Echinococcal lump: An unusual differential diagnosis for a right iliac fossa lump

Aim

To report the rare case of a primary peritoneal hydatid cyst in a 65-year-old lady.

Case Report

A 65-year-old female presented with a 3-month history of a painless progressive swelling in the right lower abdomen. The lump was 10 cm × 8 cm in size, non-tender, cystic in consistency, and was located in the right iliac fossa and part of the right lumbar region; mobility was restricted in all directions. CECT showed a large septated cystic lesion 14 × 9 × 8 cm in size with enhancement, and sharp regular outline in the right lower abdomen along the anterior aspect of the right psoas muscle. The liver and spleen were not affected.

Result

During surgery, a cystic swelling was exposed. Aspiration revealed a clear fluid with some floating material. The cyst wall was incised and fluid along with daughter cysts were removed keeping the pericyst in situ. Histopathological examination confirmed hydatid disease.

Conclusion

Primary peritoneal hydatid cysts, though very rare, should be kept in mind in the differential diagnosis of a right iliac fossa lump in areas where hydatid disease is endemic.

     

Retro-odontoid synovial cyst resected via an anterolateral approach without fusion

Purpose

Retro-odontoid synovial cysts are rare and attributable to degenerative changes in the atlantoaxial joints. An anterolateral approach facilitates access to lesions located anterior to the craniocervical junction without harming the atlantoaxial joints, and can also treat small lesions in the ventral mid-portion of the craniocervical junction without compression of spinal cord.

Methods

We present herein the case of a 70-year-old man with a retro-odontoid synovial cyst. A ventral midsection mass was present at the level of the atlantoaxial joint. The compressed anterior medulla led to neurological deficits. Slight atlantoaxial instability was radiologically present. An intradural cyst resection without fusion was performed via the anterolateral approach. The diagnosis of a synovial cyst was histologically confirmed.

Results

The patient was followed up for 3 years and exhibited improvements in the neurological deficits. There were no recurrence and postoperative deterioration of atlantoaxial instability.

Conclusions

The anterolateral approach for the retro-odontoid synovial cyst had little effect on C1–2 instability and yielded neurological improvements.

     

Esophageal perforation after anterior cervical surgery: a review of the literature for over half a century with a demonstrative case and a proposed novel algorithm

Purpose

To review relevant data for the management of esophageal perforation after anterior cervical surgery.

Methods

A case of delayed esophageal perforation after anterior cervical surgery has been presented and the relevant literature between 1958 and 2014 was reviewed. A total of 57 papers regarding esophageal perforation following anterior cervical surgery were found and utilized in this review.

Results

The treatment options for esophageal perforation after anterior cervical surgery were discussed and a novel management algorithm was proposed.

Conclusion

Following anterior cervical surgery, patients should be closely followed up in the postoperative period for risk of esophageal perforation. Development of symptoms like dysphagia, pneumonia, fever, odynophagia, hoarseness, weight loss, and breathing difficulty in patients with a history of previous anterior cervical surgery should alert us for a possible esophageal injury. Review of the literature revealed that conservative treatment is advocated for early and small esophageal perforations. Surgical treatment may be considered for large esophageal defects.

     

Rare complications of osteolysis and periprosthetic tissue reactions after hybrid and non-hybrid total disc replacement

Purpose

Few complications have been reported for lumbar total disc replacement (TDR) and hybrid TDR fixations. This study evaluated retrieved implants and periprosthetic tissue reactions for two cases of osteolysis following disc arthroplasty with ProDisc-L prostheses.

Methods

Implants were examined for wear and surface damage, and tissues for inflammation, polyethylene wear debris (polarized light microscopy) and metal debris (energy-dispersive X-ray spectroscopy).

Results

Despite initial good surgical outcomes, osteolytic cysts were noted in both patients at vertebrae adjacent to the implants. For the hybrid TDR case, heterotopic ossification and tissue necrosis due to wear-induced inflammation were observed. In contrast, the non-hybrid implant showed signs of abrasion and impingement, and inflammation was observed in tissue regions with metal and polyethylene wear debris.

