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A 62-year-old woman was referred to the emergency department in our hospital due to a body height fall. She was presented with severe pain in her left hip and the inability to walk. Her following examination revealed a 30-year-old femoral neck fracture. The option of treatment at that time was an arthrodesis of the left hip. Having presented with the history of trauma, we did not take into consideration a proximal femoral malignancy. However, Ungureanu et al. stated in their study that tumoral growths can be kept hidden under adipose tissue or local swelling located at the thigh level and they could appear concurrently with trauma . Therefore, the differential diagnosis was made using the patient history and the CT description given by the radiology specialist. A standard emergency anteroposterior radiograph revealed an intertrochanteric fracture, severe deformity of the left hip joint, and the migrated implants used for the arthrodesis (Fig. ). Computed tomography (CT) imaging of the left hip joint showed a displaced intertrochanteric fracture distal to the ankylosed hip joint, some artifacts due to the osteosynthesis material, and marked atrophy of the gluteus muscles (Fig. ). Due to the rarity of the pathology, several discussions with fellow surgeons were needed to establish what the best therapeutic option was. We decided to perform a surgery to remove the osteosynthesis material used for arthrodesis of the left hip and then perform the internal fixation using a locking plate and locked screws (Fig. ). The patient was positioned in dorsal decubitus; we used a lateral approach (a skin incision reaching approximately 5 cm proximal and 15 cm distal from what used to be the tip of the greater trochanter). Intraoperative passive mobilization of the limb was realized to outline some intraoperative anatomical landmarks. After initial hardware removal, normal femoral rotation was re-established and checked intraoperatively using the C-arm. A rigid secondary fixation was realized using a locked plate and 13 locking screws. Postoperatively, the patient's evolution was good, and after 2 weeks, she could walk using double crutches. Postoperatively after 3 months, the fracture showed signs of consolidation.
The volumetric CBCT dataset of a 67-year old female was referred to our department for the pre-implant evaluation of an edentulous left maxilla in the region corresponding to the first molar (and ). A medium-volume CBCT was prescribed by the implantologist and was acquired in the office of the periodontist who referred the case to us. A Carestream CBCT CS 9300 (Carestream Inc., Atlanta, GA, USA) was used with a voxel resolution of 200 µm. A limited field of view was used to capture the maxilla. No significant medical or dental history was reported by the periodontist. The patient had not been hospitalized in the recent past, and she was stable and alert at the time of presentation. The dental examination revealed multiple dental restorations, including root canal treatments, that had been done over a period of time. The left maxillary first molar was missing in the arch and the patient expressed interest in having an implant placed in that region. The office staff proceeded with the radiographic examination after the clinical examination was completed. The limited-volume CBCT was referred for radiographic consultation and reporting to the Case Western University School of Dental Medicine.\nMultiplanar CBCT reconstructions and 3D reformations demonstrated the area in question and appropriate measurements were made as part of the pre-implant evaluation of the left maxillary first molar region ( and ). In addition, an incidental finding was noted, unrelated to the clinical question. In the axial slices, a large low-attenuation area within the occipital region on the right side in close proximity to the mastoid region was observed (,,). It was a well-defined, noncorticated, transosseous defect with a homogenous density similar to that of soft tissue. Volume rendering helped isolate the mastoid foramen for better visualization (,,). Based on the radiographic examination, and since no other clinical signs and symptoms indicated intracranial abnormalities, the diagnosis of a mastoid emissary vein was made. Interestingly, a small mastoid foramen was also noted on the left side corresponding to the area on the right. In order to rule out other intracranial pathology and to confirm the diagnosis, a second opinion was sought from a neuroradiologist at the Case Western Reserve University Hospital who concurred with our diagnosis based on the history, physical data, and radiographic findings. No further advanced imaging was ordered once the diagnosis of this anatomical variation within the skull was confirmed.
A 28-year-old woman presented to the outpatient clinic of the department of ophthalmology with a small hard mass in the right medial upper eyelid that had lasted for 2 years. The patient had undergone endoscopic sinus surgery 12 years previously and had no other history of surgery or trauma. At the ophthalmology outpatient clinic, she received no definitive diagnosis and did not undergo treatment. After 2 years, the mass became larger and was accompanied by pain. For these symptoms, she visited the ophthalmology outpatient clinic again and the ophthalmologist referred her to the outpatient clinic of the department of plastic and reconstructive surgery. About 4 days prior to presentation, she had experienced swelling in her right eye area, frequent secretion of tears, and severe headaches. On physical examination, a palpable mass was observed in the right upper medial eyelid area. The mass was soft but fixed, and the patient complained of sensory disturbances in the right supraorbital nerve region. On an ophthalmic examination, the degree of exophthalmos was 21 mm on the right side and 17 mm on the left side, and eye protrusion and lateral displacement of the right eyeball were observed (). Computed tomography (CT) was performed, and an expanding cyst measuring 3.8× 2.8 cm was observed over the frontal and right ethmoid sinuses (). In addition, magnetic resonance imaging (MRI) was performed, and cystic fluid filling the frontal and right ethmoid sinuses was found to have invaded the right orbit. In order to perform a radical excision of the mucocele and to reconstruct the displaced orbital bone, a skin incision was made, and the mucocele was removed completely (). Next, we observed the medial orbital wall through the nasal cavity using an endoscope, and observed that although the protuberance had been removed, severe adhesions remained. Marsupialization was performed to drain the fluid from the remnant cyst in the ethmoid and frontal sinuses. Resection of the medial orbital wall was planned for the future in an attempt to avoid the risk of infection that would accompany immediate reconstruction. After surgery, lateral displacement of the eyeball and right-side exophthalmos resolved. At 5 days after surgery, the patient was discharged with no complications. A follow-up CT scan at postoperative 5 months showed complete removal of the mucocele with no specific complications (). The patient was followed for 10 months, and no noteworthy complications or symptoms were observed.
A 52-year-old Caucasian man with a longstanding history of Gastro-oesophageal reflux disease was under routine care in Gastroenterology clinic. He described a 5 week history of a mobile left upper abdominal mass associated with episodic pain and bloating worst after meals. He had experienced no weight loss and had regular bowel habit.\nOver the next four months the patient developed worsening discomfort, alteration in bowel habit described as increased frequency of loose motions, and weight loss. Plain abdominal radiograph demonstrated a homogenous radiolucent oval structure in the left upper quadrant. Surgical referral and a contrast enhanced C.T scan were arranged.\nThe intra-venous and oral contrast enhanced CT scan demonstrated a large 12 cm gas filled structure in the left upper abdomen that appeared to be arising from the top of the sigmoid colon. There was no mural or intra-luminal enhancement, and this was associated with mild underlying wall thickening at the neck, and thought to represent a giant sigmoid diverticulum. [Figure : Selected coronal, sagittal and axial sections from CT scan demonstrating a large gas filled structure that appeared to be arising from the top of the sigmoid colon] A barium enema was requested and this showed that the air filled structure was immediately adjacent to the apex of the sigmoid loop but barium did not enter the cavity and it did not change size on air insufflation. [Figure : Spot image from barium enema demonstrates an air collection immediately adjacent to the apex of the sigmoid loop and diverticular disease in the sigmoid and descending colon] Diverticular disease was also noted in the sigmoid and descending colon.\nDue to ongoing symptoms, the decision was made to perform an elective laparoscopy and sigmoid colectomy.\nPathologic examination demonstrated a cystic structure with a smooth lining, 11 cm in maximum diameter, with a wall thickness of 0.6-1 cm. There was no mucosa, and the wall was composed of dense fibrous tissue with foreign body reaction and acute and chronic inflammation. This made the cyst a type 1 giant colonic diverticulum or pseudodiverticulum. Diverticular disease was identified in the attached colon. The patient made an uneventful recovery.
A 47-year-old woman presented at our emergency room with anterior right knee pain, one day after a fall at home on level surface. She was unable to stand on her right leg. No previous trauma or knee pain was reported. Past medical history was positive for pituitary dwarfism and epilepsy. Physical examination revealed knee effusion and anterior hematoma. The knee was stable in all directions. Passive range of motion was complete, but the patient was unable to actively extend her knee. A complete extension lag was observed.\nKnee radiographs were obtained and demonstrated a significant diastasis between two patellar parts (Figures and ). As both parts presented regular contours without evidence of acute fracture rims, further investigation was required. Magnetic resonance imaging (MRI) confirmed the presence of an intermediate ruptured tendon between the two patellar parts ().\nThe diagnosis of an intermediate tendon rupture in a duplicate patella was stated. In order to restore the integrity and length of the extensor mechanism, we proposed an anatomical repair of the intermediate tendon. The surgery was performed the same day.\nSurgery was performed under general anesthesia, standard intravenous antibiotic prophylaxis, and tourniquet. A longitudinal 10 cm incision was centered on the patellar parts. Immediately after skin opening a voluminous hematoma was discharged at the level between the two patellar parts. A ruptured tendon was observed at this level. The two patellar parts were identified, without evidence of an acute or old fracture. A strip of tendon with the characteristics of a fully developed insertion was observed at both the distal part of the proximal patellar piece and the proximal aspect of the distal patellar part (). The medial and lateral retinacula were ruptured. The knee was positioned at 60° of flexion, and the two patellar parts were brought closer with two 1.6 mm K-wires without removing any tissue at the interface (). Tenorrhaphy was performed (without any excessive tension or shortening of the tendon) through multiple sutures with Ethibond 1 (). A figure-of-eight tension band wire was added to protect the tenorrhaphy ().\nPostoperative care consisted of full weight-bearing with a hinged brace (blocked in full extension) for six weeks. Passive knee flexion was limited to 60 degrees during the first ten days and progressively increased to achieve 90 degrees after six weeks. Isometric quadriceps contraction was initiated immediately after surgery. Active knee motion (flexion and extension) and isokinetic quadriceps contraction were authorized after six weeks.\nThe tension band was removed after 6 months for slight discomfort, although the patient had already recovered a full active knee range of motion. The patient presented for a final visit 8 months after the surgery. She had a painless knee with full range of motion and symmetric quadriceps extension strength (no extension lag). The last radiographs illustrate a typically healed duplicate patella with a free space between the two parts, as bone healing was not the goal ().
A 33-year-old male patient presented to a tertiary care hospital with intermittent abdominal pain, nausea, vomiting, constipation and numbness of bilateral lower limb extremities, of 3 days duration. He was conservatively managed in a surgical unit as partial intestinal obstruction and was awaiting diagnostic laparoscopy. The patient developed confusion and found to have systemic hypertension, and, therefore, was transferred to a medical ward for further management. He is a non-diabetic and did not have a previous history of hypertension. The drug history revealed usage of over-the-counter analgesics for 6 weeks.\nThe past medical and surgical history revealed similar neurovisceral attacks requiring five acute hospital admissions over 2 years, which ended up in questionable diagnoses. The sixth acute attack raised the suspicion of an acute porphyria. The first attack in January 2013 led to a diagnosis of appendicitis. Because the symptoms worsened following the surgery an emergency laparoscopic exploration was done. But the exploration revealed no cause to explain the worsening symptoms. The second attack was managed as sinus tachycardia and he was started on beta adrenergic blockers. The third attack which was associated with a fever was conservatively managed for a questionable renal colic. Forth attack was complicated with transient hyponatremia and transiently high serum creatinine levels. These complications were attributed to a questionable interstitial nephritis based on the fact that patient had used 50 mg of diclofenac sodium twice a day for 6 weeks, repeating the prescription given by a general practitioner. Another attack in 2015 was managed as partial intestinal obstruction and diagnostic laparoscopy was done. In all these presentations, findings from the ultra sound scans and diagnostic laparoscopy did not support a diagnosis of intra-abdominal pathology.\nOn examination he was thin built (BMI = 20 kg/m2) and pale. Brachial blood pressure was 160/90 mmHg. There were scars of previous appendectomy and laparoscopy surgeries on the abdominal, but, otherwise, the abdominal examination was unremarkable. Muscle power was 4/5 in all four limbs (could not move against a good resistance).\nThe laboratory investigations performed during this admission showed severe hyponatraemia of 115 mmol/L (136–145) with serum osmolality of 255 mOsmol/Kg (275–295) and urine osmolality of 460 mOsmol/Kg (50–1200 mOsmol/Kg). Serum creatinine concentration was 106 µmol/L (80–115) with blood urea level of 20 mg/dL (6–20). Hemoglobin concentration was 8.2 g/dL (13.5–17.5) and the red cell morphology was normochromic and normocytic. The total cholesterol level was 282 mg/dL (5th to 95th centile; 142–258) with LDL fraction of 225 mg/dL (5th to 95th centile; 78–185). Serum ferritin level was 646 ng/mL (20–250). Arterial blood gas analysis was suggestive of a metabolic acidosis. Echocardiogram showed evidence of left ventricular hypertrophy. There were no significant radiological findings in abdominal X-ray film or abdominal ultrasonography. Blood lead concentration was 3 μg/dL (< 5 μg/dL).\nA urine sample collected during the acute attack was sent to the Department of Chemical Pathology for biochemical analyses. On standing the urine sample gradually turned dark brown. The Watson and Schwartz test for urinary porphobilinogen (PBG) was positive (Fig. ). Spectrophotometry of urine for total porphyrins showed a “Soret band”. Urine total porphyrin level, calculated using Allen corrected absorbance of the urine sample was 5505.5 nmol/L (< 300 nmol/L). Genetic studies were carried out in an overseas laboratory. The full analysis of HMBS gene was performed by PCR amplification of extracted DNA followed by exon specific primer extension analysis of all exons, exon intron boundaries and promotor regions. The gene analysis revealed a previously reported missense mutation, c.517C>T encoding p.R173W in the HMBS gene. Targeted mutation analysis was performed by PCR amplification of extracted DNA followed by allele specific primer extension analysis, in five first-degree relatives. Among these, four were heterozygous for the same HMBS gene mutation (Fig. and Table ).\nSince heme arginate is not available in Sri Lanka the patient was managed only symptomatically. Carbohydrate loading with intravenous dextrose and oral carbohydrates was the only feasible option. All the medications used for symptomatic management were checked for safety in acute porphyrias. Patient was discharged from the ward after symptoms gradually improved over 6 days to a degree that he can be managed as an out-patient. Response to treatment could not be assessed due to unavailability of quantitative tests to measure urinary aminolevulinic acid (ALA) and PBG in Sri Lanka. The patient was educated regarding precipitating factors of acute porphyria. A diagnostic card with information regarding medications to avoid was provided to the patient. Patient was followed up at the clinic with regular renal functions, hemoglobin and blood pressure monitoring. Follow up of the patient over 1 year following diagnosis revealed that patient suffered from two mild attacks which didn’t require in-patient management. Nerve conduction studies were not carried out because neurological symptoms were not observed in-between acute attacks.\nPre-symptomatic relatives who inherited the HMBS mutation were also advised to avoid the trigger factors of acute attacks such as certain medications, fasting, alcohol and hormones. The brother of the proband was counseled regarding the risk of his children inheriting the HMBS mutation and recommended targeted mutation analyses for both children.
A fifty-four-year-old woman who had been in menopause for four years was admitted to our center with the complaint of postcoital bleeding for one year. Gynecologic examination revealed a 5 cm exophytic fragile lesion arising from the cervix. A biopsy confirmed the diagnosis of at least microinvasive adenocarcinoma. Computed tomography detected bulky lymph nodes at least 3 × 2 cm in size, which were found at the obturator fossa, the common iliac artery bilaterally, and at the right para-aortic region. Radiotherapy was planned after the resection of the bulky lymph nodes. Magnetic resonance imaging before treatment revealed a cervical mass measuring 58 × 31 × 30 mm. There was no invasion through the vagina or the uterus. The tumor extension reached the pelvic sidewall.\nWritten informed consent was obtained from the patient for the robotic surgery. Mechanical bowel preparation was performed 1 day before surgery. A prophylactic antibiotic and low molecular weight heparin were administered 1 h before the operation. The patient was placed in a low dorsal and steep Trendelenburg position. An appropriate shoulder support was placed to prevent the patient from slipping off the table. The patient underwent insertion of an indwelling Foley catheter. A five-trocar transperitoneal approach was used. The first skin incision for the 12 mm trocar was made 3 to 4 cm above the umbilicus. A direct trocar insertion was performed through the incision, and CO2 insufflation was continued until the intra-abdominal pressure was 16 mmHg. All subsequent ports were placed under direct visualization. The 8 mm trocar was introduced into the left upper quadrant of the abdomen, 10 cm lateral to and 1 to 2 cm below the camera port. The 8 mm right trocar was placed symmetrical to the left port. The third robotic instrument port was placed 8 cm lateral to the left trocar and 1 to 2 cm below the left port. A 10 mm assistant port was placed into the left upper quadrant between the camera port and left 8 mm robotic port. V-care (Conmed, USA) was used for uterus manipulation. The bowels were folded into the right paracolic region using a grasper to expose the pelvic anatomy. After the docking procedure, that is, fastening of the patient side cart to the trocars, the camera and endowrist instruments were introduced through the trocars. Monopolar scissors on the right side and bipolar forceps on the left side with either a fenestrated grasper or a Maryland dissector for retraction were used. After the setup, the first author continued the surgery at the console. During the inspection, there was no presence of disease within the abdominal cavity. For the pelvic lymphadenectomy, the paravesical and pararectal regions were identified. After the dissection of the internal and external iliac artery bifurcation, the ureter was retracted medially. There was a bulky lymph node that was 3 × 3 cm in size between the external iliac vein and the superior vesical artery (). The psoas muscle was identified and the lymphatic tissue between the external iliac artery and the vein was dissected off the pelvic sidewall. The bulky lymph node was extended to the obturator fossa. The obturator space was entered by reflecting the external iliac vein and the bulky lymph node medially, and the bulky lymph node was dissected from the posterior attachment to the external iliac vein and lateral attachment to the pelvic sidewall while preserving the obturator nerve (). For the right para-aortic lymphadenectomy, the right ureter and the psoas muscle were identified after the dissection of the peritoneum over the right common iliac artery. A fenestrated grasper in the fourth arm was used to retract the ureter out of the operative field. There was a bulky lymph node on the medial side of the right common iliac artery that was 2 × 3 cm in size. The lymph node was sent for frozen-section examination, and the result revealed the metastasis of the squamous cell carcinoma. The operation was followed by the pelvic and para-aortic lymphadenectomy procedure on the left side. There were two bulky lymph nodes on the left side; one was on the medial side of the left common iliac artery () and the other was in the left obturator fossa (). The sizes of the bulky lymph nodes were 3 × 2 cm and 2 × 2 cm, respectively. The bulky lymph nodes were removed with no complication (Figures and ). The dissected lymph nodes within the endobags were removed through the assistant port.\nThe robotic-assisted operation time was 255 minutes, and the mean console time was 215 minutes. The estimated blood loss was 70 mL. The hospital stay of the patient was three days. The number of lymph nodes retrieved was 28, and the number of the dissected para-aortic lymph nodes was 13. The number of the lymph node metastases was eight. The operation was completed with no conversion to laparotomy. Radiochemotherapy was planned after the surgical intervention.
This is the case of a 57 year old female who presented to the surgical clinic with a one month history of attacks of right upper quadrant abdominal pain, nausea and vomiting. An abdominal ultrasound demonstrated the presence of cholelithiasis and biliary sludge. The patient was diagnosed with symptomatic cholelithiasis and laparoscopic cholecystectomy was recommended to the patient on an elective basis. At the beginning of the procedure the peritoneal cavity was inspected with no masses, scar tissue or other abnormal pathology noted. During dissection of the gallbladder there were chronic omental adhesions noted but the gallbladder was not acutely inflamed. The cholecystectomy was able to be performed without complication and the gallbladder was sent for histopathological assessment. The pathology report was consistent with metastatic adenocarcinoma with signet ring features consistent with metastatic lobular carcinoma as well as chronic cholecystitis and cholelithiasis (see , ). Breast biomarker studies performed on the gallbladder were significant for PASD positive staining, antibodies that were positive included CK88, CK7, BRST2, and GATA3 (see ). Estrogen and progesterone receptors were both strongly positive, HER2 was negative.\nAt her follow-up appointment in the office a focused breast history and physical exam was performed. The patient denied family history of breast cancer. Full risk stratification and oncologic workup was pursued. Her BMI was 32.4, age of menarche was 13, her first pregnancy was at age 35, menopause began at 37 years old at which time she briefly was placed on estrogen therapy. She denied family history of cancer. She had a right breast lumpectomy in 2012 with benign pathology. Her last mammogram was in 2018 with no concerning findings at that time. A Gail score was calculated revealing a 12.5 % lifetime risk of breast cancer.\nBreast MRI revealed several spiculated masses in her right and left breasts as well as suspicious bilateral axillary lymph nodes. Potential areas of osseous metastasis were noted in her sternum and several ribs (see ). The study was deemed as BI-RADS 5 and she was sent for ultrasound guided biopsy.\nUltrasound guided biopsies of these masses revealed:Left breast: 11:00 spiculated mass, invasive ductal carcinoma with components of high grade ductal carcinoma in situ Left axillary lymph node: metastatic lobular carcinoma Right breast: 9:00 11 cm from nipple, lobular carcinoma Right axillary lymph node: metastatic lobular carcinoma\nAll locations showed immunohistochemistry that consisted of estrogen receptor positive, progesterone receptor positive, and HER 2 negative. The samples were CK88 positive; CD3, CD20 and CD21 were all normal (see , ).\nWhole body bone scan demonstrated multiple foci of increased radiotracer activity within the calvarium and posterior ninth rib (see ). This imaging grossly under detected the extent of osseous metastases that was detected on MRI of her brain which showed significant diffuse bony metastasis including the calvaria. There were no metastatic brain lesions noted.\nThe patient was initially treated with a CDK4/6 inhibitor (Palbociclib) which is a category 1 preferred first line treatment option for hormone receptor positive, HER2 negative metastatic breast cancer per the NCCN guidelines. She was also treated with zoledronic acid to reduce skeletal related events given the extensive osseous metastases as well as letrozole given her hormone receptor status. There are plans for restaging every 3 months.
A 59-year-old African-American man with past medical history significant for cervical thyroidectomy for goiter five years prior presented to the emergency center with acute strider and respiratory embarrassment. His oxygen saturations remained stable at 99% on a 50% non-rebreather face mask with a respiratory rate of thirty-two breaths per minute. The patient had been seen in consultation by the thoracic surgical service 6 months prior with the complaint of dysphagia and chest discomfort. He was found on computer tomography (CT) scan to have a large 9 cm posterior mediastinal mass adjacent to the trachea and displacing the esophagus. Serum markers were non-diagnostic. He was recommended for biopsy and surgical removal however he failed to return for any further surgical or medical intervention until his current presentation. The patient reported a recent upper respiratory tract infection including productive yellow cough, runny nose and subjective fevers. He had not sought any treatment until with continuous coughing overnight he experienced progressive stridor and respiratory distress which led him to his presentation to the emergency room. A repeat CT scan revealed the mass encroaching and compromising the tracheal lumen with displacement of the esophagus laterally ().\nThe patient was taken emergently to the operating room. Intubation was performed in the presence of the surgical team under direct fiberoptic visualization while maintaining spontaneous respiratory effort until the airway could be secured. A single lumen #6 endotracheal tube was passed beyond the tumor and positioned in the left main bronchus for single lung ventilation. A right posterior-lateral thoracotomy was performed through the fifth intercostal space giving good exposure of the mass. Gross distortion of the peri-tracheal structures was present secondary to the large space-occupying lesion (). The mass was densely adhered to the posterior mediastinum and right lateral tracheal wall, requiring meticulous dissection off these structures. After gross resection of the mass, a single chest tube was placed and the thoracotomy closed in a standard layered fashion. Final pathology was consistent with benign thyroid goiter (). Due to concerns of tracheomalasia, the patient was kept intubated 48 hours following surgery. After endoscopic confirmation of airway patency, the endotracheal tube was removed under direct visualization. The patient did well, however, was noted to have persistent hoarseness and vocal cord paralysis consistent with right recurrent nerve injury. Surgical medialization of his vocal cord was performed and at 6-month follow-up he was doing well.
A 9-year-old medically free boy presented to our emergency 25 days after sustaining an open ulna fracture following a motorbike accident. The patient was seen at a peripheral primary healthcare center, the wound was small as per the family description, it was cleaned and covered and his X-ray showed and ulna fracture which his was given an above elbow splint and due to the unavailability of an orthopedic surgeon, he was asked to visit a higher center.\nThe patient was thin and below the 50th percentile for his weight, he was uncomfortable and the local examination showed a small 1 cm healed scar on the surface of the ulna with a mild deformity. Wrist and shoulder examination were intact but his elbow range of motion was limited to 70–110° of flexion. His distal neurovascular examination was intact.\nOn reviewing his X-ray at presentation, it showed a proximal ulna fracture with associated radial head dislocation (, ).\nThe patient was admitted and the social services were informed to rule out non-accidental injury or neglect and they concluded that there was no concern or suspicion and the family was undereducated with 14 kids and came from a low socioeconomic status. The patient was consented for closed reduction under general anesthesia with the possibility of internal fixation versus open reduction and internal fixation. Although closed reduction would be likely unsuccessful, it was attempted regardless to ovoid open reduction. After failure of closed reduction, an antegrade flexible nail was inserted, and the proximal and distal segment were manipulated and the radial head was still irreducible, open reduction was performed using the Kocher interval and removal of the interposed soft tissue was performed along with annular ligament repair. Two antegrade flexible nails were inserted to optimize the stability and provide more rigid fixation. Although the reduction was found to be stable, intraoperative range of motion was found to be significantly limited, especially extension. The patient was placed then in an above elbow splint in slight hyperflexion to maintain the reduction (, ).\nThe patient was kept for 48 h postoperatively to monitor the neurovascular status and to discuss with the family the intraoperative findings, he was discharged and given follow-ups at 2, 6, and 8 weeks. At the 8 weeks follow-up, the patient was readmitted as a day surgery case and the flexible nails were removed and the fracture showed radiographic union (, ). A formal supervised physical therapy protocol was initiated to overcome the patient’s elbow stiffness which included flexion and extension exercises, and at the 6-month follow-up, the patient showed drastic improvement in range of motion but still not acceptable for his age, the patient continued formal physical therapy for 6 months in the form of weight-assisted exercises and at 1 year, he showed a 30–120 flexion and extension arc and near full pronosupination.
A 15-year-old male patient presented to our orthopedic outpatient department with a rapidly enlarging protruding tumor on the left chest anterior wall, which had gradually increased in size over the preceding year. He had no history of preceding trauma or local irritation. The tumor was asymptomatic but was a physical obstacle due to its protruding nature. On examination, a protruding lesion was noted on the left chest wall, measuring approximately 4 × 3 cm in size (). Magnetic resonance imaging revealed a tumor measuring 4 × 3 × 3 cm, protruding subcutaneously superior to the clavicle (Figures and ). Computed tomography revealed that the tumor had not invaded the clavicle. Histopathological examination following hematoxylin and eosin staining of the needle biopsy specimen revealed that the mass comprised fibromyxoid tissue with focal spindle cell proliferation and inflammation in a loosely myxoedematous matrix with extravasated red blood cells (). Further diagnostic testing via FISH analysis with a USP6 Dual Color Break Apart Probe was performed. FISH analysis revealed many USP6 rearrangements by splitting of the red and green signals in both nuclei in this field, strongly suggesting a diagnosis of NF (). Although the histopathological results did not match the clinical course, such as extremely rapid growth, he was followed up without treatment. The tumor size rapidly increased to 8 × 6 cm, and the tumor protruded further in a few weeks. One month later, the tumor spontaneously separated and fell off (). The separated tumor measured approximately 6.5 × 5.3 × 3 cm and was mostly a necrotic lesion with bleeding. Following this, the remaining tumor on the chest wall continued to grow rapidly ().\nAlthough histopathological results confirmed the diagnosis of NF, the clinical findings, which included a protruding lesion that separated and fell off spontaneously, large tumor size, and rapid enlargement, suggested the possibility of malignancy, prompting the need for wide resection. Intraoperatively, we observed that the tumor had not invaded the muscle and bone. The postoperative period was uneventful. The resected tumor measured approximately 5.5 × 4.5 × 3 cm (). Histopathological examination of the resected tumor following hematoxylin and eosin staining and FISH analysis with a USP6 Dual Color Break Apart Probe showed similar results as that of histopathological examination of the preoperative needle biopsy specimen. Furthermore, the fusion gene USP6-MYH9 was confirmed by polymerase chain reaction. These findings were consistent with a diagnosis of NF. After 1 year of follow-up, the patient did not show any recurrence, metastases, or other complications.
A 54-year-old black woman came to the emergency department brought by an ambulance after being found unconscious in her bed. The patient ingested all the pills she had at home. After medical stabilization, she was admitted to the Inpatient Unit. The patient was born in Cuba and moved to Spain at the age of 25. Divorced and married again. She lived with her current husband and her daughter and was unemployed. No medical condition or substance abuse had experienced in the past. Regarding mental illness, she had paranoid psychotic symptoms focused in her job that required admission and was treated with olanzapine 15 mg/day ten years ago. During these last years, the patient had undergone follow-up at the Mental Health Center. She continued on olanzapine but the dose of olanzapine was gradually reduced to 5 mg per day and duloxetine 60 mg was added because she referred depressive symptoms. Despite all of this, in the last year, her functionality had been poor and she had tendency to apathy, low activity and social withdrawal, symptoms that could be characterized like negative symptoms without apparent positive symptoms. Nevertheless, last 8 weeks, her husband said she has been more absent, with moments in which she stated hearing critical comments from neighbors and felt they were entering her house to rob and move her things around to annoy her. She also had delusions of persecution when occasionally leaving the house, thinking people were watching her.\nThe patient refused to take olanzapine after admission because of weight gain and drowsiness, two common side effects associated with this medication. Cariprazine 3 mg at night was prescribed and diazepam was added at 10 mg to promote rest.\nThe first days of her admission, she was very hostile to the staff with moments of verbal aggressiveness and other periods when she was isolated in her room. She even refused to eat. On the third day, cariprazine was increased to 6 mg since it was well tolerated and an improvement in her behavior was experienced on day 8 of admission. She started to talk to other patients and showed some criticism of the delusional thought about neighbors entering her home. Gradually, her mood improved, and she expressed desire to resume her daily life by returning home. Also, the thoughts of death disappeared. The patient accepted current treatment, saying that it has been useful for improving his mood and feeling better.
A 16-year-old, Sinhala ethnic Sri Lankan woman in her first pregnancy, was admitted with severe preeclampsia at 29 weeks of gestation. She has made her booking visit at ninth week of gestation and all the booking investigations were normal except for the platelet count which was 112,000 per liter. During her pregnancy, the lowest platelet count was 80,000 per liter at 27 weeks of gestation and no specific intervention has been done except for regular monitoring of the platelet count. She had been diagnosed with gestational hypertension at 22 weeks of gestation and prescribed labetalol and methyldopa. Other than that, she has had few erythematous, itchy macular lesions over the palm of her right hand from early in the first trimester onwards and had persisted throughout the pregnancy. She has had mild pain in her right small finger from first trimester onwards. But she had not worried about these symptoms so they had gone unnoticed. She had been apparently well until late 28 weeks of gestation and then she has developed a severe headache and worsening of bilateral lower limb oedema with frothy urine leading to hospitalization. She was diagnosed with severe preeclampsia (blood pressure of 185/115 mmHg) at 29 weeks of gestation. An emergency caesarean delivery was arranged soon after this presentation. Her baby was admitted to the premature baby unit with a birth weight of 1000 grams. She was in intensive care unit in first 24 hours after delivery and received intravenous magnesium sulphate as a prophylactic anticonvulsant.\nHer pain in the right finger worsened after delivery and erythematous macular lesions have been increased in number and spreading over the dorsal aspect of the right forearm. She was not worried and lesions have gone unnoticed especially with her dark skin complexion. Her blood pressure was under control with oral nifedipine. At the eighth postpartum day, her right small finger was noted to be cold with increased pain. Discoloration of the above skin lesions was more prominent and started to appear over the palm and the ventral aspect of the forearm of the right hand too, with preserved capillary refilling time. Both radial and ulnar artery pulsations were felt. There were no similar lesions in any other part of the body. She was soon transferred to a medical ward for further management.\nShe was subjected to an urgent arterial duplex study, which revealed proximal ulnar artery thrombosis in the right side with partial occlusion to the blood flow. And soon she was started on unfractionated heparin and eventually bridged with oral anticoagulants (warfarin) in order to archive the target international normalized ratio (INR) of 2.0-3.0. With anticoagulation treatment, her symptoms and signs were markedly improved. Sequential macroscopic changes of the affected arm and fingers have been shown in .\nRoutine laboratory analyses were within the normal range including subsequent platelet count, but she got positive results for direct Coombs test. Her reticulocyte count was high with normal haemoglobin concentration. Her ANA titre was strongly positive (1:320). And also anti-cardiolipin antibodies (anti-CL) and anti-β2 glycoprotein-I (anti-β2GPI) levels were also noted to be positive. However, her ds DNA and C3/C4 levels were within normal limits. Her blood pressure readings too have come back to normal level with no requirement of medications. Also proteinuria was settled. Her laboratory tests for APS were positive even after 12 weeks of initial testing. Therefore, it was diagnosed as a case of primary APS.
