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Cureus Jan 2023The spleen is typically located in the left upper quadrant and is held in position by the suspensory ligaments, which include the gastrosplenic ligament, the splenorenal...
The spleen is typically located in the left upper quadrant and is held in position by the suspensory ligaments, which include the gastrosplenic ligament, the splenorenal ligament, and the phrenicocolic ligament. Abnormalities within these ligaments result in the mobility of the spleen, so it may be located in the pelvis or iliac region, which is termed a wandering spleen. We present a case of a middle-aged man who presented to the emergency department with generalized abdominal pain and diffuse guarding and tenderness. The patient had a previous history of peptic ulcer disease and multiple emergency department visits for gastritis. Given the assumed diagnosis of perforated viscus, the patient underwent a computed tomography scan that demonstrated the absence of the spleen in its usual location and showed an ectopic pelvic spleen. The patient underwent successful surgical treatment with splenopexy. The wandering spleen is a rare medical condition that presents a clinical diagnostic challenge and requires a high index of suspicion. Despite its rarity, the wandering spleen should be considered in patients with recurrent abdominal pain.
PubMed: 36741617
DOI: 10.7759/cureus.33246 -
Journal of Digital Imaging Feb 2020The volume of pelvic hematoma at CT has been shown to be the strongest independent predictor of major arterial injury requiring angioembolization in trauma victims with...
The volume of pelvic hematoma at CT has been shown to be the strongest independent predictor of major arterial injury requiring angioembolization in trauma victims with pelvic fractures, and also correlates with transfusion requirement and mortality. Measurement of pelvic hematomas (unopacified extraperitoneal blood accumulated from time of injury) using semi-automated seeded region growing is time-consuming and requires trained experts, precluding routine measurement at the point of care. Pelvic hematomas are markedly variable in shape and location, have irregular ill-defined margins, have low contrast with respect to viscera and muscle, and reside within anatomically distorted pelvises. Furthermore, pelvic hematomas occupy a small proportion of the entire volume of a chest, abdomen, and pelvis (C/A/P) trauma CT. The challenges are many, and no automated methods for segmentation and volumetric analysis have been described to date. Traditional approaches using fully convolutional networks result in coarse segmentations and class imbalance with suboptimal convergence. In this study, we implement a modified coarse-to-fine deep learning approach-the Recurrent Saliency Transformation Network (RSTN) for pelvic hematoma volume segmentation. RSTN previously yielded excellent results in pancreas segmentation, where low contrast with adjacent structures, small target volume, variable location, and fine contours are also problematic. We have curated a unique single-institution corpus of 253 C/A/P admission trauma CT studies in patients with bleeding pelvic fractures with manually labeled pelvic hematomas. We hypothesized that RSTN would result in sufficiently high Dice similarity coefficients to facilitate accurate and objective volumetric measurements for outcome prediction (arterial injury requiring angioembolization). Cases were separated into five combinations of training and test sets in an 80/20 split and fivefold cross-validation was performed. Dice scores in the test set were 0.71 (SD ± 0.10) using RSTN, compared to 0.49 (SD ± 0.16) using a baseline Deep Learning Tool Kit (DLTK) reference 3D U-Net architecture. Mean inference segmentation time for RSTN was 0.90 min (± 0.26). Pearson correlation between predicted and manual labels was 0.95 with p < 0.0001. Measurement bias was within 10 mL. AUC of hematoma volumes for predicting need for angioembolization was 0.81 (predicted) versus 0.80 (manual). Qualitatively, predicted labels closely followed hematoma contours and avoided muscle and displaced viscera. Further work will involve validation using a federated dataset and incorporation into a predictive model using multiple segmented features.
Topics: Deep Learning; Hematoma; Humans; Pelvis; Tomography, X-Ray Computed
PubMed: 31172331
DOI: 10.1007/s10278-019-00207-1 -
BMC Women's Health Jun 2022Primary clear cell adenocarcinoma of the urethra is extremely rare, reported only in single case reports, and its histological origin is not clear. There is no standard... (Review)
Review
BACKGROUND
Primary clear cell adenocarcinoma of the urethra is extremely rare, reported only in single case reports, and its histological origin is not clear. There is no standard treatment for CCAU at present, and surgery is still the main treatment for CCAU without distant metastasis.
CASE PRESENTATION
A 67-year-old female complained of gross hematuria with frequent micturition and urgency. No urethral diverticulum was found by cystoscopy or MRI, and the mass grew around the urethra. Urethral and anterior pelvic viscera resection was performed. Clear cell adenocarcinoma was confirmed by immunohistochemistry after the operation, and no recurrence or metastasis was found after one year of follow-up.
