Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . 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. Conservative Management of Large Rectosigmoid Perforation under Peritoneal Reflection: Case Report and Review of the Literature Tue, 31 Mar 2015 16:46:04 +0000 Colonoscopy is accepted as the best method in diagnosis, treatment, and follow-up of colorectal diseases. As the amount of the usage of diagnostic and therapeutic colonoscopy rises, iatrogenic complications are more likely to be seen. The most important complications are perforations and bleeding. Whereas perforation is a complication that is seen rarely, because of the high ratio of morbidity and mortality, it should be analyzed more carefully. There is not a common view on the optimal treatment of colonoscopic perforation. Most cases require urgent surgery, and in some cases the iatrogenic perforation of colon can be managed by conservative methods. In this report, we present a rectosigmoid perforation under peritoneal reflection and conservative management of this case. G. G. Akgul, E. Yenidogan, Z. Ozsoy, I. Okan, H. A. Kayaoglu, S. Tali, and M. Sahin Copyright © 2015 G. G. Akgul et al. All rights reserved. Aggressive Behaviour of Metastatic Melanoma in a Patient with Neurofibromatosis Type 1 Sun, 29 Mar 2015 12:29:09 +0000 Malignant melanoma is a common skin neoplasm bearing poor prognosis when presenting with metastases. Rarely melanoma metastases present without an identifiable primary cutaneous lesion despite exhaustive workup. We describe the case of a solitary lung metastasis in a patient with neurofibromatosis type 1 without an identifiable primary tumour. The rapid progression of this malignant neoplasm that led to the patient’s death within 1 year is described. Robert W. Foley, Robert M. Maweni, Aurelie Fabre, and David G. Healy Copyright © 2015 Robert W. Foley et al. All rights reserved. Multiple Abdominal Cocoons: An Unusual Presentation of Intestinal Obstruction and a Diagnostic Dilemma Sun, 29 Mar 2015 07:51:48 +0000 Sclerosing encapsulating peritonitis (SEP) or abdominal cocoon is a rare acquired condition with an unknown aetiology. It is characterized by encapsulation of the small bowel by a fibrous membrane and can lead to intestinal obstruction. We present the case of a 42-year-old gentleman with a history of hepatitis C, tuberculosis, and previous abdominal surgery, who presented with subacute intestinal obstruction. Surgical exploration of the abdomen revealed that the entire contents were enclosed into three distinct sacs by a dense fibrous membrane. Excision of the sacs was performed followed by adhesiolysis. This is believed to be the first reported case of multiple cocoons within the abdominal cavity. The case is discussed with reference to the literature. Mohammad Zain Sohail, Shumaila Hasan, Benan Dala-Ali, Shahanoor Ali, and M. A. Hashmi Copyright © 2015 Mohammad Zain Sohail et al. All rights reserved. Laparoscopic Resection of an Intra-Abdominal Esophageal Duplication Cyst: A Case Report and Literature Review Thu, 26 Mar 2015 08:01:43 +0000 Duplication of the alimentary tract is a rare congenital malformation that occurs most often in the abdominal region, whereas esophageal duplication cyst develops typically in the thoracic region but occasionally in the neck and abdominal regions. Esophageal duplication cyst is usually diagnosed in early childhood because of symptoms related to bleeding, infection, and displacement of tissue surrounding the lesion. We recently encountered a rare adult case of esophageal duplication cyst in the abdominal esophagus. A 50-year-old man underwent gastroscopy, endoscopic ultrasonography, computed tomography, and magnetic resonance imaging to investigate epigastric pain and dysphagia that started 3 months earlier. Imaging findings suggested esophageal duplication cyst, and the patient underwent laparoscopic resection followed by intraoperative esophagoscopy to reconstruct the esophagus safely and effectively. Histopathological examination of the resected specimen revealed two layers of smooth muscle in the cystic wall, confirming the diagnosis of esophageal duplication cyst. Ikuo Watanobe, Yuzuru Ito, Eigo Akimoto, Yuuki Sekine, Yurie Haruyama, Kota Amemiya, Fumihiro Kawano, Shohei Fujita, Satoshi