Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Dropped Gallstones Causing a Perihepatic Abscess and Empyema Tue, 02 Jun 2015 11:25:25 +0000 Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy is a well-known occurrence; however, the consequences of spillage of gallstones in the peritoneum and particularly intrathoracic complications are less defined. We describe the delayed development of a perihepatic abscess and empyema in a patient’s five-year status of postlaparoscopic cholecystectomy secondary to dropped gallstones. A 53-year-old man with medical history significant for a laparoscopic cholecystectomy five years prior to acute cholecystitis presented with purulent cough, hemoptysis, night sweats, and right-upper quadrant (RUQ) pain. Computed tomography (CT) scan revealed 5.4 cm right-sided subpulmonic and 5.9 cm perihepatic fluid collections with an 8 mm focal radiopaque density within the perihepatic fluid collection. Open intra-abdominal exploration resulted in retrieval of a 1 cm intraperitoneal gallstone. Laparoscopic cholecystectomy is a common surgical operation during which gallstone spillage can occur, causing both intra-abdominal and intrathoracic complications, presenting even years after surgery. This necessitates an attempt to retrieve all free intra-abdominal gallstones during the initial operation. J. R. Robinson, J. K. Wright, and S. K. Geevarghese Copyright © 2015 J. R. Robinson et al. All rights reserved. Filiform Polyposis Secondary to Colonic Tuberculosis Presenting as Acute Colo-Colonic Intussusception Sun, 31 May 2015 08:01:59 +0000 Filiform polyposis represents a rare but recognised manifestation on the varied spectrum of histopathology in colonic tuberculosis. We report a case of filiform polyposis secondary to colonic tuberculosis presenting as colo-colonic intussusception diagnosed on an abdominal computed tomography (CT) scan. The patient required urgent hemicolectomy and defunctioning ileostomy. Examination of the resected bowel lesions revealed filiform polyposis. Induced sputum samples from the patient grew Mycobacterium tuberculosis. The patient recovered well from the surgery and received treatment for tuberculosis. At last follow-up, he was awaiting the reversal of his ileostomy. The protean nature of histological findings in colonic tuberculosis and other current diagnostic challenges are discussed. The importance of maintaining a high index of suspicion for colonic tuberculosis and instituting early treatment is highlighted in this case. Jacob S. Heng, Alan Baird, Marco R. Novelli, Robert N. Davidson, and Rajinder P. Bhutiani Copyright © 2015 Jacob S. Heng et al. All rights reserved. Huge Intravascular Tumor Extending to the Heart: Leiomyomatosis Sun, 31 May 2015 06:28:42 +0000 Intravenous leiomyomatosis (IVL) is a rare neoplasm characterized by histologically benign-looking smooth muscle cell tumor mass, which is growing within the intrauterine and extrauterine venous system. In this report we aimed to present an unusual case of IVL, which is originating from iliac vein and extended throughout to right cardiac chambers. A 49-year-old female patient, who was treated with warfarin sodium due to right iliac vein thrombosis, was admitted to our department with intermittent dyspnea, palpitation, and dizziness. Physical examination was almost normal except bilateral pretibial edema. On magnetic resonance venography, there was an intravenous mass, which is originated from right internal iliac vein and extended into the inferior vena cava. Transthoracic echocardiography and transesophageal echocardiography revealed a huge mass extending from the inferior vena cava through the right atrium, with obvious venous occlusion. Thoracic, abdominal, and pelvic MR showed an intravascular mass, which is concordant with leiomyomatosis. Surgery was performed through median sternotomy. A huge mass with 25-cm length and 186-gr weight was excised through right atrial oblique incision, on beating heart with cardiopulmonary bypass. Histopathologic assessment was compatible with IVL. Exact strategy for the surgical treatment of IVL is still controversial. We used one-stage approach, with complete resection of a huge IVL extending from right atrium to right iliac vein. In such cases, high recurrence rate is a significant problem; therefore it should be kept in mind. Suat Doganci, Erkan Kaya, Murat Kadan, Kubilay Karabacak, Gökhan Erol, and Ufuk Demirkilic Copyright © 2015 Suat Doganci et al. All