A Well-Differentiated Grade-3 Neuroendocrine Tumor in the Ascending Colon: A Case Report.

BACKGROUND Gastrointestinal neuroendocrine tumors (NETs) are indolent hormone-secreting pathologic illnesses that can occur throughout the whole digestive tract. They are classified by site and grade. Colon neuroendocrine neoplasm (NEN) is an unusual histologic finding that needs to be further investigated. Well-differentiated (WD) Grade-3 (G3) is a new category of NEN that falls between neuroendocrine tumor (NET) and neuroendocrine carcinoma (NEC). CASE REPORT A 60-year-old man with a past medical history of diabetes mellitus presented with severe anemia and significant weight loss. Tumor markers (CEA and CA 19.9) were unremarkable. Colonoscopy showed a large fungating mass in the proximal part of the ascending colon. Biopsy results suggested colonic adenocarcinoma. Contrast-enhanced computed tomography of the chest, abdomen, and pelvis demonstrated a 5×5 cm ascending colon mass with few locoregional lymph nodes and no distant metastasis. A laparoscopic right hemicolectomy performed and histopathologic examination revealed T4N1, WD-NET G3. Postoperative completion work-up was done. Chromogranin-A was in the normal range and nuclear scans (PET and gallium 68) showed no abnormal uptake or residual disease. Extensive review, expert opinion, and multidisciplinary meetings failed to establish guidelines for adjuvant therapy due to the paucity of data in the literature. CONCLUSIONS Well-differentiated grade 3 NETs of the ascending colon is a rare finding in a rare disease. This entity of NENs is an unmet medical issue on the border between NET and NEC that remains a matter of great debate in terms of establishing an accurate diagnosis and outlining proper management.

Complex bronchial ruptures in blunt thoracic trauma: management and outcome.

Complex bronchial ruptures are rare. Primary surgical repair is the preferred procedure. The aim of this retrospective case series was to study the clinical presentation of these complex bronchial injuries and their management and outcomes. Patients with injuries to the trachea or those who had simple single bronchial rupture and isolated lobar and segmental injuries were excluded. Twenty-one patients were operated for bronchial rupture due to blunt chest trauma. Seven patients had complex bronchial injuries and had right bronchial tree injury (n = 3), left bronchial tree injury (n = 3), and rupture of both right and left main bronchi (n = 1). Fibreoptic bronchoscopy established the diagnosis in all patients. Postoperative complications included atelectasis in four patients (57%) and left recurrent laryngeal nerve paralysis (n = 1; 14.3%), and one patient required tracheostomy (14.3%). All patients had follow-up bronchoscopy 2 months later, which showed no stenosis or scar formation in any of the patients. We concluded that primary repair of complex bronchial injuries, with preservation of the normal functioning lung, is the preferred option as it carries favorable immediate- and long-term results.

Symptomatic Giant Primary Nonparasitic Splenic Cyst Treated with Laparoscopic Decapsulation: A Case Report and Literature Review.

BACKGROUND Primary nonparasitic splenic cysts (PNSC) are unusual epithelial fluid lesions of the spleen. They are considered congenital cysts and are often discovered incidentally in young people. Larger cysts can be symptomatic and are traditionally managed with splenectomy. This report is of a woman with a large symptomatic PNSC that was managed surgically by laparoscopic decapsulation. CASE REPORT A 22-year-old Lebanese woman presented with left upper-quadrant pain, left pleuritic pain, food intolerance, and significant weight loss. Investigations showed a 20×17×15 cm cystic lesion in the spleen. Secondary causes were ruled out and tumor marker and hydatid serology were unremarkable. Laparoscopic decapsulation of the cyst with spleen preservation was performed with no perioperative complications. The patient's 3-year follow-up visit revealed no clinical or radiological recurrence. CONCLUSIONS True congenital splenic cysts are rare clinical findings. Generally, they do not have malignant potential. The development of minimally invasive techniques has shifted the trend toward splenic salvaging procedures. Literature review revealed an acceptable recurrence rate with near-total rather than partial unroofing. Laparoscopic decapsulation can be a safe and adequate therapeutic option in selected cases.

