International Journal of Surgery Case Reports最新文献

Introduction and importance: Coexistence of malignant and granulomatous pulmonary lesions can represent a diagnostic and therapeutic challenge. Distinguishing between tumor recurrence, infectious, or iatrogenic conditions is crucial for guiding appropriate management.

Case presentation: We report the case of a 69-year-old woman referred to our center for evaluation of a 6-mm solid nodule in the left lower lobe, incidentally discovered during a coronary computed tomography scan. Endobronchial ultrasound-guided transbronchial needle aspiration confirmed invasive adenocarcinoma, whereas granulomatous inflammation was identified exclusively in the postoperative surgical specimen. The postoperative course was uneventful, and the patient was discharged in good condition.

Clinical discussion: This case highlights the importance of considering differential diagnoses when encountering granulomatous changes adjacent to malignant tumors. The overlap between iatrogenic, infectious, and tumor-related findings can complicate the diagnostic process. Our experience underscores the importance of histopathological confirmation to avoid misinterpretation, ensure adequate oncological treatment, and prevent overtreatment.

Conclusion: Granulomatous lesions concomitant with lung cancer are rare but clinically relevant. Awareness of this possibility is essential for accurate diagnosis and optimal patient management.

Introduction and importance: Dieulafoy's lesion is a rare but severe cause of gastrointestinal bleeding. It is characterized by an aberrant submucosal arteriole eroding through the gastrointestinal mucosa, typically causing sudden, painless, and massive gastrointestinal hemorrhage that may present with intermittent, recurrent bleeding episodes. We report a case of hemorrhagic shock secondary to massive gastrointestinal bleeding caused by a jejunal Dieulafoy's lesion.

Case presentation: A 31-year-old female without significant medical comorbidities acutely developed recurrent, high-volume hematochezia and hypotensive shock. She was hemodynamically unstable with a hemoglobin level of 35 g/l upon admission. After hemodynamic stabilization and transfusion, endoscopy failed to localize the bleeding source, which was later identified in the jejunum by angiography. Selective arterial embolization was implemented but failed to achieve hemostasis. Consequently, exploratory laparotomy with segmental jejunal resection of the Dieulafoy's lesion was performed. The patient demonstrated satisfactory recovery and was discharged on the fifth postoperative day.

Clinical discussion: Jejunal Dieulafoy's lesion is an exceedingly rare cause of gastrointestinal bleeding, accounting for merely 1% of all Dieulafoy's lesions. Diagnosis is challenging due to the inaccessibility of jejunum with conventional endoscopy and the intermittent nature of hemorrhage. Angiographic embolization is effective for active bleeding when endoscopic therapy fails. Surgery remains an option when other interventions are unsuccessful, particularly in hemodynamically unstable patients.

Conclusion: Jejunal Dieulafoy's lesion, though rare, is a potentially life-threatening cause of gastrointestinal hemorrhage that demands prompt diagnosis and intervention. A multidisciplinary approach - combining endoscopic therapy, angiography, and surgery - significantly enhances clinical outcomes.

Introduction and importance: Rhabdomyosarcoma (RMS) is a malignant soft tissue sarcoma arising from primitive mesenchymal cells. It is rare in childhood and adolescence but is one of the more common pediatric soft tissue sarcomas. Hence, clinical presentation and prompt treatment strategies of such cases should be known for better management.

Case presentation: A 3-year-old girl presented with a one-and-a-half-year history of progressive vaginal mass protrusion and serosanguinous discharge. Abdominal examination revealed a large suprapubic mass extending above the umbilicus. MRI revealed a lesion involving the entire uterus. She underwent a Wertheim-Meigs hysterectomy. Histopathology confirmed embryonal RMS, botryoid variant, originating from the uterine cervix with vaginal extension.

Clinical discussion: RMS originates from rhabdomyoblasts, immature skeletal muscle cells. Botryoid RMS typically presents as multiple grape-like vaginal masses with serosanguinous discharge.

Conclusion: Prognosis depends on tumor site, size, extent, residual disease, and histologic sub type. Vaginal lesions generally have better outcomes than cervical ones.

Introduction: The optimal surgical route for large or potentially malignant ovarian mature cystic teratomas (MCTs) remains debated.

Case presentation: We retrospectively included 139 consecutive patients with pathologically confirmed MCT managed laparoscopically at a tertiary center (June 2013-August 2024). Mean cyst size was 9 cm (range 4-20); adnexal torsion occurred in 6%. All procedures were completed minimally invasively; cystectomy and adnexectomy were performed in 40% and 60%, respectively. Intraoperative spillage was 2.2%, with no intra- or postoperative complications. One illustrative case is described: the laparoscopic removal of a giant 8.5-kg MCT and its management.