CONCLUSION
CCAU is very rare, and most cases originate from the urethral diverticulum and some may also originate from tissues around the urethra. For CCAU patients without distant metastasis, the main treatment is still surgery, and radiotherapy and chemotherapy can be performed for patients with distant metastasis. Gene detection may provide guidance for the precise chemotherapy of CCAU.
Topics: Adenocarcinoma, Clear Cell; Aged; Diverticulum; Female; Humans; Magnetic Resonance Imaging; Urethral Neoplasms; Urinary Tract
PubMed: 35751118
DOI: 10.1186/s12905-022-01835-6 -
Diseases of the Colon and Rectum Nov 2023Salvage surgery is the only potentially curative treatment option for recurrent squamous cell carcinoma of the anus. Where adjacent pelvic viscera, soft tissues, and...
BACKGROUND
Salvage surgery is the only potentially curative treatment option for recurrent squamous cell carcinoma of the anus. Where adjacent pelvic viscera, soft tissues, and bone are involved, pelvic exenteration with a wide perineal excision may be required to ensure clear surgical margins and increase the likelihood of long-term survival.
OBJECTIVE
To report oncological, morbidity, and quality-of-life outcomes of pelvic exenteration for anal squamous cell carcinoma.
DESIGN
Cohort study with retrospective analysis of prospectively collected data.
SETTINGS
This study was conducted at a high-volume pelvic exenteration center.
PATIENTS
Those who underwent pelvic exenteration for anal squamous cell carcinoma between 1994 and 2022.
MAIN OUTCOME MEASURES
Local recurrence-free and overall survival, intraoperative and postoperative complication rates, R0 resection rate, and long-term quality-of-life outcomes.
RESULTS
Of 958 patients who underwent pelvic exenteration, 66 (6.9%) had anal squamous cell carcinoma. Thirty-two patients (48.5%) were male and the median age was 57 years (range, 31-79). Ten patients (15%) had primary anal squamous cell carcinoma, 49 (74%) had a recurrent tumor, and 7 (11%) had a re-recurrent tumor. Twenty-two patients (33%) and 16 patients (24%) had a major complication and unplanned return to the operating theater, respectively. Of the 62 patients who underwent pelvic exenteration with curative intent, 50 (81%) had R0 resection, and the 5-year overall and local recurrence-free survival rates were 41% and 37%, respectively. R0 resection was associated with a higher 5-year overall survival (50% vs 8%, p < 0.001). The mental health component scores and several individual quality-of-life domains presented improved trajectories postoperatively (all p values <0.05).
LIMITATIONS
The generalizability of the findings outside specialist pelvic exenteration centers may be limited.
CONCLUSIONS
Morbidity, long-term survival, and quality-of-life outcomes after pelvic exenteration for anal squamous cell carcinoma are comparable to published outcomes of pelvic exenteration for other tumor types.
EXENTERACIN PLVICA POR CARCINOMA EPIDERMOIDE DE ANO RESULTADOS ONCOLGICOS, DE MORBILIDAD Y DE CALIDAD DE VIDA
ANTECEDENTES:La cirugía de rescate es la única opción de tratamiento potencialmente curativa para el carcinoma de células escamosas del ano recurrente. Cuando están involucradas vísceras pélvicas, tejidos blandos y huesos adyacentes, puede ser necesaria una exenteración pélvica con una escisión perineal amplia para asegurar márgenes quirúrgicos claros y aumentar la probabilidad de supervivencia a largo plazo.OBJETIVO:Informar sobre los resultados oncológicos, de morbilidad y de calidad de vida de la exenteración pélvica por carcinoma anal de células escamosas.DISEÑO:Estudio de cohortes con análisis retrospectivo de datos recogidos prospectivamente.ENTORNO CLINICO:Este estudio se realizó en un centro de exenteración pélvica de alto volumen.PACIENTES:Aquellos que se sometieron a exenteración pélvica por carcinoma anal de células escamosas entre 1994 y 2022.PRINCIPALES MEDIDAS DE VALORACIÓN:Supervivencia global y libre de recidiva local, tasas de complicaciones intraoperatorias y posoperatorias, tasa de resección R0 y resultados de calidad de vida a largo plazo.RESULTADOS:De 958 pacientes que se sometieron a exenteración pélvica, 66 (6,9%) tenían carcinoma anal de células escamosas. 32 pacientes (48,5%) eran varones y la mediana de edad fue de 57 años (rango 31-79). 10 pacientes (15%) tenían carcinoma anal primario de células escamosas, 49 (74%) tenían un tumor recurrente y 7 (11%) tenían una segunda recurrencia. 22 (33%) y 16 pacientes (24%) tuvieron una complicación mayor y regreso no planificado al quirófano, respectivamente. De los 62 pacientes que se sometieron a una exenteración pélvica con intención curativa, 50 (81%) tuvieron una resección R0, las tasas de supervivencia global y libre de recidiva local a los 5 años fueron del 41% y el 37%, respectivamente. La resección R0 se asoció con una mayor supervivencia general a los 5 años (50% frente a 8%, p < 0,001). Las puntuaciones del componente de salud mental y varios dominios de calidad de vida individuales presentaron trayectorias mejoradas después de la operación (todos los valores de p < 0,05).LIMITACIONES:La generalización de los hallazgos fuera de los centros especializados en exenteración pélvica puede ser limitada.CONCLUSIONES:Los resultados de morbilidad, supervivencia a largo plazo y calidad de vida después de la EP para el carcinoma anal de células escamosas son comparables a los resultados publicados de la exenteración pélvica para otros tipos de tumores. (Traducción-Dr. Ingrid Melo ).
