Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Gossypiboma Posing as a Diagnostic Dilemma: A Case Report and Review of the Literature Mon, 15 Dec 2014 00:10:38 +0000 The term gossypiboma is used to describe a retained surgical sponge after operation. It is a rare but serious complication which is seldom reported because of the medicolegal implications. Gossypiboma usually has varied and vague presentation and is also difficult to detect on radiological investigations. It can even remain silent and present years after the operation. We report a case of a 38-year-old lady who presented with vague pain and chronic lump in the right iliac fossa region. She had a history of cesarean section 4 years ago. Radiological investigations were inconclusive in detecting the retained sponge. A working diagnosis of mesenteric cyst was made and an exploratory laparotomy was done where she was found to have a large gossypiboma densely adhered to the small bowel and surrounding structures. Though rare, gossypiboma should be kept in mind as a differential diagnosis in postoperative cases presenting as vague pain or chronic lump even years after the operation. K. N. Srivastava and Amit Agarwal Copyright © 2014 K. N. Srivastava and Amit Agarwal. All rights reserved. Bisphosphonate-Induced Periprosthetic Fracture: A Cause of Painful Total Hip Arthroplasty Wed, 10 Dec 2014 00:10:52 +0000 Background. Cases have been reported in the literature of periprosthetic fractures associated with the use of bisphosphonates occurring in the long term following a Total Hip Replacement (THR). We report an interesting case of periprosthetic fracture secondary to bisphosphonate use only a few months after a THR. Case Report. A 72-year-old lady (on bisphosphonates for 10 years) underwent a THR for osteoarthritis. She was pain-free in the first four months postoperatively. Thereafter, she developed spontaneous onset of pain in the lateral aspect of her thigh and groin and found it difficult to weight-bear. X-rays and blood tests were unremarkable. An ultrasound and MRI scan showed no evidence of effusion/collection or periprosthetic fracture. A radionuclide bone scan showed an abnormal appearance of the right femoral shaft. A subsequent CT scan showed an oblique vertical split on the anterior surface of the upper right femoral shaft. This stress fracture was managed nonoperatively with protected weight bearing. She has progressed well with good clinical and radiological signs of fracture healing. Conclusion. This case is an important addition to our knowledge that bisphosphonate-induced periprosthetic stress fractures can be a cause of hip pain only a few months following a THR. Rahul Bhattacharyya, Stephanie Spence, Gavin O’Neill, and Kumar Periasamy Copyright © 2014 Rahul Bhattacharyya et al. All rights reserved. Prune Belly Syndrome with Overlapping Presentation of Partial Urorectal Septum Malformation Sequence in a Female Newborn with Absent Perineal Openings Tue, 09 Dec 2014 00:10:19 +0000 Prune belly syndrome (PBS) is a rare congenital anomaly characterized in males by a triad of anomalous genitourinary tract, deficient development of abdominal wall muscles, and bilateral cryptorchidism. Although similar anomalies have been reported in females, by definition they do not full fill the classical triad. Urorectal septum malformation sequence (URSM) is a lethal condition characterized by presence of ambiguous genitalia, absent perineal openings (urogenital and anal), and lumbosacral abnormalities. In this original case report, the authors discuss the presentation and management of what would be analogous to a Woodhouse category 1 PBS in a female newborn associated with an overlapping presentation of URSM. Azhar Farooqui, Alaa AlAqeel, and Zakaria Habib Copyright © 2014 Azhar Farooqui et al. All rights reserved. Sentinel Bleeding as a Sign of Gastroaortic Fistula Formation after Oesophageal Surgery Tue, 02 Dec 2014 07:33:39 +0000 Gastroaortic fistula formation is a very rare complication following oesophageal resection and, in most cases, leads to sudden death. We report the case of a 65-year-old male with an adenocarcinoma of the oesophagus who underwent neoadjuvant chemoradiation followed by a minimally invasive transthoracic oesophagectomy with gastric tube