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  • menin Internal herniation is a rare cause

    2018-10-22

    Internal herniation is a rare cause of IO, accounting for < 3% of cases, and few cases have been reported worldwide. It occurs due to the unintentional creation of a transmesocolic defect during medial mobilization of the left colon along the line of Toldt, facilitating the migration of small bowel into a potential space in the renal bed. Small bowel strangulation is rarely observed; however, delayed presentation and misdiagnosis can engender a catastrophic outcome with increased mortality. Radiological imaging may not reveal the exact point of obstruction or clearly demarcate the transitional zone between collapsed and dilated bowel segments; hence, a high index of clinical suspicion can be lifesaving. The gold standard treatment includes reduction of herniation and closure of the defect. The presence of a compromised bowel segment warrants resection and primary anastomosis. A meticulous dissection technique should be considered in such cases to avoid any unnecessary mesenteric tears and repair the evident mesenteric defects observed during the intraoperative period.
    Introduction Fibrovascular polyp of the menin is a rare, slow-growing, intraluminal, benign submucosal tumor and represents < 2% of all benign esophageal tumors. It usually occurs in middle-aged men and mostly arises from the upper one-third of the esophagus, adjacent to the cricopharynx. Most patients remain undiagnosed; however, symptomatic patients generally present with dysphagia, especially for solid food. Rarely, these giant polypoidal tumors may prolapse through the mouth and become stuck. The resultant acute airway obstruction may cause lethal asphyxia. The elongated sausage-shaped polyp is covered by normal squamous epithelium, because of which these lesions are usually not diagnosed in upper gastrointestinal (GI) endoscopies. In our case, a giant fibrovascular polyp prolapsed through the mouth and stuck during endoscope retrieval, inducing breathing difficulty. Subsequently, the tumor was removed through a left transcervical approach. Tumor recurrence is rare, and few cases have been reported.
    Discussion Fibrovascular polyps are very rare intraluminal benign tumors of the esophagus. To date, only ∼100 cases have been reported, with the largest single series reporting 16 cases. Most patients were men in their 60s and 70s, but a few cases have been reported in infants as well. The male-to-female ratio for fibrovascular polyp incidence is approximately 3:1. The most common occurrence site is the upper one-third of the esophagus (the inferior part of cricopharynx and rarely from the hypopharynx), with tumor size ranging from a few centimeters to large tumors that reach up to the stomach. These tumors are usually pedunculated because of a combination of the propulsive act of swallowing and propulsive peristalsis of the esophagus toward the caudal end. Clinically, patients present with nonspecific symptoms, and these tumors mostly remain undiagnosed until they become huge. The most common symptoms are dysphagia (87%), respiratory difficulty (25%), and regurgitation through the mouth (10%). Rarely, they cause asphyxia because of obstruction of the larynx and can thus be lethal. Tumors usually show a uniform, fibromyxoid appearance on the cut surface. Histological examinations typically show benign squamous epithelium on the underlying lamina propria, which is expanded because of a mixture of highly vascularized loose and dense fibrous tissue with intervening lobules of adipose tissue and small clusters of mature adipocytes. Focal areas of spindle cell differentiation may also be present. Initial diagnosis menin is usually made after barium studies and a review of patient history; the most common finding is a smooth intraluminal sausage-shaped mass with a bulbous tip with varying degrees of lobulation. During an upper GI endoscopy, the esophageal lumen and the surface of the polyp can resemble normal esophageal mucosa; therefore, it is frequently missed during endoscopies, as in our case. Endoscopic ultrasound is useful in revealing the site of origin of the stalk and the size and vascularity of the polyp. It also enables guided fine-needle aspiration for cytology. CT and magnetic resonance scans are valuable tools for determining the appropriate surgical treatment. Multiplanar CT scanning provides information on the location, size, and pedicle attachment of the tumor, which is critical for deciding the surgical treatment. Magnetic resonance scans with axial, coronal, and sagittal views can help in precise identification of the stalk.