Category: English

Understanding a Life-Threatening Gastrointestinal Emergency

Ischemic colitis represents the most common form of gastrointestinal ischemia, occurring when blood flow to the colon becomes compromised, leading to tissue damage ranging from superficial mucosal injury to full-thickness transmural necrosis. While many cases of ischemic colitis can be managed conservatively, the development of multiple colonic perforations represents a life-threatening surgical emergency requiring prompt intervention. A recent case at Burjeel Hospital highlights the critical importance of early recognition and aggressive surgical management in this challenging clinical scenario.

The Clinical Presentation: From Subtle Symptoms to Systemic Sepsis

The patient in this case presented with what initially appeared to be a routine case of ischemic colitis, with symptoms including:

• Progressive abdominal pain, initially cramping but becoming more severe and diffuse
• Bloody diarrhea
• Nausea and vomiting
• Low-grade fever
• Progressive abdominal distension

What distinguished this case from more typical presentations of ischemic colitis was the rapid clinical deterioration, with the development of signs of peritonitis, including:

• Rebound tenderness and guarding
• Absent bowel sounds
• Progressive hemodynamic instability
• Rising inflammatory markers (leukocytosis, elevated C-reactive protein)
• Metabolic acidosis

These findings raised immediate concern for colonic perforation as a complication of severe transmural ischemia, representing a surgical emergency requiring prompt intervention.

Diagnostic Approach: Rapid Assessment for Optimal Management

The diagnostic workup for suspected ischemic colitis with perforation must be expedited to enable timely surgical intervention. In this case, the diagnostic approach included:

Laboratory Studies

• Complete blood count revealing leukocytosis with left shift
• Comprehensive metabolic panel showing electrolyte abnormalities
• Elevated lactate level suggesting tissue ischemia
• Coagulation studies to assess for hypercoagulable states

Imaging Studies

• Abdominal X-ray demonstrating free air under the diaphragm, indicative of perforation
• CT scan of the abdomen and pelvis with intravenous contrast revealing:
  • Segmental thickening of the colonic wall, particularly involving the splenic flexure and descending colon
  • Pneumoperitoneum consistent with perforation
  • Multiple sites of discontinuity in the colonic wall indicating multiple perforations
  • Surrounding inflammatory changes and free fluid

The combination of clinical findings and imaging studies confirmed the diagnosis of ischemic colitis complicated by multiple perforations, necessitating immediate surgical intervention.

Surgical Management: Principles and Approach

The management of perforated ischemic colitis requires a systematic approach focused on:

1. Aggressive Resuscitation:
   • Fluid resuscitation with crystalloids and colloids
   • Vasopressor support as needed
   • Correction of electrolyte abnormalities
   • Initiation of broad-spectrum antibiotics to cover gram-negative and anaerobic organisms
2. Prompt Surgical Intervention:
   • Exploratory laparotomy to assess the extent of disease
   • Resection of all nonviable bowel segments
   • Assessment of vascular supply to remaining intestine
   • Decision-making regarding primary anastomosis versus ostomy creation
3. Postoperative Care:
   • Continued intensive care monitoring
   • Nutritional support
   • Wound management
   • Prevention of complications including thromboembolism

The Operative Findings and Surgical Decision-Making

Upon exploratory laparotomy, the surgical team encountered:

• Extensive purulent peritonitis throughout the abdominal cavity
• Multiple perforations primarily involving the splenic flexure and descending colon
• Transmural necrosis extending from the mid-transverse colon to the sigmoid colon
• Relatively sparing of the right colon and rectum
• No evidence of occlusive vascular disease in the major mesenteric vessels

Based on these findings, the surgical team proceeded with:

1. Extended Left Hemicolectomy: Resection of the affected colonic segments, including the distal transverse colon, splenic flexure, descending colon, and proximal sigmoid colon
2. End Colostomy Creation: Given the presence of peritonitis and the compromised tissue quality, the decision was made to avoid primary anastomosis and instead create an end colostomy (Hartmann’s procedure) with a distal rectal stump
3. Thorough Peritoneal Lavage: Copious irrigation with warm saline to clear purulent material and reduce bacterial burden
4. Drain Placement: Strategic placement of drains to monitor for ongoing leakage or abscess formation

Pathological Findings: Confirming the Diagnosis

The resected colonic specimen was sent for pathological examination, which revealed:

• Transmural ischemic necrosis with multiple areas of perforation
• Vascular congestion and hemorrhage within the bowel wall
• Inflammatory infiltrate consistent with acute ischemic injury
• Microvascular thrombosis in small vessels of the colonic wall
• No evidence of vasculitis, malignancy, or infectious etiology

These findings confirmed the diagnosis of severe ischemic colitis with multiple perforations, likely related to non-occlusive mesenteric ischemia.

Postoperative Course and Outcome

The immediate postoperative period was characterized by:

• Continued intensive care support with mechanical ventilation and hemodynamic monitoring
• Gradual resolution of sepsis with appropriate antibiotic therapy
• Progressive improvement in inflammatory markers
• Initiation of enteral nutrition on postoperative day 4
• Stoma function beginning on postoperative day 3

The patient was discharged from the intensive care unit on postoperative day 7 and from the hospital on postoperative day 14. Following a period of recovery and nutritional optimization, the patient would be evaluated for potential colostomy reversal, typically considered 3-6 months after the initial procedure.

Risk Factors and Preventive Strategies

Several factors may increase the risk of ischemic colitis and subsequent perforation:

• Advanced age and atherosclerotic vascular disease
• Cardiac arrhythmias, particularly atrial fibrillation
• Recent major cardiovascular surgery
• Severe heart failure or hypotension
• Hypercoagulable states
• Vasopressor use
• Certain medications including NSAIDs and hormone replacement therapy
• Chronic obstructive pulmonary disease

Preventive strategies for high-risk patients include:

• Optimization of cardiac output and blood pressure
• Careful management of fluid status
• Anticoagulation when appropriate
• Cautious use of vasopressors
• Monitoring for abdominal symptoms in patients with risk factors

Learning Points and Clinical Significance

This challenging case highlights several important clinical lessons:

1. Early Recognition Is Critical: The progression from mucosal ischemia to transmural necrosis and perforation can be rapid, emphasizing the importance of vigilant monitoring and early recognition of deterioration.
2. Imaging is Essential: CT imaging plays a crucial role in diagnosing ischemic colitis complicated by perforation and guiding surgical decision-making.
3. Resuscitation Before and During Surgery: Aggressive fluid resuscitation, antibiotics, and hemodynamic support are essential components of management.
4. Surgical Principles: In the setting of multiple perforations and peritonitis, resection of all affected segments with diversion (stoma creation) is generally preferred over primary anastomosis.
5. Multidisciplinary Approach: Optimal management requires collaboration between emergency physicians, surgeons, intensivists, and interventional radiologists.

Conclusion: The Importance of Timely Intervention

Ischemic colitis with multiple perforations represents a life-threatening surgical emergency requiring prompt diagnosis and intervention. This case from Burjeel Hospital demonstrates that with early recognition, appropriate imaging, and timely surgical management, even patients with this severe complication can achieve favorable outcomes.

The multidisciplinary approach employed in this case, along with adherence to fundamental surgical principles for managing perforated viscus, illustrates the high level of care available for complex gastrointestinal emergencies at Burjeel’s surgical facilities.

Experts

Understanding a Rare Skull Base Tumor

Clival chordomas represent one of the most challenging pathologies in neurosurgery. These rare tumors, arising from remnants of the primitive notochord, occur at an incidence of only about 0.8 per 100,000 people, with approximately 35% affecting the spheno-occipital region. Despite their rarity, these tumors demand attention due to their locally aggressive behavior and tendency to compress critical neural structures, particularly the brainstem. A recent case at Burjeel Medical City highlights the sophisticated surgical approaches now available for these complex lesions.

The Clinical Presentation: From Subtle Signs to Serious Symptoms

The patient in this case presented with a constellation of progressive neurological symptoms that had developed over several months, including:

• Persistent headaches that gradually increased in severity
• Visual disturbances including diplopia (double vision)
• Progressive weakness and coordination problems
• Difficulty with swallowing and speech articulation

What made this case particularly concerning was the evidence of significant brainstem compression on imaging studies. The brainstem houses vital neural pathways and control centers for essential functions such as breathing, heart rate regulation, and consciousness. Any compression of this critical structure represents a life-threatening condition requiring urgent intervention.

Advanced Imaging: Revealing the Full Extent of the Challenge

The diagnostic workup for this patient included state-of-the-art neuroimaging that revealed the true complexity of the case:

• MRI demonstrated a large, heterogeneously enhancing mass centered in the clivus
• The tumor showed characteristic “honeycomb” appearance typical of chordomas
• Critical findings included significant ventral compression of the brainstem
• Evidence of T2 signal changes within the brainstem suggested early signs of damage from compression
• CT imaging revealed extensive bony erosion of the skull base

The proximity to vital neurovascular structures, including the basilar artery and multiple cranial nerves, further complicated the surgical planning. This constellation of findings characterized a skull base chordoma with significant brainstem compression—a scenario that represents one of the most technically demanding challenges in neurosurgery.