Omori, Shozo Miyano, Taijiro Kosaka, Michio Machida, Toshiaki Kitabatake, Kuniaki Kojima, Asumi Sakaguchi, Kanako Ogura, and Toshiharu Matsumoto Copyright © 2015 Ikuo Watanobe et al. All rights reserved. Intramyocardial Dissection following Postinfarction Ventricular Wall Rupture Contained by Surrounding Postoperative Adhesions Thu, 19 Mar 2015 13:50:56 +0000 Introduction. Dissection of the myocardium is a rare form of cardiac rupture, caused by a hemorrhagic dissection among the spiral myocardial fibers, its diagnosis is rarely established before the operation or death, and extremely few cases have been reported in the literature and none of these cases seem to have a history of previous cardiac surgery which makes our report unique. Case Presentation. A 61-year-old female patient was admitted into the emergency room with complaints of progressive chest pain for 2 days. She had a history of second time prosthetic aortic valve replacement and was under anticoagulation therapy. She was diagnosed with an acute inferoposterior myocardial infarction and underwent emergency coronary angiography revealing spontaneous recanalization of the right coronary artery. During the follow-up, she developed cardiogenic shock and a new occurring systolic ejection murmur. Transthoracic echocardiography showed a left ventricular free wall rupture; then, she was taken in for emergency surgery. During the operation, a rupture zone and a wide intramyocardial dissecting area were detected. Intraventricular patch repair technic with autologous pericardial patch was used to exclude the ruptured area. Following the warming period, despite adequate hemostasis, hemorrhage around suture lines progressively increased, leading to the patient’s death. Conclusion. Pericardial adhesions might contain left ventricular rupture leading to intramyocardial dissection. Abdulkadir Ercan, Orcun Gurbuz, Gencehan Kumtepe, Hakan Ozkan, Ilker Hasan Karal, Yusuf Velioglu, and Serdar Ener Copyright © 2015 Abdulkadir Ercan et al. All rights reserved. A Primary Retroperitoneal Mucinous Tumor Thu, 19 Mar 2015 07:53:32 +0000 A twenty-five-year-old female presented with a large retroperitoneal mass. Workup included history and physical exam, imaging, biopsy, colonoscopy, and gynecologic exam. After surgical resection, the mass was determined to be a primary retroperitoneal mucinous tumor (PRMT). Clinically and histologically, these tumors are similar pancreatic and ovarian mucinous neoplasms. PRMTs are rare and few case reports have been published. PRMTs are divided into mucinous cystadenomas, mucinous borderline tumors of low malignant potential, and mucinous carcinoma. These tumors have malignant potential so resection is indicated and in some cases adjuvant chemotherapy and/or surveillance imaging. Alicia A. Heelan Gladden, Max Wohlauer, Martine C. McManus, and Csaba Gajdos Copyright © 2015 Alicia A. Heelan Gladden et al. All rights reserved. Retroperitoneal Lymphangioma in an Adult: A Case Report of a Rare Clinical Entity Tue, 17 Mar 2015 11:29:21 +0000 Background. Retroperitoneal lymphangioma is a rare, benign mesodermal tumor arising from the retroperitoneal lymphatics which usually presents in infancy and it is worthy to report a case when it has presented in an adult. After a thorough literature search in English we concluded that less than 200 cases of adult retroperitoneal lymphangioma have been reported so far. Apart from being a rare entity it also presents as a diagnostic dilemma and final diagnosis is often made on surgical exploration. Case Presentation. We report a case of retroperitoneal lymphangioma in a 55-year-old male who presented with abdominal distension and dull aching abdominal pain. Conclusion. Retroperitoneal lymphangiomas are rare tumors of infancy but may also present in adults where they are a diagnostic challenge. Differentiating cystic lymphangiomas from other cystic growths by imaging studies alone are often inconclusive and surgery is frequently required for definitive diagnosis and to ameliorate the symptoms. Mayank Tripathi, Sanjeev Parshad, Rajender Kumar Karwasra, Ashish Gupta, Saket Srivastva, and Ankush Sarwal Copyright © 2015 Mayank Tripathi et al. All rights reserved. Benign Multicystic Peritoneal Mesothelioma: A Rare Tumour of the Abdomen