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A 49-year-old Caucasian woman was referred to a general surgeon by her primary care physician for a right nipple lesion. She reports no past medical history, and social history is notable for tobacco use. The patient stated that she first noticed a small, yellow, and fleshy bump on her right nipple approximately two years prior. She became concerned due to its rapid growth in the last year. Four months prior, she visited her primary care provider who performed a shave biopsy of the lesion. Initial pathology results suggested squamous cell carcinoma, but this was thought to be discordant with the clinical picture. At consultation, she reported that her right breast had also started feeling hot and tender for two weeks duration. On examination, her right breast was erythematous and rigid with a 2.2 cm lesion consuming the right nipple. Her nipple also drained yellow pus. The patient was placed on a course of antibiotics due to concerns for an abscess.\nAn MRI was ordered to investigate possible underlying breast malignancy. Results of the MRI showed no solid mass underlying the nipple. A wedge biopsy of the nipple was performed to confirm the initial shave biopsy pathology (). Pathology showed verrucous histologic features with chronic inflammation and underlying abscess with concerns for a possible cutaneous malignancy. Specifically, there was marked papillomatosis with hypergranulomatosis between the papillae as well as a lack of granules at the papillary surfaces. Immunohistochemical testing was also positive for HPV L1 capsid protein. Because the initial shave biopsy showed SCC with positive margins, this clinical picture suggested that an inadequate sample was taken during the wedge biopsy. After consultation of literature, excision with wide margins was determined to be appropriate for removal of the lesion.\nThe patient underwent a wide excision of the right nipple-areola complex for removal of the growth. A 6.2 cm x 3.2 cm skin ellipse was excised encompassing the 2.2 cm nipple lesion. On final histologic examination, the lesion was found to be a large tumor with verrucous features, hyperkeratosis, dyskeratosis, and nests of keratin pearl formation (). Two areas showed microinvasion of the dermis with loss of the basal lamina. There were also significant acute and chronic inflammatory responses in the deep dermis representing an underlying abscess. These findings are congruent with the diagnosis of a well-differentiated squamous cell carcinoma with arising within verruca vulgaris. All margins were found to be clear of tumor cells. The post-op course was uneventful. She continues to follow up to monitor potential recurrence of the growth.

A 60-year-old female presented to the outpatient cardiology clinic for evaluation of worsening chronic hypertension for which she had been on hydrochlorothiazide/Valsartan for 10 years. Her systolic blood pressure exceeded 200 mmHg in the office, and aggressive medical therapy was initiated in the outpatient setting. She returned to the emergency department the following day with headache and malaise and systolic blood pressure above 200 mmHg for which she was treated and discharged.\nShe returned to the emergency department again 5 days later, this time with complaints of word finding difficulty, blurred vision, and lower extremity tingling. Her blood pressure on presentation was 216/81 mmHg. She was admitted, and workup demonstrated no acute intracranial process or carotid stenosis. Echocardiography revealed mild concentric left ventricular hypertrophy with a preserved ejection fraction. Her blood pressure continued to be refractory to medical therapy despite five antihypertensive agents and eventual initiation of an esmolol infusion. A renal artery ultrasound identified renal artery stenosis with flow at the arterial origin measuring 350 cm/s on the right and 208 cm/s on the left (); flow velocity in the supraceliac aorta was also noted to be elevated. She had no history of kidney disease and no elevation of her creatinine. Vascular surgery was consulted and a history of lower extremity claudication was elicited. On exam she had weak but palpable femoral pulses and an audible abdominal aortic bruit; ankle-brachial index measurements were deferred and the patient was scheduled for angiogram.\nThe patient underwent aortography the following day and on selective angiography the renal arteries were found to be widely patent. Significant stenosis was identified at the distal thoracic aorta extending into the abdominal aorta but terminating proximal to the celiac trunk. The degree of stenosis was deemed to be greater than 90% and a pressure gradient between the upper extremity and intra-aortic measurements exceeded 100 mmHg. CTA was subsequently performed to evaluate the extent of the lesion and confirmed a stenosis 1.3 cm proximal to the celiac origin measuring 5 mm at its narrowest point (Figures and ). The patient underwent arteriogram; the stenosis was successfully navigated and a Protege 14 × 40 x 12 mm nitinol stent (Medtronic Vascular, Santa Rosa CA) was delivered followed by a 10 mm postdilation balloon. A completion arteriogram demonstrated excellent flow across the stent.\nAfter stenting, the patients' systolic blood pressure was 140-160 mmHg, and she experienced resolution of her lower extremity claudication. She was discharged from the hospital on Aspirin and Plavix and a blood pressure regimen consisting of lisinopril, hydralazine, amlodipine, and carvedilol.\nShe was lost to follow-up until two years later when she returned to the hospital with a blood pressure of 220/85 mmHg, with complaints of chest discomfort. CTA demonstrated stenosis in the distal portion of the aortic stent. An angiogram was performed, and the stent was ballooned to 12 mm. Pressure gradient measurements taken before and after dilatation decreased from 60 mmHg to 20 mmHg. On follow-up one year later, she continued to experience excellent blood pressure control.

A 57 year old male presented with unstable angina. Risk factors included hypertension and hypercholesterolaemia. Significant past history included multiple episodes of deep vein thrombosis and pulmonary embolism. Coronary angiography demonstrated a single coronary artery arising from left coronary sinus (fig ) which divided into a normal sized left anterior descending artery (LAD) and a circumflex (Cx) artery. LAD had a 99% stenotic lesion beyond the first septal and was a good sized vessel going just beyond the left ventricular apex (Fig ). From its proximal segment, beyond the origin of first diagonal and prior to the origin of first septal artery, arose 3 right ventricular branches, the largest of which crossed the right ventricular outflow tract (RVOT), 2 centimetres below the pulmonary valve, to gain the anterior right atrioventricular groove (Fig , ), descended in the groove to anastomose with the distal right coronary artery (Fig ), which arose as a continuity of the circumflex artery (Fig ), as described below. The second right ventricular branch crossed the RVOT below the first but petered out well before it could gain the anterior right AV groove. The third branch supplied the right ventricle and followed a course close to the LAD (fig ). The diagonal artery was a large bifurcating artery with significant proximal stenosis. The circumflex artery had severe stenosis proximally after which it gave a large obtuse marginal branch and then the PDA in the posterior interventricular groove and thereafter continued in the AV groove as the right coronary artery (Fig ). This right coronary artery then gave off a ventricular branch to the inferior surface of the right ventricle and thereafter anastomosed with the proximal RCA arising anomalously from the LAD as described above (Fig ). There was no stenotic lesion in this composite, anomalously arising proximal and distal right coronary arterial system.\nPatient was taken to theatre for urgent CABG. Operative findings confirmed the following: Proximal RCA was arising as a branch from the proximal LAD after the first diagonal, crossed the RVOT and gained the anterior aspect of the right AV groove to anastomose with the distal RCA which arose as a continuity of circumflex artery. LAD gave off two further branches to supply the right ventricle (Fig ). The distal circumflex continued to the crux of the heart, gave off PDA in the posterior interventricular groove (Fig ) and thereafter continued as RCA till just above the acute margin of right ventricle. This distal RCA also gave off a right ventricular branch to the inferior right ventricular surface below the acute margin of the heart (Fig ). Employing cardiopulmonary bypass, with antegrade cold blood cardioplegic arrest, quadruple coronary artery bypass grafting was performed. Left internal mammary artery (LIMA) graft was anastomosed to LAD and separate saphenous vein bypass grafts were constructed to Dx, OM Cx and PDA from Cx. Bypass was discontinued easily in sinus rhythm, without ionotropes and patient transferred to ICU in a satisfactory haemodynamic condition. He was transferred to ward on first postoperative day and home 8 days after surgery.

An 18-year-old female patient reported to the Department of Prosthodontics with the chief complaint of missing teeth. On intraoral examination, high arched palate was observed with uncoordinated mandibular movements as a consequence of the patient was suffering from a neurological disorder []. It was also found that the patient had restricted vertical mouth opening of 15–20 mm. These signs were foreseen to be problematic while making impressions in a conventional manner. The high arched palate present in the patient further hampered the dentist's requirement of recording an ideal impression. The customized balloon impression tray appears to have been made in an attempt to optimize dental impression under the conditions presented by the patient.\nThe key for a successful prosthesis is an accurate impression, as the prosthesis that is fabricated in the laboratory is only as accurate as the impression made.\nThe stock tray was modified by reducing the height of the flanges and removal of the palatal part of the tray. The trimmed tray devoid of the palatal extension was attached with a flat acrylic palatal plate with auto-polymerizing resin. The flat palatal part thereby enabled the attachment of a latex balloon over it The latex balloon selected for attachment was tube-shaped so as to ensure proper adaptation to the palate when inflated and not expand horizontally to a considerable extent. The selected latex balloon was then attached with cyanoacrylate on the flat palatal plate of the impression tray []. In case of latex allergy nonlatex balloon can be used as an alternative The outlet of the balloon was then connected to a clinical sphygmomanometer bulb with the rubber pipe for air passage which would aid in inflating the balloon The prepared tray assembly was now equipped for recording the impression. Minimal amount of addition polysiloxane impression material sufficient enough to cover the entire area of the balloon was loaded onto the tray. The tray was then positioned inside the oral cavity with no pressure being applied toward the palate The balloon was then inflated with the help of a sphygmomanometer bulb and deflation was prevented by locking the knob of the sphygmomanometer bulb [] The balloon was inflated till the adequate amount of pressure was applied until the patient expressed a feel of the expanding balloon over the palate. The pressure was maintained until the impression material had set On completion of setting time of the impression material, the air pressure was relieved by deflating the balloon which helped in the easy removal of the impression. The impression was subsequently removed from the oral cavity and disinfected for cast fabrication [Figures and ] Cast was poured with balloon in inflated state using multiple pours to reduce flow and permanent deformation [].

A 29-year-old Middle Eastern male bodybuilder with a history of prior repeated synthol injections presented at our clinic with ongoing pain and deformity in both upper arms. At the age of 25, our patient had 3mL synthol repeatedly injected by an unlicensed friend into both biceps brachii muscles. Injections were administered four times per week for a total period of four weeks. The total number of injections was 16 injections per biceps muscle. Our patient experienced pain and pressure in the injected muscle directly after each injection. The pain was rated initially as four using a visual analogue scale retrospectively. Despite this, a training session was carried out by our patient after each injection. His perception of pain gradually increased to six out of ten, and after two years our patient ceased training due to the severe pain (rated seven out of ten). Initially, our patient had been able to withstand the pain but, after two years of drug administration, the pain was increasing and not tolerable due to its constant and persistent nature.\nUpon physical examination, our patient was observed to have rubbery firm hypertrophic and dysmorphic biceps in both arms (Figure ) with a free range of motion. He complained of a constant painful pressure within his right muscle more than his left one, and muscle deformity. He had several tender points all over his biceps muscle. A diagnosis was made through magnetic resonance imaging (MRI), which revealed a swollen right biceps muscle and cystic lesions scattered throughout the muscle tissue with a hyperintense signal. MRI indicated these lesions to be oil deposits between muscle fibers, termed oleomas (Figure ). It was concluded that his muscle underwent fibrotic changes in its appearance. In addition, contrast enhancement was inhomogeneous, indicating the presence of inflammation (Figure ).\nFor ongoing pain and with no therapeutic alternatives, an open surgical excision of the anterior third of his biceps was carried out through an anterior bicipital approach. Intraoperative findings showed no common muscle tissue left but massive fibrotic tissue similar to scar tissue. Postoperatively, our patient experienced a release of the subjective pain and intracompartmental pressure.\nThe operative specimen, measuring 11.0cm × 5.0cm × 5.0cm, was sent to the Department of Neuropathology for histological examination. The diagnosis was reconfirmed as fibrosis. Sections of the unfixed material revealed a white to yellowish lesion with intermingled small fragments of muscle. Histology showed a predominance of connective tissue with vacuoles (Figure A,B,C) and small areas of striated muscle with myopathic changes (Figure A,B,C; asterisks). Several necrotic muscle fibers were observed. The connective tissue contained inflammatory infiltrates that were in part diffusely distributed, in part accumulated in foci (Figure A,B; arrows). The infiltrates were dominated by CD68+ macrophages (Figure D) with numerous multinucleated giant cells (Figure D; arrows) and lymphocytes (Figure D; arrowhead). Immunohistochemistry identified the lymphocytes as CD4+ and CD8+ T-cells as well as CD20+ B-cells (not shown).\nTwo weeks postoperatively, our patient was satisfied with the outcome. He was advised to withhold vigorous training for a period of 12 weeks. No complications were reported. After six months, the patient requested the same procedure to be done on his left biceps and surgery was carried out later.

A 78-year-old Caucasian gentleman presented with a painful 2 cm irregular swelling in the nail bed of the distal phalanx of the right middle finger, with brown discolouration of the nail bed. The swelling in the digit had been present for ∼30 years, which had begun following a fracture of the terminal phalanx and had gradually increased in size over the preceding 6 months. There was no axillary or cervical lymphadenopathy and the patient was fit and well.\nClinically a differential diagnosis of an aggressive adenocarcinoma was suspected, but this was not supported by multiple radiological investigations. CT and MRI of the lesion showed a vascular destructive lesion that was causing severe erosion of the distal interphalangeal bone (Figs and , respectively). A plain chest radiograph at that time showed no pulmonary metastasis.\nAs the radiological investigations had shown that the distal phalanx was not viable and a lack of proximal invasion, it was felt appropriate to perform an amputation at the level of middle to distal third of the middle phalanx. Such an amputation was aimed at being curative, in addition to providing a definite diagnosis, maintaining function and allowing for primary closure.\nThe patient underwent an amputation of the middle phalanx of the right middle finger. Histopathology of the specimen showed a high mitotic grade lesion with a small focus of lymphovascular invasion, diagnostic of ADPA (Fig. ). The tumour was 0.7 mm from the nearest resection margin. The high rates of recurrence and metastasis were explained to the patient, who declined further surgical treatment.\nSeventeen months following initial presentation, the patient developed a mass in the right axilla. In addition, subsequent plain chest radiograph (Fig. ) and CT of the thorax showed multiple pulmonary metastasis. An axillary clearance was performed and one of the ten nodes confirmed metastatic disease. Shortly after this, the patient suffered an intracranial haemorrhage into the right internal capsule. Over the last 2 years the patient has remained only mildly short of breath due to his pulmonary metastasis and was improving neurologically. At a recent review, the patient showed features of deterioration due to the pulmonary metastasis.

A 60-year-old female presented to the outpatient cardiology clinic for evaluation of worsening chronic hypertension for which she had been on hydrochlorothiazide/Valsartan for 10 years. Her systolic blood pressure exceeded 200 mmHg in the office, and aggressive medical therapy was initiated in the outpatient setting. She returned to the emergency department the following day with headache and malaise and systolic blood pressure above 200 mmHg for which she was treated and discharged.\nShe returned to the emergency department again 5 days later, this time with complaints of word finding difficulty, blurred vision, and lower extremity tingling. Her blood pressure on presentation was 216/81 mmHg. She was admitted, and workup demonstrated no acute intracranial process or carotid stenosis. Echocardiography revealed mild concentric left ventricular hypertrophy with a preserved ejection fraction. Her blood pressure continued to be refractory to medical therapy despite five antihypertensive agents and eventual initiation of an esmolol infusion. A renal artery ultrasound identified renal artery stenosis with flow at the arterial origin measuring 350 cm/s on the right and 208 cm/s on the left (); flow velocity in the supraceliac aorta was also noted to be elevated. She had no history of kidney disease and no elevation of her creatinine. Vascular surgery was consulted and a history of lower extremity claudication was elicited. On exam she had weak but palpable femoral pulses and an audible abdominal aortic bruit; ankle-brachial index measurements were deferred and the patient was scheduled for angiogram.\nThe patient underwent aortography the following day and on selective angiography the renal arteries were found to be widely patent. Significant stenosis was identified at the distal thoracic aorta extending into the abdominal aorta but terminating proximal to the celiac trunk. The degree of stenosis was deemed to be greater than 90% and a pressure gradient between the upper extremity and intra-aortic measurements exceeded 100 mmHg. CTA was subsequently performed to evaluate the extent of the lesion and confirmed a stenosis 1.3 cm proximal to the celiac origin measuring 5 mm at its narrowest point (Figures and ). The patient underwent arteriogram; the stenosis was successfully navigated and a Protege 14 × 40 x 12 mm nitinol stent (Medtronic Vascular, Santa Rosa CA) was delivered followed by a 10 mm postdilation balloon. A completion arteriogram demonstrated excellent flow across the stent.\nAfter stenting, the patients' systolic blood pressure was 140-160 mmHg, and she experienced resolution of her lower extremity claudication. She was discharged from the hospital on Aspirin and Plavix and a blood pressure regimen consisting of lisinopril, hydralazine, amlodipine, and carvedilol.\nShe was lost to follow-up until two years later when she returned to the hospital with a blood pressure of 220/85 mmHg, with complaints of chest discomfort. CTA demonstrated stenosis in the distal portion of the aortic stent. An angiogram was performed, and the stent was ballooned to 12 mm. Pressure gradient measurements taken before and after dilatation decreased from 60 mmHg to 20 mmHg. On follow-up one year later, she continued to experience excellent blood pressure control.

The patient was a 69-year-old woman whose abnormality was initially identified by chest radiography at a local hospital in 2008. At that time, transthoracic echocardiography revealed a calcified and immobile mass on the posterior mitral valve leaflet. She was referred to our hospital for evaluation of the mass. Her past history was significant with pulmonary tuberculosis at the age of 6 years and systemic hypertension. However, there was no history of infectious endocarditis or chest trauma. Any thrombus formation due to a hypercoagulable state was not recognized. Differential diagnoses included calcified cardiac fibroelastoma and myxoma. We offered her a surgical treatment option because of the potential risk of a thromboembolic event. However, she refused the surgical intervention. She was managed on an outpatient basis and periodically underwent transthoracic echocardiographic evaluations every 6 months.\nThe patient claimed to have chest discomfort in March 2011 and was admitted to our hospital in October 2011. A transthoracic echocardiogram showed that the calcified mass measuring 19 × 8 mm was located between the P2 and P3 areas of the posterior mitral valve leaflet. There was no mitral regurgitation, and her ejection fraction was 67%. There were no findings suggestive of infectious endocarditis (Figure ). On cardiac catheterization, the coronary arteries were intact without an obvious thrombo-occlusive lesion. Computed tomograms (CT) confirmed the severe calcified mass on the posterior mitral valve leaflet (Figure ). Laboratory examinations were unremarkable.\nBecause there was potential risk of thromboembolism, surgical intervention was indicated for the calcified mass or tumor on the mitral valve. Definitive diagnosis was also expected after surgical excision of the mass.\nThe patient underwent surgical removal of the mass with the aid of cardiopulmonary bypass. The mitral valve was inspected through a right-sided left atrial incision. A round mass was originating from the P2 area and measured 8 mm in diameter. The calcified process was localized to the posterior leaflet itself. The entire mass was excised and submitted for histopathological examination. The defect on the posterior leaflet of the mitral valve was patched with a glutaraldehyde-treated autologous pericardium.\nNo regurgitation was detected after the procedure. Weaning from the cardiopulmonary bypass was uneventful.\nGrossly, the mass was white and measured 9 × 5 × 2 mm. Histological examination revealed nodular calcification in the fibrous connective tissue with dense fibrin and mixed inflammatory infiltration, predominantly with plasma cells and lymphocytes. There were no identifiable myxoma cells or malignant cells. Consequently, a definitive diagnosis of cardiac CAT was made (Figure ).\nThe patient recovered uneventfully and was discharged without any adverse events. No recurrent cardiac mass has been detected at 38 months after the surgery.

A 13-year-old male patient reported to the orthodontic clinic with the chief complaint of irregularly placed teeth in upper and lower jaw. His medical and dental history was noncontributory. On examination, he had an asymmetrical face with straight profile and competent lips. Chin was deviated toward the right side in occlusion due to the functional shift of mandible. There were no other associated signs or symptoms of temporomandibular disorder. Molar relation was Class I on both sides on Class III skeletal bases with average mandibular growth pattern. Posterior crossbite extended from canine to the first molar on the right side and on first molars on the left side. Maxillary and mandibular anterior crowding with deep bite was present with highly placed maxillary right canine and lingually placed lower left lateral incisor. There was upper midline shifted toward left side by 3 mm and lower midline shifted toward right side by 3 mm [].\nCephalometric analysis revealed that he had cervical vertebrae maturation index stage 3, Class skeletal bases due to retrognathic maxilla with retruded maxillary and mandibular anteriors. Panoramic radiograph showed full complement of teeth in maxillary and mandibular arch except third molar in all quadrant, which was in almost crown completion stage [].\nModel analysis showed that patient had overjet of 1 mm and overbite of 6 mm with arch length deficiency of 7 mm in maxillary arch and 5 mm in mandibular arch. Asymmetric maxillary arch with a constriction of 4 mm in the molar and 2.5 mm in the premolar region on the right side was found on occlusogram. The initial contact point of upper and lower tooth of patient during closing of jaw [].\nTreatment objective was to correct the posterior crossbite to prevent the functional shift of the mandible toward the right side, to coincide upper and lower midlines and to relieve the maxillary and mandibular anterior crowding and achieve normal overjet and overbite with good intercuspation. The patient was planned to be treated with RME device to expand the maxillary arch and simultaneously correct the upper midline shift with fixed mechanotherapy.\nRME was done using a banded type Hyrax appliance which was palatally soldered bilaterally to the bands of first molar and first premolar on either side with a 19-Gauge stainless steel wire. The molar bands were welded with molar tubes on either side. The removable lower posterior bite plane was given from mesial of the first premolar to the second molar bilaterally on lower arch to jump the bite and Hyrax appliance framework was cemented to the maxillary arch. The screw was turned twice each day, once in the morning and once in the evening, for a total of 0.5 mm activation per day. The activation was carried out until desired 5 mm expansion was achieved in 10 days.\nImmediately after the expansion, 0.022 slot McLaughlin, Bennett, Trevisi preadjusted brackets were bonded on the maxillary arch to correct the maxillary anterior crowding []. The central incisor started moving towards the midline diastema reciprocally by the residual forces of the elastic transseptal fibers and also using power chain. Tight figure of eight was given from maxillary right central incisor to right upper canine to prevent reciprocal movement of the right central incisor. The expansion appliance was left for 4 months aid to in retention. After the removal of the Hyrax appliance, the removable maxillary anterior bite plane was used for bite opening as well as retention. The mandibular arch was bonded, and 0.014″ NiTi is placed for alignment. Once the alignment was completed, coordinated 0.017″ × 0.025″ SS wire was placed in upper and lower arch. Pre- and post-model symmetry were compared with ortho grid. Posttreatment records show proclination of upper and lower anteriors for compensation of arch length-tooth size discrepancy []. Lateral cephalometric superimposition shows a significant amount of growth changes in maxilla, mandible, and soft tissue of face [].

A 51-year-old Asian woman presented to a gynecologist with an irregular menstrual cycle, for which she was prescribed oral contraceptives for 3 months. During that period, she complained of a growing, preexisting mass inferior to her left breast over the costal ridge. This painless mass showed no skin hyperpigmentation or visible small blood vessels. She reported occasional congestion a couple of days prior to menstruation as a result of this mass. No oozing secretion was ever detected when breastfeeding. She did not have a fever or experience any changes in appetite or weight at the time of the visit, after which she was referred to a surgeon.\nHer weight was 49.40 kg and her height was 150 cm, with a body mass index (BMI) of 21.96 kg/m2. She did not have any underlying diseases and was not on any medications but the prescribed oral contraceptives. Her first menstruation came at 14. She currently has two children, giving birth to the first at 32. She breastfed her first child and her second child for 2 years and 1 year, respectively. Prior to the aforementioned treatment for her irregular menstrual cycle, she had not received any contraceptive or hormonal drug. There was no history of alcohol consumption or tobacco smoking. There was no family history of breast and gynecologic cancer. Her maternal aunt was diagnosed as having colon cancer in the eighth decade of life.\nAt the first physical examination, she had no fever. Her vital signs showed a pulse rate of 80 beats per minute, a respiratory rate of 18 times per minute and a blood pressure reading of 126/72 mmHg. A well-defined round mass of 2 cm diameter was detected inferior to her left breast. This mass was not attached to the skin or chest wall and did not appear to cause any inflammation or skin retraction. No abnormality was detected at the equivalent location on her right breast. Axillary and supraclavicular lymph nodes were also not palpable.\nThe mass was initially investigated by ultrasonography. Several lobulated hypoechoic nodules were shown outside the breast tissue, inferior to our patient’s left breast: a large nodule of 15.6 × 9.5 mm and two smaller ones of 4.0 × 2.3 and 2.7 × 1.6 mm with marked hypervascularization. Her mammographic finding was classified into Breast Imaging Reporting and Data System (BIRADS) 3, showing mild scattering, round and benign microcalcifications in both breasts, and unremarkable visualized axillary lymphadenopathies.\nThe mass was excised (Fig. ) without suspicion of malignancy and the tissue subjected to pathological examination. A pathology report showed the 2 × 1.8 × 1.5-cm tumor to be a poorly differentiated adenocarcinoma, morphologically consistent with invasive ductal carcinoma of no special type arising in ectopic breast tissue. All margins were negative. No lymphovascular invasion was seen. For immunohistochemical studies, estrogen receptor (ER) was negative but the positivity of the receptors of progesterone (PgR) was 40% of the neoplastic cells. Her2/neu was negative. Ki-67, used as a proliferation index, was 70%. The tissue was considered to be the luminal B subtype.\nAs the tissue was malignant, nodal metastasis must be considered. Seven days following excision, the surgeon performed sentinel lymph node biopsy in our patient. Radionuclide was injected into the left periareolar area and the lesion site where the excision was done. No metastatic neoplasm presented in any of all four lymph nodes. We then considered this a typical breast cancer with TNM classification of T1cN0M0, stage Ia.\nShe was scheduled for adjuvant therapy, in which she received four cycles of chemotherapy with cyclophosphamide 960 mg and docetaxel 120 mg per cycle. She then received hypofractionated and boost radiation (42.5 Gy in 16 fractions and boost doses of 10 Gy). Tamoxifen was prescribed as an antihormonal therapy following the radiation. No serious adverse effect resulted. After 2 years of follow up, no evidence of disease recurrence was detected by physical examination and mammography.

A 60-year-old female presented to the outpatient cardiology clinic for evaluation of worsening chronic hypertension for which she had been on hydrochlorothiazide/Valsartan for 10 years. Her systolic blood pressure exceeded 200 mmHg in the office, and aggressive medical therapy was initiated in the outpatient setting. She returned to the emergency department the following day with headache and malaise and systolic blood pressure above 200 mmHg for which she was treated and discharged.\nShe returned to the emergency department again 5 days later, this time with complaints of word finding difficulty, blurred vision, and lower extremity tingling. Her blood pressure on presentation was 216/81 mmHg. She was admitted, and workup demonstrated no acute intracranial process or carotid stenosis. Echocardiography revealed mild concentric left ventricular hypertrophy with a preserved ejection fraction. Her blood pressure continued to be refractory to medical therapy despite five antihypertensive agents and eventual initiation of an esmolol infusion. A renal artery ultrasound identified renal artery stenosis with flow at the arterial origin measuring 350 cm/s on the right and 208 cm/s on the left (); flow velocity in the supraceliac aorta was also noted to be elevated. She had no history of kidney disease and no elevation of her creatinine. Vascular surgery was consulted and a history of lower extremity claudication was elicited. On exam she had weak but palpable femoral pulses and an audible abdominal aortic bruit; ankle-brachial index measurements were deferred and the patient was scheduled for angiogram.\nThe patient underwent aortography the following day and on selective angiography the renal arteries were found to be widely patent. Significant stenosis was identified at the distal thoracic aorta extending into the abdominal aorta but terminating proximal to the celiac trunk. The degree of stenosis was deemed to be greater than 90% and a pressure gradient between the upper extremity and intra-aortic measurements exceeded 100 mmHg. CTA was subsequently performed to evaluate the extent of the lesion and confirmed a stenosis 1.3 cm proximal to the celiac origin measuring 5 mm at its narrowest point (Figures and ). The patient underwent arteriogram; the stenosis was successfully navigated and a Protege 14 × 40 x 12 mm nitinol stent (Medtronic Vascular, Santa Rosa CA) was delivered followed by a 10 mm postdilation balloon. A completion arteriogram demonstrated excellent flow across the stent.\nAfter stenting, the patients' systolic blood pressure was 140-160 mmHg, and she experienced resolution of her lower extremity claudication. She was discharged from the hospital on Aspirin and Plavix and a blood pressure regimen consisting of lisinopril, hydralazine, amlodipine, and carvedilol.\nShe was lost to follow-up until two years later when she returned to the hospital with a blood pressure of 220/85 mmHg, with complaints of chest discomfort. CTA demonstrated stenosis in the distal portion of the aortic stent. An angiogram was performed, and the stent was ballooned to 12 mm. Pressure gradient measurements taken before and after dilatation decreased from 60 mmHg to 20 mmHg. On follow-up one year later, she continued to experience excellent blood pressure control.

A 14-year-old male, diagnosed as juvenile nephronophthisis was initiated on continuous ambulatory peritoneal dialysis (CAPD) at the age of 7 years. The initial peritoneal equilibration test (PET) test revealed a low transporter status and he had good ultrafiltration. After 3 months of being on CAPD, he underwent a live related renal transplantation at the age of 7 years with the mother as the donor. Unfortunately, he had primary graft failure due to thrombosis of graft renal artery, and he continued CAPD. After about 18 months, he had an episode of fungal peritonitis with candida albicans isolated on culture. CAPD catheter was removed, and he was initiated on hemodialysis via right internal jugular tunneled catheter. After about 5 months, he developed catheter-related blood stream infection not responding to antibiotic therapy requiring removal of hemodialysis catheter, and he was reinitiated on CAPD. Despite four exchanges with 1 L dwell volume, he remained fluid overloaded and the PET test repeated showed high transporter status. Since he had no permanent vascular access, he continued to be on CAPD with fluid restriction and high dose diuretics with occasional hemodialysis support through temporary vascular access. After 54 months of peritoneal dialysis, he started experiencing abdominal symptoms in the form of intermittent abdominal pain, nausea, vomiting, weight loss with abdominal distension. Ultrasound scan of the abdomen revealed moderate ascites with septations. The ascitic fluid study revealed exudative ascites and predominant lymphocytes with negative adenosine deaminase. Antituberculous therapy was started as tuberculosis is highly prevalent and has a similar presentation. CAPD was discontinued, and he was started on hemodialysis. After 2 months of antituberculous therapy, the patient continued to be symptomatic with progressive abdominal pain and abdominal distension. Computed tomography abdomen with oral and intravenous contrast revealed prominent bowel loops with thickened peritoneum [] barium meal follow through done revealed dilated small intestine confined mainly to the left side of the abdomen.\nHe was taken for explorative laparotomy because of worsening abdominal symptoms. Intraoperatively, there were dense adhesions of bowel loops to the parietal wall and between bowel loops. Omentum was seen plastered onto bowel loops. Adhesions were released and enterolysis done. Peritoneal and omental biopsies wtaken and were sent for histopathological examination. Histopathologic examination revealed adipose tissue cells with large areas of fibrosis, collagenization, inflammatory cells, hemorrhage, and hemosiderin-laden macrophages consistent with sclerosing peritonitis [].\nAntituberculous therapy was stopped, and oral prednisolone was started at the dose of 1mg/kg/day, tapered gradually after a period of 4 weeks to the maintenance dose of 10 mg/day. He was also started on tamoxifen 10 mg/day. He continued to be on hemodialysis support. During the period, he had abdominal discomfort and was advised small frequent meals. After about 1 year, he received a deceased donor renal allograft with antithymocyte globulin induction and tacrolimus, mycophenolate mofetil and prednisolone for maintenance immunosuppression. Tacrolimus trough levels were maintained at 8–10 ng/mL during the initial 3 months, reduced to 5–8 ng/mL thereafter.\nTamoxifen was continued for another 6 months and stopped. Now almost 16 months since transplantation, he is doing well with normal allograft function (serum creatinine of 0.9 mg/dL) and no abdominal symptoms.

A 70-year-old man previously being treated for stable alcoholic liver disease presented with gradually progressive diffuse abdominal pain associated with vomiting and constipation for 7 days. Physical examination revealed gaseous abdominal distention without tenderness or mass. He had a history of 2 laparotomies in the past both for small bowel obstruction secondary to enterolith impaction that had failed to resolve with conservative measures.\nThe finding on first operation 3 years ago was that of a 3 × 5 cm obstructing enterolith in the ileum 20 cm proximal to the ileocaecal junction. This was removed through an enterotomy and the affected segment of ileum was resected with primary end to end anastomosis. There were no diverticula or any other inciting factors identified. The histopathology of the resected small bowel was reported to have no specific findings.\nFollowing this, he presented 2 years later with similar symptoms. On second operation the findings were again similar to that of the first operation with an impacted enterolith in the mid ileum along with minimal adhesions. He underwent enterotomy and removal of the enterolith. Following the second operation he was asymptomatic till this presentation.\nAt the current presentation, his hematological and biochemical workup was normal and abdominal radiographs were inconclusive. USG revealed a normal study.\nHe was initially managed conservatively in lines of adhesive bowel obstruction.\nIn view of patient's general condition and lack of facilities, CT scan and endoscopy could not be done.\nAfter a mild initial symptomatic improvement, he developed gradual and progressive abdominal distention with pain and obstipation. Suspecting adhesive obstruction and keeping in mind the possibility of a recurrent enterolith bowel obstruction, he was taken for an exploratory laparotomy. On table findings were those of a recurrent enterolith 5 × 5 cm in size impacted in the mid ileum with multiple dense serosal adhesions and bands as shown in Figures and . Apart from this no other abnormal findings were identified.\nThe enterolith was disimpacted through an ileal enterotomy followed by primary closure of the enterotomy.\nThe enterolith was not sent for biochemical analysis considering that it may not contribute to additional information from management point of view.\nHis subsequent postoperative course was stormy and developed burst abdomen on 8th postoperative day that required mass closure. But following this he showed gradual and steady improvement. After a total stay of 6 weeks, he was discharged in a stable state and had improved on follow-up visit at 3 months. At follow-up he was advised to avoid high roughage diet and consume stool softeners on PRN basis thinking that this would help him avoid another similar episode.

A 69-year-old woman presented with a 19-month history of pain and an enlarging soft tissue mass in the ulnar aspect of the PIP joint of the fifth finger of the left hand. She was a housewife who performed no particular work or sporting activity. She had a history of minor trauma involving bruising of the finger in a door and was referred to a neighboring clinic 14 months before the visit to our hospital. Plain radiographs taken at the previous clinic had shown no sign of fracture, but instead revealed an abnormal calcifying lesion of the soft tissue of the left fifth finger. She had visited several clinics and hospitals and had been treated with analgesics and splinting for more than 2 months, but the pain in the finger had gradually worsened. Thus, she was referred to our hospital for definitive diagnosis and treatment.\nPhysical examination revealed tenderness around the PIP joint of the fifth finger with an apparent subcutaneous tumor, measuring around 1 cm in diameter (Figs. A and B). She experienced pain around the PIP joint of the fifth finger when the fist was tightly clenched and/or when the lesion contacted another object. There were no signs of infection or neurovascular disturbances, and no history of previous infection. The range of motion of the affected PIP joint was slightly more restricted than that of the contralateral side, but there was no functional impairment of the finger. Blood chemistry analysis showed no signs of inflammation or other abnormalities.\nPlain radiographs of the fifth finger taken 5 months before the initial visit to our hospital revealed a well-defined calcified soft tissue mass overlying the ulnar side of the proximal and middle phalanges that was well separated from the adjacent bone, with no periosteal reaction (Figs. A and B). Radiographs taken at the time of presentation at our hospital revealed an enlarged 2-humped calcifying lesion overlying the ulnar side of the PIP joint (Figs. C and D). Computed tomography also showed a well-defined and rimmed calcifying soft tissue mass with calcification of the outer margins on the ulnar side of the left fifth finger, without bony destruction (Figs. A–D). T1- and T2-weighted magnetic resonance imaging (MRI) showed a well-defined soft tissue mass with low signal intensity overlying the ulnar side of the proximal and middle phalanges (Figs. A–D). T1-weighted MRI also showed that the lesion was well separated from the adjacent bone and surrounded by a diffuse high-intensity area, suggesting perilesional soft tissue edema. No periosteal reaction was detected. Moreover, there was no abnormal intensity in the bone marrow observed on either T1- or T2-weighted MRI, suggesting no progression to the bone marrow. Contrast-enhanced MRI showed no enhancement of the soft tissue mass (Fig. E). There was no cartilaginous matrix formation. Taken together, these imaging modalities indicated a well-defined subcutaneous calcifying mass with a characteristic peripheral radiopaque ring overlying the ulnar side of the proximal and middle phalanges, suggesting a benign calcifying lesion, namely a calcifying deposit. An excisional biopsy was recommended to achieve a definitive diagnosis, but this was declined by the patient. Thus, no invasive treatments were administered, and she was treated with analgesics and encouraged to massage the affected finger.\nThe pain in the left fifth finger gradually improved during the following 6 months. In addition, the limited range of motion completely recovered, and follow-up radiographs showed complete resolution of the calcifying mass at 6 months after the initial visit to our hospital (Figs. A and B). At the final follow-up conducted 3 years after the initial visit to our hospital, the patient had a full range of motion without recurrence of acute calcific arthritis.

