Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Superior Mesenteric Artery Syndrome: An Infrequent Complication of Scoliosis Surgery Wed, 22 Oct 2014 11:33:10 +0000 Superior mesenteric artery syndrome is a rare condition that causes a proximal small intestinal obstruction due to contraction of the angle between the superior mesenteric artery and the aorta. Scoliosis surgery is one of the 15 reasons for superior mesenteric artery syndrome, which can present with acute or chronic manifestations. Although conservative treatment is usually possible, surgical treatment is required in certain cases that cannot be treated using conservative methods. In this paper, we describe a patient who developed superior mesenteric artery syndrome after scoliosis surgery and was treated with duodenojejunostomy due to failure and complications of conservative treatment. Metin Keskin, Turgut Akgül, Adem Bayraktar, Fatih Dikici, and Emre Balık Copyright © 2014 Metin Keskin et al. All rights reserved. An Option of Conservative Management of a Duodenal Injury Following Laparoscopic Cholecystectomy Tue, 21 Oct 2014 14:00:18 +0000 Duodenal injury following laparoscopic cholecystectomy is rare complications with catastrophic sequelae. Most injuries are attributed to thermal burns with electrocautery following adhesiolysis and have a delayed presentation requiring surgical intervention. We present a case of a 47-year-old gentleman operated on for laparoscopic cholecystectomy with a bilious drain postoperatively; for which an ERC was done showing choledocholithiasis with cystic duct stump blow-out and a drain in the duodenum suggestive of an iatrogenic duodenal injury. He was managed conservatively like a duodenal fistula and recovered without undergoing any intervention. MA Modi, SS Deolekar, and AK Gvalani Copyright © 2014 MA Modi et al. All rights reserved. Modified Kraske Procedure with Mid-Sacrectomy and Coccygectomy for En Bloc Excision of Sacral Giant Cell Tumors Thu, 16 Oct 2014 14:41:30 +0000 Sacral giant cell tumors are rare neoplasms, histologically benign but potentially very aggressive due to the difficulty in achieving a complete resection, their high recurrence rate, and metastization capability. Although many treatment options have been proposed, en bloc excision with tumor-free margins seems to be the most effective, being associated with long term tumor control, improved outcome, and potential cure. An exemplifying case of a 29-year-old female with progressive complaints of pain and paresthesias in the sacral and perianal regions, constipation, and weight loss for 6 months is presented. The surgical technique for en bloc excision of a large sacral giant cell tumor through a modified Kraske procedure with mid-sacrectomy and coccygectomy is described. Complete resection with wide tumor-free margins was achieved. At 5 years of follow-up the patient is neurologically intact, without evidence of local recurrence on imaging studies. A multidisciplinary surgical procedure is mandatory to completely remove sacral tumors. In the particular case of giant cell tumors, it allows minimizing local recurrence preserving neurovascular function, through a single dorsal and definitive approach. Vítor M. Gonçalves, Álvaro Lima, João Gíria, Nuno Carvalho, José Parreira, and Manuel Cunha e Sá Copyright © 2014 Vítor M. Gonçalves et al. All rights reserved. Multidimensional Sternal Fixation to Overcome a “Floating” Sternum Tue, 14 Oct 2014 11:55:00 +0000 This case report describes the repair of a complete sternal dehiscence of the lower right sternum using sternal wires, manubrial plates, and a Talon closure device for rigid, multidimensional sternal fixation. Sternal dehiscence is a rare but significant cause of morbidity for patients undergoing median sternotomy. The risk factors for this complication are well described and although sternal wires have traditionally been used for primary closure, rigid fixation with sternal plates is a viable alternative to avoid dehiscence in this high-risk cohort. William Rothstein, Tyler Spata, Bryan Whitson, and Ahmet Kilic Copyright © 2014 William Rothstein et al. All rights reserved. Intestinal Malrotation: A Rare Cause of Small Intestinal Obstruction Thu, 09 Oct 2014 08:28:56 +0000 Background. The diagnosis of intestinal malrotation is established by the age of 1 year in most cases, and the condition is seldom seen in adults. In this paper, a patient with small intestinal malrotation-type intraperitoneal hernia who underwent surgery at an older age because of intestinal obstruction is presented. Case. A 73-year-old patient who presented with acute intestinal obstruction underwent surgery as treatment. Distended jejunum and ileum loops surrounded by a peritoneal sac and located between the stomach and transverse colon were determined. The terminal ileum had entered into the