Gall stone ileus: Unfamiliar cause of bowel obstruction. Case report and literature review.

INTRODUCTION: Gallstone ileus is a rare sequela of cholelithiasis. The pathology occurs as a result of bilioenteric fistula due to erosion by the offending gallbladder stone. It is most commonly encountered in elderly females and CT imaging is diagnostic in the majority of cases. Surgical intervention aims to promptly relief the obstruction by removing the gallstone and dealing with the fistula. Morbidity and mortality are usually high since it usually occurs in elderly patients. PRESENTATION OF CASE: An 88-year-old lady with multiple chronic medical problems and no history of biliary manifestation presented with acute small bowel obstruction. Abdominal CT imaging revealed a bilioenteric fistula and an impacted gallstone in the jejunum causing occlusion. Laparotomy was performed and the stone was removed via enterolithotomy. Manipulation of the cholecystoduodenal fistula was not attempted due to severe inflammatory adhesions. The patient had uneventiful postoperative course and remained symptom free on one year follow-up. DISCUSSION AND CONCLUSION: Management of gallstone ileus is mainly surgical. Delay in detection and treatment of gallstone ileus may result in significant morbidity and mortality. The choice of surgical option is influenced by the preoperative medical status of the patient. A literature review generally supports the employment of enterolithotomy in high-risk patients and reserving cholecystectomy and resection of the fistula for less comorbid patients with feasible anatomy.

Distinctive vasculopathy with systemic involvement due to levamisole long-term therapy: a case report.

BACKGROUND: Levamisole belongs to the antihelminthic class of drugs that are sometimes administered to patients with frequently relapsing or steroid-dependent nephrotic syndrome, owing to its steroid-sparing effects. Neutropenia and skin lesions, compatible with vasculitis, have been reported as drug complications, but they are rarely associated with any systemic involvement. CASE PRESENTATION: We report a case of a 9-year-old Arab boy with steroid-dependent nephrotic syndrome who was treated with levamisole after his third relapse. The drug was initially well tolerated, but mild isolated neutropenia occurred 6 months after levamisole administration. This was followed by cutaneous vasculitis of both ears and the left cheek. The patient also developed hepatosplenomegaly and anemia. Levamisole was discontinued, and his disease remained in remission. All the systemic manifestations disappeared gradually over the course of 1 month. The patient remained in remission until 1 year after levamisole withdrawal, when clinical nephrosis recurred. CONCLUSIONS: Despite levamisole's being a useful drug for maintaining remission in steroid-dependent nephrotic syndrome, patients on long-term levamisole therapy should be monitored closely to prevent serious complications that can easily be resolved by simple drug withdrawal.

Total Gastric Necrosis Due to Mucormycosis: A Rare Case of Gastric Perforation.

BACKGROUND Spontaneous gastric perforation is usually a complication of peptic ulcer disease, or a postoperative complication resulting from gastric torsion. Mucormycosis (or zygomycosis) is an uncommon opportunistic fungal infection that is usually seen in immunocompromised patients and is associated with significant morbidity and mortality. This report is of a rare case of spontaneous gastric perforation due to mucormycosis infection. CASE REPORT A 52-year-old woman, with a past medical history of heroin abuse, diabetes mellitus, hypertension, and chronic kidney disease treated by dialysis, presented to the emergency department with cellulitis of the arms. Following hospital admission, her medical condition deteriorated, and she developed septic shock and multiorgan failure, requiring transfer to the intensive care unit (ICU), where she was diagnosed with a perforated hollow viscus as the cause. Surgical exploration showed that the mucosa of the stomach was necrotic and perforated, but the remaining bowel appeared normal. Total gastrectomy was performed, and a jejunostomy feeding tube was inserted. Histopathology of the gastric tissue confirmed infection with mucormycosis. The patient was treated with adjunctive liposomal amphotericin B, her condition improved, and she was extubated on postoperative day 2. However, the patient died on postoperative day 21 due to sepsis and multiorgan failure. CONCLUSIONS Mucormycosis is an opportunistic angioinvasive fungal infection, and gastric perforation is a rare clinical presentation. However, knowledge of the association between gastric necrosis and perforation and mucormycosis infection might lead to early diagnosis and treatment and reduce patient morbidity and mortality.