A 22-year-old male patient, a labour worker by occupation, had presented to our outpatient department with a diagnosis of concomitant nonunion of the shaft and neck of the left femur of eight months duration. On the basis of history and previous records, it was known that the patient had sustained an open grade IIIA fracture of shaft femur and a closed ipsilateral femoral neck fracture of the left side following road traffic eight months prior to the above presentation. The femoral shaft fracture was managed with an external fixator application, and the femoral neck fracture management was delayed due to unhealthy soft tissue conditions around the proximal lateral aspect of the thigh. The treatment of both fractures was further delayed because the patient developed an infection of the open wound of the femoral shaft fracture. To add to the complications, he had developed pin site infection as well. Following that, open debridement of the femoral shaft wound site was performed, and the external fixator was removed at the primary treating institution. Thereafter, the limb was kept splinted on a Thomas splint. Subsequently, the wound and pin sites were healed and the patient was referred to our center, which is a tertiary care center and teaching medical institute, after a total duration of eight months following injury. Clinicoradiological examination confirmed the non-union of the left femoral shaft fracture and ipsilateral femoral neck fracture (Figure ). Blood investigations revealed raised serum inflammatory markers (erythrocyte sedimentation rate (ESR)=25 mm/hr and C-reactive protein (CRP)=12 g/L). However, there were no clinical signs of local inflammation around the fracture sites, the healed wound, and the pin sites. An MRI evaluation of the hip joint and the affected thigh was planned but was deferred as the patient was claustrophobic and not comfortable. Instead, an ultrasound evaluation along the femoral shaft and the hip joint was performed, which revealed nil collection or edema. A CT evaluation was performed to evaluate the femoral neck fracture and femoral head to look for any resorption of fracture ends, and any signs of bony abnormality in the femoral head. The hip joint space was normal, sufficient length of the neck in the proximal head fragment was preserved and there were no signs of lucencies, sclerosis, or resorption in the femoral head (Figure ). We, therefore, assumed that the femoral head to be viable and salvageable.\nWe reserved our plan for definitive fixation with bone grafting or staged fixation depending upon the exposure of the fracture site. Considering the need for open reduction of both the fracture sites we positioned the patient on a fluoroscopically translucent standard operating table. The femoral shaft fracture was exposed through the previous debridement scar site that was located anterolaterally. Contrary to the clinical evaluation, the medullary cavity on both sides of the fracture was filled with pus with no extraosseous collection. Samples were taken for culture and sensitivity testing. The medullary canal and the surrounding bone were thoroughly lavaged and debrided. The previously paced external fixator pin sites were curetted and were found to be healthy. After thorough femoral shaft debridement, further lavage was performed after reaming of the intramedullary cavity proximally up to the greater trochanter and distally up to the condylar region in order to further clean the canal of any necrotic or infective debris. Thereafter, the anterolateral incision was further extended proximally towards the greater trochanter tip. The canal was entered through the trochanteric tip. We inserted a rush nail based cylindrical antibiotic cement spacer into the medullary canal up to the reaming site in the distal fragment. Antibiotic simplex® cement was used to prepare the cement spacer which consists of colistin and erythromycin. The previous wound culture reports were suggestive of Klebsiella pneumoniae that was sensitive to colistin. Along with that, we placed antibiotic cement beads in the surrounding extraosseous space as well. The femoral neck fracture was not exposed considering the risk of contaminating the joint with distal infection. We rather attempted aspiration of the affected hip joint from a sterile zone. Only a minimal amount of clear joint fluid could be aspirated that was also sent for culture sensitivity testing. Following that, the shaft femur fracture was stabilized by an external rail fixator with antibiotic cement coated pins proximally and distally. There was a medial defect at the shaft femur nonunion site, and therefore, the rail fixator was tensioned in compression laterally to prevent varus failure (Figure ).\nThe femoral neck fracture was aligned under fluoroscopic guidance and a positive inferomedial cortical edge was induced to prevent varus failure. The femoral neck fracture was also spanned by two antibiotic cement-coated Schanz screws. The lateral ends of those pins were incorporated in the rail external fixator and tensioned in valgus force to prevent varus collapse of the femoral neck. The wound was closed in layers without drain after meticulous hemostasis. Empirical intravenous antibiotic therapy based on previous culture reports was initiated in the immediate postoperative period. Thereafter, according to the culture isolates (coagulase-negative Staphylococcus aureus and K. pneumoniae), we initiated intravenous antibiotics, tigecycline, levofloxacin, and clindamycin, and continued them for three weeks. The systemic impact of antibiotic therapy was monitored periodically and was uneventful. The patient was discharged on sensitivity-based oral antibiotics for three more weeks. The hip joint aspirate was found to be sterile upon culture testing. The postoperative wound healed without any complications and pin sites remained healthy and were regularly cleaned. The antibiotic beads were removed after six weeks. The patient was mobilized using a walker with a toe touch stance on the affected side. Our plan was to remove the intramedullary cement spacer and the external fixator at three months duration anticipating the inflammatory parameters to be normalized by that time. However, the plan to remove the intramedullary antibiotic cement spacer was deferred after the evaluation of the follow-up radiographs (Figure ). The radiographs revealed bridging bone formation from the bone adjacent to the fracture margins. Also, the gap at the femoral neck fracture site appeared reduced. While we did not anticipate the healing of the femoral neck fracture, the callus formation at the shaft fracture was a good sign for the possibility of fracture union. The blood counts and inflammatory parameters were all normal at this stage. The patient was further followed for another three months duration, and there was sequential progress in the bridging bone formation around the shaft fracture site and no gap was appreciable at the femoral neck fracture site throughout the follow-up (Figure ).\nInterestingly, the medial defect at the shaft fracture also had the signs of bridging bone formation. However, the patient complained of pin loosening. The rail fixator was thus removed. Post fixator removal, the patient had no symptoms at hip and the shaft fracture site. Pin sites were free of any discharge. Since the radiographs were insufficient to precisely evaluate the status of femoral neck fracture and only biplanar healing of the shaft fracture could be evaluated, a CT scan was ordered after the fixator removal. Surprisingly, the CT scan revealed a complete union and consolidation of the femoral neck fracture nonunion, and more than three-fourths of cortical bridging of the femoral shaft fracture. Based on this finding, the patient was allowed a partial weight-bearing for a month and full weight-bearing from the next. The most recent radiographs revealed complete further consolidation. Currently, after one year of the last surgery, the patient is not on any antibiotic therapy and the levels of the inflammatory marker are within normal limits. The patient had some stiffness of the knee that has been recovering with regular exercises. The patient had been advised for the removal of the intramedullary cement spacer. However, the patient has opted for a later date for the removal of the intramedullary cement spacer. The hip movements are completely normal and painless. The patient is able to walk without any limitation, and also able to perform labor activities.

A 78-year-old woman was referred to our department due to a mass in the lower abdomen. She had a history of type 2 diabetes mellitus and had been insulin-dependent for more than 7 years. She was admitted to the Internal Medicine Department because of deteriorating blood glucose control. Her HbA1c was 10.6% and total daily insulin dose was 58 units. On admission, physical examination revealed a firm mass in the lower abdomen with no pain or tenderness, and she was referred to our department for further treatment.\nComputed tomography revealed a mass measuring 28 × 18 × 30 mm in the subcutaneous tissue (). She had injected insulin into the abdomen near the mass. We suspected that this was a skin-related complication of insulin therapy, and the patient was instructed to refrain from injecting insulin into the mass. To confirm the diagnosis, we planned excision of the mass. However, several days later, she fell on the floor and sustained right femoral neck fracture. She was admitted to the Orthopedic Department for surgical treatment, and excision of the mass was postponed. During this hospitalization, the floor nurses supervised her insulin injection. Her blood glucose control improved rapidly, and she had experienced hypoglycemia several times. Two months after visiting our department, her HbA1c was 7.8% and daily insulin dose was decreased to 33 units. She was discharged from our hospital, but she had not visited our department at that time.\nFour years later, she was admitted to the Internal Medicine Department because of renal anemia and referred to our department again due to the same mass in the lower abdomen, which was suspected to be a malignant soft tissue tumor. The mass was enlarged compared to her first visit. Her HbA1c was 7.4% and daily insulin dose was 22 units. Computed tomography revealed that the mass had expanded to 60 × 20 × 35 mm with unclear borders. We found her previous abdominal computed tomography results and confirmed that the mass had already existed 8 years previously, but it had been much smaller (17 × 12 × 14 mm) ().\nWe excised the mass under local anesthesia. The mass was yellowish elastic hard, and had unclear boundaries. We excised the mass with indurated subcutaneous fat (). On pathological examination, hematoxylin and eosin staining showed broadly degenerated subcutaneous tissue and large amounts of homogeneous eosinophilic material in the tumor tissue. Congo red staining confirmed that they were amyloid deposits. There was no evidence of vascular involvement. Amyloid-AA, kappa-chain and lambda-chain were not detected immunohistochemically (). These findings confirmed the pathological diagnosis of insulin injection-related local amyloidosis. The patient recovered uneventfully. No specific change was observed in her blood glucose level. She was treated her renal anemia in the Internal Medicine Department and discharged from our hospital at 25 days postoperatively. No wound complication was observed.

A 39-year-old man presented to the radiation oncology clinic for surgeon’s consultation, requiring an adjuvant radiation to his scalp after extensive resection of a primary scalp lesion.\nSix years earlier, the patient had developed a scalp lesion on the right parietal side and underwent a resection. The initial pathology report indicated squamous cell carcinoma. After nearly 6 years of being disease-free, he noted a new lesion on the same spot, which had disseminated and involved almost all scalp tissue within one month. On magnetic resonance imaging, a vegetative and enhancing mass over the right parietal bone measuring 74 mm × 74 mm × 38 mm was noted, with suspicious invasion to the external table of bone and adjacent bone marrow. Multiple suspicious lymphadenopathies on the left cervical levels 2 and 5 as well as the left occipital and parotid regions were reported with short axis diameter (SAD) of about 10 mm. A core needle biopsy of suspicious lymph nodes indicated squamous cell carcinoma and later, the patient underwent an extensive scalp surgery for resection of the lesions. The skin defect was covered with a rotational flap and skin grafting.\nThe surgical pathology report indicated a 9-centimeter large tumor with 2.5 cm thickness, and the tumor was classified as poorly differentiated SCC. The tumor showed lymphovascular invasive features, but perineural invasion was not detected. Deep margin of the excised tissue was affected by the tumor; however, bone trabeculae and intervening marrow were not involved. The surgeon additionally resected two other suspicious lesions on the right frontal and left parietal regions of the scalp. The former was reported to be actinic keratosis grade 3 (Bowen’s disease), while the latter showed features of early invasive SCC in a background of actinic keratosis with a thickness of 2.2 mm and close medial margin (3 mm).\nWe intended to treat the patient with adjuvant radiotherapy to a total dose of 66 Gy with 6 MV photons. However, it was soon realized that such a procedure would require a significant brain volume to receive high radiation doses. For this reason, planning and treatment was divided into two steps, including EBRT and brachytherapy (BT).\nFor EBRT treatment, the patient was immobilized using U-shape thermoplastic head mask. A fine cut (1 mm) computed tomography (CT) scan was acquired and transferred to Eclipse 13 planning software (Eclipse, Varian Medical Systems, USA). Clinical target volume (CTV) was defined as the total thickness of skin down to the periosteum of the skull bone. Also, a 10 mm radial margin to the surgical scar was considered. Planning target volume (PTV) was delineated as CTV with a 5 mm margin. Using 3D conformal radiotherapy, scalp (including the graft tissue, tumor bed, and surgical scars) and neck was irradiated with 6 MV photons to a cumulative dose of 42 Gy in 21 daily fractions, including two right and left lateral fields. The treatment of neck was continued for nine more fractions to a cumulative dose of 60 Gy with 6 MV photons by 3D conformal radiation delivered through two antero-posterior and postero-anterior fields bilaterally to cover cervical nodal levels 2 to 5. The patient received concurrent weekly cisplatin infusion, with a prescribed dose of 35 mg/m2. EBRT treatment was delivered by Elekta Compact linear accelerator.\nFor BT part of treatment, we prepared an exclusive mould and inserted 21 brachytherapy catheters in a specific pattern ( and ). The mould was created with a waxy material to cover all diseased scalp tissue, and its thickness varied between 9 and 21 mm, depending on the thickness of reconstructed scalp tissue in different loci. Eight confronting pairs of catheters, with a distance of about 1 cm from each other, were placed through frontoparietal part of the mould towards frontal and occipital directions, and 5 supplemental catheters were placed through occipitotemporal part of the mould to cover the remaining scalp skin. The catheters had a constant distance from the upper surface of the mould.\nPlanning CT scan with 1 mm slice thickness was acquired for patient with mould fixed in place with a U-shape thermoplastic head mask in prone position. Images were transferred to HDR plus planning system, where catheters’ position was reconstructed (). A TG-43 task group algorithm was used for HDR brachytherapy treatment planning. The patient received high-dose-rate brachytherapy boost with Cobalt-60 MultiSource HDR brachytherapy unit (Eckert & Ziegler BEBIG GmbH, Germany) to a total dose of 22.4 Gy in 8 once-daily fractions. Each treatment session lasted for nearly thirty-two minutes. Considering an α/β ratio of 10 Gy for tumor, the equieffective dose in 2 Gy per fraction (EQD2) of the brachytherapy boost was calculated to be 23.9 Gy, according to Dale et al. []. Therefore, the patient received 66 Gy to the bed of the primary scalp lesion through combined radiotherapy with brachytherapy boost without surpassing the radiation limit to the brain.\nFor better comprehension of the advantages of brachytherapy boost treatment, we also created a treatment plan with sole EBRT application to the final dose of 66 Gy in 33 fractions, with two lateral fields to the whole scalp tissue and bilateral cervical nodal levels, similar to the initial plan. Brain and orbital structures, including optic nerves, chiasma, and lenses were contoured as organs at risk, and dose volume histograms (DVH) were calculated for both plans ( and , []).\nThe patient experienced temporary grade 1 skin erythema and hyperpigmentation during the brachytherapy treatment, which resolved in two weeks after the completion of treatment.\nFour months after brachytherapy to the scalp lesion, the patient remains disease-free without an evidence of recurrence, with acceptable cosmetic results considering the serious and extensive surgery (). Fortunately, no latent skin toxicity was evident, and he did not complain of any treatment-related side effects. Neurological and physical examination were typical.

A 54-year-old female patient presented to our clinic with complaints of occasional pain, numbness, and paralysis of her right hand. She began to notice weakness of her left hand that had begun 2 years earlier. She had no history of trauma and no family history of amyloid neuropathy. She had a history of ovarian tumor 25 years ago and thyroid tumor 5 years ago, both of which healed after surgical resection.\nPhysical examination revealed a mass 5 × 3 cm in the ulnar side of her left proximal forearm shown in Figure . The lesion was firm, nonpulsatile, and tender on palpitation. She had numbness on the ulnar side of her left hand and fingers. The 2-point discrimination test revealed that 15 mm at the lateral side of the ring finger 10 mm at the little finger. She had muscle weakness with abduction and adduction of the ring finger and the little finger, but no deficit in the range of motion in the elbow. The electrophysiological study revealed a significant decrease in the motor nerve conduction velocity of the ulnar nerve from distal to the mass to proximal to the mass. MRI revealed that the ulnar nerve was swollen longitudinally, had a spindle shape, and measured 3.0 × 2.7 cm in the axial plane and 7.2 cm longitudinally shown in Figure . The swollen lesion had a relatively homogeneous isosignal intensity on T1-weighted images and had relative heterogeneous enhancement after the intravenous administration of gadolinium (Gd)-based contrast agent with the findings of flow void. Based on these findings, the differential diagnoses included a vascular malformation that surrounded and compressed the ulnar nerve. Excisional biopsy was not performed because of the risk of hemorrhage and iatrogenic nerve injury. The lesion was instead surgically explored with a longitudinal incision shown in Figure . The operative findings showed no vascular malformation; however, the ulnar nerve fascicles were swollen and degenerated. The affected lesion had changed into a yellow tissue shown in Figure . After the yellow tissue was carefully removed microscopically, approximately 7 cm defects remained between intact nerve fascicles. The resected tissue was hard and had a stick-like shape shown in Figure .\nThe histopathological examination showed degenerated connective tissue with diffuse eosinophilic deposition, which included calcification, ossification, and chondroid tissue shown in Figure and b. No intact nerve tissue remained. The deposit was positive for Congo red stain and appeared apple-green under polarized light, which suggested the diagnosis of amyloid neuropathy shown in Figure .\nImmunohistochemical staining showed that the deposit was immunopositive for light-chain λ antibody shown in Figure . The deposit was immunonegative for amyloid A, transthyretin, and light-chain κ. Therefore, the pathological diagnosis was AL amyloidosis.\nTo determine the association with systemic involvement, we conducted screening examinations. Bone marrow aspiration, cerebrospinal fluid examination, echocardiography, electromyography of the legs, chest computed tomography, and MRI of the brain and legs showed negative results. Physical examination revealed no sign of macroglossia or purpura on the skin. Autonomic dysfunction, including orthostatic hypotension, was not present. The only positive results were from the blood test, which showed high serum levels of amyloid protein A (159.2 μg/mL [<8.0]).\nTwo months postoperatively, the patient underwent nerve transplantation for reconstruction of the ulnar nerve. The sural nerve was sacrificed from the left lower leg and transplanted to the defect of the ulnar nerve. One year postoperatively after the nerve transplantation, she had no apparent evidence of metastasis or local recurrence. There was no recovery of numbness in the ring and little finger and the muscle weakness still had no recovery.

A 78-year-old male patient with coronary artery disease status post coronary stent placement was found to have a lung nodule on the chest radiograph at that time. The patient underwent a computed tomography (CT) scan, and bronchoscopy, and was found to have a 9 mm fatty endobronchial lesion in the bronchus intermedius above the middle lobe with 2 cm extraluminal fatty lesion into the right hilum. An endobronchial ultrasound with biopsy of the mass was performed, which showed benign bronchial epithelial cells. Since endobronchial resection of the mass would lead to a large defect in the right bronchus intermedius, the decision was made to perform robotic-assisted resection of the lesion (Video ).\nWe used the Da Vinci Xi robot to perform resection of the endobronchial lesion and hilar mass with right lower lobe superior segmentectomy to remove the lesion. The patient had a “five on a dice” port placement for the operation [, ]. First, we performed the right lower lobe superior segmentectomy to obtain adequate exposure of the hilar mass. We mobilized the superior segmental branch of pulmonary artery and superior segmental branch of the right lower lobe going to the inferior pulmonary vein and divided them with the vascular robot stapler. We divided the superior segmental branch of right lower lobe bronchus with the robot blue load stapler. We used indocyanine green angiography to define the borders of the superior segment of the right lower lobe, which was divided using the robot blue load stapler. This provided access to the hilar fatty tumor, which allowed for removal of the hilar mass and subsequent resection of endobronchial lesion with scissors. The frozen section on both lesions was negative for malignancy. We confirmed complete resection with intraoperative bronchoscopy that also showed a large opening in the airway.\nIn order to reconstruct the airway, we placed two 3-0 vicryl stay sutures at the proximal and distal ends of the airway and placed the suture through the posterior ports to pull the airway posteriorly away from the main pulmonary artery. We closed the opening with 4-0 PDS (polydioxanone) in an interrupted fashion eight times. This provided good closure of the opening. We performed a bronchoscopy that showed no abnormalities and the air leak test demonstrated no appreciable air leaks.\nThe patient went home on postoperative day 3 without any complications. The final pathology report was lipomatous hamartoma.

A 37-year-old male patient presented to the emergency department complaining of loss of strength in his upper right arm, right hand, and paresthesias along the arm. He also complained of neck pain that has been going on and off for about 2 years. The neurological symptoms appeared three months prior to the consultation. General examination was unremarkable. The initial neurological exam showed an upper right limb paresis, and the rest of the exam was normal. The patient had no recent travels, and lived with his wife and a son. The patient referred had no recent trauma to the head or the neck or any type of vehicle accident.\nThe initial clinical suspicion was a spinal cord compression at the upper cervical spinal cord, primarily due to the neck pain and the upper limb paresis that locate the lesion in this particular area.\nA noncontrast Computed Tomography (CT) was obtained to evaluate spine integrity (). A mass at the level of the odontoid process was seen with density similar to bone that corresponded to an old fracture of the odontoid process. Due to the changes noted in the density of the bone, the fracture has healed as pseudarthrosis. An important cervical canal stenosis was noted and immediately the patient was put in a rigid cervical collar to prevent any further damages to the spinal cord.\nDue to the high risk of myelopathy, Magnetic Resonance Image (MRI) of the cervical spine was ordered (). Signs of myelopathy are seen behind the mass of bone that was detected in the CT at the C1-C2 spinal cord levels, confirming the images on the CT that the fracture was in fact an old one, and the clinical signs of the patient were due to this injury in the spinal cord.\nOn a thoroughly second interrogation, the patient revealed a motorcycle accident that happened 23 years before this visit and listed a scalp laceration as the sole injury he had sustained at that time.\nThe patient was admitted for immediate surgery for decompression of the spinal canal. Transoral resection of odontoid process was scheduled. At the same time of the surgery an occipitocervical arthrodesis for cervical spine stabilization was also prepared. The surgery was performed without complications and the patient was then moved to the surgical Intensive Care Unit (ICU) for surgical follow-up. A CT was ordered after the surgery for a follow-up on the spine injuries. Adequate positions of the screws were seen, and almost complete removal of the pseudarthrosis was achieved.\nAfter four days in the intensive care unit, the patient continued his recovery at the neurosurgical hospitalization floor.\nAt day five of surgery, the patient presented with an acute respiratory failure secondary to obstruction of the upper airway and needed respiratory resuscitation and an emergency tracheostomy due to the difficult airway (secondary to the occipito-cervical arthrodesis, a hyperextension of the neck was difficult, and the high risk of spinal cord damage was primarily because of the short time between the surgeries). The patient was moved back to the ICU and continued his treatment with an orogastric feeding tube for 13 days waiting for the resolution of pharyngeal edema.\nTwenty-five days after the surgery, the patient was discharged to his home with the tracheostomy and without any need of gastric feeding tube. The paresthesias were in process of resolution and the paresis was slightly improving.\nThe follow-up consult was conducted one week after the surgery, neurological examination persists with a slight paresis on his right arm, he regained strength in the hand, and the paresthesias disappeared. The patient continued respiratory therapy for the tracheostomy management and was able to remove the tracheostomy tube 3 months after surgery.

A 53-year-old male with two GWH to his right cerebral hemisphere presented with a GCS score of 6 to the hospital. According to the emergency physician’s report, the patient was taken to the hospital about 3 h after the injury. The patient was on the way to the hospital with a fixed right pupil, so he was given mannitol timely in the ambulance. We speculated that the duration of brain herniation was at least 1 h. He was hemodynamically stable and intubated, there were two adjacent bullet holes in the patient’s right frontal area, and no ballistic exit was seen. Neurological examination revealed that his right pupil was fixed and dilated, and his left pupil was 2.5-mm wide and reactive. He was responsive to pain stimuli but not to verbal stimuli. A computed tomography (CT) scan of the head revealed a bullet trajectory with a right frontal comminuted fracture and bony and metallic fragments in the right frontal and right occipital lobes. There was also some brain tissue swelling with a midline shift to the left and subarachnoid hemorrhage (Fig. ). Since the patient had a brain herniation at admission, he was immediately transferred to the operating room for debridement and decompressive craniectomy after the first CT scan. Considering the specificity of the patient’s intracranial hematoma location and foreign body location, we performed an extended pterional approach and decompressive craniectomy in time. We did not temporarily remove the foreign body in the occipital lobe but waited for the patient’s vital signs to stabilize after the first operation and then evaluated whether it was suitable for removal or maintenance. The analysis of why this decision was taken is presented in detail in the surgical management section. The patient recovered well after the first operation with no infection or brain abscess development and underwent a second operation 2 weeks later to remove the foreign body in the occipital lobe (Fig. ). He was discharged 7 days later. The patient visited the hospital for a re-examination 2 months after the injury, and hydrocephalus was found to have occurred. We performed skull repair 3 months after injury. The patient came in for a 6-month follow-up. During the subsequent follow-up, hydrocephalus did not continue to develop, and head CT yielded no new or concerning findings, so we did not perform additional clinical management (Fig. ). The last telephone follow-up was performed a year after his injury. According to the patient’s family members, the self-care ability of the patient was fair, and he could complete housework alone. There was no obvious cognitive impairment, but his personality had slightly changed. The main manifestation was that he did not like to communicate with others. He did not experience seizures or other neurological symptoms. The Wisconsin card sorting test was used to assess the patient’s performance during the follow-up. The result was good. A series of non-cognitive function evaluations, such as the Functional Activity Questionnaire and Hamilton Depression Scale, were also carried out. The results were satisfactory, and the patient showed no signs of anxiety or depression.

A 59-year-old right-handed Caucasian lady, known to have migraine with aura and type-2 diabetes mellitus presented to our emergency department center with dysarthria, left upper motor neuron facial weakness and left-sided hemiparesis affecting the upper limb more than the lower limb. The patient presented with signs of a right middle cerebral artery (MCA) stroke with an National Institute of Health Stroke Scale (NIHSS) of 10 and unfortunately was out of the window period for intravenous thrombolysis as it was a wake-up stroke and last seen well (LSW) was unknown. A MRI of the brain was obtained on an urgent basis which showed an established infarction in the anterior third of the right MCA territory secondary to the occlusion of the superior M2 branch of the right MCA ().\nUpon further workup, CTA showed a filling defect in the right V4 segment of the right vertebral artery which was suspected of being a dissection or a FFT, with normal flow in the left vertebral artery and the basilar artery and its distal branches ().\nThe attending neurologist in the referring hospital discussed the case with our neurovascular on-call team and the patient was then transferred urgently to our hospital for emergent endovascular therapy (EVT).\nThe patient was transferred to King Fahad hospital of the university the same night. An urgent angiogram was performed through a 5-F femoral sheath and a diagnostic catheter, under local anesthesia. The left ICA injection showed a normal flow into the MCA territory as well as the anterior cerebral artery (ACA) territory, with no cross flow to the right hemisphere. The right ICA injection showed the previously mentioned occlusion of the superior M2 branch with deficient collaterals to central MCA core territory. The left vertebral injection showed normal flow in its intracranial segment with no reflux into the right vertebral artery with normal flow into the basilar artery and its distal branches (). The right vertebral artery was accessed just at its origin and a slow injection of contrast was administered in fear of dislodging any parts of the suspected thrombus. This injection confirmed the presence of the FFT in the V4 segment of the right vertebral artery with non-visualization of the right posterior-inferior cerebellar artery (PICA) or the distal flow into the basilar artery despite minimal filling of the contrast around the clot ().\nUsing an exchange wire, The vertebral catheter was exchanged into a 5-F intermediate catheter (Sofia; Microvention, Aliso Viejo, CA, USA). The intermediate catheter, under road map guidance; was advanced with limited wire excursion into the area of the clot. This was followed by manual aspiration that yielded a multiple clot fragments (). Post aspiration angiogram showed complete revascularization of the right vertebral artery with a slight delay in the right PICA with mild stenosis in the V3-4 junction (). The patient tolerated the procedure well and remained stable neurologically.\nImmediately after the compilation of the procedure, the patient was transferred uneventfully back to her referring hospital. The MRI obtained 24-hours post thrombectomy showed no new strokes in the posterior circulation territory (). Her stroke workup revealed the significant finding of a left atrial appendage with a thrombus which was discovered through transesophageal echocardiogram (TEE). In addition, she was found to have paroxysmal atrial fibrillation (AF). Given the presence of these 2 risk factors for cardioembolic strokes, the patient was started on anticoagulation in the form of vitamin K antagonist (VKA) warfarin for secondary stroke prevention. A follow-up echocardiogram and TEE were to be done in 3 months to assess the status of the left atrial appendage thrombus but unfortunately, the patient failed to follow up.

Three hours after being shot in the back, a 29-year-old Albanian man was admitted to the Surgical Department of our Emergency Center. An examination revealed two small caliber bullet holes over his thoracolumbar spine and sacrum, paraplegia and absence of the pulses. The deteriorating condition of our patient led to the decision to surgically explore his abdomen. No injuries to the viscera were found. A small retroperitoneal hematoma on his right side was opened. His pulse over his common iliac arteries was normal and there was no active bleeding at the area. Drains were placed and his abdomen was closed in layers. Because of an insufficient improvement of the monitored parameters, our patient was intubated and transferred to our intensive care unit for further resuscitation. Three hours later he developed ischemia in his left leg. His leg was cold, with no pulse up to the common femoral artery and there were signs of discoloration. Computed tomography of his chest and abdomen revealed two bullets - one in his left iliac fossa and a second in front of his sacrum (Figure ). Color Doppler imaging revealed an obstruction of the external iliac artery on his left side. No free fluid was found in his abdomen. There was also a multiple fracture of his twelfth thoracic and first lumbar vertebrae with no free fluids in his abdomen (Figure ). These findings alerted the vascular surgery team and after a consultation, a tentative diagnosis of a gunshot injury was made. The decision was made to re-enter the abdomen.\nA second surgery was performed eight hours after the first one. At his left iliac fossa no significant hematoma was noted. However, there was no pulse over his external iliac artery. After the division of the surrounding tissues it was possible to feel the obstructing foreign body within the common iliac artery. Once vascular control was obtained the artery was opened and the bullet removed (Figure and ). The embolectomy of the distal arteries was performed using a Fogarty catheter and a significant amount of thrombi was removed (Figure ). A pulse then returned to his leg. To alleviate developing compartment syndrome, crural and femoral fasciotomy were performed (Figure ).\nAlthough the leg performed well after the surgery, the postoperative period was complicated by multiorgan failure, which resulted in the death of our patient eighth days after receiving the injury.

The patient was a 21-year-old male with bilateral cleft lip. Severe cleft lip nose deformity, i.e. a short bridge and flat apex of the nose, were observed. Under general anesthesia, the nasal morphology was improved using cartilage of the nasal septum, and the lip deformity was improved by forming a tubercle of the upper lip using a lip switch flap with left inferior labial arterial and venous pedicles, the philtrum and bridge of the nose. The lower lip flap was designed to have a ∼10-mm width and a ∼17-mm length and transplanted to the upper lip. Its color immediately after surgery was favorable (), but marked swelling of the flap and surrounding tissue was noted 6 h after surgery, with which the flap developed venous congestion (). To release pressure due to the swelling on the vascular pedicle, sutures around the pedicle were removed, but blood circulation of the flap did not improve and congestion aggravated. Since flap necrosis was predicted, the flap that had been transplanted to the upper lip was returned to the lower lip 8 h after surgery to improve its blood circulation and prevent necrosis. Under venous sedation, the flap transplanted to the upper lip was released to a free state so that the mouth could be opened, oropharyngeal intubation was applied and sedation was switched to general anesthesia. Hematoma around the flap was removed by washing well with saline. After confirming blood flow from the flap stump, the flap was returned to the lower lip and fixed by sutures, and the transplantation site was simply sutured ().\nAfter surgery, the flap was covered with heparinized saline-soaked gauze to further reduce congestion. Congestion was improved 7 h after surgery (), and the flap returned to the donor site had almost completely recovered 1 week after surgery (). The flap was re-transplanted with sufficient tissue around the pedicle under local anesthesia (). Flap engraftment was favorable, and it was transected after 9 days. As of 2 years after surgery (), the cleft lip nose deformity had improved with a favorable course.

A 45 year old male patient who was run over by a train resulting in a right leg amputation at the level of the knee and a crush injury of the left foot. He was brought to our hospital about 2 h after the accident. The right lower limb had a severe comminution and bone loss at the knee joint, with the loss of skin and soft- tissue and crushing of muscle above and below the knee [Figures and ]. The left forefoot was completely degloved and all the toes were crushed and degloved as well [Figures and ].\nThe right lower limb was deemed not replantable as the knee joint was severely damaged and not salvageable, In addition, debridement of crushed and devitalized tissues would result in a 15-20 cm shortening and a limb that was at least 15 cm short with fused knee joint would not be functionally useful and primary insertion of prosthetic knee joint was not considered to be feasible by the attending orthopaedic surgeon.\nFocus was then shifted to the crushed left foot with a view to perform immediate debridement and early soft-tissue cover, to salvage as much of the foot as possible and get it fully healed and weight bearing at the earliest. Stable and sensate skin cover were vital, as this would be the only surviving foot. A large defect such as this would require a large distant flap or even two flaps. Best replacement for skin on the foot was anatomically identical skin from the opposite foot, which in this case was provided by the well-preserved amputated limb. The general condition of the patient was stable and he had no other life-threatening injuries. Immediate double free tissue transfer from the amputated limb was done. A plantar flap based on the posterior tibial vessels [] and a dorsal flap based on the dorsalis pedis vessels [], with the communication between the dorsal and plantar systems left intact through the deep branch of the 1st dorsal metatarsal artery. Satisfactory inset of dorsal flap [], and of plantar flap [] was achieved. Post-operatively the patient developed a hematoma below the dorsal flap. Since flaps were harvested from the amputated limb, small blood vessels that could not be seen were probably left unligated. Re-exploration and evacuation of hematoma was performed. Both flaps survived completely [Figures and ].

