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Background: Colon lipomas are rare benign lesions taking place mostly in the right colon with a female predomination. They are mainly submucosal and symptomatic when becoming > 2 cm in size. Case Report: This is the case of a 43 years old female patient presenting with bowel obstruction associated with colo-colic intussusception due to a giant colonic lipoma. A segmental partial colectomy has been performed followed by a favorable postoperative course. Conclusion: Giant colon lipomas presenting with intussusception is a rare finding. Surgery is the major treatment but, unfortunately, there is no clear consensus on the recommended procedure in the literature.

Background: Sacrococcygeal pilonidal sinus disease is a very common chronic inflammation of the natal cleft that presents frequently as an abscess. Management requires the eradication of the sinus tract and postoperative wound care. Manuka honey (Medihoney) was used in acute and chronic wounds. In our study, we sought to investigate the clinical effectiveness of Manuka honey in decreasing wound healing time post excision. Material and Methods: We describe patients’ characteristics using traditional descriptive statistics. We compared the study endpoint (wound closure time) in patients who received Medihoney versus those who did not by Kaplan-Meier analysis. Results: A total of 119 patients underwent pilonidal cyst surgery between the years 2017 and 2018. The median time for healing in the Medihoney group was 40 days compared with 39 days in the control group. After adjusting for age, BMI, wound length, wound volume, smoking and operative time, the time to healing in the Medihoney group was significantly less compared to the group not receiving the treatment (Hazard Ratio 1.56, 95% Confidence interval 1.02- 2.49, p= 0.041). Conclusion: Postoperative use of Manuka honey showed a significant decrease in wound healing time when compared to gauze fabric dressings. Further research would be beneficial to explore optimal treatment protocols for this dressing technique.

Extra-gastrointestinal stromal tumors (EGISTs) are rare mesenchymal tumors accounting for less than 1% of total gastrointestinal tumors. They tend to be aggressive and have a poor prognosis. Unfortunately, there is a lack of data or controversial data due to its scarcity. Therefore, we report a case of pelvic EGIST misdiagnosed as retroperitoneal sarcoma. We opted for surgical management followed by adjuvant oral chemotherapy with imatinib.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving apocrine glands of the skin. It carries out an important burden on the daily life of the patient. Unfortunately, it presents a major concern for medical care management in the absence of clear guidelines for proper medical and surgical treatment. Hence, we report a case of concomitant axillary and perianal HS. We opted for surgical management using a novel technique, which proved efficacy for a year of follow-up recurrence free.

Tadalafil is one of the approved phosphodiesterase type 5 inhibitors, which are used in the treatment of erectile dysfunction. Few cases of intracerebral hemorrhage have been reported in the English literature, post-ingestion of PDE-5 inhibitor. We present a case of a previously healthy 35-year-old man, presenting for acute onset of severe headache post-ingestion of tadalafil to enhance his sexual performance. CT brain showed the presence of subarachnoid hemorrhage, and angiography eliminated the presence of vascular malformation. We believe that this is the 5th and youngest case of intracerebral hemorrhage post-tadalafil ingestion.

Highlights • The spleen is normally located in the left hypochondriac region just underneath the 9th to 11th intercostal spaces. • Splenoptosis, wandering spleen or floating spleen, is a rare entity in which the spleen migrates from its normal position. • The diagnosis is confirmed by imaging modalities. • The only definitive treatment is surgical intervention., Background Splenoptosis is an uncommon disorder defined as the dislodgment of the spleen from its anatomical location in the left hypochondrium to another location in the intraabdominal cavity. This migration is the result of laxity or absence of the ligaments that fix the spleen to surrounding structures. Splenoptosis is either diagnosed after it causes symptoms, or incidentally using different imaging modalities. Surgery is the definite treatment either by splenopexy or splenectomy. Case presentation In the case presented here, we discuss a 17 years old female patient who presented to our institution for acute onset of abdominal pain, mainly suprapubic, occurring for 4 days. Ultrasound showed a suspicious right pelvic mass, which was found to be a wandering spleen with pedicle torsion. The patient was treated surgically by splenectomy. Conclusion We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of unspecific abdominal pain.

Highlights • Adrenal incidentalomas are tumors found accidentally by imaging. • Hemangiomas are quite rare and in certain cases their surgical intervention should never be overlooked. • Embolization is primarily implied but one should never neglect the failure rate and the need for surgical intervention. • There are 4 types of AH: cavernous hemangioma, venous hemangioma, capillary type hemangioma, and mixed hemangioma. • To our knowledge, our case has the largest size of an AH being reported in the literature with a 17 cm., Introduction Adrenal incidentalomas are tumors found accidentally by imaging. Among the incidentalomas, hemangiomas are quite rare and in certain cases their surgical intervention should never be overlooked. Presentation of case We present a case of 70 years old Lebanese female with an adrenal tumor presented as syncope found to have anemia on presentation and a bleeding 17 cm adrenal tumor on imaging. Patient had workup to rule out functioning adrenal tumors and decision to excise the tumor was taken after failure of embolization. Pathology report denied malignancy despite of the huge size and was in favor of hemangioma. Conclusion Adrenal hemangiomas are rare and they rarely present as syncope. Attention to such a life-threatening condition should be sustained. Embolization is primarily implied but one should never neglect the failure rate and the need for surgical intervention.

