Bronchogenic cysts are rare congenital malformations which derive from primitive ventral foregut. They are usually observed in intrathoracically. A fifty year old male was admitted for the investigation of a three month chest pain. Computed tomography scan of the thorax revealed a lesion around the esophagus and left stem bronchus. Endobronchial ultrasound with convex probe and a 19G needle biopsy revealed a bronchogenic cystic which was removed with video assisted thoracic surgery. Initial radiologic assessment although was thought to be lung cancer because of the smoking habit it turned out to be benignancy. EBUS-TBNAB with 10G needle is safe and absolutely necessary for these lesions, as they take large samples. They ma2A fifty year old man was admitted for chest pain. In specific the pain had a direction from left to the right finishing in the vertebra in the middle of the thorax. The man had the chest pain for three months, but he chose to take pain relief tablets, until he came to the hospital to be evaluated. All tests were negative for an acute ischemic event. A CT of the thorax with contrast revealed a lesion around the esophagus and the wall of the left stem bronchus . The pat3Lesions observed in the thorax are usually malignancies and positron emission tomography (PET-CT) can assist in providing us useful information before we perform a biopsy. Usually such lesions do not have F-18 fluorodeoxyglucose (FDG) uptake. However; this might not be true in all cases since false positive uptake could be observed if inflammation exists . We repoNone to declare.


Anastomotic recurrences of the colon are postulated to arise due to inadequate margins, tumor implantation by exfoliated cells, altered biological properties of bowel anastomosis, and missed synchronous lesions. In this paper, a case of unexpected early local recurrence after surgery for colon cancer is presented.A 68-year-old Caucasian man underwent right hemicolectomy for invasive G2 adenocarcinoma. Two months later, endoscopy revealed a wide and well-functioning anastomosis with a hyperemic, hard, and thickened mucosal area of about 2 cm in diameter. Biopsies showed the presence of an adenocarcinoma with the same grading of the previous lesion. Ten days later, the patient underwent a new intervention; the last 10 cm of the ileum and half of the remaining transverse colon were resected, and the patient started adjuvant therapy. Specimen examination confirmed the presence of an adenocarcinoma (G2) penetrating the muscular layer of the wall; also, in this case, resection edges were free from tumoral invasion, and the removed lymph nodes were exempt from neoplastic colonization. The patient was seen in follow-up for about 5 years, and he did not show local or systemic manifestations.Whenever a neoplastic recurrence on the anastomotic line occurs, in the presence of negative intestinal margins, as usual in right colectomies, the implantation of neoplastic cells could be the possible cause. Anastomotic recurrence (AR) after resection for colorectal cancer can assume a wide range of presentations. In the past, AR represented a clinical challenge: Data from 1948 to 1976 reported rates between 10% and 35% ; more reA 68-year-old Caucasian man with no relevant medical or surgical history or colorectal cancer family history came to our department with microcytic anemia of unknown origin. In order to understand the primary cause of the presented condition, he underwent several clinical investigations. Endoscopy allowed us to detect a tan, 4-cm-wide neoformation of the cecum with small foci of hemorrhage Fig. . BiopsieHistology of the specimen showed the presence of adenocarcinoma (G2) invading the whole intestinal wall and extending to the fibroadipose perivisceral layers. The resection edges were unharmed, and the lymph nodes were exempt from metastatic colonization Figs. , 4. The Two months later, endoscopy revealed a wide and well-functioning anastomosis with a hyperemic, hard, and thickened mucosal area of about 2 cm in diameter. Biopsies showed the presence of an adenocarcinoma with the same grading of the previous lesion. Ten days later, the patient underwent a new operation; the last 10 cm of the ileum and half of the remaining transverse colon were resected, and the patient started adjuvant therapy. Specimen examination confirmed the presence of adenocarcinoma (G2) penetrating the muscular layer of the wall; also, in this case, the resection edges were free from tumoral invasion, and the removed lymph nodes were exempt from neoplastic colonization Fig. . The patARs can be the expression of a systemic disease or a local manifestation. Most of the local recurrences that occur after 2 years should be considered as metastatic recurrences (peritoneum or soft tissue) or as second primary lesions. Local recurrence occurring before 2 years is due to inadequate excision with positive margins, penetration of the lymphatic vessels, implantation of viable neoplastic cells, or changes in the biology of the tumor or of the colonic mucosa. Even a missed synchronous lesion can present as a recurrent tumor at a later stage.Another possible cause of local recurrence could be the presence of a small synchronous neoplasia, unknown at the moment of resection but close to the anastomosis, as in case of a small, flat lesion. Synchronous colorectal cancer (SCCR) diagnosis can be made when it occurs simultaneously or within 6 months from the initial diagnosis and the histopathological criteria of Warren and Gates are respected: Each tumor has to show a clear outline of malignancy, has to be clearly distinct from the other, and must not be the metastatic expression of the other.SCCR prevalence ranges from 2.3% to 12.4% . BecauseWhenever a lesion appears over a period of 24 months after surgery, it can be classified as a second primary neoplasia (metachronous). A relevant number of studies, however, report an interval of 32–38 months before a malignant lesion occurs –25.Data extracted from the California Cancer Registry comprising a large population have shown that a metachronous cancer develops in about 32 months and, in 50% of the cases, in more than 2.5 years. In some cases, malignancies have been discovered 3 years after surgery . More reMost local recurrences can be explained by considering insufficient resection edges or hidden involvement of the lymphatics, but they could also be due to the implantation of exfoliated neoplastic cells into the intestinal wall, favored by surgical manipulations.A large number of local recurrences are more frequent after anterior resection of the rectum and more often develop from pararectal tissues, involving subsequently the anastomotic line, and are more frequent when an anastomotic dehiscence or local infection occurs. In a large number of cases, AR can be attributed to an insufficient size of the resection due to the difficulty in extending as much as possible the intestinal section beyond the neoplastic lesion. In the right colon, the possibility of greater extension of the resection edges behind and beyond the neoplastic lesion allows ruling out an insufficient extension of the resection as a cause.Implantation on the anastomotic line of exfoliated viable neoplastic cells could be considered as an additional factor in AR development. The possibility that exfoliated viable cells grow on the colic mucosa far from the primitive lesion has been fully proved also by experimental studies. Tumoral cells are often recognized in the abdominal washing liquid. This possibility, which could be favored by surgical manipulation, has been proved also by experiments involving animals. In addition, neoplastic cell homing could be favored by damaged mucosa, as in case of anastomotic margins. Importantly, neoplastic cell seeding does not depend on tumoral dimensions or neoplastic invasiveness. In order to prevent possible implantation of exfoliated cells, intestinal irrigation with cancericidal substances has been examined. This technique seems to have contributed to a significant reduction in recurrence rates in cases of anterior resection.The application of a water-based solution of polyvinylpyrrolidone for 5 minutes is usually preferred, although longer periods (15 minutes) seem to give better results; periods longer than 30 minutes damage the cells of the normal colic mucosa irreversibly.These methods seem to reduce the incidence of recurrence on the anastomotic line from 10–16% to 2–3%. At the beginning of 1947, in order to reduce the risk of relapse, Lloyd Davis and Naunton Morgan already decided to irrigate the colon and the rectal stump with a solution of mercury perchlorate, getting, in a uncontrolled study, a decrease in the rate of AR from 14% to 2% . This drThe intestinal preparation with PEG solution seems to reduce the risk of the presence of exfoliated cells in the colonic lumen. In a recent study , intestiBetween 2000 and 2015, 147 right hemicolectomies were carried out in our unit. Mechanical surgical staplers were used in 25 cases (17%); most of the anastomoses were hand-sewn using slowly absorbable sutures. Intestinal stump draping was performed in only 10% of all treated cases. We registered only two cases of AR (1.3%). Both of them belonged to the manual anastomosis group. In the first case, 13 months after surgery, a flat, 1-cm lesion was found; in this case, polyvinylpyrrolidone had not been used. The second case is our patient reported in the present article.Undoubtedly, an anastomosis could be considered an area of great proliferative instability that can influence the development of a neoplastic relapse. Several experiments carried out in animals have proved the role of these sites of proliferative stimulation in carcinogenesis, when a carcinogen is administered , 30.Whenever a neoplastic recurrence on the anastomotic line occurs in the presence of negative intestinal margins, as usual in right colectomies, the implantation of neoplastic cells or a change in the biology of the tumor could be the possible causes. In our patient’s case, the hypothesis of a neoplastic polypoid lesion missed during preoperative workup should be ruled out, because both intestinal stumps were completely exempt from neoplastic infiltration, and the presence of an adenomatous lesion was excluded by three colonoscopies performed by experienced professionals. Endoscopic follow-up can detect chronic signs of phlogosis, with occasional presence of ulcers, even more than 24 months after creation of the anastomosis. Possible areas of hyperemia, edema, and sometimes microerosions into the surgical site a few months after operation shall be considered a normal condition that will disappear within 6 months. According to data, in about 90% of cases, the recurrence can be found through endoscopy; this percentage can reach 100% by means of endoscopic ultrasound .A metachronous cancer can be excluded due to the relative earliness of the lesion detected a few months after surgery. At 2 months, a small area of hyperemia and edema with microerosions was found. Such a situation, especially when it involves all or most of the anastomotic circumference, could be considered as normal; in our patient’s case, it was only “strange” – in its small extension and hard consistency.Lymph node metastases can also be excluded due to the good number of lymph nodes isolated. Furthermore, histology carried out on each of them demonstrated the absence of tumoral cells.Surgery was carried out following scientifically proved guidelines and standard techniques: Section lines were far enough from tumoral mass; intestinal stumps were draped with gauzes soaked with a water-based solution of polyvinylpyrrolidone 5% for 15 minutes; and 4 L of PEG solution were administered orally the night before surgery. All measures that were appropriate to avoid the implantation of exfoliated cells were adopted.Refusal of adjuvant chemotherapy could be considered a crucial event for the development of AR: Taking into account that treatment usually starts 30–45 days after surgery and that the AR was diagnosed 60 days after surgery, we can affirm that missed chemotherapy could not have avoided carcinogenesis.To the best of our knowledge, the implantation of exfoliated neoplastic cells on anastomotic lines seems to represent the sole mechanism able to explain neoplastic AR. As already remarked by other authors , 33, tum


