Lesser Sac Cystic Lymphangioma: Gastric Outlet Obstruction

Lesser Sac Cystic Lymphangioma: Gastric Outlet Obstruction Cystic Lymhangioma of the Lesser Sac in adult presenting with features of Gastric Outlet Obstruction A Case Report S Suresh Kumar Sri Aurobindo Prasad Das Vikram Kate Running title: Lesser sac cystic lymphangioma causing gastric outlet obstruction Key Words: Abdominal cystic Lymphangioma; Omental Bursa; Outlet Obstruction Article type: Case Report Section (speciality): Surgery- Gastrointestinal Surgery Abstract: Non- Structured (Case Report) ABSTRACT: Background: Cystic lymphangioma is a paediatric benign tumour, occurs commonly in head and neck region. Adult Intraabdominal lymphangiomas are uncommon and only few cases of lesser sac cystic lymphangioma are reported in the literature. Case presentation: We present a case of lesser sac cystic lymphangioma in a 26 year old lady who presented with features of gastric outlet obstruction. Clinical examination of the abdomen revealed 10 x 10 cm firm, non tender, mobile intraabdominal lump in the epigastrium. An upper gastrointestinal endoscopy showed possible external compression at the boy of the stomach. Ultrasound of abdomen demonstrated a multicystic lesion measuring 10.2 X 8 cm, with internal echoes in one locule. Contrast enhanced computed tomography of the abdomen showed a large multiloculated cystic lesion with hyper-dense content in the lesser sac extending up to the left lobe of the liver and indenting the stomach, lesser sac, and upper border of pancreas. On surgical exploration, a 10X8 cm multi cystic lesion with clear fluid was found in the lesser sac very close to the lesser curvature of stomach. The descending branches of left gastric which were found coursing through the cyst were ligated and the cyst was excised in Toto. Histopathological examination of the excised lesion showed features of cystic lymphangioma showing dilated lymphatic vessels with fibro-fatty tissue ingrained in the endothelial lining. Conclusion: Though intraabdominal cystic lymphangiomas are very rare, it should be considered in all atypical cases of gastric outlet obstruction. A reasonable knowledge about these benign lesions will aid in establishing the diagnosis and surgical management. Key Words: Abdominal cystic Lymphangioma; Omental Bursa; Outlet Obstruction Background Lymphagiomas are benign lesions generally occur as a result of lymphatic system malformation and infrequently reported after trauma. 90% of the cases are seen within the first two years of life and symptomatic presentation in adults is very rare. [1] Cystic lymphagiomas commonly involves neck and axilla but can occur anywhere in the body. Though Intraabdominal lymphangioma accounts for Case presentation A 26-year old lady presented to surgical outpatient department with complaints of early satiety, vomiting few hours after food intake and vague fullness of upper abdomen. She also had features of dyspepsia for the past one year. She had developed pain and had a feeling of a mobile lump in the upper abdomen for the past one month. There was no pancreatitis episode before. General physical examination was unremarkable. Clinical examination of the abdomen revealed 10 x 10 cm lump in the epigastrium which was firm in consistency. The lump was non tender, freely mobile and intra-abdominal. Investigations The haemogram and biochemical profiles were within normal limits. An upper gastrointestinal endoscopy was done which showed normal mucosa of stomach with possible external compression at the boy of the stomach. Ultrasound of abdomen was suggestive of a multicystic lesion measuring 10 X 8 cm, with internal echoes in one locule, present superior to pancreas adjacent to the left lobe of the liver. Rest of abdomen was unremarkable. Contrast enhanced computed tomography of the abdomen showed a large multiloculated cystic lesion measuring 10.2 X 8 cm with hyper dense content in some loculi in the lesser sac extending up to the left lobe of the liver and indenting the stomach, lesser sac, and upper border of pancreas with a few branches of left gastric vessels coursing through it. (Figure: 1) Correlating the clinical, USG and CECT abdomen findings a diagnosis of possible lymphangioma was made and the patient was planned for exploratory laparotomy as the symptoms were persisting. Surgical management On surgical exploration, a 10X8 cm multi cystic lesion with clear fluid was found in the lesser sac very close to the lesser curvature of stomach. (Figure: 2) The descending branches of left gastric which were found coursing through the cyst were ligated and the cyst was excised in Toto. (Figure: 3) A drain was placed in lesser sac and abdomen was closed in layers. Outcome and follow- up Postoperative course was uneventful. The drain was removed on the 3nd postoperative day and the patient was discharged on seventh post operative day. Histopathological examination of the excised lesion showed features of cystic lymphangioma showing dilated lymphatic vessels with fibro-fatty tissue ingrained in the endothelial lining. (Figure: 4) Patient was followed up at one month, six months, one