Ureteropelvic Junction Obstruction and Parathyroid Adenoma: Coincidence or Link?

Congenital ureteropelvic junction obstruction (UPJO) is the most common cause of upper urinary tract obstruction in children. It is generally diagnosed in the routine work-up during antenatal period and is characterized by spontaneous recovery. It can be associated with urolithiasis; hence further investigation should be carried out. We report the case of a 15-year-old boy, who is known to have right UPJO, presented with right renal colic and discovered to have bilateral kidney stones. Further studies showed primary hyperparathyroidism and genetic analysis revealed a CDC73 mutation (initially HRPT2). We believe that association of UPJO and PHPT is a rare coincidence that can be linked. Careful work-up of children with UPJO and urolithiasis is recommended to exclude an underlying metabolic disease. Surgical correction can be evitable as treatment of the primary cause can lead to complete dissolution of kidney stones and improvement of the medical condition.

Laparoscopic management of a small bowel obstruction secondary to Elipse intragastric balloon migration: A case report.

INTRODUCTION: The Elipse™ intragastric balloon (IGB) for weight loss is a swallowable capsule that is filled with 550mL of fluid and resides in the stomach for four months before being excreted from the gastrointestinal tract. Although initial data showed that use of this device is safe and free from serious complications, we report for the first time the successful management of an Elipse™ IGB-related adverse event. PRESENTATION OF CASE: A 41-year-old woman presented to our emergency department following two days of abdominal pain, vomiting, and constipation. Her medical history included four caesarean sections and insertion of the Elipse™ IGB 16 weeks prior to presentation. The patient was vitally stable at presentation and abdominal examination revealed a mildly distended abdomen. Plain X-ray revealed a small bowel obstruction (SBO), and a double contrast computed tomography scan showed a dilated small bowel with mild free fluid proximal to a transition zone at the distal jejunum. Laparoscopic enterotomy was performed just proximal to the obstruction site, and the balloon was visualized and extracted after it had been incised and emptied. The enterotomy incision was closed with an intracorporeal continuous absorbable suture. The patient's recovery was uneventful and she was discharged on postoperative day 4. DISCUSSION: We discuss the possible etiologies of SBO following Elipse™ IGB insertion, and present a brief literature review regarding surgical and nonsurgical management options for such cases. CONCLUSION: Although initial data showed the Elipse™ IGB to be safe, complications can occur and be managed successfully.

Gallbladder-associated symptomatic hepatic choristoma: Should you resect?

INTRODUCTION: Hepatic choristomas or ectopic livers are uncommon, and occur due to a failure of embryological liver development. They pose a risk of carcinogenesis, with transformation to hepatocellular carcinoma (HCC) being described in the literature (Arakawa et al., 1999). It is often a silent clinical finding that can occur anywhere in the body and is usually diagnosed incidentally during abdominal surgical procedures or autopsies (Eiserth et al., 1940). We present the case of a patient with a symptomatic ectopic liver that was detected preoperatively, and removed laparoscopically with the gallbladder. PRESENTATION OF CASE: A 73-year-old lady was referred to our unit for a gallbladder tumor on ultrasound which was done for biliary colic. Tumor markers were normal. Computed tomography (CT) scan showed an enhanced soft tissue lesion measuring about 3×1.5cm interposed between the gallbladder and liver. Laparoscopic exploration revealed a bean-shaped hepatic choristoma attached to the liver on the medial wall of the gallbladder. The lesion was removed by en-bloc resection during laparoscopic cholecystectomy and extracted carefully in an endobag. Histopathological examination confirmed the absence of carcinogenesis. DISCUSSION AND CONCLUSION: Hepatic choristomas (HC) are a rare entity, usually identified during abdominal surgeries. It had been reported in several studies with different presentations. Awareness of this unexpected finding and familiarity of its potential complications and carcinogenesis will improve care delivery when encountered. Surgical treatment should be considered when the choristoma is not attached to the liver, in light of its potential transformation into HCC.