We present a case of pancreatic and splenic metastases following alveolar soft part sarcoma (ASPS), which was successfully treated by surgery.A 41-year-old male was referred to our hospital in 2012. Computed tomography (CT) showed the presence of a pancreatic tumor. In 2002, the patient had undergone surgical resection of an ASPS of the anal region. In 2009, during follow-up, CT revealed lung metastases, which prompted surgical resection of the lung, followed by resection of the head skin in 2011. Abdominal ultrasonography (US) revealed the presence of isodense masses sized 34 mm in the pancreatic head and 60 mm within the spleen. The contrast-enhanced US revealed a solitary lesion with enhancement. Contrast-enhanced CT revealed solitary lesions with enhancement within the pancreatic head, spleen, and liver. The patient underwent metastasectomies from the pancreas, spleen, and liver. The patient was discharged on postoperative day 22 without recurrence for 18 months after metastasectomy. Twelve years after primary resection and 2 years after metastasectomy, the patient died as a consequence of multiple metastases.We have presented a rare case of pancreatic and spleen metastases from ASPS. Resection by radical metastasectomy was successful without morbidity. Thus, for improved survival of patients with multiple metastases from ASPS, metastasectomy may be indicated. If multiple metastases are resectable, surgical approaches may be the preferred treatment. In 1952, alveolar soft part sarcoma (ASPS) was reported for the first time by Christopherson, Foote, and Stwart . MetastaA 41-year-old man who had undergone surgical resection of an ASPS of the anal region 10 years earlier presented to our hospital in 2012 because of a tumor of the pancreatic head detected via computed tomography (CT) during follow-up. In 2009, during follow-up, CT indicated lung metastasis. The patient underwent surgical resection of the lung, and in 2011, resection of the head skin was related to the metastasis. The abdominal ultrasonography (US) revealed the presence of isodense masses of 34 mm in the pancreatic head and 60 mm in the spleen. US with contrast revealed solitary lesions with enhancement  receptor signaling . In a stIn conclusion, we have presented a rare case of pancreatic and splenic metastases originating from ASPS. Radical metastasectomy by resection was performed successfully. Multiple metastases related to ASPS support the possibility that metastasectomy is associated with improved overall survival. If multiple metastases are found to be resectable, this procedure may be favorable candidates as part of surgical treatment.


The most common sites of metastasis for esophageal cancers include the liver, lungs, and bones. We report a rare case of esophageal adenocarcinoma with metastasis to the subcutaneous perianal region as well as to the small bowel. Physicians should consider the possibility of metastasis in a patient with esophageal adenocarcinoma even after the onset of remission. It is essential to examine these patients and maintain a high index of suspicion for possible metastases. Early recognition helps in the accurate staging of the disease and enables the initiation of life-prolonging therapy and achieving meaningful palliation. Esophageal cancer accounts for about 4% of all cancers in the United States. It is the eighth most common cancer and the sixth leading cause of cancer-related death worldwide . Every yMost cases progress locally, but about 40% of patients can present with metastatic disease, with the most common sites being the liver, lung, and bone . EsophagHere we report an unusual case of esophageal malignancy with metastasis to the small bowel as well as the perianal tissue. An 88-year-old man presented to the hospital with a chief complaint of nausea and vomiting. He had a past medical history significant for recurrent esophageal adenocarcinoma status post-chemotherapy and radiation.Fifteen months before the current presentation, following hospitalization for fatigue and melena, esophagogastroduodenoscopy (EGD) had been performed and noted mucosal changes consistent with long-segment Barrett’s esophagus associated with an esophageal nodule . The nodHe received chemotherapy and radiation. Repeat endoscopy four months later demonstrated two linear esophageal ulcers and pathology reported no evidence of malignancy. Eight months later, repeat endoscopy revealed esophageal mucosal changes consistent with long-segment Barrett’s esophagus present in the distal esophagus, which was confirmed by pathology.Three months after the last endoscopy, at the current presentation, the patient was admitted for nausea and vomiting. At this time, endoscopy revealed a single 6 mm mucosal nodule in the lower third of the esophagus along with mucosal changes compatible with the established long-segment Barrett’s disease. Histopathology of the nodule was reported as moderately differentiated adenocarcinoma. PET scan indicated focal increased FDG metabolism in the distal esophagus which was worrisome for recurrent malignancy. Furthermore, FDG metabolism was noted at the left supraclavicular, left superior mediastinal, peritracheal, right hilar, and para esophageal nodes suspicious for metastatic disease. A moderately FDG avid nodule in the left upper abdominal quadrant was also noted. This could signal mesenteric adenopathy or non-opacified small bowel. The patient was then started on oral capecitabine treatment. He had noted constipation with his last bowel movement occurring three days prior. A computerized abdominal tomography (CT) showed concerns for small bowel obstruction and small mesenteric mass . The primary differential at this point was possible chemotherapy-induced enteritis causing ileus or obstruction. Conservative measures with bowel rest and nasogastric (NG) tube decompression failed to alleviate symptoms. The obstruction persisted, and the patient was initiated on total parenteral nutrition (TPN). Surgical consultation was subsequently obtained, and an exploratory laparotomy was performed, revealing a malignant small bowel obstruction. Small bowel resection was performed with end to end anastomosis, and pathology revealed multiple deposits of moderately differentiated adenocarcinoma consistent with esophageal metastasis . Nausea Esophageal adenocarcinoma now comprises up to 80% of esophageal cancers in the United States, mainly affecting the non-Hispanic white population . The estThe most common expected sites of esophageal cancer metastasis include the lymph nodes, liver, lungs, bone, adrenal gland, and the brain . ShaheenCutaneous metastases of esophageal cancer are uncommon and have an incidence of around 1%. These commonly involve the skin of the neck, head, and abdomen. The skin overlying the primary malignancy is commonly involved, but they may also involve distant sites, with the scalp being the most common . The mosThe skin manifestation of our case was a painful perianal indurated lesion, which was not reported previously in the literature.Esophageal adenocarcinoma with metastasis to the small intestine is another rare complication that was present in our case. Until now, only one such case has been reported in the medical literature. Metastatic involvement of the small bowel from any extra-abdominal malignancy is unusual. The involved primary tumors in such cases include malignant melanoma, lung carcinoma, breast carcinoma, skin cancer (non-melanomatous), embryonal myosarcoma, and seminoma . Dasari In conclusion, physicians should consider the possibility of metastasis in a patient with esophageal adenocarcinoma even after the onset of remission. It is essential to examine these patients and maintain a high index of suspicion for possible metastases, as recognition can help in the accurate staging of the disease and enables the initiation of life-prolonging therapy and achieving meaningful palliation.The authors declare that they have no conflict of interest.


One anastomosis gastric bypass- minigastric bypass (OAGB-MGB) is an emerging bariatric surgery that is being endorsed by surgeons worldwide. Internal herniation is a rare and dreaded complication after malabsorptive bariatric procedures, which necessitates early diagnosis and intervention.We describe a 29-year-old male with chylous ascites caused by an internal hernia 8 months following laparoscopic one anastomosis gastric bypass. An abdominal CT showed enlargement of lymph nodes at the mesentery, with a moderate amount of liquid in the abdomen and pelvis. An emergent exploratory laparoscopic surgery demonstrated an internal hernia at the Petersen’s space with a moderate quantity of chylous ascites. The patient made an uneventful recovery after surgery.Internal herniation can occur after OAGB-MGB and in extremely rare cases lead to chylous ascites. To our knowledge, this is the first reported case of chylous ascites following one anastomosis gastric bypass. One-anastomosis gastric bypass- minigastric bypass (OAGB-MGB) is an emerging bariatric surgery technique currently endorsed by surgeons worldwide , 2. SimiEarly complication rates of OAGB-MGB range from 0.5 to 3.1% . This, h2; weight loss 53 kg). On physical examination, the patient’s vital signs were within normal range. The patient had no fever. Abdominal auscultation revealed normal bowel sounds. Upon abdominal palpation, the patient complained of diffuse tenderness. His lab results, including lactate, amylase and lipase were all within normal limits.We report a 29-year-old male, otherwise healthy, who presented to our emergency department, complaining of severe diffuse abdominal pain that had developed over the last 24 h, and had become progressively worse with time. The patient did not report any constipation, diarrhea, or distention despite having nausea and vomiting. He had undergone laparoscopic OAGB-MGB in a different medical center 8 months prior to his admission (Body mass index (BMI) prior to the surgery: 42 kg/mA computed tomography scan of the abdomen and the pelvis following oral and intravenous contrast administration demonstrated no evidence of intestinal obstruction or free air. Enlarged lymph nodes at the root of the mesentery were observed, with a moderate amount of free liquid of unknown origin in the abdomen and pelvis Fig. . The aboParallel to dramatic increases worldwide in obesity prevalence, surgical procedures aimed to induce and maintain weight loss have increased considerably over recent years. Both RYGB and OAGΒ-MGB are common, well-tolerated and effective operations for morbid obesity. Both surgeries carry similar rates of complications and reoperations, with leaks and hemorrhages being the most common due to the gastrointestinal anastomoses .An internal herniation is a dangerous late complication that may occur after both RYGB and OAGB-MGB procedures  and is characterized by symptoms of abdominal obstruction . CliniciChylous ascites in a bariatric surgery setting generally occurs by a loop passing through the Petersen’s defect, which causes direct compression of the mesenteric vessels and fluid extravasation. In previous case reports of patients with chylous ascites following RYGB, the complication was resolved by the release of the internal hernia compressing the mesenteric lymphatic vessels . SimilarClosure of the mesenteric defect at the time of the primary surgery has been shown to reduce the occurrence of internal hernia following RYGB procedures . AlthougIn conclusion, internal hernia is a dangerous complication following OAGB, which in extremely rare cases can lead to chylous ascites. Surgical intervention is required to release the hernia and relieve the compression of the lymphatic vessels. Closure of the potential spaces that can lead to internal herniation should be evaluated in OAGB.


