Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Management of Intrathoracic Benign Schwannomas of the Brachial Plexus Tue, 22 Jul 2014 12:01:13 +0000 Primary tumours of the brachial plexus are rare entities. They usually present as extrathoracic masses located in the supraclavicular region. This report describes two cases of benign schwannomas arising from the brachial plexus with an intrathoracic growth. In the first case the tumour was completely intrathoracic and it was hardly removed through a standard posterolateral thoracotomy. In the second case the tumour presented as a cervicomediastinal lesion and it was resected through a one-stage combined supraclavicular incision followed by left video-assisted thoracoscopic surgery. A brachial plexus tumour should be suspected not only in patients with a supraclavicular or cervicomediastinal mass but also in those with intrathoracic apical lesions. A preoperative magnetic resonance imaging study of brachial plexus should be performed in such cases in order to plan the correct surgical approach. Alessandro Bandiera, Giampiero Negri, Giulio Melloni, Carlo Mandelli, Simonetta Gerevini, Angelo Carretta, Paola Ciriaco, Armando Puglisi, and Piero Zannini Copyright © 2014 Alessandro Bandiera et al. All rights reserved. Giant Bilateral Adrenal Myelolipoma with Congenital Adrenal Hyperplasia Wed, 16 Jul 2014 08:14:05 +0000 Myelolipomas are rare and benign neoplasms, predominant of the adrenal glands, consisting of adipose and mature hematopoietic tissue, commonly discovered incidentally with increased use of radiologic imaging. Few cases of giant bilateral adrenal masses are reported, especially in the setting of congenital adrenal hyperplasia (CAH). We report the case of a 39-year-old male with a history of CAH secondary to 21-α hydroxylase deficiency on steroids since childhood, self-discontinued during adolescence, presenting with abdominal distension, fatigue, decreased libido, and easy bruising. Imaging revealed giant bilateral adrenal masses. He subsequently underwent bilateral adrenalectomy found to be myelolipomas measuring 30 × 25 × 20 cm on the left and weighing 4.1 kg and 25 × 20 × 13 cm on the right and weighing 2.7 kg. Adrenal myelolipomas are found to coexist with many other conditions such as Cushing’s syndrome, Addison’s disease, and CAH. We discuss the association with high adrenocorticotropic hormone (ACTH) states and review the studies involving ACTH as proponent leading to myelolipomas. Massive growth of these tumors, as in our case, can produce compression and hemorrhagic symptoms. We believe it is possible that self-discontinuation of steroids, in the setting of CAH, may have resulted in the growth of his adrenal masses. S. Al-Bahri, A. Tariq, B. Lowentritt, and D. V. Nasrallah Copyright © 2014 S. Al-Bahri et al. All rights reserved. Achalasia Secondary to Submucosal Invasion by Poorly Differentiated Adenocarcinoma of the Cardia, Siewert II: Consideration on Preoperative Workup Tue, 15 Jul 2014 08:18:51 +0000 Secondary achalasia due to submucosal invasion of cardia by gastric cancer is a rare condition. We report a case of pseudoachalasia, secondary to the involvement of gastroesophageal junction by poorly differentiated gastric cancer, initially mistaken as idiopathic form. We focus on the difficulty to establish differential diagnosis only on the basis of routine exams and we stress the necessity of “second level” instrumental exams; EUS in routine workup in selected patients should be considered. We support that routine workup based on history, clinical presentation, radiological and endoscopic findings, and certainly manometry could be insufficient for a correct differential diagnosis between primary and secondary forms in some patients. Antonino Agrusa, Giorgio Romano, Giuseppe Frazzetta, Giovanni De Vita, Daniela Chianetta, Giuseppe Di Buono, Silvia Di Giovanni, Vincenzo Sorce, and Gaspare Gulotta Copyright © 2014 Antonino Agrusa et al. All rights reserved. Pneumoperitoneum with Subcutaneous Emphysema after Percutaneous Endoscopic Gastrostomy Thu, 10 Jul 2014 07:45:56 +0000 Percutaneous endoscopic gastrostomy is a safe way for enteral nutrition in selected patients. Generally, complications of this procedure are very rare but due to patients general health condition, delayed diagnosis and treatment of complications can be life threatening. In this study, we present a PEG-related