Open Access Case Report

Mesenteric Fibromatosis Presenting as an Unusual Cause of Intestinal Obstruction and Anemia in a Young Male

Vijay Shivpuje, Abhishek Shahapurkar, Oksana Maliar, Nitant Vora, Amol Kanetkar

Asian Journal of Case Reports in Surgery, Page 1-4

A twenty-three-year-old male presented with on and off abdominal pain for two months with an acutely distended abdomen. He had a hemoglobin level of 6.5, and a CT scan showed a non-enhancing nodular mass compressing the small bowel with proximal distension. After resecting the mass at the mesenteric root and right hemicolectomy, the specimen was confirmed as mesenteric fibromatosis on histopathological examination. This is a rare case of mesenteric fibromatosis presenting as intestinal obstruction and anemia.

Open Access Case Report

Gastric Perforation Due to Intercostal Drainage: Is it a Clue to Missed Diaphragmatic Hernia?

Abhishek Kushwaha, Anjay Kumar, Shadab Hasan

Asian Journal of Case Reports in Surgery, Page 11-15

Acute post-traumatic diaphragmatic hernia often goes unnoticed resulting in unpalatable and disastrous consequences for the patient. There may be a delay between the injury and the diagnosis which can cause a diagnostic dilemma to the surgeon. A patient with a diaphragmatic hernia due to trauma that has long been forgotten often presents with unrelated symptoms and signs. We report a case of delayed presentation of left traumatic diaphragmatic hernia in a 60-year-old male who presented eight months after blunt trauma. An intercostal drain (ICD) was placed in the left hemithorax to drain a pleural effusion which had resulted in gastric perforation containing food particles in the drain bag.  A delay in diagnosis is often the rule in cases of diaphragmatic hernia due to blunt traumas, patients presenting with complications of missed hernia or interventions thereof because of incorrect diagnosis. This case highlights and emphasizes the importance of proper diagnosis in cases of blunt trauma and the astuteness with which history taking and investigations should be pursued before embarking on any therapeutic intervention.

Open Access Case Report

Near Carinal Tracheal Resection

Narendran Balasubbiah, Narasimman Sathiamurthy, Benedict Dharmaraj, Diong Nguk Chai

Asian Journal of Case Reports in Surgery, Page 39-43

Aims: Feasibility of surgery with non tension end to end anastomosis for near carinal tracheal resection and reconstruction with preoperative planning and surgical approach strategy.

Presentation of the Case: 55 year old male presented with central airway obstruction and haemoptysis requiring intubation. CT scan revealed a mass at the lower trachea and bronchoscopy revealed a mass which was 3 rings above the carina for which debulking was done. Tumour histopathology reported adenoid cystic carcinoma. A right posterolateral thoracotomy, near carinal tracheal resection and reconstruction, with wedge resection of the lower lobe lung lesion was done to clear the extra trachea along with the right lung lesion. Intrathoracic tracheal release manoeuvres was employed to obtain a non-tension end to end anastomosis. Patient was extubated post operatively and follow up bronchoscopy and CT scan surveillance showed no evidence of recurrence.

Discussion: Management principle of tracheal adenoid cystic carcinoma is surgery with a clear resection margin. Preoperative planning with CT scan imaging and bronchoscopy is important to determine the location, extent and invasion of the tumour both longitudinally and transversely. The feasibility of resection and extend of resection details will allow the necessary release manoeuvre and surgical approach needed before embarking on surgery. Cases which complete resection is not achievable, radiotherapy option is available; with chemotherapy for advanced palliative cases.

Conclusion: Successful near carinal tracheal resection and reconstruction requires careful preoperative planning with imaging modalities and bronchoscopy. Multidisciplinary team approach gives the best outcome managing such cases.

Open Access Case Report

A Case Report on Superior Mesenteric Artery Syndrome

Sunil Dhakal, Sapana Bhandari, Ganga Sapkota, Ijendra Prajapati

Asian Journal of Case Reports in Surgery, Page 44-48

Context: Superior mesenteric artery (SMA) syndrome first described by Rokitansky is a diagnostic dilemma for practicing clinicians. Due to commonality of symptoms often misdiagnosed. Barium follow through and Computed Tomography (CT) shows dilatation of second part of duodenum and compressed third part of duodenum between SMA and Aorta.

Case Report: 15-year-old female presented with epigastric pain with vomiting, rapid weight loss and epigastric fullness on examination.  CT revealed compressed third part of duodenum and dilated second part. Mobilization of duodenum with retrocolic side to side duodenojejunostomy was done. Conclusion: Superior mesenteric artery syndrome is difficult to diagnose. It is a life-threatening condition. Multidisciplinary approach is required to manage the case. Conservative treatment can be tried however surgery is treatment of choice.

