Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Autoimmune Gastrointestinal Paralysis: Failure of Conventional Treatment without Immunomodulation Thu, 18 Sep 2014 06:43:15 +0000 The treatment of the rare enteric nervous system (ENS) manifestations of paraneoplastic syndromes, which are most frequently associated with small cell lung cancer (SCLC), is poorly understood and described. Patients with neuroendocrine-derived tumors can develop B-cell reactivity towards the tumor with cross-reactivity for neurons located in the submucosal and myenteric ganglia of the ENS. The ensuing autoimmune neuritis causes aperistalsis and severe gastrointestinal (GI) dysfunction. Immune-directed therapy is not the standard of care but may be paramount for patient recovery. Our patient, a 63-year-old man with recent symptoms of esophageal dysmotility and newly diagnosed SCLC was hospitalized with nausea, emesis, and constipation. After an extensive work-up that included laparoscopy and celiotomy with bowel resection, we diagnosed what we refer to as Autoimmune Paraneoplastic Chronic Intestinal Pseudoobstruction (AP-CIPO). Unlike the few clinically similar reports, SCLC and AP-CIPO were diagnosed in our patient within weeks of each other, which presented the dilemma of treating the two processes simultaneously. In this report, we review the relevant literature and describe our patient’s course. We believe standard chemotherapy is not effective treatment for AP-CIPO. Based on evidence discussed herein, we suggest initiating autoimmune-directed therapy before or simultaneous with cancer-directed therapy. Craig Weinkauf, Sean McPhillips, Robert Krouse, and Ira Levine Copyright © 2014 Craig Weinkauf et al. All rights reserved. Angiomyolipoma of the Thoracic Wall: An Extremely Rare Diagnostic Challenge Mon, 08 Sep 2014 12:26:54 +0000 Extrarenal angiomyolipoma (AML) is an extremely uncommon lesion, accounting for less than 9% of all angiomyolipomas. We present a previously unreported case of a rarely located gigantic extrarenal angiomyolipoma at the posterolateral chest wall of a 35-year-old woman. Clinically, the lesion had all the characteristics of a benign tumor, being soft in palpation, painless, and growing in size in a slow rate. Histologically, the lesion consisted of convoluted thick-walled blood vessels without an elastic layer, interlacing fascicles of smooth muscle, and mature adipose tissue, features consistent with an angiomyolipoma. The mass was surgically removed, without any postoperative complications, and the patient has an uneventful postoperative course. Signs of local recurrence have not been observed. The purpose of this brief report is to point out the necessity of including angiomyolipoma in the differential diagnosis of adipose layer lesions. Georgios Gemenetzis, Eleni Kostidou, Kalliroi Goula, Vassilios Smyrniotis, and Nikolaos Arkadopoulos Copyright © 2014 Georgios Gemenetzis et al. All rights reserved. Nonocclusive Mesenteric Ischemia Associated with Ogilvie Syndrome Sun, 07 Sep 2014 11:13:08 +0000 Nonocclusive mesenteric ischemia (NOMI) is one type of acute mesenteric ischemia. Colonic pseudoobstruction, known as Ogilvie syndrome, is a disorder defined by colonic distension in the absence of mechanical obstruction. A relationship between these diseases has not yet been reported, based on a review of the literature. We report a patient with NOMI secondary to Ogilvie syndrome. An 82-year-old woman reported three days of intermittent abdominal pain. Plain computed tomography scan showed colonic obstruction at the rectosigmoid colon. Colonoscopy was performed that showed a large amount of stool and no evidence of tumor or other physical causes of obstruction. We diagnosed the patient with Ogilvie syndrome and continued nonoperative management. On the third hospital day, she complained of abdominal distension. A repeat CT scan showed pneumatosis intestinalis in the small bowel and ascending colon, with portal venous gas. Emergency laparotomy was performed with diagnosis of mesenteric ischemia. Intraoperatively, there were multiple skip ischemic lesions in the small intestine and cecum. We resected the