Case Reports in Surgery The latest articles from Hindawi © 2017 , Hindawi Limited . All rights reserved. A Case of Spontaneous Transdiaphragmatic Intercostal Hernia with Contralateral Injury, and Review of the Literature Thu, 23 Feb 2017 06:58:04 +0000 This case report discusses the diagnosis and management of a 67-year-old male presenting with a spontaneous transdiaphragmatic intercostal hernia with contralateral intercostal hernia. The patient had a history of chronic obstructive pulmonary disease (COPD) exacerbations requiring multiple prolonged courses of steroids. The patient was ultimately diagnosed with computed tomography (CT) and underwent surgical repair via thoracotomy with primary repair of the diaphragmatic defect. The patient’s postoperative course was uncomplicated. A review of the literature since the first similar case in 1977 recognizes the propensity of this injury to be found in patients with COPD and chronic steroid usage, as well as its diagnosis and management. The case reviewed is the second documented case of a concurrent abdominal wall herniation and the first one with a contralateral injury. It is important for clinicians to be aware of this pathology when evaluating patients with COPD and chronic steroid usage. Alexander A. Chapman and Steven B. Duff Copyright © 2017 Alexander A. Chapman and Steven B. Duff. All rights reserved. Island Posterior Thigh Flap Revisited in Covering Extensive Sacral Wounds: Our Experience with Two Patients Wed, 22 Feb 2017 06:54:11 +0000 Deep sacral wounds are best covered by flaps. Posterior thigh flaps have routinely been used to cover such wounds. The flap can however be modified as an island flap. Two patients with extensive sacral wounds were managed with island posterior thigh flaps. Both patients were admitted secondary to road traffic accident with subsequent soft tissue loss of the sacral area. The sacral defects in both patients were approximately 17 cm by 23 cm in dimensions. Unilateral island posterior thigh flap was raised and used to cover the wounds. Postoperatively both patients did well; the donor site and recipient sites healed without any complications. Island posterior thigh flap is thus an option in covering extensive defects of the sacral area. The flap is reliable and easy to raise and has minimal donor site morbidity. By raising it as an island flap the dog ear defect is avoided and the flap is able to be tunneled under the gluteal muscle. This maneuver enables the flap to be advanced further allowing it to cover more distal and extensive defects. F. Nangole Wanjala and Ajujo Martin Copyright © 2017 F. Nangole Wanjala and Ajujo Martin. All rights reserved. Spontaneous Intramural Oesophageal Haematoma in a Patient with Uncontrolled Hypertension: An Unusual Chest Pain Aetiology Mon, 20 Feb 2017 10:08:42 +0000 Introduction. Spontaneous intramural oesophageal haematoma is a rare condition that usually occurs secondary to an acute or chronic coagulation disorder. The presenting complaint is often with retrosternal chest pain and most patients are initially investigated to exclude more common causes in the differential diagnosis, such as acute coronary syndromes. Severe life-threatening bleeding or perforation seldom, if ever, arises. Case Presentation. We present a case of spontaneous oesophageal haematoma which appears to have developed gradually in a 69-year-old female with uncontrolled hypertension and antiplatelet medication use. The diagnosis was made on computed tomography imaging and was further evaluated with upper gastrointestinal endoscopy. Management was conservative and a follow-up endoscopy two weeks later showed almost complete resolution of the lesion. Discussion. Spontaneous oesophageal haematomas are very rare and usually result in the separation of the mucosal layer from the underlying muscle, presenting with chest pain, haematemesis, and dysphagia. Usually the diagnosis is one of exclusion, based on computed tomography imaging and endoscopy. Conservative management is almost always successful. Samantha Cooray, Dionysios Dellaportas, Clifford Caruana, and Andrew R. Davies Copyright © 2017 Samantha Cooray et al. All rights reserved. Surgical Management of Unusual Biangular Mandibular Fractures Sun, 19 Feb 2017 08:57:36 +0000 Bilateral mandibular angle fractures, while representing a rarity among mandibular fractures, are a huge challenge of complex management for the maxillofacial surgeon. There are still many open questions regarding the ideal management of such