Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Hiatal Hernia Repair with Gore Bio-A Tissue Reinforcement: Our Experience Tue, 22 Apr 2014 00:00:00 +0000 Type I hiatal hernia is associated with gastroesophageal reflux disease (GERD) in 50–90% of cases. Several trials strongly support surgery as an effective alternative to medical therapy. Today, laparoscopic fundoplication is considered as the procedure of choice. However, primary laparoscopic hiatal hernia repair is associated with upto 42% recurrence rate. Mesh reinforcement of the crural closure decreases the recurrence but can lead to complications, above all nonabsorbable ones. We experiment a new totally absorbable mesh by Gore. Case. We present a case of a 65-year-old female patient with a 6-year classic history of GERD. Endoscopy revealed a large hiatal hernia and esophagitis. pH study was positive for acid reflux; esophageal manometry revealed LES intrathoracic dislocation. With laparoscopic approach, the hiatal hernia defect was identified and primarily repaired, by crural closure. Gore Bio-A Tissue Reinforcement was trimmed to fit the defect accommodating the esophagus. Nissen fundoplication was performed. Result. Bio-A mesh was easily placed laparoscopically. It has good handling and could be cut and tailored intraoperatively for optimal adaptation. There were no short-term complications. Conclusion. Crural closure reinforcement can be done readily with this new totally absorbable mesh replaced by soft tissue over six months. However, further data and studies are needed to evaluate long-term outcomes. Agrusa Antonino, Romano Giorgio, Frazzetta Giuseppe, De Vita Giovanni, Di Giovanni Silvia, Chianetta Daniela, Di Buono Giuseppe, Sorce Vincenzo, and Gulotta Gaspare Copyright © 2014 Agrusa Antonino et al. All rights reserved. Ehlers-Danlos Syndrome—Hypermobility Type and Hemorrhoids Tue, 15 Apr 2014 16:17:02 +0000 Ehlers-Danlos syndrome-hypermobility type (EDS-HT) is a connective tissue disorder associated with chronic musculoskeletal pain. The diagnosis is based on simple clinical examination, although it is easily overlooked. Herein we present a case of EDS-HT associated with hemorrhoids and suggest that there may be an association between the two conditions. Timothy P. Plackett, Edward Kwon, Ronald A. Gagliano Jr., and Robert C. Oh Copyright © 2014 Timothy P. Plackett et al. All rights reserved. Transgastric Synthetic Mesh Migration, 9 Years after Liver Resection Tue, 15 Apr 2014 13:40:29 +0000 Complications of synthetic mesh have been described in various hernia procedures including migration and erosion, but no previous report mentions this complication after liver resection. This case describes a patient who had undergone a left hepatic resection with mesh pledgets sutured along the cut edge of the liver. He remained complication-free until nine years later when he presented with weight loss and early satiety, and endoscopy revealed mesh within the lumen of the stomach. While still attached to the liver, the mesh had eroded into the lumen of the stomach and he ultimately required surgery to remove this. The use of synthetic mesh in hepatectomies and other abdominal procedures may require further consideration by surgeons regarding its relatively unknown tendency for migration and erosion. Jae You, Neil Onizuka, and Linda Wong Copyright © 2014 Jae You et al. All rights reserved. Postoperative Ascites of Unknown Origin following Laparoscopic Appendicectomy: An Unusual Complication of Laparoscopic Surgery Sun, 13 Apr 2014 07:49:03 +0000 Postoperative ascites is a very rare complication of laparoscopic surgery. Significant iatrogenic injuries to the bowel, the urinary tract, and the lymphatic system should be excluded promptly to avoid devastating results for the patient. In some cases, in spite of investigating patients extensively, no definitive causative factor for the accumulation of fluid can be identified. In such cases, idiopathic allergic or inflammatory reaction of the peritoneum may be responsible for the development of ascites. We present a case of ascites of an unknown origin in a young female patient following a laparoscopic appendicectomy. M. Feretis, H. Boyd-Carson, and A. Karim Copyright © 2014 M. Feretis et al. All rights reserved. Outcomes after Trifocal Femoral Fractures Tue, 01 Apr 2014 09:44:31 +0000 Trifocal femur fractures are those of the femoral neck, diaphysis, and distal femur. These high-energy injuries predominantly