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A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.\nThe examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.\nThe blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous surgery site an upper GI endoscopy was performed. A small benign looking ulcer was seen at the pylorus of the stomach.\nWith a strong suspicion of gastrocutaneous fistula, a CT fistulogram was performed. An enterocutaneous fistula between the pylorus of the stomach and the anterior abdominal wall was seen. A long side branch of the fistula tract was seen communicating to a moderate sized left subphrenic collection ().\nWith confirmed diagnosis of complex gastrocutaneous fistula a repeat surgery was planned. The abdomen was entered after incising the previous scar on left lateral side and extending the incision downwards and upwards. Dense interbowel adhesions were encountered. Meticulous adhesiolysis and dissection was performed. The abscess cavity was drained and the perforation on the pylorus of the stomach was identified. It was around 1 cm × 1 cm size. Repeat omental patch repair was performed. In view of difficult dissection, feeding jejunostomy and retrograde tube duodenostomy were also made.\nAn uneventful recovery happened. He attended follow up clinic till 4 months following the discharge. There was an incisional hernia but otherwise he was doing fine. After this he was lost to follow up.\nTimeline |
This patient is a 48 year old female who was admitted with a large fungating right breast mass which measured 22 × 20 cm and elevated 12 cm above the skin surface (Figure ). The patient stated that the mass began as a very small "bump" that she believed was a cyst. One year prior she had been evaluated by her primary care physician who described a bulging, red breast mass in the upper outer quadrant which measured at least 8 cm. Core biopsies were performed and the pathology revealed a high-grade malignant neoplasm with dominant features of carcinoma and a suggestion of carcinosarcoma. The patient chose to not undergo treatment and allowed the mass to enlarge with resultant ulceration of the mass through the skin with centralized necrosis and bleeding of the mass. The patient's associated symptoms included a 50 pound weight loss over the previous 6 months with intermittent low-grade fevers.\nThe patient's past medical history was significant for hypertension and left ear deafness. No significant surgical history was reported and her family history was not significant for malignancies in any first degree relatives. Physical examination revealed a cachetic female in significant pain with a large, extensively necrotic mass on the right anterolateral breast and chest wall. The necrotic tissue was on an erythematous, dense mound of tissue that extended to the lateral and central chest wall. No cervical, supraclavicular, left axillary or inguinal lymphadenopathy was appreciated on physical exam. There was palpable lymphadenopathy within the right axilla.\nThe patient was taken to the operating room and underwent a right radical mastectomy. This encompassed removal of the entire pectoralis major and minor musculature down to the right chest wall, and a complete level III axillary lymph node dissection was performed. The skin flaps were viable, not grossly involved with tumor, and were able to be closed primarily (Figure ). The patient recovered uneventfully and was discharged two days later. The patient developed a moderate amount of right upper extremity chronic lymphedema.\nThe final pathology of the right radical mastectomy revealed a high grade carcinosarcoma measuring 22 cm in greatest diameter (Figures &). There was extensive cutaneous ulceration with underlying dermal involvement by the tumor. The deep surgical margin of resection which included the pectoralis major and minor muscle was negative for tumor. A total of 2 of 28 axillary lymph nodes were positive for metastatic carcinosarcoma with extranodal tumor extension identified. All surgical margins were negative for tumor. Immunohistochemical profile revealed a neoplasm with a dimorphic histology. The epithelial (carcinomatous) component stained positive for cytokeratin immunostain CAM5.2, and the mesenchymal (sarcomatous) component was negative for CAM5.2, actin and desmin, but positive for vimentin. The tumor was estrogen and progesterone receptor negative and not amplified for the HER-2/neu gene via fluorescence in situ hybridization (FISH). Expression of HER-1/EGFR receptor was examined by immunohistochemistry with 70% of the cells expressing the EGFR protein, classified as moderate staining intensity (Figure ). Based on available data and using AJCC criteria, the final pathologic staging was a T4b, N1a, Mx, Stage IIIb lesion.\nA post-operative whole body PET/CT fusion scan and radionuclide bone scan showed no evidence of metastatic disease. As per NCCN guidelines regarding her stage of tumor, we recommended adjuvant radiation therapy to the chest wall and axilla in addition to chemotherapy. She received dose-dense doxorubicin and cyclophosphamide followed by paclitaxel and subsequently radiation therapy to the chest wall and axilla. |
A male patient aged 42 years reported to the department of maxillofacial surgery with the chief complaint of painless huge growth over left eye and loss of vision. History revealed that the patient was apparently alright 2 years back, when he first noticed a small pea nut size ulcerative growth over left lower eyelid near medial canthus. The growth was painless and persistent in growth. It was not associated with any kind of pain or fever. Initially eye site was normal but as the growth increased his vision started to diminish from left eye due to the increase in the size of growth, approximately 1 year before patient completely loses his vision from left eye. Only due to his extremely poor economic conditions he could not seek any sort of medical treatment.\nOn clinical examination the growth extended superoinferiorly from supraorbital ridge to ipsilateral alae of nose and mesiodistally from right inner canthus of eye to left side of maxillary buttress crossing midline (). Personal history was negative for any detrimental habits. On palpation superficial cervical nodes were not palpable. The growth was ulcerative, exophytic, and fungating and exudates were present. It was approximately 6 × 5 cms in size. The vision from right eye was normal and ocular movements in all directions were intact. All other parameters were within normal range. HR-CT scan was advised. The axial and coronal sections showed large homogenous mass covering the whole left orbit involving the globe but no erosive damage was seen in any of the bony structures (). Correlating the clinical history, examination, and radiological findings a provisional diagnosis of carcinoma of left lower eyelid was suggested. Incisional biopsy was performed and histopathological report revealed dermal invasion by abnormal cells from the epidermis, pleomorphism of the tumour cells with presence of keratinization within the cells which give the cells abundant pink cytoplasm, and intraepithelial keratin in the shape of a whorl which confirmed the diagnosis of squamous cell carcinoma of lower eyelid involving the whole of the eye (). With all blood investigations repeated and keeping in mind the due risk of surgery in such a massive lesion, wide local excision of the tumour along with removal of all the contents of the respective orbit was planned along with elective neck dissection (Levels I and II). The patient was intubated using orotracheal intubation; skin incision was marked around the tumour leaving 1 cm of healthy looking skin all around which was quite a daunting task looking at the size of the tumor (). As the tumour was engulfing the whole of the globe as well as retrobulbar contents with the due consultation with the ophthalmologist, complete orbital exenteration was performed (). Elective neck dissection (I-II) performed simultaneously, and all the nodes and resected specimen were sent for the histopathological analysis. Next the pedicled temporalis muscle flap was harvested and was transpositioned medially onto left side of orbit and sutured with skin over the bridge of the nose (). Passive tube drain was placed beneath the temporalis muscle flap to drain any collection into the orbit. Split thickness skin graft was harvested from anteromedial side of left thigh approximately 4 × 3 inches and placed over the temporalis muscle flap (). The patient showed good compliance and the flap healed uneventfully.\nThe postsurgical histopathology reports confirmed the tumor-free surgical margins and the preoperative biopsy findings. All the nodes harvested from neck were free from metastasis. The patient was sent for radiotherapy (RT), 70 grays (Gy) for a period of six weeks. The patient is in follow-up for the past 10 months with no signs of recurrence or discomfort (). Ocular prosthesis was planned but looking retrospectively at the size of the tumor we still defer ourselves from giving the prosthesis and decided to wait for another 12 months. |
A 33-year-old female patient presented at the emergency room with epigastric pain, nausea, and vomiting that had persisted for a day. The patient had a history of child birth eight months prior, and had proximal deep vein thrombosis (DVT) on the left common femoral vein during the 36th week of pregnancy. An inferior vena cava (IVC) filter had been inserted instead of anticoagulation due to the high risk of bleeding during pregnancy. Anticoagulation therapy was administered immediately after the birth of her child. Removal of the IVC filter was recommended one month after insertion, but the patient refused for personal reasons. On arriving at the emergency room, her vital signs were stable and the laboratory examination did not show abnormalities other than mild leukocytosis. The patient's prothrombin time international normalized ratio value at the emergency room was 1.31 due to irregular intake of warfarin. A computed tomography (CT) scan revealed that one of the IVC filter legs had penetrated the IVC wall and caused a duodenal perforation (). There was no evidence of thrombi in the lower IVC. An endoscopy was performed to evaluate the severity of duodenal injury. A protruding IVC filter leg was observed in the lumen of the third portion of the duodenum (). In addition, the duodenum mucous membrane on the opposite side showed erythema, erosion, and nodular changes, resembling chronically progressing penetration.\nAn emergency laparotomy was performed in order to remove the IVC filter and to repair the duodenum. Because there were concerns regarding the possible IVC rupture during surgery, a cannula was placed in the superior vena cava to provide extracorporeal circulation when needed. Also, the femoral artery and femoral vein were isolated for cannulation. The portions of the IVC and the duodenum, including the penetrations, were isolated behind the colon. When the duodenum was lifted up, we found the IVC filter leg between the IVC and the duodenum. We then cut the IVC filter leg and removed the IVC filter leg remnant from the duodenum portion. The duodenal perforation was repaired directly. The IVC was found to be densely adhered to the surrounding tissue including the aorta, and fixed to the adjacent structures. We concluded that isolation and removal of the IVC filter leg remnant in the IVC were more dangerous due to the risk of rupture. The remaining leg protruding from the IVC side to the duodenum was cutoff and removed ().\nAfter the surgery, ileus occurred and the patient started to eat by mouth after 14 days. The patient was discharged on the 20th postoperative day without any complications. The patient returned to work and is currently under follow-up observation. |
A 21-year-old Greek Caucasian female rowing athlete was injured on both thighs during field training. She had to train in sprint as part of her field training program. Upon acceleration, she experienced severe pain on both thighs and fell down. She continued to suffer from severe pain on the anterior surface of her thighs and tenderness with any attempt of movement. She was also unable to stand up and walk. Her trainer observed swelling and loss of function immediately after the trauma and he tried to control the pain with compression dressing and ice packs while they were in the field. She was later brought to our clinic by an ambulance.\nOn physical examination, an oedema was found on the anterior surface of her thighs. The pain was continuous and aggravated on palpation of the quadriceps muscle and any knee movement. There was no gap in quadriceps continuity. Her active and passive knee flexion and extension were restricted and painful. She was not able to perform an isometric quadriceps contraction with her knee in full extension. The active knee's range of movement was 40° for the right and 55° for the left. The passive range of movement was the same because of the pain. We checked the pulse of her periphery arteries with a Doppler ultrasound machine and we found it normal. After the physical examination a roentgenogram was performed. The roentgenogram result was negative for fracture and the patella was not displaced.\nUltrasonography revealed haematoma formation on both her rectus femoris muscles, and magnetic resonance imaging (MRI) was then performed to estimate the size of the haematomas and to evaluate the surrounding soft tissues (Figure , Figure , Figure ). The diameters of the left and right haematomas within the muscles were 6 cm and 5 cm, respectively.\nBased on physical and MRI examinations the strains were classified as second grade or moderate. We examined the athlete to exclude the occurrence of compartment syndrome and we checked her coagulation profile by blood laboratory examination. We did not find any bleeding diathesis. She did not report any connective tissue disorder in her family and any use of anabolic steroids. Our patient was treated conservatively.\nThe treatment included compression bandage, ice application, and rest and elevation for the first 48 hours. Muscle relaxant drugs were administered for 1 week in maximum doses. We administered non-steroidal anti-inflamatory drugs (NSAID) on the 5th day to reduce the pain and to avoid the development of myositis ossificans. Afterwards, we applied isometric exercises and active stretching of the muscle within our patient's pain limits. She was instructed to perform active, pain-free quadriceps stretching 15 times a day and pain-free isometric quadriceps strengthening exercises. Two days later she started to walk using crutches.\nOn the 7th day our patient started stretching exercises, and she was able to walk without crutches. The active and the passive ranges of movement of her knees were bilaterally the same. The active range of movement was 110° and the passive was 120°. The three phases of treatment were rest, knee mobilization, and restoration of quadriceps function. The goals included pain-free knee flexion and extension and rapid, unrestricted return to her full athletic activities.\nSix weeks later MRI result was normal and she had regained a full pain-free range of movement (Figure , Figure ). She started training and two weeks later returned to her old sport activities and competitions. No recurrence of symptoms was observed during the follow-up examination. A follow-up radiographic examination was performed on the third and sixth month after the injury to exclude the development of myositis ossificans. |
A 30 year old male presented at the Surgery OPD with chief complaint of discharging wound in the upper part of the abdomen for 1 month. The problem started 6 months back when he underwent an emergency exploratory laparotomy at another medical college for 3 days old abdominal pain. A small peptic perforation was detected and was repaired with an omental patch. On fourth post-operative day the patient developed burst abdomen. It was managed conservatively. Over a period of time the bowel got contained and the patient was put on oral nutrition. The patient was discharged was doing fine at home. However his abdominal wound was not healing. In the fourth month it was covered with the split thickness skin graft. The procedure and the post-operative period was uneventful till one month. However in the fifth month a serous discharge from the upper part of the grafted surface was noticed. It was coming from a small ulcer and was small in amount. Over a the period of time till he presented at our OPD it remained small in output. It was managed by applying gauge pieces over the wound which has to be changed once or sometimes two to three times a day.\nThe examination of the abdomen revealed a 12 cm × 5 cm elliptical patch of skin graft over the middle of the abdomen. There was a small depressed ulcer of around 1 cm × 1 cm in its upper part covered with pale granulation showing serous ooze. Apart from this ulcer there were few other spots showing exuberant pale granulation (). A scar was seen at previous drain site. Palpation of the abdomen showed deficient abdominal wall below the skin graft.\nThe blood reports were all but normal. Haemoglobin was 11.4 gm/dl with total WBC count as 11.6 × 103/mm3. The total serum protein was 7.9 gm/dl with serum albumin as 3.5 gm/dl. A left subphrenic collection of size 8 cm × 7 cm was seen on the ultrasound. With a suspicion of some missed pathology at previous surgery site an upper GI endoscopy was performed. A small benign looking ulcer was seen at the pylorus of the stomach.\nWith a strong suspicion of gastrocutaneous fistula, a CT fistulogram was performed. An enterocutaneous fistula between the pylorus of the stomach and the anterior abdominal wall was seen. A long side branch of the fistula tract was seen communicating to a moderate sized left subphrenic collection ().\nWith confirmed diagnosis of complex gastrocutaneous fistula a repeat surgery was planned. The abdomen was entered after incising the previous scar on left lateral side and extending the incision downwards and upwards. Dense interbowel adhesions were encountered. Meticulous adhesiolysis and dissection was performed. The abscess cavity was drained and the perforation on the pylorus of the stomach was identified. It was around 1 cm × 1 cm size. Repeat omental patch repair was performed. In view of difficult dissection, feeding jejunostomy and retrograde tube duodenostomy were also made.\nAn uneventful recovery happened. He attended follow up clinic till 4 months following the discharge. There was an incisional hernia but otherwise he was doing fine. After this he was lost to follow up.\nTimeline |
An 8-year-old male child patient presented with a swelling and pus discharge in relation to the right side of his mandible since 1 month. Past history revealed that the patient had met with a motor vehicle accident 3 months ago and was subsequently treated for fracture of the mandible on the right side. Extra oral examination revealed an obvious swelling of 1 × 1.5 cm in size on the right side of the mandibular region with the overlying skin showing a crusty appearance []. There was a sinus opening along with pus discharge over the swelling. Intra oral examination revealed inter dental wiring done from 73 till 83 []. Dental abnormalities included missing 31, rotation of 41, 42 and 32; anterior open bite and posterior open bite on the left side. Orthopantomogram revealed presence of bone plate along with 4 screws in the region of 43 and 45, which were in close approximation with the developing roots of 43 and 45 and the plate was oriented in an oblique direction []. A fracture line on the right side of the mandible extending from interdental area of 42 and 83 vertically and horizontally along the lower border of the mandible was also observed on this radiograph. There was a step deformity in the lower border of the mandible indicating improperly reduced fracture. An associated malunion of the subcondylar fracture on the left side was also noted []. Based on history, clinical features, and radiographic features this case was diagnosed as malunited fractures of the body and the condyle of the mandible on the opposite sides. Under local anesthesia the interdental wiring was removed and a crevicular incision was made from 41 till 46, thus exposing the fracture site. The screws along with bone plate were retrieved carefully []. Prophylactic extraction of 83, 84, and 85 was done to facilitate the eruption of underlying permanent teeth and to evaluate whether any damage had occurred to these teeth in the process of bone plating. Post-operative period was uneventful and after 45 days of follow-up, the extra oral swelling had subsided and the sinus was completely healed []. Intraorally and radiographically there was evidence of eruption of 44 and 43 []. There was considerable evidence of occlusal adjustment both in the anterior and posterior regions throughout the follow-up period []. |
A 44-year-old woman presented to the accident and emergency department with acute right knee pain. While dancing the quick-step (an energetic and form-intensive style) she externally rotated about a planted right foot and felt an acute pain in her right knee with her patella shifting laterally. On arrival at hospital her right leg was locked in full extension and she was in severe pain. The patient had no history of previous knee trauma, prior dislocations, or joint hypermobility. She has no other past medical history to suggest any cause for dislocation of the patella. In particular she had no history of paediatric lower limb alignment problems that would predispose her to a dislocated patella. On inspection of the limb there was a deformity of her right patella indicative of a rare patellar dislocation (Figures and ). The patella appeared rotated on its vertical axis and the skin over the knee joint was tented. It was fixed in position. There was a mild joint effusion and no joint line tenderness. Her range of motion at the right knee was significantly reduced with any flexion from full extension causing the patient significant pain. She was able to straight leg raise on examination indicating that her extensor mechanism was intact. The limb was otherwise neurovascularly intact. The examination of the contralateral limb was entirely normal.\nThe AP radiograph revealed a laterally dislocated patella. The lateral radiograph showed an abnormal appearance with the rotated patella impacted in the intercondylar notch of the femur (Figures and ). In the accident and emergency department one unsuccessful attempt at closed reduction was made under procedural sedation with propofol and fentanyl. The knee joint was fully extended and an attempt was made to manipulate the patella to rotate it back to its normal orientation.\nUnder a general anaesthetic with muscle relaxant the patella was successfully relocated using a closed technique. The articular surface was facing anterior laterally and it was wedged in the intercondylar notch and impacted into the lateral femoral condyle.\nKnowledge of the direction of the articular aspect was vital to the reduction method. With the patient fully muscle relaxed the knee was partially flexed to 30 degrees. Pressure was applied to the medial aspect of the articular surface of the patella that was impacted in the notch. With gentle pressure anteriorly and medially this was pushed up to clear the notch. Once free the natural tension of the extensor mechanism spontaneously reduced the patella. There was no bony injury evident on image intensifier in theatre. The knee was examined under anaesthetic. There was no evidence of any ligamentous injury. There was a normal patellar glide test in assessing for medial and lateral retinaculum damage. The orthopaedic team then conducted an immediate arthroscopy under the same general anaesthetic to check for any osteochondral damage, loose bodies, or soft tissue damage. The arthroscopy findings were of a mild haemarthrosis and mild fibrillation of the lateral trochlear cartilage and lateral patella. There was no gross osteochondral defect and no loose bodies. The medial retinaculum was assessed arthroscopically and was intact. The patient was discharged that day with straight leg immobilisation and orthopaedic followup. Two weeks following her injury she was reviewed in orthopaedic clinic with normal function in her knee. The patient will be followed up at 6 months following the injury. The injury was managed acutely and had normal arthroscopic findings; therefore further investigation with MRI was not felt to be warranted. |
An 18-year-old woman without a medical history showed headache and fever for a few days and then suddenly presented with personality changes with violent behavior and speech disabilities requiring her admission to the department of neurology in our hospital. A diagnostic image of her brain showed minimal changes such as mild brain edema, and cerebrospinal fluid (CSF) analysis showed lymphocyte pleocytosis suggesting inflammatory changes. As the first presumptive diagnosis was either viral encephalitis or autoimmune encephalitis, intravenous high dose steroids, acyclovir, and glycerol were administrated. Several days after her admission, she also showed involuntary movements, disturbance of consciousness, and central hypoventilation; she was managed by assisted respiration and medicated with midazolam and propofol. Since autoimmune encephalitis was the most possible diagnosis according to further examinations, plasma exchange treatment was also started, and the patient was introduced to our department for examination for a potential ovarian teratoma. Nevertheless, neither internal examination nor transvaginal ultrasonography detected an ovarian teratoma. T1-weighted pelvic magnetic resonance imaging (MRI) revealed a 5 × 7 mm fat intensity in the right ovary that showed the possibility of a teratoma (). T2-weighted pelvic MRI showed that a large number of similar-sized ovarian follicles surrounded the teratoma (). Initially, abdominal computed tomography (CT) with 10 mm slice thickness did not detect any fatty component in the right ovary. However, by referencing to the MRI findings, CT with 1 mm slice thickness eventually detected the fatty component in the right ovary. The mean CT number of that showed −62.5 HU (Figures and ).\nAfter 18 days from the first visit to our hospital, the patient underwent a laparoscopic operation for complete resection of the right ovarian teratoma. The macroscopic appearance of the right ovary did not show any abnormalities (). We performed a partial resection of the right ovary by removing small pieces at a time starting from the most likely location of the teratoma according to the diagnostic image (). The first resected 22 × 22 mm ovarian piece contained an intact 5 × 7 mm cystic tumor in which we macroscopically identified fat and hair components (). The pathological diagnosis was mature cystic teratoma containing component of brain tissue (Figures –).\nAn anti-NMDAR-antibody test was positive in both serum and cerebrospinal fluid 1 month after the surgery. From these results and her clinical course, the patient was diagnosed with anti-NMDAR encephalitis. After the surgery, clinical findings and symptoms are gradually improving. However, the recovery of her conscious level was slow and insufficient; 50 mg/m2 of cyclophosphamide in one course was administered 6 months after the operation. After 2 courses of cyclophosphamide, she showed drastic recovery, such as the complete elimination of involuntary movements and complete restoration of consciousness. Currently, while undergoing rehabilitation, she has recovered to the level of being able to ingest food by herself and walk with some help. |
A 56-year-old male patient, whose plasmacytoma was enucleated 3 years ago from the medial side of the left mandible, was referred to our clinic due to his complaints of persistent orocutaneous fistula (Figures –). Past medical history revealed that the patient was operated three times to close the orocutaneous fistula by local flaps; however, none of these operations were successful. CT images of the patient demonstrated that the medial side of the left mandible was missing and there was a 3 × 2 cm diameter defect located between the left side of the mouth floor and the basis of the left mandible neighboring the left submandibular gland. The main reason of the failed attempts to close the fistula was considered to be the ineffective management of dead space surrounding the fistula. Consequently, it was decided to use the submandibular gland as a pedicled flap to fill the defect and support the oral and the cutaneous flaps.\nUnder general anesthesia, the fistula was excised initially and the oral and the cutaneous healthy soft tissues were prepared. At the extraoral site, the incision was extended to the posterior and anterior directions, following the previous incision lines. In the subplatysmal plane, the superficial layer of the neck fascia was dissected to reach the base of the mandible. After the dissection of the fascia, the submandibular gland and the base of the mandible were exposed, the soft tissues surrounding the submandibular gland were dissected, and the gland was mobilized by protecting the arteriovenous supply and the duct. At the oral site, the margins of the wound were released by blunt dissection and were closed by mattress sutures via 5/0 polypropylene. Following the mobilization of the gland, a soft tissue tunnel was prepared between the submandibular space and the defect area and the submandibular gland was rotated by passing the gland through the soft tissue tunnel by preserving the pedicle (). The rotated gland was sutured to the recipient site with 3/0 reabsorbable polyglaction sutures for the stabilization. At the cutaneous site, the flap was closed layer by layer by using 3/0 resorbable polyglaction for the facia and the subcutaneous layers and 3/0 polypropylene sutures for the skin. After the surgery, pressure bandage was applied for the edema control externally and the patient was ordered soft diet for a week. The postoperative healing was uneventful, and at the sixth month follow-up visit, ideal closure of the fistula was observed (Figures and ). |
Our patient was a 67-year-old woman, gravida 4, para 1. Her past medical history included epilepsy diagnosed at 56 years of age, unspecified cardiopulmonary arrest at age 57 years, peritonitis due to acute perforated gastric ulcer, venous thrombosis of the lower limb, and pulmonary arterial embolism. She was also allergic to numerous drugs and diagnostic agents (e.g., contrast media, nonsteroidal anti-inflammatory drugs, and sodium valproate). She visited the department of surgery at our hospital with chief complaints of appetite loss, nausea, and vomiting that had persisted for the prior two weeks. Because abdominal plain computed tomography (CT) revealed ileus and an abdominal incisional hernia, she was immediately admitted with a diagnosis of ileus caused by the incisional hernia. Moreover, a tumor measuring 21 cm in longest diameter was detected in the pelvis (). She was thus referred to our department for detailed examination and treatment. At the initial examination, the abdomen was soft without tenderness, rebound tenderness, or muscular defense. An easily movable mass extending from the right lower abdomen to the level of the umbilicus was palpated. The patient had undergone omental implantation for acute perforated gastric ulcer 10 years earlier. Preoperative abdominal plain CT had revealed a right ovarian tumor measuring 6 cm in diameter (), which contained a part of calcification and fatty components; however, there had been no findings suggestive of malignancy, such as a solid component or a mural nodule. The right ovarian tumor was radiologically diagnosed with a mature cystic teratoma. After surgery for the acute perforated gastric ulcer, she had not been referred to the department of gynecology. No further examination of the right ovarian tumor was performed. She had not been followed up for the ovarian tumor. When the findings of abdominal plain CT performed during the current admission were compared to those of the abdominal CT obtained 10 years earlier, the ovarian tumor was noted to have grown markedly in size and to be partially solid. The CT performed during the current admission also revealed fatty components in the ovarian cyst. On the basis of these findings, malignant transformation of the mature cystic teratoma was suspected. Furthermore, pelvic plain magnetic resonance imaging (MRI) also showed a cyst measuring 21 cm in longest diameter that was partially solid on the right side of the uterine body (). The solid components detected on T2-weighted images () showed high signal intensity on diffusion-weighted images () and low signal intensity on apparent diffusion coefficient maps, which suggested a malignant lesion. In addition, blood tests revealed tumor marker elevations: CEA, 7.1 ng/mL (<4.9 ng/mL); CA125, 58.3 U/mL (<35 U/mL); CA19-9, 405.8 U/mL (<37 U/mL); and SCC antigen, 6.2 ng/mL (<1.5 ng/mL). Based on the clinical course, imaging findings, and elevated tumor markers, malignant transformation of the previously recognized mature cystic teratoma was strongly suspected. Sixteen days after the initial examination, semiurgent surgery was performed. While neither lymphadenopathy nor distant metastasis was detected by imaging studies, the operation consisted of abdominal bilateral adnexectomy and repair of the abdominal incisional hernia in consideration of the patient's general condition. The intraoperative findings included slight accumulation of ascites with a pink tinge due to blood and swelling of the right ovary, which was larger than a newborn's head, whereas there were no signs of capsule rupture, torsion abnormality, and so on. We detected no macroscopic abnormalities in the uterus or the left adnexa. Neither disseminated lesions nor lymphadenopathy was observed in the peritoneal cavity. The tumor in the right ovary was unilocular and weighed 2960 g, containing both fatty components and hair. Moreover, protruding lesions were observed on a portion of the tumor wall (). Cytology of ascites was negative. Histologically, cystic wall was lined by squamous epithelium and contained horny materials inside the cyst. Mature bone tissue and hair were also observed. Focally, granulation tissue was formed. Squamous cell carcinoma was found in the solid part protruding inside the cyst wall. There was a transition between squamous epithelium and squamous cell carcinoma (). The postoperative clinical diagnosis was ovarian cancer FIGO stage IA, pT1aNxM0 due to malignant transformation of a mature cystic teratoma which had first been noted 10 years earlier. Given the history of allergy to multiple drugs, cardiopulmonary arrest, venous thrombosis of the lower limb, and pulmonary arterial embolism, postoperative chemotherapy was not planned. As of two years since surgery, no recurrence has been observed. |
A 33-year-old Caucasian male of Greek origin sustained a work accident. He fell from a height of 2 meters and landed on his right side. On admission he was conscious and well orientated with normal vital signs. His right shoulder and arm were painful, swollen and deformed. Clinical examination revealed a closed and neurovascular intact injury that had resulted to angulation of the arm with loss of the normal contour of the shoulder.\nRadiographs showed an anterior dislocation of the shoulder with a transverse fracture of the middle third of the humeral shaft on the same side (Figure ). The arm was temporarily immobilized in a plaster slab. We have not performed a Magnetic Resonance scan (MRI) in order to investigate possible rotator cuff pathology, because of the lack of MRI equipment in our hospital. Thus, we decided that clinical examination at later would indicate the need or not of MRI. As soon as the secondary clinical survey was completed the patient was carried to the operating theatre. Under general anaesthesia, repeated attempts for closed reduction of the dislocated shoulder failed. Strong muscle contraction, despite the induction of muscle relaxation agents by the anesthetists, and extensive swelling of the soft tissues were obstructive of a successful reduction. Because of the unstable state of the fractured humerus and the risk for further soft tissue compromise and iatrogenic neurovascular damage, it was decided not to insist on reduction maneuvers. The surgeons preferred to attempt stabilization of the shaft fracture by intramedullary nailing prior to the reduction. Under fluoroscopy the entry point was targeted on the dislocated humeral head and an incision was made on the overlying skin. Although the anatomy of the region was altered, because of the dislocation, the anteriorly placed humeral head in the subcoracoid space facilitated, rather than obstructed, the guide wire and nail insertion. Intraoperative investigation revealed no rotator cuff or biceps pathology. Unfortunately a typical intramedullary nailing procedure could not be completed because after the proximal locking screw insertion, the image intensifier equipment suffered serious damage. The weakness for targeted distal locking which would subsequently result to rotational instability and the perspective of reduction manipulations, once the fixation was concluded, implemented the use of a rotational stability providing alternative. Thus a four holes small antirotational plate was placed on the anterior cortex over the fracture site. Four screws (2 at each side of the fracture) were inserted just medial to the nail. All screws were cortical and engaged both the anterior and posterior cortex of the bone enhancing the fixation and securing rotational stability. The shoulder was then reduced by gentle manipulation which sequentially included: external rotation, mild traction and inwards placement of the head into the glenohumeral joint (Figure ).\nThe limb was immobilized in a sling and only occasional flexion-extension of the elbow was allowed. Three weeks postoperatively the patient was encouraged to start Range of Motion (ROM) and muscle strengthening exercises of the shoulder. Bone union was demonstrated radiographically four months postoperatively (Figure ). Mild pain and restriction of shoulder abduction over 90 degrees were demonstrated, due to the impingement of the proud nail in the subacromial space. Therefore, 12 months after the operation and since bone union was secured, both nail and plate were removed. After the hardware removal, the pain symptoms drastically subsided. Full muscular strength and normal ROM were regained. The patient returned to his daily routine activities. At 3 years follow-up, the patient's shoulder is painless and retains a full range of motion (Figure ). No signs of shoulder osteoarthritic lesions or calcific tendonitis are evident in the latest radiographs. |
A 31-year-old male patient was referred from the department of plastic surgery for the fabrication of an auricular prosthesis for his missing right side ear. The ear was lost as a consequence of a road traffic accident a few years ago. The patient was initially attempted for surgical reconstructing of the artificial ear using cartilage and alloplastic graft materials. As the reconstruction did not provide pleasing esthetics, it was later removed, and the patient was referred for prosthetic replacement of the missing ear. After due examination and obtaining patient's informed consent, two implants' supported custom silicone auricular prosthesis was agreed upon as the best treatment modality for the patient. Presurgical cone-beam computed tomography (CBCT) scans were made with a radiographic stent with radio-opaque markers in different probable implant positions. The scans were used to assess the proximity of dura, sigmoid sinuses, and any other limiting anatomical structure from the planned implant positions. The same radiographic stent was modified and converted into a surgical stent to conform to the planned implant sites. Two dental implants were placed at sites 11:30 and 9:30 o'clock positions at approximately 20 mm distance from the center of the external auditory meatus.[] Thinning out of the basal tissue bed was also carried out in the same surgical appointment taking into consideration the presence of residual graft material from the previous reconstruction procedure lying in the tissue bed. The implants were left to heal for 3 months. Despite the attempted thinning of the tissue bed, fresh CBCT scans revealed the tissue thickness from the top of the implant surface to the external skin surface to be in the range of 7–11 mm over both the implants at various sites []. Only custom made healing abutment of a height higher than 11 mm could prove useful in maintaining the patency of the passage from the external skin surface to the implant chamber and prevent tissues from sagging in as they heal postsurgical exposure. In this scenario, where uncertainty prevailed with regards to obtaining precise custom healing abutments to suit the clinical requirements, CBCT DICOM (.dcm) files were converted into standard tessellation language using a software (Mimics Innovation Suite 17, Materialise, Technologielaan, Leuven, Belgium). 12 mm long healing abutments were designed using CAD [Figures and ] and were then milled (CAM) in PEEK material. The healing abutments were sterilized, and readied for connection to the fixture well before the patient was scheduled for the second stage implant exposure [Figures and ]. No adverse reaction like purulent discharge, severe pain, swelling, or any other sign of periimplantitis was encountered during the entire follow-up period of 4 weeks with PEEK abutments []. The patient was taken up in the conventional manner of impressions and technique to fabricate a titanium bar framework to support a silicone auricular prosthesis over the implants [Figures -]. |
A 79-year-old right-handed male with a medical history of diabetes, hypertension, coronary artery disease, and chronic kidney disease underwent the EVAR procedure with a left renal stent for an incidental finding of a juxtarenal AAA on CT scan (). According to the vascular surgery operative report, the procedure was completed successfully through access of the bilateral femoral arteries and the left brachial artery (). After the procedure, there was no immediate recognition of any major complications other than a small contained hematoma at the brachial catheter insertion site that formed after withdrawal of the catheter.\nThe patient then presented to our outpatient pain management clinic 2 months following the procedure with symptoms of atrophy and weakness of the left forearm and pain in the left hand. During the initial examination, a pulsatile mass of 2–4 cm was palpated in the medial left upper arm in the antecubital fossa. Motor assessment of the upper extremities revealed bilateral biceps flexion/extension 4/5, left finger flexion 2/5, and left hand grip 2/5. The patient's presentation was concerning for an aneurysm of the left brachial artery. An immediate ultrasound of the left upper extremity was ordered and revealed a pseudoaneurysm of the left brachial artery. The patient was urgently referred to vascular surgery and was taken to the operating room to repair the pseudoaneurysm the following day.\nFour months after repair of the pseudoaneurysm, the patient returned to our clinic and his left upper extremity sequelae worsened. He now demonstrated significant guarding of his left hand and allodynia to the median nerve distribution and had skin changes and contracture of his digits with significant weakness and atrophy. An X-ray of the hand demonstrated significant osteopenia. A diagnosis of CRPS type II was established. The patient was referred for conservative treatment, which included but was not limited to pharmacologic intervention, occupational therapy for desensitization, and stellate ganglion blocks. The patient failed these conservative treatment measures, and 3 months after diagnosis he died as a result of sequelae from a respiratory infection unrelated to the current case. |