Multidisciplinary Treatment Planning: The Foundation of Success

The management of this complex case began with comprehensive multidisciplinary discussion, bringing together:

• Neurosurgeons specializing in skull base approaches
• Otolaryngologists with expertise in endoscopic techniques
• Neuroradiologists for detailed imaging interpretation
• Radiation oncologists for adjuvant treatment planning
• Neuro-anesthesiologists for complex airway management

This collaborative approach allowed for careful consideration of all treatment options, weighing the risks and benefits of various surgical corridors and techniques. The primary goal was maximal safe resection of the tumor to decompress the brainstem, while preserving neurological function and establishing a clear diagnosis for subsequent targeted therapy.

Surgical Approach: Endoscopic Endonasal Transclival Technique

After careful deliberation, the surgical team selected an endoscopic endonasal transclival approach for this challenging lesion. This minimally invasive technique offers several advantages:

• Direct midline access to the clivus and ventral brainstem
• Avoidance of brain retraction that would be required with transcranial approaches
• Excellent visualization of the tumor and critical neurovascular structures
• Reduced manipulation of cranial nerves
• Lower morbidity compared to traditional open approaches

The procedure involved collaboration between neurosurgery and otolaryngology teams, with specialized instrumentation including high-definition endoscopy, neuronavigation, and intraoperative neurophysiological monitoring to ensure maximal safety during this delicate operation.

Technical Highlights of the Procedure

The surgical approach consisted of several critical phases:

1. Nasal Phase: Creation of bilateral nasoseptal flaps for subsequent reconstruction, followed by creation of a wide sphenoidotomy and posterior ethmoidectomy
2. Sphenoid Phase: Removal of the sphenoid rostrum and posterior nasal septum to create a wide surgical corridor
3. Clival Phase: Removal of the clival bone using high-speed drills and ultrasonic bone cutters to expose the dura
4. Dural and Tumor Phase: Careful opening of the dura and systematic removal of tumor tissue with meticulous attention to the preservation of vital structures
5. Brainstem Decompression: Gentle dissection of tumor from the ventral surface of the brainstem, with continuous neurophysiological monitoring
6. Reconstruction Phase: Multilayered closure using the previously harvested nasoseptal flap to prevent postoperative cerebrospinal fluid leakage

Throughout the procedure, the surgical team maintained constant vigilance regarding brainstem function through neurophysiological monitoring, and preserved critical vascular structures including the basilar artery and its perforator branches.

Postoperative Course and Outcomes

Following surgery, the patient was monitored in the neurosurgical intensive care unit with particular attention to:

• Neurological status, with serial examinations to detect any new deficits
• Airway patency and respiratory function
• Fluid and electrolyte balance, with close monitoring for diabetes insipidus
• Signs of potential cerebrospinal fluid leakage

Postoperative imaging confirmed excellent tumor resection and, more importantly, successful decompression of the brainstem. The patient experienced progressive improvement in preoperative symptoms, with resolution of headaches, improvement in visual symptoms, and gradual recovery of strength and coordination.

Following a period of intensive rehabilitation, the patient was able to return to independent functioning, representing a remarkable outcome for a condition that historically carried high morbidity and mortality rates.

Adjuvant Therapy: Completing the Treatment Paradigm

Given the high recurrence rates associated with chordomas, even after apparently complete surgical resection, the treatment plan included adjuvant therapy. The patient underwent:

• High-precision proton beam therapy, which allows for delivery of high radiation doses to the tumor bed while minimizing exposure to adjacent critical neural structures
• Regular imaging surveillance to detect any early signs of recurrence
• Continued multidisciplinary follow-up to monitor for late complications

Learning Points and Clinical Significance

This challenging case highlights several important principles in contemporary neurosurgery:

1. Early diagnosis is critical: Progressive neurological symptoms, particularly when associated with evidence of brainstem compression, require urgent evaluation and intervention.
2. The value of minimally invasive approaches: Endoscopic techniques have revolutionized the treatment of skull base lesions, allowing for effective tumor resection with reduced morbidity.
3. Multidisciplinary collaboration: The complexity of skull base tumors demands the integration of multiple specialties for optimal outcomes.
4. The importance of specialized technology: Advanced neuroimaging, neuronavigation, endoscopy, and neurophysiological monitoring are essential components of safe and effective skull base surgery.
5. Comprehensive care beyond surgery: Complete management of chordomas requires integration of adjuvant therapies and long-term surveillance.

Conclusion: A Testament to Modern Neurosurgical Capabilities

The successful management of this challenging clival chordoma with brainstem compression at Burjeel Medical City demonstrates the remarkable advances in contemporary neurosurgery. Through the integration of cutting-edge technology, minimally invasive techniques, and multidisciplinary collaboration, even the most formidable neurosurgical challenges can be addressed with favorable outcomes.

This case serves as an inspiration for patients facing similar diagnoses and reinforces the critical importance of seeking care at centers with specialized expertise in complex skull base surgery.

Experts

Understanding an Exceptionally Rare Urological Anomaly

Retrocaval ureter, also known as circumcaval ureter or preureteral vena cava, represents one of the rarest congenital anomalies in urological practice. With an estimated incidence of just 0.06-0.17% worldwide, this condition presents a unique diagnostic and surgical challenge for urologists. A recent case successfully managed at Burjeel Hospital highlights both the complexity and optimal management approaches for this unusual condition.

The Embryological Puzzle

Despite its name suggesting a ureteral anomaly, retrocaval ureter actually results from an abnormal development of the inferior vena cava (IVC) during embryological development. The condition occurs when the right ureter becomes entrapped behind the IVC, coursing posteriorly and then medially around the vein before resuming its normal position distally. This creates the characteristic “fishhook” or “reverse J” deformity visible on imaging studies.

Interestingly, while the anomaly is present from birth, symptoms typically don’t manifest until the third or fourth decade of life, when progressive obstruction leads to clinical presentations.

Clinical Presentation: A Diagnostic Challenge

The patient in this case presented with a classic constellation of symptoms that characterize retrocaval ureter:

• Intermittent right flank pain persisting for several months
• Episodes of urinary tract infections
• Nonspecific symptoms that had previously led to misdiagnosis

What makes this condition particularly challenging from a diagnostic perspective is its similarity to more common conditions like urolithiasis (kidney stones). Patients often undergo multiple evaluations and treatments for suspected stones before the correct diagnosis is established.

Advanced Imaging: The Key to Diagnosis

The definitive diagnosis in this case was established through contrast-enhanced CT urography, which revealed the pathognomonic findings of:

• Right-sided hydronephrosis (dilation of the kidney collecting system)
• Hydroureter proximal to the retrocaval segment
• The classic “fishhook” or “S-shaped” appearance of the proximal ureter as it courses behind the IVC
• Normal caliber of the distal ureter after emerging from behind the IVC

This case highlights the critical importance of appropriate imaging studies in the diagnosis of rare urological conditions. While ultrasound may detect hydronephrosis, CT urography with multiplanar reconstruction provides the detailed anatomical information necessary for surgical planning.

Surgical Approach: Precision and Expertise

The surgical management of retrocaval ureter has evolved significantly over recent decades. In this case, the surgical team employed a carefully planned approach that included:

1. Preoperative stenting: Placement of a double-J ureteral stent to maintain drainage and facilitate identification during surgery
2. Transperitoneal approach: Providing excellent exposure of both the ureter and the IVC
3. Careful ureteral dissection: Identifying the point of obstruction where the ureter passes behind the IVC
4. Resection of the retrocaval segment: Removing the narrowed, often aperistaltic portion of ureter trapped behind the IVC
5. Ureteroureteral anastomosis: Precise reconnection of the ureter anterior to the IVC, positioning it in its anatomically correct location
6. Stent placement: Ensuring proper healing and drainage during the recovery period

While traditionally performed as an open procedure, advances in minimally invasive surgery have made laparoscopic repair increasingly common, offering benefits of reduced postoperative pain, shorter hospital stay, and improved cosmetic results. The surgical team’s expertise allowed for a successful outcome despite the technical challenges inherent in this rare condition.

Postoperative Care and Outcomes

Following surgery, the patient’s recovery was monitored with particular attention to:

• Urinary output and drain output
• Resolution of preoperative pain
• Follow-up imaging to confirm resolution of hydronephrosis
• Eventual removal of the ureteral stent after ensuring proper healing

The patient experienced complete resolution of symptoms following surgery, with follow-up imaging demonstrating significant improvement in the previously dilated collecting system. This successful outcome illustrates the importance of proper diagnosis and definitive surgical correction for symptomatic retrocaval ureter.

Clinical Significance and Learning Points

This case highlights several important clinical lessons:

1. Consider rare anomalies: When evaluating patients with recurrent right flank pain and hydronephrosis without obvious stone disease, rare anatomical variations should be considered.
2. Value of cross-sectional imaging: CT urography provides detailed anatomical information critical for diagnosing vascular anomalies affecting the urinary tract.
3. Timing of intervention: While the anomaly is congenital, intervention is typically only required when symptoms develop, usually in adulthood.
4. Multidisciplinary approach: Collaboration between urologists, radiologists, and surgical teams ensures optimal outcomes for these complex cases.

Conclusion

Retrocaval ureter represents a fascinating intersection of embryological development, anatomical variation, and surgical expertise. While rare, this condition serves as an important reminder of the value of thorough diagnostic evaluation and the need to consider uncommon etiologies when common explanations fail to account for a patient’s symptoms.

The successful management of this case at Burjeel Hospital demonstrates the institution’s capability in handling complex urological anomalies, providing patients with access to advanced diagnostic and surgical care for even the rarest of conditions.

