This research topic highlights a small collection of case reports from our visceral surgery section. Visceral Surgery deals with all aspects of the surgical treatment of benign and malignant diseases of abdominal organs, the entire gastrointestinal tract, endocrine organs, the abdominal wall, and the peritoneum. Case reports aim to highlight unique cases of patients that present with an unexpected/unusual diagnosis, treatment outcome, or clinical course. Case reports provide insight into the differential diagnosis, decision making, and clinical management of unusual cases and are a valuable educational tool.

Advanced and Minimally Invasive Surgery Excellence Center, American Hospital of Tblisi

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Frontiers in Surgery

Visceral Surgery

Case Reports in Visceral Surgery: 2021

After serving for several years as a review editor for Frontiers in Surgery, I was asked last year to become an Associate Editor of Frontiers in Surgery. A few months earlier I agreed to become the Editor-in-Chief of a new journal called Artificial Intelligence Surgery (AIS), the first journal to focus exclusively on artificial intelligence (AI) and surgery (<a href="#B1">1</a>). I was impressed by the level of organization of Frontiers in Surgery and I have used what I have learned at Frontiers to help improve AIS, and thanks to these insights our first issue (<a href="http://www.aisjournal.net">www.aisjournal.net</a>) was successfully launched in December 2021. I was asked to contribute an Editorial to a collection of Case Reports, which I agreed to do because my love of writing about surgery all began after I wrote my first Case Report. Unlike case series and review articles, Case Reports are much more intimate accounts of our interactions with patients and in many ways more poignant.People not in the medical field will often ask me why I write articles and publish them in journals free of charge. Doctor means “teacher,” and any academic surgeon knows that if you really want to understand a problem, the best thing to do is to write about it. I will always remember my first Case Report, a patient underwent a duodenopancreatectomy for a mass in both the gallbladder and in the head of the pancreas (<a href="#B2">2</a>). I was so surprised to find out that the patient had autoimmune pancreatitis and could possibly have avoided an unnecessary major abdominal surgery with a simple blood test that I felt obliged to broadcast this case in an effort to help surgeons avoid this in the future. A case report discussing the pre-operative misdiagnosis of a dilated cystic duct (<a href="https://doi.org/10.3389/fsurg.2021.686629">Zhang et al.</a>) reminded me of this lesson.Almost 20 years ago when I was doing a Pancreatic Surgery Fellowship in Verona Italy, I heard about a patient with a glucagonoma and migratory necrotizing dermatitis and felt compelled to ask the patient permission to take anonymized photographs of this rare rash because I had never seen it and wanted as many people to learn from this rare case as possible (<a href="#B3">3</a>). This is why I chose this Case Report of an equally rare pancreatic tumor (<a href="https://doi.org/10.3389/fsurg.2021.700229">Guo et al.</a>) for this collection.As a young Attending I found myself knee deep in an extremely hostile abdomen only to learn upon reading the final pathology that the patient had primary sclerosing peritonitis (<a href="#B4">4</a>). This case reminded me that extremely rare pathologies can present with carcinomatosis and that essentially no form of carcnomatosis acts in a benign manner. A theme reiterated in this Case Report of primary peritoneal carcinosarcoma (<a href="https://doi.org/10.3389/fsurg.2021.707929">Erz et al.</a>).I remember calling my old boss to the operating room because I could not believe that the patient could have an annular pancreas wrapped around his duodenum that was not seen pre-operatively. This patient was undergoing a laparoscopic distal pancreatectomy for a premalignant pancreatic cyst in the tail of the pancreas and had undergone every preoperative imaging exam of the pancreas imaginable (<a href="#B5">5</a>). The innumerable diagnoses that can occur around the duodenal area is reinforced by this article of a paraganglioma that was initially believed to be a duodenal gastrointestinal stromal tumor (<a href="https://doi.org/10.3389/fsurg.2021.586503">Zhang et al.</a>).Case Reports can herald the previously considered unthinkable (<a href="#B6">6</a>), and they can be cathartic. I had a young man urgently transferred to my care in New York City from across the country, only to succumb to his disease the day after I saw him even though his minimally invasive splenectomy had been scheduled for the very next day (<a href="#B7">7</a>). He was treated for inflammatory bowel disease with an immunosuppressant that is now known to increase the risk for splenic lymphoma. I like to think that it was some comfort to his family that his loss was not in vain, as hopefully his case acted as a cautionary tale for future doctors.Although Pubmed has been revolutionary in the fact that surgeons can now search and find published evidence to help them with rare cases or complex issues, the process is still cumbersome and time consuming. It is hoped that machine learning (ML) algorithms of artificial intelligence (AI) can 1 day accelerate this transmission of data. Electronic access to surgical textbooks is also an innovation that deserved mention, but due to the rapidity that new data is being published and the sheer volume of literature today still highlights the need for artificially intelligence platforms to synthesize and enhance the transmission of the latest information in a clear, concise and rapid way.Lastly, for surgeons with family members in the field, Case Reports can bring give you insights into your family's own experience into the wonders of surgery (<a href="#B8">8</a>), and remind you how you benefitted from the ability to stand on the shoulder of giants and push the envelope further (<a href="#B9">9</a>). Reading this article discussing a Bochdalek hernia complicated by a bowel perforation into the chest (<a href="https://doi.org/10.3389/fsurg.2021.755279">Ramspott et al.</a>) reminded me of the above-mentioned article that my Father authored and showed me decades ago in an effort to get me interested in academic surgery. This article more than perhaps any of the ones in this collection inspired me to agree to edit this collection. In short, Case Reports are where the journey of academic surgery truly begins and act as the gateway for us all to fall in love with the art of surgery.All authors listed have made a substantial, direct, and intellectual contribution to the work and approved it for publication.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Editorial: Case Reports in Visceral Surgery

