Omental Nodules Research Articles

Small bowel adenocarcinoma of the jejunum

Jejunal adenocarcinoma is an unusual type of gastrointestinal malignancy. The symptoms are vague, such as abdominal pain, nausea, vomiting, and, in some cases, weight loss. Due to this vague presentation as well as lack of definitive imaging techniques, diagnosis tends to be delayed and patients typically present at later stages. We present a case of a patient who presented with acute onset abdominal pain. Imaging revealed the presence of a suspicious lesion of the jejunum, with a 3,6 extension. The patient underwent a laparoscopy segmental intestinal resection and omental lymph node resection. The lesion was a 3-cm mass at proximal jejunum. The jejunum adenocarcinoma is a rare neoplasm of the small bowel. The curative resection at the early stages is still the best treatment.

Carcinoma esophagus with small bowel metastasis: a case report with review of literature.

Small intestinal metastasis is extremely rare and only 13 cases have been reported till date and almost all such patients have presented with intestinal obstruction. The 5-year overall survival for metastatic esophageal cancer is as low as 5% while the patients with small intestinal metastasis have a median survival of only 3months (range 1-12months) despite undergoing radical resection of the small bowel. We present a case of a male in his 50's who presented with difficulty in swallowing for 4months. On evaluation, he was found to have squamous cell carcinoma in the mid thoracic esophagus. He underwent radical chemo-radiation up to 60Gy in 25 fractions over 5weeks. One week after completion of treatment he presented with ileal obstruction and omental nodules and surgical resection and evaluation of the respective ileal segment and omental biopsy revealed a metastatic squamous cell carcinoma. The patient expired 3months post-surgery. Carcinoma esophagus with small bowel metastasis has a very grave prognosis that patients rarely survive beyond 1year despite undergoing resection. Hence it is imperative to consider a small bowel metastasis when such patients present with clinical features of intestinal obstruction for early diagnosis and aggressive management.

Dual-energy CT in differentiating benign gallbladder wall thickening from wall thickening type of gallbladder cancer.

To evaluate the performance of dual-energy computed tomography (DECT) in differentiating non-acute benign from malignant gallbladder wall thickening (GBWT). This prospective study comprised consecutive adults with GBWT who underwent late arterial phase (LAP) and portal venous phase (PVP) DECT between January 2022 and May 2023. The final diagnosis was based on histopathology or 3-6 months follow-up imaging. DECT images in LAP and PVP were assessed independently by two radiologists. The demographic, qualitative, and quantitative parameters were compared between two groups Multivariate logistic regression was performed to determine the association between the aforementioned factors and malignant GBWT. Seventy-five patients (mean age 56 ± 12.8 years, 46 females) were included. Forty-two patients had benign, and 33 had malignant GBWT. In the overall group, female gender (p = 0.018), lymphadenopathy (p = 0.011), and omental nodules (p = 0.044) were significantly associated with malignant GBWT. None of the DECT features differed significantly between benign and malignant GBWT in overall group. In the xanthogranulomatous cholecystitis (XGC, n = 9) vs. gallbladder cancer (GBC) (n = 33) subgroup, mean attenuation value at 140 keV LAP VMI was significantly associated with malignant GBWT [p = 0.023, area under curve 0.759 (95%CI 0.599-0.919)]. DECT-generated quantitative parameters do not add value in differentiating non-acute benign from malignant GBWT. However, DECT may have a role in differentiating XGC from GBC in a selected subgroup of patients. Further, larger studies may be necessary to confirm these findings. In patients with non-acute gallbladder wall thickening in whom there is suspicion of xanthogranulomatous cholecystitis (XGC), DECT findings may allow differentiation of XGC from wall thickening type of gallbladder cancer. Differentiation of benign and malignant gallbladder wall thickening (GBWT) at CT is challenging. Quantitative dual energy CT (DECT) features do not provide additional value in differentiating benign and malignant GBWT. DECT may be helpful in a subgroup of patients to differentiate xanthogranulomatous cholecystitis from gallbladder cancer.