Liver haemangiomas are common, but their size very rarely exceeds 40cm. Most people with liver haemangiomas are asymptomatic, and diagnosis is usually made incidentally during imaging for other complaints. When a liver haemangioma is symptomatic or produces complications, surgical intervention may be warranted. Kasabach–Merritt syndrome is an uncommon complication reported in certain rare vascular tumours in children, with only a few cases reported in adults. The syndrome describes a consumptive coagulopathy initiated within a vascular tumour, mainly tufted angiomas and kaposiform haemangioendotheliomas and, less commonly, giant haemangiomas. The process can extend beyond the tumour and become disseminated in certain cases due to trauma or surgery. The definitive treatment for giant liver haemangiomas can include arterial embolisation, surgical excision, hepatectomy or even liver transplantation. We report the case of a 32-year-old woman with a 42 × 32 × 27cm (18,870ml) liver haemangioma associated with Kasabach–Merritt syndrome. The diagnosis was challenging, even with proper imaging, owing to the rarity of the condition. It was achieved with an exploratory laparotomy with biopsy.

Highlights • Adenomyoepithelioma is a rare tumor of the breast characterized by a biphasic proliferation. • Variable spectrum of behavior ranging from benign to malignant, with tendency to local recurrence. • Combine sentinel lymph node dissection (SLND), with simple mastectomy. • Hematogenous spread is the more common means of spread. • Adjuvant chemotherapy for malignant AME cases is recommended., Background Adenomyoepithelioma is a rare tumor of the breast characterized by a dual/biphasic proliferation of two cell populations: the epithelial cells and the myoepithelial cells. The first case was reported in 1970. The majority of the cases are benign, but few malignant cases were reported in literature. Case presentation A case of a 66-year-old lady presenting with an asymptomatic breast mass, of 18 × 17 × 15 mm size with irregular borders and negative metastatic workup. The patient was operated for wide local excision of the tumor, with a confirmed negative margins intraoperatively. The final pathology was Adenomyoepithelioma. Conclusion We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of breast mass.

Highlights • Duodenal diverticula is mostly found incidentally and it rarely complicates by perforation. • Treatment is only indicated in complicated duodenal diverticula. • Micro perforation in the absence of systemic signs are better treated with conservative management. • Among surgical options diverticulectomy and single layer closure was performed. • Other surgical intervention could involve segmental duodenectomy or pylorus-preserving duodeno-pancreatectomy., Introduction Duodenal Diverticula is not uncommon and it is mostly found in the 2nd part of the duodenum. Despite the fact that it is mostly found incidentally, it can complicate however it rarely complicates by perforation. Treatment is indicated only in complicated cases and it is divided into conservative and surgical arms. Presentation of case It is a case of 78 years old Lebanese female that was diagnosed intra-operatively with a perforated duodenal diverticulum after presenting with post prandial abdominal pain, distention and pneumoperitoneum on imaging. Our case was consistent with previous reports where the diverticulum occurred in the second part of the duodenum. We opted for primary resection of the diverticulum and over-sewing. Moreover, patient had an uneventful post-operative course and progressed gradually to be discharged on day 10. Conclusion Our case aims to draw attention to a rare complication of duodenal diverticula and to widen the differential diagnosis of pneumoperitoneum thus concluding about the better treatment option. Previous reports show that proper management is still a controversial topic; however surgical approach is indicated in case of systemic signs.

Highlights • CAP can be a challenging diagnosis, with a presentation of acute abdominal pain mimicking a surgical abdomen. • In pediatric patients pneumonia is considered as the main extra-abdominal cause of acute abdominal pain. • Abdominal Pain mimics is an entity by itself with a vast differential diagnosis. • Acute abdomen requires precise and rapid diagnosis and treatment to avoid an increase in mortality. • Laparoscopy is safe and effective in setting the diagnosis., Introduction Community acquired pneumonia usually presents with typical clinical and radiological signs allowing for a quick diagnosis. Nevertheless, pneumonia can infrequently mimic acute abdominal pathologies, leading to invasive unnecessary procedures. Presentation of case We report a case of a 44-year-old man, previously healthy, admitted with a diagnosis of a surgical abdomen, investigated with an exploratory laparoscopy after inconclusive imaging and failure of improvement. Clinical evolution revealed the diagnosis of pneumonia. Discussion Community acquired pneumonia is a frequently encountered condition. While its clinical presentation is usually related to the respiratory system, extrapulmonary manifestations, including abdominal pain in the pediatric population, are well documented. However, solely severe acute abdominal pain, being as the major presentation, without respiratory symptoms or radiological signs is very rarely reported. Conclusion Community acquired pneumonia can sometimes be a challenging diagnosis. Acute abdominal pain mimicking a surgical abdomen is an infrequent presentation but can confuse physicians when no radiological or clinical signs of pneumonia are present.

