Intestinal neuronal dysplasia (IND) is a rare condition mainly affecting the children. Constipation and abdominal distension have been reported as common manifestations. In addition, the reports about adult cases are scarce.A 31-year-old man presented with pain in his left hip and intermittent fever for 1 month. The whole abdomen CT and pelvic contrast-enhanced MRI revealed a left psoas abscess (PA). The patient has been given anti-infective treatment and underwent CT-guided drainage of left PA with a temporary drain. But the patient's condition did not improve significantly. Then, the colonoscopy revealed that it may be the PA secondary to inflammatory bowel disease. But the pathology was not in line with inflammatory bowel disease. We finally performed an ileostomy surgery and took the whole layer of intestinal wall for biopsy. The pathological result revealed that a large number of proliferative ganglion cells and circuitous hyperplastic nerve fibers were found in the submucosa and muscular layer of the intestinal wall. Given pathological results and clinical manifestations, the patient was diagnosed with IND-B.In this case, we first report an extremely rare case of adult IND manifesting as PA. So, this unusual case provides a new supplement to adult cases of IND. Intestinal neuronal dysplasia (IND) is a rare anomaly of the enteric nervous system, with an estimated incidence of approximately one in 7,500 newborns . This diA 31-year-old man came to our hospital with left hip pain and intermittent fever for 1 month. For nearly a year, the patient occasionally has abdominal distention which alleviated after defecation. The frequency of defecation was about once every two days. The mass was seen as a reddish skin color around the anterior superior iliac spine which was painful and palpated.9/L (3.5–9.5), neutrophil percentage 85% (40–75), platelet 420 × 109/L (125–350), C-reactive protein 82.6 mg/L (0–10) and erythrocyte sedimentation rate 48 mm/h (0–20). The tumor-related biomarkers , serum tuberculosis antibodies and T-cell spot test for tuberculosis infection (T-TB.Spot) were within normal limits. The whole abdomen CT and pelvic contrast-enhanced MRI were performed. The imaging revealed a left PA  for biopsy. In addition, the primary closure was done after full thickness biopsy. The patient recovered well and was discharged two weeks after the operation. Moreover, followed up for 6 months after operation, the fever and pain in his left hip was no recurrence without specific treatment. The temporary stoma was scheduled to be closed one year after surgery.The result of mucosal biopsy was scattered infiltration of lymphocytes, plasma cells and eosinophils in the colonic mucosa. The Haematoxylin and Eosin staining technique has been used for hystopathological diagnosis. The pathological results revealed that a large number of proliferative ganglion cells and circuitous hyperplastic nerve fibers were found in the submucosa and muscular layer of the intestinal wall . Given pSwiss pathologist Meier-Rule first proposed the pathological phenomenon of colonic neuronal dysplasia in 1971 . It is cThere had been several adult cases reported in the past few years. In addition, constipation and abdominal distension were a common manifestation in reported adult cases , 10. RefDue to the rarity of adult cases and the non-specificity of symptoms, the diagnosis of adult IND is more difficult than that of infants. And early diagnosis remains a great challenge for IND. The auxiliary diagnostic methods include barium enema, anorectal manometry and rectal mucosa biopsy. However, the histological examination remains the gold standard of the diagnosis. Usually, it is necessary to include a sufficient amount of submucosa in the suction biopsy specimens. In this case, it is worth noting that the rectal mucosal biopsy of the patient was negative. Thus, full-thickness biopsy of colon wall can be considered as an important reference index in the diagnosis of IND.According to the latest report, blood Sox 10 promoter methylation can be used as a noninvasive and efficient diagnosis method for IND . RecentlIn conclusion, for patients with PA, physicians should consider IND as a possible diagnosis after excluding other more common causes. So, this unusual case of psoas major abscess provides a new supplement to adult cases of IND. More importantly, a non-invasive diagnostic method with a high degree of accuracy needs to be developed. No matter for the diagnosis and treatment of IND in infants and adults, further exploration is needed and attention should be paid to individual treatment.


Mediastinal teratomas are rare in children. Nevertheless, they represent the most frequent mediastinal germ cell tumor. Most often, they are discovered incidentally in older children or adolescents on chest X-ray. There are other signs of discovery but less frequent: chest pain, hemoptysis and signs of mediastinal compression. Rupture into pleural space, pericardium or tracheobronchial tree are exceptional.We report the case of 7-years old girl admitted for chest pain. The chest x-ray showed a mediastinal mass with calcifications and pleural effusion. Chest CT scan revealed a well limited heterogeneous anterior mediastinal mass with calcifications and a left pleural effusion. She underwent a median sternotomy and the tumor was completely excised. Histopathology confirmed the diagnosis of mature teratoma.Intrapleural rupture is a rare complication of mature teratoma. Calcifications on chest imaging in afebrile children with pleural effusion should be suspected of mediastinal teratoma. Teratomas represent 10% of mediastinal tumors and 50 to 70% of mediastinal germ tumorsTeratomas rarely rupture in adjacent structures such as pleural space, pericardium or tracheobronchial tree and the skin with cystocutaneous fistulaWe report an unusual case of intra-pleural rupture of mediastinal mature teratoma. This is a rare presentation of an uncommon pathology in children.F.H, 7 years old girl, was admitted for a 2-month history of left-sided dragging chest pain. She had no pathological medical history and no significant past or family history of tuberculosis. She presented worsening pain during the last week, without fever, weight loss neither dyspnoea nor deterioration of the general state.The physical examination of the patient showed a weight of 20 kg (-0.82SD), a height of 120 cm (-0.26SD), a normal body temperature and polypnea 35 cycles / min. There were decreased breath sounds on the left side with stony dull percussion note.She was investigated thoroughly to eliminate possible causes that may give similar signs and symptoms. The chest X-ray showed high-density opacities occupying two-thirds of the chest, the site of irregular calcifications with deviation to the right of the trachea, heart and mediastinum .On chest ultrasonography, multiple cysts occupying almost all of the left hemithorax associated with pleural effusion were evident .Laboratory explorations showed a WBC count of 12280/mm3 and a neutrophils count of 6990/mm3 and a serum C-reactive protein concentration of 32.72mg/l . Renal and liver functions tests were normal. Pyogenic abscess or empyema were unlikely because of absence of fever and laboratory test. The diagnosis of tuberculosis was suspected, but she had negative reaction to the Tuberculin skin test. The Sputum smear microscopy and culture were also negative for Zielh-Neelsen test. We considered an atypical intrapulmonary tumor or malformation. A contrast-enhanced computed tomography (CT) was performed, objectifying a heterogeneous mediastinal antero-left mass, well limited measuring more than 15 cm, many small areas of calcification and cavitation in the lower lobe of left lung associated with homolateral pleural effusion . Chest XBiological assays: α fetoprotein (AFP) = 5.5 ng / ml and plasma beta-human chorionic gonadotropin (βHCG) <0.5 mUI / ml have rouled out malignancy.The girl was operated on in the thoracic surgery department, by a total median sternotomy. During surgery, we saw a large tumor occupying the anterior mediastinum and almost the entire left thoracic cavity plating the lung in the costo-vertebral groove behind. The intervention consisted of a tumor resection with partial thymectomy. Biopsy and histology confirmed the diagnosis and identified a benign mature cystic teratoma consisting of different types of mature tissue. Our patient was followed up regularly at outpatients for 3 years. She was seen every 6 months to manage disease complications and screen for early recurrence. The follow-up visit included physical exam, laboratory testing and imaging. She was asymptomatic and the chest X-ray showed a well ventilated lung on the left, fetoprotein was normal one year after surgery. She remained well with no evidence of recurrence.The mature teratoma is a germ cell tumor developed in the somatic stem cell and contain elements from all three embryological layers: ecto-, endo-, and mesoderm. It represents the most common benign type of germ cell tumors of the mediastinum. Teratomas are also found in sacrococcygeal, gonadal, retroperitoneal, cervicofacial and intracranial locations. Clinical behavior varies significantly by site and sizeThe discovery of the mediastinal teratoma is most often by coincidence. Patients with unruptured teratomas are often asymptomatic. The presence of symptoms depends on the size of the tumor or on the existence of a complication such as rupture towards the bronchus causing hemoptysis or trichoptysis wich is a pathognomonic symptom, towards the pleura causing pleural effusion with chest or back pain or towards the pericardium causing tamponade or pericadial effusionThe etiology of the perforation can be explained by local ischemia, related to the progressive growth of the tumor and is responsible for an adjascent necrosis, or an infection which can weaken the wall of the teratoma. On the other hand, cystic teratomas can produce proteolytic or digestive enzymes released by the pancreatic or salivary tissues. These cause a chronic inflammatory process in the wall of the tumor cyst, subsequently giving rise ta rupture or a fistulaIntrapleural rupture of mediastinal teratoma was commonly misdiagnosed as an encapsulated effusion or abscess. If in addition we have calcification and cavitation, the diagnosis of tuberculosis must be considered. In our context, in front of a chart of sudden dyspnoea with no fever, not too much elevated inflammatory markers in serum and calcifications in chest X-ray, pyogenic lung abscess or empyema seemed unlikely, but the diagnosis of tuberculosis was reasonable especially in high burden tuberculosis country such as Tunisia. However, tuberculosis workup in our patient was negative.Moreover, mediastinal cystic or solid masses may arise in a variety of benign and malignant disorders. Lymphoma is a common etiology of mediastinal masses in children. It arise from the anterior or middle mediastinum and associate cardiopulmonary disorders. Neuroblastoma originate from the posterior mediastinum, rarely producing airways obstruction. Other possible differential diagnoses of thoracic opacities in children must be considered including hydatidosis lung, thymoma, germ cell tumor, pulmonary hamartoma, bronchogenic cyst, adenomatoid cystic malformation and intrapulmonary cystic lymphangioma. Imaging is the investigation of choice to guide the diagnosisThe chest x-ray is an important exam that leads to the discovery of most mediastinal abnormalitiesComputed tomography CT is the investigation of choice where teratomas appear as anterior mediastinal masses with fluid component, calcification, soft tissue and fat attenuation. It's good exam for studying the invasion of the surrounding tissues but it isn't the best to show the adhesionsHowever, the final diagnosis can only be made after surgical intervention.The treatment remains surgical. The median sternotomy is the most used for tumors with bilateral overflowBiopsy is important in order to study the tissue component. Specific treatment depends on the type of teratoma. It generally includes surgical removal of tumors for matutre teratoma.A combined approach of surgery and chemotherapy has been recommended for immature mediastinal teratomasMature teratomas of the mediastinum are rare. The clinical symptomatology is not specific and is most often manifested by signs of complications. Therefore, it can be difficult to diagnose especially in early stage. They should be considered in the differential diagnosis of thoracic opacity. They are often recognized by CT.The concern for the surgeon is to carry out the complete excision of the tumor, and for the pathologist to seek an immature squad within this tumor, the presence of which determines the prognosis and the complementary treatments.


