Background:Injury to the lower extremity, especially rupture of the extensor hallucis longus (EHL) tendon, is relatively rare. This case report presents a neglected case of EHL tendon rupture with a 10 cm gap, treated with a novel graft source - the iliotibial band (ITB) - using the Pulvertaft technique. Case report:A 34-year-old man presented with a previous rupture of the EHL tendon of his right great toe, with a 10 cm gap, 12 months before admission, for which a primary repair had already been performed immediately after the trauma. The pain persisted even 6 weeks post-surgery; therefore, after clinical and ultrasound evaluation, we found a rupture of the EHL tendon with the gap filled with fibrotic tissue. We performed a tendon graft for EHL reconstruction using the ITB with the Pulvertaft technique, which showed a good postoperative result. Discussion:Rupture of the EHL has proved to be troublesome, and the management of this case can be performed by direct repair in the acute setting or by tendon transfer or tendon graft. It should be performed properly to restore function. Conclusion:After the tendon grafting was performed, intraoperative evaluation found that there was no lag in the gliding of the tendon as it passed through the extensor retinaculum, and the excursion of the tendon was preserved.
Introduction and Importance:Wandering spleen is a rare clinical entity, affecting fewer than 0.5% of pediatric abdominal emergencies. It is caused by laxity or absence of the splenic ligaments, permitting abnormal mobility. Splenic torsion, as its most severe complication, leads to vascular compromise and infarction, which necessitates urgent intervention to prevent life-threatening outcomes. Presentation of case:An 8-year-old girl presented to a resource-limited emergency department with 24 hours of severe abdominal pain and a palpable right iliac fossa mass. Ultrasound revealed an ectopic, solid "liver-like" mass with some preserved perfusion, highly suspicious for a torsed wandering spleen. Emergency laparotomy demonstrated 720° torsion with infarction, necessitating splenectomy. The patient recovered well and was discharged with arrangements for post-splenectomy vaccinations. Clinical discussion:Wandering spleen is a rare mimic of common abdominal emergencies. While ultrasound is a valuable initial diagnostic tool, surgical findings ultimately dictate management. The decision between splenopexy and splenectomy hinges on intraoperative viability assessment. In cases of infarction, splenectomy is mandatory, followed by vital vaccinations. Large recent review articles confirm that ultrasound-based diagnosis is critical, and contrast-enhanced CT is used in complex cases. Splenectomy remains common for infarcted spleens. Conclusion:This case highlights that wandering spleen with torsion, though rare, must be considered in the differential diagnosis for children presenting with acute abdominal pain and atypical masses. Clinical assessment and ultrasound are vital for guiding urgent management, especially when advanced imaging such as CT is unavailable.
Introduction:Intestinal malrotation is a congenital anomaly resulting from incomplete midgut rotation. While it most commonly becomes symptomatic in infancy, adult presentations are rare and pose diagnostic difficulties. In particular, obstruction due to persistent Ladd's bands in adults is uncommon and requires surgical attention. Presentation of the case:We describe a 43-year-old male patient with recurrent episodes of small-bowel obstruction over 3 years. The initial presentation included bilious vomiting and CT evidence of duodenal obstruction, which was managed conservatively. Upon recurrence, diagnostic laparoscopy identified only adhesions; however, repeated imaging and persistent symptoms prompted a second laparoscopic intervention. Intraoperatively, intestinal malrotation with rigid Ladd's bands compressing the duodenum was identified. A laparoscopic Ladd's procedure was performed, including division of the bands and repositioning of the bowel. An appendectomy had been performed in childhood. The patient recovered uneventfully and remains symptom-free at follow-up. Discussion:Adult intestinal malrotation may present with nonspecific symptoms such as intermittent abdominal pain, nausea, or obstruction. Characteristic CT findings (e.g., inverted mesenteric vessels and abnormal bowel positioning) should raise suspicion for malrotation. Although guidelines for adults are lacking, the Ladd's procedure remains the standard of care. An elective approach may reduce complication rates compared with emergency surgery. Conclusion:In adults with recurrent duodenal obstruction and suggestive imaging findings, malrotation with Ladd's bands should be considered. Early surgical intervention via a Ladd's procedure can relieve symptoms and prevent serious complications.
