May 8, 2023
Each issue of ACS Case Reviews in Surgery will highlight a case report that is hand-selected by Editor in Chief Gerald Isenberg, MD, FACS, FASCRS, for its uniqueness and significant contributions in advancing the field of surgery and the current surgical literature.
Intercostal Hernia and Costochondral Disruption Repair
Ma LW; Bessoff KE; Forrester JD
Costochondral disruptions are a type of costal cartilage fracture originating from damage to or weakening of the costal cartilage or costochondral joint between cartilage and sternum.
Post-Recovery Complications of Gastrointestinal Abscesses and Perforations in COVID-19 Patients
Shen J; Nwoke F; Lohr C III; Fletcher S; DeMartini S; Nagubandi R
A 69-year-old man presented with small intestinal abscesses during the weeks immediately following respiratory COVID-19 recovery, confirmed via nasopharyngeal testing.
Breast Pain, Palpable Mass, and a Perplexing Diagnosis
Gupta E; Suhani S; Jana M; Mathur S; Parshad R
We herein report an unusual case of clustered nodularity developing in the region of the axillary tail of the breast in a pre-menopausal lady with a long history of mastalgia.
COVID-19 Patient Presenting with Total Pancreatic Necrosis and Pancreatico-Colonic Fistula
Samlowski EE; Brown EC; Timperley JB; Sasse SL
The COVID-19 virus has impacted people around the globe, with over 4.5 million deaths related to the virus as of August 2021. Numerous reports have linked COVID-19 to the development of acute pancreatitis.
Laparoscopic-assisted Percutaneous Drainage of Hepatic Abscesses Caused by Hypermucoviscous Klebsiella pneumoniae
Spartz EJ; Wheelwright M; Vakayil V; Leuck A-M; Kalland K; Peter L; Michelson D; Cohen M; Bulander R; Harmon JV
Hypermucoviscous Klebsiella pneumoniae is an emerging infectious agent in the United States. We propose that laparoscopic-assisted placement of a surgical drain is an effective alternative to conventional radiologic-guided percutaneous drainage for hypermucoviscous Klebsiella pneumoniae hepatic abscesses due to the viscous nature of the abscess contents
Gastrointestinal Manifestations of COVID-19 Mimicking a Surgical Abdomen
Chan SM; Ying LD; Morton JM; Ghiassi S
During the current pandemic, COVID-19 should be considered in the differential diagnosis for patients who present with abdominal pain and gastrointestinal symptoms typical of gastroenteritis or surgical abdomen, even if they lack respiratory symptoms of COVID-19.
Extracorporeal Membrane Oxygenation (ECMO) for COVID-19-Associated Refractory Hypoxemia in the Postpartum Period
Faisal H; Chen C; Masud F
We report a 30-year-old woman at 35 weeks' gestation who developed rapidly worsening respiratory distress due to (COVID-19) disease. She underwent emergent intubation, followed by an emergency cesarean section. The patient was placed on ECMO due to findings of acute right ventricular systolic dysfunction and refractory hypoxemia.
Pneumomediastinum Causing Pneumoperitoneum in a Patient with COVID-19
Yang RC; Myers A; Dilday J; McClellan G; Gorrell R
Pneumomediastinum causing pneumoperitoneum is a rare clinical condition with a paucity of reports in literature. We present the first case of pneumomediastinum causing pneumoperitoneum as sequela of COVID-19 pneumonia that spontaneously resolved with prone positioning.
Rapid Integration of ECMO Support During COVID-19
Melvan JN; Justicz A; Wang I; Dennis R; Farah S; Megano N; Echarte D; David I
Evidence for the treatment of critically ill patients suffering from coronavirus disease 2019 (COVID-19) is slowly emerging. Venovenous extracorporeal membrane oxygenation (VV-ECMO) remains a last line of defense for patients overwhelmed by this virus for whom medical therapy is insufficient. How small community hospitals can utilize this technology in the face of this pandemic remains poorly understood.