Giant gastric lipoma presenting as GI bleed: Enucleation or Resection?

INTRODUCTION: Gastric lipomas are unusual benign lesions and account for less than 1% of all tumours of the stomach and 5% of all gastrointestinal lipomas (Thompson et al.2003; Fernandez et al. 1983 [1,2]). Although predominantly asymptomatic and indolent; they may present with gastric outlet obstruction and upper gastrointestinal (GI) bleeding owing to size and ulceration. Only a few cases have been reported, presenting large in size with massive GI bleeding (Alcalde Escribano et al. 1989; Johnson et al. 1981 [3,4]). PRESENTATION OF CASE: We report the case of a 62-year-old gentleman who presented to the emergency department with massive upper GI hemorrhage. He was initially resuscitated and stabilized. Later gastroscopy showed a large submucosal tumour (Fig. 1). Biopsy revealed adipose tissue. Computed tomography (CT) scan of the abdomen and pelvis showed a huge well defined oval soft tissue lesion measuring about 16×8×8cm. The mass noted a homogenous fat density arising from the posterior wall of stomach with no extramural infiltration (Fig. 2). The tumour was completely enucleated through an explorative gastrotomy incision (Fig. 4). DISCUSSION AND CONCLUSION: Massive bleeding secondary to a giant gastric lipoma is a rare finding of a rare disease. The majority of cases in the literature result in major gastric resection. Familiarity with its radiological findings and a high index of suspicion can lead to proper diagnosis in the acute setting. If malignancy is carefully ruled out, stomach preserving surgery is an optimal treatment option.

Torsion of huge wandering accessory spleen. Case report and review of literature.

INTRODUCTION: Accessory spleens are found in 10-15% of the population, and are even more prevalent in patients with hematological disorders (Rudowski, 1985). It infrequently may become symptomatic due to torsion, spontaneous rupture or hemorrhage which may lead to death. Torsion of an accessory spleen is extremely rare, and requires prompt medical attention [2] (Coote et al., 1999). PRESENTATION OF CASE: We report the case of a 27-year-old Mediterranean lady with thalassemia trait, who presented to the emergency department with an acute surgical abdomen due to torsion of a giant accessory spleen, measuring 13cm. She was diagnosed with the aid of ultrasound and computed tomography (CT) scan and was treated surgically through resection of the spleen. DISCUSSION AND CONCLUSION: Torsion of an accessory spleen is not common, and is the surgical indication in about 0.2-0.3% of splenectomies (Mortele et al., 2004). It has variable clinical presentations, and is a difficult preoperative diagnosis due to lack of specificity of symptoms. Accessory spleens are usually smaller than 3cm, with few cases being reported as larger than 10cm larger accessory spleens have a higher rate of torsion. Knowledge of this pathology, and familiarity with its radiological findings are fundamental to accurately diagnosing and manageming this challenging condition.

Segmental arterial mediolysis with 5 splenic artery aneurysms. A rare finding of a rare disease: Case report and literature review.

