Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Huge Intravascular Tumor Extending to the Heart: Leiomyomatosis Sun, 31 May 2015 06:28:42 +0000 Intravenous leiomyomatosis (IVL) is a rare neoplasm characterized by histologically benign-looking smooth muscle cell tumor mass, which is growing within the intrauterine and extrauterine venous system. In this report we aimed to present an unusual case of IVL, which is originating from iliac vein and extended throughout to right cardiac chambers. A 49-year-old female patient, who was treated with warfarin sodium due to right iliac vein thrombosis, was admitted to our department with intermittent dyspnea, palpitation, and dizziness. Physical examination was almost normal except bilateral pretibial edema. On magnetic resonance venography, there was an intravenous mass, which is originated from right internal iliac vein and extended into the inferior vena cava. Transthoracic echocardiography and transesophageal echocardiography revealed a huge mass extending from the inferior vena cava through the right atrium, with obvious venous occlusion. Thoracic, abdominal, and pelvic MR showed an intravascular mass, which is concordant with leiomyomatosis. Surgery was performed through median sternotomy. A huge mass with 25-cm length and 186-gr weight was excised through right atrial oblique incision, on beating heart with cardiopulmonary bypass. Histopathologic assessment was compatible with IVL. Exact strategy for the surgical treatment of IVL is still controversial. We used one-stage approach, with complete resection of a huge IVL extending from right atrium to right iliac vein. In such cases, high recurrence rate is a significant problem; therefore it should be kept in mind. Suat Doganci, Erkan Kaya, Murat Kadan, Kubilay Karabacak, Gökhan Erol, and Ufuk Demirkilic Copyright © 2015 Suat Doganci et al. All rights reserved. An Unusual Cause of Abdominal Pain: Three Lead Pellets within the Appendix Vermiformis Thu, 28 May 2015 12:52:24 +0000 Most ingested foreign bodies usually pass out in the feces uneventfully. Complications such as intestinal perforation and bleeding usually occur with sharp, thin, stiff, long, and pointed objects. This case describes the management of three lead pellets within the appendix vermiformis. A 45-year-old male visited our clinic complaining of a 4-month history of abdominal pain. The patient inquiry revealed that he had eaten hunted rabbit meat on numerous occasions and had unintentionally ingested three lead pellets. Plain abdominal films and a barium enema showed foreign bodies in the right lower abdominal quadrant. Since the lead pellets were thought to have migrated extraluminally, they were removed through laparotomy under fluoroscopic guidance. An appendectomy was performed. Pathologically, three lead pellets were embedded in the appendix, which showed signs of intramucosal inflammation. Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects enter the appendicular lumen, there is a high risk of appendicitis, perforation, or abdominal pain. An appendectomy was required to remove the ingested lead pellets in the appendix. Orhan Veli Ozkan, Vecdi Muderris, Fatih Altintoprak, Orhan Yagmurkaya, Omer Yalkin, and Fehmi Celebi Copyright © 2015 Orhan Veli Ozkan et al. All rights reserved. Life-Threatening Postpneumonectomy Syndrome Complicated with Right Aortic Arch after Left Pneumonectomy Thu, 28 May 2015 06:23:37 +0000 A 54-year-old man with right aortic arch underwent left lower lobectomy and lingular segmentectomy, followed by complete pneumonectomy, for refractory nontuberculous mycobacterial infection. Three months after the pneumonectomy, he developed acute respiratory distress. Computed tomography showed an excessive mediastinal shift with an extremely narrowed bronchus intermedius and right lower bronchus compressed between the right pulmonary artery and the right descending aorta. Soon after the nearly obstructed bronchus intermedius was observed by bronchoscopy, he began to exhibit frequent hypoxic attacks, perhaps due to mucosal edema. Emergent surgical repositioning of the mediastinum and decompression