Open Access Case Report

Median Arcuate Ligament Syndrome: A Rare Cause to be Considered in Cases of Non-Specific Upper Abdominal Pain

R. Agrawal, P. Agrawal, A. Mishra, P. Motghhare, J. Chandrakar

Asian Journal of Case Reports in Surgery, Page 18-25

Introduction: The Median arcuate ligament syndrome (MALS) is a cause of chronic abdominal pain affecting both children and adults.  MALS also known as celiac artery compression syndrome (CACS) can be symptomatic, presenting as chronic abdominal pain, nausea, vomiting, weight loss and diarrhoea.

Case Report:  49 years old male presented with complaints of recurrent abdominal pain aggravated after meals. CT angiography of abdomen revealed focal narrowing of the celiac artery at its origin with a thin filling defect, characteristics hooked appearance and linear hypodense band suggestive of MALS. Laparotomy was done and division of median arcuate ligament (MAL) and celiac plexus destruction was done.

Discussion: MAL is a fibrous arch that unites the diaphragmatic crura on either side of aortic hiatus, with the normal anatomic location of the ligament being superior to the origin of the celiac axis. The cause of abdominal pain is thought to be due to either poor blood flow from CACS, nerve irritation or combination of both. Compression of the celiac artery may result in the blood flow coming from another abdominal vessel (the superior mesenteric artery) and going to the stomach and liver when a patient eats, known as ‘steal phenomenon’. The treatment options for MALS include surgical laparoscopic or robotic division of MAL, celiac ganglion destruction and bypass surgery.

Conclusion: MALS is diagnosis of exclusion. CT angiography is an excellent modality to rule out various pathologies and diagnose MALS.

Open Access Case Study

Thoracodorsal Artery Perforator Flap for Chronic Radiation-Induced Ulcer Grade 4: A Case Series Report

Kristanto Yuli Yarso, Monica Bellinda

Asian Journal of Case Reports in Surgery, Page 1-6

Background: Radiotherapy takes an important role in the management of breast cancer. Therefore, radiation-induced skin ulcer caused by the acute or chronic effects of ionizing radiation might be another challenge. The treatment of chronic radiation-induced ulcers is further complicated because they are often combined with other radiation side effects.

Case Presentation: We report two cases of women suffering from breast cancer. These                patients had mastectomy surgery 7 and 10 years ago followed with 70 gy external beam radiation therapy using cobalt 66. The first patient had a chronic expanded ulcer in the last 2 years with a diameter of 10 x 4cm now. In the second patient, the ulcers formed as a hole under the armpit in the past 1 year with a size of 3 x 2cm. Both patients’ ulcers were odorless, pale in color on surrounding tissue with no sign of granulation and no pus. After a long period of treatment with no results, we decided to use a thin layer flap rich in vascularization for both cases. The flap               chosen was the thoracodorsal artery perforator flap. From both cases, follow-up postoperative showed good results in coverage, cosmetic, and functional aspects. The flap perforator succeeds  in creating less bulky coverage, free range of motion, no infection, flap loss, and necrosis at the site.

Conclusion: Thoracodorsal artery perforator flap is a safe option for the reconstruction of skin ulcer caused by radiation. This technique has the advantage of reducing donor site morbidities.

Open Access Case Study

A Case Report of Left-Sided Appendicitis due to Midgut Malrotation

Ramazan Serdar Arslan, Doruk Barlas, Hakan Yilmaz, Suleyman Diker, Mehmet Ali Semsit

Asian Journal of Case Reports in Surgery, Page 7-11

Acute appendicitis is the most common cause of abdominal pain that still requires emergency surgery. As a result of delayed diagnosis or misdiagnosis, appendicitis perforation, abscess, generalized peritonitis and sepsis develop, and morbidity and mortality increase. Variations in the location of the appendix in the abdomen are one of the most important causes of false or delayed diagnosis. Left-sided appendicitis due to midgut malrotation is extremely rare in clinical practice and can cause laboratory and radiological findings similar to colonic diverticulitis. Its rarity may lead to a wrong diagnosis. We present a case where intravenous contrast computed tomography was crucial diagnostically and helpful for pre-surgical planning in a patient presenting with an acute abdomen on left-sited perforated appendicitis with midgut malrotation.

Open Access Case Study

Resection of Pancreatic Heterotopia Mass in the Stomach

Muhammad Ghanem, Alaa Alhanwt, Basel Abaza, Mohammed Ali Alkhder

Asian Journal of Case Reports in Surgery, Page 12-17

Heterotopic pancreas (HP) or ectopic pancreas is the presence of pancreatic tissue in anomalous location without any anatomic, vascular or neural continuity with the main body of the pancreas. We present here a case of a female who had a chronic abdominal epigastric pain. She had conservative treatment for two years .We diagnosed HP in the stomach. She had also sludge in the gallbladder. We performed laparoscopic cholecystectomy as well as we resect HP with clear margins in one procedure. Our patient was fully recovered and her pain vanished.

Open Access Case Study

Sponataneous Gall Bladder Perforation - An Unusual Cause of Acute Abdomen

M. Pravin, R. Kannan, Ashiq Ahamed

Asian Journal of Case Reports in Surgery, Page 26-30

Aim: To emphasise the importance of having a lower threshold for gall bladder perforation as a differential diagnosis in patients presenting with peritonitis of unknown etiology.

Case Report:  A 66 yr old gentleman presented with abdominal pain and distension for 2 days after a binge drink of alcohol. Clinically patient was in peritonitis. Imaging studies were not significant except for free fluid in the abdomen. Laparotomy revealed 2 litres of bile in the peritoneal cavity with a perforation in the fundus of gall bladder. Cholecystectomy was done.

Conclusion: Due to high mortality and morbidity associated with gall bladder perforation, early diagnosis and surgical management is essential.