Sarcomatoid urothelial carcinoma (SUC), a rare tumor of the urinary tract epithelium, exhibits a high degree of malignancy and therefore a poor prognosis. Due to the absence of specific clinical presentations and imaging findings, SUC of the renal pelvis masquerades as a renal abscess is frequently under-recognized or misdiagnosed as benign inflammatory disease, resulting in delayed or erroneous treatment. Here, we report a patient with SUC of the renal pelvis who presented with a renal abscess. Repeated anti-inflammatory treatment was ineffective. Unexpectedly, cancerous cells were detected in subsequent exfoliative cytology of nephrostomy drainage fluid. In accordance with this, radical surgery and postoperative chemotherapy were conducted. Fortunately, neither recurrence nor metastasis occurred during a one-year follow-up. Renal pelvis carcinomas primarily arise in the form of transitional cell carcinomas arising from the urinary tract epithelium. SUC is a rare tumor type that accounts for just 0.3% of all urothelial carcinoma (UC) cases . SUCs ar9 cells/L, urine occult blood (UOB) 1+, urinary leukocytes (U-LEU) 3+, erythrocyte sedimentation rate (ESR) 96 mm/h, urine bacterial culture (-), Widal test (-). The patient did not show any significant improvement after anti-inflammatory treatment, and underwent further evaluation at our hospital. Physical examination indicated the presence of positive percussion pain in the right renal area. Enhanced magnetic resonance imaging (MRI) showed multiple irregular mixed signals in the lower and middle parenchyma of the right kidney, with a long T1 low signal on T1WI and a long T2 high signal on T2WI, with marginal circumferential enhancement on enhancement scans. Diffusion-weighted imaging (DWI) showed a high signal and decreased analog-to-digital converter (ADC) values, with marked diffusion restriction of the pelvic wall and parenchymal lesion margins on both DWI and ADC images. The right renal pelvis and calyces were dilated and the right pelvic wall was thickened, with significant enhancement in the arterial phase seen on enhancement scans. Infectious lesions were first considered and a short review in conjunction with clinical treatment was recommended to exclude neoplastic lesions  96 mL/min. The results of the urine bacterial culture revealed the presence of enterococcus. The patient did not respond to anti-inflammatory treatment, and underwent ultrasound-guided right nephrostomy, which drained 100 mL of pus and provided significant relief of the back pain. The joint consideration of the imaging findings together with the pus drainage provided proof of the presence of a renal abscess. The laboratory findings on the puncture fluid revealed leukocytes (3+) and acid-fast stain (-). Exfoliative cytology analyses of the puncture fluid were performed, and cancerous cells were detected. Anti-inflammatory treatment was maintained for 10 days, and follow-up CT imaging revealed a nephrostomy drainage tube extending from the right renal pelvis to the outside of the body. The right renal pelvis and part of the calyces were dilated, with thickening and enhancement of the wall. The right kidney was less enhanced than the contralateral side. A mass of slight hypointense lesions, approximately 6.3 x 4.6 cm in cross-section, was seen in the lower and middle parenchyma of the right kidney, with mild to moderate heterogeneous enhancement on enhancement scans. The thickening of the right renal pelvic wall was consistent with an infectious lesion, while the abnormal enhancement of the lower and middle portions of the right kidney was thought to correspond with a tumor, suggested in conjunction with the pathology  imaging revealed abnormalities of the right kidney consistent with potential pyelonephritis. Laboratory test results were as follows: white blood cell count 14.79 x 10athology Figure 4SUC is a rare and highly aggressive tumor type that accounts for 0.3% of all UC cases . SUC genIn total, 19 cases have been reported in individuals ranging from 43-81 years of age average: 65.7 years), with more cases among males than females (M:F = 12:7). These tumors usually develop on the left side (L:R = 12:7) and are most frequently characterized by hematuria (12 cases) and lumbar pain on the affected side (6 cases), with other symptoms, including general discomfort, high fever, abdominal pain and distension, and urinary tract irritations, being relatively rare. Much as in conventional UC cases, these SUC cases were not associated with any specific symptoms . Notably5.7 yearsRenal abscesses present as a form of inflammatory disease characterized by back pain, urinary tract irritation, and a high fever . These aWhen SUCs of the renal pelvis present in combination with a renal abscess, the abscess often masks the symptoms of the associated tumor, resulting in delayed or missed diagnoses in many cases. As such, it is important that the possibility of neoplastic lesions be considered when evaluating and treating patients with renal abscesses. First, urinary cytology should be performed. It is also useful to analyze DNA methylation sites in urothelial carcinoma or chromosomal instability in the exfoliated cells to facilitate their accurate identification . TreatmeSUC tumors consist of both mesenchymal and epithelial components of monoclonal origin, and diagnosis is generally dependent on pathological examination . MicroscSUC tumors are extremely aggressive and are significantly associated with advanced pathological T-stage, higher tumor grade, and more frequent regional and distant metastases compared to urothelial carcinoma . A studyWith respect to the treatment of SUC, no specific treatment guidelines have been established, and surgery remains the preferred clinical treatment in published reports . Of patients that underwent nephrectomy, 2 exhibited ureteral stump recurrence within 20 days and 2 months after surgery, and another patient experienced surgical site recurrence 1-month post-surgery. Higher recurrence rates were reported following nephrectomy compared with nephroureterectomy. Current consensus indicates that extensive radical surgery is the most appropriate treatment course in order to ensure negative operative margins, thereby contributing to a better overall prognosis . In fourDespite the good prognosis observed, our work still contains limitations. Firstly, we did not photograph the dissected renal pelvis of the specimen, which limits our understanding of the general appearance of SUC of the renal pelvis. Secondly, the patient underwent right nephrostomy after failure of the anti-inflammatory treatment. Although cancer cells were detected on exfoliative cytology of the puncture fluid, which provided support for definitive surgical treatment as soon as possible, there is a risk of implantation metastasis after nephrostomy. Therefore, it is recommended to drain the pus with a ureteral catheter and perform cytology in patients with renal abscesses when there is suspicion of a tumor on imaging. Thirdly, in this case, lymph node dissection (LND) was not done. Based on the NCCN and EAU clinical practice guidelines, template-based and complete LND improve cancer-specific survival in patients with muscle-invasive disease and reduce the risk of local recurrence . Even inSUC is a highly aggressive and rare form of uroepithelial malignancy associated with poor prognostic outcomes. Clinicians must be aware of the potential for combined SUC of the renal pelvis in patients with clinical symptoms and imaging findings consistent with a renal abscess. At present, clinical experience in the treatment of such SUC cases is limited, and surgery remains the preferred treatment while targeted and immune therapies offer the potential for further improvements in patient survival. Maintaining negative operative margins and ensuring accurate pathological staging are both critical to accurately gauging a given patient’s prognosis. It is also essential that the delayed or missed diagnosis of such SUC cases be avoided in clinical practice through appropriate vigilance and diagnostic evaluation.The original contributions presented in the study are included in the article/Written consent for publication of this case report and its accompanying images has been obtained from the patient.CY composed the manuscript and literature review. YK performed pathological diagnosis and collected pathological pictures. WD, LF and ZZ collected the clinical data. TC and NH revising it and gave final approval of the version to be published. LJ designed the report. All authors contributed to the article and approved the submitted version.


