Ruptured carotid artery pseudoaneurysm following excision of a carotid body tumor: a rare complication managed successfully with surgery and literature review.

A 47-year-old male presented with a right-sided Shamblin type 2 carotid body tumor measuring 5*5 cm. After preoperative embolization, a sub adventitial resection of the tumor was done. He was discharged after postoperative day 5 and presented again to emergency 10 days later with a bleeding pseudoaneurysm at the surgical site causing dysphagia and dyspnea. He was taken for emergency exploration of the surgical wound and, intraoperatively, it was observed that the proximal ends of the internal carotid artery and external carotid artery close to the bifurcation were forming a pseudoaneurysm, 1 cm distal to the common carotid artery. The external carotid artery was ligated and a common carotid to internal carotid artery bypass was done with a reversed saphenous vein graft. He recovered well in the postoperative period and was discharged on day 7. Pseudoaneurysm formation following carotid body tumor resection is extremely rare and has only been reported thrice in the literature.

Um homem de 47 anos apresentou tumor carotídeo Shamblin tipo 2 no lado direito, medindo 5 x 5 cm. Após embolização pré-operatória, foi realizada ressecção subadventicial do tumor. O paciente teve alta no quinto dia pós-operatório e voltou à emergência 10 dias depois, com pseudoaneurisma hemorrágico no sítio operatório causando disfagia e dispneia. Foi levado para exploração emergencial da ferida cirúrgica, e, no intraoperatório, 1 cm distalmente à artéria carótida comum, as extremidades proximais da artéria carótida interna e da artéria carótida externa próximas à bifurcação formavam um pseudoaneurisma. A artéria carótida externa foi ligada, e foi realizada uma ponte de safena de carótida comum para a artéria carótida interna com a veia safena invertida. O paciente se recuperou bem no pós-operatório e recebeu alta no sétimo dia. A formação de pseudoaneurisma após ressecção de tumor do corpo carotídeo é extremamente rara, tendo sido relatada apenas três vezes na literatura.

Metastatic presentation of dermatofibrosarcoma protuberans as massive lower gastrointestinal bleed.

Dermatofibrosarcoma protuberans (DFSP) is an aggressive tumour with multiple local recurrences and rare metastatic potential. Fibrosarcomatous transformation occurs in a few cases of DFSP which makes them more aggressive in terms of recurrence and metastasis. Here we report the case of a woman in her late 30s who presented with massive lower gastrointestinal (GI) bleeding with a history of multiple surgeries for DFSP on her anterior abdominal wall. The bleeding source was identified to be a mass lesion in the jejunum, which was excised. The patient recovered well and the histopathology revealed fibrosarcoma of the jejunum. Follow-up investigations showed multiple lung nodules, ascites and abdominal lymph nodes suggesting progressive disease. She is currently receiving chemotherapy and progressing well 3 months postoperatively. Patients with fibrosarcomatous changes within DFSP must be followed up closely as it is associated with increased metastatic potential.

Advanced and Metastatic Gastrointestinal Stromal Tumors Presenting With Surgical Emergencies Managed With Surgical Resection: A Case Series.

