Perforation of the excluded segment without pneumoperitoneum following Roux-en-Y gastric bypass surgery: case report and literature review.

BACKGROUND: Because of the increasing prevalence of obesity and bariatric surgery (Roux-en-Y gastric bypass (RYGB) as the gold standard), there is a still growing population of people with altered post-operative anatomy. Although the most common early and late complications following RYGB are well known, they can still be difficult to diagnose. The altered anatomy after RYGB can create a real diagnostic and therapeutic challenge since routine examinations can be negative. CASE REPORT: We present a rare case of a 38-year-old woman with acute abdominal pain and a history of RYGB who proved to have a duodenal perforation in the absence of free air on radiologic examination. The perforation was closed laparoscopically and proton pump inhibitors were administered. CONCLUSIONS: Perforations of the excluded segment in RYGB patients are rare and represent a diagnostic challenge, as pneumoperitoneum is usually absent and the excluded segment is difficult to access. Despite negative diagnostic findings, laparoscopic exploration should always be considered.

Intraductal papillary neoplasm of the bile duct: a case report.

Intraductal papillary neoplasm of the bile duct (IPNB) is a rare variant of bile duct tumors, characterized by papillary growth within the bile duct lumen and is regarded as a biliary counterpart of intraductal papillary mucinous neoplasm (IPMN) of the pancreas. IPNBs are mainly found in patients from Far Eastern areas, where hepatolithiasis and clonorchiasis are endemic. The Western experience, however, remains limited. In this article, we report a 56-year-old man, referred to our hospital because of deranged liver function tests. Further imaging modalities showed a cystic lesion of 9 cm diameter, arising from the left hepatic duct. Inlying was a heterogeneous, lobulated mass. The patient underwent a left hemihepatectomy and adjuvant chemotherapy. Despite recent advanced technologies, diagnosis of IPNB is still challenging, especially in western countries due to its rarity. Early identification and resection of lesions, even in asymptomatic or minimally symptomatic patients, are however important prognostic factors.

An unusual presentation of an incarcerated Spigelian hernia.

Spigelian hernias are rare hernias, occurring through a defect in the Spigelian aponeurosis. Like other hernias, they may contain abdominal contents but are more likely to be incarcerated due to the small size of the fascial defect. Multiple intra-abdominal organs have reportedly been found in Spigelian hernias. A search of the literature showed only nine reported cases in which an appendix has been found within a Spigelian hernia. We present a patient with a history of lower abdominal pain since 10 weeks with a large intra-abdominal mass in the right iliac fossa. Due to abscess formation with spontaneous evacuation through the abdominal wall, drainage and incision were performed and the patient was treated with broad-spectrum antibiotics. An explorative laparoscopy after six weeks showed an incarcerated appendix in a Spigelian hernia.

Presacral extramedullary haematopoiesis: A diagnostic update and case report of a late diagnosis.

INTRODUCTION: We report a rare case of presacral extramedullary haematopoiesis, which manifested as a tumoural mass on a routine ultrasonography in a patient presenting with symptoms of cholecystitis. Since Ask-Upmark in 1945 reported 3 cases of pelvic extramedullary haematopoiesis, we are aware of only published 14 additional cases. PRESENTATION OF CASE: A 73-year-old female patient presented with abdominal pain in the right hypochondrium. An abdominal ultrasonography revealed cholecystitis with cholecystolithiasis and a coincidental hyperreflective mass of 9.5cm was visualised behind the bladder. A clinical examination identified a mass in the pelvis that could be palpated vaginally. A computerised tomography scan showed a large presacral, inhomogeneous, multilobular and nodular tumour. The patient was admitted for laparoscopic resection of the gall bladder and laparoscopic exploration of the presacral mass. An anatomopathological examination of the tissue revealed the presence of extramedullary haematopoietic tissue. A postoperative haematological investigation indicated that the extramedullary haematopoiesis was idiopathic. DISCUSSION: Presacral EMH may occasionally present with symptoms of nerve compression. Symptoms of haematologic disorders may accompany EMH. Barium enema, abdominal ultrasound, CT scan, MRI and radionuclide bone marrow imaging have all been used by previous authors in establishing the diagnosis. Tissue samples may be misdiagnosed when atypical megakaryocytes are misinterpreted as malignant cells, which occurred in this case. Misdiagnosis can occur even more often when EMH is not considered in the differential diagnosis due to its rare occurrence. In this case, the final diagnosis was made tissue sampling after surgery. Treatment of EMH is only necessary when it is symptomatic. CONCLUSION: This case report shows that extramedullary haematopoiesis is very rare and that it is a difficult diagnostic challenge when its location is unusual and when it is not associated with a haematologic disorder. Together with this case report, we present an update of the available diagnostic methods.