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.

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.

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.

Gastrointestinal autonomic nerve tumor of the stomach.

PATIENT: Female, 32 FINAL DIAGNOSIS: Gastrintestinal Autonomic Nerve Tumor (GANT) Symptoms: anemia • anorexia • fatigue • fever • hearburn • nausea • weight loss MEDICATION: - Clinical Procedure: - Specialty: Gastroenterology and Hepatology. OBJECTIVE: Rare disease. BACKGROUND: Gastrointestinal autonomic nerve tumors (GANT) are extremely rare tumors that are related to gastrointestinal autonomic nervous plexuses. They are distinguished from stromal tumors by their unique ultrastructural features. Hence, their diagnosis is usually made on electron microscopy and immunohistochemical analyses. Although they are apparently slow-growing tumors, they run an aggressive clinical course and often associated with poor prognosis which eventually leads to death. CASE REPORT: We report on a case of gastric GANT in a young female who was treated surgically by total gastrectomy. The disease, however ran an aggressive course with the development of distant (nodal, liver, lung, adrenal and musculo-skeletal) metastases two months after the radical resection. CONCLUSIONS: We believe this could be the first reported case of adrenal and musculo-skeletal metastases from gastric GANT soon after the radical gastric resection.

Pancreaticoduodenectomy in a tertiary referral center in Saudi Arabia: a retrospective case series.

CONTEXT: Perioperative outcome of pancreaticoduodenectomy is related to work load volume and to whether the procedure is carried out in a tertiary specialized hepato-pancreatico-biliary (HPB) unit. OBJECTIVE: To evaluate the perioperative outcome associated with pancreaticoduodenectomy in a newly established HPB unit. PATIENTS: Analysis of 32 patients who underwent pancreaticoduodenectomy (PD) for benign and malignant indications. DESIGN: Retrospective collection of data on preoperative, intraoperative and postoperative care of all patients undergoing PD. RESULTS: Thirty-two patients (16 male and 16 female) with a mean age of 59.5±12.7years were analyzed. The overall morbidity rate was high at 53%. The most common complication was wound infection (n=11; 34.4%). Pancreatic and biliary leaks were seen in 5 (15.6%) and 2 (6.2%) cases, respectively, while delayed gastric emptying was recorded in 7 (21.9%). The female sex was not associated with increased morbidity. Presence of co-morbid illness, pylorus-preserving PD, intra-operative blood loss ⩾1L, and perioperative blood transfusion were not associated with significantly increased morbidity. The overall hospital mortality was 3.1% and the cumulative overall (OS) and disease free survival (DFS) at 1year were 80% and 82.3%, respectively. The cumulative overall survival for pancreatic cancer vs ampullary tumor at 1year were 52% vs 80%, respectively. CONCLUSION: PD is associated with a low risk of operative death when performed by specialized HPB surgeons even in a tertiary referral hospital. However, the postoperative morbidity rate remains high, mostly due to wound infection. Further improvement by reducing postoperative infection may help curtail the high postoperative morbidity.

Port site metastases after a laparoscopic abdominoperineal resection of rectal cancer: report of a case.

This report describes a case of port site metastases that presented 6 months after a laparoscopic abdominoperineal resection of rectal cancer in a 75-year-old man. A surgical excision was performed to improve stoma function despite disease progression with adjuvant concurrent chemoradiation. Although port site metastases are now reported less frequently, this unfortunate consequence of laparoscopic colorectal surgery for cancer can still occur, and laparoscopic colorectal surgeons should exercise all precautions to prevent its occurrence. This report includes a review of literature on port site metastases.

Hand-assisted laparoscopic colorectal surgery: initial experience of a single surgeon.