reconstruction and intrathoracic anastomosis. After an uneventful postoperative course and hospital discharge, the patient reported blood regurgitation on postoperative day 23. Endoscopy revealed an adherent blood clot on the oesophageal wall, which after dislocation caused exsanguination. Autopsy determined the cause of death being massive haemorrhage due to a gastroaortic fistula. The sudden onset of haemorrhage makes this condition particularly difficult to treat. Recognition of warning signs such as thoracic or epigastric pain, regurgitation of blood, or the passing of bloody stools or melena is crucial in the early detection of fistula and may improve patient outcome. M. Uittenbogaart, M. N. Sosef, and J. van Bastelaar Copyright © 2014 M. Uittenbogaart et al. All rights reserved. Kimura Disease Manifesting as Synchronous Bilateral Parotid Swelling in a Young Middle-Eastern Patient Mon, 24 Nov 2014 10:16:09 +0000 Kimura disease is a rare, benign, chronic inflammatory swelling of the subcutaneous tissue, lymph nodes, and glandular tissue. Characteristic features of the disease include, but not limited to, painless subcutaneous head and neck swelling, blood and tissue eosinophilia, and markedly elevated immunoglobulin E (IgE) levels. Herein, we report a rare case of Kimura disease manifesting as synchronous bilateral parotid swelling of 12 years duration in a 33-year-old Middle-Eastern man. To our knowledge only few cases have been reported in the literature involving bilateral parotid glands, and this is the first case to be reported in the Middle East. Fatemah Faras, Fawaz Abo-Alhassan, Khalid Al-Sebeih, and Jassem Bastaki Copyright © 2014 Fatemah Faras et al. All rights reserved. Rescue ALPPS: Intraoperative Conversion to ALPPS during Synchronous Resection of Rectal Cancer and Liver Metastasis Mon, 24 Nov 2014 00:00:00 +0000 Future liver remnant (FLR) is the most important deciding factor in planning for liver resection. Portal vein embolization (PVE) was first introduced in the 1980s to induce liver hypertrophy, enabling removal of multiple/bilobar tumors. PVE was later combined with sequential hepatectomies with the aim of allowing the liver remnant to hypertrophy (15–20%) between procedures. However, the interval between the two procedures (3–8 weeks) put patients at risk for disease progression. With portal vein ligation alone or when combined with sequential hepatectomy, there is also a risk for inadequate liver hypertrophy because of intrahepatic portal collaterals leading to a high (19–30%) dropout rate. The ALPPS procedure (associating liver partition and portal vein ligation for staged hepatectomy) was recently developed as a feasible means to perform extensive/bilobar liver resections. It produces rapid, enormous hypertrophy of the remnant, making previously unresectable lesions resectable. Indications for ALPPS include any extensive liver resection with inadequate FLR. Here we present a novel indication for ALPPS as a rescue when inadequate FLR was faced intraoperatively, during a simultaneous resection of rectal primary and liver metastasis. Terence Jackson, Kelly A. Siegel, and Christopher T. Siegel Copyright © 2014 Terence Jackson et al. All rights reserved. Solitary Cecal Diverticulitis: An Unusual Cause of Acute Right Iliac Fossa Pain—A Case Report and Review of the Literature Sun, 23 Nov 2014 00:00:00 +0000 Solitary cecal diverticulitis is a rare cause of acute abdominal pain in the Western world. Its clinical presentation, in most cases, mimics acute appendicitis. A 38-year-old Caucasian man presented with acute abdomen and clinical signs of acute appendicitis. Laparotomy was performed and revealed an inflammatory, solitary diverticulum of the cecum. A typical appendectomy was performed and a catheter was inserted for draining percutaneously the inflamed diverticulum of the cecum. The patient had an uneventful recovery and was discharged on the 4th postoperative day. This frequently misdiagnosed condition, in most cases, is being suspected and identified intraoperatively as acute appendicitis. The aim of this study is to review the available different surgical management options and to present an alternative therapeutic approach that may be valuable under specific circumstances. Nikolaos Mudatsakis, Marinos