Bouveret Syndrome simultaneous with an incidental solitary Gastric Neuroendocrine Tumor in a 44-year-old female - A Case Report.

Bouveret Syndrome (BS) is a rare type of gallstone ileus, where a gallstone passes via a cholecystoduodenal fistula and causes gastric outlet obstruction. It comprises 0.3-0.5% of cholelithiasis complications. It primarily affects females with an average incidence age of 74 years. Gastric Neuroendocrine Tumors (G-NETs) make up merely 2% of all forms of gastric neoplasia and are known to be an extremely rare occurrence. Their annual incidence is estimated to be one to two per 1 million individuals, and they comprise 8.7% of all known neuroendocrine neoplasia of the gastrointestinal system. Case presentation: We present the case of a 44-year-old Middle Eastern female who presented to the clinic due to multiple episodes of food containing biliary nonprojectile emesis accompanied by epigastric pain. Preoperative radiological workup revealed a Bezoar blocking the gastric outlet and a G-NET in the mucosal layer of the stomach. Clinical discussion: Surgical intervention consisted of excising the impacted calculus to relieve the existing gastric outlet obstruction simultaneous to performing an uncut Roux-en-Y to treat the G-NET condition. The patient underwent complete recovery. Conclusion: BS is an extremely rare form of gallstone ileus and gastric outlet obstruction. Its clinical presentation is nonspecific and results in misdiagnosis. Additionally, it is rare to occur in our patient's age group. NETs are also profoundly rare forms of neoplasia. To the best of our knowledge, no previous cases of simultaneous BS and G-NET have been documented. Therefore, clinical awareness should be raised to timely implement the necessary therapeutic interventions.

A rare incidence of retroperitoneal Cystic Lymphangioma in a 45-year-old female - A Case Report.

INTRODUCTION AND IMPORTANCE: Cystic lymphangioma is an extremely rare benign vascular neoplasm of mesodermal origin, arising from lymphatic vessels and occurring principally in male children. The retroperitoneum is the rarest site, accounting for <1 % of all types of lymphangioma. The incidence of cystic lymphangioma is unknown due to the scarcity of published data. CASE PRESENTATION: A 45-year-old female presented to our hospital complaining of vague abdominal pain and intermittent episodes of vomiting over four months. Preoperative imaging via ultrasound and Computed Tomography revealed a well-demarcated retroperitoneal cystic mass between the right kidney and the liver. CLINICAL DISCUSSION: The mass was excised laparoscopically. Histopathological examination confirmed a cystic hygroma (a subtype of cystic lymphangioma). CONCLUSION: Cystic lymphangioma is rare, often misdiagnosed and may present with vague symptoms. Complete resection may be feasible and can be curative.

An exceedingly rare simultaneous incidental occurrence of synchronous primary malignancies; Invasive Ductal Carcinoma and Renal Cell Carcinoma in a male - A Case Report.

INTRODUCTION AND IMPORTANCE: Synchronous malignancies are defined as the emergence of one or more tumors which either occur simultaneously or within 6 months of each other. Populations older than 50 years of age are the most vulnerable. Documented prevalence rates of synchronous neoplasia are 4.5-11.7 %. To the best of our knowledge, ours is the first documented case of synchronous primary incidental occurrence of Invasive Ductal Carcinoma (IDC) and Renal Cell Carcinoma (RCC) in a Middle Eastern male. This type of co-occurrence must be borne in mind because such neoplastic occurrence is potentially fatal. Documentation is essential to raise awareness and to decrease the resultant morbidity and mortality. CASE PRESENTATION: We present a case of a 61-year-old male who presented to our clinic with a 22-day-history of gradual, painless, and disproportionate hypertrophy of his left breast. CT scan revealed incidental breast and right kidney masses. Therapeutic intervention included a modified radical mastectomy with Sentinel lymph node excision along with right radical nephrectomy. CLINICAL DISCUSSION: Treatment of our patient was multimodal. Accurate radiological studying together with clinical examination helped us in making a diagnosis. Treatment options for this pathology consist of a combination of surgery and/or adjuvant therapy. CONCLUSION: Synchronous IDC and RCC are an extremely rare co-occurrence, especially in males, particularly Middle Eastern males, and more specifically, those presenting asymptomatically as incidental findings. It is vital to further document and study such cases to establish innovative surgical techniques, screening modalities for males, and to overcome the consequential morbidity and mortality.

A unique case of Dermatofibrosarcoma Protuberans arising from an inguinal hernial repair scar in a Middle Eastern male - A Case Report.