A 19-year-old male with a history of a right tibial stress fracture with intramedullary nail fixation 14 months before presented to the emergency department after jumping into a shallow lake and immediately suffering severe right ankle pain and inability to bear weight. He had had the proximal intramedullary nail screw removed 3 months prior to presentation due to discomfort but reported no other medical problems. On exam, there was significant swelling of the ankle, with global tenderness to palpation. The fibula was noted to be displaced, as palpation of the lateral aspect of the ankle resulted in contact with the tibia, and palpation at the normal region of the peroneal groove revealed the distal fibula. Motion of the ankle was limited in all planes; however, the foot was neurovascularly intact and sensitive to light touch. A 3-view X-ray of the ankle confirmed the dislocation of the fibula posterior to the tibia and posterior dislocation of the talus, while showing the stable intramedullary nail and distal screw with no apparent lucencies (). Additionally, AP and lateral views of the entire tibia and fibula did not reveal any fractures, and the patient did not complain of any discomfort or tenderness to palpation outside of the ankle. Closed reduction was attempted in the emergency department; the talus was relocated, but the fibula was lodged in place and unable to be reduced. Understanding that repeated attempts at closed reduction most likely be unsuccessful and to minimize the risk of articular damage, iatrogenic fracture, or skin breakdown, the decision was made to proceed with open reduction. The patient consented to open reduction and internal fixation of the fibular dislocation and was taken to the operating room the same day. The time that elapsed from injury to operation start was just under 5 hours. From the time the patient had been seen in the emergency department to operation start was under 3 hours. A lateral incision was made, and the fibula was exposed, positioned behind the tibia. At this point, a hemostat was placed between the fibula and tibia and used as a lever to free the fibula. The fibula was reduced in an open fashion but noted to be unstable due to syndesmotic ligament disruption. The fibula was then held in place with a Kirschner wire and fixed by placing two quadricortical screws through the tibia, using radiographic guidance to avoid the previously placed nail and remaining distal screw (). Following this, the syndesmosis was noted to be stable, and the incision was irrigated and closed. At 3 months postoperatively, the fixation continued to remain stable (). The patient underwent removal of the syndesmotic screws 4 months postoperatively, and at 6 months from the initial injury, the patient reported mild pain with activity and had full strength but was limited to approximately 10 degrees of plantar flexion. His AOFAS Ankle-Hindfoot score was noted to be 85. |
A 48-year-old female patient (gravid 3, para 1) visited the private hospital because of urinary incontinence and lower abdominal discomfort. On the abdominal computed tomography (CT) scan, heterogeneously enhanced mass measuring 8 cm in size nearby the uterus and right ovary was not detected exactly. CT finding suggested the highly possibility of right adnexal tumor. The patient underwent laparoscopic exploration for treatment of this tumor. However, there was no definite abnormality on both adnexae and uterus grossly and the retroperitoneal mass on right side of uterus was detected in the operative field. The patient was referred to our institution for further evaluation and definitive treatment of right retroperitoneal pelvic mass. She had no previous medical illness except surgical history of appendectomy 22 years ago. Abdominal and vaginal examination revealed non-specific findings without palpation of abdominal mass and the laboratory findings are within normal limit including tumor marker.\nAbdominal ultrasonography revealed the right adnexal mass with echogenicity and this mass was abutting to uterus. Magnetic resonance imaging (MRI) demonstrated 8 cm-sized, enhancing mass attached to right adnexa and the uterus. This mass had the low signal intensity on T1-weighted images and heterogeneous, high signal intensity on T2-weighted images (). Because the previous laparoscopic exploration was negative for abnormality of right ovary, the ovarian tumor was excluded on diagnosis of the patient. Other possible diagnosis on MRI finding was mesenchymal sarcoma because the tumor had similar intensity to the muscle of uterus meaning originated from muscle but it looked like as separate from the uterus. Based on the imaging findings, the patient was diagnosed preoperatively as mesenchymal sarcoma on pelvic cavity and exploratory laparotomy was planned for removal the pelvic mass.\nAfter laparotomy via lower midline incision, the careful examination of pelvic cavity was performed. On the operative fields, the uterus was found to be normal size with smooth contour and there was no abnormal finding on both ovaries and fallopian tubes (). The retroperitoneal tumor of size 8 × 6 cm was palpated beneath the right broad ligament of uterus and was exposed during the opening of the broad ligament (). After the exposure the retroperitoneal space, careful dissection of the tumor was performed from adjacent organs including uterus and right iliac vessels and the retroperitoneal tumor was excised completely (). This tumor was attached to the right surface of uterus without any connection of uterus except the thin fibrous membrane. However, neither invasion nor adhesion to adjacent organs was observed.\nOn the gross findings, the tumor was well-encapsulated and contained some part of myxoid degeneration (). Hematoxylin and eosin staining revealed the intersecting fascicles of spindle cells (). The immunohistochemical staining was positive for actin, desmin, estrogen receptor (ER) & progesterone receptor (PR) and negative for alphainhibin and S-100 protein (). The final histological examination revealed the subserosal uterine leiomyoma measuring 8 × 6 × 3.5 cm in size.\nThe postoperative course was uneventful and the patient was discharged 6 days after operation. After the operation, the symptoms of urinary incontinence disappeared and she was well with no evidence of recurrent retroperitoneal leiomyoma for 3 years. |
A 43 year old male visited the clinic complaining about the discomfort and pain in the upper right molar area while biting. The clinical and radiographic examination revealed that the maxillary right second premolar and the maxillary right first molar were both associated with localized severe chronic periodontitis. In contrast, the maxillary right second molar had healthy condition without an opposing tooth ( and ). Considering the financial difficulty of the patient, autotransplantation was preferred to implant installation. Following consultation with a periodontist, the maxillary right second molar was planned to be transplanted to maxillary right first molar space and periodontal treatment was planned after that.\nScaling and root planning was performed at 1 month before autotransplantation. Due to the trismus of the patient, root canal therapy was performed after the surgery. Surgical procedure was similar to that described for case 1. Under local anesthesia, the maxillary right first molar was extracted. The recipient site was prepared with a round bur and a duplicated tooth model. The maxillary right second molar was extracted and immediately placed into the recipient site. It was stabilized with 4-0 silk sutures and a semi-rigid resin wire splint (). The extra-oral time from extraction of the maxillary right second molar to transplantation was 11 minutes. Amoxicillin 500 mg three times a day and Ibuprofen 400 mg three times a day were prescribed for a week, and a 0.1% chlorhexidine rinse was used for 7 days.\nThe root canal therapy was begun 2 weeks later. After the calcium hydroxide dressing was maintained for 2 weeks, root canal therapy was completed at 4 weeks after the surgery.\nAt the 7 month follow up, there was no clinical symptom or radiographic signs of root resorption (). As planned, the regenerative periodontal surgery was done on the maxillary right second premolar which had deep periodontal pocket. A new bone formation around the bifurcation area of the transplanted tooth was confirmed during the surgery (). The autotransplanted tooth will be restored with a full crown. At the 18 month follow up, the transplanted tooth had a normal periodontal pocket depth and no mobility. |
A 22-year-old woman, gravid 2, para 1-0-0-1, was referred to our institution for fetal echocardiography at 23 weeks of gestation because of abnormally looking great arterial arches. The pregnancy had not been complicated. The mother had not had any diseases or taken any drugs or herbal medications. There was no family history of congenital heart disease. Obstetric evaluation showed normal fetal growth, normal amount of amniotic fluid and normal placenta. The fetal echocardiography revealed the normal four chamber view, where two atria and two ventricles were normal in size and thickness (). The two atrioventricular valves moved normally. Two great arteries arose normally from the appropriate ventricles. The pulmonary and aortic valves looked normal and the size of the main pulmonary artery and aortic root was within normal limits. The aortic arch was normal in size and in location, but the ductal arch was not visualized in any views. The main pulmonary artery bifurcated into two branch pulmonary arteries but was not continuous with the DA (). However color Doppler examination showed a tortuous 'S' shaped ductus cuddled inside the aortic arch (). The DA joined the descending aorta with an obtuse angle and showed a flow signal from the main pulmonary artery to the descending aorta (). Color aliasing occurred along the course of the ductus but pulsed Doppler measurement of velocity was not attempted because of the poor angle of insonation. Flow velocity and waveforms of the two great arteries were within normal limits and no TR was found. A diagnosis of S-shaped DA with mild narrowing was made and follow up examination was arranged.\nA repeat examination was performed at 27 weeks of gestation and showed nearly the same findings as before. The RV was normal in size and thickness and no TR was noted. Because the DA was S-shaped, it was very difficult to assess size along the whole range of the DA. However, the color Doppler examination showed tortuous turbulent flow in the ductus and suggested mild obstruction. The sagittal section of the aortic arch showed a ductal junction through which low velocity forward flow from the DA to the descending aorta was noted. Obstetric evaluation showed that fetal growth was appropriate and the amniotic fluid index was adequate. No signs of hydrops were noted.\nThe third examination was performed at 33 weeks of gestation. The right atrium was big and the RV was hypertrophied and globular in shape. The intracavitary volume of the RV looked slightly smaller than normal because of the thick ventricular wall and hypertrophy of the trabeculations. The right ventricular endocardial lining and the chordae of the tricuspid valve were very bright (). Color Doppler examination showed moderate TR and its velocity was 4.5 m/sec (). Every attempt failed to demonstrate any flow through the ductus. In spite of the right ventricular overload, fetal growth was within normal range and there was no evidence of fetal hydrops.\nAfter a discussion, we decided to deliver the baby. A female infant weighing 2625 g was born at 34 weeks gestation by induced delivery. Apgar scores were 7 at 1 minute and 8 at 5 minutes. Symptoms and signs immediately after birth were tachypnea, chest retraction, grunting sound and low oxygen saturation. An echocardiography performed at 20 minutes after birth showed a small hypertrophied RV and increased echogenicity of the moderator band and chordae of tricuspid valve (). There was a moderate TR with a velocity of 3.7 m/sec (). The short axis view showed a hypertrophied RV (). The ductus was searched for but no ductus was found in 2-D and color images (). Shunt flow through the foramen ovale was mainly right to left (). She required respiratory support with a mechanical ventilator for the first 3 days. She was successfully weaned from the ventilator on her fourth day and discharged at 12 days old. Follow-up examination at the outpatient clinic showed that she did not have any cardiac symptoms or signs. Echocardiography taken at 2 months of age showed much improvement. The RV was nearly normal in size and thickness. Increased echogenicity of the RV was also nearly normalized. There remained TR with a velocity of 3.0 m/sec. At 7 months of age, all echocardiographic findings returned to normal with resolution of TR. |
We report the case of an 85-year-old healthy Caucasian man suffering from severe neck pain and headache for years with aggravation and a change in pain character since 2 months. On presentation at our department, he described his symptoms as constant boring pain not being altered by activity or rest whereas increasing at night and in the early morning. Physical exam showed a painful and restricted cervical spine motion. No sensory and motor deficits in the upper limbs were noted. General physical examination and laboratory investigations were normal. Past medical history revealed a heart attack 28 years ago and a 40 pack-year history of cigarette smoking. No regular medications were taken. He presented recent X-ray pictures showing a multi-level degeneration of cervical spine and 7-months-old MRI images showing cervical disc protrusion C4 to C7 and neuroforaminal stenosis with compression of the C6 nerve root considered to be the reason for his pain. As conservative treatment was ineffective, performance of spondylodesis and spinal decompression C5 - C7 was advised.\nA neurological examination and a closer look at the patient's detailed pain history revealed that the abovementioned complaints could not be completely explained by the spinal stenosis. Therefore, new MRI scan was requested. An osteolysis of the odontoid process highly suspicious for metastasis was seen. CT scan of the cervical spine confirmed no compromise of odontoid process stability so that a pathologic fracture of the vertebra with possible severe consequences for the patient was not expected. Complete tumor staging with abdominal and thoracic CT scans and skeleton scintigraphy was performed. A coin lesion suspicious of bronchial carcinoma in the right lung and further pancreatic and adrenal lesions consistent with metastases were discovered. Further bony metastases could not be revealed. The histological examination of the tissue obtained in bronchoscopy displayed dense infiltrates of a large cell undifferentiated carcinoma in the right upper pulmonary lobe. Following the decision of the interdisciplinary tumor board, the patient was treated with palliative radiochemotherapy. This alleviated the patient's neck pain and headache. He was discharged from hospital on his request and died 14 weeks later in a hospice. |
We report on a case of a 68 year-old healthy female who initially presented to the emergency room with pain, redness, and swelling in the regions surrounding the proximal and radial aspect of the nail fold of her right thumb in May of 2009. She noted that she had worsening symptoms over the course of one week but no prior history of similar events. The patient denied any trauma to the digit. She underwent an incision and drainage of what was diagnosed clinically as a paronychia. Cultures were positive for Staphylococcus aureus and she received IV antibiotics. The patient was discharged in stable condition with resolution of her symptoms.\nShe then presented four months later with pain along the radial aspect of her thumb with scant serous drainage from the lateral nail fold. She also pointed out the presence of a small amount of granulomatous tissue, which was subsequently resolved. She was followed conservatively and the drainage ceased. She continued to note occasional pain in the radial aspect of her nail fold as well as the interphalangeal joint. At this time, she was found to have what appeared to be a nail deformity (). The patient was taken to the operating room for a biopsy. The biopsy specimen was notable for moderately differentiated squamous cell carcinoma as well as pyogenic granuloma.\nThe cells showed nuclear pleomorphism, atypia, with increased abnormal mitoses and areas of keratin formation. The patient subsequently underwent re-excision of the nail bed, nail fold, and bone in the biopsy area with local flap reconstruction. Margins of the resection were measured 5 mm from the biopsy incision.\nTwo focal areas of squamous cell carcinoma were noted in the bony segment on final pathology (~). The patient subsequently returned to the operating room for an amputation at the interphalangeal joint of the thumb. Due to the level of bony involvement, the patient underwent sentinel lymph node biopsy, which was negative for malignancy.\nWe employed the 7500 Real Time PCR system from Applied Biosystems for evaluation for the presence of human papillomavirus. DNA extracted from the specimen was probed for human papillomavirus (HPV) DNA isotypes 16 and 18. Neither HPV type 16 nor HPV type 18 was detected by Real time PCR. In order to further identify the presence of additional HPV isotypes, we utilized a qualitative in vitro diagnostic test for detection of fourteen high-risk HPV types through a pooled probe. The sample from total DNA extracted from tissue sections demonstrated a positive reaction only with HPV oligomix group 2, which includes oligonucleotides with target-specific affinity to HPV types 18, 39, 45, 59 and 68. Thus, at least one HPV isotype in our patient's specimen was positive. |
An otherwise healthy 25-year-old female presented to our emergency department with complaints of acute onset of epigastric pain and nausea with bilious emesis. Workup in the way of liver function tests and abdominal ultrasound did not demonstrate evidence suggesting biliary or gallbladder pathology, and as such she was discharged home. She represented within hours of discharge due to worsening symptoms. She therefore underwent evaluation with a computed tomography that demonstrated a soft tissue mass located posterior to the gallbladder (). The patient then underwent further evaluation with magnetic resonance cholangiopancreatography. Again, a complex cystic structure of indeterminate etiology was observed at the porta hepatis without evidence of communication with either the biliary or vascular structures. At the time, the differential diagnosis included a ruptured hepatic adenoma, biliary cystic lesion, or enteric cyst.\nSecondary to these findings and her persistent symptoms the patient was taken to the operating room. At the time of laparoscopy a hemorrhagic pedunculated mass was identified attached to the infundibulum of the gallbladder once the fundus was retracted in a cephalad direction (). It was easily dissected off the hilar structures by blunt dissection and then resected by ligating a small pedicle of tissue connecting this mass to the gallbladder infundibulum near the cystic duct by using a harmonic scalpel. There was also a considerable amount of inflammation to the infundibulum of the gallbladder in proximity to this hemorrhagic mass with the remainder appearing normal. Therefore, a cholecystectomy was performed as well. We believe the cholecystitis was secondary to inflammation from the hemorrhagic mass. As mentioned previously, her initial ultrasound did not show any evidence of cholecystitis. Even though one could expect this inflammation to resolve once the hemorrhagic mass was removed, we decided to perform a cholecystectomy because there was considerable dissection within the region of the cystic duct and the concern of potential ischemia and stricture did exist.\nThe patient's postoperative course was uneventful and her symptoms resolved immediately. She was discharged home on the first postoperative day and was asymptomatic when seen in follow-up.\nGross pathology of the hilar mass revealed a 1.2 × 2.8 × 4.5 cm firm purple ovoid structure. Histology revealed extensive hemorrhagic necrosis in the background of normal liver parenchyma. The presence of hepatic lobules with central veins and organized portal structures ruled out adenoma and focal nodular hyperplasia (). Therefore, the final diagnosis was that of a hemorrhagic benign ectopic liver tissue. Histologic evaluation of the gallbladder demonstrated localized cholecystitis in the area adjacent to the mass. |
A 62-year-old female presented for evaluation of recurrent left lower extremity swelling. Her medical history was notable for prior deep vein thrombus in the right distal lower extremity while on hormone replacement therapy (HRT). She denied the active use of HRT and tobacco use during this admission. Venous Doppler ultrasound completed in the emergency room revealed extensive thrombosis of the left lower extremity extending superiorly towards the left common iliac vein. Further imaging with ultrasound revealed compression of the left iliac vein by the right iliac artery as well as a significantly elevated reflux time of the left great saphenous vein (14.2 seconds) suggestive of MTS. The patient was taken to the operating suite and during the procedure the common iliac vein appeared normal distally, but more proximally the vein was narrowed significantly to a diameter of less than 2 mm. Prior to entering the inferior vena cava, the common iliac vein normalized. Using intravenous ultrasound, measurements were taken and a 14 x 60 mm Luminexx stent was deployed at the area of stenosis. The stent was noted to have migrated upward into the inferior vena cava and a buttressing of this stent with a 16 x 40 mm Wallstent was placed to ensure adequate apposition. Unfortunately, this caused further migration upward into the IVC and a 14 mm Atlas balloon was used to help secure the migrated IVC stent. The area of stenosis was no longer stented given this migration. Therefore, stenting of the left common iliac vein stenosis was ultimately achieved with a 14 x 80 mm Luminexx stent (). The patient was started on warfarin with heparin bridging postoperatively. Early ambulation and the routine use of elastic stockings were encouraged following the procedure. The following day the patient complained of severe abdominal pain and an abdominal x-ray revealed only two stents located in the abdomen (). A chest x-ray was obtained and revealed the initial 14 x 60 mm Luminexx stent projecting over the right atrium (). She underwent open-heart surgery for stent retrieval and had a postoperative course complicated by atrial fibrillation and recurrent left sided lower extremity DVT managed with catheter directed thrombolysis. Hypercoagulable work-up revealed homozygosity of the Factor V Leiden gene mutation. One week after discharge, she developed hypotension and lightheadedness. She presented to the emergency department and was found to have pericardial tamponade requiring blood transfusion, pericardiocentesis, and pericardial window. Anticoagulation treatment was stopped during hospital stay and not resumed upon discharge.\nThree weeks later, she had a syncopal episode secondary to a massive pulmonary embolus (PE). Imaging also revealed residual DVT in bilateral lower extremities. She underwent thrombolysis with tissue plasminogen activator and subsequently developed a thoracic hematoma. Given the residual clot burden in the bilateral lower extremity, she underwent IVC filter placement and mechanical thrombectomy. No additional stents were placed. Throughout the hospitalization the patient required multiple blood products after developing a hematoma related to recent thoracic surgery. The patient was eventually stabilized and given the Factor V Leiden mutation and life-threatening PE, she was started on rivaroxaban indefinitely. Since these events, she has been followed closely as an outpatient with no known hospitalizations related to bleeding or thrombosis. At 5-year follow-up, the patient reports that she is doing well. She is not experiencing any complications related to rivaroxaban. She does have residual postthrombotic syndrome (CEAP class 3, Villalta Score 8) well managed with daily compression stockings. |
A 33-year-old pregnant woman was admitted to our department in the 16th week of her first gestation because of suspicion during a routine ultrasound of decreased fetal movements and fetal malformation consisting of postural deformity of both lower limbs associated with a uterine fibroid. The family history was unremarkable and the mother's medical history nonsignificant except for the presence of two intramural uterine myomas diagnosed before the current pregnancy and smaller than 47 mm in maximum diameter in previous control one year before gestation.\nOur ultrasound investigation verified the presence of an intramural-submucosal tumor with a muscular echogenic pattern and a size of 110 × 88 mm in the anterior uterine wall near to the internal cervical os and another intramural one with a size of 28 × 21 mm in the uterine fundus. Fetus presented a normal heart rate pattern and was observed with absent movements and displaced to the right uterine wall in an abnormal position, with hyperextension of head and strongly flexed lower limbs (). Fetal measures according to the gestational age and the amount of amniotic fluid were normal. On the basis of these findings, the diagnosis of arthrogryposis secondary to fetal akinesia due to giant leiomyoma was done.\nAccording to the Spanish legislation, the parents decided the elective termination of pregnancy. A vaginal delivery was induced with local prostaglandins without complications. At the time of birth, the fetus had not cardiac activity and showed external male genitals, a weight of 105 g and a length of 125 mm. His position consisted of internal rotation of the shoulders and stiffness of the limbs with symmetrically flexed and fixed elbows and wrists and severe equinovarus deformities of the feet ().\nThe pathology report concluded that internal organs of the fetus did not present abnormalities. Histopathological examination reported extraconnective tissue developed around the joints and tissue between the muscle fibers swollen with the presence of red blood cells. Chromosomal analysis was normal and the study of fetal DNA excluded the spinal muscular atrophy because there were no deletions of the SMN1 gene. |
A 65-year-old male, without any comorbidities presented to us with complaints of weakness in all four limbs and bladder involvement for the past 18 months following a fall in the bathroom. The patient was diagnosed as degenerative cervical spondylotic myelopathy with OPLL and was associated with central cord syndrome. Initially after fall, he was suggested surgical treatment but he choose to go with conservative treatment. Even after one year of conservative treatment in the form of rehabilitation programme with gait training, balance exercises and proper counseling against fall prevention, patient had negligible improvement. After one year of injury, the patient was operated at another centre wherein anterior C5 cervical corpectomy with mesh cage, bone grafting, and anterior cervical plating was done.\nAfter surgery, although neurological status of the patient remained the same but was otherwise doing well, only to return after 1.5 months of primary surgery with mild neck pain which was insidious in onset, non-progressive in nature, aggravated by activity and relieved with rest with no diurnal variation and no associated systemic symptoms. An radiograph of the cervical spine done within three days of neck pain showed loosening and back out of upper screws of the anterior cervical plate (). A total of 2.5 months after the primary surgery, there was sudden onset difficulty in swallowing, more for solid foods with associated pain in the throat. There was no history suggestive of trauma, fever, respiratory difficulty, local swelling or wound discharge. The symptoms progressed for the next 2 to 3 days after which dysphagia resolved. However, odynophagia persisted to some extent and gradually resolved in the next 2-3 weeks. Repeat radiograph of the cervical spine immediately after throat pain showed that one of the proximal screws was missing along with completely backed out plate (). The patient was immediately immobilized with rigid cervical collar and was instructed to avoid gross neck movements to restrict further backing out of screws.\nA careful search for the missing screw was done by chest radiograph and CT chest where it was not found, followed by abdominal radiograph () and CT abdomen () which finally revealed the screw in the abdomen.\nUpper GI endoscopy was done to look for status of the upper GI tract. As screw had reached the colon and showed gradual movement on serial abdominal radiographs, we waited for its spontaneous expulsion with feces but it showed no significant movement over next 10 days and remained stuck to a single place on right side of colon which warranted colonoscopic removal to avoid perforation of the colon. On colonoscopic examination and screw removal, there was an evident erosion of superficial mucosa without any perforation of colon.\nAfter screw removal from colon, patient was planned for plate removal in view of possible irritation to surrounding structures including esophagus and additional posterior stabilization to maintain alignment of cervical spine. Anteriorly via Smith Robinson approach, the plate and screws were removed. As initial surgery was done on the left side with right sided screw migrating down the colon, we preferred the right side approach for repeat surgery so that pharyngeophageal perforation could be better examined from the right side. While removing, it was found that distal screws were holding well and bone strength seemed good. Pharynx showed healing perforation while the proximal portion of esophagus was also examined properly and could not find any erosion or perforation. Mesh cage was found snugly fit with fusion taking place between C4-C6. Posterior surgery was done by Bohlman’s interspinous wiring. Postoperatively patient was rehabilitated. Presently, patient is self-voiding, independent walker with the help of a stick and able to carry most of his activities of daily living. Patient was evaluated using JOA score (Japanese Orthopaedic Association Score) with Pre-operative score of 8/17 which improved to 13/17 at final follow-up of 1.5 years. |
This is the case of a two-year-old boy who was referred to our Emergency Department by his pediatric cardiologist for evaluation of his lung condition. The physician was performing a routine echocardiogram for the assessment of the child's preexistent foramen ovale, when he saw a round opacity in the thorax, suspicious of a foreign body. This finding necessitated further evaluation by a chest radiograph.\nThe patient was hemodynamically stable upon arrival and not in distress. He had normal oxygen saturation and a normal head and neck examination. Examination of the lungs revealed mild crackles over lung bases but with no evidence of stridor or hoarseness.\nUpon questioning, the mother reported that he had been having vague upper respiratory symptoms with food regurgitation and frequent vomiting over the past seven months. She denied solid food dysphagia but reported mild daily drooling. These symptoms were progressively worsening over the past four months. He was initially diagnosed with gastroesophageal reflux disease and treated with prokinetics and proton pump inhibitors, to which he responded only minimally.\nA chest radiograph was done in the emergency room showing the presence of a round metallic density over the topography of the upper esophagus showing irregular contour, with mild mass effect on the left aspect of the trachea (). The lung fields appeared clear. Further evaluation by a CT scan showed the same round metallic object at the level of the upper esophagus (). A barium swallow was performed and showed that the patient was swallowing without difficulty, with the foreign body apparently separate from the esophageal tract.\nThe decision was made to perform an esophagoscopy in the operating room to the attempt of foreign body removal. Intraoperatively, the foreign body was not seen but a hard mass was felt at the lateral esophageal wall, which was covered by granulation tissue. Multiple attempts to remove the foreign body were performed but unsuccessful. The decision was made to abort the surgery and proceed with an external approach and the patient was transferred to the pediatric intensive care unit.\nTwo days later, the patient was scheduled for a right posterolateral thoracotomy and an extrapleural approach for removal of foreign body with esophagostomy and esophagoplasty. The surgery was successful and was followed by a smooth uncomplicated course. The foreign body retrieved was a button battery.\nForeign body ingestion is a frequently occurring problem in pediatric age groups with 75% occurring at ages less than 4 years []. Esophageal foreign body impaction (EFBI) is a rare presenting pediatric complaint due to the fact that not all are present immediately following ingestion. The majority of ingested foreign bodies pass through the GI tract with no sequelae; however, those that do cause impaction do so in the upper esophagus, the most common site accounting for more than 75% of all cases [, ].\nThe presenting symptoms can range from being completely asymptomatic to being fatal. In between these ends of the spectrum, symptoms can include GI complaints including vomiting, drooling, dysphagia, odynophagia, and respiratory complaints such as cough, stridor, and choking [, , ]. However, neither the symptoms upon presentation nor the location of impaction within the esophagus is predictive of the presence of esophageal injury [].\nThe complications resulting from ingestion are mainly related to the duration of impaction. Moreover, the type of ingested foreign body affects the complication rate [, ]. Many studies have displayed findings that support this conclusion. Denney et al. showed that foreign bodies in situ for more than 24 hours were more likely to cause esophageal ulceration (46%) as compared to those in situ for less than 24 hours (23%) []. Similarly Miller et al. concluded that a higher rate of esophageal injury is seen in foreign body ingestion of over one week []. There is a wide range of complications that have been reported in the literature. These include mucosal abrasions and lacerations, perforations with mediastinitis, strictures, pulmonary edema, and esophageal diverticulum [, , –].\nThe child described here ingested a button battery. Previously injury was believed to occur secondary to leakage of alkaline material; however, recent studies proposed that the cause is the passage of a current through the tissue causing hydrolysis of tissue fluids. Moreover, lithium cells have been associated with worse outcomes. This is due to lithium being 3 V cells instead of 1.5 V cells and since they generate more current, more hydroxide is produced and is more rapid than other cells. In addition, studies have shown that the current generates hydroxide at the negative battery pole and as a result the esophageal injury can be predicted by the anatomic location and orientation of the battery [, ].\nThis case highlights the necessity of having high clinical suspicion and intervention early on. Studies have demonstrated that the worst anatomic area of impaction is in the esophagus. Furthermore, there is chance to have injury free removal of an esophageal battery if removed within 2 hours of ingestion []. The child described above would not have developed such serious complications and would not have required major surgery had the foreign body been identified and removed early on. As a result, physicians who are caring for children who present with respiratory or GI complaints should keep a high index of suspicion of foreign body ingestion especially if the child is nonverbal. In addition, new emerging technologies discuss battery coating which if swallowed decreases the external electrolytic currents which cause tissue injury. The authors conducted animal studies and reported significant decrease in tissue injury compared with uncoated control batteries []. More importantly, parents of young children should take extra caution in storing items which could be ingested by children around the house. Small items especially ones that have chemical composition such as batteries should be kept in areas out of reach of children to insure they never have access to them. |
A 22-year-old male, driver of the car was involved in a road traffic accident when his car hit against a bridge with his ipsilateral hip and knee in flexion. He presented to the emergency department in 4 h injury time with painful deformities of the right hip and knee, along with Type I open wound right leg with abnormal mobility suggestive of fracture in the ipsilateral leg. On examination, he was drowsy and disoriented with a Glasgow Coma Scale 8/15 and found to be hemodynamically unstable. Physical examination of the extremities revealed a flexed and adducted right hip with the right knee flexed to 30° and with posterior dislocation (). Neurovascular examination revealed common peroneal nerve palsy and absent distal pulses. However, the Doppler showed weak signals over posterior tibial and dorsalis pedis artery, and the toes were found to be warm with delayed capillary filling. Computed tomography (CT) brain showed acute hemorrhagic contusion. Radiographs showed a posterior dislocation of the right hip and posterior dislocation of right knee with comminuted fracture right distal tibia ().\nThe patient was intubated and hemodynamically stabilized and immediate closed reduction was attempted. The Firstly, an ankle spanning exfix was applied to address the distal tibial fracture, and the knee dislocation was reduced by gentle traction given to the leg. Further traction on the right hip with the hip in 90° flexion with an assistant stabilizing the pelvis reduced the right hip dislocation, which was found to be stable after reduction. Then, ankle spanning external fixator extended to span the knee. Immediately following the procedure, distal pulses were clinically not palpable but relatively good flow was noted in the Doppler both in the posterior tibial and dorsalis pedis artery. The foot continued to be warm with good capillary filling of the toes. The patient was on continued ventilator support for 48 h in Intensive Care Unit and serial monitoring of the right lower limb vascularity was done using Doppler. Post reduction CT of the pelvis showed only a minor posterior wall fracture with congruently reduced hip joint () allowing conservative management. Distal pulses were felt clinically from 4th day following which locking compression plate fixation of distal tibia was done. The patient general condition improved and discharged after 3 weeks.\nAt 6 weeks, external fixator was removed and bone grafting was done for the distal tibial fracture and the right knee gently manipulated. The distal tibial fracture healed in 4 months with good recovery of common peroneal nerve. The knee flexion was 0-130° with posterior sagging and multidirectional instability. Magnetic resonance imaging (MRI) of right knee showed posterior cruciate ligament (PCL) avulsion fracture and lateral collateral ligament avulsion fracture (). It was planned arthroscopic evaluation which showed a torn PCL at tibial attachment and torn anterior cruciate ligament (ACL) at anterolateral bundle but the continuity maintained with posterolateral bundle. Arthroscopic PCL reconstruction using bio screws and open posterolateral corner repair using hamstring graft and endobutton was done. Post-operative rehabilitation included the protocol for multi-ligament instability. At 2 years follow-up, he had full range of movements at the right hip and knee. Radiographs of the pelvis showed a viable femoral head without signs of avascular necrosis. There was complete recovery of the common peroneal nerve (, ). The knee was stable and he returned to his preinjury level of activity. |
A 5-year-old male child came to the department of oral and maxillofacial surgery with a complaint of difficulty in opening the mouth for the past 2 years. The birth history was normal. No other member of the family was similarly affected. His mouth opening was normal until he met with a trauma with wooden thorn on the left cheek region. Thorn was removed by a surgeon immediately, but the patient had progressively reduced mouth opening since then. Computed tomography scan showed a radiodense mass extending in front of the anterior border of the ramus of the mandible, suggestive of ossified masseter muscle []. Magnetic resonance imaging revealed evidence of a large elongated T1–T2 intermediate signal intensity lesion with mild surrounding edema in the substance of left masseter muscle, abutting the ramus of left mandible likely to represent heterotopic bone formation (at the expected location of previous surgery for thorn extraction) []. This finding along with a history of trauma led us to the diagnosis of MOT.\nOn thorough probing into the history, the patient's father said that the patient had a history of pain and swelling in the left thigh region and limited movement of the left leg 3 years back when he was only 2 years old. The patient had consulted an orthopedic surgeon for further management of the same. His front and lateral leg radiograph showed bony growth over femur. Subsequent three X-rays of the leg were taken at an interval of 1 month which showed progressive increase in ossification [Figure -]. However, unfortunately, he was misdiagnosed for any bony growth in his left thigh and advised for surgical removal of the same. He got operated for the left leg in 2016; however, after operation, he had total immobility of the left leg. Postoperative radiograph of the leg showed cord-like ossification of the muscles and soft tissue of the left leg giving pattern of branching tree []. Local examination of the face showed that the mouth opening was reduced to nil []. A full-body examination revealed ossifications and a scar mark of previously operated site in the left leg regions []. In addition, microdactyly of the great toe on both the feet was seen []. Informed written consent was taken from the patient's parent.\nAll these clinical and radiographic features led us to conclude the diagnosis as FOP. The patient's parents were made aware of nature of disease and instructed to take possible precautions. We have kept him under observation because any surgical intervention of ossified muscle might lead to further deterioration of condition as it has been experienced by patient with two previous surgeries. |
A 25-year-old male came with complaints of pain in both groins for 1 month. Pain was more in the left groin compared to the right side. He is mason by occupation and his work involves lifting heavy objects such as stones but does not involve walking long distances. The weight of the stone was 10–15 kg and he had to lift the stones at least 3 to 4 hours a day amounting to a total of 100 to 150 stones. The pain was dull aching in nature, continuous, and nonradiating. Pain was aggravated on standing and walking. Patient was able to do all his routine activities but with pain. He was able to squat, sit, and walk. There was no history of any other comorbidities and past history and social history were not significant.\nOn clinical examination patient had an antalgic gait and there was no limb length discrepancy. There was tenderness present over the anterior joint line of both hip joints bilaterally. Extremes of rotation were painful with internal rotation being more severe. Power in both lower limbs was normal and neurovascular examination was normal.\nThe patient was evaluated by X-ray of both hip joints which showed a possible fracture line in the femoral neck on the left and no abnormality on the right (). On further investigation with MRI scan, a complete fracture line in the femur neck on the left side and an incomplete fracture line on the right side were seen (Figures , , and ). Patient was admitted, immobilised, and evaluated for the stress fracture with blood tests and DEXA scan. The tests revealed a normal blood picture and no abnormality was seen on tests done to rule out metabolic disorders. DEXA scan of lumbar spine also showed a normal T score.\nThe patient underwent surgery with internal fixation done using a 3 holed dynamic hip screw bilaterally on two sittings 2 days apart (). Weight bearing was initiated one and half months following the surgery with the aid of a walker. At 6 months and one year postoperatively patient was doing all his activities of daily living. On radiographic examination at 6 months and one year the X-ray did not show any evidence of avascular necrosis of the femur head (). |
