Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2015 , Hindawi Publishing Corporation . All rights reserved. Lornoxicam Side Effects May Lead to Surgical Mismanagement, in Case of Postoperative Intra-Abdominal Collection: A Case Report and Literature Review Mon, 31 Aug 2015 05:51:22 +0000 Postoperative collection is a known complication of abdominal surgery, especially after major surgery; however, minor surgical procedures may also be associated with this phenomenon. Utilization of nonsteroidal anti-inflammatory drugs, such as lornoxicam, and the adverse effects thereof, may affect the surgeon’s judgment regarding the need for, and extent of, draining of these collections. Here I report the case of a 25-year-old male who presented with perforated acute retrocaecal subhepatic appendicitis complicated by pleural effusion and a small abdominal collection. The pleural effusion resolved almost completely over time. However, the patient showed incomplete recovery, as demonstrated by nausea, vomiting, and mood disturbance along with abdominal pain, tachycardia, and a persistent small abdominal collection. We initially suspected infection caused by a highly virulent type of bacteria and planned to perform percutaneous drainage. However, owing to skin erythematic changes, administration of lornoxicam was ceased, which resulted in complete recovery of the symptoms and consequently in avoidance of unnecessary invasive intervention to drain the abdominal collection. These findings suggest that the utilization and adverse effects of some painkillers for postoperative pain, such as lornoxicam, may affect the surgeon’s judgment regarding the most appropriate surgical workup in cases of postoperative fluid collection. Mohammad Bukhetan Alharbi Copyright © 2015 Mohammad Bukhetan Alharbi. All rights reserved. Spontaneous Involution of a Presumably Rathke’s Cleft Cyst in a Patient with Slight Subclinical Hypopituitarism: A Case Report and Review of the Literature Thu, 27 Aug 2015 13:47:41 +0000 Rathke cleft cyst is described as benign intrasellar cyst. They are mostly small and asymptomatic; they may become large enough to cause symptoms by compression of intrasellar or suprasellar structures. We report on a case of spontaneous regression of a symptomatic RCC with subsequent recovery of preexisting endocrine dysfunction and resolution of headaches. A 60-year-old man complained about headaches. Laboratory investigation revealed a partial hypopituitarism with a slight central hypothyroidism without need for substitution. An MRI study showed a cystic, T2-hyperintense, sellar lesion compatible with a RCC. At one year follow-up, the patient had no complaints and the hormone work-up revealed a regression of the previous slight hypopituitarism. The MRI study showed a complete regression of the cystic lesion and a normal sized and shaped pituitary gland. The spontaneous regression of cystic sellar lesions is rare. The exact mechanism of the possible spontaneous involution of RCC is until now not well understood. However, spontaneous regression is possible and justifies the conservative therapy with regular clinical and radiological follow-up for asymptomatic patients or patients with symptoms not caused by the mass effect of these lesions. Diaa Al Safatli, Rolf Kalff, and Albrecht Waschke Copyright © 2015 Diaa Al Safatli et al. All rights reserved. Postoperative Complications of Beger Procedure Mon, 24 Aug 2015 09:32:49 +0000 Introduction. Chronic pancreatitis (CP) is considered an inflammatory disease that may cause varying degrees of pancreatic dysfunction. Conservative and surgical treatment options are available depending on dysfunction severity. Presentation of Case. A 36-year-old male with history of heavy alcohol consumption and diagnosed CP underwent a duodenal-preserving pancreatic head resection (DPPHR or Beger procedure) after conservative treatment failure. Refractory pain was reported on follow-up three months after surgery and postoperative imaging uncovered stones within the main pancreatic duct and intestinal dilation. The patient was subsequently subjected to another surgical procedure and intraoperative findings included protein plugs within the main pancreatic duct