Surgical Exploration Research Articles

Primary anaplastic T-cell lymphoma of the omentum presenting as small bowel obstruction and complicated with Massilia timonae infection: a case report

BackgroundAnaplastic large-cell lymphoma primarily involving the omentum is an extremely rare entity with variable clinical presentation. Owing to its rarity and nonspecific clinical manifestation, omental T-cell lymphoma is often diagnosed at a later stage, riddled with complications. While imaging modalities such as computed tomography scan can help a physician reach a diagnosis, cases that present with complications may require a multidisciplinary approach that combines surgical exploration along with consultation from Oncology.Case presentationWe hereby report a rare case of a 66-year-old African American male patient who presented to the emergency department with complaints of acute gastrointestinal obstruction. A computed tomography scan of the abdomen and pelvis revealed evidence of an internal hernia and surgical exploration revealed a hemorrhagic and infarcted omentum. Biopsies along with immunophenotypic studies confirmed the diagnosis of anaplastic T-cell lymphoma of the omentum complicated by Massilia timonae infection.ConclusionThe case highlights the significance of considering lymphoma, although rare, as a differential in a patient who presents with small bowel obstruction and the importance of investigating for malignancy for early diagnosis and treatment of primary omental lymphomas, before complications develop.

Percutaneous ultrasound-guided anchor wire placement aids in the intraoperative localization of nonpalpable, superficial foreign bodies and abscesses in dogs.

To describe and evaluate the use of preoperative percutaneous ultrasound-guided anchor wire placement to aid intraoperative localization of superficial foreign bodies and abscesses in dogs. 11 dogs. In a retrospective observational study, the medical records of dogs that underwent surgical exploration of superficial abscesses, guided by anchor wire, between 2018 and 2023 were reviewed for clinical and histopathological findings and complications. Owners or veterinarians were contacted to collect long-term follow-up information. 11 dogs were included. Superficial swelling was the most common clinical presentation. Computed tomography and ultrasound revealed an abscess cavity and suspected foreign body in 9 dogs and an abscess cavity without evidence of a foreign body in 2 dogs. Anchor wires were placed in close proximity to the foreign body or inside the abscess. All documented foreign bodies were successfully located and retrieved. Two dogs suffered minor postoperative complications. No major intra- or postoperative complications were documented. One dog displayed recurrence of clinical signs, but no further surgical management was required. Preoperative percutaneous placement of an anchor wire via ultrasound guidance was successful in aiding intraoperative localization of nonpalpable abscesses and retrieval of foreign bodies. This technique may decrease surgical time, minimize the surgical approach required, and increase the likelihood of successful localization.

Thyroid Gland Sinus Caused by Foreign Body Esophagotracheal Migration: A Case Report

Case presentation: A 56 year-old female was seen at the rural hospital with a complaint of discharging sinus for four months, prior to this complaint she presented with chronic cough that received several medical treatment including two rounds of full dose of anti-TB were unsuccessful. Surgical exploration of the discharging sinus was performed to discover a sharp metallic object traversing through the neck tissues to the trachea. The original portal of entry was unknown but logged into the trachea and making a thyro-cuteneous discharging sinus, it was successfully removed and patient improved significantly thereafter. Conclusion: Aero-digestive FB is not uncommon medical conditions that requires immediate attention, misdiagnosis can lead to wrong course of treatment and cultivate more serious complications, aero-digestive endoscopy forms the cornerstone in the diagnosis and treatment however limited by the availability of facilities and expertise in most centers worse in rural setting.

Phosphodiesterase inhibitors and testicular torsion: A systematic review and meta-analysis of animal studies.