Experts

Introduction: Navigating Pediatric Oncological Challenges

Neuroblastoma remains one of the most common extracranial solid tumors in children, accounting for approximately 8-10% of all childhood cancers. A recent case at Burjeel Medical City highlights the complex surgical management required for these challenging cases, particularly when the tumor presents with unfavorable histology. Dr. Rajasekhar Cingapagu, Pediatric Surgeon at Burjeel Medical City, shares insights from this complex case that illustrates the importance of multidisciplinary collaboration and surgical expertise in pediatric oncology.

Case Presentation: From Initial Symptoms to Diagnosis

A 2-year-old boy presented to the Emergency Department at Burjeel Medical City with complaints of constipation, generalized abdominal pain, and fever. Physical examination revealed a concerning finding: an abdominal mass on the right side.

The diagnostic journey began with an abdominal ultrasound that showed a soft tissue hyperechoic lesion in the right suprarenal region with internal vascularity and areas of cystic changes. The lesion was closely abutting the right lobe of the liver and the superior pole of the right kidney, though the exact organ of origin could not be definitively determined from the ultrasound alone.

Given these findings, the patient was referred to the Pediatric Oncology department, and a Pediatric Surgical consultation was sought to develop a comprehensive management plan.

Advanced Imaging and Preoperative Assessment

A CT scan provided crucial additional information, revealing:

• A large round to oval heterogeneous soft-tissue density mass with solid and cystic components
• Infrequent areas of calcification arising from the mid and upper pole of the right kidney
• Approximate dimensions of 11 × 12 × 13 cm
• Patchy irregular enhancement on post-contrast imaging
• Significant mass effect, with the tumor pushing the aorta and inferior vena cava (IVC) leftward

The radiological assessment raised concerns about potential vascular involvement, particularly noting:

• A severely compressed IVC at the portal region
• Unclear visualization of a segment of the IVC, raising questions about possible thrombus
• Compression of the right renal vein by the mass, though normal color flow was preserved

Multidisciplinary Approach to Treatment Planning

The case was presented at a multidisciplinary team (MDT) meeting to determine the optimal management strategy. After careful review of the imaging studies, the team concluded that the tumor was resectable since the critical vascular structures—specifically the IVC and right renal vein—were compressed but not infiltrated by the tumor.

This collaborative decision-making led to a treatment plan involving surgical resection followed by chemotherapy as needed, based on the final pathological assessment.

The Surgical Challenge: Right Radical Nephrectomy

Following comprehensive preoperative preparation, including complete blood investigations, blood reservation, and detailed discussion with the parents, the surgical team proceeded with a right radical nephrectomy using a right transverse abdominal incision.

The intraoperative findings revealed a challenging surgical scenario:

• A large tumor measuring 16 cm, with firm consistency and areas of necrosis
• A tumor nodule at the renal hilum separate from the main tumor
• Multiple enlarged lymph nodes (infra-renal and paraaortic) measuring over 2 cm
• The tumor firmly adherent to the IVC, splaying the vessel just below the hepatic hilum
• Extension of the tumor across the midline just above the renal hilum
• No evidence of tumor thrombus in the renal vein or IVC

Technical Aspects of the Procedure

The surgical approach required meticulous dissection and included several critical steps:

1. Careful dissection to ligate the left renal vein and renal artery
2. Dissection of the ureter down to its lower end, which was then transfix ligated and cut
3. Delicate release of adhesions between the tumor and liver surface at the hepatic hilum, performed without injuring the liver
4. Comprehensive dissection of multiple lymph nodes in the para-aortic and infra-renal regions
5. Placement of a drain in the sub-hepatic space
6. Layered closure of the abdominal wound

Postoperative Course and Pathological Findings

The patient made a remarkably smooth postoperative recovery and was discharged home on the 7th postoperative day. The histopathology report confirmed the diagnosis of neuroblastoma with unfavorable histology, providing essential information for planning subsequent oncological management.

Clinical Significance and Learning Points

This case highlights several important aspects of managing large pediatric renal tumors:

Diagnostic Challenges

• The initial presentation with constipation and abdominal pain is nonspecific and highlights the importance of thorough physical examination in pediatric patients
• The differential diagnosis for an abdominal mass in a child includes Wilms’ tumor, neuroblastoma, and other less common entities that require careful radiological and pathological characterization

Surgical Considerations

• The proximity of the tumor to major vascular structures necessitates meticulous preoperative planning and experienced surgical technique
• The value of a multidisciplinary approach cannot be overstated—input from pediatric oncology, pediatric surgery, radiology, and pathology is essential for optimal outcomes
• Preservation of vital structures while achieving complete tumor resection requires balancing oncological principles with functional preservation

Prognostic Implications

• Unfavorable histology in neuroblastoma is associated with a more aggressive disease course and may influence decisions regarding adjuvant therapy
• Complete surgical resection remains a cornerstone of treatment, even in challenging cases with unfavorable pathological features

Conclusion

This case from Burjeel Medical City exemplifies the complex decision-making and technical expertise required in the management of pediatric solid tumors. Through careful preoperative assessment, multidisciplinary collaboration, and skilled surgical technique, even large, complex tumors can be successfully resected, providing children with the best opportunity for long-term survival.

The successful management of this challenging case reflects the commitment to excellence in pediatric surgical oncology at Burjeel Medical City and highlights the importance of specialized centers capable of providing comprehensive care for children with complex oncological conditions.

Experts

Understanding an Uncommon Surgical Challenge

Paraduodenal hernias represent one of the rarest forms of internal hernia, accounting for less than 1% of all intestinal obstructions. Yet, their potential for serious complications makes them an important condition for both patients and medical professionals to understand. A recent case at Burjeel Hospital Sharjah, managed by Dr. Mohamed Eraki, Consultant of General and Laparoscopic Surgery, highlights the challenges in diagnosing and treating this uncommon condition.

The Clinical Presentation: A Diagnostic Puzzle

The case involved a 33-year-old man who presented with a one-year history of intermittent symptoms including lethargy, tiredness, and occasional sharp generalized abdominal pain. Notably, the pain episodes typically lasted more than two hours before resolving, prompting multiple emergency room visits.

What made this case particularly challenging from a diagnostic standpoint was the absence of classic intestinal obstruction symptoms. The patient’s pain was not associated with nausea, vomiting, or weight loss—symptoms that would typically raise immediate concern for intestinal disorders.

The Diagnostic Journey

Given the persistent nature of the symptoms, a CT scan of the abdomen with contrast was performed, revealing a critical finding: jejunal loops concentrated along the left paraduodenal region with mild prominence of the lumen (maximum diameter of 2.5 cm).

The CT scan showed:

• Normal caliber of small bowel loops following the dilated section
• No obvious air-fluid levels within the small bowel loops
• No free fluid around the small bowel loops
• No appreciable membranes noted around the small bowel loops
• Normal appearance of the remaining visualized bowel loops

Based on these findings, a diagnosis of left-side paraduodenal hernia was established.

Understanding Paraduodenal Hernias

Paraduodenal hernias occur when intestinal loops protrude through a peritoneal defect near the duodenum. Left-sided paraduodenal hernias, as seen in this case, are more common than right-sided ones, accounting for approximately 75% of all paraduodenal hernias.

These hernias develop during embryonic rotation of the midgut and abnormal fixation of the mesentery. The hernial sac typically contains small bowel loops, and in left-sided cases, the inferior mesenteric vein often forms part of the anterior border of the hernial sac, creating a potential vascular complication during surgery.

Surgical Management: The Laparoscopic Approach

To address this rare condition, Dr. Eraki performed a laparoscopic abdominal exploration, which revealed:

• Most of the small bowel collected in one sac, with a membrane to the left of the duodenum
• The terminal ileum emerging from beneath a peritoneal fold, possibly containing the inferior mesenteric vein
• Partial obstruction of the small bowel by the inferior mesenteric vein crossing the terminal ileum

The surgical management involved several critical steps:

1. Opening the peritoneal sac to reveal the small bowel
2. Carefully reducing the entire small bowel from beneath the vascular fold
3. Closing the defect between the inferior mesenteric vein and posterior abdominal wall with a continuous absorbable suture
4. Excising and plicating the peritoneal sac

Surgical Challenges and Considerations

Dr. Eraki noted two primary challenges in managing this case:

1. Accurate diagnosis – The nonspecific symptoms made initial diagnosis difficult
2. Preservation of the inferior mesenteric vein – Maintaining vascular integrity while performing hernia repair required careful surgical technique
3. Defect closure – The size and location of the defect presented technical challenges for secure closure

Clinical Significance and Learning Points

This case highlights several important clinical lessons:

1. High index of suspicion – Paraduodenal hernias should be considered in the differential diagnosis of patients with recurrent, intermittent abdominal pain, especially when symptoms are atypical.
2. Value of CT imaging – Contrast-enhanced CT scans play a crucial role in the preoperative diagnosis of internal hernias.
3. Laparoscopic management – The laparoscopic approach offers both diagnostic and therapeutic benefits, allowing for detailed visualization and definitive management with minimal invasiveness.
4. Anatomical awareness – Understanding the vascular relationships, particularly the position of the inferior mesenteric vein, is essential for safe surgical repair.

Long-term Outcomes and Prognosis

Following successful laparoscopic repair, patients with paraduodenal hernias typically experience complete resolution of symptoms and have an excellent prognosis. Early diagnosis and intervention are crucial to prevent potential complications such as bowel obstruction, strangulation, and ischemia, which can significantly increase morbidity and mortality.