Juvenile Dermatomyositis in Remission Complicates Appendicitis: A Case of Intraabdominal Appendiceal Abscess Tracking to the Foot
Vanessa M Bazan, BS, BBA; Clare Savage, MD; Maria-Gisela Mercado-Deane, MD; Joseph B. Zwischenberger, MD, FACS
A 16-year-old female child was admitted to the children's hospital with intractable right lower quadrant pain. Blood serum laboratory values indicated myositis. Imaging demonstrated diffuse muscle and soft tissue inflammation with multi-loculated abscesses tracking down the ileo-femoral artery distribution in the pelvis, right thigh and calf requiring extensive debridement and drainage to control sepsis. This is the first reported case of a ruptured appendix with multiple pelvic and right lower extremity abscesses tracking down the femoral canal to the foot.
Embolic Stroke Caused by Lower Extremity Gunshot Wound
Seyed A. Arshad, MD; Andrew C. Christensen, MD; Jonathan Marinaro, MD; and Sundeep S. Guliani, MD
Bullet embolization is a rare complication of gunshot wounds. Embolization to the heart, great vessels, and distal extremities has been well published, however, embolization from a lower extremity vessel to the brain has not previously been described. We present the case of an otherwise healthy 34-year-old male who presented with a close-range shotgun discharge to the left thigh. He was initially communicative and appropriate, but become acutely agitated in the emergency room, requiring emergent intubation. The patient had selective advanced imaging and was taken for operative repair of a superficial femoral artery injury. Shortly after arrival to the intensive care unit postoperatively, the patient developed bradyarrhythmias and was found to have a blown left pupil. Emergent computed tomography (CT) scan of the head revealed a pellet occlusion of the left middle cerebral artery (MCA) with left cerebral swelling and 1.2 cm midline shift. The patient required emergent left craniectomy and frontotemporal lobectomy.
Abdominal Pain: The Double Trouble!!!
Suhani, MS, FACS; Rajinder Parshad, MS,DNB; Ankur Goyal, MBBS, MD; Prasenjit Das, MBBS, MD; Raju Sharma, MBBS, MD; Govind K. Makharia, MBBS, MD
Mesenteric cystic masses are an uncommon entity seen in surgical practice. They usually occur as single lesion and an independent entity. Surgical excision in such scenarios is often curative. However, preoperatively, they may pose a diagnostic dilemma and may mimic other mesenteric masses, like lymph node cavitation or cystic mesenteric metastasis. This featured case report describes an unusual case of a young adult gentleman who has multiple cystic lymphangioma scattered throughout the small bowel mesentery in the background of celiac disease and associated with hemolytic anemia and autoimmune hepatitis.
A Chilling Reminder of Winter Recreational Injuries: Laceration of the Internal Jugular Vein at an Ice Hockey Game
Asad J. Choudhry, MBBS; Mohamed D. Ray-Zack, MBBS; Moustafa Younis, MBBS; Ramoncito David, MD; Matthew C. Hernandez, MD; Johnathon M. Aho, PhD; Martin D. Zielinski, MD
Hockey is an environment that is prone to injury, and hockey players are at risk for neck injuries when skate blades become airborne or in a position of movement that allows for contact with the neck of another player. That said, lacerations to the neck from ice skates are extremely rare, and the management of such life-threatening injuries is extraordinary sparse in the literature. This case details the management of a penetrating injury to zone II of the neck.
Diagnosis and Treatment of Appendiceal Mucormycosis
Kristin M. Krupa, MD; and Jason P. Tomsic, DO
Mucormycosis is a rare and aggressive infection most commonly diagnosed in immunosuppressed patients. A high mortality rate is associated with this infection, and mortality increases in the setting of disseminated infection. The following case report by Krupa and Tomsic describes a case of appendiceal mucormycosis treated with prompt surgical and medical intervention, in a 21-year-old female who was immunosuppressed due to chemotherapy for recent relapse of acute myelogenous leukemia (AML).
