Dave Harnanan

Brachial Artery Injury Accompanying Closed Elbow Dislocations

Highlights • Brachial artery injuries after closed shoulder dislocations are uncommon.• A high index of suspicion should be maintained in order to make the diagnosis early.• Exploration with excision of the injured segment and reverse vein interposition grafting is the treatment of choice in these cases.

Isolated endometriosis causing sigmoid colon obstruction: A case report

INTRODUCTION Isolated endometriosis of the intestine causing large bowel obstruction is rare. PRESENTATION OF CASE We present a case of endometriosis presenting as large bowel obstruction in a woman of childbearing age. She had no previous symptoms to suggest endometriosis and on presentation urgent surgery was required. The diagnosis of endometriosis was made only after pathological evaluation of the specimen. DISCUSSION No cases of endometriosis confined to this sigmoid colon without pelvic involvement were noted in the literature. CONCLUSION The diagnosis of endometriosis should be entertained when women of childbearing age presents with large bowel obstruction, whether or not the patient has other evidence of the disease.

Giant Cystic Pheochromocytoma with Low Risk of Malignancy: A Case Report and Literature Review

Giant pheochromocytomas are rare silent entities that do not present with the classical symptoms commonly seen in catecholamine-secreting tumors. In many cases they are accidentally discovered. The algorithm to diagnose a pheochromocytoma consists of biochemical evaluation and imaging of a retroperitoneal mass. The female patient in this case report presented with a palpable abdominal mass and was cured with surgical resection. She suffered no recurrence or complications on follow-up. The left retroperitoneal mass measured 27 × 18 × 12 cm and weighed 3,315 grams. Biochemical, radiological, and pathological examinations confirmed the diagnosis of a pheochromocytoma. In this paper, we report on our experience treating this patient and provide a summary of all giant pheochromocytomas greater than 10 cm reported to date in English language medical journals. Our patients giant cystic pheochromocytoma was the fourth heaviest and fifth largest maximal diameter identified using our literature search criteria. Additionally, this tumor had the largest maximal diameter of all histologically confirmed benign/low metastatic risk pheochromocytomas. Giant cystic pheochromocytomas are rare entities requiring clinical suspicion coupled with strategic diagnostic evaluation to confirm the diagnosis.

Minimally Invasive Surgery in the Management of Adhesive Small Bowel Obstruction: A Rare Case

Introduction: We present the management of a patient who failed conservative management of adhesive small bowel obstruction (ASBO), which was treated with laparoscopic lysis of adhesions. Presentation of Case: A 66 year old, hypertensive, diabetic patient with previous gynaecological surgery presents with symptoms of intestinal obstruction for 2 days. Clinical & radiological features are consistent with the diagnosis of SBO. Conservative treatment was started but the patient failed to show any signs of resolution. Laparoscopic adhesiolysis was successfully performed on thin adhesions between the liver and the anterior abdominal wall (possible Fitz-Hugh Curtis syndrome), which trapped the small bowel. The patient was discharged on day 4 of admission. Discussion: ASBO is a very common and actual disease and its management deserves great attention. Although surgeons are hesitant to perform laparoscopy in patients with distended small bowel due to adhesive obstruction, laparoscopic surgery performed by experienced surgeons offers the opportunity of shorter hospital stay, quick recovery and less morbidity, including wound sepsis and incisional hernia when compared with laparotomy. Conclusion: Minimally invasive surgery (MIS) in ASBO is not standard of care, however, selected patients may benefit from the advantages of this approach. Once the necessary expertises are available, an attempt to treat these patients with MIS may be safe, and as such, should be entertained.

Laparoscopic resection of a retroperitoneal myolipoma presenting in a right inguinal hernia.

INTRODUCTION Myolipoma of soft tissue is an extremely rare benign lipomatous lesion. The lesions are most commonly located in the abdominal cavity, retroperitoneum, and inguinal areas. Despite their large size, myolipomas are cured by surgical resection. PRESENTATION OF CASE We present the case of a 79 year-old man who presented with bilateral reducible inguinal hernias (right larger than left). After reducing the right inguinal hernia (RIH), the sensation of a palpable mass was noted in the right iliac fossa. CT scan suggested the content of the right inguinal hernia (RIH) to be small bowel mesentery and no other mass was noted in the right iliac fossa (possibly missed on CT scan). DISCUSSION A very large 1.8kg retroperitoneal lipomatous lesion, measuring 22cm×16cm×8cm, attached to the right spermatic cord was found and excised laparoscopically during a trans-abdominal pre-peritoneal (TAPP) approach to repair the hernias. The lesion was pathologically defined as a myolipoma. CONCLUSION The laparoscopic TAPP approach to repair inguinal hernias allows the surgeon to inspect the peritoneal cavity, and in this case it was possible to safely dissect and remove a large, lipomatous, retroperitoneal lesion laparoscopically. To the best of our knowledge, there are no reports of local recurrence, metastatic disease, or malignant transformation of myolipomas, and the laparoscopic approach to resect such a lesion has not been reported.

A rare case of massive lower gastrointestinal bleeding from a ruptured splenic artery aneurysm

Abstract Splenic artery aneurysms (SAAs) are an extremely rare cause of asymptomatic massive lower gastrointestinal bleeding with less than a handful of patients surviving such a presentation. A 24-year-old female presented in shock after multiple episodes of massive rectal bleeding. Imaging revealed a heterogeneous mass arising from the tail of the pancreas eroding into the splenic flexure of the colon. Further episodes of bleeding led to an exploratory laparotomy. Intraoperatively, a suspected neoplastic process arising from the tail of the pancreas with contiguous involvement of the splenic flexure of the colon and the greater curvature of the stomach was noted. Distal pancreaticosplenectomy, gastric wedge resection with segmental colectomy and primary anastomosis were performed. Histology revealed a SAA with rupture into the colon. This case report shows that en-bloc resection of a ruptured SAA can be performed with success in the emergency setting.

Pelvic exenteration case series: A single surgeon’s experience at one institution in Trinidad and Tobago

Highlights • This case series provides details on one surgeon’s experience performing pelvic exenterations (PEs) in a developing country.• We provide a detailed surgical approach as well as complications based on the Clavien-Dindo classification.• We offer suggestions for surgeons in developing countries planning to undertake PEs.

Clinicopathology and treatment of a giant malignant phyllodes tumor of the breast: A case report and literature review

Highlights • Phyllodes tumors are rare biphasic fibroepithelial neoplasms of breast and are classified as benign, borderline and malignant.• Resection of the tumor is the preferred treatment, whereas the role of radiation therapy, and adjuvant chemotherapy are undefined.• Wide excision or mastectomy should be performed with the goal of histological clear margins.• Axillary nodal dissection is not required.

Rare nodular malignant melanoma of the heel in the Caribbean: A case report

Highlights • Malignant melanoma of the heel is a rare melanoma subtype globally.• This is the first reported case study of malignant melanoma of the heel in the Caribbean.• Our case highlights the need for the development of strategies to increase patient adherence in developing countries.• The literature search shows that this is the first reported case of malignant melanoma of the heel among non-fair skin individuals in 40 years.• Increasing rates of malignant melanoma of the heel suggest the need for increased public awareness, early diagnosis and shared clinical decision making.