For patients experiencing unexplained, recurrent abdominal pain, this case serves as a reminder of the importance of pursuing a comprehensive diagnostic evaluation and considering uncommon etiologies when symptoms persist despite normal initial assessments.

Conclusion

Paraduodenal hernias, while rare, represent an important and treatable cause of recurrent abdominal pain. This case from Burjeel Hospital Sharjah demonstrates the value of advanced imaging, surgical expertise, and a minimally invasive approach in managing this uncommon condition. For clinicians, maintaining awareness of such rare entities can make the difference between prolonged symptoms and definitive treatment.

Experts

A Groundbreaking Surgical Procedure in the UAE

Burjeel Medical City (BMC) has successfully performed the UAE’s first totally robotic three-stage esophagectomy with pharyngo-gastric reconstruction, marking a significant milestone in the country’s advanced surgical capabilities. This innovative procedure, conducted by Dr. Ali Ayoob, HOD & Consultant Gastrointestinal Surgery at Burjeel Medical City, demonstrates the hospital’s commitment to providing cutting-edge surgical solutions for complex cases.

The Patient’s Journey

The case involved a 34-year-old woman who had undergone total radical thyroidectomy and lymph node dissection for locally advanced papillary carcinoma thyroid at another hospital. During the initial surgery, she experienced an intraoperative esophageal injury on the right lateral wall at the level of the pharynx, which was immediately addressed with primary suturing.

However, complications arose when the patient developed leakage of oral fluids through the drain site on the fourth day after surgery. Despite conservative management with nasogastric tube (NGT) aspiration, nothing by mouth (NPO) protocol, and antibiotic therapy, the esophageal leak persisted. The patient also developed mediastinitis and pleural effusion, further complicating her condition.

With evidence of a significant and persistent esophageal leak confirmed by contrast CT of the neck, she was transferred to Burjeel Medical City for specialized surgical care. Additionally, the patient was dealing with right vocal cord palsy and hypocalcemia as a result of her previous surgery.

Initial Surgical Intervention

Upon arrival at BMC, the patient underwent neck exploration surgery on October 28, 2023. The procedure included:

• Upper GI endoscopy
• Laparoscopy-assisted retrograde endoscopy
• Neck wound exploration
• Closure of the pharyngeal defect
• Closure of the distal cut margin of the esophagus
• Laparoscopic feeding jejunostomy

Following this intervention, the patient was discharged in stable condition with a plan for definitive surgery to reconstruct her swallowing pathway. During this recovery period, she received treatment with calcium supplements and Eltroxin (levothyroxine).

A subsequent CT scan of the neck and laryngoscopy revealed a completely stenotic esophageal inlet, requiring a high pharyngeal anastomosis—a particularly challenging surgical scenario.

The Groundbreaking Robotic Procedure

After thorough discussion in a multidisciplinary team meeting, the decision was made to proceed with definitive surgery. On January 3, 2024, the patient underwent the landmark procedure, which included:

1. Robotic mobilization of the intrathoracic esophagus
2. Robotic mobilization of the gastric tube in the abdomen
3. Formation of a gastric conduit, which was transported to the neck through the posterior mediastinum
4. Neck exploration from the right side with resection of the previously stenosed esophagus
5. Exposure of the pharyngeal wall on the right posterolateral aspect (right pyriform fossa)
6. Creation of a pharyngo-gastric end-to-side handsewn anastomosis
7. Placement of a nasogastric tube through the anastomosis to the stomach

The Surgical Challenge

The procedure represented a significant technical challenge for several reasons:

“We have been performing esophageal reconstruction in the neck for a long time, but reconstruction of the swallowing pathway high up in the neck onto the pharynx is a real challenging situation,” explains Dr. Ali Ayoob. “High reconstruction is usually done with removal of the larynx, but here surgery is done sparing the larynx.”

What makes this case particularly noteworthy is that while the surgical team had extensive experience with video-assisted thoracoscopic (VAT) esophagectomy, this marked the first time that the da Vinci Robot was used for esophagectomy via the thorax and gastric conduit formation in the UAE.

Benefits of Robotic Surgery for Complex Procedures

The use of robotic technology in such a complex procedure offers several advantages:

1. Enhanced precision: The robotic system provides surgeons with greater dexterity and precision, particularly valuable when operating in anatomically challenging areas like the neck and thorax.
2. Improved visualization: The high-definition, 3D visualization allows for better identification of critical structures during the procedure.
3. Minimally invasive approach: Despite the complexity of the surgery, the robotic approach typically results in smaller incisions, potentially leading to faster recovery.
4. Better outcomes for challenging reconstructions: The robotic system’s capabilities are particularly beneficial for complex reconstructions such as the pharyngo-gastric anastomosis performed in this case.

A Testament to Advanced Surgical Capabilities

This groundbreaking procedure demonstrates the advanced level of surgical expertise and technological capabilities available at Burjeel Medical City. It also highlights the importance of multidisciplinary collaboration in managing complex cases, as evidenced by the comprehensive care provided to this patient from initial evaluation through to definitive treatment.

The successful performance of the UAE’s first totally robotic three-stage esophagectomy with pharyngo-gastric reconstruction represents not just a milestone for the hospital, but for the entire healthcare landscape of the UAE.

Experts

Introduction

Oral cavity cancer represents a significant health challenge worldwide, with over 350,000 new cases diagnosed annually. Management of advanced cases—particularly those involving the mandible (lower jaw) and adjacent soft tissues—presents formidable surgical challenges that require sophisticated techniques to both eradicate the cancer and restore form and function. Achieving these dual goals demands a delicate balance between oncological radicality and functional-aesthetic reconstruction.

This case study examines the successful surgical management of a locally advanced oral cavity cancer at Burjeel Specialty Hospital in Sharjah, highlighting the complex decision-making process and advanced surgical techniques that enabled both effective cancer treatment and optimal functional reconstruction. The case demonstrates the importance of multidisciplinary collaboration and the application of state-of-the-art microvascular surgical techniques in achieving favorable outcomes for patients with advanced head and neck malignancies.

Understanding Oral Cavity Cancer

Epidemiology and Risk Factors

Oral cavity cancer constitutes a significant proportion of head and neck malignancies globally, with particularly high incidence rates in regions where tobacco chewing, smoking, and alcohol consumption are prevalent. Key risk factors include:

• Tobacco use (smoking and smokeless forms)
• Alcohol consumption
• Chronic irritation from ill-fitting dentures or sharp teeth
• Human papillomavirus (HPV) infection
• Poor oral hygiene
• Genetic predisposition

In the UAE and surrounding regions, the practice of tobacco chewing—often mixed with betel nut, lime, and other substances—remains a significant risk factor for oral cancer, particularly among expatriate populations from South and Southeast Asia.

Pathology and Progression

The vast majority (over 90%) of oral cavity cancers are squamous cell carcinomas (SCCs) that arise from the mucosal lining. These malignancies typically progress through several stages:

1. Early mucosal changes: Often appearing as leukoplakia (white patches) or erythroplakia (red patches)
2. Carcinoma in situ: Malignant cells confined to the epithelium
3. Invasive carcinoma: Penetration beyond the basement membrane
4. Local advancement: Invasion into adjacent structures (muscle, bone, skin)
5. Regional spread: Metastasis to regional lymph nodes
6. Distant metastasis: Spread to distant organs (less common in oral SCC)

When oral SCCs involve the lower alveolus (tooth-bearing portion of the mandible), they frequently invade the underlying bone, necessitating segmental mandibulectomy as part of the surgical treatment.

Case Presentation

Patient Profile

Mr. Sarwar Ali Khan, a 57-year-old male with a significant history of tobacco chewing, presented to Dr. Prasanta Kumar Dash, Medical Oncologist at Burjeel Specialty Hospital, with a chief complaint of a non-healing ulcer on the left side of his cheek that had been present for approximately 12 months. The patient worked as a driver for a government organization in Dubai.

Clinical Findings

Physical examination revealed:

• A locally advanced cancerous lesion invading the lower jaw bone and involving the overlying skin
• The lesion measured approximately 3×3 cm
• A discharging sinus was present on the left side of the cheek
• No clinically palpable significant lymphadenopathy

Diagnostic Workup

The following investigations were performed:

1. Biopsy: Revealed moderately differentiated squamous cell carcinoma
2. Contrast-Enhanced CT (CECT) scan of the neck: Confirmed the locally advanced nature of the malignancy
3. PET-CT scan: Corroborated the findings of the CECT and helped rule out distant metastasis
4. Previous imaging review: A CT scan performed in India three months earlier (September) showed a significantly smaller lesion, indicating rapid disease progression

Based on these findings, the patient was diagnosed with locally advanced left-sided oral cavity cancer (cT4a N1 M0) with invasion of the mandible and overlying skin.

Multidisciplinary Approach

Tumor Board Discussion

The case was presented and discussed in a multidisciplinary tumor board involving physicians and oncologists from across the Burjeel network. After thorough deliberation of the diagnostic findings and consideration of various treatment options, the board unanimously recommended proceeding with surgical resection as the primary treatment modality.