Beyond the Marrow: Unveiling Uncommon Sites of ALL Relapse with 18F-FDG PET/CT

AbstractExtramedullary infiltration of acute lymphoblastic leukemia/lymphoma (ALL) to genital organs is extremely rare. Here, we present a case report of an asymptomatic 49-year-old female, known case of precursor B-cell ALL, who was incidentally detected with thickened and heterogeneously hyperechoic endometrium on sonography. Contrast magnetic resonance imaging detected large polypoidal enhancing lesions showing intense diffusion restriction occupying the endometrial cavity and similar lesions in the left adnexa, left ovary, and fallopian tube which were suspicious for leukemic infiltration because of the clinical history and atypical appearance of the lesions. 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) was done which revealed intensely metabolically active lesion in the endometrial cavity, left adnexa, omental nodules, retroperitoneal lymph node, pancreatic lesion, and few irregular nodules in the right lower lobe. Biopsy findings confirmed extramedullary relapse of ALL. Hence, 18F-FDG PET/CT can act as a good whole body survey to look for extramedullary sites of relapse.

Vascularized omental tissue transfer for the treatment of lymphedema: a review

Lymphedema is a debilitating disorder caused by impaired drainage of the lymphatic system. In the Western world, lymphedema most often arises secondary to the treatment of malignancy. Patients with lymphedema experience progressive swelling, pain, numbness, and tingling, and decreased quality of life. Those with persistent symptoms may be subject to chronic cellulitis. The advent of microsurgery has enabled clinicians to transplant donor lymph nodes and their blood supply from a healthy site to the affected area in a procedure known as vascularized lymph node transplant (VLNT). One donor region is the omentum. Vascularized omental lymph node transfer (VOLT) has been shown to decrease limb volume, circumference, and subjective symptoms of lymphedema. The immunologic properties of the omentum make it a particularly useful lymph node donor site for patients with lymphedema-related cellulitis. The omentum may be harvested laparoscopically, with robotic assistance, or through a small laparotomy incision. In this review, we describe the relevant anatomy and history of VOLT as well as operative techniques. The risks, benefits, and relevant outcome studies will be reviewed. Recent applications of robotic surgery to VOLT will be addressed.

Can β-catenin, Tenascin and Fascin be potential biomarkers for personalized therapy in Gastric carcinoma?

ABSTRACT Gastric carcinoma (GC) is one of the most prevalent cancers worldwide and the fourth leading cause of cancer-related death. Studying the molecular profile of GC is essential for developing targeted therapies. β-catenin, Tenascin, and Fascin expression are among the molecular abnormalities that are claimed to cause GC progression and chemoresistance. Therefore, they could be used as potential therapeutic targets. This study aimed to evaluate β-catenin, Tenascin, and Fascin expression and their possible roles as prognostic and predictive biomarkers in GC using immunohistochemistry. This retrospective study included 84 GC cases. Tissue microarrays were constructed, followed by β-catenin, Tenascin, and Fascin immunostaining. Their expression was assessed and compared with clinicopathological parameters and survival data. The study results revealed that β-catenin nucleocytoplasmic expression, positive Tenascin, and Fascin expressions were detected in 86.9%, 70%, and 59.5% of cases, respectively. Their expression was significantly associated with poor prognostic parameters, such as deeper tumor invasion, lymph node metastasis, advanced pathological stage, vascular invasion, positive omental nodules, poor response to chemotherapy, and short overall survival. Hence, nucleocytoplasmic β-catenin expression together with Tenascin and Fascin positivity can be potential prognostic and predictive markers, and they can be used as therapeutic targets for GC.

Outcome Analysis of Combined Surgical Approaches in Advanced-stage Upper Extremity Breast Cancer-related Lymphedema.

This study aimed to discuss several surgical approaches for advanced-stage breast cancer-related lymphedema and compared their treatment outcomes. The patients who underwent surgery with International Society of Lymphology stage III lymphedema were included in this study. The three surgical methods used here were (1) suction-assisted lipectomy with lymphovenous anastomosis, (2) autologous breast reconstruction with muscle-sparing transverse rectus abdominis muscle flap combined with inguinal lymph node transfer, and (3) vascularized lymph node transfer with free omental flap. Analysis of the postoperative outcomes in the patients was based on the difference in volume between patients pre- and postoperatively, LYMPH-Q questionnaire, and bioelectrical impedance analysis. Eighty-seven patients with stage IIb or higher disease underwent surgery. 38 patients underwent suction-assisted lipectomy + lymphovenous anastomosis, 23 underwent autologous breast reconstruction with vascularized lymph node transfer + lymphovenous anastomosis, and 26 underwent right gastroepiploic omental vascularized lymph node transfer with lymphovenous anastomosis. The LYMPH-Q questionnaire, which evaluates patients' subjective satisfaction, showed that the autologous breast reconstruction group showed the greatest improvement, whereas in bioimpedance analysis, the omental flap group demonstrated the greatest postoperative improvement compared with preoperative values. However, suction-assisted lipectomy was considered the most effective surgical method for reducing limb volume in patients with high-stage lymphedema accompanied by fibrosis and volume increase. We observed slightly different clinical effects for each surgical method; however, all surgical methods demonstrated a reduction in the degree of edema and an increase in patient satisfaction.

