Renal Lymphangiectasia as an Unusual Cause of Perirenal Collections: A Case Report and Literature Review

Renal lymphangiectasia (RLM) is a rare condition characterized by dilatation of perirenal, parapelvic or intrarenal lymphatics. We report an unusual case of bilateral RLM in a 20-year-old Malay male who presented with 1 month duration of bilateral flank pain. Bedside ultrasound showed bilateral perinephric collections, which were further confirmed on computer tomography intravenous pyelogram (CT IVP). Other causes of perinephric collections were ruled out based on laboratory and radiological findings, and he was managed conservatively as for RLM with surveillance ultrasound kidneys at 3 to 6 monthly intervals.

Recurrent Graves’ Disease in Thyroglossal Duct Following Total Thyroidectomy

Introduction: A 46-year-old female with a past medical history of Graves’ disease refractory to medical management, thus requiring total thyroidectomy presented to clinic for recurrence of her hyperthyroidism and an increasing midline neck mass two years after her index operation. Case Description: CT imaging of the neck mass revealed a locally extensive enhancing abnormality immediately anterior to the hyoid bone within the infrahyoid muscles measuring 1.4x.1.9x4.0 cm. This was consistent with an exceedingly rare proliferation of a thyroglossal duct remnant secondary to recurrence of the patient’s Graves’ disease. The patient was treated with surgical resection of the neck mass shown to be ectopic Graves’ activated thyroid tissue by pathology. The patient was restarted on thyroid hormone replacement therapy and has remained euthyroid to date following surgical resection. Conclusion: The incidence of this event is estimated to be approximately one per a million persons and thus is a rare occurrence in endocrinology. This case highlights the potential shortcomings of surgical management of Graves’ disease. Following surgical resection, the autoimmune status of the patient remains unchanged. Ectopic thyroid tissue can be found anywhere along the embryologic descent of the thyroid gland and as low as the mediastinum. Thus, patients treated with total thyroidectomy should still be monitored regularly for recurrence of Graves’ disease secondary to ectopic thyroid tissue.

The Challenge of the Non-Compliant Patient: A Case of Caesarean Section Scar Ectopic Pregnancy

Ectopic pregnancy is a quite common and life-threatening pregnancy. The most common site of ectopic implantation of a fertilized embryo is the fallopian tube. In extremely rare situations, the embryo can implant in other locations, which makes the diagnosis and management even more complex. Although close observation of a new pregnancy is key in the diagnosis and treatment of an ectopic pregnancy, there is still a major risk of life-threatening outcomes. This is a case report of a 31-year-old patient with a history of multiple pregnancies who presented to a community hospital in the spring of 2021 with an ectopic caesarean scar pregnancy. A diagnosis of ectopic pregnancy was on a timely basis, and surgical management was advised. Upon refusal of treatment and admission, pharmacological management was initiated, but patient compliance challenged the success of the therapy. Patient non-compliance to close follow-up resulted in a ruptured uterus. Emergency laparotomy with supracervical hysterectomy was performed as a life-saving procedure.

Oesophageal Transection for Bleeding Varices: Case Report and Literature Review

Surgical oesophageal transection for uncontrolled variceal bleeding is a last resort measure that is rarely needed due to modern endoscopic advancements. Since it is infrequently required, most of the younger General Surgeons have not been exposed to this procedure. However, it remains a valuable consideration when endoscopic measures and balloon tamponade fail to control bleeding oesophageal varices and should remain in the armamentarium of the General Surgeon. Here we present a case of such a patient who underwent oesophageal transection as a life-saving procedure with satisfactory outcome, together with a brief literature review on this topic.

A Case of Diffuse Multicentric Metachronous Astrocytoma of Temporoinsular and Intramedullary Location

Multiple gliomas are rare glial tumors with a histology that is typically consistent with high-grade gliomas. A distinction is made between multifocal and multicentric gliomas according to criteria of anatomical continuity, as well as between synchronous and metachronous gliomas according to chronological time of onset. We present the case of a professional saxophonist with a left temporoinsular lesion who underwent awake craniotomy with monitoring of verbal and musical ability as well as primary sensory and motor cortices. Histopathological study revealed an isocitrate dehydrogenase 1 (IDH)-mutant diffuse astrocytoma. After 4 years of complete oncological remission, the patient developed impaired proprioception in all four extremities. An intramedullary lesion was detected at the level of C4 consistent with an IDH wild-type diffuse astrocytoma. We highlight the singularity of this case as it involved two low-grade glial lesions, separated in time (metachronous) and location (multicentric), as well as genetic differences between both lesions (IDH mutant and wild type).

Gastric Adenomyoma: A Case Report and Comprehensive Review of the Modern Literature

Gastric adenomyoma is a rare, benign neoplasm, often mistaken as a gastrointestinal stromal tumor and not properly identified until after surgical excision. The importance of defining the diagnosis in this entity is highlighted by the fact that these tumors do not require surgical excision. General knowledge of this neoplasm is lacking among physicians. In case reports, this tumor was either incidentally discovered and removed or found during workup for nonspecific GI symptoms and removed because of suspicion for gastrointestinal stromal tumor (GIST). Multiple papers state that surgical excision is necessary for diagnostic clarity. We present an updated review of the modern literature and a case of gastric adenomyoma, as well as define an algorithm using histology and immunohistochemical (IHC) stains (desmin, CKIT, DOG1, PDGF and CK7) for the diagnosis of gastric adenomyoma in a noninvasive manner in order to potentially avoid unnecessary surgery.

The Difference Between Malpractice and Adverse Event: Report of a Case and Review of the Literature

Background/Aim: The practice of surgery may lead to unexpected results and most such results come due to risk in the practice of medicine. Our aim is to identify the difference between malpractice and adverse event. Case Presentation: A young male patient who experienced a cascade of adverse events after a laparoscopic cholecystectomy and even though he had the ultimate treatment an unknown and extensive atherosclerotic coronary arteries disease had led to a fatal left ventricular corruption due to an extensive myocardial infarction. Results: The relatives of the patient filed a lawsuit against the surgeon due to the perception that death was caused by malpractice. Conclusion: Evidence-based medicine should not become defensive, since not every unpleasant event is due to malpractice or negligence.

Pre and Postoperative Muscle Wastage and Sarcopenia Using CT Scans in Patients Undergoing Pelvic Exenteration Surgery

Background: Sarcopenia is associated with poor postoperative outcomes in oncology patients. Computed tomography (CT) scans can be used to identify muscle wasting and sarcopenia. This study aimed to investigate if pelvic exenteration surgery leads to muscle wastage and thus, induction or exacerbation of sarcopenia. Methods: This is a retrospective review involving the analysis of CT scans before and after pelvic exenteration surgery to determine skeletal muscle index and diagnose sarcopenia. Other clinical and nutritional factors were collected. Results: A total of 34 patients met the inclusion criteria. Postoperative skeletal muscle index was significantly lower compared to preoperative skeletal muscle index (p=0.008). The incidence of sarcopenia was 62% preoperatively and rose to 74% postoperatively (p=0.073). Postoperative sarcopenia was not significantly associated with complications or mortality. Conclusion: The skeletal muscle index significantly decreased postoperatively, indicating that pelvic exenteration surgery leads to muscle wastage. The use of CT scans to recognise sarcopenia would allow focusing of resources for those at risk.