A 78-year-old male was admitted with acute ischemic stroke in the territory of the left middle cerebral artery, which was treated with venous thrombolysis. Investigation showed critical stenosis of the left ICA and 50%–69% stenosis of the right ICA on Doppler ultrasound (DUS). Angiography showed occlusion of the right ICA with reperfusion on vasa vasorum and 90% stenosis of the left ICA. The patient underwent angioplasty with stent placement in the left ICA 14 days after the episode of acute ischemic stroke []. Both the anesthetic and endovascular procedures were uneventful; the patient progressed without complaints and was discharged 2 days after the intervention. Because the patient was afebrile, and there was no active infectious focus, antibiotic prophylaxis was not given. The patient presented to the emergency department 20 days after treatment with fever. He complained of pain in the left cervical region, and a DUS of the carotid arteries was then performed, which showed only mild intimal hyperplasia within the stent.\nBlood culture showed vancomycin-sensitive Staphylococcus aureus and the association of several septic teeth in the oral cavity, suggestive of Ludwig's angina. Antibiotic therapy was started, but the patient progressed with worsening pain in the left cervical region and formation of a subcutaneous collection with local edema. A second control DUS showed fluid in the muscle planes around the stent graft, and nuclear magnetic resonance (NMR) confirmed the findings of infection at the stent site. A second cerebral angiography showed only minor irregularities at the stent site with mild intimal hyperplasia [].\nThe patient remained hospitalized for 3 weeks on ceftazidime and vancomycin therapy. The clinical course was stable, with a slight improvement of the cervical edema. A second cervical NMR was performed because of an increase in the cervical collection, which showed a giant pseudoaneurysm of the treated artery, a finding confirmed by angiography []. The case was discussed with the vascular surgery team, and because of contralateral ICA occlusion, bypass surgery for stent resection was not considered a good option, and neither was endovascular occlusion of the diseased carotid artery. Therefore, as an alternative, treatment with the placement of the Casper stent (MicroVention, CA) was suggested. This is a dual-layer braided metal stent with micro-mesh that provides greater coverage of the arterial wall. Its use was intended to achieve arterial wall reconstruction by the flow-diverting effect of the device. The course of the procedure was uneventful. Immediate results showed contrast retention within the pseudoaneurysm. Ten days later, a control angiography revealed a reduction in the pseudoaneurysm flow and volume []. However, 1 week later, a worsening of his general condition was observed, with a decreased level of consciousness, arterial hypotension, tachycardia, and tachypnea. Septicemia was diagnosed, leading to cardiac arrest and death. |
A 62-year-old female presented for evaluation of recurrent left lower extremity swelling. Her medical history was notable for prior deep vein thrombus in the right distal lower extremity while on hormone replacement therapy (HRT). She denied the active use of HRT and tobacco use during this admission. Venous Doppler ultrasound completed in the emergency room revealed extensive thrombosis of the left lower extremity extending superiorly towards the left common iliac vein. Further imaging with ultrasound revealed compression of the left iliac vein by the right iliac artery as well as a significantly elevated reflux time of the left great saphenous vein (14.2 seconds) suggestive of MTS. The patient was taken to the operating suite and during the procedure the common iliac vein appeared normal distally, but more proximally the vein was narrowed significantly to a diameter of less than 2 mm. Prior to entering the inferior vena cava, the common iliac vein normalized. Using intravenous ultrasound, measurements were taken and a 14 x 60 mm Luminexx stent was deployed at the area of stenosis. The stent was noted to have migrated upward into the inferior vena cava and a buttressing of this stent with a 16 x 40 mm Wallstent was placed to ensure adequate apposition. Unfortunately, this caused further migration upward into the IVC and a 14 mm Atlas balloon was used to help secure the migrated IVC stent. The area of stenosis was no longer stented given this migration. Therefore, stenting of the left common iliac vein stenosis was ultimately achieved with a 14 x 80 mm Luminexx stent (). The patient was started on warfarin with heparin bridging postoperatively. Early ambulation and the routine use of elastic stockings were encouraged following the procedure. The following day the patient complained of severe abdominal pain and an abdominal x-ray revealed only two stents located in the abdomen (). A chest x-ray was obtained and revealed the initial 14 x 60 mm Luminexx stent projecting over the right atrium (). She underwent open-heart surgery for stent retrieval and had a postoperative course complicated by atrial fibrillation and recurrent left sided lower extremity DVT managed with catheter directed thrombolysis. Hypercoagulable work-up revealed homozygosity of the Factor V Leiden gene mutation. One week after discharge, she developed hypotension and lightheadedness. She presented to the emergency department and was found to have pericardial tamponade requiring blood transfusion, pericardiocentesis, and pericardial window. Anticoagulation treatment was stopped during hospital stay and not resumed upon discharge.\nThree weeks later, she had a syncopal episode secondary to a massive pulmonary embolus (PE). Imaging also revealed residual DVT in bilateral lower extremities. She underwent thrombolysis with tissue plasminogen activator and subsequently developed a thoracic hematoma. Given the residual clot burden in the bilateral lower extremity, she underwent IVC filter placement and mechanical thrombectomy. No additional stents were placed. Throughout the hospitalization the patient required multiple blood products after developing a hematoma related to recent thoracic surgery. The patient was eventually stabilized and given the Factor V Leiden mutation and life-threatening PE, she was started on rivaroxaban indefinitely. Since these events, she has been followed closely as an outpatient with no known hospitalizations related to bleeding or thrombosis. At 5-year follow-up, the patient reports that she is doing well. She is not experiencing any complications related to rivaroxaban. She does have residual postthrombotic syndrome (CEAP class 3, Villalta Score 8) well managed with daily compression stockings. |
A 41-year-old female presented to the emergency department (ED) with four hours of severe sudden-onset left-sided retro-orbital headache. It was associated with blurry vision in her left eye and did not change in intensity. She initially delayed seeking medical evaluation but came to the ED when her symptoms persisted. After the headache had been present for two hours, she noted some altered sensation throughout her right lower extremity but had no complaints of focal weakness. Her medical history was only significant for depression and daily tobacco use. She did not have a history of headaches and there was no trauma.\nThe patient was evaluated by a physician at triage upon initial arrival in the department and was not noted to have any focal deficits. Her initial vital signs were only notable for a blood pressure of 125/95mmHg. She was evaluated by the treating physicians approximately 20 minutes after arrival and noted to have an NIH stroke scale score of three for slight flattening of the left nasolabial fold, drift in the right leg, and altered sensation in the right leg. Sensation was tested by comparing the perception of sharp stimuli between each lower extremity, which was reported to be more dull throughout the right lower extremity compared to the left in a non-dermatomal pattern. The patient underwent an emergent non-contrast computed tomography (CT) of the head followed by CT angiograms of the neck and brain. The on-call neurologist was consulted and noted no focal deficits on exam with an NIH stroke scale of zero approximately 40 minutes after the exam by the emergency physician. Her imaging studies were reviewed and she was found to have bilateral internal carotid artery dissections with pseudoaneurysm formation on the left creating a relative stenosis ().\nAfter discussion with the neurosurgical service, she was started on a heparin drip and admitted to the ICU for monitoring. She underwent cerebral angiography but did not require any intervention at the time, as good flow was seen distal to the dissections and pseudoaneurysm. She was discharged home three days later on an enoxaparin bridge to warfarin.\nShe re-presented to the ED 10 days later with right-sided numbness that developed into aphasia and right-sided weakness. Her initial complaint was tingling on the right side of her face and along the right arm but this progressed into severe aphasia, dysarthria, diminished strength throughout the right upper and lower extremities, and decreased response to painful stimuli on the right side while she was in the ED. She was taken back to the angiography suite and a stent was placed in the left internal carotid artery. She was discharged three days later on aspirin and clopidogrel. A follow-up CT angiogram of the neck performed four weeks later showed a stable right internal carotid artery dissection and patent left-sided carotid stent. |
A 46- year old Sudanese male has few months’ history of gastric symptoms. He was planned for upper GIT endoscopy. There was no significant past medical history and he is not on immunosuppressive therapy. One day before endoscopy, he started to feel right lower costal pain which worsened next morning. His symptoms were initially explained by anxiety from the planned procedure. In few days time, he developed severe localized pain on the right lower costal area that radiates from the spine forward to the mid abdomen. He noticed mild change in the color of the skin in this area with redness, small vesicular rash, and soreness. These gradually improved with symptomatic treatment for herpes zoster. By the end of the second week, he started to feel heaviness of the right leg and numbness on the left. There were no urinary symptoms or fever. The clinical examination 3 weeks from the onset of neurological symptoms showed an average weight and height patient with abnormal gait. The abnormalities were confined to the central nervous system in the form of flaccid right lower limb weakness (Grade III + MRC), brisk knee and ankle jerks on the right. The right planter reflex was unobtainable. The examination of the sensory part showed normal pin prick vibration, position, and temperature sensations on the right lower limb but pain and temperature were impaired on the left lower limb which had normal power. A diagnosis of herpes zoster induced autoimmune myelitis was made and a dorsal MRI was requested. The clinical features of myelitis were in the form of Brown Sequard Syndrome. Mean while the patient was started on IV methyl prednisolone injections 1 g daily for 3 days followed by a 4 week's course of oral steroids starting with 45 mg/d. The non contrast dorsal MRI was normal and LP procedure was declined by the patient. Fortunately, the motor weakness improved and at 3 months assessment, there were minimum remaining sensory abnormalities on the left lower limb with no motor weakness on the right lower limb. The final clinical diagnosis was possible D 6 herpes zoster induced myelitis presenting clinically as Brown Sequard Syndrome. The patient was reassured and discharged from the clinic without further neurological complains for 2 years now. |
A 58-year old male presented to the emergency department complaining for pain at the left side of the base of his penis 4 h after excessive forceful masturbation. His medical and surgical history was unremarkable and he was under no medications whatsoever. At physical examination there were no signs of penile deformation, or expanding hematoma although the formation of a small hematoma was noticed at the base of the penis (). Abdominal examination was unremarkable, although the bladder was distended and palpable. The scrotum was painful at palpation, but the testicles were normal. The patient was able to void without hematuria and there were no evidence of urethral injury on retrograde urethrogram. The patient was consulted that this was a case of trauma causing rupture of the cavernous body that should be best managed surgically. However he did not consent for surgical exploration of the trauma and for this reason conservative management with broad spectrum antibiotics and low molecular weight heparin was administered. As penile ultrasonography was not available for technical reasons, the next day a magnetic resonance imaging (MRI) of the penis was performed in order to further investigate the extent of the traumatic lesion. Axial T1-weighted MRI showed a small tear in the tunica albuginea and hematoma in the left side of the base of the penis. (). After 3 days of conservative treatment the area of hematoma collection became erythematous and painful giving the impression of an abscess formation while the white blood cell count increased from 9000 to 21,000. The following day the abscess drained spontaneously to the skin, the patient was relieved from pain and the blood count returned to normal (). The pus culture from the abscess revealed Staphylococcus aureus. The patient was subjected to drainage and surgical debridement of the abscess.\nThe patient was discharged after 12 days of hospitalization with per oral somministration antibiotics administered for additional 10 days. With regard to his sexual ability, 3 months after the incidence he reported normal erections although he was not willing to complete the International Index of Erectile Function (IIEF) questionnaire or undergo a penile Doppler examination. The patient did not report any other mid- or long-term complications. |
A 57-year-old woman attended for routine mammography screening. She was recalled because her screening mammograms revealed three separate lesions in her right breast and one in the left. At clinical examination, there were only two vaguely palpable masses in the upper outer quadrant of her right breast and one in the upper outer quadrant of her left breast. Overlying skin was normal and no regional lymph nodes were palpable.\nMammography of the left breast revealed a 15-mm lesion in the upper outer quadrant and on core biopsy it was shown to be a grade I invasive ductal carcinoma which was oestrogen and progesterone receptor positive. On the right side, the first mass, an area of about 13-mm of micro calcification, was situated in the upper outer quadrant at the 10'o clock position, and on core biopsy was confirmed as a grade I invasive ductal carcinoma, also both oestrogen and progesterone receptor positive. The second mass was at the 11'o clock position and the third was in the lower inner quadrant and these latter two lesions on core biopsy showed lymphoma-like features but not breast carcinoma. The core biopsies were therefore sent for expert opinion but this supplementary report was also not conclusive. Therefore, diagnostic excision biopsy was recommended. In the meantime, staging computerised tomography of her chest and abdomen was performed and was found to be normal. Treatment options were then openly discussed with the patient and her family and she opted for a right mastectomy and axillary node clearance and wide local excision and axillary node sampling on the left. She felt this would be easier than a combination of therapeutic local excision of the cancers and diagnostic needle localisation of the other masses in the right breast.\nDefinitive histopathology supplemented by immunohistochemistry was compatible with marginal zone B-cell lymphoma of right breast and involving the lymph nodes of both axillae (Figure , ). In addition, it also confirmed in the right breast an 8 mm, grade I invasive ductal carcinoma (Figure ) with intermediate grade ductal carcinoma in situ and a 12 mm grade I invasive ductal carcinoma on the left side. There was no lymphatic spread of breast cancer into either axilla. Her breast cancers were treated by radiotherapy to her conserved left breast and adjuvant hormonal therapy. The patient was referred by the breast team to the specialist lymphoma team but they did not recommend any further treatment for the Nodal marginal zone B-cell lymphoma as it was indolent tumour and they deemed it had been adequately treated by the surgery alone. She has follow up in six monthly intervals. |
This is a 63-year-old female who was referred to the radiotherapy clinic at our tertiary hospital in December 2016, for consideration of adjuvant radiotherapy for a resected retrorectal adenocarcinoma with a positive margin.\nThe patient provided a remote history of a congenital cyst that had been surgically removed when she was a newborn. Her past surgical history was also significant for a hysterectomy and unilateral oophorectomy, which were performed to address a fibroid and benign ovarian cyst more than 17 years prior to this presentation. Her past medical history was significant for diabetes, high blood pressure, high cholesterol and acid reflux. Her current presentation was that of a recent, progressive gluteal swelling associated with chronic lower back pain, which has progressed in the few months prior to presentation. Upon presentation, a cystic mass was felt in the gluteal area and needle aspiration was attempted. Over the following couple of weeks, the cystic fluid reaccumulated and she apparently developed multiple abscesses and fistulas.\nThe patient underwent surgical resection of the cystic mass through a posterior approach and recovered well from her surgery. Her back pain had completely resolved. At her first visit to our tertiary center, the only finding in her exam was that of thickening in the gluteal area scar.\nHer initial blood work revealed normal blood counts, and normal liver and renal profiles. CEA and CA 19–9 levels were not obtained at her initial presentation. The initial fluid aspirate was negative for malignancy. The final pathology of the resected mass was positive for mucinous adenocarcinoma arising within a cystic hamartoma. A review of the slides at another private tertiary hospital revealed a mucinous adenocarcinoma; primary ovarian or cervical primaries were to be excluded.\nA review of the slides was performed at our hospital. The microscopic description was that of an invasive mucinous adenocarcinoma, as evident throughout the provided tissue samples. The mucin had extravasated to the surrounding tissue and elicited a histiocytic reaction (). The tumor was seen at the margin and reached the skin’s surface with ulceration. Features associated with teratoma, epidermoid, duplication, or tailgut cyst were not seen.\nImmunohistochemistry was positive for CK7 (diffuse, strong cytoplasmic), CEA (diffuse, moderately strong, cytoplasmic), and CDX2 (focally strong, nuclear), and negative for 4CK 20, P 16, GCDFP, ER, and p63.\nAt presentation, an MRI scan of the pelvis was obtained and revealed a large, multiloculated cyst in the ischiorectal fossa, with a clear fat plane between the cyst and the rectum. No other abnormality was noted on MRI. The uterus and ovaries could not be visualized on MRI. Unfortunately, we could not retrieve the first MRI image from the other hospital.\nStaging CT scan of the chest, abdomen, and pelvis, as well as a postoperative MRI of the pelvis, were obtained after referral to our hospital. The CT of the chest was unremarkable for any metastatic disease. The CT of the abdomen revealed an ill-defined, solid mass at the right adnexa measuring 3.2 cm that could represent ovarian metastases or a metastatic lymph node; an inguinal lymph node measuring 1.6 cm was also noted on the left side (). As a result, an ultrasound of the pelvis was obtained and revealed a solid mass arising from the right adnexa, but no further characterization was possible. An MRI scan of the pelvis revealed fluid collection with high signal intensity and no enhancement on postcontrast images at the presacral region, likely representing a hematoma at the surgical area. The surgical bed demonstrated diffuse, soft-tissue edema and muscular edema, primarily involving the gluteus muscle associated with enhancement. There was circumferential wall thickening involving the rectum. The right ovary was well visualized and appeared unremarkable. There was a left inguinal lymph node measuring 1.4 cm, most likely representing a metastatic lymph node.\nSince the question arose of whether a gynecological or gastrointestinal primary mass was present, the patient was referred to a gastroenterologist and a gynecologist. The patient underwent a colonoscopy, which did not reveal any perianal, rectal, or colonic masses. As the MRI did not reveal any abnormality in the ovary and given that the patient was examined by a gynecologist who did not find any abnormalities, a gynecological malignancy had also been ruled out.\nThe patient was discussed at the tumor board. Given the remote history of the cyst and the absence of a clear primary gastrointestinal mass, the potential diagnosis of an adenocarcinoma arising in a recurrent cyst was thought to be likely, with the main differential being an occult adenocarcinoma of the rectum. The decision was made to proceed with chemotherapy. The patient received five cycles of XELOX chemotherapy (capecitabine and oxaliplatin), starting 6 weeks after her surgery.\nOnce the patient completed her chemotherapy course, a repeat staging work-up was obtained. The CT of the abdomen and pelvis revealed heterogeneous soft tissue thickening of the rectum, and clinical examination and proctoscopy/biopsy to exclude recurrent disease in the rectum was recommended. A mild reduction in the size of the metastatic left inguinal lymph node was noted. The chest CT scan did not reveal any mediastinal or pulmonary metastases. The patient was again discussed at the tumor board and the recommendation was to have her assessed by a surgical oncologist, and to repeat the colonoscopy to exclude rectal or colonic disease. The repeat colonoscopy did not reveal any masses, and a few polyps were removed and were benign. The patient was seen by the surgical oncologist and thickening at the sacrum in proximity to the previous resection was again noted, as was the inguinal lymph node. Fine-needle aspiration of the inguinal lymph node was obtained and was positive for metastatic adenocarcinoma. A CT-guided biopsy of the thickened sacral area was also obtained and revealed adenocarcinoma ().\nFour months after the completion of chemotherapy, a repeat MRI scan was done. It showed a large, speculated, intense, enhancing, soft-tissue mass at the surgical bed. It measured 9 cm×5.3 cm (). The tumor was inseparable from the coccyx and was associated with multiple enlarged mesorectal lymph nodes measuring up to 5 mm. There was a large, pelvic lymph node on the left-side wall. Multiple foci of cystic components were also identified adjacent to the tumor. The rectum was unremarkable. In conclusion, there was significant Interval progression at the surgical bed of the tumor, in keeping with recurrence. The patient was again discussed at the tumor board, and the surgical oncologist advised that she had unresectable disease. The patient with then referred to the radiation oncology service for palliative radiotherapy, as she started complaining of pain at this time.\nIn October 2017 (10 months after diagnosis), the patient completed a long course of high-dose palliative radiation therapy. She received a dose of 45 Gy in 28 fractions to the entire pelvis and inguinal area, with concomitant 58.8 Gy delivered to the sacral mass and the enlarged inguinal lymph node ().\nIn January 2018, the patient repeated the MRI scan, and no significant interval change was noted. She continued to suffer from moderate to severe pain and was referred to the pain clinic, as her pain was not responding to regular narcotics. A superior hypogastric nerve block was administered to her.\nA repeat MRI in March 2018 revealed stable disease in the pelvis; however, now in the field of view of this MRI scan were new bone lesions at the level of the lumbar spine. In April 2018, a repeat CT scan of the abdomen and pelvis, as well as a CT scan of the chest revealed no distant metastatic disease apart from the bone metastasis. At this point, the patient’s clinical presentation included non-healing ulcers in the sacral area with skin nodules. Her CEA measured 21.9 and her carcinoembryonic antigen (CA)19.9 measured 4767. She was re challenged with maintenance capecitabine. reflects the change in her CEA level over the clinical course.\nThe patient was last seen at our hospital in December 2018. At that time, she demonstrated major clinical progression and had a poor performance status. Her chemotherapy was stopped, as she had refused further treatment apart from pain and symptom management.\nThe patient was last seen in our hospital in December 2018. According to her family, she died on March 26, 2019 (28 months after her diagnosis). She had suffered from severe anemia and went into a coma secondary to a major stroke, potentially having suffered from disseminated intravascular coagulation. |
A 10-month-old girl born of nonconsanguineous marriage with normal developmental history, with no prior medical problems, was brought to our emergency room with history of fall on the head when the child was trying to walk on her own. She cried for a brief period and there was no loss of consciousness. There was no vomiting or convulsions following the head injury. Next day morning, about 12 hours after the injury, child developed weakness involving right side of the face, right arm, and the right leg. Child was unable to sit or stand. On examination child was conscious and active showing decreased movements in the right half of the body with muscle power 2/5 in both right upper and lower extremity along with right sided UMN type of facial palsy, with a positive Babinski sign on the same side. There were no signs of raised intracranial pressure or meningeal irritation. Other neurological examinations were normal. Child did not have any signs suggestive of nonaccidental injury and did not have any external signs of trauma to the head or elsewhere on the body. Child had no clinical history suggestive of varicella, measles, or ear discharge in the past. There was no history of feeding difficulty which suggests that there was no lower cranial nerve involvement. Perinatal history was uneventful. There were no significant family history suggestive of thromboembolic disorders and no history of recent vaccination. Investigations like routine blood count, peripheral smear, serum electrolytes, bleeding, and coagulation profile were done and found to be within normal limits. MRI brain suggested acute infarct involving the left capsuloganglionic region (Figures and ). Child was managed conservatively with osmotic diuretics to reduce perilesional oedema and also was started on anticoagulant therapy subcutaneously. Low molecular weight heparin was given for a total of 5 days and was stopped without any continuation of oral antiplatelet therapy. Parents could not afford other relevant investigations including MRA, Doppler evaluation of the vessels, lipoprotein A and homocysteine estimation, protein C and S, antithrombin III, and antiphospholipid antibody. The child started moving her right leg with gain in power after 12 hrs of anticoagulant therapy. The facial paralysis and the hemiparesis improved following 5 days of treatment and the child was discharged with advice of physiotherapy. Neurological evaluation on follow-up after 10 days of treatment showed good clinical resolution, with power 5/5 in both right upper and lower limbs with normal reflexes and no residual facial weakness. |
A 41-year-old woman with end stage renal disease (ESRD) from ADPKD was referred to our tertiary care center for urgent renal replacement therapy. Considering her actual state, the very long distance from hemodialysis centers and the possible opportunity for a future renal transplantation we concluded to start with peritoneal dialysis. Before starting PD we applied several sessions of hemodialysis using a subclavian temporary cathether. Two weeks after the peritoneal cathether implantation she started peritoneal dialysis. She continued on PD for two years but after a grave episode of peritonitis accompanied with a septic state, dialysis failure, long hospitalization, she was transferred urgently to hemodialysis. Her transplantation plans failed because her mother, the only possible donor died from a heart attack. She was maintained on regular HD, but her dialysis care was complicated by recurrent vascular access thrombosis. The first fistula functioned only 3 months and the second, third and fourth fistula were immature and not functioning. Both grafts didn’t function and were clotted till the first days. During this time the catheters were her vascular access of necessity with all the difficulties and hazardous situations that they bring with them. The third graft that was performed in Turkey, was clotted till the first days then was done the thrombectomy and then clotted again. The salvage procedures failed again. During this time the ongoing of hemodialysis was compromised from the recurrent septic states with seizures and bacteremia especially in the first hour of hemodialysis sessions. We usually used the cathether antibiotic locking in the end of hemodialysis with cephazolin or gentamicin but she gradually went on severe malnutrition due to long term infectious states and inefficient hemodialysis. She was supported with parenteral nutrition, more frequent HD sessions and intravenous antibiotics. This long calvary of suffering continued to the extent that only one access site was available for her routine renal replacement treatment.\nA thorough thrombophilia screen confirmed the presence of antiphospholipid antibodies, while antinuclear antibody and anti ds-DNA antibodies were negative. A diagnosis of APAS was made and she was anticoagulated with warfarin. The surgeon created the left femoral graft. It was used only after 4 weeks with extreme precautions. From 1.5 years it is still working and functioning well. Now she has a better quality of life, better hemoglobin levels, URR and she is free of temperature, seizures and rigid catheters that were her nightmare. Now she is not anxious, but for how much time? What if this AVG doesn’ t function any more? What to do with her? A lot of answers? |
A 50 year old female patient previously healthy has undergone an abdominal ultrasound demanded by her primary care physician when her routine checkup blood test showed a slightly elevated level of liver enzymes with no other lab abnormalities. This ultrasound showed right adrenal lesion of 9 cm of diameter. An Abdominal MRI was then done and revealed a soft tissue necrotic encapsulated mass of 10 × 9 cm of right adrenal gland origin. She was completely asymptomatic and the physical exam was strictly normal. Endocrinological evaluation was done with normal hypothalamic-pituitary-adrenal axis function and no hyper secretion of catecholamines. The patient was considered to have a non-secreting right adrenal mass for which an adrenal scan was done and showed a well encapsulated 10 × 9 × 7 cm heterogeneous right adrenal mass with areas of necrosis and calcifications without local invasion (). The decision of right laparoscopic trans peritoneal adrenalectomy was taken with the patient. The surgery was done under general anesthesia after central and arterial lines insertion, the patient was on left decubitus position. 5 trocars were inserted as follows: The first 12-mm port was inserted at the lateral border of the rectus abdominis muscle just above the level of the umbilicus to accommodate the camera. Two subcostal 11 mm ports were also placed; one in the midclavicular line and the other in the lateral border of the rectus abdominis muscle. The forth 5-mm subcostal trocar was inserted in the anterior axillary line to retract the liver and the fifth 5 mm one was inserted in the epigastrium and used specially for aspiration and irrigation. After liver retraction, the peritoneum along the lateral aspect of the IVC was incised to expose the IVC just below its intrahepatic course. The duodenum which was diverted by the mass was mobilized. Dissection was next carried inferiorly by incising the peritoneum along the lateral edge of the vena cava to the superior edge of the renal vein. Dissection of the mass was subsequently carried out with special care at the medial aspect where we found that the wall of the IVC and the renal vein were very adherent to the mass which had a lot of small vessels that were oozing during all the time of the surgery (). In addition, the mass was extended posterior to the vena cava and we could not do a medial retraction of the IVC since the tumor was adherent to it. In front of these facts, we decided to convert to open surgery by a sub-costal incision (between two trocars) that allowed us to remove the mass safely (). A drain was put in the retro peritoneum at the end of the surgery, the operative time was 200 min, the blood loss was 850 cc and no transfusion was done. The drain was removed at the second post-operative day and the patient was discharged uneventfully on the sixth day after surgery.\nHistologically, the tumor consisted of spindle cells with alternating areas of compact hypercellularity with irregular streams and without atypia or mitosis (). This tumor was completely compressing and reducing the adrenal gland that was laminated but intact without histological abnormalities (). Immunohistochemical analysis demonstrated negative CKAE1-AE3, synaptophysine and chromogranine. In contrast to these results, S-100 and CD68 (PGM1) staining were diffusely positive across the tumor (). Thus, the evidences corresponded to a benign schwannoma (). |
We present a 55-year-old female with ESRD on HD secondary to Diabetic nephropathy who presented initially for creation of a hemodialysis access. She had a thirty pack a year history of tobacco use with current use of tobacco products. She had Charcot's disease of the left lower extremity, amputation below knee of her left lower extremity and required use of wheelchair for ambulation. She underwent creation of left basilic vein to the left brachial artery AVF with a plan to perform a second stage superficialization and transposition 6 weeks later. She denied any complaints in the immediate postoperative period. Physical exam during this visit revealed left arm with good grip strength, radial artery pulse of at least 2, and good thrill in the venous segment of the fistula. She was seen again in the vascular clinic 4 weeks after her surgery with the plan to superficialize her AVF. However, she was now complaining of numbness and mild pain in the left hand which is increased at night. She stated in retrospect that some of these symptoms had started about 4 days after the creation of the fistula. At this point, there was concern for steal syndrome; however, on her exam her hand was pink and warm, and there was still a good radial pulse and a duplex doppler ultrasound revealed good flow in the fistula with no significant reversal of flow and no decreased blood flow in the lower part of the left arm. An electromyogram (EMG) was ordered to evaluate for neurological etiologies to investigate the cause of her left-hand pain. On a subsequent follow-up to the clinic, she was noted to have muscle wasting of the left medial palm and dorsum. Sensation was found to be decreased along the medial aspect of the left arm from the elbow including part of the third, fourth, and fifth digits. Fasciculations were noted in the fingers of the left hand and strength was noted to be reduced. EMG reported a moderate to severe generalized sensorimotor axonal neuropathy in both. A repeat doppler ultrasound of the fistula showed a patent left brachial artery to basilic vein AVF in the left antecubital fossa with partial reversal of flow in the proximal left ulnar artery representing partial steal syndrome. MRI of the left upper extremity showed entrapment of the median nerve (Fig. , ) and cubital tunnel syndrome. A diagnosis of nerve compression syndrome was made and patient was scheduled for surgical exploration. At surgery, she was found to have extensive scarring leading to median nerve compression in the upper arm adjacent to the brachial artery-basilic vein AVF. There was evidence of ulnar neuropathy in the cubital tunnel with hourglass deformation of the ulnar nerve without significant subluxation, and there was also evidence of median neuropathy at the wrist with hourglass deformation of the median nerve in the carpal tunnel. She had exploration and neurolysis of median nerve in left upper arm, left cubital tunnel release with anterior subcutaneous transposition, left carpal tunnel, and left ulnar release. The fistula was also superficialized, retunneled, reanastomozed to the above elbow brachial artery. Following this surgery, our patient reported her pain in the left arm had improved but did not resolve completely. Her fasciculations however improved significantly. Hemodialysis was started successfully 8 weeks later utilizing the left brachial artery-basilic vein fistula. In subsequent months after surgery, her pain in the left arm and left arm muscle weakness significantly improved. |
An 80-year-old man was admitted to the Emergency Department (ED) with right upper quadrant abdominal pain and a cutaneous lesion with white, purulent discharge that appeared a week ago in the same region. The patient’s medical history was notable for an operation for the removal of a liver abscess of unknown etiology fifteen years ago; otherwise, no other chronic illnesses were present.\nDuring physical examination, the abdominal wall was tender on palpation, and the examination of the lesion in the upper right quadrant revealed a fistula opening with white fluid discharge. The physical examination of other systems was normal. The abdominal ultrasonography performed in the ED showed a cystic mass with a diameter of 6 cm in the seventh and eighth segment: the cyst had a calcified membrane and a comet-tail artifact that indicated the presence of air. The cystic lesion appeared to protrude to the subcapsular area and subcutaneous tissue: these findings were highly suggestive of a fistula. The biochemical values and complete blood counts were within normal limits. An abdominal computed tomography with intravenous contrast revealed a single, calcified, membranous lesion in segments 8 and 4A with a fistula to the abdominal anterior wall (Fig. ). In addition, the increased subcutaneous density within the cyst was noted. Surgical drainage by subcostal incision under local anesthesia resulted in approximately 100 mL of purulent material. The cyst was not excised due to the advanced age of the patient. Nonetheless, bradycardia and hypoglycemia that developed during the postoperative recovery necessitated the patient to be admitted to the intensive care unit for further treatment. Importantly, the analysis of the purulent material from the cyst failed to confirm an Echinococcus infection; however, Klebsiella pneumonia that was susceptible to most commonly used antibiotics was cultured from the purulent material, upon which a 14-day course of ampicillin-sulbactam was initiated. The patient underwent repeated abdominal ultrasonography, which failed to show a recurrence of similar cystic lesions in the abdomen. The patient was discharged 7 days after hospitalization and was followed at the outpatient clinic. The evaluation of the patient at an outpatient setting by ultrasound imaging 6 months after the procedure did not show a recurrence of the cyst. |
A 25-year-old male with a history of intermittent abdominal pain for the last six months was admitted to our emergency department complaining of intractable postprandial abdominal pain, along with bloody vomiting. Having been subject to a preliminary evaluation in our emergency department, the patient was transferred to the gastroenterology clinic for further investigation and treatment, where oral intake was stopped and replaced with parenteral replacement therapy. The patient’s medical background revealed nothing remarkable other than recurrent epigastric pain. He also had a history of receiving proton pump inhibitor drugs on an irregular basis. Upon physical examination, his general clinical status was good, with stable vital parameters. A palpable mass of 5 × 5 cm, along with tenderness in the epigastric region on palpation, was detected during abdominal examination. The laboratory test results, including liver and renal function tests, complete blood count, coagulation profiles and tumor markers were within normal limits. Upper GIS endoscopy revealed a submucosally located mass lesion of dense vascularity at the antrum-corpus junction on the greater gastric curvature. The appearance of the mass evoked the impression of a gastrointestinal stromal tumor of mesenchymal origin (). Accordingly, a biopsy was taken from this area. No definite focus of active bleeding was evident. In abdominal computed tomographic evaluation, an isodense and smooth contoured mass lesion of 52 × 25 × 32 mm that contained focal calcifications and was located on the greater gastric curvature in the left upper abdominal quadrant was detected (). Since the biopsy report indicated that the material was insufficient for a definitive diagnosis to be made, a deeper biopsy sampling was recommended. As such, Positron Emission Tomography (PET) was performed in an attempt to identify whether or not the mass was malignant. PET showed a smooth contoured mass of 5 × 5 cm, projecting from the gastric corpus into the lumen and containing scattered calcifications, which displayed no evidence of malignant transformation. A 6 × 4 × 5 cm mass was detected at the the greater gastric curvature on the anterior gastric surface during intraoperative exploration. The mass was not invading into adjacent tissues, and contained dense vascular structures (). No pathology associated with other intraabdominal organs was identified. Unluckily, no preoperative histopathological evaluation could be implemented due to the device for frozen sectioning in our hospital being out of order. The lesion appeared macroscopically to be benign. A wedge resection was first undertaken, since the lesion was consistent with a gastric hemangioma. The patient suffered no complications during the post-operative follow-up, and was discharged from the hospital on the seventh postoperative day. The pathology report was consistent with varicous dilatations of the submucosal veins and gastric cavernous hemangioma (). |
An 83-year-old female patient presented to outpatient oncology clinic with a large ulcerated nodule located in the left cheek and extending into the left neck region. Five years ago, a previously documented squamous cell skin cancer lesion located in the left mandibular region was excised with clear margins. The lesion recurred 12 months before presentation to the medical oncology clinic; however, due to poor socioeconomic status she was unable to admit to the hospital. Her clinical condition recently deteriorated because the cancerous lesion became too painful and she was not capable of oral food intake any longer. Radiation oncology department decided that it would be difficult for the patient to tolerate radiotherapy because the lesion was deeply ulcerated and it was occupying a large region of the left side of the face. A tissue biopsy was taken to confirm tumor recurrence (). A computer tomography of the head and neck region demonstrated extensive soft tissue invasion of the tumor. She was referred to medical oncology department for chemotherapy. Standard cisplatin-based chemotherapy was not found appropriate because of the patient’s poor clinical status and therefore a decision was made to start her treatment with single agent cetuximab.\nThe patient was treated with cetuximab administered at a dose of 400 mg/m2 every 15 days, from September 29, 2013 to April 10, 2014. After the second cycle of the treatment, performance status improved and regression of the ulcerous lesion was visually observed. While the treatment continued, grade 2 acneiform rash on her face, neck, and mediastinum developed, which was successfully treated with vitamin K1 cream without needing dose reduction. She developed grade 3 anemia at the fifth month of treatment, which was treated with red blood cell transfusions as needed and the treatment was stopped at the end of 6 months because she denied any further therapy. The tumor lesion had completely regressed at the time the treatment was terminated (). At her last follow-up visit, which was 12 months after the end of cetuximab therapy, she was still in complete clinical remission. |