massive pneumoperitoneum and subcutaneous emphysema in a patient with neuro-Behçet. Yalin Iscan, Bora Karip, Yetkin Ozcabi, Birol Ağca, Yesim Alahdab, and Kemal Memisoglu Copyright © 2014 Yalin Iscan et al. All rights reserved. Cecal Endometriosis Presenting as Acute Appendicitis Wed, 09 Jul 2014 10:27:55 +0000 The aim of our paper is to show the diagnosis of Coecal endometriosis as an infrequent reason of right iliac fossa pain. cecal endometriosis manifesting with right lower quadrant pain is difficult to diagnose, and it may even sometimes require laparotomy for diagnosis and treatment. We report here a case of cecal endometriosis causing clinically resembled acute appendicitis. In our patient, a diagnosis of cecal endometriosis was made postoperatively by microscopic examination of excised right colon, and the patient symptoms and general condition were improved after the surgery (open right hemicolectomy and ileocolic anastomosis). Hamidreza Alizadeh Otaghvar, Mostafa Hosseini, Ghazaal Shabestanipour, Adnan Tizmaghz, and Gandom Sedehi Esfahani Copyright © 2014 Hamidreza Alizadeh Otaghvar et al. All rights reserved. Laparoscopic Right Hemicolectomy in an Automated Peritoneal Dialysis Patient without Removal of the PD Catheter: A Case Report Tue, 08 Jul 2014 13:07:28 +0000 Introduction. Laparotomy in patients on peritoneal dialysis (PD) is associated with an increased risk of morbidity. Furthermore, standard protocol recommends removal of the PD catheter when surgery on the intestine is required. As far as we are aware, this is the first case report of laparoscopic right hemicolectomy in a patient on automated PD where the PD catheter was left in situ. Case Report. A 61-year-old man man on APD who presented with a caecal carcinoma was stabilised on temporary haemodialysis (HD) prior to undergoing a laparoscopic right hemicolectomy without removal of the PD catheter. He made an uneventful recovery and APD was resumed successfully 2 weeks after surgery. Discussion. PD patients undergoing intra-abdominal surgery are at increased risk of complications. While the benefits of laparoscopic surgery in the standard surgical population are well established, there is limited experience of the technique in PD patients. Possible advantages could theoretically be early resumption of PD as well as less PD failure due to the formation of adhesions. Conclusion. Our experience with this case indicates that laparoscopic right hemicolectomy in a background of PD can be undertaken without removal of the PD catheter and is associated with early resumption of PD. Joseph A. Attard and Alexander Attard Copyright © 2014 Joseph A. Attard and Alexander Attard. All rights reserved. Incidental Phaeochromocytoma on Staging PET-CT in a Patient with a Sigmoid Tumour and Situs Inversalis Totalis Tue, 08 Jul 2014 09:51:40 +0000 An adrenal “incidentaloma” is defined as an unexpected finding on radiological imaging performed for unrelated indications. Improvements in radiological technology have seen a dramatic increase in this phenomenon. We report the unique case of a 60-year-old female presenting with a 6-month history of abdominal pain, altered bowel habit, and rectal bleeding. Her past medical history included situs inversus totalis and a patent ductus arteriosus. Colonoscopy revealed an ulcerated tumour in her sigmoid colon. Staging PET-CT confirmed a sigmoid tumour and also identified a large heterogenous enhancing FDG-avid right adrenal mass. Biochemical testing/MIBG imaging confirmed a right adrenal phaeochromocytoma. Hypertension was controlled and excision was performed via a transperitoneal laparoscopic adrenalectomy, in the left lateral decubitus position. Uniquely, liver retraction was not required due to its position in the left hypochondrium. Histology confirmed a benign 46 mm phaeochromocytoma. Subsequent uncomplicated sigmoid colectomy/right salpingo-oophorectomy for a locally advanced colonic tumour was performed with adjuvant chemotherapy. This case highlights the importance of accurately identifying functioning adrenal tumours before elective surgery as undiagnosed phaeochromocytomas carry significant intraoperative morbidity/mortality. Right adrenalectomy was made easier in this patient by the liver’s unique position. Uncomplicated colorectal resection was made possible by combined preoperative functional/anatomical