Clinical application of magnetic resonance lymphangiography in the vascularized omental lymph nodes transfer with or without lymphaticovenous anastomosis for cancer-related lower extremity lymphedema.

The recent increase in the number of patients with lower extremities lymphedema and the development of microsurgery techniques have led to a rise in lymphedema treatment. Vascularized omental lymph node transfer (VOLT), an emerging treatment modality for extremity lymphedema, has shown its unique advantages in reconstructing lymphatic circulation and absorbing exudated lymphatic fluid. Patients who underwent radical tumor resection with/without radiation therapy treatment often present with impairment or degeneration of the inguinal lymph nodes. For such cases, VOLT could provide adequate lymph nodes and tissue to absorb edema fluid in these areas. Therefore, we analyzed the operative outcomes of VOLT under the guidance of magnetic resonance lymphangiography (MRL) in this study, as this individualized and precise surgical procedure could benefit patients and improve their quality of life. From November 2021 to September 2022, a total of 14 patients' 19 legs with extremity lymphedema underwent a VOLT with or without lymphaticovenous anastomosis (LVA). Outcomes, including circumference reduction rates, preoperative and postoperative MRL results, and other complications, were analyzed. The mean follow-up period was 8.86±1.41 months (range, 7-11 months). The mean circumference reduction rates {circumference reduction rate (%) = [1 - (postoperative affected limb - healthy limb)/(preoperative affected limb - healthy limb)] × 100%} of different planes (i.e., ankle, 10 cm above the knee, 10 cm below the knee, 10 cm above the ankle, and 20 cm above the knee) were 15.64%±40.08%, 11.79%±30.69%, 20.25%±24.94%, 7.73%±30.05%, -1.517%±16.75%. Notably, one patient had multi-drug-resistant gram-negative infections, which resulted in the loss of three flaps. The postoperative MRL showed improved lymphatic drainage and lower extremity volume in the remaining 13 cases. The precision evaluation of inguinal lymph nodes and lower extremities lymphatic system through MRL using VOLT can provide surgeons with a comprehensive understanding and reliable evidence for the treatment of cancer-related lower extremity lymphedema.

What We Have Learned About Combining a Ketogenic Diet and Chemoimmunotherapy: a Case Report and Review of Literature.

A high-fat, moderate-protein, low-carbohydrate ketogenic diet has been reported in the literature as a treatment option for patients with cancer. A 69-year-old veteran was initially diagnosed with stage III colorectal cancer and progressed to having liver, pancreatic, and omental lymph node involvement despite completing adjuvant FOLFOX (fluorouracil, leucovorin calcium, and oxaliplatin) after surgery. The patient was treated with FOLFIRI (fluorouracil, leucovorin calcium, and irinotecan hydrochloride) and bevacizumab, followed by encorafenib and cetuximab on progression. Subsequently, he received pembrolizumab but continued to progress. The patient was later placed on trifluridine/tipiracil and bevacizumab concurrent with a ketogenic diet. Positron emission tomography and carcinoembryonic antigen levels indicated disease stabilization for 10 months. On progression, the patient was transitioned to ipilumimab and nivolumab and continued to adhere to the ketogenic diet. The patient's disease has continued to remain stable for the past 1 year. His degree of ketosis was determined using the glucose ketone index. The patient continues to have a good quality of life during concurrent ketogenic diet and therapy. This case supports the tolerability of the ketogenic diet along with chemotherapy and immunotherapy and should be considered as an adjunct to standard cancer treatment. In this report, we reviewed the latest literature about cellular mechanism of the ketogenic diet and the efficacy and relationship with chemotherapy and immunotherapy. We are about to open a ketogenic diet protocol at the Veterans Affairs Central California Health Care System in Fresno.