A 78-year-old man who was a chronic smoker presented to the maxillofacial department at a district general hospital with a 6-week history of difficulty in swallowing solids together with pain in his pharynx.\nOn examination, he was noted to have a 3 × 2 cm solitary pedunculated lesion on the right side of the anterior two-thirds of his tongue crossing the midline. His tongue mobility was normal and there was no palpable cervical lymphadenopathy.\nSystematic examination of chest, abdomen and heart were normal. The lesion was biopsied and initially reported as a primary squamous cell carcinoma with some clear cell changes. His blood tests including renal functions were normal. His case was discussed in the head and neck cancer multidisciplinary team (MDT) meeting and subtotal glossectomy was planned after a staging MRI (magnetic resonant imaging) scan followed by adjuvant radiotherapy to the head and neck region. While awaiting an MRI, he presented to the hospital with severe pain in his oral cavity and difficulty in swallowing. His tongue lesion had doubled in size in a matter of two weeks and was now protruding outside the mouth (Figure ). It was considered unusual for primary squamous cell carcinoma of tongue to behave like that. The pathology was therefore reviewed at the same MDT meeting and this time the lesion was reported as partly squamous epithelium covered by fibromuscular tissue showing infiltration by a carcinoma, seen in the nests with extensive clear cell changes. The differential diagnosis was considered to be squamous cell carcinoma with clear cell changes, metastatic salivary gland neoplasm or metastases from RCC. It was decided to arrange an urgent CT scan and to debulk the tongue lesion surgically, to improve his symptoms. The patient had not described any suspicious urinary symptoms.\nA CT scan of the neck, chest and abdomen revealed a 4.7-cm sized irregular mass in the left kidney suggestive of RCC (Figure ). There was no local extension and the left renal vein was clear. A solitary tongue lesion with no neck nodes was reported. No metastases were seen in the lungs, liver, adrenals, spleen and bones.\nAs per the MDT decision, he underwent a debulking surgery of the tongue metastasis, which was performed without complication. His swallowing improved significantly. Postoperatively, he received radiotherapy to his oral cavity delivering a dose of 60 Grays in 30 daily fractions over 6 weeks, which was well tolerated. Radiotherapy was given to treat the microscopic disease in his head and neck region.\nA post-radiotherapy CT scan, 18 weeks after initial presentation, was arranged before radical nephrectomy, which unfortunately revealed early evidence of lung metastases. As the patient reported shoulder pain, a plain X-ray and bone scan were carried out and this revealed evidence of a solitary bone metastasis in the right scapula.\nFollowing his debulking surgery and adjuvant radiotherapy, he underwent a radical left-sided nephrectomy. Histopathology confirmed a Fuhrman grade 3 clear cell carcinoma of the left kidney with extension into the superior perirenal fat but not into the renal sinus and with no microvascular infiltration. The maximal dimension of the tumour was 5 cm. The patient has subsequently been treated with interferon-alpha (dose: 3 MU, three times a week) as a systemic treatment for his metastatic disease. A repeat CT scan after six months of treatment showed a complete response with no evidence of any distant metastases.

A 46-year-old female presented with severe bifrontal orthostatic headaches with vomiting. She could not continue working due to her symptoms. MRI scan of the brain showed pachymeningeal enhancement and a progressive acquired Chiari malformation in keeping with findings of intracranial hypotension [ and ]. The intracranial hypotension was idiopathic as the patient had not had any trauma, fractures, surgery, or lumbar puncture before the onset of her orthostatic headaches. No abnormalities were noted on her physical examination including the fundus examination. Multiple MRI scans of the brain and spinal cord were done to identify the source of the leak, but the source could not be identified. The patient was given dexamethasone 1.5 mg daily to help with the headaches and an epidural blood patch was done. After the failure of the first blood patch, the patient underwent two more epidural blood patches and dihydroergotamine mesylate 0.3 mg IV every 8 h for 72 h was started for symptomatic relief. Dihydroergotamine mesylate resulted in symptomatic relief for the first 5 hours but the headache reoccurred in the 3 hours before the next dose. The blood patches resulted in a mild reduction in the severity of her headaches but did not completely resolve the symptoms. The patient also developed a headache above the left eye with blurry vision after the third blood patch that resolved after 1.5 weeks. The patient was reluctant to have any further blood patches after this experience. A CT myelogram of the cervical, thoracic, and lumbar spine was done to identify the source of the leak but was found to be negative. Dexamethasone 1.5 mg and oxycodone/ acetaminophen 2.5 mg every 4 hours were the only two agents that provided any persistent improvements in her symptoms. The patient was admitted to the hospital due to intractable vomiting secondary to her headaches on several occasions. Ondansetron 8 mg PO before meal 3 times a day improved her nausea and vomiting. Pharmacological treatments for the headaches proved to be ineffective and an MRI of the brain 3 years after the original MRI scans showed an acquired Chiari malformation []. An MRI of the thoracic spine was done at this point which did not identify the source of the CSF leak. The patient was referred to neurosurgery for a posterior fossa decompression with a C1 laminectomy which relieved her symptoms mildly for two months, however, it got worse so a T11-T12 laminotomy and open thoracic and lumbar blood patching were done. An epidural catheter was inserted in the thoracic region and 10 cc of blood was injected. 8 cc of blood was injected in the lumbar spine through another epidural catheter. Two months after surgery, the patient had a reduction in her headaches and was able to walk, and there was a reversal of the cerebellar ectopia on MRI [-]. Three months after the surgery, the patient continued to improve with on and off headaches. An 8-year follow-up phone call was done, and the patient is still having mild on and off headaches.\nThe patient was intubated, her head was held in Sugita pins and she was turned prone on the table. The patient was given preoperative antibiotics. A midline incision was made between the level of C2 and the occiput. The lower part of the occipital bone and the foramen magnum was removed. As the tonsils were going below the C1 level on the MRI, a C1 laminectomy was also conducted. The dura was opened with the arachnoid left intact with no evidence of CSF leak. The lower part of the cerebellar tonsils was seen at the upper edge of the C2 lamina. A duraplasty was done using a piece of fascia lata graft with no attempt to dissect the arachnoid or the tonsils and the incision was closed in layers.\nA midline incision was made over the T11-T12 spinous process. The T11 and T12 spinous process and lamina were exposed in subperiosteal fascial dissection. A laminotomy at the T11-T12 level was done on the patient’s left side. The ligamentum flavum was removed and a 6 French (Fr) pediatric catheter was passed in the epidural space cranially for 20 cm. A laminotomy at the T11-T12 level was also done on the right side with an epidural catheter passed caudally into the lumbar spine for 15 cm. Venous blood was collected from an intravenous line in the patient’s forearm and 10 CCs were injected into the thoracic spine and 8 CCs in the lumbar spine while withdrawing the catheter. The catheters were removed, and the incision was closed in layers.

A 61-year-old woman with a history of dyslipidemia presented in the emergency room with recurrent vomiting. Her blood pressure was 62/37 mm Hg on arrival, and she was admitted to our critical care center. She had only mild abdominal pain despite abdominal distension. Her face was pale, and there was weak palpation of the radial artery. The patient's hemoglobin level at admission was 12.4 g/dL. A venous sheath was inserted in the left femoral vein, and rapid infusion by crystalloid fluid of approximately 1000 mL was initiated in the resuscitation room. Enhanced computed tomography (CT) scan was performed after confirming increased blood pressure; this revealed a ruptured PDA aneurysm and celiac axis stenosis that was compressed by the median arcuate ligament (Figure ). We decided to perform transarterial embolization (TAE) as an endovascular treatment. The patient was anesthetized and underwent oral intubation followed by transfer to the emergency angiography room.\nThe patient's blood pressure suddenly dropped, and she developed hemodynamic shock. Her hemoglobin level dropped to 7.3 g/dL. It was difficult to secure the right femoral artery because the patient was obese. The pulse was weak, and the artery had collapsed as a result of the hemorrhagic shock. After several times to puncture the artery, she developed a subcutaneous hematoma and local arterial dissection was suspected. We attempted to access the left femoral artery; however, this too was difficult to secure. The blood pressure declined gradually, and prompt management to control the hemodynamics became necessary. We decided that the treatment was difficult with interventional radiology and it was necessary to switch to surgical treatment. We also believed that performing REBOA promptly would be more important to maintain the hemodynamics until a surgical intervention can be performed. Surgical exposure of the left femoral artery was performed to insert an aortic balloon occlusion catheter.\nCeliac artery arteriography was performed to confirm the point of rupture before inserting the balloon catheter (Figure ). The position of the aortic balloon was confirmed using fluoroscopy, and inflation of the balloon resulted in increased blood pressure. Hemodynamics were stabilized, and the patient was moved to an operating room.\nLaparotomy revealed a massive retroperitoneal hematoma surrounding the duodenum. Intraoperative bleeding was controlled by REBOA; therefore, the bleeding did not hinder the surgery. The point of bleeding was determined to be the point of rupture that was revealed by collapsing the balloon. The rupture point was confirmed, and both ends of the aneurysm were secured and ligated.\nAlthough there were other visceral aneurysms visualized on the CT scan, we decided against performing any additional interventions since saving life was the priority.\nHemoglobin levels decreased from 12.4 g/dL to 5.5 g/dL. She required 8400 mL of red cell concentrate, 7920 mL of fresh frozen plasma, and 600 mL of platelet concentrate. After intensive care was performed, the patient was extubated on day 8.\nA second surgery for incision of the median arcuate ligament and removal of the remaining aneurysm was performed as an elective surgery on day 12.\nFinally, the patient was discharged on day 22. She was followed up at the hospital for 6 months. No complications were observed, and no repeat interventions were required.

A 30-year-old primiparous woman was seen at our hospital for preterm contractions for seven days with reduced fetal movements at 27 weeks and 4 days of gestation. A threatened premature labor was diagnosed. Ultrasound showed a female fetus with normal development and amniotic fluid volume. Small bowel appeared mildly dilated (14 mm) with thickened and hyperechogenic intestinal wall. There was a typical whirlpool configuration of the bowel (). First and second trimester ultrasounds were unremarkable. Screening for infectious diseases was negative. A molecular genetic testing of CFTR was realized in the parents who were tested for the 32 main mutations of CFTR during a genetic counseling. This testing was negative in both of the parents. So, the fetus was not screened for cystic fibrosis. The patient received atosiban for tocolysis and steroids for fetal lung maturation. Ultrasound follow-up one week later and every two weeks showed absence of significant modification in small bowel dilatation and normal fetal development and amniotic fluid volume up to 33 weeks and 1 day of gestation when a peritoneal calcification appeared leading to the suspicion of meconium peritonitis. Fetal biometry measures including the abdominal circumference and amniotic fluid volume were normal throughout the follow-up in antepartum period. Ultrasound follow-up at 36 weeks and 4 days of gestation revealed a significant aggravation of intestinal dilatation (30 mm) appearing more extensively with persistent intestinal peristalsis, and some parietal calcifications appeared with a meconium pseudocyst but there were no ascites (). Fetal vitality was good with a satisfying Manning's score; there were neither ascites nor significant increasing in abdominal circumference nor abnormality in fetal heart rate and the amniotic fluid volume was normal. So, the patient was hospitalized for close monitoring of fetal heart rate. After consultation with members of pediatric surgery team, induction of labor was decided at 37 weeks and 2 days of gestation given the worsening ultrasound images associated with reduced fetal movements and reduced fetal heart rate variability for neonatal surgical management. Furthermore, the patient had a favorable Bishop score of 6 on clinical examination. A 2,470 g girl was born vaginally with vacuum assistance at 37 weeks and 2 days of gestation, with Apgar scores of 3, 7, and 10 at 1, 3, and 5 minutes, respectively. The neonate was ventilated for three minutes after birth with good neonatal adaptation. She received a nasogastric tube and was immediately hospitalized in pediatric intensive care unit. Her vital and biological parameters were normal except for hemoglobin. The newborn was mildly anemic with a hemoglobin level of 15 g/dl. She had neither hyperthermia nor biological inflammatory syndrome (leukocyte count = 12,0 × 109/l, CRP < 2,9 mg/l). Clinical examination showed no abnormality with an abdomen soft and painless on palpation but slightly distended. The postnatal plain abdominal X-ray showed a voluminous dilated bowel loop (). The water-soluble contrast enema revealed a vacuous colon in normal position, a caecum in the right iliac fossa, and an opacification of a few centimeters of the last ileal loop (). A right transverse laparotomy was performed the day after birth and revealed a segmental small bowel volvulus with a perforated meconium pseudocyst secondary to in utero perforation of distal ileum and a type II small bowel atresia five centimeters above ileocaecal valve (). The residual length of small bowel was sufficient with 100 cm above atresia and 4 cm below atresia. No microbiological test has been performed during surgery because there was no sign of extensive inflammation. The meconium pseudocyst, the volvulus loop, and 16 cm of very dilated and unstressed small bowel were resected. The diameter of the loop below atresia was much smaller but ileocaecal valve was permeable. Given the significant difference in the diameter of the two loops, the distal loop was opened on its antimesenteric side to realize a termino-terminal ileoileal anastomosis more congruent without perioperative complication (). Immediate postoperative care was simple. Recovery of bowel movements occurred two days after surgery and a normal diet with breast milk was started three days after surgery. The Guthrie (neonatal heel prick) test was negative. The anatomopathological examination revealed peritonitis signs on the serosa and the mesentery of the surgical specimens in the form of more or less voluminous calcifications. Moreover, there was panparietal ischemic necrosis of the mucosa and all other layers of the intestinal wall. Finally, there was diffuse vascular congestion and stigma of intraparietal hemorrhage. A satisfying weight curve permitted her return home thirteen days after surgery. One year after surgery, feeding and bowel movements were normal with a good growth. She did not suffer from short bowel syndrome.

A 60-year-old gentleman presented to the outpatient department with complaints of a wound on the left lumbar region associated with foul smelling discharge for the past 6 months. The patient had no other complaints associated with the wound. The wound had appeared initially as a swelling which burst spontaneously after taking antibiotics, 6 months ago. Since then the patient had been undergoing treatment in the form of antibiotic and anti-inflammatory agents off and on with regular dressings. The discharge used to reduce while the patient took the medication but increased again after stopping therapy. There was no history of associated abdominal pain, bowel complaints, or urinary disturbances. The patient gave history of trauma to the left leg 1 year back leading to fracture of the neck of femur for which he underwent placement of a hip screw. Examination revealed a single wound on the left lumbar region [] associated with mucoid discharge. There was no surrounding erythema or tenderness and the abdominal examination was essentially normal. Urine culture grew E. coli sensitive to nitrofurantoin, and was repeated after 1 week of therapy to ensure sterility of the urinary tract. An X-ray of the abdomen and KUB region was suggestive of a solitary renal calculus and a radio-opaque hip screw in the left hip joint. A sinogram was performed using 60% urograffin which revealed a complex fistula communicating with the left pelvicalyceal system []. An intravenous pyelogram performed with the intent of assessing the functional status of the kidney showed a non-functioning left kidney with a solitary pelvic calculus on the left side and a normally functioning kidney on the right side. A renal nuclear scan with DTPA showed poor left-side function with a GFR of 8 ml/min and a differential function of 11%. Based on these findings the patient was planned for nephrectomy and excision of the sinus tract. The patient was operated in a flank position by open flank approach, and dense adhesions were present in the renal fossa. A subcapsular nephrectomy was performed along with radical excision of the sinus tract, most of which was located in the subcutaneous plane [Figures and ]. A drain was placed and the incision was closed in layers. The patient had an uneventful postoperative course and was discharged on the 5th postoperative day. On follow up for a period of 6 months, the patient had no fresh complaints.

A 43-year-old Pakistani woman presented for gynecologic surgery for an ovarian mass. Seventeen years prior, she had an emergency TV replacement with a St Jude bileaflet tilting disc prosthetic valve for bacterial endocarditis of her TV. The reasons for choosing a mechanical valve at that time are not known. Anticoagulation with warfarin without an antiplatelet agent was maintained and managed largely by our patient along with her primary care doctor. After her TV replacement she had three episodes of TV thrombosis, for which she received thrombolytics. Two of these episodes occurred during the discontinuation of warfarin and initiation of heparin or low molecular weight heparin for pregnancy, necessitating the termination of her pregnancies. Her international normalized ratio on admission was at a therapeutic level of 2.5; heparin was initiated with a goal prothrombin time of 80 seconds and warfarin discontinued for the gynecologic surgery. A preoperative echocardiogram showed a mean gradient across the TV of 5 mmHg.\nOur patient underwent an exploratory laparotomy, oophorectomy, removal of an ovarian mass and a cystotomy repair. The surgery was four hours long and she had 400 cm3 of blood loss. Heparin was off for a total of 13 hours. On postoperative day one, our patient complained that she could not hear the click of her mechanical valve. She was hemodynamically stable with a heart rate of 105 beats per minute. Doppler echocardiography showed a mean TV gradient of 18 mmHg (Figure ). A transesophageal echo showed the St Jude valve to be stuck in the open position. This was confirmed by fluoroscopy (Figure and ).\nThrombolytics were not an option as she was in a recent postoperative state. She was maintained under close observation and serial echocardiograms showed that the gradients across her TV remained stable. Limited blood testing did not show any disorders in blood coagulation. Ten days after her initial surgery, when it was deemed safe to be placed on bypass, her St Jude TV was removed and a bioprosthetic valve was placed in the TV position. The explanted prosthesis showed fibrin and pannus that involved both discs (Figure ). Our patient tolerated the procedure well and went home in stable condition.

A 35-year-old male patient visited the King Khalid University dental clinic for the replacement of both maxillary and mandibular anterior missing teeth. The patient was extremely unhappy with existing transitional, removable partial denture due to its poor stability, especially during speech and mastication. He gave a history of teeth extraction six months before due to mobility. He also reported on chronic mouth breathing due to enlarged adenoids and blocked nasal breathing, which was surgically treated a year back. The patient gave a graphic history of continued, progressive labial flaring of anterior teeth that subsequently became mobile to be extracted. On examination, it was observed that the patient had lost both maxillary central incisors and all four mandibular incisors (). The adjacent maxillary lateral incisors showed slight labial flaring and grade 1 mobility; intraoral periapical X-ray confirmed approximately 20–25% alveolar bone loss. Routine TMJ examination showed no signs of pathology. The patency of nasal airways were checked by requesting to close the lip together and occluding one naris with the index finger alternatively. Ask the patient to breathe normally through open naris. The tongue movements were within normal limits. The evaluation of swallowing process without the removable prosthesis showed slight space between posterior teeth and minor hyperactivity of orbicularis oris and mentalis muscles. On complete evaluation of clinical signs symptoms along with clinical examination, it was diagnosed as loss of maxillary and mandibular anterior teeth due to combined effect of periodontal diseases, chronic mouth breathing, and tongue thrusting.\nThe treatment objectives were to replace the missing maxillary and mandibular central incisors along with rehabilitation of tongue thrusting habit. Treatment options to replace the missing anterior teeth was discussed with the patient, including the implant supported fixed prosthesis. The tooth that supported conventional fixed partial denture was selected according to the patient desire. The potential abutments were evaluated by the clinical and radiological examination to ascertain periodontal and pulpal health. The intentional root canal treatment was performed on maxillary right lateral incisors to gain common path of insertion. The bilateral canines and lateral incisors were the abutment for maxillary central incisors, while bilateral canines were selected as abutments for mandibular incisors []. The absence of gross soft or bony defect in the corresponding residual ridge of missing teeth was also favorable for tooth that supported fixed partial denture.\nThe diagnostic casts were made from irreversible hydrocolloid impression materials, with the help of face bow records mounted on a semiadjustable articulator. The existing removable denture had more teeth to compensate the slightly larger residual ridge space. To ascertain the esthetic outcome and patient response, the diagnostic wax up for the missing teeth structure was done (). To obtain the acceptable esthetic proportion between the teeth, it was decided to distribute the excess edentulous area between abutment and pontics.\nThe autopolymerized acrylic denture base for the edentulous area was fabricated on dental cast; the modelling plastic compound was used to make the occlusal rim. The vertical height of the occlusal rims was adjusted according to the anatomic landmarks, visibility, and phonetics. The modelling plastic compound was softened and the patient was asked to perform all physiological muscle functions by sucking, swallowing, and phonetics. The recontoured modelling compound gave the exact tooth position and inclination according to the neutral zone [].\nSplit putty indexing was made to guide the dental technician on the exact position and inclinations of pontics during fabrication of provisional restoration. The abutments were prepared for metal ceramic retainers; the definitive impression was made with heavy body-light body silicone impression materials. The poly ethyl methacrylate provisional fixed partial dentures were fabricated with indirect method. The provisional bridges were cemented with noneugenol temporary luting cement after minor correction for aesthetics, phonetics, and occlusion (). The Patient was given an instruction to follow the tongue neuromuscular sensory stimuli by brushing and resistance to regain the desirable motor response []. The patient was recalled after 24 hours to evaluate the patient opinion, gingival health, and comfort. The patient was given a scheduled appointment for six weeks to evaluate the overall satisfaction of esthetics, phonetics, and function. The continuous required minor adjustments were made to the provisional bridge during evaluation period. The provisional restorations with acceptable anterior guidance, esthetics, phonetics, and comfort were replicated to minute detail in permanent restoration.\nThe alginate impression with the cemented provisional restoration was made, and dental cast was mounted on the semiadjustable articulator with face bow transfer (). The autopolymerized acrylic customized incisal guidance table was prepared on the semiadjustable articulator from the mounted casts (). The customized incisal table enabled the dental technician to replicate the exact anterior guidance in the final restorations. The putty indexing of the provisional restorations was used to remake the labial contour, shape, and inclination in the final metal ceramic fixed partial denture. The final prosthesis was cemented with the glass-ionomer type-I luting cement after required occlusion refinements (Figures , , and ).\nThe patient was recalled after one week to evaluate the residual cement, gingival health, and occlusal integrity. The patient was monitored during the first three months with a two-week-interval, followed by a month intervening three months. The patient showed a remarkable improvement in speech and controlling the tongue thrusting. He was highly satisfied with the aesthetic outcome of the prosthesis.

A 78-year-old male patient with coronary artery disease status post coronary stent placement was found to have a lung nodule on the chest radiograph at that time. The patient underwent a computed tomography (CT) scan, and bronchoscopy, and was found to have a 9 mm fatty endobronchial lesion in the bronchus intermedius above the middle lobe with 2 cm extraluminal fatty lesion into the right hilum. An endobronchial ultrasound with biopsy of the mass was performed, which showed benign bronchial epithelial cells. Since endobronchial resection of the mass would lead to a large defect in the right bronchus intermedius, the decision was made to perform robotic-assisted resection of the lesion (Video ).\nWe used the Da Vinci Xi robot to perform resection of the endobronchial lesion and hilar mass with right lower lobe superior segmentectomy to remove the lesion. The patient had a “five on a dice” port placement for the operation [, ]. First, we performed the right lower lobe superior segmentectomy to obtain adequate exposure of the hilar mass. We mobilized the superior segmental branch of pulmonary artery and superior segmental branch of the right lower lobe going to the inferior pulmonary vein and divided them with the vascular robot stapler. We divided the superior segmental branch of right lower lobe bronchus with the robot blue load stapler. We used indocyanine green angiography to define the borders of the superior segment of the right lower lobe, which was divided using the robot blue load stapler. This provided access to the hilar fatty tumor, which allowed for removal of the hilar mass and subsequent resection of endobronchial lesion with scissors. The frozen section on both lesions was negative for malignancy. We confirmed complete resection with intraoperative bronchoscopy that also showed a large opening in the airway.\nIn order to reconstruct the airway, we placed two 3-0 vicryl stay sutures at the proximal and distal ends of the airway and placed the suture through the posterior ports to pull the airway posteriorly away from the main pulmonary artery. We closed the opening with 4-0 PDS (polydioxanone) in an interrupted fashion eight times. This provided good closure of the opening. We performed a bronchoscopy that showed no abnormalities and the air leak test demonstrated no appreciable air leaks.\nThe patient went home on postoperative day 3 without any complications. The final pathology report was lipomatous hamartoma.

A 60-year-old female presented to the outpatient cardiology clinic for evaluation of worsening chronic hypertension for which she had been on hydrochlorothiazide/Valsartan for 10 years. Her systolic blood pressure exceeded 200 mmHg in the office, and aggressive medical therapy was initiated in the outpatient setting. She returned to the emergency department the following day with headache and malaise and systolic blood pressure above 200 mmHg for which she was treated and discharged.\nShe returned to the emergency department again 5 days later, this time with complaints of word finding difficulty, blurred vision, and lower extremity tingling. Her blood pressure on presentation was 216/81 mmHg. She was admitted, and workup demonstrated no acute intracranial process or carotid stenosis. Echocardiography revealed mild concentric left ventricular hypertrophy with a preserved ejection fraction. Her blood pressure continued to be refractory to medical therapy despite five antihypertensive agents and eventual initiation of an esmolol infusion. A renal artery ultrasound identified renal artery stenosis with flow at the arterial origin measuring 350 cm/s on the right and 208 cm/s on the left (); flow velocity in the supraceliac aorta was also noted to be elevated. She had no history of kidney disease and no elevation of her creatinine. Vascular surgery was consulted and a history of lower extremity claudication was elicited. On exam she had weak but palpable femoral pulses and an audible abdominal aortic bruit; ankle-brachial index measurements were deferred and the patient was scheduled for angiogram.\nThe patient underwent aortography the following day and on selective angiography the renal arteries were found to be widely patent. Significant stenosis was identified at the distal thoracic aorta extending into the abdominal aorta but terminating proximal to the celiac trunk. The degree of stenosis was deemed to be greater than 90% and a pressure gradient between the upper extremity and intra-aortic measurements exceeded 100 mmHg. CTA was subsequently performed to evaluate the extent of the lesion and confirmed a stenosis 1.3 cm proximal to the celiac origin measuring 5 mm at its narrowest point (Figures and ). The patient underwent arteriogram; the stenosis was successfully navigated and a Protege 14 × 40 x 12 mm nitinol stent (Medtronic Vascular, Santa Rosa CA) was delivered followed by a 10 mm postdilation balloon. A completion arteriogram demonstrated excellent flow across the stent.\nAfter stenting, the patients' systolic blood pressure was 140-160 mmHg, and she experienced resolution of her lower extremity claudication. She was discharged from the hospital on Aspirin and Plavix and a blood pressure regimen consisting of lisinopril, hydralazine, amlodipine, and carvedilol.\nShe was lost to follow-up until two years later when she returned to the hospital with a blood pressure of 220/85 mmHg, with complaints of chest discomfort. CTA demonstrated stenosis in the distal portion of the aortic stent. An angiogram was performed, and the stent was ballooned to 12 mm. Pressure gradient measurements taken before and after dilatation decreased from 60 mmHg to 20 mmHg. On follow-up one year later, she continued to experience excellent blood pressure control.

A 51-year-old male presented with gross macroscopic hematuria, and the ultrasound imaging suggested the presence of a bladder wall tumor, which was confirmed with a cystoscopy. Patient underwent a transurethral resection of the bladder tumor. The pathology report confirmed a pT2 muscle invasive bladder cancer. The computed tomography of the abdomen and pelvis was negative for metastases. After 10 days the patient was subjected to a radical cystoprostatectomy and urinary diversion to an orthotopic ileal neobladder with a modified S-pouch. The final pathology report described a tumor to the posterior wall and the dome of the bladder. The prostate, the seminal vesicles, the distal ureters, and the lymph nodes were free of cancer involvement. The surgical margins were also negative. Patient did not receive chemotherapy in a neoadjuvant or adjuvant setting. The patient 8 months postoperatively complained of left thigh pain and a palpable mass. Thereafter, a full body MRI was performed and revealed a lesion of about 8 cm in diameter in the upper portion of the sartorius muscle, with no other abnormalities or metastatic sites.\nThe patient underwent surgical resection of the lesion after induction of general anesthesia. The mass involved only the muscular plane of the sartorius, 10 cm approximately from the origin without evident contact with the tendon or adjacent muscle. A marginal excision of the lesion was performed. Macroscopically, it was an 8 × 4 × 4 cm lesion with smooth margins and the cross-section was white and shiny (Figures and ). The postoperative period was uneventful. The pathology of the lesion reported a 9 × 4 × 3,9 cm skeletal muscle with a solid lesion of a maximal diameter of 7,2 cm. The skeletal muscle was infiltrated from a malignant lesion compatible with a high grade urothelial carcinoma positive to the CK7 marker and negative to the CK20 (). The marker of cellular proliferation Ki67 was 40% positive. The patient subsequently received systematic chemotherapy with gemcitabine and cisplatin (6 cycles) and was subjected to radiotherapy at the site of the excision of the skeletal muscle metastasis and that of the cystectomy. The patient 7 months after the excision of the muscle metastasis in the left thigh is still alive and with a good performance status with a negative imaging follow-up.

This is a case of a 68-year-old female presented to the clinic for a 2-month history of recurrent left ankle pain, associated with swelling and edema. The patient had a history of thyroid follicular adenocarcinoma which was treated surgically with total thyroidectomy and postoperative iodine treatment 25 years prior to presentation. At 12 years post thyroidectomy, she was diagnosed with a calcaneal mass of the same pathology and diagnosed with delayed distant thyroid carcinoma metastasis to the calcaneus. 10 years after calcaneal mass excision, the patient was diagnosed with a proximal tibial mass that turned out to be also delayed metastasis of the same pathology.\nAt the first presentation 15 years ago, she initially presented complaining of mild edema of the left ankle with intermittent pain upon daily activity. Physical exam showed full range of motion of the ankle joint with intact motor power and intact neurovascular status. There were no cutaneous lesions.\nPlain radiographs of the left ankle showed a 3-centimeter oval lytic lesion in the anterior aspect of the calcaneum ().\nAn MRI of the left ankle showed a 3.2 cm well-defined benign-looking lytic lesion of the calcaneal neck reaching the cortex which appeared to be mildly irregular with mild degenerative disease of the posterior subtalar joint consistent with an intraosseous ganglion cyst of the calcaneus ().\nMedical treatment with NSAIDs and paracetamol was initiated, along with partial weight bearing and relative rest with no improvement at follow-up at 4 weeks. Surgical intervention was decided due to the persistent pain. The cyst was resected with a margin of surrounding fibro-osseous tissue and the bone grafted. Histopathological evaluation revealed a metastatic carcinoma of the thyroid gland. Immunostaining showed that the cells expressed cytokeratin, cytokeratin 7, and thyroglobulin, all of which confirm the diagnosis ().\nFor further confirmation, the recently excised cyst slides were compared to the pathology slides of the thyroid excision undertaken 12 years prior to the calcaneal presentation and were found out to be of the same pathology ().\nThe patient had a smooth postoperative hospital stay and clinical recovery from pain before discharge; postoperative follow-up showed necrosis of the upper part of the wound which healed by secondary intention.\nThe patient had a complete bone metastasis workup; chest X-ray showed a right upper lobe nodule for which an FNA biopsy under CT scan was done demonstrating the same pathology as for the calcaneus. A bone scan was ordered showing no definitive sign suggesting metastasis with no specific abnormality of the manubrium-sterni joint and the right proximal metaphysis of the right tibia which was nonspecific for distant metastasis according to the nuclear radiologist. After the discussion with the oncologist, decision for radioactive iodine therapy was made.\nAt 3-month postoperative follow-up, while the patient was undergoing chemotherapy, she recomplained of ankle pain upon ambulation, associated with edema. The patient had 5/5 motor strength, no numbness, and no sign of infection. A left ankle X-ray and MRI were ordered () to rule out any recurrence at the surgical site. The new investigations showed oval-shaped lytic lesion of 2.8 cm, and MRI showed increase in size of the calcaneal mass without pathologic fracture.\nThe patient was treated symptomatically; a follow-up MRI at 8 months showed postoperative enhancement in the surgical bed suggestive of viable tissue, and at 10 months, a follow-up MRI showed that there was near total healing of the calcaneal region.\nAfter 10 years post calcaneal mass excision, keeping in mind that the patient was symptom-free with respect to her ankle since the surgery, the patient presented to the clinic complaining of recurrent right knee pain. Investigation showed right proximal tibial metastasis with invasion of the patellar tendon. Surgical resection of the metastasis with repair of the patellar tendon was performed, and pathology was also consistent with thyroid follicular cell carcinoma (Figures and ).\nThe oncologist was consulted, and the decision for treatment with teroglobulin as well as adjuvant radiation therapy was made.

The 8-year-old boy first presented in January 2012, having been referred by the family dentist, to the Department of Orthodontics at the Medical Center of the University of Göttingen for a routine orthodontic control and evaluation of treatment need (). The clinical examination of the asymptomatic patient showed no extra- or intraoral pathological findings. The medical history of the boy included a mild pulmonary valve stenosis and a secundum atrial septal defect with a left-right shunt. He showed a good physical and cardiac fitness and a normal nutritional status. The family history was positive for maxillofacial anomalies: the boy's older sister had been previously diagnosed with a dysplastic fibroma, a rare benign fibrovascular defect in the mandible, and a resection of the affected area in the mandible had been performed. His father and paternal grandmother had a positive history of odontogenic cysts as well as basal cell carcinomas, although the family history of OKCs was negative. The radiological examination showed three suspicious hypomineralisations visible as radiolucencies in the panoramic radiograph associated with the retained teeth 13 and 23 and the ectopic tooth 27 (). The young patient was referred to the Department of Maxillofacial Surgery for a surgical examination of the radiologic anomalies.\nThe operation was performed under general anesthesia. The suspected pathological area around teeth 23 and 13 showed no visible intraoperative pathological signs. A bone and soft tissue biopsy for histological examination was taken. In the area of tooth 27, a well-marked membrane was revealed, filled with a viscid fluid and fully enclosing the dental crown. The clinical aspect was consistent with a follicular cyst. During the radical cystectomy, tooth 27 was removed due to massive attachment loss. The histopathological biopsy showed a fibroosseous lesion in the area of teeth 13 and 23. The biopsy from region 27 showed an odontogenic connective tissue cyst wall with intramural odontogenic cell islands. On request of the surgeon, samples were sent for further diagnosis to the Bone Tumor Reference Center of the Swiss Society of Pathology at the University Hospital in Basel, Switzerland. The initial histological diagnosis was corrected to an OKC of the parakeratin variant. Microscopically, the cyst shows a squamous epithelium. The basal cells are palisading, with hyperchromatic nuclei (HE staining, 5x magnification) (). Due to the high recurrence of OKCs, a radiological control interval of 6 months was indicated (). Furthermore, orthodontic treatment was initiated.\nIn August 2014, during a regular radiological control, a new radiolucency was detected, associated with the retained and displaced teeth 47 and 48 (). The surgical removal of the cystic lesion and tooth 47 was performed under general anesthesia. The pathological finding was consistent with an OKC.\nThe regular control examinations were interrupted by missed appointments, so the next evaluation took place one year later, in October 2015 (). New radiolucencies were detected in the panoramic radiograph associated with the retained teeth 18, 17, 37, 38, and 48 as well as an evident enlargement of the radiolucency around the crown of tooth 13. A cone beam computer tomography scan was performed and showed well-defined radiolucent areas, associated with the retained teeth. Details of the surgical enucleation of the cysts with the extraction of teeth 18, 17, 13, 37, 38, and 48 are shown below. The postoperative radiological examination is depicted in . Clinical and radiological examinations were then performed every 6 months.\nWe describe the surgical enucleation of the cystic lesions using the example of the third operation (2015). This was performed under general anesthesia; the affected regions were exposed after lifting a mucoperiosteal flap. After a careful removal of a thin bone cortex, the cystic capsule was found () and separated from the bone with an obtuse instrument. The aim was to leave no epithelial remnants on the trabecular bone. All four lesions were associated with a retained tooth, which was only loosely anchored in the alveolar bone. Due to the high recurrence rate of the cystic lesions in this particular case, all affected teeth were extracted. In the area of the mandible, the use of Carnoy's solution was not indicated because of the exposure of the lower alveolar nerve (). Due to their large size, the cystic cavities were filled with a collagen graft, which stabilized the formation of a coagulum. No reconstruction with iliac crest bone or allogenic bone grafts was attempted. Subsequently, the mucoperiosteal flap was reverted back to its original position and fixed by sutures.\nBy October 2016 and August 2017, bone remodeling of the affected area had been detected and no new lesions were observed (Figures and ).\nDue to the recurrence and the appearance of new lesions, Gorlin-Goltz syndrome was suspected in the patient. After genetic counselling at the Institute of Human Genetics of the University Medical Center of Göttingen, molecular genetic analysis of the genes PTCH1 and PTCH2 was performed in 2015. Sanger sequencing revealed the heterozygous germline variant c.2779_2793del (p.Ser927_Val931del) in the PTCH1 gene. This variant leads to an “in-frame” deletion of 5 amino acids between amino acid positions 927 and 931 of the protein. This variant is listed neither in the Human Gene Mutation Database (HGMD) nor in the Leiden Open Variation Database (LOVD). However, a pathogenic effect of the variant seemed likely as many pathogenic variants have already been described in this region of the PTCH1 gene, even several in-frame deletions [, ]. Since the boy's father had shown similar symptoms (odontogenic cysts, basal cell carcinomas) that could be in line with a Gorlin-Goltz syndrome, he, too, was tested for the PTCH1 variant and resulted to be carrier of the variant.\nIn summary, clinical and molecular data together with the positive segregation analysis led to the classification of the variant as “probably pathogenic” and being responsible for Gorlin-Goltz syndrome in the patient and his father. The importance of talking precautions (e.g., sun protection due to the high risk of basal cell carcinomas) and regular medical surveillance (e.g., regular orthodontic care and annual dermatologic examinations) was emphasized.