ischemic bowel and performed a distal jejunostomy. Her residual small bowel measured just 20 cm in length. Postoperatively, her general status gradually improved. She was discharged with total parenteral nutrition and a small amount of enteral nutrition. Takashi Sakamoto, Toshiyuki Suganuma, Shinichiro Okada, Kensuke Nakatani, Sawako Tamaki, and Alan T. Lefor Copyright © 2014 Takashi Sakamoto et al. All rights reserved. A Fatal Case of Wernicke’s Encephalopathy after Sleeve Gastrectomy for Morbid Obesity Sun, 07 Sep 2014 08:18:28 +0000 Wernicke’s encephalopathy is an acute neuropsychiatric disorder, due to thiamine (vitamin B1) deficiency. It is traditionally described in chronic alcohol abusers; however obesity surgery is an emerging cause, as the number of bariatric procedures increases. A high index of clinical suspicion is required, since initial symptoms may be nonspecific and the classic triad of ophthalmoplegia, gait and stance disorders, and mental confusion is present only in one-third of patients. Laboratory tests can be within normal range and typical MRI brain lesions are found only in 50% of cases. Aggressive supplementation with intravenous thiamine should not be delayed until confirmation of diagnosis, as it may fully reverse symptoms, but almost half the patients will still display permanent neurological deficit. We present our experience with a fatal case of Wernicke’s encephalopathy, following laparoscopic sleeve gastrectomy for morbid obesity. Dimitrios K. Manatakis and Nikolaos Georgopoulos Copyright © 2014 Dimitrios K. Manatakis and Nikolaos Georgopoulos. All rights reserved. Massive Submandibular Sialolith: Complete Radiographic Registration and Biochemical Analysis through X-Ray Diffraction Tue, 02 Sep 2014 14:14:38 +0000 Sialolithiasis is a pathologic condition that affects 60 million people per year, which is caused by the presence of calcified structures, named sialoliths, inside the salivary glands and their salivary ducts. Despite the large incidence of sialolithiasis, its etiology is still unknown. In the present case report, a 47-year-old female patient, presenting with local pain and hampered mouth opening, underwent a surgical approach for the removal of a 20 mm sialolith, which was further analyzed through X-ray diffraction. In parallel, a radiographic registration of 8 years, covering all the period for sialolith formation, is presented along the case report. Ademir Franco, Mayara Jessica de Carvalho Mattos, Francine Ferrari, José Manoel dos Reis Neto, Luiz Carlos Carta Gambus, Paulo Henrique Couto Souza, and Soraya de Azambuja Berti-Couto Copyright © 2014 Ademir Franco et al. All rights reserved. Papillary Fibroelastoma of the Right Ventricular Free Wall Tue, 02 Sep 2014 09:52:12 +0000 Papillary fibroelastoma is a rare benign cardiac tumor that usually arises from the valvular endocardium and its development in the cardiac chambers is extremely rare. A 52-year-old woman complained of palpitations and echocardiography revealed a cardiac tumor. Resection was performed via the right ventricle and main pulmonary artery under cardiopulmonary bypass. Histological examination of the resected tumor showed that it was a papillary fibroelastoma. The patient’s postoperative course was unremarkable and no complications have been detected on followup. Tetsuya Niino and Satoshi Unosawa Copyright © 2014 Tetsuya Niino and Satoshi Unosawa. All rights reserved. Intraosseous Inflammatory Myofibroblastic Tumor in the Mandible: A Rare Pathologic Case Report Mon, 01 Sep 2014 07:52:59 +0000 Inflammatory myofibroblastic tumor (IMT) is an extremely rare lesion found in the maxillofacial region. Its frequency diminishes further when found in the bone. Although classification has varied throughout its history, the histologic features are often diagnostic, particularly with its strong association with anaplastic lymphoma kinase-1 (ALK-1) staining. The current mode of treatment for such a lesion is surgical removal with careful followup. In this rare case report, we describe the diagnosis and treatment in a 16-year-old male. Although this rare pathology can present as—and at times mimic—more serious