BACKGROUND/AIM: As totally laparoscopic colorectal surgery is considered challenging and technically demanding with a long steep learning curve, we adopted hand-assisted laparoscopic colorectal surgery as a bridge to totally laparoscopic assisted colorectal surgery. This prospective study aims to highlight the initial experience of a single surgeon with this technique. MATERIALS AND METHODS: A prospective analysis of the first 25 cases of hand-assisted laparoscopic colorectal resections which were performed by a single surgeon over a 15-month period. There were 15 males and 10 females with a mean age of 55.5 (range 20-82) years. RESULTS: The indication in majority of cases was cancer (76%). The procedures consisted of 18 (72%) various colectomies and 7 (28%) anterior resections. The operative time ranged between 110-400 (mean 180) min. There was one conversion (4%) and the mean operative blood loss was 80 (range 60-165) ml. The number of lymph nodes retrieved in the cancer cases was 5-31 (mean 15) nodes. The mean length of hospital stay was five (range 3-10) days. The total number of short-term complications was six (24%) and there was one death due to anastomatic leak and multiorgan failure. Long-term complications after a maximum follow up of 30 months were two incisional hernias at the hand port site, but none of the patients developed adhesive small bowel obstruction or late anastomotic stricture. Currently all our colorectal procedures are conducted laparoscopically. CONCLUSION: Hand-assisted laparoscopic colorectal procedures are easy to learn as a good bridge to master totally laparoscopic colorectal surgery.

Blood transfusion in patients with sickle cell disease requiring laparoscopic cholecystectomy.

BACKGROUND: Surgery in patients with sickle cell disease is associated with high morbidity. To reduce this high morbidity, different preoperative transfusion regimens were introduced. However, blood transfusion is associated with problems. This prospective study aims to establish the safety of conducting laparoscopic cholecystectomy without transfusion in sickle cell disease patients. METHODS: Forty patients (16 males and 24 females; mean age 26.6 years) undergoing laparoscopic cholecystectomy for cholelithiasis were divided into 2 matched groups: Group I "no transfusion" (n=24 patients; 60%) and Group II "transfusion" (n=16; 40%). In Group II, 9 patients (22.5%) received a simple transfusion and 7 (17.5%) a partial exchange transfusion. RESULTS: Group II patients had significantly higher levels of Hb-S prior to transfusion. They developed a significantly higher complication rate (25% vs. 0%) and subsequently longer hospital stay (3.9±2 vs. 2.1±1.4). Moreover, there was no significant difference in the complications between the simple transfusion and partial exchange transfusion subgroups. CONCLUSION: Surgery in SCD patients is safe without a preoperative blood transfusion. Moreover, preoperative blood transfusion is associated with significantly higher postoperative complications and longer hospital stay. Hence, a "no transfusion" policy is recommended.

Staple Line Polyposis and Cytomegalovirus Infection after Stapled Haemorrhoidectomy.

Early bleeding after stapled haemorrhoidectomy (SH) is not uncommon. Late and persistent bleeding occurring weeks or months after SH, however, is rare; it has only been described in more than 10% of cases. It is attributed to the development of inflammatory polyps at the staple line. Occurrence of rectal bleeding in the presence of palpable polypoid lesions at the stapled anastomotic line can cause diagnostic confusions, and it is not uncommon that such lesions are initially confused with rectal carcinoma. We report a case of a 38-year-old male who presented with persistent rectal bleeding some 6 months after SH performed in another hospital. Rectal and colonoscopic examinations revealed polypoid lesions at the anastomotic line. The biopsy failed to confirm malignancy, but identified cytomegalovirus (CMV) infection. The development of multiple inflammatory polypoid lesions in conjunction with CMV infection at the stapled anastomotic line has caused a diagnostic confusion, but - after exclusion of cancer - this complication was efficiently treated by CMV infection eradication combined with surgical excision of the remaining polyps due to persistence of bleeding. This case is reported to highlight late bleeding due to inflammatory polyps after SH and to increase the awareness of surgeons and gastroenterologists of this benign but somewhat common complication.

Management of appendiceal mass: controversial issues revisited.

PURPOSE: Although appendix mass occurs in 10% of patients with acute appendicitis, its surgical management is surrounded with controversy. This article reviews some of the controversial issues in the management of appendix mass. METHODS: A search of the English literature was conducted for "appendiceal mass," "interval appendicectomy," and "laparoscopic appendicectomy" and manual cross-referencing. RESULTS AND CONCLUSION: The majority of the studies were small and retrospective. Emergency appendicectomy for appendix mass is emerging as an alternative to conventional conservative treatment. It is feasible, safe, and cost-effective, allowing early diagnosis and treatment of unexpected pathology. However, the appropriate timing for emergency surgery is not clear. After successful conservative management, interval appendicectomy is not necessary and can safely be omitted, except in patients with recurrent symptoms. In patients over 40 years of age, other pathological causes of right iliac mass must be excluded by further investigations (colonoscopy and computerized tomography scan), and a close follow-up is needed. Laparoscopic appendicectomy whether in emergency or interval settings is feasible and safe and should replace the conventional open method. Large prospective, randomized controlled trials are lacking, and therefore, such trials are needed to scientifically compare emergency surgery vs conservative management without interval appendicectomy.