Nikolaou, Konstantinos Krithinakis, Michail Matalliotakis, Nikolaos Politis, and Emmanouil Andreadakis Copyright © 2014 Nikolaos Mudatsakis et al. All rights reserved. Successful Outcome of Triangle Tilt as Revision Surgery in a Pediatric Obstetric Brachial Plexus Patient with Multiple Previous Operations Sun, 23 Nov 2014 00:00:00 +0000 Introduction. Obstetric brachial plexus injury (OBPI) occurs during the process of labor and childbirth. OBPI has been reported to be associated with shoulder dystocia, macrosomia, and breech delivery. Its occurrence in uncomplicated delivery is possible as well. Case Presentation. The patient in the present report is a 6.5-year-old girl, who suffered a severe brachial plexus injury at birth and had many reconstructive surgical procedures at an outside brachial plexus center before presenting to us. Discussion. The traditional surgical treatments by other surgical groups were unsuccessful and therefore the patient came to our clinic for further treatment. She had triangle tilt surgery with us, as a salvage procedure. Conclusion. The OBPI patient in this study clearly showed noticeable clinical and functional improvements after triangle tilt surgical management. The posture of the arm at rest was greatly improved to a more normal position, and hand to mouth movement was improved as well. Triangle tilt surgery should be conducted as a first choice treatment for medial rotation contracture of the shoulder in OBPI patients. Rahul K. Nath, Vishnu Halthore, and Chandra Somasundaram Copyright © 2014 Rahul K. Nath et al. All rights reserved. Transvaginal Appendectomy in Morbidly Obese Patient Thu, 20 Nov 2014 11:07:11 +0000 Introduction. Laparoscopic appendectomy has significant benefits in obese patients. However, morbid obesity can be accepted as an exclusion criterion for natural orifice transluminal endoscopic surgery (NOTES). Here, we present a transvaginal appendectomy in a 66-year-old morbidly obese (BMI 36 kg/m2, ASA III) patient. Case and Technique. Acute appendicitis was suspected based on history, physical examination, laboratory tests, and ultrasound findings. During laparoscopic surgery, a 5 mm trocar was inserted through the umbilicus and a 5 mm telescope was placed. A 12 mm trocar and a 5 mm grasper were inserted separately through the posterior fornix of the vagina under laparoscopic guidance. The appendix was divided with an endoscopic stapler through the transvaginal 12 mm trocar and removed from the same trocar. The operating time was 75 minutes with minimal blood loss (<10 mL). The patient was discharged 16 hours after surgery uneventfully and she did not require any analgesic administration. Conclusion. To the best of our knowledge, this is the first clinical case that focuses on the transvaginal appendectomy at morbid obesity. We can say that morbid obesity does not constitute an obstacle for treatment of acute appendicitis by transvaginal endoscopic surgery. Mehmet Ali Yagci, Cuneyt Kayaalp, and Mustafa Ates Copyright © 2014 Mehmet Ali Yagci et al. All rights reserved. Necrotising Myositis, the Deadly Impersonator Wed, 19 Nov 2014 14:04:00 +0000 We report two cases of patients with necrotising myositis who presented initially with limb pain and swelling on a background of respiratory complaints. Patient 1, a previously well 38-year-old female, underwent various investigations in the emergency department for excessive lower limb pain and a skin rash. Patient 2, a 61-year-old female with a background of rheumatoid arthritis and hypertension, presented to accident and emergency feeling generally unwell and was treated for presumed respiratory sepsis. Both deteriorated rapidly and were referred to the plastic surgery team with soft tissue necrosis, impending multiorgan failure and toxaemia. Large areas of necrotic muscle and skin were debrided, which grew group A streptococci, Streptococcus pyogenes. Patient 1 had a high above knee amputation of the left leg with extensive debridement of the right. Despite aggressive surgical intervention and microbiological input with intensive care support, patient 2 died. These two cases highlight the importance of early diagnosis and prompt surgical and pharmacological intervention in managing this life-threatening disease. Pain is the