Succinate dehydrogenase deficient gastrointestinal stromal tumors (SDH-deficient GISTs), which lack KIT or PDGFRA mutations demonstrate unique clinical and pathological features, and they respond poorly to standard targeted therapy. We herein present a novel case of SDH-deficient GIST in a three-month-old infant’s colon mesentery, and he is the youngest patientto date.The infantpresented with complaints of blood in the stool. CT showed a 6.3 × 4.6 cm mass in the left lower retroperitoneal. Complete resection of tumor and segmental bowel resection was performed without regional lymphadenectomy. Histologically, tumor cells were distinctive in their multinodular colon wall involvement with interspersed tracts of colon wall smooth muscle. The tumor was composed mainly of epithelioid cells. Immunohistochemically, the tumor cells were positive for Vim, CD117, PDGFR, while negative for SDHB. Mutational analysis showed a synonymous mutation for SDHB and wild-type for KIT and PDGFRA. Two months after surgery, metastases were found and Imatinib was administered. Unfortunately, the disease continued to progress, and the infant died 5 months after surgery.SDH-deficient GISTs comprise a subgroup of a relatively rare tumor type and show a number of clinically and biologically unique features, especially for infants. It is of great importance to developing new therapeutic targets and novel specific drugs. Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract which have been recognized as genetically and biologically heterogeneous tumors. Most GISTs harbor activating mutations of KIT or platelet-derived growth factor receptor alpha (PDGFRA) . Approxi12/L. The baby’s parents and elder sister are in good health and no related neoplastic lesions were found.A three-month-old baby boy presented with complaints of blood in the stool with a duration of more than half a month. On clinical examination, B-ultrasound results suggested that solid hypoechoic mass was detected in the left lower abdomen, the size was about 6.9 × 5.0 × 3.9 cm. Enhanced Computed tomography (CT) showed a 6.3 × 4.6 cm mass in the left lower retroperitoneal Fig. a. The boComplete resection of the tumor and segmental bowel resection was performed without regional lymphadenectomy in the pediatric surgery department. The tumor located in the left mesentery with invasion into the colon and sigmoid junction. Adjuvant anti-cancer treatment was not undertaken after the operation on account of bad general condition.Microscopically, under low magnification, tumors were distinctive in their multinodular colon wall involvement with interspersed tracts of colon wall smooth muscle Fig. a, and thThe panel of immune-histochemical stains included CD117, Dog1, CD34, SDHB, S100, SMA, Desmin, Vim, and Ki67. Among them, Vim, CD117, and PDGFR were diffusely and strongly positive Fig. c, d, whiMutational analysis showed a wild-type for KIT and PDGFRA at the five exons examined . In addition, all other targets (Her2、EGFR、RET、ROS1、PI3KCA、ALK、KRAS、NRAS and MET) showed no mutation. However, CCND2 amplification and amino acid missense mutation at position 932 of exon 19 of the PTCH1 gene were detected, which may have a significant impact on gene function. At last, we performed SDHB gene sequencing in Jinan Boshang Biotechnology Co. Ltd. The sequencing of SDHB in tumor showed synonymous mutation at position 169 of exon 1(C-A)  is an enzyme complex composed of four protein subunits . This complex acts at the interphase of the tricarboxylic acid cycle and electron transport chain. The SDH-complex participates in the Krebs cycle with subunit A (SDHA) being the catalytic unit responsible for the conversion of succinate to fumarate. Subunit B (SDHB) is an iron-sulfur protein that participates in the electron transport chain for the oxidation of ubiquinone to ubiquinol. Subunits C and D (SDHC and SDHD) are membrane-anchoring subunits. Remarkably, immunohistochemistry for SDHB becomes negative whenever there is bi-allelic inactivation of any component of SDH, which is very rare in the absence of syndromic disease . Loss ofSDH-deficient GISTs demonstrate unique clinical and pathological features, including an exclusively gastric location, absence of KIT or PDGFRA mutations, typically showed plexiform muscularis propria involvement, and epithelioid hypercellular morphology. Based on current experience, SDH-deficient GISTs occur mainly in the stomach and were more likely to occur in younger, female patients. In this report, we showed a colon mesentery tumor case in a three-month-old infant, which was the youngest patient also in an unusual location reported to date , 8, 11. SDH-deficient GISTs are characterized by a distinctive multinodular/ plexiform architecture and epithelioid or mixed epithelioid and spindle cell morphology . In our In addition, CCND2 amplification and amino acid missense mutation at position 932 of exon 19 of the PTCH1 gene was found. CCND2 belongs to the highly conserved cyclin family, forms a complex with CDK4 or CDK6, and functions as a regulatory subunit of the complex, whose activity is required for cell cycle G1/S transition. CCND2 amplification has been previously reported in GIST . PTCH1 eSDH-deficient GISTs do not seem to have a marked tendency for familial occurrence, as compared with SDH mutation syndrome associated paragangliomas that show familial occurrence. Due to the rarity of SDH-deficient GISTs, treatment experience is limited, especially for pediatric patients. Complete surgical removal of the primary tumor and locoregional  metastases should be performed whenever possible. There is no uniform about the adjuvant treatment of patients with SDH-deficient GISTs to date. Traditional cytotoxic chemotherapy is generally ineffective for SDH-deficient GISTs, as it is for KIT/PDGFRA mutant GISTs. SDH-deficient GISTs respond poorly to standard targeted therapy such as tyrosine kinase inhibitor drugs, neither the first line inhibitor imatinib mesylate nor a second line multikinase inhibitor sunitinib malate, although the stable disease has been observed in some cases , 8, 20. Conventional risk stratification fails to predict the progression of SDH-deficient GISTs . SDH defConsequently, SDH-deficient GISTs comprise a subgroup of a relatively rare tumor type and show some clinically and biologically unique features. It is of great importance to developing new therapeutic targets and novel specific drugs. The priority for further research in this molecular subtype is more extensive sequencing with methods such as whole-exome sequencing, RNA sequencing, and whole-genome sequencing to discover novel genomic events affecting kinases that could suggest therapeutic vulnerabilities. We reported the youngest case of SDH-deficient GIST arising in colon mesentery, and reviewed the relevant literature to make a deeper understanding of the disease, and provide useful parameters for further gene therapy.


Leiomyosarcomas of the vascular system (vLMSs) are rare tumors that commonly originate from large proximal and central veins. Pancreatic metastasis is rare for sarcomas, and surgical excision with large margins is the treatment of choice. We present a case of a 32-year-old female with primary vLMS originating from the distal crural veins and local invasion of the fibula. A prior open biopsy site was suboptimal. The patient was treated with neoadjuvant chemotherapy and radiotherapy, followed by surgery. The follow-up radiological imaging showed pancreatic head metastasis, which is also an extremely rare site for vLMS. Leiomyosarcomas of the vascular system (vLMSs) are rare tumors that commonly originate from large veins. Distally originated tumors are very rare. Leiomyosarcomas represent about 5-7% of all soft tissue sarcomas, and vLMSs represent only 2% of all these neoplasia. Bones and lungs are the most frequent metastatic sites of sarcomas. The pancreas is a very rare metastatic site for vLMSs as well as other sarcomas. The mean age for leiomyosarcomas is the sixth and seventh decades, and patients younger than 50 are rare.The decision regarding the biopsy site and the tract is crucial for general bone and soft tissue malignancy management. It is preferable for the biopsy to be done by the center that is planning the surgical procedure. The biopsy should be accepted as the last stage of diagnosis and the first stage of treatment.We present a case of a 32-year-old female with primary vLMS originating from the distal peroneal vein and local invasion of the fibula.A 32-year-old female patient had a history of leg pain that started in March 2018. After multiple conservative treatment cycles, Doppler ultrasound (USG) and computed tomography (CT) scans were performed due to persistent pain. A soft tissue mass was detected in the distal cruris, and an open biopsy from the posteromedial aspect of the distal cruris was performed in February 2019. The pathology report indicated biphasic synovial sarcoma, and the patient was referred to our institution with that diagnosis. The pathologic samples were reevaluated and reported as spindle cell sarcoma (French Federation of Cancer Centers Sarcoma Group histologic grade 3). Magnetic resonance imaging (MRI) showed a tissue mass measuring 4.82 x 4.16 x 20 cm in the mid-to-distal third of the posterior crural compartment with cortical destruction of the distal fibula just proximal to the ankle  with intact surgical margins and 90% necrosis (Figure Leiomyosarcomas originating from vascular structures are rare, with the most common age of presentation in the sixth and seventh decades . Most ofDistal vLMSs are very rare but must be considered in the case of extremity soft tissue sarcomas, even among patients of a young age. The biopsy sites should be planned in accordance with the final surgical approach. Metastatic lesions are not rare for vLMS, so even if the site is unusual and the radiological findings inconsistent, all suspicious lesions should be accepted as metastasis until proven otherwise. Surgical excision with wide margins is the treatment of choice, and high rates of local recurrence should be kept in mind when planning the surgery.


