Idiopathic omental hemorrhage: a case report and review of the literature.

BACKGROUND: A spontaneous rupture of an omental vessel can cause severe intraabdominal hemorrhage. We present a case of idiopathic omental hemorrhage caused by a vascular malformation. The literature is systematically reviewed. CASE PRESENTATION: A 65-year-old Iranian man was admitted to the emergency department for 10 days with abdominal pain. His medical history was not significant. Fever, vomiting, nausea, or anorexia were not reported. However, he was suffering from diaphoresis and malaise at the time. He did not smoke or drink alcohol. During physical examination, blood pressure was 82/60 mmHg with a temperature of 36.6 °C; heart rate was 96 beats/minute and respiratory rate was 18 breaths per/minute. An abdominal examination revealed mild tenderness in the periumblical. The focused assessment with sonography in trauma examination yielded positive results. The complete blood count showed 14 × 103/mcL of white blood cells and 185 × 103/mcL of platelets. The hemoglobin value was 6.7 g/L at admission. To stabilize the patient's condition, a unit of packed cell was administered. A double contrast enhancement abdominal computer tomography was performed, which revealed a massive hemoperitoneum. Subsequently, an exploratory laparoscopy was performed to search for the responsible pathology. But it was not successful. The surgical plan was changed to laparotomy. The hemorrhage source was not found during laparotomy. Observation revealed a massive hemoperitoneum originating in the omental vessels. A portion of the omentum located on the greater omentum at the greater curve was removed. Based on the pathological examination of the extracted tissue, vascular malformations were identified. The patient recovered uneventfully and was discharged from the hospital 7 days after surgery. Previous reports assessing idiopathic omental bleeding were systematically reviewed. A total of 14 hits were identified in PubMed and Scopus from 2015 to November 2022 for idiopathic omental bleeding. CONCLUSION: Presence of positive focused assessment with sonography in trauma, abdominal pain, imaging evidence of fluid accumulation, and a reduction in hemoglobin levels collectively indicate the likelihood of arteriovenous malformation occurrence. The treatment options include surgical intervention and transcatheter arterial embolization. Surgical intervention is recommended for subjects with hemodynamic instability, persistent hypotension and those whose diagnosis is unconfirmed.

A diagnostic challenge; pelvic solitary fibrous tumor (SFT) mimicking Peri-Anal gastrointestinal stromal tumor (GIST): A case report.

Key Clinical Message: The study reports a rare case of pelvic solitary fibrous tumor (SFT) that was initially considered as a peri-anal gastrointestinal stromal tumor due to similar radiologic/pathologic features. SFT diagnosis can be challenging due to its rarity and wide range of diagnoses that must be ruled out precisely. Abstract: Solitary fibrous tumors (SFTs) are rare tumors that can occur in any part of the body. Although usually benign, malignant SFTs have been reported, especially outside the lungs. Radiology can help with diagnosis, but immunohistochemistry is necessary to distinguish SFTs from other possible diagnoses such as gastrointestinal stromal tumors (GISTs). This study presents a rare case of pelvic SFT initially considered to be a peri-anal GIST, highlighting the importance of accurate diagnosis given the rarity of SFTs and the need to rule out other potential diagnoses.

Distant Metastasis as the First Presentation of Thyroid Carcinoma.

Introduction: Thyroid carcinoma is the most common endocrine cancer which may manifest with unusual presentations. We addressed distant metastases as the first presentations of thyroid carcinoma in several patients, though previously considered to occur rarely. Methods: In this case series, 10 patients are introduced with signs and symptoms of distant metastasis. Detailed history, physical examination, laboratory data, and histopathologic final report of thyroid cancer are presented. Conclusion: Although it seems unusual to discover a distant metastasis without abnormal thyroid examination, several reports of similar findings urge the need to improve screening process. It is prudent to bear in mind these presentations for early detection of thyroid carcinoma.

Early closure compared to late closure of temporary ileostomy in rectal cancer: a randomized controlled trial study.