Highlights • Liposarcomas are a malignant transformation of fat tissue, found in two major subtypes according to their differentiation. • Enhanced CT is essential for diagnosis and confirmed by percutaneous large core needle guided biopsies. • Surgery remains the standard practice in treating non-metastatic liposarcomas. • No clear definition for giant liposarcoma, Only 52 cases reported between 1998 and July 2020. • Our patient has the longest reported follow up in the literature of 10 years, with 3 operations and 3 recurrences., Introduction This case is of a patient with a recurrent giant retroperitoneal liposarcoma, followed-up and operated multiple times over 10 years. We report this case because of its rarity and review all previous articles reporting “Giant Retroperitoneal Liposarcoma” in the English literature. Case description A 70 years old man presented to our clinic for dizziness and fatigue. He was incidentally found to have a large retroperitoneal mass filling all the length of the abdominal cavity and shifting all intraabdominal viscera and kidney to the left side. En bloc excision of a 50 × 30 × 18 cm, 9 kg tumor was performed. Final pathology revealed a well-differentiated liposarcoma. Five years later, the patient was reoperated for recurrence and a well-differentiated liposarcoma was excised in 2 pieces (the biggest measuring 14 × 11 × 7 cm) along with the appendix. Four years later the patient was operated on again for a second recurrence, and again a well-differentiated liposarcoma (16 × 10 × 7 cm) extending into the right inguinal canal was excised. One year thereafter, the patient was diagnosed with a third recurrence (22 × 12 cm). Discussion Retroperitoneal Liposarcomas are rare tumors, presenting with different histological differentiation. They are diagnosed using multiple imaging modality, mainly CT scan, and it is confirmed by percutaneous large core needle biopsy. R0 Surgical excision remains the proper treatment for non-metastatic tumors, which may necessicate multiorgan resection. They rarely grow to reach a large size and be labled as “Giant Retroperitoneal Liposarcoma”.

Highlights • The small intestine is an essential constituent of the digestive system and plays a major role in the absorption of nutrients. • Acute mesenteric ischemia remains an emergency case. • Failure to adapt and the inadequate nutritional supply result in Short bowel syndrome. • A minimal indispensable length is required for nutritional autonomy. • Parenteral Nutrition still presents a pertinent problem of complications, charges and impairment in quality of life., Introduction The small bowel is an essential organ for maintaining adequate nutrition. Decrease in length could be associated with malnutrition and may require that the patient receives parenteral nutritional support. We report a case of a 59-year-old man who survived32 years with a short bowel of 35 cm length without any parenteral nutrition. Case presentation A 59-year-old gentleman, with a history of hypercoagulable state, presented for severe abdominal pain and obstipation of one day's duration. Upon presentation, the patient was hemodynamically unstable, with abdominal guarding and tenderness upon physical examination. Laboratory studies showed metabolic acidosis with leukocytosis and electrolyte disturbances, and an abdominal CT scan showed thickening of the sigmoid and multiple air-fluid levels. The patient was operated urgently for suspicion of mesenteric ischemia, however, he was found intraoperatively to have a very short dilated small bowel with jejunotransverse anastomosis. Discussion The necessity for surgical resection of the small bowel can arise for a sum of reasons. However, the removal of a big amount of small bowel may not be adaptive and appropriate digestion will no more be possible. In the aftermath of the resection, patients require parenteral nutrition for a certain period after which they may switch to enteral and oral nutrition, and subsequently intestinal adaptation by thickening and growth of the remaining intestinal villi. Conclusion Patients with a short bowel, particularly those surgically removed, can survive even with a very short remaining bowel length, as a result of intestinal adaptation, nutrition enhancement, and elimination of parenteral nutrition.

Highlights • Bouveret’s syndrome is a rare entity which takes part of the gallstone ileus entities. • There are no standardized recommendations for workup and management, and there is a high chance of misdiagnosis. • In front of its vague presentation, various differential diagnosis should be taken into consideration. • The diagnosis is usually confirmed by CT scan, showing the fistula and Rigler’s Triad. • Surgery is most of the times the definitive treatment., Introduction This report is a case of proximal gastric outlet obstruction, misdiagnosed after esophagogastroduodenoscopy as invasive pancreatic malignancy. We report this case because of its rarity and to encourage physicians to take this etiology into consideration as part of differential diagnosis. Presentation of case We present a case of 88 year-old lady presenting for 3 days history of post-prandial coffee ground vomiting associated with obstipation, misdiagnosed as pancreatic malignancy with duodenal invasion after outpatient gastroscopy. The proper diagnosis was confirmed by CT Scan which revealed the presence of large calculi with aerobilia and gastric stasis. Surgery done to extract two impacted large gallstone of 2 × 2 × 1 and 6 × 3.5 × 3 cm followed by cholecystectomy, closure of fistulae, gastrojejunsotomy and vagotomy. Discussion Bouveret Syndrome is referred to as rare presentation of gastric outlet obstruction by passage of large gallstone through a fistula between the gallbladder and proximal gastrointestinal tract. It has a vague presentation, and can be misdiagnosed due to non-specific symptoms. The diagnosis is usually confirmed by a CT scan and it is treated surgically most of the time. Conclusion Bouveret syndrome is a rare entity, and should be taken into consideration as a differential diagnosis in front of proximal gastric outlet obstruction.