Discussion: With strict containment (controlled decompression, systematic endobagging, sealed extraction) and appropriate expertise, laparoscopy is feasible and oncologically prudent even for giant MCTs and in scenarios at risk of malignant degeneration.

Conclusion: In a high-expertise setting using strict no-rupture retrieval protocols, laparoscopy was feasible for MCTs across a broad size range. These results apply to benign-appearing lesions in our single-center series; the accompanying giant cyst is presented as an illustrative case and is not included in pooled outcomes.

Introduction: Intrahepatic splenosis (IS) is a rare benign condition developing after splenic tissue autotransplantation, usually post-trauma or splenectomy. In HBV-infected patients, it can mimic hepatocellular carcinoma (HCC), leading to misdiagnosis and unnecessary surgery.

Presentation of case: A 42-year-old man with chronic HBV infection and prior splenectomy had a 4-cm hepatic lesion with arterial enhancement and venous washout, consistent with HCC. Laparotomy revealed a dark-purple mass and diaphragmatic nodules; frozen and histopathology confirmed splenic tissue. The patient recovered well and remained recurrence-free after 1 year.

Discussion: IS should be considered in patients with previous splenectomy and hepatic masses to avoid misdiagnosis. Noninvasive imaging such as Tc-99m-labeled RBC scintigraphy can prevent unnecessary resections.

Conclusion: Increasing awareness of IS may help prevent unnecessary liver resections in similar cases.

Introduction and clinical importance: Concurrent remnants of the omphalomesenteric duct and urachus are exceptionally found. Diagnosis of Meckel's diverticulum is mainly incidental, but a patent urachus is usually clinically possible.

Case presentation: We admitted a 48-hour-old female patient for an eviscerated Meckel's diverticulum with a history of urine smelling around the umbilicus. Preoperative ultrasound did not identify an associated urachal anomaly. During emergency surgical exploration, a patent urachus was identified. Both remnants were resected, with the Meckel's diverticulum presenting gastric heterotopia. The postoperative course was unremarkable after a 2-year follow-up.

Clinical discussion: An asymptomatic Meckel's diverticulum is usually an incidental finding. In this patient, umbilical cord rupture due to a patent urachus eased the diagnosis. As ultrasound is operator dependent, its negation for associated urachal remnant must still indicate meticulous intraoperative exploration to definitively rule out concurrent urachal remnant when its association with an omphalomesenteric duct remnant is suspected.

Conclusion: Association between Meckel's diverticulum and patent urachus is rare, but possible. Identification of both anomalies is crucial for comprehensive management.

Introduction: Articular cartilage injuries constitute a predominant musculoskeletal disease in athletic populations. These lesions frequently precipitate the progressive degeneration, culminating in premature career termination and increased functional impairment. However, current treatment methods for cartilage injury are not entirely satisfactory, especially for large full-thickness cartilage defects.

Presentation of case: A 13-year-old male adolescent with documented high-intensity athletic engagement (training >15 hours/week) presented a huge exercise-induced full-thickness cartilage defect (6 cm²) over the sulcus of the trochlea. The patient underwent arthroscopic implantation of our laboratory-engineered type II collagen-chondroitin sulfate-hyaluronic acid (Col II-CS-HA) biomimetic matrix gel, a tri-component hydrogel designed to mimic native cartilage extracellular matrix composition. Serial evaluations over 12 months postoperatively demonstrated significant improvement in both structural regeneration (7 T MRI T2-mapping showing >95% defect filling with hyaline-like tissue) and functional recovery (IKDC score increased from 31 to 100), with no adverse events reported. Notably, the patient resumed pre-injury sports activities at 9-month follow-up.

Discussion: Current treatment strategies for cartilage defects, including microfracture and autologous chondrocyte implantation, demonstrate limited long-term efficacy for large full-thickness cartilage defects (>2 cm²). The avascular nature of articular cartilage limits its inherent regenerative capacity. Tissue engineering approaches have emerged as promising solutions by providing biomimetic scaffolds and recruiting endogenous chondroprogenitor cells for hyaline-like cartilage regeneration.

Conclusion: The case we present demonstrates the effectiveness of this Col II-CS-HA cartilage biomimetic matrix gel, which is expected to become a new effective solution for huge cartilage defects in future clinical practice.

