Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Ancient Schwannoma of Ansa Cervicalis: A Rare Clinical Entity and Review of the Literature Thu, 08 Oct 2015 15:09:01 +0000 Ancient schwannoma is an uncommon variant of schwannoma, a benign tumor arising from the nerve sheath. It is reported to arise from any nerves except optic and olfactory. However, only six cases of ancient schwannomas arising from ansa cervicalis nerve have been reported to date in English literature. Proper preoperative evaluation is necessary to rule out other causes of neck mass such as thyroid lesions, lymphadenopathy, and carotid body tumor. We report a case of ancient schwannoma arising from the ansa cervicalis nerve. The origin of the lesion from ansa cervicalis was confirmed by intraoperative finding. Postoperative histopathological examination revealed degenerative changes including pleomorphism, cellular atypia, large nuclei with prominent nucleoli, and paucity of mitotic figures. Periphery of the mass showed nuclear palisading with characteristic verocay bodies. Immunohistochemical evaluation for S-100 showed diffuse positivity of the tumor cells, thereby confirming the diagnosis of schwannoma. We consider that schwannoma of cervical region can have origin from any nerve and should try to identify the origin pre- and intraoperatively. The postoperative complications depend on the nerve of origin and the precision of the surgery performed. Satyajit Rath, Prakash K. Sasmal, Kaushik Saha, N. Deep, Pritinanda Mishra, Tushar S. Mishra, and Rakesh Sharma Copyright © 2015 Satyajit Rath et al. All rights reserved. Insulinoma-Induced Hypoglycemia in a Patient with Insulinoma after Gastrojejunostomy for Prepyloric Ulcer Thu, 08 Oct 2015 06:20:57 +0000 Hyperinsulinism due to dumping syndrome following gastric surgery is an uncommon condition. It is specified with hypoglycemic attacks. However, linking symptoms to dumping syndrome in each patient to whom gastric surgery was performed leads to inappropriate diagnosis and therapy. Insulinoma and other causes that give rise to hyperinsulinemia should not be ignored and these diagnoses should be excluded. In this paper, 71-year-old male patient who was followed up for 2 years with a false conclusion of dumping syndrome and operated on due to insulinoma diagnosed at endoscopic ultrasonography is presented in the light of the literature. Yavuz Savas Koca, Bünyamin Aydın, Tugba Koca, Mustafa Tevfik Bülbül, and Mehmet Numan Tamer Copyright © 2015 Yavuz Savas Koca et al. All rights reserved. Gastrotracheal Fistula as a Result of Transhiatal Esophagectomy for Esophageal Cancer: An Unusual Complication Sun, 04 Oct 2015 16:36:47 +0000 Gastrotracheal fistula following open transhiatal esophagectomy (Orringer’s technique) for esophageal cancer is an unusual but lethal complication. Surgical intervention with resection of the fistula tract and primary interrupted suturing of gastric and tracheal orifices using a muscle flap interposition has proved to be a successful method. We report the case of a 73-year-old male with an adenocarcinoma of the distal part of the esophagus, who underwent open transhiatal esophagectomy (Orringer’s technique) with gastric tube reconstruction and cervical anastomosis. The patient did not receive induction chemoradiotherapy before the esophagectomy. Two attempts of surgical repair of fistula failed and the patient died. Being aware of warning signs such as dyspnea and respiratory distress accompanied by bilious content in the tracheal tube is helpful in the early detection and treatment of this type of fistula. Heshmatollah Salahi, Mehdi Tahamtan, Bijan Ziaian, Mansoor Masjedi, Zahra Saadati, Nazanin Hoseini, and Elahe Torabi Copyright © 2015 Heshmatollah Salahi et al. All rights reserved. Hepatic Tuberculosis Mimicking Biliary Cystadenoma: A Radiological Dilemma Sun, 04 Oct 2015 12:17:16 +0000 Primary involvement of liver in tuberculosis is a rare entity. It is difficult to diagnose in absence of previous history of tuberculosis or concurrent pulmonary involvement. It is usually misdiagnosed as neoplastic liver lesion, which misdirects the treatment protocol and delays proper treatment. Here we are presenting a case of 36-year-old male