Transanal minimally invasive surgery for benign and malignant rectal lesions: midterm outcomes from a tertiary center.

BACKGROUND: Although transanal minimally invasive surgery (TAMIS) for rectal neoplasia has gained wide acceptance, the mid-term and long-term outcomes are not widely reported in the literature. OBJECTIVE: Describe the mid-term outcomes of patients who underwent TAMIS for benign and malignant rectal lesions in a single center. DESIGN: Retrospective cohort study. SETTINGS: Tertiary referral center. PATIENTS AND METHODS: Demographic, clinical, and oncological outcomes of patients who underwent TAMIS between January 2015 and December 2022 were prospectively collected. The indication for TAMIS was based on the National Comprehensive Cancer Network guidelines. The follow up for the cancer patients included clinical examination, tumor markers every 6 months and MRI rectum at the end of one year. In addition, colonoscopy and CT scan at years one and three and a final CT scan and colonoscopy at year five. MAIN OUTCOME MEASURES: Mid-term oncological and clinical outcome. RESULTS: Thirty elective TAMIS procedures included adenocarcinoma for 33.3% (n=10) of the patients, 20% (n=6) neuroendocrine tumor and the 40% (n=12) were adenomatous lesions. Negative resection margins were achieved in all malignant lesions. Perioperative complications occurred in 2 patients (6.6%), one patient had breaching into the peritoneal cavity, and postoperative hypotension occurred in another patient. The median follow-up time was 23 months (range: 5-72 months). Two patients with adenoma and positive margins developed recurrent adenoma (6.6%) and one patient with initial polypectomy biopsy of adenocarcinoma, had TAMIS with histopathology of adenoma and distant metastasis had developed. CONCLUSIONS: TAMIS for local excision of rectal neoplasia is a valid option with favorable mid-term outcomes provided there is adherence to careful selection criteria. LIMITATIONS: Retrospective nature and small number of the patients.

Colonic medullary carcinoma: an exceedingly rare type of colorectal malignancy: a case report and review of the literature.

BACKGROUND: Medullary carcinoma of the colon is a rare subtype of colorectal cancer that has a unique, and sometimes varied, clinical and histologic profile. It usually presents in adult patients older than 50 years. Here, we report a unique case of young male patient who initially presented with abdominal pain followed by a large bowel obstruction. CASE PRESENTATION: A 40-year-old SriLankan male presented with right-sided abdominal pain and on examination, there was a palpable right iliac fossa mass. Colonoscopy and a computed tomography scan revealed cecal mass. Later, while waiting for elective resection, the patient developed symptoms and signs of a large bowel obstruction. He underwent a laparoscopic right hemicolectomy with an uneventful postoperative course. The histopathologic evaluation of the resected specimens showed invasive carcinoma with syncytial growth pattern, foci of lymphoid host response, and dirty necrosis, in keeping with a medullary carcinoma pT4a pN2b. Unlike most reported medullary carcinoma cases, this patient was young and caudal-related homeobox transcription factor 2 positive. CONCLUSION: We have reported another case of medullary carcinoma of the colon in a young patient with unique histologic characteristics. Reporting such cases helps in refine understanding of the histologic and genetic, as well as clinical, phenotypes of medullary carcinoma of the colon.

Spontaneously Ruptured Idiopathic Mesenteric Hematoma: A Case Report With Review of Literature.

Ruptured mesenteric hematoma is a rare entity that is not frequently reported in the literature. Spontaneous rupture of mesenteric hematoma has been vaguely described in a handful of cases. The majority of cases (unlike ours) had a reported etiology, like trauma, postoperative complications, connective tissue disease, and coagulopathy. To our knowledge, only two cases were reported for spontaneous rupture of idiopathic mesenteric hematoma. We, herein, present a 45-year-old male presented with abdominal pain, nausea, and vomiting associated with hypotension. His investigations, including abdominal computed tomography (CT) scan, showed a large lobulated mesenteric structure involving the small bowel mesentery, representing a mesenteric hematoma. Due to suspicion of intra-abdominal bleeding; we proceeded for exploratory laparotomy. Intraoperative findings showed a large mesenteric hematoma. The patient was stabilized after the evacuation of hematoma and no specific source of bleeding was identified. Ruptured idiopathic mesenteric hematoma is an extremely rare condition that poses a diagnostic challenge, it should be kept among deferential diagnoses, especially, in unstable patients with abdominal symptoms.

