A young man with intimomedial mucoid degeneration of the brachial artery.

Intimomedial mucoid degeneration is a rare disorder and has been described as a distinctly different entity from Erdheim's cystic medial necrosis. Most studies show a strong predominance in African American females with hypertension. In our case report, we describe the presence of a large brachial aneurysm in a young white male with intimomedial mucoid degeneration.

Delayed primary closure of the septic open abdomen with a dynamic closure system.

BACKGROUND: The major challenge in the management of patients with an infected open abdomen (OA) is to control septic peritonitis and intra-abdominal fluid secretion, and to facilitate repeated abdominal exploration, while preserving the fascia for delayed primary closure. We here present a novel method for closure of the infected OA, based on continuous dynamic tension, in order to achieve re-approximation of the fascial edges of the abdominal wall. METHODS: Eighteen cases with severe peritonitis of various origin (e.g., gastrointestinal perforations, anastomotic leakage) were primarily stabilized by laparostomy, sealed with either the vacuum-assisted closure abdominal dressing or the Bogotá bag. After hemodynamic stabilization and control of the sepsis, the Abdominal Re-approximation Anchor System (ABRA; Canica Design, Almonte, Ontario, Canada) was applied. This system approximates the wound margins through dynamic traction exerted by transfascial elastomers. Before ABRA application, 5/18 patients had a grade 2B, 2/18 a grade 3, and 11/18 a grade or 4 status according to the open abdomen classification of Björck. RESULTS: In this severely ill population the mean time before ABRA system application was 12 days (range: 2-39 days). Two of 18 patients died of non-ABRA-related causes within three weeks. In 14 of the remaining 16 patients (88%) primary abdominal closure of the midline was accomplished in 15 days (range: 7-30 days). The other two patients needed a component separation technique according to Ramirez to reach closure. However, secondary wound dehiscence occurred in both these patients. Two thirds of patients (12/18) developed pressure sores to the skin and/or dermis, but all healed without further complications. During outpatient clinic follow-up, 4/14 successfully closed patients still developed a midline hernia. CONCLUSIONS: Delayed primary closure of OA in septic patients could be achieved in 88% with this new approximation system. However, the risk of hernia development remained. We consider this system a useful tool in the treatment of septic patients with an open abdomen.

[A woman with a symptomatic abdominal swelling]. / Een vrouw met een symptomatische zwelling in de buik.

A 51-year-old woman visited the surgery outpatient clinic with an abdominal swelling. The swelling had become larger over the past few years and caused mechanical complaints. With MRI a liver cyst measuring 14 x 11 cm was diagnosed. The patient underwent laparoscopic deroofing of the liver cyst.

Colorectal Liver Metastasis, Primary Gallbladder Carcinoma and Myelofibrosis Present Simultaneously in a Liver Resection Specimen.

Myelofibrosis and gallbladder carcinoma are both very rare diseases. This case report describes a patient with a history of myelofibrosis and colorectal carcinoma who was diagnosed with colorectal liver metastases. Surgery was performed to remove the metastases, and on site, the gallbladder was removed because of involvement in one of the liver lesions. After pathological examination, a primary gallbladder carcinoma and myelofibrosis were found in addition to the liver metastases. The combination of diseases was not likely to be interconnected but rather an unlucky course of events for the patient.

Acute small bowel volvulus in a 2-month-old infant.

KEY CLINICAL MESSAGE: Abdominal cystic lymphangiomas are rare and occur secondary to congenital malformation of the lymphatics, mostly in the mesenterium. Acute or chronic volvulus of the small bowel may occur by traction of the lymphangioma. Therapy includes resection of the lymphangioma and of the small bowel involved.

Abdominal inflammatory myofibroblastic tumor.

