Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Lumbar Herniation of Kidney following Iliac Crest Bone Harvest Wed, 30 Nov 2016 14:21:33 +0000 The iliac crest is a popular source for autogenous bone harvesting, but the process is rife with complications. This case report presents a patient that experienced incisional lumbar herniation of her kidney following an iliac crest bone harvesting procedure. A discussion is included on the underappreciated complications of this procedure and recommendations for improving outcomes with more thorough evaluation and documentation. Michael Justin Willcox Copyright © 2016 Michael Justin Willcox. All rights reserved. Laparoscopic Fenestration of a Giant Pseudocyst after Totally Extra Peritoneal Inguinal Hernia Repair Mon, 28 Nov 2016 11:28:25 +0000 A giant pseudocyst is a rare complication after hernioplasty and is seldom seen. The pathophysiology is unclear; it characteristically does not contain epithelial lining and can be considered giant if the diameter exceeds 10 cm. Pseudocysts are mostly described after incisional hernia repairs and are usually treated with surgical resection. We report a case of a giant pseudocyst three years after totally extra peritoneal inguinal hernia repair. Laparoscopic fenestration without removing the pseudocyst with or without removal of the polypropylene mesh is a safe and effective minimal invasive approach to the treatment of a symptomatic pseudocyst and should also be considered in the approach of other large symptomatic cysts. Yu-Ting van Loon and Maaike S. Ibelings Copyright © 2016 Yu-Ting van Loon and Maaike S. Ibelings. All rights reserved. Metastatic Inflammatory Myofibroblastic Tumor of the Spleen: A Case Report and Review of the Literature Mon, 28 Nov 2016 07:59:54 +0000 Introduction. Inflammatory myofibroblastic tumors (IMT) of the spleen are rare neoplasms and only little is known about the origin and behavior of these tumors. Here we report the case of a 37-year-old woman with an atypical spindle cell neoplasm showing features strongly suggesting an IMT of the spleen with hepatic metastasis. Methods. A 37-year-old patient had been complaining about pain in the left upper abdomen for the last two months. A CT scan revealed a tumor mass in her spleen and liver. After complete staging, a splenectomy and atypical liver resection of segments VII and VIII were performed. Literature was screened for similar cases and existing further literature. Results. A R0 resection was achieved. Histological analysis showed a multinodular infiltration of the spleen by an atypical mesenchymal neoplasia. Immunohistochemically there was an expression of histiocytic markers (CD4, CD68) as well as smooth muscle cell markers (SMA, H-Caldesmon) in the tumor cells. A diagnosis of an atypical spindle cell neoplasm showing features most suggestive of an IMT was rendered. Conclusion. Synchronous hepatic metastasis of an IMT of the spleen is a rarity. Therefore no experience in the treatment of these tumors exists. Fibroblastic reticular cell tumor is a differential diagnosis, but differentiation of these two entities is difficult. Luca Koechlin, Andreas Zettl, Dieter Koeberle, Markus von Flüe, and Martin Bolli Copyright © 2016 Luca Koechlin et al. All rights reserved. The Cause of Unexpected Acute Abdomen and Intra-Abdominal Hemorrhage in 24-Week Pregnant Woman: Bochdalek Hernia Sun, 27 Nov 2016 13:22:12 +0000 Bochdalek hernia (BH) is the most common type of congenital diaphragm hernia and is rarely seen in adults. In adult patients, BH often remains asymptomatic or presents with nondiagnostic symptoms and may lead to complications, though rarely. The necrosis and perforations occurring in the hernia may lead to mortality. In this report, we present a 34-year-old pregnant woman at 24 gestational weeks who presented with Bochdalek hernia causing gastric volvulus associated with perforation and intra-abdominal hemorrhage associated with splenic rupture. Yavuz Savas Koca, Ibrahim Barut, İhsan Yildiz, and Rasih Yazkan Copyright © 2016 Yavuz Savas Koca et al. All rights reserved. Technical Considerations of Giant Right Coronary Artery Aneurysm Exclusion Sun, 27 Nov 2016 08:49:00 +0000 Giant coronary artery aneurysms are rare clinical entities. We report the case of a 49-year-old man who presented with