Introduction and importance:Intestinal malrotation is a rare congenital anomaly that results from incomplete midgut rotation. Although 90% of cases present in infancy, adult presentations account for only 0.2%-0.5% of cases. Congenital peritoneal bands causing obstruction in a virgin abdomen are rarely considered, making this a clinically important and easily overlooked diagnosis. Case presentation:A man in his early thirties presented to the emergency department with a 2-day history of severe colicky abdominal pain, nausea, vomiting, and abdominal distension, and without prior abdominal surgery. Contrast-enhanced CT demonstrated pathognomonic features of Type I intestinal malrotation (non-rotation). After resuscitation and nasogastric decompression, urgent open laparotomy confirmed Ladd's bands causing a complete small-bowel obstruction. Ladd's procedure, with appendectomy and prophylactic colopexy, was performed. The patient was discharged on postoperative day 6 and had complete symptom resolution at the 12-month follow-up. Clinical discussion:CT achieved a prompt diagnosis via the characteristic CT triad of abnormal superior mesenteric vein-artery orientation, malpositioned duodenojejunal junction, and right-sided small-bowel clustering. The open operative approach was selected due to high-risk physiology, massively dilated bowel, and anticipated difficulty with laparoscopic visualization, consistent with published guidance favoring primary open laparotomy in this setting. Conclusion:Congenital intestinal malrotation must be considered in adults with acute small-bowel obstruction, even in a virgin abdomen. Contrast-enhanced CT is diagnostic, and the open Ladd's procedure in the acute setting achieves excellent outcomes.
Introduction and importance:Brown tumors are rare osteolytic lesions resulting from prolonged excess of parathyroid hormone (PTH). Although they typically affect the axial skeleton, jaw involvement is uncommon and may represent the first manifestation of previously undiagnosed hyperparathyroidism. Because these lesions closely mimic other giant cell-rich jaw pathologies, accurate diagnosis requires careful clinicobiochemical correlation. Methods:This retrospective single-center case series included three consecutive female patients treated between 2022 and 2023 for expansile giant cell-rich jaw lesions associated with elevated PTH levels. Clinical, radiological, biochemical, therapeutic, and follow-up data were analyzed descriptively. Results:Three patients, aged 22-60 years, presented with painless mandibular or maxillary swellings. Imaging showed radiolucent or mixed lesions with cortical expansion, including perforation in two cases. Histopathology revealed multinucleated giant cells within a fibrovascular stroma. Biochemical evaluation confirmed primary hyperparathyroidism in two patients and secondary hyperparathyroidism in one patient on hemodialysis. Parathyroidectomy led to lesion regression in the primary cases, while the secondary case was managed conservatively. Discussion:Jaw brown tumors may represent sentinel manifestations of systemic endocrine disease and can be easily misdiagnosed because of their radiological and histological resemblance to other giant cell lesions. Recognition of this association is crucial, as correction of the underlying endocrine disorder frequently leads to spontaneous lesion regression, avoiding unnecessary maxillofacial surgery. Conclusion:Brown tumors of the jaws should be considered in the differential diagnosis of giant cell-rich jaw lesions. Early biochemical investigation and multidisciplinary management are essential to identify underlying hyperparathyroidism and ensure appropriate treatment.
Introduction:Breast schwannoma is a very rare benign peripheral nerve sheath tumor, accounting for approximately 0.2% of all breast tumors. With fewer than 70 cases reported in the literature, the diagnosis is usually challenging and is often not considered. Case presentation:We present a case of a 62-year-old Black female with a history of right breast cancer, status post right modified radical mastectomy, and chemoradiation 30 years ago, without prior evidence of recurrence. She presented with a mass in the left breast. Initial diagnostic mammogram and ultrasound reported the mass as a benign lymph node. A repeat mammogram showed interval growth, prompting an ultrasound-guided core-needle biopsy. Histological results were consistent with schwannoma. The patient underwent a left I-125 radioactive seed-localized partial mastectomy for definitive diagnosis and treatment, due to her high risk of breast cancer and preference. Discussion:This report highlights the importance of continued clinical and radiographic surveillance in patients with a history of breast cancer, as new breast lesions may warrant further evaluation despite benign-appearing imaging characteristics. Although rare, breast schwannoma should be included in the differential diagnosis of benign breast masses. While breast schwannomas may be managed with observation, in select cases, surgical excision provides a definitive histopathologic diagnosis and is curative when intervention is clinically indicated. Conclusion:A low threshold for tissue diagnosis is warranted in breast cancer survivors who present with new breast lesions, even when imaging characteristics appear benign. Management of benign-appearing breast masses should be individualized, and surgical excision for definitive diagnosis and treatment should remain a consideration in cases of interval growth, persistent concern for occult malignancy, or when ongoing imaging surveillance poses a significant burden or inconvenience to the patient.