of the bronchus was indicated. After complete adhesiolysis of the left thoracic cavity was performed, to maintain the proper mediastinal position, considering the emergent setting, an open wound thoracostomy was created and piles of gauze were inserted, mildly compressing the heart and the mediastinum to the right side. Thoracoplasty was performed three months later, and he was eventually discharged without any dressings needed. Mediastinal repositioning under thoracostomy should be avoided in elective cases because of its extremely high invasiveness. However, in the case of life-threatening postpneumonectomy syndrome in an emergent setting, mediastinal repositioning under thoracostomy may be an option to save life, which every thoracic surgeon could attempt. Takahiro Karasaki and Makoto Tanaka Copyright © 2015 Takahiro Karasaki and Makoto Tanaka. All rights reserved. Surgical Extirpation of Apical Left Ventricular Thrombus in Takotsubo Cardiomyopathy Tue, 26 May 2015 09:12:03 +0000 We report a patient with takotsubo cardiomyopathy who underwent surgical resection of apical left ventricular thrombus. A 59-year-old woman was transferred to our hospital in shock with hypothermia and diabetic ketoacidosis. The electrocardiogram showed ST segment elevation, while echocardiography revealed a reduced ejection fraction with apical and midventricular akinesis. Emergency coronary angiography showed normal coronary arteries, so takotsubo cardiomyopathy was diagnosed. Follow-up echocardiography revealed improvement of the ejection fraction. A mobile apical thrombus was also detected. Thrombectomy was performed via a left apical incision and postoperative recovery was uneventful. Tetsuya Niino and Satoshi Unosawa Copyright © 2015 Tetsuya Niino and Satoshi Unosawa. All rights reserved. Adrenal Schwannomas: Rare Tumor of the Retroperitoneum Tue, 26 May 2015 08:57:19 +0000 Schwannoma is a benign neurogenic tumor originating from Schwann cells. These produce the myelin sheath that covers peripheral nerves that are often affected. This latter localization is extremely rare, and only a few case reports can be found in the medical literature. Studies have shown that approximately 0.5% to 5% of schwannomas are retroperitoneal, constituting 0.2% of adrenal incidental tumors. These usually present as incidental findings, nonsecreting adrenal masses in asymptomatic patients. Diagnosis of a schwannoma is based on detection of spindle cells with Antoni A and Antoni B regions in histological sections and positive staining for S-100 protein by immunohistochemical analysis. We report a case of an incidentally identified during an abdominal ultrasound examination with schwannoma localized in the left adrenal gland. Emanuele Grasso and Michele Simone Copyright © 2015 Emanuele Grasso and Michele Simone. All rights reserved. Primitive Neuroectodermal Tumor of the Pancreas: A Case Report and Review of the Literature Tue, 26 May 2015 07:27:44 +0000 Primitive neuroectodermal tumors (PNETs) are presented as rare malignant neoplasms. In unusual cases, those neoplasms may arise in solid organs containing neuroendocrine cells, such as the pancreas. Herein the case of a 28-year-old patient that underwent gastroduodenopancreatectomy after the diagnosis of a huge mass (PNET) located in both head and body of the pancreas is reported. This is the 19th case of pancreatic PNET reported in literature. Uirá Teixeira, Marcos Goldoni, Michelle Unterleider, João Diedrich, Diogo Balbinot, Pablo Rodrigues, Rodolfo Monteiro, Daniel Gomes, José Sampaio, Paulo Fontes, and Fábio Waechter Copyright © 2015 Uirá Teixeira et al. All rights reserved. Surgical Treatment of Renal Fibromuscular Dysplasia in a Young Child Thu, 21 May 2015 15:57:30 +0000 During a routine checkup in a 10-year-old male with Attention-Deficit Hyperactivity Disorder, blood pressure of 180/120 mmHg was found. Physical examination was completely normal. Ultrasound examination showed poststenotic dilatation of the left renal artery which was confirmed by CT-angiography showing a short, high grade stenosis of the left renal artery. Percutaneous Transluminal