dyspnoea and exertional chest pain. Investigations confirmed an aneurysmal right coronary artery measuring 4 cm with a fistulous communication to the right atrium. Following right atriotomy, the fistula was oversewn and the aneurysmal right coronary artery ligated at its origin and at several points along its course. A saphenous vein graft was anastomosed to the posterior descending artery. Persistent ventricular fibrillation occurred upon chest closure, attributed to ischaemia following ligation of the aneurysmal coronary artery. Emergent resternotomy and internal defibrillation were successfully performed. The sternum was stented open to reduce right ventricular strain and closed the following day. The patient made an unremarkable recovery. We here address the technical challenges associated with surgical repair of right coronary aneurysms and the physiology and management of potential complications. James Barr, Metesh Nalin Acharya, Antonios Kourliouros, and Shahzad Gull Raja Copyright © 2016 James Barr et al. All rights reserved. Ectopic Pregnancy in a Cesarean Section Scar: Successful Management Using Vacuum Aspiration under Laparoscopic Supervision—Mini Review of Current Literature Thu, 24 Nov 2016 10:16:15 +0000 A cesarean scar ectopic pregnancy (CSEP) is a fairly uncommon presentation wherein the conceptus is implanted deep in the myometrium and at the exact scar site of the previous cesarean section. There are various CSEP management options that range from medical treatment to surgical interventions such as dilatation and curettage, laparoscopic excision, resection by laparotomy, or, sometimes, a combination of these modalities. Establishing a diagnosis of CSEP can be challenging. Given the relatively rare incidence of CSEP, its management is controversial and current standards of therapy have been derived from data obtained from a limited number of patients. Herein, we present transvaginal ultrasonography (TVUS) imaging findings and management strategies used in a case of CSEP along with the short review of current literature. Mustafa Koplay, Nasuh Utku Dogan, Mesut Sivri, Hasan Erdogan, Selen Dogan, and Cetin Celik Copyright © 2016 Mustafa Koplay et al. All rights reserved. Urethral Leiomyoma: A Rare Clinical Entity Wed, 23 Nov 2016 13:27:10 +0000 Extrauterine leiomyomas are encountered occasionally, which can pose a diagnostic dilemma and challenge to the gynaecologist. We report a rare case of urethral leiomyoma. A 31-year-old woman with history of primary subfertility presented with mass at her urethral meatus and lower urinary tract symptoms. She underwent examination under anaesthesia and excision of the urethral mass. Histopathological examination confirmed leiomyoma. Diagnosis and management of this common growth situated at a rare location were reviewed and discussed. Ng Beng Kwang, Aruku Naidu, Azyani Yahaya, and Lim Pei Shan Copyright © 2016 Ng Beng Kwang et al. All rights reserved. Rectus Abdominis Endometrioma after Caesarean Section Wed, 23 Nov 2016 13:26:58 +0000 Isolated rectus abdominis muscle endometriosis is very uncommon with less than 20 case reports being published to date since its first description in 1984 by Amato and Levitt. We report another case of isolated rectus abdominis endometriosis in a 37-year-old patient with a previous caesarian section. We also discuss the diagnostic and treatment particularities in these patients. In our case, the treatment was only surgical and currently the patient is disease-free during the 24-month follow-up. Igor Mishin, Anna Mishina, Sergiu Zaharia, and Gheorghe Zastavnitsky Copyright © 2016 Igor Mishin et al. All rights reserved. A Rare Type of Primary Internal Hernia Causing Small Intestinal Obstruction Wed, 23 Nov 2016 12:39:28 +0000 Primary internal hernias are extremely rare in adults. They are an important cause of small intestinal obstruction and lead to high morbidity and mortality if left untreated. Clinical presentation of internal hernia is nonspecific. Imaging has been of limited utility in cases of acute intestinal obstruction; moreover, interpretation of imaging features is operator dependant. Thus, internal hernias are usually detected at laparotomy and preoperative diagnosis in an emergency setting is either difficult or most of the time not suspected. We report herein