A case of retroperitoneal abscess: A rare complication of Meckel’s diverticulum

IntroductionThe frequent complications of Meckel’s diverticulum are hemorrhage, intestinal obstruction, and inflammation, and perforation. The presentation as a retroperitoneal abscess as complications of Meckel’s diverticulum is a very rare clinical entity.Presentation of caseWe report a rare case of perforated Meckel's diverticulum with retroperitoneal abscess.A 31-year-old presented with a half-hour history of severe epigastric pain and diffuse periumbilical pain. Abdominal computed tomography (CT) revealed pneumoperitoneum and retroperitoneal abscesses which air, with diffuse infiltration of the small bowel mesentery and a tubular structure that originated in the ileum at the umbilicus level. Preoperative diagnosis was perforation of Meckel's diverticulum or small bowel perforation. We performed an approximate 10-cm segmental resection of the ileum that contained the Meckel’s diverticulum.DiscussionRetroperitoneal abscesses are rare complications of Meckel’s diverticulum and are associated with its perforation.ConclusionThe complications of Meckel’s diverticulum should be kept in mind in the differential diagnosis of retroperitoneal abscesses.     

Robotic-assisted laparoscopic bladder diverticulectomy and concomitant ureteral re-implantation: initial clinical experience

We present our initial clinical experience with robotic-assisted laparoscopic bladder diverticulectomy with associated ureteral re-implantation. A 75-year-old man was referred to us for recurrent urinary tract infections and lower urinary tract symptoms. On computed tomography of abdomen and pelvis the patient was found to have a 13 × 14 × 6 cm diverticulum in the left posterior bladder wall. The patient elected to undergo robotic-assisted laparoscopic removal of the diverticulum. The patient’s preparation, draping, and trocar placement was performed as per standard fashion of robotic-assisted laparoscopic radical prostatectomy. The bladder was mobilized and diverticulum was identified and removed. The left ureter was transected secondary to its passage through the diverticulum, and required re-implantation. After hemostasis was achieved, the repair was tested and confirmed. The operation was completed in 207 min without any complications. Estimated blood loss was 150 cc. On postoperative day 1, the patient was placed on oral analgesic and discharged home. Our initial report of robotic-assisted laparoscopic bladder diverticulectomy and ureteral re-implantation illustrates that this minimally invasive technique is an effective method of treatment of bladder diverticulum. Proximity of the ureter to the diverticulum should not be a deterrent for this approach of repair.     

Exactitud de la urotomografía computarizada para detectar tumores vesicales en pacientes con hematuria microscópica

ObjectiveOur objective was to evaluate the sensitivity, specificity, predictive value, and accuracy of computed tomographic urography for the detection of bladder tumors in patients with microscopic hematuria.Material and methodsPatients with microscopic hematuria initially evaluated with computed tomography and cystoscopy from January 2006 to December 2009 were evaluated. Computed tomography detecting a bladder lesion suspicious of malignancy was considered positive. Cystoscopy was classified as positive when a lesion requiring biopsy or resection was found. Performance characteristics of computed tomography were determined by comparing with cystoscopic and pathological findings.ResultsA total of 112 patients were eligible for analysis. Seven tumors were found on cystoscopy; of these, 2 were correctly diagnosed by computed tomography and 5 were missed. An additional case was considered erroneously positive. The results are a sensitivity of 29%, specificity of 99%, positive predictive value of 67%, negative predictive value of 95%, and accuracy of 95%.ConclusionsAlthough computed tomography has a high specificity its sensitivity is limited. For this reason conventional cystoscopy should be considered the standard for bladder evaluation of patients with microscopic hematuria.     

Simultaneous antegrade urography of the upper urinary tract and retrograde cystography combined with computed tomography imaging in the management of ureteral complications after renal transplantation

BackgroundTo investigate the significance of simultaneous urography of the upper and lower urinary tract of transplanted kidneys combined with computed tomography urography (CTU), computed tomography arteriography (CTA), and computed tomography venography imaging in the planning of open surgery performed to treat any ureteral complications of a transplanted kidney.MethodsIn all, 24 patients with ureteral complications after renal transplantation were admitted, 12 of whom had renal graft ostomy during open surgery. Simultaneous antegrade urography of the upper urinary tract and retrograde cystography of the transplanted kidneys were performed on the patients. With the use of computed tomography imaging results, surgical planning was carried out.ResultsAll surgeries were successfully completed according to preoperative planning. Three patients underwent end-to-end anastomosis of the ureter and bladder muscle flap, 8 patients underwent ureterocystostomy, and 1 patient underwent an end-to-end ureteral anastomosis. After the follow-up up to now, all the patients had stable renal function, and no complications such as ureteral stenosis or urine leakage have thus far reoccurred in the transplanted kidneys.ConclusionsWhen open surgery is required to treat any ureteral complications following renal transplantation, preoperative multiangle imaging can be used to better understand the condition of the transplanted urinary tract and thus aid considerably in surgical planning.     