The accessory hepatic lobe (AHL) is a rare congenital malformation of the hepatic tissue, among which the giant AHL is the rarest in children. Patients without complications are usually asymptomatic, and most auxiliary examinations cannot provide a definitive preoperative diagnosis. Surgical procedure is the only recommended management for patients who suffered from the complications of AHL. We report the case of a rare pediatric giant AHL torsion combined with left hepatic vein branch thrombosis which was successfully treated by laparoscopic lobectomy followed by excision of AHL. An accessory hepatic lobe (AHL) is a rare congenital malformation of the liver, and even rarer in the case of AHL with a stalk. When it is large and lacks anatomical fixation by hepatic ligaments, it is susceptible to rotation or even torsion, which can lead to ischemic infarction , 2. It iA 12-year-old male child was admitted to the emergency room with abdominal pain; the child presented with persistent vague pain in the right abdomen without cause, accompanied by vomiting a gastric content. Vital signs were stable, and a tough mass about 19 cm × 10 cm × 6 cm in size detected in the right lower and middle abdomen was movable and obviously painful. Laboratory tests showed only mild elevation of alanine aminotransferase and portal aminotransferase. Abdominal Doppler ultrasound revealed a hypoechoic mass measuring approximately 146 × 44 mm connected to the liver was identified in the left outer lobe of the liver. On 25 April 2021, the abdominal enhancement computed tomography (CT) was performed in the Emergency Department of the Affiliated Hospital of Zunyi Medical University, suggesting a large mass of approximately 170 × 95 × 40 mm in size protruding into the pelvis and attached to the left lobe of the liver by a twisted stalk . The abdin vitro, and a large amount of thrombosis was obtained . A total of four 5 mm trocars were placed at the following port sites: an infraumbilical, a left upper quadrant, and two right upper quadrant ports. During the laparoscopic procedure, it was diagnosed that a giant AHL of an estimated size of 18 × 10 × 6 cm was visible at the left side of the hepatic round ligament, with only a 2 cm in diameter liver tissue forming a stalk adjacent to the left liver, through which the branch of the left hepatic vein, the left branch of the portal vein, the left hepatic artery, and the bile duct were passing through . The twiobtained . The hisobtained . The proThe exact pathogenesis of AHL remains unknown. One theory states that it is associated with a malformation of the caudal foregut of the endoderm and an abnormal division of the tissue buds during the 3rd week of gestation . AHL is Patients with uncomplicated AHL are usually asymptomatic. Large AHL torsion with strangulation of the supplying vessels often resulting in severe hepatic ischemia is possibly caused by strenuous exercise or trauma . In thatMost reports do not provide a definitive preoperative diagnosis. Ultrasonography, CT, and magnetic resonance imaging (MRI) are recommended for the diagnosis of large diameter AHL, while the auxiliary examinations could not detect the small diameter AHL. Some researchers proved that ultrasonography had a limited diagnostic value in the diagnosis of AHL . MRI indMost patients with an AHL will not demand medical treatment. A close follow-up would be advisable in asymptomatic cases. Surgical management is only necessary for those individuals suffering from complications such as torsion, rupture, and pedunculated AHL. Prompt management and emergency excision or laparoscopy should be recommended in cases of suspected AHL torsion , 17. EveThis case is the first report of a rare stalk giant AHL torsion along with the left hepatic vein branch thrombosis. The AHL was resected by laparoscopic-assisted surgery, thus minimizing disruption to the abdominal cavity. When it is large and lacks anatomical fixation by hepatic ligaments, it is susceptible to rotation or even torsion, which can lead to ischemic infarction. The AHL needs to be differentiated by pediatricians from any other abdominal disease. We recommend laparoscopy as the first-choice treatment modality for complicated AHL.The original contributions presented in this study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.Written informed consent was obtained from the minor(s)’ legal guardian/next of kin for the publication of any potentially identifiable images or data included in this article.XX and YL wrote the first draft of the manuscript. ZJ wrote sections of the manuscript. All authors contributed to manuscript revision, read, and approved the submitted version.


Desmoid tumors are rare lesions. Although they demonstrate tumor characteristics, such as infiltrative growth and tendency towards local recurrence, they lack the ability to metastasize. To date, the cause of desmoid tumors is unknown. They can occur in both sexes, but predominant slightly in women, including nulliparous women, of reproductive age, but mostly during and after pregnancy.A 36-year-old nulliparous Nigerian woman presented with a large desmoid tumor of the anterior abdominal wall, mimicking recurrent leiomyoma. At presentation, she had a painless abdominal mass for 1 year, which was first noticeable as a small induration that progressively increased in size. The patient had a previous surgical history of open myomectomy for symptomatic fibroids of 3 years duration, prior to presentation. Treatment comprised a complete excision of the tumor with a wide margin and partial omentectomy and the anterior abdominal wall closed in layers, though without prosthesis. The patient subsequently developed incisional hernia.Large desmoid tumors may be misdiagnosed or mistaken for uterine leiomyoma or other abdominal or pelvic tumors. Attention should therefore be paid to detailed patient history and systematic clinical evaluation. To guard against incisional hernia associated with surgical resection of huge desmoid tumors, mesh reconstruction is recommended. Desmoid tumors originate from mesenchymal tissues as a result of disproportionate fibroblast proliferation . They arThe cause of these tumors is unknown, but studies have shown that desmoid tumours most likely occur in individuals with a family history of colon cancer and polyposis coli . In postA 36-year-old nulliparous Nigerian petty trader presented at the gynecology outpatient clinic with a painless abdominal mass of 1-year duration. The mass first appeared as a small induration and progressively increased in size. She had menarche at age 14 years, with 3 days of menstruation in a 28-day cycle. There was no history of dysmenorrhea, menorrhagia and bowel or urinary change, and no significant past medical history although she was taking the antihypertensive amlodipine  for hypertension. She had a surgical history of open myomectomy for symptomatic fibroids 3 years prior to presentation. There was no personal or family history of diabetes mellitus, asthma, cancer or sickle cell disease. She defined herself as a social drinker and non-smoker (no history of smoking). The results of a prior ultrasound examination at a different hospital suggested adenomyosis, and based on this scan, she was offered a hysterectomy at that hospital prior to her presentation at our own facility. General and neurological examinations were unremarkable, with a pulse rate of 74 beats per minute, a blood pressure of 130/80 mmHg, and a body temperature of 36.2 °C. Abdominal with bimanual pelvic examination revealed a giant abdominopelvic mass, equivalent to a 36-week gestational uterus, extending in all directions to fill the abdominal cavity. It was not attached to the overlying structures but seemed to have originated from the pelvic cavity.+ (positive), sero-negativity for hepatitis B and C, and normal values for urinalysis, electrolytes, urea, and creatinine. The abdominopelvic scan revealed an anteverted, empty, and markedly bulky uterus that measured about 283 × 156 mm, with the fundus close to the xiphisternum. The endometrial stripe measured about 4 mm in thickness, with what appeared to be diffuse enlargement of the uterine myometrium with no succinct myometrial mass. There was no adnexal mass and no fluid in the Pouch of Douglas. The visceral organs showed noting of significance. The diagnosis was adenomyosis uteri. A computed tomography scan and magnetic resonance imaging were not performed due to the unavailability of these facilities. Two units of whole blood were cross matched for her, and she then underwent an exploratory laparotomy for the excision of the tumor. Intra-operation findings included a huge 6.5-kg abdominal mass of firm consistency and 40 cm in diameter  of 36%, fasting blood sugar of 80 mg/dl, blood group 0We present here a case of massive desmoid tumor in a nulliparous woman with a previous history of open myomectomy. It was a clear-cut case of diagnostic masquerader that mimicked a recurrent uterine leiomyoma and indeed any other abdomino–pelvic tumors. Hence, this diagnosis was a retrospective one.Desmoid tumors are deep benign fibromatoses that can originate from the fascia and aponeurosis of the muscle with local infiltrating growth. They can occur in any part of the body  and can Clinicians, especially those working in remote areas, are often clinically challenged when presented with abdominal tumors. Misdiagnosis or confusion in providing a reliable diagnosis may be associated with hasty evaluation, the large size of the tumor, uncommon site, and conflicting outcomes from different analytical and diagnostic tools, such as computed tomography and ultrasound scan, among others. In female patients, a large number of the pelvic masses regularly encountered by clinicians are of various tumour types, such as leiomyoma, desmoid tumors, ovarian cyst, and ovarian malignant tumour, leading to possible misdiagnosis . Our patThe pathobiology of desmoid tumors is poorly understood, and as the behavior of these tumours is erratic, there is no standardized surgical or medical therapy . TherefoIn addition to the association between desmoid tumors and trauma, estrogen therapy, FAP and Gardner syndrome, there is a relationship between the tumor and patient’s previous history of abdominal or pelvic surgery . This waIncisional hernia and abdominal wall bulging, among others, are complications associated with the surgical resection of abdominal desmoid tumors. These are delayed complications, noted during the post-operative patient follow-up visit . ExpertsLarge-sized desmoid tumours may be misdiagnosed or mistaken for recurrent leiomyoma or other abdominal or pelvic tumors. Such misdiagnoses are often associated with a hasty and poor evaluation, tumor size, and uncommon tumor site. Therefore, a detailed history, systematic physical examination, and good knowledge of the differential diagnosis of desmoid tumours are key to overcoming this challenge. To guard against incisional hernia associated with surgical resection of huge desmoid tumours, mesh reconstruction is recommended.


