Case Reports in Surgery最新文献

Introduction and importance: Enterocutaneous fistulas (ECFs) caused by ingested foreign bodies are extremely rare. Accurate fistula localization is essential for guiding management, especially in comorbid patients at high surgical risk.

Case presentation: We report a 76-year-old woman who developed an ECF secondary to a swallowed chicken bone. Initial imaging suggesting a high small-bowel fistula and severe peristomal skin breakdown prompted consideration of surgery. Extended conservative management allowed skin healing, and follow-up imaging revealed a more distal fistula, supporting continuation of nonsurgical management.

Clinical discussion: Management of ECF is challenging due to morbidity from intestinal failure, electrolyte disturbances, sepsis, and skin damage. Optimal care requires multidisciplinary strategies guided by sepsis control, nutritional support, anatomical assessment, and procedure planning (SNAP framework).

Conclusion: This case highlights the importance of individualized management and careful assessment of fistula location. It also illustrates that prolonged conservative management can achieve acceptable outcomes in high-risk patients.

Gallstones and alcohol consumption are the most common causes of acute pancreatitis. Lung carcinoma typically presents with respiratory symptoms, and in some cases, locoregional or distant metastases. However, acute pancreatitis as the initial manifestation of lung carcinoma is rare. Herein, we report the case of a 75 year-old man who presented with acute pancreatitis and was diagnosed with metastatic lung carcinoma upon evaluation.

Acute appendicitis is rare in the neonatal population, and delayed diagnosis is associated with increased morbidity and mortality. Pneumoperitoneum is infrequently identified on plain radiography in cases of neonatal appendicitis, which can result in delays in diagnosis and intervention. In this case, we report a 15-day-old preterm female neonate who presented with irritability and abdominal distention. A plain abdominal radiograph demonstrated significant pneumoperitoneum, and surgical exploration revealed perforated appendicitis.

Appendicitis and small bowel obstruction (SBO) are common causes of acute abdomen encountered in clinical practice. However, appendicitis as a cause of SBO is very rare and often overlooked, commonly resulting in delayed diagnosis and management. Appendico-ileal knotting, a rare but dangerous way appendicitis could lead to mechanical SBO, occurs when an inflamed appendix forms a ring-like structure through which a small bowel loop herniates, resulting in closed-loop obstruction that could be complicated by small bowel strangulation and gangrene if not identified and intervened early. Preoperative diagnosis of appendico-ileal knotting is very challenging, with most cases diagnosed intraoperatively. We present a case of a 35-year-old female who presented with crampy abdominal pain of 2 days duration associated with vomiting, abdominal distension, and constipation. Blood pressure was unrecordable, and abdominal examination was positive for diffuse guarding, rigidity, and rebound tenderness. A plain abdominal X-ray revealed multiple centrally located air-fluid levels, after which she was diagnosed with SBO and taken to the operating room for exploratory laparotomy. With the intraoperative finding of appendico-ileal knotting complicated by distal ileal gangrene, she was managed with appendectomy, ileal resection, and end ileostomy. Appendico-ileal knotting is a very rare condition with a limited number of case reports in the existing literature. This case report aims to contribute to a better understanding of this condition and emphasize the significance of early identification and intervention in reducing the substantial risk of morbidity and mortality associated with the condition if not managed timely.

Introduction: Although the reported incidence of congenital vascular malformations is ~1.5% of the general population, the true incidence of these lesions is difficult to assess due to the heterogeneity of vascular anomalies and the variability in terminology used in reporting. These vascular anomalies can involve capillaries, lymphatics, venous, and/or arterial structures and can occur anywhere in the body. Rarely does a vascular malformation originate from the gastrointestinal (GI) mesentery and present as a bowel obstruction.

Case report: This report describes an adolescent patient with an unusual presentation of a vascular malformation involving the GI mesentery, manifesting as midgut volvulus. Emergent laparotomy revealed a large intra-abdominal cystic structure that volvulized resulting in a small bowel obstruction. The lesion and involved segment of small bowel were resected and found to be a mesenteric venous malformation on pathology.

Conclusion: Vascular anomalies of the GI tract are uncommon but should be included in the broad differential for patients presenting with abdominal pain, symptoms consistent with a small bowel obstruction, and/or a cystic intra-abdominal mass. In addition, utilization of accurate and standardized terminology when reporting these lesions is important to facilitate prompt and accurate diagnosis and treatment of patients and to establish a reliable foundation of continued research on vascular anomalies.

Introduction and importance: Wandering spleen (WS) is a rare condition caused by the absence or laxity of splenic suspensory ligaments, predisposing the spleen to displacement and potential complications. While torsion is the most commonly reported issue, infarction due to vascular compromise is a serious and rare complication, particularly in pregnancy. We present a case of splenic infarction in a WS during pregnancy, emphasizing diagnostic challenges and management strategies.

Case presentation: A 19-year-old primigravida at 5 months of gestation presented with progressively worsening abdominal pain and a palpable right-sided abdominal mass. Ultrasound and magnetic resonance imaging (MRI), chosen for its safety in pregnancy, confirmed an enlarged, ectopic spleen with infarction and splenic vein thrombosis. Conservative management with anticoagulation and supportive therapy was initially attempted but failed due to worsening pain and clinical deterioration. Surgical intervention was deemed necessary, and a splenectomy was performed. The patient recovered well postoperatively, with fetal well-being maintained throughout.