An Unusual Case of Fibromatosis of the Breast with Numerous Intraductal Papillomas
Yitian Liu, MD; George Thomas Budd, MD; and Mita Patel, MD
Fibromatosis, a benign desmoid tumor of the breast, is a rare diagnosis that constitutes less than 0.2 percent of all primary breast tumors. Even rarer is fibromatosis with numerous intraductal papillomas. The following Liu et al case report discusses the complexities of appropriate workup as well as management of this disease in a previously healthy 18‐year‐old woman. To date, no report of intraductal papillomas within the fibromatous tissue, as presented in this case, has been published.
Congenital Epulis: Unusual Etiology of Airway Obstruction and Feeding Failure in a Newborn
Cody L. Mullens, BS; Luke J. Grome, MD; Shilpa S. Vishwanath, MD; Harold J. Williams, MD; and Aaron C. Mason, MD, FACS, FAAP
Congenital epulis (CE) is a rare lesion of the newborn gingiva or alveolar mucosa. Tumor sequelae may include polyhydramnios during the prenatal period as well as respiratory obstruction and feeding failure postnatally. CE remains largely underreported in the medical literature, and this illustrative report discusses the origin of these rare tumors, their diagnosis, and their appropriate treatment modality. Ideally, surgeons will be able to use the information in this report to promptly identify and surgically intervene in order to minimize morbidity in this rare patient population.
Management of a Complex Multifocal Intraductal Papillary Mucinous Neoplasm
Hardaway JC; Kanitra JJ; Kurane PH; Kavuturu S
The Fukuoka and European consensus guidelines are the current standard for the management of IPMNs, but it is important to realize that these guidelines are not exhaustive and that surgeons must rely upon clinical judgment and a mutual decision-making process involving the patient and surgeon in some circumstances. This case presents a patient with DM and a single first-degree relative with pancreatic adenocarcinoma who elected for total pancreatectomy outside of consensus guidelines.
The "No-Zone" Approach to Penetrating Neck Trauma
Ryan B. Fransman MD, Faris K. Azar MD, William Mallon, MD, Abhinav Nalluri, BS, Joseph V. Sakran, MD, MPH, MPA, Elliott R. Haut, MD, PhD
The rapid and accurate management of penetrating neck trauma is crucial to preventing the high potential morbidity and mortality associated with this injury type. With the advent of high resolution cross-sectional imaging, a "no zone" approach to penetrating neck trauma is becoming more accepted. The featured report below describes the case of a 35-year-old male presenting with neck trauma and highlights the advantages of the "no zone" approach.
Postpartum Bowel Perforation after Normal Vaginal Delivery without History of Inflammatory Bowel Disease
Laffoon AN, Knijnikov A
Ischemia complicates up to 42 percent of bowel perforations and increases the mortality in these patients significantly. Bowel perforation is a very rare occurrence in any postpartum patient, but it can be seen more commonly following a Caesarean section than following a normal vaginal delivery. This case presents a previously healthy, 22-year-old female with no surgical history who developed a perforation of the right mid-colon five days post-normal vaginal delivery.
Use of Extracorporeal Membrane Oxygenation (ECMO) for Refractory Hypercarbic Respiratory Failure Due to a Severe Inhalation Burn Injury
Spanie MJ, Jara CB, Carter DW, Groom RC, Rappold JF
Extracorporeal membrane oxygenation has evidence supporting its use in hypoxemic respiratory failure; however, most published experience has been in medical and burn patients with hypoxemia as the indication for therapy.
Primary Hyperparathyroidism Presenting as Hypercalcemic Crisis
Wachtel H, Sadow PM, MD, PhD, Phitayakorn R, Parangi S
Hypercalcemic crisis is an infrequent presentation of primary hyperparathyroidism. This case report clearly describes the clinical features and management of hypercalcemic crisis as well as the important features of primary hyperparathyroidism.