Hepatic undifferentiated embryonal sarcoma of the liver (UESL) is a rare hepatic malignancy found more commonly in pediatric patients. It has been associated with poor outcomes in adults and the role and timing of systemic therapy is unclear. There have been very few case reports detailing combination neoadjuvant and adjuvant chemotherapy use for hepatic undifferentiated embryonal sarcoma in adults. In this report, a 22-year-old male admitted with right upper quadrant pain was diagnosed with a 20 x 10 x 10 cm well-circumscribed, highly vascularized hepatic mass in the entirety of the left lobe. Biopsy confirmed the diagnosis of UESL. PET/CT showed no evidence of metastatic disease, and he received four cycles of Doxorubicin and Ifosfamide with demonstrated reduction in size and decrease in PET avidity. He underwent left hepatectomy with periportal lymphadenectomy, cholecystectomy, and partial gastrectomy with negative margins and received adjuvant Doxorubicin, Ifosfamide and Mesna. At 48 months, the patient was alive without evidence of disease. We hereby emphasize the potential advantages of combination chemotherapy and surgical resection in the management of UESL in adults. First described in 1978, undifferentiated embryonal sarcoma (UESL) of the liver is a rare mesenchymal tumor, almost exclusively found in pediatric age patients . The aveAccounting for less than 1% of all primary liver neoplasms in adults, an optimal treatment regimen for UESL is still being determined . SurgicaA 22-year-old male presented with one month of decreased appetite and sharp, intermittent epigastric pain radiating to the right upper quadrant. The patient did have a history of anemia but was otherwise healthy with no significant family history. Physical exam revealed abdominal distension, with visible protrusion in the LUQ, and no tenderness. Laboratory tests revealed anemia and neutropenia with elevated alkaline phosphatase, lipase, lactate dehydrogenase and bilirubin . Alpha Fetoprotein, AST and ALT levels were normal. Hepatitis serologies were negative.Abdominal computed tomography (CT) revealed a solitary 20 x 10 x 10 cm well-circumscribed, highly vascularized hepatic mass in the entirety of the left lobe with relative sparing of the right lobe Figure 1Patient was treated with neoadjuvant chemotherapy modeled after protocol ARST 1321 Regimen B by the Children’s Oncology Group. Preoperative chemotherapy consisted of Ifosfamide (2.5g/m^2) per dose intravenously on days 1 to 3) with MESNA and doxorubicin (37.5 mg/m^2 per dose intravenously on days 1 to 2) at 3-week intervals for 4 cycles. Beyond generalized malaise, the patient did not experience any adverse side effects to chemotherapy. Repeat CT scan indicated a decrease in tumor size to 15.2 x 7.7 x 8.1 cm. Repeat PET scan corroborated the decrease in tumor size and indicated a significant decrease in FDG uptake, with a maximum SUV of 5.4 Figure 3Intraoperatively, the hepatic mass of the left lobe was identified with significant omental and gastric adhesions. The tumor was also invading the medial gallbladder wall. Intraoperative ultrasound was used to delineate intraparenchymal tumor borders and ultimately the patient underwent left hepatectomy with periportal lymphadenectomy, cholecystectomy, and partial gastrectomy. Surgical margin was negative defined as greater than 1mm. The patient recovered with no surgical complications. Postoperatively, the patient underwent an additional two cycles of adjuvant Doxorubicin, Ifosfamide and Mesna. 3 weeks after surgery the patient received 2 cycles of Doxorubicin/Ifosfamide and one of Doxorubicin only at 3 week intervals, with or without Pazopanib, completing all therapy at week 25 .For surveillance the patient underwent CT or MRI of the abdomen and pelvis plus a chest X-ray or CT. Surveillance protocol included CT scan every three months for the first year, every four months the second year, every six months through the third year and then once yearly beyond three years. The patient has since been noted to be in good health with no evidence of local or distant recurrence at present, 4 years post-resection.At 2 to 15% of cases, UESL is the third most common hepatic malignancy in pediatric populations after hepatoblastoma and hepatocellular carcinoma , 8. It iUESL can have a differential appearance on imaging. Ultrasound demonstrates a solid hepatic mass, generally isoechoic to normal liver, with anechoic areas corresponding to areas of tumor necrosis or degeneration , 13. CT Histopathology demonstrates that UESL is composed of undifferentiated spindle cells with mitotic figures and myxoid stroma , 16. ThePrognosis for UESL has historically been considered dismal with reported 5-year overall survival rate of approximately 65% in all patients with worse outcomes reported in adults . FactorsAs shown in one study, 12 of 17 children with UESL treated with a multimodal approach between 1979 and 1995 were alive at 2.4 to 20 years follow-up . A thirdin vivo. These advantages have been reported for other cancers such as gastric, gastroesophageal and pancreatic cancers (A review of multimodal treatment regimens for UESL are outlined in  cancers , 35. OurThe raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.This case report is exempt from IRB approval. Patient did provide consent to publication of this manuscript.RV and SK completed review of the literature, acquisition of data, drafting and completion of the manuscript. SK and GM participated in the critical review of the paper. All authors contributed to the article and approved the submitted version.Funding for publication was obtained from the Western Michigan University Homer Stryker MD School of Medicine Department of Surgery research fund.We would like to thank Bronson Methodist Hospital, West Michigan Cancer Center, and Western Michigan University for allowing us to conduct this project.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Hepatic portal venous gas (HPVG) detected by ultrasound (US) following liver transplantation or in suppurative cholangitis was described previously. To our knowledge, there have been no descriptions of HPVG detected by US in acute mesenteric ischemia. Here we present diagnostic images of a 52-year-old female who was admitted to the intensive care unit (ICU) following successful embolization of a ruptured saccular aneurysm of the right vertebral artery. During their stay in the ICU, the patient developed hypotension with low systemic vascular resistance and hypovolemia. Based on physical examination of the abdomen and laboratory results, preliminary diagnosis of intra-abdominal sepsis was made. Early abdominal US was performed to find the source of sepsis. The preliminary diagnosis of stomach/small intestine ischemia was made by ultrasonic detection of HPVG. Other less likely diagnoses were pneumobilia due to cholangitis, hepatic micro-abscesses, and punctuate calcifications. The diagnosis was confirmed by multi-phase abdominal computed tomography. The explorative laparotomy revealed necrosis of the stomach, small intestine, and liver. Due to the severity of necrosis, surgical treatment was abandoned. Provided sonographic images show HPVG as an ominous sign of small intestine and stomach ischemia. Early liver US should be performed whenever intra-abdominal pathology is suspected.


Primary hepatopancreatobiliary lymphoma (PHPBL) is extremely rare, which is defined as a lympho-proliferative disease confined to the hepatobiliary system and pancreas without any involvement of lymph nodes, bone marrow, or other organs. The clinical and imaging manifestations of PHPBL are variable and non-special, which are akin to those of tumors of the hepatobiliary and pancreatic systems. The overall prognosis and management of PHPBL differ from those of other tumors in the hepatobiliary system and pancreas. Proper diagnosis and prompt treatment are essential for improving clinical outcomes. Due to its rarity, the optimal treatment has not been issued. However, combination chemotherapy is considered as a standard treatment for them. This review provides an overview of the pathogenesis, diagnosis, pathology, and management of PHPBL and offers clinicians the diagnosis and management schedule for PHPBL. Lymphoma accounts for about 4.8% of newly diagnosed cases of cancer in the United States, 90% of which is non-Hodgkin lymphoma (NHL), and about 3.6% of all cancer deaths . LymphomThe commonly accepted diagnosis criteria for PHPBL, as defined by previous studies, include a mass in the hepatobiliary and pancreatic systems, no enlargement of superficial and mediastinal lymph nodes, no involvement of other organs, and normal leukocyte count in the peripheral blood smear , 6.Primary hepatic lymphoma (PHL), primary biliary lymphoma (PBL), and primary pancreatic lymphoma (PPL) are rare and account for 0.4%, 0.4%, and 1% of extranodal non-Hodgkin’s lymphomas, respectively –9. PHL aIn this article, we will discuss the pathogenesis, epidemiology, clinical presentation, imaging feature, pathological finding, and treatment of PHPBL 3. We aiH. pylori infection , hepatitis B or C virus infection, liver cirrhosis, and primary biliary cirrhosis –17. Likenfection . In addinfection , 20, thonfection –23.In all conditions, chronic inflammation of the liver represents the common steps in the pathogenesis of PHL, which induce lymphocyte migration to liver, mediated by some adhesion molecules, and cause B lymphocyte chronic proliferation, eventually leading to hepatic lymphoma , 25. LacAmong all these conditions, hepatitis C virus (HCV) infection is strongly associated with PHL , which cIn primary hepatic MALT lymphoma, the most frequent translocation is t , 18 q32Figure 1TNFAIP3 plays a key role in the regulation of several inflammation signaling pathways, which can negatively regulate the NF-κB pathway by inhibiting signals from various surface receptors to activate the signaling pathway. Therefore, the inactivating mutation or deletion of TNFAIP3 gene can downregulate its expression and reduce the repression of NF-kB activation Figure 1Cyclic adenosine monophosphate response element binding protein (CREBBP) is a transcriptional coactivator, which is involved in several signaling pathways. Due to the lack of acetylation, the mutant CREBBP protein can activate BCL-6 and decrease the tumor suppressor activity of p53, thus protecting atypical lymphocytes from apoptosis. Deletion of CREBBP gene can downregulate the expression of MHC-II gene, leading to immune escape of malignant cells for proliferation and invasion Figure 1PHL is extremely rare, which makes up only 0.4% of extranodal NHL, and 0.016% of all NHL . PHL affAlthough the clinical features of PHL are wide-ranging, patients with PHL usually present with a complaint of upper right abdominal pain . The typTypical serum findings include variably elevated lactic dehydrogenase (LDH), bilirubin levels, as well as elevated liver enzyme levels , 36. TheThe imaging features of PHL are wide-ranging, and are commonly evaluated by abdominal ultrasound (US), CT, and MRI. At imaging, PHL can appear as a solitary mass, multiple lesions, or diffuse infiltration , mimickiOn US, PHL mostly appears as homogeneous hypoechoic lesions confined in the liver , 42. AneOn CT, PHL always presents as hypoattenuating lesions, with or without distinct margins 3A 46, , 46, 47,-3 mm2/s) than other malignant hepatic diseases  and hyperintense signal on the T2-weighted images (T2WI) 3C,D 5050, 51. Sdiseases . Like CTdiseases .PET/CT has been an excellent modality for the