a case of a 45-year-old male who presented with acute intestinal obstruction which was attributed later to a very rare type of internal hernia on exploratory laparotomy. A loop of ileum was found to enter the retroperitoneum through a hernia gate which was located lateral to the sigmoid colon in the left paracolic gutter. The segment of intestine was reduced and the hernial defect was closed. Our finding represents an extremely rare variant of retroperitoneal hernias. Sibabrata Kar, Vandana Mohapatra, and Pratap Kumar Rath Copyright © 2016 Sibabrata Kar et al. All rights reserved. A Case Report of Acute Diverticulitis in “Pseudodiverticulosis” after Hemorpex System® Procedure Tue, 15 Nov 2016 12:41:30 +0000 Introduction. In the last years many mini-invasive approaches were developed in order to reduce postoperative pain and complication after haemorrhoid surgery: one of these alternatives is represented by Hemorpex System, a relatively young technique that combines transanal dearterialization with mucopexy through a dedicated proctoscope. Case Presentation. A 78-year-old male patient was admitted to the Emergency Department for acute urinary retention and elevated temperature. Hemorpex procedure was performed 4 years before. Clinical, endoscopic, and radiological findings demonstrated the presence of multiple diverticula-like structures fulfilled by purulent fluid and a deep alteration of the normal anatomy of the rectum. He was treated following the standard protocol of acute diverticulitis and full recovery from symptoms was achieved. Discussion. Hemorpex System is a young technique, and nowadays-available studies lack long-term follow-up data. Anatomical changes induced by the procedure are consistent and definitive. Our patient luckily demonstrated a prompt response to conservative treatment, but it must be taken into account that, in case of medical treatment failure, surgical approach would be necessary and the actual patient anatomical changes could lead the surgeon to unavoidable threatening maneuvers. Tommaso Testa and Federico Costanzo Copyright © 2016 Tommaso Testa and Federico Costanzo. All rights reserved. Ollier’s Disease of the Iliac Bone with Sacroiliac Joint Involvement in an Adolescent Patient Sun, 13 Nov 2016 12:18:33 +0000 Ollier’s disease of the hip bone involving the sacroiliac joint has not yet been reported in the English-language literature in both the mature and immature skeletons. The authors present such a unique case in an adolescent girl that posed a significant diagnostic challenge secondary to the rarity of the lesion and atypical clinical picture. Olga D. Savvidou, George D. Chloros, Panagiotis Koutsouradis, Evangelia Skarpidi, and Panayiotis J. Papagelopoulos Copyright © 2016 Olga D. Savvidou et al. All rights reserved. Laparoscopic Repair of Morgagni Hernia: Three-Case Presentation and the Literature Thu, 10 Nov 2016 06:48:22 +0000 Introduction. Morgagni hernia is a rare form of congenital diaphragmatic hernia. Case Presentation. We present three cases of Morgagni hernia with GI symptoms treated by laparoscopic surgery. Discussion. Hernial sac was excised in two cases and left in situ in one case. There was no recurrence in symptoms after 30 months from surgery. Gholamali Godazandeh and Farzad Mokhtari-esbuie Copyright © 2016 Gholamali Godazandeh and Farzad Mokhtari-esbuie. All rights reserved. Laparoscopic Extirpation of a Schwannoma in the Lateral Pelvic Space Wed, 09 Nov 2016 13:21:31 +0000 Schwannomas in the lateral pelvic space are very rare. Here, we report the case of a 48-year-old woman who had a tumor detected in her abdomen by abdominal ultrasonography. Abdominal computed tomography and magnetic resonance imaging revealed a well-defined solid tumor of 65 mm in diameter in the right lateral pelvic space. We performed laparoscopic surgery under a diagnosis of a gastrointestinal tumor or neurogenic tumor. The tumor was safely dissected and freed from the surrounding tissues using sharp and blunt maneuvers. The tumor originated from the right sciatic nerve. Complete laparoscopic extirpation was performed with preservation of the right sciatic nerve. Pathological examination suggested schwannoma. The patient recovered well but had remaining sciatic nerve palsy in her right foot. Laparoscopic extirpation for a