Vol 44 # 4 December 2012 - Kma.org.kw

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331 Double Appendix: Report of a Case December 2012 Wallbridge [6] modified Cave’s [5] original classification of duplicated vermiform appendix into three types as follows: A: Partial duplication of the appendix on a single cecum B: Single cecum with two completely separate appendices B1: “Bird-like appendix” called so because of its resemblance to the normal arrangement in birds, where there are two appendices symmetrically placed on either side of the ileo-cecal valve B2: One appendix arises from the usual site on the cecum, with another rudimentary appendix arising from the cecum along the line of the tenia at varying distance from the first C: Two ceca, each bearing its own appendix Though majority of the cases are diagnosed at surgery or on postmortem examination, some of the cases can be picked up preoperatively on barium enema. Peddu et al reported an incidental finding of Type B1 double appendix by barium enema in a 73-year-old man who was investigated for the rectal bleeding [7] . In such cases the patient may be informed about the abnormality; however the role of conventional / laparoscopic appendectomy for the removal of the asymptomatic double appendix has not been welldefined. Although preoperative diagnosis could be made with the aid of radiological studies such as a barium enema, in cases associated with duplication of colon, the majority of cases have been diagnosed at surgery or upon pathological examination [8] . The present case represents type B2 of appendicular duplication, thought to represent the persistence of the “transient appendix”. Duplication of the vermiform appendix must be distinguished from a solitary diverticulum of the cecum [5,6] . True double appendices have lymphoid tissue and muscular walls, but a cecal diverticulum does not contain lymphoid tissue and is merely an out-pouching of mucosa and submucosa through a muscular defect [5,6] . In the current case, there were two separate appendices which were proved microscopically. Some cases of double appendix are associated with intestinal, genitor-urinary or vertebral malformation [8,9] . We should be aware of these possible malformations and the patient should be explored for the same at time of operation. The risk of associated malformation seems to be greater in young children, especially those with type B1 and C malformations [9] . In our present case, double appendix was incidentally found while performing laparoscopic appendectomy and we did not find any other gastrointestinal congenital anomalies like intestinal duplications that were commonly associated with double appendix. But she had other anomalies like scoliosis and skin lesions which were recorded for further notification with double appendix in the future. Kothari et al [3] reported duplex appendix in association with imperforate anus [3] . In patients with double appendix, when only a single appendix is found to be inflamed on exploration or laparoscopy, both the appendices should be removed so as to avoid diagnostic confusion that may arise on removal of a single appendix [10] . To the best of our knowledge, surgical management for the double appendix is same as the conventional / laproscopic appendectomy. No literature describes any unique technique for double appendix differently. However, one should explore for the possible associated malformation. In the current case, only the bigger and longer appendix was inflamed, however we removed both the appendices including the smaller noninflamed one. CONCLUSION Double appendix is extremely rare. Surgical residents should be aware of the possibility of duplication of appendix to avoid missing double appendix and its medico-legal consequences. REFERENCES 1. Chew DK, Borromeo JR, Gabriel YA, Holgersen LO. Duplication of the vermiform appendix. J Pediatr Surg 2000; 35:617-618. 2. McNeill SA, Rance CH, Stewart RJ. Fecolith impaction in a duplex vermiform appendix: An unusual presentation of colonic duplication. J Pediatr Surg 1996; 31:1435- 1437. 3. Kothari AA, Yagnik KR, Hathila VP. Duplication of vermiform appendix. J Postgrad Med 2004; 50:285-286. 4. Kelly HA, Hurdon E. Anatomy: The vermiform appendix and its diseases. Philadelphia: WB Saunders 1905:55-74. 5. Cave AJ. Appendix vermiformis duplex. J Anat 1936; 70:283-292. 6. Wallbridge PH. Double appendix. Br J Surg 1962; 50:346- 347. 7. Peddu P, Sidhu PS. Appearance of a Type B duplex appendix on barium enema. Br J Radiol 2004; 77:248- 249. 8. Kabay S, Yucel M, Yaylak F, et al. Combined duplication of the colon and vermiform appendix in an adult patient. World J Gastroenterol 2008; 14:641-643. 9. Gilchrist BF, Scriven R, Nguyen M, Nguyen V, Klotz D, Ramenofsky ML. Duplication of the vermiform appendix in gastroschisis. J Am Coll Surg1999; 189:426. 10. Lin BC, Chen RJ, Fang JF, Lo TH, Kuo TT. Duplication of the vermiform appendix. Eur J Surg 1996; 162:589-591.