rights reserved. An Unusual Cause of Abdominal Pain: Three Lead Pellets within the Appendix Vermiformis Thu, 28 May 2015 12:52:24 +0000 Most ingested foreign bodies usually pass out in the feces uneventfully. Complications such as intestinal perforation and bleeding usually occur with sharp, thin, stiff, long, and pointed objects. This case describes the management of three lead pellets within the appendix vermiformis. A 45-year-old male visited our clinic complaining of a 4-month history of abdominal pain. The patient inquiry revealed that he had eaten hunted rabbit meat on numerous occasions and had unintentionally ingested three lead pellets. Plain abdominal films and a barium enema showed foreign bodies in the right lower abdominal quadrant. Since the lead pellets were thought to have migrated extraluminally, they were removed through laparotomy under fluoroscopic guidance. An appendectomy was performed. Pathologically, three lead pellets were embedded in the appendix, which showed signs of intramucosal inflammation. Foreign bodies causing appendicitis are rare. However, if stiff or pointed objects enter the appendicular lumen, there is a high risk of appendicitis, perforation, or abdominal pain. An appendectomy was required to remove the ingested lead pellets in the appendix. Orhan Veli Ozkan, Vecdi Muderris, Fatih Altintoprak, Orhan Yagmurkaya, Omer Yalkin, and Fehmi Celebi Copyright © 2015 Orhan Veli Ozkan et al. All rights reserved. Life-Threatening Postpneumonectomy Syndrome Complicated with Right Aortic Arch after Left Pneumonectomy Thu, 28 May 2015 06:23:37 +0000 A 54-year-old man with right aortic arch underwent left lower lobectomy and lingular segmentectomy, followed by complete pneumonectomy, for refractory nontuberculous mycobacterial infection. Three months after the pneumonectomy, he developed acute respiratory distress. Computed tomography showed an excessive mediastinal shift with an extremely narrowed bronchus intermedius and right lower bronchus compressed between the right pulmonary artery and the right descending aorta. Soon after the nearly obstructed bronchus intermedius was observed by bronchoscopy, he began to exhibit frequent hypoxic attacks, perhaps due to mucosal edema. Emergent surgical repositioning of the mediastinum and decompression of the bronchus was indicated. After complete adhesiolysis of the left thoracic cavity was performed, to maintain the proper mediastinal position, considering the emergent setting, an open wound thoracostomy was created and piles of gauze were inserted, mildly compressing the heart and the mediastinum to the right side. Thoracoplasty was performed three months later, and he was eventually discharged without any dressings needed. Mediastinal repositioning under thoracostomy should be avoided in elective cases because of its extremely high invasiveness. However, in the case of life-threatening postpneumonectomy syndrome in an emergent setting, mediastinal repositioning under thoracostomy may be an option to save life, which every thoracic surgeon could attempt. Takahiro Karasaki and Makoto Tanaka Copyright © 2015 Takahiro Karasaki and Makoto Tanaka. All rights reserved. Surgical Extirpation of Apical Left Ventricular Thrombus in Takotsubo Cardiomyopathy Tue, 26 May 2015 09:12:03 +0000 We report a patient with takotsubo cardiomyopathy who underwent surgical resection of apical left ventricular thrombus. A 59-year-old woman was transferred to our hospital in shock with hypothermia and diabetic ketoacidosis. The electrocardiogram showed ST segment elevation, while echocardiography revealed a reduced ejection fraction with apical and midventricular akinesis. Emergency coronary angiography showed normal coronary arteries, so takotsubo cardiomyopathy was diagnosed. Follow-up echocardiography revealed improvement of the ejection fraction. A mobile apical thrombus was also detected. Thrombectomy was performed via a left apical incision and postoperative recovery was uneventful. Tetsuya Niino and Satoshi Unosawa Copyright © 2015 Tetsuya Niino and Satoshi Unosawa. All rights reserved. Adrenal Schwannomas: Rare Tumor of the Retroperitoneum Tue, 26 May 2015 08:57:19 +0000 Schwannoma is a benign neurogenic tumor originating from Schwann cells. These produce the myelin sheath that covers peripheral nerves that are often affected. This latter localization is extremely rare, and only a few case reports can be found in the medical literature. Studies have shown that