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.     

When eating makes you sick – Gastric stump obstruction caused by a phytobezoar. A case report and literature review

Introduction and importanceBezoars result from undigested material having an incidence of 0.4–1% (Gunner et al., 2012). Impaired gastrointestinal motility is one of the risk factors. The aim of this article is to highlight the importance of this commonly disregarded entity as well as the different treatment modalities available.Case presentationA 68-year-old female presented to our emergency department complaining of colicky lower left abdominal pain associated with vomiting and absence of bowel movements for the past 4 days. She had a previous history of a subtotal gastrectomy due to gastric cancer. The physical examination revealed a lower left quadrant palpable mass. Abdominopelvic CT scan showed distension of the gastric remnant with anastomotic obstruction caused by a bezoar. Attempted endoscopic dissolution of the bezoar was unsuccessful. The patient then underwent surgery enterotomy proximal to the obstruction with extraction of the mass.Clinical discussionBezoars are responsible for 0.4%–4% of cases of mechanical gastrointestinal obstruction (Dikicier et al., 2015). Contrast-enhanced CT scan is the best diagnostic test with a sensitivity and specificity of 90% and 57%, respectively (Kim et al., 2003). Treatment options differ according to the type, size and location of the bezoar as well as clinical presentation. Conservative measures such as chemical dissolution and endoscopic fragmentation and extraction can be used with surgery being usually required for a bezoar-induced gastrointestinal obstruction.ConclusionThe clinical findings of bezoar-induced ileus do not differ from the other different causes of mechanical intestinal obstruction. Hence, a high grade of suspicion and an early radiological exam are the keys for a prompt diagnosis and treatment.     

Fournier’s gangrene as a rare complication in patient with uncontrolled type 2 diabetes treated with surgical debridement: A case report and literature review

IntroductionFournier’s gangrene is a potentially fatal emergency condition, supported by an infection of perineal and perianal region, characterized by necrotizing fasciitis with a rapid spread to fascial planes. FG, usually due to compromised host, may be sustained by many microbial pathogens.Case reportA 66-year-old man, with a history of uncontrolled type 2 diabetes, obesity with BMI 38, chronic kidney failure and chronic heart failure, was admitted to the Emergency Department with a large area of necrosis involving the perineal and perianal regions.DiscussionFournier’s gangrene is favoured by hypertension, obesity, chronic alcoholism, renal and heart failure. Generally, Fournier’s gangrene needs other procedures in addition to wound debridement such as colostomy, cystostomy, or orchiectomy.ConclusionWe report a case of FG found as complication in a patient with uncontrolled type 2 diabetes, treated with effective combination therapy with surgical debridement and antibiotics infusion.     

Immediate rehabilitation of a rheumatoid arthritis patient with single-piece implants

Introduction and importanceThe aim of this article is to report the long-term outcome of full mouth rehabilitation with single piece, smooth surface implants following immediate loading protocol on a patient suffering with RA and severe unilateral condylar resorption.Case presentationHere, we present a challenging case of a patient suffering from Rheumatoid Arthritis who was stabilized and completed successfully with a 4 year follow-up period. Prosthetic management optimized the inter-occlusal relationship to maintain both function and esthetic integrity. Single piece implants are designed to engage and take support from the cortical bone low in metabolic activities thus promoting the force transmission through apical threads that are engaged in the cortical bone.DiscussionRheumatoid Arthritis [RA] is an auto-immune inflammatory condition in which the inflamed and hypertrophic synovial membrane grows into the articulation surfaces. The Temporomandibular Joints [TM] are frequently involved in rheumatoid arthritis. According to the literature on RA, due to frequent periodontitis, decreased salivary secretion, medication, as well as decrease in bone regenerative potential, RA is often considered as a relative contraindication in the use of implants. Atrophic jaws and cases with comorbidities like osteoporosis, diabetes, rheumatoid arthritis, periodontally infected cases are restored with high success by single piece smooth surface.ConclusionTo the best of our knowledge, this may be the first case of immediate functional loading by bi-cortical single piece implants.     

Abdominal wall endometriomas. Should the approach vary based on its relationship to the fascia? A case report and review of the literature

IntroductionAbdominal wall endometrioma (AWE) is a rare encountered condition with a prevalence of 1–2%. Multiple diagnostic and treatment modalities are available; however, no clear guidelines exist. On occasions muscle and fascia excision might be necessary to achieve a clear margin. To avoid mesh complications, we believe the treatment should depend on tumor location in relation to the abdominal wall fascia. As far as we know this approach has not been previously discussed.PresentationA 29-year old female with a surgical history of 3 C-sections presented to us with 6 months of cyclical abdominal pain in the left lower quadrant. Imaging studies confirmed the presence of a mass overlying the left lower rectus abdominis muscle. After imaging studies, the mass was surgically excised. Pathology confirmed a benign endometrioma.DiscussionUnfortunately, the surgical literature has not established a consensus on the best approach for diagnosis and management of this condition. The purpose of this report is to not only to present another case of this rare phenomenon, but to address the need for guidelines and review the current diagnostic and treatment available options. We also attempt to increase the awareness of this condition, it’s unlikely malignant degeneration and potential morbidity of surgical excision.ConclusionSurgical excision remains the standard of care for AWEs. In those patients where the fascia and muscle must be excised, we recommend less invasive modalities to avoid mesh complications. The need for guidelines remains.     

