Background. Rhinosporidiosis is a common disease entity in tropical countries; however, it can be encountered in other parts of the world as well due to increasing medical tourism. It may mimic other more malignant and vigorous pathologies of the involved part. Case Report. We present a case of a 36-year-old male presenting with proptosis due to involvement of nasolacrimal duct which is rare. We will discuss typical CT and MRI features of the disease which were present in the case. Conclusion. For a surgeon and a radiologist, this is a necessary differential to be kept in mind for sinonasal masses. CT and MRI are invaluable investigations. However, FNAC is confirmatory. Both clinical and radiological aspects are required to reach correct diagnosis. Rhinosporidium seeberi. Pathologically, there is nasal polyposis and other manifestations like hyperplasia of nasal mucosa [Rhinosporidiosis is mainly prevalent in south Asian countries. Frequent bathing in stagnant water ponds is a risk factor for this infection . It is al mucosa . Recurrel mucosa . This isl mucosa .Here, we are presenting a case of a 36-year-old male patient presenting with proptosis due to involvement of nasolacrimal duct which is rare. We will discuss typical CT and MRI features of the disease which were present in the case.A 36-year-old male presented with long standing history of proptosis of right eye since 1 year and foul smelling nasal discharge since 2 months. The patient also gave history of spells of nasal itching. There is no history of constitutional symptoms. There is no history of similar complaints in the family. He works as a farmer in rice fields. Local examination of the eye showed proptosis of lower eyelid and there was a firm and round swelling near medial canthus of right eye. Local examination of the nasal cavity showed friable polypoidal reddish mass in inferior turbinate which was extending into opening of nasolacrimal duct.In nasopharynx multiple polypoidal reddish friable mass which would bleed on touching was seen originating from the base of the skull. Biochemical and haematological tests done on the patient were normal.A CT scan of paranasal sinuses and orbits was ordered which showed intensely enhancing extraconal mass lesion in inferior portion of right eye. There was rarefaction of inferior orbital wall and bony portion of nasolacrimal duct. Nasolacrimal duct was enlarged with rarefaction of bony walls.T2-weighted sagittal section showing heterogeneously hyperintense multilobulated mass originating from nasal cavity and nasopharynx and extending into oropharynx. Lesion shows few flow voids withinPostcontrast T1-weighted coronal section showing enhancing mass lesion in inferior portion of right orbit. There are few nonenhancing areas within. Lesion is extending into the inferior turbinate via nasolacrimal ductPostcontrast T1-weighted sagittal section showing intensely enhancing multilobulated mass originating from nasal cavity and nasopharynx and extending into oropharynx. Lesion shows few nonenhancing areas within. Lesion shows multilobulated external surface mimicking cerebriform appearance of inverted papillomaPostcontrast T1-weighted sagittal section showing extraconal, intraorbital, intensely enhancing mass extending into the nasal cavity via nasolacrimal duct. The mass is protruding outside of the orbital margins causing proptosisFinally, FNAC (H&E staining) of the orbital lesion was done, which showed groups of spore of rhinosporidium of varying sizes (Similarly, enhancing mass was seen in inferior turbinate and nasopharynx. There were few areas of air specs and calcification within the lesion. There was a leash of blood vessels seen originating from the nasopharyngeal wall and supplying the mass . Following sizes . Followi Rhinosporidium seeberi presently classified in class Mesomycetozoea [Rhinosporidiosis is a chronic granulomatous disease caused bycetozoea . The patcetozoea . This excetozoea , 8. Nasacetozoea . Other mOn CT, it looks like irregular or lobulated lesions of soft tissue density showing moderate-to-intense postcontrast enhancement. Small foci of calcification and air can be seen within the lesions. Multiple dilated vessels can be also seen arising from nasopharyngeal mucosa which can be seen supplying the lesion. Lesions arising from oropharynx or trachea can be relatively hypoenhancing compared to the lesions at other sites. Bony involvement may appear as thinning of wall, rarefaction, or complete erosion .MRI shows heterogeneous mixed density mass lesion with prominent flow voids on T2-weighted imaging. Postcontrast imaging shows intense enhancement of the mass. Multilobulated appearance may give rise to cerebriform appearance as described for inverted papilloma in the literature. The main imaging differentials are inverted papilloma, juvenile angiofibroma, lobular capillary hemangioma, angiomatous polyp, and sinonasal malignancy .Diagnosis can be done by FNAC and examination under 10% KOH or Papanicolaou smear. However, usually histopathological examination is required. Both of the above methods show pathogen in its various stages of development , 12.Surgical removal with wide margins remains the main cornerstone of the treatment with electrocautery of the base. Dapsone can be added as adjuvant medical therapy; however, no definite benefits of dapsone therapy have been proven. Even after the treatment with wide excision, there are high chances of recurrence probably due to hematogenous spread of the disease during surgery –15.Rhinosporidiosis is a common disease entity in tropical countries; however, it can be encountered in other parts of the world as trend of medical tourism is increasing. It may mimic other more malignant and vigorous pathologies of the involved part. For a surgeon and for a radiologist, this is a necessary differential to be kept in mind for sinonasal masses. Both clinical and radiological aspects are required to reach correct diagnosis.Inferior meatus is a common site of involvement in the nasal cavity because of its close proximity with the nasolacrimal duct. It is more likely that lesion began in the nasal cavity and then extended into the orbit via the nasolacrimal duct. The presence of other lesions in the nasopharynx may further support this.


Dear SirCongenital hernia of the umbilical cord is rare; only few cases of its association with other congenital intestinal anomalies have been previously described in the literature. [1-5] We report a case of congenital hernia of the umbilical cord associated with type IIIa ileal atresia in a newborn. A 2-day-old, term male neonate, weighing 2.1 kg, 1st in birth order was born by normal delivery. He presented to our department with a small fleshy swelling at the base of the umbilicus, bilious vomiting and epigastric fullness. Antenatal ultrasounds were not done. On examination, the baby was hemodynamically stable, pulse rate-150/min and respiratory rate-50/min. anicteric and mildly dehydrated. Abdominal examination revealed hernia of umbilical cord. There was mild epigastric distension, soft on palpation and absent bowel sounds; nasogastric aspirate was bilious. Laboratory tests were normal except for hypocalcaemia  and raised C-reactive protein. Upright abdominal radiograph showed dilated small bowel loops with multiple air-fluid levels with paucity of distal air; there were multiple defects involving the lumbar vertebra . Laparotomy revealed proximal ileal atresia, type IIIa. The proximal part of distal unused ileum was herniating into the umbilical cord, ending blindly and stuck inside the sac of hernia of umbilical cord . It was dissected and freed; end to back ileoileal anastomosis was performed after excision of 10-12cms of dilated loop and confirming distal bowel patency. Post-operative recovery was uneventful and the child is doing well at follow-up.Hernia of umbilical cord has a benign appearance, surgical correction is easy, and if left as such spontaneous epithelialization of the coverings of the hernia occurs. Hernia of umbilical cord is rarely associated with other congenital anomalies, as against abdominal wall defects  which are commonly associated. [6] A small number of cases of hernia of umbilical cord associated with intestinal atresia, patent vitellointestinal duct, Meckel's diverticulum, incarceration of liver and gall bladder, and persistent cloaca have been reported earlier. [1-7] Intestinal atresia associated with congenital hernia of umbilical cord is extremely rare. The earlier reported cases were type I proximal jejunal atresia, type IIIb ileal atresia, type I colonic atresia, and jejunal with colonic atresia . [1-5] Intestinal atresia occurs as a consequence of in-utero vascular insult. We hypothesize that incarceration of bowel followed by vascular insult due to persistence of herniation of the midgut is the cause of type IIIa ileal atresia in our case. This early vascular accident was followed by resorption of devascularised fetal intestines. The mesenteric defect at the level of ileum and incarceration at umbilical cord and vascular insufficiency leading to entry/exit level intestinal atresia as proposed by Mirza et al appears to be the best possible explanation. [1] To summarize, congenital hernia of the umbilical cord presents with fleshy swelling at the base of cord. Its rare association  like intestinal atresias should be borne in mind to achieve better clinical outcome. The vascular insult due to incarceration inside the sac of hernia of umbilical cord is the cause of type IIIa ileal atresia in our case.Source of Support: NilConflict of Interest: None