Intestinal malrotation (IM) is a congenital aberrancy of midgut rotation during development, which manifests among neonates more than adults. Older reports have estimated an incidence of one in 6,000 live births, which is now as high as one in 500. This congenital anomaly is generally indolent in the adult population. Recent literature research has failed to reveal any publications regarding the incidence within a Caribbean population. This paper aims to discuss the isolated case of a patient with this rare condition, who presented to a non-paediatric centre in Trinidad. This case highlights the implications of the initial radiological interpretation in conjunction with perioperative and intraoperative decision making.An 18-year-old male presented with a one-day history of abdominal pain, radiating to the epigastrium with nausea and excessive vomiting. Vital signs and blood investigations were normal. Initial CT scan results were interpreted as an internal hernia, which was surgically managed as such. Repeat imaging and a second laparotomy were required to correctly diagnose and perform the appropriate Ladd procedure.IM occurs due to the arrest of rotation of the midgut during fetal maturation. The incomplete rotation variant was seen in this case and is predominantly responsible for the symptomatology and morbidity associated with adult intestinal malrotation (AIM). Stringer has classified these anomalies based on the stage of embryonic development that is disrupted. CT helps with diagnostics in 97.5% of cases. This case highlights the implication of incorrect assessment on imaging and how it may misguide the interpretation of the findings at laparotomy leading to inappropriate surgical procedures. As many as 20% of cases undergo surgery without adult intussusception diagnosed.The incidence of IM seems to have increased but is scarcely encountered in the adult setting. When encountering this condition at a low-volume centre in the Caribbean, the adult specialist may be blindsided, and unknowingly underprepared without a high index of suspicion. Diagnosis at childhood should be discussed with the family and again with the patient on approaching adulthood. Patient education may help with the surgical assessment. Intestinal malrotation (IM) is a congenital aberrancy of midgut rotation during development, which manifests among neonates or infants more than adults ,2. OlderA paediatric database analysis of 2,744 cases has found that 60% of patients presented before the age of one year and 75% by the age of five years . Renal and liver function tests were within normal ranges. Plain supine abdominal radiographs demonstrated distended large bowel but two air-fluid fluids on erect films.The complete blood count was within normal parameters [Haemoglobin (Hb): 14.5g/dL, white blood cells (WBC): 8x10He was further investigated via contrast-enhanced CT (CECT). This revealed the ‘whirlpool’ sign (WS) Figure , as wellFollowing adequate resuscitation, the patient was taken to the surgery by a senior resident and an attending with over 10 years of experience. Laparoscopy was considered; however, instrument availability was a limiting factor in our setting. A midline laparotomy skin incision was performed. On initial examination, the caecum was instantly noted in an ectopic position in the right upper quadrant. Further assessment while following the small intestine revealed a shortened small bowel mesentery with 180-degree clockwise rotation Figure .This would have been attributed to the SMV appearing to the left of the SMA on the previous contrast studies. The bowel appeared viable as there was no evidence of ischaemia. Careful assessment of the positioning of the mesenteric vessels and gentle anticlockwise detorsion was achieved.Congenital intermesenteric adhesions were noted between the ascending colon and small bowel Figure . AdhesioThe patient had three uneventful postoperative days. On the fourth postoperative day, the patient experienced sudden-onset projectile vomiting. A nasogastric tube (NGT) was positioned, draining over a litre of bilious effluent on placement. Oral contrast was administered followed by a CECT of the abdomen showing pooling of contrast in the stomach and compression of D3 with little contrast beyond this transition point Figure .The preoperative and postoperative CT scans were compared and re-examined in conjunction with the findings at the laparotomy to diagnose a Stringer IIIa malrotation. The patient returned to the theatre for re-exploration. The cecopexy was reversed. Complete adhesiolysis of Ladd’s bands followed by Kocherization was conducted. The bowel was then arranged in a nonrotation position with the small bowel to the right of the midline and the colon to the left.Intraoperatively, the patency of the small bowel was assessed by instilling water via the NGT while occluding the mid jejunum. Distension of bowel beyond the duodenum was observed confirming the passage of contents beyond the initial transition point.The patient began oral fluids the next day and tolerated a normal diet by day three without any associated abdominal discomfort. He was discharged from the hospital on day four with no further issues.IM is an anatomical anomaly caused by the failure or arrest of rotation of the midgut during fetal maturation between the third and tenth week of development . OrdinarInterruption in this process results in nonrotation or incomplete rotation anomalies. The nonrotation variant is the one that is frequently encountered. The small bowel remains situated on the right of the abdomen with the colon contralateral . Most ofIncomplete rotation, as in this case, occurs when there is an arrest during the revolution, usually at 180 degrees. The pre-arterial duodenojejunal limb remains to the right of the midline with the post-arterial distal segment and caecum located in the upper mid-abdomen ,14. ThisInfrequent variants include hyper-rotation beyond 270 degrees and reverse rotation, where the duodenum lies anterior to the SMA and right colon creating a paraduodenal hernia . StringeThe clinical presentation of AIM includes three types: incidental, chronic, and acute . ChronicFrequent symptoms during the acute presentation are severe epigastric or periumbilical pain, vomiting, and distension. The presence of peritonism, haematemesis, haematochezia, or shock implies perforation or vascular compromise with possible necrosis, which indicates emergent laparotomy .A recent systematic literature review by Neville et al. found that CT helps with diagnostics in 97.5% of cases, regardless of contrast enhancement [This case echoed the radiological findings that were expected; however, a closed-loop obstruction from a possible internal hernia was the diagnosis initially entertained. The implication of this assumption was mirrored in the findings interpreted at the initial laparotomy and the incomplete surgery performed. The literature maintains that 20% of cases of AIM underwent previous abdominal surgery without diagnosis . This maThough ultrasound is not recommended for diagnosing malrotation and reportedly has a sensitivity of 62.5%, it is appropriate for children and infants. The gold standard remains an upper gastrointestinal series that depicts the following: a displaced duodenum with the ligament of Treitz to the right, a ‘corkscrew’ duodenum sign, or a ‘beaked’ appearance of the proximal jejunum if a volvulus is present ,17. PatiThe recommended surgical procedure was modified after William Ladd in 1932, who first described the division of the fibrous bands involving the duodenum, caecum, and right lateral wall . The LadThe steps taken in the prime operation predisposed the patient to re-obstruction. Failure to divide the Ladd’s bands permitted extrinsic compression of the duodenum, compounded by fixing of the caecum in an unnatural orientation in this patient. Thus, a poor outcome can be seen associated with the omission of any step of the Ladd procedure.Insufficient evidence exists in favour of elective Ladd procedures for asymptomatic adult patients, though it is proposed by a large number of experts, to avoid possible future complications . In the The incidence of IM is seemingly on the rise but remains scarcely encountered in the adult setting. When encountering this condition at a low-volume centre, the adult specialist may easily be blindsided, being unknowingly unprepared to perform the correct Ladd procedure. It is self-evident that irregularities detected on imaging in the acute virgin abdomen should encourage the pursuit of other subtle congenital anomalies that may impact surgical decisions. It would be prudent that any incidental diagnosis made during childhood should be discussed with the family and again with the patient on approaching adulthood. They should be educated on their condition, and on the signs and symptoms to prompt urgent surgical assessment, should observation be implemented.