HER3 expression status following systemic chemotherapy treatment in biliary tract cancers.

e16153 Background: Erb-b2 receptor tyrosine kinase 3 (HER3) is frequently overexpressed in a variety of cancers. Activation of HER3 signaling serves an important role in promoting cell proliferation and is associated with chemoresistance. Thus, there is interest in exploring HER3 status of tumors as a potential prognostic and/or therapeutic target. Prior studies have reported HER3 status in various cancers after treatment with chemotherapy (CT). However, HER3 expression profile in biliary tract cancer (BTC) remains unknown. Here, we evaluated HER3 status of patients with BTC post CT. Methods: The medical records of patients (pts) who had been initially diagnosed with BTC and treated at the National Cancer Center Hospital (Tokyo, Japan), between January 2010 and June 2020, were retrospectively analyzed. Pts whose post CT specimens were available were included in this study. Immunohistochemical staining for HER3 was performed using HER3/ErbB3 (D22C5) XP Rabbit mAb (Cell Signaling Technology) as a primary antibody. IHC scoring (0, 1+, 2+, 3+) of membranous staining intensity was performed according to HER2 IHC gastric scoring guideline. Results: A total of 19 pts with BTC, with a median age of 59 (range 44-79) years, had specimens available after post CT and were evaluated for HER3 expression status. HER3 status was 3+ in 10 pts, 2+ in 3 pts, 1+ in 4 pts, and 0 in 2 pts. The specimens were obtained from liver in 17 pts, bone in 1 pt, and omental lymph node in 1 pt. The histological type was adenocarcinoma in all pts, and HER3 status according to primary tumor type is shown in the table below. Fourteen pts were treated with gemcitabine (GEM) plus cisplatin (CDDP), 1 pt with GEM plus CDDP plus S-1, 1 pt with GEM plus S-1 as first-line CT for advanced BTC, and 3 pts with S-1 as an adjuvant treatment. Fifteen pts were biopsied after CT to participate in clinical trial. The remaining 4 obtained specimens after CT during primary surgery or surgery for metastases or for cholangitis. The median overall survival of pts with advanced BTC was 23.6 months in HER3 3+, 17.1 months in HER3 2+, 27.7 months in HER3 1+, and 24.6 months in HER3 0. Four pts had specimens available from pre and post CT, all of which were intrahepatic cholangiocarcinoma with the treatment of GEM plus CDDP. HER3 status was upregulated in 3 pts (1 pt 1+ to 2+, 2 pts 2+ to 3+) and downregulated in 1 pt (1+ to 0) at post CT. Conclusions: HER3 expression (1+, 2+, 3+) was observed in 89.5% of previously treated pts with BTC, and HER3 status was upregulated after CT in some pts. These results suggest that HER3 might be a potential therapeutic target in BTC post CT. [Table: see text]

E030 Rheumatologists beware! Digital ischaemia as a presenting feature in metastatic ovarian cancer

Abstract Background/Aims Digital ischaemia is an umbrella term to describe the spectrum of acral vascular phenomena irrespective of aetiology, ranging from temporary (as in Raynaud’s phenomenon) to permanent (necrosis). It can be the presenting feature in multiple cancer types, and can be present with or without other features of connective tissue disease. Methods A 54-year-old woman was referred to Rheumatology with a four-day history of acute pain and ischaemic discolouration of all her fingertips bilaterally. There was no history of Raynaud’s phenomenon and no other clinical features of connective tissue disease. She had never smoked. There was a family history of breast cancer in her maternal aunt. She was admitted under vascular surgery for urgent review. All ten fingertips were ischaemic, with a capillary refill time of greater than five seconds. The history was otherwise significant for abdominal bloating, altered bowel habit and fatigue. Examination revealed normal peripheral pulses with no bruits, normal heart sounds and chest sounds. Her abdomen was soft with a mildly enlarged liver. Results FBC, U&E, and LFTs showed no abnormalities. CRP, ESR, ANA, serum protein electrophoresis and complement levels were all normal. Blood tests for ANCA, rheumatoid factor and anti-CCP were also negative. Lupus anticoagulant, anti-cardiolipin and anti-B2-glycoprotein were all negative. The tumour marker CA125 was markedly elevated at 837kU/L (0.0-35.0kU/L). A CT abdomen & pelvis showed a large right-sided adnexal mass with multiple enhancing peritoneal and omental nodules and moderate ascites. Biopsy of a metastatic deposit in the omentum revealed high grade serous ovarian adenocarcinoma. Partial improvement in digital ischaemia was achieved with iloprost and maintenance apixaban and sildenafil. Four cycles of carboplatin and paclitaxel chemotherapy produced near-complete resolution of digital ischaemia symptoms, corresponding to a fall in her CA125 level and reduction in the size of the ovarian mass and intra-abdominal metastases on CT. Ten cases of digital ischaemia associated with ovarian cancer have been described prior to this. The age of onset ranged from 45 to 71, with a median age of 56. Most patients had digital ischaemia without features of connective tissue disease. Four had no blood test abnormalities other than a raised tumour marker CA125. The time from onset of digital ischaemia to diagnosis of ovarian cancer ranged from less than one week to 2 years, with a median time of four months. Conclusion This case study supports previous findings that patients with digital ischaemia associated with ovarian cancer may have normal markers of inflammatory or rheumatological disease. Marked therapeutic responses can be achieved with systemic anti-cancer therapies. Therefore, underlying cancer should be suspected in patients with new-onset or worsening digital ischaemia over the age of 45. A high index of suspicion is required - rheumatologists beware! Disclosure J.H. Miller: None. P. Merry: None.

