Search

While ingestion of a foreign body by children is common, diagnosis is often challenging, especially when the consumption by a young child is unwitnessed and presenting symptoms mimic other medical conditions. If the foreign body does not pass spontaneously, radiological imaging studies are typically performed, but visualization and identification of the ingested foreign object can be inconclusive, especially when an unidentified mass is radio translucent. Under this circumstance, physicians often have to go on a "fishing expedition", using exploratory endoscopy and/or surgery to identify and extract the object that became lodged. In this report we discuss a case of a 3 year-old boy who presented with abdominal pain and signs of bowel obstruction. Imaging revealed an ingested "radiolucent" foreign body, masqueraded as soft-tissue mass and enteric duplication cyst, delaying the diagnosis. Systematic shape and density reanalysis of CT and US imaging suggested a hollow object lodged at the terminal ileum. The patient underwent exploratory laparotomy with extraction of a hollow toy "fish". There is a dearth of literature regarding hollow ingested objects. This case report highlights the importance of systematic density and shape imaging analyses in order to identify and locate hollow ingested objects.

Purpose Pelvic fractures are characterized by high energy injuries and often accompanied with abdominal and pelvic organ injury. CT has been applied for several decades to evaluate blunt pelvic trauma patients. However, it has a certain rate of inaccurate diagnosis of abdominal hollow viscus injury (HVI), especially in the early stage after injury. The delayed diagnosis of HVI could result in a high morbidity and mortality. The bowel injury prediction score (BIPS) applied 3 clinical variables to determine whether an early surgical intervention for blunt HVI was necessary. We recently found another clinical variable (iliac ecchymosis, IE) which appeared at the early stage of injury, could be predicted for HVI. The main objective of this study was to explore the novel combination of IE and BIPS to enhance the early diagnosis rate of HVI, and thus reduce complications and mortalities. Methods We conducted a retrospective analysis from January 2008 to December 2018 and recorded blunt pelvic trauma patients in our hospital. The inclusion criteria were patients who were verified with pelvic fractures using abdomen and pelvis CT scan in the emergency department before any surgical intervention. The exclusion criteria were abdominal CT insufficiency before operation, abdominal surgery before CT scan, and CT mesenteric injury grade being 5. The MBIPS was defined as BIPS plus IE, which was calculated according to 4 variables: white blood cell counts of 17.0 or greater, abdominal tenderness, CT scan grade for mesenteric injury of 4 or higher, and the location of IE. Each clinical variable counted 1 score, totally 4 scores. The location and severity of IE was also noted. Results In total, 635 cases were hospitalized and 62 patients were enrolled in this study. Of these included patients, 77.4% (40 males and 8 females) were operated by exploratory laparotomy and 22.6% (8 males and 6 females) were treated conservatively. In the 48 patients underwent surgical intervention, 46 were confirmed with HVI (45 with IE and 1 without IE). In 46 patients confirmed without HVI, only 3 patients had IE and the rest had no IE. The sensitivity and specificity of IE in predicting HVI was calculated as 97.8% (45/46) and 81.3% (13/16), respectively. The median MBIPS score for surgery group was 2, while 0 for the conservative treatment group. The incidence of HVI in patients with MBIPS score ≥ 2 was significantly higher than that in patients with MBIPS score less than ≤ 2 (OR = 17.3, p Conclusion IE can be recognized as an indirect sign of HVI because of the high sensitivity and specificity, which is a valuable sign for HVI in blunt pelvic trauma patients. MBIPS can be used to predict HVI in blunt pelvic trauma patients. When the MBIPS score is ≥ 2, HVI is strongly suggested.

Highlights • Diverticular disease may result in complications like inflammation, abscess, bleeding and formation of fistula to adjacent organs. • Colouterine fistula secondary to diverticular disease are extremely rare. • Accurate diagnosis of a colouterine fistula requires correlation of clinical presentation, properly selected radiologic examination and endoscopic evaluation. • Colouterine fistulas from other causes must be considered to properly select appropriate management. • The surgical treatment of choice will be dictated by patient factors, local tissue conditions and available expertise., Introduction and importance Colouterine fistulas related to diverticulitis are very rare due to the thickness of the uterine myometrium. Other causes related to colouterine fistula formation particularly malignancy, have to be considered. Diagnosis by imaging or endoscopy may be inconclusive. Case presentation We are presenting a case of a 70-year-old female who presented with malodorous vaginal discharge and painful labial lesions. No previous history of surgery, gynecologic malignancy or other possible causes of the fistula was elicited. CT scan imaging suggested a colouterine fistula. The patient was admitted and underwent Exploratory laparotomy, Hartmann’s procedure and total hysterectomy with bilateral salpingo oophorectomy. The patient was discharged without perioperative complications. Clinical discussion Colouterine fistulas are extremely rare complications of diverticular disease. Diagnosis entails clinical astuteness and judicious use of imaging and endoscopic modalities. Accurate diagnosis is essential to select the appropriate surgical approach, along with intraoperative findings patient status and prevailing conditions. Conclusion This case is being presented not only for the rarity of the case but also for the complexity of the management and decision making during the period of the pandemic.

Highlights • Gallstone ileus is an uncommon complication of untreated cholelithiasis affecting an aged population. • Amyotrophic lateral sclerosis has documented dysautonomia causing significant delays in colonic transit times and gastric emptying. • Intestinal hypoperistalsis and adrenergic hyperfunctioning may be related to impaired gallbladder contractility resulting in sludge and stone accumulation. • We present a unique case of gallstone ileus in a patient with amyotrophic lateral sclerosis., Introduction and importance Gallstone ileus is a rare disease that most commonly occurs in elderly females with a history of cholelithiasis. It has not been previously associated with Amyotrophic Lateral Sclerosis (ALS); a neurodegenerative disease that primarily affects the motor neurons at the spinal and bulbar levels. Autonomic malfunction, in particular, gastrointestinal dysfunction has been documented in ALS patients which may predispose this population to the development of gallstones and gut dysmotility. Case presentation In this paper, we report a case of gallstone ileus in a patient with diagnosed ALS. We performed an exploratory laparotomy, enterolithotomy, and an open cholecystectomy with takedown/closure of a cholecystoduodenal fistula. The patient had a relatively uncomplicated postoperative course and was discharged from the hospital on postoperative day nine. Clinical discussion Delays in gastric emptying and colonic transit times in ALS patients may pose a risk for the development of gallstones and the potential impaction of a gallstone ileus in patients who are left untreated. Multifactorial evaluation of this patient population is necessary when assessing a potential causal pattern of gallstone ileus in patients with significant comorbidities. Conclusion We present an unusual pathology without an established incidence, which has pertinent multidisciplinary implications. The suspicion of ALS as a potential cause for the development of a gallstone ileus is relevant and essential in the diagnostic workup for an elderly patient who develops a small bowel obstruction with multi-comorbidities.

This clinical case reports prerupture diagnosis of a rudimentary horn pregnancy in a 27-year-old formerly healthy woman presented with moderate to severe suprapubic abdominal pain at the gestational age of 12 + 0 weeks. The suspected diagnosis of this pregnant rudimentary horn via transvaginal ultrasound was acknowledged during an emergency exploratory laparotomy. The simple transvaginal ultrasound criteria suggested by the present study would help clinicians avoid time-consuming inefficient investigative procedure and rule out this rare life-threatening condition by taking into account the rudimentary horn pregnancy as a differential diagnosis in patients presenting with abdominal pain.

Highlights • Peutz-Jeghers syndrome (PJS) is an inherited polyposis syndrome. • PJS-characteristic hamartoma polyps occur in the gastrointestinal (GI) tract. • In patients with intussusception, the presence of a hamartoma polyp may have been the trigger. • Hamartoma polyps in the GI mucosa and hyperdense macular lesions on the lip and buccal mucosa are pathognomonic signs of PJS., Introduction Peutz-Jeghers syndrome (PJS) is an uncommon autosomal dominant syndrome with a variable to high penetrance that leads to the development of polyps within the gastrointestinal mucosa. Here we report a case of an adult female suffering jejunoileal intussusception due to PJS. Presentation of case A 30-year-old woman came to an emergency department with a small bowel obstruction caused by intussusception. The patient underwent an emergency exploratory laparotomy. An intussusception at the level of 60 cm from the ligamentum treitz was revealed, and the intussusception small bowel segment was not viable; we decided to perform segmental jejunoileal resection with the Bishop-Koop procedure, and the specimen histopathology of the segmental jejunoileal resection showed a typical hamartomatous polyp features. Two month later, diagnostic endoscopy showed multiple polyps (between 5 and 15 mm) in the large bowel. The polyps were removed with endoscopic polypectomy and examined histopathologically, showing characteristics of PJS. Further detailed family history was obtained, and similar skin lesions were detected on our patient’s child (since birth). Although endoscopy screening identified multiple polyps in the child’s ileum and large bowel, he was not suffering from abdominal symptoms. Conclusion In patients with intussusception at a young age, PJS can be caused by the presence of a hamartoma polyp as a trigger for intussusception. If there are multiple polyps found in the gastrointestinal mucosa and other pathognomonic signs are found, such as hyperdense macular lesions on the lip and buccal mucosa, such cases should be confirmed as PJS.