Introduction and importance:Roux-en-Y gastric bypass (RYGB) is an effective metabolic procedure with durable weight loss and metabolic benefits. However, catastrophic late-onset malnutrition is rarely reported, particularly when multiple long-term complications interact sequentially. We present a case illustrating a multihit cascade of skeletal and gastrointestinal events culminating in life-threatening refractory malnutrition long after RYGB. Presentation of case:A 67-year-old woman with a history of RYGB for severe obesity developed an osteoporosis-related fragility fracture, followed by prolonged immobilization. During subsequent hospitalization, she experienced stress- and medication-induced marginal ulceration, complicated by perforation and prolonged fasting. These events collectively precipitated profound macro- and micronutrient deficiencies that were refractory to conventional oral and parenteral supplementation. The patient was managed with intensive nutritional rehabilitation, including combined enteral feeding via the oral route and a feeding gastrostomy, alongside parenteral nutritional support. Recovery was markedly protracted, underscoring the severity and refractoriness of the nutritional derangement. Clinical discussion:This case demonstrates that patients who have undergone RYGB remain vulnerable to delayed, synergistic complications arising from altered gastrointestinal anatomy, impaired absorptive capacity, chronic acid suppression, and age-related physiological decline, which can culminate in catastrophic malnutrition years to decades after surgery. Conclusion:Increased awareness among general clinicians, particularly during hospitalizations for unrelated medical conditions, together with lifelong nutritional surveillance, early multidisciplinary involvement, and timely referral to bariatric specialists is essential to prevent irreversible nutritional deterioration in long-term survivors of bariatric surgery.
Introduction and importance:Road traffic accidents (RTAs) are the leading cause of polytrauma worldwide. Traumatic hernias from pelvic fracture defects and multiple hollow viscus injuries are very rare in blunt abdominal trauma and may involve high-energy mechanisms. Their coexistence with complex pelvic ring fractures and thoracic injuries poses significant diagnostic and management challenges, particularly in physiologically unstable patients. Case presentation:This is a case report of a 66-year-old male who presented to the emergency department following a high-velocity RTA with hemorrhagic shock and multiple musculoskeletal injuries. After initial resuscitation, further examination and imaging revealed a traumatic hernia through a right iliac fracture defect, with associated bilateral pelvic fractures and a hollow viscus injury. Management was complicated by the patient's severe physiological derangement and delayed operative consent from surrogate decision-makers. A definitive repair, rather than damage-control strategies, was performed. However, he later suffered a cardiopulmonary arrest and could not be resuscitated. Discussion:This case documents a previously unreported combination of injuries in a hemodynamically unstable patient. Clinical decisions for management must be guided by the patient's physiological status, as the intervention itself may influence the patient's outcome. While damage control surgery is the standard of care, it was precluded by the family's refusal due to financial constraints, reflecting real-world realities in low-resource settings. Conclusion:Severe blunt polytrauma with a pelvic fracture-associated traumatic hernia and concurrent hollow viscus injuries, including sigmoid transection with devascularization, represents a surgical emergency. This case adds to the limited literature on herniation via traumatic pelvic fractures.