Perforated gist of Meckel's diverticulum

Meckel diverticulum is the most common congenital abnormality of gastrointestinal track (2-4%), however complications occur rarely (4-16%). We describe a case of 63- years old female presenting simultaneously two serious complications of Meckel diverticulum. Operated patient was diagnosed with perforated tumor of Meckel diverticulum. Segmental resection of small bowel including tumor was performed. Pathology examination revealed gastrointestinal stromal tumor (GIST) in Meckel diverticulum. No significant malignancy risk factors were found (low mitotic count). Consequently, computed tomography periodic surveillance was implemented.We report the possibility of simultaneous presentation of two serious complications of Meckel diverticulum. Tumors of Meckel diverticulum may mimic other abdominal pathologies and thus, they should be considered in differential diagnosis of abdominal tumors.     

Two cases of nephrogenic adenoma in the bladder diverticulum

We report two cases of a nephrogenic adenoma in the bladder diverticulum. The first patient was an 81-year-old man with gross hematuria. Cystoscopy revealed bladder diverticulum and a papillary tumor within. Bladder diverticulectomy was performed and the histopathological diagnosis was a nephrogenic adenoma. The second patient was a 50-year-old man with gross hematuria and dysuria. Transabdominal ultrasound revealed bladder diverticulum. Transurethral coagulation of the bladder diverticulum was performed. Then three papillary tumors were detected, and were resected transurethrally. The histopathological diagnosis was a nephrogenic adenoma. These are the first and second cases of a nephrogenic adenoma in the bladder diverticulum reported in Japan.     

Low-grade mucinous neoplasia in a cecal diverticulum: A case report

IntroductionLow-grade mucinous neoplasia is an uncommon benign tumor that develops in the appendix. The development of mucocele disease has never been reported in a colonic diverticulum. We present a case developing low-grade mucinous neoplasia in a cecal diverticulum.Presentation of caseA tumor in the ileocecal region was found during a medical examination of a 66-year-old woman. Three months later, the tumor was still present and the patient developed abdominal pain. Laparoscopic ileocecal resection with D2 lymph node dissection was performed. Histopathological examination revealed a low-grade mucinous neoplasm in a cecal diverticulum.DiscussionColonic mucoceles reportedly originate from the appendix. There are no previous reports of mucocele disease in a colonic diverticulum worldwide. This report reviews and discusses the management of the appendiceal mucoceles.ConclusionThe incidence of colonic diverticula has recently begun to increase in Japan. The possibility of a mucocele within a colonic diverticulum should be considered in patients with submucosal colonic tumors.     

Reduced port laparoscopic surgery using umbilical zigzag incision for Meckel’s diverticulitis

IntroductionReduced port laparoscopic surgery using an umbilical zigzag incision is comparable to conventional multiport laparoscopic surgery. This method is associated with improved cosmesis and decreased wound pain.Presentation of caseA 67-year-old man visited our hospital. He presented emergency room with a chief complaint of right lower abdominal pain by walking. The patient was diagnosed Meckel’s diverticulitis by computed tomography (CT). At first, antibiotics therapy and fasting were performed. Three months later, the patient underwent resection of Meckel’ diverticulum with zigzag transumbilical laparoscopic surgery. The patient’s postoperative course was good, and he rarely felt wound pain. The patient started oral intake three days after surgery, and was discharged 10 days after surgery.DiscussionZigzag transumbilical laparoscopic surgery is very useful for resection of the small intestine. This method is associated with improved cosmesis and decreased wound pain. In the case of Meckel’s diverticulitis, we suggest that interval resection of Meckel’s diverticulum was very useful as it was an operation that could be performed easily.ConclusionReduced port laparoscopic surgery using an umbilical zigzag incision is considered to be an excellent technique in terms of operability and aesthetic outcomes.     

