Ogilvie's Syndrome in a 66-Year-Old Man after Diaphragmatic Plication Surgery: A Rare Postoperative Complication.

BACKGROUND Mechanical and functional intestinal obstruction are serious postoperative complications. Acute colonic pseudo-obstruction (Ogilvie's syndrome) is an acute functional obstruction of the large intestine with various causes, including electrolyte disturbances, certain drugs, trauma, hypothyroidism, and, less often, certain procedures, such as abdominal, pelvic, orthopedic, cardiac, and, rarely, thoracic surgeries. It presents with abdominal distension without evidence of mechanical obstruction. This report is of a 66-year-old man with postoperative Ogilvie's syndrome 1 day after diaphragmatic plication surgery CASE REPORT We present a case of a 66-year-old man with no pre-existing chronic diseases who underwent diaphragmatic plication surgery performed to treat symptomatic diaphragmatic eventration, which was associated with chronic colonic dilation. One day after the procedure, the patient experienced hemodynamic instability, abdominal tenderness and distention, leukocytosis, and elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). An abdominal CT scan revealed massive colonic dilation with interposition of the splenic flexure into the diaphragm. Consequently, the patient underwent emergency exploratory laparoscopy, which was later converted to upper laparotomy, during which colonic decompression was performed without identifying any evidence of incarceration. Subsequently, colonic decompression was repeated via sigmoidoscopy, and no mechanical obstruction was found. Lastly, medical treatment was effective in improving the patient's condition CONCLUSIONS In this complicated case, identifying the definite diagnosis was challenging due to the unusual presentation. This rare case might contribute to recognizing a new risk factor for postoperative colonic obstruction, which is preoperative colonic dilation. Also, this case has highlighted the importance of promptly diagnosing postoperative Ogilvie's syndrome to prevent large-bowel perforation.

Histiocytoid variant of invasive lobular breast carcinoma. A case report and literature review.

INTRODUCTION: Histiocytoid breast carcinoma (HBC) is a variant of invasive lobular carcinoma. The occurrence of HBC is rare and the natural history and clinical course of HBC is still not well known due to limited numbers of reported cases. In reality, many tumors have been misdiagnosed and reported as benign lesions. CASE PRESENTATION: A 66-year-old- postmenopausal women, who has previous personal history of right breast invasive ductal carcinoma, for which she underwent right breast wide local excision with negative sentinel lymph node biopsy and received adjuvant radiotherapy and hormonal therapy. Two years later, a new left breast suspicious lesion was detected by Imaging. Breast Ultrasound showed left breast hypo-echoic area at 12-1 o'clock with irregular spiculated lesion 3 cm away from the nipple with posterior acoustic shadowing measuring 1 × 0.7 × 0.7 cm and mild tissue distortion with thicken cortical left Axillary lymph node. Mammography of both breasts confirmed the left breast lesion at 12o'clock with necrosis and irregular margins measuring 1.1 × 1.0 cm. MRI breasts showed, left breast heterogeneously enhancing mass at 12 o'clock with no other suspicious mass in the left or right breast. Ultrasound guided left breast biopsy of the suspicious lesion seen at 12-1 o'clock which confirmed the diagnosis of invasive lobular carcinoma, histiocytoid variant She underwent wire guided left breast wide local excision with left sentinel lymph node and axillary clearance. Final histopathology showed invasive lobular carcinoma, histiocytoid variant. CLINICAL DISCUSSION: The recognition of histiocytoid breast carcinoma is often a challenge, particularly when histiocytoid tumor cells occur in a metastatic site before the primary diagnosis of breast cancer. An awareness of histological features are needed to make the accurate diagnosis. CONCLUSION: Findings that support the correct diagnosis include identifying tumor cells with more cytological atypia, the presence of cytoplasmic vacuoles and secretions. Moreover, coexistence with invasive lobular carcinoma and/or lobular neoplasia and the use of immunohistochemistry to confirm their epithelial nature. clinico-radiological correlation is essential, as any discordance should trigger further diagnostic determination.

Intestinal Obstruction Secondary to Multiple Gastrointestinal phytobezoars, A Rare presentation.

INTRODUCTION: Intestinal obstruction considered to be one of the most common surgical presentation. Adhesions secondary to previous operations, hernias, neoplasms, inflammatory bowel disease, intussusception, or volvulus are the usual causes of intestinal obstruction but bezoar can presents in 0.4-4%. Bezoar can be trapped in different locations throughout the gastrointestinal tract and it can be solitary or multiple lesions. CASE PRESENTATION: This is a 37-year-old male, known case of diabetes mellitus, Presented to the Emergency Department complaining of generalized abdominal pain for 2 days duration. Associated with abdominal distention, fever, nausea, vomiting and obstipation. There was a history of persimmon intake. Unremarkable past surgical history. On examination, He was tachycardic, other vital signs were within normal. Abdominal examination showed abdominal distention and Sluggish bowel sound. Abdominal X-ray revealed multiple air-fluid levels. An abdominal CT scan with IV contrast revealed an intra-luminal mass in the ileum and intra-gastric mass with suspicious of bezoars. He underwent exploratory laparotomy, gastrostomy to remove intra-gastric bezoar, and enterotomy to remove the ileal bezoar. CLINICAL DISCUSSION: Intestinal obstruction is considered to be the most common complication of this entity; other possible complications include gastric ulcer, gastritis, and gastric perforation. Due to limitations of endoscopy and barium enema in the diagnosis of bezoar, Abdominal CT-scan is considered to be the gold standard in the diagnosis. The management of phytobezoar can be either conservative or surgical, depends on the lesion size and location. CONCLUSION: Although intestinal obstruction secondary to bezoar is rare, multiple levels of gastrointestinal obstruction should raise the suspicion of bezoar.

