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BackgroundHeterotaxy syndrome is a rare clinical entity that is characterized by abnormal visceral organ arrangement in the chest and abdomen. Left atrial isomerism is a subcategory of heterotaxy syndrome characterized by the presence of multiple spleens with or without cardiac anomalies. Patients may remain asymptomatic their whole lives until they are diagnosed incidentally. Given that patients with left atrial isomerism might demonstrate atypical presentations of acute intrabdominal pathologies, it is important to keep a high index of suspicion when encountering such cases.Case presentationIn this report, we present a case of a 9-year-old boy with a known history of left atrial isomersim who presented with left lower quadrant pain and positive McBurney, psoas, and obturator signs on the left side. A computed tomography scan of the abdomen confirmed the diagnosis of perforated acute appendicitis on the left, which prompted an emergent laparoscopic appendectomy.ConclusionOur case highlights the importance of keeping a high index of suspicion for a heterotaxy syndrome that is complicated by acute appendicitis in pediatric patients presenting with vague abdominal pain. Planning the location of trocar placement in patients with situs anomalies is of paramount importance to avoid technical difficulties in laparoscopic procedures.

Indirect and extraperitoneal penetrating liver injury is an extremely uncommon phenomenon. In this report, we highlight the case of an 18-year-old male patient that sustained a gunshot wound with an entry site through the right buttock and landed in the liver. He presented to us in sepsis due to developing a hepatic abscess at the site of the dislodged bullet that was confirmed with computed tomography. Interestingly, the ballistic missile did not cause any visceral injury due to its indirect and extraperitoneal trajectory. The patient underwent diagnostic laparoscopy, where the hepatic abscess was unroofed and evacuated. A free-floating bullet was found and extracted, and a small bile duct leak was repaired. The patient had an uneventful post-operative course and was duly discharged on an empiric course of antibiotics.

Mesenchymal hamartomas of the chest wall are rare lesions usually detected incidentally in the neonatal and pediatric populations. Despite having a rather alarming appearance on imaging, these lesions are generally benign and carry virtually no risk of malignant transformation. Thus, management is primarily conservative for asymptomatic lesions while surgical resection is reserved for the more severe and symptomatic cases. Herein, we report our experience in the prenatal detection of a large mesenchymal hamartoma of the chest wall at gestational week 33 and the subsequent emergent resection of the lesion after the neonate was delivered prematurely due to spontaneous rupture of membranes. The patient was found to be in respiratory failure and a CT chest confirmed the presence of a large intrathoracic mass on the right side causing pulmonary hypoplasia due to mass effect. The patient underwent excision of the mass just five hours after birth, after which he had a prolonged course in the neonatal intensive care unit. In this case report and literature review, we demonstrate our prenatal findings and discuss the pathology, clinical presentation, radiologic findings, management and possible complications of this clinical entity.

Hepatocellular carcinoma (HCC) constitutes most of primary liver cancers. HCC invading the gastrointestinal tract (GIT) is considered a rare entity with limited reports in the literature. Management can either be palliative or curative such as transarterial chemoembolization (TACE) followed by definitive resection. Here, we present a case of direct HCC invasion of the GIT that was managed by surgical resection.A 74-year-old male with a history of a liver mass, found to have HCC. Admitted for medical optimization prior to definitive resection, however his stay was complicated by hemorrhagic shock, with imaging findings of hemoperitoneum suggestive of spontaneous rupture of the mass. TACE was done to stabilize the patient prior to resection. Patient was taken immediately to the operating room for definitive resection.Most cases of direct HCC invasion into the GI tract present mainly with GI bleed. Some patients, present with abdominal pain without any warning signs of an occult GI bleed. Thus, absence of an occult GI bleeding does not exclude a GIT invasion. Management options are several, but in advanced stages, management is not limited to palliation.GIT invasion is a rare complication of HCC reported in scarcity in the literature. Most cases present with GI bleeding but with some rare cases, they present with more generalized symptoms like abdominal pain, weight loss or fatigue. Despite having a poor prognosis, complete surgical resection of the tumor may be a reassuring and life prolonging treatment option for these patients.

