Treatment of persistent complex seroma postventral incisional hernia repair by capsulectomy and scarification using argon beam coagulator.

We present a case of chronic complex seroma following ventral incisional hernia repair with a mesh. The patient was managed initially conservatively by observation followed by multiple percutaneous aspirations and tube drainage. After 6 months of conservative management, the patient remained symptomatic and the surgical scar showed evidence of ulceration, skin necrosis and sinus formation. Therefore, a definitive surgical treatment in the form of capsulectomy and scarification using argon beam coagulator was performed. He remained asymptomatic with no sign of seroma development or hernia recurrence at a 3-year follow-up.

Obscure Gastrointestinal Bleeding Due to Non-steroidal Anti-inflammatory Drug-Induced Colopathy.

Obscure gastrointestinal (GI) bleeding poses a diagnostic challenge and is associated with high mortality. We report a case of life-threatening obscure GI bleeding precipitated by the ingestion of a non-steroidal anti-inflammatory drug (NSAID). The source of bleeding could not be identified preoperatively, and hence exploratory laparotomy was performed. An ileocaecal resection was undertaken based on the findings of the intraoperative enteroscopy. However, the bleeding recurred and repeated endoscopy examination identified the source to be multiple NSAID-induced ulcers that were scattered in the colo-rectum. The bleeding stopped spontaneously after a period of intensive supportive therapy and sulphasalazine enemas. This case highlights the diagnostic challenge of obscure GI bleeding. It also highlights the potentially life-threatening danger of GI bleeding secondary to NSAID-induced colopathy, even after a short course of treatment.

Endoscopic removal of an incidentally discovered intrauterine contraceptive device eroding into the rectum.

Intrauterine contraceptive device (IUCD) is a common birth control method. It is safe but can be associated with serious complications including migration into the peritoneal cavity and penetration into other intra-abdominal and pelvic viscera; most commonly the rectosigmoid colon. Different retrieval methods including endoscopy, laparoscopy or open abdominal surgery have been described. We report the case of 38-year-old woman who became pregnant shortly after insertion of the IUCD 6 years prior to presentation. She delivered vaginally and 'expulsion' of the device was assumed. Some 4 years later, she had another IUCD inserted and remained asymptomatic till she recently presented with iron-deficiency anaemia. As part of the investigation, diagnostic colonoscopy was performed. Surprisingly, the old IUCD was found penetrating into the midrectum. Uneventful endoscopic removal was performed and she remained well at 3-month follow-up. Migrating IUCD remains asymptomatic and may be discovered accidentally during routine investigation for some other symptoms.

Boerhaave's Syndrome: Delayed Management Using Over-the-Scope Clip.

BACKGROUND The diagnosis of Boerhaave's syndrome is often missed or delayed. This subsequently leads to a high mortality rate, which could be greatly reduced if treatment is instituted early, within 24 hours of perforation. Treatment ranges from conservative management to operative intervention depending on the time of presentation and the patient's clinical condition. Endoscopic intervention in the form of over-the-scope clip (OTSC) application is gaining popularity with very promising results. CASE REPORT A 43-year-old male was diagnosed with Boerhaave's syndrome and treated initially by insertion of bilateral chest drainage, intravenous broad-spectrum antibiotics, and total parenteral nutrition. He was transferred to our facility 9 days later. Upper gastrointestinal endoscopy revealed a 1.5 cm deep longitudinal ulcer involving the distal esophagus and extending to the Z-line. Due to the perforation site, a size 12 OTSC clip was used. Application of a second clip was needed to achieve complete closure of the perforation site. Contrast swallow was done 4 days later showed no leak. The patient was started on oral intake and was discharged home in good general condition after a hospital stay of 16 days. CONCLUSIONS Delayed presentation of Boerhaave's syndrome can be treated safely by an over-the-scope clip. This endoscopic method hastens recovery and shortens the hospital stay.

Congenital right diaphragmatic hernia in an adult.