patient with vague right upper quadrant abdominal pain. All the laboratory values were within normal limits. Radiological investigations were in favor of biliary cystadenoma but final diagnosis was primary focal involvement of liver in tuberculosis which was histopathologically proven to be tuberculous granulomas on biopsy of the resected mass. Rajaram Sharma, Amit Kumar Dey, Kartik Mittal, Prasad Udmale, Udai Singh, Sumit Mitkar, and Priya Hira Copyright © 2015 Rajaram Sharma et al. All rights reserved. Island Latissimus Dorsi Muscle Flap and a Perforator Flap in Repairing Post-Gunshot Thoracic Spine CSF Fistula: Case Presentation Mon, 28 Sep 2015 14:28:58 +0000 Persistent posttraumatic CSF fluid leakage may present a challenge to manage. Failure to address the leakage may result in complications such as meningitis, septicemia, radiculopathy, muscle weakness, and back pains. While the majority of the leakages may be managed conservatively, large dura defects as a result of gunshot wounds or motor vehicle accidents are best managed by surgical interventions. This may range from primary closure of the defect to fascial grafts, adhesive glues, and flaps. We present our experience with the use of flaps in a patient who had sustained such wounds in the thoracic spine. An island latissimus dorsal flap and a perforator fasciocutaneous flap were used to close the defect. Postoperatively the patient recovered well and the wounds healed without any complications. Nangole F. Wanjala and Khainga Ominde Stanley Copyright © 2015 Nangole F. Wanjala and Khainga Ominde Stanley. All rights reserved. Pediatric Granular Cell Tumor of the Breast: A Case Report and Review of the Literature Sun, 27 Sep 2015 06:17:07 +0000 Objective. Granular cell tumors arise from neurogenic mesenchymal stem cells and can occur anywhere throughout the body. They rarely present as breast masses and should be included in the differential diagnosis of pediatric breast neoplasms. We report a rare presentation of a pediatric breast granular cell tumor and a review of the literature. Participant. A 15-year-old female presented with an enlarging breast mass. She underwent ultrasound imaging and excisional biopsy, which revealed a granular cell tumor. Granular cell tumors of the breast are difficult to diagnose using ultrasound and mammography due to numerous similarities to other breast masses. Histopathologic staining best differentiates breast granular cell tumors from other breast masses with their positive staining for S100, CD68, and neurospecific enolase. Conclusion. Although rare, granular cell tumors of the breast should be considered as a possible diagnosis for pediatric breast masses to allow for proper management and follow-up for these patients. Although rare, these tumors do have malignant potential necessitating a correct and timely diagnosis. Nathan P. Heinzerling, Shannon M. Koehler, Sara Szabo, and Amy J. Wagner Copyright © 2015 Nathan P. Heinzerling et al. All rights reserved. Laparoscopic Removal of Gossypiboma Wed, 16 Sep 2015 06:01:38 +0000 Gossypiboma is defined as a mass caused by foreign body reaction developed around the retained surgical item in the operative area. When diagnosed, it should be removed in symptomatic patients. Minimal invasive surgery should be planned for the removal of the retained item. The number of cases treated by laparoscopic approach is rare in the literature. We present a case of forty-year-old woman referred to emergency room with acute abdomen diagnosed as gossypiboma and treated successfully with laparoscopic surgery. Zeki Özsoy, Ismail Okan, Emin Daldal, Mehmet Fatih Dasıran, Yavuz Selim Angın, and Mustafa Şahin Copyright © 2015 Zeki Özsoy et al. All rights reserved. The Great Pretender: Rectal Syphilis Mimic a Cancer Tue, 15 Sep 2015 11:59:50 +0000 Rectal syphilis is a rare expression of the widely recognised sexual transmitted disease, also known as the great imitator for its peculiarity of being confused with mild anorectal diseases because of its vague symptoms or believed rectal malignancy, with the concrete risk of overtreatment. We present the case of a male patient with primary rectal syphilis, firstly diagnosed as rectal cancer; the medical, radiological, and