CASE PRESENTATION: We discuss a case of right vocal fold cryptococcus infection in a healthy, immunocompetent 71-year-old man with no history of inhaled corticosteroid, presented with hoarseness and intermittent aspiration symptom for 1 year duration. Further examination showed right anterior vocal fold mass with presence of right vallecular cyst.
CLINICAL DISCUSSION: Patient underwent direct laryngoscopy, excision of right vocal fold mass and marsupialization of vallecular cyst. Histopathological examination revealed cryptococcal infection. Patient subsequently treated with oral fluconazole 400 mg daily for 6 months. To date, hoarseness and aspiration symptoms have resolved.
CONCLUSION: We are sharing our experience in managing laryngeal cryptococcus infection in an immunocompetent patient where the associated risk factors discussed in previous literatures are absent.
CASE REPORT: We present herein the rare case of a 30-year-old man who developed thigh compartment syndrome 8 days after soccer injury due to severe edema of vastus intermedius and large thigh hematoma secondary to rupture of the profunda femoris vein. MRI revealed "blow-out" rupture of the vastus lateralis. Decompressive fasciotomy and vein repair performed with subsequent split-skin grafting of the wound defect resulted in a good functional outcome at 2-years follow-up.
CONCLUSION: A high index of suspicion for compartment syndrome is needed in all severe quadriceps contusion. Vascular injury can cause thigh compartment syndrome in sports trauma. MRI findings of deep thigh muscle swelling and "blow-out" tear of the vastus lateralis are strongly suggestive of severe quadriceps injury, and may be a harbinger of delayed thigh compartment syndrome.
PRESENTATION OF CASE: A 30-year-old woman, who had a previous cesarean delivery, opted for another cesarean section (CS) during this pregnancy. She claimed that her tummy was lax after her first experience of CS even with regular exercise. A standard CS procedure was carried out along with the new modified undermined suture technique for rectus muscle re-approximation. Post-operatively, the pain score was 2/10 without any evidence of hematoma, seromas or infection and the patient ambulates well. The patient did not complain of any pain or complications upon follow up after 2 weeks and 2 months post-operation. She claims that her abdomen is firmer, flatter and more stable compared to her previous operation experience.
DISCUSSION: This newly modified method prevents any defect or weakness on the anterior abdominal wall even if the rectus muscles fail to oppose itself during the healing process. It also mimics the function of the linea alba and avoid interrupting the contraction or injuring the muscle in order to avoid pain. Adhesion of the anterior uterine wall and the rectus sheath can be prevented by closure of the rectus muscle and burying the suture material within the muscle.
CONCLUSION: The newly modified undermined suture rectus muscle technique at cesarean delivery has the potential to improved patient's post-operative satisfaction.
PRESENTATION OF CASE: We describe a 55-year-old lady who presented to the emergency department with epigastric pain and symptoms of anaemia for one day duration. She was normotensive but tachycardic. Blood investigations revealed haemoglobin level of 6.5 g/dL and serum alpha-fetoprotein of 3136 g/dL. Contrast enhanced computed tomography scan revealed ruptured HCC of segment 2 and 3. She underwent emergency laparoscopic resection of the ruptured HCC. The postoperative recovery was uneventful and she was discharged well on postoperative day 7. Histology confirmed a 10 cm ruptured HCC with 3 mm tumour-free resection margin.
DISCUSSION: Ruptured HCC is associated with a high mortality rate of 25-75 %. Traditional treatment involves initial stabilization and hemostasis through transarterial embolization followed by staged hepatic resection. However, laparoscopic liver resection has been shown to be superior than open surgery in terms of postoperative outcomes.
CONCLUSION: Laparoscopic resection of bleeding HCC is achievable and can be considered in the treatment algorithm of selected patients.
CASE PRESENTATION: A young healthy 31-year-old male patient presented with maxillary midline diastema. Probing depth of 6 mm was also noted over the mesial aspect of the same teeth with localised osseous defect radiographically which lead to a diagnosis of localized chronic periodontitis in relation to those teeth. A Whale's tail technique flap for papilla preservation was performed together with a regenerative procedure using bone graft and GTR membrane.
DISCUSSION: Midline diastema is a common reported complaint in dentistry due to both aesthetic and functional reasons. Following the treatment, 12 months postoperatively, patient had a probing depth reduction of 3 mm and a gain in clinical attachment of 2 mm. The surgical technique allowed regeneration of wide intrabony defects involving the maxillary anterior teeth with notable interdental diastemas.
CONCLUSION: This lead to significant improvement of the hard and soft tissue contour as well as it recreated a functional reattachment which was documented up to 12 months postoperatively.
PRESENTATION OF CASE: A 21 year old lady presented with worsening of chronic abdominal pain for 3 years, associated with nausea and vomiting. Physical examination showed a vague mass located at epigastric region. Consecutively, computed tomography images showed a well-defined, oval, hypoechoic spleen extending from center of abdomen up to epigastric region measuring 15.5 × 13 cm with twisted pedicle. Finally the patient underwent surgical treatment. The intraoperative findings were consistent with computed tomography images. The patient made a full recovery and was discharged well.