schwannoma in the lateral pelvic space was safe and feasible due to the magnified surgical field afforded by laparoscopy. Eiji Hidaka, Yasuhiro Ishiyama, Chiyo Maeda, Kenta Nakahara, Shoji Shimada, Shumpei Mukai, Naruhiko Sawada, Fumio Ishida, and Shin-ei Kudo Copyright © 2016 Eiji Hidaka et al. All rights reserved. Urachal Cyst Causing Small Bowel Obstruction in an Adult with a Virgin Abdomen Wed, 09 Nov 2016 12:19:54 +0000 Introduction. A patent urachus is a rare congenital or acquired pathology, which can lead to complications later in life. We describe a case of urachal cystitis as the etiology of small bowel obstruction in an adult without prior intra-abdominal surgery. Case Report. A 64-year-old male presented to the acute care surgery team with a 5-day history of right lower quadrant abdominal pain, distention, nausea, and vomiting. He had a two-month history of urinary retention and his past medical history was significant for benign prostate hyperplasia. On exam, he had evidence of small bowel obstruction. Computed tomography revealed high-grade small bowel obstruction secondary to presumed ruptured appendicitis. In the operating room, an infected urachal cyst was identified with adhesions to the proximal ileum. After lysis of adhesions and resection of the cyst, the patient was subsequently discharged without further issues. Conclusion. Although rare, urachal pathology should be considered in the differential diagnosis when evaluating a patient with small bowel obstruction without prior intraabdominal surgery, hernia, or malignancy. Michael P. O’Leary, Zane W. Ashman, David S. Plurad, and Dennis Y. Kim Copyright © 2016 Michael P. O’Leary et al. All rights reserved. Xiphoidectomy: A Surgical Intervention for an Underdocumented Disorder Wed, 09 Nov 2016 09:20:51 +0000 Two patients who presented with nonspecific thoracic and upper abdominal symptoms and tenderness of the xiphoid process are discussed. Both patients had undergone extensive examinations, but no source for their symptoms could be found. Plain chest radiographs revealed an anterior displacement of the xiphoid process in both patients. Physical examination confirmed this to be the primary source of discomfort. Anterior displacement of the xiphoid process may be the result of significant weight gain. Repeated trauma of the afflicted area, unaccustomed heavy lifting, exercise, and perichondritis are, amongst other causes, believed to contribute to the development of xiphodynia. Both patients were treated by performing a xiphoidectomy, resulting in disappearance of the symptoms. Dirk Pieter Hogerzeil, Klaas Albert Hartholt, and Mark Rem de Vries Copyright © 2016 Dirk Pieter Hogerzeil et al. All rights reserved. Adult Embryonal Sarcoma of the Liver: Management of a Massive Liver Tumor Tue, 08 Nov 2016 10:04:17 +0000 Undifferentiated embryonal sarcomas of the liver are extremely rare cases in adults. We report the case of a 30-year-old male who presented with early satiety and abdominal pain due to a massive tumor originating from the left liver and occupying the entire epigastrium. The patient underwent bland embolization in an attempt to decrease the size of the tumor. He then underwent a formal left hepatectomy with resection of liver segments 2, 3, and 4. Extrahepatic inflow control of the portal vein and hepatic artery was performed prior to parenchymal transection. No Pringle maneuver was required. Pathology analysis showed a 45 cm tumor consistent with an undifferentiated embryonal sarcoma and negative microscopic margins. The epidemiology, treatment, and prognosis of this unusual cancer presentation are reviewed. Daniela Treitl, Alexandra Roudenko, Siba El Hussein, Magda Rizer, and Philip Bao Copyright © 2016 Daniela Treitl et al. All rights reserved. Complex Perineal Trauma with Anorectal Avulsion Mon, 07 Nov 2016 13:13:52 +0000 Introduction. The objective of this case report is to illustrate a severe perineal impalement injury, associated with anorectal avulsion and hemorrhagic shock. Results. A 32-year-old male patient was referred to our hospital for an impalement perineal trauma, associated with complex pelvic fracture and massive perineal soft tissue destruction and anorectal avulsion. On arrival, the systolic blood pressure was 85 mm Hg and the hemoglobin was 7.1 g/dL. The patient