Insights into Human Cystic Echinococcosis in the Kurdistan Region, Iraq: Characteristics and Molecular Identification of Cysts.

Cystic echinococcosis (CE) is a neglected worldwide distributed parasitic disease caused by the Echinococcusgranulosus sensu lato (s.l.) species complex. For a better understanding of the pathways of transmission of this parasite, clinical and molecular epidemiological studies are particularly needed from endemic areas where data are scant, such as in the Middle East. The study aimed to identify the characteristics, location, cyst stage and species/genotypes of E. granulosus s.l. complex in humans from the Kurdistan region, Iraq. To this aim, from June 2019 to February 2021, 64 echinococcal cysts were surgically removed from 62 patients in Azadi and Vajeen reference Hospitals at Duhok city, Duhok governorate (Kurdistan region, Iraq). The results confirmed the liver as the most common anatomical site of CE with 72.58% of the cases, followed by the lungs in 19.35%, while 66.13% of CE cases were females. The highest rate of infections occurred in the age class 21−30 (27.42%). High rates of CE were reported among patients living in rural areas and housewives, which were 54.84% and 43.55% of the CE patients, respectively. The fertility of echinococcal cysts was 82.81%, and the viability of fertile protoscoleces was 70.53%. Cysts were staged with ultrasound according to the WHO-IWGE classification as 32.8% CE1, 32.8% CE2, 7.8% CE3a, 9.4% CE3b, 15.6% CE4 and 1.6% CE5. Molecular analyses using mitochondrial NAD5 gene showed that all analyzed samples (n = 59) belonged to the genotypes G1 or G3 of E. granulosussensu stricto (s.s.), thus, confirming sheep−dog−human transmission in the Kurdistan region, Iraq. No statistically significant correlation was found between the genotypes G1−G3 of E. granulosus s.s. and variables, such as the fertility, location and cyst stage classification. Based on the present findings, it is necessary to implement monitoring and control programs in sheep and dog populations to decrease the odds of human infections. Public health education campaigns are required to be implemented at the community level to reduce the risk of acquiring CE in humans in the Kurdistan region, Iraq.

Strangulated small-bowel internal hernia through a defect in the broad ligament of the uterus presenting as acute intestinal obstruction: A case report.

BACKGROUND: Internal hernias rarely lead to bowel obstruction; they are caused by a natural or unnatural opening within the peritoneal cavity. Defects in the broad ligament are extremely rare. Patients present with features of intestinal obstruction and most cases are diagnosed during surgery. CASE PRESENTATION: A 62-year-old parous woman presented with epigastric pain and attacks of vomiting for 1 week. The patient had had constipation for the last 5 days. She had no history of abdominal surgery. Abdominal examination revealed a distended abdomen with evidence of generalized abdominal tenderness.Abdominal CT scan showed evidence of intestinal obstruction. During laparotomy there were dilated small-bowel loops with an evidence of internal hernia through a 3 cm × 3 cm defect in the left broad ligament, through which a segment of strangulated terminal ileum was passing. Resection of the strangulated bowel was performed with end-to-end intestinal anastomosis. The broad ligament defect was closed with a slowly absorbable suture material. CONCLUSION: Surgery for intestinal obstruction due to internal hernias should follow the same principles of any case of intestinal obstruction, whether performed by the open conventional technique or laparoscopically. Surgery should not be delayed, to avoid increased morbidity and mortality. During surgery it is mandatory that the surgeon looks for any other possible defects and close them to avoid recurrence. Internal hernias caused by broad ligament defects are best managed by either closure of the defect or salpingectomy; the course of the ureter must be identified during surgery to prevent injury.

Hydatid cyst of the ovary - a very rare type of cystic ovarian lesion: A case report.

