Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Uncommon Presentation of Isolated Jejunal Lymphoma Masquerading as Crohn’s Disease Mon, 23 May 2016 11:29:42 +0000 Primary gastrointestinal lymphoma is a rare entity, commonly involving stomach, small bowel, and colorectum. The usual location for small bowel B cell lymphoma is distal ileum due to abundant lymphoid tissue. We are reporting the case of a 53-year-old lady presumptively diagnosed as Crohn’s disease on clinical and radiological grounds but histopathologically proven to be an unusual variant of isolated primary non-Hodgkin’s lymphoma. Swati Sattavan, Lalit Aggarwal, and Priyadarshi Dikshit Copyright © 2016 Swati Sattavan et al. All rights reserved. How to Surgically Remove the Permanent Mesh Ring after the Onstep Procedure for Alleviation of Chronic Pain following Inguinal Hernia Repair Thu, 19 May 2016 12:34:49 +0000 A promising open inguinal hernia operation called Onstep was developed in 2005. The technique is without sutures to the surrounding tissue, causing minimal tension. A specific mesh is used with a memory recoil ring in the border, which may cause pain superficial to the lateral part of the mesh for slender patients. The aim of this study was to illustrate an easy procedure that alleviates/removes the pain. A male patient had persistent pain six months after the Onstep operation and therefore had a ring removal operation. The procedure is presented as a video and a protocol. At the eleven-month follow-up, the patient was free of pain, without a recurrence. It is advised to wait some months after the initial hernia repair before removing the ring, since the mesh needs time to become well integrated into the surrounding tissue. The operation is safe and easy to perform, which is demonstrated in a video. Stina Öberg, Kristoffer Andresen, and Jacob Rosenberg Copyright © 2016 Stina Öberg et al. All rights reserved. Acute Deep Vein Thrombosis in Venous Aneurysm following Closure of the Chronic Traumatic Arteriovenous Fistulae of the Lower Extremities Wed, 18 May 2016 12:30:40 +0000 Chronic traumatic arteriovenous fistula (AVF) commonly results from an unrecognized vascular injury. In this report, there were two cases of chronic traumatic AVF of the legs with a long history of stab (case 1) and shotgun wounds (case 2). Both cases presented with varicose veins together with hyperpigmentation around the ankle of the affected leg. Angiograms showed a single large AVF in case 1, whereas, in case 2, there was a single large AVF together with multiple small AVFs. In both cases large venous aneurysm was found next to a large AVF. An open surgical AVF closure for the large AVF was performed in case 1 successfully, but patient developed acute deep vein thrombosis (DVT) in a large venous aneurysm. In the second case, in order to prevent DVT, only closure of the large AVF was performed, which preserved arterial flow into the venous aneurysm. Case 2 did not have acute DVT. This report raised the concern about acute DVTs in venous aneurysms following the closure of chronic traumatic AVF in terms of prevention. Also chronic traumatic AVF is commonly due to misdiagnosis in the initial treatment, so complete and serial physical examinations in penetrating vascular injury patients are of paramount importance. Saranat Orrapin, Supapong Arworn, and Kittipan Rerkasem Copyright © 2016 Saranat Orrapin et al. All rights reserved. Progressive Dyspnea in a 40-Year-Old Man Caused by Giant Mediastinal Thymolipoma Tue, 17 May 2016 09:11:51 +0000 Thymolipomas are rare tumors of the anterior mediastinum containing both thymic stroma and an abundance of fat. We present a 40-year-old man with no underlying disease who presented with cough and progressive dyspnea. Clinical evaluation revealed a giant mass of lipid density filling almost the entire left hemithorax with mediastinal shift. Total excision of the 40 33 8 cm mass weighing 4 kg was performed via a left thoracotomy and the histopathologic diagnosis of the mass was reported as thymolipoma. The patient remains alive and disease-free, twelve months after the intervention. Mohammad Vaziri and Kamelia Rad Copyright © 2016 Mohammad Vaziri and Kamelia Rad. All rights reserved. Laparoscopic Treatment of Type III Mirizzi Syndrome by T-Tube Drainage Sun, 15 May 2016 06:56:16 +0000 Mirizzi syndrome (MS) is an impacted stone in the cystic