A 28-year-old woman was referred to our hospital because of abdominal pain, weight loss and a palpable intra-abdominal mass. A CT scan revealed a tumor with a diameter of 7 cm with sharp margins, intra-tumoral fatty components and enhancing soft tissue. After initial workup, which suggested an inflammatory myofibroblastic tumor (IMT), she underwent laparotomy with complete resection. Pathological examination indeed revealed IMT. IMT is a rare benign neoplasm and has been described in nearly the entire body. It presents with nonspecific symptoms. The therapy of abdominal IMT consists of radical surgery because of high local recurrence rates. In this case report clinical, surgical, radiological and histological features with a review of the relevant literature are described.

[A woman with bilateral linear striations in femur and tibia]. / Een vrouw met beiderzijds strepen in femur en tibia.

A 20-year-old woman was referred to our hospital with complaints of both knees due to patellofemoral pain. Osteopathia striata, a rare radiographic skeletal disorder, manifested by fine, linear striations primarily in the long bones, was a chance finding.

Stomal mucocutaneous dehiscence as a complication of a dynamic wound closure system following laparostomy: a case report.

Dynamic retention suture techniques that allow gradual reapproximation of abdominal midline muscles and fascia as well as sufficient freedom of movement for breathing and patient care commonly are used to prevent lateral retraction of the abdominal fascia in patients whose abdominal wound closure must be delayed. A 58-year-old otherwise healthy man was admitted with severe abdominal sepsis and following surgery, which included the creation of a stoma, a dynamic wound closure system was applied. Mucocutaneous stomal dehiscence was observed a few days after starting the treatment. The complication was believed to have occurred as a result of traction on the proximal end of the stoma (the bowel inside the abdomen) due to tension on the sutures of the small part of the bowel outside the abdomen. Definite, primary closure of the abdominal fascia was achieved after 16 days, at which point the stoma was reinserted with good results. Since using a modified procedure that involves cutting a groove in the protective drape and carefully placing two flaps around the stoma, this complication has not been observed with similar patients in the authors' facility. This complication is not unique to this wound closure system; it also has been reported with other treatment modalities such as negative pressure wound therapy. The relatively small number of patients requiring delayed closure of the abdomen, coupled with the uniqueness of each case due to a wide variety of indications and comorbidities, hampers the development of evidence-based guidelines of care for these patients. A worldwide data exchange that includes patient experiences and descriptions of successful and failed attempts to address problems and complications in these patients is necessary. In the meantime, experiences with these types of wounds need to be shared in the literature.

[A woman with a mass in her abdomen]. / Een vrouw met een massa in de buik.

A 43-year-old woman was referred; she had felt an abdominal mass on her left side. Imaging showed a cystic lesion. The lesion was removed via laparotomy. Pathological examination showed a benign mucinous cyst.

Giant Diverticulum of the Duodenum.

A 50-year old female presented herself with abdominal bloating and pain in the Emergengy Department. The symptoms persisted and a clinical evaluation was made. A lesion suspect for a giant duodenal diverticulum was seen on the CT-scan, which was confirmed by enteroclysis. Surgical resection was performed. The diagnosis was histological confirmed after surgery. Small bowel diverticula are relatively common, with an estimated 5 - 22% incidence in the healthy population. They are usually asymptomatic, but can present with abdominal pain and weight loss. Complications such as bleeding and perforation can occur. Surgical resection is the treatment of choice in symptomatic patients.

Gastric Schwannoma Presenting as an Incidentaloma on CT-Scan and MRI.

A 67 year old female was referred because of an incidentaloma on CT-scan and MRI which showed a 5.0 cm large mass in the wall of the distal stomach. After an initial work-up which suggested a gastrointestinal stromal tumor (GIST), a partial gastrectomy with a Billroth II gastrojejunostomy was performed. The histological diagnosis was a schwannoma. Gastric schwannomas are rare tumors which comprise 0.2% of all gastric tumors and 4% of all benign gastric neoplasms with a peak of incidence in the 4th and 5th decade of life. Gastric schwannomas are usually asymptomatic, but can present with ulceration and/or gastrointestinal bleeding. Clinical, endoscopical, surgical, radiological and histological features of this case are described and the relevant literature is reviewed.