approximately 0.5% to 5% of schwannomas are retroperitoneal, constituting 0.2% of adrenal incidental tumors. These usually present as incidental findings, nonsecreting adrenal masses in asymptomatic patients. Diagnosis of a schwannoma is based on detection of spindle cells with Antoni A and Antoni B regions in histological sections and positive staining for S-100 protein by immunohistochemical analysis. We report a case of an incidentally identified during an abdominal ultrasound examination with schwannoma localized in the left adrenal gland. Emanuele Grasso and Michele Simone Copyright © 2015 Emanuele Grasso and Michele Simone. All rights reserved. Primitive Neuroectodermal Tumor of the Pancreas: A Case Report and Review of the Literature Tue, 26 May 2015 07:27:44 +0000 Primitive neuroectodermal tumors (PNETs) are presented as rare malignant neoplasms. In unusual cases, those neoplasms may arise in solid organs containing neuroendocrine cells, such as the pancreas. Herein the case of a 28-year-old patient that underwent gastroduodenopancreatectomy after the diagnosis of a huge mass (PNET) located in both head and body of the pancreas is reported. This is the 19th case of pancreatic PNET reported in literature. Uirá Teixeira, Marcos Goldoni, Michelle Unterleider, João Diedrich, Diogo Balbinot, Pablo Rodrigues, Rodolfo Monteiro, Daniel Gomes, José Sampaio, Paulo Fontes, and Fábio Waechter Copyright © 2015 Uirá Teixeira et al. All rights reserved. Surgical Treatment of Renal Fibromuscular Dysplasia in a Young Child Thu, 21 May 2015 15:57:30 +0000 During a routine checkup in a 10-year-old male with Attention-Deficit Hyperactivity Disorder, blood pressure of 180/120 mmHg was found. Physical examination was completely normal. Ultrasound examination showed poststenotic dilatation of the left renal artery which was confirmed by CT-angiography showing a short, high grade stenosis of the left renal artery. Percutaneous Transluminal Angioplasty of the stenosis was not successful and therefore the stenosis was excised with reimplantation of the renal artery in the aorta. Pathological examination of the excised segment showed media-type Fibromuscular Dysplasia (FMD). Six years after surgery, the kidney is completely normal regarding size and function. There are no signs of restenosis of the left renal artery. Nevertheless, the hypertension remained although less severe and requiring less medication. Arjan W. J. Hoksbergen, Lennaert Renwarin, and Willem Wisselink Copyright © 2015 Arjan W. J. Hoksbergen et al. All rights reserved. A Case Report and Review of the Literature of Adult Gastric Duplication Cyst Thu, 21 May 2015 13:41:36 +0000 Gastrointestinal (GI) duplication cysts are a rare congenital disease. They may involve any level of the alimentary tract, but they most commonly involve the ileum, esophagus, and jejunum. Gastric duplication cysts represent approximately 4–8% of GI duplication cysts, the majority of which present in early childhood. We present a rare case of adult gastric duplication cyst in a 25-year-old female found to have abdominal mass on computed tomography imaging. There are several potential methods to diagnose gastric duplication cyst and treatment of choice is complete surgical resection. Scott Samona and Richard Berri Copyright © 2015 Scott Samona and Richard Berri. All rights reserved. Inguinal Herniation of the Urinary Bladder Presenting as Recurrent Urinary Retention Sun, 17 May 2015 12:07:59 +0000 Herniation of the urinary bladder into the inguinal canal is an uncommon finding, observed in 0.5–4% of inguinal hernias (Curry (2000)). It is usually associated with other conditions that increase intra-abdominal pressure such as bladder neck obstruction due to prostatic hypertrophy. Consequently, in men, it is usually associated with some degree of urinary retention. We present a 42-year-old man in whom herniation of the urinary bladder was the cause of urinary retention, and not vice versa. The patient was on tumor necrosis factor alpha antagonist (TNFA) (Etanercept) for severe Ankylosing spondylitis. Initially, the urinary retention was thought to be a side effect of the medication, but after the drug was discontinued, urinary retention persisted. CT and MRI demonstrated huge herniation of the urinary bladder into the inguinal canal. Immediately after the hernia was repaired, bladder function was restored. TNF treatment was restarted, and no further urinary symptoms were observed in the next two