transverse mesocolon from the right lower part, resulting in kinking and subsequent segmentary obstruction. The obstruction was relieved, and the small intestines were placed into their normal position in the abdominal cavity. Conclusion. Small intestinal malrotations are rare causes of intestinal obstructions in adults. The appropriate treatment in these patients is placement of the intestines in their normal positions. Mesut Sipahi, Kasim Caglayan, Ergin Arslan, Mustafa Fatih Erkoc, and Faruk Onder Aytekin Copyright © 2014 Mesut Sipahi et al. All rights reserved. Pneumatosis Coli Mimicking Colorectal Cancer Tue, 07 Oct 2014 09:49:08 +0000 Pneumatosis coli (PC) is a rare condition of the gastrointestinal tract involving extraluminal gas confined within the bowel wall. We report the case of a 40-year-old gentleman presenting clinically and endoscopically with suspected colorectal cancer. In light of the patient’s red flag symptoms, and carpet of polyps seen endoscopically, surgical management by an anterior resection was performed with the patient making a successful recovery. Histological analysis of the resected specimen confirmed pneumatosis coli with no evidence of colonic neoplasia. Although PC can be an incidental finding in asymptomatic patients and considered a benign condition, it can also present as a life-threatening emergency with bowel necrosis and obstruction requiring emergency surgical intervention. Also, when PC mimics malignancy, surgical management is the most appropriate step to ensure that the diagnosis of cancer is not missed. Teresa Jacob, Mohammad Paracha, Marta Penna, Dhili Arul, and Jonathan Wilson Copyright © 2014 Teresa Jacob et al. All rights reserved. Acute Ascending Thrombosis of Abdominal and Suprarenal Aorta Tue, 07 Oct 2014 09:01:00 +0000 We report the diagnostic and successful therapeutic images of an acute occlusion of the abdominal and suprarenal aorta. This lesion is a rare but catastrophic pathology which can cause severe ischemic manifestations, depending on the site of obstruction, with high rate of mortality even after treatment. In the majority of cases it represents a surgical emergency. Although the mechanism of the thrombosis has not been delineated, the proposed etiologies include propagation of thrombus from distal artery occlusion, cardiac thromboembolism, dislodgment of a mural thrombus, or coagulation disorders. Frequent risk factors include advanced atherosclerosis combined with a low flow state because of poor cardiac performance. The management of this condition includes immediate intervention with systemic heparinization, improvement of the cardiac condition, and surgical revascularization based on the clinical and anatomical presentation. In this case the authors highlight the importance of an early detection and early intervention to enhance survival rates and reduce morbidity. Alessandro Robaldo, Stefano Pagliari, and Patrizio Colotto Copyright © 2014 Alessandro Robaldo et al. All rights reserved. Flexor Carpi Ulnaris Muscle Flap for Soft Tissue Reconstruction after Total Elbow Arthroplasty Tue, 07 Oct 2014 08:19:20 +0000 The soft tissue at the tip of the olecranon is very thin, leading to the frequent occurrence of wound complications after total elbow arthroplasty. To cover a soft tissue defect of the elbow, the flexor carpi ulnaris muscle flap is thought to be appropriate for reconstruction of the elbow with regard to its size, location, and blood supply. We got positive clinical results, so we report our experiences of using a flexor carpi ulnaris muscle flap for soft tissue reconstruction after total elbow arthroplasty. Syunro Okamoto, Kaoru Tada, Hachinota Ai, and Hiroyuki Tsuchiya Copyright © 2014 Syunro Okamoto et al. All rights reserved. Giant Lipoma of Posterior Cervical Region Thu, 02 Oct 2014 09:50:08 +0000 Lipomas are the slow growing soft tissue tumors of benign nature. They commonly grow on torso and extremities but may also develop in head and neck region. Rarely lipomas can grow to acquire gigantic proportions, turning into an entity termed as giant lipoma. Such lipomas are entitled to immediate attention as they have a relatively high malignant potential. We report a rare case of giant cervical lipoma in an elderly gentleman, followed by a brief discussion on diagnosis and management of the disorder. Mahendra Singh, Ashish Saxena, Lovekesh Kumar, Snehal K. Karande, and Yuvraj Kolhe Copyright © 2014 Mahendra Singh et al. All rights reserved. Evolution of SILS Cholecystectomy in the Caribbean: The Direct Transfascial Puncture Technique Using Conventional Instruments without Working Ports Thu, 02 Oct 2014 00:00:00 +0000 Introduction. Single incision laparoscopic cholecystectomy (SILC) has become accepted as an alternative to conventional multiport cholecystectomy. However, SILC is still limited in applicability in low resource