Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Lipoma of the Small Intestine: A Cause for Intussusception in Adults Wed, 29 Jul 2015 15:36:24 +0000 Intussusception as a cause of intestinal obstruction in adults is rare. There is invariably an underlying pathology which leads to intussusception in adults. A case of intussusception in an adult due to a small intestinal lipoma is presented in view of this association. Ultrasound and CECT may help in a preoperative diagnosis. However early surgical intervention is the mainstay of treatment in order to confirm the diagnosis of the underlying pathology, thereby avoiding misdiagnosis of an underlying cancer. Ketan Vagholkar, Rahulkumar Chavan, Abhishek Mahadik, and Inder Maurya Copyright © 2015 Ketan Vagholkar et al. All rights reserved. Multifocal Insulinoma in Pancreas and Effect of Intraoperative Ultrasonography Wed, 29 Jul 2015 13:54:20 +0000 Insulinoma is the most frequently seen functional pancreatic neuroendocrine tumor. The incidence of multifocal insulinoma is lower than 10%. Its treatment is direct or laparoscopic excision. The present case was examined with the findings of hypoglycemia and hypercalcemia, and as there was high insulin and C-peptide levels the initial diagnosis was insulinoma. The case was investigated in terms of MEN 1. During preoperative screening for localization, there was one focus in the head of the pancreas in the abdominal tomography and two foci in endoscopic ultrasonography. No other focus was detected through intraoperative visual or manual palpation. However, five foci were detected during operation by intraoperative ultrasonography. The relation of masses with the main pancreatic canal was evaluated and they were excised by enucleation method. There was no recurrence during the postoperative 18-month follow-up of the patient. As a result, during treatment for insulinoma, it should be kept in mind that there might be multifocal foci. In all insulinomas, the whole pancreas should be evaluated with intraoperative ultrasonography because none of the current preoperative diagnostic methods are as sensitive as manual palpation of pancreas and intraoperative ultrasonography. The intraoperative detection of synchronous five foci in pancreas is quite a rare condition. Ersin Borazan, Alper Aytekin, Latif Yilmaz, Muhsin Elci, Mehmet Salih Karaca, Selim Kervancioglu, and Ahmet Abdulhalik Balik Copyright © 2015 Ersin Borazan et al. All rights reserved. Bilateral Ureteral Obstruction in Children after Appendectomy Wed, 29 Jul 2015 10:16:31 +0000 Acute renal failure due to bilateral ureteral obstruction is a rare complication after appendectomy in children. We report a case of bilateral ureteric obstruction in a 14-year-old boy nine days after surgery for an acute appendicitis. After saline-filling of the urinary bladder, transabdominal ultrasound demonstrated bilateral hydronephrosis of moderate degree. No abscess was found with CT but presence of millimetric stones on both distal ureters was shown, with bilateral calyceal dilatation. Cystoscopy revealed inflammatory changes in the bladder base. Following introduction of bilateral ureteric stents, there was rapid normalisation of urinary output and serum creatinine. M. Grande, G. Lisi, D. Bianchi, P. Bove, R. Miano, A. Esser, F. De Sanctis, A. Neri, S. Grande, and M. Villa Copyright © 2015 M. Grande et al. All rights reserved. The Impact of Radiation on an Unusual Case of Omental Epithelioid Angiosarcoma Tue, 28 Jul 2015 09:40:20 +0000 Epithelioid angiosarcoma is a rare high-grade tumor with irregular vascular morphology. We report an unusual case of intra-abdominal epithelioid angiosarcoma affecting the omentum and peritoneal surfaces resulting in significant hemorrhagic and inflammatory changes. As in other cases of this tumor this patient had previously undergone radiation treatment for a history of cervical cancer. Sumana Narayanan, Mitchell Parker, Jonathan Shayo, Min Zheng, Theodore Matulewicz, and Glenn Parker Copyright © 2015 Sumana Narayanan et al. All rights reserved. Management of a Gastrobronchial Fistula Connected to the Skin in a Giant Extragastric Stromal Tumor Tue, 28 Jul 2015 08:53:29 +0000 Introduction. Gastrointestinal stromal tumors first treatment should be surgical resection, but when metastases are diagnosed or the tumor is unresectable, imatinib must be the first option. This treatment could induce some serious complications difficult to resolve. Case Report. We present a 47-year-old black man with a giant unresectable gastric stromal