Reversed rotation of the midgut in adults – a case report

Intestinal obstruction is a common surgical emergency. It is often due to adhesions; however, when the patient is young and has a virgin abdomen, we have to consider uncommon causes. We present a rare case of reversed rotation of the midgut as a cause for intestinal obstruction.     

The anatomy of the short head of biceps – not a tendon

Background:

The short head of biceps brachii has been the subject of little investigation when compared to the long head or distal biceps tendons. The aim of this study was to dissect and describe the origin and proximal portion of the short head of biceps brachii.

Materials and Methods:

Three left and two right (n = 5) fresh-frozen human cadaver shoulders were dissected and the proximal short head was measured and photographed.

Results:

The origin of the short head of biceps consisted of muscle fibres attaching directly to the tip of the coracoid process, with a thin, tendinous aponeurosis covering its anterior surface, rather than a true tendon as previously described.

Conclusion:

The short head of biceps does not attach to the coracoid process via a true tendon. These findings have implications for procedures that utilise the short head of biceps.

Level of Evidence:

Basic science study.     

Primary carcinoid tumor of the filum terminale—a case report

Carcinoid tumors with a primary site in the central nervous system have not been reported in literature yet. We report here about a 41-year-old patient with recurrent and progressive low back pain and bilateral S1 radiculopathy on admission. The patient underwent hemi-laminectomies of the vertebral bodies L5 and S1 and an en bloc resection of the tumor. Postoperative histopathological examination resulted in a well-differentiated intrathecal neuroendocrine tumor (carcinoid) of the terminal filum. Postoperative staging showed no pathological abnormalities and no tumor recurrence after 6 months. Even though rare, carcinoids should be considered as differential diagnosis of tumors occurring in the CNS.     

An unusual case of chronic anal pain – a pin in the bum?

We report the case of a 70-year-old woman who had previously undergone anterior resection in 2001 for a diverticular stricture. Bleeding from pelvic veins intra-operatively necessitated the use of two thumbtacks to aid haemostasis. Over the next 7 years, she presented repeatedly with anal pain, bleeding and mucus discharge per rectum. Multiple lower gastrointestinal endoscopies failed to make a definitive diagnosis until a single thumbtack was found eroding through the rectal mucosa. This was removed and she has been subsequently asymptomatic. This condition was clearly difficult to diagnose and requires a high index of suspicion in those patients who have previously undergone pelvic surgery.     

Duodenum-preserving pancreatic head resection in solid pseudopapillary neoplasm—Report of a case

INTRODUCTION

Solid pseudopapillary neoplasm (SPPN) was first characterized by Virginia Frantz in 1959. The duodenum-preserving pancreatic head resection (DPPHR) has been described as treatment for low-grade malignant tumors of the head of the pancreas including eight cases of SPPN.PRESENTATION OF CASE: A 16-year-old white female patient presented with abdominal pain and dyspepsia. Computed tomography scan of abdomen showed a 10 × 9 × 10 cm³ lesion on the pancreatic head. After radiological diagnosis of SPPN the patient was submitted to DPPHR. Resection was achieved with clear margins. Immunohistochemical study demonstrated positivity for progesterone receptor, β-catenin, cytoplasmic paranuclear dot-like CD99, negativity for chromogranin and S100 protein and Ki 67 index of 1%.

DISCUSSION

A large encapsulated pancreatic mass with well-defined borders that contains areas of calcifications and intratumoral hemorrhage on CT scan in a young female is virtually diagnostic of an SPPN. A particular dot-like intracytoplasmic expression of CD99 appears to be highly unique for SPPN

CONCLUSION

DPPHR should be considered in cases of SPPN in the pancreas head if there is no compromise with oncologic radicality.     

Infiltrating giant cell tumor in a case of Paget’s disease of bone

Giant cell tumor (GCT) of the bone, also called osteoclastoma, is a rare complication of Paget’s bone disease. We report a patient from Southern Italy who developed a GCT infiltrating the neighboring tissues. The natural history and the therapeutic outcomes of this unique complication of Paget’s bone disease are presented.     

Solid-pseudopapillary tumor of the pancreas – a rare and frequently misdiagnosed neoplasm

Introduction: We describe a young woman with an unusual pancreatic tumor. Findings and discussion: Intraoperatively, a smoothly demarcated and encapsulated tumor was exposed. It was large (5 cm×4 cm) and of solid consistency, with a small stalk attached to the uncinate process. The tumor was partially surrounded by the pancreatic head. The macroscopic appearance suggested a benign tumor. Frozen sections revealed a benign pancreatic tumor, most likely of endocrine nature. Based on these findings, tumor enucleation was performed. The patient recovered rapidly from the intervention and was discharged from hospital after 2 weeks. One year after surgical treatment, the patient is without recurrence. The final diagnosis of the tumor was a solid pseudo-papillary tumor. Received: 9 July 1998 Accepted: 14 September 1998     

Surgical treatment of megaduodenum in familial visceral myopathy – report of a case and review of the literature

Introduction: Familial visceral myopathy (VM) is a rare genetic disease that affects intestinal motility and results in pseudo-obstruction. Medical treatments can provide supportive measures but no curative treatment.

Case report: A 20-year-old male with known diagnosis of VM was referred to our Unit in May 2013 with recurrent episodes of vomiting and hospital admissions not responding to medical treatment. Pre-operative imaging showed megaduodenum with marked delayed transit and normal small and large bowel transit. He underwent an elective Roux-en-Y duodeno-jejunostomy. The post-operative course was uneventful with complete resolution of the symptoms with a 2 years follow-up.