duct or Hartmann’s pouch that mechanically obstructs the common bile duct. We would like to report laparoscopic treatment of type III MS. A 75-year-old man was admitted with the complaint of abdominal pain and jaundice. The patient was accepted as MS type III according to radiological imaging and intraoperative view. Laparoscopic subtotal cholecystectomy, extraction of impacted stone by opening anterior surface of dilated cystic duct and choledochus, and repair of this opening by using the remaining part of gallbladder over the T-tube drainage were performed in a patient with type III MS. Application of reinforcement suture over stump was done in light of the checking with oliclinomel N4 injection trough the T-tube. At the 18-month follow-up, he was symptom-free with normal liver function tests. Fahri Yetışır, Akgün Ebru Şarer, H. Zafer Acar, Yılmaz Polat, Gokhan Osmanoglu, Muhittin Aygar, A. Erdinc Ciftciler, and Omer Parlak Copyright © 2016 Fahri Yetışır et al. All rights reserved. A Low-Grade Fibromyxoid Sarcoma of the Internal Abdominal Oblique Muscle Tue, 10 May 2016 13:16:11 +0000 A low-grade fibromyxoid sarcoma (LGFMS) is a rare tumor, with a benign histologic appearance but malignant behavior. This report describes a 74-year-old man with an internal abdominal oblique muscle mass. The tumor appeared as a well-defined ovoid mass on computed tomography, with mild uptake on fluorine-18-fluorodeoxyglucose positron-emission tomography images. Radical resection with wide safe margins was performed. Histologically, the tumor was composed of spindle-shaped cells in a whorled growth pattern, with alternating fibrous and myxoid stroma. MUC4 expression, a highly sensitive and specific immunohistochemical marker for LGFMS, was detected. Therefore, we diagnosed the tumor as LGFMS. At the 3-month follow-up, there was no sign of recurrence or metastasis. We report the first case of LGFMS arising from the internal abdominal oblique muscle. Masakazu Hashimoto, Kei Koide, Michinori Arita, Koji Kawaguchi, Yoshihiro Mikuriya, Jun Iwata, and Toshiyuki Iwamoto Copyright © 2016 Masakazu Hashimoto et al. All rights reserved. Sampson’s Artery Hemorrhage after Inguinal Hernia Repair: Second Case Reported Tue, 10 May 2016 10:45:22 +0000 Sampson artery is normally obliterated in postembryonic development. In rare cases it can remain patent and complicate a routine outpatient herniorrhaphy when severed. This is the second reported case in the available English literature of hemoperitoneum due to bleeding from a patent Sampson’s artery following an open inguinal hernia repair. Joseph Adjei Boachie and Eduardo Smith-Singares Copyright © 2016 Joseph Adjei Boachie and Eduardo Smith-Singares. All rights reserved. Resection and Abdominal Wall Reconstruction of a Desmoid Tumor with Endometrioma Features Tue, 10 May 2016 07:21:00 +0000 Desmoid tumors are rare, musculoaponeurotic mesenchymal origin tumors arising from the proliferation of well-differentiated fibroblasts. Desmoid tumors may arise from any location with the abdominal cavity, abdominal wall and extremity locations being most frequent. We present the case of a 35-year-old female with a history of endometriosis who presented palpable abdominal mass and cyclic abdominal pain. Resection was performed for a presumed desmoid soft tissue tumor. Final pathology demonstrated desmoid histology admixed with abdominal wall endometriosis (endometrioma). This unique pathologic finding has only been rarely reported and is discussed with a brief review of the literature. Jaqueline Majors, Nathaniel F. Stoikes, Reza Nejati, and Jeremiah L. Deneve Copyright © 2016 Jaqueline Majors et al. All rights reserved. A Giant Aggressive Angiomyxoma of the Pelvis Misdiagnosed as Incarcerated Femoral Hernia: A Case Report and Review of the Literature Thu, 05 May 2016 08:09:19 +0000 Aggressive angiomyxoma (AA) is an uncommon mesenchymal tumor that is mostly derived from the female pelvic and perineal regions. AA is a locally infiltrative slow growing tumor with a marked tendency to local recurrence. Painless swelling located around the genitofemoral region is the common symptom; thus, it is often misdiagnosed as a gynecological malignancy or a groin hernia. A 35-year-old female patient who previously underwent surgery for left femoral hernia operation resulting in surgical failure was reoperated for a giant AA