Asian Journal of Case Reports in Surgery

Surgical Management of an Extensive Axillary Cystic Hygroma in a 4 Day Old Neonate: A Case Report

Amit Agarwal — 2026-06-02

Cystic hygroma is a benign developmental malformation of the lymphatic system resulting from a lack of communication between the lymphatic and venous systems. Most common site of occurrence of a cystic hygroma is the neck (about 75%) followed by the axilla (20%) and about 1% in the mediastinum, groin and retroperitoneum. Small, simple cystic hygromas can be managed conservatively, whereas massive, complex cystic hygromas most often need surgical intervention. Patient-specific multidisciplinary approach, involving obstetrician, radiologist, paediatrician, paediatric surgeon (where available) and plastic surgeon, is advised in cases where extensive cystic hygromas are diagnosed pre-natally. Here we have a case of a neonate born with an extensive cystic hygroma in the left axillary region extending medially onto the chest wall upto the 8th rib and laterally till elbow that was managed via careful planning and surgical excision, while safeguarding the underlying muscular and neurovascular structures, followed by reconstruction.

Mcswain Type V Appendiceal Intussusception as a Lead Point in Infantile Ileocolic Intussusception: A Rare Case Report

Sukrit Singh Shah — 2026-05-28

Both appendicitis and intussusception can have similar presentations which can pose diagnostic and therapeutic challenges. Appendiceal intussusception is a rare condition, particularly in infants, and may serve as a pathological lead point for ileocolic intussusception. While most early intussusceptions can be managed by non-surgical reductions, these appendiceal intussusceptions stand out as exceptions. Of the available literature, the youngest cases reported has been in 4-year old child and above. We report a 5-month-old male presenting with abdominal pain, red currant jelly stools, and a palpable abdominal mass. Imaging suggested ileo-colic intussusception, and surgical exploration revealed a markedly elongated appendix (~10 cm) acting as the lead point. Appendectomy with vice versa reduction of intussusception was performed successfully. This case highlights the importance of considering rare lead points in atypical presentations of intussusception in infancy.

Single-Incision Gasless Laparoscopic Management of Non-Parasitic Splenic Cyst: A Case Report

Pradeep Singh — 2026-06-01

Background: Non-parasitic splenic cysts are rare benign lesions that pose diagnostic and therapeutic challenges because of their varied etiology and clinical presentation. Recent advances in minimally invasive surgery, particularly single-incision gasless laparoscopy, have provided safer and cosmetically superior alternatives for spleen-preserving management. Splenic cysts possess an epithelial lining and often result from parasitic infection, whereas secondary splenic cysts (pseudocysts) lack an epithelial lining and typically arise secondary to trauma, infarction, or infection.

Aims: To describe the successful application of single-incision gasless laparoscopic fenestration for the management of a large non-parasitic splenic cyst in a young female patient, and to review the operative technique and clinical outcomes of this spleen-preserving minimally invasive approach.

Presentation of Case: A 19-year-old female presented with a two-month history of left upper abdominal discomfort. Imaging revealed an 8 × 8 cm cystic lesion at the superior pole of the spleen. Hydatid serology was negative, confirming a non-parasitic splenic cyst. Spleen-preserving laparoscopic fenestration via a single infraumbilical incision using a gasless technique was performed. Approximately 500 ml of serous fluid was aspirated and the anterior cyst wall was excised using a Ligasure device. The postoperative course was uneventful and the patient was discharged on the third postoperative day. Histopathology confirmed a splenic pseudocyst. At one-year follow-up, the patient was asymptomatic with no recurrence.

Discussion: Non-parasitic splenic pseudocysts are uncommon benign lesions increasingly managed with minimally invasive, spleen-preserving techniques. Single-incision gasless laparoscopic fenestration combines the cosmetic advantages of reduced port surgery with the physiological benefits of avoiding pneumoperitoneum-related hemodynamic and respiratory disturbances. This approach is particularly suited to superficially located cysts.

Conclusion: Single-incision gasless laparoscopic fenestration is a safe, effective, and cosmetically favorable approach for appropriately selected patients with non-parasitic splenic cysts. Careful patient selection, precise surgical technique, and diligent postoperative surveillance are essential to achieving optimal outcomes. This case report highlights significance of cosmetic minimally invasive spleen preserving approach for management of splenic cysts in a young female.

Enterobius Vermicularis: A Rare Presentation as Acute Appendicitis

Swaraj Sambit Samal — 2026-06-01

Enterobius vermicularis (pinworm) is a common intestinal helminth infection worldwide, particularly in developing regions. Although typically associated with mild gastrointestinal symptoms, its role in acute appendicitis remains controversial, with reports suggesting it may mimic or contribute to appendiceal inflammation.

We report the case of an 18-year-old female who presented with persistent lower abdominal pain, nausea, and anorexia. Clinical findings raised suspicion of acute appendicitis; however, ultrasonography was unremarkable and did not reveal definitive features of appendiceal inflammation. Despite negative imaging results, persistent symptoms necessitated surgical intervention.

Diagnostic laparoscopy and appendectomy were performed. Intraoperatively, the appendix was found to be inflamed and dilated, and a live E. vermicularis worm was observed emerging from the appendiceal lumen following transection, confirming appendiceal enterobiasis. Histopathology showed nonspecific chronic inflammatory changes. The patient received postoperative anti-helminthic therapy with albendazole and had an uneventful recovery with complete symptom resolution.

This case highlights the diagnostic challenge of parasitic appendiceal disease, particularly when routine laboratory and imaging findings are inconclusive. It underscores the importance of considering helminthic infection in patients with atypical presentations of suspected appendicitis, especially in endemic and resource-limited settings.

Uncommon Isolated Unilocular Splenic Hydatid Cyst: A Case Report

Md. Mahamud Khan — 2026-06-02

Background: Hydatid disease is a parasitic infection commonly affecting the liver and lungs, while isolated splenic involvement is rare. Unilocular splenic hydatid cysts are uncommon and often present with nonspecific clinical symptoms, making diagnosis challenging.

Aims: To report a rare case of isolated unilocular splenic hydatid disease and to demonstrate the safety, feasibility, and clinical outcomes of a minimally invasive, spleen-preserving laparoscopic approach, including operative technique and perioperative management.

Presentation of Case: A 29-year-old male presented with a one-year history of dull, intermittent left hypochondrial pain. Imaging revealed a 5 × 4 cm unilocular cystic lesion at the superior pole of the spleen with internal septations and daughter cysts, classified as Gharbi Type II (WHO CE3b). Despite negative IgG serology, imaging characteristics were strongly suggestive of splenic hydatid disease. Following five days of preoperative albendazole therapy, laparoscopic spleen-preserving partial peri-cystectomy was performed using hypertonic saline as a scolicidal agent. Blood loss was minimal, and the postoperative course was uneventful. Histopathology confirmed an acellular laminated membrane with brood capsules and hydatid sand. At 12-month follow-up, the patient was asymptomatic with no evidence of recurrence.