Testicular torsion is a common urological emergency in children and teenagers that, in most cases, requires surgical exploration and detorsion. However, even after a successful intervention, a high number of patients still develop irreversible damage. To investigate whether the administration of phosphodiesterase inhibitors (PDE) in animal models of testicular torsion can reduce damages caused by the ischemia-reperfusion syndrome. A systematic search of the Medline, Web of Science, Embase, and Ovid databases for studies up to December 2023 was performed using PRISMA guidelines. A detailed search was conducted using the following key terms: "testicles," "ischemia," "reperfusion," and "phosphodiesterase inhibitors." There was no restriction regarding language or year of publication. We investigated spermatogenesis by the Johnsen's biopsy score (JTBS) and histological damage by the Cosentino's biopsy score (CBS). Malondialdehyde (MDA), nitric oxide (NO), superoxide dismutase (SOD), and glutathione peroxidase (GPx) testicular levels were also analyzed. Initially, 296 articles were identified. However, only 20 studies met the inclusion criteria. PDE inhibitors improved JTBS (MD=2.53, CI=1.94 to 3.13), CBS (MD=-1.11, CI=-1.25 to -0.97) and SOD (SMD=3.27, CI=1.59 to 4.95) outcomes. PDE did not improve MDA (SMD=-0.93, CI=-2.19 to 0.34), NO (SMD=-0.54, CI=-1.56 to 0.48), and GPx (SMD=0.77, CI=-0.38 to 1.92) outcomes. A higher dose of PDE inhibitors only improved CBS outcome. This review indicates that the administration of PDE inhibitors in rats ameliorated the outcomes, representing a promising complementary strategy for spermatogenesis recovery following testicular torsion. Our review suggests that JTBS and CBS could be translated into future human studies, validating and extending these findings within the context of human physiopathology, while providing applicability of interventions in real clinical practice.

Case Report: Acute Abdomen Due to Ruptured Ovarian Ectopic Pregnancy at 8 Weeks

Background Ovarian pregnancy is a rare type of ectopic pregnancy, accounting for 0.5% to 1% of all ectopic pregnancies, with an incidence ranging from 1 in 2,100 to 1 in 60,000 pregnancies. Due to its rarity and the lack of common risk factors, diagnosing ovarian pregnancy is often challenging and typically occurs during surgical exploration. Case Presentation We present the case of a 40-year-old woman who experienced severe pelvic pain, light vaginal bleeding, and 8 weeks of amenorrhea. Upon arrival at the hospital, she was hemodynamically unstable, with low blood pressure and a rapid heart rate. An ultrasound revealed an empty uterus, an irregular mass on her right ovary, and free fluid in the pelvis. Her beta-hCG level was elevated, and her hemoglobin level was low. Given the suspicion of an ectopic pregnancy, she underwent emergency surgery. During the operation, the surgical team discovered a large amount of clotted blood and a ruptured mass on her left ovary measuring 10 x 9.5 cm. Due to heavy bleeding, they performed a left oophorectomy and salpingectomy. Histopathological analysis later confirmed the diagnosis of ovarian pregnancy. Conclusion This case underscores the challenges in diagnosing ovarian pregnancy and highlights the necessity for prompt surgical intervention, particularly in unstable patients. Early detection and appropriate management are critical to prevent life-threatening complications.

Testicular Torsion Following MMR Vaccination in an 18-Month-old Infant: A Case Report

Introduction: The measles, mumps, and rubella (MMR) vaccine is associated with known complications, such as salivary gland involvement and aseptic meningitis. Isolated reports of epididymal orchitis following MMR vaccination have also been reported, but no reported case of testicular torsion in infancy has been explicitly attributed to the MMR vaccine. Objective: Here, we report an 18-month-old male infant presented with a history of gradually worsening painful left scrotal swelling following a booster dose of MMR that finally led to orchiectomy with the diagnosis of testicular torsion. Case Presentation: An 18-month-old male infant presented with a one-day history of gradually worsening painful left scrotal swelling following a booster dose of MMR. No evidence of blood flow was detected in the left testicle in color Doppler sonography, which was compatible with testicular torsion. In surgical exploration, the left testicle seemed firm and dark in color. The spermatic cord vessels were thrombotic in appearance, and the testicular appendix seemed completely necrotic. The nonviable left testicle was removed. Conclusions: Although testicular torsion after MMR vaccination is rare, in the case of any pain, swelling, and redness of the scrotum, the patient should seek an urgent medical consultation. Physicians should be aware that testicular swelling after the MMR vaccine might not be just epididymal-orchitis but really a medical emergency.