Tue, 17 Mar 2015 08:37:17 +0000 Benign multicystic peritoneal mesothelioma: a rare tumor of the abdomen, is a diagnostic dilemma. This report emphasizes the importance of diagnostic laparoscopy in the diagnosis of the tumour. Soundappan Somasundaram, Monty Khajanchi, Tejas Vaja, Bhushan Jajoo, and Amit Kumar Dey Copyright © 2015 Soundappan Somasundaram et al. All rights reserved. Single-Incision Laparoscopic Surgery for Undiagnosed Small Bowel Obstruction in a Patient without a History of Abdominal Surgery Mon, 16 Mar 2015 08:02:02 +0000 We herein report a 66-year-old female patient who developed an undiagnosed small bowel obstruction without a history of prior abdominal surgery and was successfully treated by single-incision laparoscopic surgery. A small bowel obstruction with unknown cause typically requires some sort of surgical treatment in parallel with a definitive diagnosis. Although open abdominal surgery has been generally performed for the treatment of small bowel obstructions, laparoscopic surgery for small bowel obstructions has been increasing in popularity due to its less invasiveness, including fewer postoperative complications and a shorter hospital stay. As a much less invasive therapeutic strategy, we have performed single-incision laparoscopic surgery for the treatment of an undiagnosed small bowel obstruction. We were able to make a definitive diagnosis after sufficient intra-abdominal inspection and to perform enterotomy through a small umbilical incision. Single-incision laparoscopic surgery appears to be comparable to conventional laparoscopic surgery and provides improved cosmesis, although it is an optional strategy only applicable to selected patients. Noriaki Koizumi, Hiroki Kobayashi, Tsuyoshi Takagi, and Kanehisa Fukumoto Copyright © 2015 Noriaki Koizumi et al. All rights reserved. Surgical Resection for a Second Primary Lung Cancer Originating Close to the Initial Surgical Margin for Lung Squamous Cell Carcinoma Tue, 10 Mar 2015 11:23:28 +0000 Few reports have described surgical resection for second primary lung cancers originating close to the initial surgical margin for lung cancer. A 64-year-old man had undergone left segmentectomy with lymph node dissection for small peripheral squamous cell lung cancer using video-assisted thoracic surgery, with pathology confirming a small tumor 12 mm in diameter identified about 3 cm from the surgical margin. Eighteen months after initial surgery, computed tomography revealed a 30 mm pulmonary nodule close to the initial surgical margin in the residual left upper lobe and the serum level of carcinoembryonic antigen was found to be increased. Local recurrence on the staple-line of the surgical margin was suspected, and completion left upper lobectomy was performed. Histological examination identified not only a squamous cell carcinoma component but also a small cell carcinoma component. The immunohistochemical staining pattern of the second tumor differed from that of the initial resected lung squamous cell carcinoma. The final pathological diagnosis was a second primary tumor with mixed small cell carcinoma and squamous cell carcinoma histology. Seijiro Sato, Terumoto Koike, Takehisa Hashimoto, and Masanori Tsuchida Copyright © 2015 Seijiro Sato et al. All rights reserved. A Rare Cause of Colonic Obstruction “Colonic Intussusception”: Report of Two Cases Tue, 10 Mar 2015 06:46:01 +0000 Colocolic intussusceptions are rare clinical entities in adults and almost always caused by a leading lesion which often warrants resection. Mostly being malignant, the leading lesions are rarely benign lesions where intraluminal lipomas are the most frequent among them. Most adult intussusceptions require surgical resection owing to two major reasons: common presence of a leading lesion and significantly high risk of malignancy—reaching as high as 65% regardless of the anatomic site—of the leading lesion. Resection of the affected segment is usually the treatment of choice, since preoperative diagnosis of the lesion is usually ineffective and most leading lesions are malignant. This paper represents two cases of adult colocolic intussusception caused by intraluminal lipomas with a brief review of the literature. Tayfun Yoldas, Avni Can Karaca, Safak Ozturk, Mutlu Unver, Cemil