Diaphragmatic hernia in the absence of trauma in adults is very rare. It occurs as a result of unilateral diaphragmatic agenesis. The diagnosis of this rare condition is typically made in early infancy. However, in asymptomatic patients, the diagnosis is often delayed for months and even years. We present a case of a 27-year-old female, who was referred 48-hours after Caesarean section with suspected pulmonary embolism. Computed tomography scan revealed herniation of the liver as well as bowel loops into the right hemi-thorax. Exploration through a right thoracotomy revealed right diaphragmatic agenesis. The contents were reduced into the abdomen, and the defect was repaired using a mesh. The patient had an uneventful postoperative recovery and was discharged home 10 days later. This case highlights the acute late presentation of right diaphragmatic eventration with abdominal visceral herniation in adulthood. The condition may be triggered by the increasing size of gravid uterus.

Late metastatic endometrial carcinoma at the repair site of an abdominal wall incisional hernia.

The abdominal wall is a very rare site for endometrial cancer metastases. Its appearance generally indicates advanced cancer with poor prognosis. We report a case of a 55-year-old female who presented with an incisional hernia 4 years after abdominal panhysterectomy for endometrioid adenocarcinoma in 2009. Open hernia mesh repair was performed but on follow-up, she complained of pain and a swelling at the repair site. This was radiologically diagnosed as fibromatosis, but tru-cut biopsy confirmed presence of fibromatosis as well as a metastatic endometrial carcinoma. She was started on neoadjuvant chemotherapy, but had poor response, and therefore, radical excision was performed. She remained well with no metastatic recurrence at 12-month follow-up. This case illustrates late appearance of abdominal wall metastasis from abdomino-pelvic malignancies and highlights the need to exclude the presence of recurrence or metastases prior to surgical repair of incisional hernia occurring after the resection of abdominal or pelvic malignancy.

Malignant peripheral nerve sheath tumor with extensive osteosarcomatous and chondrosarcomatous differentiation: A case report.

BACKGROUND: Malignant peripheral nerve sheath tumor is an uncommon tumor of the peripheral nerves. The commonest presenting symptom is soft tissue mass and pain with local neurological findings. Imaging modalities are unhelpful in making a reliable diagnosis. Treatment is radical resection with adequate clear resection margins. Radiotherapy improves the local control, but the prognosis remains poor especially in those with divergent differentiation. SUMMARY: A 23-year-old man with no history of neurofibromatosis presented with a swelling on the back which has been gradually increasing in size and causing him discomfort. The tumor was surgically excised and the histopathological examination revealed malignant peripheral nerve sheath tumor with extensive osseous and cartilaginous differentiation. He developed pulmonary metastases one year after the surgical resection. Pulmonary metastatectomy was therefore performed and the histopathology of the metastatectomy specimen revealed metastatic malignant peripheral nerve sheath tumor, but without any osseous or cartilaginous differentiation. He remained well with no recurrence or metastases at 9-month follow-up. CONCLUSION: Malignant peripheral nerve sheath tumor is a malignant tumor that behaves aggressively despite adequate radical resection. This case also illustrates extensive osseous and cartilaginous divergent differentiation of the primary tumor which was surprisingly absent in the metastatic lesions. This finding warrants further research.

Laparoscopic excision of abdominal wall desmoid tumor.

Open surgical resection is the mainstay treatment for desmoid tumors. Laparoscopic resection is rarely used and not well described in the literature. We report a case of a single, 35-year-old woman who presented with palpable abdominal wall desmoid tumor. The patient had had laparoscopic cholecystectomy 2 years earlier, and the tumor was at the insertion site of the right upper quadrant trocar. The diagnosis was made by a Tru-Cut biopsy at another institution, after the lesion had increased in size and caused increased discomfort. The patient underwent successful laparoscopic resection of the tumor. This report aimed to promote laparoscopic resection of abdominal wall desmoid tumors, whenever feasible, and describe the laparoscopic technique. We believe this is the second case of laparoscopic excision of desmoid tumor reported in the English-language literature.

