Jejunal diverticulosis: A case report.

INTRODUCTION: Jejunal diverticulosis is a rare entity that presents a challenging diagnosis due to its vague and non-specific clinical presentations. 40 % of the patients remain asymptomatic until the development of complications. CASE PRESENTATION: We report a case of 84 years old female who presented to the hospital with vomiting and abdominal pain, found to have jejunal diverticulosis complicated by perforation in a CT scan. The patient underwent emergency expletory laparotomy with segmental intestinal resection and anastomosis. DISCUSSION: The incidence of jejunal diverticulosis ranges between 3 and 5 %, with most patients discovered incidentally. Therefore, medical or surgical treatment management depends on clinical presentation and complications that necessitate surgical intervention. CONCLUSION: Jejunal diverticulosis is a rare entity that commonly affects the elderly with significant morbidity and mortality; it is an important clinical entity to consider when approaching patients with acute abdomen.

Primary Pulmonary Synovial Sarcoma with Hemothorax: a Case Report.

Background: Synovial sarcoma is a rare and aggressive soft tissue malignancy most commonly arises from periarticular tissue of the extremities. Although several cases in the literature have reported different origins, primary pulmonary synovial sarcoma (PPSS) is an exceedingly rare and underrecognized entity, accounting for 0.5% of all lung malignancies. Clinical presentation includes chest pain, dyspnea, cough, and hemoptysis. The finding of hemothorax is a rare presentation and was barely reported in the literature. Due to its rarity and aggressive nature, the optimal treatment is unclear, while the mainstay remains surgical resection with chemo- and/or radiation therapy. Objective: To report a case of hemorrhagic effusion subsequently diagnosed with primary pulmonary synovial sarcoma with the main objective of enriching the literature regarding this rare malignancy. Case report: A 52-year-old male smoker with a background of coronary artery disease, hypertension, and diabetes mellitus was referred to our hospital. The patient presented with a history of chest pain, dyspnea, and massive right-sided pleural effusion. Laboratory investigations were unremarkable except for anemia. Chest x-ray showed a complete opacity on the right lower zone with right-sided pleural effusion. Thoracentesis was done and revealed hemorrhagic exudative effusion. Computed tomography (CT) scan showed a right heterogeneous lung mass compressing the medial segment of the middle lobe. Subsequently, the patient underwent bronchoscopy, which showed compression and edema on the right middle lobe bronchus with traces of blood coming from the right lower lobe. The patient underwent a right posterolateral thoracotomy, a fungating mass eroding the medial segment of the middle lobe was resected that was diagnosed as high-grade primary pulmonary synovial sarcoma. Radiotherapy was instituted. The patient died after two years due to recurrence. Conclusion: PPSS is an aggressive disease with poor prognostic outcomes, and Its presentation is almost similar to other lung malignancies. Meanwhile, there is no definitive management guideline, and most management depends on surgical resection if feasible with adjuvant chemo-radiation therapy.

Transduodenal resection of periampullary neuroendocrine tumor: A case report.

INTRODUCTION AND IMPORTANCE: Periampullary tumors are characterized as tumors that emerge nearby to the major papilla in the duodenum. They are rare lesions with an incidence rate of 0.4-0.48 per 100,000. Neuroendocrine tumors (NETs) constitute only 3% of all duodenal tumors. Their proximity to the major and minor papillae along with the gastric outlet raises a surgical challenge. CASE PRESENTATION: Our patient is a 40-year-old, male, medically free. He presented with history of a testicular mass. A CT scan of the abdomen and pelvis was done and showed a large retroperitoneal lymph node. A biopsy of the epididymal mass showed no evidence of malignancy. Excision of the left para-aortic mass revealed a metastatic lymph node of a well-differentiated neuroendocrine tumor. Further evaluation by gallium-68 PET-CT scan showed a periampullary neuroendocrine tumor. The decision to operate was concluded in a multidisciplinary team meeting, and intraoperatively the duodenum showed a well-defined mass between the first and second part of the duodenum which was excised via a trans-duodenal submucosal approach. A frozen section confirmed a negative margin. The final histopathology report showed a grade 2 metastatic well-differentiated neuroendocrine tumor. The latest follow-up was 3 years post-op via fluorine-18 fluorodeoxyglucose PET-CT and it showed no FDG avid disease at the duodenum or pancreases with no FDG avid lymphadenopathy or distant metastasis. CONCLUSION: Periampullary tumors that fall under certain parameters could be resected via transduodenal local resection. This procedure yields equivalent results to more invasive surgeries, such as a Whipple's procedure, with less morbidity.