Discussion: Due to the early age of presentation, VM affects patient both psychologically and physically. Surgical treatment of megaduodenum in visceral myopathy in the absence of motility disorder of the small bowel seems to achieve satisfactory symptomatic relief and could be considered in this rare cohort of patients.     

Surgical strategy in abnormally increased Fluorine-18 fluorodeoxyglucose uptake in an asymptomatic lower esophageal submucosal tumor – Report of a case

INTRODUCTION

Leiomyoma is the most common benign tumor of the esophagus (67–80%), it represents 0.4–1% of all esophageal tumors.

PRESENTATION OF CASE

An incidentally discovered gastro-esophageal submucosal tumor was found to have increased fluorine-18-fluorodeoxyglucose (FDG) uptake on positron emission computed tomography (PET/CT). After laparoscopic surgical exploration and local enucleation the tumor turned out to be a benign esophageal leiomyoma.

DISCUSSION

There are few reports of esophageal leiomyomas with a positive uptake on (PET/CT) and even fewer adopting our combination of a minimally invasive approach and frozen section examination as a management plan. Our approach avoided excessive morbid surgical resections and underestimation of a malignant disease.

CONCLUSION

We report this case hoping to expand the existing literature on the topic and to highlight the limitations of PET/CT in guiding the diagnosis and subsequently the management of esophageal submucosal tumors.     

Precoccygeal epidermoid cyst in a child — A unique case report

Introduction

Epidermoid cyst is a benign tumour frequently observed throughout the body. It can grow in size and may get infected over a period of time.

Arthrogram assisted reduction of radial neck fracture in a child with unossified radial head – A case report and review of literature

Radial neck fractures account for 1% of all paediatric fractures and constitute 5–10% of elbow injuries. Radial neck fractures rarely occur at age 2 or less. It is difficult to assess and reduce radial neck fractures in children with unossified radial head. We report a case of 2 years old female child presented to emergency with history of fall from stairs on an outstretched hand. Radiograph showed a metaphyseal spike in the proximal radius which prompted us to think of a radial neck fracture. Since the radial head was not ossified, the amount of displacement and angulation was not exactly quantifiable on radiographs only. Hence an arthrogram was planned. Intra operative use of radio opaque dye injection into elbow joint delineates the radial head and capitellum. It helps in identifying the fracture morphology and will also assist in reduction. We reduce radial head by K wire leverage technique and the intramedullary elastic titanium nail was added to assist in reduction and to improve fixation stability. We recommend arthrogram to be a safe and reliable option for proper assessment and reduction of radial neck fracture in an unossified radial head.     

Buschke-Löwenstein tumor in childhood: a case report

Buschke-L?wenstein tumor or giant condyloma is a warty verrucous lesion, characterized by slow growth, locally infiltrating and disfiguring lesions. Despite its benign histological appearance and low risk of metastasis, Buschke-L?wenstein tumor is an intermediate lesion between condyloma acuminatum and verrucous carcinoma. It has been linked to human papilloma virus, mainly subtypes 6 and 11. Other factors implicated in this disease include poor hygiene, chronic irritation, promiscuity, and cellular immunocompromised states. It rarely occurs in children. The first line of treatment is radical surgical excision with or without adjuvant chemotherapy. We report the case of a 12-year-old girl with a giant perianal condyloma that was treated with surgical excision and a 6-week course of 5-fluorouracil beginning 6 weeks after surgery, with excellent functional and cosmetic results.     

Multiple desmoid tumors in a patient with Gardner's syndrome – Report of a case

INTRODUCTION

Desmoid tumor (DT) is a common manifestation of Gardner''s Syndrome (GS), although it is a rare condition in the general population. DT in patients with GS is usually located in the abdominal wall and/or intra-abdominal cavity.

PRESENTATION OF CASE

We report a case of a 32 years-old female patient with familial adenomatous polyposis (FAP), who was already submitted to total colectomy and developed multiple DT, located in the abdominal wall and in the left breast. The patient underwent several surgical procedures, with a multidisciplinary team of surgeons. Wide surgical resections of the left breast and the abdominal wall tumors were performed in separate steps. Polypropylene mesh reconstruction and muscle flaps were needed to cover the defects of the thoracic and abdominal walls. After partial necrosis of the adipose-cutaneous flap in the abdomen that required a new skin graft, she had a satisfactory outcome with complete healing of the surgical incisions.

DISCUSSION

DT is frequent in GS, however, breast localization is very rare, with few cases reported in the literature. Recurrence of DT is not negligible, even after a wide surgical resection. GS patients must be followed up closely, and clinical examination, associated with imaging studies, should be performed to detect any signs of tumor.

CONCLUSION

DT represents one of the most significant causes of the morbidity and mortality that affects FAP patients following colectomy. In general, the surgical procedures to excise DT are highly complex, requiring a multidisciplinary team.     

Free peritoneal perforation in a patient with Crohn's disease – Report of a case

INTRODUCTIONBowel perforation with free peritoneal air is a rare complication of Crohn's disease (CD).PRESENTATION OF CASEWe report a case of a 36 year-old male patient, with history significant for CD and he presented to the emergency room with a free peritoneal perforation, which was diagnosed by abdominal X-ray and confirmed by CT scan. The patient underwent a laparotomy surgery; however, no site of perforation was identified. The surgical approach was to clean the cavity, close the abdominal wall and administer antibiotic therapy. He demonstrated good early and late postoperative outcomes.DISCUSSIONWe report a rare case of free perforation to the peritoneum in a patient with CD. The most likely hypothesis is that it was a micro-colonic perforation. Antibiotic therapy and a conservative surgical approach without colon resection can be performed and it is reported in the literature.CONCLUSIONEmergency conditions in CD may result in significant morbidity, but are normally associated with low mortality, if identified and treated properly.