Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. Recurrent Volvulus of an Ileal Pouch Requiring Repeat Pouchopexy: A Lesson Learnt Sun, 06 Jul 2014 10:00:51 +0000 Introduction. Restorative surgery for ulcerative colitis with ileal pouch anal anastomosis (IPAA) is frequently accompanied by complications. Volvulus of the ileal pouch is one of the most rarely reported late complications and to our knowledge no report exists on reoperative surgery for this condition. Case Report. A 58-year-old woman who previously had undergone restorative proctocolectomy due to ulcerative colitis with an IPAA presented with volvulus of the pouch. She was operated with a single row pouchopexy to the presacral fascia. Two months later she returned with a recurrent volvulus. At reoperation, the pouch was found to have become completely detached from the fascia. A new pexy was made by firmly anchoring the pouch with two rows of sutures to the presacral fascia as well as with sutures to the lateral pelvic walls. At follow-up after five months she was free of symptoms. Conclusion. This first report ever on reoperative surgery for volvulus of a pelvic pouch indicates that a single row pouchopexy might be insufficient for preventing retwisting. Several rows seem to be needed. Pär Myrelid, Pelle Druvefors, and Peter Andersson Copyright © 2014 Pär Myrelid et al. All rights reserved. Transabdominal Approach for Chylorrhea after Esophagectomy by Using Fluorescence Navigation with Indocyanine Green Tue, 01 Jul 2014 11:16:58 +0000 A 70-year-old man who underwent two sessions of thoracoscopy-assisted ligation of the thoracic duct to treat refractory chylorrhea after radical esophagectomy for advanced esophageal cancer received conservative therapy. However, there was no improvement in chylorrhea. Then, transabdominal ligation of the lymphatic/thoracic duct at the level of the right crus of the diaphragm was performed using fluorescence navigation with indocyanine green (ICG). The procedure successfully reduced chylorrhea. This procedure provides a valid option for persistent chylothorax/chylous ascites accompanied by chylorrhea with no response to conservative treatment, transthoracic ligation, or both. Takeshi Matsutani, Atsushi Hirakata, Tsutomu Nomura, Nobutoshi Hagiwara, Akihisa Matsuda, Hiroshi Yoshida, and Eiji Uchida Copyright © 2014 Takeshi Matsutani et al. All rights reserved. Customized Polymethyl Methacrylate Implants for the Reconstruction of Craniofacial Osseous Defects Mon, 30 Jun 2014 12:35:27 +0000 Craniofacial defects represent alterations in the anatomy and morphology of the cranial vault and the facial bones that potentially affect an individual’s psychological and social well-being. Although a variety of techniques and restorative procedures have been described for the reconstruction of the affected area, polymethyl methacrylate (PMMA), a biocompatible and nondegradable acrylic resin-based implant, is the most widely used alloplastic material for such craniomaxillofacial reconstruction. The aim of this study was to describe a technique for aesthetic and functional preoperative customized reconstruction of craniofacial bone defects from a small series of patients offered by the Brazilian public health system. Three adult male patients attended consultation with chief complaints directly related to their individual craniofacial bone defects. With the aid of multislice computed tomography scans and subsequent fabrication of the three-dimensional craniofacial prototype, custom-made PMMA implants were fabricated preoperatively. Under general anesthesia, with access to the craniofacial defects with a coronal approach, the PMMA implants were adapted and fixated to the facial skeleton with titanium plates and screws. Postoperative evaluation demonstrated uneventful recovery and an excellent aesthetic result. Customized prefabricated PMMA implants manufactured over the rapid prototyping models proved to be effective and feasible. André Luis Fernandes da Silva, Alexandre Meireles Borba, Niverso Rodrigues Simão, Fábio Luis Miranda Pedro, Alvaro Henrique Borges, and Michael Miloro Copyright © 2014 André Luis Fernandes da Silva et al. All rights reserved. Middle Segment-Preserving Pancreatectomy for Recurrent Metastasis of Renal Cell Carcinoma after Pancreatoduodenectomy: A Case Report Mon, 30 Jun 2014 11:26:03 +0000 Many cases of surgical resection of metastatic pancreatic tumors originating from renal cell carcinoma have been reported; however, cases of reresection of recurrent pancreatic metastasis of renal cell carcinoma in the remnant pancreas are rare. We performed a second resection for recurrent pancreatic metastasis of renal cell carcinoma six years after pancreatoduodenectomy with pancreaticogastrostomy reconstruction. By performing middle segment-preserving pancreatectomy, we were able to successfully spare the exocrine and endocrine pancreatic function compared to that observed after total pancreatectomy, with no signs of recurrence for two years after the surgery. Aiyama Takeshi, Inagaki