A Rare Case of COVID-19 Infection Leading to Colonic Stricture: Case Report and Review of Literature.

Coronavirus disease 2019 (COVID-19) predominantly targets the respiratory tract; despite gastrointestinal (GI) symptoms that may present in many patients, colonic strictures in coronavirus disease (COVID-19) patients are extremely rare and, to our knowledge, have never been reported. We, herein, present a case of a 59-year-old lady who developed intestinal obstruction due to colonic strictures shortly after recovering from complicated COVID-19 pneumonia. Ultimately, she underwent laparoscopic subtotal colectomy with ileorectal anastomosis. After a long recovery period, she was discharged in good status. It has been more than two years since COVID-19 was declared as a pandemic by the World Health Organization. Infected individuals have highly variable clinical manifestations, yet the pathogenesis, diagnosis and ideal management of each of these complications is not well described in literature.

Bilateral Primary Adrenal B-Cell Lymphoma Diagnosed by Workup for Primary Adrenal Deficiency.

Primary adrenal lymphoma (PAL) often occurs bilaterally and is a rare malignancy of old age. Workup for primary adrenal insufficiency often unmasks this underlying grave pathology. In this article, we present a case of a 73-yearold patient who presented with features of primary adrenal insufficiency and renal colic. Diagnostic abdominal imaging revealed bilateral suprarenal masses as the cause of adrenal gland destruction and the patient's symptoms. FDG PET-CT scan and histopathology confirmed the diagnosis of mature bilateral B-cell primary adrenal lymphomas. Though the patient showed an excellent initial response to the first four chemotherapy cycles, a relapse resulted in metastatic disease. This article highlights the PAL's disease course, imaging features, and management dilemma due to Chemotherapy's side effects and a higher recurrence rate. Keywords: Primary adrenal lymphoma, Primary adrenal insufficiency, R-CHOP, Role of imaging.

First Schistosomal Cholecystitis Complicated by Cholangitis and Liver Abscess: Case Report and Review of Literature.

Schistosomiasis is one of the most prevalent parasitic infections in the developing world. When it affects the gastrointestinal system specifically the liver, it causes periportal fibrosis followed by cirrhosis. Cholecystitis however is a rare presentation, and associated liver abscess has certainly never been reported to date. We report a case of acute cholecystitis complicated by cholangitis and liver abscess in a 46-year-old man. After complex course of treatment, he had laparoscopic cholecystectomy, and the histology report confirmed schistosomiasis. Gallbladder schistosomiasis is an uncommon disease that is associated with dense fibrotic changes that strongly mimics xanthogranulomatous cholecystitis. Liver abscess may occur during the disease evolution especially in patient originating from endemic backgrounds. We present the case and a comprehensive literature review.

Acute Appendicitis Presenting As Epigastric Pain Due to Incomplete Intestinal Malrotation.

Acute appendicitis is one of the most frequent causes of acute abdominal pain. Clinical signs, blood tests, and imaging are important to confirm the diagnosis. The classic presentation consists of periumbilical abdominal pain that migrates to the right lower quadrant, guarding, tenderness, and rebound tenderness in the region. We present the case of a 51-year-old male who presented with a one-day history of worsening supraumbilical pain. Abdominal computerized tomography (CT) scan showed intestinal malrotation in which the cecum assumed a midline supraumbilical location with CT features of acute appendicitis. This case highlights that the site of pain in acute appendicitis can be altered depending upon the anatomical location of the appendix, and relying on the pain's location can be misleading. We also suggest that patients with abdominal pain, which is not typical for acute appendicitis, should be investigated by abdominal CT if leukocytosis and inflammatory markers are raised.

Epidemiology, histopathology, clinical outcomes and survival of 50 cases of appendiceal mucinous neoplasms: Retrospective cross-sectional single academic tertiary care hospital experience.