Highlights • Gastric volvulus is characterized by a rotation, in its long or short axis. • Most of the patients come for medical attention due to abdominal pain. • It is important to carry out studies for standardizing the management., Introducción Gastric volvulus is characterized by a rotation, in its long or short axis, generating various degrees of obstruction, which can occur acutely or chronically. Case A 45-year-old female. Refers to the performance of laparoscopic Nissen fundoplication 4 years ago. In December 2018, she presented a recurrence of the symptoms associated with reflux, for which a new laparoscopic fundoplication was performed (outside our medical unit) without eventualities or apparent complications. Six months later, he was admitted to our medical unit due to intolerance to the oral route. Thoraco-abdomino-pelvic tomography reports images suggestive of gastric volvulus and mixed hiatal hernia with protrusion of colon, stomach, duodenum, jejunum and mesenteric vessels, with data suggestive of complication or ischemia of these structures. An emergency operating room was requested to perform an exploratory laparotomy. Gastric volvulus, ischemia and gastric necrosis were observed in the cavity, for which a total gastrectomy and restitution of the intestinal transit were carried out by means of an esophagus-jejunum end-to-side Roux-en-Y anastomosis. Discussion There is no scientific evidence or algorithms described for the management of this condition, according to the management described in the literature, decision-making by our team surgical procedure matches current recommendations. Conclusion In accordance with what is described in the literature, we consider it important to carry out a retrospective study that describes the bases for standardizing the management of this complication, and assessing models for conducting prospective multicenter studies that allow the creation of an algorithm and clinical guideline.

Inflammatory myofibroblastic tumors (IMT) are rare soft tissue tumors of intermediate malignant potential with tendency for local recurrence. Although they can occur at all age groups, occurrence in infants is extremely unusual and their imaging characteristics are not well described. A 3-month-old female infant presented with gradually progressive abdominal distention without any fever or weight loss. She had a large ill-defined homogenous hypodense lesion of size 8.4 × 11.4 × 11.3 cm (APxTraxSag) in the abdomen showing mild delayed post contrast enhancement. She underwent exploratory laparotomy with gross total excision of mesenteric mass, histopathology of which was suggestive of IMT. She had recurrence within 6 months of complete resection with a well-defined heterogeneously enhancing lesion of size 1.8 × 1.8 × 2.3cm (APxTraxSag) in right paravesical region abutting the bladder without invasion with a similar lesion of size 4.4 × 2.1 × 3 cm (APxTraxSag) in left subdiaphragmatic region abutting superior surface of spleen (no invasion). Since, surgery in our patient would have entailed splenectomy and partial cystectomy, systemic therapy with ceritinib (anaplastic lymphoma kinase [ALK] inhibitor) was planned for her with which she had a near complete response after 2 months. A high index of suspicion is required to differentiate IMT from other common causes of mesenteric masses in children and role of radiologist is quintessential in this regard. Local recurrence with abutment but without invasion of surrounding structures points to the intermediate malignant pathology of IMT and may provide a clue to diagnosis. Systemic therapy is effective in patients who are ALK positive and destructive surgery should be avoided.

Highlights • Intrathoracic gastric volvulus. • Robotic Lobectomy unusual complication. • Para esophageal hernias a cause for concern during robotic thoracic procedures. • Gastric Ischemia. • Etiology of gastric volvulus., Unrecognized intrathoracic gastric volvulus can be a life-threatening condition, especially in elderly individuals undergoing major surgical procedures. We herein report the first case of a gastric volvulus after a robot-assisted left upper lobectomy for non-small-cell lung cancer in a patient with a known paraesophageal hernia. The operative procedure was performed by Dr Jacques Fontaine a senior thoracic surgeon at Moffitt Cancer Center in Tampa Florida a major academic institution. This operation was complicated by a large type-III hiatal hernia, with most of the stomach having herniated into the left pleural cavity and demonstrating organo-axial torsion one day after the indexed operation for the lung cancer. The patient required emergency surgery due to gastric ischemia. The patient underwent exploratory laparotomy with reduction of the volvulus and closure of the esophageal hiatus at that time. The patient was taken back to the operating room for a planned relook 24 h after the exploratory laparotomy to assess viability of the stomach. Unfortunately, the second look revealed necrotic areas of the stomach, which required to be resected. Given her age and poor nutritional status, we elected to place a feeding jejunostomy tube. Her postoperative course was marred by an abdominal wound infection treated with a wound vacuum-assisted closure device. Ultimately she was discharged home on POD#19 tolerating a regular diet. This case report highlights that in the elderly patients undergoing left lung resection with a known large hiatal hernia, the index of suspicion for herniation must be high and prompt recognition can avert mortality or morbidity.

Objectives Risk factors for placenta percreta are placenta previa and prior cesarean delivery. Placenta percreta–induced ruptures at non-cesarean sites are very rare, particularly in the early second trimester. Case report A 30-year-old woman with a prior cesarean delivery was brought to our emergency department at 17 weeks' gestation for sudden-onset consciousness loss and generalized convulsions. Hypovolemic shock was identified. Computed tomography scans suggested uterine rupture and massive ascites, r/o hemoperitoneum. Emergency exploratory laparotomy revealed a ruptured hole over the left uterine fundus with protruding placental tissue; placenta percreta was impressed. An intact intrauterine sac was dissected and removed. The placenta was removed and hysterorrhaphy was completed. Conclusion Placenta percreta is dangerous and is rarely seen in the early second trimester. Uterine rupture should always be kept in mind in pregnant woman with acute abdomen associated with hypovolemic shock, even in those of early pregnancy without scarred uterus. Routine sonographic examination of placentation, even in early second trimester, should be emphasized.

Background Resection of pancreatic ductal adenocarcinoma (PDAC) with synchronous liver metastasectomy is still a matter of debate. We aimed to evaluate the feasibility of synchronous resection of PDAC and liver metastases for curative intent at a high-volume surgical center. Methods Patients who underwent pancreaticoduodenectomy (PD) with synchronous liver metastasectomy (M1 resection group, n = 50) were matched 1 : 1 based on tumor and nodular stage, age, gender, body mass index and concomitant disease with two control groups (M0 resection and M1 no resection). The M0 resection group included patients who underwent PD without metastases. The M1 no resection group included patients with liver metastases who underwent palliative bypass or exploratory laparotomy without resection followed by palliative and adjuvant therapies. Results M1 resection group had a longer operation time, larger intraoperative blood loss, and longer postoperative hospital stay than other two groups. R0 resection rate of M1 resection group was similar to that of M0 resection group (92% vs. 94%, p = 1.000). Postoperative complications were comparable between the groups. The overall median survival in M1 resection, M0 resection, and M1 no resection group was 16, 30, and 6 months, respectively. Cumulative survival rates for 1-, 2-, and 3-year of the M1 resection, M0 resection, and M1 no resection group were 63.8%, 29.0%, and 6.7%; 94.0%, 74.4%, and 25.1%; 24.0%, 2.0%, and 0%, respectively. The survival of M1 resection group was worse than that of M0 resection group (p = 0.009), however significantly much better than that of M1 no resection group (p = 0.001). Univariate analysis showed carcinoembryonic antigen >8 ng/ml and non-R0 resection were associated with death. Multivariate analysis revealed that M1 resection group had improved survival compared with M1 no resection group. Conclusions PD with synchronous liver metastasectomy for oligometastatic PDAC is safe and feasible, it might provide survival benefits for selected patients., Highlights • A retrospective, case–control study was conducted at a high-volume surgical center. • 50 patients underwent pancreaticoduodenectomy with synchronous liver metastasectomy. • Complications were similar in M1 resection, M0 resection and M1 no resection groups. • Carcinoembryonic antigen >8 ng/ml and non-R0 resection were associated with death. • The survival of M1 resection group was much better than that of M1 no resection.

