An accessory aberrant testicular artery branching from the inferior suprarenal artery: embryologic and genetic consideration
During routine educational dissection of a cadaver (61-year-old, male, white descent), multiple aberrant right testicular artery and veins were discovered. Detailed analysis of the abdominal vascular pattern showed that the accessory aberrant testicular artery branched off the right inferior suprarenal artery. It crossed the anterior pararenal space, gave several branches to the soft tissues of the posterior pararenal space, and descended towards the deep inguinal ring. The accessory aberrant testicular vein accompanied the aberrant artery and was drained by the right inferior suprarenal vein into the renal one. Two other testicular veins followed a typical course and opened into the inferior vena cava. The anatomical variability reported in this paper requires attention of the related specialists, as it may significantly complicate surgical and minimally invasive procedures on the organs of the retroperitoneal space and inguinal region. Thorough preoperative investigation regarding the variability of the vascular pattern should be conducted in patients considered for intervention on the adrenal gland, kidney, or testis.
Autologous Tenocyte Implantation for the Treatment of Chronic Degenerative Rotator Cuff Tendinopathy
The use of injectable cell therapies to treat tendon pathology has become significantly more popular in recent years. They are appealing treatment modalities as they are minimally invasive, autologous, non-surgical management options which theoretically allow tendon regeneration and return to function. This case report will focus on the use of autologous tenocyte implantation (ATI) injection therapy to treat chronic degenerative rotator cuff tendinopathy.
Successful use of a novel biological plug in the percutaneous treatment of a refractory gastro-cutaneous fistula following omental patch repair of perforated peptic ulcer
Background: Gastro-cutaneous fistula following re-leak of omental patch repair of perforated peptic ulcer is a very rare but challenging surgical complication. We describe the use of a novel biological plug as a viable repair for gastro-cutaneous fistula that failed medical, endoscopic, and operative management. Additionally, we present a thorough literature review of reported cases of gastro-cutaneous fistulae following omental patching of peptic perforations to further highlight their treatment challenges. Summary: A 69-year-old man underwent repair of a perforated pyloric ulcer with a pedicled omental patch. After one week, patient developed a re-leak from the omental patch, and underwent a second laparotomy with repeat omental patching of the gastric perforation. Ten weeks after the second operation, the patient developed a gastro-cutaneous fistula that failed conservative management with nil per os and enteral nutrition delivered distal to the fistula site; multiple image-guided percutaneous attempts at fistula closure by interventional radiology via fibrin sealant injection and collagen-based vascular closure device; and endoscopic clipping by gastroenterology. Ultimately, this refractory gastro-cutaneous fistula was closed with a novel biological plug (Biodesign® Enterocutaneous Fistula Plug, Cook Biotech). Conclusion: Gastro-cutaneous fistulae following omental patching of perforated peptic ulcer represent a significant complication requiring a multidisciplinary management approach. The Biodesign® Enterocutaneous Fistula Plug offers a promising new tool for the non-operative treatment of refractory gastro-cutaneous fistulae.
The 5-year survival rate of advanced non-small cell lung cancer is less than 5%. In recent years, immunotherapy represented by PD-1 antibody has become the standard treatment recommended by many lung cancer guidelines. With the treatment, the total survival time and quality of life have been significantly prolonged in patients with advanced Primary non-small cell lung cancer (NSCLC). In this study, the domestic anti-PD-1 monoclonal antibody, Camrelizumab, combined with chemotherapy was used to treat advanced non-small cell lung cancer. The efficacy of Camrelizumab and occurrence of cutaneous capillary hyperplasia (CCEP) were analyzed.
Background: Heterotropic ossification is a common entity, but in a young adolescent causing patellar tendon rupture is rare. Case description: A 13-year-old male presented to us with knee pain and inability to extend since six weeks following trivial trauma. Preliminary radiological investigations revealed a high riding patella with ossification in the patella tendon. The magnetic resonance scan confirmed the same with patellar tendon disruption and heterogenous ossification. He underwent surgery with patella tendon repair, augmentation with autograft and had complete recovery at six months follow-up. Conclusion: Heterotropic ossification caused by repetitive trauma leading to disastrous effects.
A 53 year old gentlemen, with a history of intravenous drug use, presented to the Emergency Department in septic shock with an acute abdomen. He had been recently treated with dalteparin for a deep venous thrombosis of his left leg. He was resuscitated with fluids and antibiotics, and cross-sectional imaging suggested a diagnosis of necrotising fasciitis of the abdominal wall. He was admitted to ITU, and a laparotomy, abdominal washout, muscle debridement and laparostomy was performed overnight. No bowel perforation or contamination was identified. Over the next few weeks he underwent multiple debridements, and a negative pressure abdominal dressing was utilised. After a prolonged rehabilitation phase he was discharged home to live independently. He is currently in discussion with the plastics team regarding reconstruction of his abdominal wall. We would like to stress the importance of consideration of necrotising fasciitis as a diagnosis in the context of a critically unwell and septic patient with a history of subcutaneous/intravenous medication usage.