endoscopic features are discussed below. Andrea Pisani Ceretti, Matteo Virdis, Nirvana Maroni, Monica Arena, Enzo Masci, Alberto Magenta, and Enrico Opocher Copyright © 2015 Andrea Pisani Ceretti et al. All rights reserved. Management of Necrotizing Fasciitis and Fecal Peritonitis following Ostomy Necrosis and Detachment by Using NPT and Flexi-Seal Thu, 10 Sep 2015 14:23:47 +0000 Management of necrotizing fasciitis and severe faecal peritonitis following ostomy in elderly patient with comorbid disease is challenging. We would like to report management of frozen Open Abdomen (OA) with colonic fistula following ostomy necrosis and detachment in an elderly patient with comorbid disease and malignancy. 78-year-old woman with high stage rectum carcinoma was admitted to emergency department and underwent operation for severe peritonitis and sigmoid colonic perforation. Loop sigmoidostomy was performed. At postoperative 15th day, she was transferred to our clinic with necrotizing fasciitis and severe faecal peritonitis due to ostomy necrosis and detachment. Enteric effluent was removed from the OA wound by using the Flexi-Seal Fecal Management System (FMS) (ConvaTec) and pesser tube in deeply located colonic fistula in conjunction with Negative Pressure Therapy (NPT). Maturation of ostomy was facilitated by using second NPT on ostomy side. After source control, delayed abdominal closure was achieved by skin flap approximation. Fahri Yetışır, Akgün Ebru Şarer, and H. Zafer Acar Copyright © 2015 Fahri Yetışır et al. All rights reserved. Asymptomatic Glomus Tumor of the Mediastinum Wed, 09 Sep 2015 11:46:07 +0000 Glomus tumors are rare benign neoplasms that predominate in limbs. Infrequently, they can occur in a wide anatomic distribution, to include sites not known to contain glomus cells. Although glomus tumors are usually small, pain and tenderness are common clinical symptoms. We report the case of a 69-year-old man with an asymptomatic large mediastinal glomus tumor, who underwent surgical resection. Meletios Kanakis, Nikoletta Rapti, Maria Chorti, and Achilleas Lioulias Copyright © 2015 Meletios Kanakis et al. All rights reserved. A Pleural Solitary Fibrous Tumor, Multiple Gastrointestinal Stromal Tumors, Moyamoya Disease, and Hyperparathyroidism in a Patient Associated with NF1 Wed, 09 Sep 2015 11:07:42 +0000 Neurofibromatosis type 1 (NF1), also called von Recklinghausen’s disease, is a multisystemic disease caused by an alteration of the NF1 gene, a tumor suppressor located on the long arm of chromosome 17 (17q11.2). Loss of the gene function, due to a point mutation, leads to an increase in cell proliferation and the development of several tumors. We report a 60-year-old female patient manifesting hypercalcemia due to hyperparathyroidism, a solitary fibrous tumor (SFT) of the pleura, multiple gastrointestinal stromal tumors (GISTs), and moyamoya disease associated with NF1. The SFT and GISTs were removed by staged operations. Then, hypercalcemia was successfully controlled after resection of the parathyroid adenoma. Based on a literature review, these combinations have never been reported, and the relevant literature is briefly discussed. Yoko Yamamoto, Ken Kodama, Shigekazu Yokoyama, Masashi Takeda, and Shintaro Michishita Copyright © 2015 Yoko Yamamoto et al. All rights reserved. Anastomosing Haemangioma of the Kidney Involving a Segmental Branch of the Renal Vein Mon, 07 Sep 2015 07:44:05 +0000 Anastomosing variant of capillary haemangioma is a rare and recently described vascular tumour with a proclivity for the genitourinary tract. Here we present the case of a 64-year-old man with incidental finding of 3.4 cm renal mass on CT who had laparoscopic nephrectomy with a good postoperative recovery. Histopathological diagnosis of anastomosing haemangioma of the kidney was made and the patient was followed up for 10 months without evidence of tumour recurrence. Ayodeji Oluwarotimi Omiyale, Anurag Golash, Amandeep Mann, Dimitris Kyriakidis, and Karthik Kalyanasundaram Copyright © 2015 Ayodeji Oluwarotimi Omiyale et al. All rights reserved. A Model Example: Coexisting Superior Mesenteric Artery Syndrome and the Nutcracker Phenomenon Thu, 03 Sep 2015 13:07:19 +0000 Superior