Images for surgeons
887
References
Fig. 3. Paratesticular spindle cell proliferation set in collagenous and myxoid stroma. Lesion arising from the tunica albuginea, with normal testicular parenchyma below (courtesy of PALMS Pathology, Gosford).
Partial orchiectomy via an inguinal approach, with frozen section confirmation of benign histology, could be considered in future instances.
1. Gorlin RJ, Goltz RW. Multiple nevoid basal-cell epithelioma, jaw cysts and bifid rib. A syndrome. N. Engl. J. Med. 1960; 262: 908–12. 2. Lo Muzio L. Nevoid basal cell carcinoma syndrome (Gorlin syndrome). Orphanet J. Rare Dis. 2008; 3: 32. 3. Jones MA, Young RH, Scully RE. Benign fibromatous tumors of the testis and paratesticular region: a report of 9 cases with a proposed classification of fibromatous tumors and tumor-like lesions. Am. J. Surg. Pathol. 1997; 21: 296–305. 4. Frias-Kletecka MC, MacLennan GT. Benign soft tissue tumors of the testis. J. Urol. 2009; 182: 312–3. 5. Ueda M, Kanematsu A, Nishiyama H et al. Testicular thecoma in an 11-year-old boy with nevoid basal-cell carcinoma syndrome (Gorlin syndrome). J. Pediatr. Surg. 2010; 45: E1–3. 6. Watson RA, Harper BN. Paratesticular fibrous pseudotumor in a patient with Gorlin’s syndrome: nevoid basal cell carcinoma syndrome. J. Urol. 1992; 148: 1254–5. 7. Park SB, Lee WC, Kim JK et al. Imaging features of benign solid testicular and paratesticular lesions. Eur. Radiol. 2011; 21: 2226–34.
Nicholas Bull, MBBS Mark Louie-Johnsun, MBBS, FRACS (Urol) Gosford Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12558
Spontaneous oesophageal perforation after laparoscopic hiatus hernia repair A 67-year-old man was admitted acutely 12 days after a laparoscopic hiatus hernia repair. At the initial surgery he was found to have 75% of his stomach intrathoracically, and a polypropylene mesh was used to close the hiatal defect. Ten days after surgery he complained of halitosis and had one episode of vomiting after eating solid food, but was otherwise well. Two days later he presented acutely with dysphagia and a leukocytosis, but no systemic upset. An erect chest X-ray was reported as showing an intrathoracic stomach (Fig. 1). At laparotomy the stomach was situated intra-abdominally with an intact 360-degree fundoplication and an intact mesh. A large abscess consisting of falciform ligament and lesser omentum was encountered. On further dissection of the right crus, undigested food was found coming from the thoracic cavity. The wrap and hiatus was taken down and the mesh removed. A 4-cm linear oesophageal perforation was seen extending proximally from the gastrooesophageal junction (Fig. 2). This was surrounded by a contained abscess within the right chest. Because of the degree of contamination, the oesophagus was excluded and a thorough lavage of the chest cavity was performed. The patient spent the night ventilated on the intensive care unit. The next day he was stable and not requiring inotropic support so he returned to theatre and an Ivor–Lewis oesophagectomy was performed. © 2014 Royal Australasian College of Surgeons
Fig. 1. Erect chest X-ray reported as intrathoracic stomach.
Spontaneous oesophageal perforation or Boerhaave’s syndrome classically presents as vomiting followed by severe dyspnoea, mediastinal or subcutaneous emphysema and cardiovascular collapse usually after overindulgence with eating or drinking. The
888
Images for surgeons
presence of all of these symptoms can be uncommon, and therefore reliance on this classical presentation can lead to the diagnosis being overlooked.1 The patient we describe had vomiting but none of the other classical symptoms. His vomiting and dysphagia combined with the chest X-ray findings lead to a diagnosis of an acute wrap slippage being made. The lack of sepsis or mediastinitis can be attributed to the fact that the contamination had been contained within an abscess cavity. Although an iatrogenic injury is a possibility, we believe that the presentation and operative findings in this case favour a spontaneous oesophageal perforation. This case of spontaneous oesophageal perforation after laparoscopic hiatus hernia repair is likely due to patient vomiting after eating solid food. The air fluid level seen on chest X-ray was not an intrathoracic stomach but rather an abscess cavity.