and pancreaticojejunal anastomosis stricture. A V-shaped enlargement and main pancreatic duct dilation in addition to the reconstruction of the previous pancreaticojejunal anastomosis were performed. The patient recovered with no further postoperative complications in the follow-up at an outpatient clinic. Discussion. Main duct and pancreaticojejunal strictures are an unusual complication of the Beger procedure but were identified intraoperatively as the cause of patient’s refractory pain and explained intraductal protein plugs accumulation. Conclusion. Patients that undergo Beger procedures should receive close outpatient clinical follow-up in order to guarantee postoperative conservative treatment success and therefore guarantee an early detection of postoperative complications. Nayana Samejima Peternelli, Tali Wajsfeld, Felipe Henrique Yazawa Santos, Otavio Schmidt de Azevedo, Rodrigo Altenfelder Silva, and Adhemar Monteiro Pacheco Junior Copyright © 2015 Nayana Samejima Peternelli et al. All rights reserved. Overlap of Acute Cholecystitis with Gallstones and Squamous Cell Carcinoma of the Gallbladder in an Elderly Patient Wed, 19 Aug 2015 11:22:28 +0000 Introduction. The incidence of gallbladder cancer presenting with acute cholecystitis is 2.3%, squamous cell carcinoma is rarely seen, and overlap of acute cholecystitis and squamous cell carcinoma is a very rare condition in the literature. Presentation of Case. A 75-year-old woman was admitted to emergency service with a pain in the right upper quadrant, nausea, and vomiting. The patient was considered as having acute cholecystitis. During the exploration because Hartman’s pouch was not dissected, it was adhered to the cystic duct and had fibrotic adhesion. It could not be understood whether this adhesion was a tumor or a fibrotic tumor and thus we performed cholecystectomy with a 1 cm resection of the choledochus. Pathological examination revealed the presence of (R0), T1 N0 M0 squamous cell carcinoma with clean resection borders and there was no in tumor five dissected lymph nodes. The patient has been followed up for about two years and no clinical problem has been observed throughout the follow-up. Discussion. Acute cholecystitis with gallstones may overlap with gallbladder cancer and generally presents nonspecific symptoms. No additional imaging techniques were performed since no clinical sign except for the wall thickening was detected and no suspected malignancy such as mass was detected on USG. Squamous cell carcinoma of the gallbladder shows poor diagnosis, but since its overlap with cholecystitis presents early symptoms and thus leads to early diagnosis and effective treatment, the localization of the carcinoma is of prime importance. Conclusion. Gallbladder cancer should be kept in mind in elderly patients with acute cholecystitis. İhsan Yıldız, Yavuz Savas Koca, and İbrahim Barut Copyright © 2015 İhsan Yıldız et al. All rights reserved. Chronic Thoracic Aortic Aneurysm Presenting 29 Years following Trauma Thu, 13 Aug 2015 16:00:41 +0000 Blunt, nonpenetrating injuries of the thoracic aorta are uncommon and associated with a high mortality rate within the first hour. Aortic injury is missed in 1-2% of patients that survive to hospital, and a chronic thoracic aortic aneurysm may subsequently form. We present a case in which a chronic thoracic aortic aneurysm was diagnosed 29 years following a significant motor vehicle accident. We discuss the epidemiology, presentation, and management of this uncommon consequence of blunt, nonpenetrating aortic injury. Our case illustrates an important clinical lesson; a past medical history of trauma should not be overlooked at any patient assessment. Sarah Miller, Prashant Kumar, Rene Van den Bosch, and Adib Khanafer Copyright © 2015 Sarah Miller et al. All rights reserved. Simultaneous Bilateral Spontaneous Pneumothorax Revealed Birt-Hogg-Dubè Syndrome Tue, 04 Aug 2015 13:09:30 +0000 Simultaneous bilateral spontaneous pneumothorax is a very rare clinical event, comprising approximately 1% of all spontaneous pneumothoraces. Clinical signs and symptoms may vary from mild chest pain and dyspnea to severe respiratory failure; nevertheless immediate treatment is mandatory