PubMed: 37493254
DOI: 10.1097/DCR.0000000000002919 -
Magyar Sebeszet Dec 2022A sixty-five-year-old female patient underwent surgery for severe gastrointestinal symptoms, following an alarming CT image. Laparotomy revealed irresectable gastric...
CASE REPORT
A sixty-five-year-old female patient underwent surgery for severe gastrointestinal symptoms, following an alarming CT image. Laparotomy revealed irresectable gastric cancer and peritoneal carcinosis. Palliative gastro-jejunostomy and ileo-descendostomy were performed. The endoscopic diagnosis - linitis plastica - and the intraoperative macroscopic appearance matched and agreed on the histologically presumed shigillocellular carcinoma. Three years following the initial abdominal symptoms, histological samples taken from newly detected cutaneous metastases which developed during oncological palliative treatment verified occult lobular breast carcinoma. Histological revision of the sample taken from abdominal exploration confirmed the latter diagnosis. The hormone receptor positive, human epidermal growth factor receptor-2 negative malignancy showed very good regression for the palliative hormone treatment.
DISCUSSION
About ten percent of breast cancer cases are lobular carcinomas, which are more often multicentric, bilateral, occult and have a propensity to metastasize to serous membranes, abdominal and pelvic viscera. Due to the increasing survival of breast cancer patients, the number of abdominal metastases of breast cancer is expected to increase. Histological confirmation is indispensable even in case of advanced abdominal malignancies, especially in the case of an unusual medical history. The currently rare case demonstrates the need for multidisciplinary cooperation in all diagnostic and therapeutic fields of breast cancer.
Topics: Female; Humans; Aged; Carcinoma, Lobular; Linitis Plastica; Breast Neoplasms; Stomach Neoplasms
PubMed: 36515915
DOI: 10.1556/1046.2022.40003 -
International Journal of Surgery Case... May 2022Internal hernias are a rare phenomenon, and even rarer is a herniation through the foramen of Winslow. The clinical presentation of patients with an internal hernia is...
INTRODUCTION
Internal hernias are a rare phenomenon, and even rarer is a herniation through the foramen of Winslow. The clinical presentation of patients with an internal hernia is often vague and difficult to diagnose clinically. If internal hernias go undiagnosed and untreated, patients can develop bowel compromise leading to a high morbidity and potential mortality. Radiologic imaging is helpful in bringing the diagnosis to the forefront of the clinicians mind, but the diagnosis is often made intra-operatively.
PRESENTATION OF CASE
An eighty-one year old female presenting with a few months of vague abdominal symptoms who was found to have a cecal bascule internally herniating through the foramen of Winslow was treated successfully with surgical intervention.
DISCUSSION
Internal hernias occur when there is a protrusion of a viscera through the peritoneum or mesentery and confined within the abdominal cavity. Internal hernias are classified according to location and vary from paraduodenal, transmesenteric, and pelvic to name a few. Hernias through the foramen of Winslow are a rare subset, and were the internal hernia found in our patient intra-operatively. Our patient's clinical presentation was vague with generic abdominal complaints and radiologic imaging was inconclusive for a definitive diagnosis. However, prompt surgical intervention resulted in a good outcome for our patient.
CONCLUSION
Internal hernias, to be diagnosed and treated promptly, require a high index of suspicion from a clinician based on clinical presentation and radiologic imaging. These patients belong in the operating room, and interventions are directed based on the anatomical findings intra-operatively.
