Introduction:In the absence of complications, transient jaundice has been observed in postoperative patients after abdominal surgery. This jaundice has been previously attributed to intrahepatic cholestasis due to oxidative stress from surgery and can be marked within the first postoperative weeks. However, this change has often been seen in patients with significant comorbidities. This report describes the case of a young, healthy patient who developed severe postoperative jaundice after a routine laparoscopic cholecystectomy with no evidence of biliary injury or obstruction, leading to endoscopic retrograde pancreatography and severe necrotizing pancreatitis. Case Presentation:A 45-year-old male with no medical comorbidities presented to our hospital with signs and symptoms consistent with acute cholecystitis. He promptly underwent an uncomplicated laparoscopic cholecystectomy with routine intraoperative cholangiogram (IOC) that was unrevealing. He represented on postoperative day two to the emergency department with a severe conjugated hyperbilirubinemia with unremarkable cross-sectional imaging. He subsequently underwent endoscopic retrograde pancreatography without evidence of biliary obstruction or biliary leak, after which his hyperbilirubinemia resolved without any further intervention over the following days. As a result of the endoscopic retrograde pancreatography, he developed a complicated case of necrotizing pancreatitis, with a course including multiple operative interventions. Conclusion:In patients with severe postoperative jaundice, postoperative intrahepatic cholestasis should be considered on the differential in the absence of evidence of other surgical complication. Surgeons should be aware of potential benign causes of hyperbilirubinemia. After laparoscopic cholecystectomy, many important complications are diagnosed and treated with endoscopic retrograde pancreatography. Given its associated potential morbidity, pursuing biliary imaging should be a consideration.
Pulmonary cement embolization (PCE) is a recognized, often asymptomatic complication of percutaneous vertebroplasty (PVP), a procedure commonly used to stabilize vertebral compression fractures. Here, we report the case of a 58-year-old male who, after vertebroplasty for multiple acute thoracic and lumbar fractures, exhibited segmental, peripheral PCE on postoperative imaging. Despite cement leakage into the pulmonary vasculature, the patient remained asymptomatic, stable, and was discharged following brief observation. A review of the literature reveals varied management approaches for asymptomatic PCE, from conservative monitoring to anticoagulation therapy, with outcomes generally favorable regardless of intervention. Our case supports the safety of conservative management in asymptomatic PCE, highlighting the need for standardized guidelines to aid clinical decision-making. Early detection through postoperative imaging, combined with tailored patient management, may improve outcomes while minimizing unnecessary interventions for asymptomatic PCE. Emergency physicians should be aware of PCE as a potential postoperative complication of vertebroplasty, even in asymptomatic patients, to ensure timely recognition, appropriate monitoring, and avoid unnecessary interventions.
Cardiac lipomas are rare benign tumors, comprising ~8.4% of all benign primary cardiac tumors. They can arise in various cardiac chambers, though right ventricular (RV) involvement is uncommon. While most cardiac lipomas are asymptomatic and detected incidentally, those originating in the RV may present with unusual features, including pseudoaneurysmal appearances. Such anomalous structural changes can increase right atrial and ventricular pressures, placing the patient at risk of progressive hemodynamic compromise and rupture. We report a case of an RV lipoma initially diagnosed as a pseudoaneurysm that was successfully resected. An 81-year-old man with an incidentally detected RV mass was admitted to our hospital. Contrast-enhanced computed tomography (CT) showed that the mass contained a large amount of fatty tissue with a pseudoaneurysmal appearance, suggesting it to be an RV lipoma. Transthoracic echocardiography revealed to-and-fro blood flow between the RV and the aneurysm through the slits. Although the patient was asymptomatic, considering that the right atrial pressure and RV end-diastolic pressure (RVEDP) were 12 and 25 mmHg, respectively, based on right heart catheterization, we decided to perform surgical resection to avoid the risk of future enlargement or rupture. A fat-covered mass was found in the anterior aspect of the RV and resected. The residual RV and slits were closed using a patch. The patient had a good postoperative course with normalized right heart pressure and was discharged on the postoperative day 14. While the indications for surgery in asymptomatic patients remain unclear due to the rarity of this condition, these findings suggest that early surgical intervention may be considered in cases presenting with structural compromise and elevated right-sided pressures.
