Dilemma of Blunt Abdominal Trauma in Patients with Crohn's Disease, Can Intestinal Perforation be Missed?

Background: Isolated intestinal injury after blunt abdominal trauma is a rare challenging clinical entity. Patients with Crohn's disease (CD) are considered more prone to spontaneous intestinal perforation rather than normal population However, spontaneous intestinal perforation remains rare. In the literature, there are few cases reports discussing intestinal perforation after blunt abdominal trauma in CD patients. Objective: Herein, we report a young male patient with CD who had missed traumatic intestinal perforation along with literature review of similar cases. Case Presentation: A young male patient, known to have CD, was brought to the emergency department after a road traffic accident. He had mild tenderness over his right iliac fossa with no signs of peritonitis. His chest X-rays revealed right-sided pneumothorax. His pan-computed tomography revealed thickened terminal ileum and minimal collection between the intestinal loops that were interpreted as interval regression of his Crohn's disease. On the second day, he remained hemodynamically-stable with no signs of peritonitis but his chest X-rays showed air under diaphragm. A repeated CT showed pneumoperitoneum, air foci around the terminal ileum and mild free fluid. An ileal perforation was found around 25 cm from the ileo-cecal valve. The involved ileal segment was completely resected with double-barrel ileostomy. Conclusion: Traumatic intestinal injury in patients with Crohn's disease represent both diagnostic and management dilemma. Inaccurate interpretation of radiological signs may lead to a delayed or missed diagnosis and surgical intervention. Abdominal CT scan should be routinely repeated, within 24 hours, for such patients, regardless absence of symptoms or signs suggestive of intestinal perforation.

Reconstruction of Infected Mediastinal Wound with an Omental Flap Harvested Laparoscopically After Cardiac Surgery: Report of Two Cases and Literature Review.

Background: Deep sternal wound infection and dehiscence are two serious complications after open cardiac surgery. Omental flap harvesting is recognized as one of the management options, with traditionally non-favorable outcomes due to laparotomy stress on patients. Objective: Herein, however, we report our experience with two patients who have developed a mediastinal wound infection following coronary artery bypass grafting and were reconstructed with omental flaps harvested laparoscopically. Case Presentation: Two 74-year-old females, who were known to have multiple comorbidities, developed a sternal wound infection after coronary artery bypass graft. Several operative trials and non-operative measures have been attempted to manage the infections and/or reconstruct the wound but failed. Both patients then underwent laparoscopic omental flap harvesting for reconstruction and exhibited significant clinical improvement postoperatively. Discussion: Omental flap is considered a feasible option for reconstruction of sternal wound dehiscence developing after open cardiac surgery because it is usually well-vascularized, contains a large number of immunologically active cells and has the ability to absorb wound secretions. The traditional method of harvesting is conventional laparotomy, but it carries high rates of morbidity. Therefore, laparoscopic harvesting can be utilized as an alternative with better outcomes. Conclusion: Laparoscopic omental flap harvesting is considered a feasible and safe procedure to manage sternal wound dehiscence after open cardiac surgery, with satisfactory surgical outcomes.

Synchronous Malignant Peritoneal Mesothelioma and Sigmoid Adenocarcinoma: a Challenging Clinical Entity.

Background: Malignant peritoneal mesothelioma (MPM) represents a rare clinical entity. The synchronous existence of MPM with other malignancies as colonic adenocarcinoma have been rarely reported. Its diagnosis and management are challenging given its complexity and rarity. Objective: Herein, we report a case of epithelioid subtype of MPM occurring synchronously with sigmoid colonic adenocarcinoma, along with review of the literature. Case presentation: An elderly female patient was referred as case of rectosigmoid mass. She reported history of abdominal pain, per-rectal bleeding, anorexia, and significant weight loss. Her computed-tomography scan of the abdomen revealed a fistulizing sigmoid mass and multiple enlarged lymphnodes with omental nodulation. The colonoscopy revealed a large fungating mass and the endoscopic biopsies were reported as colonic adenocarcinoma. The patient was scheduled laparoscopic low anterior resection. However, the diagnostic laparoscopy revealed several nodules disseminated all over the peritoneum, suggestive of peritoneal mesothelioma. Therefore, the decision was changed to create transverse colostomy after examination obtaining multiple biopsies from the omental and peritoneal nodules. The histopathological revealed MPM and the final diagnosis was sigmoid adenocarcinoma with synchronous MPM. The patient was started on palliative chemotherapy (capecitabine) without active management of MPM because of her general condition. She was followed up with a good clinical course. Conclusion: MPM is an overlooked entity with vague clinical presentation. Synchronous MPM with colorectal cancer is rare with only few published case reports. Its diagnosis is challenging, and its management should be tailored according to the patient. This case is the first reported case in Saudi Arabia and the Middle East.

Gastric Schwannoma In a Patient Undergoing Sleeve Gastrectomy: Uncommon Gastric Tumor Discovered Incidentally During a Common Gastric Procedure.

BACKGROUND Obesity is a major global health issue associated with significant co-morbidities. Regarding its treatment, the use of bariatric procedures is increasing due to their efficacy in weight reduction and improved management of the associated medical conditions. Although comprehensive preoperative evaluation is essential, routine upper endoscopy is controversial. CASE REPORT We present the case of a 27-year-old woman with a history of morbid obesity, hypertension, and diabetes mellitus. She had multiple unsuccessful attempts at lifestyle modification for weight reduction. Accordingly, she was scheduled for sleeve gastrectomy. However, the operation was canceled due to the incidental intra-operative finding of a gastric mass. She was diagnosed as having gastric schwannoma, which is considered a rare gastrointestinal neoplasm. CONCLUSIONS Comprehensive preoperative evaluation of patients undergoing bariatric procedures is essential. The present case is a good example of the value of upper endoscopy in the evaluation of patients, including those who are asymptomatic.