Mitsuhiro, Akabane Hiromitsu, Yanagida Naoyuki, Shibaki Taiichiro, Shomura Hiroki, Kudo Takeaki, Shonaka Tatsuya, Oikawa Futoshi, Sakurai Hiroharu, and Nakano Shiro Copyright © 2014 Aiyama Takeshi et al. All rights reserved. Axillary Artery Injury Caused by Fracture of Humerus Neck and Its Repair Using Basilic Vein Graft Mon, 30 Jun 2014 10:36:18 +0000 Proximal humerus fractures are rarely associated with axillary artery injury. We present a case of a 59-year-old female who had fracture neck humerus along with absent pulsations in the left upper limb after blunt trauma. Computed tomographic angiogram revealed complete occlusion of the left axillary artery. Urgent surgical intervention was done in the form of fixation of fracture followed by exploration and repair of axillary artery. Axillary artery was contused and totally occluded by fractured edge of humerus. Repair of the axillary artery was done using basilic vein graft harvested through the same incision. Postprocedure pulsations were present in the upper limb. Vikas Deep Goyal, Vipin Sharma, Sandeep Kalia, and Manik Sehgal Copyright © 2014 Vikas Deep Goyal et al. All rights reserved. Intestinal Obstruction due to Bilateral Strangulated Femoral Hernias Thu, 26 Jun 2014 10:51:46 +0000 Introduction. Femoral hernias are at high risk of strangulation due to the narrow femoral canal and femoral ring. This can lead to symptoms of obstruction or strangulation requiring emergency surgery and possible bowel resection. To our knowledge, there is only one previous published report of bilateral strangulated femoral hernia. We present our case of this phenomenon. Case Report. An 86-year-old woman presented with symptoms of small bowel obstruction. Examination revealed two tender lumps in the area of the femoral triangle. CT scan revealed bilateral femoral hernias. Both hernias were repaired and a small bowel resection on the right side was performed with side to side anastomosis. She made an uneventful recovery. Conclusion. Bilateral femoral hernias are a rare occurrence with only one reported case of bilateral strangulation. Our case highlights the importance of meticulous history taking and clinical examination as any delay in diagnosis will increase the risk of mortality and morbidity for the patient. Hernias should always be considered as a cause if one presents with symptoms of abdominal pain or obstruction. Ioannis Nikolopoulos, Eshan Oderuth, Eleni Ntakomyti, and Bengt Kald Copyright © 2014 Ioannis Nikolopoulos et al. All rights reserved. Bilateral Chylhotorax after Falling from Height Thu, 26 Jun 2014 00:00:00 +0000 Chylothorax is accumulation of chyle in the pleural cavity due to disruption of the thoracic duct. The causes can be classified as neoplastic, traumatic (iatrogenic or noniatrogenic), congenital, sporadic, spontaneous, and miscellaneous. A 22-year-old man with no feature in his history and family history was referred to emergency department with the case of falling from height. Abdominal computed tomogram (CT) revealed laceration of liver, grade 5 splenic laceration, fracture of the left acetabulum, and dislocation of the left hip. He was optimized for emergency splenectomy and close left hip reduction. On the 2nd day of the operation, bilateral chylotorax revealed. The treatment depends on its etiology, the amount of drainage, and the clinical picture. Treatment can be classified into 3 categories treatment of the underlying condition, conservative management (such as bed rest, nil by mouth or low fat medium chain triglycerides by mouth and total parenteral nutrition), and surgical management by ligation or clipping of the thoracic duct with open thoracotomy or video-assisted thoracoscopic surgery. The main purpose of surgical treatment is to stop the chylous leak. Vildan Akpinar, Fulya Yilmaz Duran, Elif Duman, Murat Yasar Özkalkanli, Özgür Duran, and Burcu Horsanali Copyright © 2014 Vildan Akpinar et al. All rights reserved. Spontaneous Rupture of the Spleen Masquerading as a Pulmonary Infection Thu, 19 Jun 2014 08:10:48 +0000 Atraumatic rupture of a normal spleen represents a rare clinical phenomenon. We report on an atypical presentation of a spontaneous splenic rupture in a 44-year-old previously healthy Greek male admitted to the emergency department due to left-sided pleuritic thoracic pain in the course of a pneumonia diagnosed 2 days before. During his stay, pain extended to the epigastric region. Abdominal examination revealed generalized tenderness. We presume that coughing secondary to respiratory infection was the main factor that precipitated splenic rupture. Despite the rarity of the condition physicians have to consider the diagnosis of spontaneous nontraumatic splenic rupture when they encounter healthy patients with nonspecific lower thoracic or abdominal pain. Prompt diagnosis is essential for a better outcome. Dimitrios Anyfantakis, Miltiades Kastanakis, Paraskevi Karona, Giorgios Fragiadakis, Ioannis Kokkinos, and Emmanouil Bobolakis Copyright © 2014 Dimitrios Anyfantakis et al. All rights reserved.