The patient is a right-handed, 40 year old woman employed as a teacher in primary school. She was referred to our neurological centre for sporadic generalized epileptic seizures and reactive depressive syndrome. Early medical history reported depressive-apathetic episodes during adolescence and early adulthood lasting for some months and treated with benzodiazepines. The first generalized seizure occurred at the age of 26 and was accompanied by attention and memory deficits for one week. Three further generalized seizures occurred in 9 years and interictal EEGs showed widespread slow wave activity. She reported several unsuccessful therapeutic attempts with carbamazepine (1000 mg/day) and fenobarbital (150 mg/day). Personality disorder with several cyclic episodes of depression and maniacal excitation were reported by the patient and in the past ten years she had been treated with paroxetine by outpatient psychiatric services. In the last six years she did not experience further seizures and she spontaneously decided to withdraw carbamazepine. In the last year further episodes of depression and anxiety had recurred, and were accompanied by two suicide attempts by poisoning. After the last suicidal attempt, an EEG was recorded in the intensive care unit and the observation of widespread slow wave activity prompted her referral to our clinic. Her cognitive performances were normal (Mini-Mental State Examination score: 30/30). During psychological assessment, beyond a logorrheic and anxious attitude, a history of peculiar events could be evicted even though the patient manifested initial severe resistance to express the reason of her distress. She reported to experience daily symptoms consisting of seeing the image of her entire body as in a mirror or from an external point of view. She saw herself not from an elevated visuo-spatial perspective, as in out of body experience, but in front of her in normal size and colour without a definable facial expression. The patient could not clearly define her localization in space. She reported unclear changes in the awareness of her body describing herself as projected out of her body with a feeling of dissociation of mind and body for a few seconds. When she saw her double from an external view she maintained sidedness, i.e. right and left sides were represented as in the real body, unlike images reflected by a mirror: if she held an object with the right hand her autoscopic image would hold the same object with the right hand. Her heautoscopic experience lasted for less than one minute. These experiences occurred independently of daily activities, either when she was quiet alone or working. When the double appeared, it kept acting the patient's activities. She explained that the experience to see her double was terrifying and that the attempted suicides were prompted by this distressing experience. She reported to have access to the autoscopic body's thoughts, words and actions and that the experience of bilocation was petrifying and shocking. She explained that these experiences had occurred since her early adolescence, had never subsided and were still present when she was receiving carbamazepine and fenobarbital. These episodes were interpreted as he-autoscopic seizures.\nIn a previous brain MRI performed in another neurological institution, an abnormal signal from the splenium of corpus callosum was suspected. But an MRI-based tractography performed in our institution showed integrity of white matter tracts. MRI scans were performed using a 3T Philips Achieva scanner. Diffusion tensor images were acquired in the axial plane with diffusion sensitization gradients applied in six non-collinear directions with b-value of 1000s/mm2. All image volumes were acquired with six optimized directions using six repetitions to increase the number of measures. In addition NMR spectroscopy evidenced no alteration in the right and left temporo-parietal junction (Figure ).\nInterictal brain SPECT with 99mTC-ECD showed cerebral hypometabolism in both right and left parietal and occipital lobes (Figure ).\nA previous interictal EEG showed sporadic posterior bilateral slow wave activity 3-3.5 Hz (Figure ). During her repeated evaluations the patient was instructed to signal verbally or by hand gestures the possible occurrence of her hallucinations. We recorded a video-EEG during one of her autoscopic experiences showing an epileptic activity (Figure ) consisting of a brief (about 1 second) and slow (3.5 Hz) right centro-parietal activity followed by abrupt discharges represented by fast activity of polyspikes and sharp-waves of 100-120 uV amplitude and in reversal phase at the P4 lead. After a few seconds the discharge involved right fronto-temporal channels and then the left parieto-occipital channel. The discharge lasted about 30 seconds. The final critical activity was represented by a 3.5-4 Hz spike and slow wave complexes overlapping to widespread slow activity. No ictal automatisms or motor signs were present.\nDuring the video-EEG recording, before the onset of the seizure, the patient reported an unclear change in the awareness of her body, with feelings of derealisation. Then she signalled by hand gesture the abrupt appearance of her entire body exactly in front of her, in upright position and in the same perspective of her previous experiences. This sensation was coincident with the seizure. During an a posteriori interview she reported the impression of bilocation. In this episode the double was motionless and silent. This view of herself in normal size, with the same clothing and facial expression was concomitant to the right centro-parietal discharge characterized by fast activity of polispikes and sharp-waves in reversal phase at the P4 lead. When the discharges involved right fronto-temporal channels we noted an impairment of consciousness: the patient, with fixed eyes, stopped answering our questions, even though she did not report clouding of consciousness in the a posteriori interview. No ictal automatisms or motor signs were observed. During the widespread slow EEG activity the patient reported again an unclear perception of her body, but she signalled that the autoscopic image had disappeared.\nWe aimed to study functional connectivity by means of functional magnetic resonance imaging (fMRI) [], but the patient expressed her unavailability to further examinations.\nWe prescribed Levetiracetam (3000 mg/day) which resolved her he-autoscopic seizures. Levetiracetam was administered following the evidence of the seizures.\nIn the following two months the reported that the seizures did not recur, but depression was evidenced in repeated evaluations, with apathy, anaedonia and anxious agitation. We decided to address the patient to psychiatric care due to severe depressive symptoms and to the high risk of further suicidal attempts. |
A 66 year-old male patient had been followed for nearly two years with a mediastinal mass. Two years ago a mass was observed near the left cardiac margin measuring 6.5 × 5.7 cm in a modified left parasternal view of the transthoracic using echocardiography (). Further radiological evaluation had been offered but the patient had refused any further evaluation or surgical intervention. Nearly two years after the initial diagnosis, the patient was readmitted to thoracic surgery department for further evaluation. On chest roentgenogram, a well-circumscribed mass in the middle zone of the left lung field was observed (). Chest tomography showed a well-circumscribed huge cystic mass measuring nearly 11 × 8 cm neighboring the aortic arch and left pulmonary artery, and a small cystic mass approximately measuring 5.0 cm on the sixth costosternal junction. A small nodular solid area was observed at the inferior margin of the huge cystic mass. These two masses were both well defined and homogeneous (Figures and ). During preparation for surgery, angina pectoris developed, and a cardiologic evaluation was performed. The patient underwent coronary angiography, and an atherosclerotic lesion causing significant stenosis was found in proximal and mid portions of left anterior descending artery and left circumflex artery. After the coronary angiography, a decision was made to undertake surgery in order to remove the tumors and to perform coronary artery bypass grafting.\nIn preoperative evaluation, we considered it possible that the mass dwelling on the aortic arch may make it impossible for proximal anastomoses of coronary bypass. In order to avoid this complication, we decided to first remove the mass, then perform coronary artery bypass grafting using sternotomy, in a one-stage combined operation. The chest was opened by sternotomy, and a huge encapsulated mass was observed dwelling the aortic arch and the left pulmonary artery with a proximal extension to the ascending aorta (). After preserving the nervus vagus, the huge mass was removed by blunt and sharp dissection. The smaller tumor that originated from the intercostal nerve was also removed from the sixth costosternal junction. Following this phase, the ascending aorta became available for the proximal anastomoses of the saphenous vein grafts. Thereafter coronary artery bypass grafting was performed (sequential left internal thoracic artery proximal and mid left anterior descending artery, aorta saphenous circumflex.) Perioperative findings confirmed our preoperative suspicions.\nThe gross appearances of these two masses were alike. They were reddish, bright, encapsulated masses measuring 13 cm and 5 cm in diameter, respectively. The cut surfaces had a bright, tan/yellow, gelatinous appearance, and a small solid area was observed in the larger one (Figures and ).\nOn histological examination degenerative changes and atypical nuclear features were noted, but a mitotic figure was lacking. Immunohistochemical analysis was positive for S-100 protein (Figures and ).\nThe patient was discharged on the sixth day after the operation with a slightly elevated left diaphragm. Voice hoarseness was observed on control examination. On further control examinations, the elevation of the diaphragm had gone back to normal and the voice had improved. Whole body examination to exclude the possibility of Von Recklinghausen's neurofibromatosis revealed no additional tumors. The patient recovered fully one year after the operation; recurrence and metastasis were not observed. |
A 29-year old woman who was in her seventh month of pregnancy presented with chief complaints of sudden onset of pain and watering in her left eye of 4 days duration. Her past history revealed the onset of myopia at the age of 12 years which gradually increased and stabilized by 18 years of age. At the age of 20 years she underwent radial keratotomy in both eyes for myopic correction. She developed secondary angle closure glaucoma in left eye following radial keratotomy (probably there was microperforation at the time of radial keratotomy, leading to shallow anterior chamber with formation of peripheral anterior synechiae leading to raised IOP) for which she underwent glaucoma filtering surgery without Mitomycin C elsewhere 8 months later. Records revealed IOP of less than 21 mmHg till few months postoperatively. A year later, she presented to us with a painful eye which on examination revealed flat anterior chamber in the periphery and very shallow centrally (Fig. ). The intraocular pressure as measured by applanation tonometer was 40 mmHg and her vision was light perception with inaccurate projection of rays. Posterior segment examination revealed glaucomatous optic atrophy in left eye. Cyclocryotherapy was done after which the intraocular pressure came back to normal. She remained asymptomatic for the next few years, during which she conceived. The first and second trimesters were uneventful, but during the seventh month of pregnancy she presented with sudden onset of pain, redness and watering but no discharge in the left eye. Examination revealed central corneal melting measuring 6 × 6 mm and an area of corneal perforation inferiorly of approximately 2 × 3 mm. There was mild corneal edema without any evidence of active infiltration and rest of the cornea was clear. Corneal sensations were normal and equally brisk in both eyes. On slit lamp examination, a very thin layer of posterior corneal stroma could be seen in the area of melting. The anterior chamber was flat (Fig. ). Intraocular pressure was low digitally. Gram and KOH stain and culture on Blood and Sabouraud's dextrose agar were negative. There was no history of trauma or any other systemic illness and the patient did not exhibit any clinical features of systemic vasculitis or autoimmune condition. Rheumatoid factor, antinuclear antibody, anti-cytoplasmic and anti-DNA antibodies were negative. Patient had not used any topical drops during the intervening period. The vision in her right eye was 6/6 with -1.50 Diopters and the examination was essentially unremarkable. The patient being in the late stage of pregnancy and having a poor visual prognosis, conservative management was planned. Cyanoacrylate glue and bandage contact lens were applied and topical antibiotics, cycloplegics and lubricating drops were prescribed (Fig. ). After 3 weeks of conservative treatment, corneal edema decreased and corneal perforation gradually healed. Anterior chamber remained flat, although the intraocular pressure was normal digitally. She was kept on regular follow up and on her last visit; leucomatous corneal opacity was seen at the involved site (Fig. ). |
A 50 year old female patient previously healthy has undergone an abdominal ultrasound demanded by her primary care physician when her routine checkup blood test showed a slightly elevated level of liver enzymes with no other lab abnormalities. This ultrasound showed right adrenal lesion of 9 cm of diameter. An Abdominal MRI was then done and revealed a soft tissue necrotic encapsulated mass of 10 × 9 cm of right adrenal gland origin. She was completely asymptomatic and the physical exam was strictly normal. Endocrinological evaluation was done with normal hypothalamic-pituitary-adrenal axis function and no hyper secretion of catecholamines. The patient was considered to have a non-secreting right adrenal mass for which an adrenal scan was done and showed a well encapsulated 10 × 9 × 7 cm heterogeneous right adrenal mass with areas of necrosis and calcifications without local invasion (). The decision of right laparoscopic trans peritoneal adrenalectomy was taken with the patient. The surgery was done under general anesthesia after central and arterial lines insertion, the patient was on left decubitus position. 5 trocars were inserted as follows: The first 12-mm port was inserted at the lateral border of the rectus abdominis muscle just above the level of the umbilicus to accommodate the camera. Two subcostal 11 mm ports were also placed; one in the midclavicular line and the other in the lateral border of the rectus abdominis muscle. The forth 5-mm subcostal trocar was inserted in the anterior axillary line to retract the liver and the fifth 5 mm one was inserted in the epigastrium and used specially for aspiration and irrigation. After liver retraction, the peritoneum along the lateral aspect of the IVC was incised to expose the IVC just below its intrahepatic course. The duodenum which was diverted by the mass was mobilized. Dissection was next carried inferiorly by incising the peritoneum along the lateral edge of the vena cava to the superior edge of the renal vein. Dissection of the mass was subsequently carried out with special care at the medial aspect where we found that the wall of the IVC and the renal vein were very adherent to the mass which had a lot of small vessels that were oozing during all the time of the surgery (). In addition, the mass was extended posterior to the vena cava and we could not do a medial retraction of the IVC since the tumor was adherent to it. In front of these facts, we decided to convert to open surgery by a sub-costal incision (between two trocars) that allowed us to remove the mass safely (). A drain was put in the retro peritoneum at the end of the surgery, the operative time was 200 min, the blood loss was 850 cc and no transfusion was done. The drain was removed at the second post-operative day and the patient was discharged uneventfully on the sixth day after surgery.\nHistologically, the tumor consisted of spindle cells with alternating areas of compact hypercellularity with irregular streams and without atypia or mitosis (). This tumor was completely compressing and reducing the adrenal gland that was laminated but intact without histological abnormalities (). Immunohistochemical analysis demonstrated negative CKAE1-AE3, synaptophysine and chromogranine. In contrast to these results, S-100 and CD68 (PGM1) staining were diffusely positive across the tumor (). Thus, the evidences corresponded to a benign schwannoma (). |
A 50 year old female patient previously healthy has undergone an abdominal ultrasound demanded by her primary care physician when her routine checkup blood test showed a slightly elevated level of liver enzymes with no other lab abnormalities. This ultrasound showed right adrenal lesion of 9 cm of diameter. An Abdominal MRI was then done and revealed a soft tissue necrotic encapsulated mass of 10 × 9 cm of right adrenal gland origin. She was completely asymptomatic and the physical exam was strictly normal. Endocrinological evaluation was done with normal hypothalamic-pituitary-adrenal axis function and no hyper secretion of catecholamines. The patient was considered to have a non-secreting right adrenal mass for which an adrenal scan was done and showed a well encapsulated 10 × 9 × 7 cm heterogeneous right adrenal mass with areas of necrosis and calcifications without local invasion (). The decision of right laparoscopic trans peritoneal adrenalectomy was taken with the patient. The surgery was done under general anesthesia after central and arterial lines insertion, the patient was on left decubitus position. 5 trocars were inserted as follows: The first 12-mm port was inserted at the lateral border of the rectus abdominis muscle just above the level of the umbilicus to accommodate the camera. Two subcostal 11 mm ports were also placed; one in the midclavicular line and the other in the lateral border of the rectus abdominis muscle. The forth 5-mm subcostal trocar was inserted in the anterior axillary line to retract the liver and the fifth 5 mm one was inserted in the epigastrium and used specially for aspiration and irrigation. After liver retraction, the peritoneum along the lateral aspect of the IVC was incised to expose the IVC just below its intrahepatic course. The duodenum which was diverted by the mass was mobilized. Dissection was next carried inferiorly by incising the peritoneum along the lateral edge of the vena cava to the superior edge of the renal vein. Dissection of the mass was subsequently carried out with special care at the medial aspect where we found that the wall of the IVC and the renal vein were very adherent to the mass which had a lot of small vessels that were oozing during all the time of the surgery (). In addition, the mass was extended posterior to the vena cava and we could not do a medial retraction of the IVC since the tumor was adherent to it. In front of these facts, we decided to convert to open surgery by a sub-costal incision (between two trocars) that allowed us to remove the mass safely (). A drain was put in the retro peritoneum at the end of the surgery, the operative time was 200 min, the blood loss was 850 cc and no transfusion was done. The drain was removed at the second post-operative day and the patient was discharged uneventfully on the sixth day after surgery.\nHistologically, the tumor consisted of spindle cells with alternating areas of compact hypercellularity with irregular streams and without atypia or mitosis (). This tumor was completely compressing and reducing the adrenal gland that was laminated but intact without histological abnormalities (). Immunohistochemical analysis demonstrated negative CKAE1-AE3, synaptophysine and chromogranine. In contrast to these results, S-100 and CD68 (PGM1) staining were diffusely positive across the tumor (). Thus, the evidences corresponded to a benign schwannoma (). |
A 77-year-old Japanese man consulted our hospital with a 1-month history of right alar swelling with hard pain as his chief complaint. A physical examination revealed a submucosal tumor with an intact and smooth surface in the right nasal vestibule. The result of biopsy was suspected malignancy. Computed tomography (CT) scan showed a round lesion 1 cm in length in the right nasal vestibule close to the pyriform fossa edge of the right maxillary bone (). He had severe pulmonary dysfunction due to recurrent end stage lung cancer and diabetes. The expected remainder of his life would be half a year. Therefore, his very poor condition precluded general anesthesia. To relieve the nasal pain, shorten the stay in the hospital and improve the quality of life (QOL), we performed minimally invasive surgery under local anesthesia. In the operation, nasal vestibular tumors arising from the bone surface of the pyriform fossa could be resected using a right alar incision approach combined with a right gingival incision approach. After removing the tumors, a right alar flap was used to cover wounds with exposed bone (). Histopathology of the specimen indicated poorly differentiated squamous cell carcinoma (). These cancer cells could be found in the submucosal areas in the nasal vestibule, but not on the surface or in the epithelial layers. The edges of the resected tumor did not show cancer cells. Postoperatively, the right nasal pain soon disappeared. The patient was discharge from our hospital 4 days after the operation. Two months later, findings in CT scan revealed widespread destruction of the maxillary bones. We consulted pathologists and radiologists. As a result, it was thought that maxillary bone metastasis from lung carcinoma had caused submucosal swelling of the nasal vestibule. The evidence was as follows. In the histopathological examination, cancerous areas were located in the submucosa but not in the upper layer, and the operative findings confirmed that cancer tissues had generated from the surface of maxillary bone. Moreover, the patient had undergone lung cancer surgery four years before. The histopathological characteristics of the lung cancer were similar to those in the present case. The patient desired palliative care rather than active therapy and died at home 6 months after the operation.\nIn 2008, Sakai reported that paranasal sinus metastasis from lung cancer was exceedingly rare, with only 4 cases in Japan, and tended to occur in males. A final diagnosis requires histopathological examination. Many histopathology results showed adenocarcinoma. Bernstein described that the chief complaints of paranasal sinus metastasis from lung cancer were nasal swelling and mass, as our case. When paranasal sinus metastasis from lung cancer is diagnosed, in most cases the patient is already advanced or end stage lung cancer. Therefore, hospitals it is difficult to radically and aggressively treat the metastatic focus, resulting in a poor prognosis. In most patients, the survival p after the diagnosis would be less than 3 months. However, Miyahara described that surgical resection for metastatic tumors in the paranasal sinus was important for alleviating the symptoms. Our minimally invasive surgery could improve the QOL by relieving the nasal pain until the cancer recurred. |
A 66-year-old male patient with history of previous papillary urothelial carcinoma of bladder was referred to our vascular surgery clinic. The patient had undergone radical cystectomy and ureterostomy seven years ago. Recurrence of malignancy had occurred five years after the operation. The patient had a mass at right side of pelvis compressing the right external iliac vein on magnetic resonance imaging. The patient had also bilateral diffuse lung metastasis on lung computed tomography. The patient had received 12 courses of chemotherapy. Resection of pelvic mass was not indicated because of diffuse lung metastasis. Right lower extremity had severe swelling. Above knee and thigh of the affected limb had larger diameter of 6.5 and 9.5 cm than the contralateral limb respectively. The patient suffered from right lower extremity pain and had a venous ulcer at right medial malleolus.\nWe did venography to reveal the underlying cause of venous stasis in right lower extremity. We did the imaging on prone position. A 5F sheath was introduced through the right popliteal vein. The external iliac vein had severe stenosis and invasion of pelvic mass into the vein was evident. This procedure was done under close monitoring of vital signs and local anesthesia. We transformed the patient to supine position to cannulate right superficial femoral vein (SFV). An 8F sheath was introduced into SFV by ultrasound guidance and Seldinger technique 10cm below the inguinal ligament. The reason for changing the position of the patient was that the procedure of stenting is painful. We wanted to do the procedure under deep sedation and it was not possible to do this in prone position because of general condition of the patient. A repeat venogram was obtained at supine position and similar results were found (). Venography was repeated at 45 and 90 degrees of left lateral oblique views and severe stenosis and tumor invasion were confirmed. A 0.035 hydrophilic standard guidewire was introduced through the sheath and the stenosis was crossed. Then a 40 mm length and 10 mm diameter CONQUEST balloon (BARD) was introduced over the guidewire. Venoplasty of external iliac vein was conducted throughout the stenosis and at proximal and distal parts. Then a venous stent of 80 mm length and 12 mm diameter (VENOVO, BARD) was introduced over the guidewire and deployed in the external iliac vein with the stenosis trapped inside the length of the stent. The completion venogram illustrated dilatation of the stenosis and reestablishment of flow of contrast material through the external iliac vein (). Then a 40 mm length and 12 mm diameter CONQUEST balloon (BARD) was introduced over the guidewire. Balloon dilatation was done through the stent and its proximal and distal landing zones. 7500 units of intravenous heparin was administered during the procedure. A loading dose of 300mg Clopidogrel was administered to the patient after the procedure at the recovery theater. The patient was anticoagulated by heparin for 48 hours and Clopidogrel 75mg daily was also administered during that period. Rivaroxaban 10mg per 12 hours and Clopidogrel 75 mg daily was administered on discharge. The patient was on Aspirin 80 mg daily before the procedure and we advised him to continue the same dose.\nDramatic clinical response was evident since postoperative day two. The patient was followed after three and six months. Swelling of right lower extremity was resolved dramatically and the venous ulcer at right medial malleolus was healed. A venous duplex study was done at follow-up visits. Normal venous flow was present. |
A 69-year-old female with a history of prothrombin gene mutation was scheduled for living donor kidney transplantation. After developing spontaneous left subclavian and brachial artery thrombosis 17 years ago, patient underwent therapeutic anticoagulation and maintenance on warfarin for 1 year. With therapy, her thrombosis was found to have completely resolved; however, 8 years later following an arthroscopic procedure on her right knee, she developed venous thrombosis of her right lower extremity. She was subsequently found to have a heterozygous form of the prothrombin gene 20210 mutation and hence was maintained on chronic anticoagulation with warfarin. Over the past 2 years, patient developed end-stage renal disease in the setting of diabetes and hypertension.\nAfter careful discussion and institutional approval, patient and her son elected to undergo living donor kidney transplantation. Patient underwent general endotracheal anesthesia with smooth intravenous induction. She had a tunneled internal jugular double-lumen central venous catheter placed preoperatively and radial arterial line placed after induction. Access is sometimes difficult in renal transplant recipients and more so in our patient due to history of spontaneous subclavian and brachial artery thrombosis. As a routine practice in our institution, we place tunneled catheters preoperatively with interventional radiology for our scheduled kidney transplant recipients. There was no evidence of clots or thrombi in the internal jugular vein or vessels prior to placement of the line with ultrasound examination. A peripheral intravenous cannula was placed intra-operatively for additional access.\nShe received methylprednisolone and thymoglobulin for immunosuppression. In view of the patient's history of prothrombin gene mutation and history of prior thrombosis, she was maintained on a heparin infusion with a aim of maintaining the partial thromboplastin time (PTT) in the range of 70-75. To achieve this target PTT we gave a 2000 units bolus of heparin followed by an infusion of 1000 units/h. She remained stable throughout, maintaining a mean arterial pressure goal of > 80-85 mmHg after reperfusion. Trachea was extubated in the operating room and she was transported stable to the surgical intensive care unit. She received 2 l of albumin, 4.5 l of normal saline and 2 units of packed red blood cells during the case.\nOn the 3rd day post-operative, due to continued anticoagulation with heparin, patient developed retroperitoneal hematoma requiring re-exploration and washout. However, her allograft demonstrated good function and her creatinine remained stable post-operatively. She was transitioned to warfarin for anticoagulation and discharged home. Her continued immunosuppressive regimens include prednisone, tacrolimus and mycophenolate. Patient subsequently developed ureteral calculus, hydronephrosis and acute renal failure requiring nephrostomy tube placement. She has since had the nephrostomy tube removed and to date, her allograft continues to function well fifteen months later. |
We present a 46-year-old female patient. The patient was first diagnosed with urethra adenocarcinoma 8 years ago. Total resection of the urinary bladder with lymphatic dissection was performed followed by combined chemotherapy and radiotherapy. One and a half-year after the first operation the patient was reoperated on for metastasis of the urethral adenocarcinoma and vulvectomy with left inguinal radical lymph node dissection was performed. The pathology report was in compliance with the first report of the urethral adenocarcinoma. Postoperatively, the patient received 54 Gy/30 fraction radiotherapy. At the end of the same year the patient suffered a mass in her right thigh that caused a suspicion of another metastasis. Tru-cut biopsy was performed and pathology specimens revealed malignant mesenchymal tumor. 28 Gy/8 fraction preoperative radiotherapy was applied due to close neighbourhood of the tumor to the femoral artery and the tumor being larger than 5 centimeters in diameter. Following preoperative radiotherapy, wide resection of the tumor was performed. The pathology reports showed a high grade pleomorphic sarcoma. The oncology consultation did not recommend postoperative chemotherapy, but 20 Gy/10 fraction adjuvant radiotherapy was applied.\nFor the next three years the patient was regularly followed and no evidence of local or systemic relapse was present. The patient quit the routine control examinations and could not be followed until 4 months ago when MRI evaluation was performed for a mass in her left thigh. A subcutaneous lesion was detected in the left thigh with typical features of a lipoma. In addition, a large mass in the right femur was coincidentally observed with a satellite cutaneous nodule close to the previous incision scar (Figures and ). Tru-cut biopsy and PET scan were performed to grade the new lesion. The tru-cut biopsy has reported a low grade periosteal chondral tumor. An apical lesion of the right lung which was thought to be a metastasis was also present. MRI and CT angiographic evaluation showed the soft tissue component of the tumor enclosing the bone lesion 180 degrees medially and also involving a 10 cm segment of the femoral artery and vein ().\nThe patient was reoperated on. Wide resection for the metastatic nodule of the skin was performed first and the frozen pathology reported it as a malignant mesenchymal tumor. The tumor of the right femur was also removed with wide resection including the involved 10 cm segment of the femoral artery and vein in the Hunter canal (). Frozen pathology results reported clean margins and the lesion being possibly periosteal chondroblastic osteosarcoma. The femoral artery and vein were reconstructed using saphenous vein from the left leg. Saphenous vein of the right leg was not used in order not to disturb both venous drainage systems of the same leg and to avoid a possible venous insufficiency postoperatively. The 22 cm long bony defect was reconstructed using a massive allograft of femur and plate-screw fixation of the proximal and distal osteotomy sites was performed following locked intramedullary nailing (). The docking sites were grafted with 10 cc of demineralized bone matrix each. Pathologic evaluation revealed the mass of the right femur to be a juxtacortical chondroblastic osteosarcoma and the soft tissue mass anterior to it to be an indifferentiated pleomorphic sarcoma, the latter being in compliance with a relapse of the pleomorphic mesenchymal tumor that was resected in 2008. Pathologic evaluation of the resected dumbbell-shaped lesion of the left thigh revealed angiolipoma.\nThroughout the routine radiologic evaluations and PET scan before surgery, a lesion in the right lung was also detected and was reported as a metastatic lesion (). Three weeks after the last surgery, thoracoscopy assisted wedge resection of the metastatic lesion was planned. At this time, the frozen biopsy displayed a primary adenocarcinoma of the upper lobe of the right lung and the patient underwent a lobectomy. |
A 50 year old female patient previously healthy has undergone an abdominal ultrasound demanded by her primary care physician when her routine checkup blood test showed a slightly elevated level of liver enzymes with no other lab abnormalities. This ultrasound showed right adrenal lesion of 9 cm of diameter. An Abdominal MRI was then done and revealed a soft tissue necrotic encapsulated mass of 10 × 9 cm of right adrenal gland origin. She was completely asymptomatic and the physical exam was strictly normal. Endocrinological evaluation was done with normal hypothalamic-pituitary-adrenal axis function and no hyper secretion of catecholamines. The patient was considered to have a non-secreting right adrenal mass for which an adrenal scan was done and showed a well encapsulated 10 × 9 × 7 cm heterogeneous right adrenal mass with areas of necrosis and calcifications without local invasion (). The decision of right laparoscopic trans peritoneal adrenalectomy was taken with the patient. The surgery was done under general anesthesia after central and arterial lines insertion, the patient was on left decubitus position. 5 trocars were inserted as follows: The first 12-mm port was inserted at the lateral border of the rectus abdominis muscle just above the level of the umbilicus to accommodate the camera. Two subcostal 11 mm ports were also placed; one in the midclavicular line and the other in the lateral border of the rectus abdominis muscle. The forth 5-mm subcostal trocar was inserted in the anterior axillary line to retract the liver and the fifth 5 mm one was inserted in the epigastrium and used specially for aspiration and irrigation. After liver retraction, the peritoneum along the lateral aspect of the IVC was incised to expose the IVC just below its intrahepatic course. The duodenum which was diverted by the mass was mobilized. Dissection was next carried inferiorly by incising the peritoneum along the lateral edge of the vena cava to the superior edge of the renal vein. Dissection of the mass was subsequently carried out with special care at the medial aspect where we found that the wall of the IVC and the renal vein were very adherent to the mass which had a lot of small vessels that were oozing during all the time of the surgery (). In addition, the mass was extended posterior to the vena cava and we could not do a medial retraction of the IVC since the tumor was adherent to it. In front of these facts, we decided to convert to open surgery by a sub-costal incision (between two trocars) that allowed us to remove the mass safely (). A drain was put in the retro peritoneum at the end of the surgery, the operative time was 200 min, the blood loss was 850 cc and no transfusion was done. The drain was removed at the second post-operative day and the patient was discharged uneventfully on the sixth day after surgery.\nHistologically, the tumor consisted of spindle cells with alternating areas of compact hypercellularity with irregular streams and without atypia or mitosis (). This tumor was completely compressing and reducing the adrenal gland that was laminated but intact without histological abnormalities (). Immunohistochemical analysis demonstrated negative CKAE1-AE3, synaptophysine and chromogranine. In contrast to these results, S-100 and CD68 (PGM1) staining were diffusely positive across the tumor (). Thus, the evidences corresponded to a benign schwannoma (). |
A 58-year-old female was admitted to the emergency unit of our hospital suffering from acute dyspnoea, multiple episodes of vomiting, productive cough, and fever since 3 days. The patient reported a previous medical history of right mastectomy due to breast cancer followed by chemoradiotherapy and laparoscopic cholecystectomy for cholelithiasis ten months earlier. In the beginning of the operation after injection of anesthesia and endotracheal intubation, the patient developed pneumothorax which led to postponing the cholecystectomy. The pneumothorax was treated by inserting a thoracic drainage tube. After removing the thoracic drainage tube, chest X-ray and CT scan of the thorax were performed, but there was no evidence of diaphragm defect or herniation. Α laparoscopic cholecystectomy was performed four months later under general anesthesia with no complications. On admission to our department, the patient was febrile, pale, had considerable usage of accessory respiratory muscles, and had abdominal distention. On physical examination, the right lung presented decreased sounds during inspiration, while the abdomen was distended with diminished bowel sounds and peritonism. The blood exams were within normal values, while the arterial blood analysis demonstrated increased lactic acid levels and compromised pO2 values. Chest X-ray revealed that the right lung was totally suppressed by the intestine and suggested that due to intestinal transposition to the thoracic cavity, a functional right pneumonectomy had occurred (). CT scan of the thorax and abdomen detected a right diaphragm defect and herniation of the small intestine, which was also ischaemic due to venous circulation occlusion (). Urgent exploratory laparotomy was performed, and it revealed a diaphragm defect of 10 × 2 cm extending from the anterior side of the right diaphragm to the posterolateral side. Almost all the small intestine and part of the transverse colon were extending to the right thoracic cavity through the defect and were ischaemic and immobilized due to venous stasis. The herniated part of the small intestine and transverse colon were separated from the lung and retracted into the abdominal cavity, whereas the diaphragmatic defect was closed by direct suturing with Prolene 2-0 in two layers. Two vacuum drainage systems were placed in the right thoracic cavity and the right subphrenic area, subsequently. The abdominal wall was closed the next day after confirming the small and large intestine viability. The patient was hospitalized in the ICU for 11 days and was discharged from the hospital 20 days after the operation. The patient's postoperative course was complicated by an episode of acute myocardial ischaemia with increased troponin levels and mild ECG ischaemic changes which was treated successfully with beta blockers and dual antiplatelet agents. Mild fever due to retention of bronchial secretions and atelectasis was treated successfully by IV administered antibiotics. The patient was discharged the 20th postoperative day. A year after the operation, the patient remains free of symptoms and the postoperative CT of the thorax remains without findings. |
A 28-year-old male patient reported to the Department of Periodontology and Oral Implantology with a chief complaint of a fractured crown in relation to root canal treated maxillary left central incisor. The patient had undergone root canal treatment of the tooth 3 years back and had received fixed bridge prosthesis in relation to the bilateral maxillary central incisor regions. The patient reported that the prosthesis got avulsed and the crown portion of the maxillary left central incisor was fractured following the biting into a hard food substance. The patient also reported the previous dental treatment to be unsatisfactory in terms of the final esthetic and functional outcomes of the prosthesis. Patient expressed preference for a single crown prosthesis and considered his previous bridge prosthesis, a failure in simulating the natural tooth appearance. There were no other relevant dental and medical histories. The patient was a teetotaler and his family history was non-contributory, whereby the confounding environmental and genetic risk factors were deemed absent. Intraoral examination revealed a fractured root canal treated maxillary left central incisor. The right maxillary central incisor had undergone tooth preparation as a part of the previous bridge prosthesis. Oral hygiene maintenance was satisfactory and on examination, the gingival and periodontal status of the patient also appeared to be apparently healthy.\nThe patient was explained in detail about the various treatment modalities available, the advantages and disadvantages of each type of therapy as well as the cost factor related to each therapeutic mode. Taking into consideration the esthetic and functional demands in the anterior esthetic region and the patient's request for an implant-based fixed prosthetic rehabilitation, the final treatment plan was formulated. An atraumatic extraction of the fractured, root canal treated maxillary left central incisor and an immediate implant placement was decided upon as the final treatment plan for the patient. A written informed consent was obtained from the patient prior to commencement of the surgical procedure.\nThe surgical site was anesthetized by local administration of 2% lignocaine hydrochloride (LOX, Neon Laboratories Ltd., Mumbai, India) with 1:200,000 adrenaline. A modified crestal incision was made beyond the palatal surface of the tooth. The conventional mid-crestal incision was placed just apical to the palatal margin of the fractured tooth. This incision was then continued with the oblique releasing incisions placed along the mesial line angles of the maxillary right central and left lateral incisors, extending beyond the mucogingival junction to obtain a tension-free flap with a broad base. This type of envelope flap design with two releasing incisions is called the four corner flap. This mucoperiosteal flap was reflected and the fractured tooth exposed sufficient enough to facilitate atraumatic and careful extraction []. The tooth was extracted by conventional forceps technique and the socket was thoroughly curetted for complete removal of infected granulation tissue, if any. The socket was flushed with sterile isotonic saline solution and osteotomy site preparation was performed for receiving the implant. A self-threaded titanium implant (4.2 mm × 10 mm, Lifecare Devices Pvt. Ltd, Chennai, India) was inserted at the extraction socket and adequate primary stability was accomplished from the residual alveolar bone. However, a small amount of space was present at the palatal and proximal surfaces of the implant in the cervical aspect []. Autogenous bone harvesting was decided upon and the patient was explained in detail regarding the procedure. A second written informed consent was obtained from the patient prior to proceeding with the bone harvesting procedure.\nAutogenous block bone graft was harvested according to the “minimum button-hole” technique described by Kumar et al. in 2011.[] A minimal vestibular incision was placed apical to the roots of mandibular left incisors. Soft tissue attachments were carefully relieved using a periosteal elevator until mandibular symphysis bone in the size of a “button-hole” was exposed. An 11 mm diameter cylindrical autogenous block bone was harvested using a round trephine bur []. Next, the block bone graft was crushed into bone chips using a bone rongeur.\nThe bone chips were carefully packed around the palatal and proximal aspects of the implant []. A bio-resorbable collagen membrane (Healiguide, Advanced Biotech Products, Chennai, India) was adapted over the implant site to establish complete coverage and protection of the implant and bone graft material []. The recipient and donor sites were sutured using an absorbable suture material (4-0 Vicryl, Ethicon, Inc., Johnson and Johnson, Somerville, NJ, USA).\nA prescription of 8 mg of betamethasone was given jointly with 2 g/day of amoxicillin for 10 days. The patient was advised to rinse with warm salt water rinses for the initial 15 days to promote wound healing. The patient was also instructed in the use of chlorhexidine gluconate 0.12% (Peridex, Zila Pharmaceuticals, Phoenix, AZ, USA) as part of home care regime. The patient experienced very minimal post-operative discomfort and no complications were reported.\nIn order to protect the recipient site and eliminate undue stress and forces from acting upon the surgical area, the placement of a temporary prosthesis was avoided with a mutual consent obtained from the patient. This ensured an undisturbed interior milieu facilitating appropriate healing of surgical site. Six months post-operatively, the recipient and donor surgical sites exhibited excellent wound healing with adequate amount of interdental papilla present at the recipient site around the implant fixture []. A second phase surgery was performed to uncover the implant, and the final fixed prosthesis involving two separate crowns were delivered in relation to both the maxillary central incisors []. The separate crown suprastructures were fabricated keeping in mind the patient's request and preferences. The patient was extremely satisfied with the final outcome of the restoration, fulfilling both esthetics and functional needs. |