tumor under imatinib therapy who presented serious complications such as massive gastrointestinal bleeding and a gastrobronchial fistula connected with the skin, successfully treated by surgery and gastroscopy. Discussion. Complications due to imatinib therapy can result in life threatening. They represent a challenge for surgeons and digestologists; creative strategies are needed in order to resolve them. Emilio Muñoz, Fernando Pardo-Aranda, Noelia Puértolas, Itziar Larrañaga, Judith Camps, and Enrique Veloso Copyright © 2015 Emilio Muñoz et al. All rights reserved. A Rare Complication of Biliary Stent Migration: Small Bowel Perforation in a Patient with Incisional Hernia Sun, 26 Jul 2015 14:13:17 +0000 Endoscopic biliary stents have been recently applied with increasing frequency as a palliative and curable method in several benign and malignant diseases. As a reminder, although most of the migrated stents pass through the intestinal tract without symptoms, a small portion can lead to complications. Herein, we present a case of intestinal perforation caused by a biliary stent in the hernia of a patient with a rarely encountered incarcerated incisional hernia. Özkan Yilmaz, Remzi Kiziltan, Oktay Aydin, Vedat Bayrak, and Çetin Kotan Copyright © 2015 Özkan Yilmaz et al. All rights reserved. Single Incision Laparoscopic Cholecystectomy for Gallbladder Duplication Wed, 22 Jul 2015 12:48:54 +0000 Duplication of the gallbladder is a rare congenital anomaly of the gallbladder, with an estimated prevalence of 1–3 per 3800 individuals. Unless properly diagnosed preoperatively, it can lead to biliary tract injuries and postoperative complications which may require reoperative surgeries. While previously reported cases have been treated with conventional laparoscopic cholecystectomy (LC), treatment with single incision laparoscopic surgery (SILS) has not been reported yet. We herein present the case of a 58-year-old female with gallbladder duplication who was successfully treated with SILS cholecystectomy. Esin Kabul Gürbulak, Hamdi Özşahin, Yiğit Düzköylü, Ismail Ethem Akgün, Muharrem Battal, and Bünyamin Gürbulak Copyright © 2015 Esin Kabul Gürbulak et al. All rights reserved. Duodenal Obstruction as First Presentation of Metastatic Breast Cancer Tue, 21 Jul 2015 13:14:05 +0000 The metastatic breast cancer to the duodenum is rare in spite of common breast cancer. In this paper, we are reporting a rare case of 50-year-old lady who presented with intestinal obstruction as result of metastatic breast cancer which completely responds to chemotherapy. The tumor presents again as brain metastasis after stop of Herceptin due to cardiac toxicity. Sami Khairy, Ayman Azzam, Shamayel Mohammed, Kausar Suleman, Abdurahman Khawaji, and Tarek Amin Copyright © 2015 Sami Khairy et al. All rights reserved. Conservative Management of an Iatrogenic Esophageal Tear in Kenya Tue, 14 Jul 2015 11:20:56 +0000 Since its description over 250 years ago, diagnosis of esophageal perforation remains challenging, its management controversial, and its mortality high. This rare, devastating, mostly iatrogenic, condition can quickly lead to severe complications and death due to an overwhelming inflammatory response to gastric contents in the mediastinum. Diagnosis is made with the help of esophagograms and although such tears have traditionally been managed via aggressive surgical approach, recent reports emphasize a shift in favor of nonoperative care which unfortunately remains controversial. We here present a case of an iatrogenic esophageal tear resulting from a routine esophagoscopy in a 50-year-old lady presenting with dysphagia. The esophageal tear, almost missed, was eventually successfully managed conservatively, thanks to a relatively early diagnosis. Peter Waweru and David Mwaniki Copyright © 2015 Peter Waweru and David Mwaniki. All rights reserved. Laparoscopic Repair of Internal Transmesocolic Hernia of Transverse Colon Sun, 12 Jul 2015 09:45:11 +0000 Introduction. Internal hernias are often misdiagnosed because of their rarity, with subsequent significant morbidity. Case Presentation. A 61-year-old Japanese man with no history of surgery was referred for intermittent abdominal pain. CT suggested the presence of a transmesocolic internal hernia. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We found internal herniation of the small intestine loop through a defect in the transverse mesocolon, without any strangulation of the small intestine. We were able to complete the operation laparoscopically. The patient’s postoperative course was uneventful and the patient was discharged on postoperative day 6. Discussion. Transmesocolic hernia of the transverse colon is very rare. Transmesocolic hernia of the sigmoid colon accounts for 60% of all other mesocolic hernias. Paraduodenal hernias are difficult to distinguish from internal mesocolic transverse hernias. We can rule out paraduodenal hernias with CT. Conclusion. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We report a case of a transmesocolic hernia of the transverse colon with intestinal obstruction that was diagnosed preoperatively and for which laparoscopic surgery was performed. Tomokazu Kishiki, Toshiyuki Mori, Yoshikazu Hashimoto, Hiroyoshi Matsuoka, Nobutsugu Abe, Tadahiko Masaki, and Masanori Sugiyama Copyright © 2015 Tomokazu Kishiki et al. All rights reserved. Small Bowel Perforation as a Postoperative Complication from a Laminectomy Wed, 08 Jul 2015 10:49:50 +0000 Chronic low back pain is one of the leading chief complaints affecting adults in the United States. As a result, this increases the percentage of patients that will eventually undergo surgical intervention to alleviate debilitating, chronic symptoms. A 37-year-old woman presented ten hours postoperatively after a lumbar laminectomy with an acute abdomen due to the extraordinarily rare complication of small bowel injury secondary to deep surgical penetration. Robert H. Krieger, Katherine M. Wojcicki, Andrew C. Berry, Warren L. Reuther III, and Kendrick D. McArthur Copyright © 2015 Robert H. Krieger et al. All rights reserved. Extraskeletal Ewing’s Sarcoma Arising from the Sciatic Nerve: A Diagnostic Challenge Wed, 08 Jul 2015 10:32:02 +0000 Ewing’s sarcoma is a common bone tumour of childhood but is a rare occurrence in individuals over 20 years of age. Few cases are reported as originating from peripheral nerves. We present an unusual case of extraosseous Ewing’s sarcoma originating from the sciatic nerve in a 66-year-old patient which had the clinical hallmarks of a benign nerve sheath tumour. Following discussion at a multidisciplinary meeting, excision biopsy of the suspected benign nerve sheath tumour was planned. At operation, the mass had malignant features. Histology confirmed the presence of Ewing’s sarcoma. Due to the morbidity of nerve resection, radiotherapy and chemotherapy were commenced. Ewing’s sarcoma is known to mimic benign pathologies. In this case there were subtle signs of a malignant process in the form of unremitting pain. It is vital to keep in mind the less common tumours that can affect the peripheral nervous system in such cases. Aadhar Sharma, Kate Brown, John Skinner, Jeremy Whelan, and Michael Fox Copyright © 2015 Aadhar Sharma et al. All rights reserved. Extradigital Glomus Tumor of Thigh Wed, 08 Jul 2015 07:27:17 +0000 Glomus tumors are benign neoplasms that arise from neuromyoarterial glomus bodies. They represent around 1–5% of all soft-tissue tumors. High temperature, sensitivity, and pain and localized tenderness are the classical triad of symptoms. Most glomus tumors represent in the subungual area of digits. Extradigital glomus tumors are a very rare entity. There are rare cases of these tumors reported to be in shoulder, elbow, knee, wrist, even stomach, colon, and larynx. We are reporting a case of a glomus tumor on thigh and discuss the histological and immunohistochemical features. Kemal Beksaç, Lutfi Dogan, Nazan Bozdogan, Gulay Dilek, Gokhan Giray Akgul, and Cihangir Ozaslan Copyright © 2015 Kemal Beksaç et al. All rights reserved. Developmentally Delayed Male with Mincer Blade Obstructing the Oesophagus for a Period of Time Suspected to Be 6 Months Wed, 08 Jul 2015 07:11:39 +0000 Introduction. Sharp, retained foreign bodies in the oesophagus are associated with severe complications. Developmentally delayed patients are especially subject to foreign objects. We describe a 37-year-old, developmentally delayed male with a mincer blade obstructing the oesophagus. Six months prior to surgical intervention, the patient was hospitalized in a condition of sepsis and pneumonia where the thoracic X-ray reveals a foreign body in the proximal oesophagus. When rehospitalized 6 months later, a mincer blade of the type used in immersion blenders was surgically removed. During these 6 months the patient’s main symptoms were dysphagia, weight loss, and diarrhoea. When developmentally delayed patients present with dysphagia, we strongly encourage the awareness of the possible presence of foreign bodies. To our knowledge this is the first