primary symptom with skin changes being a late and subtle sign in a septic patient. The Laboratory Risk Indicator for Necrotising Fasciitis (LRINEC) may be of use if there is concern to aid diagnosis of this life-threatening disease. A. Rahman, A. K. Abou-Foul, A. Yusaf, J. Holton, and L. Cogswell Copyright © 2014 A. Rahman et al. All rights reserved. Giant Mature Primary Retroperitoneal Teratoma in a Young Adult: Report of a Rare Case and Literature Review Wed, 19 Nov 2014 12:39:22 +0000 Teratomas are neoplasms of the embryonic tissues that typically arise in the gonadal and sacrococcygeal regions of adults and children. Primary adult retroperitoneal teratomas are rare and demand challenging management options. We report a case of a unilateral primary retroperitoneal mature cystic teratoma mimicking an adrenal mass in a 28-year-old female patient. Complete resection of the mass was performed by a laparotomy approach. Because of the risk of malignancy, follow-up radiographic studies were performed to ensure the oncologic efficacy of resection. The patient remains free of recurrence to date. Walid Sasi, Giuseppe A. Ricchetti, Laila Parvanta, and Robert Carpenter Copyright © 2014 Walid Sasi et al. All rights reserved. Single-Incision Laparoscopic Surgery for Intersigmoid Hernia Wed, 19 Nov 2014 12:38:42 +0000 Intersigmoid hernia is a rare form of internal hernia. Here, we report a case of intersigmoid hernia and provide a brief review of the 62 cases involving the mesosigmoid reported in Japan from 2000 to 2013. In the current case, a 26-year-old man with no previous history of abdominal surgery presented with abdominal pain and vomiting. Abdominal computed tomography revealed an extensively dilated small bowel and a closed loop of small bowel in the mesosigmoid. The patient was diagnosed with an intestinal obstruction due to an incarcerated internal hernia involving the mesosigmoid. There was no blood flow obstruction at the incarcerated bowel. An elective single-incision laparoscopic surgery was performed after decompression of the bowel using ileus tube. As the ileum herniated into the intersigmoid fossa, the patient was diagnosed with an intersigmoid hernia. The incarcerated small bowel was reduced in order to make it viable, and the hernial defect was closed with interrupted sutures. The patient had an uneventful recovery and was discharged on postoperative day five. Takahiro Watanabe, Hidetoshi Wada, Masanori Sato, Yuichirou Miyaki, and Norihiko Shiiya Copyright © 2014 Takahiro Watanabe et al. All rights reserved. Fournier’s Gangrene as a Postoperative Complication of Inguinal Hernia Repair Wed, 19 Nov 2014 07:00:11 +0000 Fournier’s gangrene is the necrotizing fasciitis of perianal, genitourinary, and perineal regions. Herein, we present a case of scrotal Fournier’s gangrene as a postoperative complication of inguinal hernia repair. A 51-year-old male with giant indirect hernia is presented. Patient underwent inguinal hernia repair, and after an unproblematic recovery period, he was discharged. He applied to our outpatient clinic on the fifth day with swollen and painful scrotum and it turned out to be Fournier’s gangrene. Polypropylene mesh was not infected. Patient recovered and was discharged after repeated debridements. Basic principles in treatment of Fournier’s gangrene are comprised of initial resuscitation, broad-spectrum antibiotics therapy, and early aggressive debridement. In the management of presented case, aggressive debridement was made right after diagnosis and broad-spectrum antibiotics were given to the hemodynamically stable patient. In these circumstances, the important question is whether we could prevent occurrence of Fournier’s gangrene. Tolga Dinc, Selami Ilgaz Kayilioglu, Isa Sozen, Baris Dogu Yildiz, and Faruk Coskun Copyright © 2014 Tolga Dinc et al. All rights reserved. Mucinous Adenocarcinoma Arising in Chronic Perianal Fistula: Good Results with Neoadjuvant Chemoradiotherapy Followed by Surgery Tue, 18 Nov 2014 07:37:00 +0000 Chronic perianal fistulas are a common clinical condition. However, their evolution to adenocarcinoma is rare. We report the case of a 48-year-old man with perianal chronic fistulas, who developed two perianal ulcerated lesions near the external orifices of the fistulas, which