diagnosis, staging, and follow-up of tumor, which can evaluate the involvement of other sites in patients with lymphoma and differentiate primary liver lesions from metastatic diseases , 56. TheThe clinical and radiological findings of PHL are non-special, and a definite diagnosis can only be made after pathological analysis. Liver tissue can be obtained by fine needle biopsy (FNB), image-guided percutaneous biopsy, laparoscopic biopsy, or open biopsy , 58.As the most common subtype of PHL, diffuse large B-cell lymphoma (DLBCL) accounts for up to 80% of all PHL cases , followeMicroscopically, on low-power magnification, the lymphoid cells infiltrate the hepatic parenchyma and form solitary, multiple nodules or diffuse infiltration . On highImmunohistochemistry is always required for classification of lymphoma, which is important to obtain the correct diagnosis. Most PHLs are of B-cell origin, which are always positive for part of or all the B-cell markers, usually including CD19, CD20, and CD79a, and negative for CD3 3H, I 7–74. HoweDue to non-special symptoms and imaging features, a number of liver diseases should be considered during differential diagnosis of PHL including hepatocellular carcinoma, metastatic disease of liver, cholangiocarcinoma, hepatitis, or systemic NHL with secondary hepatic involvement. Some clinical and imaging features are helpful in differentiating between these entities.Hepatocellular carcinoma appears as marked enhancement in late arterial phase, which becomes both progressive washout of contrast compared to healthy liver tissue in portal venous or delayed phases . The “buAlthough some features are useful clues in diagnosis, it is difficult to make a definite diagnosis without histological analysis, which is the gold standard of diagnosis.PHL with different infiltration types has a different prognosis. The 1-year and 3-year survival of patients with nodular infiltration are 70% and 57%, respectively, whereas those of patients with diffuse infiltration are 38% and 18%, indicating a poorer prognosis . In addiBecause of the rarity of PHL, no consensual recommendation for treatment has been issued. The choices of management for PHL contains surgery, chemotherapy, radiotherapy, or combinations of the above modalities . Liver tDue to the rarity of PBL, the exact etiological factor is obscure. Several studies found that half of all reported cases had gallstone, and this implies that PBL may be related to inflammation such as chronic cholecystitis or cholangitis associated with cholelithiasis or infected bile . FurtherWhatever the specific cause of inflammation, cholecystitis or cholangitis induces lymphocyte migration to the mucosa of the biliary tract and prolonged lymphoid reactive proliferation, which is antigen-dependent, and accumulation in the site of inflammation, thus leading to irreversible chromosomal translocations, which can inhibit apoptosis and cause antigen-independent proliferation –113. BisIn addition, another possible pathogenesis was reported by Angelopoulou and his colleagues. In PBL, the malignant transformation of the original clone could have occurred outside the biliary system with subsequent homing by an adhesion molecule mechanism .PBL is an extremely rare entity, which could be divided into intrahepatic bile duct and the extrahepatic biliary system. The clinical and radiological findings of lymphoma of the intrahepatic duct resemble those of hepatic lymphoma. Hence, we only discuss primary lymphoma of the extrahepatic biliary system here. Extrahepatic biliary non-Hodgkin’s lymphoma (EBNHL) constitutes 0.6% of malignant biliary tumors, including lymphoma of gallbladder and extrahepatic bile duct . PrimaryPatients with primary gallbladder lymphoma commonly present with symptoms of acute or chronic cholecystitis, and the most common symptom is upper right abdominal pain , 116. ThThe common abnormalities revealed by laboratory test results associated with PBLs include variably elevated bilirubin and liver enzyme levels, which suggest cholestasis . InterleRadiological characteristics of PBL depend on their pathological classifications. Their imaging appearances can be divided into two morphological groups : a solidUS is the modality of choice in the initial evaluation of gallbladder and biliary diseases . The comThe common CT feature of primary gallbladder lymphoma is a thickened gallbladder wall with intact mucosa and layered enhancement after administration of the contrast agent , 125. ThOn MRI, the gallbladder or bile ductal lesion shows lower and slightly higher signal intensity on the T1WI and T2WI, compared to the surrounding normal liver parenchyma , 127. HoOn PET/CT, the location and size of PBL are similar to other imaging modalities. The common imaging feature with PET/CT demonstrates hypermetabolic activity in gallbladder or bile duct without other metastatic areas , 130. PELike other lymphoma, adequate biopsy is needed for definitive diagnosis. Most PBL patients obtain pathologic specimens by surgery, while it can also be obtained under CT, EUS, or ERCP guidance .Grossly, low-grade PBL presents as thickening of the bile duct and gallbladder with intact mucosal layer; however, in high-grade PBL, it shows a mass defined in the biliary system. Histologically, a dense and diffuse infiltration of atypical lymphoid cells in the gallbladder or bile duct wall, with intact mucosal layer and occasional lymphoid follicles, could be observed in patients with low-grade lymphoma , 132, whAs summarized in PBL is a rare disorder that can be present as a focal mass or a thickening in the gallbladder or bile duct wall and imitate the characteristics of biliary tumors such as adenocarcinoma or inflammatory process such as sclerosing cholangitis and cholecystitis .Patients with cholangiocarcinoma presented as concentric or eccentric wall thickening without intact mucosa, resulting in varying degrees of luminal stenosis . GallblaThe prognosis and treatment of PBL are different from other biliary diseases, and the proper diagnosis of the disease is important. The histological analysis is indispensable for a correct diagnosis.PBL has a better prognosis than cholangiocarcinoma and gallbladder carcinoma . Like otDue to the low incidence of PBL, there is no consensus on the optimal treatment. As shown in Due to the rarity of PPL, the consensus of pathogenesis is still not issued. It is commonly associated with immunosuppression, related to HIV infection or solid organ transplantation . A few sHowever, to our knowledge, HBV and HCV are hepatotropic and are main etiologies of liver cancer. The possible reasons that hepatitis virus can cause pancreatic damage are the proximity of the liver to the pancreas and shared blood vessels and ducts. The possibility is further supported by findings of hepatitis B surface antigen (HBsAg) in pancreatic juice and hepatitis virus replication in pancreatic cells among patients with HBV infection , 143.Like PHL, HBV or HCV infection may indirectly give rise to inflammation-associated lymphomagenesis in the pancreas. It may induce cytokine and cytokine growth, perhaps affecting various genes and causing proliferation of lymphoid cells . MoreovePPL is a rare disease and accounts for approximately 1% of extranodal lymphoma and 0.5% of pancreatic cancers . PPL comClinical features of PPL are non-specific and include epigastric pain, abdominal mass, weight loss, obstructive jaundice –146, intThe tumor marker levels in PPL patients, such as CA19-9 and CEA, are commonly normal or slightly elevated in the case of biliary obstruction, which are apparently increased in most pancreatic adenocarcinoma patients . An elevRadiologically, the lesions of PPL appear as focal and well-defined lesions or diffuse infiltration of pancreas , as summThe most common US finding is a bulky homogeneous hypoechoic mass confined to the pancreas, with or without dilatation of bile ducts. Peripancreatic vessels are encompassed by mass, but are always not infiltrated, which can be distinguished from pancreatic adenocarcinoma , 156. ThBoninsegna et al. found that PPLs have the following common CT features: a large and hypo-attenuation mass with mild enhancement , 159. ThThe MRI characteristics of PPL appear as a bulk lesion with mild enhancement, without significant pancreatic duct dilatation, which has a lower signal intensity on T1WI and a higher signal on T2WI , 164. UnThe most common PET/CT feature is a solitary hypermetabolic lesion in the pancreas, with SUVmax ranging from 7.4 to 26.5 (the mean SUVmax is 13.2) –171.Pancreatic tissue can be obtained by percutaneous/endoscopic FNA or biopsy , exploraAs confirmed in The specific pathologic and immunohistochemical findings of PPL are demonstrated in The clinical manifestations of PPL may mimic those of other neoplastic or inflammatory pancreatic diseases, such as pancreatic adenocarcinoma, pancreatic neuroendocrine tumor, acute pancreatitis, and autoimmune pancreatitis (AIP) . AlthougIn contrast to PPL, pancreatic ductal dilatation, and ductal and peripancreatic vascular invasion were frequently shown in pancreatic adenocarcinoma , 197.Both PPL and AIP might appear as diffuse enlargement, a focal lesion, or multifocal lesions, making differential diagnosis difficult. Ishigami et al.  observedEven if some findings can help with the diagnosis, histological analysis is still required for a definitive diagnosis.The prognosis for PPL is much better than that of other pancreatic malignant tumors. A cohort study showed a median overall survival of 53 months . PatientThe rarity of PPL patients makes it difficult to draw a definite conclusion about the optimal treatment, which is mainly determined by the histological subtype. As summarized in PHPBL often overlaps with other diseases of hepatobiliary and pancreas in clinical and radiological features, resulting in misdiagnosis and delayed treatment. Since early diagnosis depends on the alertness of clinicians, mainly radiologists, gastroenterologists, and hepatopancreatobiliary surgeons, it is important for them to know more clinical and imaging features of PHPBL, in order to obtain a proper diagnosis and management. Clinical manifestation, imaging findings, and laboratory studies could provide helpful clues for diagnosis, whereas histological analysis is the gold standard for accurate diagnosis and subtype analysis. Due to the rarity of the disease, there is no consensus on treatment options. The optimal therapeutic choice, including surgery, chemotherapy, radiotherapy, immunotherapy, or other treatments, either alone or in combination, needs further investigation. The management of PHPBL needs an experienced multidisciplinary team, involving radiologists, gastroenterologists, hepatopancreatobiliary surgeons, pathologists, hematologists, and radiation oncologists, to provide individualized therapy and better prognosis Figure 7Conceptualization, BZ. Literature search, QW, YL, and ZS. Investigation, KW and XZ. Project administration, BZ and SW. Writing—original draft, QW. Data curation, KW, XZ, and SW. Formal analysis, YL and ZS. Writing—review and editing, BZ. All authors have read and agreed to the published version of the manuscript.This review was funded by grants from the National Natural Science Foundation of China (No. 81570698).The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Aflibercept is an antiangiogenic agent used in patients with metastatic colorectal cancer who have progressed to a first-line oxaliplatin-based regimen. The main adverse effects (AEs) of antiangiogenic agents are