Discussion: Isolated splenic hydatid disease accounts for less than 2% of all hydatid cases. Diagnosis relies on a combination of imaging and serology, though serological tests may be negative in up to 40% of splenic cases. Laparoscopic partial peri-cystectomy, combined with perioperative albendazole and meticulous intraoperative technique to prevent spillage, offers outcomes comparable to open surgery while preserving splenic immunological function.

Conclusion: Splenic hydatid disease warrants a high index of clinical suspicion, particularly in endemic regions. Laparoscopic management represents a safe and effective minimally invasive option, offering the dual advantages of spleen preservation and reduced postoperative morbidity when performed with meticulous technique and appropriate perioperative medical therapy.

Gastric Necrosis: An Unexpected Complication of Transarterial Embolization in a Critically Ill Poly Trauma Patient

Sai Trinadh — 2026-06-04

Transarterial embolization (TAE) is an effective minimally invasive procedure used for the management of gastrointestinal bleeding in hemodynamically unstable patients. Although the procedure has a high technical success rate, ischemic complications such as gastric necrosis are extremely uncommon because of the rich vascular supply of the stomach. We report a rare case of gastric necrosis following TAE for a pseudoaneurysm of the right gastroepiploic artery in a 22-year-old polytrauma patient. The patient sustained multiple traumatic injuries following a fall from a train and subsequently developed hemorrhagic shock, disseminated intravascular coagulation (DIC), septic shock, and multiorgan dysfunction requiring extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT). Despite successful embolization with coils, the patient developed progressive gastric ischemia and necrosis requiring emergency total gastrectomy with Roux-en-Y esophagojejunostomy. The patient gradually recovered and was discharged on follow-up. This case highlights the importance of considering ischemic complications after TAE in critically ill trauma patients with severe coagulopathy, vasopressor dependence, and prolonged hypoperfusion. Early recognition and timely surgical intervention are essential for improving patient outcomes.

Recurrent Refractory Iliopsoas Abscess Requiring Definitive Open Surgical Drainage with Adjunctive Marsupialization: A Case Report

Faiz Nazri — 2026-06-06

Background: Iliopsoas abscess (IPA) is an uncommon yet potentially life-threatening retroperitoneal suppurative infection associated with significant morbidity and mortality, particularly among immunocompromised individuals. Clinical manifestations are frequently nonspecific, often resulting in delayed diagnosis and progression to systemic sepsis. Although broad-spectrum antimicrobial therapy combined with image-guided percutaneous drainage remains the cornerstone of treatment, recurrent or refractory disease may necessitate definitive surgical intervention.

Case Presentation: We report the case of a 59-year-old female with poorly controlled diabetes mellitus and neurogenic bladder who presented with persistent pyrexia, right lumbar pain, and urinary tract infection. Initial radiological assessment demonstrated bilateral pyelitis, for which prolonged antimicrobial therapy was instituted. Despite extended intravenous antibiotic treatment and multiple image-guided percutaneous drainage procedures, the patient subsequently developed a persistent multiloculated left iliopsoas abscess with repeated recurrence. Serial computed tomography (CT) imaging demonstrated incomplete radiological resolution and progressive extension into the iliacus musculature. Owing to failure of conservative and minimally invasive management, the patient ultimately underwent definitive open surgical drainage with adjunctive marsupialization for durable source control and facilitation of postoperative cavity management.

Discussion: This case underscores the therapeutic challenges posed by recurrent iliopsoas abscesses in immunocompromised hosts. Although percutaneous drainage is generally associated with high success rates, refractory disease may persist in the presence of multiloculated collections, chronic inflammatory cavities, or impaired host immunity. Open surgical drainage provides direct access for complete evacuation of purulent material and disruption of loculations. Adjunctive marsupialization, a technique more traditionally employed in the management of Bartholin gland pathology, may provide additional benefit through sustained drainage, enhanced postoperative wound surveillance, and reduction of recurrent cavity formation.

Conclusion: Failure of prolonged antimicrobial therapy and repeated percutaneous drainage in iliopsoas abscess should prompt early consideration of definitive operative management. Adjunctive marsupialization may represent a valuable yet underreported surgical adjunct in the management of complex recurrent iliopsoas abscesses.

Incidental Solid Pseudopapillary Neoplasm of the Pancreas in a Young Female: Case Report and Literature Review

Chaymaa Khyat — 2026-06-08

Introduction: Solid pseudopapillary neoplasm (SPN) of the pancreas is a rare epithelial tumor with low malignant potential, predominantly affecting young women, and is often discovered incidentally.

Presentation of Case: We report the case of a 21-year-old female with no significant medical history who presented with one-month secondary amenorrhea. An abdominal ultrasound revealed an incidental pancreatic mass. Contrast-enhanced computed tomography and magnetic resonance imaging demonstrated a well-circumscribed lesion in the pancreatic body, without vascular invasion or metastatic spread. Endoscopic ultrasound-guided biopsy revealed solid and pseudopapillary architecture, and immunohistochemistry confirmed SPN. After multidisciplinary discussion, the patient underwent central pancreatectomy. Histopathological examination confirmed SPN staged pT2 Nx. The postoperative course was uneventful.

Conclusion: SPN should be considered in the differential diagnosis of pancreatic lesions in young women, even when incidentally discovered. In general, complete surgical resection, including parenchyma-sparing procedures such as central pancreatectomy, is associated with excellent long-term outcomes and prognosis in the vast majority of cases.

Laparoscopic Deroofing with Omentoplasty for Splenic Epidermoid Cyst: A Case Report

Mihir Dungrani — 2026-06-09

Background: Splenic cysts are benign lesions which can be revealed by pain or a palpable mass, or present as complications: cyst rupture, intracystic haemorrhage or cyst infection.

Aim: The study aims to report a rare case of a large splenic epidermoid cyst successfully managed by laparoscopic deroofing combined with omentoplasty, highlighting a safe, organ-preserving surgical approach.

Presentation of Case: A 31-year-old female presented with a two-month history of intermittent dull aching pain in the left upper quadrant. Contrast-enhanced CT revealed a large (12.5 × 7 × 8 cm) septated cystic lesion at the upper pole of the spleen. Hydatid serology was negative. She underwent laparoscopic deroofing with omentoplasty without complications and was discharged on postoperative day five. Histopathology confirmed a splenic epidermoid cyst lined by stratified squamous epithelium.

Discussion: Splenic epidermoid cysts are rare congenital benign lesions with a predilection for young women. Laparoscopic deroofing with omentoplasty is a technically feasible, spleen-preserving strategy associated with low morbidity, rapid recovery, and low recurrence rates.

Conclusion: Laparoscopic deroofing with omentoplasty is a safe, effective, minimally invasive treatment for large symptomatic splenic epidermoid cysts. Post-operative surveillance imaging is recommended to detect any recurrence.