Gliomatosis peritonei associated with mature cystic teratoma – A case report

The case report aims to highlight a rare entity called gliomatosis peritonei. We report a case of a 23-year-old female presenting with an ovarian mass along with multiple omental nodules. On histopathological examination, the ovarian mass was diagnosed as mature cystic teratoma and the omental nodules showed features of gliomatosis peritonei. Gliomatosis peritonei is a rare entity characterized by peritoneal or omental implants of mature glial tissue. GFAP (Glial Fibrillary Acidic Protein) was positive in the omental nodules. Gliomatosis peritonei is an exceptional finding and requires long term follow up of the patient.

Malignant peritoneal mesothelioma with unresolving haemorrhagic ascites- A case report

Peritoneal mesothelioma being a rare tumor is difficult to diagnose and start treatment. Pleura is the most common area being affected by mesothelioma, peritoneum being the second common site, and in some cases synchronous pleural and peritoneal mesotheliomas are observed (30–45% of the cases). The presentation of mesothelioma is not up to mark leading to difficulty in diagnosis due to lack of specific symptoms and clinical findings. In addition, in the absence of previous asbestos exposure a delay in the diagnosis is not rare. Here we report a case of malignant peritoneal mesotheliomas. The diagnostic and therapeutic approaches for these rare neoplasms are discussed. A 24 year old male patient was admitted with complaints of pain abdomen (on & off) and abdominal distension since 15 days, with no inhalational exposure to asbestos, causing diagnostic confusion. He had history of unresolving haemorrhagic ascites. No drug allergy was noted. Diagnostic laproscopy was done, shows multiple omental nodules. Omental biopsy along with immunohistochemistry leads to diagnosis of malignant peritoneal mesothelioma. Peritoneal mesotheliomas are infrequent clinical entities. However, patients presenting with prolonged abdominal pain and ascitis should be considered to have atypical pathologies with peritoneal mesotheliomas being one of the differentials.

Second Look Laparoscopy Surgery Boon for Fully Treated Patients of CA Ovary but Raising CA 125 Levels and Localised Tumors