BACKGROUND: A temporary loop ileostomy is one of the most common methods for the prevention of anastomotic leakage in rectal cancer patients who underwent low anterior resection. However, the optimal timing of loop ileostomy reversal remains unknown. The main objective of this study was to evaluate the debilitating complications caused by early closure of ileostomy in comparison with late closure in rectal cancer patients. DESIGN: A randomized, controlled, unblinded, and monocentric trial. METHODS: A total of 104 rectal cancer patients were randomly assigned to the case group of early closure of ileostomy (n = 50) and the control group of late closure of ileostomy (n = 54). This trial was undertaken in a single colorectal institution, a university-affiliated teaching hospital in Tehran, Iran. Randomization and allocation to the trial group were conducted by using variable block randomization based on quadruple numbers. The primary endpoint of this trial was determined by the complications of early ileostomy closure versus those of late closure in rectal cancer patients who had undergone low anterior resection. In early closure, loop ileostomy is reversed 2-3 weeks after the first two courses of adjuvant chemotherapy, while in late closure, the ileostomy is reversed 2-3 weeks after the last course of adjuvant chemotherapy. RESULTS: Follow-up of 1 year demonstrated a reduction in the risk of complications and an improved quality of life in patients with rectal cancer following low anterior resection and chemotherapy (neoadjuvant and adjuvant) in the case group but did not reach a significant difference (p = 0.555). In addition, there was no significant difference in perioperative outcomes, such as blood loss, operative time, readmission, and reoperation; also, no statistically significant differences were reported between the groups in patients' quality of life or LARS score. CONCLUSION: In summary, it seems that early closure of ileostomy is not better than late closure in improving patients' quality of life with rectal cancer following low anterior resection and chemotherapy (neoadjuvant and adjuvant); no statistical difference was observed for reduction of risk of ostomy complications. Thus, neither of these methods (early closure versus late closure) is superior to the other, and controversy still exists. TRIAL REGISTRATION NUMBER AND DATE OF REGISTRATION: IRCT20201113049373N1.

Genetic and immunologic evaluation of children with inborn errors of immunity and severe or critical COVID-19.

BACKGROUND: Most severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected individuals are asymptomatic or only exhibit mild disease. In about 10% of cases, the infection leads to hypoxemic pneumonia, although it is much more rare in children. OBJECTIVE: We evaluated 31 young patients aged 0.5 to 19 years who had preexisting inborn errors of immunity (IEI) but lacked a molecular diagnosis and were later diagnosed with coronavirus disease 2019 (COVID-19) complications. METHODS: Genetic evaluation by whole-exome sequencing was performed in all patients. SARS-CoV-2-specific antibodies, autoantibodies against type I IFN (IFN-I), and inflammatory factors in plasma were measured. We also reviewed COVID-19 disease severity/outcome in reported IEI patients. RESULTS: A potential genetic cause of the IEI was identified in 28 patients (90.3%), including mutations that may affect IFN signaling, T- and B-cell function, the inflammasome, and the complement system. From tested patients 65.5% had detectable virus-specific antibodies, and 6.8% had autoantibodies neutralizing IFN-I. Five patients (16.1%) fulfilled the diagnostic criteria of multisystem inflammatory syndrome in children. Eleven patients (35.4%) died of COVID-19 complications. All together, at least 381 IEI children with COVID-19 have been reported in the literature to date. Although many patients with asymptomatic or mild disease may not have been reported, severe presentation of COVID-19 was observed in 23.6% of the published cases, and the mortality rate was 8.7%. CONCLUSIONS: Young patients with preexisting IEI may have higher mortality than children without IEI when infected with SARS-CoV-2. Elucidating the genetic basis of IEI patients with severe/critical COVID-19 may help to develop better strategies for prevention and treatment of severe COVID-19 disease and complications in pediatric patients.

Rectus Sheath Hematoma in COVID-19 Patients as a Mortal Complication: A Retrospective Report.

