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INTRODUCTION: Reduction en masse is a rare diagnosis in which an inguinal hernia is reduced; however, the bowel remains entrapped inside the hernia sac within the preperitoneal space. Although this occurs infrequently, missed diagnosis can significantly affect patient outcomes. PRESENTATION OF CASE: A 73-year-old male presented with obstructive symptoms in the setting of no prior abdominal operations and recently self-reduced inguinal hernia. Diagnosis of reduction en masse of an inguinal hernia was made with history and cross-sectional imaging. The patient remained obstructed following reduction and underwent urgent laparoscopic exploration. The small bowel was reduced from a preperitoneal hernia sac and appeared viable, negating the need for resection. The patient subsequently underwent inguinal hernia repair and was discharged home. DISCUSSION: Although rare, clinicians should be aware of the possibility of reduction en masse of herniae as the cause of intestinal obstruction. This case presentation emphasizes the need for thorough history-taking and imaging to assist in diagnosis. When reduction en masse is diagnosed, proceeding urgently to the operating room is critical. When feasible, it is acceptable to start with laparoscopic exploration to free the bowel and assess for viability. Laparoscopic repair is even an option. Timely diagnosis and operative intervention can preserve the bowel. CONCLUSION: Reduction en masse of an inguinal hernia is a rare but potentially morbid cause of intestinal obstruction as the incarcerated inguinal hernia is essentially converted to an internal hernia with ongoing risk of bowel strangulation. Knowledge of this rare diagnosis and its associated imaging findings is essential for appropriate and timely intervention.
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CONTEXT: Data on giant pheochromocytomas (PHEO), defined based on size ≥ 10 cm, are scarce. OBJECTIVE: to compare presentation, management, and outcomes of patients with giant vs non-giant PHEOs. DESIGN: retrospective cohort study, 2000-2023. SETTING: referral center. PATIENTS: consecutive patients with giant PHEO and randomly chosen patients with non-giant PHEO (referents) at a 1:6 ratio. OUTCOMES: perioperative complications, metastases, mortality. RESULTS: Of 828 patients with PHEO, 31 (3.7%) had giant PHEO (median size 12 cm, IQR 10.0-13.5). In comparison to referents (n=186, median size 4 cm, IQR, 2.9-5.0), patients with giant PHEO had more symptoms of catecholamine excess (median of 2 vs 1, P=.04) and presented with a higher prevalence of severe catecholamine excess (76% vs 30%, P<.0001).Adrenalectomy was performed in 94% of patients with giant PHEOs and 100% referents. In addition to preoperative alpha-adrenergic blockade (89%), metyrosine was used in 14 (7%) patients, mostly in patients with giant PHEO (26% vs 3%, P<.0001). Patients with giant PHEO had a higher perioperative complication rate (31% vs 10%, P=.004).During a median follow-up of 3 years, metastases developed at a higher rate in patients with giant PHEOs (45% vs 4% in referents, P<.0001). Disease-specific mortality was 7% in patients with giant PHEOs and 0% in referents (P=.02). CONCLUSION: Patients with giant PHEO as compared to referents were more symptomatic, had a higher degree of catecholamine excess, and had a higher rate of perioperative complications. Almost half of patients with giant PHEO developed metastases, warranting a close follow-up.