Conclusions

In both cases, wear debris and inflammation may have contributed to osteolysis. Surgeons using ProDisc prostheses should be aware of these rare complications.

     

Harnröhrenrekonstruktion bei vorausgegangener Hypospadieoperation

Background

The tasks involved in reconstructing the urethra after failed hypospadias repair range from correction of a trivial meatal stenosis to reconstruction of the entire anterior urethra.

Objectives

To describe pathological findings in the urethra after failed hypospadias repair and the respective surgical methods used for their correction.

Materials and methods

The various pathological findings after unsuccessful hypospadias surgery are classified according to their location and complexity.

Results

The general rules of reconstruction that should be applied in each particular situation are described.

Conclusions

Successful reconstruction of the urethra in patients with failed hypospadias surgery requires experience and good knowledge of the anatomy of the normal and hypospadic urethra and penis. Mastery of plastic surgical techniques and profound knowledge of the various surgical methods of hypospadias surgery are essential.

     

Anterior cervical intradural arachnoid cyst,a rare cause of spinal cord compression: a case report with video systematic literature review

Purpose

Mostly seen at the thoracic level, arachnoid cysts are a very rare cause of cervical spinal cord compression. Generally treated by laminectomy and cyst fenestration, this approach does not allow removing the cyst in its entirety without manipulating the weakened spinal cord. The aim of this report is to present the case of a cervical intradural arachnoid cyst surgically removed by an anterior approach with corporectomy.

Methods

Here is the case of an 18-year-old amateur boxer presenting with a voluminous cervical intradural anterior arachnoid cyst, extending from C2 to C5. Symptoms were cervical pain, quadriparesis, and clumsiness of both arms which had appeared just after a traffic accident. An anterior approach was chosen, through a C5 corporectomy.

Results

The patient totally recovered from his sensitive symptoms at discharge and from his motor symptoms 6 weeks later. Early as well as 3-years post-operatively, MRI confirmed expansion of the spinal cord without any centro-medullar signal. The patient remained asymptomatic 3 years after surgery. Since the first report in 1974, 16 cases of symptomatic cervical intradural arachnoid cysts were treated via a posterior approach, one by MRI-guided biopsy, and one was re-operated on through an anterior approach. For 14 patients, their conditions had improved, while one died of pneumonia, one presented a condition worsened, and one had a stable neurological status.

Conclusion

Using an anterior approach is a safe procedure that allows resection of a cervical arachnoid cyst without any manipulation of the weakened spinal cord, while giving the best possible view.

     

Giant cystic sacral schwannoma mimicking tarlov cyst: a case report

Purpose

To present a rare case of a giant schwannoma of the sacrum mimicking a Tarlov cyst.

Methods

A 58-year-old woman had a 1-year history of low back pain. MRI revealed a large cystic mass in the sacral canal with bony erosion. Radiological diagnosis of Tarlov cyst was made.

Results

The patient underwent surgical treatment for the lesion, which revealed a solid mass. Histopathological examination of the tumor confirmed the diagnosis of schwannoma. The postoperative course was uneventful and the patient has had significant improvement in her pain 1 month postoperatively.

Conclusion

Giant cystic schwannoma of the sacrum is a very rare diagnosis overlooked by practitioners for more common cystic etiologies, but its treatment is significantly different. Care should be taken to include this diagnosis in a differential for a cystic sacral mass.

     

Musculoskeletal Echinococcus infection as a rare first presentation of hydatid disease: case report

Background

Hydatid disease (HD) is a cosmopolitan parasitosis caused by Echinococcus granulosus that can potentially affect any part of the human body. Liver and lungs are the most frequent localizations. Primary musculoskeletal hydatidosis are seldom reported in literature and their incidence is unknown.

