Year 2020, Volume 4 - Issue 8

Background: Anorectal malformations are a rare presentation. The standard treatment modality for imperforate anus is surgery. The abdominoperineal pull-through procedure was popular in the past for this malformation, but, with recent advancement, the posterior sagittal anorectoplasty and colostomy as a staged procedure are other options. Chronic constipation following pullthrough procedures for imperforate anus may also lead to degeneration of the anorectal segment. Case Presentation: A 28-year-old male presented with the complaint of on and off constipation and painful defecation since childhood. The patient had a history of imperforate anus congenitally, for which a pull-through procedure was done after birth at another hospital. He underwent multiple surgeries for constipation. During this time period, the patient had constant complaints of difficulty in defecation and constipation, for which he used to use Hager’s dilators to dilate the anal canal. He also used per rectal enema and suppositories. His digital rectal examination showed narrowed anal opening. Colonoscopy was planned, which showed ulcerated and necrotic area at 6–8 cm from anal verge. Biopsy came out to be moderate-to-poor differentiated adenocarcinoma with signet ring cell differentiation. His computed tomography scan was performed, which showed circumferential mural thickening starting from the anal verge to the rectosigmoid junction with local infiltration to prostate, bilateral levator ani, and posterior sacral space. The patient was given a diversion colostomy and was referred for neoadjuvant chemoradiotherapy. Conclusion: All patients undergoing pull-through procedures should be closely followed in a multidisciplinary unit with interval colonoscopy for the early detection and prompt management of rectal cancer.

Background: Hemoptysis is an alarming symptom. Its etiology may vary from mild infections to malignancies. Pulmonary infections are a common cause of hemoptysis in young adults. However, vascular malformations are also enlisted among the sources of hemoptysis. Case Presentation: A 33-year-old female presented to the institute with hemoptysis. The etiology of hemoptysis was ascertained to be an anomalous vascular connection between the descending aorta and inferior pulmonary vein draining into the left atrium. Conclusion: Descending aortopulmonary fistula (DAPVF) is a rare congenital vascular malformation representing a left-toleft shunt, and cardiac failure is a presenting feature as described in some reported cases in children. DAPVF may present as hemoptysis in adults.

Background: The novel concept of endourology was first introduced to the world in 1978 by three legendary doctors Elwin Fraley, Arthur Smith, and Paul Lange. Fast forward 40 years, endourology today mostly rules the overall management of the majority of urinary tract calculi with some rare exceptions. Large, giant, massive distal-impacted ureteric calculi seem to be one such subset of exceptional situation, where laparoscopic ureterolithotomy (LUL) may have an edge over endourological manipulation. Even though LUL is a well-recognized option, the usage of the same is declining ever since the advent of endourology and its advances. This article brings to light the importance of the role and relevance of LUL versus endourology for the management of select large, giant ureteric stones and aims to bring to light certain inherent combined advantages of LUL versus endourology, such as effectiveness, short learning curve, single-staged nature of procedure, and being minimally invasive. Case Presentation: A 30-years-old female presented to our clinic with complaints of right flank pain and recurrent episodes of Urinary tract infection for the past 4 months. Clinical evaluations/investigations revealed a large distal ureteric calculus with a poorly functioning right kidney without any underlying anatomic/metabolic abnormality. The patient underwent LUL with a modified three-port technique and a large stone of 3.5 × 2 cm was retrieved uneventfully with the placement of a Double J stent. Conclusion: LUL is the preferred therapeutic surgical management modality of choice for select uncomplicated giant/large ureteric calculi, as it is coupled with the dual advantage of being minimally invasive and is accompanied by complete clearance with minimal morbidity thereby acting as a bridge to combine the positives of both endourological and open procedures. We encourage researchers to consider LUL in the minimally invasive management of select large impacted distal ureteric calculi in the otherwise anatomically normal renal units.