Surgical Management of a Giant Retroperitoneal Liposarcoma Presenting with Progressive Abdominal Distension: A Case Report

Amine Maazouz — 2026-06-09

Background: Retroperitoneal liposarcoma is a rare malignant soft-tissue tumour of mesenchymal origin that often remains clinically silent until it attains a considerable size. Owing to its deep anatomical location and nonspecific presentation, diagnosis is frequently delayed, making surgical management challenging.

Case Presentation: A 50-year-old man with a history of hiatal hernia surgery presented with progressive abdominal distension over six months, associated with compressive symptoms and a weight loss of 7 kg. Physical examination revealed a massive abdominal mass. Ultrasonography demonstrated a large heterogeneous retroperitoneal lesion compressing adjacent abdominal organs. Contrast-enhanced computed tomography identified a giant retroperitoneal fatty mass measuring 36 × 20 × 27 cm, displacing neighbouring viscera without evidence of distant disease. Laboratory investigations, including tumour markers, were within normal limits. Owing to concerns regarding tumour dissemination, preoperative biopsy was not performed. The patient underwent complete en bloc surgical excision of the tumour through a midline laparotomy. Histopathological examination confirmed the diagnosis of sclerosing liposarcoma. The postoperative course was uneventful, and the patient was placed on regular radiological surveillance.

Conclusion: Giant retroperitoneal liposarcomas are uncommon tumours that may reach enormous dimensions before diagnosis. Cross-sectional imaging plays a pivotal role in preoperative assessment, whereas complete surgical resection remains the cornerstone of treatment and offers the best chance for local disease control. Long-term follow-up is essential because of the high risk of local recurrence.

Transoral Migration of a Ventriculoperitoneal Shunt (VPS) Catheter in a Six-Month-Old Boy: A Case Report

Mahamat Mahamat Saleh — 2026-06-12

Introduction: Ventriculoperitoneal Shunt (VPS) is the gold standard for the treatment of hydrocephalus. Gastrointestinal perforation is rare, and perforation above the angle of Treitz is exceptional. We report a rare case of a VPS catheter externalized through the mouth in a six-month-old boy.

Case Presentation: This was a six-month-old patient with a history of spina bifida, for which he underwent surgery on his sixth day of life, followed by a ventriculoperitoneal shunt (VPS) for malformation-related tri-ventricular hydrocephalus on his tenth day of life. The reason for consultation was the protrusion of the VPS catheter through the mouth. The patient was admitted to the operating room for an exploratory procedure, and the end of the catheter protruding from the oral cavity was cut off under sterile conditions. The surgical exploration revealed multiple adherences between the loops. During adhesiolysis, the catheter was accidentally dislodged and ended up in the abdomen. We tried to locate the perforation but were unsuccessful. Conservative treatment was administered. The postoperative course was uneventful, and the patient was discharged on the eighth day.

Conclusion: Exteriorization of the VPS through the mouth is an extremely rare complication. Management requires emergency surgery, involving both a gastrointestinal exploration and verification of the VPS.

A Rare Case of Xanthogranulomatous Cholecystitis: Diagnostic Challenges and Surgical Management

Amine Maazouz — 2026-06-12

Background: Xanthogranulomatous cholecystitis (XGC) is a rare benign chronic inflammatory disease of the gallbladder characterised by destructive inflammation and xanthogranulomatous infiltration. Its clinical, radiological, and intraoperative resemblance to gallbladder carcinoma often creates significant diagnostic and surgical challenges.

Case Presentation: A 63-year-old man with no significant medical history presented with a four-month history of right upper quadrant pain radiating to the right shoulder. Physical examination revealed right upper quadrant tenderness and a positive Murphy’s sign. Ultrasonography demonstrated a multilithiasic gallbladder with thin walls, while laboratory investigations were within normal limits. Laparoscopic exploration revealed a markedly thickened gallbladder with inflammatory changes suggestive of a more aggressive pathology. Cholecystectomy was successfully performed without complications. Histopathological examination confirmed xanthogranulomatous cholecystitis and excluded malignancy.

Discussion: XGC predominantly affects older adults and is frequently associated with gallstones. Despite advances in imaging, distinguishing XGC from gallbladder carcinoma remains difficult due to overlapping clinical and radiological features. Intraoperative findings may appear suspicious for malignancy, potentially leading to extensive surgical procedures. Histopathological evaluation remains the gold standard for definitive diagnosis, while complete cholecystectomy is generally curative and associated with favourable outcomes.

Conclusion: This case highlights the diagnostic complexity of XGC and the crucial role of histopathological examination in establishing an accurate diagnosis. Awareness of this uncommon entity is essential to avoid unnecessary radical surgery and to ensure appropriate surgical management.

Neglected Tibial Fracture with Severe “Saber-Shin” Deformity Revealing Osteogenesis Imperfecta in a 12-Year-Old Girl: A Case Report

Ayoub Boutahar — 2026-06-13

Background: Osteogenesis imperfecta (OI), also known as brittle bone disease, is a rare genetic multisystem disorder of Type I collagen associated with bone fragility, fractures and connective tissue abnormalities, with highly heterogeneous phenotypic features and varying genetic basis. Delayed or neglected fractures in affected individuals may lead to severe deformities and functional impairment.

Case Presentation: We report the case of a 12-year-old female admitted for a significant deformity of the right leg following a neglected tibial diaphyseal fracture sustained eight months prior. Clinical examination revealed short stature and characteristic blue sclerae, suggesting an underlying connective tissue disorder. Radiographic evaluation demonstrated a malunited tibial shaft fracture with severe anterior bowing, producing a characteristic “saber shin” deformity. Management required a multidisciplinary approach, including corrective osteotomies with intramedullary nailing and the initiation of bisphosphonate therapy and rehabilitation.

Discussion: In the present case, delayed orthopaedic management resulted in a malunited tibial fracture with severe anterior bowing, producing the characteristic “saber shin” deformity. The coexistence of this deformity with systemic features such as blue sclerae and short stature strongly suggested an underlying connective tissue disorder, leading to further investigation and confirmation of osteogenesis imperfecta. This case highlights the importance of early recognition of osteogenesis imperfecta in children presenting with atypical fractures or progressive deformities, as prompt diagnosis and appropriate management are essential to prevent severe skeletal complications and improve functional outcomes.

Conclusion: Neglected fractures in children with undiagnosed osteogenesis imperfecta may lead to severe progressive deformities. Early recognition of systemic signs and appropriate orthopaedic management are essential to prevent disabling skeletal complications.

Synchronous Pancreatic Head Well-Differentiated Neuroendocrine Tumor and Left Adrenal Composite Pheochromocytoma: A Rare Case with Successful Pancreaticoduodenectomy and Left Adrenalectomy

Srikanta Kumar Patro — 2026-06-15

Background: Synchronous pancreatic neuroendocrine neoplasms and adrenal tumors represent rare diagnostic and therapeutic challenges.