Study Objective To define role of 2nd look laparoscopy in fully treated in Ca ovary patient with persistent raised Ca 125 levels. Design Prospective analysis. Setting Patient undervent 3D laparoscopy, all procedures done by experienced and qualified team. Patients or Participants Fully treated Ca ovary patient with raised Ca 125 levels. Interventions 2nd look laparoscopy with excision of Case1- Retroperitoneal solid cystic mass near left iliac vessels. Case 2- Aortocaval (para-aortic) node. Case 3- solid cystic recurrent mass from remnant of left ovary. Case 4- Peritoneal deposit from anterior abdominal wall and omental nodule. Measurements and Main Results all the patient reviewed at monthly interval followed by 3 monthly interval with Ca 125 level & 3 monthly USG (A+P), none of the patient needed further chemotherapy as Ca 125 continues to be normal and USG (A+P) WNL, PET scan done at the end of 6 months did not reveal any evidence of recurrence. Median follow-up 18 months. All patients are diseased free. Conclusion 2nd look laparoscopy was always an armamentarium for gynecologist but using laparoscopy 2nd look surgery become beneficial for specific group of patients with persistent raised CA125 level & no major recurrence on imaging. To define role of 2nd look laparoscopy in fully treated in Ca ovary patient with persistent raised Ca 125 levels. Prospective analysis. Patient undervent 3D laparoscopy, all procedures done by experienced and qualified team. Fully treated Ca ovary patient with raised Ca 125 levels. 2nd look laparoscopy with excision of Case1- Retroperitoneal solid cystic mass near left iliac vessels. Case 2- Aortocaval (para-aortic) node. Case 3- solid cystic recurrent mass from remnant of left ovary. Case 4- Peritoneal deposit from anterior abdominal wall and omental nodule. all the patient reviewed at monthly interval followed by 3 monthly interval with Ca 125 level & 3 monthly USG (A+P), none of the patient needed further chemotherapy as Ca 125 continues to be normal and USG (A+P) WNL, PET scan done at the end of 6 months did not reveal any evidence of recurrence. Median follow-up 18 months. All patients are diseased free. 2nd look laparoscopy was always an armamentarium for gynecologist but using laparoscopy 2nd look surgery become beneficial for specific group of patients with persistent raised CA125 level & no major recurrence on imaging.

S2027 Extrinsic Compression of the Hepatic Flexure from Metastatic Cholangiocarcinoma Masquerading as Cecal Bascule

Introduction: Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement. We present a case in which a patient with a hepatic flexure obstruction from extrinsic compression masqueraded as a cecal bascule on imaging. Case Description/Methods: A 66-year-old woman with history of stroke, hypertension, recent obstructive cholestasis due to choledocholithiasis requiring biliary stent placement, presented with 3 days of right sided abdominal pain, 15lb weight loss and 3 weeks of constipation with thin stools. Computed Tomography (CT) revealed dilated loops of distal small bowel and cecum that folded anteriorly and superiorly with extensive pneumatosis (Figure A), consistent with cecal bascule (type III cecal volvulus). The ascending colon was dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized. She had a normal colonoscopy a few months prior. The patient was initially managed conservatively, however a lower gastrointestinal series showed persistent obstruction at the hepatic flexure with bird-beak appearance (Figure B). She underwent an exploratory laparotomy that discovered a mass in the right upper quadrant involving the gallbladder and liver, causing extrinsic compression of the hepatic flexure and numerous omental nodules. Biopsies confirmed metastatic cholangiocarcinoma. The patient began evaluation for cancer staging, but ultimately passed one month after diagnosis. Discussion: The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus, or after abdominal surgery such as open appendectomies which require extensive division of peritoneal attachments to the cecum. Clinical presentation can be variable with abdominal pain, distention and nausea being most common symptoms and ranging to an acute abdomen and perforation. Diagnosis of type III cecal volvulus requires CT imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel as colonoscopic detorsion may lead to recurrence. This is a unique case of an extrinsic malignant obstruction causing a cecal bascule, highlighting the importance of a comprehensive evaluation for underlying etiologies.Figure 1.: A: Cecal bascule with extensive pneumatosis on CT. B: Lower gastrointestinal series showing obstruction at hepatic flexure with bird-beak appearance.