A 69-year-old male with impalement injury with rusted iron rods on his face came to the emergency department. He was found by a passerby in upside down position with iron fence stuck in his forehead and body lean on the wall. The rescue team cut off the fence and took him to hospital. When he arrived at our hospital, the rusted iron bars penetrated through his forehead bilaterally. On the right side, the bar penetrated on the forehead in a downward angle running along the cheek and exiting through right ear, and on the left side, the bar out through the left mandible angle (, ). Intravenous broad spectrum antibiotics were started and tetanus vaccination with tetanus immunoglobulin was injected. He was fully drunken but conscious and had no sign and symptom of brain and facial nerve injury. Facial bone and neck computed tomography (CT) scan revealed that there was no penetration of facial bone or skull, no injury of major vascular, and organ injury of face such as parotid glands. There were two dense radio-opaque metallic foreign bodies in both frontotemporal scalp with penetrating into right auricle and left masticator space and left lateral neck with no definite parotid gland penetration (, ). He was admitted to the plastic surgical department and got emergent operation for removal of foreign bodies under general anesthesia (). After removal of the materials, the tunneling wounds on his both parietal areas were massively irrigated with normal saline and surgical drains were placed to prevent hematoma collection. The patient was treated with broad spectrum antibiotics and wound irrigation and debridement was done daily in operating room. At eleventh day after his trauma, he underwent a delayed wound closure under local anesthesia. Postoperatively the patient recovered well. Postoperative CT scan showed no sign of development of intracranial hemorrhage, hematoma, and the residual foreign bodies. His facial motor and sensory examination revealed normal findings. The patient was discharged without complication after fourth day of delayed wound closure. There have been no complication and sequelae related with trauma, wound infection and scar contracture at 3-year follow-up.

A 72-year-old man was referred to our hospital because of an abnormal pulmonary shadow found on a routine chest X-ray. Chest X-rays revealed a mass shadow in the left middle lung field and a positive silhouette sign for the left second arch (Fig. ). The aortic arch aneurysm was saccular aneurysm associated with a greater risk of rupture, and connected to the pulmonary mass in the left upper lobe with a possible risk of tumor adhesion or invasion to the aneurysm (Fig. ). Three-dimensional CT revealed that the aortic aneurysm was located in front of the arch near the left subclavian artery, and the brachiocephalic and left common carotid arteries branched from the aorta with a common duct (Fig. ). These findings led to the diagnosis of aortic arch aneurysm and lung carcinoma. There were no distant metastases of the lung carcinoma (clinical stage T2bN0M0 stage IIA). We decided to perform left upper lobectomy and patch angioplasty if the arch of aorta between the left common carotid artery and the left subclavian artery could be temporarily occluded. If not, we planned to perform aortic arch replacement under selective cerebral perfusion with systemic extracorporeal circulation through the groin.\nA fourth intercostal thoracotomy was performed. As the lung carcinoma adhered to the aortic arch aneurysm but did not invade it, we could detach the visceral pleura of the left upper lobe from the aortic arch aneurysm. We performed left upper lobectomy. After that, we confirmed that the aneurysm was proximal to the left subclavian artery. Because of the position of the TAA, it was difficult to perform patch angioplasty. We decided to perform aortic arch replacement for the aortic arch aneurysm with a 3-branched artificial vessel under selective cerebral perfusion with systemic extracorporeal circulation. The thoracotomy was extended to the right with a transverse incision of the sternum.\nA 30-mm intimal defect was observed in the aorta, and half of the aneurysm was filled with organized thrombus. It was morphologically diagnosed as pseudoaneurysm. Under deep hypothermia, circulatory arrest and separate cerebral and systemic extracorporeal circulation, aortic arch replacement was performed with a 3-branched artificial vessel. First, the brachiocephalic artery and the left common carotid artery were rebuilt by the first branch of the graft. The second branch was ligated, and the subclavian artery was rebuilt by the third branch. Forming a stump, the distal aorta was anastomosed to the entire circumference of the graft and was reinforced with Teflon felt strips. The operative time was 683 min, the extracorporeal circulation time was 213 min, and the aortic cross-clamp time was 121 min. He was diagnosed with a moderately differentiated squamous cell carcinoma that was graded pathologically as T2bN0M0-stageIIA.\nAfter the surgical treatment, postoperative pneumonia developed that was treated by ventilator management. The patient was removed from the ventilator on the 23rd postoperative day. He was discharged from our hospital on the 72nd postoperative day.

This patient is a 60-year-old male who worked in accounting and engineering. His work was mostly stationary and required minimal physical activity. He started to experience dizziness after traveling in airplanes prior to the beginning of this study. He noticed a significant body shift while walking and increased dizziness. His dizziness was most severe in extremely light or dark conditions. He found himself becoming increasingly afraid to drive. In particular, he was most anxious about driving his vehicle in heavy traffic or on narrow streets. He found that he was not able to pay immediate attention to traffic when turning around to look over his shoulder and then turning back to the road ahead. As a result, he had to give up most independent travel and came to rely on his family members to provide transportation for him. Because of his symptoms, the patient was depressed, had low self-confidence and was disappointed with his ability to perform his daily activities. His primary goal was to be able to return to safely driving a motor vehicle. The caloric test results 1 week prior to the study showed a left-sided canal paresis of 28%.\nThe patient was under a considerable amount of stress, and his training progress was relatively slow. By the time he returned home after the 1st week of training, his family members reported that his body shift while walking had increased. His body shift had significantly improved by the 2nd week of training. At this point, the patient began riding a motorcycle and driving around the neighborhood. He started to experience discomfort and dizziness when checking over his shoulder for oncoming cars. Because of these symptoms, he immediately gave up this initial driving attempt. By the 3rd and 4th weeks of training, he experienced less frequent episodes of severe dizziness. He began to ride his bicycle or motor vehicle on wide streets in his neighborhood. However, he still experienced dizziness when exposed to intense light. By the end of the 6th week of training, the patient was able to drive himself from home (approximately 32.9 kilometers) for his post-test assessment. Between the 5th and 6th weeks of training, he was able to drive himself to work, and he reported increased stress only while driving at high speeds on the highway.\nOne month after training, his overall performance had improved significantly. The SOT and DVA assessments confirmed the persistence of the improvements observed at the completion of training. His DGI and self-confidence assessments also revealed sustained improvements in the training results.

A 78-year-old Japanese male presented to the emergency department of our hospital with low back pain on exertion for 1 week. The pain was described as dull and gradually worsens. Although the location was near the thoracolumbar spine, he denied radiation of the pain to any parts of the body. Severity of pain using a numerical rating scale was 10/10 at the day of admission. The character and intensity of the pain were not affected by changes in physical movement or by rest. He denied any other symptoms such as fever, nausea, dysuria, hematuria, abdominal pain, and leg numbness during his clinical course.\nHe had a past medical history of rectal cancer with liver metastasis and had undergone surgery and chemotherapy. At the time of diagnosis, rectal cancer was stage IV (TNM classification of malignant tumors; T3N2M1), grade 3, and was revealed to be adenocarcinoma during histopathology. Liver metastasis affected segments 3 and 6. He underwent low anterior resection of the rectum and resection of the affected liver segments. He then underwent chemotherapy using fluorouracil that was arterially infused through a catheter inserted into the femoral artery and implanted into the hepatic artery through the celiac artery. He initially had good response to treatment but 2 years after diagnosis, he had a recurrence of liver metastasis. He underwent partial resection of segment 6 of the liver and was followed by chemotherapy using FOLFOX6 + bevacizumab protocol instead of arterial infusion. After finishing chemotherapy, he achieved complete remission 11 years after initial diagnosis. As a result of the possibility of another recurrence, the catheter remained in place without being replaced. His other past medical history was hypertension and he remained on amlodipine 5 mg daily and imidapril 5 mg daily. Social history revealed that he had smoked approximately 10 cigarettes a day for 50 years and drank alcohol occasionally. Family and environmental history was unremarkable. His employment history was an office worker, but he retired at the age of 60 and has not worked since then.\nOn the day of admission, his blood pressure was 171/75 mmHg, heart rate was 67 bpm, SpO2 97% at ambient room air, and body temperature was 36.6 °C. He denied abdominal pain, and pain or numbness in the lower extremities. General appearance was not in acute distress. There was no conjunctiva pallor or icterus. Respiratory sounds were clear to auscultation bilaterally and there were no wheezes or crackles. Cardiovascular examination revealed normal S1 and S2. There was no S3, S4, or murmurs. Abdominal examination revealed a flat and soft abdomen with audible bowel sounds. There was no bruit. There was no abdominal tenderness or hepatosplenomegaly. There was no spinal tenderness or costovertebral angle tenderness on percussion. There was no edema of his lower extremities. There was no joint swelling bilaterally at the wrists, ankles, and knees. General physical examinations revealed no abnormalities. His neurologic examination 2 to 12 were intact. There were no abnormalities with sensation and strength throughout with normal reflexes. Although laboratory analysis revealed normal results for complete blood count, electrolyte level, creatinine level, liver function, and coagulation test, levels of beta-d-glucan were slightly elevated at 24 pg/mL (reference value, < 20 pg/mL) (Table ). Urinalysis was negative for proteinuria, pyuria, and hematuria (Table ). Blood culture of aerobic and anaerobic bacteria including fungi and urine culture were all negative (Table ). Transthoracic echocardiography revealed no valve vegetation, no valve regurgitation, no stenosis, and a normal ejection fraction. Computed tomography (CT) of the chest and abdomen revealed an irregularly shaped aortic aneurysm measuring 45 × 33 mm at the origin of the celiac artery and a partially expanded common hepatic artery with disproportionate fat stranding; no extravasation was observed using contrast enhancement (Fig. ). There was a high possibility that the aortic aneurysm was infected because it was at the site of the catheter that was inserted for the femoral artery via the common hepatic artery. The patient was diagnosed with impending rupture of acute thoracoabdominal aortic aneurysm and was admitted to the intensive care unit of our hospital. Graft replacement was performed for the thoracoabdominal aortic aneurysm, and the implanted catheter was removed during surgery and tested for culture. Pus was discharged from the aortic aneurysm wall incision and collected with swab for culture. The cultures of both the removed catheter and the pus of the aneurysm revealed Escherichia coli, Serratia marcescens, Eikenella corrodens, Streptococcus anginosus, α-Streptococcus, and Candida glabrata. The reported antimicrobial sensitivities of these organisms are shown in Table . Antimicrobial susceptibilities were determined by the disk diffusion method, and the results were interpreted according to the Clinical and Laboratory Standards Institute (CLSI) guidelines. Results of pathology examination of the wall tissue of the aneurysm were compatible with those of the infected aneurysm cultures because the former showed infiltration of neutrophils mainly in the small blood vessels around the adventitia and infiltration of neutrophils, lymphocytes, and plasma cells in the media of the blood vessels (Fig. ). On the basis of these findings, a diagnosis of catheter-related thoracoabdominal infected aortic aneurysm was made.\nOn the day of admission, antibiotics therapy was considered for implanted catheter-related infection. The patient was administered a combination of vancomycin 1.0 g intravenously every 12 hours, piperacillin/tazobactam 4.5 g every 6 hours, and micafungin 150 mg every 24 hours until all culture results were confirmed for a week at first. After determination of the drug susceptibilities of all strains, these antibiotics were found to be suitable and were continued. Although the thoracoabdominal aneurysm was resected and pus was drained, antibiotics were administered for 6 weeks in consideration of infection of the perivascular area from the celiac artery to the hepatic artery. His symptoms and laboratory test results improved after surgery and administration of antibiotics. The patient was discharged on day 45, and no recurrence of infected aortic aneurysm was observed on subsequent follow-up CTs as an outpatient for 1 year.

A 77-year-old woman was admitted to our hospital with atypical symptoms. She had dyspnea when she lay on her back or in supine position. Also, she complained of the symptoms of superior vena cava syndrome in the mornings but in hours her symptoms were relieved. The symptoms and signs of superior vena cava syndrome in this case were intermittent cough and dysphagia, facial and neck swelling, bilateral jugular venous distention and collateral venous circulation. In her medical history, there was no history of previous surgical intervention and she only had the existing diagnosis of hypertension. Physical examination demonstrated a slight decrease in breath sounds over the right hemithorax. Chest radiography showed widened mediastinum, increased cardiothoracic ratio, deviation of the trachea, and convexity of the right superior mediastinum ( and ). A contrast enhanced computed tomography (CT) scan confirmed the existence of ascending aortic aneurysm which compressed the superior vena cava, and its maximum diameter was 14 cm (). It was decided that a prompt open surgical repair of this giant AAA was the most appropriate treatment option, due to the existence of high risk of rupture of aneurysm, hemorrhagic shock and death. After informing about the operation and obtaining the informed surgical consent form from the patient, she was transferred to the operating room and operated on in supine position under general anesthesia. Right common femoral vessels were exposed and cannulated in order to establish cardiopulmonary bypass, and then a median sternotomy was performed. A giant AAA was occupying most of the space in the pericardial cavity (). The aorta was cross clamped across the aortic arch. Under normothermic condition, an aortotomy was made and we used selective cardioplegia directly into both coronary ostia. Afterwards, the ascending aorta was excised (), and the aneurysm was replaced with a size 32 mm Dacron polyester fabric graft as supracoronary by using 3-0 prolene sutures supported by teflon strips, without performing any aortic valve and coronary artery procedures (). Weaning from cardiopulmonary bypass and postoperative course were uneventful. The patient was discharged 6 days after the operation. She was followed up regularly, and no major problem was observed in her control visits.

A 17 year old girl from India, Asia presented with a swelling in the right cheek of five months duration. She first noticed the swelling while washing her face. Swelling gradually increased in size, becoming more pronounced during mastication and while waking up in morning. Over the last one month she developed pain over the swelling. She gave no history of trauma or oral contraceptive pill usage. On physical examination there was a swelling in the region of the right parotid measuring 3 x 2 cm which was non-tender. Swelling was 3 cm in front of the tragus and 2 cm below the zygoma. There was no compressibility and the overlying skin was normal. On clenching the masseter the swelling diminished in size. There was no facial nerve involvement and parotid duct orifice was normal.\nFNAC revealed greenish color aspirate, cytology of which did not reveal any cellular material, this probably was extravasated blood and the greenish tinge, due to breakdown products of hemoglobin. This was evident as areas of hemorrhage on histology. A contrast CT was done () which showed a well defined heterogenous mass lesion involving the right masseter muscle which was highly vascular and a diagnosis of rhabdomyosarcoma was made. Preauricular skin incision was made as for a parotidectomy. Skin flaps were raised A normal looking parotid was found and the underlying masseter showed a diffuse bulge with no surface abnormality. The facial nerve trunk was identified and a superficial parotidectomy was done after carefully identifying and preserving the branches of the facial nerve. The facial nerve was seen spread over the diffuse bulge involving the masseter muscle (). The nerve fibres were subsequently dissected from its masseteric bed and gently raised with a hook. There was no definite encapsulated lesion or a palpable swelling which could be excised. The whole masseter exhibited compressibility with gradual filling. The facial nerve branches were gently lifted with a wooden spatula and under this arch the masseter was mobilized from the mandible and also severing it's attachment from the zygomatic arch. Through the same incision the external carotid artery was slinged and proximal vascular control was achieved. Anteriorly the masseteric fascia was preserved protecting the fine communications of the facial nerve. () displays the branches of the nerve after excision of the masseter. Complete excision of the masseter did not cause any significant morbidity in terms of cosmesis. There was temporary paresis of the marginal mandibular nerve which recovered in 4 weeks. The histopathological examination revealed capillary hemangioma. An ER [Estrogen Receptor] and PR [Progesterone Receptor] study was done which was negative.

A 62-year-old man was admitted to hospital with urinary infection 1 week after a surgical intervention for nephrolithiasis. He received ciprofloxacin 500 mg twice a day. Four days after the first intake of the antibiotic therapy, the patient started to present severe numbness in the feet gradually ascending towards the calves and sensory disturbances in the hands, but not flaccid paresis. During the examination of the patient, he had full strength in his extremities and only vibratory sensory distal deficit. Patellar and Achilles reflexes were absent. Cranial nerves were not involved, and no ataxic or autonomic features were reported. An electrodiagnostic test performed in the fourth week revealed that the peroneal and tibial nerves, as well as the sensory nerves in the lower limbs, were not excitable. In the upper limbs, the amplitudes of the compound motor action potentials (CMAPs) of the median and ulnar nerves were extremely low, less than 80% of the lower normal limit of motor amplitude, indicating axonal degeneration []. The sensory and motor nerve conduction velocity was severely diminished with temporal dispersion, especially at common entrapment sites, but no conduction blocks were registered (Table ). Distal CMAP latencies in the median and ulnar nerves were prolonged as electrophysiological evidence of demyelination features []. The H reflex recorded from the soleus muscle after the stimulation of the tibial nerve was bilaterally abolished. The electromyography revealed active denervation with increased temporal recruitment in the distal part of the lower limbs with no neurogenic pattern in the proximal muscles. One month later, it was discovered that the same clinical phenotype with lack of tendon reflexes was present in the lower limbs. The electrodiagnostic test reported more than 50% reduction of normal values of the sensory amplitudes in the median and ulnar nerves and inexcitability of the sural nerve (Table ). In our case, the involvement of the upper limbs was also prominent, even if the length-dependent pattern was respected. The fibular and tibial nerves became electrically excitable late in the disorder, but the compound motor action amplitudes were severely reduced with a comparatively lower reduction of motor conduction velocities. The subsequent reduction of nerve velocities of more than 30% and the increase in distal motor latencies of more than 50% fulfilled demyelination criteria []. Therefore, we concluded that the demyelination features were secondary to axonal degeneration.\nCerebrospinal fluid analysis did not detect albuminocytologic dissociation. The routine laboratory testing, including comprehensive metabolic profile, erythrocyte sedimentation rate, thyroid-stimulating hormone levels, and also vitamin B1, B12, and E, was normal. Furthermore, we found that the antibodies anti-GM1b and anti-GD1a were absent. The vitamin profile showed low amounts of serum folic acid at 2.7 ng/mL. The patient denied excessive alcohol consumption, which was confirmed by biological features. Additionally, there was no evidence that the neuropathy occurred secondary to other known causes. Despite the discontinuation of the antibiotics treatment, there was no relief of symptoms, and the patient was treated with pregabalin [] and, at the same time, with oral folate supplementation for 3 months. The electrophysiological studies 6 months after the first ciprofloxacin intake showed an important improvement, particularly in the excitability of the sural nerve, which regained a normal amplitude, and also in the distal compound motor action latencies of the amplitudes of the peroneal, tibial, median, and ulnar nerves, respectively. The H reflex of the tibial nerve remained abolished. The serum folate level became normal again at 33.8 ng/mL. Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) as a differential diagnosis was ruled out due to the lack of albuminocytologic dissociation. The clinical recovery lasted more than 6 months after drug intake.

A 40-year-old male patient was admitted to the Department of Urology, Calcutta National Medical College, with a complaint of clear fluid discharge from an intra-abdominal drain placed on the right side of his lower abdomen. He had a history of an open appendicectomy done at a primary health care center 3 weeks previously for clinically suspected acute appendicitis. According to the operating surgeon's brief, there was a mass in the right iliac fossa. The appendix was inflamed and was densely adhered to the mass. The surgeon was able to dissect out the appendix with difficulty. During the dissection, the mass sustained an injury that resulted in clear discharge through it. The surgeon suspected a ureteral injury but was unable to repair it; hence, he inserted a drain and referred the patient to us for further management.\nOn examination, the patient was anxious but his clinical parameters, hemogram, renal function tests, and serum biochemistry were normal. The patient had no significant medical or surgical history apart from the present episode. There was an output of approximately 500 to 600 mL per day from the abdominal drain. Analysis of the drain fluid revealed a high creatinine level, which suggested that the output was urine. Ultrasound examination of the abdomen could not delineate the left kidney. The right kidney and ureter were normal on the intravenous pyelogram (IVP) but the left kidney was not seen in its anatomical position. On careful examination of the IVP, a faint shadow with areas of contrast excretion could be seen on the right side, especially in late films at the level of the fourth and fifth lumbar vertebrae (). Considering the possibility of crossed renal ectopia, contrast enhanced computed tomography (CECT) was performed, which confirmed the diagnosis (). The ectopic left kidney was small and showed excretion of contrast with evidence of hydronephrosis. The two renal units were not fused with each other. Cystoscopy revealed a normally placed left ureteric orifice. A retrograde pyelogram (RGP) on the left side showed a hydronephrotic kidney with distorted pelvicalyceal system. There was extravasation of the contrast from the kidney. There was also an area of narrowing in the ureter suggestive of stricture, which presumably led to the hydronephrosis (). The ureter above the narrowing was normal but tortuous. A micturating cystourethrogram did not show any reflux. The patient was diagnosed to have a dual injury, renal as well as ureteric.\nA 5-Fr Double J (DJ) stent was placed in the ectopic kidney, albeit with some difficulty, under fluoroscopic guidance (). The drain output decreased to 50 mL the next day. The drain was removed on the second postoperative day. Abdominal ultrasound, performed on the fifth postoperative day, did not reveal any abdominal collection. The DJ stent was removed in the sixth postoperative week. At the 9-month follow-up, the patient was doing well. The diethylene triamine pentaacetic acid (DTPA) scan performed in the follow-up period showed preserved renal function with prompt washout of the tracer with furosemide.

An 8 year-old girl with a past medical history of constipation presented with a history of vomiting for nine months. The vomiting was intermittent, non-bloody, at times bilious, and occasionally contained food particles. An abdominal ultrasound was performed which demonstrated debris within a dilated proximal duodenum. The superior mesenteric artery (SMA) and superior mesenteric vein (SMV) were visualized with the SMA lying to the left of the SMV with normal anatomic alignment []. No large solid or cystic masses were seen.\nA standard barium single contrast upper gastrointestinal (UGI) series was performed with the contrast entering the antrum and duodenal bulb. The proximal duodenum and descending duodenum were markedly dilated in caliber with apparent tapering of the third part of the duodenum. There was an abrupt cutoff with no contrast extending beyond approximately the mid abdomen []. Delayed images were obtained while the patient was supine with contrast never extending beyond the third portion of the duodenum [].\nPatient was subsequently placed prone for several minutes with eventual slight transit of contrast []. Thirty minute delayed prone images demonstrated contrast in the proximal small bowel, however proximal duodenum remained markedly dilated and contrast/debris filled []. Additionally delayed overhead images demonstrated contrast extending to the distal small bowel after patient had been upright for greater than 30 minutes []. Markedly dilated proximal duodenum with abrupt cutoff in the third portion of the duodenum raised concern for a questionable mass like positionally dependent extrinsic compression of the third portion of the duodenum.\nA subsequent computed tomography (CT) of the abdomen and pelvis was performed with oral and intravenous contrast. The duodenum was distended with the third part of the duodenum tented downward []. The duodenal/jejunal junction was severely narrowed and coursed distally anterior to the right common femoral artery below the bifurcation [].\nThe patient was taken for an exploratory laparotomy and found to have dense vascularized bands without intestinal malrotation. Upon entering the abdomen, the cecum was noted to be in normal anatomical position. Further exploration in the abdomen revealed the proximal jejunum tethered by dense vascularized bands running from approximately five inches distal to the ligament of Treitz down into the pelvis. The cecum was incidentally noted to be folded back on itself and adherent to this tented portion of the jejunum. After these adhesions were ligated, the bowel was examined and no other anatomical abnormalities were discovered. The patient experienced a normal post-operative course with subsequent complete resolution of symptoms.

A 12-year-old girl presented with a complex deformity with progressive shortening involving her right dominant upper extremity. The mother gave a history of hospitalization for fever and pain in the right upper limb at 6 months of age. There was no history of trauma or surgery on the shoulder joint. The child had adapted to carry out the daily chores with her left hand. She had stopped schooling, as her writing speed and clarity with her left hand was impaired. Activities of personal hygiene were managed well.\nA thorough examination ruled out congenital deformity. There was a scar along the posterior axillary fold healed with secondary intention. The affected humerus was shortened by 16 cm (right humerus measured 8 cm, left 24 cm) without angular deformities. The shoulder was dislocated with the head situated inferior and posterior to the glenoid cavity rotating the entire extremity through almost 180°. The palm facing posteriorly and the olecranon anteriorly. Attempts to position the arm across the chest actively exaggerated the deformity [].\nThe humeral head was enlarged but easily reducible. This significantly improved the disability by placing the hand in front of the chest. The elbow joint and the hand were normal with wasting of upper limb. There was no neurovascular abnormality.\nPlain roentgenograms showed a dislocated glenohumeral joint with enlarged humeral head and a small dysplastic glenoid fossa. The humeral shaft was short and thin, condyles were dysplastic, but the elbow joint was normal. There were no angular deformities.\nA clinicoradiological correlation revealed two components of the deformity, instability as major cause of functional impairment and humeral shortening that led to the cosmetic deformity.\nWe decided to correct the deformity by combining shoulder arthrodesis with humeral lengthening as a single-stage procedure. The obstacles were dysplasia of the shoulder that decreased the area of contact at the glenohumeral joint, small girth of the humeral shaft, quality of bone, type of fixation, and the soft tissue constraints during lengthening. We formulated the following surgical plan. The patient was kept in the lateral position. Arthrodesis of the shoulder was performed through the deltoid splitting approach, with three 4 mm cannulated cancellous screws (two across the joint and one to transfix the acromion). An Ilizarov frame was constructed to provide unifocal lengthening of the humerus and stabilization of the arthrodesis site. Five 3.5 mm Schanz pins were inserted, two in the scapular spine, two in the proximal humerus, and one in the distal humerus. The distal humeral fixation was augmented with two 1.5 mm wires. A frame was assembled with 180° half-ring for the scapula and the proximal humerus and a 5\8 ring for the distal humerus. Osteotomy was performed just distal to the deltoid tubercle [].\nThe elbow range of movement exercises were encouraged as soon as the pain subsided. The distraction was commenced one week after the surgery at the rate of 0.25 mm four times a day. Roentgenograms were taken twice weekly for one month and then once monthly for three months. Uniform column of regenerate was observed. There was no distraction at the arthrodesis site, which went on to good fusion. A lengthening of 9 cm was achieved []. There was no neurovascular compromise and the elbow movement was maintained with limitation of terminal flexion. Problems encountered were superficial pin tract infection in the distal humeral pins, pain due to soft tissue stretching, and angular deformity of the regenerate. The distraction phase was discontinued after 14 weeks because of formation of a cyst in the regenerate with thinning of the bone. The consolidation phase lasted for further eight months, till corticalization of the regenerate and healing of the cyst was observed. The frame was then removed and a shoulder spica given for three months.

A female child aged 12 years, initially presented to a surgeon elsewhere, with a history of sudden onset of severe pain in the upper abdomen and no history of trauma to the abdomen. There was tachycardia with normal blood pressure (BP). The surgeon on abdominal examination found to have a vague epigastric mass associated with tenderness. Then the patient underwent ultrasonography of the abdomen and suspected to have the possibility of internal bleeding within pseudocyst of the pancreas, occupying whole of the lesser sac. Then patient was referred to us for further management.\nThere was severe pain in the abdomen with tachycardia and BP was 100/60 mm of Hg. As other routine blood investigations were within normal limits, patient was subjected to CT scan of the abdomen, which revealed a well-demarcated mass of size 10 cm × 13 cm arising from the body of pancreas, which was composed of a solid-cystic portion with enhancement of contrast in solid portions and occupying the whole of the lesser sac, posteriorly abutting to the splenic vessels with a breach in the anterolateral part of the capsule (rupture) of tumor with minimal hemoperitoneum. The distal tail of pancreas could not be made out. The impression was SPT arising from the body of pancreas without any metastasis to the liver.\nThen it was planned for surgical excision of the mass along with possible splenectomy. An informed consent was taken for the same. The roof top incision was taken. On the exploration, there was a significantly large tumor mass arising from the body of the pancreas, extending to the left subhepatic region, displacing the gastrohepatic ligament anteriorly. The tumor was abutting the transverse mesocolon. There were no metastatic lesions on the surface of the liver. There was minimal hemoperitoneum, which may be due to rupture of the tumor. With meticulous dissection whole mass was removed along with a tail of pancreas. The dissection to separate splenic vessels from tumor and tail of pancreas was possible; in view of low malignant potential of tumor and without any metastasis, it was decided to preserve the spleen. The head of the pancreas was preserved by dividing the head from the body by using staplers.\nThe excised tumor was of size 10 cm × 13 cm. The histopathological examination (HPE) of specimen revealed an encapsulated tumor with hemorrhagic and necrotic areas admixed with solid areas. The surgical margins were negative. Microscopic examination revealed features of SPT. Immunohistochemistry was reactive for CD56 and alpha-1-antitrypsin and negative for chromogranin.

An active 67-year-old male presented with recent onset of impaired effort tolerance, dyspnoea, orthopnea and paroxysmal nocturnal dyspnoea. His previous medical history included an oesophagectomy and left upper lobectomy via left thoracotomy for oesophageal cancer 6 years prior to this presentation. Post oesophagectomy, a surveillance gastroscopy was done with successful dilation of a stricture. There was no history of severe reflux or excessive symptoms of gastrointestinal inflammation. The patient was a retired cardiologist from the same institution, and he gave full consent for his case to be reported.\nCardiac examination and transthoracic echocardiography diagnosed severe mitral valve regurgitation (MR) because of prolapse of his posterior mitral valve leaflet. A mutual cardiology and surgical decision was made to proceed with a minimally invasive mitral valve repair procedure via right-side minithoracotomy, performed by a surgeon experienced in this technique.\nThere was a strong team feeling that the patient would benefit from an intraoperative TOE to guide surgical management and intraoperatively confirm a successful procedure. Careful and critical consideration was given to the risks and benefits of TOE probe placement and manipulation in this patient in light of his previous surgical history. All surgical discussions included the thoracic surgeon who performed this patient’s lobectomy and oesophagectomy procedures. Opinion was that because the oesophagus was removed and part of the stomach, with its larger lumen, was in the patient’s thorax this would simplify TOE probe placement and make it atraumatic. A gastroscopy was not performed prior to surgery although it is acknowledged that this may have guided the risk of TOE placement. The patient and his close relatives were well informed of all risks and were included in discussions throughout the surgical planning stages. Informed written consent for surgery, anaesthesia and TOE was obtained. While epicardial echocardiography may have been helpful with the intraoperative management, the surgical and anaesthetic teams both felt that the images from epicardial echocardiography would not have been able to provide the same degree of continuous detail that was obtainable through the use of TOE.\nAfter induction of anaesthesia, the patient remained hemodynamically stable. The 3D TOE transducer (Vivid E9) was placed carefully without any difficulty. There was no resistance to either its placement or manipulation. Interesting and unfamiliar TOE views were observed, with no clear mid-oesophageal views obtainable. The usual upper oesophageal short- and long-axis views of the big vessels were observed. When the transducer was advanced from there, it would go straight into hybrid transgastric short- and long-axis views (, , , and ). These views were noted to be at unusual angles due to the displaced cardiac anatomy from previous thoracic surgeries.\nThe mitral valve was carefully assessed before and after CPB. The preoperative examination confirmed severe MR because of prolapse of the posterior mitral valve leaflet. A flail posterior leaflet P2 scallop ( and ), due to chorda tendineae rupture ( and ), was clearly demonstrated. There was a severe eccentric regurgitant jet present, going into an anterior direction (). Severity was confirmed by demonstrating systolic flow reversal in the pulmonary veins (), and a vena contracta of more than 7 mm diameter. Ventricular systolic function was preserved with only moderate pulmonary regurgitation present (). A small left atrium indicated fairly acute/recent chordal rupture and MR.\nThe mitral valve procedure was uneventful and completed in a minimally invasive videoscope-assisted fashion via a right-side minithoracotomy. The mitral valve was repaired with two artificial Goretex chordae and a size 32 annuloplasty ring. The patient was separated from CPB without problems, on minimal inotropic support, and after heparin reversal, the minithoracotomy incisions were closed. TOE confirmed a successful repair with no residual regurgitation under normal loading conditions. The valve was competent with no pathological pressure gradient/drop across it. The annuloplasty ring was well seated. The TOE transducer was removed in the operating theatre and inspected for blood or signs of bleeding, neither of which was observed.\nAfter the patient woke up in ICU a few hours post surgery, and his airway was extubated, a careful history and communication showed no evidence of injury to the patient’s neo-oesophagus/upper gastrointestinal system. The patient started to take small sips of clear fluids a few hours post surgery and soon after that soft food, without any complications. The patient was discharged from hospital after 5 days and intermittently followed up over the next month, with no indication of any further cardiac, thoracic or upper gastrointestinal complications.\nThis case highlights the importance that when indicated, a TOE examination is possible in a patient with a previous oesophagectomy or oesophago-gastrectomy. It is important to always consider the risk–benefit ratio of TOE in this subgroup of patients. This is particularly relevant when TOE is crucial to a successful outcome, such as in this case of surgical mitral valve repair. Similarly in any other situation where TOE may be lifesaving, its use should be critically considered where potential contra-indications exist. To the best of our knowledge, this is the first report in which TOE has been done in a patient after a previous oesophagectomy. See accompanying figures (, , , , , and ) and video clips (, , , , and ).

A 24-year-old male smoker presented to his GP with a 6-month history of right foot pain extending from the base of the first toe to the plantar surface of the foot. The pain was fluctuating in severity, did not correlate with specific activities, and was only partially relieved with common analgesics. The patient's work involved prolonged standing and heavy lifting. He had had bilateral pes planus and valgus heels during his childhood but had been asymptomatic for several years. Two abdominal nodules had been excised by a dermatologist two years prior to the onset of his presenting complaint. The histopathology report confirmed they were a fibroma and a leiomyoma of no particular clinical significance. Apart from a few other minor injuries, his past medical and surgical history was otherwise unremarkable.\nThe pain was attributed to the patient's previous pes planus deformity and was treated conservatively with common analgesia by the GP. Over the next three months the pain did not resolve and the patient was referred to the local orthopedics outpatient clinic. Extensive X-ray studies and blood tests including inflammatory and immunological markers were all normal, and the patient was referred to Orthotics for foot arch support.\nDespite the arch support, the pain progressively worsened over the next 6 months. A foot MRI revealed mild, early degenerative 1st MTP joint changes with a small amount of fusion, but no other abnormalities. The diagnosis of reflex sympathetic dystrophy was also considered and supported by the findings of a radionuclide isotope scan. Although rocker soles and stronger analgesia (including oral morphine) were suggested, these failed to control the symptoms. Although this was followed by physiotherapy and multiple guanethidine blocks, symptoms remained uncontrolled and caused significant disability 18 months after the patient's first GP visit.\nIn the following weeks the patient developed progressive weight loss, fatigue, and muscle wasting below the knee. He noticed for the first time a firm round mass (approximately 15 cm) on the lower aspect of the posterior thigh. He was referred back to Orthopaedics and an urgent MRI confirmed an oval, smoothly defined heterogenous mass in addition to signal changes in both right and left femurs, most likely representing metastatic foci ().\nThe appearances were most suggestive of metastatic malignant peripheral nerve sheath tumour (MPNST), and the patient was urgently referred to Oncology. Chest CT and whole-body MRI revealed the presence of multiple lung and bone metastases, consistent with stage IVb malignant disease. Predisposing factors for this rare malignancy including NF-1 were considered. A detailed clinical examination revealed freckling of the right axillary region. In addition, the histology slides from the patient's abdominal skin nodule biopsy were reexamined by a specialist. The initial fibroma diagnosis was inconsistent with histopathological findings, which were more in keeping with an intraneural neurofibroma, part of a plexiform neurofibroma.\nBased on the National Institute of Health (NIH) diagnostic criteria, the patient was diagnosed with neurofibromatosis type I []. The patient was started on palliative chemotherapy with doxorubicin, but unfortunately died 4 months later, almost 24 months from his initial complaint.