Outcomes and management of Haemoptysis in the Fontan population

Abstract Background Patients with a Fontan circulation for palliation of a univentricular congenital heart defect commonly possess pulmonary vascular abnormalities including arteriovenous malformations (AVM), aortopulmonary and venous-venous collaterals (1). These vessels are prone to haemorrhage which may result in life-threatening haemoptysis (2). This risk is increased with oral anticoagulant medication, given to reduce the risk of thromboembolism in Fontan patients (3). Management of these patients is difficult, and strategies vary across institutions. Purpose We aim to describe our experience with managing adult Fontan patients presenting with haemoptysis in a tertiary centre with a large Fontan cohort. Methods We retrospectively reviewed the records of 410 adult Fontan patients. Individuals admitted to our institution with an episode of haemoptysis were included. Details relating to anticoagulation regimens, interventions and mortality of patients were captured. Results From a cohort of 410 Fontan patients, 35 haemorrhagic events were observed in 11 patients (2.68%). The median age at initial haemoptysis was 24.5 years (range 19 to 43 years). 6 of the 11 patients were female (54.5%). Haemoptysis recurred in 8 of the 11 patients (72.7%). 2 out of 11 had a prior history of haemoptysis in childhood. All patients were administered with oral vitamin K antagonists at presentation. 24 of the 35 events were managed conservatively with IV fluids, anticoagulation reversal and tranexamic acid (66.7%). 11 events required catheter-based interventions, with coil and/or plug embolization of bleeding vessels. Prior to intervention, CT successfully identified potential bleeding sites in 10 of the 11 events (90.9%) but could not visualise all vessels that were subsequently embolized. The most common culprits for haemoptysis were aortopulmonary collaterals, followed by AVMs and venous-venous collaterals. In severe cases, more extensive management was required including transfusions, bronchoscopy, intubation, surgical exploration (1 patient) and pneumonectomy (1 patient). 3 patients died following recurrent severe haemoptysis (27.3%), and 2 patients died of subsequent Fontan failure and sudden cardiac death respectively. Total mortality of the cohort is 5 out of 11 (45.5%) with a median follow up of 10.75 years (range 3 days to 27 years). Conclusions Haemoptysis is a rare but potentially fatal complication in patients who have undergone a Fontan procedure. The variability in presentation of this condition mandates an individualised approach to management with involvement of a multidisciplinary team. There is a high rate of recurrence following haemoptysis and a comprehensive assessment of all potential bleeding sites is necessary. CT is a useful tool to help facilitate this and guide further management. Our policy is to close all potential sources of bleeding as CT and invasive angiography rarely identifies an active point of bleeding.

Hydatid cyst in the tail of the pancreas: a rare case report

Hydatid cysts, caused by Echinococcus granulosus, are rare but significant when found in the pancreas, particularly in endemic regions. This case report discusses a 32-year-old female with a pancreatic tail cyst presenting with epigastric pain and intermittent fever. Diagnostic imaging, contrast enhanced computed tomography (CECT) and magnetic resonance cholangiopancreatography (MRCP), and serological tests were inconclusive, making preoperative diagnosis challenging. Differential diagnoses included pancreatic pseudocysts, benign neoplasms, abscesses, and other cystic lesions. The patient underwent surgical exploration, where a hydatid cyst was identified and treated with cyst removal, partial pericystectomy, and marsupialization. Postoperative management included albendazole therapy. Pancreatic hydatid cysts, though rare, should be considered in differential diagnoses for pancreatic cystic lesions, especially in endemic areas. Accurate diagnosis typically requires a combination of imaging, serology, and histopathological examination, with surgery often necessary for definitive diagnosis and treatment.

