Surgical challenges during open pancreaticoduodenectomy in a patient with situs inversus totalis: A rare case report and literature review.

Background: Situs inversus totalis is a rare congenital anomaly defined by a mirror-image of thoracic and abdominal viscera. Discrete cases of situs inversus totalis and its association with gastrointestinal tumors have been reported. Here we report the first case of pancreatic-head serous cystadenoma in patient with situs inversus totalis. Case presentation: A 68-year-old woman presented with an abdominal mass that appeared four months ago. She was otherwise asymptomatic and her physical examination was unremarkable. Chest X-ray revealed dextrocardia. CT scan confirmed situs inversus totalis with an irregular, clear border, heterogenous pancreatic-head mass measuring 11 cm. Laboratory studies were within the reference range and pancreatic tumor markers were normal. We performed an elective open pancreaticoduodenectomy followed by an end-to-side pancreaticojejunostomy, an end-to-side choledochojenunostomy, and a side-to-side gastrojejunostomy. The immediate postoperative course was uneventful, and she was discharged four days later without any complications. Four-month of follow-ups revealed no recurrent or relapsed disease. Discussion: Although the steps of the Whipple procedure are almost the same in SIT patients. The main differences during the operation in SIT patients are the anatomical variations and how the surgeon will cope with them to avoid any mistakes. Conclusion: The surgeons should improve their skills and gain control in both hands to easily adjust with the anatomic variations of situs inversus totalis and reduce the operation time and the associated risk of long operation time.

MELAS syndrome with rare manifestations misdiagnosed as vasculitis in the absence of lactic acidosis: A case report.

Introduction: The syndrome of mitochondrial encephalomyopathy with lactic acidosis and stroke-like episodes (MELAS) is one of the most common inherited mitochondrial disorders. Presentation of case: A 33- year-old male was admitted due to edema, urinary retention, and reduce urinary output. The medical history included a pigmentary retinopathy (PR) at age of 22 and uveitis at age of 30, which were both treated with prednisolone. At age of 32, unapparent bilateral sensorineural hearing loss (SNHL) and symmetric basal ganglia calcifications were observed in neurologic study, and received prednisolone for the diagnosis of migraine and undefined vasculitis. Also, he described a right transient ischemic stroke (TIA) in the past 4 months. His family history included a dead brother, who had nearly similar components. Physical exam on admission corresponded with parkinsonism. The status points to MELAS but the genetic test was not available. Additional tests were applied, excluding all other disorders. Lactate was normal in serum and CSF. Kidney tests revealed a nephrotic syndrome and glomerulopathy, and the biopsy showed a single hyalinized glomerulus, which most likely suggests focal segmental glomerulosclerosis (FSGS). Muscle biopsy showed ragged red fibers. Conclusion: Here, we report a challenging case of MELAS syndrome with rare manifestations including uveitis, PR, parkinsonism, and FSGS in the absence of lactic acidosis with unapparent muscle or hearing impairments. Since, clinicians might misdiagnose MELAS as vasculitis or other disorders due to its heterogeneous presentations, a proper investigations should guide the diagnosis of these conditions to reduce the delay of diagnosis and ineffective treatments.