We present a case of a 13 year old boy with Loey's Dietz syndrome and a history of a David procedure (valve sparing aortic root replacement) when he was 9 months old with aortic valve and aortic root replacement at 2 years of age with subsequent post-operative complete heart block requiring pacemaker insertion. He ultimately underwent a Bentall procedure at 12 years of age. Upon routine cardiology clinic follow-up an incidental finding of a cystic structure in the liver was noted during echocardiography ().\nHe was asymptomatic from a cardiac and gastrointestinal standpoint. The remainder of his echocardiogram showed normal mechanical aortic valve function and normal left ventricular function. His pacemaker function was normal.\nAn abdominal CT was obtained to further characterize the lesion. Compared to a CT obtained 4years previously a new, well demarcated, heterogenously enhancing mass or aneurysm was identified between the lesser curvature of the stomach and the liver measuring 3.9 cm × 5.3 cm × 4.3 cm ( and ). A small branch off the left gastric artery appeared to enter the left anterior aspect of the mass ().\nAn abdominal ultrasound with Doppler performed after the CT scan was consistent with a patent aneurysm or pseudoaneurysm impressing upon the left hepatic lobe ( and ). Color Doppler flow into the aneurysm was demonstrated from the left gastric artery. No thrombus was identified.\nSuccessful embolization of what was found to be a left gastric artery pseudoaneurysm () by interventional radiology was performed using 5 detachable GDC coils (Boston Scientific Corporation, Natick, MA) in the left gastric artery at the neck of the pseudoaneurysm ().\nHe was also noted to have a markedly ectatic superior mesenteric artery (SMA) with several irregular beaded second and third order vessels from the SMA thought to possibly represent manifestations of his disease. Two months following the coil embolization, an abdominal CT scan with contrast demonstrated the excluded large pseudoaneurysm with no enhancement noted within it. Nine months later, an abdominal ultrasound showed interval resolution of the embolized and thrombosed pseudoaneurysm without any residual abnormalities demonstrated in the area. There were no new aneurysms identified. He remains stable from a cardiac perspective as well.

A 49-year-old Caucasian woman was referred to a general surgeon by her primary care physician for a right nipple lesion. She reports no past medical history, and social history is notable for tobacco use. The patient stated that she first noticed a small, yellow, and fleshy bump on her right nipple approximately two years prior. She became concerned due to its rapid growth in the last year. Four months prior, she visited her primary care provider who performed a shave biopsy of the lesion. Initial pathology results suggested squamous cell carcinoma, but this was thought to be discordant with the clinical picture. At consultation, she reported that her right breast had also started feeling hot and tender for two weeks duration. On examination, her right breast was erythematous and rigid with a 2.2 cm lesion consuming the right nipple. Her nipple also drained yellow pus. The patient was placed on a course of antibiotics due to concerns for an abscess.\nAn MRI was ordered to investigate possible underlying breast malignancy. Results of the MRI showed no solid mass underlying the nipple. A wedge biopsy of the nipple was performed to confirm the initial shave biopsy pathology (). Pathology showed verrucous histologic features with chronic inflammation and underlying abscess with concerns for a possible cutaneous malignancy. Specifically, there was marked papillomatosis with hypergranulomatosis between the papillae as well as a lack of granules at the papillary surfaces. Immunohistochemical testing was also positive for HPV L1 capsid protein. Because the initial shave biopsy showed SCC with positive margins, this clinical picture suggested that an inadequate sample was taken during the wedge biopsy. After consultation of literature, excision with wide margins was determined to be appropriate for removal of the lesion.\nThe patient underwent a wide excision of the right nipple-areola complex for removal of the growth. A 6.2 cm x 3.2 cm skin ellipse was excised encompassing the 2.2 cm nipple lesion. On final histologic examination, the lesion was found to be a large tumor with verrucous features, hyperkeratosis, dyskeratosis, and nests of keratin pearl formation (). Two areas showed microinvasion of the dermis with loss of the basal lamina. There were also significant acute and chronic inflammatory responses in the deep dermis representing an underlying abscess. These findings are congruent with the diagnosis of a well-differentiated squamous cell carcinoma with arising within verruca vulgaris. All margins were found to be clear of tumor cells. The post-op course was uneventful. She continues to follow up to monitor potential recurrence of the growth.

A 45 years old unemployed man following a bout of alcohol binge presented to the hospital emergency with history of suicidal ingestion of approximately 100 ml of sulphuric acid. Examination of the oral cavity revealed superficial ulcers on the inner cheeks, the posterior pharyngeal wall and erythema of the epiglottis. There was no respiratory discomfort or hemodynamic instability. A chest X-ray and abdominal X-ray done to look for perforation was normal. After the initial resuscitation, he was taken up for upper gastrointestinal endoscopy which revealed deep ulcers of esophagus at approximately 20 cm from the incisors and scattered superficial ulcers in the rest of the esophagus along with diffuse erythema. There were deep ulcers in the antrum of the stomach extending to the pylorus along with ulcers in the mid body on the posterior surface. Duodenum was normal.\nThe patient was managed conservatively and discharged after 10 days of hospitalization. Two months after discharge he presented with complaints of dysphagia and recurrent vomiting of brownish foul smelling liquid. An upper gastrointestinal examination revealed a tight stricture at 20 cm, which did not allow the endoscope (Pentax videoscope EG 3840) to go beyond. A barium swallow and meal follow through examination showed the presence of a 3 cm long stricture in the upper esophagus. The rest of the esophagus was normal. The stomach showed slight lack of distensibility with slight thickening of the folds in the fundus. There was very little flow of barium into the duodenum, but instead the transverse colon showed opacification along with descending colon, suggesting a possibility of gastro-colic fistula in the proximal body of the stomach from the greater curvature ().\nSubsequent upper gastrointestinal endoscopy of the stomach done after esophageal dilatation with Savary Gilliard dilators revealed severe antral and pyloric stenosis with scarring. The endoscope could not be negotiated into the duodenum. No definite gastro-colic opening could be appreciated. A colonoscopic examination done to look for any abnormal opening in the colon also revealed no abnormal opening.\nA feeding jejunostomy was done and patient was planned for a second stage definitive surgery. Laparatomy was done three months later. The procedure performed was distal gastrectomy along with Billroth 1. Operative findings were pyloric stenosis, scarring and adhesions between the stomach and colon. The scarred site was probably the site of fistula, which had healed. Subsequently the feeding jejunostomy was removed. The patient is doing well and is gaining weight.

A 67-year-old male veteran presented a 28-year history of above the left knee amputation because of blast injury. He was a patient with well controlled type II diabetic mellitus attending our clinic with above the knee amputation stump pain and could not wear his prosthesis for 3 weeks. The history report from rehabilitation department was that the patient experienced a blast injury on his left thigh and leg. He underwent above the knee amputation 28 years ago. Approximately 6 weeks after the surgery, the prosthesis was made for the patient and a rehabilitation at home program was started. Neuropathic stump pain was recorded 3 months thereafter. Stump neuroma and bone spur were suspected to be the pain origin. The patient underwent stump revision with excision of neuroma and bone spur. After the second operation, no evidence was found of stump complication, and the patient was admitted in the military ward with orthopedic trauma services. He had some degree of posttraumatic stress disorder countered with psychiatric team support. No suicidal or homicidal ideation while admitted was noted. Daily life activities and self-care ability were supported by a physiotherapist. The patient was discharged at every 2–3 weeks follow-up appointments for 2 months and every 3 months thereafter. After 12 months, he missed his scheduled follow-up appointment.\nTwenty-eight years later, the patient attended our clinic presenting severe burning and stabbing sensation and clinical sign suggesting sciatic neuroma. He exhibited limited ability to use his prosthesis and subsequently stopped wearing the prosthesis because of uncontrolled pain for 3 weeks. He complained his prosthesis had not fit the stump for 1 year because of muscle atrophy and mild intensity of the stump pain for 9 months. However, he encountered to keep on tolerating stump pain and finally presenting severe neuropathic pain. The physical examination revealed positive Tinel’s sign and palpable lump at the proximity of the posterior stump. The diagnosis block test result with lidocaine was positive. Conventional radiography () showed no evidence of osseous origins of pain such as heterotopic ossification or osteomyelitis. Magnetic resonance imaging (MRI) ( and ) showed features suggesting a sciatic neuroma.\nThe initial treatment was non-operative including nonsteroidal anti-inflammatory drugs, high-dose pregabalin, physical therapy, local steroid injection, and high-power laser therapy. A new prosthesis was made for the patient. At a routine follow-up clinic visit, the patient still limited his daily life activities due to neuropathic stump pain.\nThe decision was made to perform sciatic nerve traction neurectomy and muscle implantation, which are techniques involving gentle pulling of the bulbous portion of the nerve before proximal dissection allowing the tension to retract the sciatic nerve back up into the soft tissue and bury the end of the proximal nerve stump within the surrounding muscle [, , ]. This theoretically reduces pressure on the sciatic nerve ending and prevents neuroma formation. Intraoperative appearance of sciatic neuroma at the above-knee amputation stump is shown in (). After approximately 30 minute of neurectomy and muscle implantation, the stump was revised and closed. The patient received in a soft dressing about the wound and multimodal analgesia was administrated. After the operation, no surgical wound infection, PLS or PLP, was observed. The patient was able to wear the prosthesis with optimally functional outcome and proper physiotherapy protocol after surgical wound stitch off. At the first follow-up appointment, the patient was asymptomatic. At the most recent follow-up visit, 3 years after the surgery, he continued to perform daily life activities well, with no clinical signs of unpleasant sensation or recurrence.

A case of a 62-year-old male, a concrete block maker/bricklayer who presented at the Dental Centre, University College Hospital, Ibadan on account of a non-healing ulcer on the left side of his face of 6 months duration. The lesion was said to have started as a small firm painless swelling in the left infra-orbital region, which gradually increased in size until 3 months later when it became ulcerated with associated pain and purulent discharge. Physical examination revealed a cachectic and pale elderly man with an obvious facial asymmetry due to a fleshy exophytic mass on the left side of the face. The patient was not a known diabetic or hypertensive and had no other known systemic disease. There was no history of tobacco or alcohol use and he was not being treated for any chronic condition. The mass measured about 16 cm in its widest diameter and extends from the left supra-orbital region to the left maxillary area and also to the left temporal area about 1 cm anterior to the left auricle. The mass caused a deviation of the lateral wall of the left nostril to the right, though clinically the nasal wall did not appear infiltrated by the tumor. It also extended superiorly such that the left eye globe could not be visualized [].\nThe exophytic mass had a necrotic central area which was covered with slough tissue. There was impaired mouth opening; the left buccal sulcus was fully obliterated by the tumor mass but the palate appeared clinically normal.\nFine needle aspiration cytology suggested a malignant epithelial neoplasm possibly a salivary gland malignancy or a skin adnexia malignant tumor. Following incisional biopsy, sections showed a malignant epithelial neoplasm composed of islands of large oval to polyhedral malignant squamous cells with eosinophilic to amphophilic cytoplasm and vesicular nuclei with some of the nuclei peripherally placed. There were areas showing clear cell differentiation of the malignant squamous cells with some cells arranged in a pseudo-glandular pattern and isolated areas showing keratin pearl formation []. Overall features were suggestive of a clear cell variant of SCC of the skin. shows lesion to be negative for periodic acid schiff (PAS), mucicarmine and alcian blue stains but was strongly positive for AE1/AE3 (immunostain).

A 62-year-old man was admitted to our orthopedic hospital presenting severe lower back pain and a sciatic disorder following the L5 dermatome. The patient described the pain starting 6 days ago with a sudden onset. Initially, the patient took several non-steroidal anti-inflammatory drugs, such as diclofenac 150 mg and metamizol 1000 mg per day, without having any pain relief. After 3 days the patient consulted his general practitioner, where he received a local pain relief injection with a corticosteroid. Having no pain relief again and with a progressive symptomatology in the right leg accompanied by numbness, the patient was admitted to our hospital.\nAt admission the patient showed severe lumbar spine pain with radiation alongside the dermatome L5 on the right side till the first toe persisting for 6 days and suggesting a nucleus pulposus prolapse. Since 2 days the patient had a hypoesthesia in the same dermatome with a maximum in the lower leg and foot. The femoral nerve stretch test was positive on the right side and the straight leg raise test was early positive at 20° elevation of the right leg while these tests were negative on the left side. The Achilles tendon reflex and the patella tendon reflex could be provoked on both sides similarly. There was no motoric deficit in both legs, no bladder or bowel dysfunction, and no saddle anesthesia. Importantly, the skin had no abnormal findings. The medical history was unremarkable except of arterial hypertension and a nucleotomy of a cervical disc. For ambulant non-controllable pain the patient was admitted to our hospital. Under intravenous pain therapy the medical condition ameliorated slightly. For differential diagnosis the patient underwent a MRI scan of the lower back. This showed no herniated disc but a slight spinal stenosis between L4 and L5, as well as, an unspecific swelling of the spinal nerve root L5 on the right side (). Based on these findings a conservative treatment including oral analgesia, physiotherapy and a series of lumbar epidural corticosteroid infiltrations was initiated. After the first lumbar epidural infiltration the patient developed a stain on the skin of his lower back. A closer examination of this mark showed an erythema with a group of small red blisters which had been partially dried out (). There was no sign for a bacterial skin infection induced by the infiltration therapy. Also, the laboratory infection parameters including the leucocyte count and the C-reactive protein showed normal values.\nThe epidural infiltration therapy was stopped immediately and the patient was sent to a dermatological specialist who diagnosed a herpes zoster infection with neuralgic pain and hypoesthesia in the dermatome L5. After a pain therapy with ibuprofen 600 mg 3 times a day combined with a systemic antiviral treatment with acyclovir 800 mg oral 5 times a day for a period of 7 days the patient could be discharged soon from our hospital in a considerable ameliorated condition.

A 36-year-old female patient was admitted to our department, presenting progressive enlarging mass and restricted range of motion of the left shoulder () for 6 years since year 2009. At the time of admission, she had completely lost occupational capacity of her left upper limb. Multiple foul smelling ulcers had developed over the swelling. Physical examination revealed a solid mass over proximal part of left upper limb measuring 450mm × 250mm with loss of normal contour of the left shoulder. Two discharging ulcers and a huge necrotic ulcer with slough were seen at the posterolateral and posterior surfaces respectively of the left arm. The swelling was bony hard in consistency but not tender on palpation. Dilated veins were noted on its surface. No lymph nodes were palpable over cervical and axillary regions. Computed tomography (CT) and Magnetic Resonance Imaging (MRI) were unable to be performed on admission due to its enormous size of swelling. Hence angiography of the left upper limb was performed to locate the anatomical position of major vessels and to detect anomalies as well. Trucut biopsy of the mass was performed and the histopathological examination showed fragments of tumour tissue composed of predominantly cartilaginous tissue with nuclei which were plump and hyperchromatic with occasional two nuclei per lacuna, which is consistent with well differentiated chondrosarcoma.\nAn informed consent was obtained from the patient prior to the operation. A multi-disciplinary intervention by the orthopaedic, radiological, anaesthetist and oncology team was adopted. She underwent forequarter amputation of her left upper limb. The tumour tissues were excised with maximum possible surgical safety margins. Intraoperatively there was neither excessive bleeding nor development of major complications. The resected mass measured 450 × 415 × 250mm and weighed 31kg () and was submitted for histopathological examination. It was reported as a well differentiated chondrosarcoma. She was discharged uneventfully one month later with a well healed wound (). Prior to discharge CT thorax, abdomen and pelvis revealed no evidence of distant metastases. Adjuvant chemotherapy was initiated three months following the operation. The patient was advised for regular follow up to monitor the disease progression.\nMicroscopically, the sections showed lobulated tumour composed of chondrocytes with hyperchromatic nuclei. There was minimal cellularity which exhibited rare small, dark nuclei and multinucleated forms. Mitotic activity was rare. Minimal tumour necrosis was present. Lymph vascular permeation -noted. There was no osteoid formation. The tumour cells involved part of the adjacent bone and its marrow, adjacent soft tissue and adjacent muscle. No joint or neurovascular bundle at margin were involved by tumour cells. Two lymph nodes were positive for metastatic chondrosarcoma.

The 8-year-old boy first presented in January 2012, having been referred by the family dentist, to the Department of Orthodontics at the Medical Center of the University of Göttingen for a routine orthodontic control and evaluation of treatment need (). The clinical examination of the asymptomatic patient showed no extra- or intraoral pathological findings. The medical history of the boy included a mild pulmonary valve stenosis and a secundum atrial septal defect with a left-right shunt. He showed a good physical and cardiac fitness and a normal nutritional status. The family history was positive for maxillofacial anomalies: the boy's older sister had been previously diagnosed with a dysplastic fibroma, a rare benign fibrovascular defect in the mandible, and a resection of the affected area in the mandible had been performed. His father and paternal grandmother had a positive history of odontogenic cysts as well as basal cell carcinomas, although the family history of OKCs was negative. The radiological examination showed three suspicious hypomineralisations visible as radiolucencies in the panoramic radiograph associated with the retained teeth 13 and 23 and the ectopic tooth 27 (). The young patient was referred to the Department of Maxillofacial Surgery for a surgical examination of the radiologic anomalies.\nThe operation was performed under general anesthesia. The suspected pathological area around teeth 23 and 13 showed no visible intraoperative pathological signs. A bone and soft tissue biopsy for histological examination was taken. In the area of tooth 27, a well-marked membrane was revealed, filled with a viscid fluid and fully enclosing the dental crown. The clinical aspect was consistent with a follicular cyst. During the radical cystectomy, tooth 27 was removed due to massive attachment loss. The histopathological biopsy showed a fibroosseous lesion in the area of teeth 13 and 23. The biopsy from region 27 showed an odontogenic connective tissue cyst wall with intramural odontogenic cell islands. On request of the surgeon, samples were sent for further diagnosis to the Bone Tumor Reference Center of the Swiss Society of Pathology at the University Hospital in Basel, Switzerland. The initial histological diagnosis was corrected to an OKC of the parakeratin variant. Microscopically, the cyst shows a squamous epithelium. The basal cells are palisading, with hyperchromatic nuclei (HE staining, 5x magnification) (). Due to the high recurrence of OKCs, a radiological control interval of 6 months was indicated (). Furthermore, orthodontic treatment was initiated.\nIn August 2014, during a regular radiological control, a new radiolucency was detected, associated with the retained and displaced teeth 47 and 48 (). The surgical removal of the cystic lesion and tooth 47 was performed under general anesthesia. The pathological finding was consistent with an OKC.\nThe regular control examinations were interrupted by missed appointments, so the next evaluation took place one year later, in October 2015 (). New radiolucencies were detected in the panoramic radiograph associated with the retained teeth 18, 17, 37, 38, and 48 as well as an evident enlargement of the radiolucency around the crown of tooth 13. A cone beam computer tomography scan was performed and showed well-defined radiolucent areas, associated with the retained teeth. Details of the surgical enucleation of the cysts with the extraction of teeth 18, 17, 13, 37, 38, and 48 are shown below. The postoperative radiological examination is depicted in . Clinical and radiological examinations were then performed every 6 months.\nWe describe the surgical enucleation of the cystic lesions using the example of the third operation (2015). This was performed under general anesthesia; the affected regions were exposed after lifting a mucoperiosteal flap. After a careful removal of a thin bone cortex, the cystic capsule was found () and separated from the bone with an obtuse instrument. The aim was to leave no epithelial remnants on the trabecular bone. All four lesions were associated with a retained tooth, which was only loosely anchored in the alveolar bone. Due to the high recurrence rate of the cystic lesions in this particular case, all affected teeth were extracted. In the area of the mandible, the use of Carnoy's solution was not indicated because of the exposure of the lower alveolar nerve (). Due to their large size, the cystic cavities were filled with a collagen graft, which stabilized the formation of a coagulum. No reconstruction with iliac crest bone or allogenic bone grafts was attempted. Subsequently, the mucoperiosteal flap was reverted back to its original position and fixed by sutures.\nBy October 2016 and August 2017, bone remodeling of the affected area had been detected and no new lesions were observed (Figures and ).\nDue to the recurrence and the appearance of new lesions, Gorlin-Goltz syndrome was suspected in the patient. After genetic counselling at the Institute of Human Genetics of the University Medical Center of Göttingen, molecular genetic analysis of the genes PTCH1 and PTCH2 was performed in 2015. Sanger sequencing revealed the heterozygous germline variant c.2779_2793del (p.Ser927_Val931del) in the PTCH1 gene. This variant leads to an “in-frame” deletion of 5 amino acids between amino acid positions 927 and 931 of the protein. This variant is listed neither in the Human Gene Mutation Database (HGMD) nor in the Leiden Open Variation Database (LOVD). However, a pathogenic effect of the variant seemed likely as many pathogenic variants have already been described in this region of the PTCH1 gene, even several in-frame deletions [, ]. Since the boy's father had shown similar symptoms (odontogenic cysts, basal cell carcinomas) that could be in line with a Gorlin-Goltz syndrome, he, too, was tested for the PTCH1 variant and resulted to be carrier of the variant.\nIn summary, clinical and molecular data together with the positive segregation analysis led to the classification of the variant as “probably pathogenic” and being responsible for Gorlin-Goltz syndrome in the patient and his father. The importance of talking precautions (e.g., sun protection due to the high risk of basal cell carcinomas) and regular medical surveillance (e.g., regular orthodontic care and annual dermatologic examinations) was emphasized.

A 30-year-old male patient was electively admitted to our general surgery clinic in June 2009 with a diagnosis of fistula in ano. His past medical history revealed a serious fall during a football game which resulted in a left acetabular fracture in 1993. Open reposition and internal fixation procedures had been performed two months after this accident. Postoperatively, he had developed abscesses on the upper medial aspect of his left thigh in the second month and on the lateral aspect of the left gluteal region in the third month. All these abscesses had been treated by surgical drainage and with antibiotics. Three years after the hip operation, he had developed a perianal abscess which was also drained. However, the intermittent spontaneous purulent discharge in the perianal region continued for 13 years since the patient did not seek any medical care during this period. His past medical history was not conclusive for any inflammatory bowel disease. Pelvic magnetic resonance imaging (MRI) performed in a different medical center eight months prior to his admission demonstrated an abscess cavity, measuring 2 cm in diameter, located superior to the levator ani muscle and its tract of 10 cm coursing from its internal opening in the rectum down to the perianal region (). The laboratory analysis including complete blood count, blood biochemistry, and erythrocyte sedimentation rate were within normal limits. Physical examination revealed the presence of two external openings 7 cm and 3 cm from the anal verge at the 3 o'clock and 2 o'clock positions, respectively. The results of digital rectal examination and colonoscopy were normal and the internal opening of the tract was not visualized. Based on these clinical findings, surgical intervention for the complex fistula in ano was planned. After bowel preparation, the patient was taken to the operation room. Under general anesthesia, the patient was placed in a jack-knife position and the buttocks were taped apart. The fistula tracts were laid open to the level of the anal sphincters. At this level, digital examination was performed towards the upper part of the tract and a foreign body located above the levator ani muscle was felt. A nonabsorbable braided thread of 5 cm in length and 6 mm in thickness was extracted (). After partial excision and curretage of the tract, a penrose drain was placed and the wound was closed with interrupted simple absorbable sutures (). Following the discovery of this object, a plain pelvic radiography was performed, this demonstrated advanced left acetabular degeneration with no other foreign body visible. Following an uneventful postoperative recovery, the patient was discharged home on the third postoperative day. On follow-up visits, complete resolution of the perianal fistula was observed after a month. The patient remained symptom-free during the 7-month follow-up period.

A 62-year-old female non-smoker presented in July 2005 with a hard palate lesion on the left side that she had been aware of for six months and was gradually increasing in size and associated with left otalgia and left cheek pain. There was no dysphagia, no neck mass, and no weight loss or loss of appetite. Other ear, nose, and throat (ENT) history was unremarkable.\nOn oral cavity examination, there was a left hard palate lesion of approximately 2 × 2 cm that appeared ulcerative and bled easily. Other ENT examination results were normal. The patient underwent left incisional biopsy of the hard palate mass, which suggested adenoid cystic carcinoma, and computed tomography (CT) of the chest, abdomen, and pelvis revealed no metastases.\nThe patient was scheduled for left inferior maxillectomy and the insertion of a prosthesis, and the final histopathology results confirmed the diagnosis of adenoid cystic carcinoma. Postoperatively, the patient received radiotherapy of 66 GY per 33 fractions. No postoperative radiological imaging was found for this patient because the procedure and treatment were performed outside the hospital.\nThe patient again presented at our ENT clinic in May 2011 with a tongue lesion on the right side, as shown in Figure , which she had been aware of for approximately one month without any history of dysphagia, dyspnea, or neck mass. On physical examination, the patient looked cachectic and depressed. Tongue examination revealed a tongue mass on the right side measuring 2 × 1 cm and involving the base of the tongue but not crossing the midline, which was hard on palpitation. Neck examination revealed no remarkable findings and other ENT examinations were normal. CT scanning of the neck revealed an exophytic tongue mass of approximately 2 × 2 cm on the right side. Magnetic resonance imaging (MRI) revealed a lesion signal on the surface of the tongue on the right side that was confined to the intrinsic muscle fiber, with no evidence of lingual septum, root of the tongue, or bone infiltration involvement. Lymph nodes of the neck were sub-centimetric and there was no pathological lymph node enlargement. Ear, nose, and throat structures, including the nasopharynx, oropharynx, and hypopharynx, were normal.\nAn incisional biopsy from the mass suggested well-differentiated squamous cell carcinoma, as shown in Figure . The patient underwent right partial glossectomy and right neck dissection. Histopathology confirmed the diagnosis of well-differentiated squamous cell carcinoma. There were 35 lymph nodes, all without metastases. The depth of the tumor was 5 mm, it had negative margins, and no lymphatic invasion was apparent. She did not receive any postoperative treatment.\nIn April 2017, the patient again presented to the ENT clinic complaining of left-side hearing loss. On examination, there was otitis media, with effusion on the left side. Nasal scoop examination revealed a nasopharyngeal mass on the left side. Biopsy suggested well-differentiated skeletonizing squamous cell carcinoma, as shown in Figure . CT scanning revealed a nasopharyngeal soft tissue mass involving the superolateral nasopharyngeal wall on the left side, as shown in Figure . Other surrounding structures were normal but there was an enlarged level 1B lymph node on the left side measuring 0.9 cm and an enlarged level 2 lymph node on the right side measuring 1.8 cm. MRI depicted an ill-defined infiltrative mass of the nasopharynx involving both sides but, predominantly, the left side with extension to the left parapharyngeal fat, retropharyngeal muscle, and clivus consisting of stage T3 tumor. No obvious perineural split was apparent.\nThe patient was diagnosed with nasopharyngeal carcinoma and received radiation therapy consisting of 72 GY per 60 fractions b.i.d. Post-treatment MRI revealed changes on the left side of the nasopharynx associated with residual inflammatory changes extending to the left side of the sphenoid bone. The study was limited because there was an artifact.\nDuring her regular follow-up, the patient presented to the dental clinic because she had developed a fracture of the upper jaw. Examination revealed an enlarged upper neck lymph node of approximately 1 × 2 cm on the right side. CT scanning of the neck revealed the recurrence of the previously observed nasopharyngeal asymmetry with fat infiltration noted in the left nasopharyngeal space involving the lateral pterygoid muscle with subtle superior extension to the left pterygopalatine fossa reaching the lower fibers of the left temporalis muscle. A lytic lesion was noted within the odontoid process with tiny air pockets on its deeper fascia.\nWith regard to the neck status, recurrences of the previously observed sub-centric pathological lymph nodes at level 1A, 1B bilateral, and 2A and 2B, predominantly on the left side, were identified via post-radiotherapy imaging, but they were not enlarged according to cross-section criteria. The aforementioned findings at the left nasopharynx skull base odontoid process were highly suggestive of local recurrence. Nasopharyngoscopy revealed an irregular infiltrative mass involving the whole nasopharynx. The patient was diagnosed as having recurrent nasopharyngeal cancer and was considered a palliative case. She was classified as “no code” due to her poor medical condition and treatment-resistant disease.

We present the case of 62-year-old female patient with a history of chronic heel ulcer associated with calcaneal osteomyelitis. She also had the diagnostic of systemic arterial hypertension and diabetes mellitus Type II for 17 years. The patient reported having been admitted to another hospital unit for the treatment of ischemic stroke, which was complicated by peripheral vascular complications and the need for amputation of the right hand, right hallux, and distal phalanx of the left hallux. She also presented with a pressure ulcer associated with the right calcaneal osteomyelitis due to being bedridden for a prolonged period. This was treated with debridement, tenotomy of the calcaneus tendon, and antibiotic therapy in the unit of origin. The culture result showed polymicrobial growth. She was discharged for outpatient follow-up and oral antibiotic therapy with ciprofloxacin and vancomycin. The infection persisted without ulcer healing, and after 14 months of follow-up, she was referred to the Foot and Ankle Surgery Service of Santo Antônio Hospital and was admitted in March 2016. In the initial evaluation, the patient used a wheelchair for mobility due to a posterior calcaneal ulcer with purulent secretion and exposure of necrotic bone tissue (). She did not present neurological sequelae related to stroke but had bilateral plantar hypoesthesia, symmetrical filiform distal pulses, delayed capillary filling, and operative wounds of healed amputations ( and ) and a score of 45 on the American Orthopaedic Foot and Ankle Society (AOFAS) scale. After the first consultation, hospital admission was indicated to improve the clinical status and subsequent surgical treatment. Several studies show that adequate glycemic control, nutritional status, and laboratory parameters improve the prognosis of surgery [, , ]. In April 2016, after 1 month hospitalization, subtotal calcanectomy was performed with excision of all necrotic tissue and primary closure of the wound with the use of a vacuum drain in the first 48 h postoperatively (). The ankle was held in a position of maximal plantar flexion until healing of the lesion to avoid tension on the operative wound ().\nThe culture result showed polymicrobial growth. The patient was hospitalized for 2 months to receive empirical venous antibiotic therapy with ceftriaxone metronidazole. Antibiotic resistance is at all-time high in all the parts of the world. The high economic burden in the health-care sector has become a burning issue, due to extended hospital stays, isolation wards, stringent infection control measures, and treatment failures []. Infections in diabetic feet are often polymicrobial and are related to high prevalence of multi- resistant pathogens []. Despite the bacterial resistance to ciprofloxacin and clindamycin initially observed, there was an excellent response to the therapeutic regimen proposed during hospital admission with normalization of the laboratory tests after 8 weeks.\nComplete healing of the wound occurred 10 weeks after surgery (), at which point it started motor rehabilitation. When the patient presented for evaluation, after 12 weeks of rehabilitation, she had independent gait without support, adaptation to conventional shoes ( and ) the radiography showed no signs of osteomyelitis (), and a score of 90 on the AOFAS scale.

Here is a case of a 5-year-old girl who reported to us 2 days after encountering trauma due to fall from an elevated platform. Clinical examination revealed a discontinuity of the lower border of the mandible on the left side. Her mouth opening was restricted to 10 mm and the mandible was seen to deviate to the left side on opening. Intra oral examination revealed a derangement of occlusion. There was no mobility of the fractured segments. A hematoma was present on the buccal aspect in the parasymphyseal region on the right side []. Further, the orthopantomograph confirmed our clinical observations []. A diagnosis of fracture of the body of the mandible on the left side associated with a fracture of the parasymphysis on the right side of the mandible was made.\nThe treatment approach chosen was a unique one, involving a modification of the conventional transosseous wiring technique. The procedure was carried out under general anesthesia. The body fracture was exposed using a buccal vestibular incision. Two holes were drilled on either side of the fracture line into the buccal cortical plate; one at the region of external oblique ridge to avoid damage to the permanent tooth germ of the first molar and the other close to the lower border of the mandible. Two intermaxillary fixation (IMF) screws with eyelets, 1.5 mm diameter and 10 mm in length were inserted into the holes such that they were perpendicular to the cortical plate following which a 26 gauge stainless steel wire was passed into the eyelets and fastened. Having assuring reduction and fixation of the fractured ends, wound closure was achieved. Fracture reduction and stabilization was concluded satisfactory as shown by the post-operative occlusion. Recovery from general anesthesia was uneventful. An orthopantomograph was made post-operatively to confirm the approximation of the fractured ends []. The patient was discharged on the third post-operative day with instructions for a soft diet and maintenance of good oral hygiene.\nSubsequently, satisfactory healing was observed. Four weeks after placement of the screws, following the confirmation of the stability of the fractured ends both clinically and radiographically a decision was made to remove the screws []. The patient was followed periodically, and presently shows satisfactory occlusion [].

A 22-year-old female, weighing 53 kg, with a height of 153 cm, data entry operator by profession, presented to the outpatient skin department in January. The patient reported with gangrene and black spots of multiple fingers and toes with severe pain since last one month. She was diagnosed with SLE and was started on prednisolone and hydroxychloroquine. A Doppler examination of limbs was performed with contrast injected intravenously through the left internal jugular vein to prevent venous contamination in limbs since all limbs were affected and were to be evaluated. CT angiography of upper limbs revealed attenuation of bilateral radial and ulnar arteries with poor distal run off seen in left radial artery and in left ulnar artery run off till hand was seen. No thrombus was seen. In the lower limbs, bilateral arteries below the knees were attenuated. Right anterior tibial artery and right peroneal artery were attenuated and left posterior tibial artery was totally obliterated []. No thrombus was seen.\nFor the management of pain and gangrene of her fingers and toes, she was referred to the pain clinic of the anaesthesia department. On examination, she had gangrene in the right index and middle finger, left thumb and index finger with multiple black spots in rest of the fingers and toes []. She had rest pain of numerical rating score (NRS) 8 in upper limbs and NRS 6 in lower limbs. She was very anxious and being a data entry operator required her to primarily use her fingers while working on the computer. After taking her consent, she was admitted for sympathectomy blocks. All blocks were performed in the pain clinic block room after securing an intravenous cannula on the wrist and attaching pulse rate and non-invasive blood pressure monitors and pulse oximeter. The monitors were attached on ear lobes as none of her fingers and toes showed any waveform or value on pulse oximetry. She was given ultrasound-guided stellate ganglion nerve block (USGNB) with a linear probe of 13–6 MHz (Fujifilm SonoSite Edge) with 5 ml of 0.25% ropivacaine and clonidine 15 μg on the more-affected right side. Clonidine was added as an adjuvant to prolong the effect of ropivacaine and for its vasodilatory effects as demonstrated previously.[] The block was performed in long axis with 26 gauge 1.5 inches hypodermic needle attached to a 10-cm extension line without giving prior local anaesthetic because of the small-gauge needle used to perform the block []. The needle was inserted from lateral to medial side of the neck, placing the needle tip between longus colli muscle and carotid sheath at level C7 vertebra—the anatomical location of stellate ganglion. Before injecting the drug, saline was injected to ensure the needle tip is not placed either in longus colli muscle or within the carotid sheath []. After monitoring for any untoward side effects for an hour, a left-sided USGNB with the same drug volume was injected, and the patient was observed for another 1 hour. Her NRS decreased to 3 but, after 5 hours, she again complained of pain of similar intensity. Therefore, a bilateral USGNB was repeated in the evening with similar drug injectate and precautions. The next morning, she reported NRS >5, and thus a continuous stellate ganglion block on the more-affected right side with plain 0.25% ropivacaine 2 ml/h was planned with left side USGNB planned twice a day. For continuous infusion under ultrasound guidance, an epidural needle was used to perform the block and epidural catheter was threaded to place the catheter tip between longus colli muscle and carotid sheath at level C7 vertebra. The catheter was also tunnelled at the skin entry point. Left-sided USGNB was performed twice a day, both times, after stopping the infusion of the right side for an hour before and after the block. Catheter was inserted thrice in the course of treatment of 35 days. Catheter tip was checked for correct position twice a day, and infusion was disconnected at night between 12 and 4 am for the patient to sleep comfortably. The average time of correct position of the catheter tip was 3–5 days. At every block, the spread of local anaesthetic was looked for to prevent deposition of drug either in the adjoining vessels or inside the carotid sheath to avoid phrenic nerve palsy. In addition, precaution was taken to avoid deposition of drug in longus colli muscle, which would result in an ineffective block. In about a week, the gangrene of the patient's fingers started improving. She was admitted for 35 days during which a total of 64 USGNB injections were given. For lower limbs, a single epidural injection block was given twice with 8 ml of 0.25% ropivacaine and a continuous epidural infusion was given once with 3 ml/h of 0.125% ropivacaine for 3 days. None of this resulted in any motor weakness. With this treatment, the blackness of toes of lower limbs and pain completely regressed. Upper and lower limb infusions were never given simultaneously, and the total dose of ropivacaine was calculated at all times and kept within safe limits with intense monitoring during the peri-block period. 20% lipid and resuscitative equipment were kept in stand-by at all times. Supportive treatment to keep all limbs warm with gloves/socks was ensured and enforced at all times. Medical management was continued.\nAt every block, the pulse oximeter probe was attached to all fingers and toes, which showed improvement in the quality of waveform and/or pulse oximeter value after every block. Thirteen days after the commencement of blocks (around halfway through the 35-day treatment), repeat computed tomography (CT) angiography revealed bilateral ulnar arteries to be unremarkable in contrast to previous report. Right radial artery was normal and there was increase in calibre of left radial artery, both showing improvement from previous reports. Similarly there was marked improvement seen in lower limbs with normal bilateral anterior tibial arteries, bilateral peroneal arteries and right posterior tibial artery. Only posterior tibial artery remained attenuated [].\nBy the end of 35 days, she had no rest pain in any of the fingers and toes. All her fingers with wet gangrene had dried. No repeat CT angiography was done due to financial constraints of the patient. Pulse oximetry waveform pattern improved in all fingers and toes with improvement in waveform and a value of >95% in all fingers.\nAt the 7-month follow-up, there was no pain or blackening of her fingers and toes, however, she had lost the distal part of the terminal phalanx of the right finger which was worst affected when she had first reported to us []. Nevertheless, this did not affect her profession and she was happy to return to her job successfully. She is under follow-up with us since the last 2 years with no similar complaints.

