BackgroundLate presentations of congenital diaphragmatic hernia are rare and differ from the classic neonatal presentation. The association with other congenital malformations in children, mainly intestinal malrotation, is well documented. The diagnosis of this association in adults is very rare, and depends on a high degree of suspicion.Case presentationWe report a case of a 50-year-old female Caucasian patient with a previous history of intestinal malrotation diagnosed in adolescence and treated conservatively. She was referred to the hospital with signs and symptoms of intestinal obstruction. The patient undertook computed tomography that confirmed small bowel obstruction with no obvious cause, and a right subphrenic abscess with right empyema was also present. An exploratory laparotomy was performed that revealed an intestinal malrotation associated with a right gangrenous and perforated Bochdalek hernia. Resection of the affected small bowel, closure of the Bochdalek foramen and the Ladd procedure were carried out.ConclusionThis case shows a rare association of two rare conditions in adults, and highlights the challenge in reaching the diagnosis and management options.

BackgroundGallstone ileus accounts for 1% to 4% of cases of mechanical bowel obstruction, but may be responsible for up to 25% of cases in older age groups. In non-iatrogenic cases, gallstone migration occurs after formation of a biliary-enteric fistula. In fewer than 10% of patients with gallstone ileus, the impacted gallstones are located in the pylorus or duodenum, resulting in gastric outlet obstruction, known as Bouveret’s syndrome.Case presentationWe report an 86-year-old female who was admitted to hospital with a 10-day history of persistent vomiting and prostration. She was in hypovolemic shock at the time of arrival in the emergency department. Investigations revealed a gallstone in the duodenal bulb and a cholecystoduodenal fistula. She underwent surgical gastrolithotomy. Unfortunately, she died of aspiration pneumonia on the fourth postoperative day.ConclusionThis case shows the importance of considering Bouveret’s syndrome in the differential diagnosis of gastric outlet obstruction, especially in the elderly, even in patients with no previous history of gallbladder disease.

Keywords:Breast cancer One-step nucleic acid amplification Sentinel lymph node Non-sentinel lymph node metastasis Axillary lymph node dissection Total tumor load a b s t r a c t Background: This study aimed to determine the relationship between CK19 mRNA copy number in sentinel lymph nodes (SLN) assessed by one-step nucleic acid amplification (OSNA) technique, and nonsentinel lymph nodes (NSLN) metastization in invasive breast cancer. A model using total tumor load (TTL) obtained by OSNA technique was also constructed to evaluate its predictability. Methods: We conducted an observational retrospective study including 598 patients with clinically T1-T3 and node negative invasive breast cancer. Of the 88 patients with positive SLN, 58 patients fulfill the inclusion criteria. Results: In the analyzed group 25.86% had at least one positive NSLN in axillary lymph node dissection. Univariate analysis showed that tumor size, TTL and number of SLN macrometastases were predictive factors for NSLN metastases. In multivariate analysis just the TTL was predictive for positive NSLN (OR 2.67; 95% CI 1.06e6.70; P ¼ 0.036). The ROC curve for the model using TTL alone was obtained and an AUC of 0.805 (95% CI 0.69e0.92) was achieved. For TTL >1.9 Â 10 5 copies/mL we got 73.3% sensitivity, 74.4% specificity and 88.9% negative predictive value to predict NSLN metastases. Conclusion: When using OSNA technique to evaluate SLN, NSLN metastases can be predicted intraoperatively. This prediction tool could help in decision for axillary lymph node dissection.