extended proximally as a pararectal tumor. No intestinal lesion was seen at endoscopic examination. Histopathological biopsy indicated mucinous adenocarcinoma. Staging was performed by pelvic magnetic resonance imaging (MRI) and thoracoabdominal CT scan. The patient underwent a laparoscopic colostomy followed by neoadjuvant chemoradiotherapy and then laparoscopic abdominoperineal resection followed by adjuvant therapy. We have seen a favorable outcome with no recurrence at 3 years of follow-up. Marisa D. Santos, Carlos Nogueira, and Carlos Lopes Copyright © 2014 Marisa D. Santos et al. All rights reserved. Giant Subcutaneous Leiomyosarcoma of Anterior Abdominal Wall Tue, 18 Nov 2014 06:38:57 +0000 Subcutaneous leiomyosarcomas are rare tumors accounting for 1% to 2% of all superficial soft tissue malignancies. Although they may arise anywhere in the body, they most frequently occur in the lower extremities. The incidence of subcutaneous LMS affecting the anterior abdominal wall is very rare. We herein report the case of a patient with a giant subcutaneous leiomyosarcoma arising in the anterior abdominal wall. It was diagnosed by histopathology and immunohistochemistry and treated accordingly. Sanghamitra Jena, Samir Bhattacharya, and Shravasti Roy Copyright © 2014 Sanghamitra Jena et al. All rights reserved. A Rare Presentation of Maydl’s Hernia Tue, 18 Nov 2014 06:32:27 +0000 We present a case of an unsual type of obstructed indirect inguinal hernia with impending strangulation. The operative findings revealed a sliding Maydl’s hernia with an ischemic inner ileal loop and an adherent inflamed appendix. This case highlights the importance of intraoperative examination of the intra-abdominal bowel loops proximal to the hernia sac of an incarcerated, obstructed, or strangulated hernia. Elroy Patrick Weledji, Martin Mokake, and Marcelin Ngowe Ngowe Copyright © 2014 Elroy Patrick Weledji et al. All rights reserved. Primary Pneumatosis Intestinalis of Small Bowel: A Case of a Rare Disease Mon, 17 Nov 2014 06:30:31 +0000 Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled cysts are located in the bowel wall; it can represent a wide spectrum of diseases and a variety of underlying diagnoses. The present report describes the case of an 86-year-old man with symptomatic primary PI of small bowel treated with surgical approach after periodic episodes of cysts rupture and superimposed inflammation revealed on the basis of a clinical suspicion thanks to abdominal computed tomography. Moreover, after one year of followup, there has been no recurrence of digestive symptoms. Daniela Berritto, Raffaello Crincoli, Francesca Iacobellis, Francesca Iasiello, Nunzia Luisa Pizza, Francesco Lassandro, Lanfranco Musto, and Roberto Grassi Copyright © 2014 Daniela Berritto et al. All rights reserved. Malignancy within a Tail Gut Cyst: A Case of Retrorectal Carcinoid Tumour Thu, 13 Nov 2014 09:39:15 +0000 Purpose. Tailgut cysts with malignant transformation are rare entities. We discuss the diagnostic strategy and treatment of a malignancy within a tailgut cyst. Methods. In this study we report on the case of a 61-year-old man with a malignant neuroendocrine tumour arising within a tailgut cyst and an overview of the literature emphasising the histopathological characteristics and differential diagnosis. Results. Our patient presented with lower back pain, rectal pain, and increased urgency of defecation. MRI scan and CT-guided biopsy on histological analysis revealed a diagnosis of carcinoid tumour of the presacral space. The patient subsequently underwent an abdominoperineal excision of the rectum. Conclusions. This case highlights the importance of tailgut cysts as a differential diagnosis of presacral masses. It is a rare congenital lesion developing from remnants of the embryonic postanal gut and is predominantly benign in nature. Approximately half of cases remain asymptomatic; therefore, diagnosis is often delayed. Magnetic resonance imaging is the investigation of choice and an awareness of the possibility of malignant potential is critical to avoiding missed diagnosis and subsequent morbidity. Complete surgical excision allows accurate diagnosis, confirmation of oncological clearance, and prevention of