mesenteric artery (SMA) syndrome is a rare cause of gastrointestinal obstruction, caused by external compression of the third part of the duodenum by the SMA. It may be associated with the Nutcracker phenomenon: external compression of the left renal vein. To our knowledge, there are few reports in the literature describing the coexistence of these two conditions and so we take this opportunity to highlight a rare cause of the acute abdomen that might otherwise be overlooked in cases of nonspecific abdominal findings and potentially unremarkable initial investigations. We report a case of SMA syndrome and Nutcracker phenomenon in a 19-year-old female who presented to our emergency department with a short history of epigastric pain and emesis. The SMA syndrome is thought to develop as the result of an abnormally narrow angle between the proximal SMA and the aorta, for which a number of predisposing factors have been described. Surgical options exist; however, the SMA syndrome is typically managed conservatively in the first instance, consistent with the approach described in this case. The Nutcracker phenomenon may give rise to the Nutcracker syndrome in the presence of typical clinical manifestations; however, these did not feature in this case. Rebecca Nunn, Jaimie Henry, Alistair A. P. Slesser, Rukshan Fernando, and Nebil Behar Copyright © 2015 Rebecca Nunn et al. All rights reserved. Lornoxicam Side Effects May Lead to Surgical Mismanagement, in Case of Postoperative Intra-Abdominal Collection: A Case Report and Literature Review Mon, 31 Aug 2015 05:51:22 +0000 Postoperative collection is a known complication of abdominal surgery, especially after major surgery; however, minor surgical procedures may also be associated with this phenomenon. Utilization of nonsteroidal anti-inflammatory drugs, such as lornoxicam, and the adverse effects thereof, may affect the surgeon’s judgment regarding the need for, and extent of, draining of these collections. Here I report the case of a 25-year-old male who presented with perforated acute retrocaecal subhepatic appendicitis complicated by pleural effusion and a small abdominal collection. The pleural effusion resolved almost completely over time. However, the patient showed incomplete recovery, as demonstrated by nausea, vomiting, and mood disturbance along with abdominal pain, tachycardia, and a persistent small abdominal collection. We initially suspected infection caused by a highly virulent type of bacteria and planned to perform percutaneous drainage. However, owing to skin erythematic changes, administration of lornoxicam was ceased, which resulted in complete recovery of the symptoms and consequently in avoidance of unnecessary invasive intervention to drain the abdominal collection. These findings suggest that the utilization and adverse effects of some painkillers for postoperative pain, such as lornoxicam, may affect the surgeon’s judgment regarding the most appropriate surgical workup in cases of postoperative fluid collection. Mohammad Bukhetan Alharbi Copyright © 2015 Mohammad Bukhetan Alharbi. All rights reserved. Spontaneous Involution of a Presumably Rathke’s Cleft Cyst in a Patient with Slight Subclinical Hypopituitarism: A Case Report and Review of the Literature Thu, 27 Aug 2015 13:47:41 +0000 Rathke cleft cyst is described as benign intrasellar cyst. They are mostly small and asymptomatic; they may become large enough to cause symptoms by compression of intrasellar or suprasellar structures. We report on a case of spontaneous regression of a symptomatic RCC with subsequent recovery of preexisting endocrine dysfunction and resolution of headaches. A 60-year-old man complained about headaches. Laboratory investigation revealed a partial hypopituitarism with a slight central hypothyroidism without need for substitution. An MRI study showed a cystic, T2-hyperintense, sellar lesion compatible with a RCC. At one year follow-up, the patient had no complaints and the hormone work-up revealed a regression of the previous slight hypopituitarism. The MRI study showed a complete regression of the cystic lesion and a normal sized and shaped pituitary gland. The spontaneous regression of cystic sellar lesions is rare. The exact