imaging. M. R. Boland, A. J. Lowery, S. Walsh, D. Beddy, R. S. Prichard, D. O’Shea, S. J. Skehan, and E. W. McDermott Copyright © 2014 M. R. Boland et al. All rights reserved. Laparoscopic-Assisted Resection of Jejunojejunal Intussusception Caused by a Juvenile Polyp in an Adult Mon, 07 Jul 2014 06:54:51 +0000 Most bowel intussusceptions in adults have a leading point. However, there have been few reports of jejunojejunal intussusception secondary to a solitary juvenile polyp in adult. We report herein the case of a 19-year-old female with a solitary juvenile polyp in the jejunum causing intussusception. Laparoscopic-assisted reduction and segmental resection of the jejunum were successfully done for the patient. Sung Il Kang, Jeonghyun Kang, Min Ju Kim, Im-kyung Kim, Jungseob Lee, Kang Young Lee, and Seung-Kook Sohn Copyright © 2014 Sung Il Kang et al. All rights reserved. Recurrent Volvulus of an Ileal Pouch Requiring Repeat Pouchopexy: A Lesson Learnt Sun, 06 Jul 2014 10:00:51 +0000 Introduction. Restorative surgery for ulcerative colitis with ileal pouch anal anastomosis (IPAA) is frequently accompanied by complications. Volvulus of the ileal pouch is one of the most rarely reported late complications and to our knowledge no report exists on reoperative surgery for this condition. Case Report. A 58-year-old woman who previously had undergone restorative proctocolectomy due to ulcerative colitis with an IPAA presented with volvulus of the pouch. She was operated with a single row pouchopexy to the presacral fascia. Two months later she returned with a recurrent volvulus. At reoperation, the pouch was found to have become completely detached from the fascia. A new pexy was made by firmly anchoring the pouch with two rows of sutures to the presacral fascia as well as with sutures to the lateral pelvic walls. At follow-up after five months she was free of symptoms. Conclusion. This first report ever on reoperative surgery for volvulus of a pelvic pouch indicates that a single row pouchopexy might be insufficient for preventing retwisting. Several rows seem to be needed. Pär Myrelid, Pelle Druvefors, and Peter Andersson Copyright © 2014 Pär Myrelid et al. All rights reserved. Transabdominal Approach for Chylorrhea after Esophagectomy by Using Fluorescence Navigation with Indocyanine Green Tue, 01 Jul 2014 11:16:58 +0000 A 70-year-old man who underwent two sessions of thoracoscopy-assisted ligation of the thoracic duct to treat refractory chylorrhea after radical esophagectomy for advanced esophageal cancer received conservative therapy. However, there was no improvement in chylorrhea. Then, transabdominal ligation of the lymphatic/thoracic duct at the level of the right crus of the diaphragm was performed using fluorescence navigation with indocyanine green (ICG). The procedure successfully reduced chylorrhea. This procedure provides a valid option for persistent chylothorax/chylous ascites accompanied by chylorrhea with no response to conservative treatment, transthoracic ligation, or both. Takeshi Matsutani, Atsushi Hirakata, Tsutomu Nomura, Nobutoshi Hagiwara, Akihisa Matsuda, Hiroshi Yoshida, and Eiji Uchida Copyright © 2014 Takeshi Matsutani et al. All rights reserved. Customized Polymethyl Methacrylate Implants for the Reconstruction of Craniofacial Osseous Defects Mon, 30 Jun 2014 12:35:27 +0000 Craniofacial defects represent alterations in the anatomy and morphology of the cranial vault and the facial bones that potentially affect an individual’s psychological and social well-being. Although a variety of techniques and restorative procedures have been described for the reconstruction of the affected area, polymethyl methacrylate (PMMA), a biocompatible and nondegradable acrylic resin-based implant, is the most widely used alloplastic material for such craniomaxillofacial reconstruction. The aim of this study was to describe a technique for aesthetic and functional preoperative customized reconstruction of craniofacial bone defects from a small series of patients offered by the Brazilian public health system. Three adult male patients attended consultation with chief complaints directly related to their individual craniofacial bone defects. With the aid of multislice computed tomography scans and subsequent fabrication of the three-dimensional craniofacial prototype, custom-made PMMA implants were fabricated preoperatively. Under general anesthesia, with access to the craniofacial