was transported to the operating room, and perineal lavage, hemostasis, and repacking were performed. After 12 hours in the Intensive Care Unit, the abdominal ultrasonography revealed free peritoneal fluid. We decided emergency laparotomy, and massive hemoperitoneum due to intraperitoneal rupture of pelvic hematoma was confirmed. Pelvic packing controlled the ongoing diffuse bleeding. After 48 hours, the relaparotomy with packs removal and loop sigmoid colostomy was performed. The postoperative course was progressive favorable, with discharge after 70 days and colostomy closure after four months, with no long-term complications. Conclusions. Severe perineal injuries are associated with significant morbidity and mortality. Their management in high volume centers, with experience in colorectal and trauma surgery, allocating significant human and material resources, decreases the early mortality and long-term complications, offering the best quality of life for patients. Adelina Maria Cruceru, Ionut Negoi, Sorin Paun, Sorin Hostiuc, Ruxandra Irina Negoi, and Mircea Beuran Copyright © 2016 Adelina Maria Cruceru et al. All rights reserved. Spontaneous Intramural Duodenal Hematoma: Pancreatitis, Obstructive Jaundice, and Upper Intestinal Obstruction Mon, 07 Nov 2016 09:37:29 +0000 Nontraumatic intramural duodenal hematoma can cause upper gastrointestinal tract obstruction, upper gastrointestinal hemorrhage, jaundice, and pancreatitis and may be present in patients with normal coagulation. However the pathogenesis of the condition and its relationship with acute pancreatitis remain unknown. We present a case of spontaneous intramural duodenal hematoma and a case of successful nonoperative treatments. Chalerm Eurboonyanun, Kulyada Somsap, Somchai Ruangwannasak, and Anan Sripanaskul Copyright © 2016 Chalerm Eurboonyanun et al. All rights reserved. Strangulated Morgagni’s Hernia: A Rare Diagnosis and Management Mon, 07 Nov 2016 09:15:00 +0000 Morgagni hernia is a rare type of congenital diaphragmatic hernia. It accounts for only 3% of all diaphragmatic hernias. The defect is small and hernia being asymptomatic in the majority presents late in adulthood. Obstruction or incarceration in Morgagni hernia is uncommon. We report a rare occurrence of strangulated Morgagni hernia. A 40-year-old gentleman presented to our emergency department with features of intestinal obstruction. Computed tomography of the chest and abdomen showed a strangulated right Morgagni hernia. An exploratory laparotomy was performed with resection of the ischemic bowel segment with anastomosis and a primary repair of the diaphragmatic defect. Postoperative recovery was uneventful and asymptomatic at follow-up. Malav Modi, Amit Kumar Dey, Ajay Mate, and Samir Rege Copyright © 2016 Malav Modi et al. All rights reserved. Sapovirus Gastroenteritis in Young Children Presenting as Distal Small Bowel Obstruction: A Report of 2 Cases and Literature Review Sun, 06 Nov 2016 13:25:43 +0000 Abdominal pain and distention in children are commonly encountered problems in the pediatric emergency room. The majority of complaints are found to be due to benign entities such as gastroenteritis and constipation. What confounds these diagnoses is that young children often deliver a challenging and unreliable exam. Thus, it often becomes exceedingly problematic to differentiate these benign conditions from surgical conditions requiring prompt attention including small or large bowel obstruction, volvulus, and appendicitis. The cases highlight Sapovirus as a cause of severe abdominal distention and vomiting in children and this report is the first to describe and demonstrate the impressive radiologic findings that may be associated with this infection. Surgeons should heed this information and hesitate to emergently operate on similar children. Lynn Model and Cathy Anne Burnweit Copyright © 2016 Lynn Model and Cathy Anne Burnweit. All rights reserved. Rebleeding of a Splenic Artery Aneurysm after Coil Embolisation Mon, 31 Oct 2016 11:31:24 +0000 Background. Splenic artery aneurysm (SAA) is an uncommon and difficult diagnosis. SAA is more common in females. Only 20% of SAA is symptomatic and may present as a rupture. A ruptured SAA is associated with a 25% mortality rate. Case Presentation. We present a case of a male