An unusual bile collection after postcholecystectomy bile leakage.

Leakage from the cystic duct stumps accounts for the majority of postlaparoscopic cholecystectomy leaks. It commonly presents with a localized bile collection in the gallbladder fossa and endoscopic retrograde cholangiopancreatography (ERCP) with biliary stenting is a common method of treatment. However, bile may collect in other intra-abdominal locations away from the gallbladder fossa. We present here a case of a patient who developed upper abdominal pain with distension, anorexia, and vomiting a week after laparoscopic cholecystectomy. Ultrasonography and computed tomography scans showed an intra-abdominal collection and ERCP showed a cystic duct stump leak. A biliary stent was inserted and the collection was percutaneously drained. His symptoms, however, recurred 2 weeks later, with fever, anorexia, and weight loss. Abdominal computed tomography scan showed 9.3x8.5 cm cystic mass in the left hypochondriac area and ERCP showed persistent leakage from the cystic duct stump. The stent was changed to a larger size Fr12 and the collection was again drained percutaneously. His clinical condition improved dramatically. The biliary stent was removed after 8 weeks and remained well at 9-month follow-up.

Laparoscopic diagnosis of splenic tuberculosis.

Isolated tuberculous splenic microabscesses are uncommon except in immunocompromized patients. The diagnosis is often made after splenectomy and histologic examination of the spleen. We report here a case of splenic tuberculosis in an immuno-competent patient. The diagnosis was made solely by laparoscopic biopsy of the spleen without the need for splenectomy. The patient was started on antituberculosis therapy with marked recovery. We believe that this might be the first reported case of isolated splenic tuberculosis ever diagnosed by laparoscopy only.

Pseudomyxoma peritonei.

Pseudomyxoma peritonei is very rare, and its exact pathogenesis is unknown. It is characterized by intra-abdominal extracellular gelatinous fluid collections. We report a case of pseudomyxoma peritonei in a 38-year-old Saudi male who presented with right iliac fossa mass and weight loss. He was treated initially as an appendicular mass and computed tomography was helpful in making the diagnosis. He was treated by laparotomy, right hemicolectomy and omentectomy, but no perioperative intraperitoneal chemotherapy was instilled. He received postoperative chemotherapy and remained alive with no recurrence at 18-month follow-up.

Fibrous histiocytoma of the breast.

Two Saudi females aged 26 and 14 years presented with giant fibroadenomas. The histology after surgical excision revealed benign fibrous histiocytomas. Patient one remained well with no apparent recurrence after 5 years of the initial excision. However, in patient 2 the benign fibrous histiocytoma recurred with low-grade malignancy after a year of the initial excision. A high-grade recurrence developed after 3 months of the second excision. This was treated by radical wide excision. It was felt later that mastectomy was more appropriate and therefore was performed. The second patient highlights the fact that malignant histiocytoma can occur in the pediatric age group and that the initial surgical treatment of benign fibrous histiocytoma should be aggressive to avoid recurrence and development of malignant changes. We believe that our second patient is the youngest age ever reported in the literature with malignant fibrous histiocytoma.

Combined parathyroid adenoma and an occult papillary carcinoma.

Although the pathological association of thyroid and parathyroid disease is common, the association of both parathyroid adenoma and thyroid cancer is rare. We report here a case of a 45-year-old Saudi woman who was diagnosed to have primary hyperparathyroidism due to a single parathyroid adenoma as confirmed biochemically and radiologically. At operation, the adenoma was found to be an intrathyroid and therefore a thyroid lobectomy was performed. Histology of the excised lobe revealed in addition to the intrathyroid parathyroid adenoma a concurrent occult thyroid papillary carcinoma. This interesting association is discussed based on a literature review.