Development of a novel immunocompetent murine tumor model for urothelial carcinoma using in vivo electroporation

A lack of advanced preclinical mouse tumor models impedes the progress in urothelial carcinoma research. We present here a novel fast, robust, reliable, and highly reproducible model for the genetic induction of bladder cancer in immunocompetent mice. Different sets of oncogenic transposons (Cmyc, Kras) and Cre drivers were transfected into the murine bladder wall of two different genetic backgrounds (Trp53fl/fl and BrafV600E, Ptenfl/fl, Ctnnb1exon3-fl/fl). Transfection was carried out using in vivo electroporation of the bladder after surgical exploration and transmural or transurethral intravesical plasmid injection. Up to 100% of animals developed urothelial carcinomas of the bladder. Time to tumor onset ranged from 16 to 97 days with a median of approximately 23 days in the fastest groups. Histological examination identified orthotopic urothelial carcinomas in most cases, in some experimental groups up to 100%. The resulting tumors were highly invasive and often metastatic. Metastases were found in up to 100% of tumor bearing mice per group. Taken together, this study establishes the proof-of-principle that in vivo electroporation can be versatilely employed as a reliable, fast, and robust method for the highly reproducible induction of urothelial carcinomas in the murine bladder wall. This novel murine tumor model could pave the way towards more easily modelling subtype specific urothelial carcinomas in mice.

Application of anterior esophageal wall full layer fixation and gastric tube guidance in total laparoscopic overlap method for intracorporeal esophagojejunostomy

Objective: To explore the application of anterior esophageal wall full layer fixation and gastric tube guidance in total laparoscopic overlap method for intracorporeal esophagojejunostomy. Methods: Overlap esophagojejunostomy with anterior esophageal wall full layer fixation and gastric tube guidance is suitable for patients with advanced gastric cancer (clinical stage: cT1b~4aN0~3M0) and esophageal invasion <3 cm, who underwent radical total gastrectomy+ overlap esophagojejunostomy. The main operation procedure was performed as follows: A titanium clip was used for fixation of the full anterior wall of esophagus before overlap esophagojejunostomy, and the side-to-side esophagojejunostomy was performed with the linear stapler under the guidance of gastric tube. Then the titanium clip was removed after confirming that the correct cavity was entered. Finally, the common outlet was closed by two barbed sutures. A descriptive case series study was conducted. The clinical data of patients who underwent laparoscopic radical gastrectomy and overlap esophagojejunostomy with anterior esophageal wall full layer fixation and gastric tube guidance in Guangdong Provincial Hospital of Chinese medicine and the First Affiliated Hospital of Guangzhou University of Chinese medicine from May 2021 to June 2023 were retrospectively analyzed. Results: A total of 42 patients were collected, and all of them were successfully completed laparoscopic total radical gastrectomy without conversion to laparotomy or perioperative death. The esophagojejunostomy time, operative time, intraoperative blood loss was 17(5-25) minutes, (258.8±38.0) minutes and 50(20-200) ml, respectively. The incidence of esophageal false lumen was 0%, and there were no intraoperative complications. The time of gastric tube removal, initial fluid diet intake and the duration of postoperative hospital were 2(1-5) , 4(1-8) and 8(4-21) days, respectively. There were no postoperative anastomotic hemorrhage, anastomotic stenosis and other related complications. One patient (2.38%) developed a Clavien-Dindo IIIb complication, which was abdominal hemorrhage after operation. The second surgical exploration confirmed that the patient was bleeding due to gastroduodenal artery rupture. After intraoperative suture hemostasis, fluid expansion, blood transfusion and other treatments, the patient was discharged on the 15th day after the operation. Three patients (7.14%) developed Clavien-Dindo grade II complications, including anastomotic leakage, chylous leakage and pulmonary infection, and were discharged after conservative treatment such as anti-infection and prolonged retention of drainage tube. Conclusions: Laparoscopic overlap method for intracorporeal esophagojejunostomy with anterior esophageal wall fixation and gastric tube guidance can shorten the time of esophagojejunostomy and prevent the occurrence of false lumen, and do not increase anastomose-related complications.