mechanism of the possible spontaneous involution of RCC is until now not well understood. However, spontaneous regression is possible and justifies the conservative therapy with regular clinical and radiological follow-up for asymptomatic patients or patients with symptoms not caused by the mass effect of these lesions. Diaa Al Safatli, Rolf Kalff, and Albrecht Waschke Copyright © 2015 Diaa Al Safatli et al. All rights reserved. Postoperative Complications of Beger Procedure Mon, 24 Aug 2015 09:32:49 +0000 Introduction. Chronic pancreatitis (CP) is considered an inflammatory disease that may cause varying degrees of pancreatic dysfunction. Conservative and surgical treatment options are available depending on dysfunction severity. Presentation of Case. A 36-year-old male with history of heavy alcohol consumption and diagnosed CP underwent a duodenal-preserving pancreatic head resection (DPPHR or Beger procedure) after conservative treatment failure. Refractory pain was reported on follow-up three months after surgery and postoperative imaging uncovered stones within the main pancreatic duct and intestinal dilation. The patient was subsequently subjected to another surgical procedure and intraoperative findings included protein plugs within the main pancreatic duct and pancreaticojejunal anastomosis stricture. A V-shaped enlargement and main pancreatic duct dilation in addition to the reconstruction of the previous pancreaticojejunal anastomosis were performed. The patient recovered with no further postoperative complications in the follow-up at an outpatient clinic. Discussion. Main duct and pancreaticojejunal strictures are an unusual complication of the Beger procedure but were identified intraoperatively as the cause of patient’s refractory pain and explained intraductal protein plugs accumulation. Conclusion. Patients that undergo Beger procedures should receive close outpatient clinical follow-up in order to guarantee postoperative conservative treatment success and therefore guarantee an early detection of postoperative complications. Nayana Samejima Peternelli, Tali Wajsfeld, Felipe Henrique Yazawa Santos, Otavio Schmidt de Azevedo, Rodrigo Altenfelder Silva, and Adhemar Monteiro Pacheco Junior Copyright © 2015 Nayana Samejima Peternelli et al. All rights reserved. Overlap of Acute Cholecystitis with Gallstones and Squamous Cell Carcinoma of the Gallbladder in an Elderly Patient Wed, 19 Aug 2015 11:22:28 +0000 Introduction. The incidence of gallbladder cancer presenting with acute cholecystitis is 2.3%, squamous cell carcinoma is rarely seen, and overlap of acute cholecystitis and squamous cell carcinoma is a very rare condition in the literature. Presentation of Case. A 75-year-old woman was admitted to emergency service with a pain in the right upper quadrant, nausea, and vomiting. The patient was considered as having acute cholecystitis. During the exploration because Hartman’s pouch was not dissected, it was adhered to the cystic duct and had fibrotic adhesion. It could not be understood whether this adhesion was a tumor or a fibrotic tumor and thus we performed cholecystectomy with a 1 cm resection of the choledochus. Pathological examination revealed the presence of (R0), T1 N0 M0 squamous cell carcinoma with clean resection borders and there was no in tumor five dissected lymph nodes. The patient has been followed up for about two years and no clinical problem has been observed throughout the follow-up. Discussion. Acute cholecystitis with gallstones may overlap with gallbladder cancer and generally presents nonspecific symptoms. No additional imaging techniques were performed since no clinical sign except for the wall thickening was detected and no suspected malignancy such as mass was detected on USG. Squamous cell carcinoma of the gallbladder shows poor diagnosis, but since its overlap with cholecystitis presents early symptoms and thus leads to early diagnosis and effective treatment, the localization of the carcinoma is of prime importance. Conclusion. Gallbladder cancer should be kept in mind in elderly patients with acute cholecystitis. İhsan Yıldız, Yavuz Savas Koca, and İbrahim Barut Copyright © 2015 İhsan Yıldız et al. All rights reserved. Chronic