A case report of surgical management of a solitary Non-Hodgkin's Lymphoma (NHL) arising from the proximal sciatic nerve.

INTRODUCTION AND IMPORTANCE: Solitary lymphomas of the peripheral nervous system are very rare and lymphomas of the sciatic nerve are uncommon, especially those arising from the proximal part of the nerve. This case report describes a rare presentation of solitary B cell Non-Hodgkin's Lymphoma arising from the proximal sciatic nerve that was managed via surgical excision. CASE PRESENTATION: A 28-year-old man experienced severe pain, motor and sensory issues in his right lower limb for a year. Magnetic Resonance Imaging identified a malignant peripheral nerve sheath tumour in the sciatic nerve involving S1 and S2 roots. No metastasis was found in CECT scans. Surgical resection via combined inguinal and gluteal approaches was followed by adjuvant chemoradiotherapy. Biopsy revealed diffuse large B-cell Lymphoma, non-Germinal Centre B-cell like subtype. Pain was reduced, and muscle power improved. CLINICAL DISCUSSION: Neurolymphomatosis (NL) is a rare condition where lymphoma cells invade nerves. It mostly involves peripheral nerves, particularly the sciatic nerve. Cases often present with painful neuropathy. Treatment varies, with surgery followed by chemotherapy and radiotherapy used in this unique case involving the pelvic sciatic nerve. Individual patient factors guide management due to limited case data. CONCLUSION: We present a unique case of neurolymphomatosis involving the proximal sciatic nerve, a rare occurrence. Surgical excision utilized a complex intra-abdominal and perineal approach, unprecedented in this context. This atypical presentation underscores the need to consider such cases in diagnosing unusual sensory motor neuropathies.

Challenging refractory type B lactic acidosis in gastric adenocarcinoma-a successfully managed case.

Type B lactic acidosis is a rare complication of gastric adenocarcinoma and is associated with poor prognosis. Very few cases have been reported in the literature. A 48-year-old female presented with recurrent episodes of vomiting, loss of appetite and loss of weight for 1 month duration. Endoscopy and subsequent biopsy revealed poorly differentiated adenocarcinoma at the pyloric antrum causing gastric outflow obstruction. Contrast enhanced computed tomography scan of the chest, abdomen and pelvis revealed a malignant neoplasm of the pylorus with no distant metastasis. She developed refractory lactic acidosis not responding to medical treatment. Distal gastrectomy with limited lymph node clearance was done and lactic acidosis improved. Pathophysiology of type B lactic acidosis in solid organ malignancies can be due to the rapid turnover of cells inducing anaerobic glycolysis, thiamine deficiency and extensive hepatic metastasis. This patient did not have hepatic metastasis. This is a successful, surgically managed case of type B lactic acidosis in a patient with gastric adenocarcinoma so far reported in the region. Type B lactic acidosis is very rare in gastric cancer. Patients with refractory lactic acidosis should bring about high suspicion of solid organ malignancies and good clinical outcomes can be obtained by the reduction of tumour burden.

Intermittent malperfusion of bilateral upper limbs - An uncommon presentation of Type A Acute Aortic Dissection (TAAD).

INTRODUCTION: Aortic dissection occurs following a tear in the tunica intima of the aortic wall resulting in blood entering between the intima and media. Type A aortic dissection can rarely manifest as upper limb malperfusion. CASE PRESENTATION: This is regarding a patient who presented with intermittent malperfusion of the bilateral upper limbs and was initially managed as acute limb ischemia. An attempt of embolectomy didn't yield any clots. Urgent imaging with computed tomography angiogram of bilateral upper limbs revealed type A aortic dissection (TAAD). DISCUSSION: TAAD is a surgical emergency which can rarely manifest as intermittent malperfusion of upper limbs. This could be explained by the dissection flap's dynamic obstruction of the right brachiocephalic trunk and left subclavian artery. CONCLUSION: In patients with a discrepancy in pulse between both limbs or intermittent ischemia of limbs, aortic dissection should be considered a differential diagnosis.

Minimal invasive management of generalized peritonitis as a result of spontaneous ureteral rupture.

INTRODUCTION AND IMPORTANCE: Generalized peritonitis following proximal ureteral rupture is a very rare complication. This is about a successfully managed case without open surgical intervention. CASE PRESENTATION: A lady in her 70s presented with generalized abdominal pain, high spiking fever and low urine output for 3 days. She was haemodynamically unstable on admission and was resuscitated and managed at intensive care unit. CECT abdomen revealed partial anterior ureteral rupture with pyonephrosis. She was managed with percutaneous nephrostomy and subsequent anterograde stenting. Her recovery was uneventful and follow up imaging revealed no features of malignancy. CLINICAL DISCUSSION: Generalized peritonitis due to renal pathology is very rare and it can be due to urolithiasis or neoplasm. Retroperitoneal infections may lead to irritation of peritoneum or fistulation into the peritoneum leading to generalized peritonitis. This can be managed by various surgical and non-surgical management modalities. CONCLUSION: There are various pathological causes for acute abdomen. One of the rare causes is spontaneous rupture of ureter in pyonephrotic kidney which can also be managed successfully with minimal intervention.

Distant Lung Recurrence of Rectal Cancer 20 Years After Primary Surgery.

A male patient in his 70s, who had undergone an abdominoperineal (A1) resection for rectal cancer 20 years prior, presented with hemoptysis. Imaging studies revealed distant lung recurrence, with no evidence of local recurrence. Biopsy revealed an adenocarcinoma, possibly of rectal origin. Immunohistochemical markers were suggestive of rectal cancer metastasis. However, carcinoembryonic antigen (CEA) levels were normal, and colonoscopy did not reveal any metachronous lesions. Curative left upper lobe resection was performed via posterolateral thoracotomy. The patient's recovery was uneventful.

Prevalence of Neuroendocrine Tumours (NET) in Patients Undergoing Appendicectomy for Acute Appendicitis: A Tertiary Care Study.

Introduction Acute appendicitis is one of the common causes of acute abdomen in adults, which is managed widely with appendicectomy. Neuroendocrine tumours are the most common appendiceal tumours diagnosed incidentally on appendicectomy specimens.  Methods  Demographic data, presenting complaints, indications for appendicectomy, and the histology findings based on histopathological reports of the patients who have undergone appendicectomy for appendicitis at surgical units of Teaching Hospital, Jaffna, from 1st of January 2019 to 31st of December 2022 were retrospectively analyzed.  Results Of the 1341 histopathology reports, 0.2% (n=3) were neuroendocrine tumours (NET). The mean age of the patients with NET was 48.6, and 66.6% of them were females. All three NETs identified in appendicectomy specimens were well differentiated and smaller than 2 cm. All three had negative resection margins and were managed only with appendicectomy.  Conclusion  NETs of the appendix are the commonest appendiceal neoplasms. The majority of them are diagnosed incidentally in appendicectomy specimens. Surgical management of the tumours is either by appendicectomy or hemicolectomy, which depends mainly on tumor size. Surgical decisions should be tailor-made to the patients based on multi-disciplinary team decisions.