located in the pelvis. The tumor was completely excised with free margins. Histopathologic examination revealed an AA. The tumor size was measured as 24 × 12 × 6 cm with a weight of 4.2 kg. Immunohistochemically, the cells show positive staining with vimentin, desmin, estrogen, and progesterone receptor. S100, MUC4, CD34, and SMA were negative in the tumor cells. AA should be considered in the differential diagnosis of any painless swelling located in the genitofemoral region, particularly in women of reproductive age. The principle treatment should be complete surgical excision with tumor-free margins. Long-term follow-up and careful monitoring are essential due to its high tendency of local recurrence in spite of wide excision of the tumor. Adjuvant antihormonal therapy yields promising results for preventing recurrence. Alper Sozutek, Oktay Irkorucu, Enver Reyhan, Kemal Yener, Ali Ayberk Besen, Kivilcim Eren Erdogan, Gulfiliz Gonlusen, and Figen Doran Copyright © 2016 Alper Sozutek et al. All rights reserved. Extraction of a Large Central Airway Foreign Body Using Flexible Bronchoscopy Combined with an Endobronchial Blocker Wed, 04 May 2016 07:42:21 +0000 Adult foreign body (FB) aspiration is an uncommon but potentially fatal event. Options for extraction include flexible bronchoscopy (FLXB), rigid bronchoscopy (RB), and surgical extraction. We report the case of a large, smooth aspirated rock causing airway obstruction in an elderly male. RB is generally the preferred approach for extraction of a large complex FB; however, due to its size, the FB had to be removed using FLXB combined with an endobronchial blocker. In this report, we describe the anesthetic and surgical considerations and the novel technique used to extract the FB. Tyler Paradis, Michael Wollenberg, and Brandon Tieu Copyright © 2016 Tyler Paradis et al. All rights reserved. Vascular Anomalies in Pancreaticoduodenectomy: A Lesson Learned Thu, 21 Apr 2016 13:39:15 +0000 It is essential to identify any variant anatomy prior to surgery as this could have a drastic effect on surgical planning. We describe a case in which two vascular irregularities, an Arc of Buhler and celiac stenosis, were identified on angiogram after completion of a pancreaticoduodenectomy. While there could have been catastrophic results from his surgery in the setting of celiac stenosis, the presence of the aberrant Arc of Buhler allowed this patient to emerge without any permanent morbidity. Joana E. Ochoa, David T. Pointer Jr., and John B. Hamner Copyright © 2016 Joana E. Ochoa et al. All rights reserved. Concurrent Occurrence of Tumor in Colon and Small Bowel following Intestinal Obstruction: A Case Report and Review of the Literature Wed, 20 Apr 2016 09:25:09 +0000 An intestinal obstruction occurs when either the small or large intestine is partly or completely blocked so it prevents passing the food or fluid through the small/large bowel. This blockage is due to the existence of a mechanical obstruction such as foreign material, mass, hernia, or volvulus. Common symptoms include cramping pain, nausea and vomiting, changes in bowel habits, inability to pass stool, and lack of gas. We present a case of an 83-year-old man who had been referred to Taleghani Hospital with symptoms of bowel obstruction. He underwent the surgery. The findings of exploration of the entire abdomen showed two types of mass separately in two different organs. In postoperative workup, pathology reported two types of tumors (adenocarcinoma and neuroendocrine tumors). Seyed Mohammad Reza Nejatollahi and Omid Etemad Copyright © 2016 Seyed Mohammad Reza Nejatollahi and Omid Etemad. All rights reserved. Robotic Compartment-Based Radical Surgery in Early-Stage Cervical Cancer Mon, 18 Apr 2016 07:39:46 +0000 A radical hysterectomy with pelvic lymphadenectomy is the recommended treatment option in patients with early-stage cervical cancer. Although various classifications were developed in order to define the resection margins of this operation, no clear standardization could be achieved both in the nomenclature and in the extent of the surgery. Total mesometrial resection (TMMR) is a novel procedure which aims to remove all components of the compartment formed by Müllerian duct in which female reproductive organs develop. TMMR differs from the conventional radical hysterectomy techniques in that its surgical