defects with a coronal approach, the PMMA implants were adapted and fixated to the facial skeleton with titanium plates and screws. Postoperative evaluation demonstrated uneventful recovery and an excellent aesthetic result. Customized prefabricated PMMA implants manufactured over the rapid prototyping models proved to be effective and feasible. André Luis Fernandes da Silva, Alexandre Meireles Borba, Niverso Rodrigues Simão, Fábio Luis Miranda Pedro, Alvaro Henrique Borges, and Michael Miloro Copyright © 2014 André Luis Fernandes da Silva et al. All rights reserved. Middle Segment-Preserving Pancreatectomy for Recurrent Metastasis of Renal Cell Carcinoma after Pancreatoduodenectomy: A Case Report Mon, 30 Jun 2014 11:26:03 +0000 Many cases of surgical resection of metastatic pancreatic tumors originating from renal cell carcinoma have been reported; however, cases of reresection of recurrent pancreatic metastasis of renal cell carcinoma in the remnant pancreas are rare. We performed a second resection for recurrent pancreatic metastasis of renal cell carcinoma six years after pancreatoduodenectomy with pancreaticogastrostomy reconstruction. By performing middle segment-preserving pancreatectomy, we were able to successfully spare the exocrine and endocrine pancreatic function compared to that observed after total pancreatectomy, with no signs of recurrence for two years after the surgery. Aiyama Takeshi, Inagaki Mitsuhiro, Akabane Hiromitsu, Yanagida Naoyuki, Shibaki Taiichiro, Shomura Hiroki, Kudo Takeaki, Shonaka Tatsuya, Oikawa Futoshi, Sakurai Hiroharu, and Nakano Shiro Copyright © 2014 Aiyama Takeshi et al. All rights reserved. Axillary Artery Injury Caused by Fracture of Humerus Neck and Its Repair Using Basilic Vein Graft Mon, 30 Jun 2014 10:36:18 +0000 Proximal humerus fractures are rarely associated with axillary artery injury. We present a case of a 59-year-old female who had fracture neck humerus along with absent pulsations in the left upper limb after blunt trauma. Computed tomographic angiogram revealed complete occlusion of the left axillary artery. Urgent surgical intervention was done in the form of fixation of fracture followed by exploration and repair of axillary artery. Axillary artery was contused and totally occluded by fractured edge of humerus. Repair of the axillary artery was done using basilic vein graft harvested through the same incision. Postprocedure pulsations were present in the upper limb. Vikas Deep Goyal, Vipin Sharma, Sandeep Kalia, and Manik Sehgal Copyright © 2014 Vikas Deep Goyal et al. All rights reserved. Intestinal Obstruction due to Bilateral Strangulated Femoral Hernias Thu, 26 Jun 2014 10:51:46 +0000 Introduction. Femoral hernias are at high risk of strangulation due to the narrow femoral canal and femoral ring. This can lead to symptoms of obstruction or strangulation requiring emergency surgery and possible bowel resection. To our knowledge, there is only one previous published report of bilateral strangulated femoral hernia. We present our case of this phenomenon. Case Report. An 86-year-old woman presented with symptoms of small bowel obstruction. Examination revealed two tender lumps in the area of the femoral triangle. CT scan revealed bilateral femoral hernias. Both hernias were repaired and a small bowel resection on the right side was performed with side to side anastomosis. She made an uneventful recovery. Conclusion. Bilateral femoral hernias are a rare occurrence with only one reported case of bilateral strangulation. Our case highlights the importance of meticulous history taking and clinical examination as any delay in diagnosis will increase the risk of mortality and morbidity for the patient. Hernias should always be considered as a cause if one presents with symptoms of abdominal pain or obstruction. Ioannis Nikolopoulos, Eshan Oderuth, Eleni Ntakomyti, and Bengt Kald Copyright © 2014 Ioannis Nikolopoulos et al. All rights reserved. Bilateral Chylhotorax after Falling from Height Thu, 26 Jun 2014 00:00:00 +0000 Chylothorax is accumulation of chyle in the pleural cavity due to disruption of the thoracic duct. The causes can be classified as neoplastic, traumatic (iatrogenic or noniatrogenic), congenital, sporadic, spontaneous, and miscellaneous. A 22-year-old man with no feature in his history and family history was referred to emergency department with the case of falling from