BACKGROUND: Appendicular neoplasms are rare, most commonly as carcinoids followed by appendicular mucinous neoplasms (AMN). To date, there remains controversy regarding the best treatment of AMN and factors affecting its prognosis. METHOD: Retrospective chart review of patients operated for appendicular pathology (January 2011-December 2018, follow up to December 2020) at our institution. For all AMN patients, data included pre-operative clinical presentation, and operative/post-operative findings. RESULTS: 12454 patients underwent appendectomy, of whom 50 (0.4%) had AMN histopathologically (mean age = 47.2). Most patients had laparoscopic appendectomy as primary surgery. Low grade AMN was the most common subtype (n = 41, 82%), and pseudomyxoma peritonei (PMP) was found in 8 (16%) patients. Based on histopathology and margin involvement, the 50 patients were categorized into 3 prognostic categories of recurrence risk (no risk, 24 patients; low risk, 8; high recurrence risk, 18 patients). Disease-free survival (DFS) was lowest for high recurrence risk group (P < 0.001). Eleven (22%) patients had AMN involving resection margin, of whom 3 had no completion surgery and had no recurrence. Higher tumor markers were associated with lower DFS, however it was not statistically significant. CONCLUSION: AMNs are rare but serious due to the risk of PMP. Laparoscopic approach for AMN may be feasible. Prognostic categories were significantly inversely correlated with recurrence risk; hence useful in predicting prognosis. Contrary to previous proposals, AMNs with acellular mucin at margin or local acellular mucin spillage may not require secondary surgery, especially if the patient is in low recurrence risk group. Tumor markers may predict risk of recurrence.

Platelet to Lymphocyte Ratio Associated with Prolonged Hospital Length of Stay Postpeptic Ulcer Perforation Repair: An Observational Descriptive Analysis.

BACKGROUND: The predictive role of platelet to lymphocyte ratio (P/LR) in patients with perforated peptic ulcer (PPU) is not well-studied. We aimed to investigate the association between the P/LR ratio and the hospital length of stay (HLOS) for surgically treated PPU. METHOD: This is a retrospective observational study for surgically treated adult cases of PPU at Hamad Medical Corporation during the period from January 2012 to August 2017. Patients were categorized into two groups based on their HLOS (I week). The receiver operating characteristic (ROC) curve was plotted to determine the cutoff value for lymphocyte count, neutrophil to lymphocyte ratio, and P/LR ratio for predicting the prolonged hospitalization. RESULTS: One hundred and fifty-two patients were included in the study. The majority were young males. The mean age was 38.3 ± 12.7 years. Perforated duodenal ulcer (139 patients) exceeded perforated gastric ulcer (13 patients). The HLOS > 1 week was observed in 14.5% of cases. Older age (p = 0.01), higher preoperative WBC (p = 0.03), lower lymphocyte count (p = 0.01), and higher P/LR ratio (p = 0.005) were evident in the HLOS > 1 week group. The optimal cutoff value of P/LR was 311.2 with AUC 0.702 and negative predictive value of 93% for the prediction of prolonged hospitalization. Two patients died with a mean P/LR ratio of 640.8 ± 135.5 vs. 336.6 ± 258.9 in the survivors. CONCLUSION: High preoperative P/LR value predicts prolonged HLOS in patients with repaired perforated peptic ulcer. Further larger multicenter studies are needed to support the study findings.

Appendicitis Secondary to Trauma following a Camel Kick: Case Report and Review of Literature.

INTRODUCTION: Independently, trauma and appendicitis are two of the most common conditions in surgical practice. Rarely, both conditions may coexist, which raises the controversy whether it is merely a coincidence or trauma may lead to acute appendicitis. Presentation of Case. We report a case of acute appendicitis after blunt abdominal trauma caused by a camel hoof kick to the abdomen in a young man and discuss the potential underlying pathophysiologic mechanisms with review of the pertinent literature. CONCLUSIONS: Blunt abdominal trauma caused by a camel kick to the abdomen requires a close observation of the patients. A camel kick may increase intra-abdominal pressure and cause internal organ injury including the appendix. Therefore, acute appendicitis should be considered in differential diagnosis in any patient with abdominal pain resembling appendicitis following blunt abdominal trauma.

Meckel's Diverticulum Enterolith: A Rare Cause of Perforation and Small Bowel Obstruction Presenting as Acute Abdomen.

Meckel's diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract. MD enteroliths are an uncommon entity that could rarely present with complications. We, herein, present a case of a 56-year-old man who presented with severe abdominal pain. Preoperative CT showed an inflamed structure with central calcification connected to distal ileum lumen with an air pouch associated with small bowel obstruction. Upon laparotomy, a perforated MD was found with phlegmon formation. He underwent resection of the loops containing MD with end-to-end anastomosis.  This highlights the importance of radiological imaging in preoperative diagnosis of these conditions which should be kept in mind if we find a calcified lesion in an inflamed diverticulum around the midline region.