pathologies, it is important for the attending surgeon to initially manage the pathology conservatively. Dale E. Stringer, Chad N. Allen, Katina Nguyen, and Rahul Tandon Copyright © 2014 Dale E. Stringer et al. All rights reserved. Uncommon Metastasis of Laryngeal Cancer to Small Bowel Causing Intestinal Obstruction Treated by Laparoscopic Approach Mon, 01 Sep 2014 05:54:19 +0000 Metastatic laryngeal cancer to the small bowel is extremely rare. Management of small bowel obstruction used to constitute a relative contraindication for the use of laparoscopic modality. We are reporting a case of an elderly man known to have laryngeal cancer who presented with small bowel obstruction due to metastatic deposit to the small bowel. The condition was successfully treated by laparoscopic assisted approach. A review of the natural history of advanced laryngeal cancer, common and uncommon sites of metastasis, and the rare presentation as small bowel obstruction is illustrated in this review. Omar Bekdache, Lateefa Al Nuaimi, Haytham El Salhat, Vasudev Sharma, Ghodratollah Nowrasteh, and Sadir J. Al Rawi Copyright © 2014 Omar Bekdache et al. All rights reserved. Uncommon Progression of an Extradural Spinal Meningioma Wed, 27 Aug 2014 08:19:55 +0000 Extradural spinal meningiomas are rare. Our understanding of purely extradural spinal meningiomas is still incomplete and they may be easily confused with malignant neoplasms, much more common in this location. We report a rare case of a purely extradural thoracic spine meningioma in a 70-year-old man, with an unusual progression. In addition we discuss the pathogenesis of these tumors and the potential pitfalls in differential diagnosis and review the relevant literature concerning their treatment and outcome. Atef Ben Nsir, Mohamed Boughamoura, Houda Mahmoudi, Mohamed Kilani, and Nejib Hattab Copyright © 2014 Atef Ben Nsir et al. All rights reserved. Incidental Benign Metastasizing Leiomyoma in a Patient with Bone Sarcoma: A Case Report Tue, 26 Aug 2014 00:00:00 +0000 Background. The benign metastasizing leiomyoma is an exceptionally rare entity; it presents with ectopic leiomyoma nodules with a benign pattern. Symptoms vary according to the anatomic location. The diagnosis is histopathological, usually in patients with history of hysterectomy. Case Presentation. A 36-year-old female with 2-month history of left knee pain was diagnosed with bone fibrosarcoma. A CT scan showed pulmonary nodules. The patient started neoadjuvant chemotherapy. Conservative surgery of pelvic limb was achieved. A new CT scan reported pulmonary nodules that remained in relation to the previous CT. A nodule resection by thoracotomy and TOB (transoperative biopsy) was performed. The final pathology report described benign proliferative lesions consistent with benign metastatic leiomyoma. Conclusions. Benign metastatic leiomyoma is a rare condition presenting with uterine and extrauterine nodules most commonly in the lung. The diagnosis is histopathological. The surgical procedure must be reserved for selected patients. Zanndor Jacob del Real-Romo, Carlos Montero-Cantú, Oscar Villegas-Cabello, José Antonio Díaz-Elizondo, Danae Reyes-Salas, Rene Palomo-Hoil, Guillermo Peralta-Castillo, David Martínez-Sánchez, and Eduardo Flores-Villalba Copyright © 2014 Zanndor Jacob del Real-Romo et al. All rights reserved. Laparoscopic Incidental Finding of Pneumatosis Intestinalis in Acute Appendicitis Thu, 21 Aug 2014 00:00:00 +0000 Pneumatosis intestinalis (PI) is a rare condition where the gas trapped inside the bowel wall. It is commonly found as an incidental finding on routine abdominal imaging or scans. We present a case of incidental laparoscopic finding of pneumatosis intestinalis on a 32-year-old male, who underwent a laparoscopic appendectomy for an acute appendicitis. Laparoscopic appendectomy was performed and pneumatosis intestinalis managed conservatively. Patient did well and was discharged home. Management of PI depends on clinical presentation; asymptomatic PI can be managed adequately by treating underlying causes. We report a case of incidental laparoscopic finding of Pneumatosis intestinalis, which