Case Presentation: This study reports a 39-year-old woman presenting with vague abdominal pain and recurrent vomiting. Imaging (USG, CECT, MRCP) revealed a cystic solid lesion in the pancreatic head and a separate left adrenal mass. Tumor markers (CEA, CA 19-9) were normal. The patient underwent pancreaticoduodenectomy and left adrenalectomy with an uneventful postoperative course. Final histopathology confirmed a well-differentiated Grade 1 neuroendocrine tumor of the pancreatic head and a composite pheochromocytoma of the left adrenal gland. At 3-month follow-up, the patient remained asymptomatic and continued surveillance and endocrine evaluation. ¹⁸F-FDG PET/CECT demonstrated only mild postoperative inflammatory uptake in the surgical beds, with no evidence of residual, recurrent, or metastatic disease, supporting complete oncological resection and favorable early outcome.

Conclusion: This case highlights the importance of multimodal imaging and surgical management in synchronous tumors and suggests consideration of genetic evaluation.

Hepatic and Retrovesical Hydatid Disease: A Rare Case of Multivisceral Hydatidosis

Amine Maazouz — 2026-06-15

Hydatidosis is endemic in Morocco. Although hepatic involvement is common, pelvic and retrovesical localizations are exceptionally rare. This study reports the observation of a patient aged 60 years who has presented for one year with paroxysmal pain in the right hypochondrium and a sensation of heaviness, as well as a notion of pollakiuria. Clinical examination revealed a firm, painless, and well-defined abdominal mass extending from the right hypochondrium to the epigastric region. Abdominal and pelvic CT revealed multiple hydatid cysts in the left liver and a retrovesical cystic mass. The diagnosis of hydatid cyst of the bladder was made intraoperatively. The surgical procedure involved resecting the protruding dome, aspirating the hydatid fluid, removing the daughter vesicles, and thoroughly washing the endocyst. Early recognition and appropriate surgical and medical management are essential to prevent complications and recurrence. Strengthening primary prevention measures, particularly canine control and food hygiene, remains fundamental to reducing the burden of hydatid disease in endemic countries.

Massive Pneumoperitoneum from Barogenic Gastric Injury Complicating Difficult Mask Ventilation: A Case Report

O. Aragon — 2026-06-15

Background: Gastric insufflation during airway management is common, but progression to gastric wall injury with pneumoperitoneum is rare. This report describes a case of massive pneumoperitoneum caused by barogenic gastric injury after difficult mask ventilation during an elective procedure performed under sedation.

Case Presentation: A 55-year-old woman with a history of three previous abdominopelvic operations for uterine leiomyoma underwent direct laryngoscopy under sedation for a left vocal-fold polyp. The procedure was complicated by oxygen desaturation, requiring prolonged bag-mask ventilation and several intubation attempts before the airway was secured. Marked abdominal distension developed and did not resolve after nasogastric aspiration. Thoraco-abdomino-pelvic computed tomography demonstrated a large-volume pneumoperitoneum, and the patient was transferred for emergency surgical management. On arrival, she was haemodynamically stable, with diffuse abdominal distension and tympany. Diagnostic laparoscopy confirmed pneumoperitoneum and revealed three serosal lacerations of the stomach, each approximately 3 cm long. There was no peritoneal effusion, and the colon and small bowel were intact. A methylene-blue leak test was negative, indicating no demonstrable full-thickness gastric leak at the time of surgery. The gastric lacerations were repaired with simple interrupted 2-0 polyglactin sutures. The postoperative course was uneventful, bowel transit resumed by the third postoperative day, and the patient was discharged in good condition on the fourth postoperative day.

Conclusion: Acute abdominal distension after difficult mask ventilation or repeated intubation attempts should prompt suspicion of barogenic gastric injury. Even when intraoperative leak testing is negative, partial-thickness gastric tears may be clinically significant and warrant careful inspection and repair.

Subocclusive Syndrome Revealing a Lithophagia-Type PICA in a 5-Year-Old Child: A Case Report

Mahamat Mahamat Saleh — 2026-06-17

Background: Pica is defined by the persistent ingestion of non-nutritive substances and may lead to gastrointestinal and haematological complications. Lithophagia, the ingestion of stones, is an uncommon form of pica and is rarely reported as a cause of subocclusive syndrome in children. This case report describes a five-year-old child with lithophagia complicated by colonic accumulation of stones, subocclusive symptoms and severe anaemia.

Case Presentation: A five-year-old female child from the Fez-Meknes region of Morocco presented with a three-day history of failure to pass stools, abdominal pain during attempts at defecation and a two-year history of pica with passage of stones in the stool. She had no previous hospitalisation and no reported family history of behavioural or psychiatric disorders. On examination, she was conscious and clinically stable, with pale conjunctivae and mild abdominal distension. The abdomen was soft but firm in some areas and painful on deep palpation. A plain abdominal X-ray showed multiple calcified opacities throughout the colonic region. Laboratory investigations revealed microcytic anaemia with a haemoglobin level of 5.6 g/dL, thrombocytopenia of 33,000 cells/mm³, a white blood cell count of 21,000 cells/mm³ and a C-reactive protein level of 43 mg/L. The diagnosis was subocclusive syndrome in the context of lithophagia-type pica complicated by severe anaemia. Management included dietary measures, rehydration, analgesia, antibiotic therapy, red blood cell transfusion, oral laxatives and repeated manual rectal evacuation under sedation. After three evacuation procedures, the colon was radiologically cleared and bowel movements resumed normally. The patient was discharged after ten days and referred for child psychiatric follow-up.

Conclusion: Lithophagia should be considered in children presenting with constipation, abdominal symptoms and unusual eating behaviour. Early diagnosis and multidisciplinary management may allow successful conservative treatment and avoid surgical intervention.

Finding of Antral Heterotopic Pancreas in a Patient with a History of Laparoscopic Sleeve Gastrectomy: A Case Report and Review of Surgical Implications

Rene M. Gordillo — 2026-06-22

Aims: Heterotopic pancreas (HP) is a rare congenital anomaly in which pancreatic tissue is present without anatomical or vascular continuity with the main gland. This case report describes the incidental identification of an antral HP in a 40-year-old male who had previously undergone laparoscopic sleeve gastrectomy (LSG), and it highlights the surgical implications of recognising this lesion during bariatric assessment.

Presentation of Case: The patient had a history of grade II obesity and underwent LSG 14 months before the current evaluation. During the preoperative work-up, an external oesophagogastroduodenoscopy described a small antral lesion as a simple polyp, and superficial biopsy showed only normal gastric mucosa. At routine 14-month postoperative surveillance, the patient remained asymptomatic, with no abdominal pain, dyspepsia, or gastrointestinal bleeding. Follow-up endoscopy showed a well-healed gastric sleeve and a prominent 2 cm vulcaniform subepithelial lesion in the distal gastric antrum, with central umbilication consistent with HP.