Highlights • Volvulus of the transverse colon is a rare surgical emergency. • Its diagnosis is challenging for the surgeon and the definitive diagnosis is frequently made intra-operatively. • Delay in the diagnosis carries high morbidity and mortality rates. • Early surgical intervention with resection and anastomosis is essential for better outcome and avoiding complications., Introduction Transverse colon volvulus incidence is comparatively rare when compared to cecal and sigmoid volvulus. Its diagnosis is still challenging for the surgeon. Delay in the diagnosis of this condition carries high morbidity and mortality rates. Aim To report a rare case of transverse colon volvulus in a young adult male that presented as large bowel obstruction and was operated upon in the General Surgery department in the Jordanian Royal Medical Services (JRMS), Amman, Jordan. Presentation of case An 18-year-old male presented with severe generalized abdominal pain of 12-h-duration, associated with significant abdominal distention and constipation of one-day duration. His abdominal examination revealed a massively distended, tender abdomen; however, there were no signs of peritonitis. Abdominal radiographs showed a massively dilated large bowel. He underwent exploratory laparotomy that revealed the diagnosis of transverse colon volvulus. His condition was managed operatively with transverse colectomy with a primary anastomosis. The patient had a satisfactory postoperative recovery. Discussion Only 3–5% of all cases of intestinal obstruction are caused by colonic volvulus. Transverse colon is involved in 2–4% of them. The diagnosis of transverse colon volvulus can be delayed and difficult because it does not have the same classically recognizable radiographic features as cecal and sigmoid volvulus. Conclusion Transverse colon volvulus is a rare entity. A swift suspicion of diagnosis is key to preventing severe outcomes. It can result in bowel perforation and fecal peritonitis. The definitive diagnosis is frequently made intraoperatively. Early surgical intervention is essential for better outcome and avoiding complications.

Highlights • We describe a rare case of duodenal perforation related to foreign body ingestion which has rarely been reported in the literature. • Foreign body perforations were uncommon and often missed in view of its atypical and latent presentation. • Early multiplanar reformatting CT images help in identifying the cause and also to locate the foreign body in most of the patients, thus making it an important tool for preoperative diagnosis which assists in surgical planning. • Though the majority of patients will require an exploratory laparotomy, minimally invasive procedures can be attempted in stable patients similar to this case., Introduction Foreign body ingestion is a common clinical scenario encountered in clinical practice. Perforations related to foreign bodies are rare (

Highlights • Despite hemodynamic stability on presentation, pediatric patients suffering GSW injuries should undergo extensive assessment to rule out any significant internal injuries. • Renal laceration can be successfully managed with conservative observation in hemodynamically stable patients., Introduction Trauma remains the leading cause of mortality in the pediatric population. Penetrating thoracic injuries can result in devastating trauma to multiple organ systems. When these injuries occur, prompt diagnosis and swift treatment of internal organ injury are of utmost importance. Case presentation A 13-year-old male presented to our Trauma Center after sustaining a gunshot wound (GSW) to the left chest. Despite his hemodynamic stability on presentation, CT scan revealed multiple injuries including splenic and renal lacerations. Exploratory laparotomy resulted in splenectomy, but no intervention was performed for the renal laceration. Instead, clinical monitoring alone was sought. Patient was discharged on hospital day 13 in stable condition. Discussion Pediatric penetrating injuries secondary to GSWs can impact multiple organ systems. Despite hemodynamic stability on presentation, adequate staging of internal damage with CT allowed a targeted approach. In our case, non-operative management of the renal injury was implemented after hemorrhage control of his additional injuries. Failure to have done so would have inevitably complicated his overall management and made kidney salvage not feasible. Conclusion Prompt diagnosis and treatment are required in order to prevent significant morbidity and mortality in the pediatric patient from GSW-mediated penetrating thoracic injuries. Despite hemodynamic stability on presentation, patients should be emergently assessed for severe injury, with immediate surgical management as needed. Failure to do so could lead to rapid clinical deterioration, and inability to enact other conservative measures that lead to positive outcomes.

Highlights • Ileocolic intussusception is the most common type of intussusception. • Jejunojejunal intussusception rarely occur. • Most common Causes of intussusception in adult are adhesion, adenoma, lipoma. • Jejunojejunal intussusception may be a complication of a jejunostomy feeding tube., Background Intussusception can occur anywhere in the small and large bowel, ileocolic intussusception is the most common type in adult and there are few reported cases of jejunojejunal intussusception. Here we report a case of jejunojejunal intussusception due to an iatrogenic lead point at the feeding jejunostomy closure site. Case presentation In 2019 we received a 63-year-old female complaining of abdominal pain, constipation, and repeated vomiting for five days. On physical examination, she was dehydrated, in pain, and had a nasogastric tube that was draining bilious fluid. The abdomen was tender, there was a long midline incision with tension sutures at the lower of incision. CT of the abdomen showed ileoileal intussusception. Proper resuscitation and preoperative preparation were done. During exploratory laparotomy, there was jejunojejunal intussusception. The intussusception was reduced gently and completely. Resection of the lead point segment done with end to end anastomosis. The patient recovered uneventfully and discharged home on the 5th postoperative day. The patient followed up after one and three months with no complications. Conclusion During the closure of the feeding jejunostomy site by hand-sewn technique, over invagination of the second (seromuscular) layer of the wall of the jejunum might become so thick at the site of the closure that it acts as a lead point for intussusception. We reported a case of such a scenario.

Highlights • Metastatic undifferentiated pleomorphic sarcoma (Malignant Fibrous Histiocytoma) is a rare entity in the visceral organs. • We report a case of a metastatic primary cardiac undifferentiated pleomorphic sarcoma which presented with a recurrent small bowel intussusception in a young man. • Laparotomy by a small midline incision performed on the same day identified an intussusception of a 15-cm section of small intestine caused by a 4-cm intraluminal metastasis from undifferentiated pleomorphic sarcoma. • Metastasis intussusception in the small intestine is a very rare condition and they are part of differential diagnosis in patient with a history of tumor who present with intussusception., Introduction Undifferentiated metastatic pleomorphic sarcoma (Malignant Fibrous Histiocytoma) is a rare entity in the small intestine, especially when the primary tumor is of cardiac origin. Case Report We report a case of metastatic intestinal undifferentiated pleomorphic sarcoma in a young patient with a history of primary cardiac tumor in the left atrium and recurrent small bowel intussusception. He was admitted for abdominal pain and constipation. A segmental resection of the small intestine was performed with side-to-side entero-enteroic anastomosis. Discussion Intussusception of the small bowel is rare in adults and it represents about 1–3% of intestinal obstructions. It mainly affects the fifth decade with a male/female ratio of 1:5 More than 60% of patients with intussusception have a tumor with 50% being malignant. This type of intussusception can be diagnosed on the CT abdominalscan. Radiological features include a typical “target” sign with overdistention of the proximal intestine and air-fluid levels, but the diagnosis of certainty is made by exploratory laparotomy. Conclusion The metastatic tumors that cause intussusception represent a rare clinical condition in adult patients, but much more common than primary ones. Metastasis to the small intestine are part of differential diagnosis in patient with a history of tumor who present with intussusception.