Background: Wandering spleen (WS) is an uncommon splenic disorder defined as the displacement of the spleen from its usual anatomical position. It is most prevalent in females in their reproductive age. It can be encountered incidentally or may present with symptoms. Risks of complications exist and vary with the presentation. Several imaging techniques are able to define it clearly preoperatively. Laparoscopic surgery is the definitive diagnostic and therapeutic method. Case Report: A 24-year-old pregnant female patient presented to the Emergency Department complaining of intermittent dull abdominal pain and pelvic heaviness for 9 days. Contrast- Enhanced Computed Tomography and a color Doppler sonography of the abdomen and pelvis showed a large-sized spleen in the pelvis corresponding to a diagnosis of WS, without ischemic signs. The patient underwent a laparoscopic splenectomy and was vaccinated for Haemophilus influenza, meningococcus, and pneumococcus postoperatively. The post-operative period was uneventful, and the patient later delivered a full-term baby girl by a Cesarean section. Conclusion: This is, to the best of our knowledge, the second reported case of laparoscopic splenectomy in a pregnant patient with WS. While splenopexy is associated with better outcomes, splenectomy seems to be preferred in pregnant patients, who may undergo a vaginal delivery, but guidelines and data are still scarce regarding the management of WS in pregnancy. Vaccination against encapsulated bacteria is required in case of splenectomy

Highlights • Colorectal cancer can infrequently present as inguinal hernia. • Perforated colorectal cancer only rarely presents as incarcerated inguinal hernia, like our case. • When presenting with perforation, colorectal cancer tends to have a worse prognosis. • When encountered during hernia surgery, surgeons should attempt oncologic resection., Background Inguinal hernias are common among the population and usually contain part of the omentum or small bowel, however, other unusual contents have been reported. We report a case of a patient who presented for an incarcerated left inguinal hernia and was found to have an underlying perforated sigmoid cancer. Summary An 87 years old man presented with typical signs of an incarcerated left inguinal area. During surgery, we dissected free a herniated hard inflammatory mass until it was found to be covering an underlying perforated sigmoid tumor. Inguinal hernia is a common condition affecting many individuals, and colorectal cancer is one of the rare contents reported inside these hernias. Due to the rarity of such a presentation, the surprise encounter during groin surgery may lead to suboptimal treatment. Perforated colorectal cancer, like in our case, may signify a more aggressive disease, and hence a correct diagnosis is crucial to improve outcomes. When underlying colon cancer is suspected during hernia surgeries, proper exploration and oncologic resection might be the optimal choice. Conclusion Surgeons should keep the possibility of underlying colorectal cancer in mind when operating on inguinal hernias and opt for oncologic resection of the identified tumor along with proper lymph node dissection.

Highlights • Gastric stenosis is seldom encountered in adult patients. Suicide attempt should be considered as differential diagnosis. • Multiple etiologies results in gastric stenosis. They do not usually cause acute gastric obstruction. • Both acidic and alkaline chemicals are implicated. • 4th type of gastric strictures is the “Linitis-Plastica-like” appearance. • The management of caustic gastritis ranges from supportive to surgical treatment., Introduction This report is a case of a suicide attempt by bleach ingestion. mistaken for gastric cancer after oral contrast studies and esophagogastroduodenoscopy. We report this case to encourage physicians to take this etiology into consideration as part of differential diagnosis especially in front of a secretive patient. Presentation of case We report a case of a 38-year-old lady admitted for an acute onset of symptoms leading to a diagnosis of antral stenosis. Further workup which included endoscopic and surgical biopsies failed to reveal an underlying malignancy. After 24 days of inconclusive inpatient investigations, and due to failure of conservative treatment, distal gastrectomy was performed. Final pathology also revealed an absence of any signs of malignancy, and reported only inflammatory changes. One month after discharge, the patient confessed that she had attempted suicide by ingestion of corrosive agents before the symptoms started and wanted to keep the incident as a secret. Discussion Gastric stenosis is seldom encountered in adult patients, however, it can occasionally result secondary to gastric ulcer disease, malignancies, foreign body ingestion, certain drugs or chemicals, or after endoscopic or surgical interventions. These etiologies do not usually cause acute gastric obstruction, and usually follow a more indolent course. Identification of an underlying etiology is mandatory to determine the proper medical or surgical treatment to relieve the obstructive symptoms. Conclusion We report this bizarre case to encourage physicians to keep this etiology in mind in otherwise unexplained gastric stenosis.

