Optic nerve coloboma

A 20 years old female presented for a routine eye examination. Her best corrected visual acuity (BCVA) was OU - 20/20 Snellen chart. Fundoscopy of the right eye revealed a massive optic disc coloboma with no other associated abnormalities. Fundoscopy of the left eye revealed a normal eye fundus. Optic nerve coloboma is a congenital condition caused by incomplete closure of embryonic fissure. It usually occurs bilaterally, autosomal dominantly inherited, or sporadic cases. Serous macular detachment and visual field loss can be frequently observed in this condition. It can also be associated with other colobomas (lens, cilliary body and choroid), microphtalmos, retinal dysplasia, or can be part of systemic anomalies like Aicardi syndrome, Meckel syndrome and CHARGE association, with poor visiual prognosis. Subjects with isolated optic nerve coloboma, with no other associated abnormalities, like this case, can have excellent visual prognosis.

Left hepatic lobe necrosis after laparoscopic treatment of a hiatal hernia

The patient aged 66 years was admitted to the General Surgery Clinic for pain in the upper abdominal quadrant with posterior irradiation and weight loss. Two and a half years before the patient underwent surgery for a hiatal hernia when a Nissen fundoplication was performed by laparoscopic approach. CT was performed which confirmed the presence of a large abscess at the level of the left hepatic lobe and lobe atrophy (Figure no. 1, Figure no. 2). Surgery was undertaken. Abdominal exploration identified ischemia and necrosis of segments 2 and 3 of the liver so a resection was decided upon (Figure no. 3, Figure no 4). The postoperative evolution was favorable. NB: Ischemic necrosis of the left hepatic lobe most likely occurred after the surgical treatment of the hiatal hernia when the left hepatic artery was resected on dissection which was probably the only source of blood supply for the left lobe. It is important that these vascular abnormalities are known by the surgeon so during dissection of the gastrohepatic ligament any arteries identified should be protected to avoid a possible necrosis of the left hepatic lobe.

Inside of an adrenal cyst

This is a 36-year old menstruating female who accused abdominal pain of non-specific pattern during the last days. Abdominal ultrasound and computer tomography confirmed a left adrenal mass of 6 centimetres with cystic appearance without solid elements. No other causes of abdominal pain were identified. Adrenalectomy was performed. The pre- and post-operatory panel of endocrine assessments was normal. Pathological report confirmed an endothelial cyst at the level of a normal adrenal gland. The endothelial cells are introduced in hematoxylin eosin stain at histological report (Figure I: 4X, Figure II: 40X). The immunochemistry reaction is positive for factor VIII in cyst cells of adrenal origin. (Figure III: FVIII positive immunostain in fused and cubic cells, 20X, Figure IV: FVIII in fused cells, 20X). Further on the clinical evolution was good. Adrenal cysts may be endothelial related, epithelial derived and pseudocysts. They are found in both adults and children but the level of evidence varies from cases series to cases reports. (1,2,3) The risk of malignancy or rupture are the major complications. (1) Endothelial cysts seem more frequent in women. (2) The scenario of detection may be of a typical adrenal incidentaloma or starting from non-specific local as seen here.

Christmas Tree Cataract

Christmas tree cataract is a rare type of lens opacification which is usually age related, though several cases have been seen in patients with myotonic dystrophy. It consists of highly refractive multicolored needle-shaped opacities within the deep cortex of the lens (1). The exact mechanism of crystals is not exactly known, but different theories have been proposed. Shun-Shin et al. postulated that the crystals were most likely of cystine due to an age-related aberrant breakdown of lens induced by elevated Ca++ levels (1). According to Anders and Wollensak, the crystals were cholesterol in nature and were the result of lens metabolism (2). A 64 years old female presented with reduced visual acuity in her right eye. Her best corrected visual acuity (BCVA) in right eye was 6/10 Snellen chart. Slit lamp examination after pupillary dilatation revealed highly reflective, polychromatic, needle-shaped crystals in the temporal and inferior cortex of the right lens with associated nuclear sclerosis. This aspect of glittering multi-colored opacities varying with the angle of light incidence resembles the colored lights decorating the Christmas tree(Fig.1). As the visual acuity was significantly reduced and there were no other associated ocular pathologies, we decided for a cataract surgery in the right eye. Since the crystals are highly refringent and change considerably the viewing of the surgeon during the procedure, an increased time of surgery should be avoided (3) (4). Uneventful extracapsular phacoemusification of the lens with monofocal artificial intraocular lens implantation within the capsular bag was performed with very good results.