Highlights • Lymphangioma is a benign tumor that rarely arises in gastrointestinal tract. • Small bowel lymphangioma can cause intussusception in adults. • The symptoms of small bowel intussusception in adults resemble those of adhesive small bowel obstruction. • Reduction is not sufficient and surgical resection of affected bowel should be performed., Introduction Adult intussusception and lymphangioma in gastrointestinal tract are uncommon entities respectively. Recurrent intussusception due to lymphangioma of the small intestine is extremely rare and mimics adhesive small bowel obstruction (SBO). Presentation of case A 37 year old man presented with acute abdominal pain and vomiting. He had been admitted several times for adhesive SBO after laparoscopic cholecystectomy at age 21. He was initially managed with a long tube placement, with which he used to get well. This time, the symptoms once relieved but soon relapsed, so an exploratory laparotomy was performed. Intraabdominal adhesiolysis was performed alongside the excision of a small segment of damaged jejunum. Intussusception of jejunum was noted and its reduction was also performed. Unfortunately, the symptoms continued after the operation, and computed tomography revealed a recurred intussusception of the jejunum. A reoperation with an additional resection of small intestine surrounding intussusception was performed. The symptoms subsided after the second operation and the patient was discharged. Pathological examination revealed lymphangioma within the affected lumen. Discussion Intussusception in an adult is often caused by a tumor but can be caused by postoperative adhesion. The reduction is a potential option of treatment if there is no tumor suspected, but sometimes it would be uneasy to affirm the non-existence of tumors. Conclusion We present this rare case of recurrent jejuno-jejunal intussusception caused by small bowel lymphangioma with review of literature. Taking the possibility of recurrence and malignancy into account, the resection should always be considered in such patients.

Highlights • Assault with iron made belan is the first case in its kind to be reported as per my best knowledge. • Penetration of iron made belan inside the vagina is the rare mode of assault. • Timely intervention, and definitive surgical interventions to control bleeding are the key steps in managing such patient. • The secondary survey is very important to assess the extent of injury with such a rare weapon., Introduction Assault with iron made belan causing penetration of it into vagina and perforation of posterior fornix is extremely rare. The commonly used weapon in assault are knife, wood, iron stick, wire, bomb or gun and most commonly affected body parts are cheeck, throat, back, abdomen, chest wall and extremities. Presentation of case We report a case of iron made belan penetrated into vagina with posterior fornix perforation and mesenteric tear in a 30 years old lady with history of pregnancy of 14 weeks. She was haemodynamically unstable at the time of presentation. She was treated with advanced trauma life support Protocol (ATLS), taken to operation room where iron made belan was removed with repair of posterior fornix and mesentery was done. Discussion Assault to genital organ in female is not uncommon. In present case the offender used the metallic iron made belan for assault which is the house hold material in India. In such situation high degree of suspicion and diagnostic modality are helpful to save the golden hour of patient and save the life of patients. General principles of trauma management is really very helpful to save the life threatening conditions. Urgent exploratory laparotomy with control of bleeding and repair of damaged structures are the cornerstone steps to manage such cases. Conclusion Assault with iron made belan and its penetration inside vagina is extremely rare mode of injury. Timely intervention, concept of ATLS and definitive surgical interventions are the key steps in managing such patient.

Highlights • Diverticuli are found throughout the gastrointestinal tract from esophagus to rectum. • In the jejunum diverticuli are most commonly proximal, multiple and asymptomatic. • A large solitary jejunal diverticulum caused life endangering midgut volvulus. • In the absence of timely surgical intervention the condition would have been fatal., Background Jejunal diverticula are a rare subtype of false diverticula found in the gastrointestinal tract. When present, they are usually multiple, in the proximal jejunum and asymptomatic. Rarely, they can cause acute complications that can develop into an acute abdomen requiring surgical intervention. We present the rare manifestation of a single jejunal diverticulum causing midgut volvulus and bowel ischemia. Early surgical intervention with small bowel derotation allowed complete recovery. Methods Data regarding the case, operative intervention, and patient follow-up was prospectively accumulated with permission of the patient at an academic institution. All patient identifiers were removed. All research steps were performed under guidance outlined in the SCARE criteria. Results We present the case of a 78-year-old man who presented to our institution with an acute abdomen. CT imaging demonstrated a whirlpool sign without an obvious lead point. The patient was without prior surgical intervention. Urgent exploratory laparotomy revealed a midgut volvulus with associated bowel ischemia and impending infarction secondary to adhesive disease from a large single jejunal diverticulum. Derotation resulted in gradual recovery of bowel vascularity. Resection of the portion of the jejunum containing the diverticulum resulted in full clinical recovery of the patient. Conclusions Complications of jejunal diverticula, although rare, should be considered as part of the differential diagnosis of an acute abdomen of unknown etiology. Urgent surgical intervention was required to avoid a potential catastrophic outcome.

Highlights • We should consider the differential diagnoses of an abdominal cyst. • In premenopausal women, ovarian cysts are frequent and may grow to considerable size. • Some ovarian cysts cause symptoms, such as obstipation, vomiting and malnourishment. • US is the primary imaging study for an ovarian cyst. • Persistent simple ovarian cysts larger than 10 cm should be considered for surgery., Introduction Most abdominal cysts derive from the ovary. The range of differential diagnoses is wide. Unfortunately, imaging studies not always determine its origin. Presentation of case The authors present the case of a 20-year-old female patient, admitted to the emergency department due to abdominal pain and distension, whose imaging studies revealed a gigantic abdominal cyst of unknown origin. She underwent an exploratory laparotomy that disclosed an ovarian cyst that was removed by a left adnexectomy. It weighed 10Kg and was 60 cm wide. The pathology report showed a mucinous cyst adenoma. Discussion Once a patient present with an abdominal cyst, one should always consider the extensive list of differential diagnoses. In premenopausal women, ovarian cysts are very frequent. Cysts may grow to considerable size. Our patient was symptomatic, malnourished and dehydrated. Neither ultrasonography nor computed tomography were able to define the origin of the cyst. Persistent ovarian cysts larger than 10 cm, particularly if symptomatic, should be considered for surgery. Conclusion Progressive abdominal distension in premenopausal women should raise suspicion of an ovarian tumor, such as mucinous cystadenoma. These tumours are benign, but when their size is considerable, complications do arise and their surgical removal may be life threatening.

Highlights • The unicentric form of Castelman's disease (CD) is rarely present as an isolated retroperitoneal tumor. • Because of its rarity even experienced surgeons may misdiagnose retroperitoneal CD. • Surgeons should consider this disease because surgical resection is the only treatment of the unicentric form., Introduction Castleman’s disease (CD) is a rare disorder characterized by benign angio follicular lymphoid hyperplasia, with gentle behavior. Its etiology and prevalence are unclear. It is usually found in the mediastinal area and it is rare to see this tumor in the retroperitoneum. Presentation of case A 53 year old male with a retroperitoneal hypervascular calcified mass densely adherent to the psoas muscle that was accidentally encountered on a CT scan. Provisional diagnosis of retroperitoneal liposarcoma was made and the patient underwent an exploratory laparotomy. The histologic examination of the surgically resected specimen disclosed « a hyaline type of Castleman’s disease ». Discussion Castleman’s disease, is a rare heterogenous group of lymphoproliferative disorders that arises mostly in the mediastinum. The retroperitoneal localization is very rare. Clinically, CD can be subdivided into a localized form (unicentric disease) and a generalized form (multicentric disease) according to the number of lymph nodes involved. A careful histological and immunohistochemical examination of the tumor tissue after surgery is the only way for tumor diagnosis. Conclusion Castelman’s disease is a rare entity that has often benign and non invasive behavior, but remains a diagnostic challenge. There is no reliable diagnostic method and its definitive diagnosis is based on histopathology report. For treating the unicentric variant, radical surgical resection is considered to be the gold standard.

Highlights • Development of a triad of intussusception, volvulus, and internal hernia after RYGB surgery is rare. • In patients with history of RYGB and acute abdomen, high suspicion for obstructive complications is required to allow for timely diagnosis and early surgical intervention. • Early surgical intervention of SBO secondary to RYGB was sufficient for preventing bowel necrosis and subsequent bowel resection., Introduction The Roux-en-y gastric bypass (RYGB) surgery is one of the most common and successful weight loss procedures. Procedure mortality is low, but intestinal complications account for a high percentage of associated morbidity. Internal hernias remain one of the most common complications while volvulus and intussusception are rare. Presentation of case A 22-year-old woman with a past surgical history of laparoscopic RYGB six years prior presented with a 12 -h history of abdominal pain. Exploratory laparotomy revealed concomitant volvulus, internal hernia and intussusception at the J-J anastomosis which was reduced without need for bowel resection. Her post-operative course was unremarkable and she was discharged home five days later. Discussion Many previous cases of intussusception related to RYGB surgery have required treatment with bowel resection secondary to delayed surgical intervention. Due to high variability in clinical presentation of post-RYGB obstruction, a high index of suspicion is necessary for prompt recognition. Early surgical intervention may prevent the need for bowel resection and improve patient outcomes. Conclusion This case represents an unusual complication of RYGB involving intussusception, internal hernia and volvulus that was successfully managed without need for bowel resection due to early identification and surgical intervention.