A 16-year-old boy with a history of ulcerative colitis (UC), diagnosed at age 15, and complicated by primary sclerosing cholangitis presented with pleuritic chest pain and low-grade fevers in the setting of an IBD flare with presenting symptoms of six to seven bloody stools per day and abdominal pain with labs significant for a leukocytosis and elevated ESR and CRP. Prior to admission, his symptoms had been well controlled with azathioprine for maintenance therapy. A chest x-ray demonstrated right upper and left lower lobe pulmonary opacities, and a subsequent CT scan revealed multiple pulmonary nodules with associated hilar lymphadenopathy. Due to concern regarding a possible infectious etiology that would preclude administration of additional medical therapy, a thoracoscopic biopsy was performed. There were no perioperative complications. The chest tube, which was placed routinely for the treatment of potential pulmonary air leak, was removed on post-operative day two after no air leak was identified. The pathology demonstrated necrotic neutrophilic nodules without granulomas, which were consistent with pulmonary manifestations of his UC. Operative cultures and additional infectious workup were negative. He was then treated with a three-month course of corticosteroids and started on mesalamine for maintenance therapy with subsequent improvement in his symptoms and a decrease in size of the nodules on CT scan 10 days after initiation of therapy. He presented again two years later with similar symptomatology in the setting of an IBD flare, and the nodules were noted to be larger, but in the same locations. Between these presentations, his UC maintenance therapy was changed to azathioprine. He was again treated with a three-month course of corticosteroids while continuing azathioprine with resolution of his symptoms and a decrease in size of the nodules on CT scan one month later. One year later, he had developed left-sided pleuritic chest pain and worsening of his UC symptoms. The decision was made to initiate infliximab for the management of his UC, and a CT scan was repeated to evaluate the nodules prior to change in therapy. The nodules were noted, again, to be larger, but in the same locations. Another thoracoscopic biopsy was performed to rule out an infectious etiology, which showed cryptogenic organizing pneumonia (COP; formerly called bronchiolitis obliterans organizing pneumonia), suppurative pneumonia, and macrophagic pneumonitis, again, favored to represent pulmonary manifestations of IBD (Figure ). This was, again, suggestive of pulmonary manifestations of his UC. Infliximab was initiated, and symptoms dramatically improved, with resolution of nodules noted on CT scan four months later. |
A 12-year-old male child presented to our emergency room with an injury to the elbow following a fall on the outstretched hand. He had a diffuse swelling around the elbow, with no external wounds. On examination there was diffuse swelling with a hard bony lump on medial aspect of the elbow. The radial head was not in place clinically. He had weakness of the flexors of the fifth and fourth digits of the hand with a hypoaesthesia in the distribution of the ulnar nerve.\nA radiograph of the elbow showed a fracture of the radial neck with dislocation of the radial head onto the medial side. However radial head was intact [].\nThe patient was taken up for open reduction on an emergency basis. The radial head was palpable in the subcutaneous plane and it was approached through a short curvilinear incision on the medial side centered over the displaced radial head, and the head could be delivered out. A separate lateral Kocher incision was used to approach the proximal radius; the radial head was repositioned anatomically and fixed with a mini fragment T plate, and the annular ligament was repaired. The stability was checked in the elbow. The ulnar nerve was not explored A posterior above elbow slab was used to protect the elbow for 3 weeks followed by active elbow mobilization.\nPostoperatively, an ulnar nerve injury was confirmed on detailed examination once pain had come down and the child was more cooperative. The patient was started on indomethacin 25 mg empirically twice a day for 3 weeks. The patient was lost to followup from this time onward for the next few months. He reported back to the outpatient department at 6 months for review. He had a range of motion at the elbow from 30° to 130° with no supination and good pronation. He was satisfied with function. The ulnar nerve had not recovered [Figures -]. The X-ray taken showed a suspicious developing proximal radioulnar synostosis and union of the fracture site. The implants were removed. He was advised an electromyography and nerve conduction study which he did not get done. |
A 32-year-old Caucasian woman presented to an outside orthopaedic spine surgeon at 31 weeks of pregnancy because of a right leg pain and difficulty walking. The patient reported that the pain had come on gradually and it had caused her to go from walking independently to requiring the use of a cane and to eventually a walker. The patient underwent an MRI of the lumbar spine 1 month prior to delivery because of concerns that her pain and weakness were radicular in nature. A limited MRI of the lumbar spine, with only sagittal and axial reconstruction and without extension to the pelvis or hips, showed a mild disk bulge at L3-4 and L4-5. She was prescribed a Medrol Dosepak for a herniated disk and right lower extremity radiculopathy.\nThe patient continued to experience pain and difficulty ambulating. She presented to the obstetric service at 38 weeks with elevated blood pressure and headaches, and was admitted to labor and delivery for induction of labor. After 16 hours of labor, the decision was made to perform a cesarean section because of concerns for worsening of the right lower extremity radiculopathy and suspected fetal macrosomia, complicated by intrapartum hemorrhage. After her cesarean and delivery, the patient experienced increased severe pain in her right hip and was unable to ambulate. The obstetrics and gynecology team first consulted the neurology service, and an MRI of the pelvis was recommended to evaluate for possible compressive femoral nerve neuropathy. The neurology team also started her on a low dose of prednisone. On the pelvic MRI, she was found to have a displaced right femoral neck fracture with signs of femoral head bone marrow edema and a focal area of bone edema in the left femoral head with mild flattening of the femoral head (Figure ). The radiologist described the areas of edema in both hips as possible ON. At this point, the orthopaedic service was consulted and a pelvic radiograph was obtained (Figure ).\nThe patient had no known history of trauma or falls during her pregnancy. She further had no known history of rheumatologic disease nor oncologic disease, prolonged steroid use, smoking, or alcohol abuse. The patient did subsequently undergo an oncologic and rheumatologic workup, including antinuclear antibody, rheumatoid factor, and protein electrophoresis, all of which were found to be negative. We believe that the patient had an undiagnosed nondisplaced fracture that went on to displace during her cesarean, most likely as a result of previously undiagnosed hip pathology associated with pregnancy. Since the timing of her fracture was unclear and because of the degree of displacement, we discussed with the patient that open reduction and internal fixation had a high risk of failure and decided to proceed with arthroplasty. Five days postpartum, the patient underwent a right total hip arthroplasty (Figure ). The right femoral head and neck were sent for pathology, which reported a “thin trabecular bone structure and recent medullary hemorrhage, consistent with fracture site.” No malignant pathologic process, necrosis, or any other significant pathology was noted. Although the radiologist in his report associated the bony edema in the right hip with ON underlying the femoral neck fracture, the diffuse area of edema seen on the MRI and noted in the pathology report, without mention of bony necrosis, were more consistent with TOH.\nBeginning on postoperative day one, the patient was allowed to weight bear as tolerated and began to work with physical therapy. The patient did not report any pain in the left hip or groin; therefore, despite an MRI showing a small focal area of edema, she was allowed to weight bear bilaterally. She was found to have hypoalbuminemia (albumin level 1.6) attributed to malnutrition, for which she was referred to a nutritionist as an outpatient.\nAt 6 months postpartum, the patient was ambulating with a nonantalgic gait and had full and painless range of motion of bilateral hips. The patient also underwent a repeat MRI of the left hip to monitor the area of edema in the left femoral head (Figure ). This MRI showed near-complete resolution of the previous findings of edema and flattening of the femoral head on the left, again more consistent with a diagnosis of TOH. |
A 29-year-old Saudi woman presented to our Emergency Room with a five-day history of epigastric and lower abdominal pain associated with lower abdominal and pelvic fullness that she attributed to fibroids. The pain was intermittent, colicky in nature and associated with nausea and vomiting. She denied any history of fever and there had been no change in her bowel habits or urinary symptoms. For several months she had been followed up regularly at the gynecology clinic due to the lower abdominal heaviness and distension. Her gynecological history revealed a nulliparous woman with no vaginal bleeding. Her medical history was significant for epilepsy since childhood, which was well controlled by medication, and a laparoscopic appendectomy one year ago. On examination, she was alert and conscious. Her vital signs were stable. Her abdomen was distended with a palpable pelvic-abdominal mass that was hard, non-tender and slightly mobile. Her liver and spleen were within the normal range and she had normal bowel sounds. No lymph nodes were enlarged and digital rectal examination revealed no abnormalities.\nA computed tomography (CT) scan of her abdomen and pelvis showed a pelvic/abdominal mass adjacent to the distal small bowel loops separate from the uterus and ovaries, heterogeneously enhancing, measuring roughly 65 × 99 mm with multiple areas of necrosis (Figure ). A CT scan of her chest showed indeterminate multiple bilateral subpleural 2 mm to 4 mm lung nodules, too small to biopsy.\nThe case was discussed by the multidisciplinary tumor board and the advice was to confirm the diagnosis to eliminate the possibility of an ovarian origin of the tumor because of its very close proximity.\nSurgical exploration was indicated due to the finding of a large mass that was composed of a cystic and also a large solid component that needed to be investigated to eliminate the possibility of lymphoma or tuberculosis, which is quite common in our population. However, there was some radiological confusion about the origin of this mass and to some colleagues it was necessary to confirm it with a histological biopsy. For this reason, our patient underwent diagnostic laparoscopy, which showed a moderate amount of ascetic fluid with a large mass in the lower abdomen. When a biopsy was attempted, a large vein on the mass ruptured and bleeding made visualization extremely difficult. Therefore, the procedure was converted to an open one through a small lower midline incision. A 10 × 10 cm mass arising from the terminal ileum, occupying the pelvis and reaching to the umbilical area was found.\nThe uterus, ovaries and the urinary bladder were not involved. After a minimal dissection the tumor was excised with 10 cm free margins of small bowel and primary side-to-side anastomosis was performed. Our patient tolerated the procedure very well and her recovery period was unremarkable. She was discharged home on the seventh post-operative day. She was reviewed on an out-patient basis by our colleagues in radio-oncology and due to the radical nature of the surgery she was not offered any adjuvant treatment. She is still being followed up by our surgical oncology team and has shown no evidence of local or distant metastasis based on clinical and CT scan results after 24 months of follow-up.\nGross pathology revealed a segment of small bowel measuring 17 × 2 cm. It was adherent to a portion of ascending colon. An 8 × 7 × 3 cm white solid mass with a homogeneous cut surface was bulging from the serosal side of the small bowel; it was 4 cm away from the proximal resection margin. The tumor was adherent to the large bowel but not infiltrating it grossly. Few lymph nodes were identified within the mesenteric fat. Microscopy showed that the tumor was composed of cellular spindle cells with a mild to moderate degree of pleomorphism arising from the small bowel wall and mainly involving the submucosa, muscularis propria and serosa. Focal mucosal erosion was identified. The tumor cells showed a moderate amount of eosinophilic cytoplasm, evenly distributed nuclear chromatin and a few conspicuous nuclei (Figure ). The mitotic count was one to two per 10 high-power fields. A metastatic focus was identified within a single mesenteric lymph node (Figure ).\nImmunohistochemical testing results showed that the tumor was positive for S100, epithelial membrane antigen (EMA), B cell lymphoma 2 (Bcl 2), and vimentin (Figure ). CD99 tests were negative (Figure ) and CDl17 tests were positive (Figure ), in addition to calretinin (focal) and synaptophysin (focal), and CD56 (few cells). The specimen tested negative for CD34, CAM5.2, cytokeratin 7, 20, and 5/6 (Figure ), cytokeratin AE1/AE3, neuron-specific enolase (NSE), CD31, desmin (Figure ), chromogranin, smooth muscle actin (SMA), HMB45, factor 8, Ber/EB4, and melan-A.\nA cytogenetic study of the specimen was conducted on a formalin fixed paraffin embedded tumor sample. The result of a real-time polymerase chain reaction (RT-PCR) procedure for synovial sarcoma-associated fusion transcript (SYT-SSX1 and SYT-SSX2) was negative.\nOur patient was seen periodically in our surgical oncology clinic and she has remained disease free for 24 months with no clinical or radiological evidence of local recurrence. |
A 33 year old right handed male i.v. drug abuser presents to the emergency department three hours after reportedly self injecting water dissolved crushed zolpidem tablets into the right forearm. His chief complaint was forearm tenderness extending down to the hand. The patient described an immediate onset of pain, which radiated down the arm into the hand. Clinical examination revealed a fresh injection mark at the ulnar side of the distal right forearm without signs of local inflammation. The patient had a neurovascular intact hand with 5/5 motor strength for wrist and finger extension and flexion. Digital two point discrimination, as well as capillary refill of acral digits was found to be within normal limits and a strong radial pulse was palpated, no ulnar pulse was documented. No further apparative diagnostic were performed at initial presentation. The patient was discharged with analgesic medication and told to return if symptoms aggravated. 18 hours after the injection the patient was urgently referred back to the ED by his general practitioner and presented with an ischemic hand. The right hand was found to be cold and held in a flexed position. There was absent ulnar artery pulse and only a faint radial artery pulse palpable, Allen's test was pathological. The hand showed blue discoloration and there was tenderness over the thenar eminence and hypoesthesia over the digits 1 through 5 as evidenced by a two point discrimination of greater than 8 mm (See Fig ). Emergent angiography revealed no flow in the distal ulnar artery and absent deep and superficial palmar arch perfusion (Fig. ). The patient was admitted to the intensive care unit and urokinase lysis via an indwelling intraarterial catheter was started at 20 hours after injection with 240.000 IU/h over 2 hours followed by half the dose for 2 hours.\nThe patient was closely monitored for possible compartment syndrome of the forearm and hand with potential need for decompressive surgical intervention. Within 3 hours after start of thrombolytic therapy there was a return of normal skin color to the right hand and restoration of a strong Doppler detectable ulnar artery and palmar arch pulse signal. Clinically, the Allen test turned normal. There was no need for compartment decompression and follow-up angiography the next day (Fig. ) demonstrated restoration of ulnar as well as digital artery flow with normal Allen test. Patient was continued on i.v. heparin until discharge at day 6 after trauma. In addition he was placed on 100 mg aspirin/day for 2 weeks. At discharge he had regained full motor strength of finger flexion and extension as well as hand intrinsics with the exception of a 4/5 strength of thumb opposition. A follow-up at 3 months showed bilateral equal skin coloration, no trophic changes to skin and skin appendages of the right hand, normal Allen test and an intact neurovascular exam with 5/5 motor function throughout and intact sensation (Fig ). |
A 40 years old female reported to the emergency department of a level II trauma center after an epileptic convulsion with complaints of pain and restriction of movements of both shoulder joints. Physical examination revealed hollowness below the acromion process on either side with flattening of the normal contour of the shoulders with the arm held in external rotation and abduction on the left side and in slight internal rotation on the right side. No peripheral neurological deficit was noted. No specific history of the mode of injury could be elicited as there was no witness of the episode and the patient could not clearly recall the event.\nRadiographs revealed anterior shoulder dislocation with a displaced greater tuberosity fracture on the left side () and posterior dislocation with lesser tuberosity fracture on the right side (). Both the dislocations were promptly reduced by closed manipulation in the emergency department and post-reduction radiographs showed persistent but decreased displacement of both the tuberosities (more on the side with the greater tuberosity fracture) (, ). A CT scan of both shoulder joints was done for better demonstration of the fracture pattern (, ).\nAfter preoperative workup, anesthetic evaluation, physician consultation and informed consent, patient was taken up for surgery. Lesser tuberosity fracture on the right side was fixed using two partially threaded cannulated screws using deltopectoral approach to the shoulder (). The greater tuberosity fracture on the left side was similarly fixed using two partially threaded cannulated screws via direct lateral approach (). Post-operatively both the shoulders were immobilized in a shoulder immobilizer for three weeks. Physical therapy was started as tolerated by the patient at four weeks. She was able to resume her daily activities by two months. At one year follow-up, the patient was free of pain in both shoulder joints and radiographs revealed consolidation at the fracture site with no re-dislocations occurring during the follow up period. After aggressive physiotherapy, the range of motion was near normal on the left side but slight limitation of abduction (range 0-120 degrees) was noted on the right side. |
Patient 2 was a 45-year-old male patient who presented with a T3 N0 M0 recurrent squamous cell carcinoma involving the entire lower lip, chin, neck, cheek and mandible. He had undergone previous resections of his lower lip carcinoma and a left tonsillectomy a year before. He had received postoperative radiation and chemotherapy and presented with a recurrence of his cancer as well as osteoradionecrosis of the mandible requiring composite resection of his tumor and bilateral neck dissection.\nThe patient’s mandibular and intraoral mucosal defect was reconstructed with a free fibula flap from the right leg with a skin paddle measuring 17 × 8 cm along with a 2.4-mm reconstruction plate. A closing wedge osteotomy was performed at the area of the mandibular symphysis on the fibula to allow for the bend of the fibula into the contours of the mandible. An ALT flap from the right leg with a skin paddle measuring 14 × 22 cm was used to reconstruct the external soft tissue. The left lingual artery and the internal jugular vein served as recipient vessels for the free fibula flap. The ALT flap was anastomosed to the ipsilateral facial artery and the internal jugular vein. As in the previous case, a tensor fascia lata sling anchored bilaterally on the anterior aspect of the zygoma was used to suspend the lower lip reconstruction and restore oral competence ().\nOn postoperative day 3 the patient presented with an acute arterial thrombosis of the ALT artery. The arterial anastomosis was revised and the left ascending pharyngeal artery was employed as a recipient vessel for reanastomosis to the ALT artery. Despite revision of the anastomosis, the flap progressed on to total necrosis likely due to the no reflow phenomenon. The patient received a second ALT flap from the left thigh with a 14 × 26 cm skin paddle. An end-to-side anastomosis between the ALT artery and the right common carotid artery was performed. The right internal jugular vein served as recipient vessel for the venous anastomosis. The right neck was chosen since this area was likely less scarred from prior surgery. At the conclusion of the case a strong Doppler signal over both artery and vein was heard and the flap appeared to be well perfused with good capillary refill. The patient's course was further complicated by superficial dehiscence and wound breakdown of the left ALT flap and he was taken to the operating room on postoperative day 14 for neck exploration and closure of the flap dehiscence.\nThe patient’s arterial thrombosis was most likely the result of exuberant atherosclerosis due to a significant history of smoking, substance abuse and radiation. The second ALT flap survived completely and healed uneventfully. On 3-month follow-up the patient’s tissue coverage was stable and he had adequate oral competence allowing him to tolerate an oral diet. |
The patient was a 30-year-old woman who was diagnosed with peripheral vascular disease 9 years prior to this encounter. She presented to our clinic with complaints of worsening pain in the lower extremities with activity and sometimes pain at rest. The patient had a medical history of hypertension and admitted to non-compliance with medication. She has been smoking cigarettes for 11 years and usually consumes 1 pack per day. In addition, she reported a strong family history of coronary artery disease. The patient was taken to the office-based lab located within the clinic and was prepared sterilely for a catheter arteriogram.\nCatheter arteriogram results showed significant occlusion of the left iliac artery ( and ), the right iliac artery (), as well as the distal abdominal aorta (). There were numerous collateral vessels noted, indicating the presence of long-standing proximal stenosis (). The decision was made to use angioplasty to help widen the areas of stenosis. An 8 mm × 40 mm Passeo balloon was advanced from the right femoral artery into the left iliac artery () and insufflated to 6 mmHg (). The balloon was allowed to remain expanded for 1 min and then was deflated. Next, the distal aorta was repaired in a similar fashion. The balloon was advanced into the distal aorta from the right femoral access and insufflated to 12 mmHg (). The balloon was allowed to remain expanded for 90 s.\nLastly, the right iliac artery () was treated using the same method (). After completion of the angioplasty procedure, catheter arteriogram was repeated to visualize the effectiveness of the procedure in relieving the extensive stenosis. The imaging revealed almost complete restoration of the diameter of both left and right iliac arteries ( and ). The distal aorta also showed improved diameter after the procedure (). Angiogram of both lower extremities was also performed. The catheter was passed distal to the stenosis that was previously present in the left iliac artery, to help visualize perfusion of its distal branches ( and ). The catheter was removed from the right femoral artery and reinserted in a distal fashion, to help visualize downstream perfusion. The right popliteal artery was well visualized on angiogram (), signifying strong perfusion. The patient was strongly advised to discontinue smoking cigarettes. In addition, the patient was advised to maintain regular physical exercise as tolerated and take baby aspirin daily to prevent thrombotic events. |
A 55-year-old woman visited our clinic in September 2018 with stage IV breast cancer. She was a mother of two sons with a history of contraceptive injection use for 5 years and suffered from type II diabetes for 4 years with routine insulin treatment. She presented with a left breast mass that had appeared several months ago. In the past 3 months, the mass grew quickly and developed a 15 × 15 cm inflammatory wound. A core needle biopsy was performed in the district hospital on June 2018 on this unresectable lesion. Pathology tests revealed ductal invasive breast cancer. An immunohistochemistry test revealed a positive estrogen receptor at 90%, a negative progesterone receptor, a negative Her2 and 75% of KI 67 expression and a poor histology grade. Her referral process to our clinic was slow because of the convoluted administration. During this process, she developed a cough. When presented in our clinic for chemotherapy she had shortness of breath. The clinical and imaging examination revealed a moderate pericardial effusion, a pleural effusion, pneumonic and subpleural type pulmonal metastases (Figure ) and bone metastasis in the form of a wedged fracture in the 12th thoracic vertebra. The pericardial effusion progressed significantly and she very quickly developed a life-threatening cardiac tamponade (Figure ). She was then referred to the cardiology ward. Echocardiography revealed a massive pericardial effusion with flying heart and collapsed right atrium and right ventricle. To release the pericardial fluid, a pericardial window procedure was immediately applied. A chest tube was placed within the pericardial cavity to drain the pericardial fluid from the pericardial space. Further, cytology examination confirmed that both the pericardial effusion and the pleural effusion contained metastatic breast cancer cells. One week after the pericardial window procedure she recovered from the severe dyspnea and all the devices were then removed. A total deep vein thrombosis in her right popliteal vein was also identified and treated with unfractionated heparin followed by 20 mg daily oral rivaroxaban.\nWe then considered a palliative chemotherapy treatment despite her low performance (ECOG 3) because she opted for it. With consent from the patient and her family, we started a weekly intravenous docetaxel infusion with a 30 mg/m2 dose based on previous publication. We planned the weekly regimen for 6 cycles with 2 week rest which would be continued until disease progression. She could tolerate the first cycle of her treatment and went home as part of the ambulatory program. During subsequent treatment cycles she gradually showed an increase in her quality of life and improvement in her whole performance (ECOG 1). A remarkable response to her respiratory symptoms was noticed and after the sixth cycle of chemotherapy her chest rontgenography demonstrated the decrease of pleural and pericardial effusion. Weekly docetaxel was then continued and planned for another three cycles.\nAfter the seventh docetaxel cycle, she sufferred from a cough and headache. Diagnosed as immunocompromised pneumonia she was treated with antibiotic and recovered completely. A head contrast-enhanced computedtomography (CECT) scan was also performed to look for any signs of brain lesions. It revealed a cortical edema without any sign of brain metastasis (Figure ). In the ninth cycle, she experienced a generalized tonic-clonic seizure during the administration of docetaxel without any preceeding symptom. Seizure occurred four times, for about an hour, and she fell asleep afterward. She also had a slight decrease in consciousness after the seizure. She was admitted to the hospital for brain metastasis consideration and treated with a phenitoin infusion and a dexamethason injection to relieve the neurologic symptoms. Her biochemical examination was within normal limits. An electroencephalogram showed diffuse epileptiform waves and a slowing pattern. Furthermore, her chest rontgenography showed the disappearance of the pericardial effusion that was confirmed by echocardiography (Figure ). The echocardiography also demonstrated dilatation of her right atrium and right ventricle with good left ventricle function and an ejection fraction of 78%. Locally, a breast ultrasound showed a decrease in the breast lump and inflammatory lesion, but a new axillary lymphadenopathy was found, confirming the progression of the disease. Doppler ultrasound of the extremities showed the disappearance of the thrombus lesion.\nAfter full recovering from her neurologic symptoms, the patient visited our clinic with ECOG performance 2. We then planned to initiate a second-line chemotherapy and did not give her hormonal treatment due to the consideration of brain metastases although CECT reassessment did not confirm it. Oral combination of capecitabine and cyclophosphamide is among metronomic palliative options as suggested by the guideline. Since oral cyclophosphamide was not available locally, we modified the regimen with four cycles of a 600 mg/m2 cyclophosphamide infusion on day 1 and a capecitabine 825 mg/m2 bid on day 1 to 14. The combination regimen was given at 3-week interval. This approach was continued with metronomic capecitabine for maintenance till the disease progression. There was no dyspnea episode or signs of a pericardial effusion and seizure observed during this second-line treatment program, and the patient's quality of life was stable. On June 2019, she started feeling frequent breast pain and had difficulty finding the words she wanted to say. She then experienced a sudden seizure episode at home, with similar characteristics to the prior event. She was readmitted for treatment of her neurology symptoms with dexamethasone and a phenytoin infusion. This time, magnetic resonance imaging (MRI) with contrast showed multi-focal brain metastases (Figure ). A breast ultrasound also demonstrated additional lesions in her left breast. She received a palliative 30 Gy of whole-brain radiotherapy (WBRT) fractionated into 10 series in July 2019. In August 2019, she started the third-line palliative chemotherapy with paclitaxel 175 mg/m2 after refusing our option for a weekly navelbine regimen. Some days after receiving chemotherapy she had a sudden shortness of breath and passed away at home. The cause of death remains unclear since she was not admitted to the hospital. We assumed it might be related to the central symptom of her brain lesion. |
A 66-year old right hand dominate female, with no significant past medical history, presented to the emergency department at our institution with left shoulder pain after an accidental trip and fall onto an outstretched hand that occurred the same day. She had noticeable deformity of the upper arm and was neurovascularly intact distally. Radiographs were obtained which demonstrated a four-part proximal humerus fracture and dislocation of the left glenohumeral joint (). The patient was admitted, and on hospital day 3, she underwent open reduction internal fixation of her proximal humerus fracture dislocation (). A deltopectoral approach was utilized for this procedure. Venous bleeding was controlled with electrocautery. The cephalic vein was properly identified during the dissection and was not injured. There were no other intraoperative complications. Postoperatively, the patient had an uneventful hospital course and was discharged on postoperative day two on 325 mg acetylsalicylic acid once daily for DVT prophylaxis. On postoperative day five the patient returned to our outpatient clinic complaining of increased swelling and discomfort of the left upper extremity. Physical exam showed increased swelling with pitting edema and an intact neurovascular exam. An upper extremity duplex ultrasound was obtained which demonstrated occlusive thrombosis in the cephalic and deep brachial veins of the left forearm. The patient was referred to our Vascular Medicine service and anticoagulation therapy was initiated with enoxaparin 40 mg subcutaneously once daily for two days followed by rivaroxaban 15 mg twice daily for 21 days. Follow-up examination demonstrated improvement in symptoms and reduction in swelling. The patient was then transitioned to long-term prophylaxis using rivaroxaban 20 mg daily for eight weeks. A repeat upper extremity duplex ultrasound was obtained showing resolution of the DVT. She completed the remainder of her therapy with aspirin 81 mg daily for 16 weeks at which time her symptoms had completely resolved. The patient did not experience any recurrent thromboembolic events or any complications from her anticoagulation therapy. Of note, the patient continued her routine postoperative rehabilitation program with early passive range of motion followed by gradual transition to active range of motion and strength training with physical therapy. In addition, postoperative radiographs were obtained throughout her follow up which showed continual consolidation of the fracture site with complete bony union at seven months. |
A 50 year old female patient previously healthy has undergone an abdominal ultrasound demanded by her primary care physician when her routine checkup blood test showed a slightly elevated level of liver enzymes with no other lab abnormalities. This ultrasound showed right adrenal lesion of 9 cm of diameter. An Abdominal MRI was then done and revealed a soft tissue necrotic encapsulated mass of 10 × 9 cm of right adrenal gland origin. She was completely asymptomatic and the physical exam was strictly normal. Endocrinological evaluation was done with normal hypothalamic-pituitary-adrenal axis function and no hyper secretion of catecholamines. The patient was considered to have a non-secreting right adrenal mass for which an adrenal scan was done and showed a well encapsulated 10 × 9 × 7 cm heterogeneous right adrenal mass with areas of necrosis and calcifications without local invasion (). The decision of right laparoscopic trans peritoneal adrenalectomy was taken with the patient. The surgery was done under general anesthesia after central and arterial lines insertion, the patient was on left decubitus position. 5 trocars were inserted as follows: The first 12-mm port was inserted at the lateral border of the rectus abdominis muscle just above the level of the umbilicus to accommodate the camera. Two subcostal 11 mm ports were also placed; one in the midclavicular line and the other in the lateral border of the rectus abdominis muscle. The forth 5-mm subcostal trocar was inserted in the anterior axillary line to retract the liver and the fifth 5 mm one was inserted in the epigastrium and used specially for aspiration and irrigation. After liver retraction, the peritoneum along the lateral aspect of the IVC was incised to expose the IVC just below its intrahepatic course. The duodenum which was diverted by the mass was mobilized. Dissection was next carried inferiorly by incising the peritoneum along the lateral edge of the vena cava to the superior edge of the renal vein. Dissection of the mass was subsequently carried out with special care at the medial aspect where we found that the wall of the IVC and the renal vein were very adherent to the mass which had a lot of small vessels that were oozing during all the time of the surgery (). In addition, the mass was extended posterior to the vena cava and we could not do a medial retraction of the IVC since the tumor was adherent to it. In front of these facts, we decided to convert to open surgery by a sub-costal incision (between two trocars) that allowed us to remove the mass safely (). A drain was put in the retro peritoneum at the end of the surgery, the operative time was 200 min, the blood loss was 850 cc and no transfusion was done. The drain was removed at the second post-operative day and the patient was discharged uneventfully on the sixth day after surgery.\nHistologically, the tumor consisted of spindle cells with alternating areas of compact hypercellularity with irregular streams and without atypia or mitosis (). This tumor was completely compressing and reducing the adrenal gland that was laminated but intact without histological abnormalities (). Immunohistochemical analysis demonstrated negative CKAE1-AE3, synaptophysine and chromogranine. In contrast to these results, S-100 and CD68 (PGM1) staining were diffusely positive across the tumor (). Thus, the evidences corresponded to a benign schwannoma (). |
A 62-year-old female presented for evaluation of recurrent left lower extremity swelling. Her medical history was notable for prior deep vein thrombus in the right distal lower extremity while on hormone replacement therapy (HRT). She denied the active use of HRT and tobacco use during this admission. Venous Doppler ultrasound completed in the emergency room revealed extensive thrombosis of the left lower extremity extending superiorly towards the left common iliac vein. Further imaging with ultrasound revealed compression of the left iliac vein by the right iliac artery as well as a significantly elevated reflux time of the left great saphenous vein (14.2 seconds) suggestive of MTS. The patient was taken to the operating suite and during the procedure the common iliac vein appeared normal distally, but more proximally the vein was narrowed significantly to a diameter of less than 2 mm. Prior to entering the inferior vena cava, the common iliac vein normalized. Using intravenous ultrasound, measurements were taken and a 14 x 60 mm Luminexx stent was deployed at the area of stenosis. The stent was noted to have migrated upward into the inferior vena cava and a buttressing of this stent with a 16 x 40 mm Wallstent was placed to ensure adequate apposition. Unfortunately, this caused further migration upward into the IVC and a 14 mm Atlas balloon was used to help secure the migrated IVC stent. The area of stenosis was no longer stented given this migration. Therefore, stenting of the left common iliac vein stenosis was ultimately achieved with a 14 x 80 mm Luminexx stent (). The patient was started on warfarin with heparin bridging postoperatively. Early ambulation and the routine use of elastic stockings were encouraged following the procedure. The following day the patient complained of severe abdominal pain and an abdominal x-ray revealed only two stents located in the abdomen (). A chest x-ray was obtained and revealed the initial 14 x 60 mm Luminexx stent projecting over the right atrium (). She underwent open-heart surgery for stent retrieval and had a postoperative course complicated by atrial fibrillation and recurrent left sided lower extremity DVT managed with catheter directed thrombolysis. Hypercoagulable work-up revealed homozygosity of the Factor V Leiden gene mutation. One week after discharge, she developed hypotension and lightheadedness. She presented to the emergency department and was found to have pericardial tamponade requiring blood transfusion, pericardiocentesis, and pericardial window. Anticoagulation treatment was stopped during hospital stay and not resumed upon discharge.\nThree weeks later, she had a syncopal episode secondary to a massive pulmonary embolus (PE). Imaging also revealed residual DVT in bilateral lower extremities. She underwent thrombolysis with tissue plasminogen activator and subsequently developed a thoracic hematoma. Given the residual clot burden in the bilateral lower extremity, she underwent IVC filter placement and mechanical thrombectomy. No additional stents were placed. Throughout the hospitalization the patient required multiple blood products after developing a hematoma related to recent thoracic surgery. The patient was eventually stabilized and given the Factor V Leiden mutation and life-threatening PE, she was started on rivaroxaban indefinitely. Since these events, she has been followed closely as an outpatient with no known hospitalizations related to bleeding or thrombosis. At 5-year follow-up, the patient reports that she is doing well. She is not experiencing any complications related to rivaroxaban. She does have residual postthrombotic syndrome (CEAP class 3, Villalta Score 8) well managed with daily compression stockings. |
A 62-year-old female presented for evaluation of recurrent left lower extremity swelling. Her medical history was notable for prior deep vein thrombus in the right distal lower extremity while on hormone replacement therapy (HRT). She denied the active use of HRT and tobacco use during this admission. Venous Doppler ultrasound completed in the emergency room revealed extensive thrombosis of the left lower extremity extending superiorly towards the left common iliac vein. Further imaging with ultrasound revealed compression of the left iliac vein by the right iliac artery as well as a significantly elevated reflux time of the left great saphenous vein (14.2 seconds) suggestive of MTS. The patient was taken to the operating suite and during the procedure the common iliac vein appeared normal distally, but more proximally the vein was narrowed significantly to a diameter of less than 2 mm. Prior to entering the inferior vena cava, the common iliac vein normalized. Using intravenous ultrasound, measurements were taken and a 14 x 60 mm Luminexx stent was deployed at the area of stenosis. The stent was noted to have migrated upward into the inferior vena cava and a buttressing of this stent with a 16 x 40 mm Wallstent was placed to ensure adequate apposition. Unfortunately, this caused further migration upward into the IVC and a 14 mm Atlas balloon was used to help secure the migrated IVC stent. The area of stenosis was no longer stented given this migration. Therefore, stenting of the left common iliac vein stenosis was ultimately achieved with a 14 x 80 mm Luminexx stent (). The patient was started on warfarin with heparin bridging postoperatively. Early ambulation and the routine use of elastic stockings were encouraged following the procedure. The following day the patient complained of severe abdominal pain and an abdominal x-ray revealed only two stents located in the abdomen (). A chest x-ray was obtained and revealed the initial 14 x 60 mm Luminexx stent projecting over the right atrium (). She underwent open-heart surgery for stent retrieval and had a postoperative course complicated by atrial fibrillation and recurrent left sided lower extremity DVT managed with catheter directed thrombolysis. Hypercoagulable work-up revealed homozygosity of the Factor V Leiden gene mutation. One week after discharge, she developed hypotension and lightheadedness. She presented to the emergency department and was found to have pericardial tamponade requiring blood transfusion, pericardiocentesis, and pericardial window. Anticoagulation treatment was stopped during hospital stay and not resumed upon discharge.\nThree weeks later, she had a syncopal episode secondary to a massive pulmonary embolus (PE). Imaging also revealed residual DVT in bilateral lower extremities. She underwent thrombolysis with tissue plasminogen activator and subsequently developed a thoracic hematoma. Given the residual clot burden in the bilateral lower extremity, she underwent IVC filter placement and mechanical thrombectomy. No additional stents were placed. Throughout the hospitalization the patient required multiple blood products after developing a hematoma related to recent thoracic surgery. The patient was eventually stabilized and given the Factor V Leiden mutation and life-threatening PE, she was started on rivaroxaban indefinitely. Since these events, she has been followed closely as an outpatient with no known hospitalizations related to bleeding or thrombosis. At 5-year follow-up, the patient reports that she is doing well. She is not experiencing any complications related to rivaroxaban. She does have residual postthrombotic syndrome (CEAP class 3, Villalta Score 8) well managed with daily compression stockings. |
