Fetus-in-fetu (FIF) is a rare entity resulting from abnormal embryogenesis in diamniotic monochorionic twins, being first described by Johann Friedrich Meckel (1800s). This occurs when a vertebrate fetus is enclosed in a normally growing fetus. Clinical manifestations vary. Detection is most often in infancy, the oldest reported age being 47. We report the case of a 4-day-old girl who was referred postnatally following a prenatal fetal scan which had revealed the presence of a multi-loculated retroperitoneal mass lesion with calcifications within. A provisional radiological diagnosis of FIF was made. Elective laparotomy revealed a well encapsulated retroperitoneal mass containing among other structures a skull vault and rudimentary limb buds. Recovery was uneventful. Here we discuss the difference between FIF and teratomas, risks of non-operative therapy and the role of serology in surveillance and detection of malignant change.
Congenital cholesteatoma (CC) rarely presents with Luc's abscess. As a result of widespread usage of antimicrobial agents, Luc's abscess is hardly encountered in current clinical practice. Herein, we report a case of Luc's abscess as the first presenting symptom in a 5-year-old boy with underlying CC. Patient's clinical findings, radiological investigations and treatment were also discussed.
Trans-mesenteric hernia is a form of internal hernia which is an extremely rare cause of intestinal obstruction in adults compared with the pediatric population. It often presents with complications such as acute intestinal obstruction and peritonitis requiring immediate surgical intervention. We report a case of a 21-year-old woman who presented to us with an acute abdomen and peritonitis that required an immediate exploratory laparotomy. She was found to have a small congenital mesenteric defect with strangulated segment of ileum. Gangrenous portion of the ileum was resected and the congenital defect was closed. The patient made an uneventful recovery. The occurrence of trans-mesenteric hernia in adults is rare and difficult to be diagnosed clinically; thus, the patient's clinical features may lead to early surgical intervention in order to reduce morbidity and mortality.
Sinus of Valsalva aneurysm (SVA) is a relatively rare cardiac condition, in which the patient is usually asymptomatic. However, once this aneurysm ruptures, patients present with acute symptoms of heart failure. Timely surgical intervention is essential. We present the case of a 27-year-old woman, who had a ruptured SVA with a ventricular septal defect (VSD). The patient collapsed before the emergency operation and needed cardiopulmonary resuscitation. The patient required preoperative high inotoropic support and postoperative management was difficult because of multiple organ dysfunction. However, the patient recovered after using inhaled nitric oxide and veno-venous hemofiltration and tracheostomy, and was discharged with no further complications. To the best of our knowledge, no such case of a ruptured SVA with VSD, complicated by preoperative cardiac arrest and multiple organ dysfunction that culminated in a successful recovery, has been reported to date.
The clinical presentation of a sphenoid fungal ball (FB) is often non-specific and tends to be overlooked, particularly in hosts with an intact immune status. Rarely, potentially life-threatening complications may arise, owning its anatomical characteristics with contiguous structures. Herein, we present an unusual case of sphenoid FB complicated with orbital apex syndrome in an immunocompetent patient. The diagnosis dilemma and subsequent management are further discussed.
Shiitake mushroom is a common ingredient in East Asian cuisines. Food processing/preparation can cause the mushroom to be soft and slimy, leading to accidental swallowing. Due to its high insoluble fibre content, it remains the same size and shape in the intestinal tract. We present two cases of small bowel obstruction caused by shiitake mushroom requiring surgical intervention. Preoperative imaging showed dilated small bowel with a suspicious mass in the ileum. However, the exact cause was unclear. For both cases, exploratory laparotomy and enterotomy were then performed and undigested shiitake mushroom was found. Both patients recovered well from the surgery.
Short bowel syndrome in adults occurs as a result of massive small intestinal resection commonly due to severe Crohn's disease, volvulus or tumors. Diarrhea and weight loss are hallmarks of malabsorption which are aggravated if the colon is removed along with the small intestinal resection. Enteral nutrition autonomy is difficult to achieve in such cases of malabsorption where parenteral nutrition are required more often than not. We report a case of short bowel syndrome with severe malabsorption following extensive small bowel removal. The patient eventually underwent intestinal rehabilitation surgery and achieved independence from parenteral nutrition.