years of follow-up. In this case, the primary illness and its treatment were distracting barriers to early diagnosis and treatment. In younger patients with a large hernia who develop unexpected urinary retention, herniation of the urinary bladder should be highly considered in the differential diagnosis. Amit Frenkel, Aviel Roy-Shapira, Ilan Shelef, Gadi Shaked, Evgeni Brotfain, Leonid Koyfman, Abraham Borer, and Moti Klein Copyright © 2015 Amit Frenkel et al. All rights reserved. Reversed Intestinal Rotation Presented as Bowel Obstruction in a Pregnant Woman Sun, 17 May 2015 06:54:27 +0000 A rare case of complete large bowel obstruction in a pregnant woman, without previous surgical history, due to previously undiagnosed reversed intestinal rotation is presented. The young woman was admitted with progressive nausea and vomiting which did not respond to conventional therapy. Her plain abdominal film revealed signs of small bowel obstruction. On laparotomy, her transverse colon was found to be located beneath the root of small bowel mesentery and completely obstructed by congenital fibrous bands. Postoperative recovery was unremarkable. Surgery for this unusual developmental anomaly is discussed. David Aranovich and Ilan Schrier Copyright © 2015 David Aranovich and Ilan Schrier. All rights reserved. When Operating on Dead People Saves Lives: Benefits of Surgical Organ Donor Intensivists Mon, 11 May 2015 13:35:31 +0000 Solid organ transplantation has emerged as a life-saving treatment for many patients suffering from end-stage organ failure. Organs have been successfully recovered after a variety of aggressive interventions. We propose that decompressive laparotomy, when clinically indicated, should be considered in the aggressive resuscitation of potential organ donors. A thorough literature review examining aggressive interventions on potential organ donors was conducted after experience with a unique case at this institution. Articles were reviewed for the types of interventions performed as well as the time frame in relation to organ donation. In our case, several ethical issues were raised when considering decompressive laparotomy in a patient pronounced dead by neurologic criteria. We propose that having a surgical intensivist involved in the management of potential donors will further increase the salvage rate, as more invasive resuscitation options are possible. Kristin Long, Cynthia Talley, Rebecca B. Yarrison, and Andrew Bernard Copyright © 2015 Kristin Long et al. All rights reserved. A Pancreatic Fistula after the Laparoscopic Sleeve Gastrectomy Mon, 11 May 2015 12:53:14 +0000 Laparoscopic sleeve gastrectomy (LSG) is a popular surgical weight-loss procedure in the treatment of morbid obesity. There are some complications regarding this procedure in the literature. This report presents a pancreatic fistula (PF) case, which has not been previously seen. Gökhan Selçuk Özbalcı, Ayfer Kamalı Polat, İsmail Alper Tarım, Murat Derebey, Mehmet Selim Nural, Volkan Tümentemur, and Ufuk Karabacak Copyright © 2015 Gökhan Selçuk Özbalcı et al. All rights reserved. Surgical Tips in Frozen Abdomen Management: Application of Coliseum Technique Sun, 10 May 2015 11:43:59 +0000 Wound dehiscence is a serious postoperative complication, with an incidence of 0.5–3% after primary closure of a laparotomy incision, and represents an acute mechanical failure of wound healing. Relatively recently the concept of “intentional open abdomen” was described and both clinical entities share common pathophysiological and clinical pathways (“postoperative open abdominal wall”). Although early reconstruction is the target, a significant proportion of patients will develop adhesions between abdominal viscera and the anterolateral abdominal wall, a condition widely recognized as “frozen abdomen,” where delayed wound closure appears as the only realistic alternative. We report our experience with a patient who presented with frozen abdomen after wound dehiscence due to surgical site infection and application of the “Coliseum technique” for its definitive surgical management. This novel technique represents an innovative alternative to abdominal exploration, for cases of “malignant” frozen abdomen due to peritoneal carcinomatosis. Lifting the edges of the surgical wound upwards and suspending them under traction by threads from a retractor positioned above the abdomen facilitates approach to the peritoneal cavity, optimizes exposure of intra-abdominal