A 71-year-old male presented with pain and decrease of vision for 2 months, with clinical features exactly similar to the previous 2 cases [Fig. and ]. He had been diagnosed as necrotizing scleritis elsewhere and was given three doses of intravenous cyclophosphamide and methylprednisolone. He complained of severe pain during instillation of the eye drops and refused to instill any drops in the eye, for which he had been referred to the psychiatric department that had initiated him on several antipsychotic medications. When the patient was seen at our institute for the 1st time, he was wheeled in on a stretcher and was heavily sedated.\nHe was on seven topical medications all of which appeared more yellow than normal []. Without any delay, due to the very high index of suspicion this time, all the bottles were checked for pH using the pH strip that turned out to be <2 []. A fresh vial of each of the topical medications available at our pharmacy was obtained and checked for comparison that showed a near neutral pH. All seven bottles were subjected to biochemical investigations that revealed the nature of the liquid in all seven bottles to be hydrochloric acid (HCl) [].\nThe patient was accompanied by his family members who did not respond to any interrogation regarding the contents of the bottles. This time around, the nearest police station, was informed of the same who in turn referred it to the jurisdiction to which the patient belonged, which in this case was from a different state. The case was registered as medicolegal at our institute. The institutional authorities informed the DCGI. The medical care of the patient was continued. He required tenonplasty and amniotic membrane transplantation thrice in both the eyes []. All his systemic medications were stopped. Three months later, the patient walked in healthy into the clinic for a follow-up with a healed ocular surface, requiring cataract surgery later. His visual acuity in both eyes was counting fingers at 2 feet. He was accompanied by another attendant.

The 8-year-old boy first presented in January 2012, having been referred by the family dentist, to the Department of Orthodontics at the Medical Center of the University of Göttingen for a routine orthodontic control and evaluation of treatment need (). The clinical examination of the asymptomatic patient showed no extra- or intraoral pathological findings. The medical history of the boy included a mild pulmonary valve stenosis and a secundum atrial septal defect with a left-right shunt. He showed a good physical and cardiac fitness and a normal nutritional status. The family history was positive for maxillofacial anomalies: the boy's older sister had been previously diagnosed with a dysplastic fibroma, a rare benign fibrovascular defect in the mandible, and a resection of the affected area in the mandible had been performed. His father and paternal grandmother had a positive history of odontogenic cysts as well as basal cell carcinomas, although the family history of OKCs was negative. The radiological examination showed three suspicious hypomineralisations visible as radiolucencies in the panoramic radiograph associated with the retained teeth 13 and 23 and the ectopic tooth 27 (). The young patient was referred to the Department of Maxillofacial Surgery for a surgical examination of the radiologic anomalies.\nThe operation was performed under general anesthesia. The suspected pathological area around teeth 23 and 13 showed no visible intraoperative pathological signs. A bone and soft tissue biopsy for histological examination was taken. In the area of tooth 27, a well-marked membrane was revealed, filled with a viscid fluid and fully enclosing the dental crown. The clinical aspect was consistent with a follicular cyst. During the radical cystectomy, tooth 27 was removed due to massive attachment loss. The histopathological biopsy showed a fibroosseous lesion in the area of teeth 13 and 23. The biopsy from region 27 showed an odontogenic connective tissue cyst wall with intramural odontogenic cell islands. On request of the surgeon, samples were sent for further diagnosis to the Bone Tumor Reference Center of the Swiss Society of Pathology at the University Hospital in Basel, Switzerland. The initial histological diagnosis was corrected to an OKC of the parakeratin variant. Microscopically, the cyst shows a squamous epithelium. The basal cells are palisading, with hyperchromatic nuclei (HE staining, 5x magnification) (). Due to the high recurrence of OKCs, a radiological control interval of 6 months was indicated (). Furthermore, orthodontic treatment was initiated.\nIn August 2014, during a regular radiological control, a new radiolucency was detected, associated with the retained and displaced teeth 47 and 48 (). The surgical removal of the cystic lesion and tooth 47 was performed under general anesthesia. The pathological finding was consistent with an OKC.\nThe regular control examinations were interrupted by missed appointments, so the next evaluation took place one year later, in October 2015 (). New radiolucencies were detected in the panoramic radiograph associated with the retained teeth 18, 17, 37, 38, and 48 as well as an evident enlargement of the radiolucency around the crown of tooth 13. A cone beam computer tomography scan was performed and showed well-defined radiolucent areas, associated with the retained teeth. Details of the surgical enucleation of the cysts with the extraction of teeth 18, 17, 13, 37, 38, and 48 are shown below. The postoperative radiological examination is depicted in . Clinical and radiological examinations were then performed every 6 months.\nWe describe the surgical enucleation of the cystic lesions using the example of the third operation (2015). This was performed under general anesthesia; the affected regions were exposed after lifting a mucoperiosteal flap. After a careful removal of a thin bone cortex, the cystic capsule was found () and separated from the bone with an obtuse instrument. The aim was to leave no epithelial remnants on the trabecular bone. All four lesions were associated with a retained tooth, which was only loosely anchored in the alveolar bone. Due to the high recurrence rate of the cystic lesions in this particular case, all affected teeth were extracted. In the area of the mandible, the use of Carnoy's solution was not indicated because of the exposure of the lower alveolar nerve (). Due to their large size, the cystic cavities were filled with a collagen graft, which stabilized the formation of a coagulum. No reconstruction with iliac crest bone or allogenic bone grafts was attempted. Subsequently, the mucoperiosteal flap was reverted back to its original position and fixed by sutures.\nBy October 2016 and August 2017, bone remodeling of the affected area had been detected and no new lesions were observed (Figures and ).\nDue to the recurrence and the appearance of new lesions, Gorlin-Goltz syndrome was suspected in the patient. After genetic counselling at the Institute of Human Genetics of the University Medical Center of Göttingen, molecular genetic analysis of the genes PTCH1 and PTCH2 was performed in 2015. Sanger sequencing revealed the heterozygous germline variant c.2779_2793del (p.Ser927_Val931del) in the PTCH1 gene. This variant leads to an “in-frame” deletion of 5 amino acids between amino acid positions 927 and 931 of the protein. This variant is listed neither in the Human Gene Mutation Database (HGMD) nor in the Leiden Open Variation Database (LOVD). However, a pathogenic effect of the variant seemed likely as many pathogenic variants have already been described in this region of the PTCH1 gene, even several in-frame deletions [, ]. Since the boy's father had shown similar symptoms (odontogenic cysts, basal cell carcinomas) that could be in line with a Gorlin-Goltz syndrome, he, too, was tested for the PTCH1 variant and resulted to be carrier of the variant.\nIn summary, clinical and molecular data together with the positive segregation analysis led to the classification of the variant as “probably pathogenic” and being responsible for Gorlin-Goltz syndrome in the patient and his father. The importance of talking precautions (e.g., sun protection due to the high risk of basal cell carcinomas) and regular medical surveillance (e.g., regular orthodontic care and annual dermatologic examinations) was emphasized.

A 49-year-old Caucasian woman was referred to a general surgeon by her primary care physician for a right nipple lesion. She reports no past medical history, and social history is notable for tobacco use. The patient stated that she first noticed a small, yellow, and fleshy bump on her right nipple approximately two years prior. She became concerned due to its rapid growth in the last year. Four months prior, she visited her primary care provider who performed a shave biopsy of the lesion. Initial pathology results suggested squamous cell carcinoma, but this was thought to be discordant with the clinical picture. At consultation, she reported that her right breast had also started feeling hot and tender for two weeks duration. On examination, her right breast was erythematous and rigid with a 2.2 cm lesion consuming the right nipple. Her nipple also drained yellow pus. The patient was placed on a course of antibiotics due to concerns for an abscess.\nAn MRI was ordered to investigate possible underlying breast malignancy. Results of the MRI showed no solid mass underlying the nipple. A wedge biopsy of the nipple was performed to confirm the initial shave biopsy pathology (). Pathology showed verrucous histologic features with chronic inflammation and underlying abscess with concerns for a possible cutaneous malignancy. Specifically, there was marked papillomatosis with hypergranulomatosis between the papillae as well as a lack of granules at the papillary surfaces. Immunohistochemical testing was also positive for HPV L1 capsid protein. Because the initial shave biopsy showed SCC with positive margins, this clinical picture suggested that an inadequate sample was taken during the wedge biopsy. After consultation of literature, excision with wide margins was determined to be appropriate for removal of the lesion.\nThe patient underwent a wide excision of the right nipple-areola complex for removal of the growth. A 6.2 cm x 3.2 cm skin ellipse was excised encompassing the 2.2 cm nipple lesion. On final histologic examination, the lesion was found to be a large tumor with verrucous features, hyperkeratosis, dyskeratosis, and nests of keratin pearl formation (). Two areas showed microinvasion of the dermis with loss of the basal lamina. There were also significant acute and chronic inflammatory responses in the deep dermis representing an underlying abscess. These findings are congruent with the diagnosis of a well-differentiated squamous cell carcinoma with arising within verruca vulgaris. All margins were found to be clear of tumor cells. The post-op course was uneventful. She continues to follow up to monitor potential recurrence of the growth.

MG is a 75 year old man who presented with a single episode of gross hematuria in October 2017. He is overweight and has insulin dependent diabetes mellitus. He has some lower urinary tract voiding symptoms. These consist of nocturia twice and some daytime frequency. His urinary stream is slow.\nHis past medical history is pertinent for a left radical nephrectomy in 2009 for an organ confined renal cell carcinoma. He had a hospitalization in 2012 for acute diverticulitis, which was treated medically. He does not have any cardiac problems. His serum creatinine is 1.8.\nA CT scan of the chest, abdomen, and pelvis were normal except for the absent left kidney and a five cm mass on the left bladder wall. There were no enlarged lymph nodes. There was no obvious extension of the bladder wall mass beyond the bladder.\nHis physical examination was unremarkable with the exception of his large abdominal girth, the scar from the left nephrectomy, and a moderately enlarged prostate.\nAfter medical clearance he underwent a cystoscopy and a transurethral resection of the bladder tumors. The endoscopy indicated a normal appearing bladder with the exception of a 4– 5 cm sessile mass beginning at the left trigone and extending to the left bladder wall (–). There was also an adjacent papillary tumor. (). A transurethral resection was performed. The papillary tumors were easily resected and appeared to be confined to the mucosa, i.e. Ta. The sessile tumor extended well into the muscularis propria and the color of the underlying muscle was altered ().\nThe pathology report showed a high grade muscle invasive urothelial cancer with lymphovascular invasion, pT3, and a papillary low grade (grade 2) tumor confined to the urothelium, pTa.\nI had a lengthy discussion with the patient and they preferred to consider a bladder preservation approach. He received 4 cycles of gemcitabine and cisplatin. He tolerated this well despite the reduced renal function.\nA flexible cystoscopy after two cycles revealed no evident tumor and a negative urinary cytology. The patient and family elected to observe and not proceed with radiation therapy.\nAn office cystoscopy in May 2017 indicated a subtle change at the prior tumor location and a TUR bladder tumor was performed ( and ). This revealed persistent high grade muscle invasive urothelial cancer. A CT scan identified a 1 cm left pelvic lymph node and was otherwise free of metastasis. The patient now consented to a cystoprostatectomy.\nThe patient has a solitary right kidney, has some reduction in his renal function and is overweight (250 lbs.). The patient now consents to undergo a radical cystoprostatectomy. He has medical clearance. Would you perform an ileal conduit or consider a cutaneous ureterostomy? The advantage of the latter, assuming the ureter appears healthy and will easily reach the abdominal wall, would be a shorter operative time, no need for a bowel anastomosis and thus possible accelerated recovery, and omitting an anastomosis between the ureter and the ileum with a risk of subsequent stricture. The disadvantage might be stricture of the cutaneous ureterostomy site.\nThe final pathology revealed a muscle invasive urothelial cancer with transmural extention to the serosa, pT3b, with two of 14 lymph nodes containing metastatic urothelial cancer. Is there a role for adjuvant therapy?\nWe invite our readers to review and comment on the case and management by using the online comment section below the case: https://www.bladdercancerjournal.com/challenging-cases

In 2013 a 72-year-old female patient was admitted to the Clinical Department of General and Colorectal Surgery for elective resection of a tumor located in the perianal area with the TEM technique. The patient had an extraordinary medical record with no clear concluding diagnosis. In August 2005 the patient had laparoscopic cholecystectomy due to symptomatic cholecystitis. The surgery was not performed in our hospital. The postoperative course was reported as uncomplicated and the patient was discharged. However, 3 years later, in 2008, the patient complained about consistent, sharp, abdominal pain which was not accompanied by fever, nausea or vomiting. Improper food intake was also ruled out as a potential source of consistent abdominal pain. The patient was subsequently hospitalized several times in gastroenterology wards with no clear diagnosis. It was suspected that symptoms were connected with diverticular disease, hemorrhoids or gastroenteritis. From March 2011 the patient additionally complained about consistent pain within the lower part of the rectum. In June 2011 the patient was again hospitalized and underwent computed tomography of the abdomen and pelvis which, apart from diverticular disease, revealed chronic perianal abscesses which were diagnosed as a postinflammatory process after diverticulitis. Laboratory tests were within the normal range. Colonoscopy showed diverticular disease and a 2 mm polyp in the descending colon which was removed and sent for histopathologic examination, which revealed a tiny tubular adenoma with low-grade dysplasia with complete removal. After the hospitalization and the patient's discharge, symptoms were somewhat reduced, but not entirely alleviated.\nIn November 2011 symptoms again intensified and the diagnostic process needed to be repeated. Computed tomography was repeated and revealed diverticular sigmoid colon with numerous diverticula sized up to 18 mm as well as segmental, irregular thickening of the sigmoid wall and the rectum up to 9 mm. This image was considered to be an inflammatory process rather than a hyperplastic process. Curiously, two oval objects approximately 30 mm in size were identified in the sigmoido-rectal region. They were communicating with the colon lumen and, at first glance, they could be characterized as chronic diverticulitis.\nTransanal endosonography showed a tumor located on the posterior rectal wall between 9 and 13 cm from the anal verge. Due to numerous artefacts and an unacceptably high level of discomfort, it was impossible to define the tumor's depth of mucosal invasion. Nevertheless, it was defined as T1/T2 grade tumor. During this round of examination an enlarged lymphatic node was also revealed. Colonoscopy was repeated. There were no apparent changes in the rectum. In the anal canal there were small hemorrhoids. The sigmoid colon (20 cm from the anal verge) exhibited diverticulum with surrounding intense mucosa redness and edema accompanied by slight bleeding from its bottom. In the entire colon, especially in the proximity of the sigmoid and descending colon, there were multiple diverticula and many of them were filled with fecal masses. In the transverse colon, 70 cm from the anal verge, there was a tiny 2 mm round polyp which was completely removed (tiny tubular adenoma with low-grade dysplasia removed completely). Tumor markers were within the normal range: CA-19.9 < 0.600 U/ml, CEA 2.52 ng/ml.\nThe patient was qualified for surgery using the TEM technique for the removal of the tumor from the retrorectal space. Transanal endoscopic microsurgery surgery was performed in the gynecological position. The per rectum examination showed hard, oval, 3 cm long resistance of the posterior wall of the rectum, 8 cm from the anal verge. Initially, after using the rectoscope attachment, the performing surgeon visualized the rectum and sigmoid colon for a distance of up to 20 cm from the anal verge and observed no apparent pathologic changes. However, during instrument retraction, we observed partial deformation of the posterior wall, which constituted evidence of a tumor just beyond the rectal wall. In the first stage of the surgery the mucosa was incised transversally above the tumor. During mesorectum preparation with the ThermoStapler sealing system the surgeon found an object resembling a 3 cm gallstone in the presacral area and removed it. During the preparation, the peritoneal wall was slightly opened, causing a gradual increase of the pneumoperitoneum. A 10 mm trocar was inserted into the left lower part of the abdomen. Laparoscopic inspection of the peritoneal cavity did not reveal any damage to adjacent internal organs. An incision in the peritoneum was sutured and carbon dioxide leakage was stopped. The trocar was removed and replaced with a Redon drain. The aperture in the rectal wall was closed with sutures. The patient's postoperative course was uneventful. On the third day after surgery the drain was removed and the 72-year-old patient was discharged after five days. Approximately a month after surgery, the patient's wound was healed and all symptoms subsided.\nAfter the surgery the removed object was submitted for histopathologic examination. Its results confirmed that it was a gallstone. The chemical analysis yielded a makeup of: cholesterol 75%, bile acid 0%, oxalates 10%, calcium 10%, phosphorus 5%, magnesium 0%, ammonia 0%, cystine 0%.

A 93-year-old male was admitted to the 1st University Department of Otorhinolaryngology via the Accident and Emergency Department due to trauma to the oral cavity. He was found unconscious, by his relatives, bleeding from the oral cavity, and with a blood stained knife in his hand. He was urgently transferred to the hospital, where he received the appropriate resuscitation treatment. Examination of the oral cavity revealed extensive trauma to the soft and hard palate, without any other lesions to be seen in the head and neck region. Following stabilization of his condition the patient reported that he repeatedly stabbed his palate due to the intolerable character of the ongoing local pain, over the last few months, which he could not tolerate. He wanted to die from bleeding because he could not eat and he felt helpless. He preferred to die quickly using a knife instead of dying of thirst and hunger. Prior to the incident he had chronic limited mobility due to osteoarthritic problems and he spent most of the day confined to bed. Further history retrieved from the patient and his family revealed that over a period of approximately two months prior to the event the patient reported a painful oral cavity. He had a burning sensation in the tongue, and he was complaining of oral sensory discomfort, including dryness and taste alterations. The clinical symptomatology had led to a decrease in oral consumption of food and liquids, causing a significant weight loss of more than 10 kg during the last two months. Despite various visits and treatments by the family physician the condition had not improved and the emotional condition of the patient had progressively deteriorated. On admission to the Department of Otorhinolaryngology, Head and Neck Surgery, a psychiatric evaluation following his recovery revealed depressed mood most of the day, marked diminished interest or pleasure in all or almost all activities, insomnia, and fatigue with diminished ability to think or concentrate, and the Beck Depression Inventory (BDI) [] showed a score of 24. During the clinical assessment, the patient had a mini-mental score of 29 with no delusions and the diagnosis of cenesthopathic schizophrenia was excluded. Regarding somatoform disorders, pain in the oral cavity started the last three months, only in this specific anatomic area, and the patient had no gastrointestinal or sexual or pseudoneurological symptoms. Paroxetine was gradually administered, with a starting dose of 20 mg once a day that over a period of three weeks increased to 40 mg a day. During the following days, the traumatized area presented normal healing with no obvious abnormalities. Further clinical examination of the oral cavity and pharynx, biopsies from the soft and hard palate, and appropriate imaging did not reveal any other pathologies. On discharge, 3 weeks later, he scored 14 on the BDI. The patient reported on his last assessment, one month later, that he could now enjoy his daily activities and be more active and less fearful of his pain symptoms that now were milder after the antidepressant treatment while suicidal ideation had fully resolved.

A 25-year-old male was referred to physical therapy OPD with complaints of weakness in both the hands and feet for four years. The patient had a history of insidious onset of weakness in both the upper and lower limbs. Initially it started as a feeling of tingling and numbness in the right foot followed by the left foot. Thereafter weakness developed in both feet. He faced difficulty in performing daily activities like walking because he had to drag his feet as there was a presence of foot drop due to progressive weakness and he faced difficulty in holding slippers while walking. After a couple of months, he developed a similar type of weakness in both hands and therefore holding and grasping became difficult. As the severity was progressive, it started affecting his normal mobility components like standing balance, walking, overhead activities, holding various objects and fine skill movements. With the passage of time, he started losing sensations and because of this he developed an open wound at the ball of the great toe. He was referred to a private neurologist and underwent nerve biopsy as advised. The results showed axonopathy and but there was no evidence of inflammation. After taking physical therapy treatment for two months in some private clinics, he came to Maharashtra Railway Vikas Corporation health center physical therapy department for further management and here he underwent physical therapy treatment with regular follow-ups for three consistent months. On further assessment, family history was found to be present. Patient’s father was known to have the same presentation when he was around 30 years of age.\nOn observation, gross wasting of both the hands and lower leg and foot muscles was seen. The patient was using a walker to walk. Higher mental functions were intact. There was a loss of sensations over bilateral hand (volar and dorsal) and below the knee region in bilateral lower limbs. On the motor examination, the patient was found to have hypotonia in hands and lower leg muscles bilaterally.\nBy convention method, the deep tendon reflexes are graded as follows in Table .\nManual muscle testing was done using Medical Research Center (MRC) Gradings and the findings are as follows in Table . Previous status indicates the findings during first assessment of the patient and current status denotes follow-up assessment findings taken one day before patient’s last visit.\nRange of motion was full for all joints except wrist because the presence of hypotonia made it hypermobile. Initially, there was mild tightness in hip flexors, because he uses to walk with anterior pelvic tilt, but later on successive treatment sessions, tightness was relieved and gait improvements were noticed.\nFunctional status of the patient is shown in Table .\nInvestigations like electromyography (EMG) and nerve conduction velocity (NCV) testing were done. Results are shown in Tables , , .\nThe patient was diagnosed with polyneuropathy because of Charcot-Marie-Tooth disease (CMT) based on the EMG+NCV study’s findings as well as history and familial presentation along with the progression of the symptoms.\nDiagnostic challenges\nHereditary neuropathies are divided into four major subcategories: hereditary motor and sensory neuropathy, hereditary sensory neuropathy, hereditary motor neuropathy, and hereditary sensory and autonomic neuropathy. The most common type is Charcot-Marie-Tooth disease, one of the hereditary motor and sensory neuropathies. Symptoms of the hereditary neuropathies vary according to the type and may include sensory symptoms such as numbness, tingling, and pain in the feet and hands, or motor symptoms such as weakness and loss of muscle bulk, particularly in the lower leg and feet muscles. Certain types of hereditary neuropathies can affect the autonomic nerves, resulting in impaired sweating, postural hypotension, or insensitivity to pain. Some people may have foot deformities such as high arches and hammer toes, thin calf muscles (having the appearance of an inverted champagne glass) or scoliosis (curvature of the spine). The symptoms of hereditary neuropathies may be apparent at birth or appear in the middle or late life. They can vary among different family members, with some family members being more severely affected than others. The hereditary neuropathies can be diagnosed by blood tests for genetic testing, nerve conduction studies, and nerve biopsies.\nDiagnosis was made based on EMG+NCV study reports and familial predisposition. Also on examination, diabetes was ruled out to rule out for diabetic neuropathy. The patient was suggested to undergo nerve biopsy, but because of financial constraints patient denied opting for it.\nIntervention\nElectrical Stimulation\nInterrupted galvanic current used to target intrinsic muscles of the hand and foot muscle with 90-90-90 set of contortions given. Along with the facilitation techniques were used to enhance the outcome of muscle contraction, which is achieved through electrical stimulation. This was continued for three weeks.\nStrengthening Exercises\nFor lower limb and pelvis muscles was done as it was grade 3 in the initial. With the help of De Lorme’s; progressive resistance exercise (PRE) program based on 10 repetitions maximum (10RM) where the patient begins sets of training by performing the first set of 10 at 50% 10RM, the second at 75% 10RM and the third (final) at 100% of the 10RM. This was started at the end of two weeks to six weeks of treatment duration.\nAt the end of six weeks core and abdominal strengthening exercises were also carried out to enhance the lower extremity muscle function. There are dearth of literature suggests that core stability is an important component of nearly every gross motor activity. The reason behind core strengthening proving effective in development of extremity strength can be justified by overflow irradiation concept which says when a resistance is applied; it causes irradiation or overflow from stronger patterns to weaker patterns or from stronger muscles to weaker muscles within a pattern of movement. Also the role of core is considered important in upper and lower proximities strengthening as the maintenance of position in which strengthening is performed have activation and recruitment of core muscles in order to maintain truncal stability.\nMore of functional task in the form of gripping activities were done using different objects of different shapes. Stretching of tight muscles was done and once all these things were achieved, patient was mad to undergo gait training first in parallel bar and later out of the parallel bar. We used the plantar flexed assist orthosis to improve his gait function and facilitated the dorsiflexor muscles. Once gait was improved markedly, patient was put under endurance training via static cycling.\nAt the end of eight weeks balance exercises were started with dynamic sitting balance training followed by static balance training in standing followed by dynamic balance training in standing and later on balance exercises on dynamic surfaces like physio ball and balance board were given.\nAlso endurance training was done incorporated in form of breathing exercises, static cycling and walking with normal speed and in normal pattern.\nLimitations\nAs this disease is progressive, sustained exercises must be implemented for prolonged functional independence and also care must be taken to make sure exercises focus on maintaining muscle properties so that neural status affection would cause a slow deterioration in activities of daily living (ADL) performance.

A 31 years old male patient attended the Accident and Emergency department after he had fallen directly onto both knees the day before. He was allegedly assaulted and tripped when he was running to safety. The patient had no past medical history. He was a keen bodybuilder who competed at a semi-professional level. His drug history included current use of anabolic steroids. He complained of pain in both knees and examination revealed effusion and pain over bilateral quadriceps tendons. There was a tender palpable suprapatellar gap on the left and to a lesser extent on the right side. There were bilateral lack of active extension and the patient was not able to straight leg raise bilaterally. Plain radiographs of both knees did not show any bony injury. ( and )\nThe clinical diagnosis of bilateral quadriceps tendon rupture was confirmed by urgent ultrasonography and the patient was admitted for surgical repair the next day. ( and ) The patient did not complain of any other symptoms at the time. Intraoperative findings consisted of a musculo-tendinous junction tear on the right and an insertional tear of the quadriceps tendon on the left which were surgically repaired with sutures and suture anchors respectively. The patient was discharged the following day after an uneventful postoperative recovery. Both knees were immobilised in extension splints and the patient was allowed to fully weight bear with the support of crutches.\nAt the first follow up appointment the patient admitted to non compliance to the post operative plan of strict immobilisation and he had taken the splints off to see whether he could move his knees on numerous occasions over the last two weeks. Furthermore he mentioned pain in his left calf, which he apparently recognised on the day of discharge from Hospital. He left this unreported to any member of the medical staff for two weeks. Calf squeeze test as described by Simmonds revealed no plantar flexion of the foot on compressing the calf muscles.[]\nAn urgent Ultrasound scan of the left TA was organised and confirmed a TA rupture. () The patient declined admission to the Hospital and the left leg was immobilised in an extended above knee equinus cast. The bilateral quadriceps tendon repairs were found to be intact. The patient did not attend the urgent follow up appointment after the ultrasound scan confirming a TA rupture, but only re-resented six weeks later. Direct surgical tendon repair was not attempted due to tendon retraction. The patient therefore underwent reconstructive surgery of his left TA as a delayed procedure.

An 8-year-old Caucasian boy with a complex urinary tract anomaly and chronic kidney disease presented with a mass in the renal pelvis in ultrasound during routine check-up. The urinary tract anomaly was first revealed in the 26th week of pregnancy with bilateral hydronephrosis and possible posterior urethral valve in prenatal ultrasound. The delivery was uncomplicated with a birth weight of 3860 g and an Apgar score of 10. During the neonatal period, a voiding cystourethrography was performed and ruled out a posterior urethral valve as well as vesicoureteral reflux. Dynamic renal scintigraphy showed significant loss of the left kidney function and impaired urinary outflow from the right kidney with dilatation of the urinary tract. Due to significant hydronephrosis and residual left kidney function, the consulting urologist qualified the patient for a left side nephrectomy, which was performed without complications. A progression in the chronic kidney disease was observed with recurrent urinary tract infections during infancy. At the age of 11 months, the child was qualified for a Sober ureterostomy due to persistent right side ureterohydronephrosis. The procedure had to be performed twice, at 1-month interval, because of an early stomal stenosis. The mother of the patient maintained proper care of the ureterostomy, with daily use of urostomy bags and sealing paste, and no further complications were observed for several years. At the age of 8 years, during a routine follow-up, abdominal ultrasound showed a dilation of the right renal pelvis up to 11 mm with a slightly hyperechogenic structure within it, measuring 19 mm × 8 mm (Fig. ), with a strong acoustic shadow but no twinkling artifact. Due to the unclear ultrasound picture, an abdominal computed tomography (CT) was perform and showed an oval structure (22 mm × 7 mm × 13 mm) with a density similar to body fat in the slightly dilated right renal pelvis. A smaller structure (< 10 mm) with similar density was located within the urinary bladder. A definitive diagnosis could not be established and the suggested differential diagnosis included, apart from atypical nephrolithiasis, a foreign body and lipoma. A first uroscopic attempt to identify the nature of the finding was also inconclusive, with no typical urolithiasis seen within the collecting system. A puzzling discrepancy arose between the abovementioned innocuous uroscopic picture and follow-up ultrasounds that persistently showed a large hyperechogenic structure with strong shadowing. After further analysis of the computed tomography examination, staghorn calculi were definitely ruled out on the basis of the low density of the lesion (minus 118–129 Hounsfield units). Lipoma still was taken into consideration. At the age of 10 years, the dimensions of the described structure in ultrasound were of 44 mm × 29 mm, with a very clear acoustic shadow and, now also, a multi-point twinkling artifact, meeting ultrasound criteria for a kidney stone. The right ureter was widened along its entire length, reaching a maximum of 21 mm between the stoma and the bladder. The child was at this point referred to an experienced pediatric urology center of reference for a second uroscopic assessment.\nWhat are common complications of high, noncontinent urine diversions? What is the final diagnosis?

A 56-year-old female presented to our hospital complaining of acute right hip pain after a motorcycle accident. A plain pelvic radiograph revealed a stable intertrochanteric fracture (). The patient was scheduled for surgical fracture fixation. Fixation of the fracture was performed using a ZNN (Cephalomedullary Asia) with the closed method under image intensifier guidance on an orthopaedic traction table. Intraoperative problems associated with the implant including lag screw insertion were not detected during the operation. Postoperatively, an anteroposterior pelvic radiograph was taken (). Neither surgical wounds nor neurovascular complications were observed in this patient postoperatively. Complete bone union was obtained within 3 months after the operation. At 14 months postoperatively, the patient came to our hospital and desired removal of the implant. Physical examination revealed no abnormal findings with normal joint range of motion. A plain anteroposterior pelvic radiograph showed complete bone union with no sign of implant failure (). Then, the operation for removal of the implant was scheduled. Implant removal was planned through the previous incision with the patient in lateral position. Intraoperatively, a problem was detected during removal of the lag screw. According to the manufacturer's protocol, after insertion of the original Zimmer lag screw inserter and retaining shaft (), it was attempted to remove the lag screw by maneuvering it in the counter-clockwise direction. However, an unpredicted breakage of the tail portion of the lag screw occurred. Two pieces of the broken part of the tail portion of the lag screw were removed (). A wider skin incision was made to obtain a good exposure of the tail of lag screw associated with clearing the bone and soft tissue around it. The use of clamping device was not possible, then removal of the lag screw was successfully performed by making new matched slots for reinserting the original Zimmer lag screw inserter and retaining shaft into the lag screw with use of a high speed burr with a 2 mm size of burr tip (). Selection of the tip burr size and the burring site was important in order to make new matched slots (). No significant problem was detected during nail removal after removing the lag screw. A bone allograft was inserted to fill the bone space after removing all implant parts. No complications occurred after the removal operation, and an anteroposterior pelvic radiograph was also taken postoperatively ().

This is a case of a 68-year-old female presented to the clinic for a 2-month history of recurrent left ankle pain, associated with swelling and edema. The patient had a history of thyroid follicular adenocarcinoma which was treated surgically with total thyroidectomy and postoperative iodine treatment 25 years prior to presentation. At 12 years post thyroidectomy, she was diagnosed with a calcaneal mass of the same pathology and diagnosed with delayed distant thyroid carcinoma metastasis to the calcaneus. 10 years after calcaneal mass excision, the patient was diagnosed with a proximal tibial mass that turned out to be also delayed metastasis of the same pathology.\nAt the first presentation 15 years ago, she initially presented complaining of mild edema of the left ankle with intermittent pain upon daily activity. Physical exam showed full range of motion of the ankle joint with intact motor power and intact neurovascular status. There were no cutaneous lesions.\nPlain radiographs of the left ankle showed a 3-centimeter oval lytic lesion in the anterior aspect of the calcaneum ().\nAn MRI of the left ankle showed a 3.2 cm well-defined benign-looking lytic lesion of the calcaneal neck reaching the cortex which appeared to be mildly irregular with mild degenerative disease of the posterior subtalar joint consistent with an intraosseous ganglion cyst of the calcaneus ().\nMedical treatment with NSAIDs and paracetamol was initiated, along with partial weight bearing and relative rest with no improvement at follow-up at 4 weeks. Surgical intervention was decided due to the persistent pain. The cyst was resected with a margin of surrounding fibro-osseous tissue and the bone grafted. Histopathological evaluation revealed a metastatic carcinoma of the thyroid gland. Immunostaining showed that the cells expressed cytokeratin, cytokeratin 7, and thyroglobulin, all of which confirm the diagnosis ().\nFor further confirmation, the recently excised cyst slides were compared to the pathology slides of the thyroid excision undertaken 12 years prior to the calcaneal presentation and were found out to be of the same pathology ().\nThe patient had a smooth postoperative hospital stay and clinical recovery from pain before discharge; postoperative follow-up showed necrosis of the upper part of the wound which healed by secondary intention.\nThe patient had a complete bone metastasis workup; chest X-ray showed a right upper lobe nodule for which an FNA biopsy under CT scan was done demonstrating the same pathology as for the calcaneus. A bone scan was ordered showing no definitive sign suggesting metastasis with no specific abnormality of the manubrium-sterni joint and the right proximal metaphysis of the right tibia which was nonspecific for distant metastasis according to the nuclear radiologist. After the discussion with the oncologist, decision for radioactive iodine therapy was made.\nAt 3-month postoperative follow-up, while the patient was undergoing chemotherapy, she recomplained of ankle pain upon ambulation, associated with edema. The patient had 5/5 motor strength, no numbness, and no sign of infection. A left ankle X-ray and MRI were ordered () to rule out any recurrence at the surgical site. The new investigations showed oval-shaped lytic lesion of 2.8 cm, and MRI showed increase in size of the calcaneal mass without pathologic fracture.\nThe patient was treated symptomatically; a follow-up MRI at 8 months showed postoperative enhancement in the surgical bed suggestive of viable tissue, and at 10 months, a follow-up MRI showed that there was near total healing of the calcaneal region.\nAfter 10 years post calcaneal mass excision, keeping in mind that the patient was symptom-free with respect to her ankle since the surgery, the patient presented to the clinic complaining of recurrent right knee pain. Investigation showed right proximal tibial metastasis with invasion of the patellar tendon. Surgical resection of the metastasis with repair of the patellar tendon was performed, and pathology was also consistent with thyroid follicular cell carcinoma (Figures and ).\nThe oncologist was consulted, and the decision for treatment with teroglobulin as well as adjuvant radiation therapy was made.