year and two year after surgery. On each visit, clinical examination and USG was done which showed no evidence of recurrence. The lady is presently on regular follow up for past 2 years with no evidence recurrence till date. Discussion Intra-abdominal cystic lymphangiomas are uncommon benign tumours that can involve the mesentery, omentum, colon, spleen, pelvis, groin, and retroperitoneum [5, 6]. We had a case of cystic lymphangioma in the lesser sac which is very rare. Cystic lymphangiomas are considered to originate from malformed or malpositioned lymphatic tissue. Factors such as abdominal trauma, inflammatory process, lymphatic obstruction due to radiation therapy or surgery may lead to secondary formation of such tumors. Our patient did not have any of the mentioned inciting factors; the cause was probably congenital which had manifested late in life. Commonly known to present in childhood, lymphagiomas sometimes remain asymptomatic until late adulthood, and are discovered during evaluation of vague and chronic nonspecific symptoms like anorexia, nausea, vomiting, fatigue, and weight loss, which are secondary to mass effect [4]. This was seen in our patient who had early satiety and vomiting after food intake probably due to mass effect and had a vague feeling of mass in the abdomen. Other ways of presentation such as acute abdomen, mimicking acute appendicitis has also been reported [3]. Contrast CT done in our patient revealed multicystic lesion measuring 10.2 X 8 cm, present superior to pancreas, in the lesser sac adjacent to the left lobe of the liver. Cystic lymphangioma usually presents as a large multilocular cystic mass with enhanced walls with multiple thin septa containing uncomplicated fluid on abdominal ultrasonography and contrast enhanced computerized tomography which is very often diagnostic [7]. The differential diagnosis includes cystic lesions of, enteric urogenital or mesothelial origin. Pancreatic pseudocysts from trauma, dermoid cysts or teratomas and cystic degeneration of solid tumours are also to be considered before making this rare diagnosis. Management of intra-abdominal cystic tumours depends on the clinical symptoms, size of the cyst, and the degree of clinical suspicion for malignancy. Imaging usually provides useful information for the planning of treatment. Complete removal of the tumour offers an excellent prognosis and laparoscopic removal of lymphangioma also shown feasible in few reports. We therefore decided to perform a laparotomy and complete excision of the cyst was done. On the other hand, recurrence has been reported in 10% of patients in whom primary resection was incomplete.[9] If the feeding lymphatics are not completely ligated, chylous ascites may also occur. Conclusion: Though intra-abdominal cystic lymphangiomas are very rare, it should be considered in cases of gastric or biliary obstruction where the cause could not be recognized clearly. Reasonable knowledge about these benign lesions will aid in establishing the diagnosis during such instances. Complete surgical excision offers the best chance for cure and should be attempted in all the cases to avoid recurrence. Consent Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor of this journal. Competing interests disclosures The authors have no potential or real conflict of interests The authors have no financial support or ties to disclose The authors have no financial or non financial competing interests to declare Authors contributions Suresh Kumar S, Das S A and Kate V diagnosed and managed the case. Suresh Kumar S, Das S A did the literature search. Suresh Kumar S and Das S A collected the images. Suresh Kumar S and Kate V drafted the manuscript. All authors read and approved the final manuscript. References Hanagiri T, Baba M, Shimabukuro T, Hashimoto M, Takemoto H, Inoue A, Sugitani A, Shirakusa T. Lymphangioma in the small intestine: Report of a case and review of the Japanese literature. Surgery Today 1992; 22: 363-367 Roisman I, Manny J, Fields S, Shiloni E. Intra-abdominal lymphangioma. Br J Surg 1989; 76: 485-489 Benjamin HL Tan, Teegan Lim. Cystic lymphangioma of the lesser sac presenting as acute appendicitis: A case report. Cases J. 2008; 1: 147. Massoud Baghai-Wadji, Azadeh JalalKamali, ToorajReza Mirshekari. Cystic lymphangioma of the lesser sac. Can J Surg. 2006; 49: 292. Fernandez Hurtado I, Bregant J, Mulet Ferragut JF, et al. abdominal cystic lymphangioma. Cir Pediatr. 1998 ; 11: 171-3 Chuang-Wei Chen, Sheng-Der Hsu, Chien-Hua Lin, Ming-Fang Cheng, Jyh-Cherng Yu Cystic lymphangioma of the jejunal mesentery in an adult: A case report. World J Gastroenterol 2005; 11: 5084-5086 Angela D. Levy, Vito Cantisani, Markku Miettinen. Abdominal Lymphangiomas: Imaging Features with Pathologic Correlation. AJR 2004; 182: 1485-1491 8. Kenney B, Smith B, Bensoussan AL. Laparoscopic excision of a cystic lymphangioma. J Laparoendosc Surg. 1996; 6: S99-101. 9. Steyaert H, Guitard J, Moscovici J, Juricic M, Vaysse P, Juskiewenski S: Abdominal cystic lymphangioma in children: benign lesions that can have a proliferative course. J Pediatr Surg 1996, 31:677-680. 1