INTRODUCTION: Splenic artery aneurysms (SAA) are uncommon findings. They are usually single and isolated; however they can be multiple; hence vasculopathy and segmental artery mediolysis may be considered. PRESENTATION OF CASE: In our manuscript we present a case of a 54year old multiparous lady who was discovered incidentally to have a diseased splenic artery containing five SSAs. The largest aneurysm was close to the takeoff of the vessel and the smallest was distal embedded in the splenic hilum. Endovascular option was technically not feasible. Therefore the patient underwent a complete splenic artery resection with splenectomy and the histopathologic examination was suggestive of segmental arterial mediolysis (SAM). DISCUSSION AND CONCLUSION: Multiple SAAs remains a rare finding of a rare disease. Complications can be crucial and high index of suspicion is important. Segmental arterial mediolysis can be considered in patients with several aneurysms on one anatomic site; Angiography is the gold standard diagnostic and therapeutic method. Complete splenic artery resection with splenectomy is the best treatment option for solitary vessel involvement.

Gallbladder Mucus Plug Mimicking Ascaris Worm: An Ambiguous Cause of Biliary Colic.

Biliary colic is a visceral pain caused by attempts of the gallbladder or bile duct to overcome the obstruction in the cystic duct or ampulla of Vater. Obstruction can be due to different etiologies such as stone, mass, worm, and rarely by mucus plug. We report the case of a 31-year-old gentleman who presented with recurrent biliary colic and weight loss. Work-up showed linear calcifications in the gallbladder extending to the common bile duct suggesting hepatobiliary ascariasis. Further investigations including stool analysis, upper endoscopy, endoscopic ultrasonography (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) did not support our provisional diagnosis. Laparoscopic cholecystectomy was performed. Histopathological finding was grossly ambiguous; a rope-like mucus plug resembling ascaris worm was noted. The patient's condition improved instantly after the procedure. To our knowledge, we are reporting the first case in the English literature describing this unique entity of symptomatic gallbladder disease to increase awareness and improve its management.

The recipient celiac trunk as an alternative to the native hepatic artery for arterial reconstruction in adult liver transplantation.

During liver transplantation (LT), the recipient hepatic artery (RHA) cannot always be used, and alternatives include aortohepatic conduits and the splenic artery (SA). We report our experience with arterial reconstruction on the recipient celiac trunk (RCT), which has rarely been described. Since January 2013, we have been using the RCT when the RHA could not be used. All cases were discussed in a multidisciplinary LT meeting, and arterial patency or anomalies were systemically viewed with computed tomography (CT) scan. The RCT was used after section-ligation of all celiac trunk collaterals. Until May 2014, the RHA could not be used in 11/139 (8%) patients who underwent LT. Postoperative arterial patency was assessed by serial Doppler ultrasound and CT scan. The advantages and disadvantages of the different arterial conduits were evaluated. The RCT was used in 7/11 (64%) patients. Mean follow-up was 10 (6-15) months. The patency rate was 100%, and 1 patient with associated portal shunting died at day 20 from septic complications. No related gastric or splenic complications were encountered. The RCT could not be used in 4 patients with reconstruction on the SA (n = 2), infrarenal (n = 1), and supraceliac aorta (n = 1). The patency rate was 75%. One patient with SA conduit and portal shunting developed pancreatitis/anastomotic pseudoaneurysm with secondary rupture. An emergency infrarenal conduit was created, which was later embolized because of infected pseudoaneurysms. Although the literature reports a higher risk of thrombosis with aortohepatic conduits, no long-term results are available for the SA conduits, and only 1 report is available for the RCT. In conclusion, this study shows that the RCT is a good alternative to the RHA and can be used in two-thirds of patients with inadequate RHA flow.

Rapid and sustained recovery of renal function with transient placement of an intrauretral nephrostomy catheter in an infant with ureteropelvic junction obstruction and acute renal failure.