Background: Rectus sheath hematoma is a rare self-limited presentation that has become a concern in hospitalized COVID-19 patients receiving anticoagulant therapies. Method: A retrospective multicentric study was conducted in referral hospitals affiliated with the Tehran University of Medical Science, Tehran, Iran, between June and August 2021. Patients with a confirmed diagnosis of COVID-19 that were complicated with rectus sheath hematoma during hospitalization were included. Median (lower quartile to upper quartile) was used to report the distribution of the results. Result: This study was conducted on nine patients with confirmed COVID-19 pneumonia, including eight females and one male. The severity of viral pneumonia was above average in eight patients. The median age and median body mass index were 65 (55.5 to 78) years and 29.38 (23.97 to 31.71) kg/m2. The duration of anticoagulant therapy was 10 (6 to 14) days, and the median length of hospital stay was 20 (10 to 23.5) days. Rectus sheath hematoma occurred after a median reduction of 4 (2.7 to 6.6) units in blood hemoglobin. Although 66.7% received ICU care and all of them were under full observation in well-equipped hospitals, the mortality rate was 55.6%. Conclusion: In summary, increased levels of inflammatory markers such as lactic acid dehydrogenase along with an abrupt decrease in blood hemoglobin in COVID-19 patients should be considered as predisposing factors for rectus sheath hematoma, especially in patients with moderate to severe COVID-19 pneumonia under anticoagulant therapy. This complication had been considered a self-limited condition; however, it seems to be fatal in patients with COVID-19 pneumonia. Further studies in larger sample sizes should be conducted to find out suitable management for this complication.

COVID-19 patients presenting with gangrenous acalculous cholecystitis: Report of two cases.

Introduction and importance: COVID-19 virus is thought to complicate underlying conditions, including acalculous cholecystitis. Two COVID-19 patients with gangrenous gallbladder are reported who were not involved with severe pneumonia. Case presentation: We present two non-critically ill patients with COVID-19 presenting with acalculous cholecystitis. Both patients had gangrenous gallbladder and had to undergo cholecystectomy. Upon surgery, one of the patients showed patchy gangrene on gallbladder and the other, a fully gangrenous gallbladder. Conclusion: There may be a possibility for COVID-19 patients with cholecystitis to develop ischemic gallbladder.

Does ultrasound evaluation of the axilla increase the rate of axillary lymph node dissection in early stage clinically node negative breast cancer patients?

BACKGROUND: Management and axillary staging of breast cancer has become less invasive and more conservative, over the decades. Considering Z011, axillary lymph node dissection (ALND) can be avoided in T1-2 N0-1 breast cancers with one or two positive sentinel lymph nodes (SLNs), if they are candidates for breast conserving surgery and radiotherapy. The aim of this study was to recognize if pre-operative axillary US evaluation in early-stage breast cancer could lead to more ALND in post Z011 era. METHOD: 463 breast cancer patients were evaluated. 368 early-stage breast cancer patients (T1-2 N0) were included. We did not perform axillary US in early stage clinically node negative patients; however, 97 patients had axillary US prior to our visit. If axillary US could detect more than two suspicious LNs, US guided biopsy was performed. The remaining clinically node negative patients underwent upfront SLNB. ALND was performed if more than two SLNs were metastatic, or US-guided ALN biopsy proved metastatic involvement. RESULTS: 97 patients had axillary US evaluation before the surgery. 67 patients (69.2%) did not have any suspicious US detected axillary LNs, 17 patients (17.5%) had one, 7 patients (7.2%) had two, and 6 patients (6.2%) had more than two suspicious LNs according to their axillary US evaluation. Those with more than two suspicious LNs underwent ALN US-guided biopsy. Metastatic involvement of the LNs was proved in all of them and they underwent upfront ALND. ALND revealed more than 2 metastatic LNs in 2/6 patients (33.3%). 91 patients who were evaluated by axillary US, had less than two US detected suspicious LNs and underwent SLNB. Amongst 24 patients with one or two US detected suspicious LNs, 1/24 patient had more than two positive SLNs and underwent ALND. In this group 15.6% underwent ALND and 5.2% of them were unnecessary according to the recent guidelines. Axillary US had a false positive rate of 36.6%. The sensitivity of axillary US in distinguishing patients with more than two suspicious LNs in clinically node negative patients was 25%. In the second group (without pre-operative axillary US evaluation), SLNB was performed. 204/272 patients (75%) did not have LN metastasis. 54/272 patients (19.9%) had one or two metastatic SLNs and according to Z011, ALND was omitted. 5.1% had more than two metastatic SLNs and underwent ALND. CONCLUSION: US evaluation of the axilla in early stage, clinically node negative breast cancer patients, is not sensitive enough to recognize more than two metastatic ALNs. It leads to more unnecessary ALND. Despite the small number of patients in this study, these results question the rationale of axillary US guided biopsy in low burden (less than two) suspicious LNs. looking for an imaging modality with a higher sensitivity in detecting the Burdon of axillary metastatic involvement is mandatory.