Calıskan, and Mustafa Ali Korkut Copyright © 2015 Tayfun Yoldas et al. All rights reserved. Small Bowel Obstruction Mimicking Acute ST-Elevation Myocardial Infarction Sun, 08 Mar 2015 08:35:28 +0000 We present a case of a 42-year-old female who presented to our institution with a small bowel obstruction and had emergent surgical decompression. Thirteen days postoperatively, the patient became tachycardic and had worsening epigastric pain. Electrocardiogram showed significant ST-segment elevations in leads II, III, aVF, and V3–V6, suggesting the possibility of acute inferolateral myocardial infarction. Subsequent workup revealed the cause of the ST-elevations to be due to recurrent small bowel obstruction. Although intra-abdominal causes of ST-elevation have been reported, our case may be the first to be associated with small bowel obstruction. Kunal Patel, Nai-Lun Chang, Oleg Shulik, Joseph DePasquale, and Fayez Shamoon Copyright © 2015 Kunal Patel et al. All rights reserved. Limy Bile Syndrome Complicated with Primary Hyperparathyroidism Tue, 03 Mar 2015 15:35:46 +0000 Limy bile is a relatively rare condition, in which a radiopaque material is visible in the gallbladder on plain radiography or computerized tomography. Cases of complicated hyperparathyroidism are extremely rare. We report a patient with right upper quadrant and epigastric pain and extremity weakness in whom abdominal tomography showed limy bile in the gallbladder and laboratory values showed high levels of serum calcium and parathormone. Yavuz Savas Koca, Tugba Koca, and Ibrahim Barut Copyright © 2015 Yavuz Savas Koca et al. All rights reserved. Congenital Agenesis of the Internal Jugular Vein: An Extremely Rare Anomaly Tue, 03 Mar 2015 11:35:11 +0000 Vascular anomalies of major venous vessels are rarely seen. Moreover, congenital absence of internal jugular vein is extremely uncommon. In our case, a female patient presented with primary unknown left cervical mass. Cervical ultrasonography demonstrated absence of right internal jugular vein. In addition, computed tomography and dynamic magnetic resonance imaging scans confirmed this diagnosis. Compensatory left internal jugular vein enlargement mimicked sort of cervical mass. Venous magnetic resonance imaging images revealed the absence of right internal jugular vein with compensatory left internal jugular vein dominance. In the literature, the agenesis of IJV was mentioned in a case with concomitant multiple problems. Here, an asymptomatic case is reported with an incident diagnosis. No interventions were planned upon the patient's request. It should be kept in mind that any kind of anomalies can be seen during venous access and neck surgery. Oguz Kayiran, Caglar Calli, Abdulkadir Emre, and Fatih Kemal Soy Copyright © 2015 Oguz Kayiran et al. All rights reserved. Retroperitoneal Perforation of the Appendix Presenting as a Right Thigh Abscess Sun, 01 Mar 2015 12:21:41 +0000 A rare case of a retroperitoneal rupture of the appendix is being reported here. A 53-year-old male presented to us with a right sided thigh abscess. There were not any abdominal complaints at presentation. There was continuous discharge after incision and drainage from the thigh. Isolation, in culture, of an enteric bacterium from the pus prompted an evaluation of the gastrointestinal tract as a possible source. An MRI scan revealed fluid tracking from the right paracolic gutter over the psoas sheath and paraspinal muscle into the thigh. A CT scan revealed the perforation at the base of the appendix into the retroperitoneum. At laparotomy the above findings were confirmed. A segmental ileocaecal resection was done. The patient made an uneventful recovery. The absence of abdominal symptoms at presentation leads to delay in diagnosis in such cases. Nonresolving thigh and groin abscesses should lead to the evaluation of the gastrointestinal tract as origin. Diagnostic clues may also be provided by culture reports what as happened in this case. Aditya J. Nanavati, Sanjay Nagral, and Nitin Borle Copyright © 2015 Aditya J. Nanavati et al. All rights reserved. A Case of Ruptured Aortic Arch Aneurysm Successfully Treated by Thoracic Endovascular Aneurysm Repair with Chimney Graft Sat, 28 Feb 2015 07:54:48 +0000 We report the case of aortic arch