Pulmonary neuroendocrine tumors (NETs) are a group of rare tumors that pose a high financial burden on patients and the United States healthcare system. The usual presenting symptoms include cough or wheezing, hemoptysis, or chest pain. Due to bronchial obstruction, patients may also present with recurrent pneumonia. Acute pancreatitis has yet to be documented as the initial manifestation of this disease. Atypical carcinoids - a subtype of NETs - are heterogeneous regarding their site of origin, biological behavior, and malignant potential. Studies show that the most common primary tumor site varies by race, with the lung being the most common in white patients and the rectum being the most common in Asian/Pacific Islander, American Indian/Alaskan Native, and African American patients. Certain carcinoid tumors, such as those of the rectum, are over-represented among the Black and Asian populations within the United States, suggesting the role of genetics in the development of this intriguing disease. Furthermore, the pancreas is not a usual site of metastasis for primary lung NET. Our case study describes the rare occurrence of a primary pulmonary NET  metastasizing to the pancreas and presenting as acute pancreatitis. Pulmonary neuroendocrine tumors (NETs) are a group of rare pulmonary neoplasms characterized by neuroendocrine differentiation . AccordiA 37-year-old Hakha Chin speaking female without any significant past medical history presented with epigastric pain, nausea, and vomiting for three weeks. She was admitted with acute pancreatitis in the setting of elevated lipase (1153 units/liter) and computed tomography abdomen and pelvis (CTAP) consistent with a large fluid collection arising from the neck of the pancreas Figures -1B.Incidentally, CTAP also showed a left lower lung (LLL) mass-like consolidation Figure , which wThe patient was started on bowel rest, aggressive intravenous hydration, analgesics, and anti-emetics. Given a lack of risk factors  following initial stabilization, a robust workup was undertaken to explore possible etiologies for patients' pancreatitis. Magnetic resonance cholangiopancreatography (MRCP) confirmed the above CTAP findings but was negative for biliary pathologies Figures -5.An endobronchial ultrasound-guided biopsy from mediastinal LN stations 7 and 11 revealed sheets and clusters of neuroendocrine cells with focal pseudo-acinar formation Figure -6B.These cells demonstrated strong immunohistochemical staining for chromogranin, synaptophysin, with a Ki-67 labeling index of 5% and were negative for thyroid transcription factor-1, consistent with a metastatic atypical lung carcinoid tumor. Oncology was consulted for treatment recommendations and to establish outpatient care. Following the clinical improvement of pancreatitis, the patient was discharged with a strong outpatient follow-up. Outpatient breast biopsy revealed similar findings as the lymph node biopsy, with tumor cells showing neuroendocrine differentiation and strong immunohistochemical staining for synaptophysin and chromogranin with a Ki-67 < 20%. Positive emission tomography/computed tomography (PET/CT) Figures  and magnThese studies revealed widespread metastatic disease with approximately 20 cerebral and cerebellar lesions and possible metastasis to the pancreas. In light of Ki-67 being <20%, platinum-based chemotherapy was deemed questionable. The patient was considered a poor surgical candidate and was referred for whole-brain radiation, which she is currently pursuing for palliation.Due to its origin from proximal airways (as in our patient), lung AC commonly presents with lower respiratory symptoms: cough, wheezing, hemoptysis, chest pain, and recurrent pneumonia in the same pulmonary segment/lobe due to bronchial obstruction . Our patAtypical carcinoids are heterogeneous regarding the site of origin, biological behavior, and malignant potential. Genetic and epigenetic alterations may play a seminal role in these factors. Epigenetic studies have shown that the most common primary tumor site varied by race, with the lung being the most common in white patients, and the rectum being the most common in Asian/Pacific Islander, American Indian/Alaskan Native, and African American patients. Certain carcinoid tumors, such as those of the rectum, appear to be over-represented among the Black and Asian populations within the United States, suggesting the role of genetics in the development of this intriguing disease. More work needs to be done to identify potential biomarkers that could impact the diagnostics, prognostic stratification, and planning of personalized therapy .With this article, we are bringing to light a novel presentation of atypical pulmonary carcinoid, which presented as acute pancreatitis. Racial differences are noted in the primary distribution of this tumor. Appropriate and speedy diagnosis is necessary to provide the patient's timely high-value care.


A 26-year-old male patient with no significant past history presented with a two-day illness of nausea and abdominal pain, mimicking acute appendicitis. The appendix was poorly visualized on the ultrasound scan so a CT scan was done which revealed infarction of the omentum on the right side of the abdomen. The patient was closely monitored and managed conservatively with analgesics, fluids and antibiotics. Spontaneous improvement occurred in a day, and oral feeding was resumed. The clinical course was uncomplicated, and the patient was discharged, circumventing unnecessary surgery. Literature search has revealed that omental infarction is a rare cause of acute abdomen and it can mimic acute appendicitis or cholecystitis. The treatment needs to be individualized, and surgery may or may not be required. Acute appendicitis is one of the most common causes of an acute abdomen presenting to the emergency departments worldwide . In mostA 26-year-old male patient developed non-colicky pain in the right lower abdomen which reached its zenith in two days. It was associated with nausea and mild fever, but he had no trouble passing stools and flatus. There was no history of any dysuria or dysentry. He walked into the emergency room unaided. Examination revealed a lean individual with a pulse of 100 beats per minute, a blood pressure of 130/70 mmHg and an axillary temperature of 100°F. Abdomen was soft, albeit with tenderness in the right lumbar and iliac region. Bowel sounds were normal and per rectal examination was unremarkable. Bilateral testes were normal, and there were no signs of epididymo-orchitis. There was no significant past medical or surgical history. At this point, the clinical differential diagnoses considered were acute appendicitis, acute cholecystitis, acute pyelonephritis, ureterolithiasis, bacterial enteritis or typhlitis and amebic colitis.9/L) and elevated C-reactive protein (39 mg/dL). The hemoglobin and platelet indices were within normal range. The renal and hepatic functions were normal, and serum amylase and lipase were not elevated. Urine analysis and microscopy were normal. Stool examination did not reveal any ova or cyst. Ultrasound of the abdomen reported the finding of heterogeneously hyperechoic mesentery in the right iliac fossa and lumbar region with mild free fluid, and non-visualization of appendix separately. These findings were inconclusive and did not provide a definite diagnosis. Management till this point included intravenous fluids, parenteral ciprofloxacin (200 mg BID), metronidazole (500 mg TID) and tramadol (100 mg BID). The surgical team was of the view that a CT scan be done before undertaking any surgical intervention.Initial blood investigations displayed an acute phase response with leukocytosis , antineutrophil cytoplasmic antibodies (ANCA) and antiphospholipid antibodies (APLA) were not detected. Prothrombin and activated partial thromboplastin times were normal. Levels of protein C, protein S and antithrombin III were within normal range, and factor V mutation was not identified.Omentum is a fat laden structure lying anteriorly in the abdominal wall . The greInfarction of the omentum is an uncommon phenomenon and has been known to mimic other surgical conditions, such as acute appendicitis and cholecystitis . ItenberLindley and Peyser encountered a case similar to the one described in this report . The CT Omental infarction is a rare but plausible cause of right-sided abdominal pain, and awareness about this condition can be valuable for surgeons as well as physicians. Diagnosis is not possible on clinical grounds alone as the condition is a great impersonator. Emergency abdominal ultrasonography might be suboptimal; hence, a contrast-enhanced CT is preferred for confirmation of the diagnosis. No definite guidelines exist for management, but anecdotal data suggest that a trial of non-surgical management is reasonable for most patients, provided they are closely monitored.


Angiomyolipoma (AML) is a mesenchymal tumor that arises from perivascular epithelioid cells most commonly seen in the kidney and rarely in extrarenal sites. Adrenal AML is a rare clinical entity with only 16 cases reported in the literature according to the World Health Organization report in 2017. We present a 68-year-old male evaluated in our emergency room with worsening chronic right upper quadrant abdominal pain. Computerize tomography (CT) revealed a large right adrenal mass. Adrenelectomy was performed, and the histopathology report confirmed the diagnosis and the tumor size was the largest ever reported. Patient was discharged uneventfully. Angiomyolipoma (AML) is a mesenchymal tumor derived from perivascular epithelioid cells and consist of blood vessels, muscle cells, and fat tissue . ExtrareA 68-year-old male presented to our emergency room with acute on chronic right upper quadrant pain physical examination revealed a right upper quadrant mass with discomfort on deep palpation. Past medical history includes diabetes mellites, renal insufficiency, and hypertension requiring multiple medications to control. CT revealed a 17.3 x 14.6 x 16 cm fat-containing mass originating from the right adrenal gland , aldosterone (1.0) ng/dL (0.0-30.0), cortisol 13.25 mcg/dL (3.1-22.4), ACTH 40.3 pg/mL (7.2-63.3), plasma metanephrine 12 pg/mL ( 0-62), plasma normetanephrine 104 pg/mL (0-145). Urine 24-h metanephrine 48 ug/24hr (45-290), urine 24-h normetanephrine 244 ug/24hr (82-500). Patient was taken to the operating room and a right adrenalectomy was performed (Figure Histopathology confirmed the diagnosis Figure .The patient had an uneventful recovery and was discharged from the hospital.In 1951, Morgan described a benign renal tumor composed of blood vessels, muscle, and fat and the term "angiomyolipoma" was introduced . The useAML is a mesenchymal tumor usually found in the kidney. Extrarenal AML is uncommon, with the adrenal gland being an exceedingly rare location. They are often misdiagnosed as sarcomatoid carcinoma, carcinoma or sarcoma and are known to be diagnostic challenges to pathologists. The tumor can grow to a significant size, and we believe our case is the largest ever reported. An asymptomatic small tumor can be managed with active surveillance; however, large or symptomatic tumors should be resected to avoid complications including spontaneous rupture likely due to the presence of abnormal elastin. Angioembolization or cryotherapy are considered as other options of therapy.