was adequately managed by treating underlying appendicitis. N. Mayooran, A. Olu Shola, and N. Iqbal Copyright © 2014 N. Mayooran et al. All rights reserved. Acquired Abdominal Intercostal Hernia: A Case Report and Literature Review Sun, 17 Aug 2014 08:05:09 +0000 Acquired abdominal intercostal hernia (AAIH) is a rare disease phenomenon where intra-abdominal contents reach the intercostal space directly from the peritoneal cavity through an acquired defect in the abdominal wall musculature and fascia. We discuss a case of a 51-year-old obese female who arrived to the emergency room with a painful swelling between her left 10th rib and 11th rib. She gave a history of a stab wound to the area 15 years earlier. A CT scan revealed a fat containing intercostal hernia with no diaphragmatic defect. An open operative approach with a hernia patch was used to repair this hernia. These hernias are difficult to diagnose, so a high clinical suspicion and thorough history and physical exam are important. This review discusses pathogenesis, clinical presentation, complications, and appropriate treatment strategies of AAIH. Salim Abunnaja, Kevin Chysna, Inam Shaikh, and Giuseppe Tripodi Copyright © 2014 Salim Abunnaja et al. All rights reserved. Transmediastinal and Transcardiac Gunshot Wound with Hemodynamic Stability Sun, 17 Aug 2014 00:00:00 +0000 Cardiac injuries caused by knives and firearms are slightly increasing in our environment. We report the case of a 43-year-old male patient with a transmediastinal gunshot wound (TGSW) and a through-and-through cardiac wound who was hemodynamically stable upon his admission. He had an entrance wound below the left clavicle, with no exit wound, and decreased breath sounds in the right hemithorax. Chest X-ray showed the bullet in the right hemithorax and large right hemothorax. The ultrasound revealed pericardial effusion, and a chest tube produced 1500 cc. of blood, but he remained hemodynamically stable. Considering these findings, a median sternotomy was carried out, the through-and-through cardiac wounds were suture-repaired, lung laceration was sutured, and a pacemaker was placed in the right ventricle. The patient had uneventful recovery and was discharged home on the twelfth postoperative day. The management and prognosis of these patients are determined by the hemodynamic situation upon arrival to the Emergency Department (ED), as well as a prompt surgical repair if needed. Patients with a TGSW have been divided into three groups according to the SBP: group I, with SBP  mmHg; group II, with SBP 60–100 mmHg; and group III, with SBP  mmHg. The diagnostic workup and management should be tailored accordingly, and several series have confirmed high chances of success with conservative management when these patients are hemodynamically stable. Leire Zarain Obrador, Yusef Mohamed Al-Lal, Jorge de Tomás Palacios, Iñaki Amunategui Prats, and Fernando Turégano Fuentes Copyright © 2014 Leire Zarain Obrador et al. All rights reserved. Blunt Force Thoracic Trauma: A Case Study of Pericardial Rupture and Associated Cardiac Herniation Tue, 12 Aug 2014 09:31:08 +0000 Pericardial rupture, with associated cardiac herniation, is generally fatal. Diagnosis is difficult and frequently missed due to the subtlety of identifying characteristics. We report a case of a left sided pericardial rupture and cardiac herniation resulting from a high speed motorcycle collision. This report describes the course of treatment from the emergent admission to the diagnosis of the pericardial tear to retrospective CT analysis and rupture identification. In addition the difficulties of initial diagnosis, key symptoms, and identification of CT images are presented and discussed. O. S. Glotzer, A. Bhakta, and T. Fabian Copyright © 2014 O. S. Glotzer et al. All rights reserved. Diagnosing Intraoperative Pneumothorax in Patients Undergoing Autologous Breast Reconstruction: A Useful Clinical Sign Tue, 12 Aug 2014 09:15:06 +0000 Intraoperative pneumothorax during breast reconstruction can be difficult to diagnose. Even a small pneumothorax can become a tension pneumothorax under positive pressure ventilation. The