Case Reports in Surgery

The case of vascular reconstruction of the superior mesenteric and portal vein confluence using a left renal vein (LRV) graft has been researched in this paper. The patient was a 66-year-old female who presented with features of biliary obstruction. A contrast-enhanced computed tomography scan revealed bile duct dilatation and a common bile duct tumor mass. Four years ago, she underwent stomach resection with subsequent Billroth II gastrojejunostomy due to gastric cancer. After surgical resection, on histopathological and immunohistochemistry examination, a recurrence of previously resected poorly cohesive gastric cancer was found.

Introduction. Mesenteric panniculitis (MP) includes a spectrum of nonspecific fibroinflammatory disorders of unknown aetiology that affects mainly the root of the mesentery. Case Report. A 68-year-old man is incidentally diagnosed with MP during follow-up investigation for a fusiform coeliac artery aneurysm. Four years since the diagnosis, he is completely asymptomatic. After discussing with him and presenting the current evidence, he decided not to proceed with biopsy because the finding was incidental and he is asymptomatic. Moreover, tumour markers were within the normal range. He has been scheduled for annual follow-ups with computerized tomography (CT) scans and tumour markers. Conclusions. MP is a rare chronic fibroinflammatory disease with contradictory evidence regarding its definition and management. Watchful follow-ups with CT scan and tumour markers are recommended for asymptomatic patients.

Background. Hepatocellular adenoma (HCA) is an uncommon solid, solitary, benign liver lesion that develops in an otherwise normal-appearing liver. Hemorrhage and malignant transformation are the most important complications. Risk factors for malignant transformation include advanced age, male gender, use of anabolic steroids, metabolic syndrome, larger lesions, and beta-catenin activation subtype. The identification of higher risk adenomas enables the selection of patients most suitable for aggressive treatment and those who benefit with surveillance, minimizing the risks for these predominantly young patients. Case Presentation. We present the case of a 29-year-old woman with a history of oral contraceptive intake for 13 years, which was sent to evaluation in our Hepato-Bilio-Pancreatic and Splenic Unit because of a large nodular lesion in segment 5 of the liver, compatible with HCA, and was proposed to surgical resection. Histological and immunohistochemical investigation revealed an area with atypical characteristics, suggesting malignant transformation. Conclusions. HCAs share similar imaging characteristics and histopathological features with hepatocellular carcinomas; therefore, immunohistochemical and genetic studies assumes great importance to discriminate adenomas with malignant transformation. Beta-catenin, glutamine synthetase, glypican-3, and heat-shock protein 70 are promising markers to identify higher risk adenomas.

Background. The use of oral or nasal route for enteral feeding is a standard practice in intensive care patients with a safe profile in general. However, complications associated with the insertion of a nasogastric (NGT) or orogastric tube (OGT) are common in the medical literature compared to the removal of such tubes. Case presentation. We presented a 38-year-old male who was involved in a motor-vehicle collision and found with low Glasgow Coma Scale outside his vehicle. He had polytrauma and was intubated—and commenced on enteral feeding via an OGT. Esophageal bezoar developed within a few days around the feeding tube, resulting in significant force being required to remove it, which was complicated by esophageal perforation. The esophageal injury was treated conservatively with uneventful recovery. Discussion and conclusions. Although limited case reports of esophageal enteral feeding bezoar formation do exist in the literature, we believe that this is the first case report of esophageal perforation due to the forceful removal of a wedged OGT secondary to esophageal bezoar formation. Morbidity associated with OGT/NGT is not common and may require a high index of suspicion to be identified. This is especially true if resistance is appreciated while removing the NGT/OGT. Gastroenterology consultation is recommended as early as possible to detect and manage any complications, however, their role was very limited in such stable case. In addition, early computed tomography (CT) can be considered for timely recognition of esophageal perforation. Non-operative management may be considered in stable patients, especially if the leak is in the cervical portion of the esophagus. Finally, prevention is better than cure, so being diligent in confirming NGT/OGT position, both radiologically and by measuring the tube length at the nostril/mouth, is the key to avoid misplacement and complication. This case raises the awareness of physician for such preventable iatrogenic event.

Necrotizing fasciitis travels along the fascial plane and surrounding soft tissue, leading to ischemia and necrosis. Fournier’s gangrene is a type of necrotizing fasciitis invading the deep and superficial planes of the perineal/genital region. It is rapidly progressive in nature and may have life-threatening consequences. Fournier’s often exhibits a misleading clinical presentation and can be mistaken for other conditions, such as hematoma, phlebitis, cellulitis, or septic arthritis. Since the ramifications of delayed diagnosis can be clinically significant, recognition of potential mimics is important to prevent morbidity or mortality. We report a case of Fournier’s gangrene mimicking a second-degree burn, an exceedingly rare presentation.

Metastatic lesions to the breast from extramammary malignant neoplasms are rare and reported account for 0.5–6.6% of all breast malignancies. Distant metastasis of thymoma is even rarer, especially to extrathoracic regions. We reported a woman with invasive malignant thymoma postneoadjuvant and resection of the thymoma, who developed breast metastasis 7 years later. Breast imaging showed high-density lesion with no intralesional microcalcifications and no significant axillary lymphadenopathy. Core biopsy and histopathology proved the lesion to be metastatic thymic carcinoma. Despite rarity, breast lumps with underlying extramammary malignancy should raise the suspicious of breast metastasis.