organs, and prevents operative injury to the innervation and blood supply of abdominal wall musculature, a crucial step for subsequent hernia repair. Ioannis D. Kyriazanos, Dimitrios K. Manatakis, Nikolaos Stamos, and Christos Stoidis Copyright © 2015 Ioannis D. Kyriazanos et al. All rights reserved. Late Onset Remnant Gastric Cancer with Afferent Loop Syndrome 47 Years after Billroth II Surgery Sun, 10 May 2015 11:25:56 +0000 Remnant gastric cancer is a rare clinical entity. Herein we describe a patient with remnant gastric cancer that presented with afferent loop syndrome 47 years after Billroth II surgery. Symptoms of serious bilious vomiting were an indication to perform early endoscopic diagnosis, followed by complete gastric resection. In particular, patients that have undergone surgery due to benign indications should be examined endoscopically, even a long time after initial surgery. Memduh şahin, Bahattin Ozlu, Kivilcim Eren Erdogan, and Tahsin Colak Copyright © 2015 Memduh şahin et al. All rights reserved. An Unusual Neck Mass: A Case of a Parathyroid Cyst and Review of the Literature Thu, 07 May 2015 09:51:33 +0000 Parathyroid cysts (PC) are an unusual cause of neck swellings. The majority are nonfunctioning and prove to be a diagnostic challenge given their nonspecific physical and radiological characteristics. This is compounded by their rare occurrence, leading them to be overlooked in the differential diagnosis of neck lumps. Imaging techniques fail to determine the origin of these lesions, but a preoperative diagnosis can be achieved by fine-needle aspiration and measurement of cystic fluid C-terminal parathyroid hormone levels. Treatment of nonfunctioning cysts remains controversial and includes needle aspiration, injection of sclerosant, or surgical excision. We present a case of a 44-year-old female presenting with an asymptomatic anterior neck swelling, diagnosed postoperatively as a parathyroid cyst. Anand Goomany, Amy Rafferty, and Ian Smith Copyright © 2015 Anand Goomany et al. All rights reserved. An Unusual Presentation of a Posterior Mediastinal Schwannoma Associated with Traumatic Hemothorax Thu, 07 May 2015 09:51:01 +0000 Schwannomas of the thoracic cavity are typically an asymptomatic, benign neurogenic neoplasm of the posterior mediastinum. In this case, we present a traumatic hemothorax as the initial presentation for a previously undiscovered mediastinal mass. The patient presented with shortness of breath and right-sided chest pain after being struck in the chest with a soccer ball. An operative exploration was pursued due to persistent hemothorax with hemodynamic instability despite resuscitation and adequate thoracostomy tube placement. The intraoperative etiology of bleeding was discovered to be traumatic fracture of a large hypervascular posterior mediastinal schwannoma. Surgical resection is the treatment of choice for these tumors. Specific serological markers do not exist for this tumor, and radiographic findings can be variable, so tissue diagnosis is of importance in differentiating benign from malignant schwannomas, as well as other posterior mediastinal tumors. However, most patients have excellent survival following complete resection. Ruchi Amin and Brett H. Waibel Copyright © 2015 Ruchi Amin and Brett H. Waibel. All rights reserved. Fatal Necrotizing Fasciitis following Episiotomy Thu, 07 May 2015 09:02:09 +0000 Introduction. Necrotizing fasciitis is an uncommon condition in general practice but one that provokes serious morbidity. It is characterized by widespread fascial necrosis with relative sparing of skin and underlying muscle. Herein, we report a fatal case of necrotizing fasciitis in a young healthy woman after episiotomy. Case Report. A 17-year-old primigravida underwent a vaginal delivery with mediolateral episiotomy. Necrotizing fasciitis was diagnosed on the 5th postpartum day, when the patient was referred to our tertiary care medical center. Surgical debridement was initiated together with antibiotics and followed by hyperbaric oxygen therapy. The patient died due to septic shock after 16 hours from the referral. Conclusion. Delay of diagnosis and consequently the surgical debridement were most likely the reasons for maternal death. In puerperal period, a physician must consider necrotizing fasciitis as a possible diagnosis in any local sings of infection especially when accompanied by fever and/or tenderness. Early diagnosis is the key for low