Open Access Case Report

Giant Splenic Artery Pseudo Aneurysm with Contained Rupture: Intra Operative Challenges

M. Venu Bhargav, Krishna Ramavath, G. Prashanth, L. Gopisingh, S. Chiranjeevi, K. Lekha, S. Murthuza

Asian Journal of Case Reports in Surgery, Page 110-114

Splenic artery pseudo aneurysm is a rare entity. The presentation often varies so it will be a challenging  case to diagnosis early and to give good outcome. It occurs due to blunt trauma abdomen, chronic pancreatitis, pseudo cyst of pancreas, liver transplantation, and peptic ulcer disease. The splenic artery aneurysm accounts for approximately 60% of all visceral arterial aneurysms. After abdominal aorta and iliac artery involvement visceral artery aneurysms arises commonly from splenic artery which is the third most common artery to involve. Even pseudoaneurysm of the splenic artery is a rare condition to occur,  and fewer than 200 cases are reported in English literature till now.

Case: We are presenting a one case of giant splenic artery  pseudo aneurysm of size 14x8 cm with contained rupture due to alcoholic pancreatitis  of pseudo aneurysm into the pseudo cyst of pancreas and managed successfully with open surgical procedure.

Conclusion:  The modality of treatment for the patients with giant splenic artery pseudo aneurysms with suspected rupture of the pseudo-aneurysm, is exploratory laparotomy. Early diagnosis and the modality of the treatment will give good prognosis to the patients.

Open Access Case Report

Adenocarcinoma of Ileum Presenting as Acute Abdomen – A Rare Case Report

Sushil Deshpande, Sangeeta Deshpande, Santosh Kasture, Dinesh Kulkarni

Asian Journal of Case Reports in Surgery, Page 121-124

Benign and malignant tumours of small intestine are uncommon. Small bowel malignancies are rare and often present with non-specific symptoms. Because of this, diagnosis of small bowel malignancies is often missed. The primary malignant tumours of small intestine constitute only 1-3% of all primary gastrointestinal malignancies. Adenocarcinoma account for 40-60% of small bowel malignant tumours. Ileum is involved in 13% of patients. Our patient presented with features of acute abdomen. Resected ileal segment revealed thickened wall and histologically it was adenocarcinoma invading upto muscularis, serosa was spared and no nodes were involved. We report this case for uncommon involvement of small intestine with malignant lesion and perforation.

Open Access Case Report

A Rare Imaging Case of Median Arcuate Ligament Syndrome

M. A. A. Ansari, P. B. Gada, R. Sachdev, T. Jadhav

Asian Journal of Case Reports in Surgery, Page 125-129

Aims: This case report aims to demonstrate a rare case of median arcuate ligament syndrome (MALS) and the importance of multimodal imaging in a setting of resource restriction.

Presentation of Case: Patient presented with a long term intermittent postprandial abdominal pain not controlled on analgesia. Interestingly the US abdomen and pelvis along with the Oesophagogastroduedonoscopy was normal. On review it was decided that the patient should still undergo CTangiography of the celiac trunk as a final investigation which revealed a thickened median arcuate ligament causing celiac trunk compression. Laparoscopic surgery was undertaken to release the ligament. Post operative follow up indicated near total resolution of symptoms. 

Discussion: The case highlights the importance of using multimodal radiological findings to diagnose median arcuate ligament syndrome which in itself is a rare condition. This is particularly important in low resource settings with heavy demands as further investigations may not be instigated due to increasing wait-lists. The case is also a good reminder that MALS, though rare, should not be excluded as a differential without a CT angiography in patients with postprandial abdominal pain.

Open Access Case Report

A Giant Primary Adrenal Hydatid Cyst: The First Case Report in a Endemic Country: Algeria

Mahmoud Benatta, Merad Yassine

Asian Journal of Case Reports in Surgery, Page 134-138

Introduction: Echinococcus is endemic in Algeria and Mediterranean countries and represents an important public health problem, but the localization of hydatid cysts in the adrenal gland is very rare.

Case Report: We report a case of a voluminous primary hydatid cyst of the adrenal gland presented in our College Hospital of Oran, the second largest city in Algeria and the most important city in the western part of our country.

