Early postoperative colonic ventriculoperitoneal shunt migration with trans-anal protrusion: A unique case report

Introduction and importanceColonic ventriculoperitoneal shunt (VPS) migration with trans-anal protrusion remains uncommon. Patients may be asymptomatic, and diagnosis may only be made on visualization of the prolapsed catheter from the anus. This unique case of early post-operative trans-anal shunt protrusion highlight the possibility of this rare complication specially when shunt revision accompanies bowel surgery.Case presentationThe authors present a case of early postoperative colonic shunt migration in a thirteen-year-old female with who underwent Malone Antegrade Continence Enema (MACE) with concomitant revision of the distal part of the peritoneal catheter. She presented two weeks post operatively with shunt catheter protruding from the anus. This was noticed by her carer and she was asymptomatic on her presentation.Clinical discussionDelayed post-operative shunt related bowel perforation and trans-anal shunt protrusion is an uncommon complication after ventriculoperitoneal shunting. Most cases present months after surgery and majority are asymptomatic on presentation. The exact pathophysiology is not established, and mechanisms have been proposed. Early post -operative trans-anal shunt protrusion is rare and suggests inadvertent occult bowel injury especially when shunt placement or revision accompanies extensive bowel surgery.ConclusionThe authors recommended shunt imaging within the first two to three weeks after shunt revision in patient who undergo concomitant bowel surgery with risk of inadvertent bowel injury to identify early colonic migration and avoid its potentially fatal sequelae.     

Case report of Brunner’s gland hyperplasia: A rare “mimic” of malignant pathology

IntroductionBrunner’s gland hyperplasia is a rare, benign lesion of the duodenum. The symptomology can range from asymptomatic (as an incidental finding on endoscopy) to gastrointestinal obstruction or haemorrhage.Case presentationWe report a case of a 60-year-old man presenting with post-prandial vomiting and weight loss. Inpatient evaluation led to the likely diagnosis of a duodenal malignancy for which the patient underwent a laparotomy and proximal duodenectomy.Clinical discussionBrunner’s gland hyperplasia is a rare, benign condition that can be overtreated due to the difficulty in obtaining an accurate pre-operative diagnosis. The literature has been reviewed to discuss the approach to diagnosis.ConclusionThis case highlights the potential for Brunner’s gland hyperplasia mimicking a malignancy.     

Remote medulla ablongata ventral acute subarachnoid hemorrhage following cervical spinal surgery: A case report

IntroductionThe incidence of remote intracranial hemorrhage (RICH) in patients during spinal surgery is rare and the detailed mechanism remains unclear.Presentation of caseA 55-year-old man had undergone cervical discectomy and fusion at C5–6 and C6–7 due to herniated disc and secondary spinal canal stenosis. He had severe headache 20 h postoperatively and his drain output increased from 100 to 350 mL in the second 10 h after surgery. Computed tomography (CT) and magnetic resonance imaging (MRI) were performed and he was diagnosed with acute subarachnoid hemorrhage in the ventral medulla oblongata. The drainage tube was quickly removed. Infusion of hypertonic saline was used to reduce intracranial pressure and nimodipine prevented vasospasm around the brainstem. The patient made a gradual, satisfactory recovery with conservative treatment.DiscussionThe most likely pathomechanism leading to RICH is venous bleeding due to rapid leak of a large amount of cerebral spinal fluid (CSF) after spinal surgery. If the patient has a headache or neurological complaints after spinal surgery, immediate imaging is recommended to confirm the diagnosis. Treatment depends on the amount and location of intracranial hemorrhage.ConclusionRICH is a serious but rare complication of spinal surgery and cerebellar hemorrhage is the most common. The most important pathomechanism leading to RICH after spinal surgery is venous bleeding due to rapid leak of a large amount of CSF. Timely CT is necessary to exclude RICH. Treatment of RICH depends on the size of the intracranial hematoma and the patient’s symptoms.     

Pancreaticoduodenectomy combined with splenectomy for a patient with pancreatic cancer and pancytopenia due to liver cirrhosis: Case report

Introduction and importanceThe incidence of patients with liver cirrhosis (LC) is increasing. Patients with LC are known to have a greater risk of postoperative morbidity and mortality than patients without LC. A treatment option such as pancreaticoduodenectomy (PD) has not been validated to be safe for these patients, especially those with pancytopenia due to portal hypertension (PH). Providing an effective treatment option for these patients is essential.Case presentationHerein, we describe a patient with pancreatic cancer with pancytopenia due to LC that was successfully treated with PD combined with splenectomy. The patient was a 70-year-old woman who was referred to our hospital for evaluation of a mass in the pancreatic head after she developed obstructive jaundice. She was diagnosed with T2N0M0, Stage IB pancreatic cancer and pancytopenia due to PH associated with LC. She received 2 cycles of adjuvant gemcitabine/S-1 chemotherapy and underwent radical subtotal stomach-preserving pancreaticoduodenectomy with splenectomy to improve her pancytopenia. Histopathological examination of the resected specimen revealed an R0 resection showing an Evans grade IIa histological response. Her pancytopenia improved rapidly after surgery.Clinical discussionStrict indications for PD, haemostatic control of intraoperative bleeding, and optimal perioperative management were important for preventing hepatic decompensation in this patient. Splenectomy is effective for thrombocytopenia due to LC; however, attention to postoperative complications such as overwhelming post-splenectomy infection and portal vein thrombosis is required.ConclusionFor patients with pancreatic cancer with pancytopenia due to LC, PD combined with splenectomy plus optimal perioperative management is effective.     

Morel-Lavallée lesion diagnosed 25 years after blunt trauma

IntroductionMorel-Lavallée lesions are closed degloving injuries in which the skin and subcutaneous tissues separate from the underlying fascia secondary to a shearing force. These injuries are uncommon and can be misdiagnosed in acute settings. If treated incorrectly, they can recur, causing complications requiring multiple surgical interventions. Therefore, it is important to discuss the clinical presentation and imaging characteristics in order to improve their diagnosis and management.Presentation of caseThis is the case of a 44-year-old male patient with a Morel-Lavallée lesion of the left thigh that presented 25 years after trauma. He was successfully treated with open surgical excision. The patient underwent multiple surgical interventions before the lesion was accurately diagnosed and treated.DiscussionMorel-Lavallée injuries can lead to chronic symptoms, such as pain and swelling, affecting the patient’s quality of life. Treatment options include minimally invasive procedures, such as compression bandages or percutaneous drainage. However, if diagnosed late, a fibrotic capsule can form, which may require surgical excision. Our patient was diagnosed more than 20 years after the trauma. Earlier noninvasive treatment options were unsuccessful.ConclusionThe patient was treated with open surgical excision of the chronic lesion. There was no report of any recurrence up to 10 months after surgery. Such lesion treatments should be guided based on the chronicity of the injury and the patient’s symptoms. To the best of our knowledge, this is the first case with such delayed presentation.