Giant Adrenal Lipoma with Hemorrhage Requiring Extended Surgical Resection

Adrenal lipoma is a rare, benign tumor, reported to account for 0.7% of primary adrenal tumors. A 69-year-old man presented with left lateral abdominal pain. Computed tomography (CT) was performed, and a huge, irregularly shaped retroperitoneal tumor of uneven internal density was identified, with the border between the tumor and the pancreas and kidney being unclear. Active hemorrhage was also depicted. The tumor consisted mainly of fat, with the exception of the hematoma; it measured 200 mm; and the boundary between it and nearby organs, such as the pancreas, was unclear. Despite angiography being performed twice, the responsible vessel was not identified. Thus, for the purpose of both diagnosis and treatment, we resected the tumor, and considering the possibility of a malignancy, such as liposarcoma, we also resected the pancreatic body and tail and the spleen. The final histopathologic diagnosis was benign adrenal lipoma with hemorrhage, with no invasion to surrounding tissue. Hemorrhage within an adrenal tumor is rare. Most adrenal lipomas are small “incidentalomas” and asymptomatic. With development of a large adrenal lipoma comes the possibility of hemorrhage along with the possibility of features suggestive of malignancy. We encountered a giant adrenal lipoma with hemorrhage and, because of the aforementioned features, performed extended surgical resection, seen in retrospect as oversurgery. The widespread use of CT has led to an increased number of reported cases of adrenal lipoma. We anticipate an accumulation of case reports, which will allow for development of an appropriate treatment algorithm.

Lessons learned from hybrid surgery with preoperative coil embolization for an aberrant artery in pulmonary sequestration

Background The optimal management of an aberrant artery in pulmonary sequestration (PS) is controversial. Several studies have shown that hybrid surgery with preoperative coil embolization for an aberrant artery and surgical resection of the sequestrated lung is effective. However, there are no clear indications for the procedure. Case presentation A 68-year-old woman without any complaints was diagnosed with right intralobar PS, which was supplied by an aberrant artery from the thoracic aorta, via computed tomography performed during a medical examination. In addition, lung adenocarcinoma was detected over the border between the right upper and middle lobes. Preoperative coil embolization was performed by an interventional radiologist the day before surgery to decrease the risk of severe intraoperative hemorrhage. On the following day, bi-lobectomy of the right upper and middle lobes for lung adenocarcinoma with systemic lymph node dissection and segmentectomy of the sequestrated lung with thoracotomy was performed. Although no active hemorrhage was observed during surgery, the aberrant artery was challenging to dissect using an energy device due to the presence of an intravascular coil. Eventually, the coil stump was exposed, and it was cut with scissors. The postoperative course was uneventful. Conclusions We reported the pitfall of the hybrid surgery for intralobar PS. Preoperative coil embolization can prevent fatal intraoperative hemorrhage. If embolization is performed using a coil for an aberrant artery supplied from the thoracic aorta, where and how to dissect the aberrant artery should be cautiously determined based on preoperative images, with consideration of the presence of an intravascular coil.

Life-threatening hemoptysis accompanied by internal thoracic artery aneurysms in a 28-year-old perinatal woman: a case report

Background Life-threatening hemoptysis presents an immediate diagnostic and therapeutic challenge, especially during the perinatal period. Case presentation A 28-year-old perinatal woman with no significant past medical or surgical history presented with repeating hemoptysis and respiratory failure. Computed tomography revealed a 2.1 × 3.2 cm2 inhomogeneous tumorous lesion in the right superior mediastinum and a right main bronchus obstruction along with atelectasis of the right lung. Bronchoscopy showed a tumorous protrusion blocking the right main bronchus with active hemorrhage, and malignancy was suspected. Bronchial artery embolization (BAE) was performed to control the bleeding. The arteriogram revealed tortuosity, dilation and hypertrophy of the right bronchial arteries and aneurysms of the internal thoracic artery (ITA). The bleeding completely stopped after BAE. Bronchoscopy was performed again to remove residual blood clots. The patient recovered soon after the procedure and was discharged. Conclusions Life-threatening hemoptysis concomitant with ITA aneurysms, which may have a misleading clinical diagnosis and treatment options, has not been reported previously in perinatal women. BAE could be used as a first-line treatment irrespective of the underlying causes.