The patient was a teacher. He was 46 years old, from a semi-rural region in the north of Algeria, with no animal contact. He complained of lumbar pain over the city in Algeria. Ultrasonography and abdominal CT scan showed a 14 cm cystic mass of the left adrenal gland and a spectacular mass effect on the kidney. Immunological test for echinococcus (Elisa) was positive. Surgical treatment consisted of resection of the protruding dome of the cyst by open retroperitoneal surgery. Diagnosis Visualization of hydatid cyst daughter and macroscopic examination of the resected piece. The cyst was multiloculated and filled with daughter cysts. The postoperative course was uneventful. No recurrence had occurred after months of follow-up.

Conclusion: Primary Hydatid cyst in the adrenal gland is exceptional. Ultrasonography and tomodensitometry in conjunction with immunological tests can confirm the diagnosis. The cornerstone of treatment for this parasitic disease is prevention of parasite transmission. Surgical treatment for such a voluminous cyst has been performed in an open fashion and consists of peri-cystectomy of the protruding dome of the adrenal hydatid cyst after protection of the adjacent fields with compresses soaked in hydrogen peroxide and intracystic injection of hydrogen peroxide or concentrated saline into the cyst.

Open Access Case Report

Solitary Pleomorphic Adenoma of the Palate

Ashima Bhalla, Jyoti Taneja, Lalit Verma

Asian Journal of Case Reports in Surgery, Page 144-149

Pleomorphic adenoma (PA) is the most common tumor of salivary glands .The parotid gland is the most common site (90%) of origin and it is rarely seen in other minor salivary glands. Nearly 8% of  PA involves minor salivary glands- the palate (60-75%) followed by lips and other sites. We report a palatal mass in a 52-year-old gentleman. The patient’s major concern was swelling in his oropharynx with voice change and dysphagia. History revealed, the swelling was painless and gradually grew over two years to its present size. The initial diagnosis of pleomorphic adenoma was confirmed upon histopathology reports after incisional biopsy. The case was treated successfully by creating a mucoperiosteal flap under local anaesthesia after tracheostomy. No recurrence till date have been reported after follow up of several months. Pleomorphic adenoma of the palate is a rare tumor, and thus a high index of suspicion and a long-term follow-up is required.

Open Access Case Study

Coronary Artery Bypass Graft in a Patient with Dextrocardia with Situs Inversus: A Case Report

K. C. Suraj, Santosh Sharma Parajuli, Battu K. Shrestha, Sidhartha Pradhan, Nivesh Rajbhandari, Aditya Dahal, Amrit Bogati

Asian Journal of Case Reports in Surgery, Page 5-10

Coronary Artery revascularization commonly called Coronary Artery Bypass Graft (CABG) creates a new route around narrowed and blocked coronaries, allowing sufficient blood flow to deliver oxygen and nutrients to the heart muscle. Dextrocardia with Situs inversus is a rare congenital abnormality with the apex of the heart on the right side of the body in contrast to the normal heart where the apex is oriented to the left. Though technically challenging CABG in dextrocardia yields a good outcome. We are reporting a case of 55 years male with Coronary artery disease with dextrocardia with Situs inversus who underwent CABG, which is also one of the rerest cases performed to date.

Open Access Case Study

A Bolt from the “Band” - Case Report of an Unusual Mesodiverticular Band Causing Small Bowel Obstruction

Monirah Zeya, Iqbal Singh, T. K. Aravind

Asian Journal of Case Reports in Surgery, Page 16-21

Background: Aberrations in the normal involution of the Vitello-intestinal duct results in a broad entity termed the Omphalomesenteric Duct Remnants (ODR) with the Meckel’s Diverticulum being its most popular member. This article focusses on one atypical variant of ODR, the mesodiverticular band which disrupts the apparent innocuous image of the ODRs often predisposing to life threatening situations in affected individuals as opposed to the usual ODR variants. This article brings to light the importance of such a rare entity with a brief review of available literature and attempts to invoke questions in the minds of the readers regarding several unexplored aspects of these disorders.

Presentation of Case: A 28-year-old man who presented to the emergency with complaints of pain lower abdomen gradually spreading to the entire abdomen for the symptom duration of 2 days. Evaluation revealed the presence of a closed loop obstruction of the distal ileal segment with no clear etiology. The patient underwent laparotomy with resection of the obstructed gangrenous segment caused by a mesodiverticular band associated with a Meckel’s diverticulum. The post op course was uneventful and discharge of the patient was done on POD-5.