A case report of double cystic duct during laparoscopic cholecystectomy in patient with chronic calcular cholecystitis

IntroductionAbnormal anatomy of the biliary tree predisposes patients to higher risks of ductal injury and postoperative complications. One of the extremely rare abnormalities of the cystic duct is the duplication of the cystic duct with a single gallbladder. The diagnosis is usually established during surgery. we report a case of double cystic duct with literature review.Presentation of caseA forty-two years old female patient who complained of recurrent biliary colic 9 months prior to the presentation. Murphy’s sigh was negative and with no other relevant clinical signs.Diagnosis and therapeutic interventionAbdominal ultrasound showed multiple gall stones; the largest one was about 11 mm in diameter. Laparoscopic cholecystectomy was done under general anesthesia with 4 ports insertion. A double cystic duct accidentally encountered after clipping and cutting what was apparently a single cystic duct. Intraoperative cholangiogram was done to confirm the anomaly and exclude CBD injury.ConclusionDouble cystic duct is a very rare variant of the cystic duct anomaly. Proper knowledge of this anomaly should be kept in mind to avoid any unnecessary steps.     

Cranial floor fracture: A growing orbital roof fracture with encephalocele – Case Report

Orbital roof fractures are among the rarest of craniofacial fractures. The mechanism of injury is typically a high-impact blunt force vector directly to the orbit or forehead. Most patients are males between 20 and 40 years old, involved in motor vehicle accidents. Although most orbital roof fractures are managed conservatively, there is a significant risk of ophthalmologic and neurologic complications. Detailed craniofacial examination and high-resolution CT imaging is necessary for diagnosis. A multidisciplinary team approach is required for these challenging fractures.     

Unusual collision tumor with infiltrating ductal carcinoma and breast skin squamous cell carcinoma: A case report and literature review

IntroductionBreast cancer is the most common diagnosed cancer among women worldwide. Invasive ductal carcinoma (IDC) is the most common type, on the other hand, squamous cell carcinoma of the skin (SCC) overlying the breast is a rare tumor. The co-presence of two tumor types in one organ is even a rarer entity, termed as collision tumor. Only 3 known cases of collision tumor with breast invasive ductal and skin squamous carcinoma were reported in the literature.Case presentationAn otherwise medically free 91-year-old, postmenopausal, female presented with left breast fungating mass for four months. Pre-operative core tissue biopsy and incisional skin biopsy revealed two distinct tumor subtypes of invasive ductal carcinoma, positive for progesterone, estrogen receptors and negative for human epidermal growth factor receptor 2, as well as skin squamous cell carcinoma, and axillary lymph node metastasis. Patient underwent left breast modified radical mastectomy and split skin grafting for wound closure. The final histopathology was consistent with grade 2 IDC. The nipple and areola complex were involved by moderately differentiated squamous cell carcinoma. Currently patient on adjuvant hormonal treatment. Follow up showed no local recurrence or distal metastasis.ConclusionCollision tumors of the breast with IDC and SCC of the overlying skin is very rare. The surgeon has to be aware of of such entity as the proper peri-operative management should be tailored to target the most aggressive histologic subtype.     

Isolated comminuted trapezium fracture: A case report and literature review

Introduction and importanceTrapezium, as a carpal bone positioned at the distal row, is often associated with other wrist injuries such as distal radius fracture. Isolated trapezium fracture, especially in a comminuted form, rarely occurs. There are only six reports of isolated comminuted trapezium fractures in the literature to the best of our knowledge.Case presentationWe present a case with an isolated comminuted trapezium fracture presenting pain in his thenar eminence and thumb motion limitation. He was treated by Open Reduction and Internal Fixation (ORIF) with the K wire pin.Clinical discussionWe searched the published related studies and summarized the signs and symptoms of patients presented with trapezium fracture. The most common presentation of trapezial fracture include pain/tenderness at the base of the first metacarpal bone, pain/tenderness at the snuffbox area and 1st digit motion limitation. The treatment options described in the literature for isolated comminuted trapezium fracture are also presented. Open reduction and fixation with pin is the most common treatment mentioned in the literature. The priority is restoring the scaphotrapezial and trapeziometacarpal joint congruency to save the 1st digit range of motion.ConclusionComminuted trapezial fracture may happen following either low energy (like our patient) or high energy trauma. This paper highlights the fact that even a comminuted trapezium fracture can be easily missed. Regardless of the trauma mechanism (high energy versus low energy trauma), a high index of suspicion and delicate work up would be necessary in order not to miss this type of fracture.