A 16-year-old, Sinhala ethnic Sri Lankan woman in her first pregnancy, was admitted with severe preeclampsia at 29 weeks of gestation. She has made her booking visit at ninth week of gestation and all the booking investigations were normal except for the platelet count which was 112,000 per liter. During her pregnancy, the lowest platelet count was 80,000 per liter at 27 weeks of gestation and no specific intervention has been done except for regular monitoring of the platelet count. She had been diagnosed with gestational hypertension at 22 weeks of gestation and prescribed labetalol and methyldopa. Other than that, she has had few erythematous, itchy macular lesions over the palm of her right hand from early in the first trimester onwards and had persisted throughout the pregnancy. She has had mild pain in her right small finger from first trimester onwards. But she had not worried about these symptoms so they had gone unnoticed. She had been apparently well until late 28 weeks of gestation and then she has developed a severe headache and worsening of bilateral lower limb oedema with frothy urine leading to hospitalization. She was diagnosed with severe preeclampsia (blood pressure of 185/115 mmHg) at 29 weeks of gestation. An emergency caesarean delivery was arranged soon after this presentation. Her baby was admitted to the premature baby unit with a birth weight of 1000 grams. She was in intensive care unit in first 24 hours after delivery and received intravenous magnesium sulphate as a prophylactic anticonvulsant.\nHer pain in the right finger worsened after delivery and erythematous macular lesions have been increased in number and spreading over the dorsal aspect of the right forearm. She was not worried and lesions have gone unnoticed especially with her dark skin complexion. Her blood pressure was under control with oral nifedipine. At the eighth postpartum day, her right small finger was noted to be cold with increased pain. Discoloration of the above skin lesions was more prominent and started to appear over the palm and the ventral aspect of the forearm of the right hand too, with preserved capillary refilling time. Both radial and ulnar artery pulsations were felt. There were no similar lesions in any other part of the body. She was soon transferred to a medical ward for further management.\nShe was subjected to an urgent arterial duplex study, which revealed proximal ulnar artery thrombosis in the right side with partial occlusion to the blood flow. And soon she was started on unfractionated heparin and eventually bridged with oral anticoagulants (warfarin) in order to archive the target international normalized ratio (INR) of 2.0-3.0. With anticoagulation treatment, her symptoms and signs were markedly improved. Sequential macroscopic changes of the affected arm and fingers have been shown in .\nRoutine laboratory analyses were within the normal range including subsequent platelet count, but she got positive results for direct Coombs test. Her reticulocyte count was high with normal haemoglobin concentration. Her ANA titre was strongly positive (1:320). And also anti-cardiolipin antibodies (anti-CL) and anti-β2 glycoprotein-I (anti-β2GPI) levels were also noted to be positive. However, her ds DNA and C3/C4 levels were within normal limits. Her blood pressure readings too have come back to normal level with no requirement of medications. Also proteinuria was settled. Her laboratory tests for APS were positive even after 12 weeks of initial testing. Therefore, it was diagnosed as a case of primary APS.
A 28-year-old Indian male, shopkeeper by occupation, presented to us with history of pain and swelling on the ulnar aspect of the distal part of left forearm since one year. The swelling was painless and had increased in size gradually. There was no history of fever, loss of weight or appetite, swelling at other sites or history of similar complaints in the past. The family, occupational, recreational and drug histories were not significant. The general physical and systemic examinations were within normal limits.\nOn examination this swelling was comparatively smaller i.e. 3 cm long and 2 cm wide. The overlying skin was normal and free from the swelling. It was firm in consistency and adherent to the ulna. The distal neurovascular status was normal.\nPlain radiographs revealed a lytic lesion of the distal aspect of ulna with an indistinct medial margin (). A provisional diagnosis of Enneking stage 3 GCT ulna was made. After discussing the condition, prognosis and treatment options with the patient, we decided to perform wide resection.\nWe performed a wide resection of the distal 6 cm of the ulna that included 3 cm of the normal bone. ECU stabilization was done in the same fashion as described in Case #1 and the wound was closed over drain.\nThe post operative protocol was similar as described for Case #1. This patient had normal function and muscle strength, no pain or ulnar instability and full range forearm flexion - extension and pronation - supination. He scored 18 out of 18 points on the Ferracini scale.\nHisto-pathological examination of the resection specimen in both cases was consistent with the diagnosis of giant cell tumor. We achieved tumor free margins in both cases. Radiographic evaluation was done in by measuring the axis between the long axis of the radius and the third metacarpal on lateral view and ulnar subluxation of the carpus on AP view. Both cases had a normal radiographic outcome (, ). There were no instances of recurrence in either case at three years of follow-up.
A 34-year-old premenopausal female with a locally advanced tumour presented as a dirty ulcer, perforating the skin, in her right breast is described. Biopsies of the damaged tissue showed an invasive, grade III ductal carcinoma, with areas of papillary shaping, areas of necrosis, and invasion of the skin. The breast tumour was classified as triple negative, since there was a lack of estrogen and progesterone receptor expression and absence of HER2 oncoprotein after immunohistochemical staining. Staging revealed multiple lung metastases and enlargement of right axillary lymph nodes. Consequently, she was diagnosed with a stage IV infiltrating ductal cancer in her right breast which was triple negative and grade III.\nThe patient was started on first line chemotherapy with the regimen carboplatin 2AUC and paclitaxel 80 mg/m2 weekly plus bevacizumab 10 mg/Kgr on days 1 and 15. Initially she had a partial response to this treatment. However, her disease relapsed and she started on second line chemotherapy with the regimen docetaxel 75 mg/m2, adriamycin 60 mg/m2, and cytoxan 600 mg/m2 every 21 days. She received only two cycles of this chemotherapy because she was admitted to hospital due to multiple brain metastases. She was administered whole brain radiotherapy with minimal improvement of her clinical symptoms. Taking into account the triple negative, along with the BRCA1 mutation status, the patient was considered as a candidate for entering a clinical trial with PARP inhibitors. Unfortunately, due to a rapid systemic disease progression the patient finally passed away a month later and therefore did not receive any further treatment.\nThe proband had limited family history of breast or ovarian cancer. It is noteworthy that the family was rather small (). Her grandmother from her father's side was diagnosed with breast cancer and died at her early fifties. The other reported cancer in her first degree relatives is the prostate cancer diagnosed in her father when he was 72. He underwent prostatectomy for prostate cancer, due to his elevated PSA value (7 ng/mL). The histology report revealed the existence of a low differentiated adenocarcinoma of the prostate gland with Gleason's pattern 7 (4+3). Also there were some areas with high grade prostatic intraepithelial neoplasia (PIN). The stage of the disease was T3bN0M0. Consequently, he was diagnosed with a high risk prostate cancer based on T3b. Initially, he received radiotherapy and hormonal therapy with LHRH analogue and specifically triptoreline and antiandrogen (bicalutamide).\nMany research groups have reported that BRCA1 and BRCA2 mutation carriers are more likely to develop a more aggressive prostate cancer phenotype, generally associated with a higher probability of nodal involvement, distant metastasis, and low grade tumours [, ]. This observation is consistent with this case.\nDue to the early age of breast cancer diagnosis, along with the distinct immunophenotype, the patient fulfilled the updated NCCN guidelines () and was therefore tested for deleterious mutations in BRCA1 and BRCA2 genes. The direct relationship between BRCA1 mutations and triple negative breast cancer has been widely assessed in Greek patients []. Direct Sanger sequencing revealed the nonsense mutation p.E1060X (c.3178G>T), which is located on exon 11 of the BRCA1 gene. This is a rare, to the Greek population, mutation. The proband's father was tested to be the mutation carrier, while the proband's sister (cancer free at the age of 45) did not carry the damaging allele.
A 59 year-old female patient, who has been employed as rehabilitation worker, has observed gradually enlarging formations under both her right and left scapula for approximately eight months. In anteflexion, elevation of the upper extremities and when stretching the arms forward, swellings reaching up to the rear axillary lines appear bilaterally subscapularly. They were of soft consistency at palpation. The patient also described pain in the upper extremities, and in the region of arms. She had no recollection of any accident or fall. However, she had undergone neurosurgical operating procedures of disc extrusion in the cervical and thoracic spine, and the findings of bilateral resistances were present already pre-operatively. In the another surgical workplace repeated punctures and partial resection of the swelling on the right side were implemented 5 months ago, and it came to its subsequent recurrence.\nThe magnetic resonance ((b) and (c)) on thoracic wall showed in dorsolateral parts in subscapular regions in the level of 3rd to 7th rib symmetrical limited fluid collections with dimensions of 120 × 37 x 115 mm on the right side with a volume of 250 ml and on the left side 120 × 24 x 90 mm with a volume of 130 ml. The collections were localised in the intermuscular spaces between the external intercostal muscles and the heads of the muscle serratus anterior. The contents of collections were moderately heterogeneous with sporadic internal septa. Cystic formations had slightly distinct signal, native image in T1 weighing displayed hypersensitive contents on the right side. It could be a case of chronic post haemorrhagic changes. Postcontrastly the collections were without amplification of signal intensity. On the left side postcontrastly there was present a moderate reinforcement of capsule of fluid collection. In diffuse weighing the lesions were without marks of diffusion restriction. Axillary lymphatic nodes were of physiological size, the displayed pulmonary parenchyma was without inflammatory and focal changes, without mediastinal and hilar lymphadenopathy, the pleural cavities without effusion, the pleura was without hypertrophy, the recorded skeleton was without traumatic change.\nOwing to progressing swelling and increasing difficulties a surgical resection was indicated in the female patient. She was operated on under general anaesthesia, and a resection of the encapsulated collections of fluid was implemented bilaterally ((d)), two Redon drains were introduced. In the left collection serous fluid was present, on the right side also serous fluid with admixture of old blood was present. A histological examination of cystic collections proved that it concerned pseudocystic lesions with relation to subscapular bursa without marks of malignancy. Their walls were created by collagenous, hyalinised and vascularised connective tissue with predominately perivascular nonspecific chronic inflammatory cellulation ((a)), the internal surface of which was lined by a layer of fibrin and by a nonspecific granulation tissue with a focally accentuated xanthogranulomatous, siderophagous and giant-cell reaction without epithelium ((b)). In the lumen of the cysts there were remnants of blood clots with fibrinous or fibrinoid substances with dispersive admixture of siderophages, lymphocytes, neutrophils and giant polynuclear cells ((c)). The proof of amyloid by Congo red was negative. On the lesion periphery soft-tissue structures were caught, including striated muscularis. The drains were removed the 10th postoperative day due to higher production, the surgical wounds were healed-up per primam intentionem. After the operation the female patient had a full range of movements and was without trouble and pains.
A 31-year-old pregnant woman was referred to our centre for further evaluation of the foetus due to HLHS. On foetal echocardiography at 25 + 6 weeks gestation a small left ventricle with severe endocardial fibroelastosis, aortic atresia, and mitral stenosis could be seen. The pulmonary veins presented enlarged with reduced antegrade flow and significant reverse flow on Doppler sonography (0.47 pulmonary vein TVI ratio; ). The foramen ovale seemed to be small and restrictive () but of sufficient size for postnatal interatrial shunting. The mother was then given an appointment for caesarean section in our centre at 39 + 0 weeks of gestation. In the foetal echocardiography follow-up study 1 week before admission the flow across the foramen ovale further reduced and there was still a pathological pulmonary vein TVI ratio of 0.33. After careful consideration and informed consent was given by the mother the decision to perform foetal atrial septum stenting was made. The procedure was then performed at 38 + 3 weeks of gestation under ultrasound guidance. All foetal intracardiac procedures are performed with an interdisciplinary team consisting of two paediatric cardiologists with one cardiac catheter laboratory nurse, one perinatologist with experience in intrauterine therapy, and one anaesthesiologist. General anaesthesia was used for the mother without separate analgesia of the foetus. The right atrium was punctured with an 18 G needle. Then the atrial septum was perforated and a 0.014 wire was placed into a left pulmonary vein. A 3 mm × 9 mm coronary artery stent (ProKineticEnergy®, Biotronik) was then placed into the atrial septum () and dilatation was performed up to 16 bars correlating with a 3.4 mm stent diameter. Then the needle was removed without signs of tamponade or other complications. In the follow-up echo the day after the procedure the stent was in place with improved left to right shunting (). There was furthermore increased antegrade and decreased retrograde flow in the pulmonary veins measured by TVI in Doppler sonography (0.24 pulmonary vein TVI ratio). The mother was then again admitted for caesarean section at 39 + 2 weeks of gestation. There was completely uncomplicated postnatal adaption with Apgars 9 and 9 at 1 and 5 min and saturations of 86%. The newborn was then admitted to our pediatric intensive care unit (PICU) to start prostaglandin E1 infusions. On postnatal echocardiography, the stent was still in place with a mean velocity of 1.5 m/s measured by PW Doppler (). On the 7th day of life the boy then underwent a Norwood procedure. The stent was removed and an atrioseptectomy performed. There was an uncomplicated secondary closure of the chest on the 4th postoperative day. Due to recurrent supraventricular tachycardia an antiarrhythmic therapy with amiodarone was started. There were no signs of severe pulmonary vascular disease during the entire stay in hospital and the patient was ultimately discharged on aspirin on the 63rd postoperative day with adequate saturations and sinus-rhythm. The postoperative course after discharge was uncomplicated without further episodes of supraventricular tachycardias. Bidirectional Glenn surgery was then performed at 3.5 months of age and the boy was discharged on the 9th postoperative day. After 5 months the antiarrhythmic therapy with amiodarone was stopped. The last check-up at our centre was done at the age of 10 months and the boy did not show any symptoms or abnormal findings with saturations of 84%.
A 55-year-old male with a past medical history of chronic obstructive pulmonary disease, hypertension, hyperlipidemia, and nicotine dependence presented with worsening substernal chest pain with exertion. Initial work up showed a non-contributory electrocardiogram and troponin levels within normal limits. Patient already had a recent stress test myocardial perfusion imaging scan performed at outside hospital that was negative for ischemia or scar or high-risk features. The patient’s persistent atypical pain and risk factors for coronary artery disease (CAD) soon resulted in cardiac catheterization for possible acute coronary syndrome. Left heart catheterization via the right radial artery showed a large left main coronary artery that bifurcates into left circumflex artery with minimal disease and short LAD that gave a small diagonal artery which was occluded proximally (Fig. ). Upon engaging the right sinus of valsalva, an anomalous course was discovered. The right coronary artery was small and nondominant. The long LAD emerging from the right coronary artery gave collaterals to the previously mentioned long diagonal system on the left (Fig. ). Ventriculogram showed normal ejection fraction with normal intracardiac and transvalvular pressures.\nHis unique anatomy was observed in greater detail during a CT angiogram the following day which helped to further establish the course and to ensure the LAD did not course between aorta and pulmonary arteries. It was confirmed that the right coronary artery traveled in the anterior intraventricular groove to supply left ventricular myocardium, consistent with a type IV dual LAD per Spindola-Franco classification (Figs and ). Moreover, the normal MPI was reassuring that there was not compression involved; since that was the case, intravascular ultrasound was not performed in order to further assess this point. Cardiovascular surgery was not pursued since anomalous long LAD supply of anterior and septal regions was adequate without disease. The chronically occluded native long diagonal had adequate collateralization from the right long anomalous LAD at the apex. This was effectively single vessel disease with chronic total occlusion and negative low risk stress test on intermediate medical therapy. By appropriate use criteria for revascularization, it was determined the best option would be for further optimal medical therapy. The patient was discharged on optimal medical management including multiple antianginals: isosorbide mononitrate 30 mg, ranolazine 500 mg po bid, atenolol 25 mg po daily. High-risk percutaneous intervention of the ostial D1 would be pursued if symptoms could not be properly controlled.
The patient was a 32-year old woman with a one-year history episodes of cholecystitis treated conservatively. She did not have any other disease history. After an abdominal magnetic resonance imaging that confirmed multiple gallbladder stones (Fig. a), an elective LC was performed without intra-operative complications. The recovery was uneventful and the patient was discharged two days after operation. On the second day after discharge, the patient developed severe right upper abdominal pain and she was sent to our emergency department at 8:30 pm. At arrival, her heart rate was 110 bpm and the blood pressure was 80/55 mmHg. The hemoglobin dropped to 86 g/l from 127 g/l. The CT scan showed a 10.9 × 12.5 × 6.6 cm ISH in the right liver without obvious free fluid in abdominal cavity (Fig. b). Two hours after fluid resuscitation including 2 U red blood cell, the hemoglobin further declined to 78 g/l and the hemodynamics remained unstable. The abdominal pain was not relieved, after intravenous analgesics. A Doppler ultrasound was performed, two hours later and it found the hematoma had increased in size. Active intrahepatic bleeding was suspected. We called radiologist for consultation, however, the interventional angiography and embolization was not available at mid night. We explained the potential risk of sudden rupture of hematoma during conservative methods which may cause sudden death, to the patient and her relatives. After careful consideration of the continuous decline of hemoglobin, unstable hemodynamics after fluid resuscitation, we explained our surgical plan to the patient and her relative. We planned to perform laparoscopic exploration at first, if the hematoma continued to expand, we would evacuate or drain it, if not, we would put a drainage tube under liver which could serve as an early warning of rupture. The patient requested surgical method to reduce the risk of sudden death. Therefore, an emergency laparoscopic exploration was performed under general anesthesia. The ISH was confirmed (Fig. c). Four U red blood cell and 400 ml fresh frozen plasma were transfused. After fluid resuscitation and blood transfusion, her hemodynamic became stable. During the 3-h intra-operative observation, the hematoma did not expand. Therefore, a non-sucking drainage tube was placed under the liver and she was sent to ICU ward. Next morning, she was transferred to the ordinary ward. The upper abdominal pain gradually relieved. Five days after the laparoscopic exploration, another CT scan showed that the hematoma was largely resolved and we removed drain tube (Fig. d). She was discharged, 10 days after readmission.\nTotally, 13 papers, including 16 cases of ISH after LC were reported from 1994 to 2015 (Table ). Nearly half of the patients had instability of hemodynamics. All of the cases were female patients. Age of patients ranged from 25 to 78. All hematomas were mainly located in the right lobe of liver, and some of them extended to the left lobe of liver. Only one case was ruptured at diagnosis. Hepatic capsule laceration was found in two cases, one of whom also took NSAIDS (non-steroids anti-inflammatory drugs) to control the pain after operation. Totally, 58.8% of patients took NSAIDS to control the post-operative pain, and most of them used Ketorolac, however, 35.3% of the patients still did not have definitive risk factors. The time interval to diagnose ISH after LC ranged from seven hours to six weeks. They were diagnosed most commonly (35.5%) within one day after LC. All patients had abdominal pain and 47.1% of the cases developed hypovolaemic shock.\nTreatment strategies included: conservative treatment (antibiotics, blood transfusion, strict bed-reset), percutaneous drainage under CT or B ultrasound guidance, selective embolization of the bleeding vessel, laparoscopic exploration and laparotomy. Eighteen percent of patients had stable condition without fever and underwent conservative treatments. The only case of angioembolization was complicate by infection and required percutaneous drainage. For the patients with stable condition, fever and serious compression of inferior venal cava (IVC) always were indications for percutaneous drainage under CT or B ultrasound guidance. In these 17 cases, 29.4% of the patients underwent percutaneous drainage. For the patients with hemodynamic instability, emergent reoperation was adopted. Totally, nine cases underwent reoperation, including two case of laparoscopic operation and seven cases of laparotomy. For our case, we only performed laparoscopic exploration and did not perform evacuation or drainage of the hematoma, since the hemodynamic became stable after plenty fluid resuscitation and the hematoma did not expand, during the 3 h of intra-operative observation. For another case, laparoscopic exploration found small capsule laceration, and hemostasis was performed. In the seven cases of laparotomy, six patients underwent evacuation and drainage of hematoma, only one case underwent only laparotomy without evacuation or drainage.\nAll patients survived. Most of patients stayed one to two weeks after readmission, however, the longest hospital stay was up to 31 days after reoperation.
A 44 year old lady presented with shortness of breath on minimal exertion and swelling over the legs. She was diagnosed of hypertrophic obstructive cardiomyopathy in her early twenties which was successfully treated with trans-catheter septal ablation and she could manage two pregnancies thereafter. She was apparently free of symptoms till last couple of years ago, when she started having dyspnoea on exertion and pedal oedema which worsened rapidly. Echocardiography showed severe mitral regurgitation with dilated and poorly functioning left ventricle for which she underwent mitral valve repair. Her symptoms were not relieved with the surgery and she was classified as decompensating heart failure in NYHA stage three. Echocardiography showed severely dilated left ventricle with severe systolic dysfunction (ejection fraction of 25%). The patient was assessed for heart transplantation and was put on heart transplantation waiting list. However, due to progressive clinical deterioration and hypo-perfusion related chronic renal failure, it was decided to bridge her to heart transplant with LVAD. Pre-operative echocardiography showed mild mitral stenosis (mean gradient of 4 mmHg and valve area of 2 cm2). This could have cause obstruction to flow across mitral valve and in turn inadequate flow through LVAD after implantation. Through median sternotomy, the patient was put on CPB. A circular piece of myocardium (diameter of 2 cm) at LV apex just lateral to left anterior descending artery was resected for insertion of HVAD (Heart Ware Inc, Framingham, MA) LVAD inflow cannula. Through this hole, mitral commissurotomy was performed by cutting open the previously repaired mitral valve, starting at centre and progressing to both commissures. In addition, primary chordae attached to anterior leaflet were also divided to offer complete opening of the valve. A HVAD was implanted through this hole in routine manner. Briefly, a metal ring was suture fixed around the hole and HVAD pump was implanted on LV through the ring. The outflow graft was anastomosed to ascending aorta using side biting clamp. The HVAD was started as CPB weaned off slowly to generate flows of 4 to 5 l/min. Postoperative echocardiography at discharge showed no gradient across mitral valve.
A British Caucasian female patient aged 12 years and 9 months presented to our institution with a right thoracic scoliosis, which was first noted at the age of 12 years and 5 months. She was diagnosed with DWS on the basis of her craniofacial dysmorphism and confirmed on a magnetic resonance imaging (MRI) scan obtained at age 2 years. The patient was born prematurely at 27 weeks and was ventilated for the first 12 weeks of life followed by another 2 months of oxygen support, leaving her with chronic neonatal lung disease. She was slow to achieve developmental milestones and walked independently at age 3 years. At age 5 years and 6 months, she underwent cardiac surgery to close a patent ductus arteriosus (PDA). The patient suffered from chronic constipation and dysphagia but was otherwise medically well. She also had mild coordination difficulties affecting her hands and learning problems but attended mainstream school. There was no family history of neurological/syndromic conditions or scoliosis.\nAt presentation to our clinic, she reported a 6-month history of increasing thoracic back pain, causing sleep disturbance. She was premenarchal, with height 147.2 cm, arm span 148 cm, body weight 32.1 kg, and BMI 14.8. On clinical examination, the patient was slimly built with normal physical characteristics for her age. She had a severe right thoracic scoliosis, which was rotated to the right and produced a right-sided rib prominence on the posterior chest wall, adjacent to the convexity of the curve. There was also thoracic translocation with listing of the trunk to the right and mild elevation of the right shoulder. There was waistline asymmetry with prominence of the left side of the pelvis, which was level. She had normal thoracic kyphosis and increased distal lumbar lordosis with anterior pelvic tilt. There was no evidence of leg-length discrepancy. There were no abnormalities to the skin or subcutaneous tissues overlying the spine, and the patient did not report any subjective neurological deficits. Neurological examination confirmed normal muscle power, sensation, and brisk tendon reflexes in the upper and lower limbs. Mild clonus was elicited bilaterally. She had normal gait and balance. Spinal movements were pain-free but straight leg raise was restricted due to significant bilateral hamstring and gastrocnemius tightness. There was no tenderness on palpation along the spine and paraspinal muscles. The patient had mild ligamentous laxity.\nRadiographs of the spine taken at the patient's first assessment in clinic showed a right thoracic scoliosis extending from T6 to L2 and measuring 53°. There were 12 thoracic and 5 lumbar vertebrae with no evidence of congenital vertebral anomalies and no spondylolysis or spondylolisthesis affecting the lumbosacral junction. The hips were normal with congruent joints and well-contained femoral heads. The Risser grade was 1 indicating that the patient had a significant amount of remaining skeletal growth and was therefore at high risk for scoliosis deterioration.\nDue to the severity of her scoliosis, a decision was made to proceed with surgical correction. In the presence of the underlying condition, a preoperative assessment was organized and this included a repeat head and spinal MRI, as well as cardiac, respiratory, anaesthetic, and neurology reviews.\nThe MRI of the head and spine demonstrated hypoplasia of the cerebellar vermis and cystic dilatation of the 4th ventricle () and no vertebral, intraspinal, or paraspinal abnormalities. The cardiology assessment included an ECG and echocardiogram and found a structurally normal heart and no anomalies. Chest radiographs and sleep studies returned normal results and excluded apnoeic episodes. However, preoperative spirometry recorded FEV1 56% and FVC 56% predicted identifying a restrictive lung disease. A neurology review was undertaken and confirmed the absence of neurological abnormalities. No intervention was recommended in regard to the intracranial anomalies. The anaesthetic evaluation did not demonstrate any significant airway pathology that could complicate intubation and confirmed the patient's fitness to undergo scoliosis surgery. Blood test results including full blood count, urea, electrolytes, liver function tests, C-reactive protein, and coagulation screen were within normal limits.\nSurgery was performed 4 months after initial presentation, when the thoracic scoliosis measured 60° (). Thoracic kyphosis was normal, but there was increased lumbar lordosis associated with anterior pelvic tilt and a near horizontal sacrum. The patient underwent a posterior spinal fusion extending from T2 to L3 with pedicle hook, screw, and rod instrumentation and a combination of locally harvested autologous and allograft bone. The spinal fusion extended distally to the first lumbar stable vertebra (L3) and proximally to T2 in order to restore segmental and global sagittal balance of the spine and reduce the risk of proximal junctional kyphosis. The spine was exposed subperiosteally to the tips of the transverse processes and extensive facetectomies were performed in order to increase flexibility of the curve. No congenital vertebral abnormalities were identified. A bilateral hook/screw and rod construct was used, and this was secured to the spine by a combination of bilateral pedicle hooks with 20 mm locking screws extending from T2 to T4, as well as pedicle screws placed on the right side from T8 to L1 and bilaterally across L2 to L3. The deformity was corrected using apical segmental translation and a cantilever manoeuvre on the convex side, as well as proximal/distal distraction/compression of the construct. This was followed by extensive decortication of the posterior elements and onlay of autologous bone graft harvested from the spinous/transverse processes supplemented by allograft bone in order to achieve an intertransverse/interfacetal/interlaminar fusion. Intraoperative spinal cord monitoring was performed throughout the surgery recording cortical/cervical somatosensory (SSEP) and transcranial electrical motor (MEP) evoked potentials, as well as EMGs with no abnormalities detected.\nBlood loss during surgery was 240 ml (11% estimated blood volume), and the patient did not require transfusion. Postoperatively, she was transferred to the high-dependency unit (HDU) where she remained for one day. She did not require oxygen support or nutritional supplementation through nasogastric/nasojejunal tubes. She had no neurological abnormalities and mobilised with the support of physiotherapists in the first 2 days after surgery. She did not require brace support. The patient was discharged 8 days after the procedure with radiographic evidence of good scoliosis correction and an adequate coronal and sagittal spinal balance.\nThe patient was reviewed closely in the months following surgery, and she returned to her normal level of activities with no complaints of her back. At 9 months postoperatively, she was referred for surgical treatment of bilateral hallux valgus (). During her remaining skeletal growth, she was under the care of dieticians to optimise her body weight. At latest follow-up 4 years after surgery, the patient had completed her spinal development and she was happy with the surgical outcome. Spinal radiographs showed excellent deformity correction, which was maintained at follow-up with the instrumentation in good position and no evidence of pseudarthrosis ().
A 90-year-old woman visited our hospital due to a large area of erythema and localized skin ulceration with hemorrhage of her right breast. Her breast symptoms arose 5 years ago and had been worsening. She could not visit a hospital because she expected for naturally healing and feared noticing cancer and death. She had a history of atrial fibrillation and cerebral infarction 2 months earlier, then her breast lesion was found out. The area of erythema was 15 × 15 cm2. Her nipple and alveolar complex were destroyed and had an uncertain shape. Her skin erythema was soft, and no tumor was palpable (Fig. ). Her quality of life had got worse by hemorrhage and exudate from the tumor, and she felt strong anxiety about getting more worse and death from the cancer.\nA punch biopsy indicated mammary Paget’s disease. Computed tomography showed that the tumor was only on the surface of the breast, with no metastasis including of the axillar lymph nodes. There was no underlying tumor in the breast (Fig. ).\nEven though our patient was a very elderly woman with comorbidities and her prognosis was relatively good, her symptoms were intolerable. By the request of her and her family, we decided to perform surgery to eliminate the area of erythema after receiving sufficient informed consent. The surgical treatment was performed by two teams that included surgeons and dermatologists. We drew a resection line 1 cm from the skin erythema. Dermatologists were on standby in case a skin graft was needed. We performed muscle-sparing mastectomy with sampling of an axillar lymph node. We added two stress-relaxation sutures to avoid diastasis because the excision area was very large and the tension of the skin flap was strong (Fig. a, b). Fortunately, a skin graft was not necessary and her postoperative course was good. The skin flap did not develop major complications such as necrosis, seroma, wound infection, and highly disturbance of moving the right upper limb. We removed the stress-relaxation sutures 7 days after surgery.\nA histological examination revealed mammary Paget’s disease without invasion to underlying tissues (Fig. ), no evidence of a residual tumor of the entire stumps, and no metastasis in the lymph node. Although she felt a little tightness of the surgical site, paresthesia of the chest wall, and a sense of breast loss, her quality of life improved after surgery by being freed from symptoms and anxiety related to malignancy. It was a great value for her, even if she suffered from these complications.
A 32-year old gentleman was admitted to our trauma department with a painful, immobile right knee. He sustained the injury externally rotating his knee whilst in “slight flexion” while he was moving from the driver’s seat to the passenger’s seat of his car. He had a history of two previous lateral patellar dislocations on same knee. The first event was 15 years prior, when his knee twisted in flexed position while pushing a car. He was taken to the emergency department where it was successfully reduced under sedation. The second event was four years prior, when he sustained an injury while pushing a van, this time with the right knee fully extended. On this occasion, his patella spontaneously reduced and he did not seek any medical intervention. Our patient had no other significant past medical or surgical history and explained his right knee was completely asymptomatic prior to this current event.\nOn examination, there was an obvious deformity suggesting lateral displacement of the patella with a sulcus in the skin evident over the femoral groove. Furthermore, the knee was held fixed in 15 degrees of flexion. Due to patient positioning difficulties we were unable to obtain true AP and lateral views on X-ray. The radiographs demonstrated a laterally displaced and a mal-rotated patella in the vertical plane (see Figs. and ). A manipulation under sedation was attempted unsuccessfully. A further attempt of reduction under a femoral nerve block had again been unsuccessful.\nOur patient was subsequently taken to theatre where one final attempt of closed reduction was carried out under general anaesthetic and muscle relaxation. Ultimately, this failed and an open reduction was performed. The patient was positioned supine and an anterior midline skin incision was used. Complete rupture of the medial patellofemoral ligament (MPFL) was identified with the patella situated lateral to the lateral femoral condyle, everted by approximately 100 degrees. There were no visible deficiencies of the femoral condyles or the patellar articular surface. The patella was carefully reduced by direct manipulation. Following manipulation, the knee joint was washed out with normal saline and the medial patella retinaculum was repaired. After the repair, patella tracking was satisfactory with full range of flexion and extension. Post-operative radiographs confirm the patella in a satisfactory position in the antero-posterior and lateral planes (see Figs. and ). The patient was placed in an extension splint for comfort purposes immediately post-operatively. No weight bearing restrictions were applied. Early mobilization was encouraged after 5 days and the patient was referred for early physiotherapy. At 3 months follow-up, our patient had no further episodes of dislocation, full range of knee extension and flexion, and normal patella tracking. A hypermobility assessment at this stage revealed a Beighton score of 2 with extension beyond 10 degrees of both elbows only.