Advanced and metastatic gastrointestinal stromal tumors (GISTs) presenting with surgical emergencies are rare. Neoadjuvant imatinib being the treatment of choice for non-metastatic advanced disease with a proven role in downstaging the disease may not be feasible in patients presenting with bleeding and obstruction. We present a case series with retrospective analysis of a prospectively maintained database of patients with advanced and metastatic GISTs presenting with surgical emergencies. Clinical characteristics, imaging and endoscopic findings, surgical procedures, histological findings, and outcomes in these patients were studied. Four patients were included in this case series, with three males and one female (age range: 24-60 years). Two patients presented with melena; one with hemodynamic instability despite multiple blood transfusions underwent urgent exploratory laparotomy for bleeding gastric GIST, while the other underwent surgical exploration after careful evaluation given the recurrent, metastatic disease with a stable metabolic response on six months of imatinib. One patient with metastatic jejunal GIST who presented with an umbilical nodule and intestinal obstruction was given a trial of non-operative management for 72 hours, but due to non-resolution of obstruction, segmental jejunal en bloc resection with the dome of the urinary bladder with reconstruction and metastasectomy was needed. The patient with advanced gastric GIST who presented with gastric outlet obstruction was resuscitated, and an attempt of endoscopic naso-jejunal tube placement was tried, which failed, and exploration was needed. The mean length of hospital stay was 7.5 days. Histopathological examination confirmed GIST in all four patients with microscopic negative resection margins. All patients were started on imatinib with dose escalation to 800 mg in the patient with recurrent and metastatic disease; however, the patient with bleeding gastric GIST experienced severe adverse effects of imatinib and discontinued the drug shortly. All four patients are disease-free on follow-ups of 15 months, 48 months for the patient with advanced non-metastatic disease, and six and 24 months for the patients with metastatic disease. In the era of tyrosine kinase inhibitor (TKI) therapy for advanced and metastatic disease, upfront surgery is usually reserved for surgical emergencies only. Surgical resection, the cornerstone for the treatment of resectable GIST, may also be clinically relevant in metastatic settings, although it requires a careful and individualized approach.

Hepatic artery vasospasm masquerading as early hepatic artery thrombosis in progressive familial intrahepatic cholestasis 3: a case report.

Post-liver transplant (LT) hepatic artery vasospasm is a vascular complication that is not well recognized and its incidence is not known. As a possible sequela to vasospasm, hepatic artery thrombosis is the second major cause of allograft failure after primary nonfunction and its reported incidence is 2.9% in adults and 8.3% in pediatric LT. Lacuna in knowledge regarding early hepatic artery vasospasm post-LT makes it a difficult condition to diagnose and treat, as the initial ischemic insult on graft can have devastating consequences. We report a case of pediatric progressive familial intrahepatic cholestasis type 3-related chronic liver disease who underwent cadaveric orthotopic LT and postoperatively developed fever, worsening hypotension, and elevated liver enzymes with an absence of arterial flow in intrahepatic branches on Doppler ultrasound. Suspecting early hepatic artery thrombosis, the patient was re-explored and the graft hepatic artery was found to be in a state of vasospasm. Following the infusion of intra-arterial papaverine, urokinase, and intravenous nicorandil, there was an improvement in blood flow. The patient responded well and was discharged on postoperative day 23 with normal liver enzymes.

Ruptured carotid artery pseudoaneurysm following excision of a carotid body tumor: a rare complication managed successfully with surgery and literature review / Pseudoaneurisma de artéria carótida rompida após excisão de tumor do corpo carotídeo: uma complicação rara tratada com sucesso com cirurgia e revisão da literatura

Abstract A 47-year-old male presented with a right-sided Shamblin type 2 carotid body tumor measuring 5*5 cm. After preoperative embolization, a sub adventitial resection of the tumor was done. He was discharged after postoperative day 5 and presented again to emergency 10 days later with a bleeding pseudoaneurysm at the surgical site causing dysphagia and dyspnea. He was taken for emergency exploration of the surgical wound and, intraoperatively, it was observed that the proximal ends of the internal carotid artery and external carotid artery close to the bifurcation were forming a pseudoaneurysm, 1 cm distal to the common carotid artery. The external carotid artery was ligated and a common carotid to internal carotid artery bypass was done with a reversed saphenous vein graft. He recovered well in the postoperative period and was discharged on day 7. Pseudoaneurysm formation following carotid body tumor resection is extremely rare and has only been reported thrice in the literature.

Resumo Um homem de 47 anos apresentou tumor carotídeo Shamblin tipo 2 no lado direito, medindo 5 x 5 cm. Após embolização pré-operatória, foi realizada ressecção subadventicial do tumor. O paciente teve alta no quinto dia pós-operatório e voltou à emergência 10 dias depois, com pseudoaneurisma hemorrágico no sítio operatório causando disfagia e dispneia. Foi levado para exploração emergencial da ferida cirúrgica, e, no intraoperatório, 1 cm distalmente à artéria carótida comum, as extremidades proximais da artéria carótida interna e da artéria carótida externa próximas à bifurcação formavam um pseudoaneurisma. A artéria carótida externa foi ligada, e foi realizada uma ponte de safena de carótida comum para a artéria carótida interna com a veia safena invertida. O paciente se recuperou bem no pós-operatório e recebeu alta no sétimo dia. A formação de pseudoaneurisma após ressecção de tumor do corpo carotídeo é extremamente rara, tendo sido relatada apenas três vezes na literatura.