A 78-year-old male patient with coronary artery disease status post coronary stent placement was found to have a lung nodule on the chest radiograph at that time. The patient underwent a computed tomography (CT) scan, and bronchoscopy, and was found to have a 9 mm fatty endobronchial lesion in the bronchus intermedius above the middle lobe with 2 cm extraluminal fatty lesion into the right hilum. An endobronchial ultrasound with biopsy of the mass was performed, which showed benign bronchial epithelial cells. Since endobronchial resection of the mass would lead to a large defect in the right bronchus intermedius, the decision was made to perform robotic-assisted resection of the lesion (Video ).\nWe used the Da Vinci Xi robot to perform resection of the endobronchial lesion and hilar mass with right lower lobe superior segmentectomy to remove the lesion. The patient had a “five on a dice” port placement for the operation [, ]. First, we performed the right lower lobe superior segmentectomy to obtain adequate exposure of the hilar mass. We mobilized the superior segmental branch of pulmonary artery and superior segmental branch of the right lower lobe going to the inferior pulmonary vein and divided them with the vascular robot stapler. We divided the superior segmental branch of right lower lobe bronchus with the robot blue load stapler. We used indocyanine green angiography to define the borders of the superior segment of the right lower lobe, which was divided using the robot blue load stapler. This provided access to the hilar fatty tumor, which allowed for removal of the hilar mass and subsequent resection of endobronchial lesion with scissors. The frozen section on both lesions was negative for malignancy. We confirmed complete resection with intraoperative bronchoscopy that also showed a large opening in the airway.\nIn order to reconstruct the airway, we placed two 3-0 vicryl stay sutures at the proximal and distal ends of the airway and placed the suture through the posterior ports to pull the airway posteriorly away from the main pulmonary artery. We closed the opening with 4-0 PDS (polydioxanone) in an interrupted fashion eight times. This provided good closure of the opening. We performed a bronchoscopy that showed no abnormalities and the air leak test demonstrated no appreciable air leaks.\nThe patient went home on postoperative day 3 without any complications. The final pathology report was lipomatous hamartoma.

A 7-year-old boy presented with a 9-month history of partial complex seizures. He was noted by his schoolteachers to have staring spells for a few seconds at a time, during which he was verbally unresponsive. He was thought to have attention deficit disorder or a behavioral abnormality, but EEG was performed after he described the sensation of olfactory auras at onset of these spells, and it confirmed seizures. An MRI showed a 4 × 5 × 4-cm mass in the left sylvian fissure region, very similar in appearance to the first patient (\n,\n, and\n). It was more heavily calcified than the first patient's tumor on CT (\n). He was referred for surgical evaluation and was noted to have a very mild right hemiparesis. He then underwent left frontotemporal craniotomy. The tumor was noted to be without any dural attachment and was found to be primarily intraparenchymal in location. A small incision was made in the anterior left temporal cortex, and the tumor was found 2 mm deep to the surface. The tumor was removed completely from the temporal lobe, but it also crossed into the frontal operculum, wrapping around the sylvian fissure and the major blood vessels within it. Surgery was stopped because of progressive cerebral edema before complete resection was achieved. A second surgery was performed at 2 weeks after the first through the same craniotomy, this time through a cortical incision in the anterior aspect of the frontal operculum, but the tumor was densely adherent to the MCA branches and a portion was left attached there to avoid injury to these vessels. Histologic examination showed fibrous meningioma with no mitotic figures, consistent with a WHO grade I tumor, and postoperative imaging showed only a small amount of residual tumor (\nand\n). The patient recovered well after surgery, including complete resolution of his right hemiparesis, without other neurologic deficits. His family moved out of the area and he was lost to follow-up for several years, but later returned for evaluation when his seizures recurred at about 5 years after surgery. Repeat MRI (\n) showed a large tumor recurrence, measuring once again over 5 cm, this time with dense calcification of the entire tumor seen on CT (\n).\nRepeat craniotomy was performed, but the tumor was so densely calcified that it could only be removed by drilling it with a diamond-coated burr, a slow and tedious process, and only about half of the tumor could be safely removed without undue risk of injury to the MCA vessels. Postoperatively, he had a significant expressive aphasia that lasted almost 3 weeks before it resolved completely. Pathology from this recurrent tumor showed microscopic invasion of the pial surface, consistent with transformation to WHO grade II meningioma, but no increase in mitotic rate or nuclear atypia was seen. Further surgery was deemed very high risk for permanent speech and language deficits, and he underwent fractionated external beam radiation therapy instead. His tumor remains stable in size 2 years later, but he continues to have occasional seizures, despite medication.

A 64-year-old male with a history of frequent chest infections presented to the department complaining of leakage from his speech valve and coughing on oral intake. The patient had a laryngectomy 16 years ago, following laryngeal cancer. Postoperatively, the patient was advised to care for his speech valve with a Blom–Singer voice prosthesis brush (). For the past 15 years, the patient had used the insight brush to clear tracheal mucous secretions rather than clearing the speech valve, as it allowed him deeper access to the trachea (). The patient was repeatedly advised by the medical and nursing staff to use the brush only to maintain the lifespan of his speech valve. As per the manufacturing guidelines, the brush should be used once a day only to clean the speech valve, but not to clear mucous secretions inside the trachea. After 1 month’s usage, a brush should be replaced. However, the patient went against the medical advice and used the brush vigorously several times a day to clean tracheal mucous secretions. As a result, he had mislaid voice prosthesis brushes numerous times in his bronchi or carina, which had to be removed by bronchoscopy.\nOn examination, the patient had no obvious abnormality in the valve puncture. The stoma site was normal except for some crusting around the edges. A marked abnormality on the tracheal wall ~6 cm inferior to the stoma site was revealed, through a flexible nasal endoscopic examination. The abnormality was later confirmed to be a TOF. The patient underwent a computed tomography (CT) scan to delineate the surrounding anatomy as to facilitate the planning of the surgery (–).\nInitially, direct suturing under endoscopic guidance was attempted, which was initially successful but within a day the suture line had been disrupted by use of the brush. A percutaneous endoscopic gastrostomy was inserted for nutritional support. One option was to perform a right thoracotomy to disconnect the TOF and interposition an intercostal muscle flap between the oesophagus and trachea. However, due to the patient’s obsessive habit, this conventional surgical repair could predispose him to increased risk of dislodging the anastomosis and developing serious complications, such as mediastinitis. Hence as a definitive management, inserting a salivary bypass tube (SBT) was decided. The montgomery tube was positioned with the ends several centimetres above and below the fistula site. At 4 months follow-up, the SBT is still in situ, and the patient’s quality of life has improved as he is now managing oral intake, and the fistula has reduced in size but it has not fully healed.

We present the case of a healthy 68-year-old female patient with no history of surgery who was referred to the maxillofacial surgery and traumatology unit of the University of Chile Hospital after being diagnosed with odontogenic myxoma of the left zygomatic arch. The patient reported having consulted with the maxillofacial surgery service in another city because of a slight increase in the volume in the left zygomatic region, which caused intermittent, intense and lacerating pain that irradiated to the ipsilateral temporal region with an intensity of eight on the visual analog scale and which was not relieved with common analgesics [Figures and ]. That service undertook an incisional biopsy with an intraoral approach and diagnosed an odontogenic myxoma. After a physical examination of the patient, a slight increase in volume with diffuse borders and a firm consistency was detected.\nComputer tomography (CT) was requested, revealing a lesion of 3 cm × 3 cm with clear boundaries and mixed density, which was compromising the body of the left malar bone and was spreading to the zygomatic arch [Figures -].\nAccording to the patient's clinical history, the imaging and biopsy diagnosis a tumor resection was planned with a safety margin appropriate to the initial diagnosis, accessing the lesion with a coronal approach. The tumor was resected with a reciprocating saw, leaving macroscopic margins in the healthy bone [Figures and ]. The facial architecture was reconstructed in the same surgical event, using a 2.0 mm titanium osteosynthesis plate to restore the facial arch that had been lost, in addition to a biocompatible porous high-density polyethylene alloplastic graft to restore the contour [Figures and ].\nA surgical specimen of 3 cm × 4 cm was obtained, mainly consisting of intact bone with some areas where the lesion had been exteriorized to the cortical bone. This specimen was sent for biopsy to obtain a definitive diagnosis, which was CF [].\nThe patient evolved positively with the pain symptoms completely resolved and the biopsy confirmation that the lesion had been completely eliminated, in addition to restoring her facial esthetics. Six months postoperative a CT was taken showing excellent contour and continuity of zygomatic arch [].\nThe histopathological study showed lobules with areas of myxomatous connective tissue, with islands of epithelioid cells, near muscle tissue (lower border of figure). The cells were epithelioid with central nuclei, pink cytoplasms. The myxomatous areas showed spindle and stellate cells and small blood vessels. Well-formed hyaline cartilage was not found [Figures and ].

. A 64 year-old man was referred to our hospital with a 3.8 cm sized polyp in the high body after a screening upper endoscopy at outside hospital. An elevated polyp was removed in one-piece by endoscopic submucosal dissection. The patient received a repeat endoscopy at one and two year and no remnant lesion was noted.\nA 63 year-old man presented with indigestion and abdominal discomfort. Upper gastrointestinal endoscopy revealed a 0.5 cm sized elevated nodule in the lesser curvature of the antrum. The lesion was biopsied initially and endoscopioc submucosal dissection was done. The patient repeated upper gastrointestinal endoscopy at one and two year and no residual lesion was seen.\n. A 52 year-old man was found out to have a 1.5 cm sized polyp in the lower body of the stomach during staging work up for rectal cancer. The patient underwent endoscopic submucosal dissection and the lesion was completely removed. The resected segment of rectum revealed a moderately differentiated adenocarcinoma and a incidentally found, separately located 0.6 cm sized NET. He received a repeat upper and lower gastrointestinal endoscopy at two year without any evidence of recurrence.\n. A 65 year-old man with no family hstory of multiple endocrine neoplasia presented with chronic dyspepsia. Upper gastrointestinal endoscopy and computed tomography scan revealed a 5 cm sized gastric mass in the lesser curvature aspect of the body. Initial endoscopic biopsy diagnosis at the local clinic was well differentiated adenocarcinoma. He underwent a subtotal gastrectomy and was found to have a 5.5 cm tubulovillous adenoma. Unexpectedly, small nests of tumor cells forming a mass infiltrated into the submucosa with an invasion depth of 800 μm. All sixty regional lymph nodes procured from the resected specimen were free of tumor. The patient has no evidence of recurrence or metastasis during 12 years of follow-up.\nThe histology of all four cases was similar. The clinicopathologic details of four cases are listed in Table . The glandular components of four cases were tubular adenomas with low- and high-grade dysplasia which consisted of tubular-shaped glands lined by psuedostratified columnar epithelium with elongated hyperchromatic nuclei having coarse chromatin and occasional mitotic figures. In all cases, neuroendocrine components represented only a small portion of the adenoma, which were defined as NETs. The NETs were located in the lamina propria and muscularis mucosa in three cases. In one case, the NET cells infiltrated into the submucosa (Figure ). All the NET component of each case consisted of solid nests, clusters, tubules and cords of cells that predominantly interposed between the foveolar base without disturbing the overall polyp architecture. The cells had abundant eosinophilic granular cytoplasm and cytologically bland, central and round nuclei with finely stippled chromatin. Nucleoli were absent or inconspicous and mitotic figures or necrosis were not observed. Both adenoma and NET components intermingled and merged together, and in some areas, both components were difficult to distiniguish from one another. In the base of polyps, the NET component appeared to bud off from the basal epithelium of adenoma into the lamina propria (Figure ). The transitional zones demonstrated individual polygonal cells and tiny nests of angulated cells which had enlarged nuclei with occasional prominent nucleoli and scanty mitotic activity. Multiple foci of endocrine cell proliferation with linear growth pattern were also seen adjacent to the NETs within the adenomas. The surrounding non-neoplastic gastric mucosa demonstrated diffuse atrophic gastritis with intestinal metaplasia. Immunohistochemical studies showed a biphasic staining pattern; the adenomas were negative for neuroendocrine markers including synaptophysin, chromogranin and CD56, while the neuroendocrine components were positive. However, in the basal part of adenomas, neuroendocrine markers were focally positive (Figure ).

A 75-year-old woman received medical care, complaining of intermittent pain in the right hypochondrium. Ultrasound of the abdomen revealed a few small gallbladder stones with gallbladder wall thickening. Twenty-three years ago, this patient had undergone a median laparotomy to treat generalized peritonitis due to a perforated duodenal peptic ulcer. No other previous significant disease was reported and she was in good health.\nThe patient underwent elective laparoscopic cholecystectomy without apparent complications. The first trocar, through the umbilical port, was introduced under direct vision due to the possibility of abdominal adhesions surrounding this site, which were confirmed during the surgical procedure. However, these adhesions did not impair the cholecystectomy.\nFour hours after the surgical procedure, the patient complained of increasing left lower quadrant pain and local abdominal distension was observed. Two hours later, enteric fluid leaked through the umbilical port scar, which became inflamed. The evidence of small bowel fistula indicated an immediate new surgical approach. Therefore, the patient began to receive two grams of ceftriaxone, followed by 1 g of IV twice a day.\nThe laparoscope was introduced through the umbilical port. The right side abdomen presented no abnormality and the cholecystectomy site continued to show a satisfactory appearance. The enteric leakage began to flow from the lower left abdominal flank, but a wide, left abdominal blockage by adhesions, due to the previous laparotomy, prevented a safe laparoscopic approach. A subsequent exploratory laparotomy through a paraumbilical median incision demonstrated a 0.6 cm focal perforation of the middle jejunum in the left flank, about 10 cm from the umbilical port. A peritoneal thin string adhesion was identified directly above this perforation. This adhesion most likely linked the peritoneal wall to the jejunum on the site of the perforation. During peritoneal insufflation, the distension of the abdominal wall broke the string and led to a jejunal perforation. Three stiches, using 4-0 silk thread closed the perforation [, ]. All abdominal fluid was aspirated and no abnormality was found at the cholecystectomy site or in any other part of the abdomen, except for many adhesions, mainly in the left abdomen. The abdomen was closed following common surgical procedures.\nThe patient showed an uneventful postoperative follow-up, and was fed on the second postoperative day. On the fifth postoperative day, the patient’s hematological and biochemical exams were normal and she was discharged from the hospital in good health. The patient has been undergoing follow-up for 11 months, and no abnormality or complaint occurred during this period.

A 47-year-old female presented with a large foul smelling wound of the left inguinal region with severe pain with ambulation. She had been treated with radiation therapy for a locally aggressive urologic malignancy with not distant metastasis. A surgical plan that involved resection of the tumor, femoral artery, and vein with immediate reconstruction of the vessels and soft tissues was designed for this patient. The abdomen would not be a donor site given her ureterostomy on the right and tumor involvement of both the femoral arterial and venous bifurcations on the left.\nThe patient underwent resection of the tumor and immediate reconstruction of the femoral artery and vein with heparin-bonded PTFE grafts (Propaten, W.L. Gore, Inc., Flagstaff, AZ) []. Once flow had been established to the left lower extremity, the resulting soft tissue deficit was evaluated. An 8 cm × 15 cm soft tissue defect in the inguinal region had to be reconstructed. Given the fact that the patient had a history of deep venous thrombosis, resection of the gracilis with the tumor, and reconstruction of the femoral artery and vein from just below the iliac bifurcations to the midthigh we chose to use the anterolateral thigh flap from the opposite extremity. Other flaps such as the rectus abdominis and rectus femoris are other viable options. In this particular case the diep inferior epigastric vessels were part of the resection. The rectus femoris flap is also useful in reconstruction of groin defects. It can be used without the loss of knee extension. The anterolateral thigh is extremely versatile with multiple uses for lower extremity reconstruction [, ].\nThe flap was designed on the lateral thigh in order to obtain maximal pedicle length (). Skin signals were identified and marked. An exploration incision was made to identify the descending branch off the lateral circumflex femoral artery. The most distal perforators were located and marked on the surface of the skin paddle of the flap. Typical pedicle length for this flap is approximately 12 cm, depending on the location of the flap []. The perforator was the dissected retrograde through the vastus lateralis to the source vessels. The pedicle was dissected to the rectus femoris perforator cranially. Once the dissection was completed, the flap was passed beneath the rectus femoris muscle prior to passage through a subcutaneous tunnel to the defect (). Approximately 17 cm of pedicle length was created to facilitate the transfer. The flap was inset and wounds closed over closed suction drains (). The patient has gone on to heal her wounds. She is ambulatory and pain free with no evidence of local recurrence. Her venous graft has occluded, but her limb swelling is unchanged from her preoperative status. Her arterial reconstruction remains patent.

This is a case of a 68-year-old female presented to the clinic for a 2-month history of recurrent left ankle pain, associated with swelling and edema. The patient had a history of thyroid follicular adenocarcinoma which was treated surgically with total thyroidectomy and postoperative iodine treatment 25 years prior to presentation. At 12 years post thyroidectomy, she was diagnosed with a calcaneal mass of the same pathology and diagnosed with delayed distant thyroid carcinoma metastasis to the calcaneus. 10 years after calcaneal mass excision, the patient was diagnosed with a proximal tibial mass that turned out to be also delayed metastasis of the same pathology.\nAt the first presentation 15 years ago, she initially presented complaining of mild edema of the left ankle with intermittent pain upon daily activity. Physical exam showed full range of motion of the ankle joint with intact motor power and intact neurovascular status. There were no cutaneous lesions.\nPlain radiographs of the left ankle showed a 3-centimeter oval lytic lesion in the anterior aspect of the calcaneum ().\nAn MRI of the left ankle showed a 3.2 cm well-defined benign-looking lytic lesion of the calcaneal neck reaching the cortex which appeared to be mildly irregular with mild degenerative disease of the posterior subtalar joint consistent with an intraosseous ganglion cyst of the calcaneus ().\nMedical treatment with NSAIDs and paracetamol was initiated, along with partial weight bearing and relative rest with no improvement at follow-up at 4 weeks. Surgical intervention was decided due to the persistent pain. The cyst was resected with a margin of surrounding fibro-osseous tissue and the bone grafted. Histopathological evaluation revealed a metastatic carcinoma of the thyroid gland. Immunostaining showed that the cells expressed cytokeratin, cytokeratin 7, and thyroglobulin, all of which confirm the diagnosis ().\nFor further confirmation, the recently excised cyst slides were compared to the pathology slides of the thyroid excision undertaken 12 years prior to the calcaneal presentation and were found out to be of the same pathology ().\nThe patient had a smooth postoperative hospital stay and clinical recovery from pain before discharge; postoperative follow-up showed necrosis of the upper part of the wound which healed by secondary intention.\nThe patient had a complete bone metastasis workup; chest X-ray showed a right upper lobe nodule for which an FNA biopsy under CT scan was done demonstrating the same pathology as for the calcaneus. A bone scan was ordered showing no definitive sign suggesting metastasis with no specific abnormality of the manubrium-sterni joint and the right proximal metaphysis of the right tibia which was nonspecific for distant metastasis according to the nuclear radiologist. After the discussion with the oncologist, decision for radioactive iodine therapy was made.\nAt 3-month postoperative follow-up, while the patient was undergoing chemotherapy, she recomplained of ankle pain upon ambulation, associated with edema. The patient had 5/5 motor strength, no numbness, and no sign of infection. A left ankle X-ray and MRI were ordered () to rule out any recurrence at the surgical site. The new investigations showed oval-shaped lytic lesion of 2.8 cm, and MRI showed increase in size of the calcaneal mass without pathologic fracture.\nThe patient was treated symptomatically; a follow-up MRI at 8 months showed postoperative enhancement in the surgical bed suggestive of viable tissue, and at 10 months, a follow-up MRI showed that there was near total healing of the calcaneal region.\nAfter 10 years post calcaneal mass excision, keeping in mind that the patient was symptom-free with respect to her ankle since the surgery, the patient presented to the clinic complaining of recurrent right knee pain. Investigation showed right proximal tibial metastasis with invasion of the patellar tendon. Surgical resection of the metastasis with repair of the patellar tendon was performed, and pathology was also consistent with thyroid follicular cell carcinoma (Figures and ).\nThe oncologist was consulted, and the decision for treatment with teroglobulin as well as adjuvant radiation therapy was made.

We would like to present the case of a 68-year-old gentleman who had a brachial plexus block performed at two levels as the sole anesthetic to undergo an above elbow amputation. He was a frail gentleman and suffered from severe COPD and peripheral vascular disease. He presented with a severely ischemic left forearm at the Royal Albert Edward Infirmary, Wigan, UK. He previously had an axillo-femoral bypass for the affected upper limb which failed followed by a subclavian artery stent insertion which blocked subsequently. He was consented him for a left above elbow amputation by the vascular surgeons as his forearm ischemia was rapidly worsening. He had severe ischemic pain in his left forearm, which was controlled with a supraclavicular brachial plexus block the night before his operation.\nHis forced expiratory volume in 1 second (FEV1) was measured as 1.6 liters and his echocardiogram showed moderate left ventricular dysfunction. General anesthesia deemed to carry a very high risk of cardio-pulmonary complications. Therefore, it was planned to perform this procedure under regional anesthesia as the sole anesthetic technique after obtaining patient’s consent. He was very restless due to the severe pain in his left hand and forearm and was not very cooperative.\nThe initial plan was to perform an axillary brachial plexus block to control his severe ischemic forearm pain but the axillary block could not be performed as he could not position his arm due to the severity of the pain. Therefore, the supraclavicular brachial plexus was technically easier to perform in this case and was performed using 20 mls of 0.375% bupivacaine under ultrasound guidance to control his pain and to perform surgery if the block proved adequate. The block was tested to cold and pinprick prior to the surgery but only provided adequate surgical anesthesia in the forearm up till the level of elbow, not above it.\nWe assumed that the block had been inadequate most probably due to technical difficulty to perform the block as the patient had not been able to lie still owing to the severe pain below his elbow. Having waiting for forty minutes after performing supraclavicular brachial plexus block, it was eventually decided to perform the rescue interscalene brachial plexus block. We were aware of the fact that performing an interscalene block could cause postoperative respiratory complications as the patient had severe COPD. However, as general anesthesia was considered to carry a very high risk, we decided to perform a supplementary low volume interscalene block using 7 mls of 0.375% bupivacaine under ultrasound guidance and nerve stimulation. The patient, thus eventually had adequate surgical anesthesia using the combined supraclavicular and interscalene approaches. He was cooperative throughout the surgical procedure and had the above elbow amputation completed successfully and uneventfully. He was pain free in the recovery and did not suffer from any postoperative respiratory complications.

A 25 years old male patient presented for examination. Several incidents of Grand Mal epileptic seizure were referred with the last one three weeks ago. After the last episode both shoulders' range of motion was regressed and pain was elicited with movement. The patient visited a hospital at that point and without radiographic control performed, the diagnosis of bilateral shoulder contusions was posed. About three weeks later and as the patient realised that his injury was irreversible, he presented to the emergency room of our hospital. Clinical examination made clear that bilateral anterior shoulder dislocation was the point. (Fig. ). No neurovascular injury was diagnosed in any arm. At the time of examination the patient was able to perform flexion and abduction of both arms up to 60 degrees as well as almost full external rotation with no pain restraint. From the patient's history no previous incidence of shoulder dislocation was referred. Radiographic control and Computed Tomography Scanning revealed the dislocations as well as a sizeable greater tuberosity fracture of the left humerus and Hill Sachs lesion at both sides. (Fig. ).\nBilateral reductions under general anaesthesia and internal fixation of the left greater tuberosity fracture were performed (Fig. ). The reductions were easy to perform and shoulders' stabilisation was not carried out. No post manipulation neurovascular deficit was observed. Ultrasonography performed 4 days post surgery confirmed the integrity of rotator cuffs in both shoulders. Broad arm polyslings in abduction and internal rotation were used for 2 weeks and progressive mobilization started with pendulum exercises, forward flexion and abduction. A physiotherapy program of muscle enforcement was added at 3 weeks. The recovery was successful and after 2 months the patient had regained a normal range of motion in both shoulders with a minor lack at the last degrees of flexion and internal rotation of the left shoulder. Four months post-operatively the range of motion was fully recovered bilaterally and at the final follow-up, 2 years post surgery, the patient had not undergone any recurrent dislocation.

A 6-year and 2-month-old boy who was admitted to our institution 10 weeks after a rollover motor vehicle collision. The child was ejected and found transiently unconscious and hypotensive. At the local hospital, he was intubated and underwent immediate exploratory laparotomy where a splenectomy was performed. He also had a right tibia fracture that was treated with immobilisation. The cervical spine injury was detected while recovering from the laparotomy. His initial cervical radiographs and magnetic resonance imaging (MRI) were obtained after noticing right-sided weakness ( and ()). The family brought the child to our institution after his tibia fracture had healed. The neurological assessment at arrival revealed a Frankel grade D incomplete spinal cord injury. Right brown sequard hemiplegia was documented. There was more motor weakness in the right upper extremity, especially of the hand along with sensory loss in the left hand. A repeated MRI that was done under fiberoptic intubation with general anaesthesia on the way to the operating room showed improvement of the abnormal signal intensity and reduction of the impinging C4-5 disc ().\nWe did not perform skull traction as the CT scan did show at least partial healing of the dislocated facets (), and we started posteriorly because remodelled facets were felt to be restrictive to any anterior manipulation. Altering the natural facet articulation for the posterior release increases instability even after reduction and because of the small C4 lateral mass, we instrumented two vertebrae above and below the injured level.\nThe surgical procedure constituted three approaches, starting posteriorly for facets release, which did not result in reduction (), then anteriorly where we did a C5 corpectomy as well as discectomy of the adjacent discs. For the reduction, standard techniques were employed to realign the vertebrae. Despite the small size of the vertebrae, we were able to place divergent distraction pins and used them effectively (). After the reduction, a structural allograft was placed followed by an anterior plate. We then turned the patient prone again and placed lateral mass screws and rods. The fixation was extended between C3 and C6. Due to anatomical constraints, the C4 lateral masses were not instrumented. The transcranial motor evoked potentials deteriorated momentarily twice: first, after log-rolling to the prone position while adjusting the Mayfield frame before we started the procedure, which improved once we flexed the neck slightly and corrected translation; and second during an attempt at reduction anteriorly using a laminar spreader. The deterioration resolved immediately after the release of the distraction. Although the C4-5 facets were released posteriorly, the anterior lamina spreader did not lead to satisfactory realignment under fluoroscopic assessment. Postoperatively, he was kept intubated for 2 days in the intensive care unit. He was then admitted to the rehabilitation hospital for 4 weeks and used a semi-rigid cervical collar for 3 months.\nDuring rehabilitation, the patient regained independent ambulation without walking aids or orthoses. At 2-year follow-up, the patient had no pain or functional limitations, and there was no notable restriction in neck range of motion or a limp. His neurological exam improved, but remained Frankel grade D. He was able to write clearly with his right hand. The final radiographs showed union ( and ()).

A 44-year-old female who was diagnosed with carcinoma of the lower alveolus with involvement of the middle third of the mandible, anterior floor of the mouth, gingivo-labial sulcus and the overlying skin. It was planned for composite resection followed by reconstruction with free fibula osteocutaneous flap. During the preoperative assessment, her dorsalis pedis and posterior tibial pulsations in both legs were normal by palpation. The left leg was selected and the fibula with a skin paddle of 22 × 9 cm was raised through standard anterior approach under tourniquet control. After the distal and proximal osteotomies and after ligating the distal end of the peroneal vessels and moving proximally, no septocutaneous perforators were noticed. Further dissection revealed a single musculo cutaneous perforator coming out of the soleus muscle and proceeding to the skin paddle. With the possibility of anomalous perforator in mind, the vessel was dissected along its entire length through the substance of the soleus muscle [] and was found to be originating from the posterior tibial artery 2 cm below the trifurcation. In order to be doubly sure about the contribution of this anomalous vessel to the skin paddle, we applied microvascular clamp to this vessel after releasing the tourniquet. To our surprise there was no bleeding from the margins of the skin paddle and bleeding was restored after the release of the clamp from the anomalous vessel confirming that this was the only vascular supply to the skin paddle. The rest of our flap dissection went normally and the flap was harvested as a single composite unit with two vascular pedicles [] and the donor site was closed partly with split-skin graft. After the necessary osteotomies were completed in the flap, the bone fixation was done and the intraoral inset of the flap was given. The peroneal vessels were anastomosed to the left facial artery and the left external Jugular vein and then the bleeding from the skin edge was noted once again and was found to be nil. The skin margin bleeding was satisfactory when the anomalous vessel and its and its venae commitantes were anastomosed to the left superior thyroid artery and a tributary of the left internal jugular vein []. After confirming good bleeding from the margins of the skin paddle, the final inset of the flap measuring 19 × 8 cm was given covering the floor of the mouth, inner and outer aspects of the lower lip and the chin. There were no postoperative complications and the flap settled well and the patient was referred for adjuvant radiotherapy.

A 47-year-old Iranian male patient referred to our outpatient clinic in the Imam Khomeini Hospital, Sari, with a palpable and painless mass in his left shoulder.\nThe patient did not complain about pain or weakness in this location. On examination, the mass was small, mobile, firm, and nontender located in the soft tissue of left shoulder. The skin covering the mass was intact, and there was no ecchymosis and even erythema (). The shoulder range of motion had no functional impairment, and the patient was able to do the routine tasks with no neurovascular disturbance. Medically speaking, important clinical signs and symptoms such as fever, weight loss, and respiratory symptoms were not detected.\nThere was no visible fluctuation in this field, and it was estimated 0.5-1 cm in length and width. Tumor consistency was not similar to bone, and it seemed to be a soft tissue mass. The patient denied any history of trauma and also no significant family history was identified. Interestingly, the patient was operated by general surgeon 6 times because of relapses in a way the last one was 1.5 years ago. At the first time, the patient was referred to the outpatient clinic because of gradual mass enlargement. The patient was operated by wrong method as transverse approach in the lateral border of the shoulder ().\nIn the recent recurrence, chest X-ray showed no obvious lung or bone involvement ( and ). Magnetic resonance imaging (MRI) illustrated a small extraskeletal nodular lesion with ring enhancement and no bone involvement at subcutaneous fat on lateral aspect of shoulder measuring about 13 mm which could be due to a recurrence of the previous tumor ( and ). Unfortunately, no previous documentation such as MRI was found. Thus, this caused difficulty for interpretation of the course of the main disease.\nFirst, we decided to operate the tumor as an incisional biopsy because we were not sure about the nature of the lesion. An important note in this approach was limited access to the lesion because of an incorrect previous approach. Pathologic specimen confirmed the diagnosis of chondrosarcoma. Then, he underwent a wide resection of the lesion in the beach-chair position. In surgery, the five dense fibrotic and firm masses measuring from 0.5 to 2 cm and the middle part of deltoid muscle (because of involvement) were excised and sent to pathology ward. Microscopic examination showed infiltrative hypercellular islands of pleomorphic chondrocytes composed of enlarged cells with irregular hyperchromatic nuclei and inconspicuous cytoplasm which was compatible with the diagnosis of chondrosarcoma with free surgical margins ( and ). We should say that the diagnosis was based on the characteristic clinical, radiologic, and pathological criteria; moreover, it was confirmed by immunohistochemistry. Hence, after consulting with the oncologist, radiation therapy was done. We have followed the patient for 6 months after operation, and until now, no recurrence is recognized.

A 49-year-old Caucasian woman was referred to a general surgeon by her primary care physician for a right nipple lesion. She reports no past medical history, and social history is notable for tobacco use. The patient stated that she first noticed a small, yellow, and fleshy bump on her right nipple approximately two years prior. She became concerned due to its rapid growth in the last year. Four months prior, she visited her primary care provider who performed a shave biopsy of the lesion. Initial pathology results suggested squamous cell carcinoma, but this was thought to be discordant with the clinical picture. At consultation, she reported that her right breast had also started feeling hot and tender for two weeks duration. On examination, her right breast was erythematous and rigid with a 2.2 cm lesion consuming the right nipple. Her nipple also drained yellow pus. The patient was placed on a course of antibiotics due to concerns for an abscess.\nAn MRI was ordered to investigate possible underlying breast malignancy. Results of the MRI showed no solid mass underlying the nipple. A wedge biopsy of the nipple was performed to confirm the initial shave biopsy pathology (). Pathology showed verrucous histologic features with chronic inflammation and underlying abscess with concerns for a possible cutaneous malignancy. Specifically, there was marked papillomatosis with hypergranulomatosis between the papillae as well as a lack of granules at the papillary surfaces. Immunohistochemical testing was also positive for HPV L1 capsid protein. Because the initial shave biopsy showed SCC with positive margins, this clinical picture suggested that an inadequate sample was taken during the wedge biopsy. After consultation of literature, excision with wide margins was determined to be appropriate for removal of the lesion.\nThe patient underwent a wide excision of the right nipple-areola complex for removal of the growth. A 6.2 cm x 3.2 cm skin ellipse was excised encompassing the 2.2 cm nipple lesion. On final histologic examination, the lesion was found to be a large tumor with verrucous features, hyperkeratosis, dyskeratosis, and nests of keratin pearl formation (). Two areas showed microinvasion of the dermis with loss of the basal lamina. There were also significant acute and chronic inflammatory responses in the deep dermis representing an underlying abscess. These findings are congruent with the diagnosis of a well-differentiated squamous cell carcinoma with arising within verruca vulgaris. All margins were found to be clear of tumor cells. The post-op course was uneventful. She continues to follow up to monitor potential recurrence of the growth.

A 65-year-old male presented to us with sudden painless loss of vision in the left eye of 3 weeks duration when he was thrombolised with streptokinase for an acute inferior wall myocardial infarct. There was no history of ocular trauma. The patient was on oral aspirin in the dose of 150 mg daily for an episode of ischemic heart disease since over 1 year and on high dose aspirin in the dose 600 mg daily since 4 days after the heart attack. The patient is a known case of diabetes mellitus since past 10 years and is receiving oral anti-diabetic medication. The patient does not have a documented status of blood sugar levels over past 10 years. The patient underwent uneventful cataract surgery with intraocular lens implant in both eyes elsewhere, 4 months back in the right and 2 years back in left eye. The right eye was diagnosed to have proliferative diabetic retinopathy 2 years back and was treated with panretinal photocoagulation. His best corrected visual acuity was 20/40 in his right eye and light perception with accurate projection of rays in the left eye. Right eye was pseudophakic with normal anterior segment and gonioscopy findings. Intraocular pressure (IOP) was 12 mmHg. Examination of fundus revealed findings of stable lasered proliferative diabetic retinopathy. The left eye had a posterior chamber intraocular lens (PCIOL) in the bag. There was a thick hematoma behind PCIOL and anterior to the posterior capsule in the capsular bag [Figures and ]. IOP was 12 mmHg. Fundus was not visible due to thick and total hematoma. No iris new vessels were seen. B Scan showed anchogenic vitreous cavity ruling out any vitreous hemorrhage []. There were no angle vessels on gonioscopy and angles were open. Routine hematological profile including coagulation screen was normal.\nWe had treatment options of either clearing visual axis with neodymium (Nd)-YAG Laser capsulotomy primarily aiming to restore vision or surgical removal of the clot by a limbal route. The later was preferred in view of the need to evaluate the fundus and perform a Fundus Fluoroscein Angiography (FFA) later in order to rule out a proliferative diabetic retinopathy in the left eye. Patient had a cleared clot, an intact posterior capsule, with restoration of vision of 20/40 on first post operative day []. Postoperative fundus was normal with no evidence of neovascularization on retina []. FFA done on first week follow up revealed subtle neovascularisation on disc [], for which pan retinal photocoagulation was later performed.