Juvenile polyposis syndrome (JPS) is an inherited autosomal dominant disease that is distinguished by the emergence of numerous juvenile polyps within the gastrointestinal (GI) tract and has an increased risk of cancer. JPS is associated with germline mutations of the BMPR1A or SMAD4 genes. We aim to describe a case of familial occurrence of the SMAD4 germline pathogenic variant c.403C>T in a Brazilian family. We present a case of an 18-year-old female with rectal bleeding and chronic anemia who had a family history of colorectal issues-her mother had a total colectomy due to multiple polyps, and her maternal grandfather died from colorectal cancer (CRC). Despite a negative physical examination for attenuated familial adenomatous polyposis (AFAP) signs, a colonoscopy revealed around 30 proximal colon polyps of juvenile nature. These were systematically removed through multiple sessions, and an upper digestive endoscopy uncovered a few sessile inflammatory polyps. Notably, no polyps were found in the small intestine via double-balloon enteroscopy. After polyp removal, her bleeding episodes ceased, and her anemia resolved. She now maintains her health through biennial colonoscopies, upper digestive endoscopies, and endoscopic capsule procedures. Genetic testing identified a pathogenic mutation in exon 3 of the SMAD4 gene (c.403C>T), resulting in a truncated SMAD4 protein (p.Arg135 ∗). While previously documented in international databases, this represents the first report of a Brazilian family carrying this variant. Additionally, no mutations were found in the BMPR1A gene during genetic testing. In conclusion, molecular analysis confirmed the familial occurrence of the SMAD4 germline pathogenic variant c.403C>T within this Brazilian family.
Mid-aortic syndrome (MAS) is a rare condition marked by narrowing of the thoraco-abdominal aorta, often causing severe hypertension. We present a 17-year-old male with refractory hypertension due to high-grade aortic coarctation at the viscero-renal segment. After failed endovascular interventions, open thoracoabdominal aortic repair was performed. The celiac trunk, superior mesenteric artery (SMA), and right renal artery were initially implanted into the tubegraft as a patch, but limited blood flow required revision including separate bypasses for the visceral arteries and both renal arteries. The patient was discharged with normalized blood pressure. Histopathology revealed adventitial necrosis, smooth muscle disorganization, and severe intimal thickening, suggesting intimal hyperplasia and fibrosis reduced blood flow. Separate bypasses might have been more effective than a patch for long-term patency. At a 4-year follow-up, the patient remains stable, though the right renal bypass is occluded. This case report provides unique insights into the histopathological features of MAS and their potential impact on surgical decision-making, contributing to our understanding of this rare condition.
Wireless capsule endoscopy (WCE) uses an electronic small bowel capsule to transmit images of the small bowel to diagnose pathology. In patients at risk for capsule retention, the patency capsule, a radiopaque dissolvable capsule of the same size, may be used to predict that the small bowel capsule will pass through the patient. An abdominal radiograph or scanner is used to confirm passage of the patency capsule, predicting future passage with the small bowel capsule. If the patency capsule is retained in the small bowel, it will dissolve over time, relieving a potential obstruction. Patency capsules have been noted to be highly sensitive for detecting potential obstructing lesions and have a high negative predictive value for small bowel capsule retention. However, we describe a case and management of small bowel capsule retention occurring in a patient with a remote history of bowel resection for intussusception and normal small bowel demonstrated on CT enterography and a normal patency capsule examination.
An 83-year-old man was admitted to the emergency department of our hospital with a chief complaint of melena. A computed tomography revealed a hypervascular tumor approximately 3 cm in size near the duodenojejunal flexure. On diagnosis of bleeding from the gastrointestinal stromal tumor (GST), emergency surgery was performed. At laparotomy, a whitish tumor measuring approximately 3 cm in diameter was identified on the serosal surface along the mesenteric border of the duodenojejunal flexure. Considering the need for secure hemostasis, a segmental duodenectomy including resection of the feeding vessels to the affected bowel segment was performed. For reconstruction, considering that anastomosis posterior to the superior mesenteric artery (SMA) was avoided and instead performed primary closure of the duodenal stump. To provide duodenal drainage, a Roux-en-Y jejunal limb was constructed and anastomosed to the 2nd part of the duodenum. Additionally, a gastrojejunostomy in the Billroth II configuration was performed. The patient was discharged on postoperative day 15, with no complications.