reported case of a mincer blade in the oesophagus. Christian Grønhøj Larsen and Birgitte Charabi Copyright © 2015 Christian Grønhøj Larsen and Birgitte Charabi. All rights reserved. Use of Methyl Tert-Butyl Ether for the Treatment of Refractory Intrahepatic Biliary Strictures and Bile Casts: A Modern Perspective Tue, 07 Jul 2015 10:09:30 +0000 Cholelithiasis is a prevalent problem in the United States with 14% or more adults affected. Definitive treatment of cholelithiasis is cholecystectomy. When cholecystectomy yields minimal resolution treatment options include expectant management of asymptomatic gallstones or endoscopic retrograde cholangiopancreatogram. We present a case of intrahepatic biliary casts where surgical option was not possible, interventional radiology was unsuccessful, and methyl tert-butyl ether was used to dissolve the biliary obstruction. Dissolution therapy of gallstones was first reported in 1722 when Vollisnieri used turpentine in vitro. While diethyl ether has excellent solubilizing capacity, its low boiling point limited its use surgically as it vaporizes immediately. Diethyl ether can expand 120-fold during warming to body temperature after injection into the biliary system making it impractical for routine use. The use of dissolution is out of favor due to the success of laparoscopic cholecystectomy. Epidemiological studies have shown the general population should have minimal concerns from passive exposure. Dissolution using MTBE remains a viable option if surgical or endoscopic options are not available. However, because of risks involved to both the patient and the staff, careful multidisciplinary team approach must be undertaken to minimize the risks and provide the best possible care to the patient. Gregory Kim, Saninuj N. Malayaman, and Michael Stuart Green Copyright © 2015 Gregory Kim et al. All rights reserved. Locally Advanced, Unresectable Squamous Cell Carcinoma of the Gallbladder Mon, 06 Jul 2015 11:44:02 +0000 Primary squamous cell carcinoma (SCC) of the gallbladder is a rare malignancy of the gallbladder, accounting for less than 5% of gallbladder pathology. Initial presentation is often similar to adenocarcinoma of the gallbladder. SCC tends to be more locally aggressive, however, and possesses a worse prognosis than adenocarcinoma. We report a case of locally advanced SCC of the gallbladder. Timothy J. Weatherall, Moon Fenton, Gitonga Munene, Paxton V. Dickson, and Jeremiah L. Deneve Copyright © 2015 Timothy J. Weatherall et al. All rights reserved. Multiple Bronchogenic and Gastroenteric Cysts Arising from the Stomach in a Patient with Abdominal Pain Sun, 05 Jul 2015 11:34:37 +0000 Bronchogenic cysts arising from the stomach are uncommon. We discuss a young female patient with presumed enteric duplication cysts who was found to have three bronchogenic and gastroenteric cysts upon pathologic review. We discuss the pathophysiology of bronchogenic cysts and their malignant potential. Maykong Leepalao and Jessica Wernberg Copyright © 2015 Maykong Leepalao and Jessica Wernberg. All rights reserved. Achalasia in Pregnancy: Botulinum Toxin A Injection of Lower Esophageal Sphincter Thu, 02 Jul 2015 08:27:50 +0000 Background. Achalasia, a rare esophageal motility disorder that may cause malnutrition during pregnancy, can result in fetal and maternal morbidity and mortality. Many medical treatment regimens are contraindicated or not tolerated during pregnancy, and surgery is generally avoided due to potential risks to the fetus. Case Report. Severe, medically refractory achalasia in a 23-year-old pregnant woman that caused malnutrition was successfully managed by administering a botulinum toxin A injection to the lower esophageal sphincter. The injection was performed at approximately 14 weeks’ gestation and the patient reported clinically significant relief from dysphagia. She gained weight and ultimately delivered a healthy baby girl at term, but her symptoms returned a few months postpartum. She underwent a second treatment of botulinum toxin A injection, but it offered only one month of relief. Roughly eight months after delivery, the patient underwent a laparoscopic extended Heller myotomy and Dor fundoplication. The patient resumed a normal diet one week postoperatively, and her baby has had no complications. Conclusion. This is only the second reported case of botulinum toxin A injection being used to treat achalasia in pregnancy. This treatment proved to be a safe temporary alternative without the risks of surgery and anesthesia during