A 62-year-old female presented for evaluation of recurrent left lower extremity swelling. Her medical history was notable for prior deep vein thrombus in the right distal lower extremity while on hormone replacement therapy (HRT). She denied the active use of HRT and tobacco use during this admission. Venous Doppler ultrasound completed in the emergency room revealed extensive thrombosis of the left lower extremity extending superiorly towards the left common iliac vein. Further imaging with ultrasound revealed compression of the left iliac vein by the right iliac artery as well as a significantly elevated reflux time of the left great saphenous vein (14.2 seconds) suggestive of MTS. The patient was taken to the operating suite and during the procedure the common iliac vein appeared normal distally, but more proximally the vein was narrowed significantly to a diameter of less than 2 mm. Prior to entering the inferior vena cava, the common iliac vein normalized. Using intravenous ultrasound, measurements were taken and a 14 x 60 mm Luminexx stent was deployed at the area of stenosis. The stent was noted to have migrated upward into the inferior vena cava and a buttressing of this stent with a 16 x 40 mm Wallstent was placed to ensure adequate apposition. Unfortunately, this caused further migration upward into the IVC and a 14 mm Atlas balloon was used to help secure the migrated IVC stent. The area of stenosis was no longer stented given this migration. Therefore, stenting of the left common iliac vein stenosis was ultimately achieved with a 14 x 80 mm Luminexx stent (). The patient was started on warfarin with heparin bridging postoperatively. Early ambulation and the routine use of elastic stockings were encouraged following the procedure. The following day the patient complained of severe abdominal pain and an abdominal x-ray revealed only two stents located in the abdomen (). A chest x-ray was obtained and revealed the initial 14 x 60 mm Luminexx stent projecting over the right atrium (). She underwent open-heart surgery for stent retrieval and had a postoperative course complicated by atrial fibrillation and recurrent left sided lower extremity DVT managed with catheter directed thrombolysis. Hypercoagulable work-up revealed homozygosity of the Factor V Leiden gene mutation. One week after discharge, she developed hypotension and lightheadedness. She presented to the emergency department and was found to have pericardial tamponade requiring blood transfusion, pericardiocentesis, and pericardial window. Anticoagulation treatment was stopped during hospital stay and not resumed upon discharge.\nThree weeks later, she had a syncopal episode secondary to a massive pulmonary embolus (PE). Imaging also revealed residual DVT in bilateral lower extremities. She underwent thrombolysis with tissue plasminogen activator and subsequently developed a thoracic hematoma. Given the residual clot burden in the bilateral lower extremity, she underwent IVC filter placement and mechanical thrombectomy. No additional stents were placed. Throughout the hospitalization the patient required multiple blood products after developing a hematoma related to recent thoracic surgery. The patient was eventually stabilized and given the Factor V Leiden mutation and life-threatening PE, she was started on rivaroxaban indefinitely. Since these events, she has been followed closely as an outpatient with no known hospitalizations related to bleeding or thrombosis. At 5-year follow-up, the patient reports that she is doing well. She is not experiencing any complications related to rivaroxaban. She does have residual postthrombotic syndrome (CEAP class 3, Villalta Score 8) well managed with daily compression stockings. |
A 35-year-old gravida 3, parity 2 woman was admitted to the hospital for vaginal bleeding and severe abdominal pain. Her past medical history was free of any medical problems. On her obstetric history, she had a vaginal delivery following an uneventful pregnancy course 8 years ago. Her second pregnancy was terminated via hysterotomy at 18th weeks due to multiple fetal abnormalities including hydrocephalus. She was diagnosed to have total anterior placenta previa on her third pregnancy. This last pregnancy was otherwise uneventful and the patient gave birth to a term, healthy infant via planned repeat cesarean section in a private hospital. During the operation, partially adherent placenta had been detected and the adherent part of the placenta had been left in situ. Postoperative treatment had not been given. 20 days after the operation, she had been hospitalized due to massive vaginal bleeding and had been transfused four units of packed red blood cells since her blood count revealed severe anemia with a hemoglobin level of 5.6 gr/dL. She had been discharged from hospital three days later. However, one week later, she had presented to another center due to vaginal bleeding and pelvic pain. She had been referred to our hospital with a presumptive diagnosis of placental retention because ultrasonography showed soft tissue density with irregular contour in the endometrial cavity (). On her admission, she had findings consistent with acute abdomen and moderate abdominal distention was detected. Her blood pressure was 90/60 mmHg and heart rate was 110/minute. Hemoglobin was 8.5 gr/dL on complete blood count. Ultrasonography revealed free fluid filling the pelvis and lower abdomen. Her serum human chorionic gonadotropin was negative. After obtaining informed consent including hysterectomy, an emergency laparotomy was performed. Following drainage of approximately 1000 mL of free blood from the abdominal cavity, a full-thickness defect on the anterior wall of the uterus was seen (). The defect involved the hysterotomy incision and both sides of the incision were occupied by irregular placental tissue with no obvious normal myometrium. Blood was oozing from the defect. Posterior bladder wall was also invaded by placenta and mobilization of the bladder off the lower uterine segment could not be achieved. Total abdominal hysterectomy with partial resection of the posterior bladder wall was performed (). The patient was discharged from the hospital on fourth postoperative day with a bladder catheter that was removed one week after the operation. She was asymptomatic on her control visit performed six weeks later. |
A 41-year-old woman presented to our hospital with a 2-year history of palpable mass in the right lateral aspect of the neck. There was no past history of irradiation or trauma in the head and neck. On physical examination, a firm and non-tender mass was palpable in the right lateral neck measuring 3.0 cm at the level of the cricoid cartilage without associated cervical lymphadenopathy. No abnormal laboratory findings were seen in routine laboratory investigations and euthyroid state in thyroid function test.\nNeck ultrasonography revealed a solitary nodule measuring 0.5 cm in the right thyroid gland, and a 3.0 cm mixed solid and cystic mass in the right lateral aspect of the neck at level III (). Computed tomography also showed mixed solid and cystic lesion associated with punctate calcification ().\nExamination of fine needle aspiration cytology (FNA) on thyroid gland confirmed follicular cell proliferative lesion. But, the right lateral neck mass was suggestive of metastatic papillary carcinoma. Therefore, the patient was diagnosed with presumed metastatic papillary thyroid carcinoma (PTC) in the right lateral neck and occult papillary thyroid carcinoma in the right thyroid gland.\nThe patient underwent right lateral neck dissection followed by total thyroidectomy. It must be emphasized that papillary carcinoma arising in a right lateral BCC was not in the differential diagnoses preoperatively. The intraoperative findings included a 3.0 cm dark brown fluid filled cystic mass lateral to the internal jugular vein without cyst rupture at the time of the operation, and revealed PTC on the frozen section biopsy. Therefore, a total thyroidectomy was followed.\nHistopathologic examination of the 3.0 cm cystic mass was confirmed papillary carcinoma in a BCC (). The cyst was partially lined by squamous epithelium surrounded by fibrous tissues associated with chronic inflammation (). But there was no normal thyroid tissue adjacent to the focus of papillary carcinoma within the cyst wall ().\nHistopathologic examination of the thyroid gland revealed nodular hyperplasia of the right lobe without evidence of malignancy. Repeated serial sectioning of the whole thyroid and even in postoperative positron emission tomography does not reveal any foci of carcinoma. Other harvested right lateral lymph nodes were examined but there were no evidence of any other abnormal findings.\nIt is known that immunohistochemical staining through TG, TTF-1 and p63 could help in the differential diagnosis in thyroglossal duct cyst, BCC, and papillary carcinoma in BCC (). In our case, the squamous epithelium was positive for p63 and negative for TG and TTF-1 (). On the other hand, papillary carcinoma in BCC was positive on TG and TTF-1, but negative on p63. This issue for immunohistochemical staining will be explained later on discussion.\nThe patient has remained disease free having been followed up for 28 months. She is being managed with post-operative levothyroxine replacement without radioactive iodine therapy. |
A 56-year-old man who had a 2-month history of shortness of breath was presented to a local clinic with a sudden onset of chest pain. He was transferred to the local hospital and was tested. Physical examination revealed tachycardia and mild tachypnea. Coronary arteriography showed normal coronary arteries. The next day, a chest computed tomography (CT) was performed and heavy burden of pulmonary emboli in bilateral pulmonary arteries and branches were shown (). An abdominal CT revealed a large mass in the right kidney () and a thrombus in the right renal vein extending into an inferior vena cava (IVC) (). Echocardiography showed mild to moderate tricuspid regurgitation with mild pulmonary hypertension. Low molecular weight heparin was initiated and the patient was admitted to Samsung Medical Center. Seven days later, the patient underwent a right radical nephrectomy, a resection of the extended tumor in the abdominal IVC and a pulmonary embolectomy in one session. The right radical nephrectomy was performed via laparotomy first. At the same time, the lower abdominal IVC was exposed to insert venous cannula to run the heart-lung machine. In succeeding, through a median sternotomy, ascending aortic arterial cannulation and triple venous cannulation of superior vena cava, thoracic IVC, and infra-renal IVC were made. On beating heart under cardiopulmonary bypass, resection of the extended tumor in the abdominal IVC was performed (). And then, emboli in the left pulmonary artery and its branches were pulled out with forceps via left pulmonary arteriotomy following vent catheter insertion into right ventricle through proximal main pulmonary artery with distal main pulmonary artery snaring (). The emboli on the other side were removed with same manner via right pulmonary arteriotomy (). After primary repair of both pulmonary arteries, cardiopulmonary bypass was weaned off. Total cardiopulmonary bypass time was 208 minutes. The renal mass was proved to be renal cell carcinoma. Thrombi in abdominal IVC and pulmonary arteries were confirmed as tumor emboli of renal cell carcinoma. Seventeen days after the surgery, the patient was discharged without any complications. In the follow-up chest CT taken one week after operation, most of emboli were removed except tiny remnant in the left lower lobe posterobasal segmental pulmonary artery (). Two months after operation, positron emission tomography-CT () and magnetic resonance imaging () showed single metastatic liver mass, but no pulmonary metastasis. Patient underwent radiofrequency ablation of liver mass. And the mass was completely destroyed. No further treatment was recommended by oncologist other than regular follow-up. |
A 70-year-old male patient was referred to the emergency department with a sudden- onset back pain complaint that lasted for approximately 3 days. His medical history included hypertension. Contrast-enhanced computed tomography (CT) in the arterial phase revealed the aneurysm’s origin, the aortic arch and branches in each of the three planes, and the structure of the aneurysm, its diameter, segment length, and relationship of the aneurysm with the supraaortic structures. CT from another medical center detected an impending aneurysm rupture in the descending aorta with a diameter of 64 mm (). Both carotid arteries originated from a common trunk from the aortic arch, and there was no aneurysmatic dilatation in the aortic arch. Ascending aorta aneurysm, reaching 60 mm in diameter at the largest, was detected. Aortic regurgitation was not detected in transthoracic echocardiography. Aortic arch was not aneurysmatic. The patient was evaluated in cardiovascular surgery and invasive radiology joint council. Due to the character of the back pain, only an emergent surgical intervention to impending aneurysm rupture at descending aorta was decided. Endovascular repair to the descending aortic aneurysm was planned. The occlusion of the left SA orifice was planned after it was considered that there was not enough neck to position the proximal stent graft. The right SA was aberrant, and the orifice of the right aberrant SA was within the aneurysm sac that was going to be occluded. It was decided to bypass both SAs. Since the patient had ascending aortic aneurysm, and this aneurysm had an elective surgery indication, an extra-anatomic bypass was decided instead of median sternotomy. Because of the widespread aneurysm in the patient and the associated risk of atherosclerosis and the condition of the Willis polygon are unknown, it was decided to use ECA for the donor artery if calibration was appropriate to avoid brain ischemia. To avoid arm ischemia, it was decided to perform bypass operations first.\nOne of the operating rooms at the cardiac surgery clinic in our hospital is specifically designed for diagnostic and interventional procedures using radiation. We have a C-armed scopy and carbon surgery table in this room. Hybrid interventions or operations that may require a multidisciplinary hybrid approach are performed in this room. Every day, we have common councils of cardiovascular surgery and interventional radiology departments. Interventional teams are created if necessary. We decided to perform hybrid surgery as an interventional team. The patient underwent emergent surgery by both cardiovascular surgery and interventional radiology clinics simultaneously at the hybrid operating theater. Under general anesthesia, both ECAs were explored and taken under control. Both ECAs were found to have a good calibration. Both SA were explored via infraclavicular approach and taken under control. The right ECA–right SA bypass procedure was performed with a 6-mm-ring PTFE graft (over the clavicle) by tunneling under the skin. The left ECA–left SA bypass procedure was performed with an 8-mm-ring PTFE (over the clavicle) graft by tunneling under the skin. The right common femoral artery was explored and taken under control. A 7F sheath was placed. The TEVAR procedure was performed to the descending aortic aneurysm with a Medtronic Valiant stent graft (46x46x150 mm). The aortic Zone 2 was selected as the proximal landing zone of the stent graft. Due to the position of the aberrant right RA in the descending aortic aneurysm, the right SA was occluded proximally to the anastomosis to avoid a Type 2 endoleak. No intervention was performed to the right vertebral artery. After the procedure, control angiography showed no sign of endoleak, and anastomosis with the PTFE grafts was found to be open ().\nThe patient was transferred to the intensive care unit with respiratory support. Postoperative pulses of both the radial and ulnar arteries were palpable. There was no major or minor neurological complication. Routine follow-ups were stable. We decided to perform surgery for the ascending aortic aneurysm in a further session. The patient was discharged without any problems on the postoperative 7th day. CT angiography was performed on the postoperative 30th day. There was not any evidence of endoleak in control CT angiography (, ). |
A 36-year-old man, originally from Latin America, presented at our outpatient department with complaints of abdominal pain that had persisted for 2 months. The patient had first noticed right lateral abdominal pain 2 months prior to the visit, and the pain was gradually worsening. The abdominal pain was localized in an area ranging from the right upper to the right lateral abdomen. The patient had undergone cholecystectomy for acute cholecystitis as a 32-year-old in Latin America and had moved to Japan for work approximately 3 years prior to his initial visit to our hospital. He had returned to Latin America once about 6 to 7 months before presenting at our clinic. When he went back to Japan, his weight had increased from 130 kg to 145 kg. He did not experience abdominal pain immediately after his return to Japan, but, as noted above, he started to gradually feel pain in the right lateral region about 2 months prior to presentation.\nHe first visited another hospital emergency department 1 month after onset of the pain. Initially, gastrointestinal tract spasm was suspected, and he was treated with tiquizium bromide. Though the medication partially relieved his abdominal pain, most of the pain persisted. The result of a workup by a urologist was negative, even though nephrolithiasis was suspected. His abdominal pain was exacerbated upon changing posture, and thus it was suspected to be of somatic rather than visceral origin. Abdominal pain persisted despite treatment with loxoprofen sodium hydrate, and any cause of abdominal pain was not detected on further evaluations, including hematologic laboratory analysis, urine analysis, gastroscopy, or abdominal computed tomography (CT). Finally, he was referred to our hospital for further examination.\nThe results of screening for depression were negative, and the patient did not have symptoms such as loss of interest, depressed feelings, or any specific changes of surrounding conditions, such as family or work environment changes. He had no history of sexually transmitted infection, and his vital signs were within normal limits. His physical examination result was positive for Carnett’s test, and a prior surgical scar of approximately 18 cm was apparent at the right subcostal region. The patient experienced strong pain surrounding the surgical scar that was exacerbated by tapping. There were no skin rashes localized surrounding the pain. His pain exacerbated to 8 on a pain scale when he moved, such as during standing up or rolling over simultaneously. When he stopped moving, pain was partially relieved within 1 minute (3 on a pain scale). When he moved again, abdominal pain was again exacerbated. Hence, he was awakened by the abdominal pain when rolling over. No inflammation was detected (leukocyte count was 8580/mm3 and C-reactive protein was 0.10 mg/dl), and other laboratory findings were nonspecific, including liver/kidney function, blood glucose, and electrolytes. Urinary analysis indicated red blood cell count < 1/high-power field, white blood cell count 1–4/high-power field. Additionally, no abnormality was detected for Chlamydia trachomatis IgG/IgA, and no abnormality was apparent on the electrocardiogram. Enhanced CT revealed bilateral renal stones and fatty liver.\nWe first considered abdominal wall pain due to nerve entrapment because the Carnett’s test result was positive; therefore, we scheduled a trigger point injection at the site of tenderness. About 2 weeks later, the patient visited the emergency department of our hospital, reporting that his prior abdominal pain had decreased but that he was experiencing right inguinal pain. Loxoprofen administration had no effect on the pain. Costovertebral angle pain was apparent on tapping, the result of urine analysis was positive for occult blood, and abdominal CT revealed a urinary stone at the right urinary duct to the bladder. After pentazocine hydrochloride was administered for pain relief, the urinary stone was passed the following day. However, the patient’s right lateral abdominal pain was not relieved.\nHe felt that lying in the lateral position mostly relieved his pain. He had occasional vomiting. The abdominal pain was exacerbated by movements, such as rolling over, standing up, walking, and coughing. Injection of 1% xylocaine 10 ml at a trigger point of the right lateral region led to about 30% relief in pain. The patient was referred to an anesthesiologist for further evaluation and treatment, who performed transverse abdominal plane block and administered multiple analgesic medications (tramadol hydrochloride, pregabalin, celecoxib, and scopolamine butylbromide). These medications decreased the patient’s pain somewhat, and he reported that scopolamine butylbromide was most effective when the pain worsened. Because the patient’s symptoms were not relieved after trigger point treatment to the abdominal wall, we considered potential causes that might be associated with the location between the abdominal wall and visceral wall or related to other sources, including psychosocial, physiological, and other anatomical factors. We rechecked the abdominal CT scan for a suspected adhesion or abdominal hernia at the region of tenderness due to the prior surgical procedure, and we asked a radiologist to reevaluate the right upper abdomen in more detail. The radiologist confirmed a slight abnormality in the right upper abdomen and suggested the possibility of an adhesion around the surgical scar (Fig. ). We referred the patient to a gastrointestinal surgeon for laparoscopic evaluation and adhesiolysis. The patient underwent additional investigations, including cholecystocholangiography and colonoscopy for suspected postcholecystectomy syndrome, biliary dyskinesia, or colon abnormality. However, no cause of the abdominal pain was identified. On laparoscopic evaluation, a broad adhesion was observed. Adhesiolysis was performed 6 months after the patient first visited our hospital. Figure a shows adhesion between the peritoneum and omentum, liver, and ascending colon; Fig. b shows the condition after adhesiolysis. One month after adhesiolysis, the patient’s right abdomen pain level during movement improved from 8 to 2–3 on a pain scale. Therefore, he was able to move with less pain, and he did not feel pain when rolling over. The result of Carnett’s test was negative. After the patient started walking around his house, he felt abdominal pain about 5 minutes after walking. Hence, he was afraid of recurrence of abdominal pain and felt a little depressed and frustrated because he was unable to return to work early. We recommended a gradual increase in activity. He went on a trip 4 months after the operation without problems due to abdominal pain and then resumed his job 6 months after the operation.\nHowever, his abdominal pain deteriorated within 1 month after he resumed working. He presented with bleeding at the umbilicus, which was the laparoscopic port site, and abdominal incisional hernia was confirmed on the basis of CT. Repair of the abdominal incisional hernias and laparoscopic adhesiolysis were performed 8 months after the first operation. After the second operation, although it took time for some symptoms to improve because of surgical site infection, the patient’s symptoms were ultimately relieved, and he resumed his job again 5 months after undergoing the second operation. Although he reported mild abdominal pain and required analgesic medication, his weight decreased to 133 kg, and he was able to walk normally and work full-time, 2 years after he initially visited our hospital. The timeline of interventions and outcomes is shown in Additional file . |
A 26-year old woman presented with traumatic complete T5 paralysis for 2 years after suffering a T5 burst fracture caused by falling from a tree while hunting. T5 posterior fusion and decompression was performed to stabilize her, but the injury was complete with no return of function after 2 years. A baclofen pump was inserted into the L3 level for spasticity after few months of the injury. The severity of the injury was classified as grade A using the American Spinal Injury Association (ASIA) grading, which is defined as complete loss of motor and sensory functions below the level of the injury ().\nThe stimulator that was used in this study is approved by FDA for chronic pain treatment (). After obtaining informed consent from the patient, a total of 8 leads with 8 electrodes each were implanted at L2, L3, L4, and S1 bilaterally. Four leads for a total of 16 electrodes on each nerve root with two leads each were implanted at L5 bilaterally. The procedure was performed under general anesthetic with a small laminotomy at T12 to facilitate retrograde advancement and insertion of percutaneous leads to each level (). The procedure was done and guided under fluoroscopy and the total surgical time was ~120 min. A total of 2 batteries, with four ports each, were utilized connecting in the following configuration: 8 electrodes to D port for S1, 16 electrodes with a splitter to C port, 8 electrodes from L4 and 8 electrodes to L3 with a splitter to B port, and 8 electrodes to A port from L2. This allowed activating every other contact on each lead that is plugged in the splitter. Electrodes were then anchored into the interspinous ligament and tunneled to two separate gluteal pockets on either side. All electrodes from the left were sent to the left battery and right electrodes to the right battery. This procedure allowed for a total of 64 contact points, 32 per battery, on 12 leads with implantation of 96 electrodes that covered L2 to S1 bilaterally. Each lead hugged the posterolateral gutter of the spinal canal before exiting along with the nerve root out the respective foramen ().\nAfter recovery, the patient was sent home the same day, and allowed 1 week for healing. She was then brought to an outpatient setting. The device was programmed to send electrical signals through selected implanted electrodes. Those programs were numbered and linked to the movement of different muscle groups which can be controlled by the patient using a remote control. On the first day of using electrical stimulation, the stimulator was shown to raise her leg with full leg bending and extension movements (). Increases in muscle strength with stimuli were measured and results are shown in . Patient was also able to stand with stimuli and a weight-bearing device (Rifton Tram Lift) for a maximum of 54 s before fatigue in 60-min sessions with 8 trials. |
An 11-year-old boy visited our outpatient clinic with complaints of persistent right cheek pain. His family history revealed that his father had severe hearing impairment. His medical history showed that he had allergic rhinitis and chronic sinusitis that had been treated until 3 months previously by an otolaryngologist.\nThe patient initially visited our outpatient clinic with complaints of high fever, sore throat, and comorbid right cheek pain and mild swelling 6 weeks previously. A checkup at a dental clinic performed on the day before this initial visit revealed no abnormal findings. He showed clinical symptoms of streptococcal pharyngitis. A rapid antigen test for group A streptococcal infection showed positive results. The patient was diagnosed with streptococcal infection. Facial cellulitis was also suspected and treatment with amoxicillin helped improve symptoms. However, facial pain recurred within 4 weeks of the initial visit. The patient had mild tenderness and swelling of the right cheek. Head computed tomography revealed mild mucous membrane swelling and effusion in both sinuses ( left). Because recurrence of cellulitis with sinusitis was suspected, cefditoren pivoxil treatment was initiated. However, because the pain persisted, he visited our department.\nPhysical examination revealed no abnormal findings except right cheek tenderness in the area that corresponded with the region supplied by the second branch of the trigeminal nerve (the maximally nerve). Although marked tenderness was evident, no point with hyperalgesia, where a light touch elicited severe pain, was observed. No facial paralysis or oral disorders were observed. Blood examination revealed no abnormal findings. Recurrence of sinusitis was suspected. Based on the physical examination and laboratory tests, the patient was clinically diagnosed with TN. Subsequently, oral clarithromycin administration was initiated for sinusitis that might have caused or exacerbated TN. However, administration of clarithromycin for 1 week was not effective for his facial pain. Brain magnetic resonance imaging (MRI) revealed no neurovascular compression ( right), which ruled out idiopathic, classical TN. During this time, we interviewed the patient on the nature of the right cheek pain. The patient described the pain as persistent, nagging, and dull in nature, which was completely different from the characteristics of pain associated with TN. Furthermore, trigger maneuvers failed to evoke pain. These evaluations excluded TN, and, thus, PIFP was diagnosed in week 2. Low dose of oral anticonvulsant carbamazepine (50 mg, twice a day) was initiated but was ceased due to general fatigue after the first administration.\nAlthough the patient had been previously cheerful and greeted us when entering the examination room, he became gradually emotionless with headache and nausea in week 5. In addition, feeding difficulties and numbness in the arms occurred. An orthostatic tolerance test revealed no positive findings for orthostatic dysregulation. It became difficult for the patient to attend school in week 6. Because various somatic symptoms developed in addition to PIFP, psychological factors were suspected to be pertinent in the etiology of PIFP. During a detailed medical interview with the patient and his mother, several problems were revealed: the patient loved swimming but his swimming record had plateaued after fixing his swimming form even though he practiced vigorously at a top-class swimming club team. Moreover, because of a recent finger injury, he could not practice as intensely as he wanted; therefore, his competitive ability as a swimmer deteriorated. Furthermore, in early adolescence, the patient had difficulties in communication and his relationship with his father was strained due to the father's hearing impairment. Because these suggested that the circumstances surrounding him might have led to somatoform disorders, psychological counseling was ordered in week 6.\nAs the patient faced, understood, and tolerated his psychological stress through counseling and psychotherapy twice a week, he gradually became expressive, worked up his appetite, and could attend school in week 10. Although sinusitis recurred at week 29, no facial pain developed. The patient received psychological counseling twice or thrice a month by this time. After 8 months, the frequency of counseling was reduced to once in 2 months. During this period, the patient's voice changed and became deeper at puberty. After confirming that facial pain as well as general malaise did not occur, even when the patient experienced distressing events, such as terminal examinations, counseling was ceased after 1 year and 8 months. After 3 years, the patient went on to high school and currently attends school cheerfully without any complaints and has resumed swimming. |
A 9-year-old boy had presented with frequent pneumonia. He was born vaginally at 25 weeks and 6 days at home due to an unknown reason. His birth weight was 750 g. He was in cardiopulmonary arrest when he arrived at the previous hospital. Resuscitation was performed immediately on arrival. Peritoneal drainage was performed because gastric perforation was found soon after resuscitation. Thereafter, a diagnosis of TEF was made, and gastrostomy was created in the previous hospital. He was transferred to our institution at 28 days of age. He was diagnosed as having an EA with a distal TEF (Gross C), and the primary repair of the EA with fistula division was performed at our hospital when he was 5 months of age. The postoperative course was uneventful, and gastrostomy was closed at 10 months of age. He discharged at 2 year of age. After his discharge, severe epilepsy and encephalopathy due to encephalitis occurred, and he became disabled with severe mental retardation at the age of 2. He could not feed orally. At the age of 3, he underwent Nissen fundoplication and re-gastrostomy because of gastroesophageal reflux and hiatus hernia. At the time of the operation, subglottic stenosis was suspected because he could only be intubated with a tracheal tube of 2.5 mm in diameter.\nSix months after fundoplication, a recurrence of hiatus hernia was found, which involved the herniation of the stomach and small and large intestine into the thoracic cavity. A reoperation to repair the herniation was not performed because the patient had been in stable condition. However, he had been suffering from recurrent respiratory tract infections since he was 7 years of age. In addition, severe bronchial asthma worsened his respiratory symptoms. At 9 years of age, he was referred to our hospital again because of frequent pneumonia.\nA CT scan revealed the herniation of the large and small intestine into the thoracic cavity; we were therefore of the opinion that they should be pulled down into the abdominal cavity in order to resolve the patient’s respiratory problems (Fig. ). We thought that we should perform tracheotomy or laryngotracheal separation before repairing the recurrent hiatus hernia because the patient presented with severe dysphagia as well as severe hiatus hernia. An upper gastrointestinal series and endoscopy were performed to evaluate the esophagus and stomach, revealing the presence of residual gastroesophageal reflux and an elevated esophagus due to the recurrent hiatus hernia.\nAt 10 years of age, tracheotomy was performed. However, the patient’s respiratory status did not improve; thus, we performed laryngotracheal separation 6 weeks later. Three weeks after the laryngotracheal separation, a small volume of nutritional supplement, which had been administered via gastrostomy, was aspirated from the tracheotomy. We therefore suspected the recurrence of TEF. Under general anesthesia, both esophagography and endoscopy were performed again. The anastomotic line of the esophagus was located in the cervical area, 15 cm from the incisors. A pit was identified just beside the anastomotic line (Fig. ). Indigo carmine injected from the catheter placed in the pit revealed that the recurrent fistula was located in the trachea (Fig. ). In addition, the anastomosis line of EA was thought to have been elevated to the cervical area due to the recurrence of the hiatus hernia.\nThus, the repair of the recurrent TEF was performed through the right cervical approach. It was impossible to place a catheter or guide wire through the TEF. After the separation of the esophagus and trachea, the small hole of the fistula was found and closed (Fig. ). At the site of the fistula, the esophagus and trachea had a “common wall” due to severe adhesion around the fistula. A sternothyroid muscle flap was interposed between the closure sites (Fig. ). After the operation, the respiratory symptoms of the patient improved dramatically. Three months after the repair of the recurrent TEF, the recurrent hiatus hernia was surgically treated. The postoperative course was also uneventful. The patient remains well at 2 years after the surgical repair of the recurrent TEF. There is no evidence of the further recurrence of TEF or hiatus hernia.\nWe experienced a relatively rare case of recurrent TEF that was found 10 years after the initial repair. We herein discuss the reason why the recurrent TEF had not been identified and the surgical technique that we used to repair the patient’s recurrent TEF.\nThe patient had subglottic stenosis, which made it difficult to observe the trachea. In addition to the subglottic stenosis, both bronchial asthma and recurrent hiatus hernia were thought to have caused the patient’s respiratory symptoms due to frequent pneumonia. These factors may have caused the patient’s recurrent TEF to remain unidentified. Recurrence was first suspected when a small volume of nutritional supplement that had been administered via gastrostomy was aspirated from the tracheostomy tube after the laryngotracheal separation. In general, although many cases of recurrent TEF are diagnosed by a contrast study, some require further examination by endoscopy with or without a dye test [, , , ]. In the present case, bronchoscopy (which is safer and precise) was not possible prior to tracheostomy due to the patient’s subglottic stenosis. As shown in Fig. , esophagoscopy and bronchoscopy combined with a dye test enabled us to diagnose the recurrent TEF.\nIn general, almost all patients with recurrent TEF have episodes of leakage and/or tracheal injuries [–, ]. The recurrent fistula usually opens in the trachea at the site of the original fistula site or tracheal injury [–]. In this case, there was no leakage or tracheal injury at the site of the primary repair. In contrast with other cases, the site of recurrence was found to be high in the cervical area. Thus, we suspected that the patient had both proximal and distal tracheoesophageal fistula (gross type D), and the upper pouch fistula was missed in the primary operation [, ]. However, as shown in Fig. , a pit was identified just beside the anastomotic line. The anastomotic line in the esophagus had shifted to the cervical area because of the recurrent hiatus hernia. We therefore judged that the original fistula (proximal tracheoesophageal fistula of gross type D) in the upper pouch was not found at this time. We also suspected that the trachea had been injured during laryngotracheal separation. However, during the repair of the recurrent TEF, the fistula was found to be located in an area that had not been touched during the laryngotracheal separation. Based on the above-noted findings, we diagnosed the patient with recurrent TEF.\nIn the present case, the TEF might have recurred at the age of 9, when the patient started suffering from frequent and severe pneumonia. The recurrent hiatus hernia caused GER and the poor clearance of refluxed gastric juice in the esophagus. Prolonged acid contact causing inflammation and erosion around the anastomotic site is thought to have been important in the pathogenesis of TEF in the present case.\nThere are several options for repairing recurrent TEF. Endoscopic techniques using adhesives have been presented [–]. This method is reported to be effective when the fistula tract is first de-epithelialized using several types of devices and then fibrin glue or a similar agent is injected into the tract of the fistula [, –]. However, it is thought that this technique would have been difficult in the present case because the tract was not detected clearly and because it was not possible to place a catheter under endoscopy. We therefore opted for open surgical closure. The placement of viable tissue between the suture lines may help to prevent the further recurrence of TEF [, , , ]. Previous studies have described the use of the pericardium, pleura, intercostal flap, cervical muscle flap, cartilage, and lymph nodes for this purpose [, , , ]. The flap can be harvested from the same surgical site with its own blood supply. In the present case, a sternothyroid muscle flap was chosen because the recurrent fistula was in the cervical area. In fact, in the present case, the muscle flap was easily and safely interposed between the divided ends of the fistula with a good blood supply. Based on our experience, the interposition of a muscle flap using the sternothyroid muscle is thought to be a good option for reoperation to repair a recurrent TEF in the cervical area. |
A 47-year-old woman presented with a complaint of generalized right knee pain. Physical examination of the right knee joint revealed nothing remarkable. The patient had a history of chronic alcohol consumption exceeding 400 mL of ethanol per week for the past 20 years. There was no history of steroid intake or trauma. One year before presentation, she had undergone a bipolar hip replacement for avascular necrosis of the left hip. She referred to our hospital due to the right knee pain. Radiographs revealed no destruction of the articular surfaces of the right knee, but increased radiodensity was evident in the proximal half of the tibia extending from the joint line (). MRI demonstrated large demarcated regions of abnormal signal intensity in the proximal half of the tibia and medial femoral condyle, with features of osteonecrosis (). A bone scintigram showed the abnormal uptake in the right hip, and the right and the left knee joints (Figures , , and ). A full blood screen including autoantibodies, a clotting profile, ALP, and AMY gave normal results (). Human immunodeficiency virus (HIV) and hepatitis B and C viruses and antibodies were negative. The patient complained that she had often felt mild pain in her right hip and left knee joint after a short walk. Physical examination of the right hip and left knee revealed no abnormality. However, radiographs demonstrated increased radiolucency in both, and MRI revealed demarcated regions of abnormal signal intensity in the central portion of the right femoral head with typical features of osteonecrosis (). Left knee MRI showed multiple demarcated bone marrow abnormalities with double-line sign in the distal shaft of the left femur, compatible with bone necrosis ().\nThe patient was instructed to maintain only partial weight-bearing with wheelchair mobilization for eight weeks and then to return gradually to full weight-bearing over the next two months. Eleven months after the initial presentation, she complained of mild pain in her right hip. Plain radiograph revealed the collapse of her right femoral head. A bipolar hip arthroplasty was performed on the right side. A biopsy of the femoral head confirmed the diagnosis of osteonecrosis of the femoral head. Thereafter, no symptoms were evident in both knee joints. Abstinence from alcohol was also achieved successfully. |