Urachal cysts are rare congenital anomalies in adults and are often identified incidentally during imaging studies or surgery because most remain asymptomatic. They represent the most frequent subtype of urachal anomaly. The simultaneous occurrence of acute appendicitis and a urachal cyst is exceptionally rare, with only a handful of cases reported in the literature. We describe the case of a 49-year-old man with a history of heart failure and substance use who presented with acute abdominal pain. Computed tomography (CT) demonstrated acute appendicitis and incidentally revealed a large cystic lesion adherent to the bladder dome, suggestive of a urachal cyst. Exploratory laparotomy confirmed suppurative appendicitis and a noncommunicating urachal cyst measuring 11 × 10 × 8 cm. Complete cyst excision and appendectomy were performed during the same procedure. Histopathological examination confirmed benign urachal tissue lined by transitional epithelium without dysplastic changes, together with transmural acute appendicitis. The postoperative course was uneventful, and the patient was discharged on the third postoperative day. This case emphasizes that urachal anomalies may be encountered as incidental findings during the evaluation of acute abdomen. Although infection is the most common clinical manifestation, urachal cysts may also be identified unexpectedly during surgery for unrelated conditions. Complete surgical excision provides definitive treatment while reducing the risk of recurrence and potential malignant transformation.
Postoperative knee squeaking is a rare phenomenon in native knees, with prior reports limited to ligament reconstructions. This case-based report describes the first documented instances of transient knee squeaking following arthroscopic meniscal repair. We present two cases of male patients who developed audible squeaking within 1 month postoperatively using the Meniscal Cinch II (MCII) Implant Delivery System (Arthrex). Both cases demonstrated squeaking between 60° and 120° of knee motion without swelling or mechanical symptoms. Magnetic resonance imaging (MRI) findings did not reveal displaced sutures or loose bodies. Symptoms resolved spontaneously within 8 weeks without intervention. A literature review shows that previously reported cases of postoperative knee squeaking typically required arthroscopic suture removal due to intra-articular migration. Our findings suggest that in select cases, knee squeaking may be benign and self-limiting, supporting a conservative approach. Further studies are warranted to explore the etiology and guide management strategies for this unusual postoperative symptom.
Severe iliofemoral calcification can compromise emergency endovascular control of access-site bleeding by preventing full covered-stent expansion at the landing zone. A 78-year-old man developed hemodynamic instability, right-flank pain, and severe anemia 6 h after ultrasound-guided right transfemoral primary percutaneous coronary intervention for anterior ST-segment elevation myocardial infarction. Contrast-enhanced computed tomography demonstrated a large right retroperitoneal hematoma with active extravasation from the distal external iliac artery, immediately proximal to a bulky calcified plaque involving the proximal common femoral artery (CFA). Through ultrasound-guided contralateral femoral access, an 8 mm × 60 mm self-expanding covered stent achieved immediate sealing of the external iliac artery injury but remained markedly underexpanded distally at the calcified CFA landing zone. Conventional 8-mm balloon post-dilation was attempted, but residual underexpansion persisted; further high-pressure dilation was avoided because of concern for rupture or perforation of the calcified iliofemoral segment and loss of the newly achieved seal. Bailout intravascular lithotripsy (IVL) with an 8 mm × 60 mm balloon consisted of 150 pulses delivered at 4 atm in repeated sequences, each followed by nominal-pressure post-dilation of the same balloon at 6 atm. Final angiography showed improved covered-stent expansion with approximately 30% residual stenosis and no recurrent extravasation, dissection, perforation, or distal embolization. The patient was discharged on postoperative day 8. At 12-month follow-up, duplex ultrasound confirmed covered-stent patency without edge stenosis, pseudoaneurysm, or hemodynamically significant restenosis. This case illustrates that IVL may provide a low-pressure bailout option for calcium-mediated peripheral covered-stent underexpansion during emergency vascular access-site repair; however, this off-label use requires careful device sizing, attention to covered-stent integrity, and structured imaging surveillance.