An Unusual Cause of a Cecal “Seesaw” and Pneumatosis Intestinalis

Question: A 66-year-old woman with history of stroke, previous hernia surgery with mesh placement, and obstructive cholestasis due to choledocholithiasis presented with 3 days of right-sided abdominal pain, 15-lb weight loss over 1 month, and 3 weeks of constipation with thin stools. Colonoscopy was normal a few months prior. Her prior episode of choledocholithiasis in 2017 led to endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and placement of a double pig-tail stent. She was recently admitted 1 month ago for jaundice and right upper quadrant (RUQ) pain at which time magnetic resonance cholangiopancreatography showed severe intrahepatic and extrahepatic biliary duct dilation but no liver or pancreatic lesions. The cecum was nonspecifically distended and fluid filled. Esophagogastroduodenoscopy revealed a benign-appearing intrinsic duodenal stricture felt to be related to scar tissue from the previous hernia mesh surgery. ERCP revealed an occluded biliary stent that had migrated to the major papilla and a severe burden of choledocholithiasis. The occluded stent was removed, and partial removal of stones was achieved via basket extraction. A new biliary stent was placed with a plan to follow up in 4 weeks for repeat ERCP for further stone extraction and stent removal. Before this appointment she was readmitted for worsening RUQ pain. A computed tomography scan revealed dilated loops of distal small bowel and a dilated cecum that had folded anteriorly and superiorly with extensive pneumatosis. The ascending colon was also dilated up to a decompressed hepatic flexure, where nonspecific bowel wall thickening was visualized, suggesting a transition point. No obvious mass or lesion was noted at the hepatic flexure (Figure A). Despite clinical improvement with conservative management, a lower gastrointestinal series performed a few days later showed persistent severe obstruction at the hepatic flexure with bird-beak appearance (Figure B). What is the most likely explanation for these imaging findings and how should it be managed? See the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. The patient’s imaging findings are consistent with cecal bascule (type III cecal volvulus). Cecal bascules are the rarest variant of cecal volvulus that involve upward folding of the cecum, without axial twisting or sigmoid involvement.1Rabinovici R. Simansky D.A. Kaplan O. et al.Cecal volvulus. Dis Colon Rectum. 1990; 33: 765-769Crossref PubMed Scopus (119) Google Scholar Bascule in French means “seesaw,” describing the pathophysiology of the cecal presentation. Surgical management was indicated given the persistent and severe hepatic flexure stricture seen on lower gastrointestinal series. Exploratory laparotomy revealed numerous omental nodules and a mass was discovered in the RUQ involving the gallbladder and liver that was causing extrinsic compression of the hepatic flexure. The largest nodule was excised and confirmed a diagnosis of metastatic cholangiocarcinoma. A distal loop ileostomy was created to decompress the colon and prevent ongoing colonic obstruction. No colonic resection was necessary. The patient began cancer staging and treatment planning, but unfortunately passed 1 month after diagnosis. This is a unique case of an extrinsic malignant obstruction causing cecal bascule. The development of a cecal bascule is usually attributed to an abnormally mobile cecum due to improper development and insufficient fixation of the mesentery to the posterior parietal peritoneum. A mobile cecum may also be acquired in pregnancy due to enlargement of the uterus or after abdominal surgery, such as open appendectomies, which require extensive division of peritoneal attachments to the cecum. Clinical presentation varies with abdominal pain, distention, and nausea being the most common symptoms but can progress to an acute abdomen and perforation.2Lung B.E. Yelika S.B. Murthy A.S. et al.Cecal bascule: a systematic review of the literature.Tech Coloproctol. 2018; 22: 75-80Crossref PubMed Scopus (14) Google Scholar Diagnosis of type III cecal volvulus requires computed tomography imaging confirming a distended cecum lying anterior to ascending colon. Treatment generally involves surgical resection of the affected bowel because colonoscopic detorsion may lead to recurrence.3Le C.K. Nahirniak P. Qaja E. Cecal volvulus. StatPearls Publishing. StatPearls Website, 2021Google Scholar

Giant omental lipoma, a rare etiology of right-iliac fossa pain in adult: A surgical case report.

BackgroundOmental lipoma is an uncommon abdominal tumor of mature fat cells. Those benign tumors are usually asymptomatic but occasionally can cause signs and symptoms based on their location, size, and presence of complications. Radiological investigations such as Abdominal ultrasonography (USG) and computed tomography (CT) are crucial to evaluate and diagnose intra-abdominal tumors, especially omental lipomas.PresentationA 61-year-old male patient presented to our hospital with right iliac fossa pain. Physical examination and laboratory test results were normal. The performed abdominal CT scan revealed a large right-sided intraperitoneal mass measuring about 2.4 × 10 × 20 cm. Then, an ultrasound-guided biopsy was done and the picture was most consistent with lipoma. So, surgical intervention was decided and omental lipoma was completely exteriorized via a laparoscopic approach. The weight of the excised omental mass was 2.45 kg, measuring 23 × 18 × 7 cm. The resected specimens, including omental lipoma and omental lymph nodes, were sent for histopathological studies. The postoperative period was uneventful.DiscussionOmental lipoma is an unusual entity that occurs often in children and rarely in adults. The clinical features of omental lipomas include abdominal discomfort, abdominal lump, abdominal pain, nausea, and/or weight loss. Diagnosis of the omental lipoma relies on imaging and physical examination, which was normal in the presented case. Abdominal CT provides definitive fat content characterization and its localization within the omentum.ConclusionDue to the rare etiologic origin of omental lipomas, we report the case of a 61-year-old male with right iliac fossa pain, found to be caused by detected giant omental lipoma.