This decision was based on several factors:

• Locally advanced disease amenable to surgical resection
• Absence of distant metastasis
• The aggressive progression of the disease over a short period
• The involvement of critical structures (mandible and skin) necessitating en bloc resection

Treatment Planning

Based on the tumor board recommendation, a comprehensive surgical plan was developed that included:

1. Composite resection: Involving a segment of the left mandible with wide mucosal and skin margins
2. Modified radical neck dissection: On the left side to address regional lymphatics
3. Microvascular free fibula flap: For bone and soft tissue reconstruction
4. Consideration for adjuvant therapy: Based on final histopathological findings

This complex surgical plan required careful coordination between multiple surgical specialists, including head and neck surgeons, plastic surgeons, and anesthesiologists.

Surgical Management

Procedure Details

The surgery was performed on January 6, 2024, at Burjeel Specialty Hospital in Sharjah by a multidisciplinary team led by Dr. Mohammed Basheeruddin Inamdar (Surgical Oncologist) and Dr. Rajkumar CBD (Plastic Surgeon), with support from Dr. Satish V. (ENT Surgeon) and Dr. Mohammed Eid Ali (Anesthesiologist).

The procedure consisted of several key components:

1. Tumor Resection

A complex composite resection was performed, including:

• Segmental mandibulectomy from the left first premolar to the retromolar trigone
• Wide excision of oral mucosa with appropriate margins
• Excision of involved overlying skin
• Modified radical neck dissection on the left side

2. Microvascular Free Flap Harvest and Preparation

Simultaneously, a fibula free flap was harvested from the patient’s leg:

• The fibula bone was contoured to match the resected mandibular segment
• A skin paddle was included with the flap to replace the resected oral mucosa and external skin
• The peroneal vessels (artery and vena comitantes) were meticulously dissected for microvascular anastomosis

3. Microvascular Reconstruction

The harvested free flap was positioned and secured in the defect:

• The fibula bone was shaped and fixated to recreate the mandibular contour
• Microvascular anastomosis was performed between:
  • The facial artery and peroneal artery
  • Two vena comitantes and branches of the jugular veins
• These anastomoses were completed using an operating microscope with precise suturing techniques
• The soft tissue components of the flap were inset to replace the resected oral mucosa and skin

Despite the complexity of the procedure, the operation was completed successfully with a duration of approximately 11 hours and minimal blood loss (300ml). No blood transfusion was required.

Technical Challenges and Considerations

The surgical management of this case involved several significant challenges:

1. Three-Dimensional Planning

The resection and reconstruction required meticulous three-dimensional planning to ensure:

• Complete tumor removal with clear margins in all dimensions (bone, mucosa, and skin)
• Precise shaping of the fibula to match the native mandibular contour
• Appropriate positioning of the skin paddle to replace both intraoral and external defects

2. Microvascular Expertise

The success of free flap reconstruction depends critically on the technical expertise of the microsurgical team:

• Vessel selection and preparation for anastomosis
• Precise microvascular suturing under high magnification
• Ensuring adequate blood flow to the transferred tissue
• Careful positioning to prevent vessel kinking or compression

3. Aesthetic and Functional Considerations

Beyond oncological clearance, the surgical team had to address:

• Mandibular continuity for chewing function
• Oral competence for speech and swallowing
• External facial appearance
• Minimal donor site morbidity

Outcomes and Follow-up

Immediate Postoperative Course

The patient’s immediate postoperative course was uneventful, with:

• Stable vital signs
• Good flap perfusion
• Appropriate pain control
• No evidence of complications

Histopathological Findings

The final histopathology report confirmed:

• Moderately differentiated squamous cell carcinoma
• Clear surgical margins
• Lymph node status consistent with preoperative staging

Long-term Prognosis

The complete resection with clear margins provides the patient with the best chance for long-term survival and disease control. Following this type of comprehensive surgical management, patients typically undergo:

• Regular clinical follow-up to monitor for recurrence
• Adjuvant therapy if indicated by pathological findings
• Rehabilitation for speech and swallowing as needed
• Dental rehabilitation in preparation for potential implants

Discussion

Significance of the Case

This case exemplifies several important aspects of contemporary head and neck cancer management:

1. Integrated Multidisciplinary Care

The successful outcome resulted from seamless collaboration between:

• Medical oncology for initial assessment and staging
• Surgical oncology for tumor resection
• Plastic surgery for complex reconstruction
• Anesthesiology for perioperative management
• Pathology for diagnostic confirmation and margin assessment

This integrated approach ensures comprehensive patient care from diagnosis through treatment and rehabilitation.

2. Advanced Reconstructive Techniques

The use of microvascular free tissue transfer represents the gold standard for complex head and neck reconstruction:

• Fibula free flaps provide both bone for mandibular reconstruction and soft tissue for mucosal/skin replacement
• Vascularized bone has superior healing properties compared to non-vascularized grafts
• The robust blood supply allows for better healing in previously irradiated fields
• Long-term outcomes show better functional and aesthetic results compared to other reconstructive methods

3. Evolving Standards of Care

This case reflects current best practices in advanced oral cancer management:

• Primary surgical resection for operable disease
• Immediate reconstruction to restore form and function
• Consideration of quality of life alongside oncological outcomes
• Risk-adapted adjuvant therapy based on pathological findings

Broader Clinical Implications

This case has several important implications for the broader field of head and neck oncology:

1. Importance of Early Detection

The rapid progression of this patient’s disease over just three months underscores the critical importance of early detection and intervention in oral cavity cancers. Public health initiatives focused on:

• Awareness of oral cancer signs and symptoms
• Regular dental examinations with oral cancer screening
• Education about risk factors, particularly tobacco cessation
• Prompt biopsy of suspicious oral lesions

Could significantly improve outcomes by facilitating diagnosis at earlier, more treatable stages.

2. Accessibility of Advanced Care

The successful execution of this complex procedure at Burjeel Specialty Hospital in Sharjah demonstrates the growing accessibility of advanced surgical techniques in the region. This has important implications for:

• Patient retention within regional healthcare systems
• Reduction in medical tourism for complex care
• Development of local surgical expertise and training opportunities
• Overall improvement in regional cancer care standards

3. Technical Advancement in Reconstructive Surgery

The integration of microvascular techniques into head and neck reconstruction represents a significant technical advancement that has revolutionized outcomes for patients with advanced disease:

• Before free flap techniques, reconstruction options were limited and often yielded suboptimal functional and aesthetic results
• Microvascular techniques have expanded the scope of resectable disease by providing reliable reconstruction for even the most complex defects
• Continued refinement of these techniques promises even better outcomes in the future

Future Directions

Technological Advancements

Several emerging technologies may further enhance the management of complex oral cavity cancers:

1. Virtual Surgical Planning

Computer-aided design and manufacturing (CAD/CAM) technology allows for:

• Precise preoperative planning of resection and reconstruction
• Custom cutting guides for both mandible resection and fibula osteotomies
• Patient-specific reconstruction plates that perfectly match the planned reconstruction
• Reduced operating time and improved accuracy

2. Intraoperative Navigation

Similar to GPS systems in vehicles, surgical navigation enables:

• Real-time tracking of instruments relative to the patient’s anatomy
• Enhanced precision in tumor resection
• Verification of reconstruction accuracy
• Especially valuable in complex three-dimensional reconstructions

3. Advances in Flap Monitoring

Newer technologies for postoperative flap monitoring include:

• Implantable Doppler probes for continuous blood flow assessment
• Near-infrared fluorescence angiography for real-time perfusion evaluation
• Smartphone-based photoplethysmography for nurse-driven monitoring
• These technologies can enable earlier detection of vascular compromise and improve flap salvage rates

Treatment Paradigms

Evolving treatment paradigms in oral cancer management include:

1. De-intensification Strategies

For appropriately selected patients:

• Reduction in the extent of surgery when possible
• Selective neck dissection approaches
• Risk-stratified adjuvant therapy
• These approaches aim to maintain oncological outcomes while reducing treatment-related morbidity

2. Immunotherapy Integration

The role of immunotherapy in head and neck cancer continues to evolve:

• Currently established in recurrent/metastatic disease
• Emerging data for neoadjuvant and adjuvant applications
• Potential for combination with conventional treatments
• May ultimately change the treatment landscape for advanced oral cancers

Conclusion

This case of locally advanced oral cavity cancer successfully managed at Burjeel Specialty Hospital in Sharjah exemplifies the power of multidisciplinary collaboration and advanced surgical techniques in addressing complex oncological challenges. The combination of radical tumor resection and sophisticated microvascular reconstruction enabled both cancer control and functional rehabilitation for a patient with aggressive disease.

The case highlights the importance of timely intervention, comprehensive treatment planning, and technical expertise in achieving optimal outcomes. It also demonstrates the growing accessibility of world-class cancer care within the UAE, reducing the need for patients to travel abroad for complex procedures.

For healthcare providers, this case underscores the value of specialized training in advanced surgical techniques and the benefits of multidisciplinary tumor boards in treatment planning. For patients with advanced oral cancers, it offers hope that even extensive disease can be effectively treated with approaches that prioritize both oncological clearance and functional reconstruction.

As technologies and treatment paradigms continue to evolve, the management of complex head and neck cancers will likely become even more refined, potentially leading to improved survival rates and quality of life for affected patients.

Introduction

Diaphragmatic hernias represent a significant surgical challenge, particularly when they are large, contain multiple organs, and result from previous trauma. These uncommon conditions occur when abdominal contents herniate into the thoracic cavity through a defect in the diaphragm, potentially compromising both respiratory and digestive functions. While congenital forms like Bochdalek and Morgagni hernias are well-recognized, traumatic diaphragmatic hernias (TDH) are less common and may present with delayed symptoms years after the initial injury.