height. Abdominal computed tomogram (CT) revealed laceration of liver, grade 5 splenic laceration, fracture of the left acetabulum, and dislocation of the left hip. He was optimized for emergency splenectomy and close left hip reduction. On the 2nd day of the operation, bilateral chylotorax revealed. The treatment depends on its etiology, the amount of drainage, and the clinical picture. Treatment can be classified into 3 categories treatment of the underlying condition, conservative management (such as bed rest, nil by mouth or low fat medium chain triglycerides by mouth and total parenteral nutrition), and surgical management by ligation or clipping of the thoracic duct with open thoracotomy or video-assisted thoracoscopic surgery. The main purpose of surgical treatment is to stop the chylous leak. Vildan Akpinar, Fulya Yilmaz Duran, Elif Duman, Murat Yasar Özkalkanli, Özgür Duran, and Burcu Horsanali Copyright © 2014 Vildan Akpinar et al. All rights reserved. Spontaneous Rupture of the Spleen Masquerading as a Pulmonary Infection Thu, 19 Jun 2014 08:10:48 +0000 Atraumatic rupture of a normal spleen represents a rare clinical phenomenon. We report on an atypical presentation of a spontaneous splenic rupture in a 44-year-old previously healthy Greek male admitted to the emergency department due to left-sided pleuritic thoracic pain in the course of a pneumonia diagnosed 2 days before. During his stay, pain extended to the epigastric region. Abdominal examination revealed generalized tenderness. We presume that coughing secondary to respiratory infection was the main factor that precipitated splenic rupture. Despite the rarity of the condition physicians have to consider the diagnosis of spontaneous nontraumatic splenic rupture when they encounter healthy patients with nonspecific lower thoracic or abdominal pain. Prompt diagnosis is essential for a better outcome. Dimitrios Anyfantakis, Miltiades Kastanakis, Paraskevi Karona, Giorgios Fragiadakis, Ioannis Kokkinos, and Emmanouil Bobolakis Copyright © 2014 Dimitrios Anyfantakis et al. All rights reserved. Jejunal Cancer with WRN Mutation Identified from Next-Generation Sequencing: A Case Study and Minireview Sun, 15 Jun 2014 11:42:03 +0000 Small bowel cancer is a rare, gastrointestinal cancer originating from the small intestines. Carcinogenesis in the jejunum, the middle segment of the small intestines, occurs less commonly than in the duodenum and ileum. Despite the increasing incidences globally, the cancer is still poorly understood, which includes lack of pathological understanding and etiological reasoning, as it seems to exhibit both similarities and differences with other types of cancers. A 76-year-old Asian man was presented with abdominal pain, which was later attributed to an adenocarcinoma in the jejunum. Initial immunoreactive staining results found no connections to colorectal cancer. The microsatellite instability test was further examined by immunohistochemistry which revealed them to be wild-type. From our exome-capture sequencing results, mutations of WRN may be important as they represent the only genetic defect in this jejunal cancer. The patient has since undergone surgical resection of his cancer and is currently being treated with chemotherapy. The pathology, genomic markers, and treatments are described along with literature review. Christopher Chang, Her-Shyong Shiah, Nan-Yung Hsu, Hsiu-Ying Huang, Jan-Show Chu, and Yun Yen Copyright © 2014 Christopher Chang et al. All rights reserved. A Short Bowel (Small Intestine = 40 cm), No Ileocecal Valve, and Colonic Inertia Patient Works Well with Oral Intake Alone without Parenteral Nutrition Sun, 15 Jun 2014 08:07:46 +0000 We present a 50-year-old male who suffered from ischemic bowel disease, having undergone massive resection of small intestine and ileocecal valve. He had to cope with 40 cm proximal jejunum and 70 cm distal colon remaining. In the postoperative period parenteral nutrition (PN) was used immediately for nutrition support and electrolyte imbalance correction. We gave him home PN as regular recommendation for the short bowel status after discharge from hospital. This patient has tolerated regular oral intake 2 months later and did not develop significant short bowel syndrome. There were several episodes of venous access infection which troubled this patient and admitted him for treatment during home PN. Therefore, we