Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . 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. 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. 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. 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. 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.