philosophy, terminology, and partly resection borders are different. In this paper, a TMMR with therapeutic pelvic lymphadenectomy operation that we performed for the first time with robot-assisted laparoscopic (robotic) approach in an early-stage cervical cancer patient was presented. This procedure has already been described in open surgery by Michael Höckel and translated to the robotic surgery by Rainer Kimmig. Our report is the second paper, to our knowledge, to present the initial experience regarding robotic TMMR in the English literature. Tayfun Toptas, Aysel Uysal, Isin Ureyen, Onur Erol, and Tayup Simsek Copyright © 2016 Tayfun Toptas et al. All rights reserved. Primary Hydatid Cyst of Umbilicus, Mimicking an Umbilical Hernia Tue, 12 Apr 2016 16:19:28 +0000 Hydatid cyst caused by Echinococcus granulosus demonstrates an endemic infection in several countries such as Middle Eastern countries. Liver is the most frequently involved organ, followed by the lung. The case we present is solitary primary localization of cyst in abdominal wall which is extremely rare. A 57-year-old woman presented with an abdominal wall lesion in umbilical area that had been evolving for about 2 years with recent complaint of pain and discomfort. We detected a midline abdominal mass centimeters in diameter which was bulged out in umbilicus. Preoperative clinical diagnosis of incarcerated umbilical hernia was made due to its physical examination while surgical exploration disproved the primary diagnosis and we found cystic mass adherent to superficial fascia without any communication to peritoneal space. The cyst was excised completely without any injury or perforation of containing capsule. The diagnosis of hydatid cyst was confirmed by histopathological examination of specimen. The retrograde evaluation showed no involvement of other organs. The patient was followed for two years and no recurrence of hydatid disease has been observed. Hydatid cyst should be considered as a differential diagnosis of abdominal wall and umbilical lesions especially in endemic regions. Mohammadreza Tarahomi, Hamidreza Alizadeh Otaghvar, Nazila hasanzadeh Ghavifekr, Daryanaz Shojaei, Farhood Goravanchi, and Amir Molaei Copyright © 2016 Mohammadreza Tarahomi et al. All rights reserved. A Rare Case of an Early Postoperative Obstructive Ileus in a Young Female Patient due to a Residual Trichobezoar Mass Mon, 11 Apr 2016 08:33:32 +0000 Trichobezoar is a rare cause of small bowel obstruction, whereby a mass forms most commonly in the stomach and duodenum of young females, from ingestion of hair, a condition known as trichophagia. We present a case of recurrent small bowel obstruction due to a residual hair mass that was removed surgically in a young female patient who had a laparotomy and gastrotomy for removal of a large gastric trichobezoar just two weeks prior to the current admission. This case illustrates the importance of a thorough inspection of the whole bowel to ensure that no residual bezoars remain after surgery. P. Christopoulos, S. Ross-Thriepland, H. McCarthy, C. S. Day, and W. Sasi Copyright © 2016 P. Christopoulos et al. All rights reserved. Laparoscopic Management of Acute Pancreatitis Secondary to Rapunzel Syndrome Sun, 10 Apr 2016 09:20:10 +0000 A 17-year-old girl presented with bilious vomiting and abdominal pain to the surgery department. The history was positive for trichotillomania and trichophagia. A CT scan showed a mass in the stomach, which was highly suspicious for a gastric bezoar. Drooping parts of the bezoar caused a duodenal obstruction with secondary acute pancreatitis. The bezoar was removed via a laparoscopically performed gastrotomy. Bijan Koushk Jalali, Alperen Bingöl, and Ashraf Reyad Copyright © 2016 Bijan Koushk Jalali et al. All rights reserved. Round Ligament Leiomyoma Presenting as an Incarcerated Inguinal Hernia: Case Report and Review of the Literature Wed, 06 Apr 2016 09:35:56 +0000 Leiomyomas are common benign gynecologic tumors occurring in up to 30% of women. Round ligament leiomyomas however are very rare and, if symptomatic, can present as an inguinal hernia. We report the case of a 47-year-old woman who presented with an irreducible inguinal mass consistent with an incarcerated hernia. Intraoperatively, the mass was found to be a round ligament leiomyoma, a diagnosis that was confirmed by histopathology following