International Journal of Surgery Case Reports最新文献

Introduction: Esophageal leiomyoma is the most common benign submucosal mesenchymal tumor of the esophagus, typically asymptomatic but can cause symptoms such as dysphagia, chest pain, or regurgitation when large. Diagnosis is often incidental, confirmed by imaging techniques like computed tomography (CT) and endoscopic ultrasound (EUS), with surgical enucleation being the standard treatment.

Presentation of case: A 28-year-old male presented with a one-year history of persistent epigastric discomfort and gastroesophageal reflux disease (GERD) symptoms unresponsive to proton pump inhibitors. Chest radiograph and CT scan revealed a well-defined submucosal mass in the esophagus. Upper gastrointestinal endoscopy and EUS confirmed the lesion's benign nature. Fine-needle aspiration biopsy showed spindle-shaped cells, confirming esophageal leiomyoma. The patient underwent minimally invasive tumor resection via video-assisted thoracoscopic surgery (VATS), with a smooth postoperative recovery.

Discussion: Esophageal leiomyomas are rare, often asymptomatic, and may present with nonspecific symptoms if large. CT and EUS are key diagnostic tools, and minimally invasive surgery, such as VATS, is the preferred treatment for larger tumors due to shorter recovery times and fewer complications. Early identification and appropriate surgical intervention are crucial for optimal outcomes.

Conclusion: Esophageal leiomyoma should be considered in patients with GERD-like symptoms unresponsive to therapy. Early imaging, endoscopic evaluation, and minimally invasive surgery provide excellent outcomes, with regular follow-up recommended to monitor for recurrence.

Introduction: Triorchidism is a rare anomaly whose management raised considerable discussion. Several factors must be considered, including the patient's age, the testes location, their functional status, and the accessibility and compliance for follow-up. We present a case of triorchidism diagnosed incidentally during a routine hernioplasty procedure, serving educational and informative purposes.

Case report: A 44-year-old patient, presented with uncomplicated bilateral inguinal hernias with both testicles in place. During surgery, a supernumerary testicle was discovered in the inguinal region. It was decided to preserve the testicle since the patient agreed to strict and vigilant follow-up.

Discussion: Supernumerary testis may have a scrotal, inguinal, or abdominal location. The exact etiology of polyorchidism is unclear, however accidental division of the genital ridge before 8 weeks of gestation could be a possible cause. There are various types of classifications for polyorchidism, which is made on imaging in 80 % of the cases and incidentally in 20 % of the cases. In young patients in reproductive age, orchidopexy is recommended if feasible, followed by careful observation. This monitoring is supported by the high sensitivity and specificity of imaging techniques. The situation is more intricate when the supernumerary testis is incidentally discovered and is associated to cryptorchidism, known to increase malignancy risk. These situations raise the question whether to perform orchiectomy per-operatively.

Conclusion: Polyorchidism is a rare pathology with only few cases reported in the literature. Due to the lack of consensus and the high resolution of imaging sensitivity and specificity, management tends to be conservative.

Introduction and importance: Rapunzel syndrome is a rare condition that results from trichotillomania (compulsive hair pulling) and trichophagia (hair eating), causing a trichobezoar (hairball) to form This syndrome typically affects young females with psychiatric conditions and presents with symptoms like chronic abdominal pain, nausea, vomiting, and malnutrition. The condition is often diagnosed late, leading to serious gastrointestinal complications.

Case presentation: A 19-year-old female from a rural community presented with chronic abdominal pain, vomiting, and nutritional deficiencies, including scaly skin and koilonychia. Over time, her symptoms worsened, and she discovered a palpable abdominal mass. Clinical evaluation, including an upper gastrointestinal endoscopy, revealed a large trichobezoar extending from the lower esophagus to the pylorus. The patient had a history of pica and compulsive behaviors, suggesting psychiatric involvement.

Clinical discussion: The endoscopy revealed a 20 × 13.5 × 9 cm trichobezoar. After successful surgical removal, the patient's gastrointestinal symptoms improved. Post-operatively, she received nutritional support and was referred for psychiatric evaluation to manage trichotillomania and trichophagia, with the aim of preventing recurrence in a private practice setting.

Conclusion: This case highlights the need for early recognition of Rapunzel syndrome in patients with chronic gastrointestinal symptoms and nutritional deficiencies. A multidisciplinary approach is essential for effective management and preventing recurrence.

Introduction: Appendiceal endometriosis (AE) is a rare condition, with a prevalence ranging from 0.05 % to 1.7 % in patients with endometriosis. It represents <1 % of cases of acute appendicitis (AA).