fatigue, asthenia, anorexia, hypertension, proteinuria, urinary tract infection, diarrhea, and neutropenia. Other AEs, such as hemorrhage, thromboembolic events, and gastrointestinal perforation, are much less frequent. Nasal septal perforation caused by antiangiogenic agents is even rarer. The published literature on this subject is scarce. Here, we report the case of a 54-year-old male with metastatic colorectal cancer undergoing treatment with leucovorin, fluorouracil (5-FU), irinotecan, and aflibercept who presented with epistaxis and nasal congestion. An otolaryngologist performed a rhinoscopy that revealed a perforation of the nasal septum. Aflibercept was withdrawn first, and local treatment was applied with lubricant and antibacterial lotions. It was considered a non-life-threatening side effect, and given the high risk of not continuing treatment in this patient with a recent recurrence, aflibercept was reintroduced in combination with leucovorin, 5-FU, and irinotecan. The patient continued local treatment and follow-up with medical oncology and otolaryngology with gradual improvement of symptoms. Follow-up was discontinued due to disease progression and death after 16 months of the event. Aflibercept is a recombinant fusion protein formed by portions of the vascular endothelial growth factor (VEGF) binding sites to the extracellular domains of human VEGF receptors 1 and 2, fused to an Fc portion of human immunoglobulin G1 (IgG1) [Regarding the most frequent adverse events (AEs) related to antiangiogenic drugs, we find fatigue, asthenia, anorexia, hypertension, proteinuria, urinary tract infection, diarrhea, and neutropenia. Also described but less frequent, there are thromboembolic and hemorrhagic events as well as fistula in any location . In the Here we present the case of a 54-year-old man diagnosed with colorectal cancer stage IV treated with FOLFIRI , 5-fluorouracil, and irinotecan) and aflibercept who presented with nasal septum necrosis and perforation during the treatment.We describe the case of a 54-year-old Slavic male with no previous medical records. In January 2019, he was diagnosed with acute appendicitis. The patient underwent an urgent appendicectomy. Pathologists found no signs of malignancy in this first surgery. In March 2019, he was hospitalized with the chief complaint of abdominal pain associated with fever. A computed tomography (CT) scan revealed multiple intra-abdominal abscesses in the right iliac fossa. A second urgent surgery was performed. The surgical team detected an abscessed mass on the hepatic flexure of the colon with perforation to the retroperitoneum and abdominal cavity. The surgeons then performed a right hemicolectomy, drainage, and ileocolic anastomosis. Pathology showed a poorly differentiated enteroid adenocarcinoma pT4apN1c, stage IIIB, wild-type RAS, BRAF V600E mutation.In May 2019, the patient started adjuvant therapy with capecitabine and oxaliplatin, withdrawing oxaliplatin after the third cycle due to moderate-severe nausea and diarrhea. He received seven cycles until October 2019. A follow-up CT in November 2019 showed disease recurrence in the right iliac fossa confirmed in a positron emission tomography CT in December 2019. The patient then started therapy with FOLFIRI plus aflibercept, reporting epistaxis and nasal congestion after five cycles. The subject had no previous history of nasal pathology, hypertension, or hemorrhagic diathesis. The Medical Oncology team then contacted the otolaryngology department for further evaluation.Rhinoscopy examination by otolaryngology showed a large perforation involving the cartilaginous nasal septum surrounded by necrotic mucosa, as can be seen in Figure Otolaryngologists performed multiple biopsies that showed no infectious, granulomatous, or malignant cause of perforation. They then started the patient on local treatment with lubricant and antibiotic lotions to avoid bacterial infection and improve symptoms.With all these pathology results, aflibercept was withdrawn first. We considered this a non-threatening side effect and because of the high risk of discontinuing antineoplastic treatment in this patient, we reintroduced aflibercept in combination with FOLFIRI. The patient gradually improved the local symptoms without complete resolution of the perforation during otolaryngology rhinoscopy monitoring. However, after 16 months, follow-up was discontinued due to disease progression and death.Nasal septum perforation is a clinical entity usually related to medical fields such as traumatology, infectious diseases, and substance abuse . HoweverA literature search of PubMed found few case reports published of septum perforation with bevacizumab -16. The In addition, in one article about two cases, we found evidence that docetaxel may also be associated with nasal septal perforation .The management of this entity is not clearly defined. It remains mainly symptomatic in most cases. Treatment is usually based on local measures, intranasal hydration, lubricant, antibiotic lotions, and hemostatic agents in the event of epistaxis. Surgical intervention is seldom needed, as this complication is usually controlled and successfully treated with local measures, especially in patients with poor prognoses -5. ThereOnly another case report regarding nasal septum perforation related to aflibercept therapy has been published. The article reports a 58-year-old metastatic colorectal cancer patient with nasal septum perforation treated with FOLFIRI plus aflibercept. The subject had no previous history of nasal pathology. Rhinoscopy evaluation revealed a perforation of the inferior portion of the nasal septum. He was started on topical treatment with resolution of epistaxis. Aflibercept was then restarted with no new episodes of epistaxis or other bleeding complications. Follow-up evaluations showed a persistent lesion with progressive epithelization and resolution .Nasal septum perforation is a rare complication of antiangiogenic treatment usually associated with bevacizumab. In this case report, we show what, to our knowledge, is the second case report of aflibercept-related nasal septum complication. This case report, along with the previously published one, shows that conservative treatment of the lesion and restarting therapy with aflibercept might be appropriate measures.


Iatrogenic pseudomeningocele is a common complication of cranial surgeries. However, there are no evidence-based guidelines on how to manage this condition. We report two cases of iatrogenic postoperative cranial pseudomeningocele that failed conservative management including compressive head dressing. Subgaleal shunt placement was utilized with successful resolution in both cases. We postulate that subgaleal shunt placement may be an effective method in the management of iatrogenic subgaleal pseudomeningocele. Iatrogenic pseudomeningocele is a common complication in patients who undergo cranial and spinal surgeries, with an incidence rate greater than 40% -3. PreseCase 1A 40-year-old otherwise healthy male presented with headache and confusion and was found to have a large left frontal intra-axial lesion. He underwent left frontal craniotomy and lesion resection. The dura was then closed water-tight with onlay Duragen and Duraseal. The histopathologic diagnosis was World Health Organization (WHO) grade IV glioma, and he was discharged home on postoperative day (POD) 4 without complications. However, he developed an asymptomatic pseudomeningocele that was refractory to compressive head dressing. He underwent subgaleal-peritoneal shunt placement three weeks after the first operation. A Strata II  valve was used and initially set at 1.5. The shunt was subsequently programmed to its minimal setting of 0.5 in the clinic for maximal drainage. Despite this, in combination with continuous compressive head dressing, the pseudomeningocele persisted. Six weeks after his first surgery, the patient underwent a third operation in which the valve was removed, and the proximal and distal catheters were connected directly with a connector. At this one-week postoperative visit, the patient’s pseudomeningocele had resolved Figures -1F.Case 2A 59-year-old female with a past medical history of endometrial cancer status post hysterectomy, chemotherapy, and radiation therapy presented with two episodes of generalized seizures and was found to have a left temporal intra-axial lesion. She underwent left temporal craniotomy and lesion resection. The dura was then closed water-tight with onlay Duragen and Duraseal. Histopathologic diagnosis was WHO grade IV glioma. She was discharged home on POD 7 without complication. However, she then developed an asymptomatic pseudomeningocele which was refractory to compressive head dressing. Considering the patient’s abdominal surgical history of prior cholecystectomy, Cesarean section x2, and hysterectomy, the decision was made to proceed with a left subgaleal-pleural shunt placement with the assistance of thoracic surgery one month after her initial craniotomy. A Strata II  valve was used and initially set at 1.5 which was subsequently adjusted to 0.5 in the clinic. The pseudomeningocele gradually improved and resolved without compressive head dressing Figures -2F.Iatrogenic pseudomeningocele is a common complication after cranial or spinal surgeries due to dural defects and the resultant accumulation of extradural cerebrospinal fluid (CSF) at the surgical site ,2. PseudIn case 1, the patient did not have headache, nausea, vomiting, hydrocephalus, or transependymal flow on imaging, indicating that intracranial pressure was normal. Therefore, even with the minimum shunt valve setting, the drainage was ineffective. After direct connection of the proximal and distal catheters, with the siphon effect, the subgaleal fluid collection subsided and resolved. This technique has also been effective in another case report . One potFor patients with multiple abdominal surgeries or any other contraindications to peritoneal shunt placement, the thoracic cavity is an alternative destination, as described in our second case. Considering less frequent pleural shunt placement in practice, cardiothoracic surgeons may need to be consulted for operative assistance. However, the thoracic cavity is occupied by the lungs, and its capacity for fluid absorption is limited compared to the peritoneal cavity . With plThe timing of surgery is mainly surgeon dependent. According to Tu et al. , surgicaLike any other shunt system, potential malfunction can occur. Obstruction, migration, infection, bowel perforation, pseudocyst formation, etc. have all been reported -9. Long-Regardless of the efficacy of treatments for pseudomeningocele, prevention is ideal. Techniques to reduce the risk of pseudomeningocele development include water-tight closure, duroplasty with grafts, and utilization of tissue glues and blood patch have all been proposed ,10. HoweThis study is a retrospective single-institute case report which limits its ability for generalization. The utility of this technique in cases with infratentorial pseudomeningocele also needs to be explored. Additional prospective studies with larger sample sizes are necessary to determine the efficacy of this technique in the treatment of pseudomeningocele.Iatrogenic pseudomeningocele is a common complication of cranial surgeries. For cases refractory to medical management such as observation, head elevation, fluid aspiration, compressive head wrapping, or medications, subgaleal shunt placement may be a safe and effective treatment option.


