Congenital unilateral diaphragmatic eventration in an adult: A rare case presentation.

We present a rare case of 32year old female with congenital diaphragmatic eventeration female presenting in an adult. She had symptoms of intermittent dyspnea and occasional epigastric discomfort. Patient had no previous history of trauma. Physical examination showed bowel sound involving the left hemithorax. Imaging modalities confirmed the diagnosis of a congenital left diaphragmatic eventeration. Patient underwent plication of the diaphragm using the abdominal approach. Intra-operatively, the left diaphragm was attenuated. Plication was done with 1st layer of imbricating silk heavy sutures buttressed by a second layer of interrupted absorbable sutures. She post-operatively had atelectasis on the left lung. Incentive spirometry and deep breathing exercises were started with resolution of the atelectasis after 1 week post-operatively. Patient had an unremarkable post-operative stay with resolution of symptoms. There are reports that diaphragmatic eventration diagnosed even as late 70 years old, highlighting the dogma that this is an asymptomatic disorder does not need all the time surgical therapy. But we still recommend surgical therapy as soon as diagnosis is confirmed. In this patient, there was no recurrence of symptoms after a follow-up of 2 years. Whether surgery indeed improved lung functions in these vastly asymptomatic patients, these questions could be an active area of research in the long term outcomes of these patients.

Massive hemorrhage secondary to bleeding intracystic arteries after cystogastrostomy for pancreatic pseudocyst

The authors report a patient who underwent elective cystogastrostomy for pancreatic pseduocyst and had three episodes of massive gastrointestinal bleeding postoperatively. The patient had bleeding vessels in the pseudocyst cavity of which conservative management of cold saline lavage and octreotide was instituted. Endoscopy was done after the 1st episode of bleeding and showed no active bleeding, no suture site bleeding and with blood clots inside the cavity. After the 2nd episode of gastrointestinal bleeding, there was a note of pinpoint hemorrhages on the pseudocyst wall. The plan was to do angiography but the patient succumbed to hypovolemic shock due to gastrointestinal bleeding hours after endoscopy. On retrospect, early angiography and possible embolization should have been done. Prompt surgical re-exploration is warranted among patients with hemodynamic instability.