OV17 LAPAROSCOPIC REPAIR OF A DIAPHRAGMATIC EVENTRATION

Aim Diaphragmatic eventration (DE) is a rare condition affecting 0,05% of general population. DE is the abnormal elevation of a portion of a entire hemidiaphragm due to a lack of muscle or nerve function. It can be congenital or acquired. The most common cause of DE is cardiac surgery. It can be asymptomatic or present mild symptoms as dispnea, palpitations, pneumonia. Material and Methods 61 years old male with medical history of arterial hypertension, DMII, Hyperlipidemia. He had a motor vehicle accident with 6 to 9 left ribs fractures. One month later complained of dyspnea with shortness of air to normal activity. Rx: elevation of left diaphragm. CT scan: elevation of left diaphragm without rupture, passive atelectasis of inferior left lobe of the lung. He initiated respiratory physiotherapy without improvement of the symptoms. 4 months after the accident, we had a stroke with right hemiparesis. This situation produced worsening of the dyspnea. Physiotherapy was reinforced with recuperation of the hemiparesis, but poor improvement of the dyspnea. 10 months after the accident, surgery was indicated for plication of the diaphragm to improve the respiratory function. Results The video shows the radiological exams and the surgery performed. Laparoscopic diaphragmatic plication with a reinforcement with a coated mesh (Uncoated monofilament polypropylene mesh on the anterior side with an absorbable hydrogel barrier). He was discharge 2 days after surgery. The patient improved significantly in his respiratory symptoms an imaging exams. Conclusions Posttraumatic DE must be treated surgically with low morbidity and good functional results.

Combined laparoscopic and thoracoscopic surgical repair of Bochdalek hernia in an adult: a case report

Background Bochdalek hernia is a rare disease in adults. Diaphragmatic hernia in adults has been repaired using minimally invasive surgery through laparoscopy or thoracoscopy. However, the literature regarding the combined use of laparoscopy and thoracoscopy for the repair of Bochdalek hernia is limited. Case presentation A 26-year-old man diagnosed with Bochdalek hernia was managed through combined abdominal and thoracic endoscopic surgery. On laparoscopy, the omentum prolapsed into the left thoracic cavity through the posterolateral area of the left diaphragm. On thoracoscopy, no adhesions of the omentum were seen in the thoracic cavity. The omentum was drawn back to the abdominal cavity, and a 4 × 3-cm hernial orifice was identified. The hernia orifice was repaired through simple closure with sutures laparoscopically. The patient’s postoperative course was uneventful with no recurrences within the first year post-surgery. Conclusion Combined laparoscopic and thoracoscopic surgery is a safe and effective method for Bochdalek hernial repair in adults.

Diaphragmatic Rupture With Left Colon and Spleen Herniation and Small Intestine Injury After Blunt Trauma

Traumatic Diaphragmatic Rupture (TDR) is a rare type of trauma. Small intestine injuries are the third most common type of injury resulting from blunt trauma to abdominal organs. The immediate diagnosis of TDR and bowel injuries is a daunting task. We reported a 53-year-old male patient who was transferred to the hospital by EMS because of a car accident. The chest X-ray showed the left diaphragm elevation. Also, a computed tomography scan revealed that the greater omentum, a portion of the colon, spleen, and stomach were transposed in the hemithorax through a diaphragm rupture. The patient underwent laparotomy and the incidental findings in laparotomy showed bowel injuries. This case was a common cause of traumatic left-sided diaphragmatic rupture and intestinal injury. The suspicion of diaphragmatic rupture and intestinal injury in a patient with multiple traumas contributes to early diagnosis. Surgical repair remains the only treatment for diaphragmatic rupture. The severe injury in a part of the intestine may result in the resection of that part.