Conclusion: The presence of the extremely rare mesodiverticular band with the Meckel’s diverticulum can lead to causation of devastating consequences and even death in rare occasions secondary to bowel obstruction. This article attempts to raise questions on the need for screening and identification of such Omphalomesenteric duct remnants and also wishes to alert the reading surgeon to consider this entity in patients presenting with intestinal obstruction with no apparently identifiable cause as early suspicion and prompt treatment could prove to be lifesaving in such patients.

Open Access Case Study

Malignant Myopericytoma of Left Supraclavicular Fossa: A Case Report

S. K. V. Gunasekare, S. M. M. Niyas, S. M. I. Senevirathna, A. Senevirathna

Asian Journal of Case Reports in Surgery, Page 22-26

Introduction: Myopericytoma is a rare soft tissue tumour grouped under perivascular tumours and  it is characterized by the circumferential arrangement of perivascular cells around blood vessels. Malignant myopericytoma is an extremely rare occurrence.

Case Presentation:  A 44 year old lady presented with a supraclavicular lump for 5 months duration.The lesion was excised and the histology revealed an unencapsulated lesion with   perivascular arrangement of spindle cells with nuclear pleomorphism and high Ki-67 index suggestive of a malignant myopericytoma.

Discussion: Myopericytomas are benign tumours that occur in skin and subcutaneous layers of the extremities in middle-aged patients. Myopericytomas are often diagnosed following excision as there is no pathognomonic radiological features. These are unencapsulated lesions and consist of concentric oval to spindle shaped cells that characteristically grow around blood vessels in an “onion skin” pattern. Immunohistochemical staining is positive for Alpha smooth muscle actin (ASMA) and H caldesmon. The malignant potential is identified from high cellularity, the number of mitoses, nuclear atypia, Ki 67 value.

Conclusion: Due to its rarity, myopericytomas impose diagnostic difficulties and it should be considered in the differential diagnosis of hypervascular lumps in the neck. Malignant myopericytomas are aggressive and surgical excision with a wide margin is the treatment of choice.

Open Access Case Study

Giant Epidermoid Cyst: A Case Report and Literature Review

Shafeez Shah Bin Kamal, Sarmukh Singh, Azmi Hassan, Norhidayah Jalani

Asian Journal of Case Reports in Surgery, Page 27-33

Epidermoid cyst is a common benign tumour of the skin. Giant epidermoid cyst is rarely seen in this modern day due to improvements in healthcare system and health awareness amongst society. We would like to share a case report on our experience in successfully managing a patient with giant epidermoid cyst at an unusual location from the initial presentation up to the post operative follow up care. A 70 years old gentleman was referred from our primary healthcare clinic with complains of a huge swelling over the left gluteal region. Taking into account the clinical and radiological findings, he was planned for excision biopsy and surgery went smoothly without any complications. Intraoperatively there was 2 swellings with 600mls of cheesy content and the specimen was sent for histopathological (HPE) analysis. 2 vacuum drains were inserted intraoperatively. Radiological imaging modalities are of great value in managing these soft tissue lesions thus we have briefly described the advantage of each relevant imaging from a simple radiograph up to magnetic resonance imaging (MRI). We hope that this article will help clinicians differentiate benign from malignant tumours and have a schematic idea on the management soft tissue tumours mainly epidermoid cyst.

Open Access Case Study

Inguinal Hernia- A Common Disease that Followed an Uncommon Course!

Vishakha Kalikar, Pratik Biswas, Roy Patankar

Asian Journal of Case Reports in Surgery, Page 34-38

Inguinal hernias are the most common anomaly of the inguinal region and account for about 75% of all abdominal wall hernias [1-3]. We report a case of a middle-aged gentleman who presented with a swelling in the right lower abdomen and right flank extending up to the right subcoastal margin and congenital right sided cryptochidism.Pre-operative clinical and radiological assessment were suggestive of a right iliac fossa interparietal hernia with non-visualization of the right testicle. However, on table, the patient was found to have a right indirect inguinal omentocele with the right testicle within the hernia sac, and the hernia sac extending into the intermuscular plane, up to the right subcoastal margin.