Case presentation

We deem interesting to report a case of a primary hydatid cyst in a 25-year-old patient who presented with a painful swelling of the right elbow. Meticulous examination and preoperative imaging did not reveal other localizations. Patient was admitted for surgery where total excision of cyst was done without intraoperative spillage and a cutaneous skin flap was subsequently required to make up for soft tissue loss.

Conclusion

Primary hydatid cysts are sometimes difficult to diagnose preoperatively. It should be considered in the differential diagnosis of subcutaneous cystic lesions in regions where hydatid cysts are endemic. Currently, surgical excision is deemed first choice treatment for solitary cysts and antihelminthic treatment should be initiated preoperatively in the case of risk of rupture or in the event of complications.

     

Transvaginal primary repair of a suprasphincteric rectovaginal fistula

Introduction and hypothesis

Rectovaginal fistula repair is one of the most challenging gynecological surgical procedures. This video is intended to serve as a tutorial for surgical repair.

Methods

An 80-year-old woman who developed a traumatic suprasphincteric rectovaginal fistula was managed through layered transvaginal repair without flaps.

Results

Anatomy restoration was completed without complications.

Conclusion

The procedure described in this video was effective and safe. Vaginal route should be considered as a valid surgical approach for rectovaginal fistula repair.

     

A rare case of <Emphasis Type="Italic">Candida parapsilosis</Emphasis> osteomyelitis: a literature review and proposed treatment algorithm

Background

Candida parapsilosis is a rare opportunistic pathogen that can be found in immunosuppressed patients. There are seldom-reported cases of fungal osteomyelitis surrounding orthopedic implants.

Case presentation

This is a case of chronic Candida parapsilosis osteomyelitis in an immunocompromised patient with a prior open reduction and internal fixation for a closed bimalleolar ankle fracture that went on to neglected wound complications. The patient underwent series of treatments including removal of hardware, serial irrigation and debridements, negative pressure wound therapy, and intravenous antifungal therapy. Our case illustrates the possibility of this rare pathogen involved in orthopedic surgery particularly in immunocompromised hosts.

Conclusion

Fungal and atypical pathogens should always be considered in such patients or if another diagnosis is not clear. Protracted time to culture specimens should be considered for at least four weeks in such situations. This article outlines a review of the literature and treatment algorithm to guide physicians when managing patients with this rare infection.

     

Pre-expanded epigastric flap cover for ventral hernia following fungal necrotizing fascitis of caesarian section wound: An unusual complication

Introduction

Reconstruction of anterior abdominal wall after necrotizing abdominal wall infections is a challenge.

Material and methods

A 35-year-old lady presented with 20 × 18 cm sized defect of the anterior abdominal wall following fungal necrotizing fascitis. The defect was covered by an overlay prolene mesh and the soft tissue deficit was corrected by pre-expanded epigastric flap based on the superior epigastric artery.

Conclusion

A concerted multi-specialty effort is needed to correct these defects.

     

Inflammatory Pseudotumor of the Spleen

Background and Aims

Evaluation of effectiveness in the differential diagnosis of the very rare entity of inflammatory pseudotumor (IPT) of the spleen, with presentation of its pathology and pathogenicity.

Methods

The case is presented of a 60-year-old female who underwent ultrasound (US) examination of the upper abdomen, after an accidental fall from a height, which revealed a splenic mass. Meticulous clinical and laboratory examination and imaging confirmed the presence of the splenic mass, which mimicked malignant lymphoma.

Results

Splenectomy was performed and the histopathology report revealed a tumor consisting of inflammatory cells intermingled with spindle and mast cells, consistent with the diagnosis of IPT.

Conclusions

IPTs are very rare benign tumors which mimic other benign or malignant tumors. The clinical diagnosis is difficult, but they have a very good prognosis. Surgeons should be aware of the condition in order to avoid misdiagnosis and inappropriate treatment.