What you see might not be what you get: Discrepancies between intraoperative findings and preoperative diagnosis of ovarian tumors. Appendicular mucocele presenting as an adnexal mass - Case report and review of literature.

INTRODUCTION: Adnexal masses include those affecting the ovary or fallopian tubes. We report a unique case with discrepancy between the pre-operative diagnosis (adnexal mass) and the post-operative definitive findings (appendicular tumor invading ovary). We also employ a literature review to provide four scenarios of uncertainty that are encountered between appendiceal and adnexal masses. PRESENTATION OF CASE: A 58 year old female with history of treated left colon cancer, referred to the gynecology clinic with intermittent vaginal bleeding for 5 days. Examination showed lower abdominal midline mobile non-tender mass, bulky uterus and right adnexal fullness. Other history, physical examination and laboratory tests were unremarkable. US and MRI suggested a right ovarian mass and uterine fibroids. Intraoperatively, she had a right ovarian large mobile multi-locular mass. The appendix was adherent to the ovary, with mucus extruding through its tip. Appendectomy was undertaken alongside hysterectomy and bilateral salpingo-oophorectomy. Histopathology showed right ovarian mucinous neoplasm, but the origin was a low-grade appendiceal mucinous neoplasm (pT4aNxMx). The patient was recurrence free across 3 years of follow up. DISCUSSION: Appendicular mucocele can present as adnexal mass. Pre-operative diagnosis and differentiation is sometimes difficult. CONCLUSION: Adnexal masses need careful pre-operative diagnoses. The definitive management is based on the final intra- and post-operative findings. As a variety of scenarios could be encountered, there could be a need to involve general/colorectal surgeons in case of appendicular tumors. Patients should be counselled regarding the possible change in intra-operative plan, and are better operated upon in facilities with appropriate teams and equipment.

Rare presentation of primary varicella zoster as fatal fulminant hepatitis in adult on low-dose,short-term steroid: Case report.

BACKGROUND: Varicella zoster virus presents clinically as primary (chickenpox) or secondary (herpes zoster) infection. Cutaneous and extracutaneous dissemination may occur, usually in immunocompromised patients. VZV hepatitis that progresses to fulminant hepatic failure is very rare and fatal. To the best of our knowledge, 9 cases have been reported to date, of which 7 were in immunocompromised adults, and only one patient was on short duration steroid therapy. PRESENTATION OF CASE: We present a 26-year old man who was admitted initially with acute abdomen as query persistent biliary colic. Later, he showed clinical and laboratory findings of VZV hepatitis that progressed rapidly despite maximal medical ICU support and he expired on day 3 of admission. CONCLUSIONS: Acute VZV infection may present as fulminant hepatitis. The presentation may initially be challenging for the diagnosis and should be considered if the patient has been in contact with a sick case. Low dose corticosteroid could carry a risk for fatal VZV fulminant hepatitis and should be used very cautiously especially with VZV patients' contacts. Further causative relationships remain to be established.

First sliding Amyand hernia harbouring appendicular schistosomiasis: Case report.

INTRODUCTION: Amyand's hernia (AH) is rare, schistosomiasis of the appendix is very uncommon, and both conditions coexisting together is an extremely rare event. Pre-operative diagnosis of each of the two conditions is usually difficult. To the best of our knowledge, the current paper is first to report both these two conditions in coexistence. PRESENTATION OF CASE: A 31-year old man who had no comorbidities was admitted electively as a day case of non-complicated right indirect inguinal hernia. Further history and physical examination were unremarkable. Intraoperatively the patient was found to have right sliding AH with appendicular schistosomiasis (AS). The patient underwent Lichtenstein repair of the hernia with appendectomy. On follow up he was referred to infectious disease clinic, and the post-operative course was uneventful. CONCLUSIONS: Intraoperative identification of non-typical hernia sac before its opening should alert the surgeon to the possibility of sliding hernia and the presence of an organ as a part of the sac. Rare causes of appendicular masses like schistosomiasis granuloma should be considered in endemic areas or immigrants from these areas, despite the difficulty of preoperative diagnosis. Management should follow general guidelines of appendectomy, hernia repair and dealing with the associated pathology if present.