Sutureless repair and deep sedation for a blow-out type post-infarction left ventricular free wall rupture

A 71-year-old woman who was resuscitated from cardiac arrest after pericardial drainage, was admitted to our hospital. Enhanced computed tomography demonstrated pericardial effusion due to rupture of posterior ventricular myocardium. She underwent emergent surgical repair. A 20-mm tear in the extensively necrotic left ventricular posterior wall and active hemorrhage were identified. Sutureless repair using three sheets of TachoSil (CSL Behring, Tokyo, Japan) and fibrin glue was performed. To reduce ventricular pressure to avoid re-rupture and formation of ventricular aneurysm, deep sedation was followed in the intensive care unit for 2 weeks. The patient returned to her normal daily life and is progressing well for more than 5 months after the surgery.

Automated Spleen Injury Detection Using 3D Active Contours and Machine Learning

The spleen is one of the most frequently injured organs in blunt abdominal trauma. Computed tomography (CT) is the imaging modality of choice to assess patients with blunt spleen trauma, which may include lacerations, subcapsular or parenchymal hematomas, active hemorrhage, and vascular injuries. While computer-assisted diagnosis systems exist for other conditions assessed using CT scans, the current method to detect spleen injuries involves the manual review of scans by radiologists, which is a time-consuming and repetitive process. In this study, we propose an automated spleen injury detection method using machine learning. CT scans from patients experiencing traumatic injuries were collected from Michigan Medicine and the Crash Injury Research Engineering Network (CIREN) dataset. Ninety-nine scans of healthy and lacerated spleens were split into disjoint training and test sets, with random forest (RF), naive Bayes, SVM, k-nearest neighbors (k-NN) ensemble, and subspace discriminant ensemble models trained via 5-fold cross validation. Of these models, random forest performed the best, achieving an Area Under the receiver operating characteristic Curve (AUC) of 0.91 and an F1 score of 0.80 on the test set. These results suggest that an automated, quantitative assessment of traumatic spleen injury has the potential to enable faster triage and improve patient outcomes.

Pedicled Tubular Omental Patch for Tamponade of Transfixing Gunshot Bilobar Liver Injury: A Case Report

Introduction: Liver injuries are frequent in abdominal trauma and may be managed using a variety of methods. The operative management of deep, penetrating wounds generally involves balloon tamponade of the wound tract using a Sengstaken-Blakemore catheter. Case Presentation: A haemodynamically unstable 34-year-old male with multiple thoracoabdominal gunshot wounds was transferred to the operating theatre. At laparotomy, a grade 3 transfixing (through and through) bilobar hepatic wound was discovered with active hemorrhage. Unfortunately, no suitable balloon catheters were available, so, as an alternative, tamponade of the wound tract was successfully achieved using a tubular omental patch. Discussion: Omental patches are commonly used in the management of perforated duodenal ulcers and have been used to prevent recurrence following hepatic cyst de-roofing. To the authors’ knowledge, this is the first description of this technique for the management of penetrating bilobar transfixing hepatic injury. Conclusion: A tubular omental patch may be used to achieve tamponade of deep wounds in penetrating hepatic trauma. This could be a particularly useful technique in resource-poor environments, or where a suitable balloon catheter is otherwise unavailable.

Triple threat: pancreatic cystic lesion presenting with spontaneous hemorrhage is found to harbor three distinct neoplasms

Background Pancreatic serous cystadenoma (SCA) is a benign, cystic lesion with an indolent growth pattern. Complications such as spontaneous hemorrhage or malignant transformation from SCA are extremely rare. Our case report describes an unusual presentation of a patient with a previously diagnosed SCA, made unique by the presence of three separate neoplasms in the final specimen. Case presentation A 74-year-old male with a previous diagnosis of SCA presented emergently with epigastric pain and non-bilious vomiting. Laboratory results were notable for a hemoglobin of 8.3 g/dl. CT scan of the abdomen demonstrated a complex, solid-cystic mass in the pancreatic head with a large hematoma and questionable focus of active hemorrhage. Surgical resection was recommended due to the risk of malignancy, possibility of re-bleeding, and symptoms of severe duodenal compression. Pancreaticoduodenectomy was performed, and final pathology demonstrated three separate neoplasms: serous cystadenoma, intraductal papillary mucinous neoplasm, and neuroendocrine tumor. Conclusion While pancreatic SCA are benign tumors that can be observed safely in the majority of cases, surgical intervention is often indicated in patients with large, symptomatic cysts or when diagnosis is unclear. When undergoing surveillance, it is crucial for both the patient and the care team to be aware of the possibility of rare, but life-threatening complications, such as hemorrhage. Likewise, the possibility of misdiagnosis or concurrent neoplasia should be considered.