Highlights • CAIS is a rare sexual development disorder with X-linked recessive inheritance. • Usually present with primary amenorrhea, inguinal hernias and with near normal female external genetalia. • Testosterone levels are equal or higher than in male. Different imaging types together with karyotyping are crucial in diagnosing. • Treatment debates include prepubertal or postpubertal Gonadectomy. • CAIS must be suspected in any case of young females with bilateral inguinal hernias., Introduction Complete Androgen Insensitivity Syndrome (CAIS) is a rare sexual development disorder with X-linked recessive inheritance. It is prevalent in 1:20400 to 1:99000 of female phenotypes, yet characterized by an XY genotype. Cases of CAIS usually present with primary amenorrhea together with unilateral/bilateral inguinal hernias. Case presentation A previously healthy 19 year old sexually inactive girl presents to our clinics for delay in menarche and bilateral palpable inguinal masses 3 years ago. She has normal female habitus, tanner stage 3 and external female genetalia with sparse pubic hair. She has a family history of 2 aunts (mother side) having infertility with Bilateral inguinal hernias surgery. Hormonal tests showed male range testosterone levels. MRI showed bilateral inguinal masses with Mullerian structures agenesis and a misdiagnosis of Mayer-Rokitansky-Küster-Hauser syndrome (MRHKS) was interpreted. While karyotype showed XY genotype. She is then planned for bilateral orchiectomy. Final pathology of the 2 specimens taken showed testicular tissue correlating with CAIS. Discussion CAIS patients presents with near normal female external genetalia, absence of Mullerian structures, taller status than regular females and testosterone levels equal or higher than male levels. Different imaging types together with karyotyping are crucial in diagnosing and differentiating CAIS from other entities such as MRHKS and Swyer syndrome. Treatment debates include prepubertal or postpubertal gonadectomy correlating with the age related malignancy rate and site of testis followed by Hormonal replacement therapy. CAIS management needs a multidisciplinary approach and decisions by the patient or his family sometimes. Conclusion CAIS must be suspected in any case of young females with bilateral inguinal hernias as in our case, and precise diagnostics tests such as MRI and Karyotyping must be done followed by biopsy or excision for diagnosis and then adequate treatment. Hormonal therapy must be continued after gonadectomy that is best to be postpubertal.

Introduction Parathyroid gland has a distinct physiologic and endocrinologic role in the body system. Primary hyperparathyroidism is the most common cause of hypercalcemia with a marked female dominance. It is characterized by hypercalcemia, hypophosphatemia and elevated parathyroid hormone. Parathyroid adenoma, parathyroid hyperplasia and parathyroid carcinoma form the differential diagnosis. Giant parathyroid adenomas are rarely symptomatic than non-giant parathyroid adenomas and parathyroid carcinoma. Case presentation A 41 years old previously healthy male patient with undetectable surgical and familial history presenting with left clavicle fracture by mild trauma. He was diagnosed for primary hyperparathyroidism after the finding of multiple bony lesions and elevated serum calcium and Parathyroid hormone. Preoperative imaging aided in diagnosis of a parathyroid lesion and secondary bone resorption lesions (brown tumors). After adequate medical treatment and preparation, selective right lower parathyroidectomy was held, and the final pathology came with a giant parathyroid adenoma. Conclusion Primary hyperparathyroidism should be suspected when dealing with a hypercalcemic patient having osteolytic bony lesions. Distinguishing Parathyroid adenoma from carcinoma is a challenging and essential preoperative step in planning and surgical procedure.

Highlights • There’s no consensus on definitions & types of intrabiliary hydatid rupture. • Original classification included either frank or occult rupture. • Hydatid cyst rupture should always be ruled out as a cause of biliary obstruction. • MRI may miss the diagnosis, and ERCP is valuable in diagnosis and treatment. • Surgical removal of the mother cyst is essential for treatment., Introduction A 64-year-old lady was diagnosed with having a klatskin type 3A tumor based on imaging, however, an alternative diagnosis was achieved during surgery. Presentation of case We present a case of a 64-year-old lady who presented for new-onset jaundice and was diagnosed with type 3A klatskin tumor based on MRCP findings. During surgery, it was revealed that the obstruction was caused by a frank intrabiliary hydatid cyst perforation. Choledocoscopy with irrigation, cholangiography, and removal of the mother cyst were performed, and an end-to-end biliary anastomosis over a t-tube was then done. The patient tolerated the intervention and recovered well. Discussion Hydatid cyst disease of the liver usually follows a benign course, however, intrabiliary rupture is one of the common complications associated with this disease. Intrabiliary rupture is classified into either frank or occult. Frank perforation, which is more common, is when hydatid material passes into the biliary ducts, and it may cause biliary obstruction and cholangitis with a high mortality rate. Occult perforation is when the hydatid cyst becomes infected itself, which usually leads to a silent presentation, and may only cause signs of suppuration. Diagnosis is usually achieved by imaging and relevant history. Treatment consists of medical and surgical intervention. Intraoperative cholangiography, choledocoscopy, and t-tube drainage are recommended during surgery for frank rupture. Conclusion Intrabiliary hydatid cyst perforation can mimic cholangiocarcinoma and must be considered as an alternative diagnosis in these patients prior to surgery.