Case Presentation. A 50-year-old female was referred for investigation of recent epigastric pain and a past history of recurrent pancreatitis. Imaging with computed tomography showed a gross dilatation of the entire pancreatic duct with a heterogeneous enhancement of the periductal parenchyma. A passage of oral contrast was noted from the greater curvature and pylorus of the stomach into the dilated duct suggestive of fistulae formation. Gastroduodenoscopy demonstrated these fistulae in the stomach and the proximal duodenum and an exophytic growth at the ampulla obliterating the view of ampullary opening. Endosonography- (EUS-) guided fine-needle aspiration cytology (FNAC) showed cells with high-grade atypia. A total pancreatectomy, distal gastrectomy, and splenectomy were performed, and recovery was uneventful. Histology revealed a ductal adenocarcinoma arising from an intestinal type intraductal papillary mucinous neoplasm with high-grade dysplasia. A year and a half after surgery, she is healthy with good glycaemic control and nutritional status.  Intraductal papillary mucinous neoplasms (IPMN) of the pancreas complicated by fistula formation to adjacent organs are an uncommon phenomenon. We present an IPMN of the pancreas with malignant transformation and multiple fistulae to the stomach and duodenum.  This case highlights the importance investigating patients for the aetiology in recurrent acute pancreatitis and their follow-up. Awareness of cystic pancreatic neoplasms including IPMN is important to avoid misdiagnosis or delayed diagnosis. Referral of these patients to centres with facilities for multidisciplinary input and specialised management is strongly recommended. Furthermore, fistulae appeared to predominate in malignant main duct IPMN [Intraductal papillary mucinous neoplasms (IPMN) of the pancreas are cystic neoplasms composed mainly of mucous-secreting columnar cells with variable cellular atypia . The usuuct IPMN . We presA 50-year-old female was referred for investigation of recurrent epigastric pain. She was otherwise well with no constitutional symptoms, anorexia, or weight loss and was normoglycaemic. She had a past history of recurrent pancreatitis with elevated amylase levels. The liver enzymes and abdominal ultrasonographic studies were normal. She has been asymptomatic for the preceding 3 years. A contrast-enhanced CT scan which was performed 3 years ago had been unremarkable except for evidence of acute pancreatitis and a 6 mm main pancreatic duct dilatation. The contrast-enhanced CT showed a gross dilatation of the entire pancreatic duct (diameter = 23 mm) with a heterogeneous enhancement of the periductal parenchyma of the whole gland with an irregular outline. A passage of oral contrast was noted from the greater curvature and pylorus of the stomach into the dilated duct suggestive of fistulae formation . GastrodShe underwent a total pancreatectomy, distal gastrectomy, and splenectomy. The fistula in the proximal stomach was removed with a cuff of posterior gastric wall using a linear stapler . The posMost patients with IPMN are asymptomatic and are often diagnosed incidentally. Others present with symptoms of pancreatitis due to ductal obstruction by mucin or nonspecific abdominal symptoms. Late diagnosis is not uncommon due to the insidious onset and slow progression of the disease and also lack of awareness among clinicians who do not infrequently mistake abnormalities on imaging to be due to pancreatitis. Proper evaluation of patients with cystic lesions in pancreas should be considered especially in patients with late-onset pancreatic type pain. Evaluation includes cross-sectional imaging, biochemical assay, and cytology of aspirate obtained at endosonography. Contrast CT has an accuracy of 40-81%  while MRIPMN complicated by fistula formation to the adjacent viscera has been reported. The viscera involved include the duodenum, stomach, and bile duct, and 39% were multiple [The risk of invasive carcinoma in high-risk IPMN was 12% over a mean follow-up period of 60 months . A duct Irrespective of lymph node status, adjuvant systemic chemotherapy is often recommended because of the associated aggressive behaviour of these malignancies .This case highlights the importance of investigating those with acute relapsing pancreatitis for aetiology and their follow-up. Awareness of cystic pancreatic neoplasms including IPMN is crucial in clinical practice to avoid misdiagnosis or delayed diagnosis. In the management of these patients, a multidisciplinary approach is strongly recommended. This is the first reported case of successful surgical management of a malignant main duct IPMN by total pancreatectomy in Sri Lanka.


Diaphragmatic hernias are somewhat rare complications of thoracoabdominal interventions. Given their late clinical manifestations and misdiagnosis, their incidence is unknown. These hernias have a high mortality risk when an emergency intervention is warranted due to complications from visceral strangulation.We present the case of a 67-year-old male with prior history of thoracoabdominal aortic repair, who reconsults due to upper gastrointestinal bleeding. Upon arrival, imaging shows a left diaphragmatic herniation with migration of the stomach, omentum and spleen to the thoracic cavity. Through laparoscopic approach, a left diaphragmatic hernial defect is identified with protrusion of half the stomach, omentum and the posterior aspect of the spleen with a sub capsular tear. Additionally, a severe adhesion syndrome on the chest wall and diaphragm were also evident, with entrapment of the inferior lobe of the left lung. The contents were successfully reduced, however pulmonary decortication and extensive adhesiolysis through thoracoscopy was required for complete extraction, enabling a primary repair without tension.We present an infrequent pathology without an established incidence, which has relevant clinical and surgical implications at any level of care, in this case requiring interdisciplinary management. The suspicion of diaphragmatic hernia in a patient with past medical history of thoracoabdominal aortic repair with non-specific gastrointestinal symptoms is essential. We emphasize the importance of clinical suspicion of this complication once the surgical precedent has been identified. At his arrival, non-variceal upper gastrointestinal bleeding was suspected, undergoing an esophagogastroduodenoscopy without evidence of active bleeding and a chest x-ray that identified an image of a lower left pulmonary consolidation. A chest CT-scan was performed, illustrating a left diaphragmatic hernia with protrusion of the gastric body into the ipsilateral hemithorax.Given the findings, an abdominal CT-scan was performed identifying a seven centimeter left hemi-diaphragmatic defect associated with herniation of the fundus, body and gastric antrum, along with the spleen A and B. Fifteen days after admission, the patient underwent abdominal laparoscopic surgery with evidence of a large left diaphragmatic hernia with protrusion of half the stomach, omentum and the posterior aspect of the spleen. Additional findings were the spleen had a sub capsular tear, as well as a severe adhesion syndrome on the chest wall and diaphragm with entrapment of the inferior lobe of the left lung. A hernial defect of seven by five centimeters was found, with preservation of the hiatus. The reduction of the herniated organs was achieved through abdominal laparoscopy, however a complete dissection was not possible due to the splenic interposition A–C. The Twenty-four hours postoperatively, the patient tolerated the liquid diet, presenting an uneventful recovery, being discharged on the fifth postoperative day with normal food intake. Six months later he was reviewed with an abdominal CT-scan showing a satisfactory diaphragmatic hernial correction A-B.Fig. 3According to the literature, diaphragmatic hernias result in 10 % of diaphragmatic injuries, including blunt trauma, penetrating trauma and iatrogenic lesions . DiaphraGrasping instruments, electrocautery and dissection forceps near the diaphragm may cause diaphragmatic injuries during surgery. Missed diaphragmatic tears present progressive elongation due to stress produced by the pressure gradient between the thorax and abdomen resulting in an intra-thoracic herniation ,6. Any dDiagnosis may be achieved through chest X-ray, MRI, CT-scan or abdominal ultrasonography; in some cases, invasive approaches as diagnostic laparoscopy and thoracoscopy may be considered. Chest radiography has been recognized as the most appropriate test for the diagnosis of diaphragmatic hernias. Some literature indicates that plain chest X-ray is diagnostic in 73 % of the cases , while oSurgery is the first line of treatment for this pathology, and some cases warranting emergency intervention in symptomatic hernias with visceral strangulation. According to the literature, immediate surgical intervention may be considered as the gold standard treatment of delayed diaphragmatic rupture . As for The laparoscopic approach is appropriate in clinically stable patients, good general condition, and especially those who with a left diaphragmatic hernia, resulting in a shorter length of stay . Laparot4We present the case of an infrequent pathology without an established incidence, which has relevant clinical and surgical implications at any level of care. The suspicion of diaphragmatic hernia in a patient with past medical history of thoracoabdominal aortic repair with non-specific gastrointestinal symptoms is essential. The pertinent images according to the patient’s clinical condition should be done to promptly identify this pathology and to establish the most appropriate surgical approach.The authors declare they have no conflicts of interest.This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.The Ethical and Research Committee of the Fundación Cardioinfantil – IC and the General Surgery Research Group at the Fundación Cardioinfantil – IC.Written consent was obtained from the patient for publication of this report. Any details identifying the individuals to the clinical history and images associated were eliminated as to remain anonymous.Castillo Barbosa A, Perez Rivera CJ-, Orozco-Gonzalez A and Cabrera P designed the report, analyzed the data, and wrote the paper. Mosquera Paz M and Tellez LJ collected patient’s data and were the perioperative attending physicians. All authors read and approved the final manuscript.N/A.Perez Rivera Carlos Jose.Email: cjperezrivera@gmail.com.Address: Calle 163A N° 13B-60, Bogota, Cundinamarca, Colombia.Telephone: + 57 (031) 667 2727 Ext. 12301.Not commissioned, externally peer-reviewed.Fundacion Cardioinfantil Bogota Colombia.There was financing by