Lipomas are common benign tumors usually detected on the torso, neck, upper thighs, and upper arms. However, they are rarely found in the parotid gland region. Because of their rarity at this site, they are not often considered in the differential diagnosis of parotid tumors. This report describes a rare case of a lipoma in the superficial lobe of parotid gland. A 71-year-old female patient admitted to our department complaining about swelling and pain in the posterior area of the left mandibular region since one month. Her medical history included mastectomy after breast CA fifteen years ago. Clinical examination revealed a smooth-surfaced, soft, and painful mass, with well-defined margins in the left mandibular region. Differential diagnosis of metastasis, inflammatory neck swellings, and benign salivary gland tumors were considered for the patient. Advanced imaging methods such as ultrasonography and contrast tomography revealed that the lesion was a lipoma of parotid gland. A surgical intervention under general anesthesia was planned for the removal of the mass; however patient refused the surgical treatment. Patient was placed on six-month periodic recall. This article reviews the radiographic appearance and differential diagnoses of lipoma in this rare location. The ordinary lipomas are the most common neoplasms of mesenchymal origin , 2. TheyA 71-year-old woman patient presented to the Department of Oral and Maxillofacial Radiology with a primary complaint of swelling and pain in the posterior area of the left mandibular region since one month. Patient history revealed that the swelling had been slowly increasing in size. The patient had pain at left side of her face but she cannot distinguish the exact localization. Her medical history included mastectomy after breast CA fifteen years ago. She also has diabetes and is using insulin. Clinical examination revealed a smooth-surfaced, soft, and painful mass, with well-defined margins in the left mandibular region . The sweLipoma of salivary glands is quite rare with the highest frequency reported in parotid gland that presents normally adipose tissue. Heredity, obesity, diabetes, trauma, radiation, endocrine disorder, insulin injection, and corticosteroid therapy are occasionally implicated as a possible etiologic factors of lipoma , 6.Diagnostic imaging techniques such as US, MRI, and CT help to differentiate lipomas from other soft tissue lesions while identifying the nature and exact location of lesion. For the masses in the salivary glands area, sialography, US, and radionuclide scanning are all of value . US can The principle consideration in the differential diagnosis of a mass in the parotid region is whether the salivary gland neoplasia is benign or malign. The primary differential diagnosis of neck masses as benign lesions in the subcutaneous location is a sebaceous cyst or an abscess. Sebaceous cysts are also rounded and subcutaneous. Abscesses typically have overlying induration and erythema . Other bUnless proven otherwise, any unknown neck mass, particularly symptom-free, located unilaterally and related with a known lymph node groups, must be evaluated as a metastatic lesion . LiposarLipomas usually are not treated, because most of them are asymptomatic. Only for esthetic reasons or complaints like paresthesia, lipoma has to be removed surgically . In this


Initial gastrointestinal symptoms might confuse the clinical pictures of some patients with Kawasaki disease (KD) and delay diagnosis and treatment, especially when the patient does not fulfill sufficient diagnostic criteria for KD. Here, we present the case of a 4-year-old boy with KD who complained of severe left abdominal pain and fever alone for the first 6 days. Abdominal ultrasonography showed severe wall thickening localized to the sigmoid colon, and these findings were confirmed by computed tomography and colonoscopy. Microscopic examination of a biopsy specimen revealed non-specific colitis with inflammatory cells in the lamina propria of the sigmoid colon, indicating sigmoid colitis. He subsequently exhibited typical symptoms of KD and was successfully treated with oral administration of aspirin. We suggest that KD should be considered as a differential diagnosis in any child presenting with abdominal symptoms and prolonged fever without definable cause. Abdominal ultrasonography can help evaluate the gastrointestinal complications of KD. Kawasaki disease (KD) is an acute, systemic febrile vasculitis of unknown etiology. Gastrointestinal symptoms including diarrhea and vomiting are relatively common findings. As specific abdominal complications, intestinal pseudo-obstruction , 2, hydrEscherichia coli. Abdominal radiography showed a distended bowel loop containing fecal material.A 4-year-old boy was admitted with complaints of severe left lower abdominal pain and high fever (40 °C) for 4 days. Oral antibiotics prescribed by his previous doctor had not proven effective. On admission, he had no symptoms other than left lower abdominal pain and fever. Neither diarrhea nor vomiting was seen during the course. Laboratory examinations revealed: white blood cell count, 23,000/μL; neutrophils, 67%; platelet count, 396,000/μL; and C-reactive protein, 11.7 mg/dL. Other laboratory data were within normal limits. Stool culture demonstrated only nonpathogenic Abdominal ultrasonography was performed with linear (3–7 MHz) probes on a HI VISION Avius  and Logic E9 . Ultrasonography showed significant thickening of the wall localized to the sigmoid colon, predominantly in the submucosal layer Fig. a, b. FivContrast-enhanced abdominal CT also revealed localized thickening of the bowel wall in the sigmoid colon Fig. . The remColonoscopy showed severe circumferential thickening of the bowel wall and slight redness of the mucous membranes localized to the sigmoid colon Fig. a, upper.Based on a tentative diagnosis of sigmoid colon colitis, intravenous administration of antibiotics was tried for 2 days. However, both fever and abdominal pain continued. On day 3 after admission, the patient displayed progression of eruptions over the body, swelling of both hands, swollen and cracked lips, strawberry tongue, and bilateral conjunctival hyperemia. At that time, we diagnosed KD and started oral administration of aspirin.After initiating treatment with aspirin, both gastrointestinal symptoms and main symptoms of KD gradually resolved. Ultrasonographic findings of wall thickening in the sigmoid colon also disappeared Fig. . The patAs associated symptoms outside the clinical criteria for KD, gastrointestinal symptoms  are relatively common. The severity of these symptoms is highly variable among patients. In most cases, gastrointestinal symptoms gradually resolve after the treatment of KD itself. Some case reports have described conservative treatment of small-bowel pseudo-obstruction , 2. On tIf abdominal symptoms are predominant and features typical of KD are not evident, initiation of appropriate medical treatment may be delayed, with potential consequences for the development of cardiac sequelae . AkikusaLesions of the sigmoid colon in KD are quite rare among the gastrointestinal complications of KD. To date, only one report has described KD associated with the region of the sigmoid colon. Kim et al. reported the case of a 5-year-old boy with colonic edema localized to the descending and sigmoid colon . In thatOur case showed severe thickening of the submucosal layer of the sigmoid colon. A thickened submucosal layer often indicates an acute process in various bowel diseases and corresponds to either edema or hemorrhage . In KD, No reports have described color Doppler findings in the gastrointestinal tract among patients with KD. Color Doppler signals in the sigmoid colon were not increased in our case. KD involves vasculitis of the middle-sized arteries, and histopathological examinations have demonstrated that the gastrointestinal lesions in KD are localized to the arteries of the subserosa . IschemiIn conclusion, KD should be considered as a differential diagnosis in any child presenting with abdominal symptoms and prolonged fever with no clear cause. Abdominal ultrasonography can help evaluate the gastrointestinal complications of KD.