Reference 1. Janjua KJ. Boerhaave’s syndrome. Postgrad. Med. J. 1997; 73: 265–70.
Martyn L. Humphreys, DM, FRCSEd Bevan Jenkins, BHB, MBChB Jason Robertson, MBChB Michael Rodgers, MBChB, FRACS Department of General Surgery, North Shore Hospital, Auckland, New Zealand doi: 10.1111/ans.12560
Fig. 2. Photograph of an anterior view of the resected specimen showing the site of perforation at the gastro-oesophageal junction.
Dural plasmacytoma: an unusual presentation The patient, a 76-year-old lady with a history of multiple myeloma, presented with short-term memory loss and deterioration in her general functioning over 3 weeks to the point of no longer being self-caring. She also complained of reduced peripheral vision on her left side. There were no symptoms to suggest presence of raised intracranial pressure. She was diagnosed with multiple myeloma 2 years ago after sustaining a pathological fracture of left humeral head. She was subsequently treated with bortezomib. She is also hypertensive. On examination, she had a GCS of 15. Her neurological deficits included left-sided homononymous hemianopia and left-sided hemispatial neglect. Motor and sensory functions were otherwise intact. Magnetic resonance imaging (MRI) of her brain (as depicted in Figs 1–3) revealed a large irregular right parieto-occipital extra-axial mass measuring 60 × 30 × 72 mm which has heterogenous hypointense T1 and intermediate T2 signal. The lesion demonstrated heterogeneous enhancement post contrast injection. There was a significant amount of vasogenic oedema with significant mass effect. However, there was no bony involvement of adjacent calvarium. Burrhole biopsy of the lesion revealed diffuse infiltrate of atypical plasmacytoid cells consistent with a plasmacytoma.
Fig. 1. Axial cut of MRI T1 sequence with Magnevist.
Extraosseous intracranial manifestation of plasmacytoma is uncommon. They present as either diffuse leptomeningeal disease, dural solitary tumour or intraparenchymal lesion without dural or bony involvement.1–4 There are no specific radiological features for © 2014 Royal Australasian College of Surgeons
887
References
Fig. 3. Paratesticular spindle cell proliferation set in collagenous and myxoid stroma. Lesion arising from the tunica albuginea, with normal testicular parenchyma below (courtesy of PALMS Pathology, Gosford).
Partial orchiectomy via an inguinal approach, with frozen section confirmation of benign histology, could be considered in future instances.
1. Gorlin RJ, Goltz RW. Multiple nevoid basal-cell epithelioma, jaw cysts and bifid rib. A syndrome. N. Engl. J. Med. 1960; 262: 908–12. 2. Lo Muzio L. Nevoid basal cell carcinoma syndrome (Gorlin syndrome). Orphanet J. Rare Dis. 2008; 3: 32. 3. Jones MA, Young RH, Scully RE. Benign fibromatous tumors of the testis and paratesticular region: a report of 9 cases with a proposed classification of fibromatous tumors and tumor-like lesions. Am. J. Surg. Pathol. 1997; 21: 296–305. 4. Frias-Kletecka MC, MacLennan GT. Benign soft tissue tumors of the testis. J. Urol. 2009; 182: 312–3. 5. Ueda M, Kanematsu A, Nishiyama H et al. Testicular thecoma in an 11-year-old boy with nevoid basal-cell carcinoma syndrome (Gorlin syndrome). J. Pediatr. Surg. 2010; 45: E1–3. 6. Watson RA, Harper BN. Paratesticular fibrous pseudotumor in a patient with Gorlin’s syndrome: nevoid basal cell carcinoma syndrome. J. Urol. 1992; 148: 1254–5. 7. Park SB, Lee WC, Kim JK et al. Imaging features of benign solid testicular and paratesticular lesions. Eur. Radiol. 2011; 21: 2226–34.