Natural history of abdominal wall soft tissue sarcoma is still poorly understood due to its rarity. In unpublished data of our institution, only seven cases of abdominal wall soft sarcoma with ICD-10 coding of 49.4 were found for past 10 years. We illustrate a case of juvenile fibrosarcoma of anterior abdominal wall. This is a case of young girl with anterior abdominal wall tumour, underwent wide local excision with immediate reconstruction. There are few options of surgical treatment for this case, but which is the best. It is always a challenge in managing young patient with giant abdominal wall defect in view of long term effect namely weakened abdominal wall, pregnancy related issue and risk of herniation and surgical site recurrence as well.
A neonate with cyanosis at birth was found to have a rare type of tetralogy of Fallot. Echocardiography showed dextrocardia, left aortic arch with constricting and tortuous patent ductus arteriosus (PDA). Computed tomography angiography thorax revealed visceroatrial situs inversus, mirror image dextrocardia, tetralogy anatomy and tortuous right PDA arising from bovine brachiocephalic artery. In view of severe cyanosis, emergency division of PDA and modified right Blalock-Taussig shunt through median sternotomy were performed under cardiopulmonary bypass. Post-operatively, the sternum was left open and he developed pulmonary overcirculation requiring prolonged ICU stay. He was discharged well at Day 26 post surgery. This case highlights a rare association tetralogy of Fallot, dextrocardia and situs inversus, with concomitant unilateral right PDA and bovine aortic arch.
We present a case of omental fibroma, which posed a surgical diagnostic dilemma. Primary tumours of the omentum are uncommon, and omental fibromas account for 2% of these. The rarity of omental fibroma and paucity of available information hamper an accurate diagnosis. In this particular case, the diagnostic process was misleading. The history was classical of an irreducible inguinal hernia, but the physical examination and imaging studies were suggestive of a testicular tumour. However, intraoperatively, an omental tumour and a normal testicle were found in the scrotum. Histopathological examination proved the tumour to be a fibroma. The presentation of an omental fibroma in an inguinal hernia sac had never been reported in literature. Due to the rarity of such cases, a thorough history, detailed examination, and objective investigation are the pillars to attain the correct diagnosis.
Desmoid fibromatosis is a rare, benign, locally aggressive fibroblastic proliferation that may occur in almost any anatomical location. Due to its rarity and unpredictable clinical course, there has not been a standard guideline of treatment. We encountered a case of desmoid fibromatosis in our centre. A young lady previously fit and well was referred for a symptomatic, rapidly growing left sided abdominal mass. Otherwise, she denied any bowel related symptoms or constitutional manifestation. Imaging demonstrated a large well-defined lobulated solid-cystic mass extending from vertebral level T10 to L5, measuring 10.5 cm × 15 cm × 23 cm. The mass was in close proximity with the left adrenal gland, left kidney, pancreas and spleen. Ultrasound guided biopsy interpreted it as a fibroblastic or myelofibroblastic tumour, favouring desmoid fibromatosis. Surgery was then performed where the mass was removed along with the left adrenal gland and kidney. Post-operative care was complicated with pulmonary embolism, hospital-acquired pneumonia and pancreatitis.
Toothbrush ingestion is a rare phenomenon. It is usually found in psychiatric, elderly and mentally disabled patients. Foreign bodies usually pass spontaneously and uneventfully through the gastrointestinal tract. Nevertheless, larger objects may require early intervention to avoid complications. This report describes the course of treatment for a 25-year-old woman with an accidentally ingested toothbrush.
A Bochdalek hernia is a common congenital diaphragmatic defect in infants. A late presentation during adulthood is rare with misleading signs and symptoms, resulting in misdiagnosis and errors in treatment. We describe a 30-year-old man who presented with abdominal pain and chronic choking sensation, which was previously treated as peptic ulcer disease. During the present admission, radiological imaging performed revealed loops of bowel and a gastric volvulus in the left hemithorax. The patient underwent a successful emergency surgery and repair of a Bochdalek hernia. Due to its rarity and ambiguous presentation, a symptomatic Bochdalek hernia in an adult is commonly misdiagnosed. A comprehensive evaluation is pertinent for early diagnosis and treatment, to prevent complications arising from obstruction and strangulation of herniated intraabdominal contents.
Bullet embolization from a gunshot wound is a rare entity in trauma patients. We report a case of a 37-year-old female patient who was brought to the trauma unit after sustaining multiple gunshots to the chest and abdomen. Followed by embolization of the bullet from the right subclavian artery to the right common femoral artery. Had successful retrieval of the bullet via a transverse arteriotomy.
