Vasculo-Behçet's disease with a giant pseudoaneurysm of superficial femoral artery: A case report.

INTRODUCTION AND IMPORTANCE: Behçet's Disease is a chronic, multi-systemic vasculitis of unknown aetiology that classically presents with a triple-symptom complex of recurrent oral ulcers (aphthous stomatitis), genital ulcers and uveitis (chronic iridocyclitis). Vascular involvements of Behçet disease include arterial and venous thrombosis, formation of an unusual aneurysm and arterial occlusion, known as vasculo-Behçet's disease. CASE PRESENTATION: A 21-year-old male presented with recurrent painful oral ulcers and bilateral lower limb deep vein thrombosis. Also, he presented with thigh pain and swelling, diagnosed as a giant pseudoaneurysm of the right SFA. CT angiography revealed an 80.2 × 76.9 × 69 mm pseudoaneurysm. He was scheduled to undergo emergency surgery due to severe, intractable pain. The pseudoaneurysm was excluded, and using a reversed basilic vein graft interposition, we performed a femoral-femoral bypass from the proximal femoral artery to a distal superficial femoral artery. Postoperatively, the patient had an uneventful course; pain and swelling subsided. CLINICAL DISCUSSION: The diagnosis of Behçet's disease is based on clinical criteria consisting of combinations of symptoms due to the lack of universally recognised pathognomonic laboratory tests. Arterial complications of Behçet's disease occur in 1 % to 7 % of patients, with a male predominance. Immunosuppressants, such as cyclophosphamide or azathioprine, represent the mainstay treatment of Behçet's disease and should always be considered to achieve complete remission, prevent recurrences, and reduce the risk of postoperative complications. CONCLUSION: Pseudoaneurysm is the most common presentation of arterial complications of Vasculo- Behçet's disease and should be kept in mind to prevent significant morbidity and mortality.

Ruptured abdominal aortic aneurysm treated with open surgical repair (OSR) of a patient with active COVID-19 infection: A case report.

Introduction and importance: Patients continued to present vascular emergencies during the most severe phase of the COVID-19 outbreak. An abdominal aortic aneurysm rupture was considered the most life-threatening condition. Aim: To report a case report of a patient with active COVID-19 infection presenting as a ruptured abdominal aorta aneurysm and treated with open surgical repair at the Department of Vascular Surgery, Royal Jordanian Medical Services (JRMS), Amman, Jordan. Case presentation: A 69-year-old male presented with an active COVID-19 pneumonic chest infection. Abdominal CT of angiography showed a 4.8-cm infrarenal abdominal aortic aneurysm unsuitable for endovascular aortic aneurysm repair (EVAR). After a rapid deterioration in his general condition, he underwent an exploratory laparotomy which revealed the diagnosis of an AAA rupture. We managed his condition operatively with repair using a tube Dacron graft. Clinical discussion: Ruptured AAA is considered a devastating lethal vascular emergency with high mortality and morbidity rates and needs emergency intervention n eligible patients. COVID-19 patients with AAA rupture have a significantly increased risk of intervention and require special attention regarding the type of intervention and anaesthesia. The COVID-19 pandemic has changed many guidelines in management vascular emergencies, among them AAA rupture patients. The National Societies guidelines recommended limiting interventions to emergencies only. Conclusion: The difficulties of surgical intervention, anaesthesia and the appropriate intervention selection increase the burden on the medical staff resisting the obstacles imposed on them by COVID-19 infection.

Trichilemmal carcinoma of the axilla with regional lymph nodes metastasis: A case report.

INTRODUCTION AND IMPORTANCE: Trichilemmal carcinoma is a rare malignant cutaneous adnexal neoplasm of hair follicles originating from the external root sheath epithelium. The diagnosis is rarely made clinically and is still challenging for an experienced pathologist. AIM: To report a rare case of trichilemmal carcinoma presenting as a right axillary mass with regional lymph nodes metastasis and was treated with wide local excision in the General Surgery Department Jordanian Royal Medical Services (JRMS), Jordan. CASE PRESENTATION: A 45-year-old presented with a right axillary mass of six-month duration. Physical examination revealed a hyperemic, thickened skin of both armpits with a palpable 5-cm mass in the right axilla. He underwent an excisional biopsy of the right mass. Histopathologic examination revealed a malignant adnexal skin tumour with foci of trichilemmal-type keratinisation. It was excised with adequate margins. CLINICAL DISCUSSION: Trichilemmal carcinoma usually occurs on the forehead, scalp, neck, back of hands and trunk. These neoplasms are rare lesions presenting as locally aggressive, low-grade carcinomas and have the potential for nodal involvement and distant metastasis. Therefore, the establishment of a correct diagnosis is vital to guide the treatment plan. Wide excision with adequate tumour-free margins is considered a curative treatment and offers a successful outcome. CONCLUSION: Malignant cutaneous adnexal tumours are one of the most challenging subjects of dermatopathology. Surgical excision is always required to establish a definitive diagnosis and differentiation subtypes. Trichilemmal carcinoma is a relatively rare tumour, mainly when located in the axilla.