A 26-year-old male, a young adult who is a welder by occupation, was brought on new year’s eve of 2017 to the emergency room following a history of RTA when he fell over from his motorbike as he was about to crash into a stationary vehicle and sustained injury to his right thigh, he was brought within 2 h after sustaining trauma and complained of severe pain over his right hip and inability to move his right lower limb. On examination, he was conscious and oriented, hemodynamically stable, and unable to move his right lower limb which was externally rotated and shortened with a diffusely swollen upper thigh. He had tenderness over the right groin area with a palpable lump. Distal neurovascular examination was normal. Radiographic evaluation of pelvis and right thigh revealed right hip anterior dislocation with ipsilateral subtrochanteric femur fracture (). The patient was worked up for surgery immediately and emergency surgical intervention to reduce the hip was planned. After inducing anesthesia, no attempts of closed reduction using the various techniques to reduce the anterior dislocation were tried as the patient had an ipsilateral femur fracture because all the forces pass through the fracture site. Therefore, the patient was placed on a radiolucent table and with a help of image intensifier, under strict sterile precaution, initially, one 5mm Schanz pin was placed close to the intertrochanteric region and used as a joystick to reduce the head into the acetabulum but was unsuccessful; hence, another Schanz pin was placed parallelly and connected with each other using a pin to rod connector and then the rod along with the pins was used as an external reduction tool to reduce the right hip in a closed manner without the need of open reduction, thereby reducing the chances of vascular insult on the capsule. The closed reduction was found to be satisfactory as checked under the image intensifier () and further reduction of the subtrochanteric region was done and a uniplanar external fixator was applied as a temporary procedure. This emergency procedure was done within 6 h of the insult. After 2 days, the patient was taken up for definitive procedure in the form of external fixator removal and closed reduction and intramedullary interlocking nailing using a cephalomedullary nail but used as IMIL nail () with the patient placed on a fracture table under C-arm guidance. Postoperatively, regular wound inspections and dressings were done and wound was found to be healthy. The patient was started on non-weight-bearing mobilization for 2 weeks initially and then was started on weight-bearing as tolerated and gently to full weight-bearing. The patient was also started on physiotherapy in the form of hip exercises at the end of 6 weeks. The patient resumed his daily work and had not faced any challenges. Functional assessment was done using Harris Hip Score () at 6 weeks, 3 months, 1 year and 2 years follow-up. Radiological assessment was done at the time of 2 months () and regularly until 2 years follow-up to check for fracture union and to rule out AVN of femoral head, secondary arthritis, and implant loosening. At 2 years follow-up, Harris Hip Score was found to be 95 with no restriction of movements () and fracture was united completely with no evidence of AVN and secondary osteoarthritis in the femoral head ().

The 8-year-old boy first presented in January 2012, having been referred by the family dentist, to the Department of Orthodontics at the Medical Center of the University of Göttingen for a routine orthodontic control and evaluation of treatment need (). The clinical examination of the asymptomatic patient showed no extra- or intraoral pathological findings. The medical history of the boy included a mild pulmonary valve stenosis and a secundum atrial septal defect with a left-right shunt. He showed a good physical and cardiac fitness and a normal nutritional status. The family history was positive for maxillofacial anomalies: the boy's older sister had been previously diagnosed with a dysplastic fibroma, a rare benign fibrovascular defect in the mandible, and a resection of the affected area in the mandible had been performed. His father and paternal grandmother had a positive history of odontogenic cysts as well as basal cell carcinomas, although the family history of OKCs was negative. The radiological examination showed three suspicious hypomineralisations visible as radiolucencies in the panoramic radiograph associated with the retained teeth 13 and 23 and the ectopic tooth 27 (). The young patient was referred to the Department of Maxillofacial Surgery for a surgical examination of the radiologic anomalies.\nThe operation was performed under general anesthesia. The suspected pathological area around teeth 23 and 13 showed no visible intraoperative pathological signs. A bone and soft tissue biopsy for histological examination was taken. In the area of tooth 27, a well-marked membrane was revealed, filled with a viscid fluid and fully enclosing the dental crown. The clinical aspect was consistent with a follicular cyst. During the radical cystectomy, tooth 27 was removed due to massive attachment loss. The histopathological biopsy showed a fibroosseous lesion in the area of teeth 13 and 23. The biopsy from region 27 showed an odontogenic connective tissue cyst wall with intramural odontogenic cell islands. On request of the surgeon, samples were sent for further diagnosis to the Bone Tumor Reference Center of the Swiss Society of Pathology at the University Hospital in Basel, Switzerland. The initial histological diagnosis was corrected to an OKC of the parakeratin variant. Microscopically, the cyst shows a squamous epithelium. The basal cells are palisading, with hyperchromatic nuclei (HE staining, 5x magnification) (). Due to the high recurrence of OKCs, a radiological control interval of 6 months was indicated (). Furthermore, orthodontic treatment was initiated.\nIn August 2014, during a regular radiological control, a new radiolucency was detected, associated with the retained and displaced teeth 47 and 48 (). The surgical removal of the cystic lesion and tooth 47 was performed under general anesthesia. The pathological finding was consistent with an OKC.\nThe regular control examinations were interrupted by missed appointments, so the next evaluation took place one year later, in October 2015 (). New radiolucencies were detected in the panoramic radiograph associated with the retained teeth 18, 17, 37, 38, and 48 as well as an evident enlargement of the radiolucency around the crown of tooth 13. A cone beam computer tomography scan was performed and showed well-defined radiolucent areas, associated with the retained teeth. Details of the surgical enucleation of the cysts with the extraction of teeth 18, 17, 13, 37, 38, and 48 are shown below. The postoperative radiological examination is depicted in . Clinical and radiological examinations were then performed every 6 months.\nWe describe the surgical enucleation of the cystic lesions using the example of the third operation (2015). This was performed under general anesthesia; the affected regions were exposed after lifting a mucoperiosteal flap. After a careful removal of a thin bone cortex, the cystic capsule was found () and separated from the bone with an obtuse instrument. The aim was to leave no epithelial remnants on the trabecular bone. All four lesions were associated with a retained tooth, which was only loosely anchored in the alveolar bone. Due to the high recurrence rate of the cystic lesions in this particular case, all affected teeth were extracted. In the area of the mandible, the use of Carnoy's solution was not indicated because of the exposure of the lower alveolar nerve (). Due to their large size, the cystic cavities were filled with a collagen graft, which stabilized the formation of a coagulum. No reconstruction with iliac crest bone or allogenic bone grafts was attempted. Subsequently, the mucoperiosteal flap was reverted back to its original position and fixed by sutures.\nBy October 2016 and August 2017, bone remodeling of the affected area had been detected and no new lesions were observed (Figures and ).\nDue to the recurrence and the appearance of new lesions, Gorlin-Goltz syndrome was suspected in the patient. After genetic counselling at the Institute of Human Genetics of the University Medical Center of Göttingen, molecular genetic analysis of the genes PTCH1 and PTCH2 was performed in 2015. Sanger sequencing revealed the heterozygous germline variant c.2779_2793del (p.Ser927_Val931del) in the PTCH1 gene. This variant leads to an “in-frame” deletion of 5 amino acids between amino acid positions 927 and 931 of the protein. This variant is listed neither in the Human Gene Mutation Database (HGMD) nor in the Leiden Open Variation Database (LOVD). However, a pathogenic effect of the variant seemed likely as many pathogenic variants have already been described in this region of the PTCH1 gene, even several in-frame deletions [, ]. Since the boy's father had shown similar symptoms (odontogenic cysts, basal cell carcinomas) that could be in line with a Gorlin-Goltz syndrome, he, too, was tested for the PTCH1 variant and resulted to be carrier of the variant.\nIn summary, clinical and molecular data together with the positive segregation analysis led to the classification of the variant as “probably pathogenic” and being responsible for Gorlin-Goltz syndrome in the patient and his father. The importance of talking precautions (e.g., sun protection due to the high risk of basal cell carcinomas) and regular medical surveillance (e.g., regular orthodontic care and annual dermatologic examinations) was emphasized.

The patient, aged 37 years, a female, was admitted to the Department of Maxillofacial Surgery with complaints on the mandible mobility in the frontal and right distal regions when opening and closing the mouth and impaired mastication due to partial mandibular edentulism on the right side.\nIn 2011, in a clinic at place of the patient's residence, she was diagnosed to have fibrous dysplasia of the mandible on the right side, for which the patient underwent the resection of the lower jaw from the frontal region to the right ramus with external approach. Later on she had two surgeries of microsurgical mandibular reconstruction with the use of vascularized fibular bone autografts carried out in the regional clinical center. Unfortunately, the autotransplants were removed in both cases due to vascular anastomosis failure.\nIn May 2012, a reconstruction of the right mandible was done with a free nonvascularized rib autograft in our Department. Within a year after the surgery, the patient had retention of more than 90% of the autotransplant volume and the satisfactory function of mastication on the left side. However, no consolidation was observed and nonunions were diagnosed within the proximal and distal fixation areas that caused mobility and prevented any prosthetic treatment in the mandible on the right side. Therefore, reconstructive surgery with the resection of nonunions, bone grafting, and osteosynthesis was performed. Despite the surgical intervention, a control clinical and instrumental examination in 0.5 year after the operation detected slight mobility in the frontal region and within the right ramus and no radiological evidence of consolidation (). The diastasis in the frontal mandible ranged from 5 mm on the upper edge to 14 mm on the lower one; the average tissue density between bone edges was 158.55 ± 116.29 HU; the separation between the transplant edge and the mandibular ramus on the vestibular surface achieved 9.2 mm, with the average tissue density in the nonunion area being 204.52 ± 97.84 HU.\nTaking into account a potentially poor blood supply within the fixation of the autotransplant and the mandibular fragments due to numerous operations previously performed including two failed microsurgical ones as well as a prolonged smoking experience (more than 15 years), the patient was offered to undergo a surgical treatment with the use of the gene-activated bone substitute. Considering the patient's characteristics and anamnesis, the total score according to Nonunion Scoring System [] was estimated to be 31, which corresponded with high risk of nonunion relapse and required more specialized care. Additionally, the nonunions were complicated being formed by nonvascularized bone autograft intended to be resorbed and replaced by newly generated bone tissue. The voluntary written informed consent was obtained.\nThe gene-activated bone substitute we developed consists of two components. The first one is the composite scaffold of bovine collagen and synthetic hydroxyapatite (granules with diameter of 500–1000 μm) registered as a bone substitute (CJSC Polystom, Russia) and approved for clinical use in Russia, the second one is a supercoiled naked plasmid DNA with cytomegalovirus promoter and gene encoding VEGF which is the active substance of “Neovasculgen” []. We made the gene-activated bone substitute in the form of rectangular sponge-like matrix (size of 20 × 10 × 10 mm, weight of 200 ± 10 mg) containing 0.2 mg of the gene constructs. 5 units were used for clinical study. 5 plates were used for a surgical intervention (total amount of the scaffold: 1000 mg; total dose of the plasmid DNA: 1 mg).\nThe standard surgical protocol with metal constructs removal, nonunions fibrous tissues excision, and approximated bone surfaces careful grinding was performed. Bone defects (5–14 mm in the frontal region; 7–9 mm in the distal region of the mandible) within the rib autograft, still present from previous interventions and mandibular fragments, were filled in with the gene-activated bone substitute (). The autotransplant was fixed in the correct position with four straight miniplates and miniscrews.\nIn a postoperative period, a soft diet and conservative therapy including antibiotics, analgesics, and desensitizing and anti-inflammatory agents were prescribed to the patient.\nTo evaluate the treatment results, clinical and radiological diagnostic methods were used during the first 14 days of the postoperative period (in a hospital) and in 3, 6, and 12 months after surgery.\nA pain level in the postoperative region was rated with the use of the Visual Analog Scale; edema was scored with the Numeric Rating Scale.\nA control panoramic radiograph was made the next postoperative day; dental CT was done in 3, 6, and 12 months after surgery. A manual segmentation of the mandible was performed in the software 3D Slicer (Brigham, USA). The newly formed tissues within the bone substitute grafting were separately selected; their average density was calculated in Hounsfield units (HU) by using the “Label statistics” module. 3D bone reconstruction with volume rendering in the range of 250–2,000 HU was made, which complied with an optimal “bone window” with retention of spongy and lamellar bone in a model without metal constructs. A minimal size of diastases between mandibular fragments and rib autograft edges was determined with standard morphometry in the software Planmeca Romexis Viewer (Planmeca Oy, Finland).\nNeither adverse events nor serious adverse events were observed. The postoperative pain score did not exceed 6 within the first three days after surgery; it was controlled with pain-relievers; an average score for the following four days was 3.5, no pain relief was required. Later on the patient did not notice any tenderness or discomfort within the postsurgical area. The maximal edema rated as 5 by the Numeric Rating Scale was observed on the third postoperative day. Then edema gradually decreased; its score was 3 by the end of the first week and remained at the same level for up to 14 days.\nBased on the panoramic radiograph data () the autograft was fixed in a right position, the gene-activated bone substitute was located within bone defects, and its radiodensity was approximately twice as less as that of the bone autograft.\nNo inflammation sings, edema, or pain was observed in the postsurgical area for 12 months after surgery. Control CT showed that the rib autograft and metal constructs were correctly positioned.\n3 months after surgery, increased density regions were visualized in the zones of the distal and proximal autograft fixation and bone grafting (). The average density of these areas was 402.21 ± 84.40 in the frontal fixation and 447.68 ± 106.75 HU within the distal fixation ().\nThe diastasis sizes between the bone fragments were 4.8 mm on the upper edge and 12.5 mm on the lower one in the frontal surface and 6.2 mm on the vestibular surface without dissociations on the lingual one within the distal region. No defects in the zones of proximal and distal fixation of the autograft were detected using 3D reconstruction. Heteromorphic newly formed tissues were seen in these areas; the tissues overstretched the bone boarders of the reconstructed mandible outlining to a certain extent the substitute engrafted previously ().\nThe newly formed tissues with average density about 400 HU within gene-activated bone substitute implantation area were observed in the frontal region 6 and 12 months after surgery (Figures and ). However, there was moderate partial resorption in the proximal edge of the bone autotransplant which prevented consolidation and maintained a diastasis. Clinical examination identified the appearance of minimal mandible mobility in the frontal region only 12 months after surgery, which corresponded with CT results.\nMeanwhile, the distal edge of the rib autograft was completely integrated with adjacent mandibular ramus on both latest time points which did not allow distinguishing the borders between the mandible fragment, newly formed bone tissue, and rib autograft to segment these regions (). Normotrophic bone callus with no defects was formed 6 months after surgery and fully mineralized later on revealing the average density of 921.51 ± 321.89 on the last time point. Moreover, we found the completed remodeling of newly formed bone tissue with distinguished vestibular (1028.67 ± 169.77 HU) and lingual (1528.78 ± 81.53) cortical plates and spongy bone between them in 12 months. No mandibular mobility was detected in this region.

A 42-year-old overweight woman from rural Greece visited the local physician in February 1997 reporting several episodes of mild upper abdominal pain during the previous three years, not related to food consumption. The pain was not observed elsewhere on the body nor was it correlated with other symptoms, such as fever, nausea or vomiting. In addition, the pain did not affect food intake or daily physical activity. Before medical consultation no systematic treatment had been applied for the pain, which was relieved after some minutes, only to relapse some days later.\nHistory revealed an episode of reported angina 4 months prior to consultation, with non -specific ST/T abnormalities in the ECG. Physical examination revealed no important findings. The blood tests revealed no obvious pathology, with a normal hematocrit and blood coagulation parameters. Biochemical testing for hepatic and renal was also within normal values. Imaging included a chest radiography, which revealed no abnormalities and an abdominal CT scan with oral gastrografin intake, which revealed a 3 × 6 cm cystic formation located at the lower pole of the spleen (Figure ). Due to the lack of an infectious (no compatible clinical signs, no CRP or WBC count elevation, negative serological testing for Echinococcus) or traumatic background and the lack of evidence in favor of a cystic neoplasm (homologous content, normal perimeter, no increase in cancer-associated biochemical markers, such as Ca 19-9 and CEA), a latent congenital epithelial cyst was considered most probable. Four days later an MRI examination confirmed the previous result. The symptoms were not definitely associated to the cyst and the physician related them to the patient's increased stress, assuming she had irritable bowel syndrome.\nEight years later (2005), the patient visited her physician, reporting a periodic continuation of the abdominal pain, whereas neither the character nor the frequency of episodes differed. At this point, she was referred to the Attikon University Hospital for surgical treatment. An abdominal CT scan was performed as part of the preoperative evaluation, revealing a 3 × 5 cm splenic cyst which confirmed the existence of this random finding (Figure ). The rest of the tests were within normal limits again. The patient decided to follow a conservative approach and re-evaluation at an annual basis. In November 2006, an ultrasound of the area revealed further regression of the cyst with a clear hyperechogenic perimeter, the size being estimated at less than 3 cm. For a more accurate description, an MRI scan was performed, which showed almost complete regression, with a remnant lesion of 1.8 × 1.4 cm and low T2 sign in the peripheral border (Figure ), consistent with the pattern observed in the 2005 MRI (a comparative presentation of original and subsequent lesion is provided). Her last MRI examination in 2008 revealed the cyst dimensions equal to the last two radiographic images and a periodically regression of her nonspecific symptomatology, which finally proved that the presence of the cyst was responsible for her previous symptoms.\nSurprisingly, in our case, the cyst, although particularly large, was only reported to cause mild symptoms though were not definitely linked to the finding itself, which may imply that former empirical treatment rules may not be applicable in all such cases after all.

A 78-year-old male with a medical history significant for hypertension, hyperlipidemia, and chronic smoking underwent evaluation for recurrent chest pain symptoms with coronary angiography. Access was obtained through the right femoral artery and six French sheaths were placed over the guide wire. Coronary angiography did not reveal any evidence of significant coronary artery disease. The sheath was removed without significant problems. A Mynx closure device was deployed and manual pressure was held for five minutes at the access site. The patient tolerated the procedure well and was discharged home the same day and recommended to follow up in the clinic. The patient returned to the clinic two weeks later with complaints of right groin pain, redness, and swelling that has been worsening for last one week. The patient reported that he had groin pain that started a week after the procedure which initially happened during exertion or ambulation and then progressed slowly at rest as well. Follow-up examination revealed a 2 cm mobile, pulsatile, and non-tender right groin mass in the instrumented area with associated bruising of groin and inner thigh and significant edema of the right leg. Lower extremity Doppler ultrasound was performed that showed DVT of the common femoral, superficial femoral and profunda femoral veins (Figure ).\nThe patient did not report any history of trauma, intravenous drug abuse, prolonged immobilization, family history of blood clots, and recent travel. The patient had computed tomography (CT) scan of the chest, abdomen, and pelvis to further evaluate the etiology and extent of the thrombosis. A CT scan of the pelvis showed right groin pseudoaneurysm 3.1 cm x 2.8 cm. The pseudoaneurysm was compressing the femoral veins which were responsible for DVT in the right common femoral and superficial femoral veins (Figure ).\nThe patient was started on low molecular weight heparin drip and evaluated by vascular surgery for thrombin injection the next day. Vascular surgery elected not to perform thrombin injection as pseudoaneurysm was found thrombosed in the vascular lab. The patient was started on apixaban for DVT for six months and instructed to wear a compression stocking and leg elevation to prevent stasis and complications of post-thrombotic syndrome. On follow-up evaluation one month later, the patient's symptoms had improved. The patient was recommended to continue apixaban and continue to follow up with the primary care provider.

We present the case of a 21-year-old female patient who presented in our Radiology and Imaging Department with the appearance of two subcutaneous swellings in her right arm at the extremities of a scar from previous surgical interventions. The history and clinical data has shown that the patient was diagnosed in childhood with hemangioma of the arm, with the onset at 7 years old and six recurrences within 14 years. At 7 years old, she presented with a skin tumor located in the lower third of the right arm, which was surgically removed. The histopathology diagnosis was hemangioma. Three months after the surgery, the tumor recurred for the first time. After 9 years, the patient accused swelling and local pain and was subjected to another surgery for tumor excision, with a favorable postoperative evolution. After three months, another subcutaneous formation appeared, without changes in skin coverings, which grew in size and was slightly painful to effort. Another recurrence of the tumor for which the patient underwent surgical excision was at the age of 18 years and three months after.\nThe last recurrence was at 19 years old, when the clinical examination revealed the presence of postoperative local dehiscence upon which there was a soft tissue tumor, measuring 10 cm in large diameter. The patient accused local pain exacerbated by exercise, the increase in tumor size during exercise and paresthesia.\nThe plain X-ray revealed a nonspecific soft-tissue mass in the lower third of the upper right limb with calcification inside, without any changes in the adjacent bone structures ().\nThe MRI exam demonstrated round-oval heterogeneous signal tumor mass in the biceps brachial muscles, with high signal intensity on T2 weighted images and septa (). On T1 weighted images, the tumor had an intermediate signal with diffuse areas of fat increased signal (). On T2 fat-sat sequences, punctuate signal voids areas related to phleboliths can be seen (). The imaging features were specific for the recurrence of hemangioma, therefore gadolinium was not administered.\nA classic angiography was also performed, which demonstrated the lack of connection with the arterial structures, in particular with brachial artery, and the dilatation of basilic and cephalic vein. Also this technique revealed the abnormal venous vessels inside the tumor ().\nThe therapeutic strategy included an enlarged tumor excision and exploration of brachial axis. The surgical exploration was very difficult due to the adhesion of tumor with brachial biceps and it sustained the hypothesis of venous vascular malformation. Histopathological examination of surgical sample included usual techniques for inclusion in paraffin and Hematoxylin–Eosin stained and also immunohistochemical analysis. The final diagnosis was sinusoidal hemangioma of the arm.\nCurrently, the patient presented with swelling in the upper and lower third of her arm, accusing pain in axilla and breast. The physical examination revealed two bulging in her arm, of elastic consistency, mobile on superficial anatomical plans, with a slightly irregular surface and without changes in the covering skin.\nThe MRI exam showed two large soft tissue masses, localized in the upper and lower brachial muscles, with intermediate signal intensity relative to muscle on T1 weighted images () and high-signal-intensity lesion on T2-weighted MR image (). The upper lesion advanced in the anteromedial axillary zone. The tumors had septa and also punctate low signal-intensity areas, corresponding to calcification. Round-oval areas with similar MR features were observed between these two tumors (). After contrast media administration, the tumors had heterogeneous enhancement with numerous signal voids corresponding to calcifications ().\nThe post contrast sequences evidenced late venous enhancement of the lesions and the connection to an ectatic vein ().\nWe also performed a CT with contrast and an angioCT, which revealed the intramuscular tumors with calcification inside and also the lack of involvement of bone structures and of axillary structures ().\nWe carried out maximum intensity projections (MIP) and volume-rendered reconstructions (VR) which indicated the venous anomaly and the integrity of the arterial vessels ().

A 38-year-old right hand dominant male sustained an injury to his left shoulder girdle while riding a push bike to work at moderate speed. He was seen in the emergency department of a metropolitan hospital and referred to fracture clinic for further management of his injury.\nHe was seen in the specialist fracture clinic four days after his fracture was sustained. Examination revealed a closed injury to the left shoulder girdle and localized pain over the lateral aspect of his clavicle, with associated tenderness and crepitus. Initial radiographs revealed a displaced left distal clavicle fracture with no disruption to the coracoclavicular ligaments evident (). Radiographs also demonstrated mildly displaced fractures of the left third and fourth ribs posteriorly. Formal radiology reporting also concurred with the above findings.\nThe decision was made to proceed with surgical fixation of the fracture given its displaced and distal nature. He underwent operative fixation of the left distal clavicle fracture nine days after his original injury. A 6-hole hook plate was used to stabilise the fracture. Fracture reduction was confirmed on fluoroscopy and the position of the plate was also found to be in satisfactory position (). Gentle range of motion exercises were commenced in the immediate postoperative period. His wound was checked at two weeks postoperatively and postoperative radiographs displayed his fracture alignment and hardware position to be satisfactory.\nDespite his uneventful recovery from the operative fixation, he had ongoing pain at the time of postoperative review more specifically over the medial clavicular region. Review of the preoperative radiographs in two views did not reveal any injury to that region. Concomitant medial clavicle pathology was suspected given his ongoing pain and hence a computerised tomography scan (CT scan) was organised after the postoperative review which was 28 days after the injury (). The imaging revealed a comminuted intra-articular fracture of the medial end of the clavicle. This fracture was not appreciated on earlier imaging of the affected region nor on clinical examination during the initial presentation.\nHe underwent operative fixation of the medial clavicle fracture on day 43 after injury where a distal clavicle plate was fashioned to fit to the medial side of the clavicle. The fracture was an oblique shear pattern and required some local bone grafting given its chronicity. The fracture was taken down and mobilised and was fixed with plate fixation. Screw fixation alone was inadequate in obtaining secure purchase given its chronicity, fracture pattern, and fragment size. Fluoroscopy was performed intraoperatively which demonstrated anatomical reduction of the fracture and satisfactory position of the hardware (Figures and ). His hook plate was removed 3 months after the initial procedure to fix his distal clavicle and he has since that time regained a pain-free functional range of motion in his left shoulder. Decision was made to leave the medial plate in situ because it was not affecting his clinical progress and posed further surgical risk to be removed.

A 42-year-old male presented with complaints of low back pain for the past 4years and inability to walk for the past 3 years. He was apparently normal 4years back when he developed pain over the lower back which was insidious in onset, gradually progressive, intermittent in nature, radiating to bilateral lower limbs, aggravated on any movement of both lower limbs or turning sideways, decreased on restand medications. History of rest pain was present but no history of night cries or diurnal variations. He was mobilizing with walker during the first few years of pain but he developed complete inability to walk even with support for the past 1 year. There was no history of fever or trauma, loss of weight, or appetite. There was no history of loss of sensations in the upper or lower limbs and bowel or bladder incontinence. He also gave a history of intermittent diffuse pain in the chest and left elbow for the past 3years which was not progressive. Treatment history included medications for pain for the past 4years. There was no significant family history. General examination and systemic examination of the cardiovascular, respiratory, and abdomen showed no significant findings. There was diffuse tenderness over the dorsolumbar spine from D6-L4. Movements of both hips were severely painful with tenderness over the proximal femur. Neurological examination of the upper limbs was normal. Motor power of muscles acting on the hip and knee could not be assessed due to severe pain, but muscles acting on the ankle and foot were normal. There was no sensory blunting and perianal sensations were normal with normal anal sphincter contraction. Babinski response was normal. The findings suggested that there was no cord or cauda equina compression but the back and bilateral hips pain was causing a pain inhibition of the muscles acting on the hip and knee. On examination of the left elbow, swelling and tenderness were present over the proximal third ulna. Movements of the wrist and forearm were full but associated with mild pain. All routine blood investigations were done. X-rays of the spine () showed scalloping of the end plates, X-ray of the pelvis showed bilateral Looser’s zone in the proximal femurs (), andX-ray of the left elbow showed an old proximal 1/3 ulna fracture nonunion (). He was found to have elevated levels of alkaline phosphatase (575 U/L) and low levels of phosphorus (1.1mg/dl) and Vitamin D 25OH (16.3ng/ml). 24 h urine phosphorus excretion was also found to be low (351mg/day). Hypophosphatemia was further evaluated by screening for FGF23 which was positive (>300RU/ml). Magnetic resonance imaging (MRI) of the spine showed compressed (biconcave) lumbar and dorsal vertebral bodies with multiple loose zones scattered along the ribs and spinous processes of dorsal vertebrae. Screening of hips and pelvis showed looser zones in the bilateral proximal femur, both iliac wings, sacroiliac joints, and pubic rami. Gallium DOTANOC scan done, as advised by the endocrinologist, suggested a well-defined sclerotic lesion with focal abnormal increased 68Ga uptake in the greater trochanteric region of the right proximal femur posteriorly - suggesting a possibility of oncogenic osteomalacia (). Endocrinologist opinion was sought, and the patient was started on oral phosphorus supplements. Serial serum phosphorus levels showed improvement (1.1–2.0–3.1 mg/dl),but the patient’s symptoms did not improve. A computed tomography (CT)-guided biopsy of the right proximal femur sclerotic lesion was done and was reported as spindle cell neoplasm consistent with PMT. Phosphaturic tumor was localized to be in the posterior aspect of the right greater trochanter. The intraoperatively patient was positioned in the left lateral position to facilitate access to the posterior aspect of the greater trochanter. An incision was made over the greater trochanter. Hip was initially rotated to facilitate the approach. A 2 cm × 1 cm oval cortical window was made in this region sparing the tip. The tumor was identified as a hard mass in the subcortical surface. The hard mass was burred and the cavity was packed with cement (). Resected intraoperative specimen sent for histopathology showed features consistent with a PMT. Following surgery, back pain increased probably due to the positioning of the patient for spinal and epidural anesthesia. The patient was giventhoracolumbosacral orthoses, and oral phosphate supplements were continued. Pain over the back gradually improved over a period of 2–3 weeks. Patient was mobilized with spinal orthoses and walker support 3 weeks following surgery - the 1sttime the patient had walked after 3 years! He is now walking up to a 100 m with walker support. Oral phosphorous supplementation was gradually reduced with improving and sustained levels of serum phosphorus.

A 13-year old girl was referred to our department from a peripheral hospital after traumatic perineal injury with a rolling pin. According to medical history, the patient landed on the rolling pin while doing some dancing training for a school play. She was taken to the local referral hospital where a perineal laceration was identified. Due to the nature of the wound, absence of symptoms and further clinical findings at initial clinical evaluation, as well as lack of a pediatric surgeon, the child was initially treated by the hospital’s gynecological team. She was taken to theatre for wound investigation and, according to their report, it was a penetrating wound that luckily did not injure neither the external genitalia, nor the anal sphincter. In the absence of further findings treatment was limited to suturing of the skin laceration.\nThe child was followed as an inpatient and remained symptom-free for a few hours; however, a massive bloody bowel movement raised significant concerns of the course of her treatment and a transfer to our department was arranged.\nOn arrival, the child was in a good general condition with normal vital signs; laboratory studies revealed a drop of hematocrit to 27.1% with hemoglobin of 10.2 g/dL. On physical examination the abdomen was soft without any clinical signs of peritoneal irritation; a rectal examination was performed that revealed fresh blood in the rectum indicative of active bowel bleeding and a feeling of disruption of anterior bowel wall integrity. Due to high suspicion of colorectal injury an abdominal X-ray was performed that did not reveal any indications of bowel rupture or peritoneal contamination. Patient was scheduled and taken to theatre as soon as possible. A colonoscopy preceded any surgical intervention that identified an actively-bleeding anterior bowel wall laceration 2 cm above the dentate line. No further damage to the rest of the bowel was noted.\nAt that point, a wound investigation was decided and performed. The skin laceration was just lateral and to the right of the anus. The vagina and the anal sphincter were intact but we found that the wound was extending deep enough in an oblique fashion, leading to a 2-cm-long laceration of the bowel wall; on simultaneous rectal digital examination we were surprised that the surgical glove from the digit performing the rectal examination could be seen through the perineal wound verifying the severity of the bowel injury.\nClosure of the bowel injury was performed in two stages; seromuscular closure was performed through the perineal wound while bowel mucosa was closed transanally. Finally, a protective colostomy was conducted following laparotomy for inspection of the peritoneal cavity.\nThe patient had an uneventful postoperative period and colostomy closure was performed 3 months later. After a six-month follow up period the patient is doing well with normal bowel movements.

A 2-year-old male patient from a foreign country was referred to our pediatric surgery clinic for esophageal replacement. According to the parent, esophageal stenosis developed a year ago due to corrosive ingestion. Balloon dilatation was tried first in the patient who had two strictures, one proximal and one distal. When endoscopic balloon dilatations failed for the proximal stricture, a SEMS was placed. The stent was repositioned after two weeks because of stent migration. In the meantime, the patient could not be followed up for three months due to the civil war in the country. During this time, the patient's nutritional status gradually deteriorated. In the last examination, it was revealed that the stent had migrated distally and the proximal esophagus was severely narrowed. It was thought that the stent could not be removed endoscopically. Gastrostomy was not considered, and the boy was referred for esophageal replacement. When the patient came to our clinic, he was fed with liquid food only, which took a long time, and he had difficulty swallowing his saliva. The patient was hospitalized, and total parenteral nutrition was started. Esophageal passage graphy showed almost no passage (). When we performed endoscopy, we found almost complete obstruction (). In tomography, it was revealed that the proximal esophagus was extremely widened and the stent was approximately 1 cm below (). The lumen of the esophagus distal to the stent could not be evaluated. In the first stage, we aimed to excise the strictured part of the esophagus and remove the stent before the esophageal replacement. The strictured part of the esophagus was excised and the stent was removed via a right thoracotomy. On the fifth day, oral feeding was started and the thorax drain was removed on the 7th day. On the 14th day, the patient underwent endoscopy. The proximal esophagus was normal and balloon dilatation was applied to the distal stenosis. Distal stenosis was easily dilated. The patient was discharged on the 17th postoperative day without any problems. Now he is aged 4 years and doing well.

A 60-year-old Caucasian female patient presented to our eye casualty with a sudden onset of painless loss of vision in the left eye. She had no past history of ocular problems or trauma. Because of metastatic adenocarcinoma lung with the tumour demonstrating a mutation in exon 19 of the EGFR gene, she was considered suitable for primary palliative treatment with gefitinib and has been started on this medication three months earlier. Medical history also included palliative radiotherapy on her spine and right shoulder and treatment with morphine sulphate, diclofenac, and gabapentin.\nOn examination, her left eye had very poor vision of perception to light only. Slit-lamp examination revealed a shallow anterior chamber and a perforated corneal ulcer that measured 4.7 × 5 mm, which was plugged by the iris (). The eye was white with no conjunctival injection or anterior chamber cells. There was no evidence of meibomianitis or trichomegaly. It was difficult to visualise the fundus due to the corneal pathology but ultrasound examination demonstrated choroidal detachment with no evidence of intraocular metastasis. The right eye showed no abnormality with good vision.\nAs it was suspected that gefitinib could be the cause of her corneal ulcer, her oncologist decided to stop the medication due to the potential ocular toxicity, although gefitinib treatment had reduced her lung tumour size. Initial ophthalmic management included a bandage contact lens to reform the anterior chamber and topical antibiotics. A subsequent tectonic 6.25 mm corneal graft was performed without complication ().\nPost-operatively, her eye remained quiet, however, because of the development of a dense cataract, her vision only improved to hand movement. Two months after stopping the gefitinib treatment and while awaiting cataract surgery, she developed severe left retroorbital pain. On examination, she had iris prolapse through a melting corneal graft, and the crystalline lens was extruded (). This was managed initially with botulinum toxin injected into the upper lid producing a ptosis to provide protection for the eye and oral antibiotics were started.\nIt was agreed, after consultation and counselling, that she was unlikely to benefit from repeat corneal graft surgery mainly because of her general health condition, short life expectancy as well as the potential risk of recurrent graft melt and the eye was left to self eviscerate.\nIn addition to this, given that her systemic disease was controlled, it was difficult to know whether to continue on the gefitinib, taking into consideration, the potential risks this strategy may pose to her fellow eye. After discussion, her wish was to continue with treatment. She is well with controlled lung cancer and a preserved fellow cornea 10 months later and continues on gefitinib. We have not started the patient on any prophylactic measure to protect the cornea of her healthy eye but we are considering the future use of lubricant eye drops.