Bezoar in Pediatrics: Case Series and Literature Review

Introduction: Bezoars are accumulations of indigestible material within the gastrointestinal tract, which, although rare, can lead to significant intestinal obstruction, especially in pediatric patients. This condition often necessitates not only surgical intervention to remove the obstruction but also a multidisciplinary approach to address underlying psychological issues due to the high recurrence risk associated with compulsive disorders. This study presents a series of cases involving children under 14 years old who experienced intestinal obstruction from bezoars and were treated at a tertiary care public hospital, complemented by a literature review to enhance understanding of this condition. Case Series: This descriptive case series study reviews three pediatric patients who underwent surgical treatment for intestinal obstruction caused by bezoars over the past two years. Results: The study identified three patients, all under 14 years of age, who required surgical intervention for bezoar-related intestinal obstruction. Among them, two were male and one was female. Two patients had trichobezoars (66.7%), located one in the stomach and one in the jejunum, while the remaining patient had a phytobezoar (33.3%) in the jejunum. Surgical treatment involved conventional laparotomy with exploration and two-layer enterorrhaphy in all cases. Discussion: Bezoars are categorized into four types: phytobezoars (plant material), pharmacobezoars (medications), lactobezoars (milk products), and trichobezoars (hair). Trichobezoars are most common in the studied cases, contrasting with existing literature that suggests a higher frequency of other types. Bezoars typically present with gastric symptoms but may also cause small intestine obstruction in about 10% of cases. The management of bezoars usually requires endoscopic or surgical removal, with psychological follow-up recommended due to high recurrence rates. The study emphasizes the importance of thorough surgical exploration for concurrent bezoars and integrating psychological care into treatment plans. Conclusion: Bezoars, although rare, are a serious concern in the pediatric population due to their potential to cause significant gastrointestinal obstruction. Effective management requires not only the surgical removal of the bezoar but also consideration of psychological factors to prevent recurrence. This case series highlights the need for a comprehensive approach, including psychological support and detailed surgical exploration, to optimize patient outcomes.

Classic yet challenging case of stump appendicitis: a case report

Introduction: Stump appendicitis is a rare complication of appendectomy in which residual appendiceal tissue becomes inflamed, mimicking acute appendicitis. This case report highlights the classic clinical presentation, diagnosis, and management of stump appendicitis. Case Presentation: A 61-year-old male presented with abdominal pain and a past history of open appendectomy performed four years prior. Clinical examination, laboratory, and radiological findings were highly suggestive of stump appendicitis. Surgical exploration confirmed an inflamed appendiceal stump, which was resected, and the patient had an uneventful recovery post-operatively. Discussion: Stump appendicitis is a rare but important differential diagnosis in patients with a history of appendectomy who present with acute abdominal pain. Delayed diagnosis can result in complications such as perforation and peritonitis. Imaging plays a crucial role in diagnosis, and surgical resection, typically performed through open completion appendectomy, remains the treatment of choice. Conclusion: Although stump appendicitis is rare, it should always be considered in patients with a prior appendectomy who present with acute abdomen. Early recognition and prompt surgical intervention are essential to prevent morbidity and mortality.

Diagnostic Accuracy of MRI for Detecting Nerve Injury in Brachial Plexus Birth Injury.

To determine the diagnostic accuracy of MRI for diagnosing nerve injury in brachial plexus birth injury (BPBI). Electronic databases were searched from inception to 15th February 2023 for studies reporting the accuracy of MRI (index test) compared to surgical exploration (reference standard) in detecting the target conditions of: root avulsion; any nerve abnormality; and pseudomeningocele (as a marker of root avulsion) in children with BPBI. Meta-analysis using a bivariate model was performed where data allowed. 8 studies met the inclusion criteria. In total, 116 children with BPBI were included. All included studies were at risk of bias. The mean sensitivity and mean specificity of MRI for detecting root avulsion was 68% (95% CI: 55%, 79%) and 89% (95% CI: 78%, 95%) respectively. Pseudomeningocele was not a reliable marker of avulsion. Data was too sparse to determine the diagnostic accuracy of MRI for any nerve abnormality. At present, surgical exploration should remain as the diagnostic modality of choice for BPBI due to the modest diagnostic accuracy of MRI in detecting root avulsion. The diagnostic accuracy of MRI needs to be close to 100% as the results may determine whether a child undergoes invasive surgery. Previous research regarding MRI in detecting BPBI is highly variable and prior to our study the overall diagnostic accuracy was unclear. Through conducting a systematic review and meta-analysis, we were able to reliably determine the overall sensitivity and specificity of MRI for detecting root avulsion.