Cases presentation: We present two cases of AA where the histological cause was endometriosis. Both cases involved patients around 40 years old who presented with abdominal pain in the right iliac fossa. AA was diagnosed through abdominal computed tomography (CT), which in the first case showed acute appendicitis, successfully treated with laparoscopic appendectomy. In the second case, the CT showed signs of an appendiceal phlegmon, initially treated non-operatively with poor response, leading to exploratory laparoscopy and abscess drainage 48 h later. Subsequently, a scheduled laparoscopic appendectomy was performed after 6 months. Histopathological diagnosis in both cases was AA due to AE with endometrial glands showing recent bleeding, causing hyperplasia of the appendiceal muscular layer.

Discussion: Endometriosis, characterized by the presence of endometrial tissue outside the uterine cavity, can rarely affect the appendix, termed AE. AE, though uncommon, poses diagnostic challenges due to nonspecific imaging findings and variable presentations, ranging from asymptomatic cases to AA. Histological evaluation post-appendectomy is definitive for diagnosis. AE is associated with right-sided pelvic involvement and often requires surgical management, with appendectomy typically resolving acute symptoms. However, recurrence of cyclical pain due to pelvic endometriosis may persist, underscoring the importance of comprehensive evaluation during laparoscopic procedures.

Conclusion: AA caused by AE is an uncommon condition, with very difficult preoperative diagnosis based solely on personal history, clinical presentation, and even imaging studies. It should be considered in differential diagnoses for women of reproductive age with associated pelvic endometriosis, although the recommended treatment in all cases is surgical.

Introduction and importance: Intussusception in the proximal bowel is extremely rare, with only a few reported cases of gastroduodenal intussusception (GDI). Gastrogastric intussusception is the rarest form of intussusception in adults. Here, we present an exceptionally rare case of gastro-gastric intussusception caused by a gastric Gastrointestinal Stromal Tumor (GIST).

Case presentation: A 36-year-old male presented with acute abdominal pain, suggestive of intussusception. The preoperative evaluation was unable to pinpoint the exact location or cause of the intussusception.

Clinical discussion: Intraoperative diagnosis of gastro-gastric intussusception was made, and the patient was treated with a gentle reduction of the intussusception, followed by a distal gastrectomy with Billroth I anastomosis. He was relieved of his symptoms and has been recurrence-free for the past two years.

Conclusions: Gastro-gastric intussusception is an exceedingly rare type of foregut intussusception, which presents with non-specific clinical presentation and commonly occurs in the presence of an underlying pathology. A delay in diagnosis and treatment may be fatal, so a high index of suspicion and early surgical management is paramount.

Introduction and importance: Neonatal appendicitis is a rare condition with high morbidity and mortality due to its late diagnosis in favor of more common pathologies. There are few reported cases of neonatal appendicitis and even fewer of antenatal appendicitis.

Case presentation: We report a neonate presenting with abdominal distention and gastric emesis in the setting of a suspected congenital abdominal mass, later diagnosed with neonatal appendicitis requiring intestinal resection and anastomosis.

Clinical discussion: Neonatal appendicitis presents with nonspecific symptoms and may often be mistaken for enterocolitis or intestinal malrotation. Additional imaging, including abdominal radiographs, ultrasound, or computed tomography, may facilitate diagnosis.

Conclusion: Neonatal appendicitis is a rare entity with a challenging diagnosis due to the lack of specific signs. In the current case, the patient was referred to our institution with an antenatal ultrasound showing a right flank mass which resulted in abscess formation and perforated appendicitis.

Introduction: Ectopic pancreatic tissue (EPT) is a rare congenital anomaly characterized by the presence of pancreatic tissue in an abnormal location, separate from the pancreas, without any anatomical or vascular connection to it. This anomaly is often an incidental finding during operation or autopsy. This peculiarity poses clinical and radiological challenges for surgeons, particularly during laparoscopic or open procedures.

Case report: This article presents a compelling case of EPT, discovered incidentally during a planned laparoscopic cholecystectomy. The patient, a 50-year-old male with a history of biliary colic, underwent a meticulous laparoscopy exploration revealing an undistended gallbladder with an unexpected yellowish tissue fragment resembling pancreatic parenchyma.

Clinical discussion: EPT has an incidence ranging from 0.55 % to 13.7 % in autopsy studies. While the origins of EPT remain unclear, theories regarding the embryonic separation of pancreatic tissue offer insights into its origins and displacement from the original site. Macroscopically, EPT may present as polypoid lesions or yellow nodules and is typically asymptomatic. The various attachment locations and potential manifestations in other intra-abdominal sites add complexity to its diagnosis. Imaging techniques are often ineffective, making histopathological examination essential for diagnosis.

Conclusion: Diagnosing EPT in the gallbladder before and during surgery often presents significant challenges. Pathologists should be aware of this rare incidental finding, as it can mimic a tumor and lead to an overdiagnosis of malignancy. Only a precise histopathologic examination can provide a definite diagnosis and distinguish it from malignancies. Laparoscopic cholecystectomy is sufficing treatment.