A case of primary nonleukemic myeloid sarcoma of the spleen, successfully treated by surgery and hematopoietic stem cell transplantation

Background Myeloid sarcoma (MS) is a rare disease, mostly found in conjunction with acute myelogenous leukemia or other diseases, and primary nonleukemic MS of the spleen is particularly rare. Case presentation We report a 57-year-old male who presented with a spleen mass that was found incidentally, and was enlarged. As a result of various examinations, he was diagnosed with primary MS of the spleen with suspected involvement of the transverse colon, left kidney, pancreatic tail, and left diaphragm. He underwent a total splenectomy, partial pancreatectomy, partial colectomy, left nephrectomy, and left diaphragm partial resection. Histological examination revealed splenic primary MS. Bone marrow biopsy and immunophenotypic flow cytometry revealed no evidence of myeloid leukemia. He underwent umbilical cord blood transplantation, and he is currently living without a sign of recurrence at 10 months after surgery. Conclusions We experienced a very rare case of primary spleen MS that was discovered without a hematologic malignancy. Two cases of surgically resected primary splenic MS have been reported, including the present case.

Life-threatening presentation of a parahiatal hernia after esophagectomy: a case report and review of the literature

A woman presented to our hospital with acute abdominal pain 7 months following an oesophagectomy. A chest X-ray revealed a new elevation of the left diaphragm. CT demonstrated a large left diaphragmatic hernia incarcerated with non-enhancing transverse colon and loops of small bowel. She deteriorated rapidly into obstructive shock and was urgently brought to the operating room for a laparotomy. The diaphragmatic orifice was identified in a left parahiatal position, consistent with a parahiatal hernia. Incarcerated necrotic transverse colon and ischaemic loops of small bowel were resected, and the diaphragmatic defect was closed primarily. Because of haemodynamic instability, the abdomen was temporarily closed, and a second look was performed 24 hours later, allowing anastomosis and definitive closure. Parahiatal hernias are rare complications following surgical procedures and can lead to devastating life-threatening complications, such as an obstructive shock. Expeditious diagnosis and management are required in the acute setting.

Metastatic Adrenocortical Carcinoma Co-Secreting Multiple Steroid Hormones

Background: Adrenocortical carcinoma is a rare disease which may be complicated by co-secretion of multiple steroid hormones. Clinical Case: A 53- year-old female was discovered to have 1 cm left and 1.7 cm right adrenal nodules by Chest CT scan in 2004. She had a follow-up abdominal CT scan in 2011 revealing enlargement of the left adrenal mass to 5.7 cm and a stable 1.8 cm right adrenal nodule. A laparoscopic left adrenalectomy was performed in 2012 and the surgical pathology diagnosis was benign adrenal hyperplasia. In 5/2016 the patient developed left abdominal pain and a CT scan revealed a 1.7 cm mass in the left adrenalectomy surgical bed, a 1.4 cm nodular density adjacent to the left diaphragm and the stable 1.8 cm right adrenal nodule. 6/2016 lab tests: 24 hr urinary cortisol 15 ug/24 hr (<50 μg/24hr), aldosterone 8.7 ng/dL (<31 ng/dL), renin activity 0.7 ng/ml/hr (0.5–4 ng/mL/hr) and DHEA-S 94 ug/dL (32–240 μg/dL). A re-examination of the 2012 surgical pathology resulted in an addendum diagnosis of an adrenal cortical neoplasm of indeterminate malignant potential. In 1/2018 she underwent an exploratory laparotomy with surgical resection of the 1.7 cm mass in left paracolic gutter and biopsy of numerous small retro-peritoneal and multiple liver lesions. Pathology revealed metastatic adrenocortical carcinoma with low grade mitotic activity (3 mitoses per 10 HPF) and intermediate grade Ki-67 (15–25%). 5/2018 lab results: 1. aldosterone 20 ng/dL, 2. renin activity 0.2 ng/mL/hr and 3. testosterone 34 ng/dL (<75 ng/dL). Mitotane was started in 06/2018 but was discontinued in 9/2018 due to side effects. In 3/2020 she was hospitalized for generalized weakness and was discovered to be severely hypokalemic K+ 1.5 mmol/L (3.6–5.2 mmol/L) with an aldosterone of 300 ng/dL and renin activity of 0.1 ng/mL/hr. She was treated with IV KCl to correct her hypokalemia and was discharged on oral KCl 20 meq bid and spironolactone 50 mg bid. She was readmitted to the hospital on 10/12/2020 after a near-syncopal event and lab tests revealed a K+ of 1.4, aldosterone 508 ng/dL, renin activity 0.7 ng/mL/hr, AM cortisol 13.6 μg/dL (5–20 ug/dL), testosterone 161 ng/dL, and DHEA-S 377 ug/dL, indicating co-secretion of multiple steroid hormones. Her hypokalemia was treated with IV KCl and her spironolactone dose was increased to 100 mg bid. Conclusion: This case report details the rare occurrence of an adrenocortical carcinoma which was hormonally silent but eventually metastasized and became hormonally active, co-secreting multiple steroid hormones with a predominance of aldosterone. Serial adrenal hormone lab profiles are important for optimal management of patients with this disease.