occur in young people with the potential for long-term complications and disability. We present the cases of two men who were treated with proximal dynamic hip screws and distal periarticular locking plates to effectively manage trifocal femur fractures. Our cases have shown union at 2 years with good functional outcomes without the need for reintervention. We provide evidence for a successful surgical treatment option for these rare and complex injuries. Michelle Griffin, Alastair G. Dick, and Shamim Umarji Copyright © 2014 Michelle Griffin et al. All rights reserved. Late-Onset Bowel Strangulation due to Reduction En Masse of Inguinal Hernia Tue, 01 Apr 2014 06:49:41 +0000 Incarcerated inguinal hernia is often encountered by surgeons in daily practice. Although rare, hernial reduction en masse is a potential complication of manual reduction of an incarcerated hernia. Manual reduction was performed in a case of Zollinger classification type VII (combined type) hernia in which the indirect hernia portion included an incarcerated small intestine. This procedure caused hernial reduction en masse, but this went unnoticed, and the remaining portion of the direct hernia in the inguinal region was treated surgically by the anterior approach. Because the incarcerated small bowel that had been reduced en masse was not completely obstructed, the patient’s general condition was not greatly affected, and he was able to resume eating. Twenty days after surgery, he developed sudden abdominal pain as a result of gastrointestinal perforation. When performing manual reduction of an incarcerated hernia in cases after self-reduction over a long period, the clinician should always be aware of the possibility of reduction en masse. Ikuo Watanobe, Noritoshi Yoshida, Shin Watanabe, Toshirou Maruyama, Atsushi Ihara, and Kuniaki Kojima Copyright © 2014 Ikuo Watanobe et al. All rights reserved. Isolated Retroperitoneal Hydatid Cyst Invading Splenic Hilum Wed, 26 Mar 2014 11:40:42 +0000 Introduction. Hydatid disease (HD) is an infestation that is caused by the larval stage of Echinococcus granulosus. The liver is affected in approximately two-thirds of patients, the lungs in 25%, and other organs in a small proportion. Primary retroperitoneal hydatid cyst is extremely rare. The most common complaint is abdominal pain; however, the clinical features of HD may be generally dependent on the location of the cyst. Case Presentation. A 43-year-old female was admitted with the complaint of abdominal pain. Her physical examination was normal. Computed tomography (CT) revealed a  cm cystic lesion, with a thick and smooth wall that is located among the left liver lobe, diaphragm, spleen, tail of the pancreas, and transverse colon and invading the splenic hilum. Total cystectomy and splenectomy were performed. Pathological examination was reported as cyst hydatid. Discussion. Cysts in the peritoneal cavity are mainly the result of the spontaneous or traumatic rupture of concomitant hepatic cysts or surgical inoculation of a hepatic cyst. Serological tests contribute to diagnosis. In symptomatic and large hydatid peritoneal cysts, surgical resection is the only curative treatment. Total cystectomy is the gold standard. Albendazole or praziquantel is indicated for inoperable and disseminated cases. Percutaneous aspiration, injection, and reaspiration (PAIR) technique is another nonsurgical option. Safak Ozturk, Mutlu Unver, Burcin Kibar Ozturk, Eyup Kebapci, Osman Bozbiyik, Varlık Erol, Nihat Zalluhoglu, and Mustafa Olmez Copyright © 2014 Safak Ozturk et al. All rights reserved. Utilization of a Continuous External Tissue Expansion System to Assist in Primary Closure of a Large Anterolateral Thigh Donor Site Defect Tue, 25 Mar 2014 13:58:53 +0000 Primary closure of a large anterolateral thigh (ALT) flap donor site defect with the assistance of an external tissue expansion system is presented. The dimensions of this donor site (12 cm × 40 cm) and its percentage of leg circumference (34%) would make this site likely to require skin grafting or further flap coverage based on the results of previously published literature. Andrew G. Silver and Richard C. Baynosa Copyright © 2014 Andrew G. Silver and Richard C. Baynosa. All rights reserved. The Adventitia Resection in Treatment of Liver Hydatid Cyst: A Case Report of a 15-Year-Old Boy Mon, 24 Mar 2014 07:30:22 +0000 Human hydatid disease is a significant health problem in endemic regions caused by the