Multidisciplinary management of a gastric fistula after laparoscopic sleeve gastrectomy

We present the case of a 23-year-old patient with a BMI of 42 kg / m², hypertension and gonarthrosis who presented for an evaluation regarding bariatric surgery. After the preoperative investigations and consults were obtained a laparoscopic sleeve gastrectomy was done. The first two postoperative days were uneventful but on day 3 the patient became tachycardic, febrile and purulent fluid was observed on the perigastric drain. An abdominal CT was obtained which confirmed the diagnosis of a gastric fistula. Reintervention was undertaken with primary laparoscopic suture of the gastric fistula, peritoneal lavage, and drainage. Three days after the second surgery the gastric fistula re-opened. After interdisciplinary evaluation, a conservation tactic was decided upon and an expandable gastric stent was mounted via an upper endoscopy. Seven days after, the stent migrated towards the duodenum so a second stent was mounted. The evolution after the second stent was favorable, the drainage tube was extracted 7 days and the gastric stents were extracted at 1month. One year after the surgery the patient showed a favorable evolution with considerable weight loss. Post-surgical complications in gastric-sleeve patients warrant extreme care and multidisciplinary management ensures optimal results. First picture on the left identifies the gastric fistula with a barium X-ray, the following pictures (2, 3) describe the process of mounting the stent under x-ray guidance and figure 4 demonstrates gastric contention of the barium after the stent was mounted.

Necrotizing fasciitis, poor hygiene and negligence in obese patients

The Tegument, the body's largest organ, also fulfills the protective function by preventing the pathogens from penetrating into the body. The barrier, once overcome, opens the gate to serious illnesses with varying degrees of severity. We present the case of an obese patient aged 63, BMI 40, admitted to emergency service for necrotizing fasciitis in the abdominal wall. Anamnesis and general clinical examination highlight the presence of a large area of necrosis in the lower abdominal wall, affecting the iliac fossa, the hypogastric region and the left iliac fossa, lack of substance at this level, limited supraaponvrotic, with multiple sepsis, isolated tissue areas granulation, anfractum edges, suggestive aspect for necrotizing fasciitis. Serious surgical interventions have been carried out, with the aim of broad, digital and instrumental debridement, the important lavage of the wound with hydrogen peroxide and betadine and antibiotic treatment according to the antibiogram. Subsequently, dressings were applied with negative pressure, with development of granulation tissue in the wound and in the end was chosen for secondary suture with favorable outcome and discharge from the hospital 33 days after admission. Precarius socio-economic status, poor hygiene in an obese, careless patient, without identifying other causes like diabetes or surgical history, have led to the development of a multilingual, life-threatening condition. Serious surgical attitude and postoperative care have led to a medical success, although burdened by significant costs, which could have been avoided with minimal effort especially from the patient.

A rare case of portal pneumatosis. What are the therapeutic resources?

Hepatic portal vein gas was first describes in 1955 by Wolf and Evans. It is a rare and severe condition that in 80% of cases leads to patient’s death. Most common causes are :necrotizing enterocolitis, mesenteric ischemia, sepsis , intestinal perforation. A 73-year old male patient underwent an elective rectal amputation for anal adenocarcinoma, after radiotherapy.In the 12th postoperative day the clinical state of the patient degraded, with onset of acute abdominal pain and fever.A CT scan and ultrasound examination showed the presence of hepatic portal venous gas with of pneumatosis intestinalis and an abcess in the pelvic region.Intraoperatively, two small perforations were found at the distal jejunun with no ischemia or necrosis. An ileostomy was performed, with drainage of the peritoneal cavity.Post-operatively the patient was stabilized and was eventually discharged in stable condition .The presence of hepatic portal venous gas with the of pneumatosis intestinalis is most frequently associated with ischemic bowel, ileus, diverticulitis, gastric distention, inflammatory bowel disease (IBD), hypotension post dialysis treatment, decompression sickness, trauma and iatrogenic causes from instrumentation and recent surgery.