Right-sided Bochdalek hernia is a mostly congenital condition of the diaphragm caused by a persistence of the pleuroperitoneal cavity and a rare disease in adults. As it often presents as an emergent situation, urgent diagnostics and surgical intervention are essential to reduce morbidity and mortality rates. Choosing the right surgical approach (abdominal, thoracic, or a combination of both) can be very challenging for clinicians. Here, we report a case of a 40-year-old woman, who presented with severe abdominal pain and tachypnoea. Imaging revealed a right-sided Bochdalek hernia. Emergency laparotomy was performed followed by reduction of hernia content, right-sided hemicolectomy, and side-to-side anastomosis from the ileum to the transverse colon due to intestinal ischemia and intrathoracic bowel perforation. The post-operative course was complicated by a pleural empyema. Therefore, the patient underwent thoracotomy. One year after surgical repair the patient had no recurrence. Here, we discuss feasible approaches for the surgical management of complicated Bochdalek hernias.

Right-sided Bochdalek hernia is a mostly congenital condition of the diaphragm caused by a persistence of the pleuroperitoneal cavity and a rare disease in adults. As it often presents as an emergent situation, urgent diagnostics and surgical intervention are essential to reduce morbidity and mortality rates. Choosing the right surgical approach (abdominal, thoracic, or a combination of both) can be very challenging for clinicians. Here, we report a case of a 40-year-old woman, who presented with severe abdominal pain and tachypnoea. Imaging revealed a right-sided Bochdalek hernia. Emergency laparotomy was performed followed by reduction of hernia content, right-sided hemicolectomy, and side-to-side anastomosis from the ileum to the transverse colon due to intestinal ischemia and intrathoracic bowel perforation. The post-operative course was complicated by a pleural empyema. Therefore, the patient underwent thoracotomy. One year after surgical repair the patient had no recurrence. Here, we discuss feasible approaches for the surgical management of complicated Bochdalek hernias.

Case Report: Adult Right-Sided Bochdalek Hernia Complicated by Intrathoracic Bowel Perforation

Introduction: Primary squamous cell carcinoma of the pancreas (SCCP) is a rare malignant tumor that has been reported in individual case reports only. The clinical data on primary SCCP treatment are limited. Therefore, the appropriate management strategy for this disease should be standardized.Case Presentation: We present the case of a 63-year-old man admitted to our hospital for upper left abdominal pain for 2 months without weight loss or jaundice. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed a mixed solid and cystic lesion in the pancreatic tail, measuring 35 × 37 mm in maximum diameter with enhancement. The patient was diagnosed with primary SCCP without metastasis, based on radiological and pathological findings. He did not receive neoadjuvant therapy postoperatively and was followed up by CT and MRI for 18 months without recurrence or metastasis.Result: Complete resection is the most effective treatment for early stage primary SCCP. Abdominal MRI is an effective imaging tool for preoperative evaluation and postoperative follow-up of primary SCCP. The need for neoadjuvant therapy depends on various factors.Conclusion: Primary SCCP is a tumor with poor prognosis. Risk factor control, early accurate radiologic evaluation, and individualized treatment strategies improve the quality of life and prolong the overall survival period of patients.