Guillain Barre syndrome (GBS) as a complication of hyaluronic acid (HA) exposure is an extremely rare occurrence. We report a case of GBS, acute motor sensory axonal neuropathy (AMSAN) variant, after a HA breast enhancement procedure. A 41-year-old lady underwent a HA breast enhancement procedure from an unlicensed beautician and developed anaphylaxis followed by bilateral breast abscess and neurological deficits involving both motor and sensory components. The AMSAN variant of GBS was diagnosed from the cytoalbuminologic dissociation and nerve conduction study. Her GBS and breast abscess were managed with plasmapheresis and bilateral mastectomy. In this case, GBS was highly suspected to be caused by HA with possible impurities. To the author's knowledge, the association between HA and GBS has not been reported or known, and further studies are required to establish this association. To prevent mortality and morbidity, breast enhancement procedures should be performed by trained professionals with properly vetted products.
Symptomatic giant ganglioneuromas with mediastinal compression are rare, complicating its management with significant morbidity and mortality risks. A meticulous multidisciplinary preoperative planning is pivotal in ensuring success. We describe a case of a 30-year-old man with a giant posterior mediastinal mass with compression and displacement of the mediastinal structures. Biopsy confirmed a ganglioneuroma and patient underwent excision. Surgery was challenging in view of the size and adherence to the local structures. Haemodynamic instabilities were encountered necessitating a pre-emptive femoral-femoral cannulation for CPB. A piece-meal debulking of the tumour was performed, complicated with massive haemorrhage requiring autologous blood transfusion using an intraoperative blood salvage device. The patient recovered and was discharged home well at Day 8. A thorough pre-operative planning involving a multidisciplinary approach, an understanding of the surgical anatomy as well as anticipating impending complications is of paramount importance in the management of this particular case.
About 5% of all intussusception are found in adults, up to 90% of these have an anatomical lesion with ~50% of them are malignant. Malignant melanoma commonly metastasizes to the small bowel; however, melanoma causing intussusception is rare. We describe a 57-year-old lady with a history of surgically treated malignant melanoma in her nasal cavity who came with an ambiguous intestinal obstruction. Computed tomography reported ileal-ileal intussusception, which was surgically removed via emergency open laparotomy and bowel resection. Intraoperatively the intussusception was 110 cm from the ileo-cecal valve with multiple palpable lymph nodes. Histopathology confirmed the origin as malignant melanoma with lymphovascular invasion. Our literature review found the mean prevalence of intussusception secondary to melanoma was 6.924% (SD ± 5.155). Minimally invasive techniques are reported non-inferior to open laparotomy. We argue that the open technique can provide informed decisions for adequate resection of affected bowel and lymphatic drainage.
One anastomosis gastric bypass (OAGB), considered an alternative to Roux-en-Y gastric bypass, is becoming an increasingly common procedure. It shows excellent results in terms of weight reduction and remission of metabolic disease. Among the advantages of OAGB is the lack of internal hernia due to the absence of jejuno-jejunal anastomosis. However, internal herniation in OAGB is not impossible, and multiple cases have been mentioned in the literature. We describe a laparoscopic revisional surgery of internal hernia in a patient with a 2-month history of OAGB.
Syndrome of inappropriate anti-diuretic hormone (SIADH) can be presented as a paraneoplastic syndrome in primary malignancies involving the lung and brain. However, the development of SIADH in primary thymic carcinoma is poorly documented. We report a case of an elderly, with an initial presentation of symptomatic persistent hyponatremia as a paraneoplastic syndrome of SIADH with an incidental finding of anterior mediastinal mass confirmed on imaging. Further investigations are consistent with the diagnosis of poorly differentiated locally advanced thymic carcinoma with lung infiltration (T3N1Mx). The patient underwent an En-bloc total thymectomy and subsequently completed adjuvant chemotherapy and further follow-up showed a complete resolution of hyponatraemic SIADH. In conclusion, SIADH may be presented as a paraneoplastic syndrome in primary thymic carcinoma and early detection of thymic malignancy is paramount to ensure early diagnosis and prognostication.
Carotid body tumour (CBT) is the most common paraganglioma of the head and neck and may compromise neurovascular structures such as carotid vessels, and cranial nerves. Intracranial extension from the mass is possible if left untreated. The main treatment for CBT is surgical resection albeit extremely challenging due to tumour hypervascularity and its relationship to the carotid artery. A bilateral CBT, however, is a rare occurrence. Herein, we present a case of a man who presented to us with bilateral painless and palpable neck mass. He underwent staged bilateral CBT excision and it was complicated with left hypoglossal nerve palsy, which recovered over time.