pregnancy. Nicole Hooft, Emily S. Schmidt, and Ross M. Bremner Copyright © 2015 Nicole Hooft et al. All rights reserved. Gastric Cancer in the Excluded Stomach 10 Years after Gastric Bypass Wed, 01 Jul 2015 08:59:49 +0000 According to the Brazilian health authorities, around 2,000 new cases of gastric cancer emerge in Brazil per year (Instituto Nacional de Câncer José Alencar Gomes da Silva, 2014). Indeed, gastric cancer constitutes the second most common cause of cancer-related mortality worldwide and 95% of such malignancies are adenocarcinomas (De Roover et al., 2006, and Clark et al., 2006). Roux-en-Y gastric bypass (RYGB) is a procedure frequently employed in bariatric surgery but restricted access to the excluded stomach means that discovery of gastric lesions is difficult, and diagnosis and treatment may be delayed. We report herein a case of gastric adenocarcinoma in the excluded stomach of a patient submitted to RYGB with the purpose of illustrating the difficulty of diagnosing and treating this rare condition. Augusto Tinoco, Lorena F. Gottardi, and Eduardo D. Boechat Copyright © 2015 Augusto Tinoco et al. All rights reserved. Jejunal Intussusception: A Rare Presentation of Carcinoid Tumor Mon, 29 Jun 2015 07:05:46 +0000 A 55-year-old male presented to the emergency department with sudden onset of diffuse abdominal pain for one day. Physical examination was remarkable for tenderness in the umbilical region. A CT scan of the abdomen showed intussusception involving the jejunum without any mass. The patient then underwent an exploratory laparotomy. During surgery, the distal jejunum was intussuscepted with mesenteric lymphadenopathy. Liver showed nodular deposits in both lobes of the liver. The involved small bowel segment was resected with primary anastomosis and liver was biopsied. Pathological examination showed multifocal deposits of well-differentiated carcinoids in the jejunum. The liver and mesenteric deposits were positive for metastatic carcinoid. Patient recovered well without any complications. Umashankkar Kannan, Amir A. Rahnemai-Azar, Ashish N. Patel, Vinaya Gaduputi, and Ajay K. Shah Copyright © 2015 Umashankkar Kannan et al. All rights reserved. Hemophagocytic Lymphohistiocytosis and Gastrointestinal Bleeding: What a Surgeon Should Know Thu, 25 Jun 2015 06:05:44 +0000 This paper presents to the surgical community an unusual and often ignored cause of gastrointestinal bleeding. Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH) is a rare medical entity characterized by phagocytosis of red blood cells, leucocytes, platelets, and their precursors in the bone marrow by activated macrophages. When intestinal bleeding is present, the management is very challenging with extremely high mortality rates. Early diagnosis and treatment seem to be the most important factors for a successful outcome. We present two cases and review another 18 from the literature. S. Popeskou, M. Gavillet, N. Demartines, and D. Christoforidis Copyright © 2015 S. Popeskou et al. All rights reserved. Primary Dural Spinal Lymphoma Presentation of a Rare Spinal Tumor Case Tue, 23 Jun 2015 09:43:51 +0000 Background. Primary spinal dural lymphomas (PSDL) are tumors with characteristic histopathology of a lymphoma, which are completely in the spinal epidural space without any other systemic involvement. Extranodal primary lymphoma involving nervous system prefers thalamus/basal ganglia, periventricular region, cerebellum, eyes, meninges/dura, and cranial nerves or spinal cord. Rare spinal localization with acute spinal cord compression is worth attention. Case Presentation. A 48-year-old male presented with a several-month-long history of upper back pain. Lately, he had numbness and weakness at both lower extremities and was unable to walk for one week. A spinal MRI showed a thoracic lesion with cord compression at T2–T4 levels. The patient underwent surgical decompression, with his final histopathology showing diffuse large B-cell lymphoma. Systemic work-up was negative for nodal disease. Following surgery, he received radiotherapy combined with chemotherapy. He experienced a good outcome after four years. Conclusion. The upper thoracic cord is a rare location for primary spinal lesions/metastases, both of which prefer the lower thoracic and upper lumbar regions. In cases of progressive paraparesis, there should be immediate surgical intervention in the case of denovo disease, followed by combined radiotherapy and chemotherapy procedures. Dilber Ayçiçek Çeçen, Necati Tatarlı, Hikmet Turan Süslü, Selçuk