Bezoar-induced small bowel obstruction is a rare entity. It should be highly suspected in patients with gastric hypomotility disorders, psychiatric conditions, prior abdominal or bariatric surgery, or improper intake of medication. Their diagnosis is quite challenging and surgical exploration remains the best treatment of choice to ensure the viability of the small bowel tissue and relieve the obstruction. This is a case of a 48-year-old female with no previous abdominal surgery who presented with acute abdominal pain. The patient's history was remarkable for the daily ingestion of 1.5 teaspoons of Metamucil with minimal amount of water. Computed tomography scan demonstrated dilated small bowel loops and a transition zone at the level of the mid jejunum. On laparoscopy, the patient was found to have a hard mass in the mid jejunum amenable to gentle fragmentation and breakdown. Metamucil bezoars are due to the solidification of psyllium-based substances in the gastrointestinal tract. The usual management of small bowel obstruction induced by a bezoar is exploratory laparotomy with enterotomy and primary anastomosis. Laparoscopic intervention has gained popularity among surgeons with good outcome and lower morbidity. In this unusual case, the small bowel obstruction induced by the Metamucil bezoar was safely treated with laparoscopic fragmentation alone. Bezoars are insoluble conglomerations that persist in the gastrointestinal tract. Although rare, they are usually reported in patients who have undergone previous partial gastrectomies, pyloroplasties, and vagotomies due to delayed gastric emptying and impaired motility . PhytobeA 48-year-old female presented to the Emergency Department at American University of Beirut Medical Center in August 2016 with severe and persistent crampy abdominal pain of 18 hours duration. The abdominal pain was focused around the supraumbilical region. It was associated with obstipation but no abdominal distention. She denied any fever, chills, nausea, vomiting, diarrhea, or any respiratory and cardiac symptoms. Her past medical history was only significant for a pituitary microadenoma and migraine headaches. Her past surgical history was significant for a Caesarean section and an abdominoplasty. She regularly took Imigran (Sumatriptan) 50 mg and Metamucil fiber supplements (1.5 spoons). She mentioned the ingestion of 1.5 spoons of Metamucil dissolved in a minimal amount of water.On admission, her vitals were stable: temperature 36.4°C, heart rate 63 beats per minute, blood pressure 130/80 mmHg, and oxygen saturation 96% on room air. Physical examination showed mild diffuse abdominal tenderness and hypoactive bowel sounds. There was no guarding and rebound tenderness. Murphy and McBurney signs were negative. An abdominoplasty scar was noted in the lower quadrant of the abdomen. Laboratory data were grossly normal with no evidence of electrolyte abnormalities or increased white blood cell count.Computed tomography (CT) of the abdomen and pelvis with IV and oral contrast was performed in the emergency department. Oral contrast was seen reaching the proximal jejunal loops. There was evidence of dilated duodenal and jejunal loops reaching a maximum diameter of 3.6 cm with small bowel feces sign proximal to a transition zone at the level of the mid jejunum. Distal jejunal and ileal loops were collapsed. These findings were suggestive of high-grade small bowel obstruction with a clear transition zone at the level of the mid jejunum.The patient consented for laparoscopic exploration. Laparoscopic exploration revealed a clear transition point in the mid jejunum see . No adheThe patient's postoperative course was smooth and facilitated by the use of a mild dose of polyethylene glycol. The patient's crampy abdominal pain resolved and she showed evidence of return of bowel function (flatus and stool) on postop day 1. Oral intake was resumed postop day 1 and advanced accordingly. The patient was discharged home after 2 days uneventfully and was doing well at the time of her last follow-up in clinic.Bezoars can be classified into four different entities according to their composition: trichobezoars, phytobezoars, lactobezoars, and pharmacobezoars –6. Bulk-Depending on size and location, some bezoars may remain undetected, while others show gastrointestinal signs and symptoms  . They caThis can be achieved through thorough history taking, physical examination, endoscopy, and computed tomographic (CT) scanning. The latter allows localization and assessment of the presence of multiple bezoars and can detect the cause of the obstruction in around 73–95% of patients . There hEndoscopy has been widely used for fragmentation and/or extraction of gastric bezoars using forceps, snares, argon plasma coagulation, or electrohydraulic devices . Some beSurgical intervention remains the gold standard for the treatment of bezoar-induced SBO and ileus . The optPharmacobezoars are rare causes of small bowel obstruction, especially those composed of Metamucil and psyllium-based substances. The diagnosis is challenging and patient symptoms vary with the severity of the obstruction. Gastric hypomotility disorders increase the risk of bezoars and timely intervention is critical to prevent tissue ulceration and necrosis. Laparoscopic fragmentation of the bezoar if feasible is an acceptable option sparing the patient the risk of an enterotomy.


Sclerosing mesenteritis is a rare disease of the mesentery. Associations with surgery, trauma, autoimmunity and paraneoplastic syndrome have been suggested, but most of the cases remain idiopathic. Diagnosis is often incidental, based upon the finding of a single or multiple mesenteric lesions on abdominal CT and histopathological confirmation. Optimal treatment is still controversial, but most of the cases reported have a favourable prognosis. We present a case of a 54-year-old male with long-standing abdominal pain and nausea, whose CT revealed the presence of a large mesenteric mass. A biopsy was performed, revealing benign chronic inflammation, fibrosis and IgG4-positive plasmocytes consistent with sclerosing mesenteritis. Clinical remission was achieved with corticosteroids and follow-up CTs at six and twelve months documented stability of the lesion. Furthermore, we review the current literature on the diagnosis and treatment options for this rare disease. Sclerosing mesenteritis is a rare disease, part of a spectrum of idiopathic primary inflammatory and fibrotic processes that affect the mesentery . It is oA 54-year-old caucasian male with unremarkable medical history presented with worsening of a several-year history of lower-quadrant abdominal pain and nausea. There were no abnormal findings on his physical examination and laboratory workup. An abdominal CT revealed the presence of a soft tissue mass located in the root of the mesentery, 4.7x4.1x5cm, heterogenous with some calcifications within , with thThe first case of sclerosing mesenteritis was reported by Jura in 1924 as "retractile mesenteritis" . SymptomMRI findings appear to be similar to CT, but a combination of the two has been suggested as having a higher sensitivity in the detection of sclerosing mesenteritis lesions . The difSclerosing mesenteritis is a rare disease, often diagnosed incidentally. Diagnosis is challenging due to the non-specificity of the symptoms and physical findings, requiring that physicians maintain a high level of suspicion for this disease when approaching patients with mesenteric lesions. Imaging with CT is the most sensitive diagnostic tool, but surgical biopsy is required to make the diagnosis and exclude radiological mimics. Treatment is mostly medical, with surgery being indicated in cases of severe obstruction. The disease course is believed to be benign and stable.The authors declare no competing interest.


Congenital diaphragmatic hernia (CDH) is a congenital abnormality, rare in adults with a frequency of 0.17–6%. Diaphragmatic rupture is an infrequent consequence of trauma, occurring in about 5% of severe closed thoraco-abdominal injuries. Clinical presentation ranges from asymptomatic cases to serious respiratory or gastrointestinal symptoms. Diagnosis depends on anamnesis, clinical signs and radiological investigations.From May 2013 to June 2016, six cases  of diaphragmatic hernia were admitted to our Academic Department of General Surgery with respiratory and abdominal symptoms. Chest X-ray, barium studies and CT scan were performed.Case 1 presented left diaphragmatic hernia containing transverse and descending colon. Case 2 showed left CDH which allowed passage of stomach, spleen and colon. Case 3 and 6 showed stomach in left hemithorax. Case 4 presented left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon. Case 5 had stomach and spleen herniated into the chest. Emergency surgery was always performed. The hernia contents were reduced and defect was closed with primary repair or mesh. In all cases, post-operative courses were uneventful.Overlapping abdominal and respiratory symptoms lead to diagnosis of diaphragmatic hernia, in patients with or without an history of trauma. Chest X-ray, CT scan and barium studies should be done to evaluate diaphragmatic defect, size, location and contents. Emergency surgical approach is mandatory reducing morbidity and mortality. Bochdalek hernias) are the most common hernia type (>80%) with the majority occurring on the left side (85%), less frequently on the right side (13%) or bilateral (2%) [Congenital diaphragmatic hernia (CDH) is an abnormality found in 1/2500 newborns, with a survival rate of 67% [Diaphragmatic rupture (DR) is an infrequent complication of trauma that occurs during 5% of trauma, including vehicle accidents –5. DiagnHowever, there is no consensus on the absolute indications to surgery and about the timing. The onset of complications carries highest mortality and morbidity rates; therefore, it makes emergency surgery mandatory. During the past decades, primary suture repair or covering the defect with a synthetic mesh has been the standard procedures. More recently, biologic meshes have been thought to be effective in closing the diaphragmatic defect, inducing limited inflammatory response and minimizing adhesion formation . LaparotThis paper includes the surgical experience of congenital or traumatic diaphragmatic hernia of a surgical unit in emergency setting and reports the literature.Six cases of diaphragmatic hernia were observed in emergency at our Academic Department, with respiratory and abdominal symptoms. No breath sounds were detected in the left chest area, but bowel sounds were audible. Emergency surgery was performed in all cases. The hernia contents were reduced, and the defect was closed with primary repair or mesh.Case 1: A 63-year-old woman was admitted with complaints of bowel obstruction and dyspnoea. Anamnesis revealed chronic abdominal pain, mental retardation and strabismus. In the physical