Background: Factor XII is part of the intrinsic pathway. the activity of this pathway is assessed by measuring the activated partial thromboplastin time (aPTT). Deficiency of Factor XII is rare, often inherited as autosomal recessive, nevertheless autosomal dominant pattern has also been reported. congenital deficiency is associated with mutations in the F12 gene on chromosome 5. Here we report a patient with factor XII deficiency which is considered as a rare inherited coagulation disorder. Case report: we report the case of a 37 years old gentleman known to have Diabetes mellitus, hypertriglyceridemia, past history of pancreatitis and an episode of gingival bleeding a year prior to this presentation which was attributed to periodontitis. He presented to the emergency room complaining of epigastric pain radiating to the back as well as non-projectile vomiting. He used to drink alcohol but stopped 6 years ago. physical examination showed epigastric tenderness, poor dental hygiene and periodontitis. investigations showed neutrophilic leucocytosis, high lipase and raised triglycerides level of 11.3 mmol/L. He was treated successfully for triglycerides induced pancreatitis with IV insulin, Dextrose 5% infusion and fenofibrates. Isolated prolonged aPTT was detected incidentally which was corrected with mixing study indicating a factor deficiency. Factor assays revealed factor XII deficiency (5.8%) with other factors being within normal ranges. Past records did not show any thrombotic event. No specific treatment was given for Factor XII deficiency. Conclusion: Factor XII deficiency is associated with an isolated prolonged aPTT without increasing risk of bleeding. patients with this condition should be offered regular follow up because of the increased rate of thromboembolic complications.
Background: Combined factor V and factor VIII deficiency (F5F8D) is a rare autosomal recessive inherited coagulopathy. It has a higher prevalence in the Mediterranean region (1:100,000) compare to its prevalence in the general population which is estimated to be (1:1000,000). Case report: We report a 59 years old Lebanese lady who was referred from the general surgery clinic with an asymptomatic prolongation of prothrombin time (PT), international normalized ratio (INR) and activated partial thromboplastin time (aPTT) detected during preoperative work up for an elective umbilical hernia repair. The patient had history of bleeding following dental procedures since childhood as well as easy bruising with minimal trauma. Physical examination was unremarkable. haematological investigations were normal apart from the prolonged PT, INR and aPTT which were corrected following mixing studies. Factor assay revealed factor V level of 5.5% and factor VIII level of 11.9% with other factors within normal ranges confirming the diagnosis of combined F5F8D. Conclusion: Combined factor V and factor VIII deficiency should be suspected in patients with prolonged PT, INR and aPTT especially if they are of Mediterranean, Middle east or Arabic origin with a history of consanguineous marriages. Treatment is generally not indicated unless the patient has recurrent serious bleeding manifestations.
Cesarean scar endometriosis is an uncommon disorder developed due to iatrogenic implantation of endometrial tissues in the cesarean incision site. The frequency of the scar endometriosis is assumed to increase because of the increasing trend of lower segment cesarean section in modern obstetric practice. Cesarean section might be a great risk factor for the development of scar endometriosis due to higher exposure of endometrial cells to the subcutaneous tissue during the procedure. Prevention of decidual cell contamination to the superficial abdominal layers may reduce the occurrence of iatrogenic scar endometriosis. We reported a 21-year old para 2 woman with a history of cesarean section 2.5 years back who presented with a small mass at the middle of the cesarean scar which was associated with pain and blood-stained discharge during menstruation. Based on clinical and USG findings the provisional diagnosis was made scar endometriosis and subsequently we managed her by wide local excision of the lesion followed by adjuvant hormone therapy. No recurrence of scar endometriosis was observed during her follow up period.
Background: Penile constriction rings have been used to prolong erection with vacuum devices in the treatment of erectile dysfunction. Some have also employed it for recreational purposes with the attendant risks of penile edema, strangulation and necrosis. We present two cases of entrapped phallus by penile rings. Case reports: 16 years old with pain and swelling of the phallus of 12 hours duration. This started after placement of a phallic ring to purportedly prolong erection which he was later unable to remove the ring despite several attempts and developed progressive swelling and pain in the phallus. He was also unable to pass urine. Examination revealed a circumcised phallus that was detumescent but grossly edematous, tender with shiny skin. Initial simple manoeuvres in the casualty proved abortive and ring had to be cut with an orthopaedic instrument. He was subsequently able to void without difficulty or any haematuria. 47 year old Asian male with a 12 hour history of penile pain and swelling following entrapment of a penile ring he had inserted for sexual gratification about 24 hours before presentation. There was a history of haematuria. The removal of the penile ring was achieved with a combination of cold compress squeeze, corporal aspiration and lubrication under general anaesthesia. Conclusion: Successful management of retained penile ring depends on early presentation by the patient to avoid adverse outcomes. It may require instruments not normally found in the urologist armamentarium.