Özdoğan, and Nagehan Özdemir Barışık Copyright © 2015 Dilber Ayçiçek Çeçen et al. All rights reserved. Application of Intrawound Vancomycin Powder during Spine Surgery in a Patient with Dialysis-Dependent Renal Failure Mon, 22 Jun 2015 10:46:17 +0000 Surgical site infections (SSIs) after spinal surgery are a serious complication that can be minimized with prophylaxis. Vancomycin is a common agent used in the prevention of SSI. Given that vancomycin is renally cleared, its use requires careful observation in dialysis-dependent patients due to toxicity at supratherapeutic levels. Since minimum inhibitory concentrations (MICs) for vancomycin have increased due to the emergence of resistant pathogens, the use of vancomycin in such patients is further complicated. Local instillation of vancomycin powder is thought to provide additional protection against SSI and have lower systemic absorption. We present a patient with end-stage renal disease that developed progressively debilitating cervical spondylotic myelopathy necessitating multilevel laminectomy and instrumented fusion. Prior to closure, 1 gram of vancomycin powder was sprinkled into the surgical incision. Postoperative serum vancomycin levels were well below those associated with nephrotoxicity and ototoxicity. Based on this experience, we reviewed the relevant guidelines that were designed to prevent postoperative infections in such dialysis-dependent patients. Intrawound application of vancomycin may be a legitimate and safe option for SSI prophylaxis in patients with renal failure on dialysis. Jackson Kim, Shane M. Burke, Evan Qu, Steven W. Hwang, and Ron I. Riesenburger Copyright © 2015 Jackson Kim et al. All rights reserved. A Rare Case of a Primary Squamous Cell Carcinoma of the Stomach Presenting as a Submucosal Mass Sun, 21 Jun 2015 09:15:34 +0000 We report a case of a 70-year-old man, with a status after aortic valve replacement, who presented with melena and hypotension. On physical examination, he was hypotensive, but he responded to resuscitation. Esophagogastroduodenoscopy revealed a submucosal mass in the gastric fundus. Imaging of the chest, abdomen, and pelvis showed no evidence of local or distant metastasis. He underwent a partial diaphragmatic resection, gastrectomy, lymphadenectomy, and Roux-en-Y esophagojejunostomy. Pathology showed a gastric squamous cell carcinoma (SCC) invading the diaphragm, with negative margins of resection, and one positive perigastric lymph node. He received chemoradiation, but the patient expired 27 months after surgery. Wolf von Waagner, Zhuo Wang, and Antonio I. Picon Copyright © 2015 Wolf von Waagner et al. All rights reserved. A Case of Transient Local Anesthetic Induced Bilateral Vocal Cord Palsy Wed, 17 Jun 2015 11:56:23 +0000 We report a rare case of bilateral vocal cord palsy following total thyroidectomy with successful extubation within 12 hours. The patient is a 33-year-old lady who underwent uneventful total thyroidectomy for compressive symptoms. Thirty minutes after extubation, she developed stridor and the flexible laryngoscopy showed bilaterally adducted vocal cords. The patient, thus, was reintubated and after 12 hours she met the extubation parameters and so she was extubated successfully. The repeated flexible laryngoscopy showed normal vocal cords. A review of the literature revealed limited information on this transient condition. M. Rafiq, U. Al-Zoraigi, S. Alzahrani, and Y. Alabdulkarim Copyright © 2015 M. Rafiq et al. All rights reserved. Gallbladder Volvulus Presenting as Acute Appendicitis Mon, 15 Jun 2015 13:19:59 +0000 We encountered a case of gallbladder volvulus in an 88-year-old thin female in which the initial presentation was more consistent with that of acute appendicitis. After complete work-up, including physical exam, lab work, and computed tomography, the definite diagnosis of gallbladder volvulus was not made until intraoperative visualization was obtained. Gallbladder volvulus is a rare but serious condition, which requires a high clinical suspicion so prompt surgical intervention can be undertaken. Zachary Bauman, John Ruggero, and John Lim Copyright © 2015 Zachary Bauman et al. All rights reserved. Autologous Fat Grafting Improves Facial Nerve Function Mon, 08 Jun 2015 13:18:49 +0000 We describe the case of a 45-year-old male patient who presented a retractile and painful scar in the nasolabial fold due to trauma which determined partial motor impairment of the mouth movements. We subsequently treated him with autologous fat grafting according