The WHO classification of tumors of the central nervous system described for the first time the extremely rare entity of rosette-forming glioneuronal tumors  in 2007. Due to the rarity of this entity in the pineal region, no specific therapy guidelines currently exist. With our large cohort of patients treated at a single center (from August 2018–June 2021) and with the already described cases in the literature, we would like to highlight possible therapy and follow-up concepts. After the main symptoms of headache or generalized epileptic seizure, cystic lesions adjacent to the pineal gland and the third ventricle were diagnosed in imaging. None of the patients underwent additional chemotherapy or radiotherapy after gross total (GTR)/subtotal resection or endoscopic biopsy. In cases where surgical resection seems feasible with a reasonable surgical risk, we advocate GTR. Long-term MRI follow-up is essential to detect a slow tumor progression.Background: Rosette-forming glioneuronal tumor (RGNT) is an extremely rare entity described for the first time in the WHO classification of tumors of the central nervous system in 2007. Predominantly, single case reports of RGNT in the pineal region have been published, and specific therapy concepts are pending. Methods: The study group comprised all patients with the RGNT (CNS WHO grade 1) in the pineal region that underwent microsurgical tumor removal in our center (August 2018–June 2021). Surgical strategy, histological findings, and clinical outcome are presented, and the results are evaluated and compared to published case reports. Results: Four male patients aged under 50 years (range between 20 and 48 years) and one female patient, 51 years old, were included in this study. Chronic headaches and generalized epileptic seizures were the main symptoms. Supra-cerebellar infratentorial gross total tumor resection (GTR) was performed in two cases, two patients underwent subtotal tumor resection, and an endoscopic biopsy was performed in case five. Conclusion: In cases where surgical resection seems feasible with a reasonable surgical risk, we advocate GTR. Regular and long-term MRI follow-up is essential to detect a slow tumor progression. The role of additional chemotherapy or radiotherapy remains unclear. The incidence of pineal region tumors is very low as they account for only 1% of all central nervous system (CNS) tumors in adults and 3-8% in children ,3,4. PapThis study was performed in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the University Hospital Essen.All adult patients with pineal-region RGNT CNS WHO grade 1 who underwent surgery in our institution between August 2018 and June 2021 were included in the analysis. Preoperatively, all cases were discussed in our institutional tumor board, and the indication for surgery was decided on an interdisciplinary basis. Data collected from the electronic patient records comprised: age, gender, radiological parameters , follow-up data , and histopathological diagnosis. Statistical analyses were carried out, with Statistical analysis performed using the R and R-Studio software packages .The systematic review and meta-analysis were performed according to the PRISMA guidelines . All stuBetween August 2018 and June 2021, five patients (aged between 20 and 51 years) with a pineal-region tumor and the histopathological diagnosis of RGNT CNS WHO grade 1 were treated in our center. After contrast-weighted MRI diagnostics see , GTR wasThe histopathologic evaluation of the benign tumor with neurocytic and astrocytic differentiation is shown in Case 1:A 23-year-old male patient presented with chronic headaches for several months. An MRI scan diagnosed a cystic, ring-enhancing lesion (27 × 24 × 23 mm) adjacent to the pineal gland. GTR of the tumor was achieved. After an uneventful postoperative course, the patient could be discharged home without any neurological deficit 10 days after surgery. At 15 months follow-up, there were no new neurological deficits. Due to restricted psychological and mental capacity, the patient was unable to work. Follow-up MRI showed no residual or recurrent tumor.Case 2:A 48-year-old male patient presented with a generalized epileptic seizure. The CT and MRI scans demonstrated occluding hydrocephalus with an extensive bithalamic and mesencephal cystic lesion (33 × 30 × 21 mm). An additional preoperative F18-Fluorethyltyrosine [FET] -PET-CT revealed substantial tracer uptake in the tectum but not in the thalami. An endoscopic third ventriculostomy was followed by subtotal tumor resection. Postoperatively, the patient had a transient gait disturbance and vertical gaze palsy. At the last follow-up 2 years after treatment, the gait disturbance had fully recovered, but the vertical gaze palsy had only partially recovered. As preoperatively, he was still unable to work due to his psychological condition with episodes of severe depression. Follow-up MRI showed stable residual bithalamic tumor masses and no recurrence of the resected tumor.Case 3:A 27-year-old male patient presented with a generalized epileptic seizure. A ring-enhancing cystic lesion (15 × 17 × 12 mm) in the tectum was delineated on MRI without accompanying hydrocephalus. A subtotal tumor resection was performed, and the patient could be discharged home without neurological deficits 8 days after surgery. Unfortunately, the patient was lost in follow-up.Case 4:A 20-year-old male patient presented with headaches for two weeks. MRI revealed occlusive hydrocephalus due to a small (7 × 10 × 4 mm) non-enhancing tumor extending from the pineal gland into the third ventricle. A ventriculoperitoneal shunt system was placed, as the individual anatomy did not allow for endoscopic third ventriculostomy. Follow-up MRI after three and nine months showed tumor growth with localized contrast enhancement. Gross total tumor resection was achieved. At the last follow-up, nine months after treatment, the patient had returned to work and had no general or focal neurological deficit except for some vertigo. Follow-up MRI showed no residual or recurrent tumor.Case 5:A 51-year-old female patient presented with a generalized seizure. MRI showed a multifocal lesion adjacent to the tectum extending into the third ventricle and the lateral ventricles. Endoscopic biopsy in an external hospital revealed DNET as the histopathological diagnosis. Until eight years later, yearly performed follow-up MRI showed marginal lesion growth (15 × 12 × 17 mm). At this point, the patient presented with a compensated occlusive hydrocephalus in our center. Endoscopic biopsy with septostomy and placement of a ventriculoperitoneal shunt was performed. Histopathological re-evaluation revealed an RGNT of the pineal gland (CNS WHO grade 1). The patient had no general or focal neurological deficit after surgery and in the 3-month follow-up examination. The 3-month and 10-month follow-up MRI showed stable findings.Through the systematic review, 14 adult patients’ cases of pineal-region RGNT CNS WHO grade 1 previously published in the literature could be identified ,16,17,18As RGNT CNS WHO grade 1 in the pineal region is extremely rare, standard treatment and management guidelines are missing. The present observational study, combined with the systematic literature review, aimed to evaluate treatment regimens and neurological outcomes and expand the knowledge beyond the published cases.Our single-center series presents one of the largest cohorts of adult patients with RGNT (CNS WHO grade 1) in the pineal region (n = 5). Together with the previous 14 cases, 19 patients are now reported. Due to the rarity of the disease, treatment guidelines are pending. A tumor biopsy, partial, and GTR have been reported as treatment options with varying surgical morbidity ,21,25,26Interestingly, DNET was initially diagnosed in our female patient (case 12, see The literature review and our cases suggest that RGNT has a clear male dominance showing first symptoms before the age of fifty. Although very few cases have been described so far, we would advocate GTR in cases where it seems feasible with reasonable surgical risk. Whatever treatment strategy is chosen, regular and long-term MRI follow-up is mandatory.Pineal region RGNT is a very rare tumor entity for which standard treatment and management guidelines are pending. In cases where surgical resection seems feasible with a reasonable surgical risk, we advocate GTR. Regular and long-term MRI follow-up is essential to detect a slow tumor progression. The role of additional chemotherapy or radiotherapy remains unclear.


Splenic injury is usually seen with penetrating or blunt abdominal trauma. It is also one of the rare complications of colonoscopy. Various patient and procedural factors have been reported to increase the risk of this dreaded complication. We present a case of splenic injury after outpatient colonoscopy where intra-abdominal adhesions from previous abdominal surgeries were presumed to be the cause of splenic injury. Our patient had improved outcomes with timely diagnosis and intervention. Colonoscopy is being widely used as a diagnostic and therapeutic tool. It has become a routine procedure. As with any procedure, there are complications associated with colonoscopy too. Splenic injury is one of the rare complications of colonoscopy . PneumotA 49-year-old Caucasian female presented for an outpatient esophagogastroduodenoscopy (EGD) and Colonoscopy for evaluation of nausea, vomiting, and chronic constipation. She had a history of irritable bowel syndrome constipation-predominant, laparoscopic cholecystectomy, hysterectomy, and paroxysmal supraventricular tachycardia (SVT). Both procedures were performed without difficulty. One cecal polyp was removed with the application of a hemostatic clip Figure .The EGD was unremarkable. While in the post-anesthesia care unit, the patient developed acute left upper quadrant abdominal and flank pain. Vital signs were normal. Physical examination revealed tenderness in the left upper quadrant, without distention or rigidity. Blood work showed a drop in hemoglobin (Hgb) and hematocrit from 14.7 to 9.7 N:12-15 g/dl) and 45 to 29.0 N:36-47%), respectively. X-ray kidney, ureter, and bladder (KUB) was unremarkable. CT abdomen & pelvis with contrast revealed 12.3 x 5.7 cm subcapsular peri splenic hematoma with active extravasation  and colonic perforation are common complications with an incidence of 1% to 2% and 0.1 to 2% respectively . SplenicThere has been an increase in the cases of splenic injury with an increasing number of diagnostic and therapeutic colonoscopies. Physicians should have a very low threshold to obtain a contrast-enhanced CT scan of the abdomen in suspected cases of splenic injury. Awareness of this dreaded complication is the key to timely diagnosis and intervention.