examination, no breath sounds were detected in the left chest area; however, bowel sounds were audible. Chest X-ray and barium enema showed the transverse colon displaced into the left hemithorax above the splenic flexure. Computed tomography suggested collapse of the lung and the mediastinal shift towards the right. The left diaphragmatic hernia contained the transverse and descending colon Fig. . EmergenMersilene mesh®. Thoracotomy approach was used to release the thoracic dense adhesion between the chest and the abdominal contents. Before placing the mesh, the anaesthesiologist increased the tidal volume to expand the collapsed left lower lobe of the lung and a chest drain was placed in the left pleural space. Immediate post-operative chest X-ray showed expansion of the left lung with minimal pleural effusion. Post-operative course was uneventful, and post-operative stay was 13 days.Case 2: A 50-year-old woman was admitted with complaints of dyspnoea, chest and abdominal pain. No breath sounds were detected in the left chest area. There was no history of trauma. Chest X-ray revealed mediastinal shift towards the right and bowel gas in the left chest. CT scan showed large annular diaphragmatic defect which allowed passage of the stomach, spleen and colon . The patient was discharged on the 10th post-operative day, without complications.Case 4: A 63-year-old woman was admitted with complaints of breathlessness for 2 days, which was gradually progressive and associated with left-sided chest pain and a dry cough. There was a history of a vehicle accident 6 years ago. The initial chest radiograph revealed an elevated left hemi diaphragm with presence of a colon gas shadow in the lower half of the hemithorax. CT scan suggested left diaphragmatic hernia which allowed passage of the spleen, left lobe of liver and transverse colon Fig. . SurgeryAdvanced Trauma Life Support protocol. He arrived in the emergency room with decreased breath sounds on the left side, dyspnoea, fever, left hypochondrium hematoma, subcutaneous emphysema, and chest and abdominal pain. His current medical history included obesity and treated hypertension. Initial chest radiography and barium studies demonstrated stomach in the left hemithorax. CT scan revealed stomach and spleen in left hemithorax, consistent with a traumatic diaphragmatic rupture with complete disruption of all muscular layers, collar sign and multiple rib fractures, fractured left humerus and scapula . Post-operatively, the patient was placed in an intensive care unit. He was transferred from the ICU on the 8th post-operative day and discharged on the 20th day.Case 5: A 50-year-old man was involved in a work accident. He was managed in accordance with ula Fig. . At explula Fig. . The herHodgkin’s lymphoma. The physical examination revealed a moderate peritoneal effusion without a peritoneal reaction. The introduction of a nasogastric tube remarkably improved symptoms. The chest X-ray showed a large fluid level beneath an apparently raised left hemi diaphragm , presented cases in childhood  or were not interesting human species (N = 58); 32 papers were excluded because regarded hiatal hernia, 40 paraesophageal hernia and 59 elective setting. Consequently, the full texts of 101 articles were assessed for eligibility: the ethiopathogenesis was traumatic in 697 patients and congenital in 38 , sometimes by blunt thoracic-abdominal trauma (5%) , 15. Mor%, sometiCDH formation is found 80% on the left side . Also, 8The review of literature reported in this study confirmed the high frequency of left defect 80%, and only two cases of bilateral DR were reported.Nayak et al. described severe symptoms, in 46% of CDH cases with 32% of mortality due to visceral strangulation [gold standard technique for diagnosis, offering the unique opportunity to evaluate the presence, size and location of a diaphragmatic defect, as well as the contents of various types of diaphragmatic hernias [gulation . Moreovegulation , 26. Latgulation . Indeed,gulation . Althouggulation . Obviousgulation , 30. Che hernias  and show hernias . AccordiFryns syndrome and trisomy 18, have been reported in 8.6–80% of cases [Late-presenting CDH is considered as a benign condition but it can rapidly becomes a life-threatening disease , 31, 33;of cases , 27, 28,Surgical repair typically involves primary or patch closure of the diaphragm through an open abdominal approach. When the diagnosis is delayed, due to suspicions of adhesions between viscera and chest, thoracotomy or combined thoracic-abdominal approach is preferred, as in the reported case 2. Some authors have reported success with thoracoscopic approach but vitiated by an increased incidence of hernia recurrence –36. FurtHowever, emergency surgery is the treatment of choice for diaphragmatic rupture. In delayed cases, thoracic approach is recommended to reduce viscera-pleural adhesions and to avoid intra-thoracic visceral perforation with catastrophic complications . When thWhen a diaphragmatic hernia is diagnosed, surgery is the treatment of choice, above all in emergency setting. A multidisciplinary approach in dedicated centres is advisable.


Root canal stripping is defined as an oblong, vertical perforation that appears especially in the middle section of curved root canals during endodontic treatments with nickel-titanium (Ni-Ti) instruments. Its occurrence may drastically affect the outcome of the treatment, transforming a common otherwise efficient endodontic procedure into a complication such as tooth extraction. In order to discuss the ethical and legal consequences, two cases of dental strip perforations are herewith presented. Due to the existence of risk factors for dental strip perforation, experience of the clinician and the use of magnification and modern imagistic methods (CBCT) may avoid or reduce the frequency of this type of accidents. Under correct working circumstances, dental stripping should not be regarded as a malpractice but as a procedural accident. However, the patient must always be informed, before and during the endodontic procedure, about the event and the possible complications that may occur. All these properties make MTA a material of choice for repairing root perforations. In a reduced number of cases, when the perforation of the outer root wall is minute and the amount of extruded root canal filling material is negligible, the tooth can behave like it does after a usual postfilling extrusion, and, after a couple of days of tenderness to percussion, tooth remains indefinitely symptom-free. In all the situations, the costs and stress for the patient could become significant, raising an ethical dilemma: Is root canal stripping considered a malpractice or a procedural accident? What is the correct attitude that should be undertaken by the health care provider to minimize the potential harm or to avoid placing a patient at an unreasonable risk of harm?Endodontic stripping is an oblong, vertical perforation that occurs especially in the middle section of a curved root canal, caused by excessive instrumentation of the internal wall  during tIn order to evaluate the ethical and legal aspects related to root stripping perforation resulting from an, otherwise correct, mechanical rotary preparation, two case reports are presented hereunder.A 67-year-old male patient was referred to a private dental practice, complaining of acute, pulsating pain in the mandibular left first molar (#36). In the case history, the patient reported episodes of acute pain, exacerbated during the night and temporarily alleviated with common painkillers. Pain intensifications were also diminished by rinsing with cold liquids in the affected molar region. The clinical oral examination revealed a deep carious lesion on the distal aspect of the crown, close to the cementum-enamel junction, and also a mesial decay lesion was observed at #37. Decayed dentin was present throughout the entire cavity, including the axial wall of both molars. For the first molar (#36), removing the decayed dentin led to an opening in the axial wall, with the occurrence of a puss droplet, followed by an abundant hemorrhage. The pain gradually subsided later and the tooth remained tender to percussion. Acute purulent pulpitis was established as positive diagnosis. In addition, a retroalveolar X-ray was performed .The root canal treatment was conducted in two appointments for both molars. In the first session, under local anesthesia, pulp extirpation was performed under 2.5% Sodium Hypochlorite irrigation, and a sterile cotton pellet was left in the pulp chamber. The cavity was sealed with temporary filling. In the second session, chemomechanical root shaping was performed using the manual nickel-titanium (Ni-Ti) ProTaper system according to the technique indicated by manufacturer , in association with Sodium Hypochlorite and Ethylene Diamine Tetraacetic Acid (EDTA) irrigations. The root canals were dried using paper points. At this time, a discrete blood stain on the paper point between the cervical and middle thirds of the mesial root of tooth #36 was noted. Root canals were sealed with ProTaper gutta-percha and sealing cement. In the same session, the filling of the crown cavity with composite material was performed. Postsurgical retroalveolar X-ray performed showed an incomplete and incorrect root canal filling, associated with changes of the initial curvature of the canal  for tootA 52-year-old male patient was referred to a private dental practice for endodontic advice and treatment. The patient was complaining about discomfort in the mandibular right molar region and the case history revealed spontaneous acute pain exacerbated by cold drinks, occurring a couple of months before. Intake of common painkillers helped to alleviate the pain, which disappeared later. Intraoral clinical examination revealed two metallic crowns on the right first and second molars. In addition, a retroalveolar X-ray of the tooth was performed showing a canal wall already thinned by a preexistent external distal root resorption, caused by an inflammatory lesion. After tooth opening through the metal crown, decayed dentin was noticed, including the axial wall. The opening of the pulp chamber occurred while removing the decayed dentin. Pain was not present at the opening time. The root canal probing revealed sensitivity and hemorrhage, while the tenderness to percussion test was negative. The positive diagnosis of chronic pulpitis was set. The root canal treatment was conducted in two sessions. In the first session, under local infiltration anesthesia, pulp extirpation was performed, irrigations with 2.5% Sodium Hypochlorite were carried out, a cotton pellet with a mixture of antibiotic and steroidal anti-inflammatory  was introduced in the pulp chamber, and the cavity was sealed with temporary filling.During the second appointment, a rigorous chemomechanical root shaping was performed. Manual K-files, size 15–40, were