Jim Crow Laws in to Kill a Mockingbird Essay

Whites Rise, Blacks Fall â€Å"Not only a Finch waiting on tables, but one in the courthouse lawing for n*****s!† (135). This is an insult clearly said by Mrs. Dubose, a fictional character introduced by Harper Lee in To Kill a Mockingbird. It is evident from Mrs. Dubose’s statement that blacks are discriminated against in Maycomb County, Lee’s fictional setting located in Alabama. The â€Å"Jim Crow† laws cause the inequality in the Maycomb community. The laws keep Negros from having the same rights as white citizens: â€Å"She ran to the front porch†¦she’s supposed to go around in back† (124). Scout, another fictional character created by Lee, is stating this. She is referring to the point that their black cook, Calpurnia, is going to the front door of a neighbor’s house instead of the back. The â€Å"Jim Crow† laws plainly explain that no Negro is supposed to go to the front of a white man’s house; blacks have to knock and enter from the back. Lee illustrates that the racial â€Å"Jim Crow† laws enforce segregation on social treatment to blacks and n*****-lovers in To Kill a Mockingbird. Negroes are considered as trash due to the influence of the â€Å"Jim Crow† laws. Mrs. Dubose mentions â€Å"Your father is no better than the n*****s and trash he works for!† to Scout one afternoon. (135). At this point in the story, Scout is almost accustomed to having insults thrown at her, but this is the first one from a mature adult. (136). Due to the â€Å"Jim Crow† laws, blacks and people who try to restore a bit of equality are given ghastly names. Atticus, another fictitious character of Lee and is also Scout’s father, tells Scout that â€Å"n*****-lover is just one of those terms that don’t mean anything–like snot-nose†¦ignorant , trashy people use it when they think somebody’s favoring Negroes over and above themselves. It’s slipped into usage with some people like ourselves, when they want a common, ugly term to label somebody† (144). Negroes and white citizens who do not discriminate against blacks are given the nicknames â€Å"n*****s† and â€Å"n*****-lovers†. Those who try to make life better for a colored citizen are victimized along with the blacks. â€Å"†¦ now he’s turned out a n*****-lover we’ll never be able to walk the streets of Maycomb again† (110) Most of the white population gets to be inhumane whenever blacks are mentioned in a discussion. Atticus does not get â€Å"why reasonable people go stark raving mad when anything involving a  Negro comes up† (117). Many colored citizens do not receive any education because of the â€Å"Jim Crow† laws. â€Å"Atticus said that Calpurnia had more education than most colored folks† (32) Due to the â€Å"Jim Crow† laws, the whites preside and discriminate against the Negros for a very long and dreary period. In Lee’s To Kill a Mockingbird, there is concrete evidence of the effect of the â€Å"Jim Crow† laws on her fictional characters and setting. The blacks in the story are bullied by most of the white population. The segregating laws prevent education for the blacks and regular day-to-day privileges that whites receive. Most of all, the â€Å"Jim Crow† laws counteract fairness and equality.