as this condition can deteriorate and progress to tension pneumothorax. An underlying lung disease has been commonly described; in most istances primary or secondary tumors, interstitial diseases, and infectious diseases. Birt-Hogg-Dubè syndrome is a rare inherited disorder clinically characterized by multiple fibrofolliculomas, renal tumors, lung cysts, and, in ~24% of the patients, occurrence of spontaneous pneumothorax. In this case, we firstly report the concurrence of these rare conditions, as a patient presenting a simultaneous bilateral spontaneous pneumothorax was diagnosed with Birt-Hogg-Dubè syndrome based on the typical radiological findings and genetic testing of the folliculin gene located on chromosome 17. Alessandro Tamburrini, Francesco Sellitri, Federico Tacconi, Francesco Brancati, and Tommaso Claudio Mineo Copyright © 2015 Alessandro Tamburrini et al. All rights reserved. A Four-Year Hospital Journey for a Lost and Migrating Appendicolith Tue, 04 Aug 2015 11:53:29 +0000 We report a rare case of recurrent abscess formation, including being at a retroperitoneal site, due to a lost and migrating appendicolith. Over a four-year period and following an episode of perforated appendicitis, an otherwise healthy young man underwent two operations for abscess formation with eventual stone removal. Appendicoliths can pose a challenge during the diagnostic and therapeutic journey, and adequate attempts at removal need to be made to prevent avoidable complications. In patients suffering from recurrent flank pain and abscesses after appendectomy, the possibility of a lost or overlooked appendicolith should be considered. Daniel Schraffl, Herman Frima, and P. Villiger Copyright © 2015 Daniel Schraffl et al. All rights reserved. Massive Neurilemoma of the Hard Plate in Which Preoperative Diagnosis Was Difficult Sun, 02 Aug 2015 11:37:04 +0000 The patient was an 84-year-old man who was referred to our hospital in mid-December 2012 for a close examination of a mass arising from the left side of the hard palate that was found by a local dentist. The initial examination revealed the presence of a 3.0-cm elastic soft, dome-shaped mass in the left hard palate. CE-CT showed a lesion of size 1.8 × 1.4 cm in the right hard palate, which extended upward and invaded the nasal cavity. The mass was a solid tumor associated with resorption of surrounding bone and expansion of the greater palatine canal. CE-MRI indicated that the mass extended upward and invaded the nasal cavity, and the mass showed hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and an irregular margin with internal enhancement. Abnormal uptake of FDG on PET-CT (SUVmax = 5.2) was observed in the left hard palate. The biopsy site lesion rapidly increased in size and biopsy was performed again in January 2013 due to suspicion of a malignant tumor. The histopathological diagnosis was a suspected malignant neurogenic tumor. Therefore, the patient underwent partial maxillectomy and a split-thickness skin graft in late February 2013. No recurrence was noted 29 months after the operation. Masanori Kudoh, Hiroyuki Harada, Koshi Matsumoto, Yuriko Sato, Ken Omura, and Yoshimasa Ishii Copyright © 2015 Masanori Kudoh et al. All rights reserved. Novel Technique for Management of Axillary Hidradenitis Suppurativa Using Setons Sun, 02 Aug 2015 08:47:06 +0000 Management of hidradenitis suppurativa (HS) of the axilla which is nonresponding to conservative management presents a significant therapeutic challenge. Most surgical treatment options are associated with significant morbidities and prolonged hospital stay. We present a technique of management of HS using setons which is simple and allows the ongoing treatment to be done on an outpatient basis. Given the fact that HS is a chronic relapsing condition each recurrence may again be managed using this technique. This will allow the patients to manage their recurrences with minimal impact on their activities of daily living. Sepehr Seyed Lajevardi and Jayantha Abeysinghe Copyright © 2015 Sepehr Seyed Lajevardi and Jayantha Abeysinghe. All rights reserved. Lipoma of the Small Intestine: A Cause for Intussusception in Adults Wed, 29 Jul 2015 15:36:24 +0000 Intussusception