Case 1. The patient A. M., 56 years old, male came to our attention presenting, in the upper jaw, edentulous multiple sites, mobility of the remaining teeth, periodontal disease, and severe atrophy of the maxillary edentulous alveolar ridge. The patient clearly required that the prosthetic rehabilitation be exclusively fixed and did not accept provisional phases with removable dentures. Based on the clinical examination and the evaluation of radiographs (panoramic radiograph () and computed tomography of the maxilla with DentalScan reconstructions), it was decided to treat the atrophic upper jaw with a combined sinus lift procedure and local ridge augmentation using bone grafts in the areas from 1.4 to 1.6, performed under general anesthesia. In addition, it was decided to conserve not compromised teeth until the bone grafts were integrated in order to proceed, in a second phase, with implant placement and immediate loading.\nThe patient was adequately informed about the use of FFB grafts and the subsequent implant-prosthetic treatment plan. The preoperative phase included blood tests, an interview with the anesthesiologist for the general anesthesia, the signature of the informed consent form for the surgery, the test to determine the patient's blood group, and the signature of a specific informed consent form for the bone graft from the Tissue Bank. Once the preliminary phase was completed, the tissue specimen was then booked at the reference Tissue Bank, and in particular, a specimen harvested from the iliac crest was required.\nInitially, the avulsion of the element 16 was performed and after 40 days, the reconstructive surgery was programmed. On the day of surgery, a sealed container with the graft preserved under controlled temperature was delivered. Once freed from its outer packaging, the specimen was still wrapped in a sealed double sterile bag. It was then transferred to the operating room, where the double bag was opened in a sterile environment and the tissue specimen was defrozen in an abundant solution of saline and rifampicin at a temperature of 37°C for one hour, in compliance with the instructions provided by the reference Bank. Once the specimen had been defrozen, it was debrided to remove nonbony tissue, cut into blocks and contoured or morcellized, based on the treatment plan. The bone deficit was corrected by means of a major sinus lift and an onlay graft using a precontoured allogenic cancellous bone (FFB) block harvested from an iliac crest. The graft was then fixated with osteosynthesis screws. The subantral cavity and the gaps between the graft and the alveolar bone were then filled with allogeneic bone (FFB) chips (). The whole thing, including the screws, were then covered with the same morcellized bone, which was maintained in situ by means of resorbable collagen membranes. The wound was closed by sutures after releasing and passivating the flaps. At the clinical controls conducted in the weeks following the surgery and at radiographic examination (OPT) performed 1 month after the surgical procedure, there was no evidence of any complications. Three months later, the avulsions of the elements 12, 11, 21, 22, 24, and 26 were performed, whereas the elements 17, 13, 23, and 27 were maintained in situ and rehabilitated temporarily with a reinforced resin bridge in order to control the vertical dimension, the occlusion and the mandibular movements. At five months, the surgical site was reopened () and the fixation screws were removed. The bone tissue appeared vital and well integrated; no bone resorption was revealed.\nEight endosseous dental implants (BlueSky, Bredent, Senden, Germany) were inserted at the level of areas 1.6, 1.4, 1.5, 1.2, 2.1, 2.2, 2.4, and 2.5 using a customized surgical template (). The dental implants, placed in regenerated bone in the areas 1.6, 1.4, 1.5, were left submerged and loaded at 6 months. Considering the dental implants placed in the incisal region and those located in the areas 2.4 and 2.5, the resulting torque insertion was greater than 35 N/cm. For this reason, immediate loading was performed, and a provisional screw-retained implant prosthesis was fixed on dental implants (). Six months after implant placement, a definitive metal ceramic prosthetic rehabilitation was performed (Figures , , and ).
A 54-year-old gentleman with cirrhosis and end-stage liver disease secondary to chronic hepatitis C presented for evaluation for liver transplantation. The patient was first diagnosed with hepatitis C in 1990, and subsequently diagnosed with cirrhosis in 1991 by liver biopsy. At that time he was briefly treated with interferon, but sustained a severe allergic reaction following his fourth dose prompting discontinuation. In February of 2007, he developed worsening fatigue and sought care from his primary care physician. A computed tomographic (CT) scan was performed which demonstrated a small, irregular-appearing liver consistent with cirrhosis, but no liver masses were appreciated and the portal venous system was patent (Fig. ). An alpha-fetoprotein (AFP) level was noted to be elevated at 7,100 ng/ml in September of 2007. A CT scan was repeated in October of 2007 and demonstrated thrombus within the left portal vein (Fig. ). Magnetic resonance imaging of the liver was performed and demonstrated cirrhosis with left portal vein occlusion. A heterogeneous nodular mass had replaced the entire left lobe of the liver and the caudate lobe of the liver with evidence of increased enhancement. There was another heterogeneous lesion with abnormally increased signal intensity in the medial segment of the left lobe measuring 2 cm in diameter. Both of these lesions were highly suspicious for hepatocellular carcinoma (HCC). A metastatic evaluation was negative and a repeat AFP level was 24,100 ng/ml. The patient was referred to an outside institution for transplant evaluation, and was deemed unsuitable due to evidence of an infiltrating form of HCC with evidence of portal vein thrombosis. By December of 2007, the patient's AFP level had increased to 194,000 ng/ml. A CT scan at that time demonstrated extensive thrombus within the main portal vein near the bifurcation that extended into the right and left portal veins. Sorafenib was started at a dose of 400 mg twice daily in January of 2008. The AFP level decreased to 84,800 ng/ml and continued to exhibit a remarkable decline to 7,300 ng/ml by February of 2008, and 117 ng/ml by March of 2008. As the patient developed leukopenia and thrombocytopenia, his sorafenib dose was reduced to 200 mg twice daily. By April of 2008 this was further reduced to 200 mg a day, and ultimately to 200 mg twice weekly, on which he is currently maintained. By May of 2008, his AFP level was 3.7 ng/ml, and subsequent testing at monthly intervals have shown a persistently low AFP level between 3 and 5 ng/ml (Table ).\nThe patient was subsequently referred to our institution for consideration for transplantation in March of 2009. On evaluation he reported mental slowing and difficulty with memory, and his physical examination was significant for ascites and peripheral edema. Laboratory testing at that time was significant for a platelet count of 57,000, an International Normalized Ratio of 1.4, serum albumin of 3.0, total bilirubin of 2.1, AST of 76, ALT of 68, alkaline phosphatase of 50, and an AFP level of 3.4 ng/ml. His calculated Model for End-Stage Liver Disease (MELD) Score was 13. The patient underwent exploratory laparoscopy and was found to have a grossly cirrhotic liver with no definitive mass appreciated. Intraoperative laparoscopic ultrasound examination of the liver did visualize an area in segment 4 that consisted of a nest of abnormal blood vessels. This area was thoroughly biopsied, following which radiofrequency ablation was performed due to concern for malignancy. Notably, all of the liver biopsies demonstrated cirrhosis with focal scar and chronic inflammation, and no evidence of carcinoma. Follow-up imaging in October of 2009 demonstrated a well-defined area of peripheral low density involving the anterior aspect of segment 4 of the liver, which corresponded to the site of prior RFA ablation. Just medial to this ablation site was an area of more ill-defined low density, which was suspicious for residual/recurrent tumor. A non-occlusive thrombus involving the splenic vein, extending to the portosplenic confluence was noted. In addition, non-opacification of the left portal vein, with numerous associated collaterals consistent with cavernous transformation, was appreciated. The main portal vein and right portal vein were patent. As the patient’s tumor burden decreased to within the Milan criteria, and as he had demonstrated stability at that tumor burden, the patient was subsequently listed for transplantation with MELD exception points.
An 80-year-old male patient was referred to the abdominal surgery department due to incarcerated ventral hernia and ileus. In the past he was operated due to perforated gastric ulcer. He also had arterial hypertension, chronic pulmonary obstructive disease and pulmonary hypertension, a history of smoking, he suffered an ishemic stroke in the past. He was urgently operated on the same day. Segmental resection of small bowel with end-to-end anastomosis was performed and the hernia defect was closed with direct sutures, without prosthetic mesh because the bowel was resected. There were no surgical or other complications after surgery and he was discharged from hospital after 8 days. 5 days later he was admitted to the hospital again due to early recurrence of ventral hernia. The content in hernia sac could however be reduced back to his abdomen. Laboratory findings showed leucocytosis and elevated C-reactive protein (CRP - 148 mg/l). Intestinal winding with a thickened wall up to 5 mm was found at the location of the ventral hernia by ultrasound examination. The patient underwent a second surgery 22 days after the first surgery due to obstructive ileus, which was seen on the abdominal computed tomography (CT) a day earlier. Due to additional diseases and disorders (ischemic stroke and insertion of stent in his left internal carotid artery in 2011, arterial hypertension, asthma, pulmonary fibrosis and hypertension, which were not properly treated, because the patient did not follow the prescribed treatment) the anaesthesiologist decided for the spinal anaesthesia, because the general anaesthesia would be to risky. The surgery was performed by an abdominal surgeon with 5 years experiences as a specialist and he performed more than 30 Rives-Stoppa ventral hernia repairs. The skin incision was made along the previous skin incision. In the subcutaneous tissue the small intestine was tightly adhered on to the skin. We managed to release it but unfortunately, a segment of the small intestine was damaged during adhesyolisis. Segmental resection of the damaged small bowel with end-to-end anastomosis was performed (). The small intestine was reduced back in to the abdominal cavity. Ventral hernia was repaired according to Rives-Stoppa technique with prosthetic mesh (). Other than postoperative tachycardia there were no reported issues. A couple of hours after the procedure apnoeic episodes appeared followed by unconsciousness. A computed tomographic angiography (CTA) of the brain vascular system was made and it showed a stenotic left vertebral artery (90% stenosis). Because of respiratory insufficiency and haemodynamic instability, the patient was transferred to the intensive care unit. Due to a worsening clinical condition, a CTA of the abdomen was preformed and an occlusion of superior mesenteric artery (SMA) was discovered. Interventional radiologist preformed an embolectomy and thrombus aspiration from the SMA with an insertion of a stent. The patient's condition continued to worsen so the abdominal surgeon decided for a “second look” abdominal exploration. At surgical revision we found a small intestinal and sigmoid colon gangrene. Because of the patients age, several other comorbidities and gangrene of the entire small bowel, the multidisciplinary team (abdominal surgeon, anaesthesiologist, intensivist) decided for conservative treatment. The patient died the day after surgery.
A one-year-old male child was brought to our primary care clinic by his mother. She stated that he had been teething for some time now and was biting and causing damage to his tongue. The child was examined, and healed lacerations were observed on the tongue. The child was also examined by the dental team, which commented that tongue biting could be a normal behaviour at this age.\nThe child presented to the clinic along with parents after approximately 14 months with swelling on his left arm. Parents visited the local emergency department and reported that they were not aware of any injury and had just observed the swollen arm of the child. There was no report of pain or crying observed in the child. On examination, the child was found to have a few-days-old fracture of ulna. Since no clear cause of the injury was found and the parents could not provide any explanation for the same, the protocol for the treatment of non-accidental injury was followed by the hospital. Due to the south Asian origin of parents and their poor English-speaking ability, there were some communication difficulties. They reasoned that since the child did not show any sign of distress, they were not aware of the injury and had not visited the doctor earlier. The hospital team became suspicious about the parents’ behaviour and unawareness and was not convinced by the narration of parents. The child was put under a safeguarding order, which meant a full detailed review was deemed necessary, and his inpatient medical investigations and treatment were initiated. During the course of the investigations, which included skeletal surveys, another healed fracture was found in the right lower leg. It was intimated to the parents that the child would not be discharged back to them until a complete investigation has been conducted. The parents were distressed and visited their family physician as they could not understand the safeguarding procedure. The child’s father informed the family physician (who communicated with them in their native language) that some family members in their home country have a similar problem of weak bones with no pain sensation. This information was communicated to the paediatric team, who accordingly conducted further investigations. These included genetic testing, which led to the diagnosis. The child was diagnosed with CIPA and was examined by various specialists. The child was eventually allowed to go home with the parents and continued to have follow-ups. The parents were found to have a consanguineous marriage, which could be the reason for recessive syndromes. They were recommended to consult with a genetic counsellor. Eighteen months after the diagnosis, the couple had a second child (female), who was also diagnosed with the same disorder. Follow-up of both children was conducted for the following five years and they were found to have mild learning difficulties and had delayed achievement of their milestones. Due to the history of multiple fractures, the children were at risk of developing Charcot joints. The male child had eczema, which was difficult to treat due to continuous scratching by the child since he did not have any sensation for pain. This caused significant damage to his skin. The younger sibling faced similar issues and had multiple fractures and eczema. There was some discussion with the family about testing the rest of the extended family who may have exhibited similar symptoms but this was complicated with the members living abroad.
A 37-year-old female patient presented with the chief complaint of swelling in the right side of the palate of 1-month duration associated with dull, intermittent pain. History revealed that the patient had applied rock salt over the swelling to alleviate pain. Medical history revealed that the patient was undergoing infertility treatment for 7 months and had undergone surgery for uterine fibroid 6 years back. There was no history of dry eyes, dry mouth, joint pain or weight loss. The patient was a nonsmoker and nonalcoholic and had no tobacco chewing habits.\nOn intraoral examination, a single diffuse ovoid swelling measuring approximately 1.5 cm × 1 cm was present on the right side of the posterior hard palate []. The surface of the swelling was predominantly smooth with a focal shallow ulceration in the center. On palpation, the swelling was nontender, soft to firm in consistency and fluctuant. No tooth in the quadrant was tender on percussion. There were no clinical signs of dental caries or periodontal disease.\nIntraoral periapical radiograph of the right maxillary first molar and maxillary lateral occlusal radiographs revealed no significant changes. Cone-beam computed tomography of maxilla revealed a soft-tissue shadow in the right side of the hard palate in relation to maxillary right first molar with pressure effect on adjacent bone and thinning of cortical bone with no evidence of breach in the continuity of bone [Figures and ]. There was no periapical lesion in relation to maxillary right premolars and molars. We excluded a palatal abscess or a cyst by clinical and radiographic examination. The ulceration was shallow, associated with a smooth swelling and likely to have been caused by the abrasive effects of rock salt and hence necrotizing sialometaplasia was considered unlikely. Hence, a provisional diagnosis of benign salivary gland tumor or cyst was made with the differentials of malignant salivary gland tumor and nonodontogenic soft-tissue neoplasms.\nUnder local anesthesia, an excisional biopsy was done and the tissue was sent for routine histopathological evaluation. Hematoxylin and eosin-stained soft-tissue sections showed salivary gland tissue with significant acinar destruction and replacement with dense lymphocytic infiltration [Figures and ]. Remnants of ductal structures and focal areas of myoepithelial islands were evident throughout the lesion []. Histopathological findings were consistent with BLEL.\nSerological work-up for associated autoimmune diseases were negative. ELISA for HIV was also negative. The patient was followed up for 1 year following the excisional biopsy. The healing has been uneventful, and there are no signs of recurrence.
A 54-year-old Caucasian male with a past medical history significant for anaplastic astrocytoma previously treated with chemoradiation was examined in the emergency department after experiencing two seizure-like episodes earlier that morning. These episodes involved rhythmic movements of the right arm, confusion, and aphasia. During the second episode, which occurred in the parking lot of the emergency department, the patient fell and repeatedly impacted the left side of his face on the pavement. Upon examination, the patient had significant abrasions to the left side of the face with a small, palpable subcutaneous mass over the left temporal region. The patient demonstrated no focal neurological deficits. A computed tomography (CT) scan of the patient's head obtained in the emergency department demonstrated a small focus of intraparenchymal hemorrhage for which the patient was admitted to the hospital for further observation and management.\nThe following day, a clinical examination revealed that the small bulge over the left temporal region had doubled in size (1 cm × 1 cm), was pulsatile, and freely mobile with no obvious involvement of the overlying skin. No bruit or thrill was appreciated. The patient reported minimal pain associated with the mass. A magnetic resonance image (MRI) was obtained at the suggestion of the consulting neurologist that redemonstrated a focal hemorrhage in the vertex of the left cerebral hemisphere with surrounding edema (Figures and ). The MRI also showed a 1.3 cm × 1.4 cm circumscribed, enhancing lesion in the soft tissue of the left scalp, with an appearance consistent with that of a posttraumatic pseudoaneurysm. Doppler ultrasound of the left scalp mass revealed a 1.0 cm × 1.3 cm circular lesion in the soft tissue of the left anterior temporal scalp with bidirectional flow, consistent with a pseudoaneurysm (Figures , , and ). The patient was subsequently discharged on seizure prophylaxis in stable condition with no pain or neurologic deficit. Four days following discharge, the patient represented with complaints of increasing pain in the area of the pseudoaneurysm. On focused physical exam, the left temporal bulge was noted to have increased in size (now several centimeters across), and the formation of a central black eschar overlying the mass was noted. The mass was pulsatile and tender to palpation.\nThe patient underwent surgical excision of the pseudoaneurysm under general anesthesia. The lesion was approached through an elliptical incision overlying the pseudoaneurysm, which included the skin and subcutaneous tissue down to the level of the pseudoaneurysm. Upon entering the pseudocapsule, there was a mild amount of oozing and a large hematoma and clot, which were all evacuated. The proximal and distal ends of the STA that had been feeding the pseudoaneurysm were identified and ligated. The wound was closed with vertical mattress sutures after hemostasis was verified. The patient's postoperative course was uneventful.
A 10-year-old female patient presented with complaint of a painless facial swelling for about 5 years. According to her parent, the swelling started as a small roundish and hard mass around the area below the right eye. It gradually, but consistently increased in size resulting in severe facial deformity. There was no significant medical history apart from the notable bending of spine which was noted as the child was growing and episodes of per vaginal bleeding which were noted when the patient was 5 years old.\nGeneral examination revealed an otherwise healthy young girl, who was well oriented to her surroundings, with her spine bent to the right (scoliosis), irregular skin pigmentation on the right side of the chest and back, slightly enlarged breasts, vaginal bleeding and some sparsely distributed pubic hair. Her body stature, however, was normal for her age. On local examination of the craniofacial region, the patient had bilateral frontal bossing. She also had facial asymmetry due to a massive oval shaped exophytic mass on the right side of face that measured approximately 24 by 17 cm. The mass slightly crossed the midline, the overlying skin was hyperemic and shiny with visible dilated blood vessels. The right eye was displaced superiorly without any visual disturbance. The nose was displaced towards the left side, with occlusion of the right nostril. The overstretched overlying skin had normal temperature and could not be folded. The swelling was non-tender, bony hard and fixed to the underling structures (Fig. ). Intraorally, the lesion was occupying the entire right side of the upper jaw extending just few millimeters beyond the midline to the left side of the palate. The lesion was oval in shape, with an otherwise normal overlying mucosa except on the anterior aspects where the mucosa was constantly dry due to exposure to external environment. The tumor caused displacement of all teeth on the right side of the upper jaw, however, these teeth were not mobile. Based on these clinical findings a provisional diagnosis of McCune-Albright syndrome was made.\nThe work up done on the patient included histopathological analysis, skeletal survey (CT scan of craniofacial region and a skeletal survey of the body by conventional radiographs). Also complete blood count, calcium and phosphate levels in the blood, thyroid and parathyroid function tests and echocardiogram were done. The histopathological report of the specimen taken intraorally from the right maxilla revealed a moderately cellular fibrous stroma surrounding irregular curvilinear tubercle of woven bone arranged in Chinese letter pattern matching fibrous dysplasia. Skeletal survey with conventional radiographs showed scoliosis of the spine (Fig. a). The CT image displayed a mixed density lesion with areas of ground glass appearance (which was deep peripherally and light centrally) that involved the maxilla, palate and zygoma. The anteromedial wall of the right maxillary sinus was compressed laterally reducing the size of the maxillary sinus. The vomer was displaced laterally to the left, and the right nostril was completely obliterated (Fig. b). The complete blood count, calcium and phosphate levels and the thyroid function tests were all within the normal ranges.\nThe parents of the patient were counseled and treatment options were discussed including a series of corrective surgical procedures. Thus, upon consenting, in 2015, the first surgical procedure was carried out. Due to difficulty in intubation, tracheostomy was done and partial maxillectomy was carried out. The post-operative recovery was uneventful (Fig. a), and yearly follow ups were planned. In early 2017, the patient presented with a recurrent palatal swelling and a second surgery was done. The post-operative period was uneventful (Fig. b). Currently the patient is well and is under close follow up.
A 70 year old female patient was referred to our clinic with pre-diagnosis of osteomyelitis or RSD. Her complaints were pain and swelling of left leg and left ankle. Her history revealed that she had broken her left ankle 8 years ago and was operated on her ankle twice, 8 and 4 years ago. Patient was an obese woman and in physical examination her left ankle was mildly hyperemic and edematous, there was no significant rise in heat. She rested heavily on her right leg while she was walking. In the lateral region of her left ankle there was an incision scar and in the 1/3 proximal region of her left leg there were 2 or 3 crusted lesions with about 1 cm diamater. She was on no medication and her laboratory findings were normal. 20 mCi (740 MBq) Tc-99m HDP was administered intravenously and using a large field-of-view gamma camera (Siemens E.CAM/e.soft gamma camera, USA) equipped with a low-energy all purpose collimator, dynamic imaging of both of her ankles was acquired in the anterior projection in 2-s frames for 2 minutes using a matrix size 128x128 in the supine position. After dynamic phase, blood pool image was performed and delayed static and whole body images were obtained 3 hours later. In the dynamic bone scintigraphy there was increased perfusion () and hyperemia () in her left ankle and her left leg in the field of view, compared to the counterparts on the right, but there was no significant accumulation of the radiotracer in old fracture region. In the late bone static images, taken at 3 and 24 hours, there was no pathologic radioactivity accumulation consistent with osseos infection, there was increased uptake in fracture site and moderately increased uptake in soft tissue (). We interpreted the increased perfusion and hyperemia at dynamic and blood pool images in her left ankle and her left leg as nonspecific uptake related with venous circulation disorders. But in superficial and Doppler US of patient’s lower extremity, the venous structures were totally normal. We decided to ask further questions about her leg and found out that she had Leech theraphy applied on her leg 4 times within last month, which can explain the increased perfusion and hyperemia in dynamic and blood phases of Tc-99m HDP bone scintigraphy.
A 38-year-old gravida 1, para 0 was transferred to our unit at 26 weeks of gestation with severe right iliac fossa pain and a suspicion of threatened preterm labour. She presented with a 3 day history of right iliac fossa pain, nausea, vomiting and diarrhoea. Vaginal examination and her fetal fibronectin test was negative. However, transabdominal and transvaginal ultrasound examination revealed a 6.0 × 5.5 × 5.9 cm vascular mass within the right pelvis with a clear arterial feeder and turbulent swirling intraluminal flow, leading to the diagnosis of a pseudoaneurysm (Fig. ). The diagnosis was subsequently confirmed by Magnetic resonance imaging (MRI) (Fig. ). The patient was discussed in our multidisciplinary team meeting with interventional radiologists, vascular surgeons, and anaesthetists. The risk of imminent rupture was assessed as high due to the severity of her symptoms and a 5–10 mm overall increase in the size of the pseudoaneurysm documented by sequential MRI 14 days apart. Surgery was considered high risk and so selective embolization of the pseudoaneurysm was performed. This was performed under local anaesthetic in the Interventional Radiology suite with full preparation for emergency delivery by the obstetric and anaesthetic team in case of fetal distress. The right uterine artery was identified angiographically from a contralateral femoral arterial puncture and selectively catheterised using a microcatheter. The artery was small but extravasation into the presumed pseudoaneurysm was identified near its proximal portion. The artery was embolised with a series of microcoils across the neck of the pseudoaneurysm to block flow. The procedure was uneventful and the fetus showed a continuous reactive heart rate pattern. Follow up ultrasound showed a completely thrombosed pseudoaneurysm with no flow. She had regular follow ups in the antenatal clinic with no sign of recurrence. A planned caesarean section was performed at 38 weeks gestation. A healthy baby boy was born weighing 2696 g with a blood loss of 1100mls. During the caesarean section, the thrombosed pseudoaneurysm was seen below the right broad ligament and all other pelvic organs looked completely normal (Fig. ). An ultrasound scan 3 months postpartum showed a small completely thrombosed pseudoaneurysm (Fig. ).
A 24-year-old man was presented in our department with a large, painless swelling in the lumbar region with a moderate extension to the lower thoracic and to the upper sacral area. In fact, the parents observed the last three months a protuberant mass in this region enlarging gradually. The patient initially was negative to a medical examination. The recent history was negative. The patient was an amateur soccer player, playing with a frequency of 1-2 matches per week. The recent history was unremarkable for trauma or any disease involving the liver and the coagulation tests. The recent pharmacological history for administration of anticoagulant therapy resulted negative.\nThe inspection revealed a large mass (28 cmx10 cm) from the sacral spine to the lower thoracic region without skin changes. The lesion was soft, fluctuant and painless in palpation (fig ). The examination of the abdomen, pelvis and the spine was normal. The neurological and the vascular examination of the lower leg resulted normal. The blood tests were done with the red blood, platelets, clotting factors and hepatic function resulting normal. The MRI examination demonstrated an enormous soft tissue mass with features compatible to haematoma. The intraspinal and the extraspinal structures of the lumbar region resulted to be intact (fig. ).\nWe decide to perform a surgical intervention, knowing that, in case of a large chronic haematoma the aspiration is useless because of the high possibility of recurrence. Intraoperatively, we evacuated 2L of altered blood and the findings were compatible with a large soft-tissue fibrous cavity containing a considerable quantity of altered blood clot, fibrous and granulation tissue (fig ). A complete resection of the fibrotic wall was performed. The underlying fascia was extendedly sutured with the subcutaneous tissue, in order to avoid any dead space where new haematoma can develop. The liquid and soft-tissue culture was sterile. The histopathological examination revealed abundant fibrous tissue with features of recent hemorrhage (fig ). Two years after the surgical treatment the patient has not shown any sign of recurrence.
A 55-year-old male patient underwent right femoropopliteal bypass in 2009 for intermittent claudication in the right lower limb due to arterial insufficiency in superficial femoral vessels. He was reexplored for stenosis of graft with a recurrence of symptoms. The patient underwent right iliac artery – right popliteal artery bypass using polytetrafluoroethylene (PTFE) graft in 2012. He presented 2 years later with sudden onset gross hematuria with sepsis. He was managed initially with insertion of three-way Foley catheter and irrigation. After hemodynamic stabilization, the patient underwent imaging in the form of computed tomography (CT) scan (abdomen + pelvis) with angiography. As shown in , CT scan was suggestive of fistulous communication between right iliac artery and right ureter with surrounding inflammatory changes. The patient underwent covered stenting with PTFE graft to close arterial fistula site under antibiotic coverage. The patient was monitored in intensive care unit for 48 h. Foley catheter was removed on the 5th postoperative day. The patient was afebrile throughout the postoperative period. He was discharged subsequently on the 7th postoperative day. Patient did not have any urinary complaints or any episode of hematuria in postoperative period. The patient was followed up after discharging from hospital and patient was stable. The patient presented 2 weeks later with complaints of watery discharge from scar of previous surgery. Patient underwent detailed investigations and was found to have fistulous communication between the right ureter and overlying skin as shown in . There was no communication with iliac artery on ipsilateral side. The patient did not have any other urinary complaints. The patient subsequently underwent cystoscopy and retrograde pyelography which showed communication between the right ureter and overlying skin. A JJ stent was placed over guide wire under fluoroscopic control using ureteroscope.\nThe patient was discharged subsequently on day 7 after confirming position of stent. On subsequent follow-up, patient was not having any discharge, signs of arterial insufficiency and lower urinary tract symptoms. JJ stent was removed after 6 weeks. Patient was stable on subsequent follow-ups.
A 41-yr old male patient had visited our hospital due to symptoms of severe right facial and periorbital edema, proptosis, ocular pain, decreased visual acuity, diplopia and nasal stuffiness on June 11, 2011. The patient had dental root of the right upper premolar tooth broken accidentally 2 months ago. He endured the condition untreated until the pain became very severe. He visited a private dental clinic and was diagnosed with a periodontal abscess of the right upper premolar tooth 4 days before visiting our hospital. There he was treated with antibiotics, but swelling of the right mandible and cheek area began on the first following day. In addition, periorbital swelling, proptosis and nasal bleeding began on the second following day. The facial and periorbital swelling became more aggravated and the patient was referred to our hospital (). The patient had no specific past medical history. From the ophthalmologic examination, his best corrected visual acuity was 20/100 for the right eye and 20/20 for the left eye. The intraocular pressure was 54 mmHg in the right eye and 12 mmHg in the left eye. In the examination of eyeball movement, his right eye had shown severe limitation of movement in all directions (). Exophthalmometry was measured to be 20 mm in the right eye and 14 mm in the left eye. The right eyelid was very tight and tender at palpation. Severe conjunctival injection and chemosis were also observed. Because the right eyelid could not be closed completely due to proptosis, conjunctival prolapse was observed through the lid fissure. On the slit lamp examination, epithelial erosion and mild stromal edema of the cornea were observed. The anterior chamber of the right eye showed a center depth of 2.5 CT (corneal thickness) which was rather shallower than 4 CT in the left eye. But there was no floating inflammatory cell in the anterior chamber. At the time of the initial examination, pupillary response was normal and no abnormal finding was observed from fundus examination. The color vision test was also normal. In facial CT, findings of severe sinusitis in the right maxillary sinus and inflammation of the right temporalis and mastication muscles were observed. Also, findings of severe inflammation in orbital soft tissue and extraocular muscles, which is correspond with the findings of orbital cellulitis, were observed (). Increase in leukocyte count, erythrocyte sedimentation rate, and C-reactive protein level were found in the blood sampling test. Upon diagnosis of orbital cellulitis spreading from odontogenic sinusitis, the patient was immediately hospitalized. Intravenous administration of ceftriaxone and clindamycin began with medications for lowering intraocular pressure. The intraocular pressure of the right eye had decreased to 34 mm Hg on the following day of hospitalization. However, the facial and periorbital swelling had not improved and further aggravated. Therefore, emergent maxillary sinus drainage was performed in the department of otolaryngology. On the day following surgery, the patient complained of a sudden deterioration of vision in the right eye. The measured visual acuity was only light perception and intraocular pressure was 42 mmHg with afferent pupillary defect in the right eye. Pale optic disc, cherry red spot in the fovea and retinal edema were found from the fundus examination (). In fluorescein angiography, delay of retinal circulation was observed (). Ischemic optic neuropathy and central retinal artery occlusion were diagnosed by these findings. Severe proptosis and deformation of the posterior pole of the right eye into a cone shape by severe stretching of the optic nerve were found in the orbital CT (). Immediate ocular massage, emergent anterior chamber paracentesis and lateral canthotomy were performed. However, those trials were useless. While maintaining ocular hypotensives and antibiotics, the intravenous administration of high-dose steroid (methylprednisolone, 1 mg/kg/day) started. After 5 days, the intravenous steroid was replaced with oral prednisolone at a dosage of 60 mg/day for 1 week and thereafter the dosage was gradually reduced. Meanwhile, Staphylococcus epidermidis was identified from a microbiologic culture at the time of sinus drainage. The patient began to show improvement of facial and periorbital edema after 5 days of hospitalization and the intraocular pressure had returned to normal range. After 12 days of hospitalization, proptosis, limitation of eyeball movement, and afferent pupillary defect had been resolved, but the visual loss had not recovered at all ().
A 14 year old boy was referred to the hospital with pain, tenderness and deformity of the left shoulder following a motor vehicle accident. The results of a general physical examination were normal except for the left arm, where the examination revealed pain, tenderness, and swelling in the left shoulder. The range of motion on the left shoulder was severely limited. Distal radial, ulnar and brachial pulses were not palpable and could not be detected by Doppler sonography despite the behavior of the normothermic the extremity. Capillary refill times were 4 seconds in the left and 3 seconds in the right arm. The patient was unable to extend his wrist, thumb or fingers.\nThe injury was closed and there was no ecchymosis. Radiography of the left shoulder revealed a Salter-Harris type I proximal humeral epiphyseal separation ().\nClosed reduction of the physeal injury was performed in the operating room under general anesthesia to reduce compression on the axillary artery. However, distal pulses were not palpable following the anatomic reduction and we could not detect any change in vascular status. A vascular surgeon was consulted. Angiography of the left arm revealed disruption of arterial flow in the axillary artery (). The patient was taken to the operating theatre for an arterial repair or graft. Intra-operative findings included a hematoma and arterial contusion, but no active bleeding or axillary artery laceration was not located. The axillary artery was contused and thrombosed, and the brachial plexus was intact on inspection.\nAfter resection of the contused segment of the axillary artery a reverse saphenous vein interposition graft was performed.\nThe patient was monitored for 3 days in the intensive care unit, where his radial and ulnar pulses remained palpable. The Patient was discharged with a sling and swath. After 4 weeks, radial innervated muscle weakness resolved, the sling was removed, and rehabilitation for regaing shoulder and elbow motion was started. The muscle power of wrist and hand extensors returned to normal condition after 3 months.