Open Access Case Study

Intussusception at the Site of Feeding Jejunostomy: A Rare Complication

Akula Nynasindhu, Tushar M. Parmeshwar, Krishna Ramavath, S. Rao

Asian Journal of Case Reports in Surgery, Page 49-53

Intussusceptions accounts for 1% of all bowel obstructions in adults. Feeding jejunostomy (FJ) is a common procedure done for enteral feeding as an adjunct. Intussusception is a rare complication after FJ. We have encountered a case of 18 yr old female patient with FJ done for enteral feeding post corrosive acid ingestion. He presented with upper abdominal symptoms of vomiting and pain two months after the FJ. Ultrasound abdomen at the time of presentation was normal. A CT scan was done as the symptoms did not regress on conservative management, which showed sausage shaped mass with bowel in bowel configuration s/o intussusception with small bowel obstruction pattern. Emergency exploratory laparotomy was done which confirmed jejuno-jejunal intussusception with FJ as lead point. Surgical reduction of intussusceptions and revision FJ was done. Postoperative period was uneventful. Even though Jejunostomy tube-induced intussusceotion is rare with an incidence of 1%, it should be considered in an FJ patient with upper abdominal symptoms.

Open Access Case Study

Perforation in a Rare Solitary “True” Jejunal Diverticulum

Arnab Mohanty

Asian Journal of Case Reports in Surgery, Page 54-57

Jejunal diverticulosis is a rare entity and is usually asymptomatic. However, it may present with chronic symptoms and acute complications. Most of these are false diverticuli. True diverticuli, as elsewhere in the GIT, possess all layers of the intestine, and are significantly rare. There is a high incidence of complications, such as perforation, in such diverticuli. Perforation in a true jejunal diverticulum has seldom been reported. We present one such rarely documented case where the site of perforation was within a true diverticulum in the jejunum.

Open Access Case Study

Tracheal Rupture Post Trauma Aggravated by Intubation - A Rare Complication of a Life Saving Procedure

M. Palaniappa, S. Narasimman, B. Narendran, S. Thrimourthi

Asian Journal of Case Reports in Surgery, Page 58-61

Tracheal rupture is a rare but serious complication of both trauma and intubation. Clinical manifestation includes widespread subcutaneous emphysema and respiratory distress. The management is either a surgical repair or conservative. Here we present a rare case of tracheal rupture secondary to trauma that required surgical intervention in a tertiary centre with no in-house thoracic surgeons. To our best of knowledge, this is the first reported case in South East Asia.

Open Access Case Study

Fish Bone Ingestion: An Unusual Cause of Traumatic Thyroid Gland Injury

W. Suriza War, R. A. Raflis, N. A. Hakim, A. Daphne, E. N. Aina

Asian Journal of Case Reports in Surgery, Page 62-68

Introduction: Ingestion of foreign bodies, particularly fish bones, resulting in gastrointestinal tract perforations and migration to the adjacent organs are uncommon. We reported two cases of fish bone ingestion leading to oesophageal perforation and migration into a thyroid gland.

Case Report:  Case 1: A 51-year-old lady presented with a 5-day history of left anterior neck pain following ingestion of a fish bone. Neck radiography showed a foreign body at the level of C6 - C7. The CT scan revealed a fish bone embedded in the superior pole of left thyroid lobe. Emergency neck exploration discovered a 2 cm long fish bone piercing the oesophagus into the left thyroid lobe. Left hemithyroidectomy with a simple repair of oesophageal perforation performed. Case 2: A 57-year-old lady complained of odynophagia following ingestion of a fish bone. CT scan showed a linear foreign body measuring 23.3 mm located within the right thyroid lobe piecing the strap and sternocleidomastoid muscles. Emergency neck exploration revealed a fish bone protruding from the right thyroid lobe which was subsequently extracted out.

Conclusion: Ingestion of fish bone leading to the oesophageal perforation and migration into a thyroid gland is a rare surgical emergency. Imaging such as plain radiography and computed tomography scan is important for a prompt diagnosis. Computed tomography scan can delineate the precise location of the migrated fish bone to facilitate the surgical exploration. Early surgical intervention by performing neck exploration with either simple extraction of the fish bone or hemithyroidectomy is important for successful outcomes.

Open Access Case Study

Anti-mesenteric Jejunal Diverticulosis Presenting as Intestinal Obstruction: A Case Report

Mohammad N. Athamnah, Nimah A. Rabai, Hussein S. O. Al Azzam, Odai S. Sawaqed, Mu’taz M. A. Massad, Mohammad A. K. Alshloul, Layth A. K. Alshloul, Mohammad A. M. Al Mestrihi, Amer Abu-Shanab

Asian Journal of Case Reports in Surgery, Page 69-74

In this report, we present a 38-year-old male patient who was complaining of a six-day history of progressive abdominal pain with recurrent vomiting and constipation. He was afebrile with normal blood pressure and mild tachycardia, his pain was diffused all over the abdomen but more pronounced centrally and in the left upper quadrant. Laboratory workup revealed leukocytosis and abnormal electrolytes. Imaging with abdominal x-ray, ultrasound and computed tomography (CT) scan showed signs of intestinal obstruction. The patient underwent exploratory laparotomy with resection of a 7 cm segment of jejunum containing a 3 cm diverticulum with a traction band attached to it, located on the anti-mesenteric side, and stenotic segment of jejunum just distal to the site of the diverticulum.  A primary end-to-end anastomosis was carried out. Postoperatively, the patient fully recovered with no adverse events or complications.