as a cause of intestinal obstruction in adults is rare. There is invariably an underlying pathology which leads to intussusception in adults. A case of intussusception in an adult due to a small intestinal lipoma is presented in view of this association. Ultrasound and CECT may help in a preoperative diagnosis. However early surgical intervention is the mainstay of treatment in order to confirm the diagnosis of the underlying pathology, thereby avoiding misdiagnosis of an underlying cancer. Ketan Vagholkar, Rahulkumar Chavan, Abhishek Mahadik, and Inder Maurya Copyright © 2015 Ketan Vagholkar et al. All rights reserved. Multifocal Insulinoma in Pancreas and Effect of Intraoperative Ultrasonography Wed, 29 Jul 2015 13:54:20 +0000 Insulinoma is the most frequently seen functional pancreatic neuroendocrine tumor. The incidence of multifocal insulinoma is lower than 10%. Its treatment is direct or laparoscopic excision. The present case was examined with the findings of hypoglycemia and hypercalcemia, and as there was high insulin and C-peptide levels the initial diagnosis was insulinoma. The case was investigated in terms of MEN 1. During preoperative screening for localization, there was one focus in the head of the pancreas in the abdominal tomography and two foci in endoscopic ultrasonography. No other focus was detected through intraoperative visual or manual palpation. However, five foci were detected during operation by intraoperative ultrasonography. The relation of masses with the main pancreatic canal was evaluated and they were excised by enucleation method. There was no recurrence during the postoperative 18-month follow-up of the patient. As a result, during treatment for insulinoma, it should be kept in mind that there might be multifocal foci. In all insulinomas, the whole pancreas should be evaluated with intraoperative ultrasonography because none of the current preoperative diagnostic methods are as sensitive as manual palpation of pancreas and intraoperative ultrasonography. The intraoperative detection of synchronous five foci in pancreas is quite a rare condition. Ersin Borazan, Alper Aytekin, Latif Yilmaz, Muhsin Elci, Mehmet Salih Karaca, Selim Kervancioglu, and Ahmet Abdulhalik Balik Copyright © 2015 Ersin Borazan et al. All rights reserved. Bilateral Ureteral Obstruction in Children after Appendectomy Wed, 29 Jul 2015 10:16:31 +0000 Acute renal failure due to bilateral ureteral obstruction is a rare complication after appendectomy in children. We report a case of bilateral ureteric obstruction in a 14-year-old boy nine days after surgery for an acute appendicitis. After saline-filling of the urinary bladder, transabdominal ultrasound demonstrated bilateral hydronephrosis of moderate degree. No abscess was found with CT but presence of millimetric stones on both distal ureters was shown, with bilateral calyceal dilatation. Cystoscopy revealed inflammatory changes in the bladder base. Following introduction of bilateral ureteric stents, there was rapid normalisation of urinary output and serum creatinine. M. Grande, G. Lisi, D. Bianchi, P. Bove, R. Miano, A. Esser, F. De Sanctis, A. Neri, S. Grande, and M. Villa Copyright © 2015 M. Grande et al. All rights reserved. The Impact of Radiation on an Unusual Case of Omental Epithelioid Angiosarcoma Tue, 28 Jul 2015 09:40:20 +0000 Epithelioid angiosarcoma is a rare high-grade tumor with irregular vascular morphology. We report an unusual case of intra-abdominal epithelioid angiosarcoma affecting the omentum and peritoneal surfaces resulting in significant hemorrhagic and inflammatory changes. As in other cases of this tumor this patient had previously undergone radiation treatment for a history of cervical cancer. Sumana Narayanan, Mitchell Parker, Jonathan Shayo, Min Zheng, Theodore Matulewicz, and Glenn Parker Copyright © 2015 Sumana Narayanan et al. All rights reserved. Management of a Gastrobronchial Fistula Connected to the Skin in a Giant Extragastric Stromal Tumor Tue, 28 Jul 2015 08:53:29 +0000 Introduction. Gastrointestinal stromal tumors first treatment should be surgical resection, but when metastases are diagnosed or the tumor is unresectable, imatinib must be the first option. This