A 27-year-old woman applied for a breast reshaping surgery for aesthetic purposes. There were no other complaints in her medical history. The patient underwent simultaneous mastopexy according to classical Lejour vertical scar technique and breast augmentation surgery using round silicone TSF - 415 mL implants under the pectoral muscle and a breast lift under general anesthesia (). During the operation proper hemostasis was achieved using electrocoagulation. Drains were removed next day after the operation with minimum serohemorrhaging fluid volumes. The later postoperative period was also uneventful.\nThe patient was discharged from the clinic on the second day after the surgery. Five weeks after the operation patient arrived at the clinic because of tenderness and swelling of the right breast. The patient stated that she had not sustained any traumas. During clinical examination, the upper right breast area was found to be significantly swollen and firm (). Ultrasound examination showed a 2.5 cm heterogeneous liquid strip accumulated around the implant (). The implant was intact. Complete blood count showed an increased amount of leukocytes, and red blood cells and hemoglobin were at the lower limit of the normal level.\nNo coagulopathies were found. The patient was taken to the operating room where she underwent revision surgery. The purpose was to remove the fluid and to find and stop the cause of its accumulation. During the operation (), a blood clot of 650 mL was removed (). Bleeding from one of the internal mammary artery branches in the implant pocket between the rib cage and the pectoral muscle lower pole was detected and stopped. After the revision, the implant was returned to the lodge. Vacuum drainage was used for one day only. One year after the surgery, there was no recurrence of bleeding, also no clinical evidence of the implant capsule contracture formation was found ().\nAll procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. The patient gave her informed consent prior to her inclusion in this case report. Any details that might disclose the identity of the patient under study were excluded.
A male patient aged 73 years was admitted with two ulcers to his right lower leg and rest pain, which he attributed to a traumatic injury 8 weeks prior to presentation. He was known to have peripheral vascular occlusive disease with documented stenosis in both common iliac arteries (CIA), the left external iliac artery (EIA) and common femoral artery and occlusion of the right EIA.\nHis other relevant medical history includes a renal transplant, for which he takes regular prednisolone and azathioprine. He also had ischaemic heart disease with recent cardiac drug eluting stent insertion necessitating dual antiplatelet agent therapy and a coronary artery bypass graft in 1996.\nClinically he was aypyrexic with compromised circulation to his leg, which was pale but warm, and were absent of pulses on the affected side. There was a 1 cm wide ulcer located in the gaiter area, and a 3 cm wide ulcer located in the middle third of his lower leg posteriorly. Both lesions had a punched out appearance, with evident necrosis and no discharge or foul smell. He had a normal white cell count, a CRP count of 240 mg/L, potassium levels of 5.8 mmol/L and a creatinine level of 232 μmol/L.\nHis ankle brachial pressure index values were 0.23 on the right and 0.40 on the left. An arterial Doppler study showed no change in his occlusive disease, with patent, highly calcified vessels distally with poor flow. Doppler ultrasound studies of his transplanted kidney was normal.\nTo preserve renal function, a lower leg angiogram was performed using carbon dioxide. This showed an occluded right EIA and stenosed left CIA, with otherwise patent superficial femoral arteries bilaterally.\nWhile undergoing medical assessment for a right EIA endarterectomy and left EIA stenting, the ulcers progressed in size necessitating a surgical debridement. Tissue samples from the initial debridement were sent for histopathology and microbiology.\nDespite debridement to healthy tissue and skin, there was significant deterioration of the margins as well as new areas of necrosis on the next day (Figs and ). Histopathology showed full thickness necrosis of the epidermis, dermis and subcutis, with large numbers of wide, twisted fungal hyphae seen within their blood vessels consistent with mucor. Microbiology confirmed Rhizopus oryzae.\nLiposomal amphotericin-B was started at 5 mg/kg/d. He underwent a right iliofemoral bypass and further radical debridement of his mycotic ulcers, which by now were more extensive (Figs and ).\nPost operatively he was transferred to ICU, where over the course of 5 days, he had an improved blood supply to his right leg, with no further evidence of cutaneous necrosis. Nevertheless, he developed multi organ failure as a sequela of his disease and eventually died after 5 days.
A 17-year-old female patient visited the Department of Oral Medicine and Radiology with a complaint of swelling in the lower jaw that had begun 5-6 months earlier. The lesion had progressively increased in size and been painful beginning two months earlier. There was no anesthesia or paresthesia of the lower lip, chin, or jaw, and there was no history of trauma.\nOn extraoral examination, the swelling in the mandibular anterior region measured about 8 cm×5 cm extending about 4 cm from the midline bilaterally (). Superoinferiorly, it extended from the lower lip to the lower border of the mandible. The skin over the swelling and the surrounding area appeared normal and the margins were diffuse. On palpation, there was no local rise in temperature, but the swelling was tender, especially in the anterior region. Intraoral examination revealed swelling 7 cm×5 cm obliterating the buccal and lingual vestibule extending bilaterally to the buccal sulcus of the first permanent left mandibular molar and first permanent right mandibular molar and measuring about 3.5 cm from the midline bilaterally (). The expansion of the lingual cortex in the midline region was remarkable. The swelling was bony hard in consistency. The crowns of the mandibular anterior teeth were tipped mesially. The left lateral incisor, right central incisor, and right lateral incisor were grade 2 mobile. Grade 1 mobility was present in the permanent first molar in the left mandibular region and the permanent central incisor in the left mandibular region was clinically missing. The teeth were nontender on percussion. The teeth associated with the swelling - the incisors, canines, premolars and first molars of the left and right side of the mandible - gave a negative response to a vitality test. Since the expansile lesion with clinically aggressive behavior was associated with a missing tooth, a working diagnosis of ameloblastoma was considered. Other odontogenic cysts and tumors including dentigerous cyst and odontogenic keratocyst were considered in the differential diagnosis.\nThe patient was subjected to radiographic examination including panoramic and intraoral radiographs. The panoramic radiograph revealed a large radiolucent lesion of the mandible extending from the roots of the permanent first molar in the right mandibular region to the permanent first molar in the left mandibular region with well-defined corticated borders (). The lesion was associated with an impacted permanent central incisor in the left mandibular region, which appeared to be displaced towards the inferior cortex of the mandible. A few radiopaque flecks of about 1-2 mm were noted. The roots of the premolars and molars in the right and left mandibular region showed resorption and all the roots of teeth associated with the lesion showed loss of the lamina dura and widening of the periodontal ligament space. The roots were tipped distally. The lower border of the cortex showed endosteal resorption. The mandibular occlusal radiograph revealed a striking cortical expansion, especially that of the lingual cortex with dense septae in the lingual region giving a multilocular appearance (). Several radiopaque foci of about 1-2 mm were seen scattered, which were less evident in the panoramic radiograph. Cortical thinning and resorption were evident.\nThe patient was further subjected to a computed tomography (CT) examination, which demonstrated a large expansile radiolucent lesion with multiple flecks of calcification of varying sizes, which were predominantly peripherally distributed and impacted the permanent central incisor (). The remarkable lingual and buccal expansion, perforation of the lingual cortex, and dense septae in the lingual region were evident in the CT. The soft tissue density at the periphery suggestive of a capsule was also appreciable (). The dimensions of the lesion measured 5.82 cm×3.28 cm×3.25 cm (). A multiplanar three-dimensional reconstructed image showed a multilocular appearance with thick lingual septae and the position of the impacted tooth ().\nA radiographic diagnosis of adenomatoid odontogenic tumor (AOT) was arrived at considering the multiple scattered radiopaque flecks in the lesion associated with an unerupted impacted tooth and a soft tissue capsule. However, a multilocular appearance and large size in an AOT is unusual. Hence, a differential diagnosis of other multilocular mixed lesions such as calcifying odontogenic cyst and calcifying epithelial odontogenic tumor was also considered.\nThe lesion was surgically enucleated. Macroscopically, the mass was well encapsulated with cystic areas along with an embedded permanent mandibular central incisor in the tumor mass. Histopathological examination revealed sheets, ducts, and whorls of darkly staining ovoid to round epithelial cells suggestive of odontogenic epithelial cells (). The duct-like structures were lined by columnar cells. A few basophilic calcifications were also observed. Small cystic areas containing degenerated cell debris were noted in the focal areas. The supporting connective tissue stroma was loose and less cellular in nature. Based on these findings, a histopathologic diagnosis of adenomatoid odontogenic tumor was made.\nThe patient was under follow-up and had not shown any signs of recurrence six months after surgery ().
A 62-year-old man presented with history of dysphagia to solids, night sweats, lethargy, and significant weight loss of 2 stones over 2 months. Apart from dyspepsia on symptomatic treatment, he did not have any significant comorbidities. He worked as a chef on ships and was recently admitted overseas with an episode of sun stroke for which he was hospitalised for a week.\nOn clinical examination, he had fullness in the epigastrium with minimal tenderness. Blood tests revealed leucocytosis and elevated C reactive protein with mildly deranged liver function tests characterised by raised alkaline phosphatase and lactate dehydrogenase levels. Tumour markers including CEA and CA19.9 were normal. Upper gastrointestinal endoscopy revealed inflamed and oedematous posterior gastric wall, and biopsies were positive for H. pylori infestation. Ultrasound revealed a 5 cm heterogenous mass in close relation to the head of pancreas with associated mild intra- and extrahepatic biliary dilatation. CT scan confirmed a 6 × 6 cm soft tissue mass in the pancreatic bed with a 4 cm linear calcified mass (). There was associated mesenteric lymphadenopathy with thickening of the posterior gastric wall. Differential diagnosis entertained included lymphoma, gastric cancer, and possible foreign body in view of the calcified mass.\nIn view of diagnostic ambiguity, exploratory laparotomy was undertaken. At laparotomy, a large inflammatory mass which appeared to arise from the duodenum and in close relation to the stomach, pancreas, and the liver was encountered. The initial impression was that this was probably a lymphoma. However, on further dissection, an abscess cavity in the pancreatic bed with a 4 cm foreign body was found. This was sent for histology and a drain was placed in the abscess cavity. The patient made an uneventful recovery and was discharged home within a week.\nHistology revealed soft tissue consistent with inflammatory granulation tissue, and the foreign body was reported to have haversian systems consistent with bony remodelling not found in modern bony fish and hence probably a chicken bone.\nThe patient recovered well and regained all lost weight. On further history review, he denied any history of foreign body or bone ingestion.
A 17-year-old female patient was referred to the Faculty of Dentistry of our institution for consultation. The patient was diagnosed with dental trauma in the maxillary central incisors and right lateral incisor. The patient's clinical history revealed that the patient has epilepsy, with a family history of diabetes and hypertension. On the 1st day, the patient received an emergency treatment with the restoration of central incisors and the right lateral incisor with glass ionomer cement.\nIn the right central incisor, we observed an oblique coronal fracture located below the middle third and pulp exposure. The upper right lateral incisor and left central incisor had coronary fractures extending from the mesial, almost to the level of gingival margin, to the distal end; all of the fractures had pulp exposure []. There was an active fistula in the vestibular region of the right central incisor and evidence of luxation in the same tooth [Figure and ]. Clinically, the patient still had a visible plaque index of 46.4% and gingival bleeding of approximately 31.2%. The residual roots of the #16 and #26 teeth were present as well as white spots in all molars and an active cavity at #46. Furthermore, there was a need for endodontic therapy in all incisors affected by the trauma [].\nThe treatment planning strategy for the treatment was carried out in two stages. In the first stage, endodontic procedures were performed on the three incisors. Next, the bonding procedure and restoration were performed. The teeth involved had irreversible pulp involvement, and because of the extent of the fractures associated with an occlusion overbite, the possibility of bonding failure was considered. This fact would provide the need for intraradicular pins for the reconstruction of the teeth. Thus, endodontic treatment was the choice of the professionals responsible for the patient.\nAfter the endodontic access of the incisors as described above, irrigation of the pulp chamber and cervical third with 5% sodium hypochlorite was performed with an endodontic instrument type K (Dentsply-Maillefer, Ballaigues, Switzerland). The mechanical chemical preparation was performed with irrigation, aspiration, and inundation with 5% sodium hypochlorite and 17% ethylenediaminetetraacetic acid. The canals were irrigated with saline, and a calcium hydroxide paste was added. The elements were sealed with the glass ionomer restorative cement, Maxion R (FGM Dental Products, Joinville, SC, Brazil), provisionally until the next clinical appointment for the definitive obturation of the three incisors.\nIn the third visit, after 16 days, tooth #11 displayed lower mobility than what was observed in the first clinical session. Under absolute isolation and removal of the provisional ionomer material, the removal of the intracanal calcium hydroxide and a final obturation of the root canal with mineral trioxide aggregate (MTA) (MTA-Fillapex, Angelus, Londrina, PR, Brazil) were performed []. In the next session, a dental prophylaxis was carried out. To bond the fragment in tooth #11, the composite resin Amelogen enamel B1 and A1 (Ultradent Dental, South Jordan, UT, USA) was chosen. The fragments were cleaned with chlorhexidine digluconate solution at 2% (FGM Dental Products, Joinville, SC, Brazil) for 1 min; a rubber dam (Dental Dam Hygenic, Coltène/Whaledent GmbH, Langenau, Germany) and the adjacent dental elements fracture were insulated with polytetrafluoroethylene tape (Polytubes, Pulvitec, São Paulo, SP, Brazil). The coronary fragment and the remaining tooth structure were etched with gel phosphoric acid 35% (Ultra-Etch, Ultradent Products, South Jordan, UT, USA) for 30 s on the enamel and 15 s on the dentin, followed by extensive washing with air/water spray and subsequent drying air jets.\nThe dental bonding adhesive procedures were technically similar to that performed on the three incisors. AdheSE bond (Ivoclar Vivadent AG, Schaan, Liechtenstein) adhesive was used. The clinical sequence followed an alternating pattern, starting first with the right lateral incisor [], followed by the right central incisor [] and then the left central incisor where there would be a need to complement with composite resin [Figures and ]. To facilitate the bonding, we used a securing device, OptraStick (Ivoclar Vivadent AG, Schaan, Liechtenstein), and photopolymerization for 40 s in the buccal and 40 s on the lingual surface using polymerizing halogen light with an intensity of 1400 mW/cm2 (Radii LED Curing Light, SDI, Australia).\nThe beveled end was used superficially on the tooth fragment of the vestibular external interface enamel of the teeth with the latest aid spherical diamond, FG 1012 (KG Sorensen, Cotia, SP, Brazil), and reinforced composite microhybrid Amelogen (enamel B1). The final polishing was performed using interface Sof-Lex disks (3M ESPE, St. Paul, MN, USA) and a high gloss polishing slurry (Opal L, Renfert GmbH, Hilzingen, Germany) with the aid of fur brushes mounted goat suede and cotton on the labial surface and palate of all external enamel.\nClinical and radiographic controls were performed 2 and 5 months after the adhesive bonding procedure []. The color disharmony that was encountered initially in the restored teeth resolved significantly on its own accord within the preservation period after the reattachment of the fragments.
A 62-year-old man was admitted to our hospital with complaints of dyspnea and chest pain of 1 year’s duration. His electrocardiogram (ECG) showed the normal sinus rhythm with T-wave abnormalities, echocardiography indicated an ejection fraction of 55% and a normal valve function, and coronary angiography revealed 4-vessel disease. Consequently, coronary artery surgery was decided.\nThe patient underwent 4-vessel coronary bypass surgery. After sternotomy, cardiopulmonary bypass was instituted by using ascending aortic cannulation and 2-stage venous cannulation in the right atrium. Thereafter, the aortic cross-clamp was removed and the proximal anastomosis was performed with partial clamping. There were no intraoperative complications. At the end of the operation, a single drain was placed in the mediastinum and thorax cavity. The patient had approximately 1500 cc hemorrhagic drainage in the first 24 hours in intensive care. Despite the absence of hemodynamic instability, there was hematoma in the left thoracic cavity and an enlarged cardiac silhouette in chest radiography on the second day (). Additionally, echocardiography illustrated considerable pericardial effusion, which was 1 cm around the left ventricle and 2 cm around the right atrium and the right ventricle (). The decision was made to revise the patient in order to control the hemorrhage and to evacuate the hematoma on December 17, 2018. The intensely organized hematoma was evacuated from the mediastinal site and the left thoracic cavity. In addition, blood clots, which were accumulated at the back of the heart and around the superior vena cava and the innominate venous tract, were cleared. The leak in the proximal anastomosis of the aorta- saphenous vein was repaired. No significant hemorrhagic drainage was detected after the revision. The color of the liquid in the drains turned serous, and oral fluid feeding was started on the third day. On the following day, oral solid foods were passed. The serous fluid in the mediastinal drain began to increase at the end of the fifth day. On the same day, the appearance of this liquid turned milky white (). On the seventh postoperative day, there was 1800 cc of a milky and yellowish drainage fluid. A fluid sample was taken from the mediastinal drain, and biochemical and microbiological examinations were performed. The liquid had a triglyceride level of 1916 mg/dL, a total protein level of 6.0 mg/dL, and a cholesterol level of 207 mg/dL. Neither infiltration with microorganisms nor PNL infiltration was observed, which verified the chylous fluid. The oral feeding of the patient was discontinued, and total parenteral feeding with a low-fat and medium-chain triglyceride diet was initiated. The volume of the fluid drained decreased progressively from about 1800 mL on the day after the parenteral nutrition to 100 mL 11 days later. The drainage ceased after the 12th day, and the mediastinal drain was removed on the 14th day. Since the drainage stopped, no surgical intervention was needed. Postoperative chest radiography and echocardiography confirmed no re-accumulation of the mediastinal fluid, and the patient was discharged on the 18th day on January 2, 2019. An echocardiograph 2 weeks later showed no fluid in the mediastinal space. At follow-up in June 2019, the patient was uneventful. Furthermore, there was no pericardial effusion on the echocardiographic examination and the ventricular function was good.
A 53-year-old female patient had a chronic headache for 5 years before visiting our hospital. Based on the initial magnetic resonance imaging before surgery, anaplastic astrocytoma of the left cerebellum was suspected. Neurosurgeons performed a radical resection of the tumor, and the finial pathologic diagnosis confirmed glioblastoma. The patient received radiation therapy and chemotherapy after the operation. One year later, recurrence of the tumor was suspected, and a neurosurgeon performed a second radical resection of the tumor along with cranioplasty. Four months after the operation, the wound was disrupted due to infection. A neurosurgeon removed the cranial bone and consulted our department in connection with infection control and obliteration of the dead space. Physical examination revealed a closed wound about 8 cm in length, but underneath the closed skin cranial bone or soft tissue was missing. Culturing led to the growth of methicillin-resistant Staphylococcus aureus. Unfortunately, tumor recurrence was also suspicious, and therefore, the neurosurgeon planned radical debridement and additional resection of the tumor, which required reconstruction. The defect was 8×5 cm in size, with exposure of the dura mater (). We used a serratus anterior muscle flap with a split-thickness skin graft to cover the defect. Anastomosis was performed to superficial temporal artery and vein (). Even though we had also considered local flap for reconstruction, the large size and deep depth of the defect, possibility of subclinical infection and radiation injury to adjacent tissue led us to perform free flap reconstruction firstly. Unfortunately, the flap became completely useless 7 days after the operation due to hematoma and venous thrombosis. It was detached and a bilateral rotation flap used to cover the defect with grafted donor site skin (, ). The wound healed completely without infection and the patient was discharged.\nTwo month later, the patient revisited our hospital with wound disruption and purulent discharge from the wound. Seroma with infection was found due to recurrence of the tumor (). Additional surgery was planned. For exposure, a rotation flap was elevated from the occipital area to create a window for the neurosurgeon to perform radical debridement and resection of the tumor. After resection, the resulting defect was approximately 8×8 cm with exposed brain structures and could not be covered with the previous flap. To reconstruct the defect, two perforator-based flaps were designed, and a handheld Doppler was used to map the perforators adjacent to the defect. To cover the lower portion of the defect, an 8×5 cm occipital artery perforator-based island flap was designed from the left occipital area and neck (). The flap was elevated in the suprafascial layer and rotated superiorly. To reconstruct the remaining upper portion of the defect, the previous rotation flap was re-elevated and transposed to the defect, and to cover the donor site of that flap and the previous skin graft site, an additional rotation flap was designed from the vertex and transposed inferiorly (, ). All donor sites were closed primarily. The patient was discharged two weeks after surgery without any complications. Two months later, the patient died.
A 70-year-old man was referred to the plastic surgery team for consultation because of a bowel fistula in the open abdomen 2 months after total gastrectomy for stomach cancer. He had undergone several abdominal operations, including abscess drainage and closure of the abdominal wall with absorbable mesh, and had just become free from the aid of extracorporeal membrane oxygenation, which was started when he was in severe respiratory failure and septic shock. As abdominal computed tomography showed that contrast medium in the small bowel was scattered throughout his open abdomen, it was concluded that bowel fluids were continuously contaminating his open abdomen, despite frequent dressing changes (, ). At the time of consultation, he was still on a ventilator, was undergoing continuous hemodiafiltration, and was malnourished, with a low serum albumin level of 1.1 g/dL. The general surgeons decided that a radical operation such as a re-anastomosis of the small bowels would be too risky because the patient was too critically ill to undergo successful anastomosis or exteriorization of the bowels, which are usually very fragile in the open abdomen and difficult to expose without injury. Instead, the surgeons proposed the possibility of a perforator flap elevated from the skin near the fistula. The surgeons suggested that if the output from the fistula could be decreased by coverage and any area of the open abdomen could be made free from contamination, that would potentially allow the open area to be decreased gradually by skin grafts. Using ultrasound, a perforator reliable enough for a perforator flap to be elevated was identified in the right lower skin near the fistula in the open abdomen. Its diameter was 1.06 mm (, ) as assessed using the e-flow mode of the ProSound F75 (Hitachi Ltd., Tokyo, Japan) and a steep systolic crest was noted in its waveform, forming a notch between the systolic and diastolic waves with a peak systolic velocity of 52.9 cm/sec (). The patient and his family consented to the operation. The study was approved by the Institutional Review Board of Okinawa Prefectural Hokubu Hospital (IRB No. 2016010) and performed in accordance with the principles of the Declaration of Helsinki. Written informed consents were obtained.\nIn the operating room, in the right lower abdomen, a 9×26 cm perforator flap was elevated with the anterior sheath of the rectus abdominis muscle (). This flap was based on the perforator that was previously identified using ultrasonography (). Additionally, a part of the aponeurosis of the external oblique muscle was elevated with the anterior sheath, packed into the orifice of the fistula as a plug, and sutured to the wall of the small bowel very gently (, ). To keep the orifice of the fistula plugged continuously, it was necessary to elevate another flap on the contralateral side of the skin and suture it to the first flap to make, as it were, a stout bridge (, ). Intraoperative ultrasonography was used to identify another perforator in the left upper skin by the side of the open abdomen (, ). Its diameter was 0.85 mm, as assessed in the e-flow mode of the ProSound α7 (Hitachi Ltd.), and a systolic steep crest was noted in its waveform, forming a notch between the systolic and diastolic waves with a peak systolic velocity of 20.0 cm/sec. A 5×12 cm perforator flap was elevated, transposed, and sutured to the tip of the first flap (, ). The flaps continuously covered the orifice of the fistula. The upper part of the open abdomen was covered by skin grafts harvested from the right thigh ().\nPostoperatively, the amount of bowel fluid leakage from the fistula decreased dramatically, reaching zero at 18 days after the operation. A month after the operation, the other areas of the open abdomen, including the donor sites of the perforator flaps, were covered by skin grafts (). The patient was discharged from the hospital with ambulant status 7 months after the operation, after recovering from respiratory failure and completing rehabilitation.
A 44-year-old male smoker of high BMI with a diagnosis of recurrent adamantinoma underwent excision of the lateral tibial cortex tumour and medullary curettage in April 2010. Due to a recurrence in November 2010, a segmental diaphyseal excision and application of a TSF was performed for bone transport. In the last month of a 4-month course of frame treatment he experienced a PE with symptoms of mild shortness of breath which fully resolved. Of note, this man was resident overseas and throughout the course of his frame treatment made several flights of over 3 h between the UK and his home.\nOther than surgical time (Fig. ), 47 individuals had one risk factor, six had two, and three patients had three. Risk factors are summarised in Table .\nOf the procedures for which records were obtained, patients received post-operative prophylactic dose low molecular weight heparin (LMWH) for 71 procedures. Forty of those who received LMWH had identifiable risk factors on review of case notes. Of the 31 without an identified risk factor, we have postulated the potential reason for the use of chemical thromboprophylaxis which is summarised in Table . If the first dose of chemical prophylaxis was more than 36 h post-operatively, the use of LMWH was thought to be due to prolonged immobility. For those with insufficient data to calculate a BMI, it was surmised that this was the risk factor for which LMWH was used. One individual had polio and another who underwent simultaneous application of an ipsilateral femoral and tibial frame may have been considered to be risks of thromboembolism.\nTwenty patients were found to have risk factors for thrombosis but were not treated with chemical thromboprophylaxis, summarised in Table . Of 12 adults with high BMI, only three had a BMI over 40; four whose only risk factor was age > 60 were aged between 62 and 66. These cases of patients with a BMI and age close to the threshold of a risk of thrombotic event may not have had their risk status noted on clinical assessment.\nSubsequent to this study population, there have been two further cases of DVT/PE in patients treated with external fixators by the senior authors. These cases were not included in the above data, but their histories are included below (Cases 3 and 4) to help inform further discussion.
Our patient is a 25-year-old active duty male who initially reported a five-month history of bilateral leg pain, left greater than right, which occurred frequently with exercise. His pain localized to his calf muscles and was associated with tenseness, cramping, and numbness about his feet. The timing of his pain onset was variable but occurred every time he attempted to run. Resolution of symptoms typically occurred after 20 to 30 minutes of rest. Initial radiographs and bone scan were negative.\nWhen the patient's postexercise compartment pressures were measured utilizing a Stryker intracompartmental pressure monitoring system, elevation was noted from his preexercise baseline. Preexercise baseline values and postexercise values for each compartment in the left lower extremity can be seen in . The patient's deep posterior compartment of the left leg increased from 34 mmHg (pre) to 66 mmHg (post). Based on these results, the patient underwent elective left leg fasciotomy at an outside institution. Following an uneventful recovery from the surgery, his symptoms persisted for which he sought no further treatment for two years.\nAt the time of presentation to our clinic, the patient reported not only a lack of relief following surgery, but a worsening of symptoms in his operative leg. The pain continued to be associated with activity as previously described; however onset of symptoms now occurred with decreased intensity of stimulus. Upon examination of the patient, a decreased posterior tibial pulse which became impalpable during dorsiflexion of the ankle was noted. Furthermore, the patient could immediately reproduce his symptoms through weight bearing plantar flexion. Magnetic resonance imaging (MRI) was obtained and did not indicate anatomic abnormalities of the medial head of the gastrocnemius. An angiogram was then performed by Vascular Surgery service, which detected chronic arterial wall thickening. Stress computed tomography angiography (CTA) of the left lower extremity was performed which demonstrated lack of flow in the popliteal artery during stress (). The patient was diagnosed after three years and one unsuccessful surgical procedure with popliteal artery entrapment syndrome.\nFollowing his diagnosis, the patient declined further surgical or invasive interventions. Given the exertional nature of his symptoms, he instead opted to initiate the Medical Evaluation Board (MEB) process with the military. The MEB determines whether or not a military member's medical condition enables him/her to continue to meet medical retention standards in accordance with military regulations. During this review process, he implemented activity modification and continued to follow up in the orthopedic clinic for 6 months. At follow-up, he reported fewer symptomatic events since choosing to discontinue impact and high-intensity activities.
A 73-year old male patient of 173 cm height and 52 kg weight visited hospital. The chief complaint was cellulitis in right ankle. He was under medication after being diagnosed with diabetes, hypertension, congestive heart failure, and left chronic tuberculous empyema ten years ago. He was undergoing hemodialysis three times a week after diagnosis of end-stage renal disease eight years previously. There were no specific findings during the hospital stay. He maintained normal blood pressure of 130/80 mmHg and heart rate of 65-80 beats per minute. Atrial fibrillation, normal left ventricular function, moderate concentric left ventricular hypertrophy, moderate pulmonary hypertension, severe tricuspid regurgitation, moderate mitral regurgitation, aortic regurgitation, and moderate pericardial effusion were observed in echocardiography () performed during his hospital stay. Left lung empyema, right pleural effusion, pericardial effusion were confirmed by chest CT scans () and simple chest X-rays () and pulmonary function test showed a moderate restrictive pattern. Hemodialysis was performed the day before the operation and the result of the complete blood count before hemodialysis were hemoglobin level 8.8 g/dl.\nOn the fourth day of his in-hospital stay, sudden respiratory distress occurred after performing needle aspiration test of the right pleural effusion. Despite taking a simple chest X-ray immediately, our medical staff could not find any cause and observed him with oxygen therapy via nasal cannula. Respiratory distress got worse at a respiratory rate of 30 times per minute and an oxygen saturation level of 85% with changing mental status. Our staff inserted right chest tube 2 hours 30 minutes after performing needle aspiration biopsy. Approximately 1,500 ml of blood was drained for about 10 minutes after chest tube insertion, with blood pressure of 90/40 mmHg, heart rate of 66 beats per minute, respiratory rate of 22 times per minute, and body temperature of 36.4℃. Rapid fluid replacement with 1L of normal saline via central venous catheter placed in the right internal jugular vein was performed and an emergency operation was decided upon. The patient's electronic medical record (EMR) was unidentifiable by anesthesiologists because of computer network error at that time. Hence, the emergency operation was began only by acknowledging that the patient with diabetes and hypertension was receiving hemodialysis and massive bleeding occurred during needle aspiration test at right pleura.\nHe was transferred to the operating room without any preoperative medication 20 minutes after chest tube insertion. At that time, his vital signs were blood pressure of 130/50 mmHg, heart rate of 60 beats per minute, respiratory rate of 22 times per minute, and body temperature of 34.9℃. He was stuperous and his skin was cold but other physical examination could not be performed. Preoxygenation was attempted with 100% oxygen at 8 L/min via mask and warm Voluven® (6% hydroxyethyl starch, Fresenius Kabi, Germany) was rapidly administered. In addition, non-invasive blood pressure, oxygen saturation, and electrocardiogram (ECG) were monitored. An arterial catheter for continuous hemodynamic monitoring was placed via the right femoral artery and a central venous catheter via the right femoral vein and 500 ml of Voluven® was rapidly administered. After IV administration of 90 mg ketamine and 50 mg rocuronium for induction, endotracheal intubation was performed with a 35 Fr left-sided double lumen endotracheal tube (Broncho-Cath®, Mallinckrodt Medical Athlone, Ireland) and flexible fiberoptic bronchoscope (LF-GP, Olympus, Japan) was used for confirmation of proper placement. During lung ventilation, tidal volume of 100-120 ml, a peak inspiratory pressure of 40 cmH2O, blood pressure of 130/50 mmHg, a heart rate of 65 beats per minute, and a central venous pressure of 17-18 mmHg in supine position was checked. We attempted to maintain anesthesia with 1.5 L/min of oxygen, 1.5 L/min of nitrous oxide, and 2 vol% of sevoflurane. However, inspired oxygen concentration was changed to 100%, sevoflurane administration was stopped, and 1 mg of midazolam was administered intravenously every 15 minutes after oxygen saturation fell to 84%. After the patient was changed to left-sided lateral position, the location of tube was confirmed by a flexible fiberoptic bronchoscope with a central venous pressure of 21 mmHg. Left one-lung ventilation (OLV) was performed five minutes after changing the position to left-sided lateral position. Tidal volume and oxygen saturation decreased to 170-180 ml and 80% respectively. Peak inspiratory pressure increased up to 38 cmH2O.\nImmediately on opening the right pleural cavity via right posterolateral thoracotomy, blood pressure decreased catastrophically and 1,500 ml of blood gushed out of the pleural cavity followed by about additional 1,200 ml of blood loss. Arterial blood gas analysis was performed 25 minutes after the beginning of surgery (). Subsequently, 3 L of Voluven® and 1 L of normal saline were administered rapidly during the half an hour after the beginning of surgery. At half an hour after the beginning of surgery, our hospital computer network was restored; packed red blood cells and fresh frozen plasma were administered. Then central venous pressure increased up to 38 mmHg with decreased active bleeding, fluid administration was minimized for concern about volume overload. Oxygen saturation level decreased continuously even though peak inspiratory pressure was above 40 cmH2O during one-lung ventilation. One-lung and two-lung ventilation were performed in turn along with manual and mechanical ventilation by maintaining tidal volume of 120 ml, respiratory rate of 60-70 times per minute, peak inspiratory pressure of 22 cmH2O, inhaled oxygen concentration of 100%, and oxygen saturation of 91-93%. Although fluid administration was minimized, central venous pressure increased up to 50 mmHg, blood pressure and heart rate were maintained at 120/60 mmHg and 67 beats per minute respectively and there were no abnormal ECG finding. Initial blood loss via chest tube before surgery was 1,500 ml, estimated blood loss during operation was 2,700 ml for 40 minutes and there was no urine output. The patient was administered 4,000 ml of Voluven®, 2,000 ml of normal saline, 5 pints of packed RBCs, and 5 pints of fresh frozen plasma. At 45 minutes after the beginning of surgery, central venous pressure suddenly increased up to 58 mmHg with falling in blood pressure of 70/40 mmHg, bradycardia of 25-30 beats per minute. 0.5 mg of atropine and 0.5 mg of epinephrine were administered immediately through a central line and the pericardium was checked by the surgeon for suspected pericardial tamponade while resuscitation was being prepared. The surgeon confirmed pericardial expansion and made a pericardial window immediately. After approximately 800 ml of yellow serous fluid with no blood was drained from the pericardial space, vital signs stabilized with recovering heart rate 60 beats per minute. Thereafter, blood pressure of 115/50 mmHg and heart rate of 65 beats per minute were maintained and central venous pressure was reduced to 45 mmHg. To maintain blood pressure, 20 mg of ephedrine and 1 g of calcium gluconate were administered divided. Arterial blood gas analysis was performed 30 minutes after pericardial window (). Although no active bleeding focus was found in the surgical field, blood leak continued under the damaged diaphragm. It was decided to observe the patient in the intensive care unit after primary closure. Flexible fiberoptic bronchoscopy was performed postoperatively and a small fresh blood clot was detected at the right bronchus. The patient was transferred to the ICU while maintaining a double lumen endotracheal tube from concern about failure of finding the bleeding focus and the risk of rebleeding. The total amount of fluid administrated during surgery was 4,100 ml of Voluven®, 3,000 ml of normal saline, 7 pints of packed RBCs, and 5 pints of fresh frozen plasma. Blood loss before surgery was 1,500 ml and intraoperative blood loss was 2,700 ml. Upon arrival on the ICU, the patient was stable with blood pressure of 97/72 mmHg, heart rate of 74 beats per minute and a tympanic membrane temperature of 35.7℃. No pulmonary edema was observed on postoperative chest X-ray (). Hemoperitoneum was confirmed on abdominal CT scan but we decided to observe carefully because there was no active bleeding focus in the abdominal cavity on the celiac artery angiogram. The patient exhibited stable vital signs after continuous renal replacement therapy during follow-up period and about 900 ml of bleeding via chest tube occurred on the first postoperative day. However, the chest tube was removed and hemoperitoneum was resolved as bleeding diminished 10 days postoperatively. Moderate pericardial effusion was detected again on echocardiography. The patient is currently admitted to the intensive care unit under mechanical ventilation due to respiratory failure.