Clinical discussion: Diagnosing WS in pregnancy is challenging due to nonspecific symptoms and limited imaging options. MRI plays a pivotal role in identifying ectopic spleen and assessing vascular compromise. Although torsion is commonly associated with infarction, infarction can occur through other mechanisms such as venous thrombosis or outflow obstruction. Early recognition and timely surgical intervention are essential to reduce maternal and fetal morbidity.

Conclusion: WS in pregnancy presents a diagnostic and therapeutic challenge, with infarction posing a significant but underreported risk. MRI is a valuable tool in pregnant patients, allowing safe and accurate diagnosis. A multidisciplinary approach and individualized treatment strategies are essential for optimizing both maternal and fetal outcomes.

Obesity is a challenging condition for pancreatic surgery, and some authors recommend delaying pancreatic resection for non-malignant pancreatic tumors in obese patients. We present a case of a 45-year-old woman with a body mass index (BMI) of 56 who was surgically treated in our department for a mucinous cystadenoma discovered during preoperative work-up for bariatric surgery. To decrease the risk involved in pancreatic surgery, a glucagon-like peptide-1 receptor agonist was administered for 6 months, which led to a weight loss of 20 kg and a BMI of 48 at the time of surgery. A laparoscopic left splenopancreatectomy was performed within 7 months of the diagnosis. The postoperative length of stay was 19 days. Pathology confirmed that the tumor was mucinous cystadenoma with mild dysplasia. As of 17 months later, the patient is doing well and has lost an additional 10 kg.

Introduction: Hepatic artery aneurysms (HAAs) are rare but significant vascular lesions associated with high mortality due to rupture, particularly in symptomatic cases. This report highlights the clinical importance of timely intervention and presents a case of surgical management of a true HAA.

Case presentation: We present a 58-year-old man with a history of Crohn's disease who exhibited acute right upper quadrant and epigastric pain. Initial evaluation, including CT angiography (CTA), revealed a 24-mm fusiform HAA involving the common hepatic artery. Despite transient relief of pain with analgesics, surgical intervention was deemed necessary due to the aneurysm's size and risk of rupture. The patient underwent an aneurysmectomy with reconstruction using an inverted great saphenous vein graft through a bilateral subcostal incision. The surgical procedure was completed without intraoperative complications, successfully excising the aneurysm and restoring blood flow via the graft. The patient experienced a complex postoperative course, including a sudden episode of bleeding from the left gastric artery, which was effectively managed with endovascular coil embolization. Follow-up imaging at 12 months showed no residual aneurysm and confirmed graft patency, along with favorable perfusion of the intrahepatic arteries.

Conclusions: This case illustrates that surgical repair can be a safe and effective treatment for HAAs when endovascular options are not feasible. It underscores the necessity of personalized management strategies based on individual patient characteristics and specific aneurysm features. Further studies are required to optimize treatment protocols for HAAs.

Introduction: Pancreaticoduodenal artery (PDA) pseudoaneurysm is a rare occurrence. The intricate clinical manifestations and frequent rupture present challenges in diagnosing and treating the condition.

Case presentation: A 56-year-old man was admitted to the emergency department (ED) with sudden, severe abdominal pain, dizziness, and a history of two fainting events on the same day at home. A decreased blood pressure of 75/60 mmHg was detected on arrival. He had a medical background characterized by a history of gastritis and peptic ulcer disease (PUD) with ongoing use of pantoprazole and sucralfate. A contrast-enhanced computed tomography (CT) scan revealed retroperitoneal hematoma and a saccular outpouching in the superior and inferior pancreaticoduodenal arcades, in favor of visceral aneurysm, probably with the origin of the PDA. The patient underwent a laparotomy. The ruptured pseudoaneurysm was ligated using 4.0 polypropylene threads, and a Jackson-Pratt drain was inserted. The patient's recovery following the surgery was uneventful, and he was discharged after 5 days without any issues.

Conclusion: This case highlights the importance of considering a ruptured PDA pseudoaneurysm, which should be evaluated in the differential diagnosis of abdominal discomfort and related symptoms, especially in patients with duodenal ulcers. The successful management of the condition is accomplished through suture ligation, and the diagnosis is effectively made through CT angiography.

Systemic lupus erythematosus (SLE) is a multi-system autoimmune disorder, with gastrointestinal (GI) involvement in 20%-50% of cases. Mostly, symptoms are non-specific, but lupus enteritis is a rare acute manifestation occurring in less than 6% of patients with SLE. This infrequency often leads to a delayed diagnosis, resulting in significant morbidity and mortality. We present the case of a 40-year-old female with a 9-year history of SLE, who developed severe diffuse lupus enteritis and hypovolemic shock in a regional hospital located 400 km from a tertiary care centre. The patient exhibited abdominal distension, vomiting and acute kidney injury. A contrast-enhanced CT scan revealed circumferential bowel wall thickening and free fluid, consistent with lupus enteritis. Initial management focused on stabilisation through aggressive rehydration and monitoring while awaiting transfer to a tertiary facility. Corticosteroids and supportive care led to a gradual resolution of symptoms. This case is educational for rural surgeons, highlighting the importance of recognising and managing rare acute GI manifestations of collagen vascular diseases like SLE in resource-limited settings. Early diagnosis and transfer are crucial to reducing mortality, and this case demonstrates the need for high clinical suspicion and decisive damage control intervention if indicated.