treatment could induce some serious complications difficult to resolve. Case Report. We present a 47-year-old black man with a giant unresectable gastric stromal tumor under imatinib therapy who presented serious complications such as massive gastrointestinal bleeding and a gastrobronchial fistula connected with the skin, successfully treated by surgery and gastroscopy. Discussion. Complications due to imatinib therapy can result in life threatening. They represent a challenge for surgeons and digestologists; creative strategies are needed in order to resolve them. Emilio Muñoz, Fernando Pardo-Aranda, Noelia Puértolas, Itziar Larrañaga, Judith Camps, and Enrique Veloso Copyright © 2015 Emilio Muñoz et al. All rights reserved. A Rare Complication of Biliary Stent Migration: Small Bowel Perforation in a Patient with Incisional Hernia Sun, 26 Jul 2015 14:13:17 +0000 Endoscopic biliary stents have been recently applied with increasing frequency as a palliative and curable method in several benign and malignant diseases. As a reminder, although most of the migrated stents pass through the intestinal tract without symptoms, a small portion can lead to complications. Herein, we present a case of intestinal perforation caused by a biliary stent in the hernia of a patient with a rarely encountered incarcerated incisional hernia. Özkan Yilmaz, Remzi Kiziltan, Oktay Aydin, Vedat Bayrak, and Çetin Kotan Copyright © 2015 Özkan Yilmaz et al. All rights reserved. Single Incision Laparoscopic Cholecystectomy for Gallbladder Duplication Wed, 22 Jul 2015 12:48:54 +0000 Duplication of the gallbladder is a rare congenital anomaly of the gallbladder, with an estimated prevalence of 1–3 per 3800 individuals. Unless properly diagnosed preoperatively, it can lead to biliary tract injuries and postoperative complications which may require reoperative surgeries. While previously reported cases have been treated with conventional laparoscopic cholecystectomy (LC), treatment with single incision laparoscopic surgery (SILS) has not been reported yet. We herein present the case of a 58-year-old female with gallbladder duplication who was successfully treated with SILS cholecystectomy. Esin Kabul Gürbulak, Hamdi Özşahin, Yiğit Düzköylü, Ismail Ethem Akgün, Muharrem Battal, and Bünyamin Gürbulak Copyright © 2015 Esin Kabul Gürbulak et al. All rights reserved. Duodenal Obstruction as First Presentation of Metastatic Breast Cancer Tue, 21 Jul 2015 13:14:05 +0000 The metastatic breast cancer to the duodenum is rare in spite of common breast cancer. In this paper, we are reporting a rare case of 50-year-old lady who presented with intestinal obstruction as result of metastatic breast cancer which completely responds to chemotherapy. The tumor presents again as brain metastasis after stop of Herceptin due to cardiac toxicity. Sami Khairy, Ayman Azzam, Shamayel Mohammed, Kausar Suleman, Abdurahman Khawaji, and Tarek Amin Copyright © 2015 Sami Khairy et al. All rights reserved. Conservative Management of an Iatrogenic Esophageal Tear in Kenya Tue, 14 Jul 2015 11:20:56 +0000 Since its description over 250 years ago, diagnosis of esophageal perforation remains challenging, its management controversial, and its mortality high. This rare, devastating, mostly iatrogenic, condition can quickly lead to severe complications and death due to an overwhelming inflammatory response to gastric contents in the mediastinum. Diagnosis is made with the help of esophagograms and although such tears have traditionally been managed via aggressive surgical approach, recent reports emphasize a shift in favor of nonoperative care which unfortunately remains controversial. We here present a case of an iatrogenic esophageal tear resulting from a routine esophagoscopy in a 50-year-old lady presenting with dysphagia. The esophageal tear, almost missed, was eventually successfully managed conservatively, thanks to a relatively early diagnosis. Peter Waweru and David Mwaniki Copyright © 2015 Peter Waweru and David Mwaniki. All rights reserved. Laparoscopic Repair of Internal Transmesocolic Hernia of Transverse Colon Sun, 12 Jul 2015 09:45:11 +0000 Introduction. Internal hernias are often misdiagnosed because of their rarity, with subsequent significant morbidity. Case Presentation. A 61-year-old Japanese man with no history of surgery was referred for intermittent abdominal pain. CT suggested the presence of a transmesocolic internal hernia. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We found internal herniation of the small intestine loop through a defect in the transverse mesocolon, without any strangulation of the small intestine. We were able to complete the operation laparoscopically. The patient’s postoperative course was uneventful and the patient was discharged on postoperative day 6. Discussion. Transmesocolic hernia of the transverse colon is very rare. Transmesocolic hernia of the sigmoid colon accounts for 60% of all other mesocolic hernias. Paraduodenal hernias are difficult to distinguish from internal mesocolic transverse hernias. We can rule out paraduodenal hernias with CT. Conclusion. The patient underwent a surgical procedure and was diagnosed with transmesocolic internal hernia. We report a case of a transmesocolic hernia of the transverse colon with intestinal obstruction that was diagnosed preoperatively and for which laparoscopic surgery was performed. Tomokazu Kishiki, Toshiyuki Mori, Yoshikazu Hashimoto, Hiroyoshi Matsuoka, Nobutsugu Abe, Tadahiko Masaki, and Masanori Sugiyama Copyright © 2015 Tomokazu Kishiki et al. All rights reserved. Small Bowel Perforation as a Postoperative Complication from a Laminectomy Wed, 08 Jul 2015 10:49:50 +0000 Chronic low back pain is one of the leading chief complaints affecting adults in the United States. As a result, this increases the percentage of patients that will eventually undergo surgical intervention to alleviate debilitating, chronic symptoms. A 37-year-old woman presented ten hours postoperatively after a lumbar laminectomy with an acute abdomen due to the extraordinarily rare complication of small bowel injury secondary to deep surgical penetration. Robert H. Krieger, Katherine M. Wojcicki, Andrew C. Berry, Warren L. Reuther III, and Kendrick D. McArthur Copyright © 2015 Robert H. Krieger et al. All rights reserved. Extraskeletal Ewing’s Sarcoma Arising from the Sciatic Nerve: A Diagnostic Challenge Wed, 08 Jul 2015 10:32:02 +0000 Ewing’s sarcoma is a common bone tumour of childhood but is a rare occurrence in individuals over 20 years of age. Few cases are reported as originating from peripheral nerves. We present an unusual case of extraosseous Ewing’s sarcoma originating from the sciatic nerve in a 66-year-old patient which had the clinical hallmarks of a benign nerve sheath tumour. Following discussion at a multidisciplinary meeting, excision biopsy of the suspected benign nerve sheath tumour was planned. At operation, the mass had malignant features. Histology confirmed the presence of Ewing’s sarcoma. Due to the morbidity of nerve resection, radiotherapy and chemotherapy were commenced. Ewing’s sarcoma is known to mimic benign pathologies. In this case there were subtle signs of a malignant process in the form of unremitting pain. It is vital to keep in mind the less common tumours that can affect the peripheral nervous system in such cases. Aadhar Sharma, Kate Brown, John Skinner, Jeremy Whelan, and Michael Fox Copyright © 2015 Aadhar Sharma et al. All rights reserved. Extradigital Glomus Tumor of Thigh Wed, 08 Jul 2015 07:27:17 +0000 Glomus tumors are benign neoplasms that arise from neuromyoarterial glomus bodies. They represent around 1–5% of all soft-tissue tumors. High temperature, sensitivity, and pain and localized tenderness are the classical triad of symptoms. Most glomus tumors represent in the subungual area of digits. Extradigital glomus tumors are a very rare entity. There are rare cases of these tumors reported to be in shoulder, elbow, knee, wrist, even stomach, colon, and larynx. We are reporting a case of a glomus tumor on thigh and discuss the histological and immunohistochemical features. Kemal Beksaç, Lutfi Dogan, Nazan Bozdogan, Gulay Dilek, Gokhan Giray Akgul, and Cihangir Ozaslan Copyright © 2015 Kemal Beksaç et al. All rights reserved. Developmentally Delayed Male with Mincer Blade Obstructing the Oesophagus for a Period of Time Suspected to Be 6 Months Wed, 08 Jul 2015 07:11:39 +0000 Introduction. Sharp, retained foreign bodies in the oesophagus are associated with severe complications. Developmentally delayed patients are especially subject to foreign objects. We describe a 37-year-old, developmentally delayed male with a mincer blade obstructing the oesophagus. Six months prior to surgical intervention, the patient was hospitalized in a condition of sepsis and pneumonia where the thoracic X-ray reveals a foreign body in the proximal oesophagus. When rehospitalized 6 months later, a mincer blade of the type used in immersion blenders was surgically removed. During these 6 months the patient’s main symptoms were dysphagia, weight loss, and diarrhoea. When developmentally delayed patients present with dysphagia, we strongly encourage the awareness of the possible presence of foreign bodies. To our knowledge this is the first reported case of a mincer blade in the oesophagus. Christian Grønhøj Larsen and Birgitte Charabi Copyright © 2015 Christian Grønhøj Larsen and Birgitte Charabi. All rights reserved. Use of Methyl Tert-Butyl Ether for the Treatment of Refractory Intrahepatic Biliary Strictures and Bile Casts: A Modern Perspective Tue, 07 Jul 2015 10:09:30 +0000 Cholelithiasis is a prevalent problem in the United States with 14% or more adults affected. Definitive treatment of cholelithiasis is cholecystectomy. When cholecystectomy yields minimal resolution treatment options include expectant management of asymptomatic gallstones or endoscopic retrograde cholangiopancreatogram. We present a case of intrahepatic biliary casts where surgical option was not possible, interventional radiology was unsuccessful, and methyl tert-butyl ether was used to dissolve the biliary obstruction. Dissolution therapy of gallstones was first reported in 1722 when Vollisnieri used turpentine in vitro. While diethyl ether has excellent solubilizing capacity, its low boiling point limited its use surgically as it vaporizes immediately. Diethyl ether can expand 120-fold during warming to body temperature after injection into the biliary system making it impractical for routine use. The use of dissolution is out of favor due to the success of laparoscopic cholecystectomy. Epidemiological studies have shown the general population should have minimal concerns from passive exposure. Dissolution using MTBE remains a viable option if surgical or endoscopic options are not available. However, because of risks involved to both the patient and the staff, careful multidisciplinary team approach must be undertaken to minimize the risks and provide the best possible care to the patient. Gregory Kim, Saninuj N. Malayaman, and Michael Stuart Green Copyright © 2015 Gregory Kim et al. All rights reserved. Locally Advanced, Unresectable Squamous Cell Carcinoma of the Gallbladder Mon, 06 Jul 2015 11:44:02 +0000 Primary squamous cell carcinoma (SCC) of the gallbladder is a rare malignancy of the gallbladder, accounting for less than 5% of gallbladder pathology. Initial presentation is often similar to adenocarcinoma of the gallbladder. SCC tends to be more locally aggressive, however, and possesses a worse prognosis than adenocarcinoma. We report a case of locally advanced SCC of the gallbladder. Timothy J. Weatherall, Moon Fenton, Gitonga Munene, Paxton V. Dickson, and Jeremiah L. Deneve Copyright © 2015 Timothy J. Weatherall et al. All rights reserved. Multiple Bronchogenic and Gastroenteric Cysts Arising from the Stomach in a Patient with Abdominal Pain Sun, 05 Jul 2015 11:34:37 +0000 Bronchogenic cysts arising from the stomach are uncommon. We discuss a young female patient with presumed enteric duplication cysts who was found to have three bronchogenic and gastroenteric cysts upon pathologic review. We discuss the pathophysiology of bronchogenic cysts and their malignant potential. Maykong Leepalao and Jessica Wernberg Copyright © 2015 Maykong Leepalao and Jessica Wernberg. All rights reserved. Achalasia in Pregnancy: Botulinum Toxin A Injection of Lower Esophageal Sphincter Thu, 02 Jul 2015 08:27:50 +0000 Background. Achalasia, a rare esophageal motility disorder that may cause malnutrition during pregnancy, can result in fetal and maternal morbidity and mortality. Many medical