BACKGROUND: Hydatid disease is a zoonotic condition caused by the adult or the larval stages of tapeworms belonging to the species Echinococcus granulosus or less commonly Echinococcus multilocularis. The presentation depends on the site of involvement. Many cases are not symptomatic and may be discovered accidentally. Hydatid cyst of the ovary is an extremely rare presentation and accounts for 0.2-1% of the diagnosed cases. It may be mistaken for ovarian cysts or cystic tumors of the ovary. CASE PRESENTATION: An 18-year-old woman complained of episodes of lower abdominal pain and frequent urination for the last 3 months. During abdominal examination, there was deep tenderness in the supra-pubic region with no palpable organs or masses. Ultrasound of the abdomen showed evidence of cystic left adnexal lesions. A computerized tomography scan of the abdomen revealed evidence of cystic left adnexal lesion with no enhancement after contrast injection. Laparoscopy was performed and there was evidence of a hydatid cyst of the left ovary. The cyst was extracted from the cavity using a retrieval bag. Anthelmintic medications were prescribed for 3 months, and follow-up ultrasound after 6 months was normal. CONCLUSION: A high index of suspicion is required for the diagnosis, particularly in the presence of any cystic lesion, in any part of the world. The enzyme-linked immunosorbent assay test may be informative in the active stages of the disease. Laparoscopic management involves cyst excision. Anthelmintic drugs are required after surgery to decrease the recurrence rate.

Gallbladder agenesis: An accidental finding during laparotomy for hepatic tumor.

BACKGROUND: Anomalies of the biliary system are frequently encountered. Agenesis of the gall bladder is a rare. The exact incidence is not known as most cases are asymptomatic and diagnosed incidentally during surgeries for unrelated conditions or at autopsy. This anomaly may occur alone or in association with other anomalies such as other biliary anomalies, portal vein anomalies and other vascular anomalies, or in some cases hepatic, gastrointestinal or anomalies in other body systems. CASE PRESENTATION: An elderly man diagnoses with segment VI liver tumor and planned for surgical resection. During surgery we accidentally discovered gall bladder agenesis with slightly dilated common bile duct. The tumor resected successfully and the final diagnosis was well differentiated with hepatocellular carcinoma. CONCLUSION: Careful search for the gall bladder must be done before diagnosing agenesis of the gall bladder. No conversion is required provided adequate visualization and search for the gall bladder is done during laparoscopy. Postoperative MCRP will define the biliary anatomy and to help the surgeons to have postoperative accurate decision.

Two Concomitant Right Nonrecurrent Laryngeal Nerves Encountered During Thyroidectomy (Type 4 Course): Reported for the First Time.

INTRODUCTION: The recurrent laryngeal nerve gains its name because after branching from the vagus nerve, it turns superiorly (recur) around the subclavian artery on the right and around the ligamentum arteriosum on the left, the nonrecurrent nerve has a straight direct course to the larynx and doesn't follow this course. It presents mostly on the right side. The presence of this variation places the nerve at higher risk of injury during neck surgery especially thyroid operations. CASE PRESENTATION: A 45-year-old lady presented with painless thyroid enlargement for 1 year. Thyroid examination showed a 3-cm firm nodule at the right thyroid lobe with normal thyroid function tests. Right thyroid lobectomy was done and the histopathology showed a benign follicular lesion. During surgery, we discovered 2 nonrecurrent laryngeal nerves at the right side which were arising from the vagus nerve and both were entering the larynx. CONCLUSION: Failure in identification of the nerve or overlooking the possibility of the non-recurrent laryngeal nerve may result in a serious sequelae of nerve damage, ipsilateral injury may lead to permanent hoarseness and bilateral injury may result in severe dyspnea or aphonia. Currently, there are 3 types of nonrecurrent laryngeal nerve courses. Type 1 passes near to the superior thyroid vessels. Type 2 (2A) passes parallel to the inferior thyroid artery and has a transverse course above it. Type 3 (2B) passes parallel to the inferior thyroid artery and transversely between branches of or under the inferior thyroid artery, we can add to this classification type 4, which are 2 nonrecurrent laryngeal nerves (double nerves) passing above and parallel to the inferior thyroid artery.

The correlation of antioxidant levels of breast cancer: A case controlled study.