aneurysm rupture treated successfully with thoracic endovascular aneurysm repair (TEVAR) accompanied by aortic arch debranching using the chimney graft technique. A 94-year-old man was transported to the hospital after complaining of chest pain for one day. Contrast-enhanced computed tomographic (CT) images revealed an aortic arch aneurysm rupture. Considering the patient’s age and postoperative activities of daily living, TEVAR was used. In order to place an indwelling stent graft from the ascending aorta to the periphery, the chimney graft technique was used to debranch the brachiocephalic artery. Hemodynamics was stabilized postsurgically. Plain CT performed 20 days postoperatively confirmed that the intrathoracic hematoma had decreased in size. Although respiratory failure was persistent, there were improvements and the patient was extubated 34 days postoperatively and discharged from the intensive care unit 37 days postoperatively. On postoperative day 75, he was discharged from the hospital to an elder care facility. Few reports have focused on stent grafting for treating aortic arch aneurysm rupture. TEVAR using the chimney graft technique could be an effective treatment option for patients with a decreased ability to tolerate surgery. Yohei Kawatani, Yujiro Hayashi, Yujiro Ito, Hirotsugu Kurobe, Yoshitsugu Nakamura, Yuji Suda, and Takaki Hori Copyright © 2015 Yohei Kawatani et al. All rights reserved. Laparoscopic Excision of Coexisting Left Tubal and Right Pseudotubal Pregnancy after Conservative Management of Previous Ectopic Pregnancy with Methotrexate: An Unusual Clinical Entity Tue, 24 Feb 2015 11:14:21 +0000 Tubal pregnancy concerns 97% of all ectopic pregnancies. Treatment can be either surgical (salpingostomy or salpingectomy) or medical (methotrexate administration). We present a case of a pseudotubal pregnancy after methotrexate treatment of a previous ectopic pregnancy. A37-year-old woman was diagnosed with ectopic pregnancy in the left Fallopian tube. A year ago, she had an ectopic pregnancy in the right tube, which was successfully treated with intramuscular methotrexate. During laparoscopy, two tubal masses were revealed, one in each Fallopian tube, and bilateral salpingectomy was performed. Histological analysis confirmed tubal pregnancy in the left Fallopian tube and presence of endosalpingitis in the right tube with no signs of chorionic villi. The optimal management of such cases has not yet been clarified. However, evaluation of tubal patency after a medically treated ectopic pregnancy would permit proper counsel of the patient on her fertility options, in order to choose the appropriate method of conception to achieve and accomplish a future pregnancy. Panayotis Xiromeritis, Chrysoula Margioula-Siarkou, Dimosthenis Miliaras, and Ioannis Kalogiannidis Copyright © 2015 Panayotis Xiromeritis et al. All rights reserved. A Lethal Complication after Transarterial Chemoembolization with Drug-Eluting Beads for Hepatocellular Carcinoma Mon, 23 Feb 2015 09:21:33 +0000 Background. The current standard of care for patients with large or multinodular noninvasive hepatocellular carcinoma is conventional transarterial chemoembolization (TACE). TACE may also be performed with drug-eluting beads, but serious complications of this procedure have been reported. Methods. Aim of this report is to present a patient affected by multifocal HCC who underwent TACE with drug-eluting bead (DEB-TACE). Results. Following the procedure the patient developed a hepatic abscess and biliobronchial fistula resulting in adult respiratory distress syndrome and death. Conclusion. We speculate that DEB-TACE has a prolonged effect on the tumor and the surrounding liver, resulting in progressive enlargement of the necrotic area. This activity that can extend to the surrounding healthy hepatic tissues may continue indefinitely. Adriana Toro, Gaetano Bertino, Maria Concetta Arcerito, Maurizio Mannnino, Annalisa Ardiri, Domenico Patane’, and Isidoro Di Carlo Copyright © 2015 Adriana Toro et al. All rights reserved. Delayed Total Breast Reconstruction with Brava Sun, 22 Feb 2015 17:01:05 +0000 Several surgical procedures exist in regard to reconstruction of the breast after mastectomy. The use of Brava a vacuum-based external soft-tissue expansion