Glomus tumors occur preferentially in the subcutaneous tissue of the fingers and toes, but are extremely rare in visceral organs. Although, there have been several reports of glomus tumors in the liver in adult patients, there have yet been no publications reporting glomus tumors of the liver in children. Here, we report a case of an 11-year-old girl who was admitted with a 2-week history of progressive dyspnea on exertion and vomiting. Upon physical examination, she was found to have hypertension and a palpated smooth, firm mass at the epigastrium. Abdominal MRI revealed a well-defined exophytic hypervascular mass with intratumoral hemorrhage at segment 3/4b of the liver. Ultrasound-guided biopsy revealed it to be a glomus tumor. An ultrasound conducted at a 1-month follow-up after preoperative embolization revealed that the mass had decreased in size. A subsequent exploratory laparotomy with left hepatectomy was performed and the histologic results confirmed the diagnosis. Keywords: Glomus tumor, Glomangioma, Hypervascular liver tumor, Hepatic tumor, MRI, Magnetic resonance imaging

Introduction Coronavirus disease 2019 (COVID-19) is an acute respiratory tract infection caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV2). Recent evidences mentioned the possibility of COVID-19 as a systemic infectious and inflammatory disease. Signs and symptoms of liver and gastrointestinal system are often found in post-acute COVID-19 patients. However, there are only few data found about liver abscess and necrosis in post COVID-19 patients. Case presentation A 49-year-old man admitted to the hospital with dyspnea, nausea, loss of appetite and epigastric pain, post confirmed SARS CoV-2 severe pneumonia 1 month ago in ICU with noninvasive ventilator (NIV), enoxaparin, tocilizumab, azithromycin, levofloxacin, hydroxychloroquine, and no preexisting liver condition. Swab PCR result was negative. The result of abdominal computed tomography (CT) scan with contrast was liver abscess formation with hemorrhages measuring about 16 × 12 × 11 cm & 10 × 9x9 cm occupying most of the right lobe liver. The patient underwent exploratory laparotomy, there were multiple liver abscesses in segment 8 with parenchymal liver necrosis and abscesses in segment 7 of liver. Necrosectomy and liver abscess drainage was performed. Clinical discussion Pathophysiology of liver damage in post COVID-19 are direct cytotoxicity of SARS-CoV2, immune-mediated due to severe systemic inflammatory response syndrome (SIRS) in COVID-19, hypoxemia, vascular changes due to coagulopathy, endothelitis or congestion from right heart failure, and drug-induced liver injury (DILI). Conclusion The possible pathophysiology of liver abscess and necrosis in post COVID-19 should be considered in monitoring and management for both COVID-19 patients and post COVID-19 patients., Highlights • Gastrointestinal symptoms are often found in post COVID-19 patients. • Liver abscess and necrosis in post COVID-19 patients should be considered. • Direct cytotoxicity of SARS-CoV2, severe systemic inflammatory response syndrome (SIRS), hypoxemia, coagulopathy, endothelitis or congestion from right heart failure, and drugs could induced liver damage in post COVID-19 patients.

Introduction and importance Meckel's Diverticulum (MD) is the most occurring congenital anomaly of the gastrointestinal tract. It characterizes a patent remnant of the omphalomesenteric duct. Despite remaining asymptomatic most of the time, the rarity of its occurrence is reflected by the scarcity of data involving it in the literature. Gastrointestinal bleeding, bowel obstruction, and inflammation are the most prevalent complications of MD. Perforation of MD is very rare. Case presentation We present the case of a previously healthy 32-year-old female, who presented to the emergency department with a 2-day-history of generalized abdominal pain. Radiological analysis suggested a perforated viscus and an inflamed Appendix. Clinical discussion Our patient was diagnosed preoperatively with perforated hollow viscus and an exploratory laparotomy was indicated. Intraoperatively, a perforated MD was found and treated by surgical excision of the affected loop of bowel with end-to-end anastomosis and the specimens were sent for histopathological analysis. Histopathology revealed a perforated MD containing gastric mucosa. The patient had successful recovery. Conclusion Early recognition with swift surgical intervention must take place to provide therapeutic outcome for patients and to limit the resulting morbidity. This case highlights the necessity of considering MD as core differential diagnosis in patients with acute abdomen. Due to the scarcity of data on perforated MDs in adult females, it's worthy of studying to highlight its incidence. Due to the rarity of a perforated MD in an adult female, it's worthy to consider such cases to explore preoperative assessment techniques, surgical interventions options, and postoperative complications., Highlights • MD is a rare gastrointestinal anomaly comprising 2% of congenital abnormalities of the GI tract. • Complications of MD range from GI bleeding, diverticulitis, neoplasm, to perforation. • MD mostly remains silent and is rarely complicated in adults, especially in adult females. • Perforation of MD is the rarest of the complications and it would mostly occur in males rather than in females.

The maternal death rate remains unacceptably high worldwide, predominantly in areas of poor access to quality health services. According to the WHO, in 2017, 810 women died from preventable causes related to pregnancy and childbirth. Causes of maternal death are plenty, including previous morbidity and unexpected causes. Among the latter are infectious disease-related deaths. Herein, we describe a case of a 29-year-old woman at 37 weeks’ gestation who presented with right upper quadrant pain, which was initially considered to be pregnancy-related. However, she collapsed shortly after the hospital admission. The physical examination revealed severe hypovolemic shock due to a large amount of intraperitoneal free fluid. The patient was immediately rushed into an emergency cesarean section followed by exploratory laparotomy, which demonstrated a large intra-abdominal hemorrhage. The patient and her fetus died in the operating room. An autopsy revealed acute gangrenous cholecystitis along with abundant rod-shaped bacteria within the mucosa and vessels of the gallbladder, gas gangrene and rupture of the spleen, and signs of shock. Clostridium perfringens (CP) was isolated in the culture of a splenic sample. Although CP is a well-known and dreadful infectious etiological agent, catastrophic cases still happen. The acquaintance of this infection by the caregivers is crucial for the early diagnosis and treatment. This is a quite unique way to provide a dismal chance of survival in sepsis cases by this agent.

Introduction Gastric outlet obstructions (GOO) are extremely rare outside of congenital conditions. We present a case in which a premature newborn developed a gastric outlet obstruction secondary to peritoneal drain placement for necrotizing enterocolitis (NEC). Case description A premature infant born with extremely low birth weight was admitted to the NICU. Failed attempts at an orogastric tube placement caused an esophageal perforation and pneumomediastinum which was conservatively managed. The infant developed pneumoperitoneum secondary to necrotizing enterocolitis, indicating surgical management. A Penrose peritoneal drain was placed for abdominal decompression. A gastric outlet obstruction developed, causing concern for gastric volvulus. A bedside exploratory laparotomy was performed to address the gastric outlet obstruction and intestinal perforation. GOO was caused by a kink in the peritoneal drain, which was removed, an ileostomy was created at the site of ileum perforation, and the stomach was decompressed with a gastrostomy tube. Ileostomy was reversed at 6 weeks without complication. Conclusions Peritoneal drain placement for necrotizing enterocolitis is a well-established treatment alternative to an exploratory laparotomy. Gastric outlet obstruction caused by the drain is a complication that has not been reported. The inability to pass an orogastric tube to decompress the stomach further complicated the case requiring a more invasive approach with a laparotomy.

Introduction and importance Desmoid tumors of the abdominal wall are rare fibroblastic proliferative tissue, included in the group of soft tissue tumors, not metastasizing but locally aggressive as an infiltrating tumor and a source of recurrence. Case presentation This case report describes a rare case of desmoid tumor of the anterolateral abdominal wall presented with a large mass of the left flank and iliac fossa. The diagnostic was suspected radiologically following an abdominopelvic computed tomography (CT) and magnetic resonance imaging (MRI). An exploratory laparotomy found a large mass infiltrating the left rectus abdominis muscle, a part of the flat left abdominal muscles, and the left iliac crest. The patient underwent a total resection of the mass involving the left rectus muscle with autoplasty by a pedicled flap of the left LATA fascia with the placement of a bifacial mesh. Histologic analysis of the operatory specimen confirmed the diagnosis of a desmoid tumor of the abdominal wall. The patient has been discharged from the hospital on the fifth day post-operatory with an uneventful recovery; she was in good health after a one-year follow-up. Clinical discussion Desmoid tumors of the abdomen are very rare. Although this tumor is histologically benign, it has the potential of invading vital structures and has a high rate of local recurrence. Histology staining confirms the diagnosis, surgery is the gold standard in the management of this pathology. Conclusion We highlight the importance of radical surgical excision to avoid desmoid tumor complications and to minimize the recurrence risk., Highlights • Desmoid tumor are rare benign tumor with potential of invading adjacent structures. • The final diagnosis is made upon pathology study. • Complete en-bloc resection is the gold standard treatement. • The rate of recurrence is very high, and depends on the quality of the resection.