larval form of Echinococcus granulosus. In this paper, we report a case of liver hydatid cyst. The patient, a 15-year-old boy, presented with a history of intermittent upper abdominal pain of a few-month duration was referred to our hospital for investigation. Computed tomographic scan and laboratory test suggested a hydatid cyst in the right lobe of liver. The adventitia resection of hydatid cyst was smoothly performed as there was a less bloody virtual space between adventitia and outer membrane. Our diagnosis was made using an imaging approach and was confirmed during surgery. We proposed the adventitia resection of hydatid cyst could be safe and easy to perform with low risk of bleeding and bile leakage. Zhenhua Ma, Wei Yang, Yingmin Yao, and Qingguang Liu Copyright © 2014 Zhenhua Ma et al. All rights reserved. Medial Radial Head Dislocation Associated with a Proximal Olecranon Fracture: A Bado Type V? Mon, 17 Mar 2014 13:06:12 +0000 The Monteggia fracture is relatively rare. We present an unreported configuration of a traumatic olecranon fracture with a concomitant medial radial head dislocation in a 3-year-old male. This injury was initially missed and required a subsequent operative intervention. Following surgery, there was evident fracture union, articular congruency, and a full functional recovery. Medial radial head dislocation is not accounted for in the Bado (1967) classification of the Monteggia lesion and hence we propose the addition of a Bado V category. Neil Segaren, Hani B. Abdul-Jabar, Nicholas Segaren, and Matthew Barry Copyright © 2014 Neil Segaren et al. All rights reserved. A Rare Case of Perforated Descending Colon Cancer Complicated with a Fistula and Abscess of Left Iliopsoas and Ipsilateral Obturator Muscle Sun, 16 Mar 2014 12:49:57 +0000 Perforation of descending colon cancer combined with iliopsoas abscess and fistula formation is a rare condition and has been reported few times. A 67-year-old man came to our first aid for an acute pain in the left iliac fossa, in the flank, and in the ipsilateral thigh. Ultrasonography and computed tomography revealed a left abdominal wall, retroperitoneal, and iliopsoas abscess that also involved the ipsilateral obturator muscle. It proceeded with an exploratory laparotomy that showed a tumor of the descending colon adhered and perforated in the retroperitoneum with abscess of the iliopsoas muscle on the left-hand side, with presence of a fistula and liver metastases. A left hemicolectomy with drainage of the broad abscess was performed. Pathologic report findings determined adenocarcinoma of the resected colon. Alban Cacurri, Gaspare Cannata, Stefano Trastulli, Jacopo Desiderio, Antongiulio Mangia, Olga Adamenko, Eleonora Pressi, Giorgio Giovannelli, Giuseppe Noya, and Amilcare Parisi Copyright © 2014 Alban Cacurri et al. All rights reserved. A Case of Carcinoid Likely Causing Jejunal Intussusception Sun, 16 Mar 2014 09:38:38 +0000 A 34-year-old female was admitted to Emergency Department with an abrupt onset of diffuse abdominal pain. A CT scan done prior to her transfer revealed significant dilated loops of bowel as well as multiple target signs with likely torsed bowel. The patient consented to an exploratory laparotomy. During surgery, the proximal jejunum was found to be intussuscepted, a rare finding in an adult. There was evidence of mesenteric foreshortening throughout the small bowel and multiple whitish lesions within the mesentery, both consistent with the desmoplastic response that is characteristic of carcinoid. The interest for this case report comes from the patient’s surgical findings of jejunal intussusception as well as her extensive history, which includes a bowel resection with an ileocolic anastomosis for presumed ischemia and a carcinoid tumor in the stomach which had been removed endoscopically. Jennifer Matulich, Kelly Thurston, Dan Galvan, and Subhasis Misra Copyright © 2014 Jennifer Matulich et al. All rights reserved. Postcardiotomy Mechanical Circulatory Support in Two Infants with Williams’ Syndrome Tue, 11 Mar 2014 14:38:32 +0000 Supravalvar aortic stenosis (SVAS) in patients with Williams’ syndrome is often accompanied by coronary, pulmonary, and even myocardial lesions and therefore associated with increased perioperative morbidity and mortality. Extracorporeal membrane oxygenation (ECMO) provides reliable short-term mechanical circulatory support to patients, especially young, in acute postoperative cardiac failure