Open Access Case Study

Fatal Outcome in a Patient with Acute Dilatation of Stomach without Perforation – A Case Report

Subhrajit Deb, Rupesh Pakrasi, Darshna Dutta, Achyut Kanungo

Asian Journal of Case Reports in Surgery, Page 75-80

Aims: Acute gastric dilatation (AGD) is the radiological finding of a massively enlarged stomach as seen on a plain film x-ray or CT scan of the abdomen. Due to a lack of physician awareness, it may go undiagnosed and has a high mortality if not treated promptly. Multiple aetiologies exist in this condition which can lead to ischemic necrosis and perforation of the stomach. We report its presentation in a patient of schizophrenia on anti-psychotic and anti-muscarinic agents, to share our challenges in diagnosing and treating this condition.

Presentation of Case: A 41-year-old patient presented with acute pain abdomen and distension. The patient was hemodynamically unstable. Blood analysis showed leucocytosis and raised CRP whereas serum amylase was normal. Straight X-ray abdomen showed gaseous dilatation of stomach. Patient did not improve on conservative management. Exploratory laparotomy revealed a hugely dilated stomach. Gastric decompression with anterior gastrostomy with gastropexy was performed. Patient was kept in intubated state in the post operative period in ICU and was maintained on antibiotics and inotropes. Although recovering initially, he succumbed on post operative day 3, due to multi organ dysfunction syndrome.

Discussion: AGD is an emergency requiring immediate intervention. Early detection by clinical examination and imaging followed by surgical intervention is the key for managing AGD.

Conclusion: Our case report demonstrates the importance of clinical identification of AGD and subsequent diagnosis and management. A patient with acute onset abdominal distention should be urgently investigated by proper imaging modalities. Recognition and diagnosis of this condition is required for appropriate patient management. In addition, our case report adds to the complication of antipsychotic and antimuscarinic agents resulting in this condition.

Open Access Case Study

Single-Strip Pericardium Technique for Pulmonary Valve Reconstruction in Tetralogy of Fallot: A Case Report

Ismail Dilawar, William Makdinata, Imamurahman Taslim, Moira Setiawan

Asian Journal of Case Reports in Surgery, Page 81-87

Right ventricular outflow tract (RVOT) dysfunction requiring pulmonary valve reconstruction following the surgical repair of Tetralogy of Fallot (ToF) is common. It remains a challenge in the pediatric population due to the small size of the pulmonary valve annulus, especially when the pulmonary valve is still growing in size. The use of monocusp valves and xenograft valved conduits tend to have long-term functional limitations arise over time, leading to early valve re-reconstruction or re-replacement. Studies reported the use of the Ozaki technique to reconstruct the pulmonary valve to overcome this problem. However, our centre did not have access to the equipments needed for the Ozaki procedure. We had an 8-year-old with ToF who was scheduled for total correction of ToF. However, after exposing the RVOT, we found that the pulmonary valves have fused and retracted bicuspid leaflets. We decided to reconstruct the pulmonary valve using a single strip of autologous pericardium. Postoperative transesophageal echocardiography showed mild pulmonary stenosis with a gradient of 33 mmHg without pulmonary regurgitation, as well as good neo pulmonary leaflet motion and coaptation. The patient was discharged without any complications. With this technique, we can create three equal-sized leaflets without the need of any special equipment and still achieve physiological valve hemodynamics while being more economic, easily reproducible, and much simpler to shorten bypass time. If required, the procedure can also be done together with a trans-annular patch in the correction of ToF.