Introduction and importance:Abdominal cerebrospinal fluid pseudocysts (APCs) are a rare complication of ventriculoperitoneal (VP) shunts, occurring in 1-4.5% of cases and potentially causing abdominal symptoms, bowel obstruction, or shunt malfunction. We present a case of a VP shunt-associated pseudocyst leading to mechanical small bowel obstruction. Presentation of case:A 40-year-old woman with a long-standing VP shunt presented with abdominal pain, vomiting, and obstipation. CT imaging showed a large pseudocyst encasing the shunt tip and causing mechanical ileus. Emergency surgery revealed adhesion-related small-bowel obstruction, requiring partial cystectomy and ileal resection. cerebrospinal fluid (CSF) cultures grew Cutibacterium acnes, prompting complete shunt removal, external ventricular drainage, and later placement of a ventriculoatrial shunt. She recovered with conservative management of minor postoperative complications. Clinical discussion:APCs may form due to impaired CSF absorption, inflammation, or low-grade infection. In this patient, a chronic shunt infection likely contributed to cyst development and bowel obstruction. Management typically requires cyst drainage or resection, and revision of the distal catheter, with complete shunt removal necessary when infection is present. Early diagnosis and multidisciplinary management are essential to prevent morbidity. Conclusion:VP shunt-associated pseudocysts, though rare, can cause acute abdominal emergencies. Prompt imaging, surgical intervention, and appropriate treatment of shunt infection are critical for optimal outcomes.
Introduction and importance:Renal small-cell neuroendocrine carcinoma (renal SCNEC) is an exceedingly rare and highly aggressive tumor of the urinary system, originating from peptidergic neurons or neuroendocrine cells. The disease often presents with insidious clinical symptoms and lacks specific imaging features, which can delay diagnosis and predispose to distant metastases. Here, we report a case of renal SCNEC and describe its diagnosis, treatment, and outcomes, aiming to enhance clinical understanding and management of this rare condition. Case presentation:We report the case of a 64-year-old man who presented with left-sided flank pain without hematuria. Imaging studies revealed a mass in the left kidney. Percutaneous biopsy and immunohistochemical analysis confirmed the diagnosis of SCNEC. The patient received two cycles of neoadjuvant chemotherapy consisting of cisplatin and etoposide, followed by laparoscopic radical nephrectomy. Postoperative chemotherapy was administered according to the planned regimen. During 16 months of follow-up, no evidence of recurrence was observed. Discussion:Prompt recognition and diagnosis of renal SCNEC are crucial to prevent misdiagnosis and delayed treatment. Diagnosis relies on histopathology, immunohistochemistry, and careful evaluation of common metastatic sites, including lymph nodes, liver, and bones. Treatment should be individualized based on disease stage and the patient's condition; for locally advanced renal SCNEC, platinum-based chemotherapy combined with radical surgery may be considered as part of a multimodal treatment strategy in selected patients. Given the rarity of this tumor, multidisciplinary collaboration and evidence-based research are essential to optimize management and establish standardized treatment guidelines. Conclusion:For patients with locally advanced renal SCNEC, platinum-based chemotherapy combined with radical surgery may provide a therapeutic option after multidisciplinary evaluation.
Background:Adult spinal deformity (ASD) is associated with progressive sagittal and coronal imbalance, leading to functional decline and decreased quality of life. While minimally invasive approaches, such as lateral lumbar interbody fusion, have gained popularity, they pose risks to the abdominal vessels and the lumbar plexus. Microendoscopic extraforaminal lumbar interbody fusion (ME-ELIF) provides a posterolateral corridor to the disc space, avoiding these anterior structures. However, reports of ME-ELIF for ASD correction are limited. Case presentation:A 73-year-old woman presented with low back pain and impaired standing tolerance. Radiographs showed a sagittal vertical axis (SVA) of 127 mm and a PI-LL mismatch of 32°, with preserved flexibility on fulcrum-bending films. ME-TLIF was performed at L4/5 due to facet fusion, and ME-ELIF was performed at L2/3, L3/4, and L5/S. Percutaneous pedicle screw fixation from T7 to the sacropelvis was utilized for global correction. Results:Postoperative standing radiographs demonstrated improvements in SVA (127 mm → 45 mm) and PI-LL mismatch (32° → 11°). The coronal vertical axis improved from 65 mm to 7 mm. The Oswestry Disability Index improved from 51% preoperatively to 31% at 6 months. No neurological complications were observed. Conclusion:ME-ELIF can provide effective sagittal and coronal realignment in flexible ASD while minimizing approach-related morbidity. This technique may serve as a valuable minimally invasive alternative in selected cases.