excision of the mass. Although rare, round ligament leiomyomas should be part of the differential diagnosis of an inguinal hernia in females. Marc Najjar and Marc Mandel Copyright © 2016 Marc Najjar and Marc Mandel. All rights reserved. Do the Hydatid Cysts Have Unusual Localization and Dissemination Ways in the Chest Cavity? Tue, 29 Mar 2016 12:36:29 +0000 We wanted to report our two cases of intrathoracic extrapulmonary hydatid cyst in pleural cavity due to its rarity. Our first case is a 24-year-old male patient who was admitted with a cystic mass lesion consistent with hydatid cyst which was incidentally detected in inferior lobe of the right lung neighboring to thoracic wall and diaphragm. Our second case is a 32-year-old male patient who was admitted with chest pain and a cystic lesion in apex of the right hemithorax and intercostal field in basal after he had been medically treated due to hydatid cyst of the dome of the liver for two years. The cysts were removed with thoracotomy. Extrapulmonary intrathoracic hydatid cysts were evaluated with regard to invasion ways and treatment indications and methods. Yucel Akkas, Tevfik Kaplan, Neslihan Gulay Peri, and Bulent Kocer Copyright © 2016 Yucel Akkas et al. All rights reserved. A Rare Presentation of Autonomously Functioning Papillary Thyroid Cancer: Malignancy in Marine-Lenhart Syndrome Nodule Sun, 27 Mar 2016 13:51:11 +0000 Objective. Marine-Lenhart Syndrome (MLS) is defined as concomitant occurrence of autonomously functioning thyroid nodule (AFTN) with Graves’ disease (GD). Malignancy in a functional nodule is rare. We aimed to present an extremely rare case of papillary thyroid cancer in a MLS nodule with lateral lymph node metastases. Case. A 43-year-old male presented with hyperthyroidism and Graves’ ophthalmopathy. On Tc99m pertechnetate scintigraphy, a hyperactive nodule in the left upper thyroid pole was detected and the remaining tissue showed a mildly increased uptake. The ultrasonography demonstrated 15.5 × 13.5 × 12 mm sized hypoechoic nodule in the left upper pole of the thyroid and round lymph nodes on the left side of the neck. Fine needle aspiration biopsy (FNAB) of the nodule and lymph node revealed cytological findings consistent with papillary cancer. Total thyroidectomy with central and left modified radical neck dissection was performed. On pathologic examination, two foci of micropapillary cancer were detected. The skip metastases were present in three lymph nodes on the neck. Conclusion. AFTN can be seen rarely in association with GD. It is not possible to exclude malignancy due to the clinical and imaging findings. In the presence of suspicious clinical and sonographic features, FNAB should be performed. Mehmet Uludag, Nurcihan Aygun, Alper Ozel, Feyza Yener Ozturk, Rabia Karasu, Banu Yilmaz Ozguven, Bulent Citgez, Mehmet Mihmanli, and Adnan Isgor Copyright © 2016 Mehmet Uludag et al. All rights reserved. Idiopathic Thoracic Spontaneous Spinal Epidural Hematoma Mon, 21 Mar 2016 13:28:06 +0000 A 33-year-old male patient experienced temporary sensory loss and weakness in the right lower extremity one month prior to admission. The patient was admitted to a private clinic with a three-day history of acute onset of sensory loss and weakness in both lower extremities and was treated and followed up with a prediagnosis of transverse myelitis and the Guillain-Barre syndrome (GBS). The patient was subsequently transferred to our clinic and the neurologic examination revealed paraplegia in both lower extremities, positive bilateral Babinski signs, and hypesthesia below the T10 dermatome with saddle anesthesia. The patient had urinary incontinence and thoracic magnetic resonance imaging (MRI) showed an image of a mass compressing the medulla. Abdurrahman Aycan, Seymen Ozdemir, Harun Arslan, Edip Gonullu, and Cemal Bozkına Copyright © 2016 Abdurrahman Aycan et al. All rights reserved. Spontaneous Rupture of Pancreatic Pseudocyst: Report of Two Cases Sun, 20 Mar 2016 09:49:44 +0000 Introduction. Pancreatic pseudocysts are a common complication of acute pancreatitis. Pancreatic pseudocyst’s natural history ranges between its spontaneous regression and the settlement of serious complications if untreated, such as splenic complications, hemorrhage, infection, biliary complications, portal hypertension, and rupture. The rupture of a pancreatic pseudocyst