used just to avoid a potentially dangerous enlargement of the distal and mesial canals. However, because of the initial curvature of the canal, a relocation of the canal orifice to mesial became obvious even during the mechanical preparation and a retroalveolar X-ray with manual K-file was performed. Irrigations with 2.5% Sodium Hypochlorite and EDTA were also performed. While drying the canal, blood impregnation of the paper point was observed at the middle third level of the distal root. In the same appointment, the root canals were filled using the lateral cold condensation technique. Endomethasone  was used as sealer. Temporary coronal filling was performed. The postoperative retroalveolar X-ray showed a slight overfilling of the distal root canal, a thinned distal wall of the mesial root, and a nonhomogenous radioopaque mass protruding in the periodontal space at the mid-level of the root canal . PatientIn order to analyze the ethical aspect of root canal stripping in both cases, the four-topic method  described by Jonsen et al.  were useThe topic of medical indications for both cases addressed treating the root canal by the removal of the organic material from the endodontic space and the tridimensional shaping by a progressive conical preparation, with a minimum diameter at the apical constriction level, in order to maintain its initial shape . UnfortuMandibular molars have been reported to be more susceptible to strip perforations due to their root anatomy , 16, dirMost of the root canals have a certain degree of curvature, while endodontic files, both manual and rotary, are straight and tend to straighten in curved root canals. Even precurved steel files tend to straighten once placed into the root canal due to the bending moment of the instruments. In the second case report, even stainless steel K-files may be considered as risk factors for stripping when excessively shaping the root canal.Rotary Ni-Ti root canal files represent a widely used alternative to stainless steel instruments in endodontics . FlexibiIn both reported cases, the molar roots presented an anatomy that predisposed to the risk of stripping. In the first case, the mesial root had curvatures in more than one plane, and in the second case the mesial wall of the distal root had a reduced thickness, requiring a shaping technique that would have prevented the excessive thinning of the mesial wall.Regarding patients preferences, case management included informed consent about what happened and advice about the treatment options. Referral to a specialist was decided to be in the best interest of the second patient. The first patient preferred follow-up and tooth extraction if needed. Treatment and prognosis differed from those of a lateral root perforation because of the size, oval shape, and thin edges of the stripping . If extrWhen analyzing quality of life, significant improvement was noticed in both cases, despite the reserved long-term prognosis.Regarding malpractice versus procedural accident, medical malpractice is the negligence arising out of the doctor-patient relationship, whereas negligence is the unreasonable act or omission by a provider that results in patient harm . AccordiThe specialty of endodontics, like all other dental specialties, is guided by each country's National Code of Ethics issuing guidelines (templates and not mandatory) as national standard of care. The accepted definition for standard of care is “that reasonable care and diligence ordinarily exercised by similar members of the profession in similar cases in like conditions given due regard for the state of the art” . NationaAccording to the Law on Healthcare Reform in Romania (Law Number 95/2006) , as a meIn our country, the recently introduced specialty of endodontics is guided by the Code of Ethics of the National Romanian College of Dentists . The codDespite the existence of risk factors for dental strip perforation, such as root canal anatomy and morphology as well as elastic (memory-shape) properties of modern endodontic instruments, the experience of the dental clinician is important in order to avoid or reduce the frequency of this type of accidents. Like in so many other complex situations in dentistry, the practitioner may encounter unwanted and unforeseen circumstances during root canal therapy that may affect the prognosis. Therefore, under correct working circumstances, dental stripping should not be considered a malpractice event but a procedural accident. Whenever possible, magnification and modern imagistic methods such as CBCT should be used. However, in similar cases, the patient must be informed about possible complications that may appear before and after the treatment if stripping occurs.


Our case describe a rare recurrence case of Unicentric Castleman’s disease (UCD) with hyaline vascular type 14 years after surgery.A 35-year-old Chinese female was admitted to hospital with one and half months history chest distress and chest pain. Patient reports a history of thoracic operation for mediastinal mass 14 years ago, and it was diagnosed UCD with hyaline vascular type after postoperative pathological examination. At this time, the imaging examination showed a mediastinal mass once again. Combining the medical history, postoperative microscopically examination and immunoperoxidase staining, patient was again diagnosed UCD with hyaline vascular type again. The hyaline vascular type is the most common type and usually presents as a UCD. Most patients with UCD have no clinical symptoms. The diagnosis of UCD is generally achieved with histological and immunohidtochemical findings postoperatively. Currently, the standard treatment of UCD is the complete surgical resection, with almost no relapse postoperative. The recurrence in UCD with hyaline vascular type postoperative have not previously been reported. Therefore, herein we describe a recurrence case of UCD with hyaline vascular type 14 years after surgery.Our case is the first case which reports the relapse of UCD with hyaline vascular type after completely surgery. It indicates that long term follow-up is necessary for patient who is diagnosed UCD after surgery. Castleman’s disease (CD) is a rare atypical lymphoproliferative disorder that can be easily misdiagnosed. Benjamin castleman  first deCD is an uncommon form of disorders characterized by proliferation of morphologically benign lymph nodes hyperplasia. Clinically, it may present as either unicentric  or multicentric . Keller  classifiRecently, very few relapse case of UCD with hyaline vascular type was reported. Thus we report here an unusual case of relapse UCD with hyaline vascular type after 14 years of surgical resection.A 35-year-old Chinese female was presented with chest distress and chest pain for one and a half months from November 2014. She had no obvious dyspnea, pant and cardiopalmus. Her chest pain aggravated progressively without any obvious exacerbation and alleviation factors. She had no chronic lung disease or cardiac disease history. And no fever, night swears, or weight loss was observed. But she had a history of thoracic operation 14 years ago because of a mediastinal mass, which diagnosed UCD with postoperative pathological examination. The postoperative pathologic result was consistent with hyaline vascular Castleman’s disease Fig. . The masThe Physical examination revealed no abnormal results. The patient’s biochemical profile, full blood count, erythrocyte sedimentation rate, and tumor marker test were normal. The result of the human immunodeficiency virus (HIV) screening test was also negative.Imaging revealed a homogeneous, noninvasive, large, solitary mass in the mediastinum at the local hospital. Then the patient was referred to our hospital, received chest contrast-enhanced computed tomography (CT) scans, which confirmed a mass (6.0 cm × 3.8 cm) at the right mediastinum. The non-enhanced phase revealed a homogeneous, fleshy, noninvasive, solitary mass, the value of the CT was 16HU-42HU Fig. , and eviThe patient had a history of thoracotomy 14 years ago because of a mediastinal mass. Considering a great possibility of the pleural adhesion after surgery and the location of the tumor, the thoracoscopic approach was not suitable. The patient underwent thoracotomy and mass resection from the right anterrolateral incision. Intraoperatively, the right mediastinum tumor was seen, the tumor  was 5 cm × 5 cm × 6 cm in size, firm, a rich and large vascularity in the surface.Postoperative microscopically examination Fig.  revealedImmunoperoxidase staining Fig.  showed CThe patient recovered well postoperatively and discharged 10 days after the operation. His chest distress and chest pain had completely alleviated. During the following 2 years the patient had no progression or recurrence of the disease.Unicentric Castleman’s disease (UCD)is a localized form of hypervascular lymphoid hyperplasia. It accounts for most of the cases and presents as a mass located in the thorax (30%), the neck (23%), the abdomen (20%), or the retroperitoneum 17%) and rarely affects the axillary region 5%), the groin area (3%), or pelvic region (2%) .Aother s%, the gr% and rarThe etiology and pathogenesis of CD is remain uncertain and has been described in association with a reactive lymphoid hyperplasia initiated by viral infections or a development growth disturbance of the lymphoid tissue . CurrentClinical symptoms of UCD are closely correlated with the pathological type. It mainly involves lymph node enlargements only a single site, and 90% of UCD patients are usually asymptomatic, have no indolent, slow progressive course and a rare discovery on radiographs. The clinical, radiological, or cytological typical features are relevant, confirming the correct diagnosis is difficult before the surgery. In our case, the chest contrast-enhanced computed tomography (CT) scans revealed a mediastinal mass. The non-enhanced phase revealed a homogeneous, fleshy, noninvasive, solitary mass and evident contrast heterogeneous enhancement was observed during the arterial phase. According to the medical history, clinical presentation, and the findings of chest contrast-enhanced computed tomography imaging, this case might not be diagnosed as the recurrence of UCD.The definite diagnosis of UCD is exclusively based on histological and immunohistochemical finding after resection . MicroscIn UCD, surgical resection of the mass is a standardized and preferred treatment protocol, the curative ratio can reach 95%. Some researches report surgical treatment can achieve a cure rate of approximately 100%, either with vascular type or plasma cells type , 18 is uUCD is a rare disease and difficult to diagnose. We emphasize that surgery remains as the mainly treatment means. So far, a number of studies have reported that the surgical resection of UCD can achieve a cure rate of approximately 100%, and there is no relapse postoperatively during the reported followup , 9, 11.