December 2012 KUWAIT MEDICAL JOURNAL 332 Case Report Oncocytic and Clear Cell Areas in a Solid Pseudopapillary Tumor of the Pancreas: A Case Report Anuradha C K Rao, Manna Valiathan, Padmapriya Jaiprakash Department of Pathology, Kasturba Medical College, Manipal, Karnataka, India Kuwait Medical Journal 2012; 44 (4): 332 - 334 ABSTRACT Solid pseudopapillary tumor (SPT) of pancreas is a rare, distinct, low-grade malignant neoplasm. Variable areas like clear cell foci can exist in this tumor, which can easily mislead the pathologist. Diagnosis of the same is important to distinguish from other clear cell lesions in the pancreas. Oncocytoid differentiation is rarer still and can raise doubts about the diagnosis, especially on trucut biopsies. Herein, we discuss a case of SPT of the pancreas exhibiting variable cellular morphology, of which very few cases have been reported in world literature. KEY WORDS: oncocytic, pancreas, solid pseudopapillary tumor INTRODUCTION Solid pseudopapillary tumor (SPT) is an uncommon, low-grade malignant neoplasm accounting for 1% of all exocrine pancreatic tumors. Exact histogenesis of this tumor remains uncertain [1] . As the various names for the tumor suggest, it is a solid and cystic pancreatic neoplasm with characteristic pseudopapillae and sheets of intermediate and small sized polygonal cells with minimal morphological deviation. Herein, we report a case of oncocytic variant of this tumor on account of its rarity and the few cases reported till date. CASE HISTORY A 29-year-old lady presented to the surgical outpatient department, with a history of swelling in the upper abdomen of one month duration, which was not associated with pain, vomiting or abdominal distention. Patient had a past history of exploratory laparotomy 10 years ago, for palliative gastrojejunostomy and enterostomy in view of biopsy reported as suspected neuroendocrine tumor of pancreas, which, however, was not removed. On examination, a firm to hard mass of 10 x 7 cm, moving with respiration was palpated in the left hypochondrial region. All routine laboratory investigations were within normal range except an ESR of 40. Ultrasound abdomen was normal and upper GI endoscopy revealed extraluminal compression on stomach. A CT-scan revealed a cystic neoplasm arising from the head of pancreas and a clinical diagnosis of cystic neoplasm of mucinous origin of pancreas was made, in view of which the patient underwent Whipple’s pancreatectomy. Post-operative period was uneventful and the patient was discharged on the tenth post-operative day. The patient had no fresh complaints on follow-up after two months. However, she presented with amenorrhea after four months, post-operatively. On ultrasonography, polycystic ovaries were detected and she was advised for weight reduction. The patient was lost to follow-up after that. Pathological findings Gross: The tumor was well-demarcated, nodular and unencapsulated, weighing 911 grams and measuring 16 x 11 x 10 cm. Cut section showed a multiloculated cystic tumor with variegated appearance comprising grey-white, friable irregular solid areas, yellow areas and hemorrhagic foci and peripheral rim of pancreatic tissue. Microscopy: Sections showed a well demarcated but unencapsulated tumor composed of sheets and trabeculae of loosely cohesive polygonal cells with central ovoid nuclei, few with eccentrically placed nuclei and finely stippled or granular chromatin. Focal clear cell areas (Fig. 1) were identified with abundant cytoplasmic, PAS and mucicarmine negative vacuoles and rare mitotic figures, separated by bands of hyalinised fibrous tissue with myxoid changes. Areas showing solid nests of polygonal cells with abundant eosinophilic granular cytoplasm and central vesicular nucleus with prominent nucleolus were Address correspondence to: Dr Padma Priya J, Assistant Professor, Department of Pathology, Basic Sciences Block, Kasturba Medical College, Manipal 576104, Karnataka, India. E-mail: padmapriya.j@gmail.com
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