patient with a bleeding SAA that rapidly increased in size. Distal coiling was technically impossible and despite proximal coil embolisation the SAA continued to bleed. A laparotomy including splenectomy and partial pancreatectomy was performed with an uneventful patient recovery. Discussion. Endovascular management is currently considered the optimal treatment of SAA. However, careful monitoring and follow-up is needed after embolisation as rapid recanalization of the SAA may possibly occur, especially when distal coiling of the aneurysm is unsuccessful. Conclusion. Endovascular treatment of an SAA is not necessarily effective. Surgeons must be prepared to perform open procedures to further reduce mortality rates. Kyra D. Kingma, Antonius N. van der Linden, and Rudi M. H. Roumen Copyright © 2016 Kyra D. Kingma et al. All rights reserved. Congenital Diaphragmatic Hernia with Delayed Presentation Sun, 30 Oct 2016 07:15:27 +0000 Congenital diaphragmatic hernia (CDH) is caused due to abnormal formation of the muscular parts of diaphragm. The incidence of CDH in common births ranges from 1/25000 to 1/30000. Pulmonary hypoplasia and pulmonary hypertension are factors that associate with the increase of mortality and morbidity due to CDH. We presented a 68-year-old Iranian woman with abdominal pain and tenderness in right upper quadrant who was diagnosed as having CDH. The disease was detected using chest X-ray and chest and abdomen sonography and confirmed with chest and abdomen CT scan with and without oral contrast. A defect was revealed in posterolateral right diaphragm with omentum and transverse colon herniated through it. Right posterolateral thoracotomy was performed to cure the disease. CT and CXR were the two useful methods in diagnosis of CDH in this patient, although CDH detection prior to surgery is too challenging because of rare cases and different types of CDH. In order to improve clinical cares in adult CDH patients, investigating more cases and long term follow-up are recommended. Alireza Malekzadegan and Alireza Sargazi Copyright © 2016 Alireza Malekzadegan and Alireza Sargazi. All rights reserved. Large Bowel Obstruction, a Delayed Complication of Severe Gallstone Pancreatitis Wed, 26 Oct 2016 11:32:49 +0000 Colonic complications are rare after acute pancreatitis but are associated with a high mortality. Possible complications include mechanical obstruction, ischaemic necrosis, haemorrhage, and fistula. We report a case of large bowel obstruction in a 31-year-old postpartum female, secondary to severe gallstone pancreatitis. The patient required emergency laparotomy and segmental bowel resection, as well as cholecystectomy. Presentation of obstruction occurs during the acute episode or can be delayed for several weeks. The most common site is the splenic flexure owing to its proximity to the pancreas. Initial management may be conservative, stenting, or surgical. CT is an acceptable baseline investigation in all cases of new onset bowel obstruction. Although bowel obstruction is a rare complication of pancreatitis, clinicians should be aware of it due to its high mortality. Obstruction can occur after a significant delay following the resolution of pancreatitis. Those patients with evidence of colonic involvement on pancreatic imaging warrant further large bowel evaluation. Bowel resection may be required electively or acutely. Colonic stenting has an increasing role in the management of large bowel obstruction but is a modality of treatment that needs further evaluation in this setting. Neeraj Lal, John Whiting, Rahul Hejmadi, and Sudarsanam Raman Copyright © 2016 Neeraj Lal et al. All rights reserved. Novel Approach for Enterocutaneous Fistula Treatment with the Use of Viable Cryopreserved Placental Membrane Wed, 26 Oct 2016 08:48:09 +0000 Enterocutaneous fistulas (ECF) are a difficult and costly surgical complication to manage. The standard treatment of nil per os (NPO) and total paraenteral nutrition (TPN) is not well tolerated by patients. TPN is also known for complications associated with long term central venous catheterization and for high cost of prolonged hospital stay. We present two low output ECF cases successfully treated with viable cryopreserved placental membrane (vCPM) placed into the fistula tracts. One patient is a 