Journal of Surgery

The natural history of typhoid fever poses both a diagnostic and a therapeutic challenge. Awareness of the clinical features of the primary presentation and of the complications are pivotal to early diagnosis. Typically, aggressive supportive care is all that is needed. However abdominal complications do occur and proper surgical care is required to lower morbidity and mortality.

Introduction: The extent of axillary lymph node involvement is one of the most important prognostic markers in patients of breast cancer. However, axillary dissection is associated with significant morbidity. The intra-operative sentinel node biopsy (SNB) provides a basis for omitting the routine axillary clearance however; use of in-house frozen section histopathology is required in order to substitute later. We report the use of in vitro high resolution magic angle proton magnetic resonance spectroscopy (HRMAS) for assessing the axillary nodal status with increased sensitivity.

Methods: Freshly removed axillary lymph nodes (n=17) obtained during sentinel node biopsy from 17 different patients were bisected. One segment of the bisected node was snap frozen and transported to HRMAS laboratory and was blindly subjected to 400 MHz high resolution magic angle proton magnetic resonance spectroscopy. The other portion was sent for frozen section biopsy. The tissues specimens used for HRMAS analysis and remaining portion of bisected node were then formalin fixed, paraffin embedded and sent for histo-pathological examination in separate vials. The metabolic profiles of these nodes were correlated with the routine histo-pathogical findings.

Results: On histo-pathological examination, 7 nodes were found to be positive for metastasis were as 10 nodes were negative. The spectra of nodes (n=7) found to be positive for malignant cells were exclusively dominated by signals from choline, choline containing compounds and lactate in the spectral region of 3.2 ppm and 4.12 ppm respectively. Overall the sensitivity and specificity of HRMAS in the present study was 100%.

Conclusion: Metastatic and non-involved lymph nodes in breast cancer can be accurately distinguished based on its metabolic profile. The technique of high resolution magic angle proton magnetic resonance spectroscopy can be utilized in enhancing the sensitivity and specificity of sentinel node biopsy and may replace frozen section histopathology

We report the case of a 40-year-old man who admitted to our department because of progressive increasing abdominal girth and weight loss. CT scan showed a huge retrorectal tumor. The mass was totally excised by laparotomy. At five years, the patient was doing well with disease free. Tumors occurring in the retrorectal space are rare; we report herein the first case of a myxoid fibrosarcoma of retrorectal space.

Accidental corrosive ingestion is a common occurrence in developing nations. In most of the cases these agents damage the oesophagus and stomach. Isolated injury of pylorus of stomach has a relatively low incidence. We report such a case of accidental ingestion of corrosive acid, which resulted in isolated stenosis of the pyloric antrum. The diagnosis was confirmed by Barium meal and endoscopy. The patient underwent gastro jejunostomy and recovered well after the surgery. A brief discussion of mechanism of corrosive injury, clinical features, investigations and management follows.

We report the case of a 46-year-old woman, without any known systemic disease in the past, a history of car accident two months earlier with fracture of the left arm and the jaw. She presented to a local hospital, with prolonged precordial pain of ON/OFF occurrence, where acute coronary syndrome (ACS) was diagnosed and treated with conventional (aspirin, clopidegrel, β-blockers, heparin) treatment. She was then transferred to our hospital for cardiac catheterization. Coronary angiography showed normal coronary arteries, a moving filling defect was visible in the ascending aorta. An immediate transesophageal echocardiography revealed a free floating mass attached to the left cusp of the aortic valve .and occluding the left main coronary trunk, a trace of aortic valve regurgitation. The patient was hemodynamically unstable. Urgent operation was carried on and resection of the mass was done.

Introduction: The soft-tissue defects with bone exposal at the level of the shank raises issues in choosing the optimal surgical solution of coverage, since the locoregional muscular flaps assayed from this level are limited as number. In the introduction we present the muscular locoregional flaps most used in practice for solving the defects from the anterointernal region of the shank in the order of frequency.

Case report: We exemplify the therapeutical solutions applied in a case of crush syndrome of young men of 23 years old. A hemisolear medial flap, a flexor digitorum longus flap and a split-thickness skin graft were done. Kinethotherapy was part of the recovery treatment.