Clinical case of a successful treatment of stage IV esophagal adenocarcinoma

Background. Esophageal adenocarcinoma is often diagnosed at an advanced stage. The overall five-year survival rate of metastatic esophageal adenocarcinoma is less than 15 %. The main treatment strategy is drug therapy. The search for new drugs is still ongoing. Therefore, the assessment of the effectiveness of currently existing options is of great significance.Description of the clinical case. A 45-year-old patient with advanced esophageal cancer with omental, mediastinal and subclavian lymph node metastases received 4 cycles of CF chemotherapy and 3 cycles of DCF + trastuzumab chemotherapy. After 25 cycles of maintenance therapy with trastuzumab, stable disease was observed. There were no significant adverse events associated with the use of trastuzumab. Currently, the patient has no any symptoms of disease.Conclusion. Trastuzumab for the treatment of HER2- overexpressing esophageal cancer was shown to be very effective. The presented clinical case demonstrates not only the feasibility of controlling metastatic disease using targeted therapy, but also maintaining a high level of quality of life.

Flowthrough Omental Flap for Vascularized Lymph Node Transplant of the Lower Extremity.

Vascularized lymph node transplantation is a surgical approach for the treatment of chronic lymphedema. However, there is no clinical standard for flap placement nor vascular anastomoses. The authors propose a novel flowthrough configuration for an omental vascularized lymph node transplant in the popliteal space. To prepare the popliteal space for an omental free flap, the medial popliteal fat pad and medial head of the gastrocnemius muscle were debulked. Venous anastomoses were completed with vein couplers, joining the right gastroepiploic vein to the medial sural venae comitantes and the left gastroepiploic vein to the lesser saphenous vein. Arterial anastomoses were hand sewn, joining the right gastroepiploic artery to the proximal medial sural artery and the left gastroepiploic artery to the distal medial sural artery, to create the flowthrough configuration. A retrospective review of patients who underwent this procedure at a single institution was performed. Six patients with chronic lymphedema of the lower extremity underwent vascularized lymph node transplantation from June of 2019 to November of 2020. Five patients underwent at least 3 months of postoperative surveillance, with no postoperative complications reported. In this technique contribution, the authors describe a novel flowthrough configuration for an omental free flap to the popliteal space. The popliteal space offers an aesthetically favorable recipient location when appropriately prepared. The medial sural vessels are ideal recipient vessels for the flowthrough omental flap. Therapeutic, IV.

The role of cytology as an effective tool in management of omental and peritoneal lesions: Experience of a large health care system.

The aim of this study is to assess the efficacy of cytology in omental or peritoneal lesions. A retrospective review of the pathology database for cytology cases of peritoneal or omental nodules over a 3-year period (2016-2018) was conducted. The cases consisted of either FNA only (FO); FNA and Core biopsy (FCB) or Touch prep and core biopsy (TCB). Cases were further divided based on the prior history of carcinoma. Concordance rates of cytologic diagnosis with histologic diagnosis were studied. Out of 104 cytology cases reviewed, 60 (57.7%) had prior history of cancer (PHC) and 44 (42.3%) had no prior history of cancer (NPHC). Of the cases with PHC, 43(71.66%) were recurrence, 10 (16.66%) were second cancer, and 7 (11.66%) were non-neoplastic lesions. Of the cases with NPHC, 38 (86.4%) had a second cancer diagnosis, while 6 (13.6%) were non-neoplastic. For FO only cases, 11 of 35 (31.4%) had follow up and 9 of 11 (81.8%) were concordant. For FCB cases, 6 out of 39 (15.4%) had follow up and 6 (100%) were concordant. For TCB cases, 9 out of 30 (30%) had follow up and 9 (100%) were concordant. A definite diagnosis was reached in 30/35, 39/39, and 29/30 cases in FO, FCB, and TCB, respectively. In summary, cytologic evaluation of omental lesions is an effective tool in providing accurate diagnosis and guiding further management. Also, the results based on our study show that the combined techniques are superior at reaching a definitive diagnosis.