Squamous cell carcinoma (SCC) of the colon is an extremely rare pathologic entity, accounting for less than 1 % of all colorectal cancer cases. They tend to be very aggressive with poor outcomes and treatment strategies are still controversial due to the paucity of data available to guide management.A case of a cecal mass with metastatic liver lesions. Initially diagnosed as an adenocarcinoma, the patient underwent resection with metastasectomy. Despite achieving negative surgical margins and undergoing adjuvant chemotherapy, the patient relapsed and presented with a new mass in the descending colon. The patient underwent resection with subsequent follow-up revealing distant metastasis. The patient passed away soon after.Primary colorectal SCC has similar presentation to adenocarcinoma of the colon. Unfortunately, it usually presents at a late stage. Diagnosis of colorectal SCC requires histologic confirmation of SCC plus exclusion of possible causes. Management is predominantly definitive radical resection followed by adjuvant chemotherapy and radiotherapy. Surgical margins should be at least 5 cm, preferably 10 cm. Lymph node yield greater than 20 was associated with improved survival. Studies assessing the prognosis of primary colorectal SCC following chemo-radiotherapy have not been done.Surgery remains the most vital important step in the management of colonic SCC. The role of chemotherapy and/or radiation remains questionable. Depending on the aggressiveness of this disease the need for further frequent.

IntroductionEndovenous laser ablation (EVLA) has become the gold standard for the treatment of saphenous vein reflux. We report the long-term clinical and ultrasound results of EVLA.MethodsThis study is a retrospective review of patients who underwent EVLA of saphenous vein over four years. Clinical results were assessed using venous clinical severity score (VCSS), and ultrasound results were classified according to Bush classification.ResultsOver a median follow-up time of 4.4 years, 168 EVLA-treated patients showed a drop in VCSS from 4.38 to 1.39. Ultrasound results of 140 treated great saphenous veins showed that 64% had one or more cause of recurrence. The presence of neovascularization correlated well with the lack of improvement of VCSS.ConclusionEVLA resulted in drop in VCSS from 4.38 to 1.39. Among 140 treated great saphenous veins, reflux in the anterior accessory saphenous vein was the primary cause (23.5%) of recurrence.

Injuries of the biliary tract and complex injuries involving vascular and parenchymal tissue can be detrimental despite the improved use of laparoscopy. Complex biliary injuries are variable depending on the type of injury as well as patient and surgeon factors. We present four cases of complex biliary injuries at our tertiary referral center with hepatobiliary expertise: biliary stenosis with obstruction, double duct system anatomy, combined right hepatic arterial transection and biliary duct injury, and a complete pedicle injury. Early identification and specialized repair of complex biliary injuries is essential to minimize patient morbidity. Notably, consulting a specialist intraoperatively in case of difficult dissection and visualization or a suspected injury and considering bail-out strategies such as a subtotal cholecystectomy or conversion are safe approaches to minimize complex biliary injuries. Earlier recognition and repair of complex biliary injuries improves outcomes when immediate intraoperative repair can be performed rather than delayed postoperatively.

Background and objectives: Receptor-interacting serine/threonine-protein kinase-2 (RIPK2) is an important mediator in different pathways in the immune and inflammatory response system. RIPK2 was also shown to play different roles in different cancer types, however, in colorectal cancer (CRC), its role is not well established. This study aims at identifying the role of RIPK2 in CRC progression and survival. Materials and methods: Data of patients and mRNA protein expression level of genes associated with CRC (RIPK2, tumor necrosis factor (TNF), TRAF1, TRAF7, KLF6, interlukin-6 (Il6), interlukin-8 (Il8), vascular-endothelial growth factor A (VEGFA), MKI67, TP53, nuclear factor-kappa B (NFKB), NFKB2, BCL2, XIAP, and RELA) were downloaded from the PrognoScan online public database. Patients were divided between low and high RIPK2 expression and different CRC characteristics were studied between the two groups. Survival curves were evaluated using a Kaplan–Meier estimator. The Pearson correlation was used to study the correlation between RIPK2 and the other factors. Statistical analysis was carried out using SPSS version 25.0. The Human Protein Atlas was also used for the relationship between RIPK2 expression in CRC tissues and survival. Differences were considered statistically significant at p &lt, 0.05. Results: A total of 520 patients were downloaded from the PrognoScan database, and RIPK2 was found to correlate with MKI67, TRAF1, KLF6, TNF, Il6, Il8, VEGFA, NFKB2, BCL2, and RELA. High expression of RIPK2 was associated with high expression of VEGFA (p &lt, 0.01) and increased mortality (p &lt, 0.01). Conclusions: In this study, RIPK2 is shown to be a potential prognostic factor in CRC, however, more studies are needed to assess and verify its potential role as a prognostic marker and in targeted therapy.