Open Access Case Study

Surgical Separation of Thoraco-omphalopagus Conjoined Twins after SARS-CoV-2 Infection-Thoracic Surgery Perspective: A Case Report

. Wuryantoro, David Hutagaol, William Makdinata, Primayudha Dirgatama, Rigel Kent Paat, Moira Setiawan

Asian Journal of Case Reports in Surgery, Page 88-94

Conjoined twins are a rare phenomenon of monochorionic monoamniotic twins, with an incidence of 1 in 50,000 to 200,000 births. They have a low survival rate of 7.5%, and 40% of surgically separated twins don’t survive. The SARS-CoV-2 infection has contributed to 178 million infections globally and 3.8 million deaths. Surgery after a previous SARS-CoV-2 infection should be timed to ensure the safest delivery of perioperative care. It may cause multisystem disease with short and long-term sequelae that could impact postoperative recovery. We report a case of 16-months-old thoraco-omphalopagus twins with complaints of fever and respiratory distress. The twins tested positive for SARS-CoV-2 infection, and one of them continued to experience recurrent desaturation with respiratory acidosis. The patient was not able to wean from the ventilator and had recurrent ventilator-associated pneumonia. Imaging of the lungs showed consolidation in the 2nd and 3rd segment of the right lung of one of the twins and multiple consolidations in the 1st, 2nd, 3rd, and 6th segment of the left lung, accompanied with ground glass opacities in the 1st and 2nd segment of the right lung of the other, both suggestive of pneumonia. Thus, we decided to undertake elective surgery for separation of the twins, two months after their SARS-CoV-2 infection had resolved. A multidisciplinary team performed a successful separation of the twins with minimal blood loss and no intraoperative complications. The postoperative assessment showed no signs of chronic pulmonary dysfunction, and the patients were able to wean from the ventilator after the procedure.

Open Access Case Study

A Perforated Meckel's Diverticulum Simulating Appendicular Peritonitis in a Case Report

A. Fatine, N. Fakhiri, M. Bouali, A. Elbakouri, K. El Hattabi, F. Z. Bensardi, A. Fadil

Asian Journal of Case Reports in Surgery, Page 95-99

Meckel's diverticulum is the partial persistence of the omphalo mesenteric duct. Its complications are rare. The diagnosis is most often per operative. We report the case of a 54-year-old patient admitted to the emergency room for a peritonitis picture.  The clinical examination showed a generalized abdominal tenderness, the abdominal scan showed a tumified appendix in a retro caecal position measuring 12 mm in maximum thickness with a small amount of effusion.

During the operation we found a perforated Meckel's diverticulum which is responsible for peritonitis, the patient benefited from a segmental bowel resectionwith an ileostomy.The Post-operative follow-up was normal and the patient was discharged on day 3 postop. The anatomopathological examination of the surgical specimen showed an inflammatory aspect without signs of malignancy, one month after the operation the patient benefited from a restoration of the ileal continuity.

Open Access Case Study

Secondary Small Bowel Volvulus: Utility of the Whirl Sign on CT

Ramandeep Kaur, Nina-Marie King, B. Michael Payne

Asian Journal of Case Reports in Surgery, Page 100-103

Small bowel volvulus (SBV) constitutes 1-6% of all small bowel obstructions (SBO) in adults. Clinically it can be difficult to discern whether a SBO is due to SBV hence why imaging is a key aspect of diagnosis. The presence of a whirl sign on computed tomography is a classic sign of SBV. This is a case of a 75 year old man who presented with a small bowel volvulus secondary to adhesions from prior surgery. He underwent a laparotomy with viable bowel and no resection required. The patient had an uneventful recovery and was discharged after 21 days which included a period in the rehabilitation unit.

Open Access Case Study

Schwannoma of the Lesser Occipital Nerve: A Rare Case Presentation

Pidamarthi Navya, Perka Manisha, Saai Ram Thejas, Yenganti Prashanth

Asian Journal of Case Reports in Surgery, Page 104-109

Aims: To present an atypical case of a neck swelling in the left posterior triangle.

Case Presentation: A 21 year old girl presented with a painless swelling in left upper neck since 2 months, difficulty in swallowing, fever and loss of appetite since 15 days. On inspection, the swelling could not be seen with the naked eye. On palpation, it was spherical, soft in consistency, non-tender, 2×3 cm in size, deep seated and freely mobile in all directions. The initial differential diagnoses included reactive lymphadenitis or tuberculosis. Ultrasonography revealed left infra-auricular area swelling extending to posterior triangle. Ultrasound guided FNAC suggested lymphocytic granulation tissue and thus, excisional biopsy was done. The mass was pale white in color, globular, without attachments and could be dissected all over. The Histopathological report revealed a Benign Schwannoma.

Discussion: Schwannomas are benign tumors that exhibit Schwann cell differentiation and arise from peripheral nerves. They usually present in the 3rd to the 5th decade. Schwannomas in the neck are a rare occurrence and constitute only 0.5% of all head and neck tumors. In this case, the swelling was quickly progressive in nature which meant that Schwannoma was not among the first few differential diagnoses. The fever and acute presentation gave an impression of an infective or inflammatory lesion with a likelihood of tuberculosis. On dissection, the mass appeared to be encasing a small nerve and plenty of branches were identified which further made the diagnosis totally dependent on HPE.