Introduction: Primary squamous cell carcinoma of the pancreas (SCCP) is a rare malignant tumor that has been reported in individual case reports only. The clinical data on primary SCCP treatment are limited. Therefore, the appropriate management strategy for this disease should be standardized.Case Presentation: We present the case of a 63-year-old man admitted to our hospital for upper left abdominal pain for 2 months without weight loss or jaundice. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed a mixed solid and cystic lesion in the pancreatic tail, measuring 35 × 37 mm in maximum diameter with enhancement. The patient was diagnosed with primary SCCP without metastasis, based on radiological and pathological findings. He did not receive neoadjuvant therapy postoperatively and was followed up by CT and MRI for 18 months without recurrence or metastasis.Result: Complete resection is the most effective treatment for early stage primary SCCP. Abdominal MRI is an effective imaging tool for preoperative evaluation and postoperative follow-up of primary SCCP. The need for neoadjuvant therapy depends on various factors.Conclusion: Primary SCCP is a tumor with poor prognosis. Risk factor control, early accurate radiologic evaluation, and individualized treatment strategies improve the quality of life and prolong the overall survival period of patients.

Management of Primary Squamous Cell Carcinoma of the Pancreas: A Case Report

Introduction: Carcinosarcoma, also known as malignant mixed Mullerian tumor (MMMT) is a malignant biphasic neoplasm consisting of carcinomatous and malignant non-epithelial components of mesenchymal origin. MMMTs typically arise from the female genital tract in patients over 40 years old. Primary extragenital MMMTs are extremely rare with published literature totaling 40 reported cases. The primary peritoneal carcinosarcoma is an aggressive tumor as patients with this tumor have an average survival of 7.6 months. Surgical debulking is the mainstay of treatment for these tumors and systemic chemotherapy is advised in all cases.Case: A 48-year-old Amish female presented with 5 day history of bloating and abdominal pain superimposed on a 1 year history of worsening fatigue and intermittent bloody bowel movements. She was found to have a pelvic mass on physical exam. Computed tomography scan of the abdomen and pelvis that demonstrated stricturing of the sigmoid colon, and a large multi-cystic mass in the midline pelvis measuring 12.5 × 9.9 × 11.7 cm. Colonoscopy showed stenosis due to external compression without intraluminal lesion. CEA and CA 125 levels were elevated and CA 19-9 was normal. Exploratory laparotomy was performed with en-bloc resection of a 15 cm mass originating from the sigmoid colon mesentery with several other small tumor deposits throughout the mesentery. Pathology diagnosed primary peritoneal carcinosarcoma Mullerian-type with three positive lymph nodes.Conclusion: Malignant mixed Mullerian tumor (carcinosarcoma) caries a universally grim prognosis. Herein, we report a unique case of primary peritoneal carcinosarcoma and discuss the work-up and surgical management of this rare tumor.

Introduction: Carcinosarcoma, also known as malignant mixed Mullerian tumor (MMMT) is a malignant biphasic neoplasm consisting of carcinomatous and malignant non-epithelial components of mesenchymal origin. MMMTs typically arise from the female genital tract in patients over 40 years old. Primary extragenital MMMTs are extremely rare with published literature totaling 40 reported cases. The primary peritoneal carcinosarcoma is an aggressive tumor as patients with this tumor have an average survival of 7.6 months. Surgical debulking is the mainstay of treatment for these tumors and systemic chemotherapy is advised in all cases.Case: A 48-year-old Amish female presented with 5 day history of bloating and abdominal pain superimposed on a 1 year history of worsening fatigue and intermittent bloody bowel movements. She was found to have a pelvic mass on physical exam. Computed tomography scan of the abdomen and pelvis that demonstrated stricturing of the sigmoid colon, and a large multi-cystic mass in the midline pelvis measuring 12.5 × 9.9 × 11.7 cm. Colonoscopy showed stenosis due to external compression without intraluminal lesion. CEA and CA 125 levels were elevated and CA 19-9 was normal. Exploratory laparotomy was performed with en-bloc resection of a 15 cm mass originating from the sigmoid colon mesentery with several other small tumor deposits throughout the mesentery. Pathology diagnosed primary peritoneal carcinosarcoma Mullerian-type with three positive lymph nodes.Conclusion: Malignant mixed Mullerian tumor (carcinosarcoma) caries a universally grim prognosis. Herein, we report a unique case of primary peritoneal carcinosarcoma and discuss the work-up and surgical management of this rare tumor.