to Coleman’s technique. Clinical assessments were performed at 5 and 14 days and 1, 3, and 6 months after surgical procedure and we observed a progressive release of scar retraction together with an important improvement of pain symptoms. A second procedure was performed 6 months after the previous one. We observed total restoration of mimic movements within one-year follow-up. The case described confirms autologous fat grafting regenerative effect on scar tissue enlightening a possible therapeutic effect on peripheral nerve activity, hypothesizing that its entrapment into scar tissue can determine a partial loss of function. Marco Klinger, Andrea Lisa, Fabio Caviggioli, Luca Maione, Matteo Murolo, Valeriano Vinci, and Francesco Maria Klinger Copyright © 2015 Marco Klinger et al. All rights reserved. Primary Amyloidosis Manifesting as Cholestatic Jaundice after Laparoscopic Cholecystectomy Sun, 07 Jun 2015 11:42:33 +0000 A 71-year-old female patient with cholelithiasis who had undergone laparoscopic cholecystectomy was admitted with obstructive jaundice (total bilirubin ~6 mg/dL) three months later. An ERCP was performed, in which a gallstone was found, followed by a sphincterotomy and cleansing of the bile duct. Due to deterioration of jaundice (>25 mg/dL), a new, unsuccessful ERCP and stent placement was carried out. Because of ongoing cardiac failure, she underwent an echocardiogram which revealed restrictive cardiomyopathy possibly due to amyloidosis. A liver biopsy was performed, which was positive for amyloid deposits in the liver, and the diagnosis was confirmed by the detection of monoclonal λ IgG protein in urine. The patient’s jaundice gradually deteriorated and she died one week later from hepatic insufficiency. Evangelos P. Misiakos, George Bagias, Dina Tiniakos, Konstantinos Roditis, Nick Zavras, Ioannis Papanikolaou, Panagiotis Tsirigotis, Theodore Liakakos, and Anastasios Machairas Copyright © 2015 Evangelos P. Misiakos et al. All rights reserved. Dropped Gallstones Causing a Perihepatic Abscess and Empyema Tue, 02 Jun 2015 11:25:25 +0000 Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a well-known occurrence; however, the consequences of spillage of gallstones in the peritoneum and particularly intrathoracic complications are less defined. We describe the delayed development of a perihepatic abscess and empyema in a patient five years following laparoscopic cholecystectomy secondary to dropped gallstones. A 53-year-old man with medical history significant for a laparoscopic cholecystectomy five years prior to acute cholecystitis presented with purulent cough, hemoptysis, night sweats, and right-upper quadrant (RUQ) pain. Computed tomography (CT) scan revealed 5.4 cm right-sided subpulmonic and 5.9 cm perihepatic fluid collections with an 8 mm focal radiopaque density within the perihepatic fluid collection. Open intra-abdominal exploration resulted in retrieval of a 1 cm intraperitoneal gallstone. Laparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, causing both intra-abdominal and intrathoracic complications, presenting even years after surgery. This necessitates an attempt to retrieve all free intra-abdominal gallstones during the initial operation. J. R. Robinson, J. K. Wright, and S. K. Geevarghese Copyright © 2015 J. R. Robinson et al. All rights reserved. Filiform Polyposis Secondary to Colonic Tuberculosis Presenting as Acute Colo-Colonic Intussusception Sun, 31 May 2015 08:01:59 +0000 Filiform polyposis represents a rare but recognised manifestation on the varied spectrum of histopathology in colonic tuberculosis. We report a case of filiform polyposis secondary to colonic tuberculosis presenting as colo-colonic intussusception diagnosed on an abdominal computed tomography (CT) scan. The patient required urgent hemicolectomy and defunctioning ileostomy. Examination of the resected bowel lesions revealed filiform polyposis. Induced sputum samples from the patient grew Mycobacterium tuberculosis. The patient recovered well from the surgery and received treatment for tuberculosis. At last follow-up, he was awaiting the reversal of his ileostomy. The protean nature of histological findings in colonic tuberculosis and other current diagnostic challenges are discussed. The importance of maintaining a high index of suspicion for colonic tuberculosis and instituting early treatment is highlighted in this case. Jacob S. Heng, Alan Baird, Marco R. Novelli, Robert N. Davidson, and Rajinder P. Bhutiani Copyright © 2015 Jacob S. Heng et al. All rights reserved.