Rupture of urachal diverticulum in radiation cystitis and neurogenic bladder dysfunction after radical hysterectomy

Abstract We experienced a rare case of the rupture of the urachal diverticulum in radiation cystitis and neurogenic bladder after radical hysterectomy. A 61‐year‐old woman presented with severe lower abdominal pain and urinary retention. Abdominal computed tomography revealed that the urachal remnant contained a large volume of urine that leaked to subcutaneous tissue. We excised the urachal diverticulum and bladder together and created a continent urinary diversion using transverse colon. Nine months after the operation, the patient could manage clean intermittent self‐catheterization 6 times a day through her umbilical stoma without any urinary complications.     

Incidental posterior mediastinal paraganglioma: The safe approach to management,case report

IntroductionParagangliomas are neuroendocrine tumors arising from chromaffin cells located in sympathetic paraganglia. Mediastinal paragangliomas are extremely rare and can be classified as functional or non-functional according to their ability for secreting catecholamines. Patients can be asymptomatic and the diagnosis is usually incidental. Complete surgical resection remains the standard of care for paragangliomas.Presentation of caseWe present a 44-year-old woman with a functional mediastinal paraganglioma incidentally found during the perioperative imaging workup for a diagnosed breast carcinoma. Chest radiograph and computed tomography (CT) showed a well-defined lesion in the posterior mediastinum suspicious for an esophageal malignancy. Endoscopic and CT-guided biopsies were performed confirming the diagnosis of a neuroendocrine tumor. Laboratory studies showed elevated catecholamines and chromogranin A levels, consistent with a paraganglioma. Appropriate pre-operative management was done and successful surgical resection without catecholamine related complications was achieved.DiscussionThe workup and treatment of incidentally discovered adrenal and extra-adrenal lesions are controversial. Because of the absence of symptoms and the wider differential diagnosis of extra-adrenal lesions, an attempt for biopsying and surgically remove these lesions prior to biochemical testing is not an uncommon scenario, although this could be potentially harmful. Surgeons should have an index of suspicion for catecholamine-secreting tumors and hormonal levels should be assessed prior to biopsy or surgical resection.ConclusionSurgeons should consider paragangliomas as a differential diagnosis for extra-adrenal lesions. Biochemical testing with catecholamines and chromogranin A levels should be performed prior to biopsy or surgical removal in order to avoid catastrophic complications.     

A case of carcinoma of the bladder diverticulum

Carcinoma of the bladder diverticulum is a relatively rare disease. However, its preoperative diagnosis is often difficult. Also, infiltration occurs easily because the diverticulum wall is thin, and prognosis is said to be relatively poor. Histologically, the occurrence rate of squamous cell carcinoma is markedly high. We have experienced a case of squamous cell carcinoma in the bladder diverticulum occurring simultaneously with transitional cell carcinoma of the bladder; and, report this case along with a review of the literature. The patient, a 79-year-old male, had sudden macroscopic hematuria on December 15, 1980, and went to the urology department of a separate hospital. IVU showed distortion of the right ureter, and the patient was referred to our hospital. Cystoscopy revealed a diverticulum in the right wall of the bladder. In the posterior wall of the bladder 2 papillary sessile tumors were also detected. Pathological diagnosis by cold punch biopsy done after the patient was admitted to hospital revealed a grade III transitional cell carcinoma. Total cystectomy + bilateral cutaneous ureterostomy was performed. The diverticulum was in the right wall of the bladder and a papillary sessile tumor with a diameter of 4 cm was found in the diverticulum. A papillary sessile tumor 2 cm in diameter was found in the left bladder wall. Histopathological diagnosis of the tumor in the diverticulum was squamous cell carcinoma ( pG2 , pT3b , ly1, v(-) INF beta) and that of the tumor in the bladder was transitional cell carcinoma ( ( pG3 , pT2 , ly1, v(-), INF gamma).(ABSTRACT TRUNCATED AT 250 WORDS)     