Lymphoepithelial cyst mimicking pancreatic cancer: a case report and literature review

Background Pancreatic lymphoepithelial cyst (LEC) is a rare nonmalignant cyst consisting of a benign collection of keratinizing squamous epithelial cells with lymphoid tissue. Diagnosing LEC preoperatively is considered difficult because of its non-specific clinical features; therefore, LEC is generally treated the same as a malignant tumor. Case presentation Our case was a 65-year-old man who underwent pancreatoduodenectomy 3 years previously for carcinoma arising from the ampulla of Vater. A pancreatic mass in the remnant pancreatic tail was detected through follow-up abdominal contrast-enhanced computed tomography (CT). This revealed two adjacent ring-enhanced masses that had been in tight contact with the left diaphragm and were enlarged. The tumors had high signal intensity in diffusion-weighted images of magnetic resonance imaging, and fluorodeoxyglucose-positron emission tomography (FDG-PET) showed abnormal uptake (standardized uptake value maximum: 17.4). Therefore, we conducted a partial resection of the remnant pancreas with concomitant resection of the left diaphragm. Microscopically, one of the tumors revealed rare fragments of apparently benign squamous epithelium on a background of keratinous debris, cyst contents, and scattered lymphocytes, and the adjacent mass revealed infiltrated neutrophils. The histopathological diagnosis was an LEC with chronic abscess. The patient recovered uneventfully and was discharged on postoperative day 10. Conclusions We reported a rare case of LEC with chronic abscess that was positively visualized on FDG-PET. When a pancreatic malignancy cannot be excluded, surgical resection is considered inevitable.

Diaphragm reconstruction by GORE DUALMESH in patients undergoing resection for thoracic malignancies

Background We used GORE DUALMESH for the reconstruction of diaphragms in patients with thoracic malignancies. Here, we report the results. Methods Between July 2015 and August 2017, diaphragm reconstruction using 2-mm GORE DUALMESH was performed in 7 patients undergoing surgical resection for thoracic malignancies. After resection of the diaphragm, the mesh was trimmed to the size of defect and placed with the smooth surface facing the chest cavity and the rough surface facing the abdomen. It was fixed with interrupted sutures consisting of synthetic monofilament nonabsorbable 1–0 to 2 threads. Results Indications for resection were malignant pleural mesothelioma and primary lung cancer in 5 and 2 patients, respectively. Patients with malignant pleural mesothelioma underwent pleurectomy with decortication; patients with primary lung cancer underwent lung lobectomy. Right and left diaphragm reconstruction was performed for 4 and 3 patients, respectively. Neither complications related to diaphragm reconstruction nor displacement of mesh occurred during a follow-up period ranging from 11 days to 37 months. Conclusions GORE DUALMESH is a good synthetic material for diaphragm reconstruction, because its smooth surface prevents adhesions to the lung and its rough surface allows adherence to abdominal tissue.