Abdominal cocoon syndrome (idiopathic sclerosing encapsulating peritonitis): An extremely rare cause of small bowel obstruction-Two case reports and a review of literature.

Introduction: Sclerosing encapsulating peritonitis (SEP) is a rare cause of intestinal obstruction in which the bowel and internal abdominal organs are wrapped with a fibrocollagenous cocoon-like encapsulating membrane [1,2]. SEP is divided into two entities: abdominal cocoons (AC), also known as idiopathic or primary sclerosing encapsulating peritonitis, which is of extremely rare type, and secondary sclerosing encapsulating peritonitis, which is the more common type. Case presentation: Two male patients from India, a 26 year old and a 36 year old, presented to our hospital complaining about abdominal pain associated with nausea and vomiting without any history of previous surgical interventions; the patients' vitals were stable. Preoperative diagnosis of abdominal cocoon was established by abdominal computed tomography. It showed multiple dilated fluid-filled small bowel loops in the center of the abdominal cavity with thin soft tissue, non-enhancing capsules encasing the small bowel loops with mesenteric congestion involving small and large bowel loops. Both patients underwent complete surgical excision of the sac without intraoperative complications. Patients had a smooth postoperative hospital course and were discharged home in good conditions. Conclusion: Patients with abdominal cocoons have a non-specific clinical presentation of intestinal obstruction. A high index of clinical suspicion in combination with the appropriate radiological investigation will increase the chance of preoperative detection of the abdominal cocoon. In patients with complete bowel obstruction, complete excision of the peritoneal sac is the standard of care.

Primary Ectopic Breast Carcinoma in Man Mimicking Keloid.

Background: Ectopic breast tissues (EBT) are developmental abnormality found in 1-6% of normal population. Like an orthotopic breast tissue, ectopic breast may have similar pathological changes including malignancy. Breast cancer as well as ectopic breast tissue in male are extremely rare. We present a case of ectopic breast carcinoma (EBC) in middle aged man mimicking keloid. Case report: A forty-two-year-old Indo-Aryan male referred from primary health care to the dermatology clinic with firm multi-nodular, non-tender, fleshy sessile mass on his right axilla measuring two by three cm in diameter. Excision of this lesion revealed moderately differentiated ductal carcinoma consistent with ectopic breast carcinoma. Conclusion: We report this case to shed light on such a rare condition and to keep in mind that ectopic breast carcinoma should be in differential diagnosis of any suspicious mass in axillae.

Occult Invasive Lobular Carcinoma Presenting as an Axillary Skin Metastatic Lesion Underwent Neoadjuvant Endocrine Therapy and Surgical Resection: A Case Report and Review of Literature.

Introduction: Invasive lobular carcinoma (ILC) is the second most common type of breast cancer accounting for 5-15% of all breast cancer cases. It usually presents with nonspecific signs and symptoms. Occult breast cancer presenting as an axillary mass is rare, with prevalence of 0.3-1%, less likely with isolated cutaneous breast metastasis as a first presentation. There are limited data in the literature on patients who underwent endocrine therapy and complete surgical resection. Case Presentation: A 54-year-old woman with left axillary skin swelling that had been persisting for 6 years was diagnosed with ILC 18 months ago presenting with an ulcerated axillary skin lesion and was managed with letrozole in another facility as she was estrogen receptor (ER) and progesterone receptor (PR) positive. She received letrozole for 18 months and had a partial response in the form of healing of the ulcer with persistent subcutaneous nodules. Her breast mammogram, ultrasound, and magnetic resonance imaging findings were unremarkable; however, there were few prominent left axillary lymph nodes. A biopsy of the left axillary lymph node was positive for malignancy, consistent with ILC. A skin punch biopsy of the axillary skin lesion showed ILC extending to the dermis with no background breast tissue. The patient underwent left modified radical mastectomy with excision of the left axillary skin lesion. The breast specimen comprised 0.4 mm of ILC as the primary malignancy and nine positive axillary lymph node malignancies. The patient received adjuvant radiotherapy and continued to receive letrozole. There were no signs of complications or recurrence during the follow-up period. Conclusion: Ulcerated skin lesions in the axilla should raise concerns regarding breast cancer metastasis. In cases of isolated cutaneous breast metastases, surgical excision can be considered in combination with endocrine therapy.

Stress and psychological resilience among general surgery residents during COVID-19 pandemic.

OBJECTIVES: To evaluate the impact of coronavirus-19 (COVID-19) pandemic and its consequences on general surgery residents. Methods: Cross-sectional, survey based study including surgical residents in Kingdom of Saudi Arabia and Kingdom of Bahrain. RESULTS: Surgical trainees who participated in our survey (n=234) were young (mean age 28), single (53.8%), and males (65.8%). Approximately half (50.4%) have been deployed to cover the staff shortage in intensive care units (ICUs) or emergency departments (EDs). Half of our trainees (117) scored positive in the screening tool of generalized anxiety disorder (GAD). There was a significant association between experiencing anxiety and male gender (p=0.055), level of training (p=0.002), deployment to cover ICUs (p=0.050), testing positive for COVID-19 (p=0.054) and having an infected family member (p=0.004). CONCLUSION: Coronavirus-19 pandemic has a serious effect on all healthcare workers and surgical residents have experienced a considerable amount of stress. Accordingly, this psychological burden should be appropriately addressed in organizations planning strategies. We suggest formulating guidelines to help surgical trainees to continue their learning process with least psychological burden.

A Cecal Mucormycosis Mass Mimicking Colon Cancer in a Patient with Renal Transplant: A Case Report and Literature Review.

BACKGROUND Mucormycosis is a rare, invasive, and opportunistic fungal infection that occurs in the setting of neutropenia, immune deficiency, solid-organ transplant, and iron overload. The gastrointestinal system is a rare site of mucormycosis, and gastrointestinal mucormycosis is associated with high mortality and accounts for 4-7% of all cases. CASE REPORT We present the case of a 64-year-old hypertensive man with transfusion-dependent myelodysplastic syndrome who underwent renal transplant surgery 11 years ago. He also was taking maintenance Deferasirox for iron overload. He presented with a 2-day history of right lower-quadrant abdominal pain, nausea, vomiting, and non-bloody diarrhea. An abdominal examination revealed guarding and a 5×6 cm mass in the right iliac fossa. A CT scan of the abdomen showed signs of perforation of a cecal mass. As the patient was unstable, emergency right hemicolectomy and end ileostomy were performed. After the surgery, the patient was moved to the Intensive Care Unit (ICU) and a broad-spectrum antibiotic was administered. Histopathological examination results received on postoperative day 5 showed broad pauciseptate hyphae with substantial blood-vessel infiltration, suggestive of mucormycosis. Amphotericin B was started; however, on the same day, his condition deteriorated and he was moved back to the ICU. Despite maximum cardiorespiratory support, he had multiorgan failure and died. CONCLUSIONS Gastrointestinal mucormycosis presentation is non-specific, the diagnosis is often made late or is missed, and mortality remains high. High clinical suspicion, early diagnosis, and combined antifungal and surgical treatment is the best way to reduce mortality and improve survival.