Phytobezoar in Meckel's diverticulum: A rare cause of small bowel obstruction

IntroductionMeckel's diverticulum (MD) is the prevailing anomaly of the gastrointestinal tract, found in about 2% of the population; it rarely gives rise to symptoms and its discovery is usually accidental. Phytobezoar is a concretion of poorly digested fruit and vegetable fibres that is found in the alimentary tract and rarely can be the cause of small intestinal obstruction. Herein we report a rare case of intestinal obstruction due to phytobezoar formation into a MD.Presentation of caseA 50 year-old patient, was admitted to author's institution with an history of abdominal pain, nausea and multiples episodes of vomiting. Plain X-ray showed dilated small-bowel loops. Computed tomography (CT) revealed jejunal loops with air-fluid levels. The patient underwent explorative laparotomy where we found a giant Meckel's diverticulum, filled by a phytobezoar that caused small bowel compression. We performed a segmental ileal, resection, containing the MD. The histological exam confirmed Meckel's diverticulum.DiscussionBowel obstruction due to a phytobezoar in a Meckel's diverticulum is rare: only 7 cases have been reported in literature. MD complications are rare and phytobezoar is one of them with only few cases described in literature.ConclusionThe conventional x rays studies were inconclusive whereas abdominal contrast enhanced CT led to a definitive diagnosis. Explorative laparotomy or laparoscopy is mandatory in these cases.     

Case report of a giant colonic sigmoid diverticulum causing sigmoid volvulus

IntroductionGiant colonic diverticulum is a rare complication of colonic diverticulosis that occurs when a single diverticulum enlarges to over 4 cm in diameter. There have been fewer than 200 cases reported worldwide since it was first described in 1946.Presentation of caseThe author presents a rare case of a giant colonic diverticulum that presented as a sigmoid volvulus. The patient underwent emergency surgery with resection of the diverticulum and reduction of the volvulus.DiscussionDue to their propensity to cause complications and mechanical blockage from their large size, all authors recommend surgical resection of giant colonic diverticula. This has been documented to be safely done by diverticulectomy as was performed in this patient, but also by segmental colectomy, laparoscopic diverticulectomy, or laparoscopic colectomy.ConclusionGiant colonic diverticulum is a rare entity that tends to cause many intra-abdominal complications, including volvulus. Surgical resection is recommended once identified.     

Percutaneous cement augmentation of a lytic lesion of C1 via posterolateral approach under CT guidance

Background contextPercutaneous vertebroplasty (PV) can provide pain relief and biomechanical stabilization of lytic metastasis of the spine in selected patients. Percutaneous vertebroplasty of the atlas has been reported in only five cases and has been performed with different techniques and approaches.PurposeTo describe the technique we used to perform PV of a lytic lesion of the lateral mass of C1 under computed tomography, computed tomography angiography, and computed tomography fluoroscopy guidance with a posterolateral approach, sparing the vertebral artery (VA).Study design/settingTechnical note.MethodsA 36-year-old woman with a history of intestinal carcinoid tumor presented with neck pain refractory to medical treatment. Radiological evaluation showed osteolytic destruction of the left lateral mass of the atlas, at the risk of collapse, with erosion of the VA canal. Under computed tomography and computed tomography angiography guidance, a percutaneous posterolateral oblique approach to the C1 left lateral mass was performed followed by cement augmentation under computed tomography fluoroscopy control.ResultsComplete cement filling of the osteolytic lesion was achieved. A cement leak was noted along the horizontal V3 segment of the left VA. Computed tomography angiography scan showed patency of the VA after the procedure. There were no clinical complications. The patient reported substantial pain relief and improved range of motion at 12 hours postprocedure, which remained stable at 2-month follow-up examination.ConclusionsComputed tomography–guided PV of C1 lytic lesion with posterolateral approach was effective in the described case for pain control and stabilization, and it may be a therapeutic option in selected patients to avoid occipitocervical fusion. This procedure requires good understanding of the anatomy and rigorous technique to avoid potential complications.     

A case of intestinal obstruction caused by a mesodiverticular band in Meckel's diverticulum with ectopic pancreas treated by laparoscopic surgery

IntroductionWe report a case of a patient who underwent laparoscopic surgery for intestinal obstruction caused by the mesodiverticular band of Meckel's diverticulum, with pathological specimens showing ectopic pancreas.Presentation of caseA 56-year-old woman presented to our hospital with complaints of abdominal pain and vomiting. Upon close examination, we suspected strangulated intestinal obstruction, and performed an emergency surgery. An internal hernia with a band leading to a Meckel's diverticulum was noted. Focusing on the attachment of the band, leading to the Meckel's diverticulum, we suspected a mesodiverticular band and deemed it necessary to be resected. Surgery was completed with resection of the band to relieve the intestinal obstruction, with simultaneous resection of the Meckel's diverticulum. It was necessary to resect Meckel's diverticulum simultaneously for histopathological examination. Histopathological examination revealed a mesodiverticular band in the resected band and ectopic pancreas in the Meckel's diverticulum.DiscussionWe chose to perform a complete laparoscopic resection because of the presence of simple intestinal obstruction caused by mesodiverticular bands or diverticula. We believe that small laparotomy can be opted in less severe cases, regardless of laparoscopic completion.ConclusionWe suspected adherent bowel obstruction and detected a band. We focused on band attachment and determined that the band should be resected if it was attached to Meckel's diverticulum. The resection method should be carefully selected, and the specimen should be histopathalogically examined.     