     

Video of the laparoscopic repair of a vesico-uterine fistula

Aim

Vesico-uterine fistulas (VUFs) are rare in modern gynecological practice. We aim to demonstrate with a video the surgical techniques involved in laparoscopic repair of a vesico-uterine fistula (Youssef’s syndrome).

Methods

A 37-year-old woman, para 2 and otherwise healthy, was referred to the Urogynaecology Unit 4 months following a vaginal birth after a previous cesarean, with ongoing pink-colored vaginal watery discharge. Cystoscopy and hysteroscopy confirmed the findings of a well-granulated fistulous tract connecting the base of the bladder and anterior uterine wall just above the level of the internal os. She underwent an uncomplicated laparoscopic repair of VUF.

Results

She has remained asymptomatic with resumption of normal menses and no clinical evidence of fistula recurrence at 6-week and 6-month post-operative reviews.

Conclusion

This video demonstrates the surgical techniques involved in the laparoscopic repair of a VUF, a rare case in modern gynecological practice where there are few surgical videos demonstrating techniques.

     

Longitudinal morphological change of acetabular subchondral bone cyst after total hip arthroplasty in developmental dysplasia of the hip

Purpose

The purpose of this study is to clarify morphological changes of acetabular subchondral bone cyst after total hip arthroplasty for osteoarthritis secondary to developmental dysplasia of the hip.

Methods

Two hundred and sixty-one primary cementless total hip arthroplasties of 208 patients, 18 males, 190 females, were retrospectively reviewed. Morphological changes of subchondral bone cyst were evaluated by computed tomography (CT). The mean cross-sectional area of the cyst from CT scans at 3 months postoperatively and after 7–10 years (average 8.4 years) were compared.

Results

Acetabular subchondral bone cysts were found in 49.0% of all cases in preoperative CT scans. There was no cyst which was newly recognized in CT scan performed after postoperative 7–10 years. All the cross-sectional areas of the cysts evaluated in this study were reduced postoperatively.

Conclusions

This study revealed that acetabular subchondral bone cysts do not increase or expand after total hip arthroplasty and indicated that the longitudinal morphological change of acetabular bone cysts in patients of developmental dysplasia of the hip do not influence long-term implant fixation in total hip arthroplasty.

     

Location Frequency of Missed Parathyroid Glands After Parathyroidectomy in Patients with Persistent or Recurrent Secondary Hyperparathyroidism

Background

Reoperative parathyroidectomy (RPTX) because parathyroid glands have been missed is frequently required in patients with secondary hyperparathyroidism (SHPT). The usual locations of these missed glands in patients with SHPT are yet to be fully elucidated.

Methods

We retrospectively investigated the locations of missed glands in 165 patients who underwent RPTX for persistent or recurrent SHPT at our institution from August 1982 to July 2014. At our institution, total parathyroidectomy with forearm autograft is the routine operative procedure for SHPT. We also routinely resect the thymic tongue.

Results

Of 165 patients, 82 underwent initial parathyroidectomy at our institution (Group A), and the remaining 83 underwent initial parathyroidectomy at other institutions (Group B). A total of 239 parathyroid glands were resected (Group A, 93; Group B, 146). Missed glands were most commonly located in the mediastinum (Group A, 22/93) and the thymic tongue (Group B, 31/146).

Conclusions

In patients with persistent or recurrent SHPT, ectopic parathyroid glands are frequently located in the mediastinum and thymic tongue. Therefore, resecting the thymic tongue during the initial operation may reduce the need for RPTX.

     

Ausbildung und Training des Rettungsfachpersonals und der Notärzte

Background

General threats, such as killing sprees and terror attacks, have moved into the focus of emergency medicine, with the consecutive adaptation of education and training.

Methods

Narrative review and expert assessment.