Blunt Traumatic Tracheobronchial Injury: a Clinical Pathway.

Background: Motor vehicle collisions (MVC) are a major burden on healthcare systems. Saudi Arabia is one of the countries with a high mortality rate of MVC. Blunt tracheobronchial injuries are rare; however, it is a catastrophic event that requires a high center of care. Lack of experience and advanced faculty prompt early stabilization and transfer of the victim for advanced care. Due to the uncertainty of management of these injuries, we would like to share our experience in dealing with such injuries. Objective: To address the difficulties in initial management and transfer of patient with blunt traumatic tracheobronchial injuries. Methods: This is a single-center retrospective case-series study including patients admitted as cases of trauma including all age groups with blunt acute tracheobronchial injuries confirmed by imaging or bronchoscope. Results: In our study, four patients with tracheobronchial injuries were identified, and a retrospective analysis was performed. Two of the males and one of the females are adults, while the other two are pediatrics. Two of them have a right main bronchial injury and the other two have a left main bronchial injury. Posterolateral thoracotomy and bronchial anastomosis were performed on all four patients and were followed up. Conclusion: In Saudi Arabia, blunt trauma is a prevalent type of injury, although tracheobronchial injuries are uncommon. In the event of trauma, a high index of suspicion of tracheobronchial injuries in a high mechanism injury warrants prompt treatment. Due to a lack of experienced and specialized hands in this field, management may be delayed, and eventually lead to unfavorable outcomes, hence we thought of a guide to facilitate the decision-making.

Management of Very Late Pancreatic Metastasis of Renal Cell Carcinoma 8 Years After Radical Nephrectomy: A Report of a Rare Case.

BACKGROUND The most common primary malignant neoplasm of the kidneys in adults is renal cell carcinoma (RCC), which originates inside the renal cortex and accounts for 80-85% of all primary renal neoplasms. RCCs can spread to many organs, including the liver, lungs, bones, and brain. Disease is quiescent until the late stages of disease in the vast majority of patients. CASE REPORT We report a case of 63-year-old woman who presented to her surveillance check-up after a right radical nephrectomy 8 years ago. Computed tomography of the chest, abdomen, and pelvis (CT-CAP) revealed a hypervascular mass in the body of the pancreas measuring 1 cm, consistent with metastatic appearance. Therefore, the tumor board decision was to proceed with spleen-preserving distal pancreatectomy. The final histopathology result showed metastatic clear cell renal cell carcinoma (CCRCC) with negative resection margins. The patient currently is under regular follow-up. The latest CT-CAP was done at 1 year postoperatively, which showed no evidence of recurrence or metastasis. CONCLUSIONS Patients with RCCs can develop asymptomatic metastatic lesions years after complete oncological resection of the primary tumor. Furthermore, metastatic RCCs can be misdiagnosed as other primary tumors. Hence, a meticulous long-term follow-up is essential to ensure that recurrence or a new distant metastasis is not missed. RCCs are known for their poor response to chemotherapy and radiation therapy. However, the new targeted therapies have shown a good response rate. Nevertheless, complete oncological resection of the pancreatic metastasis remains the best treatment modality and is associated with a 5-year survival rate of 75%.