Primary breast tuberculosis is a rare extrapulmonary tuberculosis mainly affecting young women of childbearing age in endemic countries. Its incidence is increasing in immunocompromized and HIV-infected people and with the emergence of drug-resistant strains of Mycobacterium tuberculosis. There are no specific clinical signs suggestive of this disease, and it often presents as a hard mass or breast abscess. There is an overlap of features with other inflammatory, infectious, benign lesions, fat necrosis, and malignant neoplasms of the breast. The detection of Mycobacterium tuberculosis remains the gold standard for diagnosis. Several diagnostic modalities are used, with varying degrees of lack of sensitivity and specificity, and with a range of false negatives. A quarter of cases were treated solely on the basis of clinical, imaging, or histological suspicion, without confirmation of the diagnosis. Therefore, we report the case of a young Vietnamese woman who presented with a non-healing breast abscess and was diagnosed with breast tuberculosis based on the patient’s ethnicity, histological findings, lack of clinical response to conventional antibiotic therapy, and a good clinical response to antituberculosis treatment.

Myofibroblastoma (MFB), also known as a solitary fibrous tumor of the breast, is a rare sporadic benign tumor composed of spindle-shaped tumor cells with myoblast differentiation. The most typical presentation is a painless unilateral mass that is not connected to any surrounding structure and seldom surpasses 3 cm in size and should be evaluated by using the triple-assessment approach. They have several subtypes, and a definite diagnosis can only be confirmed safely after surgery using immunohistochemistry. Surgical excision serves an essential diagnostic and therapeutic purpose; MFB has a favorable prognosis even when excision margins are positive, and local recurrence is extremely rare. The following is the case of a 73-year-old man who presented with a dry cough. An MFB was discovered by chance during the investigative workup and referred to our department. The patient’s presentation, imaging, and histological samples all supported the diagnosis, and he had surgical resection without incident. We present the second case of an incidental finding of breast MFB and urge clinicians to consider this differential diagnosis.

Objective: Nearly 1/5 of women with breast cancer (BC) treated by breast-conserving surgery (BCS) require reoperation due to positive margins on final pathology. In our hospital practice, intraoperative macroscopic pathological margin evaluation (IMPME) of all lumpectomy specimens is routine. The objectives of the study were to assess the accuracy of the IMPME in a large study population of BC patients treated by BCS. Methods: Patients treated by BCS from 2015 to 2017 for invasive BC were included in a retrospective analysis. The diagnostic accuracy of IMPME in predicting margin involvement was calculated by determining its sensitivity (Se), specificity (Sp), negative predictive value (NPV), and false-negative rate (FNR). Results: In all, 543 women with 562 BCS were analyzed. There were 30 (5.5%) patients with multiple BC tumors and 17 (3.1%) patients with bilateral BC. Among them, 460 (81.7%) were invasive ductal carcinomas and 79 (14%) invasive lobular carcinomas. According to intrinsic subtype classification, 504 (89.7%) were luminal tumors, 44 (7.8%) were triple-negative tumors, and 14 (2.7%) were HER2-enriched breast tumors. The mean pathological tumor size was 12.2 mm (range: 1.5–40 mm). With a cutoff value of ≤1 mm for positive margin status with IMPME, the Se, Sp, NPV, and FNR were 65.9% (29/44), 66% (342/518), 95.8% (342/357), and 4% (15/357), respectively. There were 34.2% (192/562) BCS with intraoperative re-excision after IMPME examination. The secondary re-excision rate for final positive margins after BCS was 6.6% (37/562). Conclusion: In this study population, IMPME is not sensitive and specific enough to discriminate between negative and positive margins during BCS. Nevertheless, its NPV seems sufficiently accurate to exclude the presence of residual breast tumor tissue on the surgical specimen of patients treated with BCS, which represents an effective technique for evaluating the intraoperative margin in BC patients.

Primary accessory breast cancer is an extremely rare pathology, representing less than 1% of all breast cancers, and it is found in more than 90% of cases in the axilla. The diagnosis of accessory axillary breast cancer (AABC) is often late and at an advanced stage, with an average delay of 40.5 months. Histological sampling and immunohistochemical results confirm the diagnosis. Most patients are diagnosed with stage II disease or higher, so it is considered to have a poor prognosis. There is no proper management for AABC; it follows the guidelines for orthotopic pectoral breast cancer. We therefore report the case of a 50-year-old woman diagnosed with grade II invasive ductal carcinoma found in accessory axillary breast, treated with neoadjuvant chemotherapy followed by a wide local resection and axillary lymph node dissection.

