesthesia was induced with intramuscular dexmedetomidine (5 μg/kg), butorphanol (0.3 mg/kg) and midazolam (0.3 mg/kg) and intravenous alfaxalone dose to effect. After intubation, anesthesia was maintained with isoflurane in air and oxygen.The MRI revealed a large, focal, extra-axial, lobulated, well demarcated, moderate- to highly heterogeneous mass within the lateral ventricles. This heterogeneous mass lesion was mostly hypointense to surrounding brain parenchyma on T1 as well as T2-weighted images, SPAIR and GRASE. Hyperintensities were mainly found within central parts of the mass and the mass was inhomogeneous, moderate to marked contrast enhancing , separated by septae of fibrous connective tissue Fig. . By PrusIn general, intracranial masses rarely occur in cats , 23, 24.Cryptococcus neoformans [Toxoplasma gondii [Feline Infectious Peritonitis Virus (FIPV) can lead to pyogranulomatous meningoencephalomyelitis and chorioiditis [falx cerebri [This case report describes the rare case of an intraventricular cholesterol granuloma without a detectable primary neoplastic or inflammatory insult in a cat. Primary non-neoplastic intracranial masses are extremely rare in cats . When ocoformans  or Toxopa gondii . Also, aioiditis . Cholest cerebri , 14. Oth cerebri  and in t cerebri , indicat cerebri . In the  cerebri . Future


Limb salvage surgery for calcaneal sarcomas remains challenging due to its poor compartmentalization. While below-knee amputation is still the standard choice of operative treatment, total calcanectomy with or without reconstruction was advocated. This report aims to analyze the clinical outcome of calcaneal reconstruction with cement and replantation in situ after the inactivation of tumor.We describe a 73-year-old male patient who suffered chronic pain and increasingly larger neoplasm in the left foot for about 3 years. Based on the results of percutaneous biopsy, a diagnosis of chondrosarcoma was made.The patient underwent total calcanectomy, inactivation of calcaneus tumor, and reconstruction with cement. The Achilles tendon was detached through a Cincinnati incision. No adverse events occurred both during and after the surgery. At the last follow-up of 29 months, the patient claimed no pain, no evident limp, or any limitation of daily activities. Image examination, weight-bearing test, and MSTS score revealed a satisfactory result.Calcaneal reconstruction with bone cement after total calcanectomy, inactivation of calcaneus tumor, and replantation in situ is likely to provide a feasible surgical choice and a satisfactory clinical outcome. Due to this low incidence, to the best of our knowledge, there are only 15 reports discussing 35 patients with calcaneal malignancies, including case reports and a series of cases with surgical options, and the clinical outcomes are not well known.Primary malignancies located in the calcaneus are extremely rare, accounting for less than 1% of the primary tumors of the skeleton, whereas the most common are osteosarcoma, chondrosarcoma, and Ewing’s sarcoma.Adequate local control is one of the most important factors in the treatment of primary malignant bone tumors. Amputation is the most common surgical option for achieving local control, as it is not technically demanding. However, the result of this, which is limb loss, will cause chronic pain, mental sickness, and other complications. Reconstruction of the irregular shape and weight-bearing function of the calcaneus is challenging and technically challenging. Various reconstructive techniques with allografts, autografts, or prostheses have been proposed,–18 and none have reported the reconstruction of the inactivated calcaneus and replantation in situ.Total excision of the calcaneus is the primary treatment of choice for malignant tumors. Only one side of the bone is close to the major neurovascular structure, which can be preserved in most patients to provide safe surgical margins.A 73-year-old male patient with chronic pain and an increasingly large neoplasm in the left foot for approximately 3 years was admitted to our institution in October 2019. Percutaneous biopsy revealed chondrosarcoma  or plantar flexion to avoid putting as much weight on the heel as possible.,7 Total calcanectomy is an effective method for the treatment of high-grade resectable tumors of the calcaneus, particularly in children. The Achilles tendon was then sutured to the posterior aspect of the talus. Madhuri reported the case of a 7-year-old child who underwent chemotherapy followed by total calcanectomy for a primitive neuroectodermal tumor of the calcaneum without reconstruction; the patient had near-normal function at 32 months follow-up. He believed that reconstruction after calcaneal excision is not warranted in every pediatric case. Ichiro reported the case of a 59-year-old man who underwent total calcanectomy for metastasis of renal cell cancer in the calcaneus without reconstruction. The patient complained of pain in the midfoot and could walk without aid for less than 600 m. Loss of the heel causes appearance deformities and unsatisfactory function. Compensation was achieved by placing a heel lift in the shoe. Total calcanectomy without reconstruction may not be an alternative treatment option for adults.Advances in oncological treatment modalities and wide resection have made limb salvage increasingly possible. Total calcanectomy without reconstruction has been reported in 2 cases.