Discussion: The clinical relevance of this finding is related to the risk of inadvertent stapling across ectopic pancreatic tissue during LSG. Such an event may compromise staple closure and may contribute to staple-line failure, gastric fistula, postoperative haemorrhage, or traumatic pancreatitis of the heterotopic rest. Endoscopic ultrasound and computed tomography were discussed as confirmatory investigations; however, because the patient was asymptomatic and wished to avoid additional financial burden, conservative multidisciplinary surveillance was selected.

Conclusion: Recognition of the characteristic volcano-like appearance of antral HP is important during bariatric endoscopic evaluation. Careful preoperative identification may support safe surgical planning and reduce the risk of avoidable complications.

Management of a Locally Advanced Central Face Basal Cell Carcinoma: From Micrographic Excision to Multi-segment Reconstruction

Benyoussef Jihane — 2026-06-23

Introduction: Basal cell carcinoma (BCC) is the most frequent cutaneous malignancy and may cause substantial local tissue destruction when diagnosis and treatment are delayed. Tumours of the central face are particularly challenging because oncological clearance must be balanced with preservation of the nasal, cheek, and upper lip aesthetic subunits.

Case Presentation: A 65-year-old farmer presented with a 20-year history of an extensive lesion involving the left alar rim, cheek, and upper lip. Initial excision with a 5 mm margin and histopathological assessment by the Slow Mohs technique identified an infiltrative BCC measuring 3.5 × 2 cm, with involvement of the underlying muscle plane and positive superior, inferior, and deep margins. A further Slow Mohs-guided excision of the positive margins was performed and achieved negative margins. The final full-thickness defect involved three major facial units, including transfixing involvement of the alar rim and extension to the upper white lip. Reconstruction was planned after confirmation of oncological clearance. A paramedian forehead flap was used for the nasal component, a Mustardé cervicofacial rotation-advancement flap for the cheek, and a Gillies perioral rotation flap for the upper lip. This multi-segment approach aimed to restore contour, cutaneous continuity, and oral sphincter function while respecting facial aesthetic units. At 18 months post-operatively, the clinical result documented restoration of facial contour and continuity.

Conclusion: This case demonstrates that staged margin-controlled excision with Slow Mohs, followed by tailored multi-segment flap reconstruction, can address locally advanced central facial BCC while supporting oncological safety, tissue preservation, and functional-aesthetic reconstruction.

Primary Suppurative Hydatid Cyst of the Thigh in a Child: A Case Report

Hatim Jabri — 2026-06-24

Background: Primary muscular hydatid disease is an extremely rare clinical entity, accounting for less than 3% of all echinococcosis cases. Its presentation often mimics other soft tissue tumours or infections, creating diagnostic challenges.

Aim: This report describes an unusual case of a primary suppurated hydatid cyst located in the thigh of a paediatric patient.

Presentation of Case: A 5-year-old boy with a history of close contact with dogs presented with a painful inflammatory swelling on the posterior aspect of his right thigh that had persisted for six months. Clinical examination revealed a fever of 38.9°C and homolateral inguinal lymphadenopathy. Laboratory investigations revealed hyperleucocytosis, hypereosinophilia, and elevated inflammatory markers; however, hydatid serology was negative. Ultrasonography revealed a thick-walled cystic lesion with mobile echogenic content. Magnetic resonance imaging (MRI) confirmed the diagnosis of a suppurated hydatid cyst arising from the gluteus maximus muscle. Five days after targeted intravenous antibiotic therapy, complete surgical resection of the cyst was performed. Postoperative recovery was uneventful, and no recurrence was observed during the 24-month follow-up period.

Discussion and Conclusion: Hydatid cysts should be considered in the differential diagnosis of soft tissue masses in the extremities, particularly in endemic regions or in patients with relevant exposure, even when serology is negative. Advanced imaging, specifically MRI, remains the gold standard for identifying pathognomonic signs and planning surgical excision to prevent complications and recurrence.

Isolated Small Bowel Trichobezoar: A Rare Cause of Intestinal Obstruction in a 4-year-old Child

Sarah Loubaris — 2026-06-25

Trichobezoars are rare intraluminal masses composed of ingested hair and are most commonly located in the stomach. Isolated small bowel involvement without gastric extension is particularly uncommon in paediatric patients and may present as acute intestinal obstruction, creating diagnostic difficulty because clinical findings are often non-specific. We report the case of a 4-year-old child with no significant past medical history who was admitted with acute abdominal pain, bilious vomiting that became faecaloid, and complete cessation of stool and flatus for five days. Physical examination revealed abdominal distension, diffuse tenderness, a palpable central abdominal mass, and patchy alopecia suggestive of trichotillomania. Contrast-enhanced computed tomography demonstrated a well-defined, non-enhancing intraluminal small bowel mass with entrapped air bubbles and a mottled or spongiform gas pattern, associated with upstream small bowel dilatation and air–fluid levels. The stomach was free of any intraluminal mass, supporting a diagnosis of isolated small bowel trichobezoar rather than Rapunzel syndrome. Emergency surgical exploration confirmed a firm obstructing small bowel trichobezoar, which was removed through enterotomy. The postoperative course was uneventful, and psychiatric evaluation was recommended to address the underlying behavioural disorder and reduce recurrence risk. This case underlines the value of computed tomography in preoperative diagnosis and timely surgical planning.

Idiopathic Intestinal Intussusception: A Case Report and Literature Review

Soufiane Khelloufi — 2026-06-27

Adult intussusception is uncommon and differs clinically from paediatric disease because most adult cases are associated with an identifiable pathological lead point. Idiopathic adult intussusception, particularly in the small bowel, remains incompletely understood, and management is not standardised. We report a 44-year-old man who presented to the emergency department with vomiting and worsening abdominal pain following several weeks of vague abdominal pain. Examination demonstrated upper abdominal tenderness, non-specific hyperactive bowel sounds, tachycardia of 125 beats/min and blood pressure of 108/82 mmHg. Laboratory testing showed a white blood cell count of 9,400/mm³ and C-reactive protein of 104 mg/L. Abdominal radiography demonstrated air-fluid levels, and computed tomography revealed small bowel obstruction due to ileo-ileal intussusception, without bowel ischaemia or perforation, with segmental intralesional bowel wall thickening thought to be inflammatory. Exploratory laparotomy identified ileo-ileal intussusception approximately 2.40 m distal to the initial jejunal loop. No perforation, intra-abdominal fluid collection or pseudomembranes were observed. Ileal resection with temporary ileostomy was performed. The postoperative course was uncomplicated; bowel movements resumed on postoperative day 1, and the patient was discharged on postoperative day 2. Histopathological examination confirmed small bowel intussusception and showed congested but non-neoplastic resection margins, with no malignancy. Intestinal continuity was restored one month later, and follow-up was unremarkable. This case supports consideration of adult intussusception in patients with obstructive symptoms, even when no malignant lead point is found. It also illustrates the importance of correlating imaging, operative findings and histopathological assessment in suspected idiopathic small bowel intussusception.