Introduction and importance The Potter sequence is defined as a series of congenital defects related to severe oligohydramnios, associated with polycystic kidney disease, bilateral renal agenesis, pulmonary hypoplasia, obstructive uropathy and premature rupture of membrane, which compromises the life of the neonate sometime after birth. Within the evidence published so far, which is very little, no perforation of the gastrointestinal tract has been reported as a complication of this condition. Case presentation Male neonate born preterm with prenatal diagnosis of pulmonary hypoplasia, polycystic renal dysplasia and severe oligohydramnios (Potter sequence), presented acute respiratory distress syndrome 10 min after birth, requiring mechanical ventilation and admission to the intensive care unit. During her stay in intensive care, he developed abdominal distension and presence of biliary content in the nasogastric tube. An abdominal X-ray was performed and showed signs of pneumoperitoneum, evidencing gastric perforation on exploratory laparotomy. Clinical discussion Gastric perforation in neonates is a condition that causes high health costs, morbidity, high risk of mortality and disability, regardless of the cause. The management of gastric perforation in Potter syndrome, as well as any other complication, represents a challenge due to the prognosis of these patients. Renal failure and acute respiratory distress syndrome are disorders that compromise the function of various structures and organs such as the heart and brain. Conclusion Gastric perforation is a possible complication of the Potter sequence or syndrome. In addition, there is no literature describing the benefits or disadvantages of specific surgical techniques in the resolution of perforation., Highlights • Spontaneous perinatal gastric perforation is a complication of Potter's syndrome. • Pathophysiological mechanism of gastric perforation in these cases is unknown. • There is a lack of evidence on the management of potter's syndrome.

Introduction and importance Cryptorchidism is seen in 3% of fullterm neonates. Rarely, it may cause small bowel obstruction. Knowledge of this presentation of cryptorchidism is essential to treat bowel obstruction arising due to cryptorchidism before the patient suffers complications. Case presentation We present a case of a patient who underwent exploratory laparotomy for small bowel obstruction that did not resolve with conservative management. At laparotomy, on initial exploration, this patient had adhesive bands causing the small bowel obstruction. On further exploration, the bands were found to arise from a cryptorchid testis. Clinical discussion Cryptorchidism is a common finding among newborns and needs to be corrected by 1 year of age. Failure to correct cryptorchidism in a timely manner can result in complications such as bowel obstruction. Conclusion Thorough intraoperative exploration is key at operation for all cases of small bowel obstruction, so as to find and treat anatomic causes of obstruction. Congenital causes of bowel obstruction should be suspected in all unexplained cases of bowel obstruction and may be revealed by careful physical examination and thorough intraoperative exploration., Highlights • Cryptorchidism is common and requires correction by 1 year of age. • Uncorrected cryptorchidism can present with complications such as bowel obstruction. • Complete examination physical including the scrotum, is needed in bowel obstruction. • Thorough intraoperative exploration helps find multiple points of bowel obstruction. • Bowel obstruction in patients without prior surgery needs operative exploration.

Introduction Spontaneous bladder rupture SBR is a rare condition and often missed diagnosis, especially after a nontraumatic vaginal delivery. Case presentation A 34-year-old patient who had a nontraumatic vaginal delivery presented to the emergency room 7 days later with acute abdomen and anuria. Computed tomography showed free fluid in the peritoneal cavity. An intraperitoneal rupture of the bladder dome was detected, showing extravasation of contrast into the peritoneal cavity. An exploratory laparotomy revealed a perforation on the bladder dome that was sutured. Clinical discussion SBR following vaginal delivery is an extremely rare condition. It represents a surgical emergency. Due to the low incidence and the presence of non-specific symptoms, diagnosis was usually delayed with an increased morbidity and mortality. Clinicians should consider this diagnosis in the presence of an acute abdominal pain associated to anuria or dysuria. We therefore recommend that the bladder be catheterized or drained before labour. Conclusion SBR is a rare and life-threatening condition in post-partum. Abdominal pain with elevated serum creatinine should be suspicious of urinary bladder rupture., Highlights • Spontaneous bladder rupture following vaginal delivery is an extremely rare condition. • Clinicians should consider this diagnosis in the presence of an acute abdominal pain and anuria with elevated serum creatinine • It is necessary to highlight the risk of bladder rupture occurring early in order to improve their management.

Introduction A decompensated cirrhosis sometimes develops collateral circulation due to severe fibrosis. Rupture of this collateral circulation can induce a fatal situation. Case presentation A 59-year-old man with alcoholic cirrhosis was admitted to our emergency department with a chief complaint of impaired consciousness. The patient had hypotension upon arrival, and enhanced computed tomography (CT) revealed a massive hemoperitoneum. Imaging examinations, including interventional radiography, could not identify the source of bleeding preoperatively; therefore, emergency surgery was performed. Intraoperatively, a collapsed small vessel connecting liver segment 4 and the expanded umbilical vein as collateral circulation due to portal hypertension was detected as the source of bleeding. Ligating the stump of the small vessel and postoperative intensive care saved the patient's life. The patient was discharged from our hospital 14 days after the surgery. Clinical discussion A rupture of the umbilical vein associated with cirrhosis is rare and causes a critical situation because of the fast blood flow in the collateral circulation caused by portal hypertension. Moreover, the amount of bleeding tends to increase since the abdominal cavity is a free space and patients with cirrhosis have coagulopathies, including thrombocytopenia and prolonged prothrombin time. Although a retrospective review of the enhanced CT image could identify the minute findings, arterial portography was insufficient to detect bleeding from the umbilical vein. Therefore, emergency exploratory laparotomy was required for the diagnosis and treatment. Conclusion Rupture of the reopened umbilical vein can cause idiopathic spontaneous hemoperitoneum in patients with decompensated cirrhosis., Highlights • A rupture of the umbilical vein due to cirrhosis can induce fatal hemoperitoneum. • Interventional radiology could not detect the source of bleeding. • Emergency surgery is required for idiopathic hemoperitoneum in liver cirrhosis.

Introduction Inflatable penile prostheses (IPP) consist of 2 cylinders implanted into the corpora cavernosa, a pump placed in the scrotum, and a saline-filled reservoir traditionally placed in the space of Retzius. IPPs are used to treat refractory erectile dysfunction with few rare, but serious, complications. Cases of reservoirs causing erosion into the bladder, small bowel obstructions, vascular compression, and inguinal herniation have been described. Aim We highlight the importance of keeping a broad differential diagnosis when assessing patients with bowel obstructions. Methods A 68-year-old man with a previous IPP placement presented with left lower quadrant abdominal pain, constipation and obstipation for 5 days. On exam, he was afebrile, and noted to have a firm, distended, tympanic abdomen. CT scan showed a distended cecum at 11 cm, narrowing of the proximal sigmoid with adjacent inflammatory changes, and minimal peri-colonic air, suggestive of a localized perforation. The IPP reservoir was seen in the left iliac fossa, coinciding with the lead point of the obstruction, suggesting that the reservoir may have itself caused the obstruction. The patient was taken to the operating room for an emergent exploratory laparotomy, which revealed a mass in the colon abutting the IPP reservoir. Main Outcome Measures Considerations for IPP component explantation, factors considered for reintervention, and preservation of penile length with avoidance of penile fibrosis. Results A left colectomy with transverse colostomy was successfully performed and the IPP reservoir was explanted. Intraoperative frozen section revealed adenocarcinoma. Upon initial review of the imaging, it was thought that the IPP reservoir may have caused the obstruction, but intraoperatively, the colonic tumor was found to be the culprit. Conclusion Although complications related to IPPs, including bowel obstructions, have been previously described in the literature, treatment for large bowel obstructions must take into account all possible etiologies, including malignancy. Atri E, Mallory C, Perez A, et al. A Case Report of Large Bowel Obstruction in a Patient With an Inflatable Penile Prosthesis. Sex Med 2021;9:100391.