Thoracic Aortic Aneurysm Presenting 29 Years following Trauma Thu, 13 Aug 2015 16:00:41 +0000 Blunt, nonpenetrating injuries of the thoracic aorta are uncommon and associated with a high mortality rate within the first hour. Aortic injury is missed in 1-2% of patients that survive to hospital, and a chronic thoracic aortic aneurysm may subsequently form. We present a case in which a chronic thoracic aortic aneurysm was diagnosed 29 years following a significant motor vehicle accident. We discuss the epidemiology, presentation, and management of this uncommon consequence of blunt, nonpenetrating aortic injury. Our case illustrates an important clinical lesson; a past medical history of trauma should not be overlooked at any patient assessment. Sarah Miller, Prashant Kumar, Rene Van den Bosch, and Adib Khanafer Copyright © 2015 Sarah Miller et al. All rights reserved. Simultaneous Bilateral Spontaneous Pneumothorax Revealed Birt-Hogg-Dubè Syndrome Tue, 04 Aug 2015 13:09:30 +0000 Simultaneous bilateral spontaneous pneumothorax is a very rare clinical event, comprising approximately 1% of all spontaneous pneumothoraces. Clinical signs and symptoms may vary from mild chest pain and dyspnea to severe respiratory failure; nevertheless immediate treatment is mandatory as this condition can deteriorate and progress to tension pneumothorax. An underlying lung disease has been commonly described; in most istances primary or secondary tumors, interstitial diseases, and infectious diseases. Birt-Hogg-Dubè syndrome is a rare inherited disorder clinically characterized by multiple fibrofolliculomas, renal tumors, lung cysts, and, in ~24% of the patients, occurrence of spontaneous pneumothorax. In this case, we firstly report the concurrence of these rare conditions, as a patient presenting a simultaneous bilateral spontaneous pneumothorax was diagnosed with Birt-Hogg-Dubè syndrome based on the typical radiological findings and genetic testing of the folliculin gene located on chromosome 17. Alessandro Tamburrini, Francesco Sellitri, Federico Tacconi, Francesco Brancati, and Tommaso Claudio Mineo Copyright © 2015 Alessandro Tamburrini et al. All rights reserved. A Four-Year Hospital Journey for a Lost and Migrating Appendicolith Tue, 04 Aug 2015 11:53:29 +0000 We report a rare case of recurrent abscess formation, including being at a retroperitoneal site, due to a lost and migrating appendicolith. Over a four-year period and following an episode of perforated appendicitis, an otherwise healthy young man underwent two operations for abscess formation with eventual stone removal. Appendicoliths can pose a challenge during the diagnostic and therapeutic journey, and adequate attempts at removal need to be made to prevent avoidable complications. In patients suffering from recurrent flank pain and abscesses after appendectomy, the possibility of a lost or overlooked appendicolith should be considered. Daniel Schraffl, Herman Frima, and P. Villiger Copyright © 2015 Daniel Schraffl et al. All rights reserved. Massive Neurilemoma of the Hard Plate in Which Preoperative Diagnosis Was Difficult Sun, 02 Aug 2015 11:37:04 +0000 The patient was an 84-year-old man who was referred to our hospital in mid-December 2012 for a close examination of a mass arising from the left side of the hard palate that was found by a local dentist. The initial examination revealed the presence of a 3.0-cm elastic soft, dome-shaped mass in the left hard palate. CE-CT showed a lesion of size 1.8 × 1.4 cm in the right hard palate, which extended upward and invaded the nasal cavity. The mass was a solid tumor associated with resorption of surrounding bone and expansion of the greater palatine canal. CE-MRI indicated that the mass extended upward and invaded the nasal cavity, and the mass showed hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and an irregular margin with internal enhancement. Abnormal uptake of FDG on PET-CT (SUVmax = 5.2) was observed in the left hard palate. The biopsy site lesion rapidly increased in size and biopsy was performed again in January 2013 due to suspicion of a malignant tumor. The histopathological diagnosis was a suspected malignant neurogenic tumor. Therefore, the patient underwent