–5,8–18Thus, a reconstructive procedure may be attempted to provide the patient with the best functional and durable results after calcanectomy. Previous studies have reported the main reconstruction techniques for the hindfoot after total calcanectomy, including allograft, distally pedicled osteocutaneous fibular flap, vascularized iliac flap, and 3D-printed calcaneal prosthesis, with good functional outcomes. Imanishi reported the use of a 3D-printed titanium calcaneal prosthesis in a 71-year-old calcaneal chondrosarcoma patient. Although the range of motion of the right ankle remained restricted mainly in inversion and eversion, the patient was free of pain without medication and could walk unsupported on bare feet at 5 months follow-up.Chou reported the use of a polymethylmethacrylate calcaneal prosthesis, which caused chronic moderate pain and weight-bearing limitation, and she had a mildly antalgic gait without shoes.,10,12,13 Li reported a series of 4 patients with primary calcaneal tumors who underwent total calcanectomy and reconstruction with the use of a composite of allograft and vascularized osteocutaneous fibular grafts. Revision surgery was necessary for 2 patients because of complications (skin flap necrosis and infection).The allogenic femoral head and neck graft and allogenic fresh-frozen calcaneus were reported to be used in 7 cases of primary malignant tumors of the calcaneus. Good functional results were achieved at a long follow-up, and one patient had minor pain after strenuous walking. Meanwhile, secondary osteonecrosis of the hindfoot was observed at the 4-year follow-up.–18 Reconstruction with a vascularized iliac crest flap presents many advantages; no bone donor site other than the iliac bone comes close to the required graft size for total restoration of the calcaneum. In addition, compared to the rib bone, it offers many more possibilities for bone and tendon fixation through its greater volume. Vascularized transplants have low resection morbidity, are very adaptable, and long vessels allow for a stress-free anastomosis. Moreover, if necessary, an osteofasciocutaneous flap can also be harvested from this anatomical site, enabling the simultaneous reconstruction of bone and soft tissue defects.A total of 14 patients who underwent free iliac flap or fibular flap surgery following total calcanectomy were reported in 5 articles.,18 No incision complications occurred in our patient, and prophylactic antibiotics, drain placement, and careful attention to wound closure were standard clinical protocols to reduce the risk of surgical site infection. In addition, we recommend the Cincinnati incision because it provides adequate exposure to the calcaneus and forms unsightly scars. If skin flap necrosis is found, high-pressure oxygen might be a favorable method to improve the blood supply to the wound.However, allografts, autografts, and prostheses are not suitable for simultaneous bone and soft tissue coverage, donor site morbidity, and functional recovery. Incision complications were the main concern of clinical surgeons; wound dehiscence occurred in half of the patients and needed negative pressure wound therapy or secondary intention in previous reports. The following is our experience with preventing local recurrence.Li reported 3 cases of calcaneal tumors that had local recurrence because of initial curettage procedures in another hospital.First, surgery to treat calcaneal malignancy should be performed by experienced oncologists. Second, complete inactivation and wide resection are the primary surgical principles. Finally, after the pre-installed screw channel was completed, cement was inserted, internal fixation was performed, and the procedure was not in the wrong order. The disadvantage is that a long period is required to achieve bone union with the surrounding bone tissue. We observed union at 8 months follow-up, similar to previous studies.,16Selecting the appropriate treatment for bone defect reconstruction is challenging for surgeons, and biological reconstruction may be the optimal method for reconstruction. The alcohol-inactivated method has the advantages of effectively killing tumor cells, being more economical and convenient, and yielding the same shape for reimplantation.To our knowledge, there have been no reports of cases treated with total calcanectomy with in situ reconstruction after inactivation of the calcaneus. This is a promising way to treat calcaneal malignancy as a limb salvage procedure that provides good quality of life.Calcaneal reconstruction with inactivated calcaneus is likely to provide good chances of a long-lasting result and fewer long-term complications in a weight-bearing area. Maintenance of the original heel can guarantee a better quality of life and function.WJM: Data collection, Manuscript writing. YXC, ZK, XM: Manuscript editing. All authors read and approved the final manuscript.Data curation: Jingming Wang.Formal analysis: Jingming Wang.Methodology: Xiuchun Yu, Kai Zheng.Project administration: Xiuchun Yu.Resources: Xiuchun Yu.Supervision: Kai Zheng, Ming Xu.Writing – original draft: Jingming Wang.Writing – review & editing: Ming Xu.