Prospective Validation and Comparison of Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) and Site Other Than Lower Limb, Immunosuppression, Age, Renal Impairment, and Inflammatory Markers (SIARI) Scoring Systems for Necrotizing Fasciitis.

INTRODUCTION: Necrotizing fasciitis (NF) is a rapidly progressing infection of the soft tissues associated with high morbidity and mortality and hence it is a surgical emergency. Early diagnosis and treatment are of paramount importance. LRINEC (Laboratory Risk Indicator for Necrotizing Fasciitis) and SIARI (Site other than lower limb, Immunosuppression, Age, Renal impairment, and Inflammatory markers) scoring systems have been established for early and accurate diagnosis of necrotizing fasciitis. This study compared the two scoring systems for diagnosing NF, predicting management, and elucidating the prognostic performance for re-operation and mortality. METHODS: This prospective study was conducted in PGIMER Chandigarh, India, between February 2020 and June 2021. The study was approved by the Institutional Review Board (No. INT/IEC/2020-90). The clinical presentation, laboratory parameters, and imaging were used to classify patients into NF or severe cellulitis groups. We also calculated the LRINEC and SIARI scores. Demographic variables and mortality were recorded. The area under the receiver operating characteristic was used to express the accuracy of both scores at a cut-off LRINEC and SIARI scores of ≥6 and ≥ 4, respectively. RESULTS: The study comprised 41 patients with NF and 11 with severe cellulitis. Informed written consent was taken from all the participants. At LRINEC score ≥6, the C-statistic for NF diagnosis was 0.839 (95% confidence interval [CI] 0.682-0.995, P 0.001), which was better than SIARI score at ≥ 4, C-statistic of 0.608 (95% CI 0.43-0.787, P 0.297). Both scores accurately predicted 30-day mortality. The LRINEC score showed a C-statistic of 0.912 (95% CI 0.798-1, P 0.001). Simultaneously, the SIARI score showed 70% sensitivity and 77% specificity, with a C-statistic of 0.805 (0.62-0.99, P = 0.017). CONCLUSIONS: LRINEC score is an effective diagnostic tool for distinguishing necrotizing fasciitis from severe cellulitis. Additional research is required to establish the SIARI score's external validity.

Dengue Transmission From Donor to Recipient After Deceased Donor Liver Transplant; Report of a Case and Review of Literature: Is Liver a Privileged Organ?

Nonvector transmission of dengue virus via organ transplantis rare.We report a probable case of dengue virus transmission via deceased donorlivertransplant. The donor was asymptomatic for dengue infection, and the liver recipient developed fever and thrombocytopenia 8 days after transplant. The recipient's testresults were positive forthe antigen for nonstructural protein 1 and for immunoglobulin M; however, donor serum samples were not available. Other transplant recipients (renal allograft) also showed dengue-positive test results during the same period, and these patients eventually died. Dengue illness in the liver recipient was severe and associated with shock and cardiomyopathy that required mechanical ventilation, intensive care, and cessation of immunosuppression; however, the patient subsequently improved and was discharged. This case highlights the importance of a high index of suspicion for dengue infection in the presence of graft dysfunction in dengue-endemic areas like India, as well as the importance of the test for the nonstructural protein 1 antigen during dengue outbreaks. These considerations should be included on the standard evaluation of solid-organ transplant donors.

Spontaneous Intra-abdominal Hemorrhage in a Hemophilia A Patient Masquerading as Intra-abdominal Pseudotumor.

Spontaneous intra-abdominal hemorrhage is very rare in hemophilia A patients. High index of suspicion is necessary for successful management. Surgical intervention may be required in cases of diagnostic uncertainty and for adequate hemostasis. Here we report a case of spontaneous hemorrhage in the peritoneal cavity in hemophilia A patient, who was managed with surgery and factor VIII supplementation. Patient did well in the postoperative periods.