The patient was a 32-year old woman with a one-year history episodes of cholecystitis treated conservatively. She did not have any other disease history. After an abdominal magnetic resonance imaging that confirmed multiple gallbladder stones (Fig. a), an elective LC was performed without intra-operative complications. The recovery was uneventful and the patient was discharged two days after operation. On the second day after discharge, the patient developed severe right upper abdominal pain and she was sent to our emergency department at 8:30 pm. At arrival, her heart rate was 110 bpm and the blood pressure was 80/55 mmHg. The hemoglobin dropped to 86 g/l from 127 g/l. The CT scan showed a 10.9 × 12.5 × 6.6 cm ISH in the right liver without obvious free fluid in abdominal cavity (Fig. b). Two hours after fluid resuscitation including 2 U red blood cell, the hemoglobin further declined to 78 g/l and the hemodynamics remained unstable. The abdominal pain was not relieved, after intravenous analgesics. A Doppler ultrasound was performed, two hours later and it found the hematoma had increased in size. Active intrahepatic bleeding was suspected. We called radiologist for consultation, however, the interventional angiography and embolization was not available at mid night. We explained the potential risk of sudden rupture of hematoma during conservative methods which may cause sudden death, to the patient and her relatives. After careful consideration of the continuous decline of hemoglobin, unstable hemodynamics after fluid resuscitation, we explained our surgical plan to the patient and her relative. We planned to perform laparoscopic exploration at first, if the hematoma continued to expand, we would evacuate or drain it, if not, we would put a drainage tube under liver which could serve as an early warning of rupture. The patient requested surgical method to reduce the risk of sudden death. Therefore, an emergency laparoscopic exploration was performed under general anesthesia. The ISH was confirmed (Fig. c). Four U red blood cell and 400 ml fresh frozen plasma were transfused. After fluid resuscitation and blood transfusion, her hemodynamic became stable. During the 3-h intra-operative observation, the hematoma did not expand. Therefore, a non-sucking drainage tube was placed under the liver and she was sent to ICU ward. Next morning, she was transferred to the ordinary ward. The upper abdominal pain gradually relieved. Five days after the laparoscopic exploration, another CT scan showed that the hematoma was largely resolved and we removed drain tube (Fig. d). She was discharged, 10 days after readmission.\nTotally, 13 papers, including 16 cases of ISH after LC were reported from 1994 to 2015 (Table ). Nearly half of the patients had instability of hemodynamics. All of the cases were female patients. Age of patients ranged from 25 to 78. All hematomas were mainly located in the right lobe of liver, and some of them extended to the left lobe of liver. Only one case was ruptured at diagnosis. Hepatic capsule laceration was found in two cases, one of whom also took NSAIDS (non-steroids anti-inflammatory drugs) to control the pain after operation. Totally, 58.8% of patients took NSAIDS to control the post-operative pain, and most of them used Ketorolac, however, 35.3% of the patients still did not have definitive risk factors. The time interval to diagnose ISH after LC ranged from seven hours to six weeks. They were diagnosed most commonly (35.5%) within one day after LC. All patients had abdominal pain and 47.1% of the cases developed hypovolaemic shock.\nTreatment strategies included: conservative treatment (antibiotics, blood transfusion, strict bed-reset), percutaneous drainage under CT or B ultrasound guidance, selective embolization of the bleeding vessel, laparoscopic exploration and laparotomy. Eighteen percent of patients had stable condition without fever and underwent conservative treatments. The only case of angioembolization was complicate by infection and required percutaneous drainage. For the patients with stable condition, fever and serious compression of inferior venal cava (IVC) always were indications for percutaneous drainage under CT or B ultrasound guidance. In these 17 cases, 29.4% of the patients underwent percutaneous drainage. For the patients with hemodynamic instability, emergent reoperation was adopted. Totally, nine cases underwent reoperation, including two case of laparoscopic operation and seven cases of laparotomy. For our case, we only performed laparoscopic exploration and did not perform evacuation or drainage of the hematoma, since the hemodynamic became stable after plenty fluid resuscitation and the hematoma did not expand, during the 3 h of intra-operative observation. For another case, laparoscopic exploration found small capsule laceration, and hemostasis was performed. In the seven cases of laparotomy, six patients underwent evacuation and drainage of hematoma, only one case underwent only laparotomy without evacuation or drainage.\nAll patients survived. Most of patients stayed one to two weeks after readmission, however, the longest hospital stay was up to 31 days after reoperation.
A 54-year-old diabetic male presented to our outpatient facility with a history of a calcaneal osteomyelitis after a failed calcaneal open reduction internal fixation and a large post-traumatic septic defect of the Achilles tendon area. His past medical history was only significant for type 2 diabetes mellitus controlled by his oral hypoglycemics. The patient had sustained the injury and had an urgent surgical intervention 4 weeks prior to his initial visit in our facility. Pedal radiographs and wound cultures were positive for septic necrosis of the wound and also for growth of Enterococcus and Stenotrophomonas species. The patient was then admitted for initial surgical debridement and further osseous and soft tissue reconstruction ().\nOur team's initial plan, after the bone biopsy and intraoperative cultures were obtained, was delayed coverage of the large defect with a reversed sural pedicle flap but this option was not feasible due to an intraoperative finding of a severed distal end of the sural artery. The sural artery's function was not intact and was ensured only by the supply from collateral arterial branches. The reversed flow arch that came from the lateral tarsal and anterior lateral perimalleolar vessels was interrupted. Immediately, the flap was redesigned and laterally transferred as a new flap, additionally based on the distal peroneal perforator. A partial calcenectomy was also performed, the Achilles tendon was retracted proximal in a lateral direction and reattached with two 3.5 mm absorbable bone anchors on the rest of the debrided calcaneus. The defect was also adequately covered by the additional use of a posterior tibial perforator based flap to cover subsequent marginal skin necrosis of the neighbouring flap area. In order to provide prophylactic sensation over the defect area, we also performed an end-to-end coaptation of the sural nerve with the lateral plantar nerve. The donor sites were covered with split thickness skin grafting harvested from his thigh regions. The patient was kept non-weight bearing for about 3 months after the final reconstruction and was fully ambulating at about 5 months postoperatively.
A 46-year-old male cadaver was found to have an extra-hepatic biliary system with rare morphological anomalies. This was identified during a descriptive-prospective cross sectional study of the morphological characteristics of the extra-hepatic biliary system in humans.\nThe anterior abdominal wall was opened longitudinally along the midline. The abdominal wall was separated on to the right side along the central margin up to the mid axillary line. Then the abdominal wall was divided from the right side of the pubic bone up to the anterior superior iliac spine. The anterior abdominal wall flap was reflected laterally. The stomach was retracted to the left side and the second part of the duodenum, free margin of the lesser omentum, epiploic foramen and gall bladder identified. Dissection was done to demonstrate the extra-hepatic biliary system and its vascular pattern.\nThe right and left hepatic ducts were not seen extra-hepatically and the common hepatic duct drained directly into the gall bladder neck, with absence of the common bile duct. Further drainage of the bile away from the gallbladder and into the duodenum was provided by the cystic duct. The gall bladder was lying in the gall bladder fossa in the right lobe of the liver in a transverse plane. The width and the length of the gall bladder were 2.5 cm and 4.5 cm respectively. The length of the common hepatic duct was 2.6 cm and the cystic duct that drained the gall bladder to the duodenum was 6.9 cm (Figure ).\nApart from the anomalous extra-hepatic biliary morphology, a rare abnormal arterial pattern was observed. The cystic artery was anterior to the common hepatic duct and it was originating from the right hepatic artery. The division of anterior and posterior branches of the cystic artery was not noted. The right hepatic artery was found to be communicating with the left hepatic artery by a "bridging artery" after giving rise to the cystic artery. An accessory hepatic artery originated from the "bridging artery" forming a "cruciate" hepatic arterial anastomosis (Figure ).
A 60 year old Caucasian male patient was referred to general surgery for multiple unrelated complaints including umbilical hernia and left arm lipoma. The patient also had an additional complaint of a fast-growing right leg mass located on upper lateral right calf distal to the knee. The patient had no other suspicious skin lesions and admitted to having the lesion shave biopsied two years prior by dermatologist with benign findings. No picture was taken of the lesion prior to surgical intervention as it was expected to be benign based upon prior dermatological findings. The patient stated that the leg lesion was non-painful in nature but was concerned that it may have increased in size over the previous 2 months and had a brown-gray discoloration. No prior imaging was obtained for the leg lesion. A wide margin elliptical excision was performed with a minimum goal of 1 cm margins on all sides of the lesion and the depth was resected to the muscle layer. The full specimen was marked for orientation and submitted to pathology. The excised elliptical portion measured 4.3 cm in length and 2.5 cm in width at widest points. The nodular lesion measured 2.4 × 1.8 × 0.9 cm. Ancillary studies showed that the lesion was CD31 positive, CD34 positive, and negative for cytokeratin markers. The pathology report confirmed EHE with tumor close to circumferential margins and present at the deep margin. The lesion was staged as pT1a pNX in accordance with AJCC staging. Given the deep margin extending to the thin layer of muscle just distal to the knee, the patient was referred to orthopedic surgery for further evaluation and operative intervention. The mainstay of treatment for invasive sarcoma is surgery often coupled with radiation and/or chemotherapy. A second surgical excision 19 days later following the original surgery was performed into deeper tissue. The second lenticular ellipse measured 8.1 cm in length and 2.1 cm in width at widest points at a depth of 1.4 cm. Multiple frozen sections were examined and clean margins of a minimum of 1 cm was determined in all directions.\nDue to the diagnosis of EHE, it was prudent to obtain additional imaging to determine if the malignancy had metastasized. Although incredibly rare, there have been documented cases of pulmonary epithelioid hemangioendotheliomas, as well as cases of tumors found on the liver. A CT scan was performed with IV and oral contrast of the chest and abdomen. The findings were unremarkable for the chest but multiple hepatic cysts and an enhancing lesion in the right lobe of the liver were identified. A follow up MRI with and without gadolinium confirmed a 2 cm well-defined focal area of delayed enhancement within the posterior segment of the right lobe of the liver corresponding to the CT findings, likely representing a cyst and not a metastatic lesion. These findings suggest that no metastasis had occurred and that the leg skin lesion appeared to be the primary site of EHE.
The patient is a 70-year-old man with a medical history of hypertension and diabetes, but no notable family history. He had been experiencing bleeding during bowel movements for approximately 2 months. He later noticed a mass in his anal area and visited a nearby clinic. Upon suspicion of anal cancer, the patient was referred to our department of surgery for detailed examination and treatment. Lower gastrointestinal endoscopy identified an elevated lesion centered on Herrmann's line in the anus (fig. ). A biopsy of the lesion led to the diagnosis of mucinous adenocarcinoma. Visual inspection of the anus confirmed the absence of extra-anal tumor protrusion, anal fistula, or pagetoid spread. Pelvic computed tomography (CT) (fig. ) revealed mucosal thickening with a contrast effect in the rectum, as well as swelling of the right inguinal lymph node and pararectal lymph nodes. There was no distal metastasis in the lung, liver, or any other organ. Pelvic magnetic resonance imaging (fig. ) also confirmed wall thickening with gadolinium enhancement in the rectum (Rb-P), which was consistent with the pelvic CT finding. Abdominoperineal rectal excision was performed along with bilateral lymph node dissection and bilateral inguinal lymph node dissection. The tumor infiltrated the muscularis propria, and metastasis was confirmed in the pararectal lymph nodes as well as the right inguinal lymph node. Due to inguinal lymph node metastasis and an intraoperative finding of suspected remnant carcinoma, a Cur B excision was determined to be necessary []. Macroscopic and pathological findings confirmed the diagnosis of rectal-type adenocarcinoma of the anal canal (mucinous adenocarcinoma). No increases in the levels of tumor markers such as carcinoembryonic antigen and cancer antigen 19-9 were observed relative to preoperative levels. No RAS gene mutation was identified.\nBecause our patient had advanced anal canal adenocarcinoma with multiple metastases to the lymph nodes, postoperative adjuvant therapy was scheduled according to the strategy recommended for rectal cancers with a high risk of recurrence; this regimen is in turn based on the postoperative adjuvant chemotherapy applied for colon cancer treatment. As postoperative positron emission tomography/CT examinations confirmed the absence of abnormal findings such as remnant tumors, mFOLFOX6 therapy was selected. The chemotherapy was administered uneventfully for 6 months (12 cycles). As of this writing, approximately 2 years since the surgery, the patient has no signs of recurrence. Periodical follow-up examinations will continue into the future.
A 53-year-old man noticed some swelling of his face. A chest x-ray showed a large mass projecting over the right lung field (fig ). A CT scan of the chest showed an enormous anterior mediastinal mass contiguous with the posterior aspect of the sternum and the right ribs, occluding the superior vena cava and compressing the heart (fig ). Blood tests were normal, tumor markers and Acetyl Choline Receptor Antibodies were negative. The patient underwent bronchoscopy and the biopsy showed the features of a carcinoid tumor.\nHe underwent excision of the tumor, which required resection of the superior vena cava and insertion of a graft, resection of the right phrenic nerve and plication of the diaphragm.\nThe finding at surgery was an enormous spherical tumor with an extremely vascular capsule due to the venous collaterals. The tumor was 20 cm from pole to pole and 15 cm in diameter. On the left it bulged into the left pleural space, displacing the phrenic nerve laterally. Superiorly it obliterated the left innominate vein and extend into the strap muscles. There was an enlarged lymph node. On the right it had obliterated the confluence of the innominate veins and the first centimeter or so of the superior vena cava. It enclosed the phrenic nerve over its complete length and was adherent to the medial aspects of the upper and middle lobes of the right lung. There was some thickening of the visceral pleura in this area and there appeared to be some superficial infiltration. Posteriorly it was adherent to the pericardium and there was some thickening of the ascending aorta, consistent with longstanding pressure effects. There was a small bloody pericardial effusion and a rather large right pleural effusion. There was no evidence of any pleural deposits or intrapericardial deposits.\nThe histology of the resection specimen showed a tumor weighing 2.1 kg. The tumor appeared encapsulated with an irregular surface. The tumor invaded the surrounding fat and pleura. There was infiltration into the underlying lung tissue lymphatics. There was some residual thymic tissue within the surrounding fat. Metastatic deposits were found in the right hilar lymph node and the node removed from the left cervical horn of the thymus. The tumor was classified as an atypical carcinoid of the thymus (neuroendocrine carcinoma of intermediate grade 2).\nOne month later he underwent a CT scan of the chest. There were findings consistent with a recent sternotomy and a graft of the superior vena cava. There was a fluid filled cyst at the base of the right lung and areas of atelectasis and pleural thickening were noted in both lungs.\nAn I-123 MIBG scan was performed with negative results for detection of any residual or recurrent pathology.\nHe was treated with postoperative radiotherapy and chemotherapy.\nOne year later, a follow-up CT scan of the chest was obtained with no findings of recurrence or abnormal lymph nodes in the mediastinum. Linear atelectasis was detected in the lower lobes of both lungs and elevation of the right hemi diaphragm was noted. In addition a bone scan was performed with a positive finding at the posterior arch of the 8th right rib. The patient was advised to have a SRS, for a more accurate evaluation of his status, as it was considered that "functional" imaging performed by Nuclear Medicine examinations, might detect pathological processes earlier than "structural" images, such as CT.\nSpot images of head-neck, thorax, abdomen and lumbar region were obtained 3 hr after injection of 5 mCi In-111-DTPA-D-Phe 1-pentetreotide. The scan was carried out on a Sopha single headed tomographic gamma camera coupled to a dedicated NXT computer system. Spot images of the areas of interest were obtained with a high-energy all-purpose collimator using 20% windows centered at 171 and 245 keV.\nThe SRS was reported as showing an area of abnormally increased concentration of the radiopharmaceutical at the anatomical area of the mediastinum due to either a mass remnant or a recurrence of the disease or an inflammatory process (fig. ). The bone scan finding did not take up the radiopharmaceutical. A repeat bone scan after a further 9 months was negative.\nThus, the main questions that we had to answer were: is there a mass remnant, or a recurrence of the disease? and, can we exclude a metastatic lesion at the site of the finding on the bone scan?
A 90-year-old woman visited our hospital due to a large area of erythema and localized skin ulceration with hemorrhage of her right breast. Her breast symptoms arose 5 years ago and had been worsening. She could not visit a hospital because she expected for naturally healing and feared noticing cancer and death. She had a history of atrial fibrillation and cerebral infarction 2 months earlier, then her breast lesion was found out. The area of erythema was 15 × 15 cm2. Her nipple and alveolar complex were destroyed and had an uncertain shape. Her skin erythema was soft, and no tumor was palpable (Fig. ). Her quality of life had got worse by hemorrhage and exudate from the tumor, and she felt strong anxiety about getting more worse and death from the cancer.\nA punch biopsy indicated mammary Paget’s disease. Computed tomography showed that the tumor was only on the surface of the breast, with no metastasis including of the axillar lymph nodes. There was no underlying tumor in the breast (Fig. ).\nEven though our patient was a very elderly woman with comorbidities and her prognosis was relatively good, her symptoms were intolerable. By the request of her and her family, we decided to perform surgery to eliminate the area of erythema after receiving sufficient informed consent. The surgical treatment was performed by two teams that included surgeons and dermatologists. We drew a resection line 1 cm from the skin erythema. Dermatologists were on standby in case a skin graft was needed. We performed muscle-sparing mastectomy with sampling of an axillar lymph node. We added two stress-relaxation sutures to avoid diastasis because the excision area was very large and the tension of the skin flap was strong (Fig. a, b). Fortunately, a skin graft was not necessary and her postoperative course was good. The skin flap did not develop major complications such as necrosis, seroma, wound infection, and highly disturbance of moving the right upper limb. We removed the stress-relaxation sutures 7 days after surgery.\nA histological examination revealed mammary Paget’s disease without invasion to underlying tissues (Fig. ), no evidence of a residual tumor of the entire stumps, and no metastasis in the lymph node. Although she felt a little tightness of the surgical site, paresthesia of the chest wall, and a sense of breast loss, her quality of life improved after surgery by being freed from symptoms and anxiety related to malignancy. It was a great value for her, even if she suffered from these complications.
A 61-year-old man who was diagnosed with bulbar ALS was admitted to our hospital for evaluation and management of blood backflow through a gastrostomy tube. He had been diagnosed with ALS 26 months before admission and had undergone gastrostomy 6 months before admission. Additionally, 1 month before admission, he started full tube feeding and maintained a stable diet of 500 mL per meal. At the time of admission, he was 176 cm tall and weighed 43 kg (body mass index [BMI]: 13.88 kg/m2); his weight was similar to that measured 6 months before admission. He was using the home ventilator via tracheostomy tube full-time for 24 hours and all his limb muscles were generally measured as trace grade on the manual muscle test. Esophagogastroduodenoscopy was performed, and an acute gastric ulcer with recent bleeding was identified. The gastrostomy tube was removed because irritation by the tube was thought to be the cause of bleeding. The patient underwent therapeutic fasting for 5 days, and a high-dose proton pump inhibitor was administered intravenously.\nAfter 5 days of fasting, the patient resumed enteral feeding through a nasogastric tube. Considering the healing process of the gastric ulcer, 100 cc of meal was fed through the nasogastric tube; this was increased to 200 cc per meal after 2 days. Since the patient had consumed about 1500 cc of meal per day before admission, the remaining nutrients were supplied via parenteral nutrition. A follow-up endoscopic examination confirmed a healing state of the gastric ulcer, and we re-inserted the gastrostomy tube 7 days after resuming the meal through the nasogastric tube (or 12 days after previous gastrostomy tube removal). The volume of diet administered through the gastrostomy tube was also initiated at 100 cc per meal and gradually increased. However, when the feeding amount reached 200 cc per meal, the patient presented postprandial vomiting, abdominal distention, and tachycardia. Because of these symptoms, it was difficult to increase the amount of enteral feeding volume supplied to the patient. Therefore, we adjusted the amount of the feeding and maintained it at 100 cc per meal inevitably.\nSince these symptoms were not temporary, we performed computed tomography (CT) of the abdomen. We found that the second portion of the duodenum had become narrower between the aorta and the superior mesenteric artery. The patient also had severe stomach and proximal duodenum distension (Fig. A). In addition, the distance between the superior mesenteric artery and aorta was 7.10 mm, which is shorter than the normal range (Fig. B). Based on clinical symptoms and radiological findings, we were able to diagnose SMAS. The body weight was re-measured 5 days after fasting and it had reduced from 43 kg (BMI: 13.88 kg/m2) to 39.95 kg (BMI: 12.89 kg/m2). We performed jejunal tube insertion along with tubography and observed dilatation of the duodenum and severe gastric retention. Gastric retention was so severe that we could not advance the tube to the jejunum and it was placed in the second portion of the duodenum (Fig. A). Gastric retention was improved; 6 days later, the jejunal tube was repositioned beyond the gastric obstruction (Fig. B). Then, the amount of feeding through the jejunal tube was gradually increased while maintaining parenteral nutrition. Over the next 6 weeks, the presenting symptoms of the patient gradually improved. Follow-up CT of the abdomen and tubography were performed to observe improvement in duodenal narrowing and stomach distension. The dilatation of the stomach and duodenum, which was observed in previous examinations, was no longer observed, and tubography showed a passage of contrast through the duodenum without contrast stagnation. After these follow-up examinations, the patient could maintain diet through the gastrostomy tube again, and he tolerated 500 cc of diet at discharge. His body weight at the time of discharge was 43 kg, which was the body weight at the time of admission.\nThe evaluation finding included in this case study did not contain identifiable patient's personal information, and this case study involves no more than minimal risk to human subjects. For these reasons, this study was approved a waiver of informed consent from the institutional review board of the Jeonbuk National University Hospital (CUH 2019-10-024).
A 60 year old male, who had had an open fracture of the right lower leg accompanied with the vascular injuries of the anterior tibial, posterior tibial, and peroneal artery by a traffic accident. Mangled Extremity Severity Score at the time of presentation was eight points. Although the posterior tibial artery that was repaired primarily resulted in the obstruction with thrombus, the tissue distal to the injury survived by the collateral vasculature [Figure and ]. After radical debridement of the necrosed tissue, there was a large open defect with a certain loss of bone, including the plafond in lower third of the lower leg []. Continuity of the tibial nerve was identified with severe attenuation, and both the superficial and deep peroneal nerves were lost. Since there was severe soft tissue injury proximal to the popliteal fossa for exploration of the proximal parts of the major arteries, secondary reconstruction of major arteries using arteriovenous loop was impossible and avoided. After explanation to the patient regarding the respective results and complications that could be expected with below knee amputation (BKA), and with difficult reconstruction for preservation respectively, he desired to retain the injured lower leg.\nAs the first step for reconstruction, the defect was augmented by a cross leg free rectus abdominis musculocutaneous flap as to achieve healthy recipient site for subsequent bone graft. The deep inferior epigastric artery and its venae comitantes were anastomosed to the posterior tibial artery and its venae comitantes of the normal opposite limb. The legs were immobilized by external fixator []. Three weeks later, the pedicle was severed and then external fixator for immobilization of the both legs was removed.\nAfter 8 weeks for rehabilitation to the both legs, the distally pedicled fibula osteocutaneous cross leg flap was planned. Prior to flap harvest, vascular delay to the peroneal artery at the bifurcation from the posterior tibial artery was administered []. Two weeks later, contralateral distally pedicled fibula osteocutaneous flap was elevated. The fibula was divided into two parts, and then the double-barreled fibula 12 cm in length each inserted into the bone defect between the proximal remnant of the tibia and the talus [Figure and ]. The both legs were immobilized by external fixator again. Three weeks later, the vascular pedicle was divided and then the external fixator was removed. Because the cutaneous flap put between both legs during the immobilization period resulted in necrosis due to excessive pressure, flap coverage of the grafted fibula with 3rd cross leg flap was mandatory.\nFour weeks after previous operation, the exposed bone was covered with the proximal based medial sural cross leg flap [Figure and ]. The both legs had been immobilized by external fixator for 3 weeks, and then the pedicle was divided and the external fixator was removed []. After a course of consecutive three cross leg flaps, neither contralateral knee nor ankle contracture remained due to an adequate range of motion (ROM) training in the intervals of each immobilization periods [Figure and ].\nOver 3 years after injury, including almost a year of the total period of substantive treatment, the patient can walk on crutches with patella tendon weight bearing orthosis [Figure and ]. No limitation of ROM was identified on both limbs except the fused ankle of the affected side. Deep sensation of the foot were preserved. Bone and functional results using Association for the Study and Application of the Method of Ilizarov scoring system were both good.
A 51-year-old Madheshi woman came to our neurology clinic with the chief complaint of sudden decrease in the tone and texture of her voice for the past 15 days. Her voice was very feeble but understandable and she noticed it was better by the time she got up from her bed only to worsen through the day to become nearly inaudible. She had noticed a slight change in her voice texture in the first several days which she had ignored in the beginning as it was not worth bothering about. She had no complaint of choking or coughing or aspiration or any throat discomfort. When asked for any other related and/or unrelated things she noticed in her habits, she complained about having constipation for many years otherwise she was apparently well. She had never visited hospital for any problem and no interventions had been done in the past. She denied smoking tobacco, drinking, or any other recreational drugs abuse. There was no one in her family or her parents’ family with any kind of known chronic disease. Her biological father had controlled hypertension with medication. Her psychosocial history was not significant. She came from a middle income family, and she had retired recently as an accountant for a small company. Her symptom progressively aggravated in later days to the extent that she not able to produce sound properly. It usually waned in the early morning or after enough voice rest only to wax throughout the day.\nOn physical examination, a systemic examination did not reveal any abnormality. On neurological examination, her muscle power was intact: 15/15 on Medical Research Council (MRC) scale. She had no imbalance and was able to tandem on walking. An examination of her gag reflex and other cranial nerves revealed no abnormal reflexes. Deep tendon reflexes were intact. Her speech articulation was intact and revealed no scanning of speech. Speech production was adequate and non-painful; her tone was non-nasal but the intensity was low and slow. Other neurological examinations also did not reveal any abnormality. Other systemic examinations were also non-significant.\nConcerned with her problem, she had visited an ear, nose, and throat (ENT) department for her problem and was screened for possible laryngeal disorder for hypophonia. There was no obvious laryngeal pathology found and the treatment initiated by the ENT department had no satisfying outcome. She visited our neurology clinic. The differential diagnoses considered were Parkinson’s disease (PD) or a bulbar variant of motor neuron disease (MND), and MG. MRI scanning of her brain and screening of her whole spine appeared normal. Laboratory investigations including a hematologic panel, infectious disease screening panel, and myopathy panel involving creatinine kinase and creatine phosphokinase-N-acetyl cysteine (CPK-Nac), were all within normal range. She was suspected to have MG as other diseases were ruled out. A Quantitative Myasthenia Gravis (QMG) test was performed on our patient and her QMG score was 1 (for speech). She was given neostigmine challenge test with intravenously administered injection of 2.5 mg neostigmine and the result was positive after more than 30 minutes. There was significant improvement in her voice quality and she felt her fatigability improved as well. She gained a good quality of speech within an hour. QMG scoring was repeated, and she scored QMG score of 0. The longer duration of the medicine gave us enough time to assess the improvement. The laboratory test for the AchR antibody (AchR ab) is not available in Nepal. We had to send AchR ab to India, and the report received after waiting several weeks was positive. Quantitatively, it was significantly higher, 1.11 nmol/l than the normal range (0.0–0.4 nmol/l). She was later maintained on 60 mg of orally administered pyridostigmine with 12 hourly administrations and subsequently increasing to 6 hourly along with steroids.\nPlain and contrast-enhanced computed tomography (CT) scans of her head, neck, and chest were done, and they revealed a mass in the anterior mediastinum: a well-defined, smooth outlined, approximately 4 × 2.5 × 2 cm, soft density nodule showing poor enhancement in the anterior mediastinum in the thymic space with maintained fat plane with the adjacent vessels and structure. Thymoma was suspected and she was sent to the surgical department for further surgical intervention.\nShe returned to our neurology clinic around 2 months after her first visit to us as a follow-up visit. She had undergone a successful surgery. She was doing well. Prednisolone was already tapered off. She was tapering down pyridostigmine as well, with a maintenance dosage of pyridostigmine 60 mg 12 hourly and planned to put off the medication. Her voice was clear and well maintained and she had no complaint of fatigue. She had no fresh complaint and was doing all her daily and professional activities very well.
An 8 year-old girl was referred by pediatric gastroenterology department due to persistent unexplained vomiting. She reported vomiting of 20-30 times a day during the last week of each month for the last 5 years. It was projectile, non self-induced, and started within the first 3 days of the last week of each month and lasted for 5-7 days. The vomiting disappeared spontaneously and she has been totally symptom free between vomiting episodes. Her repeated endoscopic examinations did not reveal significant findings except for esophagititis which was considered as a consequence of vomiting. Her cranial magnetic resonance imaging and EEG were within normal limits. She has been treated with several agents including lansoprazole, metoclopramide, trimethobenzamide and other antacids for 3 years without any improvement. She had been treated with fluoxetine for her anxiety symptoms for 4 months. Although her anxiety symptoms showed moderate improvement with fluoxetine, no improvement was reported in vomiting episodes.\nShe was given the diagnosis of musculoskeletal dysplasia at the age of 4 with a current height of 90 cm and weight of 20 kg. Her psychiatric examination revealed social phobia, generalized anxiety, obsessive-compulsive and attention-deficit disorders and binge eating episodes following vomiting episodes. Her psychometric evaluation revealed mild mental retardation. She was given a diagnosis of CVS and started on mirtazapine 15 mg/day at bedtime on the 25th day of the month. Her vomiting episode started on the next day with usual severity and lasted 5 days. However we continued medication and she did not have any vomiting during the next month. The mother reported that this was the first time that she did not have vomiting over the last 5 years. She developed increased appetite and some level of sedation related to mirtazapine treatment and gained 2 kg within 6 weeks. Therefore we planned to discontinue mirtazapine on the fifth day of the month and to restart it on 20th day to prevent vomiting episode at the end of the month and to avoid side effects. However she developed a milder vomiting episode on the 15th day of the month which lasted 4 days. This was the first time that vomiting episode occurred on the mid of a month. We restarted mirtazapine 15 mg/day and continued medication for the next 4 months. The number and intensity of vomiting showed very much improvement. She had milder vomiting for several times during the episodes. She reported some level of day time sedation and increased appetite related to mirtazapine treatment and gained one more kilogram.