Evidence-based surgery: The obstacles and solutions.

Surgeons are often accused of lagging behind their medical colleagues in embracing evidence based medicine and utilizing new research tools to conducting high quality randomized controlled trials. Although there has been a noticeable improvement in the quantity and quality of high quality studies in surgical journals, the widespread practice of evidence based surgery is still poor. Unlike evidence based medicine, the practice of evidence based surgery is hampered by inherent problems and obstacles. This article reviews these difficulties and the limitations of randomized controlled trials in surgical practice. It also outlines some solutions that may help remedy this ongoing problem.

Gastrointestinal autonomic nerve tumors: a clinical review.

PURPOSE: Gastrointestinal autonomic nerve tumors (GANTs) are believed to be rare accounting for 1 % of all malignant gastrointestinal tumors. Many gastrointestinal surgeons and gastroenterologists are unaware of this entity. This review aims to highlight the salient clinical features and prognosis of GANTs. METHODS: Using the common search engines and manual cross-referencing, a search of the English literature was conducted for "gastrointestinal autonomic nerve tumor." RESULTS: All of the published literature on GANTs is either case reports or small case series. From 49 retrieved articles, a total of 107 GANT cases were collected with a mean age of 54 years and equal male to female preponderance. The most commonly affected site was small bowel followed by stomach. Esophageal and colorectal GANTs were less frequent. Clinical presentation was variable ranging from non-specific symptoms, abdominal pain, weight loss, iron-deficiency anemia, to obstruction and gastrointestinal bleeding. Acute presentation due to free rupture or perforation with subsequent peritonitis was extremely rare. Endoscopic and radiological investigations were valuable in tumor localization and determination of distant spread. Thirteen patients were lost to or had no follow-up, leaving 94 patients for long-term outcome analysis. All patients were treated by radical surgical resection of the involved organ as this offered the only hope of cure. Local recurrence, metastases, or both developed in 40 % of cases despite radical surgical resection. Resection for local recurrences and hepatic metastases was feasible in some selected cases. Response to adjuvant chemoradiation was poor and imatinib mesilate was effective in cases of metastatic or inoperable CD117-positive GANTs. CONCLUSION: Radical surgical resection of GANTs is the mainstay of treatment. The aggressive behavior after radical resection coined with the poor response to adjuvant chemotherapy call for the urgent need to develop new adjuvant therapies.

A case of sigmoid colon duplication in an adult woman.

Colonic duplication is a rare congenital anomaly that is often diagnosed in childhood, but may go unrecognised until adulthood. It often presents with chronic abdominal pain and constipation, and the preoperative diagnosis may be difficult. We present a case of sigmoid duplication in a 33-year-old Indonesian woman who presented with right-sided colicky abdominal pain and vomiting. Clinical examination was unremarkable and radiological investigations raised the possibility of a giant colon diverticulum. The patient underwent exploratory laparotomy that revealed a tubular sigmoid duplication. A sigmoid colectomy with end-to-end anastomosis was performed. She was discharged a week later and remained well at 1 year follow-up. Colon duplications rarely present in adult life and the accurate diagnosis is often made at laparotomy.

Iatrogenic oesophageal transection during laparoscopic sleeve gastrectomy.

Laparoscopic sleeve gastrectomy has been hailed as an easy and safe procedure when compared with other bariatric operations. However, it may be associated with well-recognised early complications such as leaks and bleeding, as well as late ones such as stenosis and weight regain. Iatrogenic complete oesophageal transection has never been reported before as a complication. We report a case of complete oesophageal transection during laparoscopic sleeve gastrectomy that was not recognised intraoperatively. The repair of this iatrogenic injury was staged, with the final stage carried out some 3 months after the initial procedure. This case report highlights the possible occurrence of complete oesophageal transection during laparoscopic sleeve gastrectomy, and suggests steps to avoid and correct such complications.