when conventional means are ineffective. The incorporation of centrifugal pumps in these systems has made their use more efficient and less traumatic. We describe our experience of using the Levitronix CentriMag pump in two patients with Williams' syndrome who underwent surgical correction of supravalvular aortic stenosis. Constantinos A. Contrafouris, Andrew C. Chatzis, Meletios A. Kanakis, Prodromos A. Azariadis, and Fotios A. Mitropoulos Copyright © 2014 Constantinos A. Contrafouris et al. All rights reserved. Functional Recovery in Chronic Stage of Spinal Cord Injury by Neurorestorative Approach: A Case Report Tue, 11 Mar 2014 00:00:00 +0000 Spinal cord injury (SCI) at an early age can be debilitating for the child’s growth. Current treatments show a level of stagnancy, after which the recovery is minimal. Cellular therapy is an emerging area of research and has been found to possess many benefits in the previous studies. Transplantation of autologous bone marrow mononuclear cells (BMMNCs) has demonstrated therapeutic potential for many neurological conditions, including spinal cord injury. Here we report a case of 6-year-old girl with traumatic SCI at the level of C7-D1 4 years back, who underwent 2 doses of cell transplantation with autologous BMMNCs with an interval of 6 months along with standard rehabilitation. The patient did not have any major or minor side effects. The patient showed clinical improvements throughout the 6 months after transplantation, which was assessed using Functional Independence Measure (before: 82, after: 101 out of 126). There were patchy areas of sensory gain in bilateral feet recorded, with improvements in the bladder sensation and control. Improved gait was seen as a result of better strength in abdominals and back extensors. The fact that there was functional improvement in the chronic plateau phase indicates the potential of cell therapy in chronic SCI. Further clinical studies are warranted. Alok Sharma, Hemangi Sane, Dipti Khopkar, Nandini Gokulchandran, V. C. Jacob, Joji Joseph, and Prerna Badhe Copyright © 2014 Alok Sharma et al. All rights reserved. Idiopathic Thrombocytopenic Purpura after Mastectomy and Axillary Lymph Node Dissection Thu, 06 Mar 2014 12:20:22 +0000 First described in 1916, idiopathic thrombocytopenic purpura (ITP) is an autoimmune disease resulting in the destruction of platelets. Here, we present a case of an 85-year-old patient diagnosed with invasive ductal carcinoma of the breast whose surgical treatment was complicated postoperatively by acute-onset thrombocytopenia with a resultant hematoma at the operative site. Diagnostic Workup revealed no clear etiology for the thrombocytopenia; therefore, a presumptive diagnosis of idiopathic thrombocytopenic purpura was made. Previous literature has associated the development of idiopathic thrombocytopenic purpura with breast cancer. However, to the authors’ knowledge, there are no reported cases of ITP presenting immediately following surgical intervention for breast cancer in the absence of other etiologic factors. Wil L. Santivasi, Meghan M. Routt, and Alicia M. Terando Copyright © 2014 Wil L. Santivasi et al. All rights reserved. Posterior Interosseous Nerve Syndrome from Thermal Injury Thu, 06 Mar 2014 06:55:27 +0000 Background. Due to anatomical proximity to bone, the radial nerve is the most frequently injured major nerve of the upper extremity, frequently secondary to fractures (Li et al. (2013)). We describe an incidence when a branch of the radial nerve is injured as a result of a thermal injury. Observation. Radial nerve injury can occur anywhere along the anatomical course with varied etiologies, but commonly related to trauma. The most frequent site is in the proximal forearm involving the posterior interosseous branch. However, problems can occur at the junction of the middle and proximal thirds of the humerus and wrist radially. When the radial nerve is injured by a burn, a new rehabilitation dynamic arises. Not only does one agonize about the return of nerve function but also fret about the skin grafts that replaced the devitalized tissue housing that compartment. Discussion. Although posterior interosseous nerve syndrome has been described in the context of many different etiologies, it has not previously been discussed in relation to burn injuries. In this case, not only did the patient’s rehabilitation involve aggressive therapy for return of sensation and function of the arm, but