mortality. A. A. Abukar, B. J. Parcell, C. B. Lim, P. V. Patil, A. Ramsanahie, F. Carey, R. J. C. Steele, and M. A. Thaha Copyright © 2014 A. A. Abukar et al. All rights reserved. An Extremely Rare Complication of Varicose Vein Surgery: Retained Foreign Body Sun, 09 Nov 2014 12:48:30 +0000 Foreign body is among complications of surgery. But as a complication of varicose vein surgery it was reported extremely rarely and, to our knowledge, there is only one paper in the literature. A case with retained sponge which was detected five months after varicose vein surgery was presented. Orhan Fındık, Ufuk Aydın, Çağrı Düzyol, Özgür Barış, and Cevdet Uğur Koçoğulları Copyright © 2014 Orhan Fındık et al. All rights reserved. Successful Removal of Giant Intrapericardial Paraganglioma via Posterolateral Thoracotomy Sun, 09 Nov 2014 07:25:48 +0000 Intrapericardial paraganglioma remains a surgical challenge because of its hypervascular nature and firm adhesion to adjacent mediastinal structures. Here, we describe a 63-year-old female with a giant nonfunctioning intrapericardial paraganglioma tightly adhered to the left atrium. Marginal but complete resection of the tumor was achieved via right posterolateral thoracotomy. At the time of dissection between the tumor and the left atrial wall, we encountered massive hemorrhage leading to cardiac arrest. We were able to repair the wall laceration with minimal time under an optimal operative field, which avoids air embolism. She was discharged without complications and is currently in good health with no recurrence or metastasis for 15 months. Based on our experience, cardiopulmonary bypass should be considered, if surgeons are able to secure suitable sites for arterial and venous cannulations while right posterolateral thoracotomy is employed. Yoko Yamamoto, Ken Kodama, Hiroyuki Yamato, and Masashi Takeda Copyright © 2014 Yoko Yamamoto et al. All rights reserved. Difficulties of Bariatric Surgery after Abdominoplasty Thu, 06 Nov 2014 11:43:38 +0000 During laparoscopy, the main problems of patients who have undergone previous abdominoplasty are inadequate pneumoperitoneum secondary to fibrosis and reconstructed anatomic landmarks for trocar placement. In this study, we present our laparoscopic bariatric experience in two patients with previous abdominoplasty. The procedures were a laparoscopic sleeve gastrectomy and a robotic Roux-en-Y gastric bypass. Both operations were done successfully by an abdominal wall traction technique, cutting fibrotic tissue and choosing new landmarks. We conclude that after abdominoplasty bariatric surgery can be performed safely either using conventional laparoscopic technique or robotically. Bora Karip, Hasan Altun, Yalın İşcan, Martin Bazan, Kafkas Çelik, Yetkin Özcabı, Birol Ağca, and Kemal Memişoğlu Copyright © 2014 Bora Karip et al. All rights reserved. Asymptomatic Pellet Migration to the Heart: Report of a Case and Update on Proper Management Thu, 06 Nov 2014 11:29:45 +0000 We report a case of a 42-year-old male patient who was transferred to our emergency department suffering from a gunshot wound in his left lateral thigh. The patient was haemodynamically stable, and the physical examination of the abdomen and thorax was unremarkable. There was no obvious exit point and there were no other injuries. The radiologic control of the left thigh showed an intact femur and multiple pellets within the adjacent soft tissues. Routine X-ray evaluation of the thorax revealed a small-sized round object of metal density—possibly a migrated pellet—in the proximity of the right heart atrium. Computed tomography imaging confirmed this finding and showed no other cardiac or mediastinal injury. Ultrasonography of the heart was unremarkable as well. The patient was managed conservatively for the discovered pellet, and remained asymptomatic throughout the entire hospital stay, and 6 months after the discharge. Pellet migration or embolism should be suspected in any gunshot victim without a corresponding exit wound or when the signs and symptoms do not correlate with the suspected course of the missile. Conservative management remains the first choice in asymptomatic patients, although close monitoring at first and regular observation after discharge are indicated. George Galyfos, Konstantinos Palogos, and