Angioplasty of the stenosis was not successful and therefore the stenosis was excised with reimplantation of the renal artery in the aorta. Pathological examination of the excised segment showed media-type Fibromuscular Dysplasia (FMD). Six years after surgery, the kidney is completely normal regarding size and function. There are no signs of restenosis of the left renal artery. Nevertheless, the hypertension remained although less severe and requiring less medication. Arjan W. J. Hoksbergen, Lennaert Renwarin, and Willem Wisselink Copyright © 2015 Arjan W. J. Hoksbergen et al. All rights reserved. A Case Report and Review of the Literature of Adult Gastric Duplication Cyst Thu, 21 May 2015 13:41:36 +0000 Gastrointestinal (GI) duplication cysts are a rare congenital disease. They may involve any level of the alimentary tract, but they most commonly involve the ileum, esophagus, and jejunum. Gastric duplication cysts represent approximately 4–8% of GI duplication cysts, the majority of which present in early childhood. We present a rare case of adult gastric duplication cyst in a 25-year-old female found to have abdominal mass on computed tomography imaging. There are several potential methods to diagnose gastric duplication cyst and treatment of choice is complete surgical resection. Scott Samona and Richard Berri Copyright © 2015 Scott Samona and Richard Berri. All rights reserved. Inguinal Herniation of the Urinary Bladder Presenting as Recurrent Urinary Retention Sun, 17 May 2015 12:07:59 +0000 Herniation of the urinary bladder into the inguinal canal is an uncommon finding, observed in 0.5–4% of inguinal hernias (Curry (2000)). It is usually associated with other conditions that increase intra-abdominal pressure such as bladder neck obstruction due to prostatic hypertrophy. Consequently, in men, it is usually associated with some degree of urinary retention. We present a 42-year-old man in whom herniation of the urinary bladder was the cause of urinary retention, and not vice versa. The patient was on tumor necrosis factor alpha antagonist (TNFA) (Etanercept) for severe Ankylosing spondylitis. Initially, the urinary retention was thought to be a side effect of the medication, but after the drug was discontinued, urinary retention persisted. CT and MRI demonstrated huge herniation of the urinary bladder into the inguinal canal. Immediately after the hernia was repaired, bladder function was restored. TNF treatment was restarted, and no further urinary symptoms were observed in the next two years of follow-up. In this case, the primary illness and its treatment were distracting barriers to early diagnosis and treatment. In younger patients with a large hernia who develop unexpected urinary retention, herniation of the urinary bladder should be highly considered in the differential diagnosis. Amit Frenkel, Aviel Roy-Shapira, Ilan Shelef, Gadi Shaked, Evgeni Brotfain, Leonid Koyfman, Abraham Borer, and Moti Klein Copyright © 2015 Amit Frenkel et al. All rights reserved. Reversed Intestinal Rotation Presented as Bowel Obstruction in a Pregnant Woman Sun, 17 May 2015 06:54:27 +0000 A rare case of complete large bowel obstruction in a pregnant woman, without previous surgical history, due to previously undiagnosed reversed intestinal rotation is presented. The young woman was admitted with progressive nausea and vomiting which did not respond to conventional therapy. Her plain abdominal film revealed signs of small bowel obstruction. On laparotomy, her transverse colon was found to be located beneath the root of small bowel mesentery and completely obstructed by congenital fibrous bands. Postoperative recovery was unremarkable. Surgery for this unusual developmental anomaly is discussed. David Aranovich and Ilan Schrier Copyright © 2015 David Aranovich and Ilan Schrier. All rights reserved. When Operating on Dead People Saves Lives: Benefits of Surgical Organ Donor Intensivists Mon, 11 May 2015 13:35:31 +0000 Solid organ transplantation has emerged as a life-saving treatment for many patients suffering from end-stage organ failure. Organs have been successfully recovered after a