Introduction and importance:Esophageal diverticulum is a rare condition, with supradiaphragmatic esophageal diverticula being even rarer, occurring in only approximately 0.06%-4% of cases, and most of these are located on the right side of the esophagus. This article reports a rare case of a giant left-sided supradiaphragmatic esophageal diverticulum, aiming to explore its diagnostic methods, surgical strategies, and therapeutic outcomes, thereby providing a reference for similar complex cases. Case presentation:A 58-year-old male patient was found to have an esophageal diverticulum during a physical examination 3 months ago, which was prompted by long-term symptoms of acid reflux and heartburn. Gastroscopy revealed that the diverticulum was located 38 cm from the incisors, and computed tomography (CT) and barium meal radiography confirmed a left lower thoracic esophageal diverticulum measuring approximately 70 ×55 mm. The patient had long been troubled by acid reflux and heartburn. After undergoing surgery at our hospital, the patient recovered well, with no postoperative complications. Clinical discussion:Thoracic esophageal diverticula are most commonly caused by esophageal motility disorders, with left-sided occurrence being particularly rare. Diagnosis requires a comprehensive assessment combining gastroscopy, CT, and barium meal radiography, and the differential diagnosis should exclude conditions such as hiatal hernia. The combined double-endoscopic technique offers the advantages of minimally invasive surgery and precise operation, effectively reducing injury to the esophageal muscle layer and postoperative complications. Conclusion:This case demonstrates that combined double-endoscopic surgery is a preferred, safe, effective, and minimally invasive option for the treatment of giant or complex esophageal diverticula, and it holds significant value for clinical application.
Introduction and clinical importance:Idiopathic pneumoperitoneum can occur in a full-term neonate due to the administration of pure oxygen. Recognition of this rare mechanism is necessary to avoid unnecessary surgical exploration. Case presentation:We report the case of a six-day-old male neonate with a history of respiratory distress and non-invasive pure oxygen support (FiO2 = 1.00) via a nasal cannula. He progressively developed abdominal distension, but had no fever, abdominal tenderness, or redness. A massive pneumoperitoneum was noted on a plain X-ray. While preparing for surgical exploration, the distension regressed, and idiopathic pneumoperitoneum was diagnosed and managed conservatively. The respiratory distress was caused by laryngomalacia, which was also managed conservatively, with no complications noted 6 months after admission. Clinical discussion:Idiopathic pneumoperitoneum should be suspected in neonates with a history of respiratory distress but without classic clinical signs of peritonitis. Notably, noninvasive administration of pure oxygen alone can cause idiopathic pneumoperitoneum. Conclusion:In a full-term neonate, non-invasive administration of pure oxygen for laryngomalacia can cause idiopathic pneumoperitoneum, which may have a favorable outcome with conservative management.
Introduction and importance:Semi-occlusive dressings are established for selected fingertip amputations with exposed bone. Because this treatment is well described, the value of single-case reports depends on documenting the course, limitations, and long-term sequelae. Case presentation:A 47-year-old right-hand-dominant man presented to primary care after a mandoline-slicer injury causing partial amputation of the right little fingertip, with an exposed distal phalanx and a preserved nail bed, clinically consistent with an Allen type II injury. A transparent, semi-occlusive polyurethane dressing was applied and changed weekly. No systemic antibiotics were prescribed. Clinical discussion:The exposed bone was clinically covered by week 4, and near-complete pulp reconstruction was observed by week 6. At a 6-year in-person follow-up, following telephone contact, the patient reported no sick leave, pain 0/10, no cold intolerance, a complete active range of motion, and no secondary surgery, infection, or clinical evidence of osteomyelitis. The QuickDASH score was 2.3/100. Sequelae included a mild reduction in temperature and pressure perception, minor typing adaptation, and a subtle lateral nail-growth alteration of approximately 2 mm. Conclusion:This single selected case documents a favorable 6-year outcome after conservative management. No general conclusion regarding treatment effectiveness can be drawn from a single case.