Traumatic durotomy and entrapment of neural elements in a lumbar burst and laminar fracture diagnosed on preoperative imaging: illustrative case.

Traumatic dural lacerations can be caused by thoracolumbar burst fractures and, infrequently, can be associated with the entrapment of neural elements within a laminar fracture. The diagnosis of both is difficult to make on preoperative imaging, as the conditions are typically appreciated during surgical exploration. The authors present a case of traumatic durotomy with entrapment of neural elements in a laminar fracture that they believed could be appreciated on preoperative magnetic resonance imaging (MRI). A young male involved in a motor vehicle collision presented to the authors' trauma center with a lumbar burst and laminar fracture. Preoperative MRI demonstrated epidural hemorrhage and entrapment of neural elements within the laminar fracture, which was confirmed intraoperatively. The patient underwent a successful decompression, release of nerve roots, fusion, and recovery. Traumatic durotomy and entrapment of neural elements can occur after a traumatic spinal fracture, and a diagnosis made upon preoperative MRI can allow for effective preoperative planning. Clinicians should have a high index of suspicion for these pathologies when encountering certain fracture patterns and could therefore tailor the surgical approach to avoid further neurological injury during surgery. https://thejns.org/doi/10.3171/CASE24455.

Thoracic trauma in the geriatric population and possible preventive measures: a retrospective analysis of 261 cases.

The increase in the proportion of the elderly population within society is concurrently escalating their vulnerability to traumas, notably falls associated with age-related comorbidities. This retrospective analysis involved the examination of data pertaining to patients aged 65 and above who were admitted to our clinic for inpatient treatment following thoracic trauma. Various parameters were statistically compared between the groups with indoor and outdoor traumas. Of the 261 patients included in the study, 59.4% were male, and the average age in the entire sample was 75.52 ± 7.79. Moreover, 136 (52%) patients had indoor trauma, while 125 (48%) had outdoor trauma. The mean value for all the patients on the Itaki Fall Risk Scale (FRS) II score was 11.04 ± 4.18. The Itaki FRS II score was significantly higher for indoor accidents (11.90 ± 4.34) compared to outdoor accidents (10.10 ± 3.78) (p < 0.001). Additionally, the absence of a fall history and low risk according to the Itaki FRS II score were higher for outdoor accidents compared to indoor accidents, and the difference was statistically significant (p < 0.001). In geriatric trauma occurring outdoors, bilateral rib fractures and extrathoracic findings were significantly more prevalent (p = 0.011 and p = 0.010, respectively). The majority of patients were followed-up without any surgical intervention (73.9%), the most common surgical interventions were catheter (10.3%) and tube thoracostomy (10.3%), and 1.5% of the patients required surgical exploration. Trauma resulted in mortality in 1.5% of the patients. In the future, specialized measures and prospective studies tailored to the geriatric population, which will constitute the largest demographic segment of society, can facilitate the prevention of trauma-related morbidity and mortality, including associated financial costs.

Unexpected Encounters: Ossifying Fibromyxoid Tumor Unveiled During Evaluation for Inguinal Hernia