system in combination with fat transplantation is a less documented but viable option in treating patients after mastectomy. We share our experience in treating a 57-year-old patient with mastectomy, describing the complications and pitfalls we experienced when using the Brava system in combination with fat transplantation. Niels Hammer-Hansen, Thomas Bo Jensen, and Tine Engberg Damsgaard Copyright © 2015 Niels Hammer-Hansen et al. All rights reserved. Heterotopic Pancreas within the Proximal Hepatic Duct, Containing Intraductal Papillary Mucinous Neoplasm Sun, 22 Feb 2015 09:48:19 +0000 We report a unique first case of benign heterotopic pancreas arising within the proximal hepatic bile duct, containing a focus of intraductal papillary mucinous neoplasm (IPMN). The condition was diagnosed on pathological explant after left hepatic lobectomy with total extrahepatic bile duct excision. Alistair J. Lawrence, Aducio Thiessen, Amy Morse, and A. M. James Shapiro Copyright © 2015 Alistair J. Lawrence et al. All rights reserved. Hepatocellular Carcinoma with Osteoclast-Like Giant Cells: Report of the Seventh Case in the Literature Sun, 22 Feb 2015 06:09:26 +0000 Hepatocellular carcinoma with osteoclast-like giant cells is extremely rare, and only six cases have been previously reported. Its histogenesis is at the moment controversial. The authors report a case of hepatocellular carcinoma with osteoclast-like giant cells found in a 74-year-old woman. The patient came with a dull pain in the right upper abdominal quadrants due to a liver neoplasm described at CT scan. A wedge resection of the fifth hepatic segment with appendectomy, omentectomy, and debulking of the major peritoneal implants was performed. Histologically, the diagnosis of hepatocellular carcinoma with high grade differentiation associated with giant osteoclast-like cells was done without any evidence of hepatitis or cirrhosis in the surrounding hepatic parenchyma. Immunohistochemistry was positive for CD10 and CD68 and in situ hybridization revealed the expression of receptor activator of nuclear factor-kappa B (RANK) in the giant cells and receptor activator of nuclear factor-kappa B ligand (RANKL) in the tumor cells. Lorenzo Dioscoridi, Damiano Bisogni, and Giancarlo Freschi Copyright © 2015 Lorenzo Dioscoridi et al. All rights reserved. Morel-Lavallée Lesion: Report of a Case of Unknown Mechanism Tue, 17 Feb 2015 11:27:25 +0000 Morel-Lavallée lesions are cystic lesions occurring between the subcutaneous tissue and the underlying layer of a fascia. The most frequent mechanism of occurrence is posttraumatic, usually after degloving injuries. The chain of events leading to the occurrence of this lesion is the formation of a potential space between the subcutaneous tissue and the firmly attached deep fascia, which in turn fills with blood and/or lymph and/or necrotic fat, secondary to disruption of the capillaries. We present a case of a 74-year-old male patient with a cystic lesion of the lateral surface of his left thigh increasing in size over a period of six months. Despite the meticulous history acquisition, we were unable to reveal any alleged mechanism of injury of the area. The patient underwent an MRI which revealed an ovoid cyst. The patient underwent surgical excision of the cyst. The pathology examination revealed a simple cyst, lined by a fibrous capsule and filled with serosanguineous fluid, thus confirming the diagnosis. The patient made a full recovery and since has been asymptomatic. Elissaios Kontis, Antonios Vezakis, Vasiliki Psychogiou, Panagiotis Kalogeropoulos, Andreas Polydorou, and Georgios Fragulidis Copyright © 2015 Elissaios Kontis et al. All rights reserved. Pure Squamous Cell Carcinoma of the Duodenum Mon, 16 Feb 2015 11:24:07 +0000 Primary carcinomas of the small intestine are extremely rare neoplasms. Most of these are adenocarcinomas. Primary squamous cell carcinoma (SCC) of small intestine is exceptionally rare with only occasional case reports in the literature. We report here a surgically treated patient with squamous cell carcinoma arising from duodenal diverticula in the third part of the duodenum. Muharrem Battal, Ozgur Bostancı, Tulay Basak, Kinyas Kartal, and Feza Ekiz Copyright © 2015 Muharrem Battal et al. All rights reserved.