This case study explores the successful surgical management of a complex post-traumatic diaphragmatic hernia at Burjeel Hospital in Sharjah, highlighting the multidisciplinary approach required to address this challenging condition. The case is particularly notable for the large size of the defect, the extensive organ herniation, and the rare associated finding of absent pericardium.

Understanding Traumatic Diaphragmatic Hernias

Etiology and Pathophysiology

Traumatic diaphragmatic injuries occur in approximately 0.8-8% of patients with blunt thoracoabdominal trauma, most commonly from motor vehicle accidents. The injury typically results from sudden increases in intra-abdominal pressure during trauma, causing the diaphragm to rupture at its weakest points. Left-sided ruptures are more common (approximately 75% of cases) due to the protective effect of the liver on the right hemidiaphragm.

The natural history of undiagnosed diaphragmatic injuries often follows three distinct phases:

1. Acute phase: Immediately following injury, marked by respiratory distress and other trauma-related symptoms
2. Latent phase: A period of minimal or absent symptoms that may last for months to years
3. Obstructive or strangulation phase: When herniated abdominal contents become incarcerated or strangulated, leading to acute symptoms

The progressive nature of these hernias results from the pressure gradient between the abdominal and thoracic cavities, which gradually enlarges the defect and promotes herniation of abdominal contents into the thorax.

Clinical Implications

Untreated diaphragmatic hernias can lead to serious complications:

• Respiratory compromise: Due to compression of lung tissue and mediastinal shift
• Gastrointestinal obstruction: When herniated bowel becomes obstructed
• Strangulation: Compromised blood supply to herniated organs
• Pleural effusion: Accumulation of fluid in the pleural space
• Cardiac dysfunction: From compression or displacement of the heart

Early diagnosis and surgical repair are essential to prevent these potentially life-threatening complications.

Case Presentation

Patient Profile

A 29-year-old male presented to Burjeel Hospital in Sharjah with complaints of abdominal pain and difficulty breathing that significantly affected his daily activities. These symptoms had persisted for approximately two years without improvement, despite various treatments. Notably, the patient reported a history of blunt trauma to the chest and abdomen from a motor vehicle accident, which had occurred prior to the onset of his symptoms.

Clinical Presentation

The patient described progressive shortness of breath, particularly with exertion, and intermittent abdominal discomfort. Physical examination revealed decreased breath sounds over the left hemithorax and abdominal tenderness, raising suspicion for a thoracoabdominal pathology.

Diagnostic Workup

Initial investigations included:

1. Chest X-ray: Revealed elevation of the left hemidiaphragm with abnormal gas shadows in the left thoracic cavity
2. CT scan of the abdomen and chest: Demonstrated a large defect in the left hemidiaphragm with herniation of multiple abdominal organs into the left thoracic cavity, including:
   • Spleen
   • Stomach
   • Large portions of the colon
3. Additional findings: The CT scan also showed significant atelectasis (collapse) of the left lung due to compression by the herniated abdominal contents

Based on these findings and the patient’s history of trauma, a diagnosis of post-traumatic diaphragmatic hernia was established.

Surgical Management

Preoperative Planning

After thorough discussion of the case with the patient and his family, the decision was made to proceed with surgical repair. Given the complexity of the case, a multidisciplinary surgical team was assembled, including:

• General surgeons
• Thoracic surgeons
• Anesthesiologists

The surgical approach was carefully planned, taking into consideration the chronicity of the hernia, the size of the defect, and the multiple organs involved.

Surgical Approach

The surgical team, led by Dr. Mohamed Eraki (Consultant of General and Laparoscopic Surgery), Dr. Imtiaz Ahmed and Dr. Taj Mohamed (Consultant Thorax Surgeons), opted for a combined thoracoabdominal approach to ensure optimal exposure and management of both abdominal and thoracic components of the hernia.

The procedure consisted of:

1. Initial abdominal laparotomy: To access the abdominal cavity and assess the condition of the herniated organs
2. Left lateral thoracotomy: To provide direct access to the diaphragmatic defect and thoracic cavity
3. Comprehensive exploration: Of both cavities to identify all anatomical abnormalities

Intraoperative Findings

The surgery revealed several significant findings:

1. Large diaphragmatic defect: Confirming the preoperative imaging
2. Extensive herniation: The spleen, stomach, and large portions of the colon were found within the left thoracic cavity
3. Redundant diaphragm: The remaining diaphragmatic tissue was abnormally loose and stretched
4. Absent pericardium: A rare associated congenital anomaly was discovered, with absence of the pericardial sac
5. Compressed left lung: The lung was significantly atelectatic but otherwise viable

Surgical Technique

The surgical team performed several key steps:

1. Organ reduction: Carefully reducing the herniated abdominal organs (spleen, stomach, and colon) back into the abdominal cavity
2. Assessment of viability: All herniated organs were thoroughly examined and found to be viable with no signs of ischemia or strangulation
3. Diaphragmatic repair: Multiple rows of plication (folding and suturing) of the redundant diaphragm were performed from both the thoracic and abdominal approaches
4. Chest drainage: Placement of thoracic drains to evacuate air and fluid
5. Layered closure: Of both the thoracotomy and laparotomy incisions

Postoperative Care

Following the procedure, the patient was transferred to the Intensive Care Unit for close monitoring. Key aspects of postoperative management included:

• Respiratory support and monitoring
• Pain management
• Early mobilization
• Gradual resumption of oral intake

The patient’s recovery was uneventful, with progressive improvement in respiratory function and resolution of abdominal symptoms. After an appropriate period of monitoring, the patient was discharged from the hospital in good health.

Discussion

Surgical Considerations

This case highlights several important surgical considerations in the management of complex diaphragmatic hernias:

1. Approach Selection

The choice of surgical approach is critical in complex diaphragmatic hernias:

• Transthoracic approach: Provides excellent exposure of the diaphragm and thoracic cavity, allowing direct visualization of the hernia and any adhesions to thoracic structures
• Transabdominal approach: Offers better access to abdominal organs and facilitates their reduction and assessment
• Combined approach: As used in this case, provides comprehensive access to both cavities in complex cases

For large, chronic hernias with multiple herniated organs, the combined approach offers significant advantages, despite increased surgical trauma.

2. Repair Technique

Several options exist for diaphragmatic reconstruction:

• Primary repair: Direct suturing of the defect, possible when there is sufficient healthy tissue
• Plication: Folding and suturing of redundant diaphragm to restore tension and function
• Mesh reinforcement: Use of prosthetic or biologic materials for large defects with insufficient tissue
• Muscle flap reconstruction: In cases of extensive tissue loss

In this case, the redundant nature of the diaphragm allowed for effective plication without the need for prosthetic materials, which minimizes the risk of infection and erosion into adjacent structures.

3. Management of Associated Anomalies

The finding of an absent pericardium in this case represents a rare association that required no specific intervention but demonstrates the importance of thorough intraoperative exploration and readiness to address unexpected findings.

Clinical Relevance

This case underscores several clinically relevant points:

1. Delayed Presentation

The two-year interval between the traumatic event and definitive diagnosis highlights the often indolent course of traumatic diaphragmatic injuries. Healthcare providers should maintain a high index of suspicion in patients with a history of thoracoabdominal trauma who present with respiratory or gastrointestinal symptoms, even years after the initial injury.

2. Diagnostic Challenges

Diaphragmatic hernias can be challenging to diagnose, particularly when symptoms are nonspecific. CT imaging has emerged as the gold standard for diagnosis, providing detailed information about the defect size, location, and herniated contents.

3. Multidisciplinary Approach

The successful management of this complex case required collaboration between general surgeons, thoracic surgeons, and anesthesiologists. This multidisciplinary approach ensured comprehensive assessment and treatment of both thoracic and abdominal components of the hernia.

4. Long-term Outcomes

Complete resolution of the patient’s symptoms following surgical repair confirms that even long-standing diaphragmatic hernias can be successfully treated with appropriate surgical intervention. Early diagnosis and repair remain preferable to prevent complications, but even delayed repair can provide excellent outcomes.

Conclusion

This case illustrates the successful surgical management of a complex post-traumatic diaphragmatic hernia with multiple herniated organs and an associated congenital anomaly. Through a carefully planned combined thoracoabdominal approach, the surgical team at Burjeel Hospital in Sharjah was able to reduce the herniated contents, repair the diaphragmatic defect, and restore normal anatomy and function.

For clinicians, this case emphasizes the importance of maintaining awareness of diaphragmatic injuries in patients with a history of thoracoabdominal trauma, even when presentation is delayed. The case also highlights the value of advanced imaging in diagnosis and the benefits of a multidisciplinary surgical approach in complex cases.

For patients suffering from undiagnosed diaphragmatic hernias, this case offers hope that even long-standing, complex hernias can be successfully treated with appropriate surgical intervention, resulting in significant improvement in symptoms and quality of life.

Experts

Introduction

Sciatica—characterized by radiating pain from the lower back down the leg along the sciatic nerve distribution—affects millions of people worldwide and is a common cause of disability and decreased quality of life. The traditional understanding of sciatica has centered primarily around structural causes, particularly herniated discs and spinal stenosis mechanically compressing nerve roots. However, emerging evidence suggests that in some cases, sciatic pain may occur in the absence of visible structural compression on imaging studies, pointing to alternative mechanisms that are biochemical rather than mechanical in nature.