Introduction Vascular access is essential in the management of patients, and sometimes poses a problem, especially in patients requiring chronic treatment. Surgical insertion of the port-a-cath solved this problem by providing easy access, but unfortunately, it's associated with some complications. Case presentation We present a case of 32 year-old woman, diagnosed with advanced breast cancer, admitted for insertion of a port-a-cath for neoadjuvant chemotherapy. A few hours after the operation, the patient developed hoarseness and a cough. A flexible laryngoscope showed the left vocal cord which was fixed in the middle position and did not move, while the other maintained normal motility. The patient was treated conservatively. Conclusion This case demonstrated a rare and unexpected complication of the insertion of a port-a-cath, which is the result of an injury to the recurrent laryngeal nerve. We are reporting this case to encourage physicians to take note of this complication and know how to manage it., Highlights • Vascular access is primary in the management of patients • Insertion of an implantable chamber catheter is used mainly for chemotherapy • It is considered a safe surgical intervention • Damage to the recurrent laryngeal nerve can cause vocal cord paralysis • In most cases they recover by themselves

Introduction Duodenal teratoma is a rare condition with only four cases reported in the English literature. Radiological imaging and tissue sample are necessary for diagnosis in addition to tumor markers. The most effective treatment is still complete excision with safety margins. Case presentation We report a case of 26 years-old-man, in whom epigastric pain, decreased appetite, and postprandial bilious vomiting had been prevalent for 5–6 months and had exacerbated prior to the emergency room. Enhanced abdominal computed tomography revealed a 10 × 15cm heterogeneous solid mass with cystic component in the third duodenum segment. The inferior veina cava and aorta were both compressed, although there was no sign of lymphadenopathy or ascites. An ulcerating non-bleeding lesion at the D2-D3 junction of the duodenum was discovered during a gastroduodenoscopy. Biopsies and immunohistochemical investigations revealed findings that were consistent with a mixed non-seminomatous germ cell tumor. A PET-CT scan was performed, which revealed FDG uptake by the duodenal lesion but no evidence of metastatic lesions. A distal duodenal segmentectomy is performed, and then a duodeno-jejunal anastomosis is used to restore continuity. The final diagnosis was teratomatous tumor of the duodenum without malignant changes. Conclusion This is the second adult case of main duodenal teratoma that has been reported. We publish it to encourage surgeons to think about this differential diagnosis and carefully plan surgery using a multidisciplinary approach., Highlights • Duodenal teratoma is an extreme rare disorder. • Tumor markers, radiological imaging, and tissue biopsy are required for diagnosis. • Complete excision with safety margins is gold standard. • We report the fifth case in literature.

Splenosis is the autotransplantation of splenic tissue into abnormal locations due to trauma or iatrogenically. Usually, this causes no symptoms, but in rare cases the mass effect of the transplanted nodules can cause small bowel obstruction. Resection of the culprit splenic tissue is recommended, but not more extensive dissection of non-involved nodules. Our patient presented at 43 years of age with abdominal pain, distention and bilious vomiting. He had undergone a splenectomy at the age of 13 years due to splenic rupture after a motor vehicle collision. Computed tomography demonstrated a small bowel obstruction with multiple nodules suspicious of splenosis. The obstructing mass and compromised bowels. were resected. Final pathology confirmed the diagnosis. Splenosis is an uncommon aetiology of small bowel obstruction and must be considered in patients who had previous splenic trauma or surgery.

Highlights • Inflammatory fibroid polyps is a rare entity that mostly occur in the stomach. • Diagnosis is mainly postoperative with limited roles of usual diagnostic techniques. • Histopathology and immunohistochemistry are the gold standard in diagnosis. • Resection/surgery is the mainstay treatment., Introduction Inflammatory fibroid polyps is a rare entity that mostly occur in the stomach. Gastric type is usually asymptomatic or may show nonspecific symptoms. Diagnosis is mainly postoperative with limited roles of usual diagnostic techniques. Presentation of case A 42 years old healthy female presenting with chronic symptoms for epigastric discomfort and mild nausea. Labs showed mild anemia. A gastric lesion was detected by Endoscopy and being studied by echo-endoscopy and needle aspirate. Gastric Inflammatory fibroid polyp was diagnosed after distal gastrectomy by histopathology and immunohistochemistry. Conclusion Gastric inflammatory fibroid polyp is a preoperative diagnostic challenge of unclear pathogenesis. Histopathology and immunohistochemistry are the gold standard. Studies around this exact pathology are required for better management and prevention.

Highlights • Ectopic adrenocortical tissue is a rare finding that can be encountered in inguinal hernial sacs of adults. • Surgeons should be aware of this and are encouraged to resect Ectopic adrenocortical tissue when grossly identified. • Secondary hyperplasia after adrenalectomy, adrenal insufficiency, and neoplastic transformation should all be considered., Introduction A 37-year-old male patient operated for inguinal hernia repair was found to have ectopic adrenocortical tissue in the hernial sac. Case presentation A 37-year-old man was admitted for bilateral inguinal hernia. An uneventful open repair was done, and the resected hernial sacs were sent to pathology. Histopathology reported the presence of adrenocortical tissue in the right inguinal hernial sac. Discussion Ectopic adrenocortical tissue (EACT) in the groin region is not an unusual finding in children, however, it’s rarely reported in adult patients. Only 9 cases have been reported in English describing EACT in an adult’s inguinal hernia. The finding can be attributed to the close proximity of the developing gonads and adrenal cortex during embryogenesis, and subsequent mechanical translocation of adrenocortical tissue during testicular descent. Some theoretical clinical implications exist for this condition, including secondary hyperplasia after adrenalectomy, adrenal insufficiency in certain situations, and possible neoplastic transformation. Generally, it is recommended that surgeons resect ectopic adrenal glands when identified intra-operatively. However, actively searching for these glands has no known benefit and carries some surgical risks, and is hence not recommended. It is reasonable as well, that clinicians keep the clinical implications of this finding in mind during future follow-ups with such patients. Conclusion The presence of ectopic adrenocortical tissue in inguinal hernia sacs is a rare encounter in adults. The condition can have several theoretical clinical implications that need to be considered by surgeons while assessing patients in whom this phenomenon is observed.

