Thyrolipoma presentation as a huge multinodular goiter; A case report of an extremely rare entity.

IMPORTANCE AND IMPORTANCE: Thyroid lipomatosis is a rare entity of thyroid gland lesions. The exact etiopathogenesis of this condition is unknown. Most patients presented with compression symptoms. Radiological investigations such as neck ultrasonography (U/S) and computed tomography (CT) are crucial to evaluate and diagnose fat-containing thyroid tumors, while the definitive diagnosis is achieved by the histopathological study. CASE PRESENTATION: A 78-year-old female patient, with a background medical history of diabetes mellitus type II and chronic kidney disease, presented to our hospital with a seven-month history of large-sized neck swelling. On physical examination, the neck mass was firm, nodular, hard in consistency, and asymmetrical. The neck swelling was associated with swallowing difficulties and minimal voice changes. Laboratory investigations were unremarkable. Neck U/S showed thyroid goiter. FNA and FNAC were also done. Then, neck CT was performed, and bilateral lobulated fat density was detected. So, a total thyroidectomy was performed, and the resected specimen was sent for histopathology studies. The postoperative period was uneventful. CLINICAL DISCUSSION: Diffuse thyroid lipomatosis is an unusual non-neoplastic lesion. The clinical features of thyro-lipomatosis include compression symptoms. Radiological tools and cytology aid in diagnosis demonstration but the specific diagnosis is achieved by histopathology. CONCLUSION: Due to the rare etiologic origin and unknown pathogenesis of thyrolipoma, we report the case of a 78-year-old female patient with enlarged neck swelling, found to be thyroid lipomatosis.

Multiple abdominopelvic abscesses caused by fishbone: A case report of rare etiology and literature review.

INTRODUCTION AND IMPORTANCE: Foreign body ingestion, particularly fishbone, is a prevalent medical complaint in the emergency department. Usually, these foreign substances pass through the gastrointestinal tract without causing any complications. The clinical manifestations of foreign body consumption are non-specific. CASE PRESENTATION: A 32-year-old male patient presented to our hospital with severe abdominal pain. Physical examination revealed a distended abdomen and tenderness. Plain chest and abdominal X-rays were unremarkable. The performed computed tomography (CT) of the abdominopelvic region showed multiple abscesses. Then, an exploratory laparotomy was decided during which a foreign body, a fishbone, was detected and the affected omental mass was resected, and abscess drainage was done. The resected specimen was sent for histopathological studies. The postoperative period was uneventful. CLINICAL DISCUSSION: Perforation of the intestinal wall by fishbone ingestion is an unusual entity. The clinical features of intestinal perforation are usually non-specific resulting in delayed diagnosis. Based on individual situations, the treatment strategy can be surgical or non-surgical. CONCLUSION: Even though ingesting a foreign body is a frequent complaint in clinical practice, its repercussions are extremely rare. Our case presented multiple intra-abdominal abscesses and perforation as a complication of accidental fishbone ingestion.

Management of unusual complications of modified rhomboid/Limberg procedure by interventional radiology guidance; A case report and literature review.

BACKGROUND: Fragmentation of the surgical drain is an unusual negative consequence of using a drainage system postoperatively. Even though it is rare, multiple management approaches were documented in the literature. CASE PRESENTATION: A 19-year-old male patient who had a history of recurrent pilonidal sinus disease that was operated on twice 4 months apart. He presented to our hospital for postoperative follow-up, during which the inserted drain was assessed. While withdrawing the drain, part of it was damaged and missed. The location of the misplaced drain was assessed by a lumbosacral region computed tomography (CT) scan. The decision was made to proceed with less invasive methods using interventional radiology techniques to avoid wide excision and incision reopening complications and prolonged healing time. A fluoroscopy procedure was performed to create three-dimensional anterolateral, frontal posterior views. Then the fragmented drain was retrieved successfully by a minimally invasive technique. The postoperative period was uneventful. DISCUSSION: Drain fragmentation and/or dislodgement is a highly challenging event that requires highly innovative intervention. Multiple treatment options are available as open surgery techniques and endoscopic approaches. CONCLUSION: This case highlights the potential role of fluoroscopy as an outstanding effective choice that could be carried out promptly and safely at the bedside under local anesthetic and reduce the patient's hospital stay.

Endoscopic trans-septal interforniceal approach for excision of colloid cysts of the third ventricle using the rotational technique.