Abstract Introduction/Objective Soft tissue pathology often presents diagnostic surprises, elucidating the intricate nature of disease processes. In this introduction, we discuss the unexpected discoveries that can arise during clinical evaluations and emphasize the importance of thorough evaluation in soft tissue pathology. Methods/Case Report We present the case of a 40-year-old male who underwent evaluation for a right inguinal hernia, during which an ossifying fibromyxoid tumor (OFMT) was incidentally discovered. Imaging modalities intended for hernia assessment revealed a 4.5 cm mass abutting the hernia site. Surgical exploration, initiated for hernia repair, unveiled the unsuspected coexistence of a direct inguinal hernia and an OFMT. Histopathological analysis of the excised mass revealed a complex OFMT architecture, characterized by a plexiform growth pattern, fibrous to fibromyxoid matrix, and distinct cellular features. The neoplastic cells exhibited bland round to ovoid nuclei, occasional multinucleation, and scattered mitotic figures. Immunohistochemistry demonstrated variable positivity for desmin and focal positivity for S-100 protein, while CD34, keratin AE1/AE3, smooth muscle actin, and p63 were consistently negative. Notably, the tumor exhibited areas of hypercellularity and easily identifiable mitotic figures, consistent with morphologic features of malignancy in OFMT. Results (if a Case Study enter NA) N/A Conclusion This case highlights the intricate interplay between primary clinical concerns and incidental pathological findings, underscoring the necessity for comprehensive evaluation in soft tissue pathology. Understanding the nuanced histological and immunohistochemical characteristics of OFMT is pivotal for accurate diagnosis and optimal patient management. The unexpected discovery of OFMT during evaluation for inguinal hernia emphasizes the importance of thorough assessment and consideration of incidental findings in clinical practice.

Congenital Appendiceal Atresia: An Extremely Rare Disorder Presenting with Acute Abdomen

Abstract Introduction/Objective Congenital malformations of the appendix are extremely rare and difficult to diagnose preoperatively. One of those anomalies include congenital appendiceal atresia (CAA) which mimics acute appendicitis and is usually ignored in the differentials of acute abdomen. Herein, we present a case study of congenital appendiceal atresia associated with periappendicitis. Methods/Case Report A 62-year-old female with past history of diverticulitis presented with complaints of crampy, diffuse and progressive lower abdominal pain and nausea for two days. She denied fevers, chills or change in bowel movements. Physical examination revealed vitally stable patient with soft, non-distended and tender abdomen in bilateral lower quadrants, worse on the right side and showing positive rebound test. Her complete blood count and chemistry were within normal limits. A computerized tomography arterial portography (CTAP) scan with contrast demonstrated inflammatory stranding around the appendix without abscess, concerning for acute appendicitis. She then underwent laparoscopic appendectomy. Grossly, the appendix consisted of a cylindrical portion of yellow-pink fatty tissue covered by peritoneum measuring 6.2 x 3.3 x 0.5 cm. The peritoneal surface displayed patchy fibrinous exudates. Sectioning revealed yellow adipose tissue with no identifiable appendix. Microscopically, the entire specimen demonstrated a poorly formed, mainly fatty appendix without a discernible lumen or submucosal lymphoid tissue. There were scattered sparsely distributed non-continuous bundles of smooth muscle (muscularis propria) at the periphery, which were highlighted by desmin and trichrome stains. This atretic appendix, mesoappendix and peritoneal covering were acutely inflamed. The final diagnosis was poorly formed, acutely inflamed fatty appendix consistent with congenital appendiceal atresia with accompanying acute periappendicitis. Results (if a Case Study enter NA) NA Conclusion This case would add to the very limited existing literature for congenital appendiceal anomalies and highlight the importance of thorough surgical intraoperative abdominal exploration and submission of the entire specimen for microscopic examination in order to render a definitive diagnosis.

Ultrasound for infantile midgut malrotation: Techniques, pearls, and pitfalls.

Midgut malrotation with volvulus is a surgical emergency with potentially devastating outcomes which include short gut syndrome necessitating long-term parenteral nutrition, overwhelming sepsis, and death. The clinical presentation is most frequently with bilious vomiting in the first days-weeks of life, which is non-specific and common. Timely imaging investigation is therefore crucial to prevent delays to diagnosis and treatment and avoid unnecessary surgical exploration in infants with non-surgical bilious vomiting. Fluoroscopic upper gastrointestinal contrast series (UGI) has been the first-line imaging modality to investigate midgut malrotation at pediatric surgical centers worldwide. However, there is a growing body of evidence to indicate that ultrasound (US) has greater diagnostic accuracy than UGI in this context. Furthermore, US offers the benefits of accessibility, portability, lack of ionizing radiation, and the ability to identify alternative diagnoses, and is beginning to attract significant attention and consideration in the literature. Over the last 3years, we have transitioned to an "US-first" pathway for the investigation of midgut malrotation in infants with bilious vomiting. This pictorial essay illustrates our comprehensive approach, describes unique troubleshooting techniques, and highlights the variably published pitfalls we have encountered with the aim of encouraging wider adoption.