A 63-year-old man received a robotic left lateral sectionectomy for a 2 cm solitary segment (seg) 2/3 hepatocellular carcinoma (HCC). Pathology revealed clear margins without vascular invasion. Three years later patient received transarterial chemo-embolization (TACE) for suspected intrahepatic recurrence. However, follow-up computed tomography (CT) revealed solitary peritoneal metastasis which increased to 8 cm at splenic hilum despite targeted therapy and immunotherapy was given, thus a robotic excision of the peritoneal metastasis with splenectomy was performed. CT at 3 months after surgery revealed solely new intrahepatic recurrences at segs 6 and 7. A total of four TACE were given subsequently. Laparoscopic seg 6/7 wedge liver resection was performed for residual disease. Two further small recurrences occurred at seg 7 at 2 years after surgery; stereotactic body radiotherapy (SBRT) was given. Ultimately, the patient was disease-free and enjoyed good quality of life for more than 10 years since the initial operation despite episodes of extrahepatic and intrahepatic recurrences. Thus, a multidisciplinary approach for HCC management is important to optimize treatment outcomes. Long-term cure is possible with multimodality treatment for recurrent HCC, and the use of minimally invasive surgery can enhance patient's quality of life.
Background Testicular tuberculosis is a rare form of extrapulmonary tuberculosis (EPTB). Due to the nonspecific nature of its clinical manifestations and imaging features, it is often misdiagnosed as a malignant testicular tumor, leading to unnecessary radical orchiectomy. Accurate preoperative diagnosis is essential for organ preservation and appropriate antituberculous therapy. Case A 59‑year‑old male patient was admitted with a 4‑day history of left testicular enlargement. Pre‑admission ultrasonography suggested “a solid mass in the left testicle, suspected seminoma.” Physical examination revealed enlargement of the left testicle with moderate consistency. Scrotal ultrasound, contrast‑enhanced ultrasound, and enhanced CT all supported the diagnosis of testicular malignancy. The patient underwent left radical orchiectomy. However, postoperative pathology revealed extensive acute and chronic inflammatory cell infiltration, caseous necrosis, and granulomatous inflammation within the testicular tissue, consistent with tuberculous pathology. The final pathological diagnosis was “left testicular tuberculosis.” Conclusion Testicular tuberculosis is an important differential diagnosis for testicular tumors. Despite advances in modern imaging techniques, atypical presentation remains highly prone to misdiagnosis. Clinicians should maintain a high index of suspicion for testicular tuberculosis in patients with atypical clinical and imaging findings of testicular masses. When feasible, obtaining tissue samples for histopathological and molecular examination preoperatively or intraoperatively may be crucial in avoiding unnecessary orchiectomy and achieving organ preservation.
Chest impalement is a rare type of injury resulting from penetration by a large foreign object that remains in the body. Each case of chest impalement is unique, and the outcome largely depends on the trajectory of the foreign object. Here we present the case of a 48-year-old male who accidentally fell from the rooftop of his house (from a height of several meters), onto a scaffolding tube, which penetrated through the 10th left posterior intercostal space into his chest. Upon transport of the patient to the trauma center, computed tomography (CT) surprisingly revealed no significant damage to the internal organs. The foreign body was successfully removed by left posterolateral thoracotomy, and the postoperative course was uneventful. A good outcome following a chest injury requires timely transport to the trauma center, and multidisciplinary management by an experienced team. In the presented case, the foreign object’s trajectory did not cause damage to the internal organs, which was also an important factor contributing to the good outcome.