Highlights • Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases. • Pseudo-aneurysm is an overlooked complication. • Angiography followed by embolization is best for diagnosing and treating. • Common risk factors for pseudo-aneurysm include, infection, trauma, neoplasm, inflammation and surgery. • Treatment was surgical, this case was treated by interventional radiology., Introduction Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases however pseudo-aneurysm is an overlooked complication. Case For instance, we present case of a 25 year-old Lebanese woman that undergone sleeve gastrectomy and presented 3 weeks later with a bleeding left gastric artery pseudo-aneurysm. Conclusion Angiography followed by embolization is best for diagnosing and treating the pseudo-aneurysm by coiling. Serious outcomes could arise from such a complication. Hence, accurate diagnosis and treatment using the appropriate methods is essential to avoid life-threatening events.

The influence of donor and recipient gender on patients postkidney transplant (KT) is still controversial, and literature data do not present unanimous conclusions. We were concerned with the gender impact on the outcome of kidney transplantation at the level of acute rejection (AR), graft function represented by serum creatinine level, delayed graft function (DGF), graft survival, and infection rate. The impact of gender matching between donors and recipients was studied in 299 KT recipients performed in the Transplantation Unit, Middle East Institute of Health, Bsalim, Lebanon, between November 1998 and September 2014. The patients were divided into the following groups: Group I (131 patients, male donor to male recipient), Group II (55 patients, male donor to female recipient), Group III (88 patients, female donor to male recipient), and Group IV (25 patients, female donor to female recipient). AR and DGF were not statistically different among the four groups. Moreover, all groups showed excellent graft survival with no statistical difference. Interestingly, human leukocyte antigen AB-DR matching (P < 0.001) and sensitization were statistically different among the four groups (P = 0.05). The number of patients with infections was statistically significantly lower in Group I (35.4%) and Group III (37.5%) (P = 0.35). Most importantly, graft function, represented by serum creatinine, showed a statistically significant difference among the four groups (P

Case series Patients: Female, 44-year-old • Female, 62-year-old Final Diagnosis: Ectopic liver Symptoms: Asymptomatic Medication: — Clinical Procedure: Laparoscopic excision during cholecystectomy Specialty: Surgery Objective: Rare co-existance of disease or pathology Background: Incidental finding of ectopic liver is gaining more attention especially during laparoscopic cholecystectomy. It is reported to be found in different locations as gallbladder, stomach, spleen, umbilical ligament and other intra-peritoneal and intra-thoracic sites. Case Reports: We present 2 cases of ectopic liver found on gallbladder during elective laparoscopic cholecystectomy for 2 Lebanese females. Our findings were consistent with previous reports. The ectopic liver tissues measured 0.9 cm and 0.5 cm respectively, which were smaller than other reports. The liver tissue lacked a biliary system, which was similar to what has been previously reported in the literature. However, no malignant histological signs were seen when excised. Conclusions: These 2 cases highlight the fact that ectopic liver tissue may be encountered on the gallbladder during laparoscopic cholecystectomy. Awareness of this potential entity is beneficial to widen the differential diagnosis when identified on imaging studies pre-operatively or when found incidentally during surgery as in this case.

Highlights • RI is a mysterious pathophysiology that is still uncommonly present post Roux en Y gastric bypass. • Exploratory laparoscopy is a more confirmative diagnostic option. • The state of the intussuscepted intestine determines the plan of treatment. • The most adequate surgical treatment technique is still debatable., Introduction Intestinal intussusception is an uncommon entity when preceded by Roux en Y gastric bypass. Retrograde intussusception is an enigmatic phenomenon characterized by reversely intussuscepted intestinal loop that may involve any piece of the Roux en Y limbs. Computed Tomography is gold standard for diagnosis. Surgical management is highly debatable. Case presentation A 35 years old female known for morbid obesity, post roux en Y gastric bypass since 5 years with 100 % excess weight loss presenting for on-off episodes of small bowel obstruction symptoms. She was diagnosed laparoscopically for retrograde intussusception that was reduced easily with closure of Peterson’s pouch due to high suspicion of an internal hernia. She did well postoperatively and followed up adequately with no recurrence of her symptoms. Conclusion Retrograde intussusception remains an interesting uncommon phenomenon in the horizon of the roux en Y gastric bypass surgeries. Several surgical options were discussed in the last 12 years and they are still debatable.