Introduction and importance: Pancreatic pseudocysts (PPCs) cause two-thirds of pancreatic cystic diseases; pancreaticopleural fistula (PPF), a rare (0.4% in pancreatic diseases) life-threatening complication, occurs when mediastinal pseudocysts (60% from PPCs) rupture into the thorax, with 4.5% risk in PPC patients (highest in middle-aged males with alcohol-related chronic pancreatitis). Its nonspecific symptoms (dyspnea, mild/absent abdominal pain) delay diagnosis.

Case presentation: A 44-year-old male with a 3-year recurrent acute pancreatitis and hyperlipidemia was admitted for sudden dyspnea. Labs showed elevated serum/thoracentesis fluid pancreatic enzymes. Imaging (July 2023-April 2025) revealed pancreatic inflammation → pseudocyst → mediastinal cyst coalescence → left pleural effusion. Diagnosed with PPF, he received ultrasound-guided thoracentesis and supportive care; a 2-month follow-up showed resolved effusion and a smaller pseudocyst.

Clinical discussion: PPF forms via intracystic pressure elevation, diaphragmatic defects, etc., mostly causing left effusions. Diagnosis relies on pleural fluid amylase (>1000 IU/L), contrast-enhanced computed tomography (CT) (gold standard), and magnetic resonance cholangiopancreatography/ endoscopic retrograde cholangiopancreatography. Treatment includes conservative management (30%-60% success), endoscopic stenting (50%-86.36% cure), and surgery (for refractory cases).

Conclusion: Clinicians should suspect PPF in PPC patients with unexplained respiratory symptoms. Prompt CT and pleural fluid testing aid diagnosis; early management and follow-up improve outcomes.

Introduction and importance: Acute acalculous cholecystitis (AAC) can be a life-threatening condition, particularly in critically ill patients. The pathophysiology appears to be secondary to cholestasis, hypoperfusion, or ischemia. Dengue fever is a rare cause of AAC.

Presentation of case: We present the case of a 44-year-old female with non-specific symptoms including right upper quadrant abdominal pain, fatigue, anorexia, vomiting, and fevers. Her clinical examination was consistent with tenderness in the right upper quadrant, with a positive Murphy's sign. Given her deranged biochemical markers, liver function tests, and a consistent sonographic study to support acute cholecystitis, she was booked and consented for an emergency laparoscopic cholecystectomy. Preoperative imaging could not identify any obvious gallstones, and intraoperatively, there were no gallstones appreciated macroscopically. In her postoperative course, the team was notified in retrospect that she had tested positive for dengue fever.

Clinical discussion: Dengue fever is a rare cause for AAC and is rare in Australia. The proposed mechanism for its pathophysiology is critical illness including direct invasion of the gallbladder epithelial cells, vasculitis, stasis of biliary flow, and ischemia. Case reports in the literature support conservative treatment of the viral illness and resolution of the inflammation; however, surgical intervention may be required for patients with diffuse peritonitis.

Conclusion: Clinicians should consider a wide range of causes for AAC. The challenging nature of this case was to consider a rare cause for AAC in a region not endemic to dengue fever.

Introduction: Severe anterior tibial bowing due to fibrous dysplasia is rare and presents major reconstructive challenges. Taylor Spatial Frame, though ideal for such complex deformities, is currently unavailable in Afghanistan. This report describes the successful correction of a 96° anterior tibial bow with distal medial rotation and 5-cm shortening using the asymmetric lengthening technique of an Ilizarov ring fixator to achieve simultaneous angular realignment and limb-length restoration in an adult patient.

Case presentation: A 22-year-old male presented with a severe saber-shin deformity of the left tibia (angulation ≈ 100°) secondary to fibrous dysplasia, accompanied by a 5-cm limb-length discrepancy. Two tibial osteotomies were performed proximal and distal to the apex of the deformity. An Ilizarov ring construct was applied without hinge mechanisms, instead employing asymmetric distraction for gradual correction. Over a period of progressive adjustment, satisfactory realignment and near-complete limb-length equalization were achieved. Both osteotomy sites consolidated uneventfully, and at the latest follow-up, the patient was pain-free and fully weight-bearing.

Discussion: Bone deformity is a recognized complication of monostotic fibrous dysplasia. Asymmetric lengthening allowed simultaneous multiaxial angular correction and lengthening, overcoming the limitations of hinge-based systems. While the Taylor Spatial Frame offers precision, its high cost and unavailability make it impractical in resource-limited settings.

Conclusion: This case demonstrates that even extreme anterior tibial bowing secondary to fibrous dysplasia can be effectively managed with a hingeless Ilizarov modification, providing a practical and low-cost alternative for complex deformity correction.