INTRODUCTIONEctopic spleen is an uncommon clinical entity as splenectomy for treatment of ectopic spleens accounts for less than 0.25% of splenectomies. The most common age of presentation is childhood especially under 1 year of age followed by the third decade of life.PRESENTATION OF CASEThe present report refers to a patient with torsion of a pelvic spleen treated with splenectomy. The patient exhibited a period of vague intermittent lower abdominal pain lasted 65 days followed by a period of constant left lower quadrant pain of increasing severity lasted 6 days. On the first 65 days, vague pain was attributed to progressive torsion of the spleen which resulted in venous congestion. On the last 6 days, exacerbation of pain was attributed to irreducible torsion, infraction of the arterial supply, acute ischemia, strangulation and rupture of the gangrenous spleen. Diagnosis was made by CT which revealed absence of the spleen in its normal position, a homogeneous pelvic mass with no contrast enhancement, free blood in the peritoneal cavity, and confirmed by laparotomy.DISCUSSIONClinical manifestations of ectopic spleen vary from asymptomatic to abdominal emergency. Symptoms are most commonly attributed to complications related to torsion. Operative management, including splenopexy or splenectomy, is the treatment of choice in uncomplicated and complicated cases because conservative treatment of an asymptomatic ectopic spleen is associated with a complication rate of 65%.CONCLUSIONAlthough an ectopic spleen can be easily identified on clinical examination, it is commonly misdiagnosed until the manifestation of complications in adulthood.
Since Meckel's diverticulum (MD) is rarely diagnosed in adults, there is no consensus on what type of procedure to be performed for symptomatic MD and whether to resect or not an accidentally discovered MD. Treatment of symptomatic MD is definitive surgery, including diverticulectomy, wedge, and segmental resection. The type of procedure depends on: (a) the integrity of diverticulum base and adjacent ileum; (b) the presence and location of ectopic tissue within MD. The presence of ectopic tissue cannot be accurately predicted intraoperatively by palpation and macroscopic appearance. When present, its location can be predicted based on height-to-diameter ratio. Long diverticula (height-to-diameter ratio >2) have ectopic tissue located at the body and tip, whereas short diverticula have wide distribution of ectopic tissue including the base. When indication of surgery is simple diverticulitis, diverticulectomy should be performed for long and wedge resection for short MD. When indication of surgery is complicated diverticulitis with perforated base, complicated intestinal obstruction and tumor, wedge, or segmental resection should be performed. When the indication of surgery is bleeding, wedge and segmental resection are the preferred methods for resection. Regarding management of incidentally discovered MD, routine resection is not indicated. The decision making should be based on risk factors for developing future complications, such as: (1) patient age younger than 50 years; (2) male sex; (3) diverticulum length >2 cm; and (4) ectopic or abnormal features within a diverticulum. In this case, diverticulectomy should be performed for long and wedge resection for short MD.
HighlightsPneumatosis intestinalis can be benign or life-threatening.Life-threatening causes are bowel obstruction, perforation, ischemia and severe colitis.Differential diagnosis between life-threatening and benign pneumatosis intestinalis is difficult.Early severity recognition is critical as it would dictate surgical or conservative management.Surgery is needed when worrisome clinical, laboratory and imaging findings are present.
HighlightsSecondary pancreatic tumors are uncommon and account for 2–5% of pancreatic cancer.The most common secondary pancreatic tumor is secondary pancreatic lymphoma.In the setting of pancreatic lymphoma, obstructive jaundice is not the predominant symptom.Key imaging findings of secondary pancreatic lymphoma are lymphadenopathy below left renal vein and absence of bile and pancreatic duct obstruction.When a secondary pancreatic tumor is suspected pathologic confirmation is necessary before decision-making of management.
Bilateral primary spontaneous pneumothorax (BPSP) is a rare condition, accounting for ∼1.6% of spontaneous pneumothoraces. Patients with primary spontaneous pneumothorax have typically low body weight. BPSP in overweight/obese patients is an exceptionally rare event. The present report describes a case of an otherwise-healthy 20-year-old male patient with BMI 29.8 kg/m2 presented to our hospital owing to low-intensity chest pain and shortness of breath 7 days after the onset of symptoms. Plain chest X-ray revealed the presence of bilateral pneumothorax. Chest tubes were inserted on both sides. During hospitalization, a computed tomography demonstrated multiple blebs on the surface of the upper lobes of both lungs. Hereupon, the patient referred to a tertiary center and underwent elective single-stage minimally invasive bilateral video-assisted thoracoscopic surgery. The present case report shows that BPSP in overweight/obese patients is an existing condition.
Background Infectious (mycotic) aneurysms are rare with high mortality and are most commonly found at the distal branches of the middle cerebral artery (MCA). Because aneurysms of the distal MCA are located deep in the Sylvian fissure and are small in size, intraoperative identification and safe clip occlusion of these aneurysms are challenging. Thus, the use of intraoperative imaging and navigation can be beneficial. We describe the use of intraoperative real-time 3D ultrasound “angiography” (3D-iUS) in localizing and occlusion control of a ruptured MCA M3 segment mycotic aneurysm. To our knowledge, its application in the surgery of a ruptured mycotic distal MCA aneurysm is not yet reported.
Clinical Presentation A 54-year-old woman with a history of septic thrombophlebitis treated with long-term antibiotic therapy presented with sudden onset of headaches, dysphasia, and seizures. Computed tomography (CT) revealed subarachnoid hemorrhage in the distal portion of the left Sylvian fissure. Digital subtraction angiography (DSA) showed an aneurysm at the peripheral branch of the M3 segment of the MCA with characteristics of an infectious aneurysm. A microsurgical treatment was decided. 3D-iUS scan showed an aneurysm within the Sylvian fissure at a depth of 5 cm. The aneurysm was clipped and a repeated 3D-iUS scan showed total occlusion of the aneurysm and patency of the parent artery. The intraoperative findings were confirmed with a postoperative DSA.
Conclusion Our case report shows that real-time 3D-iUS, despite its limitations, is an important tool to locate and ascertain the successful clip occlusion of an aneurysm, especially when intraoperative angiography (IA) and indocyanine green (ICG) videoangiography are not available due to low-income settings.
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