Aplasia cutis congenita is a rare congenital abnormality first described in 1767 by cordon. It mostly appears as a solitary lesion involving various layers of the skin and sometimes the bone on the scalp, limbs or abdomen. Genetics, environmental and exogenous causes have been implicated as potential causes. Only about 500 cases have been reported globally as of 2013. Two cases of Aplasia Cutis Congenita (ACC) who presented with scalp and bone defects at birth are reported, one in a syndromic child delivered to a consanguineous family, with associated cardiac, skin and nail anomalies (likely Adams Oliver syndrome) and the other as an isolated scalp lesion. Both were large defects managed conservatively by a multidisciplinary team. The challenges of investigating and managing such complex scalp anomalies in sub-Saharan Africa are highlighted. Skull and skin defects are rare and devastating malformations to parents and clinicians alike. Skin defects at birth are termed Aplasia Cutis Congenita (ACC); first described by Cordon in 1767 in two sisters with skin defects of the lower extremities . It has Rupture of amniotic membrane in early pregnancy forming amniotic bands , has alsHistorical perspective: although, Cordon was the first to describe this condition in 1767 [et al. reported their experience with 29 cases managed between 1976-2011 with defect size ranging from 1-192 cm [ in 1767 . Since t in 1767 . Maillet1-192 cm . Thirtee1-192 cm . From Ce1-192 cm . Recentl1-192 cm , 17, 18,Case 1: baby NU, a male infant from Gbayi tribe delivered at term in a hospital by spontaneous vaginal delivery to a 30-year-old para 2 mother. Baby cried well at birth and weighed 3kg. He was referred at age of 4 hours on account of absence of skin and skull bone noticed at birth. Pregnancy was supervised and uneventful and mother denied use of any medications orthodox or herbal except for antenatal drugs. Ultrasound scan in second trimester was reported as normal. He was the third child of parents in a monogamous consanguineous family setting parents being cousins. Though there was a history of a fresh still birth during the mother´s first confinement, no congenital malformations were seen in that baby and there was no history of congenital anomalies in the extended family. Mother is a 30-year-old teacher and father a 35-year-old police officer and both had a secondary level of education. Physical examination revealed an irregularly shaped well-demarcated large defect on the vertex of the scalp over the parietal bone bilaterally extending to the occipital region measuring 10 x 8 cm in the midline and 6 x 6 cm in the occipital region. A yellow layer of membrane covered the defect. The patient had low set ears, he was irritable, with a tense anterior fontanelle and in respiratory distress. Other system examination were unremarkable. A diagnosis of aplasia cutis congenita with possible meningitis was made  showed absence of parietal bone towards the vertex bilaterally extending from 2 cm behind the anterior fontanelle down to the posterior fontanelle giving an area of defect measuring 8.3 cm x 5.3 cm (AP X TR). The subcutaneous scalp tissues were not visualized. However, the brain in this region was overlaid by the dural meninges. The occipital, frontal and temporal bones of the cranial vault and their overlying scalp tissues were spared. The cerebral hemispheres, cerebellum and the brain stem structures were normal in morphology and signal intensity. No intra-axial or extra-axial mass or collection seen. No area of abnormal enhancement seen. The cortical sulci, sylvian fissures, basal cisterns and ventricles are normal in calibre, outline and intensity. The orbits and retro-orbital structures are within normal limit. Conclusion: features in keeping with aplasia cutis congenita . Burns aCase 2: baby YA, Hausa by tribe was referred at 48 hours of life on account of absence of part of the skull bone noticed at birth. Baby was delivered per vaginum at home, delivery was not associated with overt trauma to the head. Patient was a product of term gestation; birth weight was unknown though admission weight was 2 kg. Mother was 25-year-old and not gainfully employed, while father was a hospital attendant. Baby was the 3rd child of parents in a monogamous, non-consanguineous setting; the two older siblings were alive and well. No known family history of congenital anomaly. There was no history of use of herbal medications and mother was not on any other medication. There was no history of exposure to radiation in pregnancy and parents did not live close to a network mask. Mother had no obstetric scan done in pregnancy. Important clinical findings at presentation were a very ill patient, febrile, cyanosed, hypertonic with a midline subcutaneous tissue defect of the scalp extending from the frontal to the occipital area extending to the right parietal region.Providencia specie and E. coli from blood and CSF respectively. Abdominal ultrasound scan was normal, unfortunately, brain MRI, echocardiography and chromosomal studies could not be done due to financial constraints. He was treated with parenteral antibiotics and wound was cleaned daily and dressed with betadine. Complications included CSF leakage and meningitis, which resolved over time. The burns and plastic unit planned for prolene mesh/titanium mesh and latissimus dorsi musculocutaneous flap cover subsequently. Patient was discharged to parents on request after 35 days on admission, however baby died 7 days post discharge.There was leakage of cerebrospinal fluid (CSF) from a likely dural involvement. He had desquamating skin, hypoplastic finger and toe nails, visible dilated abdominal wall veins as well as a grade 3 systolic cardiac murmur loudest at the left lower sternal edge. Other systems were essentially normal. A working diagnosis of multiple congenital anomalies  with meningitis was made. Differentials of Adams-Oliver syndrome and Patau´s syndrome were considered . Sepsis Aplasia cutis congenita is primarily a clinical diagnosis with no specific histological alterations . We haveGroup one encompasses Scalp ACC without multiple anomalies and can be inherited autosomal dominantly or sporadically. Group two consists of scalp ACC with associated limb abnormalities ; usually autosomal dominant inheritance, while group three encompasses scalp ACC with associated epidermal and organoid nevi. Group four includes ACC overlying embryologic malformations such as meningomyelocele, gastroschisis and omphalocele; while group five includes ACC with associated fetal papyraceous or placental infarcts. Group 6 consists of ACC that is associated with epidermolysis bullosa, while group 7 describes ACC localized to extremities without blistering, inheritance usually autosomal dominant or recessive. Group 8 is ACC caused by specific teratogens ; while the last group  is ACC aCase 2 best fits in group nine as baby had other malformations including a congenital heart disease, desquamating skin, hypoplastic finger and toe nails, visible dilated abdominal wall veins that could probably be described as Adams-Oliver Syndrome. The management of aplasia cutis congenita can be conservative or surgical depending on the presentation, size and location of defect. Conservative treatment includes the application of topical ointments such as silver sulfadiazine dressing, betadine, sofratulle dressing and use of antibiotics. Wound protection, infection prevention and nutrient supplementation are key to ensure positive treatment outcomes , 20. TheUnfortunately none had surgery at the point of discharge although case 1 is still on follow up at the clinics. Surgical treatments include split-thickness or full-thickness skin grafts, acellular dermal matrices, autologous epithelial transplantation, tissue expansion, cranioplasty and so on. Conversely, skin grafts are necessary when the defected area is large and involves critical organs or tissues such as the scalp while also accompanied by the exposure of large blood vessels or sagittal sinus . The timIn conclusion, ACC although rare, poses great challenges to clinicians in sub-Saharan Africa when it occurs, especially when the defects are large or when it is associated with other congenital malformations. This, to the authors knowledge presents the first reported cases of ACC with scalp defects from West Africa.


We present the case of a 71-year-old female with an inguinal swelling. Intra-abdominally the appendix was found in a femoral hernia sac (De Garengeot’s hernia). A laparoscopic transabdominal preperitoneal hernia repair procedure was performed with uneventful post-operative course.Clinical presentation of this type of hernia is unspecific and often not to be distinguished from a common incarcerated hernia. Computed tomography can be helpful in obtaining a diagnosis, although the definite diagnosis is mostly found intraoperatively. As surgical options are numerous, there is no consensus on the most suitable one. A laparoscopic approach incorporates the benefit of a total abdominal overview and the possibility of standard procedures. If the appendix appears normal, the use of synthetic mesh is considered safe and an incidental appendectomy is not necessarily required. De Garengeot’s hernia is defined as the presence of an appendix within a femoral hernia and was first described by a French surgeon called René Jacques Croissant de Garengeot in 1731 .We herein report a case of a 71-year-old Caucasian female patient without appendicitis or incarceration and present a literature review. This work has been reported in line with the SCARE criteria.A 71-year-old woman presented to her general practitioner complaining about a non-painful swelling in the right groin area. Physical examination revealed a mass at the right inguinal area without any further abnormalities. No laboratory tests or imaging were obtained. An inguinal hernia was the tentative diagnosis. Due to the intake of oral anticoagulation, the surgery was delayed even further.Under general anaesthesia, a transabdominal preperitoneal hernia repair (TAPP) was the procedure of choice. During the diagnostic laparoscopy, a femoral hernia with the appendix entering the femoral canal was detected . The appet al. [Femoral hernias constitute an uncommon type of groin hernias and account for only 3–5% of all abdominal wall hernias; they predominantly affect women over the age of 70 , 4, 5. Oet al.  suggesteClinical presentation is variable and acute when incarceration is present. The most common clinical finding is a mass in the inguinal region, but signs of local inflammation  can been found in a third of cases . Due to et al. [As De Garengeot’s hernia is a rare entity, there is no consensus regarding the clinical and imaging management process. A pre-operative diagnosis can only be obtained in a third of the cases; diagnosis is most often made intraoperatively. Abdominal radiographs can be useful to exclude bowel obstruction but are of no further significance. A meta-analysis by Linder et al.  have shoet al. .However, in the acute setting the surgical exploration should never be delayed by extensive preoperative diagnostics.As mentioned above, there is no recommendation regarding a specific surgical approach in the case of a De Garengeot’s hernia.In general, most surgeons choose an open approach with access for both appendectomy and hernioplasty . As an aet al. [According to Sharma et al. , incidenet al. .In this case, the operation was an elective procedure with the assumptive diagnosis being an inguinal hernia, no visible signs of inflammation or ischemia intraoperatively. Repair by synthetic mesh was performed using a laparoscopic transabdominal preperitoneal (TAPP) approach.In conclusion, the occurrence of De Garengeot’s hernia is indisputably low but has gained more attention in recent years as demonstrated by an increasing number of case reports. Therefore, it should be considered as differential diagnosis in patients presenting with acute onset of inguinal swelling with possible signs of local inflammation. Appropriate management without unnecessary delay caused by extensive imaging should lead to uneventful post-operative course. In case of large hernia defects or absence of abscess and perforation the use of a preperitoneal mesh is considered safe. An incidental appendectomy is not necessarily required when the appendix is not inflamed.Barbara Sommerhalder: data analysis and interpretation, writing and submission of the paper.Reint Burger: interpretation of data.Marco Bueter: interpretation of data, writing of the paper.Andreas Thalheimer: interpretation of data, writing of the paper.None declared.The authors received no financial support for the research, authorship and/or publication of this article.Exception from ethical approval-case report only, consent from the patient provided at request.Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.Barbara Sommerhalder. Reint Burger. Marco Bueter. Andreas Thalheimer. Provenance and peer review. Not commissioned, externally peer-reviewed.