59-year-old male with a low output ECF from a jejunostomy tube site four weeks after the surgery. The second patient is an 87-year-old male with a low output ECF following a small bowel resection secondary to a strangulated inguinal hernia. He was evaluated on day 41 after surgery. NPO and TPN for several weeks did not resolute the ECF. The fistulae were closed postoperatively in both patients with zero output on the same day after one vCPM application. On day 3 postoperatively both patients were started on clear liquid diets and subsequently advanced to regular diets. The ECF have remained resolved for over 2 months. The use of vCPM is a novel promising approach for treatment of ECF. Frederick Nichols and Aaron Overly Copyright © 2016 Frederick Nichols and Aaron Overly. All rights reserved. Kirschner Wire Breakage during Removal Requiring Retrieval Mon, 24 Oct 2016 12:27:36 +0000 Kirschner wires (K-wires) are widely used for fixation of fractures and dislocations in the hand as they are readily available, reliable, and cost-effective. Complication rates of up to 18% have been reported. However, K-wire breakage during removal is rare. We present one such case illustrating a simple technique for retrieval. A 35-year-old male presented with a distal phalanx fracture of his right middle finger. This open fracture was treated with K-wire fixation. Postoperatively, he developed a pin site infection with associated finger swelling. The K-wire broke during removal with the proximal piece completely retained in his middle phalanx. To minimise risk of osteomyelitis, the K-wire was removed with a novel surgical technique. He had full return of hand function. Intraoperative K-wire breakage has a reported rate of 0.1%. In our case, there was no obvious cause of breakage and the patient denied postoperative trauma. On the other hand, pin site infections are much more common with reported rates of up to 7% in the hand or wrist. K-wire fixation is a simple method for bony stabilisation but can be a demanding procedure with complications often overlooked. It is important to be aware of the potential sequelae. Kai Yuen Wong, Rosalind Mole, and Patrick Gillespie Copyright © 2016 Kai Yuen Wong et al. All rights reserved. A Case of a Chronic Pancreatic Pseudocyst Causing Atraumatic Splenic Rupture without Evidence of Acute Pancreatitis Mon, 24 Oct 2016 08:55:43 +0000 Atraumatic splenic rupture is a rare complication of a pancreatic pseudocyst (PP), described in the setting of chronic pancreatitis. There is common understanding, within the literature, that an inflammatory process at the tail of the pancreas may disrupt the spleen and result in such splenic complications. The authors present a case report of a 29-year-old male with a PP, associated with chronic pancreatitis. The patient had a history of excessive alcohol intake and presented to the emergency department with a short history of abdominal pain and vomiting. He denied any significant history of trauma and serum amylase levels were normal. An admission computed tomography (CT) scan of the abdomen confirmed the presence of a PP in direct contact with the spleen. The CT also demonstrated a heterogenous hypodense area of the splenic hilum, along with perisplenic fluid. The patient was admitted for observation. His abdominal pain progressed, and he became haemodynamically unstable. An emergency ultrasound scan (USS) at this time revealed intra-abdominal haemorrhage. A subsequent CT confirmed splenic rupture, which was managed surgically with a full recovery. Few such cases are documented within the literature and more understanding of preempting such events is needed. P. Moori, E. J. Nevins, T. Wright, C. Bromley, and Y. Rado Copyright © 2016 P. Moori et al. All rights reserved. Ileocolic Intussusception in a Leukemic Adult Patient: A Case Report and Review of the Literature Thu, 20 Oct 2016 14:16:02 +0000 We present a rare case of intussusception in a 41-year-old man with acute myeloid leukemia without an evidence of leukemic infiltration of the bowel. The patient presented to the emergency room with right lower quadrant pain. Initially he was diagnosed with typhlitis. CT scan was done and showed ileocolic intussusception without a definitive lead point identified. Patient underwent hemicolectomy and histopathological