An 80-year-old male patient was referred to the abdominal surgery department due to incarcerated ventral hernia and ileus. In the past he was operated due to perforated gastric ulcer. He also had arterial hypertension, chronic pulmonary obstructive disease and pulmonary hypertension, a history of smoking, he suffered an ishemic stroke in the past. He was urgently operated on the same day. Segmental resection of small bowel with end-to-end anastomosis was performed and the hernia defect was closed with direct sutures, without prosthetic mesh because the bowel was resected. There were no surgical or other complications after surgery and he was discharged from hospital after 8 days. 5 days later he was admitted to the hospital again due to early recurrence of ventral hernia. The content in hernia sac could however be reduced back to his abdomen. Laboratory findings showed leucocytosis and elevated C-reactive protein (CRP - 148 mg/l). Intestinal winding with a thickened wall up to 5 mm was found at the location of the ventral hernia by ultrasound examination. The patient underwent a second surgery 22 days after the first surgery due to obstructive ileus, which was seen on the abdominal computed tomography (CT) a day earlier. Due to additional diseases and disorders (ischemic stroke and insertion of stent in his left internal carotid artery in 2011, arterial hypertension, asthma, pulmonary fibrosis and hypertension, which were not properly treated, because the patient did not follow the prescribed treatment) the anaesthesiologist decided for the spinal anaesthesia, because the general anaesthesia would be to risky. The surgery was performed by an abdominal surgeon with 5 years experiences as a specialist and he performed more than 30 Rives-Stoppa ventral hernia repairs. The skin incision was made along the previous skin incision. In the subcutaneous tissue the small intestine was tightly adhered on to the skin. We managed to release it but unfortunately, a segment of the small intestine was damaged during adhesyolisis. Segmental resection of the damaged small bowel with end-to-end anastomosis was performed (). The small intestine was reduced back in to the abdominal cavity. Ventral hernia was repaired according to Rives-Stoppa technique with prosthetic mesh (). Other than postoperative tachycardia there were no reported issues. A couple of hours after the procedure apnoeic episodes appeared followed by unconsciousness. A computed tomographic angiography (CTA) of the brain vascular system was made and it showed a stenotic left vertebral artery (90% stenosis). Because of respiratory insufficiency and haemodynamic instability, the patient was transferred to the intensive care unit. Due to a worsening clinical condition, a CTA of the abdomen was preformed and an occlusion of superior mesenteric artery (SMA) was discovered. Interventional radiologist preformed an embolectomy and thrombus aspiration from the SMA with an insertion of a stent. The patient's condition continued to worsen so the abdominal surgeon decided for a “second look” abdominal exploration. At surgical revision we found a small intestinal and sigmoid colon gangrene. Because of the patients age, several other comorbidities and gangrene of the entire small bowel, the multidisciplinary team (abdominal surgeon, anaesthesiologist, intensivist) decided for conservative treatment. The patient died the day after surgery.
A 63-year-old male presented with swelling in the right inguinal region for the past 10 years with a sudden increase in size since two months. On examination, a single, firm three cm swelling was felt in the right inguinal region. No abnormality was detected in the left inguinal region. No other lesion such as an ulcer or swelling was noted in the right leg or thigh.\nThere was no history of fever, rigors and loss of weight or appetite in the recent past. Patient gave no history of exposure to tuberculosis.\nOn general examination, patient was well built and nourished. There was no pallor or generalized lymphadenopathy. No abnormality was detected on systemic examination. Base line blood investigations were found to be within normal limits. An ultrasonogram of the right inguinal mass showed circumscribed hypoechoic mass suggestive of a lymph node shadow. An ultrasound guided aspiration was done and the smears were submitted for cytological examination. Ultrasonogram of the abdomen was unremarkable.\nCytosmears examined were moderately cellular with dual cell population, composed predominantly of oval to polygonal cells with abundant cytoplasm and round bland nuclei resembling histiocytes []. These cells were arranged in loose clusters and as isolated forms. The background showed few discrete round cells with round nuclei and scanty cytoplasm suggestive of mature lymphocytes []. No precursor lymphoid cells were seen on cytosmears. In correlation with clinical and image findings, an impression of reactive lymph node was suggested on cytology. A clinical follow-up and excision was advised if clinically suspicious or lesion further increased in size.\nAn excision biopsy was performed which showed skin with a neoplasm located in lower dermis and subcutis. Tumor cells were arranged in nests with focal diffuse pattern. Individual cells appeared round to oval with abundant granular eosinophilic cytoplasm and centrally placed bland nuclei []. Focal collections of lymphocytes were also seen []. Tumor cells were seen surrounding the adnexal structures and nerve fibres. Immunohistochemistry showed S100 positivity in nucleus and cytoplasm ([] inset). Immunostains for CD68 and inhibin showed cytoplasmic positivity. A final diagnosis of granular cell tumor was given based on histology and immunoprofiling.
A nine year old female patient reported to the Department of Oral Medicine and Periodontics with the chief complaint of bleeding from the gums while brushing and gives history of enlarged gums for the past six months. History revealed that the enlargement of gingiva which was initially localized to the anterior two teeth in the upper and lower jaw gradually over a period of six months spread to other teeth. There was no pain associated with the enlargement and the only symptom was bleeding from the gums which occurred during brushing. On consultation with general dentist who did a thorough oral prophylaxis and put the patient on short course of systemic antihistaminics (diphenhydramine maleate). The clinical condition did not regress and the patient was referred to our hospital for further evaluation and management.\nClear history was recorded for any gastrointestinal disturbance, loss of weight, loss of appetite, cough, fever and any other systemic signs or symptoms. There was no history of any medication and allergic reactions to any food substances or drugs.\nIntra oral examination revealed enlarged gingiva of the maxillary and mandibular anterior region, which is diffuse and curtain like enlargement as shown in . There was slight bleeding on probing and minimal plaque and calculus were present. The enlargement involved the marginal gingival, interdental papilla and attached gingival extending till the mucogingival junction. Secondary changes like pus, ulcerations were not seen over the lesion. On palpation the enlarged gingiva was uniformly soft in consistency and non tender. The teeth in the region of the gingival enlargement were normal except for the fractured 21 which occurred two years before due to trauma. The fractured tooth was asymptomatic. The intra oral periapical radiographs of upper and lower anterior teeth didn’t show any abnormality. Based on the history and clinical features, clinical differential diagnosis of tuberculous gingivitis, plasma cell gingivitis, histoplasmosis, allergic gingival enlargement, gingival enlargement due to any hormonal changes or an idiopathic granulomatous enlargement.\nHematological investigation was performed for RBC. Count, WBC count, Differential Count, platelet count, ESR, Hb%, serum ACE, PCV, MCV, MCH and MCHC. All the levels were within the normal range and the ACE level was 40 U/L which is also within the normal range.\nThe mantoux test was also negative and the chest radiograph didn’t reveal any abnormal pathology. Polymerase Chain Reaction (PCR) was done to rule out Tuberculosis infection. PCR for detection of Mycobacterium tuberculosis genome by nested PCR which detects MPB64 and IS 6110 were negative, thus ruling out tuberculosis involvement.\nAn incisional biopsy of the enlarged gingiva was performed in relation to 13, 14 region and 32, 33 region and the tissue was sent for histological examination. The histological report showed the presence of parakeratinised stratified squamous epithelium of variable thickness and multinucleated giant cells with peripherally arranged nucleus suggestive of Langhans giant cell surrounded by modified macrophages suggestive of epitheleoid cells as shown in . There was also a rim of inflammatory cells primarily lymphocytes. The connective tissue showed areas of moderate vascularity and areas of hemorrhage as shown in . Multiple granulomas containing lot of giant cells suggestive of a granulomatous lesion.\nThus correlating the history, clinical findings, laboratory investigations and histopathological examination, a final diagnosis of idiopathic orofacial granulomatosis was made.\nSince in our case there was only the gingival enlargement without any systemic involvement, we planned for surgical excision. Gingivectomy of both upper and lower arches was carried out under local anesthesia. The case was followed for one year without any recurrence as shown in .
A 58-year-old female patient who lives in the rural mountain came to the clinic complaining of hearing loss and otalgia in her left ear which started one week prior to the visit. She did not have any past medical history except for a previous thyroidectomy operation. The left ear canal was impacted with a dark gray colored cystic lesion (). The cystic mass surrounded by small crusts was observed in the distal part of external ear canal skin. A pod like structure was visualized at the posterior superior quadrant of the cystic lesion () and the external organism was densely adherent to the skin medial to the pod ( in the online-only Data Supplement).\nAt first, the patient was examined by a resident to exclude the other cystic lesion on the external ear canal and an enhanced CT scan was performed to evaluate the middle ear. The enhanced CT image showed a slightly enhanced oval shaped soft tissue lesion in the mid part of the external auditory canal (). The lesion appeared heterogeneous and moderately enhanced in the ear canal (empty arrow). HU (Hounsfield unit) of the cystic lesion (empty arrow) was between 100-150. In contrast, HU of ipsilesional (arrow) and contralateral (empty arrow head) ear cartilage was below 100. For reference, a vein (arrow head) showed a HU of 130. Contrast enhancement similar to vein was observed and could be a differential point of the lesion. This lesion did not invade the middle ear and mastoid cavity with the ossicular chain intact. The patient came to an ENT specialist after the CT scan, and the cystic lesion appears like an organic structure. The cystic lesion was gently dissected from the external ear canal skin with ear forceps and sharp instrument. However, en bloc removal of the cystic lesion was not easy due to its dense adhesion to the skin of ear canal. Thus, after rupturing the cystic part, the cystic lesion was removed with grasping forceps (). The extracted specimen was suspected to be a haematophagic organism blocking the external ear canal. After the removal, symptom of the patient was relieved and did not have any systemic symptoms such as fever or myalgia.
A 24-year-old man, fully awake and aware with no significant past medical history, admitted in neurosurgery ward due to a long-lasting history of diffuse constant non-throbbing head ache and recent exacerbation accompanied with nausea and vomiting. His past medical history was unremarkable. In physical examination neither motor/sensory deficit nor cranial nerve dysfunction was detected, but bilateral small pale optic disks with sharp margins were evident in direct ophthalmoscopy. The patient underwent brain imaging to assess the potential causes of intracranial hypertension. Magnetic resonance imaging (MRI) revealed multiple septations in the right lateral ventricle resulting in a multiloculated appearance of the ventricle and bi ventricular hydrocephalus with the right side being apparently dominant (). Considering long history of headache, the septated hydrocephalus was assumed to be potentially caused by an old undiagnosed intraventricular event like hemorrhage or inflammation but remained compensated for a while. The patient was scheduled for an elective microsurgical fenestration of intraventricular septa to eliminate the intraventricular blocks and restore the normal cerebrospinal fluid (CSF) pathway. The procedure was performed via entering the right occipital horn where numerous arachnoid adhesions and bands were encountered which were released using a blunt hook. The most prominent adhesions were seen in the area of right trigone, creating multiple entrapped cavities whose walls were opened with sharp dissection. At the end of procedure, the ventricle seemed to be free of cavitation and the foramen of Monro was seen without previously adhesive barriers. The postoperative period was uneventful and the patient improved in terms of headache and vomiting. Postoperative images showed resolved hydrocephalus without formerly sulcal effacement or ventricular septation (). The patient discharged home on the third postoperative day with good general conditions and no new neurological deficits.\nHe readmitted to emergency ward 12 days after the first surgery while being confused (Glasgow coma scale: 13/15) for the last 2 days. A relatively rapid decline in the level of conscious ness occurred within the first hours of admission and his right pupil’s response to light became poor. Physical exam revealed repeated right hemiparesis. Considering the apparent unilaterally trapped right atrium and temporal horn on new images associated with significant periventricular edema and midline shift (), an emergent external ventricular catheter was inserted in the right lateral ventricle’s trigone which resulted in rapid recovery of consciousness. During the procedure, CSF was found to have very high pressure, light pinkish color, and clear appearance. The analysis of CSF revealed 600 red blood cells, 0 white blood cells, and no bacteria in direct smear. After 48 hours with the patient being relatively well and the result of CSF culture being negative, ventriculoperitoneal shunt was inserted in the trapped ventricular site. The rationale for early ventriculoperitoneal shunt procedure was to avoid probable external ventricular drainage infection, besides, there was no better option to manage trapped ventricle after a failed fenestration surgery. On postoperative images, hydrocephalus was resolved following shunting, but an acute ischemic stroke within the whole territory supplied by left SCA was evident that was not obvious in his first brain MRI study (). Brain CT-angiography was performed seven days after readmission which showed the left SCA being patent with no other vascular compromise or disease throughout the territory under study ().\nDue to the odd location of the infarct, other probable causes of juvenile stroke were investigated. Trans-thoracic and trans-esophageal echocardiography precluded the probable cardioembolic causes or underlying cardiac anomalies such as endocarditis, valvular heart diseases and patent foramen ovale. Peripheral blood smear and hemoglobin electrophoresis and complete coagulation profile studies demonstrated no hematologic abnormalities. Comprehensive investigations for suspect ed autoimmune, metabolic, and infectious causes of juvenile stroke were unremarkable.\nOn the 9th day of shunting procedure the patient discharged with good general condition and full consciousness. Subsequently, hemiparesis subsided within about 6 weeks by the aid of physiotherapy.
A 69-year-old male patient with decreased mental status and headaches after falling down the stairs visited our emergency room on around February 2010. His muscle strength was relatively preserved over a good grade on his all extremities. On the computer tomography of his brain, subdural hemorrhage on the right parietal lobe and the left frontal lobe, subarachnoid hemorrhage on the bilateral temporal lobe, and fracture on the right parietal bone were found (). The diagnosis of TBI was confirmed. He was admitted to the Department of Neurosurgery for a conservative treatment, and his mental status was gradually improved from stupor to alert. He started his rehabilitation therapy including proper evaluations from 2 weeks after the injury. On functional evaluation, he could not sit alone nor stand without assist, and these disabilities could not be ruled out from poor corporations or decreased muscle strength. Three weeks after injury, he was transferred to the rehabilitation department, and he started cognitive rehabilitation program. On 5 weeks after injury, his cognitive function was markedly improved, and his Korean Mini Mental State Examination (MMSE-K) score was 21. His functional level was improved accordingly, and Korean Modified Barthel Index (K-MBI) score was improved from 2 to 81. On 6 weeks after injury, we could evaluate his muscle strength precisely, and all his extremities showed over the good grade on manual muscle test. He was able to walk independently, and was discharged.\nHe received the rehabilitation therapy as an outpatient until 8 weeks after injury, and then he was encouraged to exercise alone at home receiving only outpatient follow-up. However, during staying in his home without serial rehabilitation therapy, his personality took on aggressive and delusional characteristics. His cognitive impairment and aggressive behavior got worse, and he was admitted to the Department of Neuropsychiatry with diagnosis of the delusional disorders on 3 months after his first discharging from the hospital. At the time he was hospitalized again, no auditory or visual hallucination was found; however, he appeared to have anxiety, delusion, and aggressive behavior. The magnetic resonance image (MRI) of his brain showed no additional lesion than the chronic changes from hemorrhages on bilateral cerebral hemisphere of his previous TBI. Accordingly, with the diagnosis of delusional disorder which occurred after TBI, he was treated with 2 mg of risperidone per day. After starting this medication, his delusion, anxiety, and aggressive behavior gradually improved enough to cooperate with the therapists. Two weeks later, he was given 10 mg of donepezil per day for his mild cognitive impairment. After 6 weeks of admission in the Department of Neuropsychiatry, he was transferred to the Department of Rehabilitation for the proper rehabilitation therapy, because he showed problems in his gait. He could walk independently, but he showed no movements in his upper extremities and his step-width was narrow. Additionally, he had scooped posture, bradykinesia, tremor in both hands, and sleep disorder. He complained of difficulty in walking, and he could not start any movement promptly. He had difficulties in all activities of daily living, and K-MBI score was 56/100. These symptoms were characteristics of Parkinsonism, and we assumed that this parkinsonian features were related with the administration of risperidone and donepezil, which were started before the onset of his parkinsonian features. Therefore, dopamine transporter imaging with [18F]FP-CIT PET-CT was performed to distinguish his parkinsonian features from idiopathic Parkinson's disease, and normal dopamine transporter density was observed in bilateral caudate nucleus and putamen (). With this result, we could exclude idiopathic Parkinson's disease, and we diagnosed his parkinsonian features as drug-induced Parkinsonism caused by concurrent use of risperidone and donepezil. We discontinued both donepezil and risperidone, and the parkinsonian features gradually disappeared. He was discharged with much improved functions, and K-MBI score was 75.
A 30-year-old male patient was air evacuated from Mt. Everest base camp post a successful mountaineering expedition after developed pain and swelling in both his feet. The patient initially noticed bluish discoloration of toes with mild pain during the expedition. He continued with the expedition after rewarming the area with water and some analgesics. The symptoms gradually increased over a 3-day period and the patient developed swelling and redness in the dorsum of both feet along with blackish discoloration and blister formation in all his toes []. The patient was initially evaluated at a hospital in Nepal where he was started on pentoxyphylline along with antibiotics and NSAIDs and was transferred to our centre for further management. The patient was subjected to a triple phase bone scan after administration of 15mCi of 99mTc MDP. The perfusion phase revealed relatively increased flow of tracer in the right foot localizing at the proximal phalanges along with decreased tracer flow in the region of distal phalanges. The left foot showed a uniform tracer flow. The blood pool phase images revealed intense tracer distribution in the soft tissue of right great toe in the proximal phalangeal area. Rest of the toes in the right foot also showed uniformly increased tracer distribution in the proximal phalangeal region along with abrupt cut off and photopenia in the region of distal phalanges. The left foot showed mildly increased tracer distribution in soft tissue around proximal and distal phalanges of all toes. The skeletal phase images obtained 3 hours after the injection of the radiopharmaceutical revealed the intense tracer uptake in the proximal phalanx of right great toe and the increased tracer uptake in proximal phalanges in rest of the toes of right foot along with a relative photopenia in the region of mid and distal phalanges. The left foot revealed the intense tracer uptake in the proximal and distal phalanges of great toe. The triple phase bone scan findings were suggestive of distal phalanx of right great toe, mid and distal phalanges of rest of toes in right foot in ischaemic zone and the proximal phalanges of all toes in right foot, proximal and distal phalanges of left foot undergoing reperfusion hyperemia []. The patient had developed dry gangrene in the distal phalange of right great toe and mid and distal phalanges of rest of toes in the right foot, which autoamputated on its own without any active intervention. The patient had no residual neurovascular deficit in the left foot and right proximal phalanges.
A 38-year-old gravida 1, para 0 was transferred to our unit at 26 weeks of gestation with severe right iliac fossa pain and a suspicion of threatened preterm labour. She presented with a 3 day history of right iliac fossa pain, nausea, vomiting and diarrhoea. Vaginal examination and her fetal fibronectin test was negative. However, transabdominal and transvaginal ultrasound examination revealed a 6.0 × 5.5 × 5.9 cm vascular mass within the right pelvis with a clear arterial feeder and turbulent swirling intraluminal flow, leading to the diagnosis of a pseudoaneurysm (Fig. ). The diagnosis was subsequently confirmed by Magnetic resonance imaging (MRI) (Fig. ). The patient was discussed in our multidisciplinary team meeting with interventional radiologists, vascular surgeons, and anaesthetists. The risk of imminent rupture was assessed as high due to the severity of her symptoms and a 5–10 mm overall increase in the size of the pseudoaneurysm documented by sequential MRI 14 days apart. Surgery was considered high risk and so selective embolization of the pseudoaneurysm was performed. This was performed under local anaesthetic in the Interventional Radiology suite with full preparation for emergency delivery by the obstetric and anaesthetic team in case of fetal distress. The right uterine artery was identified angiographically from a contralateral femoral arterial puncture and selectively catheterised using a microcatheter. The artery was small but extravasation into the presumed pseudoaneurysm was identified near its proximal portion. The artery was embolised with a series of microcoils across the neck of the pseudoaneurysm to block flow. The procedure was uneventful and the fetus showed a continuous reactive heart rate pattern. Follow up ultrasound showed a completely thrombosed pseudoaneurysm with no flow. She had regular follow ups in the antenatal clinic with no sign of recurrence. A planned caesarean section was performed at 38 weeks gestation. A healthy baby boy was born weighing 2696 g with a blood loss of 1100mls. During the caesarean section, the thrombosed pseudoaneurysm was seen below the right broad ligament and all other pelvic organs looked completely normal (Fig. ). An ultrasound scan 3 months postpartum showed a small completely thrombosed pseudoaneurysm (Fig. ).
The patient in this case is a 70-year-old female diagnosed with multiple brain metastases from primary small-cell carcinoma of the lung. She reported a significant smoking history (100 packs per year) with COPD and later developed a small-cell carcinoma of the upper lobe of the left lung. Following her diagnosis, she underwent a left upper lobe lobectomy and tolerated the surgery well. Spread to the mediastinal and hilar nodes was not observed at that time. However, tumor evidence was seen in the soft tissues surrounding the bronchial resection margin, and a single involved lymph node was noted in the pathology report of the lobectomy resection. Imaging studies performed at that time did not show evidence of the disease elsewhere in the body.\nAlthough SCLC is known to be a radiosensitive tumor histology, the patient was not felt to be a candidate for radiation therapy due to her limited pulmonary reserve. The patient was prescribed chemotherapy with Carboplatin and VP-16. The chemotherapy was given in 4 cycles within a period of three months, and the patient responded well to the treatment. A CT scan of the chest performed three months after the resection showed no evidence of tumor recurrence. The patient had no complaints at that time except for some mild shortness of breath.\nApproximately five months later, the patient presented with complaints of headaches and blurred vision. She also reported nausea without vomiting. An MRI scan revealed multiple brain metastases (three lesions). The largest of them was in the left cerebellar hemisphere (1.4 cm3). Other masses were noted in the left frontal lobe (0.56 cm3) and right putamen (0.49 cm3). The patient was then prescribed Decadron and her neurological symptoms significantly improved.\nAfter discussing the available treatment options with a radiation oncologist, WBRT was prescribed to the patient for a period of three weeks. The total radiation dose prescribed was 37.5 Gy in 15 fractions. An MRI performed one month later revealed continued postcontrast enhancement of the masses when compared to the previous MRI. The option of being treated with GKRS was then presented, and risks and benefits were discussed with the patient. The patient consented to GKRS and underwent the treatment without reporting any complications. The Gamma Knife dose prescribed for each lesion was 16 Gy to the 50% isodose line.\nAn MRI performed two months following GKRS revealed that the left cerebellar lesion and left frontal lesion decreased in size and the right putamen lesion exhibited stable changes. No new lesions were observed at that time. Follow-up MRIs were performed at two-to-three month intervals for a period of 24 months and were stable without any new foci. During this period, the patient presented with episodes of transient ischemic attacks. An MRI performed three months following the initial attacks showed the presence of two new lesions in the right caudate region (0.21 cm3) and right centrum region (0.054 cm3). The patient consented to repeat GKRS and underwent the procedure without reporting any complications. The previously irradiated left cerebellar lesion (1.3 cm3) and left frontal lesion (0.49 cm3) were also treated. The Gamma Knife dose prescribed was again 16 Gy to the 50% isodose line for each lesion. The second Gamma Knife procedure was performed approximately 27 months following the first procedure.\nAgain, the patient was followed both clinically and with serial MRI scans at two-to-three month intervals and was found to have radiographic documentation of a new brain metastasis directly medial to the previously irradiated left cerebellar lesion (0.13 cm3). The other lesions were reported to have stable changes. The patient was fully informed about the risks and benefits of being treated with a third Gamma Knife procedure. The patient consented to the treatment and was prescribed a dose of 16 Gy to the 55% isodose line. The third Gamma Knife procedure was performed approximately 16 months following the second procedure. The patient tolerated the treatment well and did not report any complications.\nFollow-up appointments with both a medical oncologist and radiation oncologist revealed a stable primary cancer and minor muscle weakness from steroid use. A serial MRI performed approximately three months following the third Gamma Knife procedure revealed a new brain metastasis within the right insular cortex (0.061 cm3). The other treated lesions were reported to have stable changes. The patient consented to a fourth Gamma Knife procedure and was prescribed a dose of 16 Gy to the 50% isodose line. The fourth Gamma Knife procedure was performed approximately three months following the third procedure.\nFurther follow-up appointments and serial MRI scans revealed stability in both her primary cancer and her neurological cancer. No new brain lesions have been reported. The patient was diagnosed with brain metastases 60 months ago and is still alive and experiencing a good quality of life despite some minor chronic neurological symptoms. She continues to be monitored closely.
A 44-year-old Iranian woman with Cacausian ethnicity presented with an anterior midline neck mass that gradually appeared without tenderness over three months. The patient had a history of frequent painful swelling of the anterior part of her neck, which subsided with antibiotics therapy. A physical examination of the patient revealed a 100 × 55 mm mass that was painless, smooth and hard. The mass was located on the anterior part of the patient's neck and extended from the suprahyoid portion to the thyroid gland. The thyroid gland could not be separated from the mass. Thyroid functional tests (serum thyroxine, triiodothyronine and thyroid stimulating hormone) were within normal limits. A thyroid scan with technetium pertechnetate detected a cold nodule corresponding to the mass in the left lobe of the thyroid gland.\nA computed tomography scan (CT) revealed a relatively large (100 × 55 × 48 mm), heterogeneous enhancing soft tissue mass with a cystic component in the midline of the anterior neck space, that extended from the base of the tongue to the inferior aspect of the thyroid gland and the bilateral aspect of the submandibular gland (Figure , Figure and Figure ). The mass was completely separated from the tongue muscles. The destruction of the hyoid bone and chondrolysis of the thyroid cartilage were also seen. A hypodense lesion in the left thyroid lobe and some adenopathy in the submandibular space were detected. A fine needle aspiration (FNA) revealed a papillary carcinoma. The tumor mass, together with the thyroid gland, the hyoid bone and the bilateral cervical lymph node were therefore removed. Although the thyroid gland was not involved, some micrometastases in the cervical lymph nodes were seen. The pathological report revealed a papillary carcinoma arising with a 100 × 53 mm TDC.\nThe pathologic report described in detail the occurrence of complex, branching and randomly oriented papillae with a central fibrovascular core and a single or stratified lining of cuboidal cells with a zoom in of 10 (×10). In addition, nuclear features showed optically clear (ground glass) nuclei and nuclear grooves (×40), indicating a malignant papillary carcinoma.\nPostoperative radioactive iodine treatment and thyroid hormone supplements were recommended. The patient was followed up with a clinical examination, thyroid scintigraphy and ultrasonography of the operation site. The tumor had not recurred one year after the operation.
A 41-year-old man was referred to our hospital with the chief complaint of progressive dyspnea over 1 month. His vital signs were almost stable with oxygen saturation of 94% on room air. A chest X-ray film showed a right hilar mass lesion and enhanced computed tomography detected a mass that completely obstructed the right pulmonary artery (Fig. ). There were also multiple nodules in both lungs, which were suspected to be metastatic lesions. Generally, we should obtain histological diagnosis of the pulmonary nodules to judge the operability by bronchofiberscopy or percutaneous needle biopsy. However, in this case, it would have been a risky procedure because of the respiratory insufficiency, and it might have been even critical if contralateral pneumothorax had been complicated after lung puncture by percutaneous needle biopsy. Regarding the main tumor, we consulted cardiologists to rule out pulmonary thrombosis and for histological diagnosis, but angiography was judged not to be indicated. Therefore, surgery was planned for both diagnosis and treatment.\nThe tumor was located in the right hilar region and was approached via median sternotomy. No pleural effusion or dissemination was detected in the ipsilateral thorax. At first, the right main pulmonary artery was encircled by approaching between superior vena cava and ascending aorta. However, main tumor was palpable and judged as impossible to transect it to ensure the surgical margin. Therefore, we tried to encircle the right main pulmonary artery on the left side of the ascending aorta. If it had been difficult to encircle it on the left side, we should have converted to the procedure under cardiopulmonary bypass. However, in this case, it was possible to encircle the vessel by blunt finger dissection and transected it with a surgical stapler. The superior pulmonary vein was also transected with a surgical stapler, but the inferior pulmonary vein could not be identified. Previously, we have added an intercostal incision to confirm the inferior pulmonary vein. However, we used a single thoracoscopic port (11.5 mm in diameter) placed at the 8th intercostal space on the mid-axillary line in the present patient. This allowed us to detect the inferior pulmonary vein easily, and we transected it safely with a surgical stapler, while avoiding additional intercostal thoracotomy and accomplishing tight pneumonectomy. The patient’s course was uneventful, and he was discharged on postoperative day 16. Nodules in the contralateral lung disappeared after surgery, suggesting that these were non-metastatic lesions.\nHistopathological examination showed that the tumor extended into the lumen and also had spread beyond the pulmonary artery. Microscopy of hematoxylin and eosin stained sections revealed a hypercellular pattern of pleomorphic spindle cells and epithelioid cells, with prominent nuclei and mitotic figures. Immunohistochemical staining showed that the cells were focally positive for alpha-SMA and were negative for HHF35, CD34, c-kit, and osteopontin. The Ki-67 proliferative index was 30% (Fig. ). Tumor was diagnosed as a pulmonary artery sarcoma, and residual tumor cells were detected at the surgical margin of the pulmonary artery. As adjuvant therapy, he received radiation (60 Gy) to the surgical stump and 4 cycles of chemotherapy (ifosfamide 2 mg/m2, epirubicin 45 mg/m2). The ipsilateral pulmonary nodules were suspected to be metastatic lesions but were found to be thrombosis, and there was no evidence of malignancy.
A 39-year-old female presented to the emergency department with acute onset of right retroorbital and temporal headache associated with left-sided weakness and numbness following sexual intercourse. She was otherwise healthy without cerebrovascular risk factors, tobacco use, or illicit drug use. She was taking oral contraceptives. There was no family history of premature coronary artery disease or stroke. Initial general examination was notable for a blood pressure of 158/98. Neurologic examination revealed a left lower facial droop and hemiparesis. Brain MRI revealed an acute stroke in the right cerebral hemisphere in a watershed distribution (). Head MRA demonstrated no flow-related enhancement within the petrous and cavernous segments of the right ICA with reconstitution of the ICA at the ophthalmic artery level. Axial fat-saturated T1-weighted MRI through the skull base demonstrated a distortion of the lumen of the petrous and cavernous segments of the right ICA by a rounded region of increased signal abnormality consistent with a dissection (). Conventional 4-vessel cerebral angiography demonstrated 360-degree loops in both cervical ICAs (). At the apex of the loop involving the proximal right internal carotid artery, there was a fusiform aneurysm filled with a subintimal thrombus resulting in poor antegrade flow into the distal ICA and cerebral circulation. The 360-degree loop in the mid-cervical portion of the left internal carotid artery was not associated with outflow obstruction. The 360-degree loop in the distal right ICA was not felt to be amenable to surgical intervention by vascular surgery due to the distal nature of the vascular anomaly. She was anticoagulated with warfarin for 7 months followed by treatment with extended-release dipyridamole plus aspirin daily. Her left hemiparesis progressively improved following discharge and she had no residual weakness after 1 month. Eight years later, she presented with acute onset of right hemiplegia associated with a global aphasia. Brain MRI revealed a large stroke in the distribution of the left middle cerebral artery (). She was discharged four months later without clinical improvement and was lost to followup.