Introduction: Hip fractures are common in elderly patients, often accompanied by comorbidities. These fractures can be combined with other injuries, such as a femoral head, neck, or shaft dislocation. The cause of this complex injury is not well-established, but factors like high-energy trauma or falls from a certain height may contribute.

Case presentation: A 55-year-old man presented with an ipsilateral femoral head and left intertrochanteric fracture with posterior hip subluxation after a 3-m fall. This rare and complex injury was diagnosed using X-rays and CT scans. Due to the risk of complications, open reduction and internal fixation (ORIF) using a proximal femoral nail anti-rotation (PFNA) was performed. Early surgical intervention with PFNA provided stable fixation and promoted early mobilization. A 6-month follow-up showed the patient's Lower Extremity Functional Scale (LEFS) was 82.5 %, and Harris Hip Score (HHS) was 85 %, while before surgery, the patient's LEFS was 0 % and HHS was 3,85 %.

Discussion: Intertrochanteric pelvic fractures are serious injuries causing avascular necrosis and traumatic osteoarthritis. They often occur with hip dislocation or acetabular wall fractures. Diagnosis is confirmed through 3D reconstruction. Management involves realigning the dislocated hip, surgical repositioning, and stabilizing the fractured femoral head. Surgical interventions include a sliding compression hip screw, side plate, or intramedullary nail. PFNA is a medical implant for complex fractures.

Conclusion: Open reduction and PFNA can effectively treat ipsilateral femoral head and intertrochanteric fractures with posterior hip subluxation, requiring early intervention, meticulous surgical technique, and appropriate implant selection.

Introduction and clinical importance: Shone complex (SC) is a rare multilevel congenital heart disease (CHD) characterized by four left-sided heart obstructive lesions: parachute mitral valve, supravalvular mitral ring, subaortic stenosis, and coarctation of the aorta (CoA), accounting for 0.6-0.7 % of CHD cases.

Case presentation: A 4-week-old male neonate presented with severe respiratory distress, tachycardia (150 beats/min), tachypnea (40/min), and hypoxia (80 % saturation). Blood pressure was 90/55 mmHg in the upper arms; lower extremity measurements were challenging. ECG showed a heart rate of 150 beats/min, normal sinus rhythm, left axis deviation, and left ventricular (LV) hypertrophy. Transthoracic echocardiography revealed mild concentric LV hypertrophy and reduced ejection fraction (45 %). A supramitral ring led to severe supravalvular mitral stenosis, and a bicuspid aortic valve caused moderate aortic stenosis. Suprasternal views confirmed severe CoA distal to the left subclavian artery. The patient underwent successful CoA repair at five months, with ongoing surveillance for other defects. One year later, he remained stable with no significant pressure gradient changes.

Clinical discussion: SC presents significant clinical challenge due to its associated congenital anomalies. Early echocardiographic diagnosis and timely surgical intervention are essential for optimizing patient outcomes, given the variability in severity and the potential for complications. Multidisciplinary management is crucial for addressing the complexities of this condition.

Conclusion: This case illustrates effective staged surgical management of partial SC, emphasizing early diagnosis and the utility of point-of-care ultrasound.

Introduction and importance: While the treatment approach for sarcomas seems straightforward and well-defined, we often encounter several diagnostic or therapeutic challenges in clinical practice. This article presents a case of retroperitoneal leiomyosarcoma in a patient with chronic kidney disease, highlighting the complexity of managing such cases.

Case report: A 63-year-old woman with a history of chronic kidney disease presented with a progressively enlarging mass in her right flank. A CT scan revealed a retroperitoneal mass affecting the muscular layer of the right lumbar ureter, without invading the kidney. Percutaneous biopsies concluded to a smooth muscle tumor with positive anti-caldesmone and anti-desmin antibodies. A 99 m Tc DMSA renal revealed significant impairment of the right kidney function while the left kidney function remained normal. The surgical procedure involved removing the mass, as well as the right kidney and ureter. Histopathological examination confirmed the diagnosis of leiomyosarcoma. No locoregional recurrence or metastases were noted after a 13-month follow-up.

Discussion: Leiomyosarcomas are malignant tumors that can affect various organs, with retroperitoneum being the second most common location. A CT scan and abdominal MRI are standard imaging technique to evaluate this disease. Percutaneous biopsy and pathology are performed to confirm the nature of the tumor, especially when neoadjuvant treatment is necessary for metastatic tumors. Compartmental resection with clear margins is the only potential curative treatment. Even after R0 resection the risk of recurrence varies between 20 and 75 %.

Conclusion: Managing retroperitoneal leiomyosarcoma, especially in patients with comorbidities like chronic kidney disease, necessitates a multidisciplinary approach.