Primary Peritoneal Carcinosarcoma: A Case Report

A 33-year-old female with a mild elevation of liver transaminase was sent to the general surgery department for medical services due to upper-right abdominal pain for 2 weeks. A liquid dark area ~4 × 3 × 3 cm in size in the theoretical location of the pancreatic segment of the common bile duct was detected by abdominal CT with no enhancement of the cystic wall found in the enhanced CT scan. The patient was then diagnosed with a choledochal cyst based on the results of the radiological images preoperatively. During the operation, the isolated cystic dilatation was found in the middle part of the cystic duct, and its caudal portion was found behind the head of the pancreas and converged into the common bile duct at an acute angle and low insertion. According to the intraoperative evaluation, the female was then diagnosed with a cystic duct cyst (CDC). The surgery was converted to a laparotomy for the unclear structure and the possibility of anatomic variation of the bile duct. The caudal portion of the cystic duct was found communicated with the common bile duct with a narrow base, and the extrahepatic bile duct was not cystic. The CDC was removed in the surgery. One week later, the patient was discharged from the hospital for the disappearance of abdominal pain and normal liver transaminase and did not report any discomfort in the 1-month-long follow-up. The lessons drawn from this case were as follows: (1) the distinction between the relatively frequent choledochal cyst and the isolated CDC should always be taken in mind; (2) a surgical strategy should be given priority for an intraoperatively confirmed CDC; (3) a common bile duct exploration is recommended for patients with choledocholithiasis or jaundice.

A 33-year-old female with a mild elevation of liver transaminase was sent to the general surgery department for medical services due to upper-right abdominal pain for 2 weeks. A liquid dark area ~4 &#xd7; 3 &#xd7; 3 cm in size in the theoretical location of the pancreatic segment of the common bile duct was detected by abdominal CT with no enhancement of the cystic wall found in the enhanced CT scan. The patient was then diagnosed with a choledochal cyst based on the results of the radiological images preoperatively. During the operation, the isolated cystic dilatation was found in the middle part of the cystic duct, and its caudal portion was found behind the head of the pancreas and converged into the common bile duct at an acute angle and low insertion. According to the intraoperative evaluation, the female was then diagnosed with a cystic duct cyst (CDC). The surgery was converted to a laparotomy for the unclear structure and the possibility of anatomic variation of the bile duct. The caudal portion of the cystic duct was found communicated with the common bile duct with a narrow base, and the extrahepatic bile duct was not cystic. The CDC was removed in the surgery. One week later, the patient was discharged from the hospital for the disappearance of abdominal pain and normal liver transaminase and did not report any discomfort in the 1-month-long follow-up. The lessons drawn from this case were as follows: (1) the distinction between the relatively frequent choledochal cyst and the isolated CDC should always be taken in mind; (2) a surgical strategy should be given priority for an intraoperatively confirmed CDC; (3) a common bile duct exploration is recommended for patients with choledocholithiasis or jaundice.