Double gall bladder or duplication of the gall bladder is a rare congenital malformation. It poses a challenge to the surgeon and the radiologist, both in preoperative evaluation and intraoperative management. In the era of minimal invasive surgery, clear knowledge of extrahepatic biliary anatomical variations is very much essential. The operating surgeon should be very careful and overcautious in identifying such variations to prevent untoward biliary tract injury. In this series of two cases, we present the clinical peculiarities, preoperative diagnosis, and laparoscopic management of the duplicate gall bladder. Duplication of the gall bladder is a rare congenital malformation that results from embryonic dysgenesis of the hepatic antrum which gives rise to the ductal system. The incidence is not exactly known but the available literature denotes a case in every 4000 live births . In the Case 1A 59-year-old woman from Northern India had been suffering from pain in her right upper abdomen for one year. She had no further concerns and her abdominal examination was unremarkable. Ultrasound of the whole abdomen revealed gall stones and suspected double gall bladder. Computed tomography of the abdomen showed a double gall bladder; one of them was with a collapsed lumen Figure .Later, the patient underwent MRCP which showed the duplication of the gall bladder Figure .The patient underwent laparoscopic cholecystectomy. Intraoperatively, we found a duplicated gall bladder with two cystic ducts entering the common bile duct Figure .The postoperative course of the patient was uneventful. On follow-up after two weeks, the patient's recovery was unremarkable. The histopathology was consistent with chronic inflammatory changes in both the gall bladders.Case 2A 61-year-old female has recurrent abdominal pain in the emergency room of our institute. On clinical examination and ultrasound examination, it proved to be a case of acute cholecystitis. The patient was taken for emergency laparoscopic cholecystectomy. To our surprise, we found an accessory gall bladder-like structure hanging to the liver's inferior surface with a normal gall bladder along with a properly established hepatocystic triangle Figure . CholecyPorta and supra duodenal areas were explored and no additional structures were found. The postoperative course of the patient was uneventful and the patient was discharged. Histopathological examination of the accessory structure confirmed that of the gall bladder .Duplication of the gallbladder is a rare congenital malformation with an incidence of one in 4000. It is usually detected when it becomes symptomatic, as an incidental finding in laparotomy, autopsy, or imaging studies. Boyden classified gall bladder duplication into three types; Type 1: bilobed gall bladder with incomplete division and one common cystic duct; Type 2: completely duplicated gall bladder with separate cystic ducts that lead to common hepatic duct; Type 3: completely duplicated gallbladder with a common cystic duct entering the common hepatic duct [Being rare, the duplication of the gall bladder is challenging to identify preoperatively and manage intraoperatively. Any disease in duplication gall bladder lacks a specific presentation and is difficult to identify by routine clinical history and clinical examination. The incidence of cholecystitis (acute or chronic), torsion, cholelithiasis, cholecysto-enteric fistula, and malignancy are similar to that of the single gall bladder . RadioloOther investigations like MRCP, endoscopic retrograde cholangiopancreatography (ERCP), hepatobiliary iminodiacetic acid (HIDA) scan, and oral cholecystography can detect the double gall bladder preoperatively . MRCP anIndications for cholecystectomy in duplicated gall bladder remain the same as in a single bladder. Laparoscopic cholecystectomy is the gold standard approach even though in the initial days, some surgeons preferred an open approach . A safe Gall bladder duplication, despite being a rare case, is challenging when presented. Gall bladder duplication should be kept in mind when the routine ultrasound finding is unclear and in this case, MRCP should be done to identify the anatomy. The operating surgeon should be overcautious to appreciate its presence if found intraoperatively and should follow the safe cholecystectomy strategy to prevent bile duct and vascular injury. Both the gallbladders should be excised without fail to prevent recurrent disease. Hence, preoperative identification of a duplicate gall bladder by imaging and knowledge about its differentials helps to avoid surprises during operation. It also prevents a second surgery and unnecessary medicolegal claims against the surgeons.