Large bowel obstruction as a consequence of transverse colon volvulus: A case report.

INTRODUCTION: Transverse colon volvulus incidence is comparatively rare when compared to cecal and sigmoid volvulus. Its diagnosis is still challenging for the surgeon. Delay in the diagnosis of this condition carries high morbidity and mortality rates. AIM: To report a rare case of transverse colon volvulus in a young adult male that presented as large bowel obstruction and was operated upon in the General Surgery department in the Jordanian Royal Medical Services (JRMS), Amman, Jordan. PRESENTATION OF CASE: An 18-year-old male presented with severe generalized abdominal pain of 12-h-duration, associated with significant abdominal distention and constipation of one-day duration. His abdominal examination revealed a massively distended, tender abdomen; however, there were no signs of peritonitis. Abdominal radiographs showed a massively dilated large bowel. He underwent exploratory laparotomy that revealed the diagnosis of transverse colon volvulus. His condition was managed operatively with transverse colectomy with a primary anastomosis. The patient had a satisfactory postoperative recovery. DISCUSSION: Only 3-5% of all cases of intestinal obstruction are caused by colonic volvulus. Transverse colon is involved in 2-4% of them. The diagnosis of transverse colon volvulus can be delayed and difficult because it does not have the same classically recognizable radiographic features as cecal and sigmoid volvulus. CONCLUSION: Transverse colon volvulus is a rare entity. A swift suspicion of diagnosis is key to preventing severe outcomes. It can result in bowel perforation and fecal peritonitis. The definitive diagnosis is frequently made intraoperatively. Early surgical intervention is essential for better outcome and avoiding complications.

Spontaneous perforation of jejunal gastrointestinal stromal tumor: A case report.

INTRODUCTION: The incidence of small bowel tumors is comparatively rare when compared to colonic tumors. They comprise less than 10% of all gastrointestinal neoplasms. Gastrointestinal stromal tumor (GIST) is the most common mesenchymal neoplasm of the gastrointestinal tract; however it accounts for less than 1% of all gastrointestinal tumors. AIM: To report a rare case of jejunal gastrointestinal stromal tumor presenting as a life-threatening emergency in a young adult male who was treated in the General Surgery department in the Jordanian Royal Medical Services (JRMS), Amman, Jordan. PRESENTED CASE: We report a 59-year-old male who presented to our emergency department with severe generalized abdominal pain. The patient was in a hypovolemic shock. Abdominal examination revealed a massively distended, tender abdomen. Abdomenal CT scan with IV contrast showed significant fat stranding around the jejunum associated with pneumoperitoneum and free fluid. Exploratory laparotomy was emergently performed, revealing diffuse peritonitis secondary to perforated small bowel tumor. En bloc resection was performed. Histopathologic examination confirmed the presence of malignant gastrointestinal stromal tumor of the jejunum with R0 clearance. DISCUSSION: Gastrointestinal stromal tumors are relatively rare and the jejunum is the least affected among other parts of the GI tract. The majority of ruptured GISTs occur spontaneously, and are located in the stomach and small bowel. Most ruptured GISTs are associated with dismal prognosis. CONCLUSION: A jejunal gastrointestinal stromal tumor can rarely present with spontaneous perforation. However, it is important to highlight this condition, as early emergency intervention constitutes the key to a good outcome.

Simultaneous small and large bowel obstruction as a consequence of internal hernia: A case report.

INTRODUCTION: Intestinal obstruction ascribed to internal hernia is quite rare, especially in adults. There are no differentiating features in the presentation of intestinal obstruction due to internal hernia as compared to other causes. Delay in the diagnosis of this condition carries a considerable risk especially in a virgin abdomen. We report a rare case of internal hernia which presented as acute small and large bowel obstruction. PRESENTED CASE: We report a 47- year- old male with generalized abdominal pain associated with vomiting and obstipation. The patient was in hypovolemic shock that only had a transient response to resuscitation. CT scans of the abdomen with contrast was done and showed both large and small bowel obstruction. Exploration laparotomy was done and revealed a concurrent nonviable portion of ileum and twisted sigmoid colon (volvulus) which protruded through a congenital transmesentric defect. Resection was mandatory, and repair of the defect was done. DISCUSSION: Incidence of internal hernia generally does not exceed 1%. The diagnosis of congenital internal hernia relies on absence history of trauma, inflammatory process and abdominal surgery. Protrusion of simultaneous small and large bowels together through transmesenteric congenital gate is uncommon. CONCLUSION: Whether the patient presenting with intestinal obstruction has a history of undergoing previous surgeries (for any reason) or not, the diagnosis of internal hernia must be kept in mind. Coexisting involvement of both small and large bowels that need resection poses the question of the need for restoration of bowel continuity with either colostomy or ileostomy.