Fulminant Severe Acute Pancreatitis Secondary to Afferent Loop Syndrome Caused by a Strangulated Incisional Hernia Following One-Anastomosis Gastric Bypass: A Case Report

J. Raúl Cavazos González — 2026-06-27

Afferent loop syndrome is an uncommon but potentially life-threatening complication of upper gastrointestinal reconstructive surgery and is a rare cause of severe acute pancreatitis after one-anastomosis gastric bypass. This case report describes a 43-year-old man with previous one-anastomosis gastric bypass who presented approximately 24 hours after symptom onset with severe epigastric and mesogastric pain, nausea, vomiting, reduced oral intake, and an incarcerated post-incisional hernia. Computed tomography showed a strangulated proximal jejunal loop with marked dilatation of the remnant stomach, duodenum, and proximal jejunum, without radiological evidence of pancreatitis. Emergency exploratory laparotomy was performed two hours after admission, and bowel viability recovered after reduction. During the first postoperative day, the patient developed persistent abdominal pain, oliguria, tachycardia, progressive metabolic acidosis, acute kidney injury, severe systemic inflammation, and clinical deterioration. Re-exploration revealed abundant serohaemorrhagic peritoneal fluid, extensive retroperitoneal inflammatory changes around the pancreas, and markedly elevated peritoneal amylase and lipase levels, supporting severe acute pancreatitis secondary to afferent loop syndrome. Despite surgical decompression, negative-pressure temporary abdominal closure, vasopressor support, mechanical ventilation, and intensive multidisciplinary management, the patient developed refractory shock and multi-organ failure and died approximately 39 hours after admission. This case emphasises the need to consider biliopancreatic limb obstruction in patients with altered upper gastrointestinal anatomy who present with bowel obstruction or unexplained metabolic deterioration.

Caecal Dermoid Cyst: A Right Iliac Fossa Diagnostic Dilemma

Riya Agarwal — 2026-06-29

Mesenteric dermoid cysts are rare extragonadal mature cystic teratomas and may present as cystic lesions in the right iliac fossa. Their clinical and radiological features are often non-specific, and preoperative distinction from more common ileocaecal and appendiceal pathology may be difficult. We report the case of a 25-year-old male who presented with intermittent dull aching pain in the right iliac fossa for two weeks, without fever, vomiting, altered bowel habit, gastrointestinal bleeding, anorexia, or weight loss. Routine haematological and biochemical investigations were within normal limits. Contrast-enhanced computed tomography demonstrated mild mural thickening of the terminal ileum and ileocaecal junction, with a well-defined 2.5 x 2.7 cm cystic lesion abutting the caecum and anterior abdominal wall. Magnetic resonance imaging showed a T2 hyperintense cystic lesion closely related to the caecum, and appendiceal mucocele and infected enteric duplication cyst were considered the principal differential diagnoses. Colonoscopy showed normal colonic and terminal ileal mucosa. Diagnostic laparoscopy identified a 5 x 3 cm cystic lesion arising from the inferior surface of the caecum, with dense central adherence to the caecal wall. Stapled wedge resection of the involved caecal segment with appendectomy was performed, and the specimen was retrieved without intraperitoneal spillage. Histopathological examination showed keratinised stratified squamous epithelium, focal sebaceous glands, and keratinous debris, confirming a mature cystic teratoma (dermoid cyst). No immature elements or malignant transformation were identified. The postoperative course was uneventful, and the patient remained asymptomatic at follow-up. This case highlights the diagnostic difficulty of caecal and mesenteric dermoid cysts and supports complete surgical excision with histopathological confirmation.

Acute Presentation of Sigmoid Volvulus in a Patient in the Fourth Decade: A Case Report

Nithin Menezes — 2026-06-29

Background: Sigmoid volvulus is a recognised cause of large bowel obstruction, but its presentation in younger adults is reported less commonly than in elderly patients. This case describes the acute presentation, diagnostic findings, operative management, and early postoperative course of sigmoid volvulus in a patient in the fourth decade of life.

Case Presentation: A 41-year-old male carpenter presented with severe abdominal pain of one day's duration and a three-month history of constipation. He initially did not undergo the advised abdominal radiograph and later returned with worsening pain and progressive abdominal distension, which increased from 76 cm to 82 cm within 24 hours. His history included chronic alcohol consumption for 20 years and smoking, with no known chronic medical illness, previous surgery, or drug or food allergy. On examination, he was tachycardic, with a pulse rate of 115 beats per minute, blood pressure of 140/95 mmHg, oxygen saturation of 94% on room air, and respiratory rate of 18 cycles per minute. Abdominal examination revealed diffuse tenderness, distension, and guarding, with sluggish bowel sounds and a roomy rectum with faecal staining. An erect abdominal X-ray demonstrated a dilated colon with the classic coffee bean sign, without radiological evidence of perforation. Ultrasonography showed mild to moderate ascites and excessive reverberation artefacts. Midline laparotomy revealed a dilated and inflamed sigmoid colon measuring approximately 15 × 10 cm. Manual derotation and decompression were unsuccessful; therefore, resection of the redundant sigmoid colon with primary colorectal anastomosis was performed. Postoperatively, the patient remained stable, was extubated after 6 to 8 hours, passed flatus and stool on postoperative day 3, and was shifted to the ward after 5 days.

Conclusion: This case emphasises the importance of early clinical suspicion and imaging in patients with abdominal pain and chronic constipation.

A Case Series on the Management of Ring Avulsion Injuries in 10 Young Patients: The Value of the Superficial Inguinal Flap for Restoring Skin Pliability and Sensory Function

Benyoussef Jihane — 2026-07-02

Background: Ring avulsion injuries are severe hand traumas characterised by circumferential degloving of the digit and are frequently associated with vascular, neural, tendinous, and skeletal damage. Although digital salvage remains a primary objective, achieving satisfactory skin pliability and sensory recovery is crucial for long-term functional outcomes, particularly in young and active patients. The present study reports our experience using a refined superficial inguinal flap technique derived from the classic MacGregor flap.

Methods: A retrospective review was conducted on 10 patients aged 8-25 years who sustained ring avulsion injuries. Initial management included meticulous debridement, assessment of tissue viability, skeletal stabilisation when required, and tendon repair. Soft-tissue coverage was achieved using a modified superficial inguinal flap in eight cases. One patient underwent skin grafting after directed wound granulation, and one patient was treated using artificial dermis followed by skin grafting.

The flap was harvested as a broad-based random-pattern flap and elevated strictly within the superficial fascial plane while preserving the main trunk of the superficial circumflex iliac artery at the donor site. This modification aimed to provide a thinner flap and reduce the need for secondary debulking procedures.