TAPP technique for congenital inguinal hernia

Laparoscopic hernia repair has opened a new era in hernia surgery shifting paradigms from anterior to posterior approaches. This has exposed surgeons to new anatomical perspective, tehnical challenges and clinical implication. We present the case of a 53-year-old patient admitted to surgery in outpatient conditions with the diagnosis of bulky inguinal-scrotum hernia. Transabdominal pre-peritoneal (TAPP) repair was our option to solve the inguinal parietal defect. Intraoperatively, in the peritoneal cavity, lateral to the epigastric vessels, the parietal flaccid defect was revealed, communicating with the right scrotum cavity, with clear evidence of testicle, suggestive of external congenital oblique hernia. Peritoneal sectioning and take-off, with Cooper's, spermatic vessels and the relevant channel, were the precursors of the dissection and 360-degree take-off of the herniated sac, with the support of the herniated suture ligament, followed by in-line, and the abandonment of the distal, open, unbounded end. The application of the 3D-MAX mesh, fixed with Capsure at the Cooper ligament, preperitoneal drainage and closure of the resorbable thread peritoneum were the endpoints of surgical intervention. The postoperative progression was favorable with discharge on the 2nd postoperative day. Control at 30 days postoperatively did not identify possible complications, it presented without painful accusations, without suggestive elements for hydrocele and without signs of relapse. The laparoscopic approach, even in the case of bulky parietal defects, remains a recommended treatment option with the best results, but largely depending on the surgical team experience.

Laparoscopic Concomitant Sleeve Gastrectomy and Repair of a Morgagni Larrey Hernia - Case Report

Anterior diaphragmatic hernias are very rare surgical entities, scarce in symptoms, which occur through openings of the costal and sternal fascicules of the diaphragm. First described by Giovanni Battista Morgagni, in 1769, they are known under many names: Morgagni, Morgagni-Larrey. These hernias can develop in the left hemidiaphragm, right hemidiaphragm or bilateral. The preferred treatment when available is the laparoscopic suture of the defect. We present the case of a 52 years old female patient, with morbid obesity (BMI = 44.10 kg/m²) and Morgagni hernia. Other associated pathologies of the patient were high blood pressure, autoimmune thyroiditis, and sleep apneea. The initial diagnosis of diaphragmatic hernia was made a year earlier at a CT investigation. Laparoscopic sleeve gastrectomy and suture of the diaphragmatic defect were achieved without incidents during one single surgical intervention. A drainage tube was placed in the remaining cavity of the hernia. The hernia sac was conserved and used to reinforce the defect. The concurrent suture of the diaphragmatic hernia and sleeve gastrectomy do not increase the postoperative morbidity. The recovery was uneventful, thus the patient was spared a second surgical intervention . If present, these hernias are quickly identified due to the fact that laparoscopy allows a through exploration of the diaphragm. When diagnosed these defects should be repaired by suture due to the fact that they can cause life threating complications to the patient such as intestinal obstruction or gastro-intestinal bleeding if elements of the digestive tract are incarcerated in the defect.

Diagnostic difficulties in a patient with Zenker diverticulum

Esophageal diverticulum has an incidence of less than 1% in the population, 70% occur in the cervical esophagus and are known as Zenker diverticulum. The treatment is indicated in symptomatic patients - dysphagia being a constant symptom. Current treatment includes minimally invasive transoral tehnics for septum dividing between diverticulum and esophagus, either with stapler or via interventional endoscopy, as well as the open technique: diverticullectomy with cervical crycopharyngiomyotomy - for large diverticulums. We present the case of a 74-yo patient, with dysphagia, regurgitation, and weight loss with progressive 2-year evolution. After an ambulatory thyroid ultrasonography that raised suspicion of a Zenker diverticulum, was reffered to gastroenterology service, where UGI endoscopy have not revealed esophageal pathology and recommends cervical CT: a voluminous diverticulous pouch in contact with the left sternocleidomastoid muscle with food remnants. (Fig.A) She is admitted to hospital for further investigations. Barium swallow: an oval round image in the cervical region, approximately the size of 3 cervical vertebrae, retentive (fig. B) EDS: broad diverticular communication with cervical esophagus, voluminous diverticulum with food and barium remnants(Fig. C) A cervical approach was decided: diverticulumlectomy with a TA 55mm stapler (Fig. D), the stapling line was reinforced by another polyglicolic 3-0 serumuscular running suture and cricopharyngeal myotomy (Fig. E) The postoperative evolution was unremarkable. The low incidence of this disease and the actual management controversy are recommendations for the treatment of patients in clinics with experience in esophageal surgery.