Ureteropelvic junction obstruction (UPJO) is a common, congenital urinary malformation in the pediatric age group. In most cases the diagnosis is made antenataly and resolves spontaneously. Postnatal diagnosis is made when symptoms of urinary tract infection or abdominal pain occur. We report a six-month-old girl with single kidney and known vesicoureteral reflux grade IV presenting with severe acute renal failure (ARF), requiring acute peritoneal dialysis (PD).After diagnosis of decompensated UPJO, a nephrostomy was performed, and renal function restored within seven days. UPJO was subsequently treated by open pyeloplasty. To our knowledge, this is the first case of UPJO requiring PD due to severe renal failure in a child. Children with UPJO and major morbidity of the contralateral kidney are at risk of renal failure and should therefore be followed carefully to prevent serious complications.

Posthepatectomy portal vein pressure predicts liver failure and mortality after major liver resection on noncirrhotic liver.

OBJECTIVES: To evaluate the predictive value of portal vein pressure (PVP) after major liver resection for posthepatectomy liver failure (PLF) and 90-day mortality in patients without cirrhosis. BACKGROUND: As elevated PVP is associated with liver failure after living donor liver transplantation, we hypothesized that the outcome after major hepatectomy may be influenced by posthepatectomy PVP. PATIENTS AND METHODS: All patients without severe fibrosis or cirrhosis who underwent a major liver resection (≥3 segments) with an intraoperative measurement of PVP at the end of the procedure were included. Outcome was analyzed regarding 3 most widely used definitions of PLF: "50-50" criteria, peak of serum bilirubin greater than 120 µmol/L, and grade C PLF proposed by the International Study Group of Liver Surgery (ISGLS). Receiver operating characteristic curves and logistic regression model were used to determine the optimal cutoff of PVP and independent risk factors of PLF. RESULTS: The study population consisted of 277 patients. Posthepatectomy PVP was gradually correlated with the PLF risk. Probability for PLF was nil when PVP was 10 mm Hg or less, ranges from 13% to 16%, depending on PLF definitions, when PVP was 20 mm Hg, and from 24% to 33% when PVP was 30 mm Hg. The optimal value of posthepatectomy PVP to predict PLF was 22 mm Hg when considering the "50-50" criteria and grade C PLF (proposed by the International Study Group of Liver Surgery). A value of 21 mm Hg best predicted PLF defined by peak of serum bilirubin greater than 120 µmol/L and 90-day mortality. At multivariate analysis, posthepatectomy PVP remained an independent predictor of PLF as well as the extent of resection, intraoperative transfusion, and the presence of diabetes. The 90-day mortality was associated with PVP greater than 21 mm Hg, older than 70 years, and intraoperative transfusion. CONCLUSIONS: Posthepatectomy PVP is an independent predictive factor of PLF and of 90-day mortality after major liver resection in patients without cirrhosis. Intraoperative modulation of PVP would be advisable when PVP exceeds 20 mm Hg.

Isolated splenic metastasis from colorectal cancer.

Splenic metastases are unusual, arising in less than 1% of all metastases. Isolated solitary splenic metastasis from colorectal carcinoma is considered exceptional. This rarity has been explained by several hypotheses relating to the anatomical, histological, and immunological features of the spleen. We review the reported cases of isolated solitary splenic metastasis from colorectal carcinoma and discuss the diagnostic and therapeutic options for this entity. We searched the English-language medical literature, using the Medline and Pubmed databases from January 1966 through July 2010, for articles reporting isolated splenic metastasis from colorectal carcinoma. Only 26 cases have been reported; four cases had synchronous splenic metastasis. Fifteen patients had regional lymph node involvement on diagnosis of primary carcinoma. The primary tumor was located in the left colon or in the rectum in 18 cases. Carcinoembryonic antigen (CEA) level was elevated in 73% of cases. All patients underwent curative splenectomy; only one patient had laparoscopic resection of the spleen. Mean reported survival interval was 19.5 months; only three patients were deceased at last follow-up. Solitary splenic metastasis from colorectal carcinoma is very rare; clinicians are advised to pay close attention when routinely evaluating patients with serial CEA levels and abdominal scans. Splenectomy seems to be the preferred treatment modality with improvement of long-term survival. However, definitive conclusions cannot be drawn from the small number of case reports available.