The tumor recurred in 2007, then called recurrent primary hepatic neuroendocrine tumor (PHNET), and the patient underwent liver transplant. Because of similarity between the neuroendocrine tumor and a thyroid tumor—specifically, follicular-like characteristics—immunohistochemical stains for thyroglobulin, TTF1, and calcitonin were performed. However, all were negative. All imaging studies revealed no evidence of a primary lesion other than the liver mass. In 2008, the patient's liver transplant failed because of ischemic cholangiopathy, and she underwent a second liver transplant. Seven years later, in 2015, she presented with metastatic neuroendocrine tumor of intermediate grade to the lung, consistent with metastatic PHNET. She underwent left upper-lobe wedge resection to remove the tumor. The patient is alive with no evidence of disease at 13 years after initial diagnosis. This rare variant of PHNET had thyroid-like morphologic characteristics but there is no evidence of primary thyroid tumor or thyroid markers in the primary and recurrent hepatic tumors and lung metastasis.We describe a primary hepatic neuroendocrine tumor of a 57-year-old Thai woman who presented in 2004 with a suspicious mass in the left hepatic lobe. She underwent left hepatectomy for the 10.5-cm mass, called Primary hepatic neuroendocrine tumors (PHNETs) are rare and poorly described entities, with fewer than 150 cases described in the literature  in 1958,Neuroendocrine tumors (NETs) in general are relatively rare tumors with an incidence rate of 2 per 100,000 cases of all gastrointestinal tract tumors . NETs caOur review showed that demographically most of patients with PHNETs are of Asian descent  , 5. TherThe patient was a 57-year-old Thai woman who was referred in August 2004 for a suspicious mass in the left hepatic lobe that had been discovered on ultrasonography. She underwent a left hepatectomy of the native liver for an estimated 10-cm mass. Grossly, the resected lobe showed both a 10.5 × 10.0 × 7.0 cm, tannish yellow, focally hemorrhagic, well-circumscribed mass and a 0.7-cm well-circumscribed yellow nodule that were within 3.5 cm of each other.On histomorphologic evaluation, the mass showed a monotonous uniform population of neoplastic cells arranged in follicles with intraluminal eosinophilic secretions. The cells were round to oval with scant eosinophilic cytoplasm that had “salt-and-pepper” chromatin  and brisA follow-up MRI in 2007 revealed an 8.9-cm liver tumor on segment VIII, described as circumscribed and hypervascular. No other primary lesion was detected on other imaging, including octreoscan, bone scan, ultrasonography of both breasts and thyroid gland, and endoscopy including a capsule study. Subsequently, the patient underwent a liver transplant following hepatectomy of the remaining native liver. The completion hepatectomy specimen of the remaining native liver showed that the liver capsule was brownish tan, focally fibrotic, and diffusely covered with adhesions. Sectioning revealed an orange well-circumscribed mass measuring 14.5 × 13.0 × 12.1 cm. The tumor had areas of cystic degeneration intermixed with areas of hemorrhage, with a variegated appearance. On microscopy, the tumor showed follicular thyroid-like morphologic characteristics reminiscent of a thyroid follicular carcinoma . HoweverThe tumor once again stained positive for neuroendocrine markers, including synaptophysin  and chroIn 2008, the patient's transplanted liver failed because of ischemic cholangiopathy, and she underwent a second liver transplant. On a posttransplant follow-up visit in 2015, a radiograph showed an enlarged left upper-lobe lung nodule. However, an octreoscan and a positron emission tomography/computed tomography scan for whole-body imaging were negative. The nodule size was found to be increasing on interval monitoring; in 2016, the patient underwent a wedge resection. Ultrasonography and MRI of the abdomen showed no liver abnormalities this time.The left upper-lobe lung wedge resection of the suspicious nodule showed a 1.4 × 1.0 × 0.6 cm, well-circumscribed, tan firm mass. On microscopy, the tumor showed similar morphologic characteristics to the 2 previous primary and recurrent hepatic tumors . ImmunohPHNET primarily occurs in patients aged 40 to 50 years and is usually located in the right lobe of the liver . PHNETs The origin of PHNET is still unknown, but possible and plausible theories include transformation of liver stem cells; neuroendocrine differentiation of ectopic adrenal tissue or of heterotopic pancreatic tissue in the liver; and transformation of neuroendocrine cells of the intrahepatic biliary ductal epithelium .Immunohistochemistry is by far the most important diagnostic tool with regard to NETs and PHNETs. NETs almost always stain positively for neuroendocrine markers . Synaptophysin is a peptide of small synaptic vesicles present in all neuroendocrine cells, and thus it is almost always positive, independent of the number of vesicles. Chromogranin A, by comparison, is part of the neurosecretory hormone granules; therefore, evidence of its presence is dependent on the number of vesicles present. Immunohistochemical staining is also useful in differentiating between NETs from other sites of origin and PHNET. TTF1 stain is frequently positive for NETs that originate from the lung, and neuron-specific enolase stain is positive in some NETs of gastroenteropancreatic origin. Both stains tested negative in this particular PHNET case. Other immunostains could be used to differentiate between a liver metastasis and PHNET. For example, thyroglobulin and calcitonin were especially useful in this case to rule out thyroid origin, which was suspected because of the thyroid-like follicular morphologic pattern.Recently, a rare variant of cholangiocarcinoma with thyroid-like morphologic traits has been described in 2 case reports , 13. HowThe present hepatic NET is unusual in its immunohistochemical profile, since all tumors (primary and recurrent hepatic tumors as well as metastasis) expressed cytokeratin 7, which is known to be expressed in cholangiocarcinoma. In addition, cholangiocarcinoma can have neuroendocrine differentiating traits, but they are usually 2 components—a conventional cholangiocarcinoma and a separate component with neuroendocrine differentiation are usually present . NeuroenNETs are classified as well differentiated (tumors) and poorly differentiated (carcinomas). They are graded into G1 and G2 tumors and high-grade (G3) carcinomas on the basis of their mitotic count or the Ki-67 labeling index, or both, with the latter being more accurate –18 Tabl.In this case of PHNET, the initial tumor was diagnosed as a G2 tumor ; the recurrent tumor was a G1 tumor  and the metastasis was G2 . This variation of Ki-67 index within individual NETs or within their metastasis is common, and the higher Ki-67 index value decides the tumor grade . InteresAnother enigma surrounding PHNETs is how they behave in the long term. Our case showed both recurrence after a left hepatic lobectomy and metastasis to the lung during the 13-year course. A 7-year retrospective study by Li et al.  reviewedResection continues to be the mainstay of therapy for localized disease, with a 5-year survival rate of 78% to 80% and a recurrence risk of 18% to 26% . In unreIn conclusion, PHNETs are rare tumors but should be included in differential diagnoses of primary hepatic tumors, especially after other sites of origin have been excluded. PHNETs can present with varying histologic findings, but immunostaining for neuroendocrine markers is the gold standard for diagnosis. Independent of tumor grade, long-term follow-up is necessary after treatment because evidence shows late recurrence in the few follow-up case reports. PHNETs are poorly described, and most likely they are an underdiagnosed entity with the tumor prognosis largely unknown.