fractures, including the following: the removal of the third molar in the fracture line, the best surgical approach, and the fixation methods. In this report the authors present the case of 40-year-old man presenting with a bilateral mandibular angle fracture referred to the Maxillofacial Surgery Department of Turin. Open reduction and internal fixation has been made for both sides. The left side third molar was removed and the internal fixation was achieved through internal fixation with one miniplate according to Champy’s technique and transbuccal access for a 4-hole miniplate at the inferior border of the mandible. Right side third molar was not removed and fixation was achieved through intraoral access and positioning of a 4-hole miniplate along the external ridge according to Champy. An optimal reduction was achieved and a correct occlusion has been restored. Stefan Cocis, Umberto Autorino, Fabio Roccia, and Chiara Corio Copyright © 2017 Stefan Cocis et al. All rights reserved. A Giant Brunneroma Causing Gastrointestinal Bleeding and Severe Anemia Requiring Transfusion and Surgery Sun, 19 Feb 2017 00:00:00 +0000 Brunner’s gland hamartoma, also called hyperplasia, adenoma, and Brunneroma, is an extremely rare benign proliferative lesion of Brunner’s glands in the duodenum. While being mostly small and asymptomatic, they can result in gastrointestinal bleeding and obstruction. We report the case of a 54-year-old man presenting with melena and severe anemia requiring blood transfusion. CT scans showed a large mass of 8 cm in diameter, presumably arising in the duodenum. Endoscopic biopsies were not conclusive. As we were unable to determine the nature of the mass preoperatively and due to the severe symptoms, its size, and the uncertain malignant potential, a classic Whipple procedure was performed. The resected specimen showed extensive proliferation of Brunner’s glands without signs of malignancy. Nicola C. Frenkel, Miangela M. Laclé, Inne H. M. Borel Rinkes, Izaak Q. Molenaar, and Jeroen Hagendoorn Copyright © 2017 Nicola C. Frenkel et al. All rights reserved. Resection of the Gastric Tube Reconstructed through the Retrosternal Route without Sternotomy Sun, 19 Feb 2017 00:00:00 +0000 With advances of combined modality therapy, prognoses in esophageal cancer have been improving. After resection of esophageal cancer, the development of gastric tube cancer is a risk. While such cancer in an early stage can be cured endoscopically, total gastric tube resection is indicated in advanced stages. A 68-year-old man underwent subtotal esophagectomy reconstructed with a gastric tube through the retrosternal route. Gastric cancer was found one and a half years postoperatively. The gastric tube was resected without sternotomy. This is the first report of a patient undergoing resection of the gastric tube reconstructed through the retrosternal route without sternotomy. Masahiro Kimura, Yasuyuki Shibata, Kotaro Mizuno, Hironori Tanaka, Motoki Hato, Satoshi Taniwaki, Yoichiro Mori, Nobuo Ochi, Takaya Nagasaki, Shuhei Ueno, and Yuki Eguchi Copyright © 2017 Masahiro Kimura et al. All rights reserved. Reconstruction of Chest Wall by Cryopreserved Sternal Allograft after Resection of Aneurysmal Bone Cyst of Sternum Sun, 19 Feb 2017 00:00:00 +0000 A 20-year-old female was referred to our hospital due to deformity and bulging in anterior aspect of chest wall in sternal area. Chest X-ray and CT scan confirmed a large mass with destruction of sternum. Pathologic diagnosis after incisional biopsy was compatible with aneurysmal bone cyst. We resected sternum completely and reconstructed large anterior defect by a cryopreserved sternal allograft. In follow-up of patient there was no unstability of chest wall with good cosmetic result. Kambiz Sheikhy, Azizollah Abbasi Dezfouli, and Farahnaz Sadegh Beigee Copyright © 2017 Kambiz Sheikhy et al. All rights reserved. Dental Implant Placement with Simultaneous Anterior Maxillary Reconstruction with Block and Particulate Fresh Frozen Allograft Bone: A Case Report with 24-Month Follow-Up Data Thu, 16 Feb 2017 00:00:00 +0000 Fresh frozen allograft bone is routinely used in orthopedic surgery for the reconstruction of large bone defects, and its use in oral and maxillofacial surgery is increasing. The purpose of this case was to demonstrate the installation of dental implants and the use of fresh frozen bone for reconstruction of anterior maxilla in the same surgery. This case report presents the insertion of dental implants followed