also prevention of contracture normally seen in replacement of full thickness burns. Vijay A. Singh, Rami E. Michael, Duy-Bao P. Dinh, Scott Bloom, and Michael Cooper Copyright © 2014 Vijay A. Singh et al. All rights reserved. The Integrative Method “Suture Dragging and Simplified Vacuum Assisted Therapy” for Complex Pilonidal Sinus Disease Tue, 04 Mar 2014 14:02:10 +0000 Complex and recurrent pilonidal sinuses are best treated with surgery. Different surgical modalities as complete excision of the pilonidal sinus leave the wound open or procedures like closing the wound with or without reconstructive flap are widely used. The open procedure is radical but may cause broad excision and prolonged morbidity, while risk of infection and rate of recurrence are higher in the closed techniques. Traditional Chinese surgical treatments are less invasive and more effective; they have been used to treat sinus and fistula disease successfully. In this case report, we have described a male adolescent with complex pilonidal sinus, who received traditional Chinese surgical treatment combined with modern wound healing technique. He recovered completely with short hospitalization, good tolerance, less pain, and scarring. Therefore, we recommend using this integrative method to treat complex pilonidal sinus disease. Chen Wang, YiBo Yao, and YongQing Cao Copyright © 2014 Chen Wang et al. All rights reserved. Malignant Peritoneal Mesothelioma: Clinicopathological Characteristics of Two Cases Tue, 04 Mar 2014 12:36:11 +0000 Introduction. Peritoneal mesothelioma is a rare tumor, presenting difficulties in diagnosis and treatment. Peritoneum is the second most common area of the mesothelioma after pleura, and even synchronous pleural and peritoneal mesotheliomas are observed in 30–45% of all cases. The diagnosis may be difficult due to lack of specific symptoms and clinical findings. In addition, a delay in the diagnosis is not rare especially in the absence of previous asbestos exposure. Here we report two cases of malignant peritoneal mesotheliomas. The diagnostic and therapeutic approaches for these rare neoplasms are discussed. Case Presentation. The cases were two men (one aged 54 years old and the other 40 years old). Prolonged abdominal pain and swelling were the primary presentation symptoms and findings. The mesotheliomas were developed in the right upper quadrant of abdomen in both of the cases. Both cases were treated with surgical resection. Final diagnosis were possible with histological and immunohistochemical documentation of tumor characteristics, which were consistent with dictating a mesothelial origin. No history of asbestos exposure was reported. Conclusion. Peritoneal mesotheliomas are rare clinical entities. However, patients with prolonged abdominal pain and abdominal masses should be considered to have atypical pathologies such as peritoneal mesotheliomas. Mustafa Cem Algın, Faik Yaylak, Zülfü Bayhan, Figen Aslan, and Nilüfer Araz Bayhan Copyright © 2014 Mustafa Cem Algın et al. All rights reserved. Unclassified Diffuse Ductal Cholangiocarcinoma; Report of a Case Tue, 04 Mar 2014 09:20:14 +0000 Cholangiocarcinoma (CCA) is the second most common malignant tumor of the liver. It is simply classified as intrahepatic and extrahepatic CCA (including perihilar and distal extra hepatic CCA) according to the anatomic localization. Various classification systems were described for staging cholangiocarcinoma. We represent an interesting case of cholangiocarcinoma which is in the shadow area of classification by involving intrahepatic, hilar, and distal extra hepatic bile ducts. To our knowledge, this is the first case in the literature with diffuse bile duct involvement. Ünal Aydın, İsmail Özsan, Türker Karabuğa, Özcan Alpdoğan, Ragıp Ortaç, Ömer Yoldaş, and Erkan Şahin Copyright © 2014 Ünal Aydın et al. All rights reserved. Appendicitis in De Garengeot's Hernia Presenting as a Nontender Inguinal Mass: Case Report and Review of the Literature Tue, 04 Mar 2014 08:35:46 +0000 Introduction. De Garengeot first described a femoral hernia containing the appendix in 1731. Appendicitis occurring in this rare clinical setting represents a challenge in diagnosis and management. Case Presentation. We present the case of a 71-year-old male with a three-day history of a nontender inguinal mass. Computed tomography (CT) suggested a femoral hernia. Intraoperatively, the hernia sac was noted to contain a perforated appendix. Discussion. This