Rare gastric neoplasm: Malignant glomus tumor of the stomach. A case report.

INTRODUCTION: Glomus tumors are rare neoplasms that aris-e from neuromyoarterial canal or glomus body. They are mainly found in the peripheral soft tissue, extremities and rarely developed inside the gastrointestinal tract. In the gastrointestinal tract, the stomach is the most common site for the development of glomus tumors, and most often found in the antrum. Usually, the symptoms of gastric glomus tumors are non specific i.e (abdominal pain, GI bleeding and/or perforation) and possibly discovered incidentally during upper GI endoscopy. CASE PRESENTATION: This is a-56-year-old-male, presented to the emergency department with upper GI bleeding i.e (melena), and signs of shock (HR: 110; BP:80/60), Blood tests showed Hemoglobin level: 5 g/dl. Resuscitation was started with IV fluid and transfusion of 4 units of PRBCs. After resuscitation, He gave a 10 days history of passing black tarry stool, palpitation, headache, dizziness, easily fatigability, malaise, and colicky epigastric abdominal pain. His abdomen was soft, lax with no tenderness, there was fullness at the left upper quadrant. Upper GI endoscopy was performed that showed a large gastric ulcer with adherent clots, necrotic base and oozing at the proximal part of the greater curvature, after that the bleeding was managed with a heater probe and epinephrine injections. The histopathological examination of the biopsy revealed a spindle and epithelioid tumor with the top differential diagnosis being GIST, however other submucosal lesions cannot be excluded. After that, He underwent exploratory laparotomy and wedge resection of the tumor. The final histopathology showed a malignant glomus tumor. CLINICAL DISCUSSION: Due to overlapping clinical and radiological features between glomus, GIST and other submucosal lesions, the histopathological examination is considered to be the gold standard for the diagnosis. Surgical resection with negative margin is the treatment of choice for gastric glomus tumors. CONCLUSION: Although gastric glomus tumor is a rare entity and accounts for 1% of all gastric mesenchymal tumors, it should be considered in the differential diagnosis, since preoperative biopsy is difficult and overlapping features with other submucosal lesions. Surgical treatment is the preferred option for gastric glomus tumor and long-term follow-up is required due to high metastatic and recurrence rate in the malignant type.

Symptomatic Abdominal Wall Schwannoma Mimicking Infected Subcutanous Soft Tissue Lesion. A Case report.

INTRODUCTION AND IMPORTANCE: Schwannomas are benign tumors of the nerve sheath, they do not typically present on the abdominal wall and cause symptoms. To the best of our knowledge, this is the second symptomatic case of schwannoma in upper abdominal wall reported according to the reviewed English medical literature. CASE PRESENTATION: A 25-year-old man post renal transplant two year ago. He presented with left hypochondrial painfull swelling, and redness. On examination, local examination revealed a lesion located in the anterior abdominal wall swelling, 3 × 3 cm, tender with minimal erythema and hotness but no discharge. An ultrasound showed superficial oval shaped with thick wall and mildly increased peripheral vascularity without internal vascularity. He underwent surgical excision and the histopathology result was schwannoma. CLINICAL DISCUSSION: Usually, a patient presents asymptomatic with a slow growing mass. However, the symptoms can vary and depending on the location. Furthermore, a growing lump can start putting pressure on the nerves around the area, and patients can show symptoms accordingly. The likability of ultrasound to pick up a well-circumscribed mass and reaching a definitive diagnosis without histopathology is nearly impossible. Therefore, a complete excision and histopathology confirmed the presence of schwannoma. CONCLUSION: Upon the rarity of schwannomas presenting in atypical regions, such as the abdominal wall. A painful mass on the abdominal wall should raise the suspicion of benign schwannoma. The recurrence rate after the treatment of choice is unusual. Moreover, complete surgical excision of the mass is the definitive treatment.

Intrathoracic Gossypiboma: An Overlooked Entity.

BACKGROUND During any surgical procedure, there are several factors that may lead to morbidity and mortality. One of those factors is a retained cotton or gauze surgical sponge inadvertently left in the body during an operation, known as gossypiboma. This clinical oversight may cause serious postoperative complications and increase the risk of mortality, particularly if left undiscovered. Furthermore, this issue adds to the economic burden on healthcare systems by increasing the rate of reoperation and rehospitalization. The length of postoperative gossypiboma diagnosis varies greatly, as patients may either present acutely with symptoms such as a palpable mass, pain, nausea, and vomiting, or remain asymptomatic for several years. CASE REPORT We report the case of a 48-year-old man who underwent a thoracotomy after a road traffic accident. The resulting empyema led to the intraoperative discovery of an intrathoracic gossypiboma, which was initially interpreted radiologically as a part of the previous surgical staple line. The causative agent was discovered by the team's nurses during the postsurgical count of instruments and sponges, and who were alerted to a recovered sponge differing in appearance from the sponges used for that procedure. CONCLUSIONS In general, proper counting and adherence to the World Health Organization 'Surgical Safety Checklist' can greatly improve the outcome of any surgery. The diagnosis of gossypiboma is often late or missed entirely and leads to additional interventions that can be avoided or detected early when the material contains a radiopaque marker. In cases under suspicion of any mistakenly left object, the use of intraoperative radiology before skin closure is highly recommended to prevent postoperative complications for the patient and organization.