Rhabdomyosarcoma (RMS) is a malignant tumor that arises from embryonal skeletal muscle cells. It's responsible for 3 % of cancer cases among children aged from 0 to 14 and 1 % among adolescents and young adults aged from 15 to 19. Embryonal RMS (ERMS) is the most prevalent subtype of rhabdomyosarcoma in the female genital tract. Botryoid sarcomas are a polypoid variant of ERMS. Our objective is to describe the clinical, pathological features and the treatment of a patient diagnosed with RMS botryoid of the cervix.We report a case of a 19-year-old female patient diagnosed with botryoid RMS of the cervix. The histopathological evaluation of the cervix showed a polypoid tumor lined by squamous epithelium exhibiting a large hypocellular edematous area. It was classified as group II and stage 1, according to the IRSG multicenter studies. Cervical polypectomy was performed as an oncological surgical treatment and adjuvant chemotherapy consisting of Vincristine 1.5 mg/m2/day and Actinomycin D 0.045 mg/kg/day (VA) for 45 weeks. After 6 months of follow up, she had no evidence of recurrence.Cervical ERMS is a rare tumor, especially in adolescence. It's usually presents as a cervical polyp or multiple polyps. Multimodal approaches have remarkably improved the prognosis and decreased the need for radical surgery with its associated morbidity.There are a variety of treatment strategies for a rare disease such as cervical botryoid RMS. This case was approached through fertility-conserving surgery, followed by adjuvant chemotherapy and oncological clinical follow up. •Rhabdomyosarcoma is a malignant tumor that arises from embryonal skeletal muscle cells.•Botryoid sarcomas are a rare polypoid variant of embryonal rhabdomyosarcoma.•Multimodal approaches improve the prognosis and decreased the need for radical surgery.•Fertility-conserving surgeries in the early stages of the disease are allowed. Predominately arising from the vagina during childhood. In 36 % of cases it occurs before the age of 5 and, uncommonly, below 1. In adolescents and postmenopausal women, the most frequent place is in the cervix and uterine corpus Botryoid sarcomas are a polypoid variant of embryonal RMS, arising from embryonal rhabdomyoblasts and constituting approximately 3 % of all RMSs 2A 19-year-old patient presented a 2-month history of a painless and fibroelastic vaginal mass of approximately 3 cm, arising from the cervix, mobile during urination and without vaginal bleeding. No surgical history, drug history, family history, including any relevant genetic information, and psychosocial history.Polypectomy of the cervix was performed with sampling of two cervical polyps of approximately 4 × 5 cm and 3 × 2 cm by hysteroscopy at the hospital of origin by a gynecologist. A histopathological slide review was performed at our institution, confirming the diagnosis of botryoid RMS with compromised margins.Oncological staging, including magnetic resonance imaging of the pelvis , computeThe cervix histopathological evaluation showed a polypoid tumor lined by squamous epithelium exhibiting a large hypocellular edematous area a. Tumor The cells that make up the cohesive nests were positive by immunohistochemistry, performing the Desmin, Myogenin, HHF35 and Myo-D1 markers .Fig. 3Th2/day and Actinomycin D 0.045 mg/kg/day (VA) for 45 weeks. She had a good adherence and tolerability to the chemotherapy intervention. Patient maintaining relative rest at home with scheduled outpatient appointments. After 6 months of follow up, she had no evidence of recurrence. The surveillances plans are hysteroscopy and computed tomography scan of the pelvis every 6 months for the first 2 years.After a multidisciplinary discussion between oncology surgeons, clinical oncologists, pediatricians, radiologists and pathologists, the patient with a diagnosis of localized tumor, non-metastatic RMS, microscopically involved margins, was classified as group II and stage 1, according to the IRSG multicenter studies 3Cervical ERMS is a rare tumor, especially in adolescence. It usually presents as a cervical polyp or multiple polyps The diagnosis is made by clinical findings and confirmed by histology, as was the case of this patient who had a vaginal mass resection, and the diagnosis was confirmed by pathological anatomy Histologically, they are polypoid tumors, characterized by a proliferation of edematous hypocellular spindle cells, with cell condensation under the epithelial surfaces, classified as botryoid. The characteristics expressed in the immunohistochemical were Desmin and Myogenin Multimodal approaches have remarkably improved the prognosis and decreased the need for radical surgery with its associated morbidity. The appropriate treatment for cervical botryoid sarcoma is still debatable. Surgical procedures include simple hysterectomies, radical hysterectomies with or without lymphadenectomy, and more conservative procedures such as polypectomies or local excisions Copeland et al. performed one of the largest series of cases of botryoid RMS of the female genital tract, that showed the evolution of treatment over a period of 30 years 4There is a variety of treatment strategies for a rare disease such as cervical botryoid RMS and are built on the experience of multiple studies. This case was approached through fertility-conserving surgery, followed by adjuvant chemotherapy and oncological clinical follow up.Non-commissioned, external peer-reviewed.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.None.None.Alejandro Delfos Hermoza.Carlos Eduardo Mattos da Cunha Andrade, MD.None.Alejandro Delfos Hermoza: Conceptualization, Methodology, Writing – original draft. Graziela de Macêdo Matsushita: Methodology, Supervision. Marcelo Henrique dos Santos: Methodology, Supervision. Ronaldo Luis Schmidt: Methodology, Supervision. Ricardo dos Reis: Conceptualization, Methodology, Supervision, Writing – review & editing. Carlos Eduardo Mattos da Cunha Andrade: Conceptualization, Methodology, Supervision, Writing – review & editing.The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.