ABSTRACT: Many free radicles are implicated to activate a number of oncogenic signaling, cause damage to deoxyribonucleic acid and tumor suppressor genes, or promote expression of proto-oncogenes. Reduced level of antioxidants and increases oxidative stress markers are associated with the development of various types of cancer.This prospective study included 60 women who were grouped into equal groups. Patients group included 30 breast cancer women and control group consisting of 30 apparently healthy women. Both groups were compared regarding the serum levels of antioxidants biomarkers (vitamin C, ceruloplasmin, glutathione) and oxidative stress biomarkers, malondialdehyde (MDA), peroxynitrite, and gamma-glutamyl transferase.In regard to the antioxidant biomarkers, there was a significant difference between the patients and the controls regarding the levels of serum ceruloplasmin and glutathione, (P values .000) for each while vitamin C showed no significant correlation (P value .053), while regarding oxidative stress biomarkers, the correlation was significant for both peroxynitrite and MDA (P value .000 and .001) respectively, and not significant for gamma-glutamyl transferase (P value 1.00).Reduced level both ceruloplasmin and glutathione is seen in patients with breast cancer while vitamin C is not associated. Elevated levels of both peroxynitrite and MDA is seen in patients with breast cancer which may be used as serum markers for the early detection of breast cancer.

Leiomyosarcoma of the inferior vena cava presenting as deep venous thrombosis; case report.

Primary tumors arising from the inferior vena cava are extremely rare, leiomyosarcoma is the most common one arising from the smooth muscle cells in the media of the wall of the vena cava. A 42-year-old lady had epigastric pain and back pain for 4 months with signs of deep vein thrombosis of the right lower limb. CT-scan showed a mass related to the inferior vena cava which was proved by histopathological examination to be leiomyosarcoma of the inferior vena cava. A multidisciplinary team is required for the diagnosis and management of tumors the vena cava. Long term follow-up is recommended.

Gastro-colo-bronchial fistula after laparoscopic sleeve gastrectomy; case report.

Obesity and its related comorbidities is a major health problem worldwide. Sleeve gastrectomy is regarded to be one of the most effective bariatric surgeries with a relatively low risks of complications. Gastrobronchial fistula is an extremely rare and a serious complication after bariatric surgeries, it is associated with major morbidity. A 48-year-old obese lady with a BMI of 40 had underwent laparoscopic sleeve gastrectomy 7 years ago, she developed leak at the 10th postoperative day which was treated with drainage. After 4 years she presented with left subphrenic abscess which was treated with drainage, splenectomy and endoscopic stent. After one year she had repeated chest infections and was coughing-up recently ingested food items. CT-scan showed left subphrenic collection with abnormal fistulous tract between the bronchial tree and the subphrenic cavity. Left thoracotomy was performed, a complex fistula was found between the remnant parts of the gastric fundus, transverse colon and lung. Resection of the fistula was performed, the stomach and colon were closed in 2 layers, resection of the affected segment of lung was performed and the diaphragm was sutured. The BMI was 19 at the last admission. Gastro-colo-bronchial fistula is unreported after sleeve gastrectomy and the management is challenging. Surgeons may follow the same principles of management as in cases of gastrobronchial fistula, but we suggest earlier surgical intervention with the administration of broad spectrum antibiotics. Nutritional deficiencies must be corrected, and such patients must be treated with multidisciplinary team, with an extended duration of follow-up.

Agenesis of the gall bladder, an unexpected finding during laparoscopy; case report.

Congenital agenesis of the gall bladder is a very rare ranging from 0.02% to 0.002% in clinical practice. There is complete absence of the gall bladder with normal intra and extra hepatic biliary tree. The exact etiology remains unclear. Low index of suspicion and failure of routine investigations will result in its unexpected discovery during surgery. The condition usually results in diagnostic dilemma both before surgery and intraoperatively. A 25-year-old lady presented with repeated attacks of right side abdominal pain for 1 year. Abdominal examination showed tenderness on palpation in the right hypochonrdium. Abdominal ultrasound showed normal common bile duct with suspicion of small contacted gall bladder. MRCP showed extrahepatic biliary tree and not visualized gall bladder. During diagnostic laparoscopy exploration of the whole peritoneal cavity was performed. The gall bladder was not visualized after complete visualization of biliary anatomy. The appendix was inflamed with multiple adhesions with the bowel. The cecum was high placed in the sub-hepatic region. Laparoscopic appendicectomy was performed. Patients with gall bladder agenesis surprisingly have symptoms similar to cholecystitis, the pain may be attributed to cholangitis, biliary stones, or sphincter of Oddi dysfunction. When the condition diagnosed at operation extensive dissection to identify the gall bladder must be avoided because it may result in biliary injury.

Duodenal gangliocytic paraganglioma: A very rare cause for upper gastrointestinal bleeding: Case report with review of literature.