INTRODUCTION AND IMPORTANCE: Dermatofibrosarcoma Protuberans (DFSP) is a rare and fatal variant of Spindle Cell Sarcoma. It has an annual incidence rate of 0.8 to 4.5 cases per one million individuals. It's locally aggressive and has vague and masquerading clinical presentations. Misdiagnosis is devastating as it can lead to time wasting, expenditure of unnecessary resources, and possibly raise morbidity and mortality for patients. It is warranted to raise preoperative clinical awareness to achieve prompt surgical therapeutic interventions to reach an up-to-par prognosis. CASE PRESENTATION: We demonstrate the case of a 50-year-old previously healthy Middle Eastern male patient, who was referred to our General Surgery clinic with the chief complaint of an expansive bulge in his left iliac fossa. Preoperative imaging could not exclude a neoplastic cause behind the presentation. Based on the clinical picture, a surgical intervention was decided. CLINICAL DISCUSSION: Our patient's treatment was consummated by means of classical surgical resection of the lesion with adequate negative margins and referring him to an oncologist specialized in DFSP to undergo the necessary adjuvant treatment. Definitive diagnosis was firmly entrenched postoperatively after finalization of the histopathological and immunohistochemical analyses of the resected protuberance. CONCLUSION: DFSP is an eminently rare entity, especially DFSPs which originate from a surgical scar -as was our patient's- and fluctuates in its clinical presentation, thus, it is our responsibility to depict, study this malignant tumor, and document its incidence, so that we can make ironclad clinical decrees to plummet the morbidity and mortality of this relentless neoplasia.

A rare case of a Low Grade Appendiceal Mucinous Neoplasm in a 46-year-old Middle Eastern female - A case report.

INTRODUCTION AND IMPORTANCE: Mucinous cell neoplasia are rare and conceivably fatal causes of surgical abdomen. Adult manifestations can be obscure and ill-defined, yielding misdiagnoses and wasting precious time and effort to reach the correct one. Clinical awareness ought to be present once presented with a surgical abdomen in such a patient because this neoplasm may present with misleading presentations which mask the actual diagnosis and masquerade as a different one, and in turn, may result in performing a dissimilar treatment intervention. Rapid learnt surgical judgments must be taken and put into action to diminish the morbidity and mortality consequential to this pathology. CASE PRESENTATION: Our case is of a 46-year-old female, who was admitted into our hospital with a 2-month-history of general fatigue. Colicky abdominal pain and discomfort developed shortly prior to admission. Multi-Slice Computed Tomography (MSCT) scan exposed cystic formation in the terminal ileum. Exploratory laparotomy was warranted, in addition to performing a right hemicolectomy. CLINICAL DISCUSSION: We treated our patient via open surgery and performing an appendectomy with right hemicolectomy in addition to the excision of several surrounding lymph nodes. Diagnosis is traditionally reached intraoperatively relying on gross morphology and postoperatively through histopathological analysis of the excised specimens. CONCLUSION: Low Grade Appendiceal Mucinous Neoplasm is a scarce entity and varies critically in its manifestations, hence, it is existential to thoroughly study this kind of neoplasia, document it, and consider it, so that we can construct precise decisions to reach ideal results for patients who suffer from this neoplasm.

A rare case of primary non-metastatic Non-Hodgkin's diffuse large B-cell lymphoma in the ileum in a 19-year-old male manifested as intestinal obstruction- A case report.

INTRODUCTION AND IMPORTANCE: The gastrointestinal system is the most common site for extra-nodal NHL. Adolescent population are among the rarest of compromised groups, especially males. The gastrointestinal system is more involved by secondary metastasis rather than by primary lymphomas. Cardinal B-Symptoms and obstipation constituted the presentation of our patient who was diagnosed postoperatively as a case primary non-metastatic NHL. NHL can have misleading presentations which result in the implementation of different treatment modalities. We ought to have high clinical suspicion when presented with a patient suffering from B-Symptoms and obstipation to make timely judgements which help in performing effective therapeutic interventions to limit the morbidity and mortality which result from this pathology. CASE PRESENTATION: We present the case of a 19-year-old male, who presented with obstipation and B-Symptoms. CT scan indicated loop dilation, a lobulated mass, and what radiologically seemed to be intussusception. Surgery was done and the resected specimens were DLBCL. CLINICAL DISCUSSION: We treated him by surgical excision of the affected ileal segments. Histopathology indicated a primary Non-Hodgkin's DLBCL of the ileum. Afterwards, we referred him for adjuvant chemotherapy. Treatment modalities for this malignancy are mainly surgical in addition to Chemotherapy. CONCLUSION: Intestinal extranodal NHL presents with an array of vague symptoms. As a result, this type of tumors can be clinically indistinguishable from other gastrointestinal malignancies. It is vital to keep this type of malignancy in mind as a differential diagnosis when presented with a surgical abdomen in a patient with B-Symptoms.