centres due to the expense associated with specialized access platforms, curved instruments, and flexible scopes. Presentation of Case. We present three cases where a modified SILC technique was used with conventional instruments and no working ports. The evolution of this technique is described. Discussion. In order to contain cost, we used conventional instruments and three transfascial ports placed in an umbilical incision, but we noted significant instrument clashes that originated at the port platforms. Therefore, we modified our technique by omitting ports for the working instruments. The technique allowed us to exchange instruments as necessary, maximized ergonomics, and prevented collisions from the bulky port platforms. Finally, the puncture left by the instrument alone did not require fascial closure at the termination of the procedure. Conclusion. The direct transfascial puncture using conventional laparoscopic instruments without working ports is a feasible option that minimizes cost and increases ergonomics. Shamir O. Cawich, Dexter Thomas, Dale Hassranah, and Vijay Naraynsingh Copyright © 2014 Shamir O. Cawich et al. All rights reserved. An Unusual Case of Swab Embolism Mon, 29 Sep 2014 07:59:52 +0000 Intravascular foreign body embolism is an exceptionally uncommon problem. We report on an unusual case of a surgical swab embolism which occurred during a thoracic surgical procedure. N. G. Naidoo, D. Kahn, and S. Mfolozi Copyright © 2014 N. G. Naidoo et al. All rights reserved. Pulmonary Hernia in a Two-Year-Old Child Sun, 28 Sep 2014 08:53:15 +0000 Pulmonary hernia, also known as lung herniation or intercostal herniation, is best explained as the lung parenchyma protruding beyond the confines of the thoracic wall. This rare finding can be classified as congenital or acquired. Acquired pulmonary herniations are often the complication of blunt or penetrating trauma to the chest wall. This report describes a two-year-old male who fell onto a rigid post, striking his left lower chest. Imaging studies demonstrated a small pneumothorax as well as pulmonary herniation. The patient underwent a diagnostic thoracoscopy and repair of a pulmonary hernia within the 7th intercostal space without complication. In this case report, we aim to add to the limited body of existing literature on the surgical management of pulmonary hernias. Jenna Fine, Bryan S. Walters, Alysia A. Agnoni, Christopher P. Coppola, Ronald J. Scorpio, and Alfred P. Kennedy Copyright © 2014 Jenna Fine et al. All rights reserved. Concomitant Small Cell Neuroendocrine Carcinoma of Gallbladder and Breast Cancer Thu, 25 Sep 2014 09:57:01 +0000 The neuroendocrine carcinoma is defined as a high-grade malignant neuroendocrine neoplasm arising from enterochromaffin cells, usually disposed in the mucosa of gastric and respiratory tracts. The localization in the gallbladder is rare. Knowledge of these gallbladder tumors is limited and based on isolated case reports. We describe a case of an incidental finding of small cell neuroendocrine carcinoma of the gallbladder, observed after cholecystectomy for cholelithiasis, in a 55-year-old female, who already underwent quadrantectomy and sentinel lymph-node biopsy for breast cancer. The patient underwent radiotherapy for breast cancer and six cycles of chemotherapy with cisplatin and etoposide. Eighteen months after surgery, the patient was free from disease. Small cell neuroendocrine carcinoma of the gallbladder has poor prognosis. Because of the rarity of the reported cases, specific prognostic factors have not been identified. The coexistence of small cell neuroendocrine carcinoma of the gallbladder with another malignancy has been reported only once. The contemporary presence of the two neoplasms could reflect that bioactive agents secreted by carcinoid can promote phenotypic changes in susceptible cells and induce neoplastic transformation. Paolo Aiello, Francesco Aragona, Valentina Territo, Anna Maria Caruso, Rosalia Patti, Salvatore Buscemi, and Gaetano Di Vita Copyright © 2014 Paolo Aiello et al. All rights reserved. Pedicled Anterior Lateral Thigh Flap in Managing a Bilateral Groin Contracture Mon, 22 Sep 2014 07:22:51 +0000 A fifteen-year-old female patient presented with a severe bilateral groin contracture for the last 8 years. She had sustained burns at the age of seven years. Three attempts to release the contracture with split thickness skin grafts had been done without success. A pedicled anterior lateral thigh flap was raised and advanced into the defect after the contracture had been released. Postoperatively the patient healed well without any complications and was able to achieve hip abduction of about 130 degrees. Ferdinand Nangole, Peter Biribwa, and Stanley Khainga Copyright © 2014 Ferdinand Nangole et al. 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.