changed home PN to cyclic tapering pattern. The patient could maintain his nutrition and hydration with oral intake alone after tapering home PN 15 months later. He has survived more than one year without PN support and still maintained 80% ideal body weight with average albumin of 3.5 ± 0.2 mg/dL. Although patient was hospitalized every two months to supplement nutrients, however, this has greatly improved the quality of life. Ming-Yi Liu, Hsiu-Chih Tang, Hui-Lan Yang, and Sue-Joan Chang Copyright © 2014 Ming-Yi Liu et al. All rights reserved. A Case of Myxoid Liposarcoma of the Retroperitoneum: A Challenging Tumour for Diagnosis and Treatment Thu, 12 Jun 2014 06:20:46 +0000 Retroperitoneal sarcomas are rare neoplasms that account for only 1%-2% of all solid tumors and liposarcomas represent the most frequent histological type. We describe the case of a 44-year-old female with a retroperitoneal myxoid liposarcoma of 22 × 19 × 8 cm in size. The only symptoms were persistent pain and progressive tenderness of the abdomen lasting for two months. The mass was radically excised during laparotomy. CT and MRI were useful to clarify the site of origin of the tumor, relationships with other organs, and planning surgery but final diagnosis was based on histological findings. Here we review the literature about the challenging diagnosis, treatment, and prognostic factors of this disease. Emanuele Grasso, Fabio Marino, Michele Bottalico, and Michele Simone Copyright © 2014 Emanuele Grasso et al. All rights reserved. Breast Metastasis from Esophagogastric Junction Cancer: A Case Report Wed, 11 Jun 2014 14:59:51 +0000 Metastasis to breast from nonmammary malignancy is only about 1.3–2.7%. A few cases of squamous cell carcinoma of esophagus and adenocarcinoma of stomach metastasizing to breast have been reported, but this is probably the first report of breast metastasis from esophagogastric junction (EGJ) cancer in the English literature. Herein we report a case of a 32-year-old patient diagnosed as adenocarcinoma of gastroesophageal junction, presenting with left breast metastasis two years after treatment. Given unusual site of metastasis in a follow-up case of EGJ cancer, not only it is challenging to differentiate it from primary carcinoma of breast but also it is important from treatment point of view. In our case, clinical data, radiology, histopathology, and immunohistochemistry (IHC) led us to reach the diagnosis. Sanghamitra Jena, Samir Bhattacharya, Arnab Gupta, Shravasti Roy, and Neetesh Kumar Sinha Copyright © 2014 Sanghamitra Jena et al. All rights reserved. Pregnancy after Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy in Pseudomyxoma Peritonei Wed, 11 Jun 2014 12:29:15 +0000 Pseudomyxoma peritonei is usually a benign tumor that is slightly more common in women. However, it requires aggressive surgical treatment and chemotherapy, often compromising future reproductive function. This report presents a case of pregnancy in a 35-year-old woman who underwent cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for treatment of pseudomyxoma peritonei. The tumor was diagnosed during a laparoscopic examination on a workup for infertility in 2008. Two months later, she underwent a peritonectomy followed by hyperthermic intraperitoneal chemotherapy and, regarding her will to conceive, ovaries and fallopian tubes were preserved. In March 2011, she went through an in vitro fertilization followed by an uneventful pregnancy and delivered a healthy child 39 weeks later. Ovaries are usually resected during the cytoreductive surgery, since they are common sites for neoplastic implants, and, even when not performed, little is known about the effects of local chemotherapy on female fertility. The largest international survey on this matter only describes seven similar cases. This particular report not only describes a rare condition but also adds to the upcoming discussion about whether ovaries can be preserved in specific situations, therefore keeping the prospect of conceiving after this treatment. Renato Gomes Campanati, Bernardo Hanan, Sérgio Simões de Souza, and Rodrigo Gomes da Silva Copyright © 2014 Renato Gomes Campanati et al. All rights reserved. Giant Perineal Leiomyoma: A Case Report and Review of the Literature Wed, 04 Jun 2014 07:04:56 +0000 We report the case of a 40-year-old woman who presented with a large perineal mass with no