PubMed: 35658294
DOI: 10.1016/j.ijscr.2022.107123 -
International Journal of Surgery Case... Jun 2021Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized...
INTRODUCTION
Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. It can be associated with abdominal andthoracic lesions, particularly cardiac, which can be life-threatening.
MATERIALS AND METHODS
Our work is a retrospective case report with a descriptive aim concerning a patient operated for a post-traumatic diaphragmatic rupture within the department of general surgery of CHU Ibn Rochd Casablanca. This work has been reported in line with the SCARE 2020 criteria (17).
CASE PRESENTATION
A 60-year-old patient was admitted to the visceral surgical emergency department following a work accident (crushing between two carts) causing a thoraco-abdominal impact point trauma without initial loss of consciousness, nor externalized digestive hemorrhage or associated signs, but with a general condition alteration. The patient was conscious, dyspneic with a blood pressure of 100/50 mmHg and afebrile. Physical examination showed diffuse abdominal sensibility. The thoraco-abdomino-pelvic CT scan revealed the presence of a left thoracic hernia with gastric, colic and epiploic contents through a lateral defect of the left diaphragmatic dome. The decision was to directly send the patient to the operating room. Exploration found a large left diaphragmatic breach of 20 cm, a denudation of the pericardia, a medium-abundant hemoperitoneum and a hematoma of the right mesocolon. The procedure consisted of right hemicolectomy with ileocolic anastomosis, treatment of a diaphragmatic breach with a 2-silk raphia, thoracic drainage with a Joly drain, pericardial drainage with a Joly drain, pre-anastomotic drainage with 2 delbet slides, drainage of the Douglas and left subthreshold with 2 Salem catheters. The post-operative follow-up was simple.
DISCUSSION
Diaphragmatic rupture is a rare and difficult to diagnose condition. Traumatic diaphragmatic rupture (TDR) was found in 0.4% of all traumatized patients and in 1.9% of blunt trauma. Associated lesions of the spleen, liver and/or lungs were found in more than 30% of cases, with an overall mortality rate of 26.8% (1). Pericardial rupture following blunt chest trauma is rare and associated with a high mortality rate ranging from 30% to 64% (9). The physiopathology of this type of injury is not well understood, but the most accepted hypothesis describes an increase in intra-abdominal pressure due to a blunt creating a sufficiently high-pressure gradient between the chest and the abdomen to cause a diaphragmatic rupture. The common clinical symptoms of a diaphragmatic rupture are a marked respiratory distress and diffuse abdominal pain but it can be asymptomatic. Medical imaging exams visualize the ascended organs but it's more difficult to visualize the rupture itself. The chest X-ray is currently the first examination to be requested (4) and also helps in the diagnosis of injuries and diaphragm rupture (13). Surgical treatment includes the reduction of any visceral hernia, repair of the diaphragm and restoration of circulation, breathing and digestive functions. Laparotomy is generally used because of the complete exploration of the abdominal viscera, although it is easier to reduce herniated tissue and repair the diaphragm.
CONCLUSION
Diaphragmatic rupture with denudation of the heart is rare with poor prognosis and requires emergency surgery with close postoperative monitoring in the intensive care setting.
SUMMARY
Post-traumatic diaphragmatic rupture is a lesion of variable severity. It is a rare and difficult to diagnose pathology, it has been found in 0.4% of all traumatized patients and in 1.9% of blunt traumas. The lesions are more frequent in the left diaphragmatic dome compared to the right one, and exceptionally bilateral. Pericardial rupture following blunt chest trauma is rare and associated to a high mortality rate. It is often unrecognized and goes unnoticed in the acute phase. The most common clinical symptoms of diaphragmatic ruptures are respiratory distress and diffuse abdominal pain, as it can be asymptomatic. Its diagnosis is essentially radiological using CT scan, and requires emergency surgical treatment as soon as the diagnosis is suspected, in order to avoid the dreaded complications. Traumatic diaphragmatic rupture remains a diagnostic and therapeutic challenge. We report the case of a patient who presented a post-traumatic diaphragmatic rupture with pericardial damage operated in the visceral emergency department at the Ibn Rochd Hospital c in Casablanca, Morocco.
PubMed: 34029846
DOI: 10.1016/j.ijscr.2021.105970 -
EJVES Vascular Forum 2020Nutcracker syndrome refers to the clinical manifestations of left renal vein compression between the superior mesenteric artery and the abdominal aorta, causing urinary...