This case study explores the successful diagnosis and treatment of chemical radiculopathy, a fascinating yet underrecognized cause of sciatica, highlighting how advanced interventional pain management techniques can provide significant relief even when conventional imaging suggests no obvious mechanical compression.

Understanding Chemical Radiculopathy

Beyond Mechanical Compression

The conventional wisdom in spine medicine has long held that sciatic pain results primarily from physical compression of nerve roots, typically by herniated disc material or bony overgrowth. However, research has increasingly revealed that inflammation and biochemical irritation of nerve roots can produce identical symptoms even without visible compression on imaging studies.

Chemical radiculopathy occurs when inflammatory mediators from degenerated discs or surrounding structures leak through annular tears (fissures in the disc’s outer fibrous ring) and irritate nearby nerve roots. This represents an early stage of disc degeneration that precedes the development of frank herniation visible on imaging.

The Inflammatory Cascade

Several biochemical substances have been implicated in this inflammatory process:

1. Phospholipase A2: An enzyme found in high concentrations in herniated disc material
2. Cytokines: Particularly tumor necrosis factor-alpha (TNF-α) and interleukins
3. Matrix metalloproteinases: Enzymes involved in disc degeneration
4. Prostaglandins: Inflammatory mediators that sensitize nerve roots to pain
5. Substance P: A neuropeptide involved in pain transmission

These inflammatory mediators can diffuse through annular tears and reach nerve roots without any significant structural displacement of disc material, explaining why some patients exhibit classic radicular symptoms despite minimal findings on imaging studies.

Case Presentation

Patient Profile

The patient was a female athlete in her 40s who was a long-distance runner. She presented with severe lower extremity pain that was more pronounced than her axial (back) pain, suggesting a predominantly radicular component to her symptoms.

Clinical Examination

The physical examination revealed several significant findings:

• Bilateral straight leg raise (SLR) was limited to 30 degrees due to pain
• Inability to bear weight on toes and heels because of pain
• No detectable neurological deficit (normal strength, sensation, and reflexes)
• Clinical pattern strongly suggestive of L5 and S1 nerve root involvement

These findings were consistent with bilateral radiculopathy affecting the L5 and S1 nerve roots, despite the absence of neurological deficits.

Diagnostic Imaging

Magnetic Resonance Imaging (MRI) of the lumbar spine revealed:

• Degenerated and desiccated L5-S1 disc (loss of normal hydration and height)
• Importantly, axial views showed the absence of mechanical compression
• Both exiting nerve roots appeared free from impingement

This created a clinical paradox: the patient had clear symptoms of nerve root irritation, but imaging showed no structural cause for these symptoms.

Interventional Management

Diagnostic-Therapeutic Procedure

Based on the clinical presentation and imaging findings, Dr. Shailendra Chauhan, Consultant in Anesthesia and Pain Management at Burjeel Day Surgery Center, performed a bilateral L5-S1 selective nerve root block under fluoroscopic guidance.

The procedure involved:

1. Precise needle placement at the L5 and S1 nerve roots bilaterally
2. Injection of non-ionic contrast to confirm appropriate spread and the absence of significant mechanical compression
3. Administration of a therapeutic mixture containing lidocaine (a local anesthetic) and Depo-Medrol (a corticosteroid)

Immediate Outcome

The results were dramatic and immediate:

• Complete resolution of pain immediately following the procedure
• Bilateral straight leg raise improved from 30 degrees to 80 degrees
• Restored ability to bear weight on toes and heels
• Significant improvement in overall mobility

This dramatic response to selective nerve root block with anti-inflammatory medication strongly supported the diagnosis of chemical radiculopathy as the underlying cause of the patient’s sciatica.

Discussion

Diagnostic Challenges

Chemical radiculopathy presents several diagnostic challenges:

1. Imaging-Clinical Mismatch: Patients exhibit classic radicular symptoms despite minimal or no compression on imaging.
2. Overlooked Diagnosis: Many practitioners continue to focus exclusively on structural causes visible on imaging, potentially missing chemical causes.
3. Early Intervention: Chemical radiculopathy may represent an earlier stage of disc pathology before structural herniation occurs, offering a window for preventive interventions.

Treatment Implications

Understanding chemical radiculopathy expands the treatment options available to patients with sciatica:

1. Targeted Anti-inflammatory Therapy: Selective nerve root blocks deliver potent anti-inflammatory medications directly to the site of inflammation.
2. Beyond Decompression: In cases where imaging shows no significant compression, pursuing surgical decompression may be unnecessary and unlikely to address the true cause of pain.
3. Annular Repair Techniques: Emerging therapies aimed at sealing annular tears may help prevent leakage of inflammatory mediators.
4. Systemic Anti-inflammatory Approaches: Oral medications, dietary modifications, and lifestyle interventions that reduce systemic inflammation may play a supportive role.

Future Management Plan

For this particular patient, a comprehensive follow-up plan was established:

1. Recommendation to repeat the procedure after 3-4 months if pain recurs
2. Consideration of discography (a diagnostic procedure to identify painful discs) in case of recurrence
3. Possible annuloplasty (a procedure to repair annular tears) if indicated by discography

Clinical Implications

This case highlights several important clinical implications:

Expanded Diagnostic Framework

The recognition of chemical radiculopathy as a cause of sciatica encourages clinicians to move beyond the traditional structure-based paradigm when evaluating patients with radicular symptoms. A more comprehensive approach should include:

1. Thorough clinical examination: Identifying patterns of pain and dysfunction that may suggest radicular involvement even in the absence of neurological deficits
2. Critical interpretation of imaging: Recognizing that “normal” or “minimally abnormal” imaging does not rule out significant radicular pain
3. Diagnostic injections: Utilizing selective nerve root blocks as diagnostic tools to identify pain generators and confirm chemical causes

Therapeutic Options

Understanding chemical radiculopathy expands the therapeutic options available to patients:

1. Targeted injections: Delivering anti-inflammatory medications directly to the site of chemical irritation
2. Pharmacological approaches: Medications specifically targeting neuroinflammation and neuropathic pain mechanisms
3. Avoidance of unnecessary surgery: Preventing surgical interventions that may not address the underlying chemical causes
4. Regenerative approaches: Emerging therapies aimed at improving disc health and repairing annular integrity

Evidence-Based Application

The case underscores the growing clinical evidence that anatomical abnormalities are not always required to cause radiculopathy, and that biochemical etiologies play a significant role in many cases. This paradigm shift is supported by:

1. Basic science research demonstrating the presence of inflammatory mediators in disc material
2. Clinical studies showing successful treatment of radicular pain with anti-inflammatory approaches
3. Observations of patients with clear radicular symptoms despite minimal imaging findings

Conclusion

This case illustrates the importance of considering chemical radiculopathy in the differential diagnosis of patients with sciatic symptoms, particularly when imaging studies fail to demonstrate significant mechanical compression. The dramatic response to selective nerve root block with anti-inflammatory medication in this patient serves as a powerful reminder that pain mechanisms extend beyond simple mechanical models.

For clinicians, this case encourages a broader conceptual framework when evaluating patients with radicular pain, incorporating both structural and chemical etiologies. For patients suffering from sciatica without clear imaging findings, the recognition of chemical radiculopathy offers hope through targeted interventional approaches.

The successful management of this case at Burjeel Day Surgery Center demonstrates the value of a sophisticated, mechanism-based approach to pain diagnosis and treatment, ultimately leading to improved outcomes and quality of life for patients with complex pain conditions.

Experts

Introduction

Ischemic colitis represents a significant challenge in gastrointestinal surgery, particularly when complicated by multiple perforations. This condition occurs when blood flow to the colon is reduced to a level insufficient to maintain normal cellular function, leading to inflammation and potentially tissue death. While ischemic colitis is more commonly seen in elderly patients with atherosclerotic disease, its occurrence in younger individuals is rare and often associated with unusual underlying conditions.

This case study presents the successful emergency management of a 32-year-old male patient with severe ischemic colitis complicated by multiple colonic perforations at Burjeel Hospital in Sharjah. The case highlights the importance of prompt recognition, appropriate diagnostic workup, and decisive surgical intervention in managing this potentially fatal condition.

Understanding Ischemic Colitis

Pathophysiology

Ischemic colitis results from inadequate blood flow to the colon, which can occur through several mechanisms:

1. Occlusive disease: Blockage of arteries or veins by thrombi, emboli, or external compression
2. Non-occlusive ischemia: Low flow states due to systemic hypoperfusion, vasospasm, or shunting
3. Venous thrombosis: Impaired venous drainage leading to congestion and secondary arterial insufficiency

The colon is particularly vulnerable to ischemia due to its relatively precarious blood supply, especially at the “watershed” areas where different vascular territories meet, such as the splenic flexure and rectosigmoid junction.

Clinical Presentation

The presentation of ischemic colitis varies widely depending on the severity and extent of ischemia:

• Mild cases: May present with crampy abdominal pain, urgency, and bloody diarrhea
• Moderate cases: More severe pain, peritoneal signs limited to the affected area, and systemic inflammatory response
• Severe cases: Peritonitis, septic shock, and multi-organ failure due to transmural necrosis and perforation

Etiology

While atherosclerosis is the most common underlying cause in elderly patients, other potential etiologies include:

• Cardiac arrhythmias and low output states
• Vasculitis and hypercoagulable states
• Medications (vasoconstrictors, estrogens, danazol)
• Vascular interventions and surgery
• Coagulopathies (inherited or acquired)
• Mechanical obstruction of mesenteric vessels

Case Presentation

Patient Profile and Initial Presentation

A 32-year-old male patient presented to the Emergency Department at Burjeel Hospital, Sharjah, with complaints of recurrent attacks of abdominal pain accompanied by vomiting. The pain was generalized but with particular tenderness in the left side of the abdomen. This was an unusual presentation for a young adult male without significant past medical history.