rectal or vaginal involvement. Imaging could not rule out malignancy. She underwent wide surgical excision. Histological analysis revealed a large atypical leiomyoma, measuring 24 × 12 × 8 cm. Followup after two years showed no recurrence and she has been asymptomatic since surgery. This is the largest perineal leiomyoma reported so far. Wolf von-Waagner, Huifei Liu, and Antonio I. Picon Copyright © 2014 Wolf von-Waagner et al. All rights reserved. S-Shaped Wide Excision with Primary Closure for Extensive Chronic Pilonidal Sinus Disease Mon, 02 Jun 2014 06:24:21 +0000 Background. The management of complex pilonidal sinus disease (PSD) with multiple pits on and beside the natal cleft is variable, contentious, and problematic. Wide excision of the sinus and reconstruction of the defect using different flap techniques have become more popular in recent years. Case Report. We report a case with a complex chronic PSD to which we applied primary closure after S-shaped wide excision. The patient’s postoperative course was uneventful, and at the end of one-year followup he is now disease-free and comes for routine checkups. Conclusion. The simplicity of the technique and the promising results support the applicability of the S-shaped wide excision in chronic bilaterally extended large PSDs. Further studies entailing large patient populations are needed to reach a definite conclusion. Kerem Karaman, Safak Ozturk, Cem Tugmen, Eyup Kebapcı, Sait Murat Dogan, Mutlu Unver, Mustafa Olmez, and Cengiz Aydin Copyright © 2014 Kerem Karaman et al. All rights reserved. Midgut Malrotation Causing Intermittent Intestinal Obstruction in a Young Adult Tue, 20 May 2014 10:57:55 +0000 Midgut malrotation is a congenital anomaly of intestinal rotation and fixation that is generally seen in neonatal population. Adult cases are rarely reported. Early diagnosis is crucial to avoid life threatening complications. Here, we present an adulthood case of midgut volvulus as a rare cause of acute abdomen. Huseyin Kazim Bektasoglu, Ufuk Oguz Idiz, Mustafa Hasbahceci, Erkan Yardimci, Yurdakul Deniz Firat, Oguzhan Karatepe, and Mahmut Muslumanoglu Copyright © 2014 Huseyin Kazim Bektasoglu et al. All rights reserved. Nodular Fasciitis of the Breast Mimicking Breast Cancer Tue, 20 May 2014 05:38:07 +0000 Nodular fasciitis is a benign proliferative lesion that is usually found in the soft tissue of the upper extremity and trunk in young to middle-aged persons. It has rarely been described in the breast. A 35-year-old woman had noticed a mass in her left breast. It was elastic-hard, 13 mm in size, and located mainly in the upper inner quadrant of the left breast. Mammography did not detect the mass. Ultrasonography revealed a hypoechoic lesion with an irregular margin. Neither fine-needle aspiration cytology nor core needle biopsy established a definitive diagnosis. Excisional biopsy was therefore performed. Histologically, the excised tumor tissue results were consistent with a diagnosis of nodular fasciitis of the breast. We report a case of nodular fasciitis of the breast, a rare histological type of breast tumor. Shinya Yamamoto, Takashi Chishima, and Shouko Adachi Copyright © 2014 Shinya Yamamoto et al. All rights reserved. Intussusception of Rectosigmoid Colon Cancer Mimicking a Pedunculated Tumor Tue, 13 May 2014 10:09:52 +0000 Intussusception in adults is a rare phenomenon involving the colon in approximately 20% of cases. A 65-year-old man was hospitalized with anorexia, anemia, dehydration, and melena. Digital rectal examination revealed a palpable mass approximately 5 cm from the anal verge. The mass moved between the rectosigmoid colon and the rectum below the peritoneal reflection during radiographic examinations and during sigmoidoscopy. We strongly suspected a rectosigmoid pedunculated tumor and performed a low anterior resection. Intraoperatively we observed intussusception of the rectosigmoid colon with easy manual reduction. The tumor was palpable in the rectosigmoid colon. The postoperative course was uneventful. This case illustrates intussusception of a rectosigmoid type 1 colon adenocarcinoma mimicking a pedunculated tumor. Susumu Saigusa, Masaki Ohi, Hiroki Imaoka, Tadanobu Shimura, Yasuhiro Inoue, and Masato Kusunoki Copyright © 2014 Susumu Saigusa et al. All rights reserved. Gallbladder Torsion: A Diagnostic Challenge Thu, 08 May 2014 13:03:05 +0000 80-year-old female