to the peritoneal cavity is a dangerous complication leading to severe peritonitis and septic conditions. It requires emergent surgical exploration that is often of great technical difficulty and with important morbidity and mortality. Case Study. We present two cases of spontaneous rupture of pancreatic pseudocysts, managed differently according to the local and systemic conditions. Conclusion. The best surgical choice is the internal drainage of the cyst to the GI tract; however, in some conditions, the external drainage is the only choice available. Ricardo Rocha, Rui Marinho, António Gomes, Marta Sousa, Nuno Pignatelli, Carla Carneiro, and Vitor Nunes Copyright © 2016 Ricardo Rocha et al. All rights reserved. Reresection of Colorectal Liver Metastasis with Vena Cava Resection Sun, 20 Mar 2016 09:32:36 +0000 The best known treatment of the colorectal liver metastasis is the complete surgical excision with clean surgical margins. However, liver resections sometimes cannot appear technically feasible due to the high number of metastases in the liver, in cases of recurrent resections or invasion of the tumors to the major vascular structures or neighboring organs. Here, we presented a colorectal recurrent liver metastasis invading the retrohepatic vena cava, right adrenal gland, and right diaphragm. En masse resection of the tumor with caudate hepatectomy combined with vena cava resection and surrounding adrenal and diaphragm resections was accomplished. Caval reconstruction was done by a 5 cm in length cryopreserved vena cava homograft under isolated caval clamping. Postoperative period was uneventful and she was discharged on day 11. As a conclusion, combined liver and vena cava resection for a recurrent colorectal liver metastasis is a feasible procedure even with additional neighboring organ resections. Isolated vena cava occlusion with the preservation of the hepatic blood flow may decrease the risk of liver injury in case of previous chemotherapy for liver metastasis. Ali Tardu, Cuneyt Kayaalp, Sezai Yilmaz, Kerem Tolan, Veysel Ersan, Servet Karagul, Ismail Ertuğrul, and Serdar Kirmizi Copyright © 2016 Ali Tardu et al. All rights reserved. A Case of Laparoscopic Resection for Carcinoma of the Gastric Remnant following Proximal Gastrectomy Reconstructed with Jejunal Interposition Sun, 13 Mar 2016 07:29:43 +0000 A 72-year-old Japanese man had a history of proximal gastrectomy for early gastric cancer located in the upper third of the stomach in 2007. Our usual treatment strategy for early gastric cancer in the upper third of the stomach in 2007 was open proximal gastrectomy reconstructing by jejunal interposition with a 10 cm single loop. Upper gastrointestinal fiberscopy for annual follow-up revealed a type 0-IIc-shaped tumor with ulcer scar, 4.0 cm in size, located in the gastric remnant near the jejunogastrostomy. A clinical diagnosis of cancer of the gastric remnant, clinical T1b(SM)N0M0, Stage IA, following the proximal gastrectomy was made and a laparoscopic approach was selected because of the cancer’s early stage. Remnant total gastrectomy with D1 plus lymphadenectomy was carried out with five ports by a pneumoperitoneal method. Complete resection of the reconstructed jejunum was undergone along with the jejunal mesentery. Reconstruction by the Roux-en-Y method via the antecolic route was selected. Total operative time was 395 min and blood loss was 40 mL. Our patient was the first successful case of resection for carcinoma of the gastric remnant following proximal gastrectomy reconstructed with jejunal interposition in a laparoscopic approach. Kazuhito Yajima, Yoshiaki Iwasaki, Ken Yuu, Ryouki Oohinata, Misato Amaki, Yoshinori Kohira, Souichiro Natsume, Satoshi Ishiyama, and Keiichi Takahashi Copyright © 2016 Kazuhito Yajima et al. All rights reserved. Combined Endoscopic and Laparoscopic Management of Postcholecystectomy Mirizzi Syndrome from a Remnant Cystic Duct Stone: Case Report and Review of the Literature Mon, 07 Mar 2016 12:47:39 +0000 Mirizzi syndrome has been defined in the literature as common bile duct obstruction resulting from calculi within Hartmann’s pouch or cystic duct. We present a case of a 78-year-old female, who developed postcholecystectomy Mirizzi syndrome from a remnant cystic duct stone. Diagnosis of postcholecystectomy Mirizzi syndrome was made on endoscopic retrograde cholangiography (ERCP) performed postoperatively. The patient was treated with a novel strategy by combining advanced endoscopic and laparoscopic techniques in three stages as follows: Stage 1 (initial presentation): endoscopic sphincterotomy with common bile duct stent placement; Stage 2 (6 weeks after Stage 1): laparoscopic ultrasonography to locate the remnant cystic duct calculi followed by laparoscopic retrieval of the calculi and intracorporeal closure of cystic duct stump; Stage 3 (6 weeks after Stage 2): endoscopic removal of common bile duct stent along with performance of completion endoscopic retrograde cholangiogram. In addition, we have performed an extensive review of the various endoscopic and laparoscopic management techniques described in the literature for the treatment of postcholecystectomy syndrome occurring from retained cystic duct stones. Arpit Amin, Yuriy Zhurov, George Ibrahim, Anthony Maffei, Jonathan Giannone, Thomas Cerabona, and Ashutosh Kaul Copyright © 2016 Arpit Amin et al. All rights reserved. T-Bar Utilization for Concomitant Coronary Artery Bypass Graft Operation and Left Upper Lobectomy Wed, 02 Mar 2016 07:36:53 +0000 Management in patients with coexisting coronary artery disease and lung carcinoma is usually a two-stage operation, with the cardiac surgery procedure followed by pulmonary resection at a later time. Delayed tumor resection on the other hand may be detrimental. Off-pump coronary artery bypass grafting could facilitate concomitant lung resection at one stage via median sternotomy. T-bar retractor may be a useful tool in the surgical approach of this combined operation. Fotios Mitropoulos, Meletios A. Kanakis, Anastasios Apostolou, Andrew Chatzis, Constantinos Contrafouris, Christos Apostolidis, and Achilleas Lioulias Copyright © 2016 Fotios Mitropoulos et al. All rights reserved. Pancreatic Aetiology for Massive Upper Gastrointestinal Haemorrhage in Pregnancy Mon, 29 Feb 2016 17:11:56 +0000 We present herein what we believe is the first reported case of massive upper gastrointestinal bleeding in pregnancy due to a pancreatic neuroendocrine tumour causing left sided portal hypertension. A 37-year-old 27-week pregnant female presented with massive haematemesis and melaena requiring transfusion of 10 units of red cell concentrate. Gastric varices were evident at endoscopy. An MRI revealed a large mass infiltrating the pancreatic tail and spleen with massive upper abdominal varix formation secondary to splenic vein invasion. A caesarean section was performed, followed by a radical en bloc partial pancreatectomy and splenectomy with resection of the fundus of the stomach and ligation of gastric and splenic varices. Her postoperative course was uncomplicated. Histology revealed a well differentiated grade 2 neuroendocrine tumour with final staging of T4N0. This case highlights an infrequently encountered cause of massive gastrointestinal bleeding. Diagnosis and management of pancreatic neuroendocrine tumours, due to their rarity and variable clinical presentation, can be challenging particularly in the setting of pregnancy where the wellbeing of a second patient must also be considered. A multidisciplinary approach with input from obstetricians and general surgeons is required when deciding optimum management, while also taking into account the patient’s preferences. Alexandra Zaborowski, Siun M. Walsh, Narayanasamy Ravi, and John V. Reynolds Copyright © 2016 Alexandra Zaborowski et al. All rights reserved. Omental Torsion after Laparoscopic Roux-en-Y Gastric Bypass Mimicking Appendicitis: A Case Report and Review of the Literature Thu, 25 Feb 2016 11:09:20 +0000 Introduction. Laparoscopic Roux-en-Y gastric bypass (LRYGBP) is a common procedure in obesity surgery. The aim of an antecolic approach is to reduce the rate of internal herniation. Our aim is to make bariatric surgeons aware of another possible complication of antecolic LRYGBP. Methods and Results. We present a case report of omental torsion 24 months after antecolic LRYGBP presenting as an acute abdomen, suggesting appendicitis. During diagnostic laparoscopy, omental infarction due to torsion was observed. Resection of the avital omentum was performed. Discussion. Omental torsion after antecolic LRYGBP is a rare complication. When appearing in the early postoperative phase, it may mimic an anastomotic leakage. It may also occur