Conclusion: Schwannomas arising from the lesser occipital nerve have rarely been seen. The atypical nature of this case with respect to the age at presentation, progression of swelling and non-linear symptoms and signs ratio makes it unique. 

Open Access Case Study

Laparoscopic Surgical Approach for Cecocutaneous Fistula in a Patient after Open Appendicectomy

Himanshu Shekhar, Prasanna Kumar Reddy, T. G. Balachandar, . Raghavendra

Asian Journal of Case Reports in Surgery, Page 115-120

Appendicectomy is among the most commonly performed emergency surgical procedure worldwide for acute appendicitis. Cecocutaneous fistula post appendicectomy is a rare complication after appendicectomy. Management of enterocutaneous fistula is variable and depends upon fistula output, location, duration of disease, patient factors, etc. Traditional surgical management requires laparotomy with bowel resection and anastomosis. Nowadays laparoscopy has become an alternative and suitable surgical management for complex problems. Here, we report a 43 years old male presented with watery and feculent discharge from a previous appendicectomy scar. Contrast enhanced Computerized Tomography (CT) Scan of abdomen demonstrated a cecocutaneous fistula. The patient was having a low output, matured fistula, and underwent laparoscopic fistula excision with stapler wedge resection of involved bowel. 

Histopathological findings of the resected specimen were consistent with chronic inflammatory fistula.

Open Access Case Study

Umbilical Pilonidal Sinus, a Lesser-Known and Underdiagnosed Clinical Condition

Prashanth Kumar Bhure

Asian Journal of Case Reports in Surgery, Page 130-133

Case Presentation: A 46-year-old male patient presented to surgery OPD with a one-year history of intermittent, seropurulent bloody discharge from umbilicus along with pain, tenderness and bulge in the area.

On examination the patient had a hairy body .The umbilicus was everted with sero-haemorrhagic discharge from the sinus and the opening was covered with exudate. Both Laboratory and sonography findings did not yield any significant abnormality. Patient underwent umbilical excision showing sinus tract with bunch of hairs.

Discussion: Umbilical discharge in adult is rare but can be quite alarming.

Failure of conservative methods of hair extraction and appropriate personal hygiene leads to compounding of the problem being recurrent, which makes surgery as an inevitable option.

They have also found that incomplete hair extraction is the commonest cause for failure of conservative management. Proper instruction to the patients at the time of discharge can further reduce the recurrence

Conclusion: Umbilical Pilonidal Sinus could easily be misdiagnosed and mistreated due to its rarity and lack of awareness of the condition. Diagnosis is easy to establish with physical examination and a detailed history. Treatment of choice for chronic, recurrent, resistant, intermittent cases is surgical removal

Open Access Case Study

Complicated Parastomal Hernia: Iatrogenic Perforation in the Efferent Loop

Antonaya Rubia E., I. Capitán Del Río, M. C. Quesada Peinado, A. Cózar Ibáñez, J. M. Capitán Vallvey

Asian Journal of Case Reports in Surgery, Page 139-143

Background: The complication of a parastomal hernia is extremely rare. Only some perforation in the proximal colon of a colostomy have been previously reported. Moreover, the extraperitoneal approach is infrequent to the treatment of this type of hernias. We observed a case of perforation, whose etiology was probably iatrogenic, in the efferent loop of a right transverse colostomy.

Case Report: A 62-years-old male who underwent a right transverse colostomy for a traumatic section of the colon 20 years ago, went to the Emergency Service for a subocclusive case. An incorrect management of a rectal catheter through the colostomy might have developed a perforation in the efferent loop of the colostomy. An extracavitary approach was made for avoid the midline dought to he presented a catastrophic abdomen because of previous surgeries. The relevance of this case report is based on the diagnostic difficulty, the hernia content, the possible associated iatrogenesis and the vital risk for the patient, as well as the treatment carried out.

Discussion and Conclusions: Parastomal hernia has an important prevalence and this condition implies high frequency to the Emergency Department. It is crucial to the current guidelines the use of prophylactic mesh in terminal stomas to prevent it. In addition, all sanitary personnel must know the basis management of a stoma to avoid possible iatrogenic complications. The peristomal approach during the surgery was critical to prevent a higher morbidity and mortality post intervention, being possible to make a right hemicolectomy through this way.