Focal nodular hyperplasia (FNH) is a benign liver lesion that is most often asymptomatic and does not require surgical intervention. Rarely, FNH may cause biliary obstruction and stasis, which can lead to intrahepatic gallstone (hepatolithiasis) formation. We describe a case of a 44-year-old female patient who was incidentally found to have biliary ductal dilation with an associated malignant-appearing 3.5 cm left liver mass. Workup included contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI). A biopsy was deferred, given the high clinical suspicion. An open anatomic left hepatectomy was performed without complications, and the patient recovered well. Pathology demonstrated a 3.5 cm FNH with extensive intrahepatic cholelithiasis but no malignancy. Despite high-quality preoperative imaging, FNH could not be distinguished from intrahepatic cholangiocarcinoma, underscoring the diagnostic challenge posed by atypically presenting benign hepatic lesions. Surgical resection was indicated, given the biliary obstruction, stone burden, and radiologic suspicion for malignancy, and was performed safely with favorable outcomes.

Lynch syndrome, an autosomal dominant disorder caused by defective DNA mismatch repair genes, is linked to early-onset colorectal, ovarian, gastric, urinary tract and, less commonly, small bowel, biliary and pancreatic cancers. We present a case of a man in his late 50s who presented with obstructive jaundice due to a biliary hilar mass with a history of urothelial malignancy requiring surgical intervention. Family history revealed colon cancer in mother and brother both below the age of 50 years. He underwent curative resection and reconstruction. Histopathology confirmed hilar cholangiocarcinoma. Due to suspicion of Lynch syndrome, microsatellite instability and mismatch repair gene mutation testing were performed, which confirmed loss of nuclear expression of MSH2/MSH6, hence confirming the diagnosis of Lynch syndrome. This enabled the decision to treat with immunotherapy for recurrence and also conduct family screening. In spite of the absence of colonic tumours, Lynch syndrome should be suspected in young patients with multiple tumours, particularly when supported by a relevant family history.

Currarino syndrome is a rare congenital disorder characterized by a triad of sacral agenesis, presacral mass, and anorectal malformation. Although it is typically diagnosed in infancy or childhood, adult presentation is rare and poses unique diagnostic and surgical challenges. We present the case of a 45-year-old woman diagnosed with Currarino syndrome during pregnancy after incidental discovery of a presacral mass associated with tethered spinal cord and sacral agenesis. Over time, the mass enlarged, causing rectal obstruction and abdominal pain. A combined neurosurgical and gastrointestinal surgical approach was used to perform tethered cord release and mass resection without cerebrospinal fluid leakage, owing to autologous omental flap placement. There were no postoperative complications except for transient urinary retention and numbness in the left foot. Adult cases of Currarino syndrome require individualized, multidisciplinary surgical management. A combined neurosurgical and gastrointestinal surgical approach, incorporating preventive techniques such as autologous omental flap placement, can result in favorable outcomes with minimal complications.

Background Endoscopic ultrasound-guided hepatico-gastrostomy (EUS-HGS) enables internal biliary drainage via the stomach in patients with altered anatomy, inadequate left hepatic duct drainage, or duodenal obstruction. The technically demanding procedure is only performed at expert centers in the Netherlands. Most available evidence originates from selected cohorts, overestimating real-world outcomes. We evaluated outcomes of EUS-HGS in a nationwide cohort. Methods This nationwide retrospective cohort study included all patients in the Netherlands who underwent EUS-HGS attempts between 2009 and 2025, outside of prospective studies. The primary outcome was technical success. Secondary outcomes included clinical success, complications, time to recurrent biliary obstruction (RBO), and overall survival. Results A total of 107 procedures in 105 patients were analyzed (median age: 68 years [IQR: 59-76]; 55%: male). Technical success was achieved in 77% (81/105). Failures were due to absence of a safe puncture tract ( n = 7), unsuccessful bile duct puncture ( n = 3), inability to achieve deep guidewire insertion ( n = 3), failed fistula formation ( n = 3), or unsuccessful or nonattempted stent placement ( n = 7). Clinical success occurred in 78% of technically successful cases (63/81), corresponding to 60% in intention-to-treat analysis (63/105). Procedural complications occurred in 16/107 (15%), and postprocedural complications in 17/107 (16%). One procedure-related death occurred. RBO occurred in 28% (23/81) during a median follow-up of 61 days [IQR: 23-131]. Median overall survival was 91 days [IQR: 66-155]. Conclusion In this nationwide real-world cohort, technical and clinical success rates of EUS-HGS were modest compared with selected expert series, underscoring the need for prospective studies to improve patient selection, stent strategies, and procedural safety.

Severe esophageal hiatal hernia can hinder endoscopic retrograde cholangiopancreatography (ERCP) by causing gastric looping and unstable duodenoscope advancement. We report a 76-year-old woman with gallbladder cancer, hilar biliary obstruction, and severe mixed-type hiatal hernia. Initial ERCP failed because recurrent looping prevented passage beyond the pylorus. During repeat ERCP, a hydrophilic splinting tube was not anchored in the duodenum but was positioned in the prepyloric stomach to maintain gastric axis reduction, defined as straightening of the looped intrathoracic stomach. This prevented recurrent looping, enabled stable duodenoscope advancement, and allowed transpapillary metal-stent placement, potentially reducing mucosal injury or perforation risk by avoiding duodenal bulb manipulation.

Gallstone ileus secondary to cholecysto-duodenal fistula is a serious and uncommon complication due to cholelithiasis, characterized by mechanical bowel obstruction due to gallstone impaction following a spontaneous biliary-enteric fistula. The case highlights the diagnostic challenge and the importance of clinical evaluation and thorough investigation of the patients.