variety of aggressive interventions. We propose that decompressive laparotomy, when clinically indicated, should be considered in the aggressive resuscitation of potential organ donors. A thorough literature review examining aggressive interventions on potential organ donors was conducted after experience with a unique case at this institution. Articles were reviewed for the types of interventions performed as well as the time frame in relation to organ donation. In our case, several ethical issues were raised when considering decompressive laparotomy in a patient pronounced dead by neurologic criteria. We propose that having a surgical intensivist involved in the management of potential donors will further increase the salvage rate, as more invasive resuscitation options are possible. Kristin Long, Cynthia Talley, Rebecca B. Yarrison, and Andrew Bernard Copyright © 2015 Kristin Long et al. All rights reserved. A Pancreatic Fistula after the Laparoscopic Sleeve Gastrectomy Mon, 11 May 2015 12:53:14 +0000 Laparoscopic sleeve gastrectomy (LSG) is a popular surgical weight-loss procedure in the treatment of morbid obesity. There are some complications regarding this procedure in the literature. This report presents a pancreatic fistula (PF) case, which has not been previously seen. Gökhan Selçuk Özbalcı, Ayfer Kamalı Polat, İsmail Alper Tarım, Murat Derebey, Mehmet Selim Nural, Volkan Tümentemur, and Ufuk Karabacak Copyright © 2015 Gökhan Selçuk Özbalcı et al. All rights reserved. Surgical Tips in Frozen Abdomen Management: Application of Coliseum Technique Sun, 10 May 2015 11:43:59 +0000 Wound dehiscence is a serious postoperative complication, with an incidence of 0.5–3% after primary closure of a laparotomy incision, and represents an acute mechanical failure of wound healing. Relatively recently the concept of “intentional open abdomen” was described and both clinical entities share common pathophysiological and clinical pathways (“postoperative open abdominal wall”). Although early reconstruction is the target, a significant proportion of patients will develop adhesions between abdominal viscera and the anterolateral abdominal wall, a condition widely recognized as “frozen abdomen,” where delayed wound closure appears as the only realistic alternative. We report our experience with a patient who presented with frozen abdomen after wound dehiscence due to surgical site infection and application of the “Coliseum technique” for its definitive surgical management. This novel technique represents an innovative alternative to abdominal exploration, for cases of “malignant” frozen abdomen due to peritoneal carcinomatosis. Lifting the edges of the surgical wound upwards and suspending them under traction by threads from a retractor positioned above the abdomen facilitates approach to the peritoneal cavity, optimizes exposure of intra-abdominal organs, and prevents operative injury to the innervation and blood supply of abdominal wall musculature, a crucial step for subsequent hernia repair. Ioannis D. Kyriazanos, Dimitrios K. Manatakis, Nikolaos Stamos, and Christos Stoidis Copyright © 2015 Ioannis D. Kyriazanos et al. All rights reserved. Late Onset Remnant Gastric Cancer with Afferent Loop Syndrome 47 Years after Billroth II Surgery Sun, 10 May 2015 11:25:56 +0000 Remnant gastric cancer is a rare clinical entity. Herein we describe a patient with remnant gastric cancer that presented with afferent loop syndrome 47 years after Billroth II surgery. Symptoms of serious bilious vomiting were an indication to perform early endoscopic diagnosis, followed by complete gastric resection. In particular, patients that have undergone surgery due to benign indications should be examined endoscopically, even a long time after initial surgery. Memduh şahin, Bahattin Ozlu, Kivilcim Eren Erdogan, and Tahsin Colak Copyright © 2015 Memduh şahin et al. All rights reserved. An Unusual Neck Mass: A Case of a Parathyroid Cyst and Review of the Literature Thu, 07 May 2015 09:51:33 +0000 Parathyroid cysts (PC) are an unusual cause of neck swellings. The majority are nonfunctioning and prove to be a diagnostic