Colloid cysts of the third ventricle are benign intracranial lesions that account for 0.5 to 2% of all brain tumors and are even rarer in pediatric population. Dandy was the first to successfully excise a colloid cyst of the third ventricle via a transcortical transventricular approach in 1921. For several decades to follow, the transcortical transventricular and transcallosal microsurgical approaches remained the cornerstone of surgical management of these lesions. With time and refinements in endoscopic equipment and techniques, endoscopic resection of colloid cysts evolved into a currently well-established and appealing minimally invasive alternative to microsurgery. Endoscopic endochannel techniques for colloid cysts of the third ventricle may either be transforaminal or trans-septal interforniceal, depending on the pathoanatomical features of the colloid cyst and its relation to the juxtaposed anatomical structures. The endoscopic trans-septal interforniceal approach is required to access the rare subset of colloid cysts that extend superior to the roof of the third ventricle between the two fornices insinuating themselves between the leaflets of the septum pellucidum. In this article, the surgical technique of the endochannel endoscopic trans-septal interforniceal approach is elaborated upon. A representative case is presented along with an operative video.

Sudden unilateral eye pain with vision loss related to carotid stump syndrome; A case report and literature review.

INTRODUCTION AND IMPORTANCE: Carotid stump syndrome (CSS) is a rare cause of recurrent ipsilateral cerebrovascular accidents (CVAs) resulting from completely occluded internal carotid artery (ICA). In this condition, hemodynamic and embolic risks are related to cerebral and retinal ischemic strokes. PRESENTATION OF CASE: A 65-year-old gentleman with multiple comorbidities, presented to our hospital with a sudden painful unilateral vision loss of the right eye. Head CT was done upon arrival, showing no evidence of ischemic or hemorrhagic brain insult and multiple right frontoparietal old infarct lesions were detected. Central retinal artery occlusion diagnosis was confirmed by an ophthalmologist. CT angiogram of the brain and carotids was done and revealed an obliterated, thrombosed, and non-opacified right internal carotid artery from the carotid bifurcation up to intracranial petrous/foramen lacerum. After taking the patient's surgical consent, right carotid stump endarterectomy and ligation of the stump under general anesthesia was done and the postoperative period was uneventful. CLINICAL DISCUSSION: CSS is an uncommon underlying etiology, causing recurrent stroke events. The clinical features of this syndrome include cerebral and ophthalmology symptoms. Diagnosis of CSS relies on imaging modalities. Internal carotid artery stump surgical excision through the ipsilateral ECA endarterectomy is the gold standard for CSS treatment. CONCLUSION: Despite being a rare entity, CSS is a treatable cause of retinal embolic events TIAs. Therefore, it is important to raise awareness of such condition. The presented case demonstrates the diagnosis, management and prognosis of CSS.

Cholecysto-hepatic fistula in type III gallbladder perforation: A rare etiology of liver abscess; case report.

INTRODUCTION AND IMPORTANCE: Gallbladder perforation (GBP) with cholecystohepatic fistula is an extremely rare complication of acute and/or chronic gallbladder diseases. Niemeier classified GBP into three types each characterized by specific signs and symptoms. Radiological investigations such as abdominal ultrasonography (USG) and computed tomography (CT) are crucial to evaluate and diagnosing GBP, while fistulae are usually identified intraoperatively. CASE PRESENTATION: A 77-year-old female patient, with a background medical history of multiple comorbidities, presented to our hospital with a one-week history of abdominal pain. Laboratory investigations showed abnormal values. The abdominal CT scan revealed a mildly enlarged liver, distended gallbladder, and liver abscess. Then, ultrasound-guided aspiration was done, and the clinical picture was consistent with calcular cholecystitis complicated with liver abscess. So, laparoscopic cholecystectomy was decided and the intraoperatively detected fistula was excised. The resected perforated gallbladder was sent for histopathological studies. The postoperative period was uneventful. CLINICAL DISCUSSION: GBP is an unusual entity that is categorized into three types. It is considered a gallbladder complication and surgical emergency. The clinical features of GBP are non-specific and radiological tools aid in diagnosis demonstration. In the presented case of type III GBP, cholecystohepatic fistula was detected and excised intraoperatively. CONCLUSION: Due to the rare entity of type III GBP in association with liver abscess, we report the case of a 77-year-old female with right lower quadrant pain, found to be caused by type III GBP with cholecystohepatic fistula and liver abscess.

An Unexpected GIST Causing Life-Threatening Bleeding after an Elective Hernia Repair.

Background Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the alimentary tract. They are usually manifested by GI bleeding. Case Presentation A 53-year-old male patient was admitted to the hospital for elective inguinal hernia repair. The patient did not have any history of GI symptoms in the past. A day after open inguinal hernia repair, the patient developed recurrent attacks of hematemesis resulting in hemodynamic instability and admission to the intensive care unit. An upper GI endoscopy identified a small bleeding gastric lesion. After multiple failed attempts to control the bleeding endoscopically, an emergency exploratory laparotomy was performed. An unexpected large fungating bleeding gastric mass was detected. The mass measured approximately 40 × 30 cm, and multiple peritoneal deposits were also discovered. A wedge resection of the anterior gastric wall along with the mass was performed. Histopathology revealed a high-grade (G2) GIST. Discussion GISTs appear in variable sizes and may lead to a variety of complications including abdominal pain, GI obstruction, and bleeding. This case highlights the unexpected presentation and sudden bleeding of a large GIST in a totally asymptomatic patient undergoing elective hernia surgery. It also illustrates that GIST can be asymptomatic and grow to large sizes before developing clinical manifestations. Conclusion The case report highlights a common complication of GIST with unexpected timing, immediately after routine hernia surgery.