A distinctive case of congenital midgut malrotation with volvulus in an adolescent female managed by Ladd's procedure - A case report.

INTRODUCTION AND IMPORTANCE: Midgut Malrotation (MM) is a potentially fatal and rare congenital anomaly that results from an incomplete rotation of the bowel 270 degrees around the Superior Mesenteric Axis. Newborns are the most affected age group, nevertheless, adult malrotation can manifest, but in a much rarer incidence rate. Clinical awareness must be present when faced with a surgical abdomen in an adolescent patient because this pathology can have several misleading signs and symptoms which may eclipse the true preoperative diagnosis and masquerade as another, and this could result in implementing a different therapeutic approach. Swift clinical informed judgments must be made and acted upon to limit the morbidity and mortality resultant from this pathology. CASE PRESENTATION: We present the case of a 15-year-old female, who was brought to our Emergency Department (ED) with a 5-day-history of biliary emesis which evolved into obstipation with continuous and excruciating abdominal pain. Computed Tomography (CT) scan indicated gastric and duodenal dilation in addition to a "Whirlpool sign". Exploratory laparotomy was done, and a Ladd's procedure was performed. CLINICAL DISCUSSION: We treated our patient by performing Ladd's procedure and adhesiolysis. Diagnosis is conventionally established pre-/intraoperatively based on radiological imaging and clinical suspicion. Therapeutic methods for this pathology are primarily surgical in nature. CONCLUSION: Midgut Malrotation is a rare entity, thus, it is crucial to further study this type of clinical presentation and keep it in mind to be able to make an accurate diagnosis to reach the optimal outcome for patients who present with acute surgical abdomen.

Spindle Cell Sarcoma (SCS); a case of primary leiomyosarcoma (LMS) of the sigmoid colon presented as intestinal obstruction.

Leiomyosarcoma (LMS) is a common form of soft tissue sarcoma. Primary colonic LMS is an extremely rare entity, comprising 1-2% of gastrointestinal malignancies. Primary mesenchymal sarcomas of the gastrointestinal system are rare and constitute just 0.1-3% of all gastrointestinal tumours. LMS is the most common variant of such tumours and represents just 0.12% of colorectal malignancies. We present a case of a 65-year-old female, who presented to the emergency department with 3 days history of obstipation and generalized abdominal pain. Radiology (X-ray and ultrasound) indicated a large pelvic mass compressing the sigmoid colon and its surrounding structures. Histopathological analysis indicated a primary LMS of the sigmoid colon. Diagnosis is established mostly postoperatively after histopathological evaluation. Prognosis and treatment modalities for this aggressive malignancy remain insufficient. LMS is relatively impervious to chemotherapy/radiotherapy. Our patient was treated by surgical excision of the tumour and referred postoperatively for adjuvant chemotherapy.

Spontaneously perforated Meckel's diverticulum due to diverticulitis with histopathological finding of gastric mucosa in an adult female - A case report.

INTRODUCTION AND IMPORTANCE: Meckel's Diverticulum (MD) is the most occurring congenital anomaly of the gastrointestinal tract. It characterizes a patent remnant of the omphalomesenteric duct. Despite remaining asymptomatic most of the time, the rarity of its occurrence is reflected by the scarcity of data involving it in the literature. Gastrointestinal bleeding, bowel obstruction, and inflammation are the most prevalent complications of MD. Perforation of MD is very rare. CASE PRESENTATION: We present the case of a previously healthy 32-year-old female, who presented to the emergency department with a 2-day-history of generalized abdominal pain. Radiological analysis suggested a perforated viscus and an inflamed Appendix. CLINICAL DISCUSSION: Our patient was diagnosed preoperatively with perforated hollow viscus and an exploratory laparotomy was indicated. Intraoperatively, a perforated MD was found and treated by surgical excision of the affected loop of bowel with end-to-end anastomosis and the specimens were sent for histopathological analysis. Histopathology revealed a perforated MD containing gastric mucosa. The patient had successful recovery. CONCLUSION: Early recognition with swift surgical intervention must take place to provide therapeutic outcome for patients and to limit the resulting morbidity. This case highlights the necessity of considering MD as core differential diagnosis in patients with acute abdomen. Due to the scarcity of data on perforated MDs in adult females, it's worthy of studying to highlight its incidence. Due to the rarity of a perforated MD in an adult female, it's worthy to consider such cases to explore preoperative assessment techniques, surgical interventions options, and postoperative complications.