INTRODUCTION: Gangliocytic paraganglioma is a rare tumors mainly arises from the second part of the duodenum. The tumor is generally benign, but some cases are associated with lymph node or distant metastasis. It must be differentiated from other tumors. The main treatment is good local surgical resection. Most patients have good prognosis after an appropriate resection. CASE PRESENTATION: A 47-year-old male patient presented with recurrent attacks of epigastric pain and melena. The general examination revealed pallor with no jaundice. The abdomen was soft with no tenderness. There were no stigmata of chronic liver diseases. The hemoglobin level was 8 gm/dl with normal liver and renal functions. The patients received compatible blood. Endoscopy showed a large pedunculated polyp with ulceration in the second part of the duodenum just distal to ampulla of Vater. During surgery, the anterior wall of duodenum was opened, and a 4 cm pedunculated polyp was excised which was arising from the posterior wall of the duodenum just distal to the ampulla of Vater. The frozen section examination revealed a benign lesion. The final histopathology result was consistent with the diagnosis of gangliocytic paraganglioma. The patient had smooth post-operative recovery and no postoperative complications. CONCLUSIONS: Gangliocytic paraganglioma is a rare tumor which mostly affects the second part of the duodenum. The tumor is considered benign but the possibility of the malignancy with lymphatic and distant metastases must be excluded before any surgery. The management plan must be addressed carefully and continuous follow up is recommended.

P53 expression and micro-vessel density in relation with 5-year survival in patients with colorectal cancer.

Colorectal cancers are among the commonest causes of cancer related morbidity and mortality worldwide. Adenomatous polyps which develop dysplastic changes are the main cause of invasive cancer. P53 inactivation is a key genetic step in the occurrence of cancer. The degree of the formation of the blood vessels inside the tumor (microvessel density) increases the ability of the tumor to have local infiltration, metastatic potential and may reflect the tumor metabolic activity. A total number of 104 patients who underwent surgeries for colorectal adenocarcinoma followed for 5 years. Patients were categorized into 4 categories based on tumor expression of P53 and micro-vessel density, 64.42% of patients were females, 58.7% died from colorectal cancer during the 5-year period, 37.5% had 5-years survival free from cancer, and 16.3% survived with recurrence, 28.8% had over expression of both P53 and MVD. A significant correlation was found between: P53 and MVD with the site of tumor occurrence being more significant with left-sided colonic tumors, the clinical stage being more significant with stage III disease, and with the survival rate being more significant in patients who died during this period, P values 0.025, 0.01, and 0.001 respectively. Overexpression of P53 and MVD are associated with higher mortality and more advanced disease. We advise a more aggressive form of therapy for colorectal adenocarcinomas expressing high level of both factors and tumors with high expression of both factors may need modification in the chemotherapeutic drugs or radiation therapy with closer follow up than tumors having lower expression.

Metastatic invasive lobular carcinoma of the breast to the endometrium presenting with abnormal uterine bleeding; Case report.

Metastatic cancer to the female genital organs is a very rare clinical presentation. The myometrium is more frequently affected than the endometrium. Prolonged use of tamoxifen has been found to be associated with endometrial hyperplasia, endometrial polyp formation, and the development of endometrial adenocarcinoma in some cases. A 55-year-old lady with a history of invasive lobular carcinoma of the breast that had been operated upon with left mastectomy 7 years previously & who had also been treated with tamoxifen for 5 years presented with irregular vaginal bleeding and lower abdominal pain. The patient had a three cm uterine fibroid with an endometrial polyp. She had anemia with hemoglobin level 8 mg/dl. Laparoscopic hysterectomy with bilateral oophorectomy was performed for a polyp in the endometrium which proved to be a metastasis from her lobular carcinoma of the breast. Patients with breast cancer who present with abnormal vaginal bleeding should alert the physicians about the possibility of metastatic breast cancer to the uterus regardless the use of the hormonal therapy such as tamoxifen. The pathologists also should be aware of this possibility and they should examine the polyps very carefully to detect any metastatic foci especially if the patient has been treated with tamoxifen.

Migrated intrauterine device presented as anterior abdominal wall abscess.