Results: All patients reconstructed with the superficial inguinal flap achieved durable coverage with preservation of finger mobility and satisfactory skin pliability. Progressive sensory recovery was observed, evolving from protective sensation to discriminative sensibility during follow-up.

Although flap thinning was performed at harvest, secondary debulking procedures were required in most patients to optimise contour and function.

The patient treated with skin grafting developed significant stiffness and poor tissue mobility due to adhesion between the graft and underlying osteotendinous structures. The artificial dermis provided improved tissue suppleness compared with skin grafting alone; however, sensory recovery remained limited.

Conclusion: The superficial inguinal flap harvested at the level of the superficial fascia represents a reliable salvage option for ring avulsion injuries in young patients. By providing well-vascularised, pliable tissue capable of progressive sensory recovery, it appears to offer superior functional outcomes compared with skin grafting. Despite the need for staged reconstruction and occasional secondary debulking, this technique provides an excellent balance between durability, pliability, and sensibility.

Meckel’s Diverticulum-Mediated Congenital Band Causing Small Bowel Obstruction in an Adult Without Previous Abdominal Surgery: A Case Report

O. Aragon — 2026-07-03

Meckel’s diverticulum is the most common congenital anomaly of the gastrointestinal tract; however, it is usually asymptomatic. Small bowel obstruction caused by a Meckel’s diverticulum–related congenital band is rare and presents a diagnostic challenge in adults with no previous abdominal surgery. We report such a case and describe the surgical management performed.

A 46-year-old man, a chronic smoker with no prior abdominal surgery, presented with one day of diffuse abdominal pain and a single episode of vomiting while still passing stool and flatus. He was afebrile and haemodynamically stable, with mild abdominal distension and diffuse tenderness but no peritoneal signs. Investigations showed a marked inflammatory response (C-reactive protein 208.5 mg/L; white cell count 14.4 × 10³/μL with neutrophilia). Computed tomography showed small bowel dilatation (up to 48 mm) with a beak-shaped transition at the umbilicus and no bowel-wall abnormality, pneumoperitoneum or effusion, suggesting mechanical obstruction due to a probable band.

At laparotomy, a Meckel’s diverticulum, whose tip was adherent to the sigmoid mesentery, formed a fibrous band beneath which a loop of small bowel had herniated and become obstructed, producing a closed loop. The band was divided, the bowel was decompressed, and segmental resection with primary anastomosis, including the diverticulum, was performed. Recovery was uneventful.

A Meckel’s diverticulum–related band should be considered in adults with mechanical obstruction and no surgical history. A marked inflammatory response may signal early ischaemia despite reassuring imaging. Early exploration with band division and resection of the diverticulum is the definitive treatment and can result in favourable outcomes.

A Rare Case of Amyand’s Hernia in an 8-Year-Old Male Child: A Case Report

Vinay Tripathi — 2026-07-03

Background: Amyand’s hernia (AH) is a rare form of inguinal hernia in which the vermiform appendix is present within the hernia sac. It may be associated with a normal, inflamed, or perforated appendix, and preoperative diagnosis is often difficult because the clinical presentation frequently resembles an incarcerated or strangulated inguinal hernia. The lack of consensus on issues such as appendicectomy for a normal appendix, use of mesh after appendicectomy, and open versus laparoscopic approaches highlights the importance of AH.

Case Presentation: An 8-year-old male child presented with a one-month history of reducible right groin swelling that became painful and irreducible over three days. Clinical examination revealed a tender, irreducible right inguinoscrotal swelling with overlying erythema, increased local temperature, and absent cough impulse. The patient was afebrile and haemodynamically stable, and laboratory investigations were within normal limits. A clinical diagnosis of incarcerated right inguinal hernia was made, and emergency surgical exploration was performed under general anaesthesia. Intraoperatively, the vermiform appendix was found within the hernia sac, confirming AH. The appendix was oedematous, hyperaemic, and inflamed, without perforation or abscess formation. Appendicectomy was performed through the hernia sac, followed by high ligation of the sac and herniotomy. Mesh repair was avoided because the patient had type II AH according to the Losanoff and Basson classification. The postoperative recovery was uneventful. At 6-month follow-up, the patient was asymptomatic without features of recurrence.

Conclusion: AH should be considered in children presenting with incarcerated right inguinal hernia. Early surgical exploration, recognition of intraoperative findings, and an individualised approach to hernia repair are important for optimal management and a favourable outcome.

Fatal Outcome of Overwhelming Post-Splenectomy Infection Due to Serratia marcescens in a Trauma Patient: A Case Report

Debraj Pal — 2026-07-03

Background: Overwhelming post-splenectomy infection (OPSI) is a rare but life-threatening complication that can progress rapidly to septic shock and multiorgan failure. The spleen, the largest lymphatic organ, performs key immunological and haematological functions and supports innate and adaptive immunity. Because of its rapid progression and high mortality, OPSI requires early identification, immediate management and vigilant post-splenectomy care.

Case Presentation: We report the case of a 56-year-old man with diabetes mellitus and hepatitis B who sustained multiple traumatic injuries following a fall from height. Computed tomography revealed a Grade IV splenic laceration requiring emergency splenectomy. He underwent operative management and received postoperative pneumococcal vaccination. Initial recovery was uneventful, and he was extubated on postoperative day 3. On postoperative day 6, he developed fever, restlessness and altered sensorium, followed by recurrent hypoglycaemic episodes. Blood cultures grew Serratia marcescens, a Gram-negative facultative anaerobic opportunistic bacterium. Despite mechanical ventilation, vasopressor support and antibiotic escalation, he deteriorated into septic shock with multiorgan dysfunction syndrome and died on postoperative day 9.

Conclusion: This case highlights the possibility of rapidly fatal infection after splenectomy, including infection caused by atypical Gram-negative organisms. It emphasises the need for early sepsis recognition, strict preventive protocols, timely empirical antimicrobial therapy, documented asplenic status, patient education and long-term multidisciplinary follow-up in splenectomised patients.

A Case Report on Facial Cutaneous Squamous Cell Carcinoma in Two Siblings: Challenges in Oncologic Resection and Local Flap Reconstruction

Benyoussef Jihane — 2026-07-04

Background: Cutaneous squamous cell carcinoma (cSCC) is a common malignant skin tumour associated with cumulative ultraviolet exposure and constitutional susceptibility. A familial presentation may reflect a shared genetic background, similar environmental exposure, or predisposition syndromes. This case report describes two brothers with facial cSCC and highlights the oncological and reconstructive challenges associated with peri-orificial facial lesions.

Case presentation: Both patients had phototype II skin, chronic tobacco use, and ulcerative-exophytic facial lesions that evolved over one year from pre-existing actinic keratoses. The first brother presented with a pretragal lesion, and the second presented with a supraorbital lesion with frontalis muscle invasion.