is an infrequently reported clinical scenario and only the 14th reported case in peer-reviewed literature which includes preoperative CT images. Our case adds to previously reported low sensitivity of CT for diagnosing De Garengeot’s hernia. Furthermore, unlike our case the vast majority of previous reports noted a painful inguinal swelling. Conclusion. Perforated appendicitis in a femoral hernia is an extremely uncommon presentation. However, consideration should be given to De Garengeot’s hernia in patients with a groin mass, even if nontender. K. Ahmed, K. Bashar, T. J. McHugh, S. M. McHugh, and E. Kavanagh Copyright © 2014 K. Ahmed et al. All rights reserved. A Case of Perforated Sigmoid Diverticulitis in Which Gram Staining of Ascitic Fluid Was Useful for Diagnosis Tue, 04 Mar 2014 07:41:04 +0000 An 85-year-old woman was admitted to our hospital for steroid therapy for relapsing nephrotic syndrome. During hospitalization, she complained of sudden epigastric pain at night. Although there were signs of peritoneal irritation, CT showed a large amount of ascitic fluid, but no free intraperitoneal gas. Gram staining of ascitic fluid obtained by abdominal paracentesis showed Gram-negative rods, which raised a strong suspicion of gastrointestinal perforation and peritonitis. Therefore, emergency surgery was performed. Exploration of the colon showed multiple sigmoid diverticula, one of which was perforated. The patient underwent an emergency Hartmann's procedure. Imaging studies failed to reveal any evidence of gastrointestinal perforation, presenting a diagnostic challenge. However, a physician performed rapid Gram staining of ascitic fluid at night when laboratory technicians were absent, had a strong suspicion of gastrointestinal perforation, and performed emergency surgery. Gram staining is superior in rapidity, and ascitic fluid Gram staining can aid in diagnosis, suggesting that it should be actively performed. We report this case, with a review of the literature on the significance of rapid diagnosis by Gram staining. Junko Tsuchida, Shouhei Fujita, Fumihiro Kawano, Ryoichi Tsukamoto, Kunpei Honjo, Shigetoshi Naito, Shun Ishiyama, Shozo Miyano, Michio Machida, Toshiaki Kitabatake, Minoru Fujisawa, Kuniaki Kojima, Kanako Ogura, and Toshiharu Matsumoto Copyright © 2014 Junko Tsuchida et al. All rights reserved. Safety of Redo Hepatectomy for Colorectal Liver Metastases after Selective Interarterial Radiation Therapy: A Case Report Tue, 04 Mar 2014 07:28:45 +0000 Surgical resection is the only potentially curative strategy in the treatment of patients with colorectal liver metastases (CLM). Unfortunately, only about 10%–15% of patients are candidates for resection. Preoperative chemotherapy aims to increase the number of patients that may be eligible for liver resection by downsizing liver metastases. For patients with unresectable, chemotherapy refractory CLM the available treatment options are limited. Selective interarterial radiation therapy (SIRT) is one of the most promising treatment options for this group of patients. Although only a small number of these patients have been reported as becoming candidates for potentially curative hepatic resection following sufficient reduction in the volume of liver metastases, the question arises regarding the safety of liver resection in these patients. We report a case of a patient who presented unresectable liver relapse of CLM after previous right hepatectomy. He underwent SIRT which resulted in downsizing of the liver metastases making the patient candidate for left lateral sectionectomy. He underwent the redo hepatectomy without any complications. To the best of our knowledge, this is the first reported case of redo hepatectomy after SIRT for CLM. Kyriakos Neofytou, Harpreet Wasan, and Satvinder Mudan Copyright © 2014 Kyriakos Neofytou et al. All rights reserved. Pericardial Window Formation Complicated by Intrapericardial Diaphragmatic Hernia Mon, 03 Mar 2014 13:35:30 +0000 In rare circumstances, a diaphragmatic defect may allow for herniation of intra-abdominal contents into the pericardial space. These occurrences are exceedingly rare and may be due to trauma or congenital defects of the septum transversum or as the result of surgical procedures. We describe a 73-year-old female who presented with cardiac and abdominal symptoms one month after undergoing a subxiphoid pericardioperitoneal window for treatment and evaluation of a symptomatic pericardial