Background:Posterior rectus sheath hernia is an exceptionally rare interparietal abdominal wall hernia in which abdominal contents herniate through the posterior rectus sheath into the retrorectus space while the anterior rectus sheath remains intact. Clinical diagnosis may be difficult because the hernia remains confined within the abdominal wall, and delayed recognition may result in bowel strangulation. We report a rare case of spontaneous posterior rectus sheath hernia complicated by bowel necrosis requiring staged operative management. Case Presentation:A 73-year-old woman with no history of previous abdominal surgery presented with a 48-h history of progressively worsening epigastric abdominal pain, nausea, and emesis. Computed tomography demonstrated a narrow-neck posterior rectus sheath hernia containing incarcerated small bowel with decreased bowel wall enhancement, proximal small bowel dilatation, and findings concerning for strangulation. Emergency exploratory laparotomy confirmed an approximately 1-cm posterior rectus sheath defect with incarcerated mid-jejunum within the retrorectus space. Following reduction, a 10-cm segment of necrotic jejunum with pinpoint perforation required resection. Because adjacent bowel viability remained uncertain, temporary abdominal closure with negative-pressure therapy was performed followed by a planned second-look laparotomy 24 h later. Re-exploration demonstrated complete recovery of the remaining bowel, allowing stapled side-to-side functional end-to-end small bowel anastomosis and primary repair of the posterior rectus sheath without mesh because of contamination. The patient experienced an uncomplicated postoperative recovery, was discharged home on postoperative day five, and remained free of recurrent posterior rectus sheath hernia or incisional hernia at 1-month clinical follow-up and 1-year computed tomography surveillance. Conclusion:Posterior rectus sheath hernia should be considered in patients presenting with small bowel obstruction and an interparietal abdominal wall defect on computed tomography, even in the absence of previous abdominal surgery. Careful recognition of the characteristic retrorectus anatomy and prompt operative intervention are essential when strangulation is suspected. This case demonstrates successful staged management with bowel resection, planned second-look laparotomy, and durable primary repair with no recurrence at 1 year.
Papillary thyroid carcinoma (PTC) usually has an intrathyroidal primary lesion and a good prognosis. In rare cases, however, individuals may also present with metastatic disease in the absence of a palpable thyroid primary, so-called occult PTC. Such cases are often difficult to diagnose and manage, especially when serial monitoring of serum thyroglobulin (Tg) levels and imaging studies demonstrate the opposite. We report the case of a 56-year-old woman who underwent total thyroidectomy for suspected multinodular goiter in 2019. The results of a histological examination revealed no intrathyroidal tumor in 78 blocks, but one central node was found to be positive for metastatic PTC. Follow-up examination proved that Tg had increased even though the results from U/S, PET/CT, and I-123 WB scans were always negative. Laboratory studies suggested potential heterophile antibody interference, but a fine needle aspiration (FNA) of a cervical node in 2023 and 2024 reported recurrence of metastatic PTC. She underwent left selective lateral neck dissection (levels II-V) with central compartment (level VI) exploration in January 2025, and a number of metastatic nodes without extranodal extension were found. Tg levels were undetectable throughout follow-up with no evidence of residual disease on US postoperatively. The patient remains well on long-term follow-up. We present a rare case of metastatic PTC with no identifiable thyroid primary, which is combined with the diagnostic difficulties of Tg assay interference and limitations of imaging in the follow-up setting. It highlights the importance of multimodal surveillance (including cytology, imaging, and biochemical testing) to ensure true recurrences are accurately detected, often many years after apparently curative surgery.
Midgut malrotation (MM) is a rare congenital abnormality that is usually diagnosed early in life during the neonatal period or the first year of life. In some rare cases, the patient may remain asymptomatic or with only mild nonspecific symptoms that delay the diagnosis until late adulthood. These nonspecific gastrointestinal symptoms can culminate in an adhesive bowel obstruction or volvulus making the presentation a surgical emergency. In our case, we present a 73-year-old male with nonspecific symptoms that led to the diagnosis of adhesive obstruction of the duodenum from Ladd bands due to undiagnosed MM. A laparotomy with Ladd’s procedure was performed.