Hemorrhagic intramedullary spinal cord metastasis from renal cell carcinoma: a rare case 15 years after cured renal cell carcinoma. Illustrative case.

Renal cell carcinoma (RCC), the most common kidney cancer, often metastasizes to bones, lungs, liver, and the central nervous system. Intramedullary spinal metastasis from RCC is rare but can cause significant neurological deficits, necessitating prompt diagnosis and treatment through surgical intervention, radiotherapy, and immunotherapy. An 86-year-old man presented with progressive right lower-limb weakness and reduced sensation over 3 weeks. His medical history included a right nephrectomy for RCC 15 years earlier and L4-S1 spondylosis. Imaging identified a bleeding lesion in the conus medullaris at T11-12 and an incidental left kidney mass. Urgent surgical exploration led to a T12 laminectomy and en bloc removal of the lesion, which was confirmed as RCC metastasis. Postoperatively, the patient received focused radiotherapy and immunotherapy, showing significant motor and sensory improvement before dying 3 months later. This case underscores the importance of comprehensive diagnostic imaging for the accurate identification and characterization of spinal lesions. An interdisciplinary approach involving neurosurgeons, oncologists, radiologists, and pathologists is crucial for optimal treatment planning. Urgent surgical intervention can effectively address acute neurological deficits caused by intramedullary lesions. Additionally, adhering to postoperative care instructions, such as deep venous thrombosis prophylaxis, is vital to prevent fatal complications. https://thejns.org/doi/10.3171/CASE24349.

Influence of Perineural (Pn), Lymphangio (L) and Vascular (V) Invasion on Survival after Resection of Perihilar Cholangiocarcinoma.

Perihilar cholangiocarcinoma is a rare malignancy of the biliary tract, for which surgery remains the treatment of choice. However, even after radical resection, the prognosis is poor. In addition to tumor size, depth of invasion and nodal/metastatic status, the TNM classification includes additional parameters such as perineural (Pn), lymphangio (L) and vascular (V) invasion. The prognostic impact of these factors is not yet fully understood. The aim of this study was to investigate the influence of these parameters on overall survival after resection of perihilar cholangiocarcinoma. Data from all patients who underwent surgical exploration for perihilar cholangiocarcinoma between January 2013 and December 2023 were included into an institutional database. The impact of perineural, lymphangio and vascular invasion on overall survival was analyzed. Over the 11-year period, a total of 214 patients underwent surgical exploration for perihilar cholangiocarcinoma. Curative intended resection was possible in 168 patients (78.5%). Perineural invasion, lymphangio invasion and vascular invasion were present in 79.2%, in 17.3% and in 14.3% of patients, respectively. Cross tabulation revealed a significant association between the presence of L1 and V1 (p = 0.006). There was also a significant association of Pn1, L1, and V1 with R-status (p = 0.010; p = 0.006 and p ≤ 0.001). While V1 was associated with significantly worse overall survival across the entire cohort, Pn1 alone showed only a tendency towards worse overall survival without reaching statistical significance. In Bismuth type IV, both L1 and V1, but not Pn1, were significantly associated with worse overall survival (p = 0.001; p = 0.017 and p = 0.065). Perineural invasion is very common in perihilar cholangiocarcinoma. Although Pn1 was associated with a tendency toward worse survival, it did not reach statistical significance. In contrast, vascular invasion significantly worsened overall survival in the entire cohort, and lymphangio invasion was linked to worse overall survival in Bismuth type IV tumors. The combination of perineural invasion with positivity of more than one additional factor (either L or V) was also associated with worse overall survival. In patients with Bismuth type IV, these pathological markers appeared to have even greater prognostic relevance.