presented with clinical findings suggestive of acute cholecystitis. Intraoperatively we discovered a dusky gallbladder with gangrenous patches and gallbladder torsion with 270 degrees clockwise rotation along the longitudinal axis. Gallbladder torsion is a rare cause of acute cholecystitis with less than 500 cases published in the literature. Gallbladder torsion should be included in the list of differential diagnoses in patients suspected of having acute cholecystitis especially when there are inconsistencies between clinical features and imaging. It is worth noting that 3-dimensional reconstructed CT may be useful in preoperative diagnosis of gallbladder torsion. Sharon Gabizon, Kimberley Bradshaw, Eshwarshanker Jeyarajan, Rafid Alzubaidy, and Victor Liew Copyright © 2014 Sharon Gabizon et al. All rights reserved. Delayed Presentation of Traumatic Right-Sided Diaphragmatic Hernia after Abdominoplasty Thu, 08 May 2014 12:48:36 +0000 Traumatic diaphragmatic hernias are rare and challenging to diagnose. Following trauma, diagnosis may occur immediately or in a delayed fashion. It is believed that left traumatic diaphragmatic hernias are more common as a result of the protective right-sided anatomic lie of the liver. If unrecognized, traumatic diaphragmatic injuries are subject to enlarge over time as a result of the normal pressure changes observed between the thoracic and abdominal cavities. Additionally, abrupt changes to the pressure gradients, such as those which occur with positive pressure ventilation or surgical manipulation of the abdominal wall, can act as a nidus for making an asymptomatic hernia symptomatic. We report our experience with a delayed traumatic right-sided diaphragmatic hernia presenting with large bowel incarceration two months after abdominoplasty. In our review of the literature, we were unable to find any reports of delayed presentation of a traumatic right-sided diaphragmatic hernia occurring acutely following abdominoplasty. Caroline C. Jadlowiec and Lois U. Sakorafas Copyright © 2014 Caroline C. Jadlowiec and Lois U. Sakorafas. All rights reserved. Simultaneous Gastric and Duodenal Erosions due to Adjustable Gastric Banding for Morbid Obesity Mon, 05 May 2014 13:58:48 +0000 Erosion is an uncommon but feared late complication of adjustable gastric banding for morbid obesity. A high index of clinical suspicion is required, since symptoms are usually vague and nonspecific. Diagnosis is confirmed on upper gastrointestinal endoscopy and band removal is the mainstay of treatment, with band revision or conversion to other bariatric modalities at a later stage. Duodenal erosion is a much rarer complication, caused by the connection tubing of the band. We present our experience with a case of simultaneous gastric and duodenal erosions, managed by laparoscopic explantation of the band, primary suture repair of the duodenum, and omentopexy. Dimitrios K. Manatakis, Ioannis Terzis, Ioannis D. Kyriazanos, Ioannis D. Dontas, Christos N. Stoidis, Nikolaos Stamos, and Demetrios Davides Copyright © 2014 Dimitrios K. Manatakis et al. All rights reserved. Tracheoesophageal Fistula due to a Damaged Tracheal Stent Mon, 05 May 2014 07:35:02 +0000 We describe the management of a tracheoesophageal fistula due to a damaged tracheal stent, which was first inserted to treat tracheal stenosis. A 29-year-old woman with a history of treated epilepsy had a seizure and suffered from smoke inhalation during a fire. Breathing difficulties appeared and gradually worsened; consultation was obtained two years afterward. After undergoing a thorough examination, the patient was diagnosed with tracheal strangulation. A noncovered, metallic stent was inserted. When the patient was 37 years old, she was admitted to our hospital for the treatment of a tracheoesophageal fistula. We diagnosed it as a tracheoesophageal fistula due to the collapse of the damaged tracheal stent toward the esophageal side, and we decided to perform a mediastinal tracheostomy. Granulation may be formed in the circumference of a stent that has been present for a prolonged period, and removal of the stent may become difficult. This case suggests that insertion of a noncovered, metallic stent is contraindicated for a benign disease. Masahiro Kimura, Yoshiyuki Kuwabara, Hideyuki Ishiguro, Tatsuya Tanaka, and Hiromitsu Takeyama Copyright © 2014 Masahiro Kimura et al. All rights reserved.