A 67-year-old man with past history of Ivor Lewis esophagectomy 6 years previously for a Barrett's esophagus presented with dysphagia, recurrent cough, regurgitation and weight-loss. Endoscopy suggested a benign anastomotic stricture, for which he underwent dilatation. However his symptoms worsened and he continued to lose weight in spite of supervised dietary therapy. Aspiration was suspected and a barium swallow was performed. This demonstrated pharyngeal in-coordination, as the probable cause of aspiration. A repeat endoscopy was non-contributory. A feeding jejunostomy was inserted to prevent continued weight loss. In spite of this, he continued to have repeated chest infections resulting in extensive bronchiectatic changes in the right lower lobe.\nA tracheostomy was planned at this stage to prevent aspiration. Whilst he was being intubated for the procedure, air was noted to escape from the right bronchus. A bronchoscopy revealed the presence of the GBF, with the bronchial opening in the right main stem bronchus located about 1 cm below the tracheal bifurcation and the gastric opening midway down the lesser curvature of the gastric conduit. The temporal sequence of events suggests that fistulation had occurred at the time of anastomotic dilatation, and thus the worsening of symptoms following the procedure. The fistula was however, difficult to diagnose in spite of extensive investigations leading to unexpected finding in the anaesthetic room.\nGiven his debilitated condition and poor respiratory function stenting was considered to occlude the fistula. However as the fistula was positioned in the middle of the gastric conduit (Figure ) it was not deemed amenable to stenting due to poor fixation of the stent and risk of migration. And similarly satisfactory stenting of right main stem bronchus was difficult to achieve due to short length of this bronchus and consequent tendency to migrate. Though associated with greater risk of morbidity and mortality, a surgical approach was deemed the best approach for this problem.\nAt operation a right-sided re-thoracotomy was performed and careful dissection carried out to display the anatomy of the GBF (Figure ). The fistula was excised with a cuff of healthy gastric conduit and bronchial tissue. The gastric and bronchial openings were closed directly with absorbable stitches with interposition of bovine pericardium in between the two suture lines. The patient made an uneventful recovery from operation. A contrast study one-week later confirmed absence of leakage from the gastric conduit and feeding was started. Histopathological examination confirmed the presence of benign GBF in the resected specimen.\nThe patient was discharged home after two weeks and remains well six months later.
A 70-year-old woman presented in our vascular clinic due to an asymptomatic juxtarenal 10 cm AAA identified as an incidental finding in a recent computed tomography (CT) scan (\n). Her medical history included mild hypertension under drug medication. At physical examination of the abdomen, a large pulsating mass was present with normal pulsation of femoral and tibial vessels. There were no complaints of previous intermittent claudication.\nThe woman was planned for open repair. She was very anxious about the result and the possible complications of the surgical procedure. The woman had intense stress, phobia for surgery, and was consulted by a psychiatrist.\nTo better define the aneurysm anatomy (with 1mm imaging slices), we performed a new CT angiography (CTA) 48 hours after admission, which surprisingly revealed complete thrombosis of the AAA just below both renal arteries without any signs of acute renal insufficiency, mesenteric ischemia, or limb ischemia (\n). The most impressive element of the CTA was the rich collateralization between the thoracic aorta and the common femoral arteries through the superficial epigastric and other arteries of thoracic and abdominal wall. This collateralization was not evident in the first CT 2 days earlier.\nThe following physical examination revealed the absence of the previous pulsating mass and absence of femoral and distal leg pulses. Both legs were warm with normal skin color. The surgical procedure was postponed and the woman was discharged from the hospital with double antiplatelet therapy and weekly follow-up for the possible signs of limb ischemia.\nAfter a month, the patient presented with severe intermittent claudication in the left lower limb. The following digital subtraction angiogram revealed a thrombosed abdominal aorta with collateral vessels between the aorta and both common femoral arteries (\n). The woman underwent a left axillary–femoral bypass with polytetrafluoroethylene No. 8 graft. The patient's postoperative course was uneventful and the symptom of intermittent claudication disappeared. She was discharged on fourth postoperative day with antiplatelet (salicylic acid 100 mg, once daily) and statin (atorvastatin 20 mg, once daily) medication.
A 90-year-old woman visited our hospital due to a large area of erythema and localized skin ulceration with hemorrhage of her right breast. Her breast symptoms arose 5 years ago and had been worsening. She could not visit a hospital because she expected for naturally healing and feared noticing cancer and death. She had a history of atrial fibrillation and cerebral infarction 2 months earlier, then her breast lesion was found out. The area of erythema was 15 × 15 cm2. Her nipple and alveolar complex were destroyed and had an uncertain shape. Her skin erythema was soft, and no tumor was palpable (Fig. ). Her quality of life had got worse by hemorrhage and exudate from the tumor, and she felt strong anxiety about getting more worse and death from the cancer.\nA punch biopsy indicated mammary Paget’s disease. Computed tomography showed that the tumor was only on the surface of the breast, with no metastasis including of the axillar lymph nodes. There was no underlying tumor in the breast (Fig. ).\nEven though our patient was a very elderly woman with comorbidities and her prognosis was relatively good, her symptoms were intolerable. By the request of her and her family, we decided to perform surgery to eliminate the area of erythema after receiving sufficient informed consent. The surgical treatment was performed by two teams that included surgeons and dermatologists. We drew a resection line 1 cm from the skin erythema. Dermatologists were on standby in case a skin graft was needed. We performed muscle-sparing mastectomy with sampling of an axillar lymph node. We added two stress-relaxation sutures to avoid diastasis because the excision area was very large and the tension of the skin flap was strong (Fig. a, b). Fortunately, a skin graft was not necessary and her postoperative course was good. The skin flap did not develop major complications such as necrosis, seroma, wound infection, and highly disturbance of moving the right upper limb. We removed the stress-relaxation sutures 7 days after surgery.\nA histological examination revealed mammary Paget’s disease without invasion to underlying tissues (Fig. ), no evidence of a residual tumor of the entire stumps, and no metastasis in the lymph node. Although she felt a little tightness of the surgical site, paresthesia of the chest wall, and a sense of breast loss, her quality of life improved after surgery by being freed from symptoms and anxiety related to malignancy. It was a great value for her, even if she suffered from these complications.
A 16-year-old right-handed male patient was referred to our tertiary university center for persistent left wrist pain. The patient had originally presented to another hospital nearly a year earlier after a fall on an outstretched hand. He was originally diagnosed with a left scaphoid fracture and treated with a forearm spica cast for 10 weeks. After removal, the pain persisted and a radiograph reported fracture consolidation. On follow-up visits, he continued to have severe pain, and despite aggressive physiotherapy, his wrist movement was very limited leading to muscular atrophy of his left hand and forearm. The patient was then referred to our facility with an impression of avascular necrosis of his scaphoid. On initial visit, the patient complained of constant pain and muscular atrophy in his left hand and forearm. On examination, marked atrophy of the left forearm and decreased muscular strength of the left hand were noted as well as hypersudation without other signs of complex regional pain syndrome. However, the patient was referred to pain management clinic for presumptive complex regional pain syndrome and further investigations were requested. On follow-up visit, the patient reported no improvement in symptoms and no longer used his left hand. Investigation demonstrated normal complete blood cell count and erythrocyte sedimentation rate. Hand radiograph demonstrated a lesion in the capitate (Fig ). Computed tomographic (CT) scan of the hand demonstrated a lesion in the left capitate of more than 1 cm with necrosis and cortical destruction of adjacent bones and the possibility of aggressive transformation with a completely normal scaphoid (Fig ). The patient underwent subsequent operation whereupon (Fig ) exploration of the left wrist joint showed complete necrosis of the capitate and inflammatory degeneration of the hamate and trapezoid. A piecemeal excisional biopsy was performed on the capitate, hamate, and trapezoid of the left hand and the remaining gap was filled with antibiotic-containing bone cement (Fig ). No frozen section biopsy was possible because of the nature of the specimen. There were no complications. Cultures performed during the excision gave negative results. The biopsy report identified an osteoid osteoma of the left capitate. This was later confirmed after review of the specimen by the pathology department at another center. Postoperatively, the patient reported a dramatic decrease in pain and an increase in range of motion of the left hand. After the final pathology report confirmed the diagnosis of osteoid osteoma, the patient underwent complete arthrodesis of the wrist with iliac crest bone graft, using the Haddad-Riordan technique. Following arthrodesis, the patient had a complete relief of pain, increasing range of motion, and complete consolidation and improvement in the shape of the forearm.
A twenty-seven year old gravida 2 parity 1 patient applied to our clinic to get pregnancy follow up at the 8th week of her pregnancy. In her past history, it was stated that she had a craniotomy operation since she had a bullet in the cranium due to a firearm injury from a close distance eight years ago. During the patient’s physical examination, it is found out that the injury was in the left frontal bone and there is a secondary defect to the operation, and the motion of the right eye is minimally limited. Despite the serious injury of the patient, luckily there was not a significant neurological deficit. She expressed that within the postoperative first 3 months, she had sight impairment, but afterwards the problem with her vision has improved. When her previous cranial imaging methods examined, by Computed Tomography (CT), it is observed that in the cranium posterior at the left parietooccipital area there was a bullet-compatible mass with 9x6 mm in diameter with high signal intensity within brain tissue (, ). Followed by neurosurgery clinic during pre-pregnancy, it is learned that the patient have had no neurological complications or sequels during follow-up.\nBy obstetric ultrasound examination, an embryo with 8-9 weeks with the localized heart rate of intrauterine was found. Subsequent follow-up of the patient has been conducted in our clinic during the pregnancy. There has been no obstetric or other systemic problems encountered. The patient has been consulted at regular intervals throughout pregnancy and at the 39th week she was examined by neurosurgery physicians, and their suggestions were taken into consideration. In line with the recommendations of the neurosurgery consultant physicians, elective cesarean delivery was determined in order to avoid increased intracranial pressure and the risk of a possible cerebral herniation, intracranial hemorrhage, and convulsions as much as possible. The patient has also been consulted by the anesthesiology physicians and due to the risk of intracranial pressure changes and herniation, it is determined to perform the operation under general anesthesia instead of regional anesthesia (spinal, epidural). After receiving written informed consent from the patient, to avoid the risk of aspiration, ranitidine and metoclopramide intravenous (iv) were administered 30 minutes before anesthesia. At the time of operation, heart rate (HR), noninvasive blood pressure and peripheral oxygen saturation (SpO2) have been monitored and on the back of the left hand vascular access was established by a 18-gauge (G) cannula and through iv, isotonic saline solution was given. After preoxygenation at induction with 100% oxygen, 10 μkg-1 atropine, 4 mg kg-1 thiopental, 0.6 mg kg-1 rocuronium and 0.5 μ kg-1 remifentanil were administered and by applying 1% sevoflurane in 50% air/O2 endotracheal intubation, the patient was supported by the mechanical ventilator. Live baby girl of 2510 g was delivered with cesarean section. Baby’s 1st and 5th minute Apgar scores were 8 and 10 respectively. The patient’s arterial blood pressure remained stable during follow-up and end tidal CO2 (EtCO2) was maintained at 30-35 mmHg. After the end of the operation the patient was extubated at 0.5% sevoflurane. The patient was transferred to the intensive care unit as in the state of conscious, cooperative, and stable vital signs. No problems were monitored in the postoperative period in our 24-hour monitored patient. The patient was discharged home on the 2nd postoperative day with recommendations.
Case 2. The patient was a 40-year-old female without history of smoking and with a history of exposure to birds. She had a history of childhood asthma and a family history of breast cancer. She was diagnosed at 37 years with bilateral invasive ductal carcinoma with axillary lymph node metastasis during pregnancy. She received neoadjuvant chemotherapy before surgery with Adriamycin and cyclophosphamide followed by docetaxel. She underwent bilateral mastectomy with dissection of axillary lymph nodes and received adjuvant chemotherapy with 4 cycles of cyclophosphamide, methotrexate, and fluorouracil with concomitant radiotherapy afterwards. The initial chest radiography after the diagnosis of breast cancer was normal. However, in the follow-up chest radiographs, a progressive loss of lung volume at the expense of the upper lobes was noticed, which manifested by superior shrinkage and distortion of the pulmonary hila, and the appearance of coarse irregular linear opacities at higher fields and biapical pleural thickening with linear opacities of scar appearance in the neighboring lung parenchyma (see ). 15 months after radiotherapy, the patient presented with acute dyspnea and chest pain. She was diagnosed with right spontaneous pneumothorax that required thorax drainage.\nSubsequently, she presented exertional dyspnea with ordinary physical activity (New York Heart Association Functional Class II) and dry cough, for which she was referred to our consult for further study.\nOn physical examination, she had a low BMI of 19, no acropachy, and diminished global vesicular breath sound. The chest X-ray showed worsening compared to the previous one, with apical pleural thickening, hilar retraction, and flattened thorax on the lateral projection ().\nThe first HRCT performed to this patient 16 months after diagnosis of breast cancer showed only discrete linear opacities of fibrotic appearance in both lung apices.\nHowever, the second HRCT, performed during the period in which the patient experienced the spontaneous pneumothorax, revealed that the upper linear opacities had progressed to pulmonary infiltrates of fibrotic appearance. Also evident was a thickening of the visceral pleura, clearly visible due to the adjacent pneumothorax (). Finally, in a HRCT made 2 years later, further worsening of biapical infiltrates with images of honeycombing, appearance of new subpleural parenchymal consolidations, and greater lung volume loss with more architectural distortion of the parenchyma were seen (). We performed a thoracic ultrasound (TUS) in the left hemithorax wall (lateral region from the anterior axillary line to the posterior axillary line) that showed visceral pleural thickening ().\nThe BAL fluid revealed 53% macrophages, 43% lymphocytes, 2% neutrophils, and 2% eosinophils. The BAL analysis with lymphocyte subsets showed CD3 75%, CD4 16%, CD 8 60%, and CD4/CD8 lymphocyte ratio of 0.26.\nIn the blood analysis, the autoimmunity was negative and serological exams showed positive test results for Aspergillus and avian precipitins. PFT showed severe restrictive pattern and an increase of the relationship between residual volume (RV) and TLC (). The patient underwent breast reconstruction; therefore, SLB was delayed for seven months. Postoperatively, she presented another right loculated pneumothorax that resolved spontaneously. The pathology revealed subpleural parenchymal fibroelastosis with extension into adjacent alveolar walls predominantly in the upper lobes (Figures and ). From an oncological point of view, by not showing recurrence at 5 years after diagnosis of breast cancer, the patient was derived to the LT list and pulmonary rehabilitation with improvement of dyspnea score (NYHA class I).
A 70-year-old woman presented in our vascular clinic due to an asymptomatic juxtarenal 10 cm AAA identified as an incidental finding in a recent computed tomography (CT) scan (\n). Her medical history included mild hypertension under drug medication. At physical examination of the abdomen, a large pulsating mass was present with normal pulsation of femoral and tibial vessels. There were no complaints of previous intermittent claudication.\nThe woman was planned for open repair. She was very anxious about the result and the possible complications of the surgical procedure. The woman had intense stress, phobia for surgery, and was consulted by a psychiatrist.\nTo better define the aneurysm anatomy (with 1mm imaging slices), we performed a new CT angiography (CTA) 48 hours after admission, which surprisingly revealed complete thrombosis of the AAA just below both renal arteries without any signs of acute renal insufficiency, mesenteric ischemia, or limb ischemia (\n). The most impressive element of the CTA was the rich collateralization between the thoracic aorta and the common femoral arteries through the superficial epigastric and other arteries of thoracic and abdominal wall. This collateralization was not evident in the first CT 2 days earlier.\nThe following physical examination revealed the absence of the previous pulsating mass and absence of femoral and distal leg pulses. Both legs were warm with normal skin color. The surgical procedure was postponed and the woman was discharged from the hospital with double antiplatelet therapy and weekly follow-up for the possible signs of limb ischemia.\nAfter a month, the patient presented with severe intermittent claudication in the left lower limb. The following digital subtraction angiogram revealed a thrombosed abdominal aorta with collateral vessels between the aorta and both common femoral arteries (\n). The woman underwent a left axillary–femoral bypass with polytetrafluoroethylene No. 8 graft. The patient's postoperative course was uneventful and the symptom of intermittent claudication disappeared. She was discharged on fourth postoperative day with antiplatelet (salicylic acid 100 mg, once daily) and statin (atorvastatin 20 mg, once daily) medication.
A 32-year-old woman presented with progressive swelling, pain and a pulsatile mass in the right antecubital space. She had undergone aneurysmectomy and autologous saphenous vein graft interposition at the same site in another hospital three years ago. The aneurysm recurred 1 month after surgery (). Physical examination revealed a pulsatile mass in the right antecubital space measuring 5×4 cm in size. Her vital signs were stable with a heart rate of 72 beats/min, systolic blood pressure of 120 mmHg, respiratory rate of 18 breaths/min, body temperature of 36.5℃. Other laboratory examination findings were within their normal ranges. The aorta, pulmonary arteries and the other peripheral arteries were normal on preoperative computed tomography. The distal radial artery flow was normal on Doppler examination. The initial diagnosis was recurrent brachial artery aneurysm. We decided to treat the patient with redo operation. After admission, echocardiography was performed. The findings on this examination were nonspecific. The operation was performed after disinfection of the right arm and left leg. A longitudinal incision was made on the prior surgical incision scar and adhesiolysis was performed. The saphenous vein graft which is anastomosed during the previous surgery was intact, but the distal part of the anastomotic site showed aneurysmal change. Aneurysmectomy including the implanted saphenous vein graft and autologous vessel graft interposition with the new saphenous vein graft which was harvested at the distal portion of the left leg were performed. The resected aneurysm revealed a true aneurysmal sac filled with internal thrombus (). After anastomosis of the saphenous vein graft at both the proximal and distal part of the brachial artery, the distal radial artery showed good patency on intraoperative Doppler examination. The histopathologic examination revealed elastic fiber disruption of the brachial artery and saccular dilatation of aneurysm (). There was an organized fibrin clot on the aneurysm wall. The patient was discharged without complications on the 10th day after surgery. During follow-up at the outpatient department, there were no signs of recurrence of aneurysmal change ().
A 59-year-old female patient with a diagnosis of locally advanced invasive ductal carcinoma of the left breast was referred for a staging CT scan of the abdomen and pelvis. The scan was done using a Philips Brilliance 64 slice multidetector CT scanner. Nonionic contrast media (Ultravist 300) in a volume of 100 mLs were administered via pressure injector at a rate of 3.5 mL/min. The liver was found to be normal; however, she had evidence of metastases to the spleen, several vertebrae, and the pelvis.\nAn incidental finding of abnormal arterial branching was noted at the upper abdominal aorta (Figures and ). The left gastric artery originated directly from the anterior surface of the abdominal aorta shortly after it entered the abdomen through the diaphragmatic hiatus. Thereafter, it followed its normal course along the lesser curvature of the stomach. At the level of the first lumbar vertebra, there was a large arterial trunk originating from the anterior surface of the aorta, consistent with the celiacomesenteric trunk described by Ishigami et al. []. After coursing 2.5 cm, the celiacomesenteric trunk bifurcated into the superior mesenteric artery and the coeliac trunk that was unusually long and tortuous (). The splenic artery coursed to the left over the superior mesenteric artery and vein toward the splenic hilum where it divided into segmental arteries to supply the spleen in normal fashion. The left hepatic took an early origin directly off the common hepatic artery and travelled up toward the hilum in a plane superficial to the portal vein but in a more medial position than usual. The right hepatic artery took its origin from the distal gastroduodenal artery behind the pancreatic head to course superiorly in the free end of the gastroduodenal ligament, posterolateral to the portal vein. The bile ducts were normal in calibre and were not well visualized on CT scans. At the hepatic hilum, the left and right hepatic arteries branched in the usual fashion to supply the liver that was divided into conventional hepatic segments.
A 74-year-old woman was initially aware of intermittent vertical diplopia which then became constant over the next 24 hours. This was followed by painless left orbital swelling with mild erythema and swelling of the left upper lid. The globe itself was normal. Visual acuity was 20/20 right eye and 20/25 left eye. There was mild erythema and swelling of the left upper eyelid. Eyelid fissures measured 10 mm on the right and 6 mm on the left. The left globe was 1 mm proptotic. Ductions of the left eye were mildly deficient in upgaze. Initial CT and MRI imaging, along with the clinical history were suggestive of a varix. She returned 1 month later with improvement of the lid swelling and diplopia however repeat MRI was unchanged raising concern for a metastasis. At surgery, a firm yellow tan nodule was seen within the superior rectus/levator muscles. Approximately 70% of the mass was removed since it seemed to involve most of the muscle. Intraoperative frozen section evaluation revealed intense necrotizing granulomatous inflammation.\nThe patient owned a dog and claimed to spend significant time outdoors in her garden. MRI of the head and orbits revealed an avidly enhancing 1.3 cm maximal dimension mass in the left superior rectus muscle (). A normal superior ophthalmic vein was identified without evidence for any inflammatory changes in the orbit fat. Of note, the patient had a history of stage I breast cancer that was treated with surgery and radiation therapy. Five-year cancer surveillance had revealed no evidence of recurrence. The differential diagnosis included metastatic disease based on MR findings versus intramuscular hematoma based on the rapid onset of symptoms. The patient was treated with antibiotics for one month for presumptive cellulitis with no change in the MRI findings. Given the persistence of the clinical symptoms and MRI findings, surgical biopsy was recommended. At surgery, a tan nodule was easily separated from the superior rectus muscle. Pathology demonstrated a necrotizing granulomatous infection with fragments of a degenerating nematode (round worm) consistent with Dirofilaria sp. (). Follow-up with infectious disease revealed no evidence of more widespread systemic disease.
A 76-year-old man was admitted to our hospital with the complaint of acute pain in the left lower limb and a pale foot. His medical history included hypertension, hyperlipidemia, and cerebral infarction. Arterial pulsation was palpable in the posterior tibial artery of the left leg, but it was unpalpable in the dorsalis pedis artery. The ankle–brachial pressure index of the left leg was within the normal range. The pulse of the left foot was recognized, and the patient maintained left foot motor function; however, the forepart of the left foot had ischemia and perceptual dysfunction. The ultrasonography findings revealed that the posterior tibial artery was patent, but the plantar artery was occluded. The presence of local occlusive lesions was suspected. The diameter of the common plantar artery was 3.0 mm, and its echo brightness was slightly high. A slight color Doppler was found on the margin of the plantar artery lumen. Fresh thrombosis or a plaque was suspected in the lumen of the common plantar artery. A CT scan revealed insufficient arterial circulation in the sural muscle of the left lower limb. The posteior tibial artery above the patient’s ankle was patent, but the plantar artery was occluded in addition to the anterior tibial artery and the dorsalis pedis artery. There was prominent atherosclerosis in the wall of the abdominal aorta. In the lumen of the abdominal aorta, atherothrombosis causing embolism was found. Compared to the abdominal aorta, no thoracic aorta or thoracic abdominal aorta was found to be likely to cause embolism ( and ).\nWe decided to perform an emergency operation to treat the lower limb ischemia. We incised the common plantar artery directly and removed the thrombus using a balloon catheter under general anesthesia. The left ankle was incised linearly, and along with the common plantar artery, the lateral and medial plantar arteries were exposed and taped. Following heparinization, blood flow to the common plantar artery was blocked. After transversely incising the common plantar artery, proximal and distal embolectomy was performed using a 2 Fr balloon catheter, directed proximally to the posterior tibial artery and distally to the lateral and medial plantar arteries. After the thrombus was removed, sufficient backflow through the distal side of the common plantar artery was confirmed. The arteriotomy was closed with an interrupted 7-0 monofilament polypropylene suture.\nHeparin was used until the next day as anticoagulant therapy after embolectomy. Although the dorsalis pedis artery was occluded, the Doppler sound of the plantar artery region became audible; therefore, we decided that no further revascularization was necessary.\nAfter examining the thrombosis, the pathological diagnosis was a cholesterol crystal (). The circulation of his left foot and pain of the left calf improved postoperatively, and postoperative CT showed a patent plantar artery ().\nThe patient was discharged from the hospital after the numbness and pain in his right leg improved. We ruled out the possibility of the abdominal aorta as the origin of embolism. Hence, the patient was hospitalized again and underwent a graft replacement of the abdominal aorta. During the 4 weeks between the day of the embolectomy and the graft replacement, he had taken time to rehabilitate because of pain in the gastrocnemius muscle and had undergone preoperative tests, including an evaluation of cardiac function. His postoperative course was uneventful, and no recurrence was observed 1 year postoperatively.
An 88-year-old female was referred to our institution for surgical management of recurrent squamous cell carcinomas (SCC). Clinical and radiological examination identified a 7.1 cm right temple mass with extensive invasion of underlying tissues including the lateral orbit. The patient experienced diplopia and diminished mobility of the right eye. A head CT revealed a mass continuous with the lacrimal gland, lateral rectus muscle and globe with extension into the lateral orbital wall and roof.\nThe tumor resection resulted in a large orbital and temporal defect. The orbital roof resection unfortunately led to a cerebral spinal fluid leak (Fig. ). The dural defect was repaired successfully with layered temporalis fascia and titanium mesh that was cantilevered off the frontal bone and rigidly fixed. A submental island flap (20 cm transverse and 6 cm vertical) was utilized for reconstruction. The flap was harvested in conventional fashion with preservation of the facial vessels and marginal mandibular nerves. The lower border of the mandible was harvested with incorporation of the right mylohyoid muscle and anterior belly of the digastric muscle into the soft tissue component of the flap to protect both skin and bone perforators. The flap was delivered via a subcutaneous tunnel in the posterior cheek to reconstruct the facial defect and the mandibular component was used to reconstruct the right lateral orbit through rigid fixation (Fig. ). The proximal skin of the SIF was deepithelialized to prevent burying of the epidermis subcutaneously and used as a full-thickness skin graft for a residual defect on the upper forehead.\nThe post-operative pathology confirmed clear resection margins. Although the flap was completely viable, radical adjuvant radiation therapy led to loss of overlying soft tissue over time (Fig. ). It is important to note that the bony segment remained healthy and well-integrated with the zygomatic and orbital remnants well after radiation. Unfortunately, the loss of soft tissue caused exposure of the bone segment and eventual devitalization of the distal flap over a year after the initial surgery. The patient received a full thickness skin graft to cover the distal defect. She remains disease-free 29 months following surgery.
A 37-year-old male patient reported to the Department of Oral and Maxillofacial Surgery with a chief complaint of pain, difficulty in closing the mouth, and swelling on the left side of the face following a road traffic accident. Direct open reduction and internal fixation via transparotid approach of the left condyle were performed []. Ten days later, the patient presented with a swelling on the left side of the face. On extraoral examination, there were no clinical signs of infection or drainage in the surgical wound and no local rise in temperature was noted. On intraoral examination, salivary secretion through the stenson's duct was relatively reduced on the left side. Neurological examination revealed that no motor loss due to severance of any branch of facial nerve in the affected side. Aspiration was done on dependable swelling which gained a 6 ml of clear, watery, and odorless fluid aspirate, giving an impression of saliva []. A laboratory test confirmed the presence of salivary amylase in the aspirate.\nIn this case, trauma in the parotid glandular substance leads to the formation of sialocele by the accumulation of extravasated saliva into the glandular parenchyma. Pressure dressing and antibiotics were given to prevent infection. Postoperatively, repeated aspiration along with compressive dressing was performed but did not result in healing. Hence, decided to place an intraoral drain under local anesthesia.\nAfter standard aseptic preparation, intraorally, a 1 cm long incision was placed on external oblique ridge behind the third molar. A small curved artery forceps were inserted through the superficial fascia of masseter reaching the sialocele. Approximately 5 cm long, slender, sterile, punched plastic tube of diameter 5 mm (intravenous cannula) [] was positioned with one end in the glandular substance and the other end in the mouth with the help of the forceps. The tube was secured along the vestibule by suturing it to the mucosal surface of the cheek, ensuring complete convenience to the patient []. After placing such a drain, there was no pooling of saliva in the glandular substance. This would have allowed healing of the gland and subsequent formation of structures necessary for drainage through the main Stensen's duct. The patient's recovery was uncomplicated, and follow-up was done for 5 months.
This female patient in her 30s with no previous medical issues presented with a short history of pain and swelling in her right thigh without any preceding trauma. An MRI scan showed the presence of a haemorrhagic tumour over 20 cm in the craniocaudal dimension lying within the vastus intermedius muscle and encircling the right femur. The biopsy confirmed a myxoid spindle cell sarcoma with features consistent with myxofibrosarcoma, and CT of the chest, abdomen, and pelvis showed a nodule in the right lower lobe of the lung. She subsequently underwent excision of the tumour, unfortunately complicated by a pathological fracture of the trochanteric region of the right proximal femur noted after a fall (). It was stabilised using an 11 × 380 mm CFR-PEEK cephalomedullary nail (). The postoperative course was complicated by a superficial wound infection due to a Klebsiella pneumoniae. Given her immunocompromised status and pre-existing deformity of her leg, it was difficult to assess whether there was a deeper implant-related infection. Due to the lack of metal artefact from the CFR-PEEK nail, it was possible to perform an MRI scan and therefore deep infection could be ruled out (Figures –). It did however show progression of tumour mass with an increase in cystic components. After wound healing, the patient was started on chemotherapy, and after the completion of two cycles, a CT chest, abdomen, and pelvis was repeated to assess response. Sadly, an increase in the size and number of the pulmonary metastases and a massive size progression of the known right thigh sarcoma were seen (). She then underwent palliative radiotherapy on her right thigh. Five fractions over seven days with a total dose of 20 Gy were given using anterior and posterior parallel opposed post fields (Figures –) and provided benefit to both the pain and swelling she experienced. With no further surgical and medical options available, the focus became palliative care for symptom control. The patient subsequently died from complications resulting from her condition.
A 69-year-old male patient, smoker and with a previous diagnosis of chronic obstructive pulmonary disease (COPD), was admitted to the emergency room with mental confusion and ataxia. The patient was in a good clinical condition, and there were no signs suggesting any source of respiratory, urinary or central nervous system infection. Chest X-ray and magnetic resonance imaging (MRI) of the brain were requested.\nChest X-ray revealed a dense nodule of approximately 13mm in diameter, in the periphery of the left lower lobe of the lung, and a prominent left hilar lymph node. The MRI detected multiple metastases associated with vasogenic edema.\nAccording to clinical history and radiologic findings, the hypothesis of small cell lung cancer was made. Chest and abdominal CT was performed to determine the stage of disease and track other disease sites. The abdomen image revealed hepatic metastasis, unspecific nodular thickening of adrenal glands, retroperitoneal lymphadenopathy and a slightly enlarged prostate. The chest image showed a left hilar mass with mediastinal invasion, with possible invasion of the descending aorta and occlusion of the left inferior pulmonary vein, besides a small pulmonary nodule to the right. Biopsy of liver metastasis was performed and confirmed diagnosis as small cell carcinoma. Immunohistochemistry result was consistent with the hypothesis of small cell lung cancer.\nFirst line palliative chemotherapy with carboplatin AUC 5 on day 1 and etoposide 100mg/m2 on days 1 to 3, every 21 days was administered. On day 8 of the first cycle, the patient presented with abdominal distention and fever. Complete blood count showed neutropenia. The patient received antibiotics and CT scans of the chest, abdomen, pelvis and sinuses were performed. Comparing with the initial scans, these images showed presence of gas dissecting the wall of sigmoid colon extending to the mesosigmoid, retroperitoneum and posterior mediastinum, and a bulky pneumoperitoneum without gas in the portal venous system. Moreover, there was the additional finding of a hematoma in the psoas major muscle associated with edema in the adjacent subcutaneous tissue ().\nThe hepatic lesions, nodular thickening of the adrenal gland and retroperitoneal lymphadenopathy had reduced size. The chest CT scan revealed a small pneumomediastinum and a significant reduction of the left hilar mass. The patient did not complain of abdominal pain, nausea, vomiting, and had no clinical signs compatible with peritoneal irritation or acute abdomen perforation. After the presumptive diagnosis of PI, the patient was given continuous high dose of oxygen and maintained antibiotic regimen. The abdominal distension progressively improved and 2 weeks after oxygen therapy new scans showed resolution of pneumatosis image according to . The etoposide dose was reduced by 30% in the second cycle of treatment. There were no new signs of PI after dose reduction. After four cycles of chemotherapy, the patient presented a partial response (reduction of mediastinal lymph nodes and hepatic lesions). Afterwards, the patient was referred to whole brain radiation therapy.