Management and outcomes: Both lesions underwent en bloc excision with 1 cm safety margins. In the second case, intraoperative evidence of muscle invasion required submuscular pre-periosteal dissection, and subsequent histology showed a narrow 1 mm deep margin, prompting additional excision of the frontal periosteum. Reconstruction was delayed until clear margins were confirmed. Histology showed well-differentiated, ulcero-infiltrating cSCCs. The pretragal defect was reconstructed with a retroauricular transposition flap, preserving auricular contour. The supraorbital defect was reconstructed with an LLL (Dufourmentel) transposition flap from the non-hair-bearing scalp, allowing tension-free closure along the orbital rim.

Conclusion: These sibling cases illustrate the combined relevance of familial susceptibility, actinic field cancerisation, margin-oriented surgery, and flap selection. Long-term surveillance and screening of first-degree relatives remain important components of management.

Postoperative Acute Pancreatitis and Its Sequelae: An Underreported Complication Post Pancreaticoduodenectomy

Ashirbad Panda — 2026-07-06

Background: Post-pancreatectomy acute pancreatitis (PPAP), recently defined by the International Study Group for Pancreatic Surgery (ISGPS), is an under-recognised complication that may contribute to postoperative pancreatic fistula (POPF) and severe postoperative morbidity. This report describes a fatal case of severe PPAP following pancreaticoduodenectomy.

Case Presentation: A 57-year-old man with a localised juxta-ampullary neuroendocrine tumour underwent pancreaticoduodenectomy with duct-to-mucosa pancreaticojejunostomy. On postoperative day (POD) 2, he developed multi-organ dysfunction with markedly elevated serum amylase levels. Computed tomography on POD 4 confirmed acute pancreatitis of the pancreatic remnant. Although initial clinical improvement was observed, he subsequently developed a late POPF on POD 9. Repeat imaging on POD 14 demonstrated pancreatic necrosis and pancreaticojejunostomy disruption, which was managed with CT-guided pigtail drainage. Following discharge, the patient was readmitted on POD 24 with haemorrhagic shock. CT angiography revealed a bleeding gastroduodenal artery pseudoaneurysm secondary to local enzymatic erosion. Despite successful endovascular embolisation, the patient died from irreversible haemorrhagic shock.

Conclusion: Severe PPAP after pancreaticoduodenectomy can progress to pancreatic necrosis, anastomotic disruption, POPF and fatal vascular complications. Early recognition, vigilant postoperative surveillance and prompt multidisciplinary intervention are essential to improve outcomes in this potentially devastating condition.

Postoperative Axillary Chyle Leak Following Modified Radical Mastectomy with Level III Axillary Dissection: A Rare Case Report of a Complication Managed Conservatively

Chinmaya Rashmi Ranjan Mohapatra — 2026-07-07

Introduction: Chyle leak after axillary lymph node dissection is a rare postoperative complication that may occur after injury to the thoracic duct or its aberrant tributaries. Early recognition is important because persistent chyle loss may contribute to nutritional, metabolic and wound-related morbidity.

Case Presentation: A 64-year-old postmenopausal woman with carcinoma of the left breast received neoadjuvant chemotherapy followed by left modified radical mastectomy with level III axillary clearance. The immediate postoperative period was uneventful. After oral feeding was initiated, the drain output became milky white on postoperative day 2 and measured approximately 790 mL. Drain fluid triglyceride was 237 mg/dL, supporting the diagnosis of chyle leak. The patient was managed conservatively with a fat-free diet, axillary pressure dressing, continued negative suction drainage and serial monitoring. Drain output progressively decreased and became minimal and serous by postoperative day 14, allowing safe drain removal without surgical re-exploration. Final histopathology showed residual mucinous cystadenocarcinoma of the breast, with free surgical margins and three positive nodes among 51 retrieved lymph nodes. The patient was disease-free at the 3-month follow-up.

Conclusion: This case illustrates that postoperative axillary chyle leak can occur after left-sided level III axillary dissection and may resolve with timely conservative management in a clinically stable patient.

Syphilitic Infrarenal Abdominal Aortic Aneurysm in a 58-Year-Old Male Successfully Managed with Preoperative Penicillin Therapy and Open Aorto-Bi-Iliac Dacron Graft Reconstruction: A Case Report

Istiaq Ahmed — 2026-07-11

Introduction: Cardiovascular syphilis is an uncommon manifestation of tertiary syphilis in the antibiotic era. Although syphilitic aortitis predominantly involves the ascending thoracic aorta, isolated infrarenal abdominal aortic aneurysm (AAA) is exceptionally rare. Prompt diagnosis and combined medical and surgical treatment are essential to prevent life-threatening complications, including aneurysm rupture, aortic dissection and coronary ostial involvement.

Case Presentation: A 58-year-old normotensive, non-diabetic man presented with a progressively enlarging pulsatile abdominal mass associated with intermittent dull abdominal pain for five months. Physical examination revealed a non-tender pulsatile mass measuring approximately 5 × 5 cm in the umbilical and hypogastric regions. His blood pressure was 135/80 mmHg, without features of aortic regurgitation. Computed tomography angiography demonstrated a 7.5-cm infrarenal abdominal aortic aneurysm with right common iliac artery aneurysmal dilatation and adequate distal runoff. Serological testing revealed positive Venereal Disease Research Laboratory (VDRL) and Treponema pallidum haemagglutination assay (TPHA) results, with titres of 1:160 and 1:360, respectively. Neurological examination was normal, and transthoracic echocardiography showed a left ventricular ejection fraction of 65%, without aortic regurgitation or ascending aortic aneurysm. Chest radiography was unremarkable.

Following consultation with a dermatology and venereology specialist, the patient received intramuscular benzathine penicillin G (2.4 million units weekly for three weeks) before surgery. Open repair was subsequently performed using a 12-mm aortic limb and 6-mm iliac limb Dacron Y-graft. Total operative time was 150 minutes, infrarenal aortic cross-clamp time was 30 minutes, and estimated blood loss was approximately 500 mL. Gross examination of the excised aneurysm demonstrated the characteristic "tree-bark" appearance suggestive of syphilitic aortitis. The postoperative period was uneventful. The patient received heparin, ceftriaxone, metronidazole, amikacin, analgesics and supportive care. Doppler ultrasonography performed during six months of follow-up demonstrated satisfactory graft patency without vascular complications.

Conclusion: Syphilitic infrarenal abdominal aortic aneurysm is an exceptionally rare manifestation of tertiary syphilis. Positive serological tests, combined with characteristic operative findings, may strongly support the diagnosis when histopathological confirmation is limited. Preoperative antisyphilitic therapy followed by timely open surgical reconstruction can achieve favourable clinical outcomes. Clinicians should consider syphilitic aortitis in patients presenting with abdominal aortic aneurysms without conventional atherosclerotic risk factors, particularly in regions where syphilis remains prevalent.