Background: The presence of two hollow viscus perforations in a single patient is a rare entity and no case report is available in the literature which shows the finding of duodenal ulcer perforation and enteric perforation in the same patient. Case presentation: A 55-year-old male presented in the emergency department of East Surgical Ward of Mayo Hospital, Lahore, Pakistan, in January 2020 with complaint of abdominal pain and vomiting for the past 3 days and fever for the past 5 days. He was a chronic smoker with a history of 10 pack-years. On examination, he had tachycardia with a pulse rate of 114 beats/minutes and respiratory rate was 30/minutes and his whole abdomen was guarding with absent bowel sounds. X-ray of the chest showed free gas under the right hemidiaphragm. The patient was resuscitated and plan of exploration was made with diagnosis of perforated duodenal ulcer. We found a 0.5 × 0.5 cm perforation on the anterior surface of the first part of the duodenum along with a 1 × 1 cm perforation on antimesenteric surface of ileum that is 1 feet proximal to ileocolic junction. Graham’s patch repair was carried out for duodenal perforation, while loop ileostomy was made for ileal perforation. The patient was discharged on the 5th postoperative day. The reversal of loop ileostomy was carried out after 2 months. Conclusion: In cases of peritonitis, general inspection of the whole gastrointestinal tract plays a very important role as more than one hollow viscus perforation can be found in a single patient which can be missed and can lead to peritonitis again.

Background: Fallopian tube prolapse (FTP), following hysterectomy, is a rare complication and it can either occur after abdominal, vaginal, or laparoscopic surgeries. It is difficult to determine the related risk factors, thus the existing data comprise case reports or case series including approximately 100 patients. Case presentation: A 42-years-old woman who had a vaginal hysterectomy 5 months ago presented with vaginal discharge. Examination revealed a 1 cm hyperemic granuloma-like lesion on the apex of the vaginal cuff. Vaginal approach was undertaken under sedative anesthesia and after dissection fallopian tubal prolapse appeared. The patient recovered uneventfully in 2 weeks. Conclusion: Since hysterectomy is the most common gynecologic surgical intervention, it is important to be aware of even uncommon complications. The clinical presentation can vary by the portion of prolapsed tubal segment into the vaginal cavity and it can be misdiagnosed as vaginal vault granuloma, especially if a very small portion of tubal segment has prolapsed.

Background: Pulmonary arterial hypertension (PAH) involves many different clinical conditions and has an important impact on the right ventricular (RV) function and patient’s prognosis. Some of these conditions can be potentially curable, for example, congenital heart disease that could be surgically repaired. Case Presentation: We present a case of 41-year-old woman with a progressive shortness of breath, without evident explication. First, she was suspected to have chronic thromboembolic PAH, which was not confirmed by clinical and imaging data. Even arrhythmogenic RV cardiomyopathy was suspected according to the data obtained from the first cardiac magnetic resonance (CMR) imaging. However, due to a step-up in oxygen saturation during the right heart catheterization (RHC), the presence of rare congenital heart disease, such as partial anomalous of pulmonary venous return (PAPVR), was suspected and then confirmed by the repeated CMR. Conclusions: PAPVR is a rare congenital heart disease that could be suspected during the RHC and represents a potentially curable cause of PAH.

Background: Benign cystic ovarian mass is a very common incidentally detected mass lesion in the reproductive age group female. A giant ovarian follicular cyst is a very rare entity described in the literature. Imaging modalities including ultrasonography (USG) and magnetic resonance imaging (MRI) play a pivotal role in the differential diagnosis of cystic ovarian mass lesions. Case Presentation: A young adult female presented to surgery outpatient department with the complaints of abdominal pain with normal vital parameters. Subsequent USG and MRI study showed a large abdominopelvic cystic mass lesion with right mild hydroureteronephrosis. Furthermore, the histopathological investigation confirms the diagnosis of a simple follicular cyst. Conclusion: Imaging modality collaboration with the histopathological findings may lead to accurate diagnosis of cystic ovarian mass. USG and MRI play a vital role in narrow down the differential diagnosis, which can be further confirmed on histopathological investigations.