A 20-year-old man farmer whose family lived in a rural area healthy, nonsmokers no history of any drug taken without any congenital anomalies were admitted to our hospital with sudden-onset pain, absent pulses, paresthesia, and the pallor of the right lower extremity that had begun two hours before admission while he was working on the farm. The pain had been increasing and a change in color of the affected right lower limb also was associated with severe headache tachycardia and irritability. An urgent Doppler ultrasound is done for lower abdomen and right lower limb which show the right common iliac artery with hypoechoic acute thrombus inside with near-complete obliteration of flow, then the patient sent for echocardiogram study show left ventricular collapse with pericardial cystic mass with thrombus inside the cyst. Chest X-ray did show the shadow of cardiac hydatid cyst as shown in then suspicious of rupture cardiac hydatid confirmed by sending the patient for computerized (CT) scan of the chest with show complicated solitary cystic mass of the LV mostly hydatid cyst as shown in The patient was referred to a tertiary center to complete his management, the patient presented in a state of hemodynamic instability, central nervous system irritability, chest pain, anuria, and elevated renal indices. The patient needed urgent surgical intervention, we take the consent and inform the relative of the patient about risk and urgency. Firstly embolectomy was done as an emergency, embolus (Fragments of the rupture infected cyst) retrieved from the right common iliac artery as shown in then open fasciotomy post embolectomy done because of a sign of compartment in legs happen as shown in a and b then the patient sent for open-heart surgery for removal of the ruptured cardiac hydatid cyst which was occupying the left ventricular apex (about the size of a tennis ball) and before of opening wall of LV injection of hypertonic saline 30%, which safe, to minimize or prevent hydatid fluid and scolices to systemic dissemination, after cystic wall opening, removal of cyst wall found connecting the true Left ventricle (LV) cavity to the ruptured cyst as shown in a, b, c, and d. Double layer closure of the left ventricular wall as shown in a and b. Smooth weaning from bypass patient sedated for 3 days in the intensive care unit, full neurologic and renal recovery, and fairly preserved LV function 7 days postoperatively. CT scanned of brain, chest, and abdomen was performed for possible dissemination of other parts of the body. There was no evidence of any another cyst so its primary LV hydatid cyst. Keep the patient on albendazole 400mg twice a day for about 6 months, continues to follow up, 11 months later the patient presented with agitation and drowsiness, so a brain CT scan did show multiples small and large brain hydrated as shown in Patient start another course of albendazole 400mg twice a day for one week which then surgery is done for larger cysts, while small cysts continue on the same regime of albendazole 400mg twice daily for 3 months every 28 days albendazole regime we wait 7 days then start another regime, patient continue albendazole treatments and follow up of the small hydatid cyst as shown in CT scan of bran 10 months post cerebral hydatid surgery The condition of the patient well, continue monitoring, most of the small cyst regress but still keep the patient on regular monitoring for watch further complication and deals accordingly. |
A 77-year-old female presented to the orthopedic hand clinic with a three-year history of an extremely sensitive small mass on her right wrist. The mass had subjectively grown over this period of time. The pain had progressively worsened over time, and she had developed significant hypersensitivity to light contact. There was no complaint of cold sensitivity to the mass. The pain occasionally radiated down the ulnar aspect of her wrist. She had no known history of previous trauma to this area; however, she did have a history of squamous cell carcinoma to the dorsal-radial aspect of that hand. This had been treated previously for which she subsequently developed a reflex sympathetic dystrophy (RSD), resulting in a delayed recovery in the range of motion. A previous stellate ganglion block did not provide relief for her RSD, and her range of motion had been slowly progressing with home exercises.\nOn physical exam, a small round nodule approximately 5 mm x 5 mm was palpable dorsal to the extensor carpi ulnaris and 1 cm proximal to the ulnar styloid. There was significant point tenderness that did not radiate or display a Tinel’s sign. Her imaging included plain films of the affected extremity that showed no abnormality outside of diffuse osteopenia.\nThe location and exam were consistent with a neuroma that had evolved from a cutaneous nerve or possibly from the dorsal sensory branch of the ulnar nerve. The patient was taken to the operative theatre and deep dissection revealed a maroon-colored mass approximately 5 mm x 5 mm, connected to a cutaneous nerve branch. The nerve and mass were excised and sent for histopathological review. The ulnar nerve and dorsal sensory branch were visualized and confirmed to have no involvement with the mass. At her first postoperative visit, she reported no pain and that she was very satisfied with the results of her surgery. Diagnostic pathological stains were consistent with a glomus tumor. This was confirmed with strong reactivity to immunostaining of type IV collagen and smooth muscle actin (Figures , ). |
This case presents a 38-year-old Asian G2P1001 female who delivered by cesarean section (CS) at 32 weeks gestation for pre-eclampsia with severe features with uncontrollable blood pressures. Her pregnancy was further complicated by a known right ovarian mass, history of endometriosis which was managed conservatively, as well as infertility. Both first and second pregnancies were conceived via in vitro fertilization by frozen embryo transfer. Her first pregnancy was otherwise uncomplicated, however resulted in primary CS for nonreassuring fetal heart tracing. No pelvic pathology was noted during that CS. The patient was first diagnosed with a right ovarian mass during her second pregnancy while on IVF treatment. The patient declined the option of removing the mass due to possibility of damaging the nearby ovarian tissue during removal of the mass and thus worsening her infertility. The IVF treatment was successful. The transvaginal ultrasonography performed during the early pregnancy suspected the right ovarian mass as endometrioma or desmoid tumor ().\nThe mass was kept under surveillance by performing periodic ultrasound imaging. Due to the change in mass characteristics and increase in size, the patient was referred to a Gynecologic Oncologist during second trimester. Considering the high risk pregnancy, recommendation was made to follow the mass with sequential ultrasound with the removal of the mass at the time of repeat CS as long as the mass did not change in size or configuration during the pregnancy and patient remained asymptomatic. Unfortunately, the patient developed pre-eclampsia with severe features at 32 weeks of gestation. Upon admission, she was given magnesium sulfate infusion for seizure prophylaxis and corticosteroids for fetal lung maturity. The Maternal-Fetal-Medicine specialists recommended delivery at thirty-four weeks of gestation unless there were new signs of maternal or fetal instability. However, three days after the admission, she underwent an emergency cesarean section due to recurrent severe blood pressure changes which were unresponsive to intravenous antihypertensive medications.\nDuring cesarean section, extensive adhesions were noted at the level of adipose tissue, rectus muscle, and anterior surface of the uterus, which were densely adhered to each other and to the anterior abdominal wall. With limited visualization of the lower uterine segment, a classical vertical uterine incision was performed. The fetus was delivered without difficulty. The uterus was exteriorized and closed in layers. At this point, the right ovarian mass was visualized, the surface of which was friable and hemorrhagic. Two units of each packed red blood cells, fresh frozen plasma, and cryoprecipitate were administered. Antibiotics were re-dosed due to prolonged surgical time. With extensive lysis of adhesions and uterine packing, the surgeons successfully ligated the uterine pedicle and the infundibulopelvic ligament to remove the large ovarian mass.\nThe pathological examination of the resected specimen revealed an ovarian mass with attached intact fallopian tube, weighing 63 g and measuring 14.0 × 10.5 × 3.0 cm ().\nThe external surface of ovarian mass was smooth, hemorrhagic but without any excrescences. The serial sectioning revealed multiple cystic lesions filled with clear to yellow fluid as well as necrotic material overall occupying 80% of the ovarian mass. Microscopically, the viable ovarian tissue demonstrated tubulocystic and papillary architecture along with focal areas of solid sheets of tumor cells displaying the clear cytoplasm. Multiple areas of hyperchromatic nuclei with conspicuous nuclei (hobnail cells) were evident (). The immunohistochemistry for Wilm's tumor-1 (WT-1) and wild type p53 were negative while positive for Pax-8 (Figures –). The findings were indicative of high grade ovarian clear cell carcinoma without expression of wild type or mutant p53. |
A 65-year-old man with no medical history was transferred from another hospital because of pain in the right side of chin and ear. He complained of frequent paroxysms of severe stabbing pain in the right side of his mandible radiating to the right ear. His pain either occurred spontaneously or was triggered by chewing and tooth brushing and lasted few seconds in each pain attack. He had experienced the pain since 5 months ago. The patient was diagnosed as TN at another hospital and was prescribed carbamazepine (200 mg a day) with only partial relief of the pain. He had a pain-free period for about 1 month before visiting our clinic and stopped medication on his own decision. In the last few days prior to the admission, his condition had got worse in terms of increase of frequency and severity of pain. He visited our clinic because of intractable pain even with medications.\nThe routine laboratory tests and electrocardiogram were normal. Neurological and nasopharyngeal assessments were normal findings. Computed tomography of the neck and magnetic resonance imaging (MRI) of the brain revealed also normal. His symptoms were fulfilled in the diagnostic criteria of TN [].\nHis pain paroxysms had occurred four or five times daily with 100 of visual analogue scale (VAS, 0 is no pain and 100 is imaginary the worst pain) at the first visit. The duration of pain attacks was measured in a few seconds. He underwent mandibular nerve block with alcohol after the test block with 1% of mepivacaine. He still complained of right ear pain even though right V3 innervated area was anesthetized and pain free after the V3 alcohol block. Ten minutes after the procedure, paroxysmal pain in right ear developed and he experienced faintness and got loss of consciousness with convulsive movement for about 1 minute. He was consulted with a neurologist to exclude seizure disorders. Electroencephalogram showed no abnormalities. Brain MRI was not able to be performed due to convulsive movement during the pain attack.\nHe was consulted to a cardiologist. His echocardiogram was normal, however, bradycardia followed by asystole during pain attacks was revealed in the continuous electrocardiography. The duration of bradycardia and asystole was in proportion to duration of pain attack. According to a careful asking about the pain characters following the V3 block with alcohol, he presented that his pain occurred in the soft palate, uvula and throat and was triggered by swallowing or mechanical stimulation of the right side of the pharynx. Bradycardia and asystole accompanied with sometimes seizure-like activity occurred always with pain attack. Based on his altered pain characters and cardiac symptoms with no specific etiology originated from heart, he was diagnosed of GPN associated with asystole.\nCarbamazepine (100 mg twice a day) was started for control of pain as well as asystole. Regardless of increasing dose of carbamazepine up to 400 mg a day, severe bradycarida, asystole and syncope preceded by paroxysmal pain continued four to five times in one hour. A temporary cardiac pacemaker was implanted via left subclavian vein by a cardiologist to prevent cerebral ischemia during asystole. Although syncope and seizure-like activity disappeared after the insertion of a temporary pacemaker, intensity or frequency of pain in the throat and ear was unchanged. Carbamazepine increased up to 600 mg a day to reach pain control for 4 days after the implantation of temporary cardiac pacemaker. On the 5 day of hospitalization, he underwent implantation of a permanent pacemaker to prevent bradycardia and asystole by a cardiologist. He was achieved pain free and no cardiac symptoms after the implantation of permanent pacemaker with daily 600 mg of carbamazepine and has maintained symptom free condition for 4 months of follow-up. |
A 77-year-old female presented to the orthopedic hand clinic with a three-year history of an extremely sensitive small mass on her right wrist. The mass had subjectively grown over this period of time. The pain had progressively worsened over time, and she had developed significant hypersensitivity to light contact. There was no complaint of cold sensitivity to the mass. The pain occasionally radiated down the ulnar aspect of her wrist. She had no known history of previous trauma to this area; however, she did have a history of squamous cell carcinoma to the dorsal-radial aspect of that hand. This had been treated previously for which she subsequently developed a reflex sympathetic dystrophy (RSD), resulting in a delayed recovery in the range of motion. A previous stellate ganglion block did not provide relief for her RSD, and her range of motion had been slowly progressing with home exercises.\nOn physical exam, a small round nodule approximately 5 mm x 5 mm was palpable dorsal to the extensor carpi ulnaris and 1 cm proximal to the ulnar styloid. There was significant point tenderness that did not radiate or display a Tinel’s sign. Her imaging included plain films of the affected extremity that showed no abnormality outside of diffuse osteopenia.\nThe location and exam were consistent with a neuroma that had evolved from a cutaneous nerve or possibly from the dorsal sensory branch of the ulnar nerve. The patient was taken to the operative theatre and deep dissection revealed a maroon-colored mass approximately 5 mm x 5 mm, connected to a cutaneous nerve branch. The nerve and mass were excised and sent for histopathological review. The ulnar nerve and dorsal sensory branch were visualized and confirmed to have no involvement with the mass. At her first postoperative visit, she reported no pain and that she was very satisfied with the results of her surgery. Diagnostic pathological stains were consistent with a glomus tumor. This was confirmed with strong reactivity to immunostaining of type IV collagen and smooth muscle actin (Figures , ). |
A 21-year-old female who presented to our outpatient clinic with complaints of pain and swelling in her left knee for 8 months before her first visit, with a sudden increase in size for later 2 months. On examination of her limb, there was gross wasting of quadriceps muscle with diffuse swelling over the lateral aspect of the distal thigh measuring approximately 12 cm long and 5 cm across. The local temperature was raised with tenderness on deep palpation restricting terminal knee flexion. On anteroposterior and lateral Roentgenogram, there was an eccentric lytic and sclerotic lesion in the left distal end femur with a narrow zone of transition without evidence of joint involvement, with some areas of soft-tissue calcification and minimal periosteal reaction. Core biopsy done reported to have cellular tissues with multinucleated osteoclast-like giant cells admixed with mononuclear cells, round to oval to spindle-shaped without significant cellular atypia and histological diagnosis of GCT was made.\nThe patient was lost to follow up, presented 3 months later with an enlarged mass measuring 15 cm x 12 cm with ulceration over the lateral aspect of the knee (). New AP and the lateral radiograph showed a large destructive lesion in the distal femur with chondroid matrix, broad zone of transition with break-in cortex, and destruction of joint margin, fresh magnetic resonance images showed a heterogeneous mass of the left distal femur with the erosion of joint margin extending about 15 cm from the joint line without involvement of femoral or popliteal vessels and nerves. CT scan of the chest was found to be normal. A final diagnosis of fungating non-metastatic giant cell tumor of the left distal femur, Campanacci Grade III with the left knee joint involvement was made.\nManagement options were explored, preferably to excise the tumor and reconstruct the limb to provide the functional ability, and the decision of wide excision with endoprosthesis application was made. Intraoperatively, careful dissection was done protecting the neurovascular bundle and the tumor was removed preventing any soft-tissue spillage. After confirmation of the safe margin through the frozen section examination, distal femoral endoprosthesis was cemented (). The post-operative specimen had features of GCT without atypia with safe bony and soft-tissue margins. The patient was put on protected weight-bearing initially, slowly progressing to full weight-bearing along with knee range of movement and quadriceps strengthening exercises. At follow-up of 2 years with extensive physical therapy, the patient has good functional results with flexion of 90° () and is walking without pain enabling her to carry on comfortably with routine activities. No evidence of infection or local recurrence was seen. |
A 66-year-old female patient was admitted with the diagnosis of an approximately 10 cm painless and immobile mass between the clavicle and the chin on the right side of the neck. A vascular mass originating from the carotid body was detected in ultrasonography and a tomography was performed. In sagittal and axial image of contrast-enhanced computed tomography (CT), a solid lesion in the right carotid area was detected that pushes the internal and external carotid artery and jugular vein; it was approximately 80 mm×90 mm×100 mm in size, with smooth contours and well-circumscribed, intense contrast enhancement (). Embolization was decided before curative surgery as the large diameter of the mass made it difficult for dissection due to compression on surrounding nerves, and dense collaterals that could cause bleeding. Digital subtraction angiography was depicted that the lesion was fed with multiple collaterals originating from the external and internal carotid arteries and the lesion was suitable for embolization (). In embolization, following the right external and internal carotid artery selective catheterization, all the feeding arteries emerging from these vessels were entered one by one and the vessels belonging to the tumor were tried to be closed with Onyx® glue-cast particles (an adhesive liquid embolic agent) under general anesthesia and subtracted fluoroscopic monitoring. Particles were introduced slowly by continuous fluoroscopy to prevent the backflow of particles. The procedure resulted in a significant decrease in blood flow and the tumor was observed to shrink in digital subtraction angiography (). No complications were noted to occur during and after the procedure. Neck contrast-enhanced CT performed after embolization showed that the intense contrast enhancement decreased, the carotid artery branches became prominent and their arching decreased in coronal and axial images (). The carotid body tumor in our case was type II, as per the classification made by Shamblin et al. Two days after embolization, the patient was taken to surgery for curative tumor excision. The tumor was dissected without damaging the internal carotid artery, and it was removed completely (). After the tumor was removed, the anatomical structure of the carotid artery became fully visible (). During the operation, residual arterial tortuous structures were seen around the left nervus vagus; all of these vascular structures were dissected while protecting the nerve. There was no nerve damage. The patient had mild swallowing difficulty in the postoperative period; however, it improved after 1 month, without recurrence. |
The Radiology Department requested an emergency surgical consultation for an 84-year-old male patient with sudden lower abdominal discomfort and pain during a diagnostic barium enema. The enema had been scheduled and administered as diagnostic tool for the evaluation of his chronic constipation. The patient had been referred to his gastroenterologist due to a history of obscure chronic constipation for more than 10 years. Although the patient had been consulted for a diagnostic colonoscopy, due to his lack of consent, the procedure had been canceled, and he was then scheduled for a diagnostic barium enema. The enema had been done using a 28F plastic rectal tube, followed by rectal infusion of 96% barium-sulfate solution at a pressure of 100 centimeters of water.\nIn our first emergent visit, the patient complained of a vague pain in his lower abdomen, which had started immediately following the rectal tube's insertion. He believed that the pain had increased during the procedure. Except for a history of chronic heart failure and atrial fibrillation, we found no other previous medical or surgical condition in the patient. He was totally conscious with stable and normal vital signs. Physical examination revealed a generalized abdominal tenderness mostly presented in lower quadrants in addition to insignificant rebound tenderness in the hypogastric region. Digital rectal exam showed a loose, bloody stool. An emergent supine plain abdominal x-ray was taken to evaluate the pattern of the administered barium within the abdomen (). The pattern of contrast extravasation in the x-ray reinforced the possibility of rectal perforation and spillage of the contrast into the surrounding tissues.\nAfter an adequate fluid replacement, resuscitation and prophylactic antibiotics, with the diagnosis of rectal perforation and barium extravasation, the patient underwent an emergent exploratory laparotomy with a midline incision. The laparotomy revealed no site of visible perforation in the distal colon or the sigmoid and upper rectum, but bright drops of barium were detected on the posterior wall of the peritoneum and around the sigmoid mesocolon and the mesoileum (). It seemed that the barium had penetrated from its initial location in retroperitoneum into the intraperitoneal cavity. Despite the adhesive characteristic of barium and its deep penetration into tissues, barium drops were extracted as much as possible, after which a massive irrigation and lavage of the peritoneal cavity was done. A diverting ileostomy was also performed to divert the fecal stream from the distal rectum that was the major site of injury. A tissue sample was also taken from the mesenteric tissue to confirm the possible etiology of peritoneal inflammation. Microscopic evaluation of the sample depicted a fat necrosis and foreign-body reaction within the tissues.\nFollowing the surgery, the patient was transferred to the intensive care unit, and broad-spectrum intravenous antibiotics were administered. Despite the proper hydration and the administration of antibiotics, signs and symptoms of sepsis gradually developed within the next two days. Thereafter, the patient underwent a rigid proctoscopy, which showed a massive inflammation and blood clots on the posterior wall of the rectum. In order to provide a better drainage system for the presacral space, we also accomplished an open, corrugated, presacral drain.\nAlthough, with close monitoring and proper medication, the general condition of the patient improved and the sepsis was resolved in a period of 10 days following the last procedure, a generalized abdominal pain developed gradually after 14 days. A high fever was also detected. In order to find possible sources of localized infection, such as abscesses within the injured sites, we performed an abdominopelvic computed tomography (CT) scan. The scan demonstrated an extensive hyperdense area within the retroperitoneal space on left side of the pelvis, with an extension to the psoas muscles (). A second laparotomy was performed at that time. During this procedure, a massive dissemination of barium up to the inferior pole of both kidneys was found. The mesentery of the colon and small intestine was covered by barium, and the retroperitoneal tissues were highly fragile and inflamed. In addition to a proper irrigation, a meticulous, but massive, debridement of necrotic tissues within the retroperitoneal area was performed. Two open, corrugated drains were also inserted.\nAfter a week, the patient had stable vital signs. The fever had disappeared, and he had regained his appetite. Both the presacral and the abdominal drains were removed, and the patient began an oral diet gradually. Finally, the patient was discharged after 10 days with a generally good and stable condition. He was also referred to the stoma care center for further support. Thereafter, he was asked to visit with his surgical team on a biweekly basis. Four months later, the diversion ileostomy was closed, and he was advised to do monthly and then bimonthly visits. He had regained his normal life at that time. After two years of postoperative follow-up, he is in very good condition, but his x-rays still show the presence of barium in his retroperitoneal space (). |
An 11-year-old boy visited our outpatient clinic with complaints of persistent right cheek pain. His family history revealed that his father had severe hearing impairment. His medical history showed that he had allergic rhinitis and chronic sinusitis that had been treated until 3 months previously by an otolaryngologist.\nThe patient initially visited our outpatient clinic with complaints of high fever, sore throat, and comorbid right cheek pain and mild swelling 6 weeks previously. A checkup at a dental clinic performed on the day before this initial visit revealed no abnormal findings. He showed clinical symptoms of streptococcal pharyngitis. A rapid antigen test for group A streptococcal infection showed positive results. The patient was diagnosed with streptococcal infection. Facial cellulitis was also suspected and treatment with amoxicillin helped improve symptoms. However, facial pain recurred within 4 weeks of the initial visit. The patient had mild tenderness and swelling of the right cheek. Head computed tomography revealed mild mucous membrane swelling and effusion in both sinuses ( left). Because recurrence of cellulitis with sinusitis was suspected, cefditoren pivoxil treatment was initiated. However, because the pain persisted, he visited our department.\nPhysical examination revealed no abnormal findings except right cheek tenderness in the area that corresponded with the region supplied by the second branch of the trigeminal nerve (the maximally nerve). Although marked tenderness was evident, no point with hyperalgesia, where a light touch elicited severe pain, was observed. No facial paralysis or oral disorders were observed. Blood examination revealed no abnormal findings. Recurrence of sinusitis was suspected. Based on the physical examination and laboratory tests, the patient was clinically diagnosed with TN. Subsequently, oral clarithromycin administration was initiated for sinusitis that might have caused or exacerbated TN. However, administration of clarithromycin for 1 week was not effective for his facial pain. Brain magnetic resonance imaging (MRI) revealed no neurovascular compression ( right), which ruled out idiopathic, classical TN. During this time, we interviewed the patient on the nature of the right cheek pain. The patient described the pain as persistent, nagging, and dull in nature, which was completely different from the characteristics of pain associated with TN. Furthermore, trigger maneuvers failed to evoke pain. These evaluations excluded TN, and, thus, PIFP was diagnosed in week 2. Low dose of oral anticonvulsant carbamazepine (50 mg, twice a day) was initiated but was ceased due to general fatigue after the first administration.\nAlthough the patient had been previously cheerful and greeted us when entering the examination room, he became gradually emotionless with headache and nausea in week 5. In addition, feeding difficulties and numbness in the arms occurred. An orthostatic tolerance test revealed no positive findings for orthostatic dysregulation. It became difficult for the patient to attend school in week 6. Because various somatic symptoms developed in addition to PIFP, psychological factors were suspected to be pertinent in the etiology of PIFP. During a detailed medical interview with the patient and his mother, several problems were revealed: the patient loved swimming but his swimming record had plateaued after fixing his swimming form even though he practiced vigorously at a top-class swimming club team. Moreover, because of a recent finger injury, he could not practice as intensely as he wanted; therefore, his competitive ability as a swimmer deteriorated. Furthermore, in early adolescence, the patient had difficulties in communication and his relationship with his father was strained due to the father's hearing impairment. Because these suggested that the circumstances surrounding him might have led to somatoform disorders, psychological counseling was ordered in week 6.\nAs the patient faced, understood, and tolerated his psychological stress through counseling and psychotherapy twice a week, he gradually became expressive, worked up his appetite, and could attend school in week 10. Although sinusitis recurred at week 29, no facial pain developed. The patient received psychological counseling twice or thrice a month by this time. After 8 months, the frequency of counseling was reduced to once in 2 months. During this period, the patient's voice changed and became deeper at puberty. After confirming that facial pain as well as general malaise did not occur, even when the patient experienced distressing events, such as terminal examinations, counseling was ceased after 1 year and 8 months. After 3 years, the patient went on to high school and currently attends school cheerfully without any complaints and has resumed swimming. |
A 59-year-old female initially presented to the emergency department 10 months prior with right arm pain and swelling. A computed tomography of the neck with contrast at the time showed two confluent masses in the right axillary and right supraclavicular regions encasing the right subclavian and axillary vein, the internal mammary artery, and narrowing of the lower internal jugular vein. Patient was subsequently diagnosed with primary mammary carcinoma of the axilla with metastasis. The patient was evaluated by the oncology and radiation oncology services and underwent multiple rounds of chemotherapy and radiation therapy. Her course of chemotherapy was complicated by thrombocytopenia and metastatic disease progression. The patient was determined to be a nonsurgical candidate. Gradually, her pain of the right upper extremity worsened, and the patient was started on opioid therapy. Despite titration of her oral medications to extended release morphine 90 mg two times a day, immediate release morphine 30 mg every 2 to 3 hours, methadone 5 mg daily, and gabapentin 800 mg three times daily, her pain control remained suboptimal. She was referred to our pain clinic for further management of her intractable pain.\nOn presentation, the patient reported a constant 10/10 pain on the numeric pain rating scale (NRS) of the right proximal humerus, right anterior and posterior shoulder, and right supraclavicular region. The pain was reported as dull, aching, burning, and electric in nature. Her pain was worsened by passive and active range of motion, and the pain at its best was a 7/10 with oral medications. Patient also reported progressive weakness of the entire right upper extremity. Magnetic resonance imaging of the brachial plexus was obtained, and the study revealed a mass encasing the right brachial plexus at the level of the divisions and cords as well as the right brachial artery ().\nDiagnostic brachial plexus block was performed in the hospital due to functional decline and acute worsening of pain. The brachial plexus was unable to be visualized using ultrasonography in the classic supraclavicular area due to the tumor effect, thus the block was performed at the level of the trunks using a lower interscalene approach. 18 mL of 0.5% ropivacaine was injected under direct ultrasound guidance. The patient reported complete pain relief lasting approximately 12 hours after the nerve block. Given the success of the diagnostic nerve block, the patient was offered the option of chemical neurolytic brachial plexus block with an extensive discussion of the unique risks, benefits, and alternatives. The patient elected to proceed to a right brachial plexus nerve block with dehydrated ethanol. |
This is a case of 11-year-old boy, who has a history of fall from the sixth floor and sustained severe traumatic brain injury when he was at 4 years of age. During trauma screening including CT brain, he was found to have multiple brain contusions and an incidental finding of extensive optic glioma. After that, an MRI brain showed that the optic glioma was very extensive in the brain parenchyma, to the point it was extending from both optic nerves through the optic chiasm and to the whole optic pathways bilaterally (). Moreover, it was extending to intraventricular system and to the sella and suprasellar region. Patient was managed and treated in the paediatric intensive care unit with conservative treatment for the head injury. The patient ended up with a Glasgow coma scale (GCS) of 8/15.\nDue to his poor neurological status, with this extensive optic glioma, it was decided by paediatric neuro-oncology tumour board that there is no further treatment that can be offered to him. During his follow-up, he was found to have a significant increase in his head circumference which reached up to 74 cm. The brain MRI was repeated and showed progression of the tumour size and the hydrocephalus; therefore, a VP shunt was inserted. After 4 months, the VP shunt was complicated by recurrent abdominal ascites due to scarring from previous abdominal exploratory surgery, and high protein in the CSF. This required us to do multiple revisions and tapping of the abdominal ascites by inserting a peg tail. At this point, he failed the management of multiple VP shunt revisions.\nCSF protein was found most of the time to be more than 20 g/L, and he was required to have frequent periodic ascitic tapping almost every 3 weeks. Because of the high protein content of the CSF, other cavities for shunt placement were excluded. For example, pleural cavity was excluded to avoid pleural effusion and cardiac atrium was excluded to avoid thrombosis. Also, the brain endoscopic surgeries like ETV was excluded due to tumour location in the lateral ventricles, anterior, and posterior part of the third ventricle (). After all these factors, we decided to proceed with VG shunt. An ultrasound of the gallbladder was done, which represented a sludge in the gallbladder; however, there were no signs of inflammation or biliary dilatation. Laparoscopic insertion of VG shunt was established through inserting the distal end of the VP shunt into the gallbladder fundus with irrigation of the gallbladder using normal saline to clean it from the sludge. The patient tolerated the procedure well with no difficulties. Evaluation of the VG shunt patency has been done by a nuclear medicine study called a shunt patency test. In this test, a radiotracer was injected into the shunt reservoir and we measured the flow of CSF in the shunt and valves. The test showed that the radiotracer filled the gallbladder and after giving the patient a meal, the gallbladder contracted and the transit of the radiotracer activity was seen in the bowel loops, which indicated the patency of the VG shunt (). After 5 weeks of VG shunt placement, the patient presented to the emergency department with a 3-day history of fever, shortness of breath and presence of jaundice on examination. |
The second patient (P2) was a 30-year old female with headache (TTH or migraine) several days a week. She was living with her boyfriend and working in primary care clinic. The patient had experienced headaches since she was a little girl and had migraine since she was 15 years old. She had tried lots of medication and had at last found one medicine that had at least some effect – if taken early it could stop an oncoming migraine attack.\nAccording to the baseline data, she had headaches every other day with intensity varying from low to very high ( and ) and sometimes she could not tell if it was migraine, TTH, or something else. The patient had marks around her tongue indicating that she had behavior of pressing her tongue against the teeth. She had negative thoughts about the headache destroying her daily life and became stressed from having headache. The patient did not exercise regularly although she thought she should. This made her feel unsatisfied with herself. She was taking her migraine medicine several times a week (), more often than she thought was healthy. Her perception of disability and feelings of loss of happiness were highly varying depending on how much headache she had (). She had a low self-efficacy for managing her headaches ().\nThere were several behaviors that were supposed to contribute to her headaches, which led to several intertwined FBAs. Contracting her muscles of shoulders, neck, and jaw was a behavioral response primarily in situations when she felt psychological stress. This physical reaction was hypothesized to be a conditioned response to situations that resembled earlier stressful situations and thereby occurred more frequently. She perceived the stress in situations when she was feeling not in control, often because of not only headache but also work-related tasks. Automatic negative thoughts were common in these situations. The consequence was tension and headache and even more stress of not being in control, which positively reinforced her automatic negative thoughts. Her feeling of anxiety for getting headaches was also in close connection with psychological stress. This behavior had the antecedent of knowing that it would not be a good time for having headache, for example, when she knew that she had important things to do that would be difficult to call off. Her low self-efficacy for managing her headaches was thought to be an important factor for maintaining the behavior of physical tension, automatic negative thoughts, and feelings of anxiety.\nSometimes her headache or fear of headache made her take migraine medicine. This operant response had the short-term positive reinforcing consequence of a feeling that she had done something to prevent the worst scenario of migraine headache. At the same time, it made her in the long run feel even less in control over her headache and worried that the medicine would not be healthy and that she would get even more headache from taking them.\nAnother behavior targeted was her physical activity level. Her headaches made her tired and she was not able to be physically active as much as she would like to. She had tried to go to classes at the gym. If she had a headache when she started, the consequence would often be worse headache afterward, a punishment that made it difficult for her to plan the activities. In the long run, her low physical activity might lead to more physical and psychological stress and more headache.\nIn summary, the interrelationship of stress and headache was obvious, and her feeling of not being in control was important for maintaining her behaviors. The short-term goals were that she would feel that she had tools to break behavioral chains earlier and, for example, start to do her exercises instead of getting tense when she felt worried. The long-term goal was set to a maximum of headache 2 days per week.\nThe treatment consisted of 14 visits with home exercises in between, including baseline and follow-up visits.\nBasic targeted physical skills were to learn to activate the deep muscles of the neck and to increase the endurance and blood circulation of neck and shoulder muscles in order to be able to control muscle tension. Cognitive basic targeted skills were to recognize negative thoughts, be aware of the reasons for taking medication, and to use support from her boyfriend to be physically active. Applied skills were better posture in everyday activities, to recognize and replace negative thoughts in activities, questioning medication intake, and to be physically active on a regular basis.\nFirst focus was set on physical skills (i.e., muscular endurance and posture), then cognitive skills (i.e., negative thoughts), after that medication overuse, and finally physical activity.\nThrough all the treatment stages, the physical therapist used techniques to support the patient’s behavior change, with self-monitoring, feedback, shaping, pacing and fading. To strengthen the patient’s self-efficacy in ability to influence the headache and to succeed in the behavior change was important.\nAll outcomes were considered as proxy measures for increased control over muscular tension, psychological stress, and medication overuse.\nThe goal of headache a maximum of two days a week was not met.\nSince the variability of the outcome in diaries through the baseline and treatment phases proved to be high, it was decided that the patient would fill in the diary continuously through the follow-up period (A3) and not only at 1 week before the follow-up visits. The diary for weeks 39 and 40 was lost by the patient.\nHeadache frequency and headache index are presented in and . The variability is high and makes it difficult to draw conclusions, although the trend is that both headache frequency and index reduced slightly from baseline, through intervention, to follow-up.\nThe behavior of migraine medicine consumption reduced considerably when this was targeted in treatment and was stable on a lower level through follow-up, although the variability was high ().\nThe behavior of over-the-counter analgesics’ consumption varied through the phases with no certain difference from baseline through treatment to follow-up ().\nFor the disability and feelings of loss of happiness the variability was high and no trends could be observed ().\nHMSE increased considerably, from baseline to after treatment and through follow-up, indicating that her self-efficacy for managing headache did increase during the treatment (). |
Case 2: A 23 year old male, presented with symptoms of crawling sensation and foreign body sensation in his right eye, and had observed a worm in this eye. He had no previous symptoms prior to his presentation. He gave a history of having worked in a cocoa farm plantation during his childhood years and had severally suffered from bites from unknown flies. He had no systemic symptoms nor signs and aside from his ocular complains was healthy. There was no swelling anywhere in the body and no itching. Upon ocular examination his visual acuity was 6/6 in both eyes. The only significant finding was the presence of an actively mobile worm in the nasal subconjunctival space of the right eye "". This worm soon migrated upwards towards the superior fornix and away from view during the examination and before removal could be attempted "". The patient was immediately asked to adopt a face down position and within 30minutes of this time; he could feel a crawling sensation again in the same eye indicating that the worm was back. He was quickly taken to the operating room and the worm was extracted successfully using a local infiltration of the conjunctiva with lignocaine anesthesia. Histological examination revealed it to be an adult Loa loa worm.\nCases 3: A 25 year old female who had suffered sensation of movement and foreign body sensation in both eyes for the past 10 years and gave a past history of swimming in rural streams during childhood years. There was no history of swelling on the body and no itching. She had noticed an increasingly frequent occurrence of a worm like movement in both eyes over these years. Following ingestion of diethyl carbamazepine she noticed a sudden appearance of a red patch in the right eye. Upon examination her visual acuity was 6/5 in both eyes. The only significant finding was a localized hyperemic raised lesion on the surface of the right eye. This turned out to be a subconjuctival worm in the inferotemporal subconjunctival space of the right eye. The worm was found to be lifeless and covered by a surrounding cyst wall "". Care was taken to dissect the conjunctival and subtenons tissue away from the encysted worm, which was carefully extracted with a toothless forceps. Conjunctival incision site was closed with interrupted sutures. Histology revealed an adult Loa loa worm. |