clinical finding of venous congestion in a pedicled latissimus dorsi flap, which could not be explained by problems with the vessels, preceded other signs of a tension pneumothorax in the case presented here. Given the difficulties of access to the chest by the anaesthetic team during breast procedures, this has the potential to be a useful adjunct in the diagnosis of this potentially serious intraoperative complication. Thomas Reekie, David McGill, and Elizabeth Marshall Copyright © 2014 Thomas Reekie et al. All rights reserved. Emergency Pancreatoduodenectomy with Preservation of Gastroduodenal Artery for Massive Gastrointestinal Bleeding due to Duodenal Metastasis by Clear Cell Renal Cell Carcinoma in a Patient with Celiac Artery Stenosis Mon, 11 Aug 2014 06:06:35 +0000 Duodenal metastasis from renal cell carcinoma is rare, and even rarer is a massive gastrointestinal bleeding from such tumours. Coeliac occlusive disease, although rarely symptomatic, can lead to ischaemic changes with anastomotic dehiscence and leaks when a patient undergoes pancreatoduodenectomy. A 41-year-old man with known metastasis to the adrenal glands and the second part of the duodenum close to the ampulla of Vater from clear cell renal cell carcinoma was admitted to our department due to massive gastrointestinal bleeding from the duodenal metastasis. Endoscopic control of the bleed was not possible, while the bleeding vessel embolization was able to control the haemorrhage only temporarily. An angiography during the embolization demonstrated the presence of stenosis of the coeliac artery and also hypertrophic inferior pancreaticoduodenal arteries supplying the proper hepatic artery via the gastroduodenal artery (GDA). The patient underwent emergency pancreatoduodenectomy with preservation of the gastroduodenal artery. The patient had an uneventful recovery and did not experience further bleeding. Also the blood flow to the liver was compromised as shown by the normal liver function tests (LFTs) postoperatively. To the best of our knowledge, this is the first report of a preservation of the GDA during an emergency pancreatoduodenectomy. Kyriakos Neofytou, Alexandros Giakoustidis, Martin Gore, and Satvinder Mudan Copyright © 2014 Kyriakos Neofytou et al. All rights reserved. Reconstruction of Traumatic Defect of the Lower Third of the Leg Using a Combined Therapy: Negative Pressure Wound Therapy, Acellular Dermal Matrix, and Skin Graft Mon, 11 Aug 2014 00:00:00 +0000 The reconstruction of lower third of the leg is one of the most challenging problems for plastic and reconstructive surgeons and current approaches are still disappointing. We show an easy option to obtain a coverage of traumatic pretibial defects with good aesthetic and functional results: the association of negative pressure wound therapy, acellular dermal matrix, and skin graft. The choice of this combined therapy avoids other surgical procedures such as local perforator flaps and free flaps that require more operating time, special equipment, and adequate training. Sergio Brongo, Domenico Pagliara, Nicola Campitiello, and Corrado Rubino Copyright © 2014 Sergio Brongo et al. All rights reserved. Hepatic Subcapsular Biloma: A Rare Complication of Laparoscopic Cholecystectomy Sun, 10 Aug 2014 09:03:06 +0000 The development of an intra-abdominal bile collection (biloma) is an infrequent complication of laparoscopic cholecystectomy (LC). These bilomas develop in the subhepatic space most often secondary to iatrogenic injury of the extrahepatic ducts. We present a case of hepatic subcapsular biloma following LC and we discuss its etiology and management. Early diagnosis is crucial and percutaneous drainage under CT guidance should be employed to resolve this complication. Vassilios Stathopoulos, Marios Georganas, Konstantinos Stratakis, Eirini Delaporta, Emmanouil Karallas, and Konstantinos Koutsopoulos Copyright © 2014 Vassilios Stathopoulos et al. All rights reserved. Hepatocellular Carcinoma Presenting with Obstructive Jaundice during Pregnancy Tue, 05 Aug 2014 08:00:22 +0000 Introduction. Both hepatocellular carcinoma (HCC) presenting during pregnancy and HCC presenting