Spontaneous thrombosis of a giant cavernous-carotid aneurysm with simultaneous ipsilateral complete parent artery occlusion: a rare phenomenon and review of the literature.

Cavernous-carotid artery (CCA) aneurysms represent about 3-5% of all intracranial aneurysms. Spontaneous thrombosis of a CCA aneurysm with simultaneous occlusion of its parent vessel is an extremely rare phenomenon with few reported cases in the literature offering different management strategies. A 54-year-old Asian female presented with a one day-history of painless left eye conjunctival injection, proptosis, and features of cavernous sinus syndrome (cranial nerve III, IV, V1, V2, and VI palsies). Imaging revealed a giant thrombosed CCA aneurysm measuring 3.6cmx3.4cm with complete thrombosis of the left cervical internal carotid artery (ICA) and adequate collaterals from the anterior and posterior communicating artery and branches of the left external carotid artery. Management was conservative with antiplatelet therapy and close clinical-radiological follow-ups. The outcome was satisfactory. Data in the literature on this condition is limited due to its exceedingly rare occurrence. The majority of patients do well via a conservative approach and surgery is rarely indicated. For clinically stable patients, especially those with adequate collateral circulation and tolerance to Balloon Test Occlusion, we advocate for a conservative approach and initiation of anti-platelet therapy to treat these patients. Emphasis is needed on close serial clinical-radiological surveillance in these cases to monitor the propagation of the thrombus as well as the development of new and/or enlarging pre-existing aneurysms in the contralateral ICA circulation.

Congenital absence of the cystic duct: Case report of a rare anomaly and review of the literature.

INTRODUCTION AND IMPORTANCE: Congenital absence of the cystic duct is one of the rare types of anomalies associated with the extrahepatic biliary tract (EHBT). It is often an incidental finding intraoperatively leading to significant implications during the perioperative period. CASE PRESENTATION: A 25-year-old lady was admitted for an elective laparoscopic cholecystectomy indicated for recurrent symptoms of right upper quadrant pain with evidence of cholelithiasis on ultrasound. During laparoscopy, the cystic duct could not be identified. After retrieval of the gallbladder, a blind ending orifice resembling an obliterated cystic duct was discovered. CLINICAL DISCUSSION: Absence of the cystic duct can result from a congenital or an acquired process. In both cases, they are difficult to diagnose pre-operatively even though magnetic resonance cholangiopancreatography (MRCP) has shown great potential in delineating the EHBT. It confers an increased risk of injury to the surrounding biliary tract during cholecystectomy. Therefore, the surgical approach depends on the surgeon's operative competency and knowledge related to EHBT anomalies. CONCLUSION: Definitive treatment for patients with symptomatic absent cystic duct is an open cholecystectomy, given its increased likelihood of iatrogenic morbidity. Nonetheless, it is important to highlight that laparoscopic cholecystectomy may be performed if the surgeon carries sufficient skills.

Giant omental lipoma, a rare etiology of right-iliac fossa pain in adult: A surgical case report.

BACKGROUND: Omental lipoma is an uncommon abdominal tumor of mature fat cells. Those benign tumors are usually asymptomatic but occasionally can cause signs and symptoms based on their location, size, and presence of complications. Radiological investigations such as Abdominal ultrasonography (USG) and computed tomography (CT) are crucial to evaluate and diagnose intra-abdominal tumors, especially omental lipomas. PRESENTATION: A 61-year-old male patient presented to our hospital with right iliac fossa pain. Physical examination and laboratory test results were normal. The performed abdominal CT scan revealed a large right-sided intraperitoneal mass measuring about 2.4 × 10 × 20 cm. Then, an ultrasound-guided biopsy was done and the picture was most consistent with lipoma. So, surgical intervention was decided and omental lipoma was completely exteriorized via a laparoscopic approach. The weight of the excised omental mass was 2.45 kg, measuring 23 × 18 × 7 cm. The resected specimens, including omental lipoma and omental lymph nodes, were sent for histopathological studies. The postoperative period was uneventful. DISCUSSION: Omental lipoma is an unusual entity that occurs often in children and rarely in adults. The clinical features of omental lipomas include abdominal discomfort, abdominal lump, abdominal pain, nausea, and/or weight loss. Diagnosis of the omental lipoma relies on imaging and physical examination, which was normal in the presented case. Abdominal CT provides definitive fat content characterization and its localization within the omentum. CONCLUSION: Due to the rare etiologic origin of omental lipomas, we report the case of a 61-year-old male with right iliac fossa pain, found to be caused by detected giant omental lipoma.