A rare presentation of low-grade appendiceal mucinous neoplasm within an amyand's hernia: a case report.

An Amyand's hernia is characterised as the presence of the appendix in an inguinal hernial sac. During laparoscopic cholecystectomy for gallbladder polyps, an incidental Amyand's hernia was discovered in a 75-year-old female patient. On examination, the hernia contained an appendiceal mucocele but no evidence of perforation. An open appendicectomy with tension-free mesh repair was performed for the hernia. The histopathological report of the appendix was a low-grade appendiceal mucinous neoplasm (LAMN), an entity that is just as rare as an Amyand's hernia. The patient had the right inguinal swelling for over 10 years but it was thought to be an inguinal intramuscular cyst as reported on a previous abdominal ultrasound. Mucocele of the appendix may have a benign or malignant appendiceal progress, leading to individualised diagnosis and treatment. We review an Amyand's hernia with LAMN and discuss the asymptomatic tendency yet malignant potential of appendiceal mucoceles along with treatment strategies.

Primary neuroendocrine tumor of the liver: A diagnostic dilemma in the management of liver mass in pregnancy.

Neuroendocrine tumor (NET) commonly occurs in the gastrointestinal tract, however primary NET of the liver is rare, especially during pregnancy. We present a 34-year-old pregnant woman gravida 3 para 2 at 16 weeks period of gestation with primary liver NET discovered incidentally during the antenatal check-up. She has no risk factors for hepatocellular carcinoma. Her serum alpha-fetoprotein was elevated. A plain magnetic resonance imaging (MRI) of the liver delineating a large well-defined exophytic liver mass at segment V/VI measuring 7.1 × 7.4 × 7.8 cm. Given inconclusive MRI findings coupled with low-risk factors of HCC, we had decided to follow up her liver mass with imaging 6 weekly. She then underwent a right hepatectomy with a caesarean delivery at 32 weeks of gestation in the same setting. The histopathological formal report revealed a neuroendocrine tumor, grade 2 with a Ki-67 index of 3% with negative lymphovascular and perineural invasion, but positive for porta hepatis lymph nodes metastasis. A follow up after 1 year shows both patient and her infant are healthy. Antenatal discovery of liver masses poses a diagnostic and management dilemma to clinicians. A multidisciplinary approach and collective decision making are crucial to determine the best approach tailored to the maternal and fetal benefit. In cases of inconclusive non-contrast MRI in pregnancy with low-risk factors and lack of clinical evidence of HCC, follow-up with imaging modalities aiming to intervene at the third trimester can offer safer, and promising outcomes.

High Resolution Impedance Manometry: A Necessity or Luxury in Esophageal Motility Disorder?

BACKGROUND The esophagus can be affected by a variety of disorders that may be primary or secondary to another pathologic process, but the resulting symptoms are usually not pathognomonic for a specific problem, making diagnosis and further management somewhat challenging. High resolution impedance manometry (HRiM) has established itself as a valuable tool in evaluating esophageal motility disorder. HRiM is superior in comparison with conventional water perfused manometric recordings in delineating and tracking the movement of functionally defined contractile elements of the esophagus and its sphincters, and in distinguishing the luminal pressurization of spastic esophageal contraction from a trapped bolus. Making these distinctions can help to identify achalasia, distal esophageal spasm, functional obstruction, and subtypes according to the latest Chicago Classification of Esophageal Motility Disorders version 3.0. CASE REPORT We report a case series of 4 patients that presented with dysphagia; and with the ancillary help of the HRiM, we are able to diagnose esophageal motility disorder and evaluate its pathogenetic mechanism. This approach aids in tailoring each management individually and avoiding disastrous mismanagement. CONCLUSIONS From the series of case reports, we believe that HRiM has an important role to play in deciding appropriate management for patients presenting with esophageal motility disorders, and HRiM should be performed before deciding on management.

The Hanikoda Method: 3-layered Negative Pressure Wound Therapy in Wound Bed Preparation.

INTRODUCTION: Negative pressure wound therapy is a widely used method of wound dressing with various commercially available brands. The authors created the Hanikoda Method (HM) for effective wound bed preparation or definite wound closure. METHODS: In this case series, the authors discuss 8 different wound cases that presented to their Plastics Unit from January 2014 to June 2015. Patients with traumatic or infected wounds were selected for treatment with the HM. Selected patients underwent multiple cycles of this method until their wounds were ready for definite wound closure or the wounds had closed by secondary closure. DISCUSSION: The purpose of any wound dressing is to encourage epithelization while ensuring no factors impede wound healing. An additional benefit is to reduce wound bed size so that it may close by secondary intention or require less skin graft coverage. Each layer of the dressing is described, along with its function in wound bed preparation or in closure. CONCLUSION: The HM facilitates reduction of wound size, wound bed preparation, and overall management.