Nicholas Bull, MBBS Mark Louie-Johnsun, MBBS, FRACS (Urol) Gosford Hospital, Sydney, New South Wales, Australia doi: 10.1111/ans.12558
Spontaneous oesophageal perforation after laparoscopic hiatus hernia repair A 67-year-old man was admitted acutely 12 days after a laparoscopic hiatus hernia repair. At the initial surgery he was found to have 75% of his stomach intrathoracically, and a polypropylene mesh was used to close the hiatal defect. Ten days after surgery he complained of halitosis and had one episode of vomiting after eating solid food, but was otherwise well. Two days later he presented acutely with dysphagia and a leukocytosis, but no systemic upset. An erect chest X-ray was reported as showing an intrathoracic stomach (Fig. 1). At laparotomy the stomach was situated intra-abdominally with an intact 360-degree fundoplication and an intact mesh. A large abscess consisting of falciform ligament and lesser omentum was encountered. On further dissection of the right crus, undigested food was found coming from the thoracic cavity. The wrap and hiatus was taken down and the mesh removed. A 4-cm linear oesophageal perforation was seen extending proximally from the gastrooesophageal junction (Fig. 2). This was surrounded by a contained abscess within the right chest. Because of the degree of contamination, the oesophagus was excluded and a thorough lavage of the chest cavity was performed. The patient spent the night ventilated on the intensive care unit. The next day he was stable and not requiring inotropic support so he returned to theatre and an Ivor–Lewis oesophagectomy was performed. © 2014 Royal Australasian College of Surgeons
Fig. 1. Erect chest X-ray reported as intrathoracic stomach.
Spontaneous oesophageal perforation or Boerhaave’s syndrome classically presents as vomiting followed by severe dyspnoea, mediastinal or subcutaneous emphysema and cardiovascular collapse usually after overindulgence with eating or drinking. The
888
Images for surgeons
presence of all of these symptoms can be uncommon, and therefore reliance on this classical presentation can lead to the diagnosis being overlooked.1 The patient we describe had vomiting but none of the other classical symptoms. His vomiting and dysphagia combined with the chest X-ray findings lead to a diagnosis of an acute wrap slippage being made. The lack of sepsis or mediastinitis can be attributed to the fact that the contamination had been contained within an abscess cavity. Although an iatrogenic injury is a possibility, we believe that the presentation and operative findings in this case favour a spontaneous oesophageal perforation. This case of spontaneous oesophageal perforation after laparoscopic hiatus hernia repair is likely due to patient vomiting after eating solid food. The air fluid level seen on chest X-ray was not an intrathoracic stomach but rather an abscess cavity.
Reference 1. Janjua KJ. Boerhaave’s syndrome. Postgrad. Med. J. 1997; 73: 265–70.
Martyn L. Humphreys, DM, FRCSEd Bevan Jenkins, BHB, MBChB Jason Robertson, MBChB Michael Rodgers, MBChB, FRACS Department of General Surgery, North Shore Hospital, Auckland, New Zealand doi: 10.1111/ans.12560
Fig. 2. Photograph of an anterior view of the resected specimen showing the site of perforation at the gastro-oesophageal junction.
Dural plasmacytoma: an unusual presentation The patient, a 76-year-old lady with a history of multiple myeloma, presented with short-term memory loss and deterioration in her general functioning over 3 weeks to the point of no longer being self-caring. She also complained of reduced peripheral vision on her left side. There were no symptoms to suggest presence of raised intracranial pressure. She was diagnosed with multiple myeloma 2 years ago after sustaining a pathological fracture of left humeral head. She was subsequently treated with bortezomib. She is also hypertensive. On examination, she had a GCS of 15. Her neurological deficits included left-sided homononymous hemianopia and left-sided hemispatial neglect. Motor and sensory functions were otherwise intact. Magnetic resonance imaging (MRI) of her brain (as depicted in Figs 1–3) revealed a large irregular right parieto-occipital extra-axial mass measuring 60 × 30 × 72 mm which has heterogenous hypointense T1 and intermediate T2 signal. The lesion demonstrated heterogeneous enhancement post contrast injection. There was a significant amount of vasogenic oedema with significant mass effect. However, there was no bony involvement of adjacent calvarium. Burrhole biopsy of the lesion revealed diffuse infiltrate of atypical plasmacytoid cells consistent with a plasmacytoma.
Fig. 1. Axial cut of MRI T1 sequence with Magnevist.
Extraosseous intracranial manifestation of plasmacytoma is uncommon. They present as either diffuse leptomeningeal disease, dural solitary tumour or intraparenchymal lesion without dural or bony involvement.1–4 There are no specific radiological features for © 2014 Royal Australasian College of Surgeons