mortality and morbidity. Faris Almarzouqi, Gerrit Grieb, Christian Klink, Dirk Bauerschlag, Paul C. Fuchs, Ziyad Alharbi, Marketa Vasku, and Norbert Pallua Copyright © 2015 Faris Almarzouqi et al. All rights reserved. Laparoscopy as a Diagnostic and Definitive Therapeutic Tool in Cases of Inflamed Simple Lymphatic Cysts of the Mesentery Wed, 06 May 2015 09:47:46 +0000 Mesenteric cysts are rare benign abdominal tumors. These cysts, especially those of lymphatic origin, very rarely become inflamed. The diagnosis of inflamed lymphatic cysts of the mesentery may be difficult. We herein report two cases of inflamed simple lymphatic cysts of the mesentery definitively diagnosed and excised by laparoscopy. Abdelrahman Abdelaal, Ibnouf Sulieman, Zia Aftab, Ayman Ahmed, Saif Al-Mudares, Mohannad Al Tarakji, Ahmad Almuzrakchi, Adriana Toro, and Isidoro Di Carlo Copyright © 2015 Abdelrahman Abdelaal et al. All rights reserved. Left Diaphragmatic Herniation following Orthotopic Liver Transplantation in an Adult Mon, 04 May 2015 06:20:12 +0000 Diaphragmatic herniation is an uncommon complication in the postquirurgic follow of the liver transplant. The associated symptoms are unspecific and may not suggest the correct diagnosis. It may explain why in many patients the diagnosis remains unmade or it is made only after a long interval of time. We present the case of a fifty-seven-year-old male who required an orthotopic liver transplant in 2010 due to a trifocal hepatocarcinoma. In postoperatory follow-up the patient showed alimentary regurgitation, vomiting, and dyspepsia. The diagnosis was made by an oesophagogastroduodenal transit with barium and an abdominal CT scan that showed a left diaphragmatic herniation with the gastric fundus into the thorax. With these findings we decided to perform a programmed surgery. After takedown of adhesions and replacement of the stomach into the upper abdomen, the palm-sized diaphragmatic opening was closed with a synthetic material. The patient’s condition remained stable throughout the entire operation. The postoperative course was uneventful and he was discharged at the fifth day after surgery with a normal digestive intake. In a 12-month follow-up the patient shows no symptoms. Adriá Rosat, Ayaya Alonso, Javier Padilla, Pablo Sanz, M. Aránzazu Varona, Javier Méndiz, Enrique Moneva, and Manuel Barrera Copyright © 2015 Adriá Rosat et al. All rights reserved. Early Identification of Traumatic Durotomy Associated with Atlantooccipital Dislocation May Prevent Retropharyngeal Pseudomeningocele Development Thu, 30 Apr 2015 18:43:38 +0000 Atlantooccipital dislocation can be complicated by a traumatic durotomy that may lead to the rare development of a retropharyngeal pseudomeningocele. To our knowledge this has been reported only five times previously. We present the case of a 60-year-old man involved in a motor vehicle accident who suffered an atlantooccipital dislocation and C5-C6 three-column injury. A unique MRI image of a defect in the ventral dura posterior to C2 was appreciated. He underwent occiput to T2 internal fixation and arthrodesis. During surgery, CSF egress was seen caudal to the right C2 nerve root. A DuraMatrix onlay patch reinforced with DuraSeal was placed to stop the CSF leak. A lumbar subarachnoid drain was also placed. The patient made a satisfactory recovery with residual mild weakness of his right upper extremity. In this report, we demonstrate that careful MRI review can reveal a ventral durotomy in a traumatic atlantooccipital dislocation and, if discovered, effective treatment including a lumbar subarachnoid drain for CSF diversion may prevent progression to a retropharyngeal pseudomeningocele. The literature on this rare presentation and associated durotomy is provided. Robert S. Qiu, Mina G. Safain, Max Shutran, Alejandra M. Hernandez, Steven W. Hwang, and Ron I. Riesenburger Copyright © 2015 Robert S. Qiu et al. All rights reserved. Intramucosal Carcinoma of the Appendix Arising from Traditional Serrated Adenoma Wed, 22 Apr 2015 09:04:09 +0000 Introduction. Serrated adenomas of the appendix are rare and usually found during appendectomy or autopsies. The preoperative diagnosis of these tumors is uncommon. This report describes a case of a sessile serrated adenoma located in the appendix diagnosed by a screening colonoscopy and successfully treated by laparoscopic removal. Presentation of Case. An 86-year-old woman underwent colonoscopy to investigate the cause of her