DISCUSSION: Wandering Spleen was first described by Van Horne during autopsy back in 1667. Its location is maintained by peritoneal attachments such as lienorenal, splenocolic, splenophrenic, gastrosplenic and phrenicocolic ligaments. Among which, the gastrosplenic ligament and lienorenal ligaments are of greatest significance. Patient with a wandering spleen may present asymptomatic, with a movable mass in the abdomen, or with chronic or intermittent abdominal pain because of partial torsion and spontaneous de-torsion of the spleen as in our case. When feasible especially in young patients, splenopexy should always be the first consideration but however if gross infarct has occurred then splenectomy is inevitable to save the patient.
CONCLUSION: Wandering spleen is a unique surgical entity moreover when appeared in congruence with horseshoe kidney. Its diagnosis should be made in prompt to prevent splenic infarction and to try to salvage with splenopexy especially in younger population. However in patient where splenic torsion with infarction has occurred, splenectomy would be the treatment of choice.
PRESENTATION OF CASE: We present a rare case of WS torsion in a 69-year-old elderly patient who presented with an acute abdomen. Physical examination revealed a tender right lower quadrant abdominal mass. Imaging studies confirmed the diagnosis of WS torsion with features of infarction. Subsequently, an emergency laparoscopic splenectomy was performed.
DISCUSSION: A WS occurs due to the hypermobility of the spleen secondary to the absence or laxity of splenic suspensory ligaments. It is more commonly seen in children and adults in the third decade of life. Symptoms are usually attributed to the consequences of splenic vascular pedicle torsion. Exhibited symptoms might be unspecific; thus, radiological modalities are essential to determine the diagnosis and aid in planning its management. The treatment of choice is either open or laparoscopic splenopexy or splenectomy.
CONCLUSION: Due to potentially life-threatening consequences and the rarity of such cases, a thorough history, detailed physical examination, and objective investigation are the pillars to attain a prompt diagnosis for appropriate management to be conducted as soon as possible to minimise complications.
CASE DESCRIPTION: A 22-year old lady presented with a history of a right neck mass for a 5-months duration. Clinical examination revealed a mass at level II neck region which measures 3.0 cm × 2.0 cm and it was mobile, non-pulsatile and had smooth surfaced. CT scan and angiogram showed that the mass arose between the carotid artery and vagal nerve and it was a highly vascular lesion. A CT scan-guided biopsy performed but complicated with neck hematoma and patient developed hoarseness. On follow up, her hoarseness persists and her tissue biopsy came back as schwannoma. She was counseled regarding surgery versus radiation for her treatment and she agreeable for surgery. Hence, surgical excision was performed and intraoperatively the mass visualized arising from the vagal nerve. Postoperatively however, her voice did not improve.
CONCLUSION: Vagal schwannoma is a rare paraganglioma of head and neck and the best treatment is still controversial. Unnecessary investigation and procedure should be avoided in order to reduce morbidity as well as improves patient's quality of life.
PRESENTATION OF CASE: 49 year old gentleman presented with fever, persistent, unresolving pain and scrotal swelling of two weeks duration. Despite close clinical monitoring, timely ultrasounds of the testis and antibiotics there was an inexorable progression to bilateral testicular ischemia.
DISCUSSION: This is only the second reported case of this nature in published literature. Epididymo-orchitis usually responds well to appropriate antibiotic therapy, although progression to testicular infarction is possible.
CONCLUSION: Clinical presentation of persistent scrotal pain and oedema in cases of epididymo-orchitis should raise strong suspicion of testicular ischemia or infarction. Despite all efforts, progression to bilateral testicular infarction resulting in castration is a possible catastrophic outcome.
CASE PRESENTATION: We described a 43 years old male who presented with a right mastoid swelling, nine years after a right retro-sigmoid craniotomy and excision for a cerebellopontine angle meningioma. He also had multiple cranial neuropathies involving trigeminal, facial and vestibulocochlear nerves. Temporal bone CT and MRI showed features suggestive of cholesterol granuloma with extensive bony erosions. He was treated with surgical excision and drainage where bone wax residues were found intraoperatively. Histopathological analysis of the lesion confirmed the diagnosis of cholesterol granuloma. Post-operatively, the mastoid swelling resolved and his recovery was uneventful.
CONCLUSION: Our case showed that CG could manifest as a complication of bone wax usage in a neurosurgical procedure. Even though further study is needed to draw a definitive conclusion on this theory, we believe this paper will contribute to the current literature as it is the only reported case of cholesterol granuloma with bone wax as the possible causative agent. This is important so that surgeons are aware of this potential complication and use this haemostatic agent more judiciously.
PRESENTATION OF CASE: We report a 63-year-old lady with incidental findings of adrenal tumour on computed tomography (CT) scan during a routine medical check-up. She underwent tumour resection in view of a large tumour of 7 cm in size.
DISCUSSION: CT scan is sensitive to diagnose adrenal myelolipoma in view of its fat-laden property and useful to monitor the tumour progress. Even previously she opted for conservative management; the decision for surgery was made in view of enlarging tumour and risk of surrounding tissue compression.