Introduction:Osteoblastoma is a rare, benign osteogenic tumor. Among patients with osteoblastoma, a small number initially seek medical treatment for pathological fractures of the patella. Importance:The patella plays a crucial role in the knee joint, contributing significantly to its normal function. Presentation of Case:This report describes the case of a young male patient with patellar osteoblastoma complicated by a pathological fracture that was treated using a 3D-printed, customized, tantalum-alloy patellar prosthesis. Clinical Discussion:Surgical intervention serves as the primary treatment modality for patellar tumors, encompassing both partial and complete resection of the patella. Conclusion:The 2-year follow-up demonstrated satisfactory efficacy, and functional recovery was attained.
Introduction:Hyoscine butylbromide is commonly administered to relieve smooth muscle spasms. Although usually well tolerated, its anticholinergic activity may influence atrioventricular (AV) nodal conduction and, in rare cases, trigger tachyarrhythmias. Case presentation:A healthy 30-year-old woman underwent elective laparoscopic myomectomy. Near the end of the procedure, after returning from the Trendelenburg position, she received intravenous hyoscine butylbromide (20 mg), paracetamol, and diclofenac. Within minutes, she developed sudden narrow-complex supraventricular tachycardia at 140-150 bpm, as shown in Fig. 1, accompanied by severe hypotension unresponsive to ephedrine or phenylephrine. Anaphylaxis was suspected, and small boluses of adrenaline along with fluid resuscitation were administered without significant improvement. Hemoglobin remained stable, serum tryptase was normal, and no surgical bleeding was identified. She spontaneously reverted to sinus rhythm during central venous catheter placement. After extubation in the intensive care unit, tachycardia recurred and was terminated with adenosine. Cardiology confirmed AV nodal reentrant tachycardia (AVNRT). The patient recovered uneventfully. Figure 1.Perioperative electrocardiograms. Discussion:The close temporal association between Buscopan administration and the onset of tachyarrhythmia strongly suggests a causal relationship. The drug's vagolytic effect may facilitate AV nodal conduction and promote reentry circuits. This case also highlights the diagnostic challenge posed by perioperative tachycardia, which can closely mimic anaphylaxis. Conclusion:Even a single intravenous dose of hyoscine butylbromide may induce AVNRT in susceptible individuals. Perioperative teams should remain alert to this rare but clinically significant complication.
Introduction and importance:Meckel's diverticulum is defined as a true diverticulum arising from the distal ileum and is the most common congenital anomaly of the small bowel, affecting approximately 2% of the population. The presence of Meckel's diverticulum within a hernial sac, especially in the inguinal canal, is uncommon and is known as Littre's hernia. Clinical presentation:A 30-year-old male with an incarcerated Littre's hernia in the right inguinal region was successfully treated with segmental ileal resection and primary anastomosis, followed by hernial repair. Clinical discussion:Meckel's diverticulum typically presents in young men with symptoms arising from ectopic gastric mucosa, where acid-related ulceration leads to complications such as painless rectal bleeding, intestinal obstruction, inflammation, and intussusception. In adults, bleeding and obstruction remain the most common manifestations, often complicating timely diagnosis. While advanced imaging modalities can aid detection in well-resourced settings, in under-resourced areas, clinical assessment remains the cornerstone of diagnosis, underscoring the importance of careful history-taking and physical examination in guiding management decisions. Conclusion:Littre's hernia is a rare type of hernia in which the sac contains a Meckel's diverticulum. The diagnosis can be challenging. In low-resource areas, diagnosis relies on clinical examination and the surgeon's skill, as access to advanced diagnostic tools is limited.