The migrated intrauterine contraceptive device can cause various presentations depending on the location, some may have late presentations like our case presenting after 5 years and after pregnancy and delivery by cesarean section. A 34-year-old lady had painful suprapubic mass for 1-week, with fever. She had history of intrauterine device (IUD) placed before 5 years. The patient became pregnant 1 year before presentation and delivery done by cesarean section. Examination showed a tender mass 3 cm above the scar of the previous cesarean section. The clinical picture was consistent with abdominal wall abscess. During surgery pus drained and the IUD extracted from the cavity of the abscess. High index of suspicion is needed when there is history of missed IUD and any abdominal complain. Abdominal X-ray and ultrasound will give better diagnostic value. Most cases need surgical extraction of the device which can be done laparoscopically.

Intra-peritoneal rupture of large hydatid cyst of the liver containing innumerable daughter cysts after blunt abdominal trauma.

INTRODUCTION: Hydatid disease is a major health concern in the Mediterranean countries and many other parts of the world. The route of transmission is fecal-oral, and then spread by the portal venous system almost all part of the body. The liver is the most commonly involved organ, followed by the lungs, and other organs are involved in order of decreasing frequency. PRESENTATION OF CASE: A middle-age male patient presented with acute abdominal pain and repeated vomiting after blunt abdominal trauma. CT-scan showed a large hydatid cyst of the right lobe of the liver with features of intraperitoneal rupture. Emergency laparotomy was performed with extraction of a countless number of daughter cysts from the peritoneal cavity. We further examined the bowel and found no abnormalities. The cyst was not causing any compression on the bile duct. Omentoplasty was performed for the cavity. The patient was discharged home eight days after the operation and the drain removed after twenty-five days when the bile leak stopped, anthelminthic drugs were given for three months after the surgery. CONCLUSION: Prevention of hydatid disease is the most effective way to control the disease, the cyst may reach a very large size and be asymptomatic. Intraperitoneal rupture may occur as a result of blunt abdominal trauma which could be trivial.

Epithelioid hemangioendothelioma of the pancreas presented as massive hematemesis.

INTRODUCTION: Hemangioendotheliomas are vascular tumors characterized by the presence of an "epithelioid" or "histiocytoid" endothelial cell. They consist of blood filled spaces mixed with cellular areas that mostly occur in the liver, but other organs can be affected. These lesions cause a wide spectrum of clinical presentations depending on the organ involved. Complete surgical excision is the primary form of treatment; they tend to recur after surgery in some cases. PRESENTATION OF CASE: A-45-year old lady presented with 2 attacks of massive hematemesis. Upper GIT endoscopy was done which showed a vascular tumor arising from the duodenal ampulla, biopsy was not taken because of the risk of bleeding. Laparotomy and duodenotomy were performed, there was a soft irregular 3 cm mass with areas of hemorrhage arising from the duodenum, complete excision was done and frozen section examination showed a benign lesion. Two months later the patient presented with melena and anemia. CT-scan of the abdomen showed a mass at the head of pancreas. Second surgery was done and during surgery a firm mass was found in the region of the head of pancreas, pancreaticoduodenectomy was done and the sample was sent for histopathological examination which showed an epithelioid hemangioendothelioma of the head of the pancreas. DISCUSSION & CONCLUSION: The treatment strategy should be tailored to the individual patient, the clinical presentation, and the rate of progression of the tumor. The natural history of the disease is still poorly understood and there is no uniform treatment form for such tumors.

Surgical excision of a giant pedunculated hydatid cyst of the liver.

Hydatid disease is caused by a tape worm Echinococcus Granulosus that lives in the intestines of the definitive host which is the dog or other carnivore. Human is the accidental intermediate host and become infected by ingesting contaminated vegetables or water with the eggs of the parasite. A-37-year old male presented with right side abdominal pain for 2 months. Abdominal examination showed a large right side abdominal mass extending from the right subcostal region to the right iliac fossa. CT-scan showed two cystic lesions in the right lobe of the and a third one extending to the pelvis. During surgery aspiration of 10 liters of bile stained fluid done. Excision of the cysts done. Tube drain put inside the cyst cavity with omentoplasty. There was bile leak to the drain which stopped over one month. The patient received anthelminthic medication for 3 months.

Acute necrotising gastritis in a 14-year-old girl.