partial maxillectomy and a split-thickness skin graft in late February 2013. No recurrence was noted 29 months after the operation. Masanori Kudoh, Hiroyuki Harada, Koshi Matsumoto, Yuriko Sato, Ken Omura, and Yoshimasa Ishii Copyright © 2015 Masanori Kudoh et al. All rights reserved. Novel Technique for Management of Axillary Hidradenitis Suppurativa Using Setons Sun, 02 Aug 2015 08:47:06 +0000 Management of hidradenitis suppurativa (HS) of the axilla which is nonresponding to conservative management presents a significant therapeutic challenge. Most surgical treatment options are associated with significant morbidities and prolonged hospital stay. We present a technique of management of HS using setons which is simple and allows the ongoing treatment to be done on an outpatient basis. Given the fact that HS is a chronic relapsing condition each recurrence may again be managed using this technique. This will allow the patients to manage their recurrences with minimal impact on their activities of daily living. Sepehr Seyed Lajevardi and Jayantha Abeysinghe Copyright © 2015 Sepehr Seyed Lajevardi and Jayantha Abeysinghe. All rights reserved. Lipoma of the Small Intestine: A Cause for Intussusception in Adults Wed, 29 Jul 2015 15:36:24 +0000 Intussusception as a cause of intestinal obstruction in adults is rare. There is invariably an underlying pathology which leads to intussusception in adults. A case of intussusception in an adult due to a small intestinal lipoma is presented in view of this association. Ultrasound and CECT may help in a preoperative diagnosis. However early surgical intervention is the mainstay of treatment in order to confirm the diagnosis of the underlying pathology, thereby avoiding misdiagnosis of an underlying cancer. Ketan Vagholkar, Rahulkumar Chavan, Abhishek Mahadik, and Inder Maurya Copyright © 2015 Ketan Vagholkar et al. All rights reserved. Multifocal Insulinoma in Pancreas and Effect of Intraoperative Ultrasonography Wed, 29 Jul 2015 13:54:20 +0000 Insulinoma is the most frequently seen functional pancreatic neuroendocrine tumor. The incidence of multifocal insulinoma is lower than 10%. Its treatment is direct or laparoscopic excision. The present case was examined with the findings of hypoglycemia and hypercalcemia, and as there was high insulin and C-peptide levels the initial diagnosis was insulinoma. The case was investigated in terms of MEN 1. During preoperative screening for localization, there was one focus in the head of the pancreas in the abdominal tomography and two foci in endoscopic ultrasonography. No other focus was detected through intraoperative visual or manual palpation. However, five foci were detected during operation by intraoperative ultrasonography. The relation of masses with the main pancreatic canal was evaluated and they were excised by enucleation method. There was no recurrence during the postoperative 18-month follow-up of the patient. As a result, during treatment for insulinoma, it should be kept in mind that there might be multifocal foci. In all insulinomas, the whole pancreas should be evaluated with intraoperative ultrasonography because none of the current preoperative diagnostic methods are as sensitive as manual palpation of pancreas and intraoperative ultrasonography. The intraoperative detection of synchronous five foci in pancreas is quite a rare condition. Ersin Borazan, Alper Aytekin, Latif Yilmaz, Muhsin Elci, Mehmet Salih Karaca, Selim Kervancioglu, and Ahmet Abdulhalik Balik Copyright © 2015 Ersin Borazan et al. All rights reserved. Bilateral Ureteral Obstruction in Children after Appendectomy Wed, 29 Jul 2015 10:16:31 +0000 Acute renal failure due to bilateral ureteral obstruction is a rare complication after appendectomy in children. We report a case of bilateral ureteric obstruction in a 14-year-old boy nine days after surgery for an acute appendicitis. After saline-filling of the urinary bladder, transabdominal ultrasound demonstrated bilateral hydronephrosis of moderate degree. No abscess was found with CT but presence of millimetric stones on both distal ureters was shown, with bilateral calyceal dilatation. Cystoscopy revealed inflammatory changes in the bladder base. Following introduction