Triple Threat; pancreatic cystic lesion presenting with spontaneous hemorrhage is found to harbor three distinct neoplasms.

BackgroundPancreatic serous cystadenoma (SCA) is a benign, cystic lesion with an indolent growth pattern. Complications such as spontaneous hemorrhage or malignant transformation from SCA are extremely rare. Our case report describes an unusual presentation of a patient with a previously diagnosed SCA, made unique by the presence of three separate neoplasms in the final specimen. Case PresentationA 74-year-old male with a previous diagnosis of SCA presented emergently with epigastric pain and non-bilious vomiting. Laboratory results were notable for a hemoglobin of 8.3 g/dl. CT scan of the abdomen demonstrated a complex, solid-cystic mass in the pancreatic head with a large hematoma and questionable focus of active hemorrhage. Surgical resection was recommended due to the risk of malignancy, possibility of re-bleeding, and symptoms of severe duodenal compression. Pancreaticoduodenectomy was performed, and final pathology demonstrated three separate neoplasms: serous cystadenoma, intraductal papillary mucinous neoplasm, and neuroendocrine tumor.Conclusion: While pancreatic SCA are benign tumors that can be observed safely in the majority of cases, surgical intervention is often indicated in patients with large, symptomatic cysts or when diagnosis is unclear. When undergoing surveillance, it is crucial for both the patient and the care team to be aware of the possibility of rare, but life-threatening complications, such as hemorrhage. Likewise, the possibility of misdiagnosis or concurrent neoplasia should be considered.

CLINICAL FEATURES OF GASTROINTESTINAL ULCERATIVE BLEEDING IN ELDERLY PATIENTS COMPLICATED BY CARDIO-VASCULAR PATHOLOGY

The aim: To determine clinical and endoscopical features of gastroduodenal hemorrhages in elderly patients with concomitant cardio-vascular pathology in a way by studying, main indicators of the immune system for drawing up further tactics. Material and methods: The study included 609 patients with ulcerative gastroduodenal bleeding, complicated by cardio-vascular system pathology in 2017-2019 years. The observed patients were distributed into the groups: I – patients, who received treatment according to the standard system of cardiovascular pathology treatment (n=541), II – “double” therapy (n=68). Control group consists of 20 relatively healthy patients were similar to the research group. Results: Blood lost of a big amount and massive blood lost were noticed in 113 (18.56%±1.58) and 121 (19.87%±1.62) patients respectively. Active bleeding (F I) was revealed in 38 patients (6.24%±0.98), a high risk of hemorrhage relapse was determined in 486 patients (79.80%±1.63). Signs of recent hemorrhage were absent in 85 patients (13.96%±1.40). A high level of pro-inflammatory cytokines IL-6, TNF-α and a low activity of the anti-inflammatory mediator IL-10 define the process activity, their long-term circulation in patients with ulcerative hemorrhages of the gastro-intestinal tract are associated with unfavorable prognosis. In 5 cases conditionally-radical surgical interventions were performed. Palliative surgery – 3 patients (р>0.05). Conclusions: The patients of second group (“double therapy”) with big and massive blood loss was 2.7 times higher than similar indices in patients of the first group (standard therapy). The patients who received “double therapy” had 3.3 times more active hemorrhage percentage than the patients who received standard therapy (р<0.05).

Treatment of Post-Evar Aortoduodenal Fistula Without Endograft Excision

An 80 year-old gentleman presented with aortoduodenal fistula 2 months after uncomplicated endovascular aneurysm repair (EVAR). Upon laparotomy and fistula takedown, there was no active hemorrhage from the excluded aneurysm. It was theorized the fistula had originated from an occult type II endoleak which had since thrombosed. The duodenum was repaired primarily; the anterior defect in the aneurysm sac was packed and covered with omentum. The patient recovered uneventfully and remains well after 9 months. This is the first case, to our knowledge, of a post-EVAR aortoduodenal fistula successfully treated without endograft excision.