Colonic complications, including colopancreatic fistulas (CPFs), are uncommon after acute and chronic pancreatitis. However, they have been reported and are serious. CPFs are less likely to close spontaneously and are associated with a higher risk of complications. Therefore, more definitive treatment is required that includes surgical and endoscopic options. We present a case of a 62-year-old male patient with a history of heavy alcohol intake and recurrent acute pancreatitis who presented with a 6-month history of watery diarrhea and abdominal pain. His abdominal imaging showed a possible connection between the colon and the pancreas. A further multidisciplinary workup by the gastroenterology and surgery teams, including endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and colonoscopy, resulted in a diagnosis of CPF. A distal pancreatectomy and left hemicolectomy were performed, and the diagnosis of CPF was confirmed intraoperatively. The patient showed improvement afterward. Both  as well , 8–10. W as well . Colonos as well . As CPFs as well , 8. Trea as well –15.A 62-year-old male patient with a history of heavy alcohol intake and recurrent episodes of acute pancreatitis presented with a 6-month history of watery diarrhea, abdominal pain, weight loss and severe electrolyte abnormalities. Clostridium difficile, ova, and parasites, esophagogastroduodenoscopy (EGD) showed mild gastritis with negative biopsies for Helicobacter pylori, and colonoscopy showed uncomplicated internal hemorrhoids. At that time, these tests did not reveal a significant pathology to explain his symptoms.The patient had had an extensive workup in the last 3 months prior to presentation. His tissue transglutaminase IgA was 1 unit/ml , stool studies showed normal split fat and were negative forUpon evaluation, he appeared to be dehydrated and distressed. An abdominal examination showed mild tenderness to palpation with no rebound tenderness, guarding, or rigidity.The initial laboratory workup showed the following levels: Na 131 mmol/L , Cl 94 mmol/L , K 3.0 mmol/L , creatinine 1.5 mg/dl , lipase 81 units/L , hemoglobin 10.9 g/dl , and WBC 9,600/cmm . The patient was admitted for fluid and electrolyte replacement, symptomatic control, and additional evaluation of his underlying symptoms.The CT scan of the abdomen without contrast showed a prominent common bile duct (CBD), dilated gallbladder (GB), and colonic wall thickening that was not thought to be significant initially. Magnetic resonance cholangiopancreatography (MRCP) was performed later  and excluded strictures in the CBD. However, it did show cystic foci in the pancreatic tail and persistent colonic wall thickening . This fiPrior to the EUS and ERCP, a CT scan angiography of the abdomen (CTA) was performed to rule out mesenteric ischemia. The pancreatic tail lesion was remarkable, with an internal focus of fluid and interval diffuse progression of circumferential colonic wall thickening. The pancreatic tail was inseparable from the colon, with a possible connection between the colon and the pancreas . The tumAn EUS showed an anechoic lesion that was 10 × 11 mm, a possible cystic structure in the pancreatic tail with mild hypoechogenicity in the surrounding parenchyma. Fine-needle aspiration (FNA) was done and revealed ductal and inflammatory cells with Gram-negative rods. This finding increased the suspicion of a colonic connection. A repeated colonoscopy  was signThe ERCP did not show an extravasation of contrast. The surgery team decided to proceed with surgery, as the patient continued to have symptoms. A pancreatectomy, splenectomy, and partial left colectomy were performed. It was possible to visualize the posterior colonic surface near the splenic flexure intraoperatively, which showed a connection between the colon and the pancreas. The patient showed improvement postoperatively, with complete resolution of his symptoms. He continued to attend surgery and gastroenterology clinics.Acute pancreatitis is an acute inflammatory condition of the pancreas. It is characterized by abdominal pain and elevated serum levels of pancreatic enzymes, primarily amylase and lipase . ChronicAcute pancreatitis is not uncommon, with a reported annual incidence ranging from 4.9 to 35 per 100,000 individuals [Colonic complications are uncommon with acute and chronic pancreatitis –7. Howev % – 10 % of patients with severe acute pancreatitis [CPFs occur in 3reatitis , 8–10. Treatitis , 16. Duereatitis .The clinical presentation of CPFs is either colonic symptoms such as bleeding or diarrhea or common symptoms of acute pancreatitis such as pain, nausea, and vomiting , 9. GastCT scan of the abdomen with or without contrast is useful in the diagnosis of CPFs and all pancreatic-enteric fistulas in general . AdditioIn contrast to upper pancreatic-enteric fistulas, which may close spontaneously, CPFs generally are less likely to close spontaneously , 8. TheySurgery usually involves resection of the involved part of the colon with or without a distal pancreatectomy. A diverting ileostomy, to preserve the colon, was reported in less severe cases , 6, 10. Less invasive interventions such as endoscopic treatment have been described in some cases , 19–23. In our case, the radiological evidence of colonic wall thickening and the proximity between the pancreases and the colon raised the suspicion of CPFs. This was supported by the growth of enteric Gram-negative rods in the FNA and the colonoscopic findings. The challenging point in the diagnosis was the failure of the ERCP to show the extravasation of the contrast. Nevertheless, we think that this can be explained by the complexity in the anatomy of the fistula that prevented the contrast from passing. In this case, the multidisciplinary decision was made to proceed with surgery, given the clinical symptoms and all the evidence described above. The direct visualization of the communication between the pancreas and the colon intraoperatively added additional evidence of the presence of CPF. The standard surgical intervention was performed based on the availability of resources and expertise. Hopefully, clear guidelines can be developed so that patients do not have to undergo these invasive procedures.Colonic complications, including CPFs, are uncommon with acute and chronic pancreatitis. However, they are reported and potentially serious. A definitive treatment, typically with surgery, is usually recommended. Less invasive interventions such as endoscopic treatment have been described as well.


We report a case of 64-year-old Tunisian woman with a 12-year history of rheumatoid arthritis, who presented with a 3-month history of increasing inflammatory neck pain. Neurological examination noted a quadripyramidal syndrome without any neurological deficit. Radiographs of her neck showed ananterior atlantoaxial subluxation (A). MRI revealed a pannus around the atlanto axial joint. It also showed a co-existing syringomyelia (B). The cervical spine is frequently involved in patients with rheumatoid arthritis. However, rheumatoid atlantoaxial subluxation with syringomyelia is very rare. Many hypothesised mechanisms were suggested for the syrinx formation. The most commonly admitted, suggested that atlanto axial subluxation may reduce the rate of ascending cerebrospinal fluid, so it would travel through the spinal cord producing syringomyelia.


Primary sarcomas of the thumb metacarpal are rare malignant lesions. Surgical treatment involves amputation versus tumor resection with thumb reconstruction. If complete tumor resection is possible, thumb preservation may be considered, as the thumb is vital to hand function. Following tumor resection, previous reports have described graft reconstruction with fusion to the trapezium or scaphoid. We present two cases of sarcoma necessitating resection of the thumb metacarpal that were reconstructed with an arthrodesis of the proximal phalanx to the second metacarpal shaft. Arthrodesis to the second metacarpal allows robust bony contact for fusion as well as improved resting position of the thumb. At 2- and 4-year follow-up, both patients have a stable, pain-free thumb without evidence of local recurrence. Primary bony tumors of the thumb metacarpal are a rare and challenging problem . ChondroA 60-year-old male was referred to the orthopaedic clinic for an enlarging left hand mass . The harPlain radiographs  revealedSurgical treatment involved en bloc resection of the affected metacarpal with a portion of the proximal phalanx of the thumb and the entire trapezium in order to obtain negative margins. The extensor carpi radialis longus (ECRL), extensor pollicis longus (EPL), and flexor carpi radialis (FCR) were resected with the tumor. The flexor pollicis longus was uninvolved and therefore preserved. Tricortical iliac crest autograft was utilized for reconstruction of the proximal thumb and secured distally to the first proximal phalanx and proximally to the second metacarpal with two 2.7 mm locking plates and a lag screw in a position of opposition to the index finger. The EPL was reconstructed with free FCR autograft which was harvested proximally, away from the zone of tumor involvement. To prevent bowstringing of the extensor tendon, the ECRL was then harvested proximal to the area of tumor involvement and was utilized to reconstruct the extensor retinaculum.Postoperative pathology confirmed clear surgical margins. The postoperative course was complicated by necrosis of the skin and a wound dehiscence which resulted in exposed hardware. An irrigation and debridement were performed resulting in a wound measuring 9 × 6 cm. Coverage of the wound was obtained with a free fasciocutaneous flap from the dorsal forearm based on the posterior interosseous artery and anastomosed to the radial artery. Most recent follow-up at 4 years postoperatively revealed a stable, pain-free thumb. His IP joint had evidence of degenerative changes and his motion was limited from 0 to 5 degrees compared to 0 to 30 degrees preoperatively. There were no radiographic or clinical signs of recurrent disease. There was radiologic  and clinA 39-year-old female was referred to the orthopaedic clinic for a left hand mass that had been enlarging over the past 9 months . PhysicaPlain radiographs revealed a large, noncalcified soft tissue mass adjacent to the thumb metacarpal with some metacarpal erosion . T1-weigA CT of the chest was normal and there was no lymphadenopathy. An open biopsy of the tumor revealed a highly cellular proliferation of spindle cells in sheets consistent with a high grade synovial cell sarcoma.Surgical resection with a staged reconstruction was then performed. A staged reconstruction was chosen in this case to confirm negative margins prior to undergoing reconstruction. A vascularized autograft was chosen to optimize the chance of arthrodesis in the setting of planned adjuvant radiation therapy. The entire thumb metacarpal, trapezium, flexor pollicis longus, EPL, and first dorsal compartment tendons were resected and the wound was closed with provisional K-wire fixation of the thumb. Pathologic examination revealed negative margins. One week later, the patient returned to the operating room for reconstruction. The metacarpal reconstruction was performed with a 5.5 cm distal radial osteofasciocutaneous flap vascularized by the radial artery. The graft was fixed proximally to the index metacarpal with a 2.4 mm locking plate and lag screw and distally to the proximal phalanx with a separate 2.4 mm locking plate. The graft was positioned to provide for index finger to thumb opposition with the thumb IP joint in flexion. Full flexion of the index finger to the palm was obtained when the thumb IP joint was extended. Approximately one-half of the distal radial shaft and metaphysis were utilized, and the defect was prophylactically stabilized with a contoured volar locking plate . An exteThe patient received adjuvant radiation to the area with a total of 50 grays of radiation. At 2 years, thumb IP range of motion was 0–70 degrees compared to 0–80 degrees preoperatively. She had functional pinch strength and no evidence of local recurrence Figures . DASH anChondrosarcoma involvement of the hands and feet comprise 1–3.2% of all chondrosarcomas, and most of these are phalangeal tumors , 10. Of Synovial cell sarcoma is an uncommon soft tissue tumor that usually presents in the lower extremities. Deshmukh et al. reported only 5 synovial cell sarcomas occurring in the hand out of a total of 135 patients . SuccessIliac crest, fibular allograft, free fibular autograft, and distal ulna have all been described for reconstruction after tumor removal at the first metacarpal , 5, 7, 8Although described previously with good results, osteosynthesis to the scaphoid presents multiple potential problems . First, The natural resting position of the thumb is in opposition to the distal phalanx of the index finger with the metacarpophalangeal (MCP) and IP joints flexed 10–15 degrees . With grIn conclusion, we described two cases of sarcoma, necessitating resection of the thumb metacarpal that were reconstructed with an arthrodesis of the proximal phalanx of the thumb to the index metacarpal. Fusion was achieved in both cases and both patients had a pain-free, functional, and cosmetically acceptable thumb with no local recurrence. Arthrodesis of the thumb to the second metacarpal is a viable treatment option after tumor resection.