of bilateral ureteric stents, there was rapid normalisation of urinary output and serum creatinine. M. Grande, G. Lisi, D. Bianchi, P. Bove, R. Miano, A. Esser, F. De Sanctis, A. Neri, S. Grande, and M. Villa Copyright © 2015 M. Grande et al. All rights reserved. The Impact of Radiation on an Unusual Case of Omental Epithelioid Angiosarcoma Tue, 28 Jul 2015 09:40:20 +0000 Epithelioid angiosarcoma is a rare high-grade tumor with irregular vascular morphology. We report an unusual case of intra-abdominal epithelioid angiosarcoma affecting the omentum and peritoneal surfaces resulting in significant hemorrhagic and inflammatory changes. As in other cases of this tumor this patient had previously undergone radiation treatment for a history of cervical cancer. Sumana Narayanan, Mitchell Parker, Jonathan Shayo, Min Zheng, Theodore Matulewicz, and Glenn Parker Copyright © 2015 Sumana Narayanan et al. All rights reserved. Management of a Gastrobronchial Fistula Connected to the Skin in a Giant Extragastric Stromal Tumor Tue, 28 Jul 2015 08:53:29 +0000 Introduction. Gastrointestinal stromal tumors first treatment should be surgical resection, but when metastases are diagnosed or the tumor is unresectable, imatinib must be the first option. This treatment could induce some serious complications difficult to resolve. Case Report. We present a 47-year-old black man with a giant unresectable gastric stromal tumor under imatinib therapy who presented serious complications such as massive gastrointestinal bleeding and a gastrobronchial fistula connected with the skin, successfully treated by surgery and gastroscopy. Discussion. Complications due to imatinib therapy can result in life threatening. They represent a challenge for surgeons and digestologists; creative strategies are needed in order to resolve them. Emilio Muñoz, Fernando Pardo-Aranda, Noelia Puértolas, Itziar Larrañaga, Judith Camps, and Enrique Veloso Copyright © 2015 Emilio Muñoz et al. All rights reserved. A Rare Complication of Biliary Stent Migration: Small Bowel Perforation in a Patient with Incisional Hernia Sun, 26 Jul 2015 14:13:17 +0000 Endoscopic biliary stents have been recently applied with increasing frequency as a palliative and curable method in several benign and malignant diseases. As a reminder, although most of the migrated stents pass through the intestinal tract without symptoms, a small portion can lead to complications. Herein, we present a case of intestinal perforation caused by a biliary stent in the hernia of a patient with a rarely encountered incarcerated incisional hernia. Özkan Yilmaz, Remzi Kiziltan, Oktay Aydin, Vedat Bayrak, and Çetin Kotan Copyright © 2015 Özkan Yilmaz et al. All rights reserved. Single Incision Laparoscopic Cholecystectomy for Gallbladder Duplication Wed, 22 Jul 2015 12:48:54 +0000 Duplication of the gallbladder is a rare congenital anomaly of the gallbladder, with an estimated prevalence of 1–3 per 3800 individuals. Unless properly diagnosed preoperatively, it can lead to biliary tract injuries and postoperative complications which may require reoperative surgeries. While previously reported cases have been treated with conventional laparoscopic cholecystectomy (LC), treatment with single incision laparoscopic surgery (SILS) has not been reported yet. We herein present the case of a 58-year-old female with gallbladder duplication who was successfully treated with SILS cholecystectomy. Esin Kabul Gürbulak, Hamdi Özşahin, Yiğit Düzköylü, Ismail Ethem Akgün, Muharrem Battal, and Bünyamin Gürbulak Copyright © 2015 Esin Kabul Gürbulak et al. All rights reserved. Duodenal Obstruction as First Presentation of Metastatic Breast Cancer Tue, 21 Jul 2015 13:14:05 +0000 The metastatic breast cancer to the duodenum is rare in spite of common breast cancer. In this paper, we are reporting a rare case of 50-year-old lady who presented with intestinal obstruction as result of metastatic breast cancer which completely responds to chemotherapy. The tumor presents again as brain metastasis after stop of Herceptin due to cardiac toxicity. Sami Khairy, Ayman Azzam, Shamayel Mohammed, Kausar Suleman, Abdurahman Khawaji, and Tarek Amin Copyright © 2015 Sami Khairy et al. All rights reserved.