as late complication, presenting with acute abdomen as an appendicitis. Alexandre Descloux, Giacinto Basilicata, and Antonio Nocito Copyright © 2016 Alexandre Descloux et al. All rights reserved. Giant Intraperitoneal Multiloculated Pseudocyst in a Male Wed, 24 Feb 2016 17:08:34 +0000 Intraperitoneal pseudocysts are rare and may be difficult to differentiate from other malignant neoplasms. Reports of occurrences are mainly associated with long-term intraperitoneal catheter use, intraperitoneal catheter infections, or major pelvic surgery in females, although there are few reported incidences without prior trauma. We present a case of a male patient found to have a 19 × 15 × 9 cm intraperitoneal pseudocyst with other multiloculated areas and a history of a right inguinal hernia repair. After a thorough review of the literature, this is the first multiloculated nonpancreatic pseudocyst reported in a male patient. Jacqueline Oxenberg Copyright © 2016 Jacqueline Oxenberg. All rights reserved. Management of a Septic Open Abdomen Patient with Spontaneous Jejunal Perforation after Emergent C/S with Confounding Factor of Mild Acute Pancreatitis Tue, 23 Feb 2016 10:04:57 +0000 Introduction. We report the management of a septic Open Abdomen (OA) patient by the help of negative pressure therapy (NPT) and abdominal reapproximation anchor (ABRA) system in pregnant woman with spontaneous jejunal perforation after emergent cesarean section (C/S) with confounding factor of mild acute pancreatitis (AP). Presentation of Case. A 29-year-old and 34-week pregnant woman with AP underwent C/S. She was arrested after anesthesia induction and responded to cardiopulmonary resuscitation (CPR). There were only ash-colored serosanguinous fluid within abdomen during C/S. After C/S, she was transferred to intensive care unit (ICU) with vasopressor support. On postoperative 1st day, she underwent reoperation due to fecal fluid coming near the drainage. Leakage point could not be identified exactly and operation had to be deliberately abbreviated due to hemodynamic instability. NPT was applied. Two days later source control was provided by conversion of enteroatmospheric fistula (EAF) to jejunostomy. ABRA was added and OA was closed. No hernia developed at 10-month follow-up period. Conclusion. NPT application in septic OA patient may gain time to patient until adequate source control could be achieved. Using ABRA in conjunction with NPT increases the fascial closure rate in infected OA patient. Fahri Yetisir, Akgün Ebru Sarer, Hasan Zafer Acar, Gokhan Osmanoglu, Mehmet Özer, and Faik Yaylak Copyright © 2016 Fahri Yetisir et al. All rights reserved. Tendency to Ingest Foreign Bodies in Mentally Retarded Patients: A Case with Ileal Perforation Caused by the Ingestion of a Teaspoon Tue, 23 Feb 2016 09:37:23 +0000 Introduction. Unintentional foreign body ingestion commonly occurs accidentally in children aged between 3 months and 6 years and at advanced ages or results from psychiatric disorders such as hallucination in patients with mental retardation. Most of the ingested foreign bodies are naturally discharged from the body but some of them may require surgical intervention. Presentation of Case. A 29-year-old mentally retarded female patient was admitted to the emergency service with a two-day history of abdominal pain, nausea, and vomiting. Physical examination revealed abdominal tenderness, defense, and rebound on palpation. Radiological examination revealed diffuse air-fluid levels and a radiopaque impression of a metal object in the right upper quadrant. The metal teaspoon causing ileal perforation was extracted by emergency laparotomy. On postoperative day 7, the patient was uneventfully discharged following a psychiatric consultation. Discussion. Foreign body ingestion can occur intentionally in children at developing ages and old-age patients, or adults and prisoners, whereas it may occur unintentionally in patients with mental retardation due to hallucination. However, repeated foreign body ingestion is very rare in individuals other than mentally retarded patients. Conclusion. Mentally retarded patients should be kept under close surveillance by surgeons and psychiatrists due to their tendency to ingest foreign bodies. İhsan Yıldız, Yavuz Savaş Koca, Gökhan Avşar, and İbrahim Barut Copyright © 2016 İhsan Yıldız et al. All rights reserved.