effusion. Jeremy Docekal and Thomas Fabian Copyright © 2014 Jeremy Docekal and Thomas Fabian. All rights reserved. Cecocolic Intussusception in Adult Caused by Acute Appendicitis Wed, 19 Feb 2014 07:58:50 +0000 Intussusception in adult is rare. The etiology is different from that of childhood. The most common cause of intussusception in adult is known as malignancy. When dealing with adult intussusception, surgical resection is usually warranted for correct diagnosis and proper treatment. This is a case report of cecocolic intussusception caused by an acute appendicitis in adult. The causes of cecocolic intussusception were reported as appendiceal adenocarcinoma, appendiceal mucocele, appendiceal adenoma, or idiopathic. Although this patient underwent laparoscopic right hemicolectomy under suspicion of malignancy at cecum base, final pathologic diagnosis revealed only acute appendicitis. Thus, the present case emphasizes the importance of prior thorough examinations including colonoscopy when we encounter this rare kind of intussusception in adult. Jeonghyun Kang, Kang Young Lee, and Seung-Kook Sohn Copyright © 2014 Jeonghyun Kang et al. All rights reserved. Splenic Artery Pseudoaneurysm Presenting as Massive Hematemesis: A Diagnostic Dilemma Thu, 13 Feb 2014 14:13:14 +0000 Introduction. Splenic artery Pseudoaneurysm, a complication of chronic pancreatitis, presenting as massive hematemesis is a rare presentation. Case Report. We present a case of 38-year-old male admitted with chief complaints of pain in the upper abdomen and massive hematemesis for the last 15 days. On examination there was severe pallor. On investigating the patient, Hb was 4.0 gm/dL, upper GI endoscopy revealed a leiomyoma in fundus of stomach, and EUS Doppler also supported the UGI findings. On further investigation of the patient, CECT of the abdomen revealed a possibility of distal pancreatic carcinoma encasing splenic vessels and infiltrating the adjacent structure. FNA taken at the time of EUS was consistent with inflammatory pathology. Triple phase CT of the abdomen revealed a splenic artery pseudoaneurysm with multiple splenic infarcts. After resuscitation we planned an emergency laparotomy; splenic artery pseudoaneurysm densely adherent to adjacent structures and associated with distal pancreatic necrosis was found. We performed splenectomy with repair of the defect in the stomach wall and necrosectomy. Postoperative course was uneventful and patient was discharged on day 8. Conclusion. Pseudoaneurysm can be at times a very difficult situation to manage; options available are either catheter embolisation if patient is vitally stable, or otherwise, exploration. Peeyush Varshney, Bhupen Songra, Shivank Mathur, Sudarshan Gothwal, Puneet Malik, Mahnedra Rathi, and Rajveer Arya Copyright © 2014 Peeyush Varshney et al. All rights reserved. A Patient with Advanced Gastric Cancer Presenting with Extremely Large Uterine Fibroid Tumor Wed, 12 Feb 2014 08:33:32 +0000 Introduction. Uterine fibroid tumors (uterine leiomyomas) are the most common benign uterine tumors. The incidence of uterine fibroid tumors increases in older women and may occur in more than 30% of women aged 40 to 60. Many uterine fibroid tumors are asymptomatic and are diagnosed incidentally. Case Presentation. A 44-year-old woman was admitted to our hospital with general weakness, dyspepsia, abdominal distension, and a palpable abdominal mass. An abdominal computed tomography scan showed a huge tumor mass in the abdomen which was compressing the intestine and urinary bladder. Gastroduodenal endoscopic and biopsy results showed a Borrmann type IV gastric adenocarcinoma. The patient was diagnosed with gastric cancer with disseminated peritoneal carcinomatosis. She underwent a hysterectomy with both salphingo-oophorectomy and bypass gastrojejunostomy. Simultaneous uterine fibroid tumor with other malignancies is generally observed without resection. But in this case, a surgical resection was required to resolve an intestinal obstruction and to exclude the possibility of a metastatic tumor. Conclusion. When a large pelvic or ovarian mass is detected in gastrointestinal malignancy patients, physicians try to exclude the presence of a Krukenberg tumor. If the tumors cause certain symptoms, surgical resection is recommended to resolve symptoms and to exclude a metastatic tumor. Kwang-Kuk Park and Song-I Yang Copyright © 2014 Kwang-Kuk Park and Song-I Yang. All rights reserved. Giant