study of the specimen did not show any leukemic infiltrate. High suspicion of intussusception should be kept in mind with leukemic patients presenting with abdominal pain. Ayoub Innabi, Wa’el Tuqan, Alia Alawneh, Alaa Saleh, Kamal Alrabi, and Lina Marei Copyright © 2016 Ayoub Innabi et al. All rights reserved. Duplicate Vas Deferens Encountered during Inguinal Hernia Repair: A Case Report and Literature Review Thu, 20 Oct 2016 09:55:27 +0000 Duplication of the vas deferens is a rare anomaly, defined as the presence of two distinct vasa deferentia within one spermatic cord, with only 28 cases reported worldwide since 1959. We report the case of a 63-year-old man with a duplicate vas deferens, presenting with abdominal pain from bowel obstruction secondary to incarcerated inguinal hernia. Spermatic cord dissection during hernioplasty revealed duplication of the vas deferens within the right spermatic cord. Doppler ultrasonography confirmed absence of waveforms in both vasa deferentia with arterial signal in the accompanying vessel. The hernia was repaired without complication. This report emphasizes recognition of duplicate vas deferens in avoiding iatrogenic injury and optimizing surgical outcome. Maxwell C. Breitinger, Evan H. Roszkowski, Adam J. Bauermeister, and Andrew A. Rosenthal Copyright © 2016 Maxwell C. Breitinger et al. All rights reserved. A Case of Stercoral Perforation Detected on CT Requiring Proctocolectomy in a Heroin-Dependent Patient Tue, 18 Oct 2016 11:40:01 +0000 Stercoral perforation of the colon is rare but carries with it significant morbidity and mortality. Stercoral perforation usually occurs in elderly, immobile patients with chronic constipation. In this manuscript, we report the case of stercoral perforation in a patient due to chronic heroin dependence. We report the case of a 56-year-old male patient with stercoral perforation, diagnosed by computed tomography, secondary to heroin dependence, requiring proctocolectomy and an end ileostomy. There are very few reports in the literature describing cases of stercoral perforation and questions have been asked about the importance of preoperative cross-sectional imaging. In our case, the diagnosis of stercoral perforation was made only on CT. Although this is not the first such case to be reported, it is significant as preoperative CT imaging was influential not only in determining the aetiology of the abdominal distension seen on the plain film, but also in detecting the pneumoperitoneum which was not evident clinically or on plain radiographs. William H. Seligman, Fahreyar Alam, Andy Planner, and Roderick J. Alexander Copyright © 2016 William H. Seligman et al. All rights reserved. Liver Transplantation Utilizing Mixed Biologic and Synthetic Arterial Conduits Wed, 12 Oct 2016 08:15:05 +0000 Arterial conduits are necessary in nearly 5% of all liver transplants and are usually constructed utilizing segments of donor iliac artery. However, available segments of donor iliac artery may not be lengthy enough or may not possess enough quality to enable its inclusion in the conduit. Although there are few reports of arterial conduits constructed solely utilizing prosthetic material, no previous reports of conduits composed of a segment of donor iliac artery and prosthetic material (mixed biologic and synthetic arterial conduits) were found in the medial literature to date. Two cases reporting successful outcomes after creation of mixed biologic and prosthetic arterial conduits are outlined in this report. Reason for creation of conduits was complete intimal dissection of the recipient’s hepatic artery in both cases. In both cases, available segments of donor iliac artery were not lengthy enough to bridge infrarenal aorta to porta hepatis. Both patients have patent conduits and normally functioning liver allografts, respectively, at 4 and 31 months after transplant. Mixed biologic and synthetic arterial conduits constitute a viable technical option and may offer potential advantages over fully prosthetic arterial conduits. Marcio F. Chedid, Tomaz J. M. Grezzana-Filho, Aljamir D. Chedid, Luiz Pedro P. Hendges, Ian Leipnitz, Mario R. Alvares-da-Silva, Ariane N. Backes, Matheus J. Reis, Cleber Dario P. Kruel, and Cleber R. P. Kruel Copyright © 2016 Marcio F. Chedid et al. All rights reserved.