Gallstone ileus is an important form of small bowel obstruction that occurs in less than 0.5% of patients who present with obstruction. A biliary enteric fistula that evolves in the setting of chronic cholecystitis may allow the passage of a large gallstone into the gastrointestinal tract distal to the common duct. A single stone that is sufficient in size (at least 2–2.5 cm diameter) may then create a mechanical obstruction, most often at the ileocecal valve or the terminal ileum where the intestinal lumen narrows, and where peristalsis is less robust. We present an unusual case of gallstone ileus in a patient whose obstruction was caused by not one, but seven individual gallstones, collectively restricted in the jejunum at the point of a previous anastomosis and occurring twenty years after cholecystectomy. Gallstone ileus is characterized by an obstruction of the intestines caused by the settling of gallstones in the lumen of the intestines. The obstruction may present in any location in the intestinal tract; yet, it predominantly occurs in the terminal ileum potentially due to less active peristalsis , 2. Due Gallstones are typically divided into three categories due to cholesterol content: cholesterol stones (cholesterol content >70%), mixed stones (cholesterol content 30–70%) and pigment stones  . Most reGI more commonly occurs in the female and elderly (over 60-years-old) population but additional risk factors include a history of cholelithiasis, large stones (larger than 2 cm) and episodes of acute cholecystitis , 6. A diA 81-year-old male with a past medical history of type II diabetes, coronary artery disease status post coronary artery bypass graft, hypertension and hyperlipidemia presents to the emergency department with a fourteen-hour history of sudden onset upper abdominal pain, which began the prior evening while taking his evening meal. The pain has been progressive, unrelenting and was associated with abdominal distention, nausea and two episodes of vomiting. He denied having had fever, chills or any recent similar episodes. He denied regular use of alcohol. Reported surgical history includes laparoscopic cholecystectomy twenty years ago, small bowel resection ten years ago and partial sigmoid colectomy six years ago.In the Emergency Department, his temperature was 97.2 F, HR87reg, BP 186/94, RR18, and his SpO2 98% on room air. His abdomen was diffusely tender, distended and tympanic. His WBC was 11.5, Alk Phos 67, Tbili 2.2. A CT scan of the abdomen and pelvis with contrast was obtained  revealinThe patient was taken to the operating room for exploratory laparotomy where the area of obstruction was readily identified. The foreign bodies were milked proximally to an area of healthy bowel and delivered through an enterotomy. Seven large gallstones each approximately 2.0 cm in diameter  were libGallstone ileus is an uncommon cause of mechanical bowel obstruction, which requires a high index of suspicion to identify. Rigler’s triad of pneumobilia, ectopic gallstones and bowel obstruction is pathognomonic for the condition. The biliary enteric fistula is a complication in as many as 3% of patients with cholecystitis and is the necessary condition to allow for the direct passage of a stone large enough to cause a mechanical obstruction . In the Research shows variations in treatment approach regarding GI. Procedure selection depends on several factors, such as patient comorbidities as well as surgeon preference and technique. The typical surgical approach has been enterolithotomy. A prior study revealed that the enterolithotomy, cholecystectomy and fistula closure technique resulted in a mortality rate of 16.9% compared to 11.7% for enterolithotomy . MoreoveThis case is particularly interesting considering the multiples of stones, which collectively caused the mechanical obstruction at the point of a prior anastomosis of the jejunum. Indeed, swallowed foreign bodies was higher on the differential than residual gallstones given the large time interval since this patient’s cholecystectomy. No anatomical anomaly, which might have supported the occult harboring of this patient’s stones, was ever identified, and a literature review revealed no similar report of multiple stones creating obstruction after cholecystectomy. Despite post-cholecystectomy GI being rare, physicians might become more cognizant of its existence, and diagnosis may be facilitated by an abdominal CT.


Hartmann procedure (HP) often causes severe postoperative adhesions in the pelvic space; therefore, the reversal of Hartmann procedure (RHP) is a challenging surgery. A new spray-type antiadhesion agent, AdSpray, has been reported to be useful in three-dimensional fields such as the liver. However, there are no reports of its use in HP. We present a case of a male patient with rectal cancer who underwent laparoscopic HP with AdSpray to prevent postoperative adhesions.A 52-year-old man presented with melena and constipation.Colonoscopy revealed an almost obstructive type II tumor at the rectosigmoid colon, and histopathological examination revealed moderately differentiated adenocarcinoma. Enhanced abdominal computed tomography revealed slightly enlarged regional lymph nodes but no ascites around the tumor, and there was no metastasis to the liver or lungs. Therefore, we diagnosed clinical stage T4aN1bM0 rectosigmoid colon cancer. Intraoperatively, a metastatic tumor of the liver surface and a high degree of valve retention in the oral colon were identified.After performing laparoscopic HP with AdSpray, we scheduled a laparoscopic RHP with staged hepatic surgery for synchronous liver metastasis from colorectal cancer 1 month later.No postoperative inflammatory adhesions were observed in the pelvis or around the rectal stump, allowing us to perform RHP by a single-incision laparoscopic surgery from the stoma site without any problem. The operation time for RHP was 80 minutes; the patient was in good general condition after the operation, and he was discharged on postoperative day 7.In laparoscopic HP, Adspray was easy to use for three-dimensional fields such as the pelvis and effectively prevented postoperative inflammatory adhesions. Thus, RHP may become less risky and be performed more as a minimally invasive surgery. However, reversal of Hartmann procedure (RHP), which restores intestinal continuity, is associated with severe peri- and postoperative complications, mainly due to a high degree of postoperative adhesions in the initial surgery. Therefore, there are many cases of permanent colostomy without RHP.Hartmann procedure (HP) involves resection of the rectosigmoid colon, followed by the closure of the rectal segment and the creation of an end colostomy. In 1921, Henri Hartmann,4 However, the pelvis is a three-dimensional field and most of the existing sheet-type antiadhesion agents do not provide a clean coating. A new type of antiadhesion agent spray, AdSpray , is reportedly useful in other three-dimensional fields such as the liver region. However, there are no reports of its use in HP.In recent years, various drugs have been developed to prevent postoperative adhesions, and there have been many reports on their effective use.Herein, we report on the case of a male patient who underwent treatment with AdSpray to prevent postoperative adhesions after HP. No pelvic adhesions were observed at the RHP performed 1 month later and the patient underwent single-incision laparoscopic surgery (SILS) from the stoma site without any complications. Therefore, we consider the use of AdSpray useful in preventing pelvic adhesions, which are the main drawback when considering RHP.2A 52-year-old man presented with melena and constipation and underwent colonoscopy. An almost obstructive type II tumor was found at the rectosigmoid. Histopathological examination revealed moderately differentiated adenocarcinoma. Therefore, the patient was referred to our department for surgical treatment.The patient had been receiving treatment for diabetes mellitus and asthma since 10 years. A physical examination revealed abdominal distension and slight left lower abdominal tenderness. He had a normal temperature, with otherwise normal vital signs. Blood test results revealed that his carcinoembryonic antigen level was 19.0 mg/dL, but all other blood test results were within the normal range. Enhanced abdominal computed tomography revealed a high-density area in the rectosigmoid colon. There were slightly enlarged regional lymph nodes but no ascites around the tumor, and there was no metastasis to the liver or lungs. Based on these findings, the patient was diagnosed with clinical stage T4aN1bM0 rectosigmoid colon cancer. For treatment, we proposed laparoscopic anterior resection with regional lymph node resection.Intraoperatively, a metastatic tumor on the surface of the lateral segment of the liver Fig. A and a hThe patient's postoperative course was uncomplicated and he was discharged from the hospital on postoperative day 10. After discharge, magnetic resonance imaging was performed. It revealed no radiological evidence of another metastatic liver tumor. He strongly requested that the colostomy be closed as soon as possible; therefore, RHP and laparoscopic partial resection of the liver were conducted simultaneously 1 month later.Due to the risk of postoperative infection, we decided to perform the 2 surgeries in separate settings, and the RHP was performed first. After the induction of anesthesia, the patient was placed in the lithotomy position  score was 1 point because the pelvic surgery could be performed without any problem with SILS, and the (B) score was 1 point because dissection of adhesions was not necessary, and the overall score was considered EASY in this case. Thus, the application of AdSpray onto the pelvis, including the rectal stump, may be useful in patients with HP who do not wish to have a permanent stoma.Postoperative adhesions due to surgical procedures are the result of damage to the peritoneum and tissue, which causes the formation of fibrin.,13 to simultaneously perform liver surgery for synchronous liver metastasis of colorectal cancer, which was observed during the HP. It is a controversial issue whether to perform simultaneous surgery or nonsynchronous resection for the treatment of simultaneous liver metastases, but in our department, we performed a planned 2-stage resection for patient safety and adequate liver examination. As for the timing of the RHP, a longer interval (>9 months) from HP to RHP is associated with a higher risk of postoperative complications and a decline in the quality of life.,17 Specifically, the treatment of highly advanced cancer with obstructive enterocolitis, such as liver metastasis, often requires chemotherapy or 2-stage surgery, as in this case, which places a heavy psychological and physical burden on the patient. Therefore, we considered early reversal as a reasonable option in this case to improve the quality of life and safety. Given that we only reported our experience with a single case, we plan to accumulate more cases in the future to confirm our findings.In this case, we decided to perform RHP on postoperative day 30, which is earlier than previously reported,In conclusion, Adspray was easy to use for three-dimensional fields such as the pelvis and was effective in preventing postoperative inflammatory adhesions during laparoscopic HP. Thus, RHP may become less risky and may be performed more as a minimally invasive surgery.3.1Written informed consent was obtained from the patient for the publication of this report.www.editage.jp) for the English language editing.We are grateful for the cooperation of the personnel from the liver team at the Department of General and Gastroenterological Surgery, Osaka Medical and Pharmaceutical University, who were involved in partial resection of the liver procedure. We also thank Editage (WO, MY, SM, HH, MI, KI, KTani, TK, YS, KTana, and JO performed the operation and provided perioperative care. WO designed and drafted the manuscript. MY, SM, HH, MI, KI, KTani, TK, YS, KTana, JO, and KU analyzed and interpreted the data. MY reviewed and revised the manuscript. KU supervised the patient's treatment and writing of the report. All authors have approved the final manuscript.Conceptualization: Wataru Osumi.Data curation: Wataru Osumi, Shinsuke Masubuchi, Hiroki Hamamoto, Masatsugu Ishii, Keisuke Izuhara, Kohei Taniguchi, Toru Kuramoto, Yusuke Suzuki, Keitaro Tanaka, Junji Okuda.Investigation: Wataru Osumi, Shinsuke Masubuchi, Hiroki Hamamoto, Masatsugu Ishii, Keisuke Izuhara, Kohei Taniguchi, Toru Kuramoto, Yusuke Suzuki, Keitaro Tanaka, Junji Okuda.Project administration: Wataru Osumi, Masashi Yamamoto.Supervision: Kazuhisa Uchiyama.Writing – original draft: Wataru Osumi.Writing – review & editing: Wataru Osumi.