Case Report: Isolated Cystic Dilatation of the Cystic Duct: A Misdiagnosed Case Preoperatively

Background: In December 2019, an outbreak of pneumonia, caused by a new type of coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It quickly spread worldwide, resulting in a pandemic. The clinical manifestations of SARS-CoV-2 range from mild non-specific symptoms to severe pneumonia with organ function damage. In addition, up to 60% of patients have liver impairment or dysfunction, confirmed by several studies by the presence of SARS-CoV-2 in the liver tissue.Methods: We report two cases of symptomatic liver cyst requiring fenestration after recent SARS-CoV-2 infection. Both patients had hospital admission due to documented SARS-CoV-2 infection. Recently, after the infection, they developed symptoms caused by an enlarged hepatic cyst: one had abdominal pain, and the other had jaundice. They underwent surgery after two negative swab tests for SARS-CoV-2.Results: Cystic fluid was sent for microbiological test, and real-time fluorescence polymerase chain reaction COVID-19 nucleic-acid assay of the cyst fluid was found to be negative in both cases.Discussion: Although there are no current data that can document a viral contamination of cystic fluid, there are data that document a hepatotropism of COVID-19 virus. Herein we report that after viral clearance at pharyngeal and nasal swab, there is no evidence of viral load in such potential viral reservoir.

Background: In December 2019, an outbreak of pneumonia, caused by a new type of coronavirus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). It quickly spread worldwide, resulting in a pandemic. The clinical manifestations of SARS-CoV-2 range from mild non-specific symptoms to severe pneumonia with organ function damage. In addition, up to 60% of patients have liver impairment or dysfunction, confirmed by several studies by the presence of SARS-CoV-2 in the liver tissue.Methods: We report two cases of symptomatic liver cyst requiring fenestration after recent SARS-CoV-2 infection. Both patients had hospital admission due to documented SARS-CoV-2 infection. Recently, after the infection, they developed symptoms caused by an enlarged hepatic cyst: one had abdominal pain, and the other had jaundice. They underwent surgery after two negative swab tests for SARS-CoV-2.Results: Cystic fluid was sent for microbiological test, and real-time fluorescence polymerase chain reaction COVID-19 nucleic-acid assay of the cyst fluid was found to be negative in both cases.Discussion: Although there are no current data that can document a viral contamination of cystic fluid, there are data that document a hepatotropism of COVID-19 virus. Herein we report that after viral clearance at pharyngeal and nasal swab, there is no evidence of viral load in such potential viral reservoir.

Case Report: Liver Cysts and SARS-CoV-2: No Evidence of Virus in Cystic Fluid

Introduction: Retroperitoneal paraganglioma (RPGL) is a rare clinical tumor derived from the retroperitoneal sympathetic paraganglion tissue. Since RPGLs are locate deeply and have no specific symptoms and imaging manifestations at the early stage, which easily causes missed diagnosis or misdiagnosis. In addition, reports on totally laparoscopic resection of RPGLs are scarce due to their close proximity to large vessels, giant size, uncertain location, and unknown malignant status.Case Presentation: We present here the case of totally laparoscopic resection of a 6.4 × 5.4 cm RPGL that was discovered during a workup for discomfort and upper abdominal pain in a 68-year-old female patient, mimicking a gastrointestinal stromal tumor (GIST) of the duodenum, Which was confirmed as a RPGL based on the histopathological and immunohistochemical findings.Conclusions: RPGL is a rare tumor, and the transperitoneal laparoscopic approach for the RPGL is a safe, applicable method with less trauma and quick recovery, which is worth clinical popularizing and application. Moreover, the survival prognosis of RPGL patients are related to metastasis, and lifelong follow-up should be emphasized.

Introduction: Retroperitoneal paraganglioma (RPGL) is a rare clinical tumor derived from the retroperitoneal sympathetic paraganglion tissue. Since RPGLs are locate deeply and have no specific symptoms and imaging manifestations at the early stage, which easily causes missed diagnosis or misdiagnosis. In addition, reports on totally laparoscopic resection of RPGLs are scarce due to their close proximity to large vessels, giant size, uncertain location, and unknown malignant status.Case Presentation: We present here the case of totally laparoscopic resection of a 6.4 × 5.4 cm RPGL that was discovered during a workup for discomfort and upper abdominal pain in a 68-year-old female patient, mimicking a gastrointestinal stromal tumor (GIST) of the duodenum, Which was confirmed as a RPGL based on the histopathological and immunohistochemical findings.Conclusions: RPGL is a rare tumor, and the transperitoneal laparoscopic approach for the RPGL is a safe, applicable method with less trauma and quick recovery, which is worth clinical popularizing and application. Moreover, the survival prognosis of RPGL patients are related to metastasis, and lifelong follow-up should be emphasized.