Butterfly vertebrae are a rare congenital vertebral anomaly. An overlap of this spinal anomaly with other diseases has been reported. However, to the authors’ knowledge, the coexistence of butterfly vertebrae and spinal cord injury has not been reported in the literature.A 42-year-old male was admitted to our emergency department after a motor vehicle accident. His complaint was back pain, and he was unable to move both lower limbs. Upon physical examination, the patient was not ambulatory. Sensory examination revealed the absence of sensation below the T12 level. The strength of the bilateral lower limbs was grade 0. The patient received a radiographic evaluation. The initial diagnosis was T11 fracture with complete paraplegia of the lower limbs. Magnetic resonance imaging (MRI) was then performed. Sagittal MRI demonstrated an isointense lesion on T1-weighted imaging and a high-signal spindle-like lesion on T2-weighted imaging of the spinal cord adjacent to the T11 vertebra. The fat-suppressed sequence also revealed hyperintensities of the cord. There was no evidence of acute injury of the T11 vertebral body except for cuneiform anterior wedging. The patient was ultimately diagnosed with complete paraplegia with a T11 butterfly vertebra. He underwent urgent posterior decompressive and fixation surgery from T10 to T12. His postoperative recovery was uneventful.The coexistence of a butterfly vertebra with spinal cord injury was reported for the first time. Although butterfly vertebrae may be incidentally detected, it is important to be familiar with their radiographic features to distinguish them from fractures. Congenital vertebral anomalies represent a spectrum of spinal deformities due to developmental defects that produce an imbalance in the longitudinal growth of the spine. Based on embryonic development, two basic types of anomalies, namely, failure of formation and failure of segmentation, have been recognized . A butteButterfly vertebrae are often asymptomatic and incidentally detected . The oveA 42-year-old male was admitted to our emergency department 3 h after a motor vehicle accident. He was thrown out of the car because he was not wearing a seatbelt. His complaint was back pain, and he was unable to move both lower limbs. His medical history was unremarkable.Upon physical examination, the patient was not ambulatory. Sensory examination revealed the absence of sensation below the T12 level. The strength of the bilateral lower limbs was grade 0. The patient underwent radiographic evaluation, which showed wedging of the T11 vertebra suggestive of a compression fracture  was further conducted to evaluate the spinal cord. Sagittal MRI demonstrated an isointense lesion on T1-weighted images Fig. a and a hThe patient underwent urgent posterior decompressive and fixation surgery from T10 to T12. The disruption of the PLC was confirmed during the operation. The patient’s postoperative recovery was uneventful. There was no wound infection, and no complications were observed. Postoperative computed tomography (CT) examinations Fig.  were perButterfly vertebrae are rare congenital malformations that resemble butterfly wings on an anterior-posterior radiographic view. This uncommon deformity is usually reported as an incidental finding and can be asymptomatic throughout life. It can occur as an isolated anomaly or in association with other congenital syndromes. However, the coexistence of this anomaly with other diseases has been reported in the literature. Delgado et al.  reportedButterfly vertebrae present a wedge-shaped configuration on a lateral view and can be easily confused with a compression fracture –11. In aInjuries of the spine most frequently occur in the thoracolumbar regions. This phenomenon is supported by a variety of biomechanical analyses . The thoIn summary, the coexistence of butterfly vertebra and spinal cord injury was reported for the first time. Although butterfly vertebrae may be incidentally detected, it is important to be familiar with their radiographic features to distinguish them from fractures. In this way, a correct diagnosis ultimately can be made, and timely measures can be taken to treat the disease.


Pericallosal lipomas are rare benign intracranial masses that arise during embryonic development, typically categorized into tubulonodular and curvilinear subtypes. A mixed variant of both tubulonodular and curvilinear subtypes is very rare. Patients with pericallosal lipomas may be asymptomatic or may have different presentations, such as headaches. Conservative medical management is the mainstay of therapy for those without epileptic seizures or associated vascular malformations. We present a case of a mixed variant pericallosal lipoma in a patient with chronic headaches that were diagnosed using head computed tomography (CT) and brain magnetic resonance imaging (MRI). Intracranial lipomas are rare congenital malformations caused by the overproliferation of lipocytes within the embryological leptomeninx . PericalThey can be classified into two subgroups based on morphology: tubulonodular and curvilinear. The tubulonodular type is the most common form, characterized by a bulky tubular mass along the anterior corpus callosum and typically measures greater than 2 cm in axial diameter. On the other hand, the curvilinear type is a thinner ribbon-like mass, curving around the splenium of the corpus callosum, and usually measures less than 1 cm in axial diameter. A mixed variant of both types is exceedingly rare, with very few cases reported in the literature -6. Tubulonodular lipomas are formed at an earlier stage of development; they have a higher incidence of corpus callosum dysgenesis and can be associated with calcifications, frontal bone defects, and cortical dysplasia , 6. PeriDifferential diagnoses include intracranial aneurysm, dural venous sinus thrombosis, pericallosal hemorrhage, dermoid cysts, and other intracranial tumors , 9.Prenatal sonographic examination typically demonstrates a hyperechoic midline mass, suggestive of pericallosal lipoma. However, postnatally, the diagnosis can be established with CT and MRI , 8. On CA 65-year-old female with no significant past medical history presents with chronic headaches for many years. She states her headaches are global and do not localize to any one region. She reports mild intermittent nausea but denies vomiting, aura, photophobia, or phonophobia. She denies any visual disturbances or other neurological symptoms. She has no known personal or family history of malignancy, aneurysm, or epilepsy. She denies recent head trauma. She takes no medications. Vital signs are within the normal range. Physical examination is unremarkable, with no focal neurological deficits noted. Basic lab results are within normal limit.Non-contrast CT of the head Figures -2 was peAfter the diagnosis of pericallosal lipoma was made, the patient was reassured and managed conservatively.Intracranial lipomas are rare and often an incidental finding , 9. TherLipomas are slowly progressive lesions; therefore, the prognosis is generally favorable. Medical therapy and conservative management are nearly always preferred for symptomatic lesions. However, there are two situations in which surgical intervention may be considered; in epilepsy and with vascular lesions .Epileptic seizures, a common symptomatic finding, are treated medically, with surgery often reserved for refractory cases. Recent studies indicate that the lipomas themselves may not be the cause of epilepsy, further discounting the benefits of surgical intervention . LipomasPericallosal lipomas, in general, are rare benign masses that arise during embryonic development. They can be associated with variable degrees of corpus callosum dysgenesis. Head CT and brain MRI with and without intravenous contrast are needed for the diagnosis. A mixed variant of both tubulonodular and curvilinear subtypes is very rare. Conservative medical management is the mainstay of therapy for those without epileptic seizures or associated vascular malformations, where surgical intervention may be considered. Appreciating the variable presentations and the different radiological morphologies can provide a better understanding of pericallosal lipomas and aid in promoting the diagnosis and the treatment plan.


Lipomas are encapsulated benign tumors typically found in the integument, central nervous system or gastrointestinal tract and represent the most common benign mesenchymal neoplasm in adults. Bladder lipoma is a rare tumor that has been reported in a handful of cases in medical literature. A literature review from PubMed, MEDLINE, EMBASE and Cochrane databases of bladder lipoma yielded less than 20 cases. We report a case of a 69 year-old Moroccan male patient with hematuria as a chief symptom. The diagnosis of bladder lipoma was suspected by flexible fibroscopy and assessed by transurethral resection. Macroscopic and histological examination revealed a lipomatous tumour with no sign of malignancy. There was no recurrence after one year of follow-up. Although bladder lipomas are rare entities, they must be considered in the differential diagnosis of bladder tumor. However, we should always keep in mind that any bladder tumor is malignant until proven otherwise. Conventional lipoma is the most common benign mesenchymal neoplasm in adults. However, bladder lipoma is a rare tumor, which has been reported in a handful of cases in medical literature. We presented an extremely rare case who was admitted to our department with hematuria and was incidentally diagnosed as bladder lipoma. Besides, a review of the literature on this subject is presented.2 . No Transabdominal ultrasonography (US) or computed tomographic scan were performed. Therefore, we realised flexible cystoscopy that showed a smooth, yellow and benign-looking tumour, at the posterior wall of bladder measuring approximately 5 mm . Urinary frequency and nocturia were other complaints. He had no comorbidity and was a non-smoker in his medical history. His physical examination, laboratory tests, and urine analysis were normal. His body mass index (BMI) was 24 kg/mely 5 mm . There wely 5 mm . The tumely 5 mm . The bleely 5 mm  A and B.Lipomas are encapsulated benign tumours typically found in the integument, central nervous system or gastrointestinal tract. The incidence of lipomas is particularly high in obesed patients suffering from diabetes mellitus or hypercholesterolemia but also in a family context . The ageet al. [Lipomas were managed with cystoscopy and removed by biopsy or transurethral tumor resection. Ukita et al. , laparoset al. . Lipomaset al. . Lipomaset al. . Liposaret al. . To the et al. reported a case of upper urinary lipoma in a 41-year-old man complaining of left flank pain. A computed tomographic urography revealed an irregular thickening of the left renal collecting system wall extending from the upper calices to the renal pelvis. The diagnosis of UUT was made and thereafter the patient underwent a nephroureterectomy with bladder cuff excision, macroscopic and histological examination revealed however a lipomatous tumour with no sign of malignancy [et al. [Lipoma is a benign tumor and no case of malignant transformation has been reported in the literature . All caslignancy . Bladder [et al. . Multipl [et al. . The keyBladder lipoma is a rare finding within bladder and have been described in only handful cases of literature. The clinical presentation is non-specific. Cystoscopy is essential after an episode of gross hematuria to evaluate the bladder for urothelial tumours in order to accurate the diagnosis and offer adequate treatment.