treatment regimens are contraindicated or not tolerated during pregnancy, and surgery is generally avoided due to potential risks to the fetus. Case Report. Severe, medically refractory achalasia in a 23-year-old pregnant woman that caused malnutrition was successfully managed by administering a botulinum toxin A injection to the lower esophageal sphincter. The injection was performed at approximately 14 weeks’ gestation and the patient reported clinically significant relief from dysphagia. She gained weight and ultimately delivered a healthy baby girl at term, but her symptoms returned a few months postpartum. She underwent a second treatment of botulinum toxin A injection, but it offered only one month of relief. Roughly eight months after delivery, the patient underwent a laparoscopic extended Heller myotomy and Dor fundoplication. The patient resumed a normal diet one week postoperatively, and her baby has had no complications. Conclusion. This is only the second reported case of botulinum toxin A injection being used to treat achalasia in pregnancy. This treatment proved to be a safe temporary alternative without the risks of surgery and anesthesia during pregnancy. Nicole Hooft, Emily S. Schmidt, and Ross M. Bremner Copyright © 2015 Nicole Hooft et al. All rights reserved. Gastric Cancer in the Excluded Stomach 10 Years after Gastric Bypass Wed, 01 Jul 2015 08:59:49 +0000 According to the Brazilian health authorities, around 2,000 new cases of gastric cancer emerge in Brazil per year (Instituto Nacional de Câncer José Alencar Gomes da Silva, 2014). Indeed, gastric cancer constitutes the second most common cause of cancer-related mortality worldwide and 95% of such malignancies are adenocarcinomas (De Roover et al., 2006, and Clark et al., 2006). Roux-en-Y gastric bypass (RYGB) is a procedure frequently employed in bariatric surgery but restricted access to the excluded stomach means that discovery of gastric lesions is difficult, and diagnosis and treatment may be delayed. We report herein a case of gastric adenocarcinoma in the excluded stomach of a patient submitted to RYGB with the purpose of illustrating the difficulty of diagnosing and treating this rare condition. Augusto Tinoco, Lorena F. Gottardi, and Eduardo D. Boechat Copyright © 2015 Augusto Tinoco et al. All rights reserved. Jejunal Intussusception: A Rare Presentation of Carcinoid Tumor Mon, 29 Jun 2015 07:05:46 +0000 A 55-year-old male presented to the emergency department with sudden onset of diffuse abdominal pain for one day. Physical examination was remarkable for tenderness in the umbilical region. A CT scan of the abdomen showed intussusception involving the jejunum without any mass. The patient then underwent an exploratory laparotomy. During surgery, the distal jejunum was intussuscepted with mesenteric lymphadenopathy. Liver showed nodular deposits in both lobes of the liver. The involved small bowel segment was resected with primary anastomosis and liver was biopsied. Pathological examination showed multifocal deposits of well-differentiated carcinoids in the jejunum. The liver and mesenteric deposits were positive for metastatic carcinoid. Patient recovered well without any complications. Umashankkar Kannan, Amir A. Rahnemai-Azar, Ashish N. Patel, Vinaya Gaduputi, and Ajay K. Shah Copyright © 2015 Umashankkar Kannan et al. All rights reserved. Hemophagocytic Lymphohistiocytosis and Gastrointestinal Bleeding: What a Surgeon Should Know Thu, 25 Jun 2015 06:05:44 +0000 This paper presents to the surgical community an unusual and often ignored cause of gastrointestinal bleeding. Hemophagocytic syndrome or hemophagocytic lymphohistiocytosis (HLH) is a rare medical entity characterized by phagocytosis of red blood cells, leucocytes, platelets, and their precursors in the bone marrow by activated macrophages. When intestinal bleeding is present, the management is very challenging with extremely high mortality rates. Early diagnosis and treatment seem to be the most important factors for a successful outcome. We present two cases and review another 18 from the literature. S. Popeskou, M. Gavillet, N. Demartines, and D. Christoforidis Copyright © 2015 S. Popeskou et al. All rights reserved.