Craniopharyngiomas are histologically benign but locally aggressive tumors in the sellar region that may cause devastating neurological and endocrine deficits. They tend to recur following surgery with high morbidity; hence, postoperative radiotherapy is recommended following sub-total resection. BRAFV600E mutation is the principal oncogenic driver in the papillary variant of craniopharyngiomas. Recently, a dramatic tumor reduction has been reported in a patient with BRAFV600E mutated, multiply recurrent papillary craniopharyngioma using a combination therapy of BRAF inhibitor dabrafenib and MEK inhibitor trametinib. Here, we report on near-radical reduction of a growing residual BRAFV600E craniopharyngioma using the same neoadjuvant therapy. Craniopharyngiomas are tumors that arise from the residual cells of Rathke’s pouch in the sellar or suprasellar region, with both a cystic and solid component. Although they are benign, WHO grade I, the difficulty in curing this disease makes their growth malignant in behavior with high morbidity rates. Cushing described them as “the most baffling problem which confronts the neurosurgeon” . The anaThe current standard treatment is surgery followed by adjuvant radiation therapy. However, there is a high recurrence rate , with adA 65-year-old male presented with nausea and involuntary weight loss. The patient had a history of subarachnoid hemorrhage in 1993 where no aneurysm was identified, and the patient did not suffer any sequelae.The patient was admitted to the hospital because of involuntary weight loss of 15 kg during a 3-month period. Malignancy investigation including CT of the thorax and the abdomen was performed and did not reveal any pathological findings, but the blood workup showed pituitary insufficiency.3)  and one neuroradiologist (JW), independently evaluated the CT and MRI scans. One of the readers (JW) was blinded to the diagnosis and the treatment plan. The clinical PACS  was used for tumor volume measurements by manually outlining the supposed tumor border on each slice, after which the software automatically calculated the volume. The two readers’ results were quite similar and are given in Fig. 3 to 7.2 cm3)  showed a 91% reduction of the tumor Fig. .The patient was clinically improved with a regression of visual deficit.Currently, the combination treatment has been paused because of drug-induced pyrexia, but will resume as soon as possible, if necessary with the support of corticosteroids. Radiotherapy will also be initiated as soon as possible.This is the second case report  on a theAlthough craniopharyngiomas are benign tumors, a total resection is desirable since the rate of progression-free survival following a subtotal resection is only 34% . HoweverThe BRAF gene is coding for a kinase that is activated by somatic point mutation in human cancer . The MAPWe decided to treat our patient by using the same treatment strategy as previously described by Brastianos et al. and obtained similar results. Following 15 weeks of treatment, the tumor size was significantly reduced. Unfortunately, the patient developed pyrexia as described previously as a possible side effect , and theIn the case report described by Brastianos et al., BRAFV600E was also detected in the peripheral blood. Unfortunately, this sampling was not included in our study and could have a high future value if it is confirmed and proven that circulating tumor cells or cell-free DNA detected in the previous report was not a result of multiple surgical treatments.The current finding and the previous case report indicate promising results for the postoperative treatment with BRAF (dabrafenib) and MEK inhibitors (trametinib) of BRAFV600E mutated papillary craniopharyngiomas. In the present case, this combination treatment reduced the postoperative tumor regrowth by 91%. Larger studies need to confirm and evaluate this combination treatment.


Cystic hygroma (CH) is a benign infiltrative malformation of the lymphatic channels. We report a case of a 28-year-old Indian female who presented with rapidly enlarging right sided neck swelling over the posterior triangle since 5 days. Complete resection of CH is sometimes not amenable because of its infiltrative nature and involvement of surrounding vital structures. However, in our patient successful complete surgical resection was undertaken. The MRI findings of our patient were consistent with brachial cleft cyst; this posed a challenge in the diagnosis of CH. The histopathological analysis of the resected mass confirmed CH. CH is rare in adults and such an acute presentation is exceptionally atypical. History of prior trauma and infection are known etiological factors for adult CH; these were conspicuously absent in our patient. CH should be considered in the differentials of rapidly enlarging cystic swelling of posterior region of neck in adults. Optimal and timely management is necessary to achieve a favorable prognosis. Therefore, we report a case of rapidly enlarging cervical CH in an adult along with extensive literature review to have a better understanding regarding epidemiology, etiopathogenesis, clinical presentation, optimal management, and prognosis of such a rare entity in adults.  Cystic hygroma is a subtype of lymphangioma and is most commonly a congenital lesion . It is sFirst case of lymphatic malformation (LM) was described by Redenbacher in 1828  coined tCH can affect any anatomic subsites in human body –9; howevCH presenting in adulthood is rarely seen , 15. TheTo date there are only few cases of adult cervical CH described in literature and the optimum management is still challenging. Preoperative diagnosis is difficult in adults and often patients are misdiagnosed. Patients with CH are frequently misdiagnosed as brachial cleft cysts on imaging as in the case reported here. Definitive diagnosis can be reached only after histopathological examination of the surgical specimen.Complete surgical removal is an important treatment modality ; howeverJust as with brachial cleft cyst and thyroglossal duct cyst, it is important to consider LM in one's differential diagnosis in the setting of an adult patient with a cystic mass of neck. For this reason, we describe a case of adult cervical cystic hygroma along with literature discussion for better understanding of disease process in adult and optimal management options.In our case, a 28-year-old Indian female presented with painless right side neck swelling since 5 days. She had no compressive neck symptoms like difficulty swallowing or difficulty breathing. There was no history of preceding neck trauma or upper respiratory tract infection.Physical examination showed a solitary swelling on the right, posterior aspect of neck measuring about 6.5 × 3 cm. Margins were ill-defined. The surface on palpation was lobular, soft in consistency, and freely movable. The swelling was immobile with deglutition. Overlying skin illustrated no erythema, warmth, or tenderness. No cervical lymphadenopathy was noted.Ultrasound scanning showed a large elliptical 8 × 7 × 3 cm cystic lesion posteromedial to right sternocleidomastoid muscle extending to right submandibular gland medially. Deep wall was abutting carotid artery and jugular vein, pushing them posteriorly. Cyst shows peripheral thin septae and tiny loculations. Cyst wall and interlocular septae were avascular . On the Magnetic resonance imaging findings showed a thin walled multilobular cystic mass with a size of 66.0 × 53.7 × 27.0 mm (CC × AP × Trans) in intermuscular plane on right side of neck. Inferiorly it extended up to the level of vocal cord; laterally it abutted the sternocleidomastoid muscle and parotid gland. Medially it abutted the carotid sheath and scalene muscle and posteriorly it abutted the submandibular gland. No communication to pharynx is seen and no inflammatory changes were noted around it. The mass appeared hyperintense on T2-weighted images and hypointense on T1-weighted images , or lymphatic obstruction have also been linked to adult LMs. Aneeskumar et al.  suggesteClinical presentation depends on the location, size, and rate of growth of malformation. Extensive lesions of the floor of mouth, oropharynx, or neck result in airway insufficiency. Cervical lesions can lead to compressive lesions like dysphagia when compressing esophagus or dyspnea on tracheal or laryngeal compression. Gorham syndrome  or vanisVarious diagnostic modalities have been mentioned in literature and imaging methods like USG, MRI, and CT scan have been used prior to treatment; however, imaging preferences vary by cost, convenience, and resolution. Preoperative imaging is even important to look for intrathoracic extension which is present in 10% of cases . FNAC isMany treatment methods have been documented in the literature, including surgery, various sclerotherapy, radiotherapy, and laser therapy. Kennedy et al.  recommenRecurrence of cystic hygroma after excision is influenced by various factors like location of lesion relative to hyoid bone, presence/absence of encapsulation, and partial versus complete excision. Ricciardelli and Richardson  reported