Case of a male infant delivered at 36 weeks of gestational age and found to have a giant omphalocele, later complicated by intestinal perforation. A giant omphalocele is an omphalocele with an opening greater than 5 cm in diameter and containing the liver. It represents a therapeutic challenge secondary to viscero-abdominal disproportion, limiting the feasibility of a primary closure. Nowadays, the standard of care for giant omphaloceles is to adopt the “paint and wait” approach with delayed closure. Intestinal perforation is a rare complication of omphaloceles. Prior reports in the literature describe intestinal perforation in the setting of small to medium size omphalocele treated with operative exploratory laparotomy to address the intestinal perforation, followed by either primary or staged closure of the abdominal wall. We report the case of an infant with giant omphalocele who developed intestinal perforation at 4 weeks of life while undergoing “paint and wait”. He was managed non-operatively with peritoneal drains, antibiotics, and supportive care, while continuing with the “paint and wait” approach until he was optimized for operative repair of his giant omphalocele.

Introduction and importance A Littre's hernia (LH) is defined by the presence of Meckel's diverticulum (MD) in any kind of hernia sac. Preoperative diagnosis of LH is a challenge because of its rarity and the absence of specific radiological findings and clinical presentation. Surgery is the appropriate treatment of complicated LH that is an extremely rare condition with approximately 50 cases reported in the literature over the past 300 years. Case presentation A 46-year-old Caucasian female was admitted to the Emergency Department with a two-day history of abdominal pain. Physical examination revealed an irreducible and painfull mass in umbilical region. Abdominal computed tomography scan showed the protrusion of greater omentum and small bowel loop through the umbilical ring. Laboratory tests were unremarkable. After diagnosis of strangulated umbilical hernia, the patient underwent exploratory laparotomy: the irreducible umbilical hernial sac was opened with presence of incarcerated and strangulated omentum and uncomplicated MD. Resection of incarcerated and ischemic greater omentum alone was performed. The postoperative course of patient was uneventful. Clinical discussion Meckel's diverticulum (MD) is a vestigial remnant of the omphalomesenteric duct, representing the most common congenital malformation of the gastrointestinal tract. Preoperative diagnosis of LH is very difficult and surgery represents the correct treatment of complicated LH. Conclusion LH represents an extremely rare complication of MD difficult to diagnose and suspect because of the lack of specific radiological findings and clinical presentation. Surgery represents the appropriate treatment of abdominal wall hernias and complicated MD., Highlights • A Littre's hernia (LH) is defined by the presence of Meckel's diverticulum (MD) in any kind of hernia sac. • LH is an extremely rare complication of MD and its preoperative diagnosis is very difficult. • Surgery represents the appropriate treatment of abdominal wall hernias and complicated MD. • Routine resection of uncomplicated MD is not advised and it should be based on identified MD’ s risk factors.

Introduction Peritoneal loose bodies are rare, often asymptomatic lesions that can be found during radiologic examinations or abdominal surgery. They don't require specific treatment unless they are complicated. Presentation of case We present a rare case of incidentally diagnosed peritoneal loose body in a 38 years old man who undergone exploratory laparotomy for the diagnosis of hypovolemic shock secondary to acute intra-abdominal bleeding with solid organ injury secondary to blunt abdominal trauma and left proximal tibia fracture. Discussion Symptomatic peritoneal loose bodies present with compressive symptoms of urinary system or bowel obstruction. As a result, they create diagnostic dilemmas in patients with previous history of abdominal surgery who present with acute abdominal pain, commonly confusing with retained foreign body. Conclusion Although most incidental loose bodies are diagnosed intraoperatively on laparatomies done for other indications, it's very unusual to suspect such findings in hemodynamically unstable polytrauma patient undergoing surgical exploration. Considering the diagnostic challenges they create in post-operative patients presenting with abdominal complaints, its better practice to consider such rare findings when exploring the abdomen in trauma settings., Highlights • Peritoneal loose bodies are quite rare intra-abdominal lesions. • Most peritoneal loose bodies are asymptomatic. • Loose bodies encountered during abdominal exploration should be removed. • Pre-operative diagnosis of loose bodies is very difficult.

Highlights • Uterine laceration is extremely rare and little known, however it sometimes causes massive intraperitoneal bleeding and has poor prognosis. • Inner myometrial laceration may be caused by intrapartum physical stress, whereas uterine laceration in relatively early pregnancy might be occurred by tissue inadaptable for uterine enlargement. • To diagnosis uterine laceration in early pregnancy is quite difficult because of the absence of specific clinical findings. • Not only uterine rupture but also uterine laceration should be considered, and exploratory laparotomy should be performed appropriately when hemoperitoneum is strongly suspected., Introduction Although uterine rupture is well discussed, uterine laceration and partial myometrial laceration are little known. A previous report hypothesized that the stress of labor was associated with uterine laceration. Presentation of case We present a rare case of uterine laceration in a patient in the second trimester. A 34-year-old primigravida woman at 16 weeks’ gestation without a history of uterine surgery complained of sudden low abdominal pain. Ultrasonography showed fetal death and intraperitoneal free fluid. A laparotomy was performed, and partial uterine laceration in the posterior wall along with active bleeding was confirmed. Discussion The etiology of uterine laceration in early pregnancy might be different from both classical uterine rupture and previously published uterine laceration. We hypothesized that tissue inadaptable for uterine enlargement, such as that owing to endometriosis and subtle injury by surgical approach, may be associated with the onset mechanism. Conclusion The diagnosis of uterine laceration in early pregnancy is quite difficult because of the absence of specific clinical findings. However, it sometimes causes massive intraperitoneal bleeding and has poor prognosis. Therefore, when uterine laceration is suspected as a cause of hemoperitoneum in a pregnant women, clinicians should perfume exploratory laparotomy appropriately.

Introduction Biliary ascariasis, although uncommon, can lead to infectious complications and severe outcomes. This study reported three patients with biliary ascariasis and who were admitted to a paediatric hospital in Salvador, Brazil. Case reports Case 1: A 1-year-old boy, with HIV, hospitalised with diarrhoea, fever, pain, and abdominal distension. He underwent an exploratory laparotomy, which showed peritonitis secondary to a perforation of the hepatic duct by ascaris. Case 2: A 3-year-old boy admitted with fever, abdominal pain and jaundice. Imaging examination was suggestive of ascaris in the intrahepatic biliary tract and a hepatic abscess. Case 3: A 7-year-old boy who was hospitalised with a history of abdominal colic, jaundice and fever, with a suggestive image of ascaris in the biliary tract and evolution to sepsis. Discussion Three cases of biliary ascariasis were reported with severe infectious complications involving peritonitis, hepatic abscess and sepsis. Conclusion In endemic regions, biliary ascariasis should be considered in cases with jaundice, abdominal pain and fever, due to its morbidity and risk of complications.

Highlights • Phytobezoar is described as an impacted indigested or incompletely digested vegetable and fruit fibers. • Bezoar is a rare cause of gastric outlet obstruction. Being multiple and giant is even rarer. • The aim of this study is to report a case of unusual gastric outlet obstruction by two giant bezoars., Introduction Phytobezoar which is described as an undigested or incompletely digested food. It is an odd cause of gastric outlet obstruction (GOO). The aim of this study is to present and discuss a case of GOO caused by multiple giant bezoars. Case report A 24-year-old female, presented with abdominal pain and vomiting (non-bilious) with negative past history. Examination and investigations revealed multiple giant bezoars requiring emergent surgical intervention. An exploratory laparotomy was conducted. Two giant bezoars were palpated in the stomach and removed through an anterior gastrotomy. Discussion Bezoars are regarded as rare benign causes of GOO. Bezoars can present with vomiting, nausea, and/or symptoms of GOO. Predisposing risk factors include delayed gastric emptying (as in case of diabetic mellitus) vagotomy, partial gastrectomy pyloroplasty, peptic ulcer disease, chronic gastritis, Crohn’s disease, and carcinoma of the gastrointestinal tract. The current case had phytobezoar without any known risk factor. Conclusion GOO caused by phytobezoar can occur in patients without history of previous gastric surgery or diabetes mellitus. Urgent laparotomy may be indicated.