Corrupt society Essay

In chapter twenty-four we learn that Jaggers treats every human interaction as it was in a court of law. Jaggers made a strong impression on Pip when Pip asked for some money, â€Å"Mr Jaggers never laughed †¦ with his large head bent down and his eyebrows joined together, awaiting an answer, he sometimes caused his boots to creak, as if they laughed in a dry and suspicious way. † This shows that Jaggers is cold and that he hides his emotions. We also learn more information about the casts. Wemmick told Pip, â€Å"These are two celebrated ones. Famous clients of ours that got us a world of credit. † The man was a person that murdered his master and did not get executed. The man then died later in New Zealand. Also, we find out that Wemmick is fond of jewellery. Wemmick gets the jewellery from the executed. â€Å"I always take ’em,† he told Pip, â€Å"Get hold of portable property. † This shows the reader that Wemmick doesn’t mind taking a dead man’s possessions. At the start of chapter twenty-six we see Jaggers washing his hands, â€Å"My guardian was in the room, washing his hands with scented soap. † He did this as he entered the office as if he was washing himself clean of his clients. We also meet Molly (Jaggers’ housekeeper) as Pip is invited to Jaggers’ house for dinner. Molly was once in love with the convict (Magwitch) and turns out to be Estella’s mother. Pip also sees some carved garlands when he enters the house. He says, â€Å"I know what kind of loops they reminded me of. † These loops have many possible meanings. This could mean that Jaggers also takes jewellery from the dead as well as Wemmick. However, these loops could also be the loops of rope that were used to hang the people he worked for. Also, the loops could have been bought using the money from the dead. In chapter fifty-one we learn that Jaggers is not heartless. Pip tells Jaggers that he knows who Estella’s parents are. Jaggers knows that her mother is Molly but does not know who is the father, â€Å"So you know who the young lady’s father, Pip? † Jaggers asks Pip. Estella’s father is Magwitch. Pip then tells Wemmick, â€Å"I know you to be a man with a gentle heart. I have seen your pleasant home, and your old father, and all the innocent cheerful playful ways with which you refresh your business life. † After that Jaggers laugh which is very unlike him. Jaggers realises that Wemmick leads two lives just like himself. Jaggers then tells Pip his side of Estella’s story when he rescues Estella from her mean beginnings. This shows that Jaggers seems to have a conscience and a moral sense. However, this chat was very unprofessional so Jaggers and Wemmick were glad when a poor client walked in and they started to turn on him. Wemmick as Jaggers’ clerk shadows his master and is compared to a pillar box but is very different when he is at home with his old father. He never shows emotions when he is at work as he sees it as being unprofessional and Jaggers would not like it if he showed emotions at work. I think Wemmick is a very emotional man at home but tries to lock up his feelings at work and does a very good job of it. Dickens shows a disillusioned approach to society in which al of the great expectations become false. I think this is because Dickens thinks that society is disillusioned and that great expectations for him personally have never become true. Jaggers works in this society but he tries to keep himself clean from it. I think this is shown greatly in chapter twenty six, â€Å"My guardian was in the room, washing his hands with scented soap. † He is trying to keep himself clean in a dirty society. Charles Dickens wants to do the same and make himself have a better life. This makes Jaggers like Charles Dickens. They both wanted to try to change the world. They both use words and are both powerful. Dickens uses words to state how bad the world is and Jaggers is very blunt when he speaks and always gets to the point. I think Charles Dickens is very much like Jaggers. Charles Dickens is very low at this time. Jaggers’ character of involvement and disengagement with society reflects this. Jaggers is very lonely as he sees most other people to be too poor and lower class than him in a dirty and corrupt society where he feels he does not belong. Charles Dickens was also very lonely with his wife which made him have an affair with Ellen Ternan. The book is about how empty these great expectations turn out to be. Jaggers shows the central idea of what you can do with a corrupt society. Jaggers knows how bad the corrupt society is but he is always trying his best to improve it whatever way he can. Jaggers also becomes powerful as many people are scared of him as he is a very good and powerful lawyer.

Business Plan and Loan Package - 1412 Words

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In 2007, the product cost of goods sold increased from costs incurred 2006 as a result of significant increases in prices of many commodities purchased by Tootsie Roll. These commodities consist of some of the major ingredients used in Tootsie Rolls and other products, such as corn syrup, dextrose, milk products, vegetable oils, sugar, and gum base ingredients (Tootsie Roll Industries, 2011). As a percentage of net sales, product cost of goods sold increased from 62.8% in 2006 to 66.5% in 2007 (Kimmel, Weygandt, amp; Kieso, 2009). Light freight and delivery costs increased as a result of increases in energy costs, such as oil used for fuel. Exchange of foreign currency on products manufactured in Canada has generated an adverse effect as well, even though sales growth has increased. Tootsie Roll Industries, Inc. has made efforts to offset the increases in costs of commodities through selective price increases and reducing costs where possible (Kimmel, Weygandt, amp; Kieso, 2009). 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