A 14-year-old female patient presented with acute generalised abdominal pain and two attacks of non-bilious vomiting for 2 days. She visited the emergency department and at presentation she was pale, dyspnaeic and there was no jaundice. Abdominal examination showed moderate abdominal distension with generalised abdominal tenderness. The bowel sounds were negative on auscultation. Plain abdominal X-ray showed hugely distended stomach with no free air detected in the peritoneal cavity. During laparotomy there was huge distension and gangrene of the stomach involving the whole stomach up to the fundus. Total gastrectomy done with roux-en-y reconstruction of the gastrointestinal continuity. The histopathological study of the sample showed gastric necrosis.

Limy bile (Milk of calcium bile) associated with gall stones discovered incidentally during laparoscopic cholecystectomy.

INTRODUCTION: Limy bile is very rare condition in which the gall bladder is filled with a whitish material formed mainly of calcium carbonate. It may be associated with gall stones and present with epigastric and right upper quadrant pain, fever, nausea, and jaundice. The diagnosis is easily made during radiology showing opacification of the gallbladder or the bile ducts on plain abdominal X-rays and CT-scan. Most patients are treated with cholecystectomy. CASE PRESENTATION: A 35-year-old lady was complaining from right hypochondrial pain for 8 months. The pain was mainly at the late night and relieved with analgesics. During examination the patient had no jaundice and during abdominal examination there was deep tenderness in the right hypochonrdium. Ultrasound of the gallbladder showed evidence of multiple gall stones with bile sludge. During laparoscopic cholecystectomy the gall bladder was found to be filled with white creamy substance and multiple gall stones. The patient discharged next day with no postoperative complications. CONCLUSION: Limy bile is a rare clinical entity of unknown etiology but obstruction of the cystic duct may be the most important step in its occurrence. The condition needs cholecystectomy as in most of the cases it is associated with gall stones. There are no reported long term sequelae and long term follows up is not recommended.

Hydatid cyst of the calf presenting as painless mass: A case report.

BACKGROUND: Hydatid disease is a zoonotic disease that is transmitted to the human by ingesting the eggs of the parasite Echinococcus granulosus, it most commonly affects the liver but every organ could be affected, musculoskeletal system involvement occurs in 0.5-4% of patients. Most patients present as soft tissue mass in the affected muscle. Preoperative diagnosis usually done radiologically by ultrasound or MRI examination. CASE PRESENTATION: We present a 60-year-old lady presented with painless mass in the right calf for 2 years. The mass was soft, non-tender, mobile from side to side. Ultrasound of the mass showed cystic lesion that contained multiple small cysts inside, and the diagnosis of hydatid disease was made before surgery. During surgery and after opening the mass the lesion appeared to be hydatid cyst containing innumerable daughter cysts. Complete evacuation of the all the daughter cysts done. The patient discharged next day with no postoperative complications. The patient received postoperative albendazole therapy for 2 months and follow up done 6 months after surgery with no complications. CONCLUSION: Hydatid disease should be thought when patients present with mass lesion in any part of the body especially in endemic areas. The most important step in the diagnosis is to exclude the presence of other cysts in other parts of the body.

Laparoscopic cholecystectomy for left-sided gall bladder in situs inversus totalis patient, a technically demanding procedure.

Situs inversus is a condition in which the anatomical viscera are placed in a reverse anatomical location, it may be partial affecting the thoracic organs or the abdominal organs, or total affecting both. A 28-year-old man who was a known case of situs inversus totalis presented with epigastric pain and left hypochondrial pain. ultrasound revealed multiple gall stones in a left-sided gall bladder, laparoscopic cholecystectomy was done successfully for him with no complications. Patient position during surgery and the sites of the laparoscopic ports greatly affect the performance during surgery. Identification of the anatomical structures which are arranged in a mirror image pattern is the key for successful surgery. The critical view of safety should be identified before any structure is clipped or divided. A right-handed surgeon will feel more impairment during surgery for a left-sided gall bladder, while a left-handed surgeon will do it with better comfort. Surgeries for such cases are better to be performed by a surgeon with massive experience in laparoscopy or by a hepatobiliary surgeon, it may not be suitable for surgeons in training. MRCP will show the biliary anatomy prior to surgery and CT-scan with dual phase contrast will help to show any associated vascular abnormalities.