Results: Follow-up at 2 years confirmed very good functional outcomes with almost complete motor function of the lower limb.

Anaplastic thyroid carcinoma presents as an extremely localy invasive neck mass while metastases in the thyroid are most commonly described as small, indolent, solitary nodules usually originating from kidney, breast, lungs and skin tumors. We report the case of a 74-year old male patient illustrating the difficulties of differential diagnosis between an anaplastic thyroid carcinoma and a thyroid metastasis of a peripheral cholangiocarcinoma in a cirrhotic patient diagnosed and operated for a locally advanced thyroid tumor. The history, clinical and imagistical features strongly pleaded for the diagnosis of anaplastic thyroid carcinoma presumably with liver metastases, also supported by the rapid recurrence following total thyroidectomy. Immunohistochemical tests showed a malignant carcinomatous proliferation with anaplastic prophile. Positive immunochemical staining for cytokeratin AE1/AE3, CK7 and negative CK20, AFP, CD15, CD30, CD5, TTF1 and thyroglobulin directed the possible diagnosis toward a secondary thyroid tumor from a peripheral cholangiocarcinoma. Immunohistochemical tests showed a malignant carcinomatous proliferation with anaplastic prophile. Positive immunochemical staining for cytokeratin AE1/AE3, CK7 and negative CK20, AFP, CD15, CD30, CD5, TTF1 and thyroglobulin directed the possible diagnosis toward a secondary thyroid tumor from a peripheral cholangiocarcinoma. A CT-guided percutaneous hepatic punction biopsy was planned but the patient presented an ischemic stroke with fatal outcome. In conclusion, in spite of surgical treatment the rapid recurrent thyroid cancer either primary or metastatic had a poor prognosis with fatal outcome mainly in the presence liver cirrhosis and cardio-vascular co-morbidities.

Cervical cancer is an aggressive malignancy with a high tendency of invasion of the surrounding organs and also with capacity to give birth to metastases on both lymphatic and hematogenous routes. Cases who present distant metastases at the moment of diagnosis are generally referred to the medical oncologist than to the surgeon; however increasing reports on the benefit of liver surgery in non-colorectal non-neuroendocrine liver metastases have decreased the general reluctance to perform radical visa surgery on such cases. We present the case of a 53 years old female diagnosed with cervical cancer and liver metastases in which a radical resection was performed with good oncologic outcomes.

Background: Esophageal leiomyomas are the most common benign esophageal tumor, originating in the smooth muscle of the esophagus. Patients may accuse dysphagia, epigastric pain, but in 50% of cases are asymptomatic. Paraclinical exams used to highlight the esophageal tumor are esophageal and stomach barium swallow, esophagoscopy, chest CT scan, endoscopic ultrasonography. Thoracoscopic enucleation in recent years has gained many followers.

Case Report: We present herein the case of 43 years old patient admitted in our department for thoracic trauma; the CT scan revealed a tumor in the middle third of the esophagus suggestive for a leiomyoma. Upper GI endoscopy showed an extrinsic compression in the middle third of the esophagus, without mucosal lesions, and esophageal barium swallow showed a slight narrowing of the lumen at this level. Given the findings suggestive of a benign esophageal tumor, possible esophageal leiomyoma, thoracoscopic approach was chosen. We performed a thoracoscopic enucleation with uneventful postoperative follow-up. Histopathology confirmed the diagnosis of esophageal leiomyoma.

Conclusions: Thoracoscopic enucleation is a feasible method to treat esophageal leiomyomas.

Background: Myelolipoma is a rarely encountered, adrenal incidentaloma diagnosed on the basis of its radiological features.

Aim: To describe a rare presentation with dual pathology.

Case presentation: Our patient, a 40-year-old lady presented with menorrhagia along with a large palpable uterine fibroid. Abdominal CECT detected a large, eight centimeter, left adrenal myelolipoma. After other possibilities were ruled out she underwent left adrenalectomy. Histopathology of the specimen revealed features of myelolipoma. She had an uneventful recovery and doing well now at six months follow up.

Conclusion: We present herewith a case of this uncommon tumour with dual pathology and discuss the clinical radiological and pathological features of adrenal myelolipoma.