diarrhea, weight loss, and anemia. During the colonoscopy, an expansive and vegetating mass of 1.5 cm in diameter was identified, protruding through the appendicular ostium with slightly lateral growth to the cecum. The patient was referred for laparoscopic surgical resection due to the location of the lesion, which did not allow its removal by colonoscopy. She underwent wedge removal of the cecum without complications and was discharged on the 4th postoperative day. Histopathological examination showed the presence of a sessile serrated adenoma with an intramucosal adenocarcinoma. The patient is currently well one year after surgery, without endoscopic signs of relapse. Conclusion. Despite serrated adenomas being a possibility rarely described in appendix it should be recognized and properly treated because it is presenting a higher risk of cancer. Carlos Augusto Real Martinez, Júlia Cutovoi, Debora Helena Rossi, Luciana Rodrigues Meirelles, Maria de Lourdes Setsuko Ayrizono, Raquel Franco Leal, and Cláudio Saddy Rodrigues Coy Copyright © 2015 Carlos Augusto Real Martinez et al. All rights reserved. Spectrum of Surgical Presentation of Eosinophilic Enteritis Thu, 16 Apr 2015 08:09:01 +0000 Eosinophilic enteritis is a rare disorder presenting mostly with diarrhea, malabsorption, abdominal pain, weight loss, and hypersensitivity. Surgical manifestation of eosinophilic gastrointestinal disorders depends on the site and extent of involvement. In our case series of four patients two of them had ileocaecal masses with recurrent subacute intestinal obstruction with past history of intake of antitubercular drugs for 9 months. On histopathological examination both of them proved to have eosinophilic enterocolitis. Thus it is a clinical dilemma to differentiate between these two conditions. The other two patients presented as acute abdomen with perforation and intussusception. All four patients were treated surgically. Postoperatively they recovered well with no symptoms on one year follow-up. In Indian setup tuberculosis being rampant there may be under reporting or wrongly diagnosed cases of eosinophilic enteritis. Thus a strong clinical suspicion and awareness of this clinical entity are essential among surgical community. Spoorthy Sudhakar Shetty and Charan Kishor Shetty Copyright © 2015 Spoorthy Sudhakar Shetty and Charan Kishor Shetty. All rights reserved. Robotic Total Pelvic Exenteration with Laparoscopic Rectus Flap: Initial Experience Thu, 16 Apr 2015 07:29:20 +0000 Total pelvic exenteration is a highly morbid procedure performed for locally advanced pelvic malignancies. We describe our experience with three patients who underwent robotic total pelvic exenteration with laparoscopic rectus flap and compare perioperative characteristics to our open experience. Demographic, tumor, operative, and perioperative factors were examined with descriptive statistics reported. Mean operative times were similar between the two groups. When compared to open total pelvic exenteration cases , median estimated blood loss, ICU stay, and hospital stay were all decreased. These data show robotic pelvic exenteration with laparoscopic rectus flap is technically feasible. The surgery was well tolerated with low blood loss and comparable operative times to the open surgery. Further study is needed to confirm the oncologic efficacy and the suggested improvement in surgical morbidity. Brian R. Winters, Gary N. Mann, Otway Louie, and Jonathan L. Wright Copyright © 2015 Brian R. Winters et al. All rights reserved. Solitary Plasmacytoma of the Cecum and the Ascending Colon: Surgical Resection as a Treatment Modality Sun, 12 Apr 2015 12:41:10 +0000 Colonic solitary plasmacytoma is a rare disease, with few reports occurring in the literature. Solitary plasmacytoma is defined as a plasma cell tumour with no evidence of bone marrow infiltration. Plasmacytoma can present as a solitary tumour in bone or in other parts of the body. The gastrointestinal tract is rarely the site of the disease. We report on the case of a 51-year-old man presenting with a colonic symptomatic mass with unclear biopsy results. A resected specimen showed a solitary plasmacytoma. Surgical resection was an adequate treatment modality in this case. Endoscopic resection, radiotherapy, and chemotherapy are also preferred treatments in selected gastrointestinal plasmacytoma cases. Tahsin Dalgic, Erdal Birol Bostanci, Tebessum Cakir, Ilter Ozer, Murat Ulas, Gulden Aydog, and