Primary carcinoma in diverticulum of the bladder: a report of three cases]

The first case was in a 48-year-old man admitted with a chief complaint of macroscopic hematuria and sense of residual urine. A tumor in the diverticulum of the bladder was detected by cystoscopy, computed tomography (CT) and magnetic resonance imaging (MRI). We made the diagnosis of an invasive tumor in the diverticulum of the bladder. Total cystourethrectomy and ileal conduit diversion was performed. Histopathological finding was transitional cell carcinoma including squamous cell carcinoma. Adjuvant chemotherapy was performed. No recurrence and metastasis has been recognized for 12 months. The second case was a 56-year-old man having an intradiverticular tumor diagnosed by cystoscopy, CT, and MRI. Total cystectomy and ileal conduit diversion was performed. Histopathological findings was squamous cell carcinoma. No recurrence has been recognized for 8 months. The last case was an 81-year-old man. The patient had the complication of a primary progressive squamous cell carcinoma of the skin. Transurethral resection of diverticular tumor was performed under the diagnosis of superficial tumor. Histopathological findings revealed transitional cell carcinoma. One hundred and sixty one cases of tumor in the diverticulum of the bladder were reviewed. Importance of aggressive treatment including total cystectomy was emphasized.     

A case of two traumatic penetrations of a duodenal diverticulum caused by a kick to the upper abdomen

Introduction and importanceA duodenal diverticulum is a pseudodiverticulum that lacks a proper muscular layer. Cases of traumatic penetration or perforation of a duodenal diverticulum are relatively rare.Case presentationA 67-year-old woman was injured when her roommate kicked her in the upper abdomen, and was transferred to our hospital 6 h after the injury with upper abdominal pain and lethargy. Computed tomography revealed a duodenal diverticulum and retroperitoneal emphysematous changes and exudates. Peritonitis due to duodenal penetration was suspected and emergency laparotomy was performed. Intraoperative findings revealed two traumatic penetrations of the duodenal diverticulum. We resected the diverticulum with an automatic suture device and covered the resection site with omentum. Twenty-one days postoperatively, she was transferred to her original hospital with no complications following an uneventful postoperative course.Clinical discussionMost causes of penetration or perforation of the duodenal diverticulum are diverticulitis, and few reports have described penetration or perforation of duodenal diverticulum due to trauma. Our case was extremely rare that caused by a kick to the upper abdomen and resulted in two penetrations of a duodenal diverticulum although factors contributing to the multiple penetrations were considered.ConclusionPenetration or perforation of a duodenal diverticulum occasionally results in a rapid deterioration to a severe state. Comprehensive judgement of the general condition and laboratory findings and selection of an appropriate treatment policy is important.     

Value of chest computed tomography in genitourinary malignancies

Fifty-one patients with genitourinary malignancies with normal chest x-ray films all had chest computerized tomography in an attempt to detect metastatic disease. One patient with a hypernephroma and another with a bladder carcinoma had metastatic nodules detected. One patient with a testicular tumor had a histologically confirmed benign nodule. Chest computerized tomography should be performed on patients with tumors that have a high likelihood of metastasizing to the lung.     

CT逆行性膀胱造影诊断膀胱憩室

目的探讨CT逆行性膀胱造影诊断膀胱憩室的价值。方法分析7例经手术证实的膀胱憩室患者的影像及临床资料。结果 7例患者均接受CT平扫,2例获得明确诊断。对3例行增强CT扫描,明确诊断2例。4例接受CT逆行性膀胱造影,均获明确诊断。同期对3例行超声检查,明确诊断1例;对4例行膀胱X线造影,明确诊断2例。结论 CT逆行性膀胱造影能准确诊断膀胱憩室,较好地显示膀胱憩室的大小、部位、形态、开口,是诊断膀胱憩室简便有效、经济的检查方法。