Duodenal teratoma: Rare case of extragonadal germ cell tumors and review of literature.

INTRODUCTION: Duodenal teratoma is a rare condition with only four cases reported in the English literature. Radiological imaging and tissue sample are necessary for diagnosis in addition to tumor markers. The most effective treatment is still complete excision with safety margins. CASE PRESENTATION: We report a case of 26 years-old-man, in whom epigastric pain, decreased appetite, and postprandial bilious vomiting had been prevalent for 5-6 months and had exacerbated prior to the emergency room. Enhanced abdominal computed tomography revealed a 10 × 15cm heterogeneous solid mass with cystic component in the third duodenum segment. The inferior veina cava and aorta were both compressed, although there was no sign of lymphadenopathy or ascites. An ulcerating non-bleeding lesion at the D2-D3 junction of the duodenum was discovered during a gastroduodenoscopy. Biopsies and immunohistochemical investigations revealed findings that were consistent with a mixed non-seminomatous germ cell tumor. A PET-CT scan was performed, which revealed FDG uptake by the duodenal lesion but no evidence of metastatic lesions. A distal duodenal segmentectomy is performed, and then a duodeno-jejunal anastomosis is used to restore continuity. The final diagnosis was teratomatous tumor of the duodenum without malignant changes. CONCLUSION: This is the second adult case of main duodenal teratoma that has been reported. We publish it to encourage surgeons to think about this differential diagnosis and carefully plan surgery using a multidisciplinary approach.

First case report of bile leak from the duct of Luschka in a patient with mini-gastric bypass: The challenge of management.

INTRODUCTION: The incidence of Bile duct injury after laparoscopic cholecystectomy approaches 0.11%-1.4%. Ducts of Luschka are the second most common site of bile leaks. The rarity of these ducts with cases of anatomical alterations in the gastrointestinal tract such as mini-gastric bypass makes the management a challenging option. PRESENTATION OF CASE: Hereby we present a unique case of 28 year old female patient with mini-gastric bypass who had done uneventful cholecystectomy. Day 3 postoperatively patient complained of diffuse abdominal pain. Computed tomography showed free fluid in the abdomen. Liver enzymes were normal. Relaparoscopy showed leaking bile duct of Luschka, which was closed by surgical clips and drains left in the spaces. However bile leak continued for 4 weeks then stopped. Patient did well after all. DISCUSSION: Endoscopic retrograde cholangiopancreatography with sphincterotomy played a crucial role for diagnosis and treatment of bile leaks with success rate near 94%. However no data were available using this method in a patient with Mini-gastric bypass procedure. Many authors have argued the role of relaparoscopy, but it is still an important way for adequate drainage and control of bile leakage. The only significant factor in determining clinical outcome in cases of non-surgical management is the type of bile duct injury. CONCLUSION: To the best of our knowledge, this is the first case report of bile leak from duct of Luschka after mini-gastric bypass treated successfully with relaparoscopy and drainage. Herein we will discuss all the available options of treatment and the challenge of it.

Primarily Proximal Jejunal Stone Causing Enterolith Ileus in a Patient without Evidence of Cholecystoenteric Fistula or Jejunal Diverticulosis.

Stone formation within the intestinal lumen is called enterolith. This stone can encroach into the lumen causing obstruction and surgical emergency. Jejunal obstruction by an enterolith is a very rare entity and often missed preoperatively. To our knowledge, most cases of jejunal obstruction, secondary to stone, were associated with biliary disease (cholecystoenteric fistula), bezoar, jejunal diverticulosis, or foreign body. Hereby we present a rare case report of small bowel obstruction in an elderly man who was diagnosed lately to have primary proximal jejunal obstruction by an enterolith without evidence of a cholecystoenteric fistula or jejunal diverticulosis. This patient underwent laparotomy, enterotomy with stone extraction, and subsequent primary repair of the bowel.