Introduction and importance:The septochoanal polyp is an exceptionally rare variant of a choanal polyp, distinguished by its origin from the nasal septum rather than the paranasal sinuses. To our knowledge, fewer than fifteen cases of true septochoanal polyps have been reported to date. Presentation of the case:A 65-year-old male presented with persistent right-sided nasal obstruction and hyponasality despite prior septal surgery. Nasal endoscopy revealed a large anterior septal perforation and a substantial polypoid lesion extending into the nasopharynx. Computed tomography confirmed a homogeneous mass originating from the superior nasal septum, with no sinus involvement. The patient underwent successful, complete endoscopic excision of the lesion, which was delivered transorally because of its size. Clinical discussion:This case contributes to the scarce literature on this rare entity. The patient's history of septal surgery and the subsequent perforation support the theory that mechanical stress and turbulent nasal airflow may be significant factors in the pathogenesis of septal-origin polyps. Endoscopic surgery, entailing complete removal of the polyp along with its pedicle and a small mucosal margin, is the definitive treatment, resulting in a low recurrence rate and an excellent prognosis. Conclusion:The septochoanal polyp, while rare, should be considered in the differential diagnosis of a unilateral choanal mass. A combination of endoscopic examination and computed tomography is essential for precise preoperative localization of its septal origin. Endoscopic surgical excision remains the treatment of choice, offering a definitive cure. This case further highlights the potential role of disrupted nasal aerodynamics in the development of this unusual polyp.
Introduction and importance:Lemmel syndrome (LS) is a rare cause of obstructive jaundice resulting from compression of the distal common bile duct (CBD) by a periampullary duodenal diverticulum. The diagnosis is frequently missed due to nonspecific clinical features and subtle radiologic findings. Case presentation:A 39-year-old woman presented with recurrent epigastric pain, fever, and jaundice. Laboratory results showed leukocytosis and elevated bilirubin levels. Ultrasonography and magnetic resonance cholangiopancreatography (MRCP) demonstrated gallstones with mild biliary dilatation and suspected CBD sludge, prompting a laparoscopic cholecystectomy with planned CBD exploration. Intraoperative findings revealed a normal cystic duct and no evidence of obstruction. Re-evaluation of the MRCP during surgery identified an air pocket adjacent to the distal CBD, suggesting a periampullary diverticulum. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) confirmed LS caused by food debris within the diverticulum. Endoscopic balloon sweep and sphincterotomy achieved complete resolution, and the patient remained symptom-free at 6 months. Clinical discussion:The case highlights a diagnostic pitfall, which is an over-reliance on radiologists' interpretations and printed MRCP images. Review of thin-slice digital MRCP images by the surgical team could have revealed the diverticulum earlier. Hospitals with infrastructure that allows simultaneous endolaparoscopic procedures offer optimal workflow and outcomes. Conclusion:Careful review of preoperative imaging, multidisciplinary coordination, and the availability of intraoperative ERCP are crucial for the accurate diagnosis and effective management of LS, preventing unnecessary bile duct exploration and reducing morbidity.
Introduction:Gastric schwannomas are rare benign mesenchymal tumors, accounting for approximately 0.2% of all gastric tumors. They are usually asymptomatic, and tumor perforation is extremely uncommon. We report a rare case of a gastric schwannoma complicated by perforation that was successfully treated with laparoscopic wedge gastrectomy following conservative therapy. Presentation of the case:A 55-year-old woman presented with abdominal pain and fever. Laboratory findings revealed leukocytosis, anemia, and elevated C-reactive protein levels. Computed tomography demonstrated a 62-mm exophytic gastric mass with perforation and localized abscess formation. Intravenous antibiotics led to resolution of her acute symptoms, and subsequent imaging confirmed improvement. Upper gastrointestinal endoscopy revealed a submucosal tumor with ulceration, and biopsy with immunohistochemistry (KIT-negative, S-100 positive) confirmed gastric schwannoma. Given the large tumor size and history of perforation, laparoscopic wedge gastrectomy was performed. Although omental adhesions surrounding the tumor were observed intraoperatively, complete resection was achieved with preservation of luminal integrity. Pathological examination confirmed schwannoma with low proliferative activity. The postoperative course was uneventful, and the patient remained recurrence-free at 6 months. Clinical discussion:Although gastric schwannomas are generally benign and slow-growing, large tumors and associated ulceration may contribute to the risk of perforation. Reports of perforated gastric schwannomas are extremely limited, and optimal management strategies remain unclear. Conclusion:To the best of our knowledge, this is the first reported case of a perforated gastric schwannoma treated by laparoscopic resection. This case suggests that laparoscopic wedge gastrectomy is a feasible treatment option for a perforated gastric schwannoma after appropriate control of local inflammation.