INTRODUCTION
Nutcracker syndrome refers to the clinical manifestations of left renal vein compression between the superior mesenteric artery and the abdominal aorta, causing urinary changes and low back pain.
REPORT
A 44 year old woman presented with low back and pelvic pain. Following the diagnosis of nutcracker syndrome, she underwent endovascular treatment with renal vein stent placement; however, the patient continued to complain of pain. Further examinations revealed left renal vein compression by the portal vein. The patient underwent a second procedure; however, improvement was temporary and her pain returned. Further investigation revealed previously undetected nephroptosis and hyperelasticity. A diagnosis of Ehlers-Danlos syndrome made, possibly explaining the mobility of viscera and unusual compression of the left renal vein by the portal vein.
CONCLUSION
Ehlers-Danlos syndrome can cause nutcracker syndrome and may give rise to visceral pain of mixed origin.
PubMed: 33078146
DOI: 10.1016/j.ejvsvf.2020.02.005 -
BMC Urology Jan 2021Although several distribution patterns of periprostatic neurovascular bundles have been proposed, variant dissection technique based on these patterns still confused...
BACKGROUND
Although several distribution patterns of periprostatic neurovascular bundles have been proposed, variant dissection technique based on these patterns still confused surgeons. The aim of this study was to describe the periprostatic neurovascular bundles and their relationship with the fascicles around prostate and provide the accurate morphologic knowledge of periprostatic tissue for prostate operation.
METHODS
The pelvic viscera were obtained from 26 adult male cadavers. They were embedded in celloidin and cut into successive slices. The slices were explored with anatomic microscopy. 3-Dimensional reconstruction was achieved with celloidin sections and series software.
RESULTS
The prostatic capsule which surrounded the dorsal, bilateral aspect of the prostate was attached ventrally to anterior fibrous muscular stroma (AFMS). The lower part of the striated sphincter completely embraced the urethral; the upper part of this muscle covered the lower ventral surface of prostate. The upper ventral surface of prostate is covered by the circular muscle of detrusor. The levator fascia and the capsule adhered on the most convex region of the lateral prostate, but separated on the other region. The pelvic neurovascular bundles (PNVB) divided into the anterior and posterior divisions. The anterior division continued as dorsal vascular complex (DVC). The distal part of DVC entered into penile hilum. The posterior division continued as neurovascular bundles, and then as the cavernous supply (CS). The distal part of CS joined into pudendal neurovascular bundles.
CONCLUSIONS
The capsule and AFMS formed a pocket like complex. There were anterior and posterior neurovascular approaches from PNVB to penile hilum.
Topics: Aged; Aged, 80 and over; Blood Vessels; Cadaver; Collodion; Humans; Male; Middle Aged; Nervous System; Prostate
PubMed: 33407368
DOI: 10.1186/s12894-020-00778-0 -
Polski Przeglad Chirurgiczny Apr 2022<b>Introduction:</b> Perineal hernia (PH), also termed pelvic floor hernia, is a protrusion of intraabdominal viscera into the perineum through a defect in...
<b>Introduction:</b> Perineal hernia (PH), also termed pelvic floor hernia, is a protrusion of intraabdominal viscera into the perineum through a defect in the pelvic floor. </br></br> <b>Aim:</b> The study was conducted to evaluate the cases of perineal hernia resulting as a complication of abdominoperineal resection (APR) of rectal cancer. </br></br> <b> Material and methods:</b> 30 cases from 24 articles published in reputable peer reviewed journals were evaluated for eight variables including [I] patient age, [II] gender, [III] time since APR, [IV] clinical presentation, [V] approach to repair, [VI] type of repair, [VII] presence/absence of pelvic adhesions [VIII] complications. </br></br> <b>Results:</b> There was a total of 30 cases (18 males and 12 females) with a mean age of 71.5 years. The time of onset of symptoms ranged from 6 days to 12 years. Perineal lump with pain was the chief presenting feature followed by intestinal obstruction. Different approaches were adopted to repair by various methods. </br></br> <b>Conclusions:</b> Perineal hernia as a complication of abdominoperineal resection is reported increasingly nowadays, as the approach to management of rectal cancer has gradually got shifted from open to minimally invasive in recent years. There is a need to spread awareness about this condition, so that it is actively looked for, during the postoperative follow-up. Management is surgical repair; the approach and type of repair should be individualized.
Topics: Female; Male; Humans; Aged; Proctectomy; Rectal Neoplasms; Intestinal Obstruction; Abdominal Cavity; Hernia
PubMed: 36468514
DOI: 10.5604/01.3001.0015.7677