challenge given their nonspecific physical and radiological characteristics. This is compounded by their rare occurrence, leading them to be overlooked in the differential diagnosis of neck lumps. Imaging techniques fail to determine the origin of these lesions, but a preoperative diagnosis can be achieved by fine-needle aspiration and measurement of cystic fluid C-terminal parathyroid hormone levels. Treatment of nonfunctioning cysts remains controversial and includes needle aspiration, injection of sclerosant, or surgical excision. We present a case of a 44-year-old female presenting with an asymptomatic anterior neck swelling, diagnosed postoperatively as a parathyroid cyst. Anand Goomany, Amy Rafferty, and Ian Smith Copyright © 2015 Anand Goomany et al. All rights reserved. An Unusual Presentation of a Posterior Mediastinal Schwannoma Associated with Traumatic Hemothorax Thu, 07 May 2015 09:51:01 +0000 Schwannomas of the thoracic cavity are typically an asymptomatic, benign neurogenic neoplasm of the posterior mediastinum. In this case, we present a traumatic hemothorax as the initial presentation for a previously undiscovered mediastinal mass. The patient presented with shortness of breath and right-sided chest pain after being struck in the chest with a soccer ball. An operative exploration was pursued due to persistent hemothorax with hemodynamic instability despite resuscitation and adequate thoracostomy tube placement. The intraoperative etiology of bleeding was discovered to be traumatic fracture of a large hypervascular posterior mediastinal schwannoma. Surgical resection is the treatment of choice for these tumors. Specific serological markers do not exist for this tumor, and radiographic findings can be variable, so tissue diagnosis is of importance in differentiating benign from malignant schwannomas, as well as other posterior mediastinal tumors. However, most patients have excellent survival following complete resection. Ruchi Amin and Brett H. Waibel Copyright © 2015 Ruchi Amin and Brett H. Waibel. All rights reserved. Fatal Necrotizing Fasciitis following Episiotomy Thu, 07 May 2015 09:02:09 +0000 Introduction. Necrotizing fasciitis is an uncommon condition in general practice but one that provokes serious morbidity. It is characterized by widespread fascial necrosis with relative sparing of skin and underlying muscle. Herein, we report a fatal case of necrotizing fasciitis in a young healthy woman after episiotomy. Case Report. A 17-year-old primigravida underwent a vaginal delivery with mediolateral episiotomy. Necrotizing fasciitis was diagnosed on the 5th postpartum day, when the patient was referred to our tertiary care medical center. Surgical debridement was initiated together with antibiotics and followed by hyperbaric oxygen therapy. The patient died due to septic shock after 16 hours from the referral. Conclusion. Delay of diagnosis and consequently the surgical debridement were most likely the reasons for maternal death. In puerperal period, a physician must consider necrotizing fasciitis as a possible diagnosis in any local sings of infection especially when accompanied by fever and/or tenderness. Early diagnosis is the key for low mortality and morbidity. Faris Almarzouqi, Gerrit Grieb, Christian Klink, Dirk Bauerschlag, Paul C. Fuchs, Ziyad Alharbi, Marketa Vasku, and Norbert Pallua Copyright © 2015 Faris Almarzouqi et al. All rights reserved. Laparoscopy as a Diagnostic and Definitive Therapeutic Tool in Cases of Inflamed Simple Lymphatic Cysts of the Mesentery Wed, 06 May 2015 09:47:46 +0000 Mesenteric cysts are rare benign abdominal tumors. These cysts, especially those of lymphatic origin, very rarely become inflamed. The diagnosis of inflamed lymphatic cysts of the mesentery may be difficult. We herein report two cases of inflamed simple lymphatic cysts of the mesentery definitively diagnosed and excised by laparoscopy. Abdelrahman Abdelaal, Ibnouf Sulieman, Zia Aftab, Ayman Ahmed, Saif Al-Mudares, Mohannad Al Tarakji, Ahmad Almuzrakchi, Adriana Toro, and Isidoro Di Carlo Copyright © 2015 Abdelrahman Abdelaal et al. All rights reserved.