An 11-year-old boy visited our outpatient clinic with complaints of persistent right cheek pain. His family history revealed that his father had severe hearing impairment. His medical history showed that he had allergic rhinitis and chronic sinusitis that had been treated until 3 months previously by an otolaryngologist.\nThe patient initially visited our outpatient clinic with complaints of high fever, sore throat, and comorbid right cheek pain and mild swelling 6 weeks previously. A checkup at a dental clinic performed on the day before this initial visit revealed no abnormal findings. He showed clinical symptoms of streptococcal pharyngitis. A rapid antigen test for group A streptococcal infection showed positive results. The patient was diagnosed with streptococcal infection. Facial cellulitis was also suspected and treatment with amoxicillin helped improve symptoms. However, facial pain recurred within 4 weeks of the initial visit. The patient had mild tenderness and swelling of the right cheek. Head computed tomography revealed mild mucous membrane swelling and effusion in both sinuses ( left). Because recurrence of cellulitis with sinusitis was suspected, cefditoren pivoxil treatment was initiated. However, because the pain persisted, he visited our department.\nPhysical examination revealed no abnormal findings except right cheek tenderness in the area that corresponded with the region supplied by the second branch of the trigeminal nerve (the maximally nerve). Although marked tenderness was evident, no point with hyperalgesia, where a light touch elicited severe pain, was observed. No facial paralysis or oral disorders were observed. Blood examination revealed no abnormal findings. Recurrence of sinusitis was suspected. Based on the physical examination and laboratory tests, the patient was clinically diagnosed with TN. Subsequently, oral clarithromycin administration was initiated for sinusitis that might have caused or exacerbated TN. However, administration of clarithromycin for 1 week was not effective for his facial pain. Brain magnetic resonance imaging (MRI) revealed no neurovascular compression ( right), which ruled out idiopathic, classical TN. During this time, we interviewed the patient on the nature of the right cheek pain. The patient described the pain as persistent, nagging, and dull in nature, which was completely different from the characteristics of pain associated with TN. Furthermore, trigger maneuvers failed to evoke pain. These evaluations excluded TN, and, thus, PIFP was diagnosed in week 2. Low dose of oral anticonvulsant carbamazepine (50 mg, twice a day) was initiated but was ceased due to general fatigue after the first administration.\nAlthough the patient had been previously cheerful and greeted us when entering the examination room, he became gradually emotionless with headache and nausea in week 5. In addition, feeding difficulties and numbness in the arms occurred. An orthostatic tolerance test revealed no positive findings for orthostatic dysregulation. It became difficult for the patient to attend school in week 6. Because various somatic symptoms developed in addition to PIFP, psychological factors were suspected to be pertinent in the etiology of PIFP. During a detailed medical interview with the patient and his mother, several problems were revealed: the patient loved swimming but his swimming record had plateaued after fixing his swimming form even though he practiced vigorously at a top-class swimming club team. Moreover, because of a recent finger injury, he could not practice as intensely as he wanted; therefore, his competitive ability as a swimmer deteriorated. Furthermore, in early adolescence, the patient had difficulties in communication and his relationship with his father was strained due to the father's hearing impairment. Because these suggested that the circumstances surrounding him might have led to somatoform disorders, psychological counseling was ordered in week 6.\nAs the patient faced, understood, and tolerated his psychological stress through counseling and psychotherapy twice a week, he gradually became expressive, worked up his appetite, and could attend school in week 10. Although sinusitis recurred at week 29, no facial pain developed. The patient received psychological counseling twice or thrice a month by this time. After 8 months, the frequency of counseling was reduced to once in 2 months. During this period, the patient's voice changed and became deeper at puberty. After confirming that facial pain as well as general malaise did not occur, even when the patient experienced distressing events, such as terminal examinations, counseling was ceased after 1 year and 8 months. After 3 years, the patient went on to high school and currently attends school cheerfully without any complaints and has resumed swimming. |
A 59-year-old female initially presented to the emergency department 10 months prior with right arm pain and swelling. A computed tomography of the neck with contrast at the time showed two confluent masses in the right axillary and right supraclavicular regions encasing the right subclavian and axillary vein, the internal mammary artery, and narrowing of the lower internal jugular vein. Patient was subsequently diagnosed with primary mammary carcinoma of the axilla with metastasis. The patient was evaluated by the oncology and radiation oncology services and underwent multiple rounds of chemotherapy and radiation therapy. Her course of chemotherapy was complicated by thrombocytopenia and metastatic disease progression. The patient was determined to be a nonsurgical candidate. Gradually, her pain of the right upper extremity worsened, and the patient was started on opioid therapy. Despite titration of her oral medications to extended release morphine 90 mg two times a day, immediate release morphine 30 mg every 2 to 3 hours, methadone 5 mg daily, and gabapentin 800 mg three times daily, her pain control remained suboptimal. She was referred to our pain clinic for further management of her intractable pain.\nOn presentation, the patient reported a constant 10/10 pain on the numeric pain rating scale (NRS) of the right proximal humerus, right anterior and posterior shoulder, and right supraclavicular region. The pain was reported as dull, aching, burning, and electric in nature. Her pain was worsened by passive and active range of motion, and the pain at its best was a 7/10 with oral medications. Patient also reported progressive weakness of the entire right upper extremity. Magnetic resonance imaging of the brachial plexus was obtained, and the study revealed a mass encasing the right brachial plexus at the level of the divisions and cords as well as the right brachial artery ().\nDiagnostic brachial plexus block was performed in the hospital due to functional decline and acute worsening of pain. The brachial plexus was unable to be visualized using ultrasonography in the classic supraclavicular area due to the tumor effect, thus the block was performed at the level of the trunks using a lower interscalene approach. 18 mL of 0.5% ropivacaine was injected under direct ultrasound guidance. The patient reported complete pain relief lasting approximately 12 hours after the nerve block. Given the success of the diagnostic nerve block, the patient was offered the option of chemical neurolytic brachial plexus block with an extensive discussion of the unique risks, benefits, and alternatives. The patient elected to proceed to a right brachial plexus nerve block with dehydrated ethanol. |
A 59-year-old female initially presented to the emergency department 10 months prior with right arm pain and swelling. A computed tomography of the neck with contrast at the time showed two confluent masses in the right axillary and right supraclavicular regions encasing the right subclavian and axillary vein, the internal mammary artery, and narrowing of the lower internal jugular vein. Patient was subsequently diagnosed with primary mammary carcinoma of the axilla with metastasis. The patient was evaluated by the oncology and radiation oncology services and underwent multiple rounds of chemotherapy and radiation therapy. Her course of chemotherapy was complicated by thrombocytopenia and metastatic disease progression. The patient was determined to be a nonsurgical candidate. Gradually, her pain of the right upper extremity worsened, and the patient was started on opioid therapy. Despite titration of her oral medications to extended release morphine 90 mg two times a day, immediate release morphine 30 mg every 2 to 3 hours, methadone 5 mg daily, and gabapentin 800 mg three times daily, her pain control remained suboptimal. She was referred to our pain clinic for further management of her intractable pain.\nOn presentation, the patient reported a constant 10/10 pain on the numeric pain rating scale (NRS) of the right proximal humerus, right anterior and posterior shoulder, and right supraclavicular region. The pain was reported as dull, aching, burning, and electric in nature. Her pain was worsened by passive and active range of motion, and the pain at its best was a 7/10 with oral medications. Patient also reported progressive weakness of the entire right upper extremity. Magnetic resonance imaging of the brachial plexus was obtained, and the study revealed a mass encasing the right brachial plexus at the level of the divisions and cords as well as the right brachial artery ().\nDiagnostic brachial plexus block was performed in the hospital due to functional decline and acute worsening of pain. The brachial plexus was unable to be visualized using ultrasonography in the classic supraclavicular area due to the tumor effect, thus the block was performed at the level of the trunks using a lower interscalene approach. 18 mL of 0.5% ropivacaine was injected under direct ultrasound guidance. The patient reported complete pain relief lasting approximately 12 hours after the nerve block. Given the success of the diagnostic nerve block, the patient was offered the option of chemical neurolytic brachial plexus block with an extensive discussion of the unique risks, benefits, and alternatives. The patient elected to proceed to a right brachial plexus nerve block with dehydrated ethanol. |
An 11-year-old boy visited our outpatient clinic with complaints of persistent right cheek pain. His family history revealed that his father had severe hearing impairment. His medical history showed that he had allergic rhinitis and chronic sinusitis that had been treated until 3 months previously by an otolaryngologist.\nThe patient initially visited our outpatient clinic with complaints of high fever, sore throat, and comorbid right cheek pain and mild swelling 6 weeks previously. A checkup at a dental clinic performed on the day before this initial visit revealed no abnormal findings. He showed clinical symptoms of streptococcal pharyngitis. A rapid antigen test for group A streptococcal infection showed positive results. The patient was diagnosed with streptococcal infection. Facial cellulitis was also suspected and treatment with amoxicillin helped improve symptoms. However, facial pain recurred within 4 weeks of the initial visit. The patient had mild tenderness and swelling of the right cheek. Head computed tomography revealed mild mucous membrane swelling and effusion in both sinuses ( left). Because recurrence of cellulitis with sinusitis was suspected, cefditoren pivoxil treatment was initiated. However, because the pain persisted, he visited our department.\nPhysical examination revealed no abnormal findings except right cheek tenderness in the area that corresponded with the region supplied by the second branch of the trigeminal nerve (the maximally nerve). Although marked tenderness was evident, no point with hyperalgesia, where a light touch elicited severe pain, was observed. No facial paralysis or oral disorders were observed. Blood examination revealed no abnormal findings. Recurrence of sinusitis was suspected. Based on the physical examination and laboratory tests, the patient was clinically diagnosed with TN. Subsequently, oral clarithromycin administration was initiated for sinusitis that might have caused or exacerbated TN. However, administration of clarithromycin for 1 week was not effective for his facial pain. Brain magnetic resonance imaging (MRI) revealed no neurovascular compression ( right), which ruled out idiopathic, classical TN. During this time, we interviewed the patient on the nature of the right cheek pain. The patient described the pain as persistent, nagging, and dull in nature, which was completely different from the characteristics of pain associated with TN. Furthermore, trigger maneuvers failed to evoke pain. These evaluations excluded TN, and, thus, PIFP was diagnosed in week 2. Low dose of oral anticonvulsant carbamazepine (50 mg, twice a day) was initiated but was ceased due to general fatigue after the first administration.\nAlthough the patient had been previously cheerful and greeted us when entering the examination room, he became gradually emotionless with headache and nausea in week 5. In addition, feeding difficulties and numbness in the arms occurred. An orthostatic tolerance test revealed no positive findings for orthostatic dysregulation. It became difficult for the patient to attend school in week 6. Because various somatic symptoms developed in addition to PIFP, psychological factors were suspected to be pertinent in the etiology of PIFP. During a detailed medical interview with the patient and his mother, several problems were revealed: the patient loved swimming but his swimming record had plateaued after fixing his swimming form even though he practiced vigorously at a top-class swimming club team. Moreover, because of a recent finger injury, he could not practice as intensely as he wanted; therefore, his competitive ability as a swimmer deteriorated. Furthermore, in early adolescence, the patient had difficulties in communication and his relationship with his father was strained due to the father's hearing impairment. Because these suggested that the circumstances surrounding him might have led to somatoform disorders, psychological counseling was ordered in week 6.\nAs the patient faced, understood, and tolerated his psychological stress through counseling and psychotherapy twice a week, he gradually became expressive, worked up his appetite, and could attend school in week 10. Although sinusitis recurred at week 29, no facial pain developed. The patient received psychological counseling twice or thrice a month by this time. After 8 months, the frequency of counseling was reduced to once in 2 months. During this period, the patient's voice changed and became deeper at puberty. After confirming that facial pain as well as general malaise did not occur, even when the patient experienced distressing events, such as terminal examinations, counseling was ceased after 1 year and 8 months. After 3 years, the patient went on to high school and currently attends school cheerfully without any complaints and has resumed swimming. |
A 16-year-old male runner fell forward over an outstretched left leg during a race. He felt a popping sensation with his left hip in deep flexion and the left knee in forced extension and a sharp pain in the posterolateral aspect of the left distal thigh. He could not bear weight on the affected leg, which prevented him from walking and he was immediately transferred to our hospital. He had no history of other trauma, chronic disease, or use of corticosteroids. A clinical examination revealed swelling and tenderness at the posterolateral aspect of the left distal thigh. The ridge formed by the left biceps femoris tendon was distinctly deficient to both visual inspection and palpation. Active extension or flexion of the left knee was prevented by severe pain. Ligamentous instability of the knee was not evident and the left knee appeared normal on plain radiography images. T2-weighted magnetic resonance images of the left thigh revealed a loss of continuity of the distal biceps femoris tendon at the musculotendinous junction surrounded by a hematoma with high signal intensity (). Isolated rupture of the distal part of the left biceps femoris tendon was diagnosed and surgical exploration proceeded under lumbar spinal anaesthesia. A lateral incision over the belly of the biceps femoris revealed that the biceps femoris tendon had completely ruptured at the musculotendinous junction (). The tear was repaired using a modified Kessler method with strong nonabsorbable sutures.\nThe knee was postoperatively immobilized in a plaster cast at 30° of flexion. However, the patient described numbness and sensory loss over the anterior aspect of the left foot and dorsiflexion of the foot was weak on the day after surgery. Common peroneal nerve palsy at the fibular head due to compression by the plaster cast was diagnosed and the cast was removed to decompress the nerve. However, this did not result in any neurological improvement. Surgical assessment was applied 2 months after the common peroneal palsy occurred. Reexploration findings showed complete repair of the ruptured tendon, but the common peroneal and sural nerves were entrapped by the surgical suture, which had also penetrated the common peroneal nerve. Both nerves were obviously constricted after removal of the surgical suture (). Both nerves were externally neurolysed and scar tissue was removed. Motor function completely recovered 15 months later, but some residual numbness in the lower left leg persisted. |
A 36-year-old man, originally from Latin America, presented at our outpatient department with complaints of abdominal pain that had persisted for 2 months. The patient had first noticed right lateral abdominal pain 2 months prior to the visit, and the pain was gradually worsening. The abdominal pain was localized in an area ranging from the right upper to the right lateral abdomen. The patient had undergone cholecystectomy for acute cholecystitis as a 32-year-old in Latin America and had moved to Japan for work approximately 3 years prior to his initial visit to our hospital. He had returned to Latin America once about 6 to 7 months before presenting at our clinic. When he went back to Japan, his weight had increased from 130 kg to 145 kg. He did not experience abdominal pain immediately after his return to Japan, but, as noted above, he started to gradually feel pain in the right lateral region about 2 months prior to presentation.\nHe first visited another hospital emergency department 1 month after onset of the pain. Initially, gastrointestinal tract spasm was suspected, and he was treated with tiquizium bromide. Though the medication partially relieved his abdominal pain, most of the pain persisted. The result of a workup by a urologist was negative, even though nephrolithiasis was suspected. His abdominal pain was exacerbated upon changing posture, and thus it was suspected to be of somatic rather than visceral origin. Abdominal pain persisted despite treatment with loxoprofen sodium hydrate, and any cause of abdominal pain was not detected on further evaluations, including hematologic laboratory analysis, urine analysis, gastroscopy, or abdominal computed tomography (CT). Finally, he was referred to our hospital for further examination.\nThe results of screening for depression were negative, and the patient did not have symptoms such as loss of interest, depressed feelings, or any specific changes of surrounding conditions, such as family or work environment changes. He had no history of sexually transmitted infection, and his vital signs were within normal limits. His physical examination result was positive for Carnett’s test, and a prior surgical scar of approximately 18 cm was apparent at the right subcostal region. The patient experienced strong pain surrounding the surgical scar that was exacerbated by tapping. There were no skin rashes localized surrounding the pain. His pain exacerbated to 8 on a pain scale when he moved, such as during standing up or rolling over simultaneously. When he stopped moving, pain was partially relieved within 1 minute (3 on a pain scale). When he moved again, abdominal pain was again exacerbated. Hence, he was awakened by the abdominal pain when rolling over. No inflammation was detected (leukocyte count was 8580/mm3 and C-reactive protein was 0.10 mg/dl), and other laboratory findings were nonspecific, including liver/kidney function, blood glucose, and electrolytes. Urinary analysis indicated red blood cell count < 1/high-power field, white blood cell count 1–4/high-power field. Additionally, no abnormality was detected for Chlamydia trachomatis IgG/IgA, and no abnormality was apparent on the electrocardiogram. Enhanced CT revealed bilateral renal stones and fatty liver.\nWe first considered abdominal wall pain due to nerve entrapment because the Carnett’s test result was positive; therefore, we scheduled a trigger point injection at the site of tenderness. About 2 weeks later, the patient visited the emergency department of our hospital, reporting that his prior abdominal pain had decreased but that he was experiencing right inguinal pain. Loxoprofen administration had no effect on the pain. Costovertebral angle pain was apparent on tapping, the result of urine analysis was positive for occult blood, and abdominal CT revealed a urinary stone at the right urinary duct to the bladder. After pentazocine hydrochloride was administered for pain relief, the urinary stone was passed the following day. However, the patient’s right lateral abdominal pain was not relieved.\nHe felt that lying in the lateral position mostly relieved his pain. He had occasional vomiting. The abdominal pain was exacerbated by movements, such as rolling over, standing up, walking, and coughing. Injection of 1% xylocaine 10 ml at a trigger point of the right lateral region led to about 30% relief in pain. The patient was referred to an anesthesiologist for further evaluation and treatment, who performed transverse abdominal plane block and administered multiple analgesic medications (tramadol hydrochloride, pregabalin, celecoxib, and scopolamine butylbromide). These medications decreased the patient’s pain somewhat, and he reported that scopolamine butylbromide was most effective when the pain worsened. Because the patient’s symptoms were not relieved after trigger point treatment to the abdominal wall, we considered potential causes that might be associated with the location between the abdominal wall and visceral wall or related to other sources, including psychosocial, physiological, and other anatomical factors. We rechecked the abdominal CT scan for a suspected adhesion or abdominal hernia at the region of tenderness due to the prior surgical procedure, and we asked a radiologist to reevaluate the right upper abdomen in more detail. The radiologist confirmed a slight abnormality in the right upper abdomen and suggested the possibility of an adhesion around the surgical scar (Fig. ). We referred the patient to a gastrointestinal surgeon for laparoscopic evaluation and adhesiolysis. The patient underwent additional investigations, including cholecystocholangiography and colonoscopy for suspected postcholecystectomy syndrome, biliary dyskinesia, or colon abnormality. However, no cause of the abdominal pain was identified. On laparoscopic evaluation, a broad adhesion was observed. Adhesiolysis was performed 6 months after the patient first visited our hospital. Figure a shows adhesion between the peritoneum and omentum, liver, and ascending colon; Fig. b shows the condition after adhesiolysis. One month after adhesiolysis, the patient’s right abdomen pain level during movement improved from 8 to 2–3 on a pain scale. Therefore, he was able to move with less pain, and he did not feel pain when rolling over. The result of Carnett’s test was negative. After the patient started walking around his house, he felt abdominal pain about 5 minutes after walking. Hence, he was afraid of recurrence of abdominal pain and felt a little depressed and frustrated because he was unable to return to work early. We recommended a gradual increase in activity. He went on a trip 4 months after the operation without problems due to abdominal pain and then resumed his job 6 months after the operation.\nHowever, his abdominal pain deteriorated within 1 month after he resumed working. He presented with bleeding at the umbilicus, which was the laparoscopic port site, and abdominal incisional hernia was confirmed on the basis of CT. Repair of the abdominal incisional hernias and laparoscopic adhesiolysis were performed 8 months after the first operation. After the second operation, although it took time for some symptoms to improve because of surgical site infection, the patient’s symptoms were ultimately relieved, and he resumed his job again 5 months after undergoing the second operation. Although he reported mild abdominal pain and required analgesic medication, his weight decreased to 133 kg, and he was able to walk normally and work full-time, 2 years after he initially visited our hospital. The timeline of interventions and outcomes is shown in Additional file . |
An otherwise healthy 22-year-old caucasian woman consulted for an initial orthopedic examination due to an accelerated growth of a large mass over the posterior aspect of her right buttock and lower lumbar region. The mass had been present for over 5 years and had gradually enlarged during this time. Recently, the lesion had increased in size rather rapidly.\nAt another treatment facility, when the patient was 18 years of age, she underwent debulking of a tumor from the right buttock, which was complicated with a very profuse intraoperative hemorrhage resulting in a severe hypotension and acute kidney failure requiring 8 units of blood for stabilization. The patient was later discharged and did not continue followup at that treatment facility. In spite of this, the mass in the right buttock and lumbar region continued undergoing slow growth until it limited her daily activities. Upon arriving at our center, physical examination revealed a large, firm, amorphous, fluctuant, soft tissue mass measuring 60 × 50 × 30 cm. that originated from the lumbar region and extended to the gluteal fold and overhanging from the posterior aspect of her thigh ().\nMRI was technically difficult due to the dimensions of the tumor. The extension of the mass was unable to be determined with certainty because portions of it remained outside of the field of view. The mass exhibited intermediate signal on both T1- and T2-weighted images, and several fluid collections were identified (). The images demonstrated multiple serpiginous flow voids in keeping with prominent vasculature. The mass did not infiltrate the underlying gluteal musculature. Core needle biopsy was performed and the results were consistent with PNF; there was no evidence of malignancy in the tissue sample.\nThe case was reviewed at our multidisciplinary musculoskeletal tumor committee. The treatment consensus opted for preoperative embolization, as this would potentially reduce the perioperative blood loss considering the vascularity and size of the lesion. Surgical resection of the bulk of the lesion would then be undertaken and closure achieved with local tissue advancement or free flap transfer. It was not feasible to widely excise the lesion as it was infiltrating almost circumferentially around the patient.\nThe diagnostic angiogram confirmed the presence of multiple vessels supplying the tumor (). The feeding vessels identified were the right intercostal and lumbar arteries (), the right superior and inferior gluteal arteries, and the right circumflex iliac artery. Branches of the right profunda femoris and the left internal iliac arteries () were also visualized. A supraselective catheterization was done to perform a selective embolization using Gelfoam and PVA particles. Exceptionally, microcoils were also used. Due to the number and caliber of vessels to treat as well as the amount of contrast that will need to be used, the preoperative embolization was performed sequentially 5 days and 1 day before surgery.\nThe final angiogram showed almost complete devascularization of the tumor (). Tumor regression was satisfactory, with large areas of skin necrosis after embolization and with no associated systemic complications.\nTwenty-four hours after the second intravascular embolization, the patient was transferred to the operating room for surgical resection (). By positioning her prone on the operating table we were able to manipulate the lesion satisfactorily. An incision was made along the right posterior medial limb from the upper portion of the buttock to the thigh. Dissection through the superficial tissues necessitated some dissection through tumor tissue, which was highly vascular with large friable vessels. To reduce intraoperative bleeding, we decided to use the system Stapling Endo (Endo GIA) (). Once deep to the lesion, it was possible to encompass it and dissect it off the deep structures through a normal fatty plane, tying off the main feeding vessels that were demonstrated by angiography. The huge pedunculated gluteal mass was removed completely (). Local skin flaps were extensively mobilized and primary closure obtained (). Estimated blood loss for the procedure was 1000 mL, and the patient received 4 units of packed red blood cells. There were no intraoperative complications.\nThe specimen weighed 16,700 gr. and measured 60 × 45 × 27 cm (). Grossly there was diffuse presence of a myxoid-like white tan tissue, infiltrating into the surrounding fat. Histological examination revealed a plexiform neurofibroma with no evidence of malignancy (). Superficial margins were positive, consistent with the intralesional procedure.\nTwo weeks after the surgery, the patient had central areas of skin breakdown and cellulitis of the right lower extremity. The patient underwent revision of the closure secondary to infection of the surgical wound. Large cavities containing pus were identified. Cavities were curetted and pulse lavaged. Cultures grew Escherichia coli and the patient was started on IV cefepime, vancomycin, and gentamicin. Vacuum-assisted wound closure (VAC; Kinetic Concepts Inc., San Antonio, TX, USA) was placed with 150 mmHg continuous suction and the patient responded well. The surgical wound healed and the patient was discharged after a total of 5 weeks and was followedup in clinic with physical examination and serial local MRI every 3 months ().\nTwo years postoperatively, the patient walked without assistance. She was asymptomatic, and physical exam did not reveal any local recurrence. There was considerable improvement in her appearance and mobility. Local MRIs have not revealed recurrence or tumor progression (). |
A 36-year-old man, originally from Latin America, presented at our outpatient department with complaints of abdominal pain that had persisted for 2 months. The patient had first noticed right lateral abdominal pain 2 months prior to the visit, and the pain was gradually worsening. The abdominal pain was localized in an area ranging from the right upper to the right lateral abdomen. The patient had undergone cholecystectomy for acute cholecystitis as a 32-year-old in Latin America and had moved to Japan for work approximately 3 years prior to his initial visit to our hospital. He had returned to Latin America once about 6 to 7 months before presenting at our clinic. When he went back to Japan, his weight had increased from 130 kg to 145 kg. He did not experience abdominal pain immediately after his return to Japan, but, as noted above, he started to gradually feel pain in the right lateral region about 2 months prior to presentation.\nHe first visited another hospital emergency department 1 month after onset of the pain. Initially, gastrointestinal tract spasm was suspected, and he was treated with tiquizium bromide. Though the medication partially relieved his abdominal pain, most of the pain persisted. The result of a workup by a urologist was negative, even though nephrolithiasis was suspected. His abdominal pain was exacerbated upon changing posture, and thus it was suspected to be of somatic rather than visceral origin. Abdominal pain persisted despite treatment with loxoprofen sodium hydrate, and any cause of abdominal pain was not detected on further evaluations, including hematologic laboratory analysis, urine analysis, gastroscopy, or abdominal computed tomography (CT). Finally, he was referred to our hospital for further examination.\nThe results of screening for depression were negative, and the patient did not have symptoms such as loss of interest, depressed feelings, or any specific changes of surrounding conditions, such as family or work environment changes. He had no history of sexually transmitted infection, and his vital signs were within normal limits. His physical examination result was positive for Carnett’s test, and a prior surgical scar of approximately 18 cm was apparent at the right subcostal region. The patient experienced strong pain surrounding the surgical scar that was exacerbated by tapping. There were no skin rashes localized surrounding the pain. His pain exacerbated to 8 on a pain scale when he moved, such as during standing up or rolling over simultaneously. When he stopped moving, pain was partially relieved within 1 minute (3 on a pain scale). When he moved again, abdominal pain was again exacerbated. Hence, he was awakened by the abdominal pain when rolling over. No inflammation was detected (leukocyte count was 8580/mm3 and C-reactive protein was 0.10 mg/dl), and other laboratory findings were nonspecific, including liver/kidney function, blood glucose, and electrolytes. Urinary analysis indicated red blood cell count < 1/high-power field, white blood cell count 1–4/high-power field. Additionally, no abnormality was detected for Chlamydia trachomatis IgG/IgA, and no abnormality was apparent on the electrocardiogram. Enhanced CT revealed bilateral renal stones and fatty liver.\nWe first considered abdominal wall pain due to nerve entrapment because the Carnett’s test result was positive; therefore, we scheduled a trigger point injection at the site of tenderness. About 2 weeks later, the patient visited the emergency department of our hospital, reporting that his prior abdominal pain had decreased but that he was experiencing right inguinal pain. Loxoprofen administration had no effect on the pain. Costovertebral angle pain was apparent on tapping, the result of urine analysis was positive for occult blood, and abdominal CT revealed a urinary stone at the right urinary duct to the bladder. After pentazocine hydrochloride was administered for pain relief, the urinary stone was passed the following day. However, the patient’s right lateral abdominal pain was not relieved.\nHe felt that lying in the lateral position mostly relieved his pain. He had occasional vomiting. The abdominal pain was exacerbated by movements, such as rolling over, standing up, walking, and coughing. Injection of 1% xylocaine 10 ml at a trigger point of the right lateral region led to about 30% relief in pain. The patient was referred to an anesthesiologist for further evaluation and treatment, who performed transverse abdominal plane block and administered multiple analgesic medications (tramadol hydrochloride, pregabalin, celecoxib, and scopolamine butylbromide). These medications decreased the patient’s pain somewhat, and he reported that scopolamine butylbromide was most effective when the pain worsened. Because the patient’s symptoms were not relieved after trigger point treatment to the abdominal wall, we considered potential causes that might be associated with the location between the abdominal wall and visceral wall or related to other sources, including psychosocial, physiological, and other anatomical factors. We rechecked the abdominal CT scan for a suspected adhesion or abdominal hernia at the region of tenderness due to the prior surgical procedure, and we asked a radiologist to reevaluate the right upper abdomen in more detail. The radiologist confirmed a slight abnormality in the right upper abdomen and suggested the possibility of an adhesion around the surgical scar (Fig. ). We referred the patient to a gastrointestinal surgeon for laparoscopic evaluation and adhesiolysis. The patient underwent additional investigations, including cholecystocholangiography and colonoscopy for suspected postcholecystectomy syndrome, biliary dyskinesia, or colon abnormality. However, no cause of the abdominal pain was identified. On laparoscopic evaluation, a broad adhesion was observed. Adhesiolysis was performed 6 months after the patient first visited our hospital. Figure a shows adhesion between the peritoneum and omentum, liver, and ascending colon; Fig. b shows the condition after adhesiolysis. One month after adhesiolysis, the patient’s right abdomen pain level during movement improved from 8 to 2–3 on a pain scale. Therefore, he was able to move with less pain, and he did not feel pain when rolling over. The result of Carnett’s test was negative. After the patient started walking around his house, he felt abdominal pain about 5 minutes after walking. Hence, he was afraid of recurrence of abdominal pain and felt a little depressed and frustrated because he was unable to return to work early. We recommended a gradual increase in activity. He went on a trip 4 months after the operation without problems due to abdominal pain and then resumed his job 6 months after the operation.\nHowever, his abdominal pain deteriorated within 1 month after he resumed working. He presented with bleeding at the umbilicus, which was the laparoscopic port site, and abdominal incisional hernia was confirmed on the basis of CT. Repair of the abdominal incisional hernias and laparoscopic adhesiolysis were performed 8 months after the first operation. After the second operation, although it took time for some symptoms to improve because of surgical site infection, the patient’s symptoms were ultimately relieved, and he resumed his job again 5 months after undergoing the second operation. Although he reported mild abdominal pain and required analgesic medication, his weight decreased to 133 kg, and he was able to walk normally and work full-time, 2 years after he initially visited our hospital. The timeline of interventions and outcomes is shown in Additional file . |
Our patient is a 38-year-old male who presented with right chest wall and shoulder pain after a weight lifting injury. The patient was performing a one-rep max bench press when he felt a pop in his right upper arm, accompanied by severe pain. There was no history of anabolic steroid use. He was initially treated with ice and a sling by a trainer and presented to the emergency department for further evaluation. Plain films were negative for fracture or dislocation and the patient was neurovascularly intact, so he was discharged home by ER staff in the sling. He presented to the orthopedic clinic the following day with moderate pain in the chest and arm. He denied numbness and paresthesia. On physical examination, there was a large amount of swelling and ecchymoses throughout the right upper arm extending into the pectoralis major muscle belly. Additionally, there was a large bulge in the anterior chest with loss of contour of the axillary fold (). The patient had full active range of motion of the elbow, wrist, and digits. He was sensory intact throughout the right upper extremity with a 2+ radial pulse. An MRI was scheduled to determine the extent of the injury and to aid in surgical planning. The patient was given oxycodone and valium to alleviate the pain and muscle spasms until surgery, which was scheduled after his MRI. The MRI demonstrated avulsion of the pectoralis major tendon from its insertion on the humerus with retraction as well as strain of the anterior deltoid (Figures and ). He was scheduled for surgery in five days. Two days later, the patient returned to our facility with severe worsening pain in the right upper arm. Intracompartmental pressure readings in the anterior compartment of the arm taken about the midpoint of the biceps at the point of maximal swelling were 37, 39, and 42 mmHg with a diastolic blood pressure of 71 mmHg (). Thus, with a diagnosis of compartment syndrome confirmed, we proceeded to the operating room for an emergency fasciotomy with repair of the pectoralis major tendon rupture.\nAn extended deltopectoral approach was used, and the deltopectoral and biceps fascia were released. Immediately, a large amount of hematoma was expelled and the muscle bellies visibly bulged from the incision sites (Figures and ). All muscles still appeared viable. No apparent vascular damage was noted. Upon further dissection, both heads of the pectoralis major were found to be avulsed from the proximal humerus (). After preparation of the footprint with curette and rongeur, three double-loaded 4.5 mm Mitek suture anchors (DePuy Synthes, Raynham, MA) were placed lateral to the bicipital groove for the repair of the tendon. The proximal and distal suture anchors were used such that one suture of each was run in a Krakow fashion along the superior and inferior aspects of the tendon, respectively. The remaining suture from each of those anchors was passed in a horizontal mattress fashion medial to the Krakow stitches. The middle suture anchor was used to place a horizontal mattress stitch with a medial ripstop stitch (). The wound was irrigated, and a negative pressure dressing was applied. The patient was made nonweightbearing and placed in a sling with a circumferential strap to ensure adduction of the arm. The patient returned to the operating room four days later to undergo irrigation and debridement with a tension-free primary wound closure. He was again placed into his sling and given strict instructions to avoid abduction and external rotation of the arm. The patient did well postoperatively and was discharged home in a stable condition that same day with a one-week follow-up appointment. He continued to do well and was instructed to remain nonweightbearing in his sling for a total of 6 weeks before beginning formal therapy. Gentle stretching and passive range of motion were then begun, followed by strengthening exercises at the 12th week mark. At his four-month follow-up, the patient had active forward flexion of the shoulder to 150°, abduction to 150°, and external rotation of 50°. His rotator cuff, biceps, triceps, wrist extensors, wrist flexors, and interossei all demonstrated 5/5 strength. There were no sensory deficits on examination. He continues to attend therapy for motion and strengthening and has a lifting restriction of <5 pounds at work. |
A 72-year old man, previously well, was admitted to a regional hospital with fever, recurrent bloody sputum, weight loss and left sided chest pain of 4 weeks duration. A chest radiograph showed a mass at the left hilum thought to be a neoplasm (see figure ). A misdiagnosis of haematemesis led to an upper gastrointestinal endoscopy showing oesophagitis. He developed respiratory failure requiring ventilation. A subsequent bronchoscopy excluded a central bronchial tumour, confirmed by histopathologic examination of biopsies. He was transferred to a specialist centre where a CT and MRT scans of the thorax showed the mass to be infiltrating the left upper lobe and was suspicious for an aneurysm of a coronary artery (see figure ). Transthoracic echocardiography and MRI confirmed this impression and he proceeded to coronary angiography, which demonstrated a giant aneurysm from the LAD (figure ). He developed cardiovascular instability and proceeded emergently to surgery.\nThe procedure was performed using right atrial to aortic cardiopulmonary bypass via median sternotomy and opening of the anterior pericardium. The aneurysm was adherent to the left anterolateral pericardial aspect and was not disturbed until cardioplegic arrest was achieved, to avoid distal embolization in a beating heart. After achieving myocardial arrest the dissection was completed, revealing the aneurysm to have entry and exit openings into the proximal and mid LAD (see figure ), and there was compression of the left upper lobe with airway inflammation rather than invasion. The adherent pericardium was removed together with the aneurysm and a large quantity of thrombus, leaving a significant pericardial defect requiring Supple-Guard patch closure. The proximal and distal communications from the LAD to aneurysm were closed. A single end-to-side vein graft was performed in the mid LAD distal to the aneurysm (see figure ). After reperfusion and rewarming cardiopulmonary bypass was weaned without difficulty. Thereafter the medial surface of the left upper lobe was inspected, confirming absence of a fistula.\nThe patient was transferred to the Intensive Care Unit where after a period of inotropic support, he was stabilised and extubated on the 2nd post-operative day but developed respiratory insufficiency requiring 5 further days of ventilation. He was discharged well on the 27th post-operative day and had no further events at follow up to 7 months. |