Hepatic Carcinoid: A Rare Tumor with a Favorable Prognosis Sun, 09 Feb 2014 00:00:00 +0000 Primary hepatic carcinoids are rare tumors that are often diagnosed at a locally advanced stage. Their primary nature can only be ascertained after thorough investigations and long-term follow-up to exclude another primary origin. As with secondary neuroendocrine liver tumors, surgical resection remains the mainstay of therapy. Despite their large size and often central location liver resection is often feasible, offering long-term survival and cure to most patients. In selected patients liver transplantation appears to be a good indication for tumors not amenable to liver resection. An aggressive surgical attitude is therefore warranted. We report a large and unusually fast-growing liver carcinoid that appeared only marginally resectable in a patient who remains free of disease four years after surgery. Serge Landen, Maxime Elens, Celine Vrancken, Frederiek Nuytens, Thibault Meert, and Veronique Delugeau Copyright © 2014 Serge Landen et al. All rights reserved. Rectus Abdominis Muscle Malignant Fibrous Histiocytoma Causing a Large Abdominal Wall Defect: Reconstruction with Biological Mesh Thu, 06 Feb 2014 09:54:55 +0000 Malignant fibrous histiocytoma (MFH) is a common soft tissue sarcoma usually involving limbs and retroperitoneum. MFH of the rectus abdominis muscle is extremely rare. Surgery in similar cases leads to large abdominal wall defects needing reconstruction. Biological and synthetic laminar absorbable prostheses are available for the repair of hernia defects in the abdominal wall. They share the important feature of being gradually degraded in the host, resulting the formation of a neotissue. We herein report the case of an 84-year-old man with MFH of the rectus abdominis muscle which was resected and the large abdominal wall defect was successfully repaired with a biological mesh. Evangelos Falidas, Stavros Gourgiotis, Christina Goudeli, Stavros Mathioulakis, Konstantinos Vlachos, and Constantinos Villias Copyright © 2014 Evangelos Falidas et al. All rights reserved. Blue Rubber Bleb Nevus Syndrome as a Cause of Lower Digestive Bleeding Wed, 05 Feb 2014 15:36:33 +0000 Introduction. Blue rubber bleb nevus syndrome is a rare disorder that is characterized by multiple recurrent vascular malformations that involve the skin and the gastrointestinal tract. The disease can present chronic anemia and severe episodes of gastrointestinal bleeding. Case Report. A 41-year-old man was admitted with recurrent episodes of lower gastrointestinal bleeding and anemia that had worsened over the last 3 months. The physical examination showed soft, diffuse, compressible, bluish nodules on all of the skin surfaces of the body. A biopsy from one of these skin lesions allowed a histological diagnosis of cavernous hemangioma. He submitted to a colonoscopy, which showed hemorrhoids and a plane vascular lesion mainly located on the right colon with recent signs of bleeding; this lesion was treated by local excision and sclerosis. The pathological study of the colon specimens also reflected the presence of cavernous hemangioma. The cutaneous hemangiomas and the presence of colonic venous malformations were compatible with blue rubber bleb nevus syndrome. The patient presented a favorable follow-up with clinical control of the anemia and without relapse of the gastrointestinal bleeding two years after the procedure. Conclusion. Although rarely diagnosed, blue rubber bleb nevus syndrome may be responsible for lower digestive bleeding. Carlos Augusto Real Martinez, Murilo Rocha Rodrigues, Daniela Tiemi Sato, Paulo Pedroso Silveira Júnior, Rafael Fernandes Gama, Christian Bornia Mattavelli, and José Aires Pereira Copyright © 2014 Carlos Augusto Real Martinez et al. All rights reserved. Coverage of the Neurovascular Unit of the Fingertip Using a Reverse Homodigital Dorsal Flap Thu, 09 Jan 2014 07:04:41 +0000 The exposure of bone, tendons, vessels, and nerves in a digital defect is one of the most frequent and severe problems to solve in hand surgery and current approaches are still disappointing. We show the use of an homodigital adipofascial flap taken from the same finger for covering the pulpar defect in a one-step surgical technique able to preserve the digital artery. Rosario E. Perrotta, Alessio Stivala, Dario Virzì, Roberto Grella, Domenico Pagliara, and Sergio Brongo Copyright © 2014 Rosario E. Perrotta et al. All rights reserved.