Nikolaos Kavouras Copyright © 2014 George Galyfos et al. All rights reserved. Mediastinal Cystic Lymphangioma in a Patient with Situs Inversus Totalis Thu, 06 Nov 2014 08:49:35 +0000 We present a case of cystic lymphangioma of the mediastinum complicated with situs inversus totalis. The 70-year-old man underwent thoracoscopic resection of a mediastinal cystic tumor, which was diagnosed as cystic lymphangioma. Cystic lymphangiomas are congenital cystic abnormalities of the lymphatic system. The head and neck area is often involved while the mediastinum is rarely affected. The rarity of this case is further attributed to the coexistence of situs inversus totalis. Teruya Komatsu and Yutaka Takahashi Copyright © 2014 Teruya Komatsu and Yutaka Takahashi. All rights reserved. Acute Abdomen due to Primary Omental Torsion and Infarction Thu, 06 Nov 2014 07:15:10 +0000 Background. Torsion of greater omentum is a quite uncommon cause of acute abdomen. It can be primary or secondary but in both cases omentum twists upon itself and causes omental segmentary or diffuse necrosis. Symptoms are unspecific and preoperative diagnosis is difficult. The widespread and increasing use of computer tomography (CT) in differential diagnosis of acute abdomen can be useful for making a specific diagnosis. Objectives. This work aims to describe primary omental torsion in order to help avoid misdiagnosis, especially with acute appendicitis, which is eventually based solely on a physical examination. Case Report. We present a case of primary omental torsion in a young man and discuss contemporary methods in diagnosis and management of the condition. Conclusions. When a right diagnosis has been posed, possible treatments for omental torsion and necrosis are two: conservative or surgical. Conservative treatment had been rarely carried out because of frequent and important sequelae just like abdominal abscesses. Nowadays, surgical treatment, laparoscopic or laparotomic, is preferred because it is a safe method in diagnosis and management of this condition. S. Occhionorelli, M. Zese, L. Cappellari, R. Stano, and G. Vasquez Copyright © 2014 S. Occhionorelli et al. All rights reserved. A Case of Retroperitoneal Castleman’s Disease and an Update on the Latest Evidence Wed, 05 Nov 2014 09:28:52 +0000 Castleman’s disease is a benign lymphoproliferative condition with three distinct histological subtypes. Clinically it presents in either a unicentric or multicentric manner and can affect various anatomic regions, the mediastinum being the most frequent location. We herein present a rare case of unifocal retroperitoneal mass proved to be hyaline vascular Castleman’s disease. We perform a review of the current literature pertaining to such lesions, focusing on the management of the various clinical and histological variants of the disease. Surgical excision is the treatment of choice for unifocal Castleman’s disease. Eleftherios Spartalis, Petros Charalampoudis, Apostolos Kandilis, Antonios Athanasiou, Petros Tsaparas, Athanasios Voutsarakis, Ioannis D. Kostakis, Dimitrios Dimitroulis, Evanthia Svolou, Penelope Korkolopoulou, Nikolaos Nikiteas, and Gregory Kouraklis Copyright © 2014 Eleftherios Spartalis et al. All rights reserved. Adenoid Cystic Carcinoma of the Submandibular Gland, Locoregional Recurrence, and a Solitary Liver Metastasis More Than 30 Years Since Primary Diagnosis Mon, 27 Oct 2014 06:41:33 +0000 Adenoid cystic carcinoma (ACC) is a relatively rare tumour of the salivary glands, accounting for approximately 5%–10% of all salivary gland tumours. An important feature of ACCs is the long clinical course with a high rate of distant metastases. The preferential sites of metastases are the lung and bone, followed by the brain and liver. Most liver metastases are derived from nonparotid ACCs, and the presentation is often related to local recurrence or metastases to other organs. Solitary metastases to the liver are rare and optimal management is unknown. We present the case of a metastatic ACC to the liver with primary disease presentation at a young age. We discuss our management and other potential treatment modalities. A. Coupland, A. Sewpaul, A. Darne, and S. White Copyright © 2014 A. Coupland et al. 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.