Initial Diagnostic Workup

The patient was admitted for further evaluation. Magnetic Resonance Imaging (MRI) of the abdomen revealed diffuse multifocal areas of wall edema with mild wall thickening and surrounding fat stranding involving the descending colon. These areas showed mild enhancement on post-contrast images. The radiological features suggested colitis, and a colonoscopy was recommended for further evaluation.

Initial Management and Clinical Course

The patient was started on medical management, including intravenous fluids, bowel rest, and appropriate antibiotics. He showed clinical improvement and was discharged after three days of inpatient treatment.

However, the improvement was short-lived. Just five days after discharge, the patient returned to the Emergency Department with severe abdominal pain and generalized tenderness, suggesting a significant deterioration in his condition.

Advanced Imaging and Preoperative Diagnosis

A contrast-enhanced CT scan of the abdomen and pelvis was performed urgently. The scan revealed a clustered loop of small bowel (jejunal loops) with bowel loops located lateral and anterior to the ascending colon, associated with a pulled branch of mesenteric vessels. There was evidence of a possible defect in the mesentery. These findings suggested the possibility of a transmesenteric (internal) hernia.

Based on the patient’s clinical deterioration and the concerning CT findings, the decision was made to proceed with emergency surgery.

Surgical Management

Operative Findings

The patient underwent emergency laparotomy, which revealed critical findings not fully appreciated on preoperative imaging:

1. Free fluid in the peritoneal cavity, indicative of peritonitis
2. Multiple areas of necrosis and perforation affecting several segments of the colon:
   • Hepatic flexure
   • Transverse colon
   • Part of the descending colon

These findings represented a severe case of ischemic colitis with multiple perforations, a life-threatening condition requiring immediate intervention.

Surgical Procedure

Given the extent and severity of the colonic involvement, the surgical team led by Dr. Mohamed Eraki, Consultant General and Laparoscopic Surgeon and Head of the Surgery Department at Burjeel Hospital, Sharjah, performed the following procedure:

1. Extended Colectomy: Resection of the affected bowel segments, including the ascending colon, transverse colon, and part of the descending colon
2. Temporary Stoma Creation: A right-sided colostomy was created to divert the fecal stream
3. Mucous Fistula: A left-sided mucous fistula was fashioned from the distal bowel segment
4. Thorough Lavage: The abdominal cavity was thoroughly irrigated to reduce bacterial contamination
5. Drainage: Two large drains were placed to monitor for potential postoperative complications

Postoperative Care

Following surgery, the patient was transferred to the Intensive Care Unit for close monitoring and management of potential septic complications. The postoperative course was successful, with gradual recovery of bowel function and overall clinical improvement. The patient was eventually discharged from the hospital in stable condition.

Diagnostic Investigation and Case Conclusion

Following recovery, a comprehensive workup was initiated to identify the underlying cause of this unusual case of ischemic colitis in a young adult. After detailed investigations, it was discovered that the patient had a congenital coagulopathy (a hereditary blood clotting disorder), which was determined to be the most likely etiology for his ischemic colitis.

This finding highlighted the importance of considering uncommon causes of ischemia in younger patients without traditional risk factors for vascular disease. Congenital coagulopathies can create a hypercoagulable state, predisposing to thrombosis in the mesenteric vessels and subsequent ischemic damage to the bowel.

Discussion

Clinical Significance

This case illustrates several important clinical points:

1. Atypical Presentation: Ischemic colitis in young adults is rare and should prompt investigation for unusual underlying causes such as hypercoagulable states, vasculitis, or vascular anomalies.
2. Diagnostic Challenges: The initial presentation and imaging findings were suggestive of colitis but did not immediately reveal the severity of the condition. The patient’s rapid deterioration after initial improvement highlights the potentially progressive nature of ischemic bowel disease.
3. Surgical Decision-Making: The case demonstrates the critical importance of timely surgical intervention in cases of suspected bowel ischemia. Delaying surgery when peritoneal signs are present can significantly increase morbidity and mortality.
4. Role of Extended Colectomy: In cases of extensive colonic ischemia with multiple perforations, extended colectomy with temporary diversion is often necessary to control sepsis and remove all compromised tissue.

Congenital Coagulopathy and Ischemic Colitis

The association between congenital coagulopathies and ischemic colitis merits special attention. Various hereditary thrombophilias can predispose to arterial and venous thrombosis in the mesenteric circulation:

• Factor V Leiden mutation
• Prothrombin gene mutation
• Protein C or S deficiency
• Antithrombin III deficiency
• Hyperhomocysteinemia

In patients with these conditions, even minor reductions in mesenteric blood flow that might be well-tolerated in individuals with normal coagulation can trigger a cascade of thrombosis, ischemia, and tissue necrosis. This underscores the importance of considering hereditary thrombophilias in the differential diagnosis of ischemic colitis, particularly in younger patients without other risk factors.

Surgical Approach to Ischemic Colitis with Perforation

The surgical management of ischemic colitis with perforation follows several key principles:

1. Control of Contamination: Removing the perforated bowel and lavaging the peritoneal cavity to reduce bacterial load and minimize septic complications.
2. Complete Resection of Non-Viable Tissue: Ensuring all ischemic segments are removed, often requiring assessment of tissue viability through direct inspection, assessment of bleeding at cut edges, and sometimes intraoperative Doppler assessment.
3. Damage Control Strategy: In critically ill patients, a staged approach may be necessary, with initial resection and diversion followed by later restoration of intestinal continuity once the patient is stabilized.
4. Temporary Fecal Diversion: Creating a stoma to protect any anastomosis or to simplify the initial procedure when the patient is unstable. This is often essential in cases of fecal peritonitis to prevent further contamination.

In this case, the extended colectomy with end stoma and mucous fistula creation represents the application of these principles, prioritizing the patient’s survival in a life-threatening situation.

Postoperative Considerations

Short-term Management

Following surgery for ischemic colitis with multiple perforations, several aspects of care are critical:

1. Hemodynamic Stabilization: Maintaining adequate perfusion to prevent further ischemic damage to other organs
2. Broad-Spectrum Antibiotics: Continued administration to control polymicrobial intra-abdominal infection
3. Nutritional Support: Early initiation of nutrition to support wound healing and immune function
4. Thromboprophylaxis: Given the underlying hypercoagulable state, appropriate anticoagulation is essential once bleeding risk is controlled
5. Stoma Management: Early involvement of stoma care specialists to optimize adaptation and prevent complications

Long-term Planning

Once recovered from the acute event, several considerations come into play:

1. Investigation and Management of Underlying Coagulopathy: Detailed hematological evaluation and long-term management plan, potentially including anticoagulation therapy
2. Restoration of Intestinal Continuity: Assessment for potential stoma reversal and colocolonic or ileocolonic anastomosis, typically considered after 3-6 months
3. Surveillance: Regular follow-up to monitor for recurrent ischemia or other complications
4. Quality of Life Considerations: Addressing the psychological and social impact of temporary or permanent stoma

Future Perspectives

Advancements in Diagnostics

Earlier diagnosis of ischemic colitis could potentially prevent the severe complications seen in this case. Several emerging modalities may help in this regard:

1. Biomarkers: Intestinal fatty acid binding protein (I-FABP), citrulline, and D-lactate have shown promise as early markers of intestinal ischemia
2. Advanced Imaging: CT angiography protocols specifically optimized for mesenteric vasculature can improve detection of early ischemic changes
3. Colonoscopic Assessment: Early endoscopic evaluation with modalities like narrow-band imaging might improve visualization of mucosal ischemic changes

Therapeutic Innovations

Evolving therapeutic approaches that may improve outcomes in ischemic colitis include:

1. Endovascular Interventions: Balloon angioplasty or stenting of mesenteric vessels in cases of occlusive disease
2. Novel Anticoagulants: Direct oral anticoagulants may offer advantages over traditional therapy for patients with thrombophilia
3. Targeted Therapies: Agents specifically addressing the inflammatory cascade in ischemia-reperfusion injury

Conclusion

This case of ischemic colitis with multiple perforations in a young patient with underlying congenital coagulopathy illustrates the importance of considering uncommon etiologies in atypical presentations. The successful outcome highlights the value of prompt surgical intervention with appropriate resection and temporary diversion in managing this life-threatening condition.

For clinicians, this case reinforces several key lessons:

1. Ischemic colitis should be included in the differential diagnosis of acute abdominal pain even in younger patients without typical risk factors
2. Rapid deterioration can occur in ischemic colitis, necessitating close monitoring and low threshold for surgical intervention
3. Extended colectomy with temporary diversion represents an appropriate damage-control approach in cases with multiple perforations
4. Underlying coagulopathies should be investigated in cases of ischemic colitis without obvious etiology, particularly in younger patients

The successful management of this complex case at Burjeel Hospital Sharjah demonstrates the high level of surgical expertise and comprehensive care available at the institution, enabling effective treatment of rare and life-threatening conditions.

Experts