Result

Terrorist attacks are rare in Germany but should be taken into account due to their special safety requirements and rare patterns of injuries. There is a need for increased awareness among the emergency medical services regarding the threat and attention to the environment and the possibility of a threat situation. Communication channels and stand-by procedures at the scene must be clarified, triage must be regularly trained, and knowledge about the treatment of these patients and appropriate tactical strategies must be taught. The training of skills is essential and leads to a higher level of safety. As human factor resources, tools such as checklists can help with preparation. Mental support and debriefing concepts are needed to maintain the health and performance of the staff.

Discussion

It is important to train relevant competencies for rare events. A variety of topics should be taught during regular training, regardless of the threat situation.

     

Surgical excision of symptomatic sacral perineurial Tarlov cyst: case series and review of the literature

Object

Symptomatic sacral perineural cysts are extremely rare. The aim of this retrospective study is to investigate the outcome of 15 consecutive patients treated by microsurgical resection of the cyst and to review the literature.

Methods

The authors retrospectively reviewed their clinical data archive from 2002 to 2014. Fifteen patients who were operated on due to symptomatic sacral perineural cysts were enrolled in the study. Patients’ symptoms, radiographs, intra-operative findings, and clinical results were evaluated. All 15 patients underwent microsurgical excision of the cyst. The literature on this topic available in PubMed was also reviewed.

Results

There were 5 men and 10 women included in the study, with a mean age of 31 years (range 7–60 years). Preoperative symptoms include low back pain, coccydynia, buttock pain, perianal pain and radicular pain. All of the patients underwent surgical resection. The mean follow-up was 54 months (range 3–160 months). All the patients experienced complete or substantial resolution of the preoperative local and radicular pain after surgery.

Conclusions

Cyst excision is an effective and safe technique for symptomatic sacral perineural (Tarlov) cysts. Careful patient selection is vital to the management and treatment of this difficult and controversial pathology.

     

Transvaginal repair of a urethrovaginal fistula using the Latzko technique with a bulbocavernosus (Martius) flap

Introduction and hypothesis

Urethrovaginal fistula is a rare disorder that may occur following sling procedures for stress urinary incontinence, excision of a urethral diverticulum, anterior vaginal wall repair, radiation therapy, and prolonged indwelling urethral catheter. The most common clinical manifestation is continuous urinary leakage through the vagina, aggravated by an increase in the intra-abdominal pressure. Appropriate management, including timing of the surgical intervention and the preferred technique, remains controversial.

Methods

This video presentation describes the transvaginal repair of a urethrovaginal fistula using the Latzko technique and a bulbocavernosus (Martius) flap.

Results

The patient’s postoperative course was uneventful. At her follow-up visit 2 months later, she was free of urinary leakage, and a pelvic examination revealed excellent healing, with complete closure of the fistula.

Conclusions

Transvaginal repair using the Latzko technique with a vascular bulbocavernosus (Martius) flap is an effective and safe mode of treatment.

     

Arthroskopische subakromiale Dekompression

Objective

Coracoacromial ligament release to widen the subacromial space, resection of the anterior undersurface of the acromion and, if needed, caudal exophytes at the acromioclavicular joint.

Indications

All types of outlet impingement after 3 months of conservative treatment.

Contraindications

Impingement syndrome with instability/muscular imbalance, massive rotator cuff tear, unstable os acromionale, posterior–superior impingement, joint infection, freezing phase of a secondary frozen shoulder.

Surgical technique

Lateral decubitus position with traction device for the arm. Diagnostic arthroscopy of the glenohumeral joint via standard portals. With arthroscope moved to the subacromial space, bursectomy, electrosurgical release of coracoacromial ligament, resection of acromial hook through standard posterior portal.

Postoperative management

Physiotherapy or self-exercises on postoperative day 1, pain-adapted analgesia to avoid shoulder stiffness.

Results

Several studies present positive long-term results compared to conservative treatment (and open acromioplasty) for partial rotator cuff tears and for elderly patients. With a 20-year follow-up, successful results have been achieved for all patients with isolated impingement syndrome.