CONCLUSION: With increased awareness, the detection rate of this tumour is improving, hence able to prevent the complications of a large tumour such as compression, bleeding and tumour necrosis.
CASE PRESENTATION: We report a case of a 40-year-old lady with primary infertility for six years with underlying polycystic ovary syndrome (PCOS) and BMI 45.7 whom was successfully conceived twice following bariatric surgery procedure in which reduction of 70% of her BMI prior to bariatric surgery lead to her spontaneous conception without fertility intervention and successful live birth.
CLINICAL DISCUSSION: Obese PCOS needs multidisciplinary approaches which include weight loss program such as dietary advice, exercise intervention as part of preliminary treatment prior to ovulation induction and counselling.
CONCLUSION: Bariatric surgery has been a mainstay treatment in patients with morbid obesity and those with BMI more than 35 associated with obesity related problems such as joint pain, hypertension or diabetes mellitus. Bariatric surgery such as laparoscopic sleeve gastrectomy should be considered more often in contrast to lifestyle modification for morbidly obese lady with PCOS and infertility prior to the use of standard ovulation induction regime for treating infertility.
PRESENTATION OF CASE: With that in mind, we describe a 66-year-old man who presented with recurrent episodes of obscure gastrointestinal bleeding for two years. Video capsule endoscopy (VCE) showed several small telangiectasias in the proximal small bowel. Oral route double-balloon enteroscopy (DBE) revealed abnormal mucosa 165 cm from incisor with central ulceration and vascular component. He subsequently underwent surgical excision. The histopathological report confirmed the diagnosis of GIST arising from the jejunum. During his clinic follow up, he remains symptom-free with no evidence of recurrence.
DISCUSSION: The diagnosis of bleeding small intestine GISTs can be challenging as these are inaccessible by conventional endoscopy. Imaging modalities such as double-balloon enteroscopy, capsule endoscopy, CT angiography, intravenous contrast-enhanced multidetector row CT (MDCT) and magnetic resonance enterography (MRE) have been used to assist in the diagnosis of bleeding small intestine GISTs. The mainstay of management for small intestine GIST is complete surgical excision.
CONCLUSION: Bleeding jejunal GIST is very rare and only a handful of case reports have been published. The mainstay of management for small intestine GIST is complete surgical excision. It is essential to obtain a complete excision of localised disease and avoiding tumour spillage in order to reduce the risk of local recurrence and metastatic spread of GISTs.
CASE PRESENTATION: We presented a 65-year-old, Asian, female with medical co-morbids, who came with both a facial squamous cell carcinoma and a long-standing lesion over her left forearm. Histopathological finding of the left forearm demonstrated eccrine porocarcinoma.
CONCLUSION: Mohs micrographic surgery is the mainstay treatment of cutaneous carcinoma. It is important to rule out associated syndromes in patient who present with multiple cutaneous appendageal tumors.
CASE PRESENTATION: We present a case of a 61-year-old lady with mitral valve prolapse (MVP) who underwent TOE with subsequent presentation of odynophagia with left neck swelling. An upper endoscopy examination was inconclusive; however, a contrasted computed tomography of the neck showed evidence of cervical oesophageal perforation. She was managed conservatively and discharged well.
DISCUSSION: The trauma caused by TOE probe insertion and manipulation accounts for most of the upper gastrointestinal complications. Mortality of patients associated with oesophageal perforation can be up to 20% and doubled if the treatment is delayed for more than 24 h. Mechanism of injury from TOE probe is likely multifactorial. Predisposing factors that increase the risk of tissue disruption include the presence of unknown structural pathology. Imaging studies and an upper endoscopy examination may aid in the diagnosis of oesophageal perforation.
CONCLUSION: A high index of suspicion, coupled with a tailored, multidisciplinary approach, is essential to achieve the best possible outcome. Conservative management may be worthwhile in a stable patient despite delayed presentation. Although TOE is considered a safe procedure, physicians should be made aware of such a dreaded complication.
CASE PRESENTATION: We present here a novel technique of using intravenous (IV) cannula as an alternative to suture passer for fascial closure during laparoscopic IPOM repair for a 59-year-old patient with an incisional ventral hernia. The placement of non-absorbable sutures for fascial closure was done with the help of a 14 gauge IV cannula instead of a transfascial suture passer. The rest of the procedural steps were the same as a standard laparoscopic IPOM repair. The patient's post-operative recovery was uneventful.
DISCUSSION: Primary fascial closure during a laparoscopic IPOM hernia repair can be done either by intracorporeal or extracorporeal techniques, using interrupted or continuous sutures. We propose a novel alternative to suture passer in primary fascial closure. IV cannulas are widely available in hospital settings. The advantage of using an IV cannula instead of a suture passer is that they are widely available. Its single-use also eliminates the risk of transmissible diseases, and as it has a smaller diameter than suture passer, it requires a lower insertion force for successful placement.
CONCLUSION: An IV cannula may be used as a more economical alternative to a transfascial suture passer. This technique is easily reproducible and does not violate the principles of primary fascial defect closure in laparoscopic ventral hernia repair.