Entero-articular fistulas are rare but serious complications following total hip arthroplasty (THA), often associated with prior abdominal or pelvic surgery, radiation therapy, or chronic steroid use. We report a case of a 65-year-old woman with metastatic ovarian cancer previously treated with pelvic exenteration and heated intra-peritoneal chemotherapy (HIPEC), who developed an entero-articular fistula following THA for avascular necrosis (AVN). Post-operatively, she presented with systemic signs of infection and polymicrobial joint cultures containing enteric organisms, raising suspicion for bowel communication. Imaging revealed gas tracking from the pelvis to the hip joint, and subsequent surgery confirmed a fistulous connection with the small bowel adherent to the pelvic wall and protrusion of the allograft into the bowel. Management involved bowel resection, mesh placement, multiple joint washouts and prolonged antimicrobial therapy. This case highlights the diagnostic challenges of entero-articular fistulas, particularly in patients with complex surgical histories and underscores the importance of a multidisciplinary approach for effective diagnosis and management.
Background:Aplasia cutis congenita (ACC) is a rare congenital disorder characterized by localized absence of skin, most frequently involving the scalp. In severe cases, the defect may extend to the skull and dura mater, exposing intracranial structures and increasing the risk of infection, hemorrhage, and venous sinus injury. Although early surgical reconstruction with duraplasty and scalp flap coverage is often successful, delayed complications such as cystic hydrocephalus may develop months after surgery. Extensive ACC with both cranial and dural defects remains exceedingly rare, and optimal management strategies are not well established. Case Presentation:We report a full-term female newborn with a large midline parietal scalp defect measuring 7 cm × 6 cm, associated with absence of the underlying calvarium and dural aplasia. The lesion was covered by a thin membranous tissue with visible brain pulsation and exposure of the superior sagittal sinus (SSS). Initial management included sterile dressings and broad-spectrum antibiotics. On day 8 of life, surgical reconstruction was performed using synthetic duraplasty followed by rotational scalp flap closure. Postoperative recovery was uneventful, and the wound healed satisfactorily. At 6 months postoperatively, the patient developed cystic hydrocephalus, which was managed with ventriculoperitoneal shunt placement. At 24-month follow-up, the patient achieved normal developmental milestones with a good cosmetic outcome. Conclusion:Extensive ACC involving the skull and dura mater represents a severe and potentially life-threatening variant of the disease. Early multidisciplinary management with synthetic duraplasty and scalp flap reconstruction can provide effective protection of intracranial structures and yield favorable long-term outcomes. Nevertheless, long-term follow-up is essential, as delayed complications such as cystic hydrocephalus may arise months after initial surgical repair.
Case:A 23-month-old girl with Morquio A syndrome (mucopolysaccharidosis IVA [MPS IVA]) scheduled for atlantoaxial stabilization surgery sustained a cervical spinal cord injury with tetraplegic symptoms following a low-energy fall. Computed tomography (CT) images showed forward translation of C1 over C2 and magnetic resonance imaging (MRI) revealed upper cervical spinal cord injury. An urgent decompression and spinal fusion from C0 to C2 were performed. Postoperative recovery showed significant neurological improvement and at 1-year follow-up, the patient was symptom-free. Conclusion:This case highlights the risk of severe cervical spinal cord injury following minor trauma in patients with MPS IVA-associated cervical instability and demonstrates the potential for neurological recovery after prompt surgical decompression and stabilization.
Velopharyngeal stenosis is a rare condition characterized by partial or complete obliteration of the velopharyngeal port and may present with snoring, obstructive sleep symptoms, and speech abnormalities, typically following oropharyngeal surgery. We report the case of a 6-year-old boy who developed persistent diurnal and nocturnal snoring accompanied by recurrent coughing 4 months after adenotonsillectomy. Endoscopic evaluation revealed significant stenosis of the velopharyngeal port. The patient initially underwent surgical release and dilation of the stenotic segment, resulting in temporary symptom improvement; however, symptoms recurred 2 months later due to restenosis. A second surgical intervention was performed with placement of a stent across the stenotic segment to maintain patency during healing. Following stent placement, the patient experienced complete resolution of symptoms, and no further recurrence was observed during follow-up. This case highlights velopharyngeal stenosis as a rare but clinically significant complication of adenotonsillectomy in children and underscores the challenges associated with its management because of the risk of recurrence. It also demonstrates the potential role of stenting as an adjunctive measure to prevent restenosis and achieve sustained symptom resolution. Awareness of this complication and meticulous surgical technique during oropharyngeal procedures may help reduce its occurrence and improve patient outcomes.
