Large schwannoma in the ulnar nerve in axilla - A case report

Introduction: Schwannomas are nerve sheath tumours which majority is benign. Only one case of solitary schwannoma in the ulnar branch of brachial plexus in the axilla is so far reported. Some are asymptomatic while others having pain and neurological disability. For diagnosis, imaging studies such as ultrasonography, computerized tomography, magnetic resonance imaging, electromyography and aid of electron microscopy and immunohistochemistry are used. Non-surgical treatment is appropriate for slow growing and asymptomatic tumours. Surgical treatment is aimed to prevent progressive neurological deficit. Damage to the parent nerve is a known complication.Case report: A 44 year old female was investigated for a lump in her left axilla. Ultrasonography showed well defined hypoechoic solid mass, suspicious of an enlarged lymph node in the axilla with normal breasts. Tru-cut biopsy was compatible with histological appearance of schwannoma. A large (7.0x5.5x4.0cm3) well circumcised white mass of tissue arising at the origin of ulnar nerve deep in the left axilla was enucleated. Histologically lesion was compatible with a schwannoma with an intact capsule. Diffusely positive S-100 protein was demonstrated immunohistochemically and malignancy excluded. Post-operatively patient had ulnar nerve palsy confirmed by nerve conduction studies. Hand physiotherapy was offered and nerve function gradually improved.Discussion: Benign schwannoma of the ulnar nerve is not a common condition encountered in general clinical practice, hence delay in diagnosis is of concern. MRI and histology is needed to diagnose schwannoma accurately and to exclude malignancy. Treatment is complete excision while preserving nerve function preferably under intra-operative electrophysiological guidance.

Management of traumatic pancreatic transection – experience in a single surgical unit

Introduction: Pancreatic transection (PT) is a rare entity of pancreatic injury encountered following blunt abdominal trauma. Management of PT is controversial and treatment depends on patient’s injury status, facilities and expertise available for diagnosis and treatment. Isolated PT is a diagnostic challenge. We present four patients with PT following blunt trauma, their management and outcome.Case report: Case-1 A 24-year old male presented four months after blunt trauma to abdomen with a bicycle-handle, with abdominal pain & distension. CT showed pseudocyst communicating with main pancreatic duct and lacerated neck of pancreas. Pancreatic duct was stented at endoscopic-retrograde-cholangio-pancreatography (ERCP) and patient recovered. Case-2 A 26-year old male presented with acute abdomen following road-traffic-accident underwent emergency exploratory laparotomy. PT was initially managed conservatively. Pancreatic duct was stented at ERCP. Patient later developed a pseudocyst and elective distal-pancreatectomy is planned. Case-3 A 26-year old male with acute abdomen following road-traffic-accident underwent exploratory laparotomy at a Provincial General Hospital. PT identified and distal pancreatic segment anastomosed to a jejunal-loop. Patient deteriorated post-operatively and transferred. Re-exploration revealed necrosed distal pancreas with anastomotic leakage. Patient succumbed due to acute severe pancreatitis and multi-organ failure. Case-4 A 27-year old male with acute abdomen following run-over injury underwent exploratory laparotomy and distal pancreatectomy performed. Patient had an uneventful recovery.Discussion: High-index of suspicion is needed for the mechanism of initial injury when diagnosing isolated pancreatic injury which presents late. ERCP is safe and reliable when treating stable patients with PT. Damage control surgery is recommended than reconstructive surgery in unstable patients