Introduction Acute liver failure (ALF) secondary to malignant infiltration of the liver from urothelial carcinoma is a very rare clinical condition and is often diagnosed only after death. Upper tract urothelial carcinoma (UTUC) is a rare, from 5% to 10% of all urothelial tumours, but possible cause of ALF when there is extensive liver metastatic involvement. We report the case of a patient who died in the intensive care unit (ICU) of our hospital from multiple organ failure (MOF) secondary to ALF, as a result of infiltration of the liver from UTUC diagnosed after surgery. PRESENTATION OF THE CASE: A 69-year-old Caucasian man was referred to our hospital for hematuria, melena, right upper quadrant (RUQ) pain and jaundice developed over the previous two weeks. After multidisciplinary discussion, he underwent emergency exploratory laparotomy to perform cholecystectomy because of suspected acute cholecystitis considered as a septic focus within the left kidney. He developed MOF and died on the 6th postoperative day. Discussion From the diagnosis of the renal mass and the death of the patient, a few days have passed, and the diagnosis of UTUC has been put only at histological examination.The most common sites of metastases from UTUC are lymph nodes, lungs, liver, bones and peritoneum. Moreover, liver metastases have been identified to have an independent negative impact on overall survival in a patient affected by UTUC. Conclusion The authors suggest that this condition should be taken into account when dealing with patients with evidence of a renal mass and simultaneous ALF., Highlights • Unusual clinical presentation of acute liver failure from upper urothelial carcinoma (UTUC). • Rarely these diseases are managed in the emergency setting. • This condition should be taken into account when dealing with patients with evidence of a renal mass and simultaneous ALF.

Highlights • In a polytrauma patient with a blunt abdominal trauma and unclear imaging studies the urgent laparotomy is a better choice then wait and see. • Intestinal and mesenteric injuries are less common and due to diagnostic difficulties they can result in therapeutic delay with severe complications. • The preservation of the ileo-cecal is an important approach., Introduction A blunt abdominal trauma especially in organs less commonly injured (such as small bowel and mesentery injury), are difficult to diagnose. Presentation of case We report a case of a blunt abdominal trauma, in a 43 year old male presented in the Emergency Department after a truck vehicle accident. He sustained a chest injury, a pelvic fracture and diffuse abdominal tenderness. The patient had tachycardia (120 pulses/min) and normal blood pressure (120/90 mm Hg). The computed tomography (CT) showed only free fluid. We placed two chest tubes (due to pneumothorax and hemothorax at both sides) and the patient went to the operating room (OP). An external pelvic osteosynthesis was performed first and then we did an exploratory laparotomy, which revealed a big mesenteric rupture. Finally, an enterectomy (circa 2 m) with a fist stage side to side anastomosis was performed. Discussion Mesentery and bowel injury constitutes 3–5% of blunt abdominal injuries. The main diagnostic challenge is to identify lesions that require surgery. Diagnostic delay over 8 h can lead to high morbidity and mortality rates. Laparotomy is the standard of care in hemodynamically unstable patients. Conclusion In polytrauma cases with abdominal pain and unclear CT findings the decision to proceed with exploratory laparotomy is better than a conservative treatment, because any surgical delay can lead to severe complications.

Introduction Leiomyomatosis peritonealis disseminata (LPD) is a rare disease that can be challenging to diagnose. In this report, we present a case of LPD arising 5 years after laparoscopic uterine myomectomy using a power morcellator. Presentation of case A 32-year-old woman was admitted to our hospital with complaints of vaginal bleeding and abdominal discomfort. Five years previously, she had undergone laparoscopic uterine myomectomy using a power morcellator. Pelvic ultrasonography and magnetic resonance imaging demonstrated multiple pelvic tumors closely attached to peritoneum with no indication of malignancy. An exploratory laparotomy revealed multiple sites of leiomyomatosis in the peritoneum, especially on the parietal peritoneum at the port site of the previous laparoscopic surgery. We surgically removed all visible tumors and performed a total hysterectomy. Histologic examination confirmed the diagnosis of LPD. Discussion The use of a power morcellator without in-bag containment system might have played a role in the pathogenesis of LPD in our case. Ultrasonography, computed tomography, and MRI are among the most effective to distinguish between leiomyomas and other solid tumors in the pelvis, but they are not of great help in the differential diagnosis of malignancies. Conclusion The physicians need to combine medical history, clinical findings, imaging techniques and histopathological examination to establish a correct diagnosis of LPD. The application of containment bags in the setting of power morcellation should be considered to reduce the risk of developing LPD. The optimal intervention strategy should be chosen according to the particular features of each patient., Highlights • Leiomyomatosis peritonealis disseminata (LPD) is a rare disease that can be challenging to diagnose. • The physician should suspect LPD when the woman has a history of hysterectomy or myomectomy, particularly if a power morcellator was used. • Ultrasonography, computed tomography, and MRI are among the most effective to distinguish between leiomyomas and other solid tumors in the pelvis, but they are not of great help in the differential diagnosis of malignancies. • Tumor markers such as CEA, CA19-9 and CA-125 seem not to be useful for the differential diagnosis, since LPD are sometimes associated with elevated levels of these markers.

Background Heterotopic pregnancy is a rare form of pregnancy that involves implantation of simultaneous pregnancies at two sites. They are normally identified in early gestation when patients become symptomatic with vaginal bleeding or abdominal pain. Case Presentation A 35-year-old woman (para 0, gravida 2) presented to the emergency department in haemorrhagic shock at 19 weeks and 5 days of gestation. On assessment she was hemodynamically unstable and was found to have a large hemoperitoneum on ultrasound. She subsequently underwent an exploratory laparotomy and right salpingectomy for a suspected ectopic pregnancy. The postoperative period was uneventful, and the intrauterine pregnancy continued to term. Conclusion Heterotopic pregnancy should be included in the differential diagnosis for women presenting with hemoperitoneum even beyond the first trimester., Highlights • Heterotopic pregnancy is the implantation of simultaneous pregnancies at two sites. • They are normally diagnosed in the first trimester on transvaginal ultrasound. • We present a case of a heterotopic pregnancy beyond the first trimester.

Introduction and importance Idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV) is a poorly understood disorder which poses a diagnostic challenge to clinicians and pathologists. Here we have described the case of a male patient with IMHMV along with a presumed history of ulcerative colitis for 1 year. Case presentation A 55-year-old male presented to the OPD with history of chronic abdominal pain. Clinical and radiological examination coupled with endoscopic findings resulted in the patient being wrongly diagnosed to be a case of ulcerative colitis and was managed accordingly. Throughout his multiple hospital visits following treatment for ulcerative colitis, the patient was persistently symptomatic. He presented with 10 days history of increasing abdominal pain and constipation following which he developed spontaneous colonic perforation for which he underwent exploratory laparotomy left colectomy and Hartman's procedure. The final pathology of the resected colon found to be consistent of Idiopathic myointimal hyperplasia of the mesenteric veins and ischemic bowel changes. Clinical discussion The absence of clear-cut endoscopic biopsy findings of ulcerative colitis made radiological picture to be the mainstay for diagnosis, which was inaccurate and exposed the patient to unnecessary treatment with immuno-modulators thus resulting in poor response to treatment. As the disease progressed, further narrowing of the vessels made the clinical picture to look closer to ischemic bowel pathology as the patient developed a top surgical emergency (i.e. bowel perforation). Such pathological finding (IMHMV) can only be diagnosed in a fully prepared tissue histology, but rather be considered when no other consistent alternative diagnosis was found. Conclusion The treating physicians must definitely consider the possibility of idiopathic myointimal hyperplasia of mesenteric veins when similar manifestations are encountered in biopsy specimens of old cases with suspected inflammatory bowel disease or non-occlusive ischemia of the distal colorectum., Highlights • Ischemic bowel disease is a serious condition, associated with high morbidity and mortality, early diagnosis and prompt treatment is crucial. • IMHMV, is a rare cause of bowel ischemia resulting in delayed diagnosis, expensive, unnecessary medical therapy, and exposure to its complications. • Despite advancement in medical care, many cases end up with variable degrees of bowel resections. • IMHMV is an extremely rare cause of bowel Ischemia that is not thromboembolic, and preoperative scans often fail to diagnose it, resulting in a delayed surgical care. • Post-resection pathological examination is the only means for diagnosis as endoscopic biopsy specimen yields non-specific changes.