with obstructive jaundice due to a tumor cast in the biliary tract are very rare. The management of these patients remains challenging. Presentation of Case. A 23-year-old lady presented with obstructive jaundice at 38 weeks of gestation. Investigations showed HCC with a biliary tumor thrombus. She received percutaneous transhepatic biliary drainage (PTBD) and caesarean section. Right hepatectomy, extrahepatic bile duct resection, and left hepaticojejunostomy were carried out when the jaundice improved. The postoperative course was uneventful. She was discharged home on postoperative day 10. Histopathology showed HCC with a tumor thrombus in the bile duct. The surgical margins were clear. One year after surgery, the mother was disease-free and the baby was well. Conclusion. With proper management, curative treatment is possible in a pregnant patient who presented with obstructive jaundice due to a biliary tumor thrombus from HCC. Huan-wei Chen, Feng-jie Wang, Jie-yuan Li, Eric C. H. Lai, and Wan Yee Lau Copyright © 2014 Huan-wei Chen et al. All rights reserved. Management of Injury to the Common Bile Duct in a Patient with Roux-en-Y Gastric Bypass Tue, 05 Aug 2014 07:21:02 +0000 Introduction. Most surgeons prefer Roux-en-Y hepaticojejunostomy (RYHJ) for biliary reconstruction following a common bile duct (CBD) injury. However, in patients with a Roux-en-Y gastric bypass (RYGB) a RYHJ may be technically challenging and can interfere with bowel physiology induced by RYGB. The use of a hepaticoduodenostomy (HD) resolves both these issues. Presentation of Case. We present a case of CBD injury during laparoscopic cholecystectomy one year after laparoscopic RYGB for morbid obesity. Due to adhesions and previous surgery with RYGB, we did not want to interfere with the RYGB physiology by anastomosing the CBD to the jejunum or ileum. Succeeding a full Kocher’s maneuver we performed biliary reconstruction by a tension-free end-to-side HD. The postoperative recovery was uneventful and the patient was discharged after eight days. At four-month follow-up, the patient had stable weight and normal laboratory test results. MRCP demonstrated normal intra- and extrahepatic bile ducts with status after HD. Discussion. We propose that HD should be considered in treatment of CBD injury in post-RYGB patients as it may reduce the risk of interfering with the post-RYGB physiology. Sheraz Yaqub, Tom Mala, Øystein Mathisen, Bjørn Edwin, Bjarte Fosby, Dag Tallak Kjærsdalen Berntzen, Andreas Abildgaard, and Knut Jørgen Labori Copyright © 2014 Sheraz Yaqub et al. All rights reserved. A Primary Hepatic Lymphoma Treated with Liver Resection and Chemotherapy Mon, 04 Aug 2014 08:09:05 +0000 Primary hepatic lymphoma (PHL) is a rare malignancy, which is frequently misdiagnosed. Although chemotherapy is the treatment of choice there are reports that a combination of surgery and adjuvant chemotherapy can offer better results. Herein we present an interesting case of a large primary non-Hodgkin lymphoma originating from liver was treated with a liver which resection and chemotherapy. Konstantinos Bouliaris, Grigorios Christodoulidis, Georgios Koukoulis, Ioannis Mamaloudis, Maria Ioannou, Eleni Bouronikou, Maria Palassopoulou, and Konstantinos Tepetes Copyright © 2014 Konstantinos Bouliaris et al. All rights reserved. Trap-Door Incision for Penetrating Thoracic Trauma: An Obsolete Approach? Sun, 03 Aug 2014 08:56:02 +0000 Penetrating injuries to the subclavian vessels are uncommon and very severe lesions. They are difficult to expose and carry a high mortality. “Trap-door” incisions have lately been dismissed as too mutilating for the occasional victim of a penetrating thoracic trauma with massive bleeding difficult that is to expose. We present a case of severe bleeding from a stab wound in the left subclavicular area in a heavy-built patient where a “trap-door” incision proved inevitable to expose and repair the injury, and most probably saved his life. Ana Fabregues Olea, Leire Zarain Obrador, Dolores Perez-Diaz, and Fernando Turégano Fuentes Copyright © 2014 Ana Fabregues Olea et al. 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.