A 17-year-old male presented to the emergency department (ED) due to new onset seizure activity. The patient had some prior neurological concerns which began with difficulty achieving major developmental milestones. He did not learn to walk until 17 months of age and required speech therapy at the age of two. Whether these details were relevant to his future diagnosis of Rasmussen’s encephalitis is unclear but it does show that he had neurological impairment from an early age, and additionally the patient had a maternal aunt with a past medical history of seizures. At age 11, he first noticed signs of right hemilateral weakness beginning in the upper extremity. By age 14, his neurological symptoms continued to progress leading to complete right hemilateral weakness causing him to hold his arm in a “drawn-up” fashion and walking with a limp, prompting the need to obtain an MRI at age 14. This MRI was read as a cerebral vascular accident and the patient was told that he would probably have residual hemilateral weakness and was diagnosed with cerebral palsy.\nA week before our patient arrived at the ED he had his first seizure around 0230 in the morning. Our patient was in the kitchen and found by his parents complaining that he could no longer feel or move his right upper and lower extremities. He did not lose consciousness and had no post-ictal state. Neither the patient nor his parents thought much of it so he returned to bed and woke up feeling normal the following morning. On the day of admission, our patient had a second simple partial seizure around 0730 while brushing his teeth. The patient stated he had aura and presyncope. He sat down and called for his parents who noted he had rhythmic jerking movements of both the right upper and lower extremities lasting 4-5 minutes. Our patient did not lose consciousness or bowel/bladder function and was able to maintain brief conversations during the event and recall the details after although he did undergo a period of Todd’s paralysis.\nIn the ED, our patient reported continued numbness and twitching in his right upper extremity that had persisted for 3-4 hours after the seizure. Our patient’s physical exam findings were pertinent for 3+ reflexes on the right side and 4/5 strength. All other physical exam findings were within normal limits. Following admission, our patient was started on oxcarbazepine and also underwent MRI with and without contrast that showed diffuse white matter disease involving the entire left supratentorial cerebral hemisphere with associated predominant white matter volume loss and severe diffuse volume loss involving the corpus callosum (Figures -). These changes were highly suggestive of Rasmussen’s encephalitis and had also caused lateral ventricle asymmetry leading to a leftward 8mm interventricular septum deviation due to diffuse volume loss.\nOur patient and family were informed of the results and instructed to follow-up with another children’s hospital capable of providing a wider variety of treatment options including hemispherectomy as Rasmussen’s encephalitis is a progressive disorder that is frequently refractory to medical therapy alone [,,].
We would like to describe the treatment of osteoradionecrosis, which appeared 5 years after radiation therapy in a 54-year-old male patient ().\nWe have performed a resection of the mandible segment and right-sided neck dissection, together with use of pectoralis major muscle vascularized muscle-skin flap for reconstruction. In this case, the method of pretreatment was applied, simultaneously with the reconstruction of the lower jaw. The side edge of the right side of the lower jaw was exposed and broken, if necessary for bone resection, as well as for insertion and fixation of the flap for reconstruction. A minimum of 3 cm was required for fixing a 3 mm titanium plate attached to the sides of the lower jaw ().\nAffected soft tissue was removed to form safe fields. Next step was the segmental resection of the lower jaw. It is advisable to fix the plate on each side of the lower jaw with the help of three screw holes (). The flap was separated from the donor site and shaped according to the recipient area. The collection time of the flap ranged from 40 to 100 minutes. A simulated pectoral major muscle-skin flap was inserted between the segments of the lower jaw. During the design of the flap, a leather protrusion was formed above the pectoral muscle. The cutaneous was protruded on the pectoral muscle splits, and the incision was continued along the anterior axillary fold.\nThe pectoralis major muscle was risen along the lateral edge of the pectoralis major muscle. The flap was usually carried out in the neck surface superficially to the clavicle through a wide subcutaneous tunnel. It should be checked that the leg did not twist during the operation. Sometimes, the tunnel can be narrow, but it can be expanded by making incisions through the medial and distal ends of the periosteum, which makes it easy to pass. As a result, pectoral major muscle-skin flap coverd the inside of the floor of the mouth, and the outside of the skin defect was covered with delto-pectoral flap ().\nIn the postoperative period, the correct occlusion of the teeth was confirmed by the assessment of the oral cavity and computed tomography. The viability of the skin-muscle flap of the pectoralis major muscle was assessed using clinical monitoring, checking the flap every four hours for the first 3 days (). After 6 months, a flap pedicle was remodeled ()
A 38-year-old gravida 1, para 0 was transferred to our unit at 26 weeks of gestation with severe right iliac fossa pain and a suspicion of threatened preterm labour. She presented with a 3 day history of right iliac fossa pain, nausea, vomiting and diarrhoea. Vaginal examination and her fetal fibronectin test was negative. However, transabdominal and transvaginal ultrasound examination revealed a 6.0 × 5.5 × 5.9 cm vascular mass within the right pelvis with a clear arterial feeder and turbulent swirling intraluminal flow, leading to the diagnosis of a pseudoaneurysm (Fig. ). The diagnosis was subsequently confirmed by Magnetic resonance imaging (MRI) (Fig. ). The patient was discussed in our multidisciplinary team meeting with interventional radiologists, vascular surgeons, and anaesthetists. The risk of imminent rupture was assessed as high due to the severity of her symptoms and a 5–10 mm overall increase in the size of the pseudoaneurysm documented by sequential MRI 14 days apart. Surgery was considered high risk and so selective embolization of the pseudoaneurysm was performed. This was performed under local anaesthetic in the Interventional Radiology suite with full preparation for emergency delivery by the obstetric and anaesthetic team in case of fetal distress. The right uterine artery was identified angiographically from a contralateral femoral arterial puncture and selectively catheterised using a microcatheter. The artery was small but extravasation into the presumed pseudoaneurysm was identified near its proximal portion. The artery was embolised with a series of microcoils across the neck of the pseudoaneurysm to block flow. The procedure was uneventful and the fetus showed a continuous reactive heart rate pattern. Follow up ultrasound showed a completely thrombosed pseudoaneurysm with no flow. She had regular follow ups in the antenatal clinic with no sign of recurrence. A planned caesarean section was performed at 38 weeks gestation. A healthy baby boy was born weighing 2696 g with a blood loss of 1100mls. During the caesarean section, the thrombosed pseudoaneurysm was seen below the right broad ligament and all other pelvic organs looked completely normal (Fig. ). An ultrasound scan 3 months postpartum showed a small completely thrombosed pseudoaneurysm (Fig. ).
A 16-year-old female patient reported to the department with a chief complaint of discolored tooth #9. Past dental history revealed that the tooth was avulsed about 10 years back and was immediately replanted by the patient's father. On clinical examination, the clinical crown height of tooth #9 was much lesser than the adjacent teeth and the cervical portion of the crown displayed a pinkish hue. A perforation was detected in the cervical third of the crown on the palatal aspect with an endodontic explorer and was seen extending mesially and distally. Profuse bleeding was evident on exploration. On the periapical radiograph, tooth #9 had the appearance of an immature apex with thin incompletely developed parallel root canal walls. The pulp canal space was obliterated by a less radio opaque material resembling bone which appeared to be in continuity with the periapical bone. A large ill defined radioluency was seen in the cervical third of the crown extending extensively in a mesiodistal direction []. Computerized tomography (CT) scan slices revealed the canal configuration of the tooth at the coronal, middle and apical levels. At the coronal level a break in the continuity of the palatal wall was observed that was indicative of a perforation. The canal space showed radio opacity resembling bone [–]. At the middle third of the root, CT slices displayed a continuity of the canal walls [–] and slices in the apical region revealed thin mesial and distal canal walls [].\nFollowing replantation of avulsed immature teeth, in growth of periodontal tissues into the canal space has been observed as an attempt at revascularization. It has been reported that well organized bone, PDL and cementum can grow into the canal space.[] In this case tooth #9 which been replanted had a wide open apex which probably provided an open pathway for the in growth of periodontal tissues following damage to the pulp. The pulpal tissue was replaced by metaplastic bone like tissue that was evident on the radiograph and the CT scan images. The perforation that was present in the cervical third of the crown on the palatal aspect and the presence of granulation tissue indicated it to be a case of external cervical resorption. Though the radiographic appearance also resembles perforating internal resorption, this diagnosis could be ruled out due to the absence of vital apical pulp tissue which is essential for internal resorption to progress. The presence of a weakened coronal tooth structure due to the extensive nature of the resorption process and the obliteration of the canal space with metaplastic bone like tissue signalled a poor prognosis for the tooth which was hence advised an extraction.
A 55-year-old Egyptian man reported to our department with a large cystic mass occupying his entire right abdominal quadrants, detected by abdominal US during a routine check-up. The features of the mass on US were consistent with HD and it was diagnosed as three cysts - hepatic, renal and retroperitoneal. Our patient had no history of liver or kidney disease or pain in his right abdominal quadrants. Serologic and immunologic studies (indirect hemagglutination, enzyme immunoassays) performed during his hospitalization confirmed the HD diagnosis and a surgical approach was the first choice because of the large dimension of the mass. However, on the basis of US images alone, it was difficult to understand the origin of the cysts and to determine if there were three cysts or just a single giant cyst.\nOur patient underwent unenhanced MRI to determine preoperatively the extent of the disease. The MRI scans showed a huge single 30×18×16cm cystic multiloculated mass, misdiagnosed as three single cysts, hepatic and renal, during the US investigation (Figures and ). The cyst was strongly adhered to his right hepatic lobe and to his right kidney. The intestinal loops were shifted to the left and his kidney was rotated and displaced down and anteriorly with partial compression of his inferior vena cava.\nOur patient was then scheduled for surgery. A week before surgery, oral therapy with albendazole was started and continued until one month after surgery. A laparotomy was performed via a bisubcostal incision with extension to the xiphoid. The mass was freed from its adhesions with his stomach and small bowel. His inferior vena cava, suprahepatic region and the space between his right and middle hepatic veins was dissected to perform the Belghiti liver hanging maneuver []. A tape was then passed between his liver and the anterior surface of his inferior vena cava. We performed a right hepatectomy, with associated en bloc hydatid mass resection with an anterior approach, leaving his liver with the mass in place during hepatic transection (Figure ). Intermittent clamping of the hepatic pedicle was used during transection to minimize bleeding from the cut surface of his liver. His postoperative course was uneventful and our patient was discharged on the seventh day after the surgery.
We report the case of a seventy four year old man who presented to the Emergency Department complaining of back pain of two months duration. This was a dull mid- thoracic back pain with radiation to the chest and upper abdomen. It was initially intermittent associated with exertion, but now was increasing in frequency and severity to the extent that it was interfering with his daily living activities. There was no history of trauma. His family history was unremarkable.\nHis only significant past medical history was that of hypercholesterolaemia for which he was prescribed a statin by his general practitioner. He underwent surgery for varicose veins in his right leg 7 years previously. His regular medications also included aspirin. He had no known drug allergies and smoked 10 cigarettes per day. He was a retired farmer who lived with his wife and was in good physical condition from an anaesthetic point of view (ASA grade I). On examination of his back the overlying skin was unremarkable although a mild thoracic kyphosis was present. Physical examination revealed conspicuous tenderness and percussion pain in the thoracic region. The straight leg raising test was negative on both sides. His neurological system was intact on examination. Systemic examination was also unremarkable.\nLaboratory studies including total blood count, sedimentation rate, C-reactive protein, electrolyte values, and alkaline phosphate levels were within the normal ranges. Chest radiography showed widening of the right paratracheal stripe, of concern for lymphadenopathy. There were also calcified left hilar lymph nodes. Plain radiographs of the thoracic spine showed mid thoracic kyphosis with loss of distinction of the posterior cortices of T7 and T8.\nAn MRI of the cervical and thoracic spine was carried out [,]. This showed an infiltrative process involving the vertebral bodies of T6 and T7, associated with expansion and some destruction. There was extensive demineralisation and destruction of the vertebral body of T6. The process extended inferiorly into the vertebral body of T7, and appeared to cross the disc space. The process also involved the superior and inferior articular facets on the left side at T5. Computerized tomography images [] further characterised the extent of the dysplastic process. Reconstructed images revealed the infiltrative process in further views []. This process extended into the pedicles bilaterally and was associated with some compromise of the foramina at T6 and T7. There was no definite nerve root compression identified and no other focal bony abnormalities were seen. Significant multilevel degenerative disc disease was seen in the cervical spine, associated with reversal of normal cervical lordosis resulting in significant multilevel spinal canal stenosis, and some evidence of signal changes in the cord, although focal cord compression was not seen. The findings of an aggressive destructive process were highly suspicious for a malignant process, although the presence of a sclerotic edge suggested an indolent aspect to the process.\nThe following day this patient underwent T2-T9 stabilization and bone grafting. Pedicle screws were inserted proximally into T3 and T4 pedicles bilaterally [], and distally into three levels at T7/T8/T9 []. Spinous processes of T2-T9 were excised. Autologous bone graft was harvested from left iliac crest and used as an onlay graft. The patient’s post-operative course was uneventful, managed with analgesia and physiotherapy to assist with mobilisation. He was discharged home day four post-operatively.\nMultiple biopsies of bony tissue were sent for histological examination. Histology revealed multiple pieces of woven bone with prominent periosteal fibroblastic reaction and areas showing new bone formation with medullary space fibrosis. In addition, there were focal areas showing irregularly oriented osteoid without osteoblastic rimming but surrounded by fibroblastic proliferation [,]. The overall features were most suggestive of reparative changes rather than a neoplastic process with some features which could be in keeping with fibrous dysplasia in the appropriate clinical settings. The patient had an unremarkable post-operative follow-up. He continuous to be asymptomatic with no evidence of recurrence on serial imaging [,].
A 61-year-old male patient visited the emergency department of our hospital due to intense pain and swelling in his right cheek area. Diabetes was the only relevant comorbidity. A blood test and computed tomography (CT) revealed odontogenic maxillary sinusitis accompanied by an abscess in the right lateral pterygoid muscle. The patient underwent immediate local intraoral debridement after admission to the hospital. However, the patient failed to recover and progressed into severe sepsis, with the abscess extending into the infratemporal fossa. The patient then underwent another radical debridement using a hemi-coronal incision and removal of a right upper tooth suffering from caries. Even after the second debridement, the patient remained in sepsis. Seven days after the first debridement, the patient suddenly developed a brain infarction and meningitis due to a thrombosis in the sigmoid sinus.\nFurthermore, the patient had a recurrent abscess in the right infratemporal fossa () and another abscess in the right intraorbital region (). The additional abscess in the intraorbital region seemed to pose the risk of spreading the infection into the intracranial region through the optic nerve and/or optic vessels (). With these widespread multifocal abscesses in the craniofacial region, we decided to use the FDF approach to achieve thorough radical debridement.\nThe FDF approach was performed following the procedures described in the literature [-]. Through this approach, we obtained a surgical field that was clear and wide enough to observe and debride all abscesses in this patient. First, the right temporal muscle, which had already necrosed due to inflammation and infection of its feeding vessels, was excised (). In the root of the temporal muscle, there was a recurrent abscess that had spread into the lateral pterygoid muscle, and this abscess was also debrided. Using the FDF approach, we were able to easily approach the right orbital wall. Part of the lateral orbital wall was removed in order to approach the intraorbital space using the FDF approach. With this additional lateral orbital approach incorporated into the FDF approach, we were able to reach the intraorbital abscess safely (), and succeeded in draining that abscess without causing contamination of the intracranial space. All wounds were irrigated with normal saline, and closed primarily in the ordinary fashion with the placement of Penrose drains.\nAfter thorough debridement of the multifocal abscess using the FDF approach, the patient successfully recovered from severe sepsis. Postoperative CT images showed that no abscess was left in the craniofacial region; thus, we had achieved full control of the patient’s disease and the patient recovered from sepsis. No unfavorable scarring occurred on the face and the facial nerves were not damaged, but there was a right temporal hollowing due to the excision of the right temporal muscle, as well as right ptosis due to cerebral infarction ().
Our patient was a 75-year-old white woman who was a carrier of the BRCA2 gene mutation. She presented to her primary care doctor with a family history of three of her daughters having been diagnosed with breast cancer. All of them were BRCA2 positive. She had no other issue otherwise. Consequently, she underwent genetic testing for BRCA gene mutations which was reported positive for BRCA2 gene mutation. The patient was then informed about the increased risks of breast and ovarian cancers. Regarding the increased risk for breast cancer, the patient was informed about the options of having screening every three years along with prophylactic treatment with tamoxifen or anastrozole or undergoing a prophylactic bilateral mastectomy with reconstruction. She chose to have screening mammogram every three years. After thorough discussion and counselling in the clinic, the patient was informed that the best option to minimize the risk of ovarian cancer would be to have the ovaries and fallopian tubes removed laparoscopically.\nThe patient was reviewed in the clinic prior to her elective procedure. Her past medical history consisted of hypertension, osteoarthritis, seborrheic dermatitis, and hepatitis A infection in 1970. Her past surgical history included laparoscopic sterilization and left knee replacement. She was on lansoprazole, amlodipine, and antihistaminic medication and she had no known allergy. She had four previous normal vaginal deliveries and she was up to date with her cervical screening, with the last one being negative. Her body mass index (BMI) was 32 and the routine blood results including urea and electrolytes, full blood count and coagulation profile were all within normal limits.\nShe had an elective laparoscopic bilateral salpingo-oophorectomy without any intraoperative complication. A small retroverted uterus was noted and both tubes and ovaries looked normal. The course of the uterer was identified on both sides. The left ovary was adherent to the left pelvic side wall and was mobilised before removal. An electrothermal bipolar tissue sealing device was used and the specimen was delivered with a laparoscopic bag. The tubes and ovaries were sent in the same container for histological examination. The blood loss was minimal. The patient had an uneventful recovery and was discharged home the same day.\nThe histopathologist reported that one of the fallopian tubes showed elements of a STIC with negative staining for p53. The Ki67 index was at least 30% but with no evidence of invasive malignancy. The other tube and both ovaries were normal. Following this, the patient’s case and the histology results were discussed in the regional multidisciplinary meeting (MDT). A decision was made for the patient to have a CT chest/abdomen/pelvis followed by completion surgery. The CT thorax, abdomen, and pelvis showed tiny omental nodules in the left anterior hemipelvis which were suspicious of metastasis (Figures -). The soft tissue stranding in the parametrium was thought to be post-surgical changes. Following a discussion in the MDT, she was seen in the centre gynae-oncology unit and was offered further surgical management.\nShe had a total abdominal hysterectomy, supracolic omentectomy, appendicectomy, peritonectomy with multiple peritoneal biopsies and resection of the disease from the pouch of Douglas. The intraoperative findings were consistent with advanced disease. The diaphragmatic surfaces were normal. The omentum appeared thickened but the lesser sac of the omentum was normal. There were small 5-10 mm miliary deposits affecting both left and right paracolic gutters, Gerota’s fascia, pouch of Douglas, and recto-sigmoid with further smaller military deposits on small bowel mesentery.\nThe histology confirmed widespread high-grade serous carcinoma amounting to primary tubal malignancy International Federation of Gynecology and Obstetrics (FIGO) stage 3c. The case was discussed again in the MDT and the patient was referred to the medical oncologist for consideration of adjuvant chemotherapy. She was commenced on adjuvant cytotoxic chemotherapy with paclitaxel and carboplatin. In view of the Covid-19 pandemic, primary prophylaxis of granulocyte-colony stimulating factor (GCSF) was offered. The plan was to commence olaparib maintenance following completion of the six chemotherapy cycles.
A 20-year-old female presented complaining of recurrent right forearm pain for the preceding three months. The pain was felt predominantly in the volar aspect of the forearm running from the wrist to the elbow and was associated with parasthesia of the entire hand. Onset of the pain was always after exertion—she was a competitive rower and typically would experience the pain after intense rowing. She also noted slight swelling and a flexion contracture with ulnar deviation of the wrist. Following cessation of activity, the pain would subside over approximately 15 minutes and sensation return to normal. She had no medical history of note and no prior trauma to the upper limb.\nOn examination, the upper limb appeared of normal bulk compared to the contralateral side. Assessment of tone, power, and sensation of the right upper limb was normal. Radial and ulnar pulses were palpable at the wrist. There was no objective evidence of Thoracic Outlet Syndrome and cervical spine movements were normal. After using an indoor rowing machine, the symptoms were reproduced, the volar aspect of the right forearm tense and the wrist held in a flexed and ulnar deviated disposition ()—attempts to manually extend the wrist and digits was painful. Symptoms subsided gradually on cessation of rowing disappeared completely by 15 minutes.\nPlain radiographs of the elbow to the wrist were normal. Nerve conduction studies showed a borderline carpal tunnel lesion but ulnar nerve function was normal both before and after provocation with exercise. Electromyography of the forearm musculature did not show any underlying myotonic or myopathic disorder. Compartment pressure testing of the volar compartments confirmed a raised resting pressure of 20 mmHg. A diagnosis of chronic exertional compartment syndrome of the flexor aspect of the forearm was made and surgical decompression offered.\nA flexor compartment release was performed of the volar compartments via an incision ulnar to the midline on the volar aspect of the forearm (). A release was made from 2 cm distal to the elbow proximally to the musculotendinous junction distally. One month following surgery, she returned to competitive rowing with no ill effects or recurrence of symptoms.
A 60-year-old female patient with a history of nephroureterectomy and cuff excision due to renal pelvic TCC was admitted to our outpatient clinic with complaints of red skin lesion in the near vicinity of the operational incision scar for 3 months. Her medical history revealed nothing but nephroureterectomy operation on her upper urinary system; moreover, it was learned that she had been ignoring what was recommended to her for routine controls. A thorough search through the database regarding patient's past medical reports revealed that the pathology report about the past operation had been compatible with high-grade TCC and that the tumor had been multifocally located in the renal pelvis with the largest one to be 2.5 cm in diameter. The past pathology report had further indicated presence of lymphovascular invasion, compatible with pT2 stage (Muscle invasion is present in the absence of parenchymal and peripelvic fat tissue invasion) and absence of tumoral tissue within the surgical border. In the physical examination, a hard, painless and immobile mass of 22 cm dimension was palpated 3 cm below the incision line. Thoraco-abdominal computed tomographic (CT) examination performed on the basis of the aforementioned findings depicted a mass lesion of 786550 mm dimension with heterogeneous contrast uptake, which originated in the abdomen at the level of left renal vein drainage into the inferior vena cava, completely surrounding the inferior vena cava and extending inferiorly to the level of aortic bifurcation. In addition, a mass lesion of 2420 mm dimension with high-contrast uptake was detected within the subcutaneous fat tissue in the right abdominal wall. The other abdominal and thoracic structures were evaluated to be normal [].\nThe skin lesion depicted in CT was surgically excised. The pathological examination of the excised material was reported to be compatible with TCC metastasis localized within the reticular dermis and hypodermis without any invasion into the epidermis and papillary dermis, and with surgical border negativity.\nThe patient was referred due to abdominal lesion to medical oncology after the operation. Followed up under chemotherapy protocol, the patient died 3 months after the metastasectomy operation.
A 72-year-old man visited our hospital with a painless mass on lateral side of his left lower limb that had developed 4 years previously. He had undergone surgery on his left lower limb twice (25 and 55 years beforehand). The patient had a history of hypertension, diabetes, and benign prostatic hyperplasia. A biopsy performed at the orthopedic department showed calcification of the soft tissue. X-rays of the left lower extremity showed extensive calcification, which included the anterior and lateral compartments and a portion of the posterior compartment ().\nThe patient presented to the hospital again with swelling and tenderness at the biopsy site. On examination, an open wound was observed on the anterolateral side of the proximal left lower leg, and a cavity had formed from which a discharge emerged. The turbid secretion contained calcium debris. The cavity extended to just above the ankle. An incision was made extending to the ankle, and debridement and irrigation were performed, after which a betadine-soaked gauze dressing was applied (). Methicillin-resistant Staphylococcus aureus (MRSA) was identified in the wound culture, and vancomycin was intravenously administered. Osteomyelitis was not confirmed in the threephase bone scan test.\nAfter continuous dressings were applied, the discharge and debris started to reduce. The patient had an open wound on the left lower leg measuring 17 × 4 cm2. The tibia was exposed inside the wound, and focal granulation tissue had formed on the bony surface. Negative-pressure wound therapy (NPWT) was applied to reduce the size of the wound. However, primary closure was not possible due to the large defect site and the slow growth of granulation tissue. Free flap coverage was planned once MRSA was no longer found in the wound culture and the calcium debris was reduced during irrigation. A hand-held Doppler test and three-dimensional angiography showed that the left anterior tibial artery displayed poor perfusion, but the posterior tibial artery and peroneal artery were intact.\nTwo anterolateral thigh (ALT) free flaps were planned: an 18 × 8 cm2 flap from the right thigh and a 25 × 7 cm2 flap from the left thigh. The purpose of the right thigh flap was to fill the cavity, while the goal of the left thigh flap was to cover the defect. After lifting both ALT flaps, we connected the right flap pedicle to the distal portion of the descending branch of the lateral circumflex femoral artery of the left ALT free flap (). With the pedicle combined, the proximal portion of the descending branch was cut and anastomosed to the left posterior tibial vessel in an end-to-side manner for the artery and an end-to-end manner for the concomitant vein. The right ALT free flap was inset in the cavity after de-epithelization and then fixed with an absorbable suture. The left ALT was used to cover the defect. After surgery, the flap perfusion was excellent, and a drainage tube was inserted into the flap and donor sites. The patient was discharged 1 month after surgery. He remained well over a 12-week follow-up period (). The surgical site did not become infected and the wound did not recur.
A 27-year-old male came to the emergency department with blood came from his left eye after falling from a motor vehicle and struck the stack of tree branches. The patient was fully conscious and had only a minor hematoma and a small wound in the left medial cantal region. Neurological examination revealed no decrease in mental status (GCS 15) with visual acuity markedly decreased. The patient could only differentiate light perception with different sizes of the right and left pupil. Ocular motility was markedly decreased ().\nNo sign of meningeal irritation was observed, the function of trigeminal and facial nerves was preserved. Unfortunately, further ophthalmologic examinations were not done. A non-contrast head CT was performed and reveal a linear-shaped foreign body, air mimicking that penetrated the medial orbit plane to the left temporal fossa. From the brain window aspect, there was no cerebral edema and fracture seen ().\nA CT angiography was also performed to see if there was a vascular injury and vascular near the foreign body or traumatic vascular aneurysm().\nThe patient underwent a craniotomy on the temporobasal approach. Neurosurgeon et al. decided to use the temporobasal approach not only because it was the closest approach to foreign body position but also to get a clear visualization of the foreign body through the intracranial cavity and also it is good for cleaning up the wood fragments that entered the intracranial cavity. The patient was lying in the supine position and temporofrontal muscles were incised layer by layer. Craniotomy was performed at the temporal basal region and the dural was incised. The brain parenchymal was retracted and the foreign body was seen (, ).\nSmall vessels were coagulated and the foreign body was retracted from the outside slowly. After that, exploration and irrigation of the wood particles with bleeding control were done meticulously. Postoperatively, the patient was admitted to ICU where broad-spectrum antibiotic was administered. No signs of infection were detected and the patient was fully recovered and discharged after 5 days. However, the patient only came to visit the ophthalmologist for late orbital complications which seen in the picture and yet never came to the neurosurgery department for further follow-up so it was difficult to detect any late intracranial complication. However, we still could contact the patient and asked several questions related to his condition. The patient said that he could not move his left eye to the lateral side, and it seemed the size of both pupils were unequal ().
A 79-year-old Japanese man underwent redo rectal resection for completely separated and obstructed anastomosis which was caused by anastomotic leakage after anterior resection. The initial surgery had been performed for advanced sigmoid colon cancer 3 years previously and the anastomotic leakage was remedied by diverging ileostomy performed 10 days after the initial surgery. Fluoroscopy conducted 1 week after the redo surgery showed good passage through the colorectal anastomosis and no anastomotic leakage. Ileostomy takedown was planned 6 months after the redo surgery for social reasons of the patient. Prior to the takedown, however, high-pressure fluoroscopy showed no passage of contrast medium through the anastomosis (Figure ). Subsequent colonoscopy could not find any orifice of anastomosis connecting oral and anal intestines to the anastomosis. Thus complete obstruction of the colorectal anastomosis was diagnosed. Abdominal computed tomography confirmed that the colon oral to the anastomotic site and the rectum anal to the anastomotic site were connected at the anastomosis but a thick membranous structure was observed in the circular staple line (Figure ). These findings suggested that patency of the anastomosis was discontinued by the thick membranous web composed in the circular stapler ring. Although one-more surgical revision was considered, we thought that further surgery should be avoided if possible because he had already undergone redo surgery for failed colorectal anastomosis and thus the next surgery would probably be more stressful than the prior surgery. It was obvious that some special techniques were required for treating this condition nonsurgically because any orifice which enables conventional balloon dilatation technique was not detectable at the anastomotic site. First of all, therefore, we applied a nonsurgical approach for treating this condition. In order to avoid thermal injury and sharp needle injury, we applied blunt penetration technique using a commercially available device for transanal ileus drainage for obstructing colorectal cancer (Transanal Ileus Tube®; Create Medic Co., Ltd., Yokohama, Japan; Figure ). Before applying this technique, a detailed written informed consent was given to the patient. It clearly described the impracticality of other conventional nonsurgical approaches, off-label use of transanal drainage tube, and the possibility of bowel perforation caused by misdirected thrust. Furthermore, we informed him that emergent receliotomy might be needed if a misdirected thrust occurred. After that, he agreed to receive this technique and thus we performed the following procedures. Firstly, we used a through-the-scope thin dilator (TTSTD); its hardness was reinforced with a reversely inserted guide wire as a penetrator. We pushed it against the center of the circular staple line to penetrate the membranous structure (Figure ). When the TTSTD was thrust, special attention was paid not to protrude the tip of the reversely inserted guide wire from the top of the TTSTD. Because the tail of the guide wire was firm and relatively sharp, it may have stuck to and injured other organs adjacent to the anastomosis if it protruded and thrust in the wrong direction. We succeeded to penetrate the TTSTD through the membrane (Figure ). Then, the guide wire was removed from the TTSTD to perform fluoroscopy via the TTSTD which confirmed that the tip of the TTSTD was present in the colon oral to the anastomosis (Figure ). If a misdirected thrust occurs and the fluoroscopy via the TTSTD shows small intestine or peritoneography other than the colon oral to the anastomosis, the procedure must be stopped and emergent celiotomy should be considered if the situation demands. Fortunately, however, the fluoroscopy showed that pushing the TTSTD was properly and successfully performed and thus we continued the procedure. After that, the guide wire was inserted normally through the dilator and pushed orally as possible. The fiberscope was removed and a thick dilator was inserted over the TTSTD through the anastomosis under fluoroscopic guidance (Figure ). After removing the dilators and guide wire, a colonoscope was reinserted and found that the anastomosis was open but too stenotic to pass the scope through. Therefore we applied through-the-scope hydrostatic balloon dilatation (Figures and ). The successful dilatation facilitated passage of the colonoscope, allowing evaluation of the entire colon. Seven days after the procedure, confirmative colonoscopy was performed and showed that the anastomosis was patent but not stenotic. Two days after the confirmative colonoscopy, ileostomy takedown was performed. The patient is currently doing well and had no complaint arising from the anastomotic stricture 12 months after the ileostomy takedown.
The present case report is about a 38-year-old female patient who presented with the complaint of a painless swelling of the upper left posterior alveolar ridge. She gave a history of extraction of a mobile upper left second molar tooth from that area 2 months ago, which had gingival swelling and was progressively mobile. On intra oral examination, a swelling of 3 cm × 4 cm was noticed on the alveolar ridge at the site of extraction in 27 region. The swelling was normal in color with smooth surface except in one area where the indentation from the opposing tooth was noticed []. The swelling started to increase following tooth extraction and started to impinge on lower tooth. Frequent lacrimation from the left eye and difficulty in breathing through the left nostril were present since 3 months. Extra oral examination revealed mild facial asymmetry due to the presence of a diffuse swelling in the left maxillary region. The orbit was pushed upwards and the left lateral ala of nose was raised [].\nOrthopantamograph showed an ill-defined osteolytic lesion in the left posterior maxilla []. Computed tomography image revealed an irregular soft-tissue lesion in the left maxillary sinus causing expansion and thinning of medial wall and erosion of anterior, inferior and superior walls. Intraorbital extension of the lesion was noticed with the involvement of inferior rectus muscle and there was extension of the tumor into the ethmoid sinus, nasal cavity, oral cavity, pterigopalatine fossa and infra temporal fossa []. Magnetic resonance imaging image showed intra orally the lesion extended into the left alveolus causing erosion and expansion of alveolus []. Based on the clinical presentation and imaging studies, the lesion was provisionally diagnosed as primary intra-alveolar carcinoma.\nLeft side maxillectomy was performed retaining the orbit. The histological sections from the orbital margin showed sheets of atypical spindle cells with indistinct cytoplasm and large vesicular nuclei showing pleomorphism []. The proliferating spindle cells were admixed with numerous inflammatory cells mainly neutrophils, lymphocytes and plasma cells []. On Immunohistochemical staining, the tumor cells were strongly positive for vimentin and smooth muscle actin (SMA), but negative for CD 1a, S100, Desmin, CD 34, activin receptor-like kinase (ALK)-1 and MPO. Nuclear positivity for the proliferative marker Ki 67 was seen in 8-10% of the tumor cells. CD 68 positive cells were seen focally indicting the presence of histiocytes. Based on the clinical presentation, histopathological features and immunohistochemistry the lesion was diagnosed as IMT with focal sarcomatous change. Following resection, patient underwent radiotherapy. At 6 months later the patient developed recurrence of the lesion and finally succumbed to death.

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