GIST case turned out to be a perforated peptic ulcer: a case report.

Gastrointestinal stromal tumors (GISTs) are tumors arising from the fourth layer of the stomach. They are the most common form of mesenchymal neoplasms in the gastrointestinal tract. The diagnosis for the aforementioned tumors is made through endoscopic ultrasonography (EUS) with no further inspection through biopsies and aspirations. Regarding the fact that biopsies are not made in these cases, pathological misdiagnoses, however rare and effectless in the final outcome of the surgery, do occur. Here, we present a case of a 35-year-old male diagnosed with GIST through the means of EUS however, the post-op pathology report showed something very interesting. This patient was reported to be a case of perforated peptic ulcer and we found vegetable fiber component in the tissue of this patient. Bearing in mind the finding, misdiagnoses of GIST patients are probable, and careful planning prior to the surgery is recommended.

Reduction en masse of inguinal hernia after self-reduction: a case report.

BACKGROUND: Reduction en mass (REM) is one of the rare complications of inguinal hernia reduction. Although REM can be detected on the basis of specific computed tomography (CT) scan findings, many radiologists are not familiar with its radiological appearance because of the scarcity of this complication, which may cause a delay in diagnosis. CASE PRESENTATION: The patient reported in this article was a 50-year-old Persian man with a history of inguinal hernia, who had been referred with the periumbilical pain that radiated to the right lower quadrant and developed following hernia replacement by the patient himself. REM diagnosis was based on clinical examination and CT scan findings, and surgical treatment was performed by the Lichtenstein repair and mesh implantation. CONCLUSIONS: Although REM usually occurs after reduction with compression in the inguinal hernia, this unique case report highlighted the possibility of REM after self-reduction. Surgeons and radiologists should consider REM in patients with a history of inguinal hernia presenting with intestinal obstruction symptoms, even without any apparent signs of hernia in the physical examination.

Enterocutaneous fistula formation thirty years after a femoral neck fracture fixation with lag screws: A case report.

INTRODUCTION AND IMPORTANCE: As the population grows older, femoral neck fracture is becoming one of the prevalent cases in orthopedics, although this fracture can also happen in younger individuals following high energy traumas. Fixation with cancellous lag screws is one treatment option for femoral neck fractures, especially for young adults and relatively active older patients. CASE PRESENTATION: In this case report, we describe a 52-year-old man referred with the formation of enterocutaneous fistula (ECF) in the surgery place for fixation of a femoral neck fracture 30 years prior to presentation. CLINICAL DISCUSSION: Interpretation of CT scan images as well as findings of the performed laparotomy suggested that fixation procedure with screws was probably the main culprit for penetration of ileum. Subsequently, the removal of screws enabled the fistula to reach the surface of skin, which presented with fecal drainage. To eliminate fistula, we performed right hemicolectomy and ileocolic anastomosis for the case. CONCLUSION: Since management of ECF remains among the most challenging problems for surgeons, this unique case report indicates the possibility for formation of such fistula following a fixation procedure in the hip joint area, even after thirty years and stresses on taking measures in order to prevent fistula formation caused by the prevalent procedures performed on the hip joint.

Management of a Penetrating Thoracic Injury with Thoracoscopy; A Case Study.

INTRODUCTION: Various strategies could be considered dealing with penetrating thoracic injuries. Thoracoscopy is much less invasive than routine thoracotomy approach for managing such cases in which the sharp object remains in the body. The case presented in this article was managed with thoracoscopy for a penetrating dorsolateral thoracic injury. CASE PRESENTATION: A 35-year-old man with a penetrating dorsolateral thoracic injury referred to the emergency department. Despite an elevated pulse rate, the patient has proper blood pressure and O2 saturation. Considering the patient's stability and the results of imaging which did not show any massive vascular injury, the patient was taken to the operation room for thoracoscopy. At thoracoscopy, we saw 4 cm of the blade in the thoracic cavity between the third and fourth intercostal space. There was a mild laceration of lung tissue without any active bleeding. Considering the position of the blade and the absence of active bleeding and vascular injury at the trauma site, we successfully removed the blade by the thoracoscope without any complications. CONCLUSION: Our experience of removing a retained knife by thoracoscopy showed that it can be an appropriate alternative for patients with penetrating thoracic injury who are hemodynamically stable and have appropriate conditions for thoracoscopy.