Case Reports in Surgery最新文献

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.

Complex aortic aneurysm repair has witnessed remarkable advancements through endovascular solutions. In current practice, many endovascular repairs of the abdominal and thoracic aorta rely on patient-specific endografts designed and manufactured on demand, as their anatomical requirements cannot be met by assembling conventional off-the-shelf components. However, the E-nside system is currently the only commercially available thoracoabdominal endograft that incorporates pre-cannulated inner branches in an off-the-shelf design. The objective of this case series is to describe and compare clinical indications, technical features, and intraoperative outcomes of complex abdominal aortic aneurysm (AAA) treated using the inner branched off-the-shelf E-nside and custom-made E-xtra Design MultiBranch endografts under real-life circumstances. Both endografts were safe for treating complex aortic aneurysms. E-nside was more suitable for emergent cases due to easy availability and quick access. Patients of the custom-made series had lower aortic coverage, but radiation exposure did not differ.

The mortality of injuries sustained from blunt thoracic trauma (TT) is significantly higher than the mortality of penetrating injuries, and decisions made during the first hour of hospitalization play a critical role in determining outcomes. Patient survival depends on the effective management of injuries that result in the disruption of respiration, circulation, or both. Presented is a case of a 44-year-old female who survived a traumatic avulsion of the right lung from the bronchus intermedius, subsequent multifactorial shock, and complications associated with her complex treatment plan, including emergent use of extracorporeal membrane oxygenation (ECMO), completion pneumonectomy, and rib fixation.

This case report presents two unique cases of reactive hydrocele formation following transabdominal preperitoneal (TAPP) inguinal hernia repair in adult patients. Although hydrocele development after pediatric inguinal hernia repairs is well-documented, cases in adults are rare and potentially underreported, likely due to the separation of surgical and urological specialties in adult care. Both patients experienced postoperative hematomas within the inguinal region, which resolved initially but subsequently led to symptomatic hydrocele formation over several months. The first patient, a 65-year-old male, developed a left-sided hydrocele with moderate to severe scrotal pain 8 months postoperatively. The second patient, a 70-year-old male, presented with a right-sided hydrocele 4 months after TAPP repair, initially managed conservatively but later requiring further evaluation due to persistent scrotal swelling and tenderness. Both patients underwent ultrasound imaging, which confirmed the presence of fluid collections around the affected testicles, with no abnormalities in testicular blood flow or echogenicity. A conservative management approach was taken in both cases, and symptoms gradually resolved without surgical intervention. These cases illustrate the potential for postoperative hematomas to exert pressure on lymphatic vessels, possibly leading to reactive hydrocele formation. The delayed onset and symptomatology underscore the importance of recognizing hydrocele as a potential delayed complication of laparoscopic inguinal hernia repair in adults. These cases contribute to the limited literature on this topic and suggest the need for larger cohort studies to explore the pathogenesis, prevalence, and potential correlation between postoperative hematomas and hydrocele formation. Awareness of this rarely reported but impactful complication may improve postoperative management and patient outcomes following TAPP procedures.

Postoperative sepsis after appendectomy can sometimes be led by surgical site infection, intra-abdominal abscess, or intestinal obstruction. However, there have been no reports that postoperative sepsis is certainly caused by only fecal retention in the intestine, including the appendectomy stump. A 60-year-old healthy woman visited a doctor with a chief complaint of right lower abdominal pain. Abdominal computed tomography (CT) showed a swollen appendix with fecal calculus, and then the patient was diagnosed with acute appendicitis. The patient underwent a laparoscopic appendectomy the next day. The appendix was resected at the level of the appendicular root with an endostapler. The patient was discharged from the hospital on postoperative day (POD) 4 in a good general condition. However, the patient visited the hospital on POD 15 with a chief complaint of fever. A medical interview revealed a decrease in the number of bowel movements compared to before the appendectomy. The quick Sequential Organ Failure Assessment (SOFA) score with the vital signs showed two points, and the SOFA score with the blood examination showed a total increase of four points compared to the previous blood examination. The patient was therefore suspected of sepsis after appendectomy. Abdominal CT showed obvious fecal retention in the ileocecal region, including the appendectomy site. Furthermore, abdominal contrast CT did not reveal any obvious thrombosis in the portal venous system. With conservative treatment by antibiotics and laxatives, the fever gradually resolved, and the patient was discharged on POD 27. Abdominal radiography showed no findings of fecal retention. The patient has had regular bowel movements and has not experienced a recurrence of the symptoms. Postoperative sepsis might be caused even in healthy patients. It was conceivable that postoperative assessment of bowel movements was necessary to detect the risk of postoperative sepsis.