Musa Akoglu Copyright © 2015 Tahsin Dalgic et al. All rights reserved. Discovery of Intra-Abdominal Hemorrhage during Hernioplasty in a Patient Taking Rivaroxaban Sun, 12 Apr 2015 09:39:56 +0000 We discuss the first ever case of rivaroxaban causing major intra-abdominal hemorrhage found in a patient during emergency hernioplasty. The source of bleeding was not identified either intra- or postoperatively. This is on a background of treatment for deep vein thrombosis (DVT) with rivaroxaban, a complication that resulted from a total knee arthroplasty performed four weeks prior. Rivaroxaban is a new generation of anticoagulants that directly inhibits factor Xa and is used for DVT treatment in major orthopaedic surgery. Here we discuss the major side effects of rivaroxaban, namely, the increased risk of major bleeding as well as the irreversibility of this anticoagulant, should such bleeding occur. We advise caution in the use of rivaroxaban even in patients that are at low risk of bleeding given the discovery of hemorrhage as presented in this case. Harry Chow and Michael K. Ng Copyright © 2015 Harry Chow and Michael K. Ng. All rights reserved. Diagnosis and Management of Perforated Duodenal Ulcers following Roux-En-Y Gastric Bypass: A Report of Two Cases and a Review of the Literature Wed, 08 Apr 2015 11:32:11 +0000 Perforated duodenal ulcers are rare complications seen after roux-en-Y gastric bypass (RYGP). They often present as a diagnostic dilemma as they rarely present with pneumoperitoneum on radiologic evaluation. There is no consensus as to the pathophysiology of these ulcers; however expeditious treatment is necessary. We present two patients with perforated duodenal ulcers and a distant history of RYGP who were successfully treated. Their individual surgical management is discussed as well as a literature review. We conclude that, in patients who present with acute abdominal pain and a history of RYGB, perforated ulcer needs to be very high in the differential diagnosis even in the absence of pneumoperitoneum. In these patients an early surgical exploration is paramount to help diagnose and treat these patients. Mazen E. Iskandar, Fiona M. Chory, Elliot R. Goodman, and Burton G. Surick Copyright © 2015 Mazen E. Iskandar et al. All rights reserved. Esophagojejunal Anastomosis Fistula, Distal Esophageal Stenosis, and Metalic Stent Migration after Total Gastrectomy Mon, 06 Apr 2015 11:48:50 +0000 Esophagojejunal anastomosis fistula is the main complication after a total gastrectomy. To avoid a complex procedure on friable inflamed perianastomotic tissues, a coated self-expandable stent is mounted at the site of the anastomotic leak. A complication of stenting procedure is that it might lead to distal esophageal stenosis. However, another frequently encountered complication of stenting is stent migration, which is treated nonsurgically. When the migrated stent creates life threatening complications, surgical removal is indicated. We present a case of a 67-year-old male patient who was treated at our facility for a gastric adenocarcinoma which developed, postoperatively, an esophagojejunostomy fistula, a distal esophageal stenosis, and a metallic coated self-expandable stent migration. To our knowledge, this is the first reported case of an esophagojejunostomy fistula combined with a distal esophageal stenosis as well as with a metallic coated self-expandable stent migration. Nadim Al Hajjar, Calin Popa, Tareg Al-Momani, Simona Margarit, Florin Graur, and Marcel Tantau Copyright © 2015 Nadim Al Hajjar et al. All rights reserved. Unexpected Anal Squamous Cells Carcinoma after Open Hemorrhoidectomy Thu, 02 Apr 2015 14:21:12 +0000 We report a case of unexpected anal squamous cells carcinoma found in hemorrhoidectomy specimen. The patient had a 3-year history of prolapsing hemorrhoids. A prolapsing hemorrhoid was present at eleven o’clock in lithotomy. Milligan-Morgan was performed and gross examination of the specimen was unremarkable. Histopathologic evaluation showed noninvasive squamous cells carcinoma. The present case report evidences the opportunity of routine histopathologic analysis of hemorrhoidal specimens particularly in case of long-standing prolapse. Questions arise in the option of those techniques where no specimens are collected or tissue is excised far from deceased area. Navarra Luca, Abruzzese Valentina, Sista Federico, and Pietroletti Renato Copyright © 2015 Navarra Luca et al. All rights reserved.