immediately by a placement of fresh frozen allograft in block and particle for a reconstruction of atrophic anterior maxillary in the same surgery. Ten months subsequent to this procedure, provisional fixed prosthesis was installed on the implants. Four months later (postoperative month 14), the final fixed prosthesis was installed and the clinical success was observed. The insertion of dental implants followed immediately by a placement of fresh frozen allograft is a safe and efficient process that results in the successful return of dental function and aesthetic rehabilitation for the patient. J. S. Vieira, E. M. Brandão-Filho, F. R. Deliberador, J. C. Zielak, A. F. Giovanini, and T. M. Deliberador Copyright © 2017 J. S. Vieira et al. All rights reserved. Stewart-Treves Syndrome Involving Chronic Lymphedema after Mastectomy of Breast Cancer Thu, 09 Feb 2017 08:10:13 +0000 Steward-Treves syndrome is a cutaneous angiosarcoma that usually appears after long evolution of a lymphoedema after mastectomy for mammary neoplasia associated with an axillary dissection. This is a rare disease develop most of the time in upper arm and often confounded with cutaneous metastasis. Only the biopsy and immunohistochemical study confirm the diagnosis. The treatment is surgical and consists of large cutaneous excision, an amputation of the limb or even its disarticulation and will be followed by chemotherapy. Despite the treatment, the prognosis remains severe with poor survival. We report the case of a patient who had a Steward-Treves syndrome 20 years after lymphoedema following a left mastectomy with axillary dissection. Smain Nabil Mesli, Amin Khayreddine Ghouali, Fouad Benamara, Fouzi Ahmed Taleb, Hicham Tahraoui, and Chakib Abi-Ayad Copyright © 2017 Smain Nabil Mesli et al. All rights reserved. Demanding Diagnosis of Splenic Angiosarcoma as Cause of Delayed Treatment of Spontaneous Splenic Rupture: A Case Report and Literature Review Thu, 02 Feb 2017 00:00:00 +0000 Background. Primary splenic angiosarcoma is a very rare mesenchymal malignant tumor associated with a poor prognosis due to its high metastatic potential. This disease can be easily neglected and spontaneous splenic rupture is a frequent manifestation at the time of diagnosis leading to a poor outcome because of peritoneal dissemination. Case Presentation. We describe the case of a 49-year-old man who presented with asthenia, left upper quadrant abdominal pain, and anemia. Computerized tomography scan showed an enlarged spleen with no nodules and a nontraumatic rupture of the splenic capsule. Splenectomy was performed on account of the severe anemia and histopathology examination showed a primary angiosarcoma. Conclusions. Splenic angiosarcoma should be considered as one of the differential diagnoses in patients with nontraumatic spleen rupture and a specific previous medical history. Regrettably, splenectomy allows for a definitive diagnosis but not a curative treatment. Sara Coppola, Andrea Leva, Fabio Pagni, Simone Famularo, and Luca Gianotti Copyright © 2017 Sara Coppola et al. All rights reserved. Juvenile Breast Hypertrophy: A Successful Breast Reduction of 14.9% Body Weight without Recurrence in a 5-Year Follow-Up Tue, 31 Jan 2017 10:05:15 +0000 Juvenile hypertrophy of the breast (JHB) is a rare and relentless disease affecting women in the peripubertal period. We present a 13-year-old girl with massive bilateral JHB, successfully treated with a breast reduction and free nipple graft technique. A total of 7300 grams of breast tissue had been removed, accounting for 14.9% of the patient’s total body weight. Prophylactic hormonal therapy was not commenced. During the 5-year follow-up period, there was no recurrence and the patient remains satisfied with the aesthetic outcome. A recent meta-analysis study indicates that subcutaneous mastectomy is associated with reduced risk of recurrence, but it is more deforming and the aesthetic result is inferior to a reduction mammaplasty. In patients treated with the latter technique, some evidence exists suggesting that the use of a free nipple graft is associated with a less frequent risk of recurrence than a pedicle technique. This present case is unique as it demonstrates the clinical course of this patient at a considerably longer follow-up period than most reported studies. We adhered to the limited available evidence and highlight the long-term reliability of breast reduction with free nipple grafting as the first line surgical option in JHB, eliminating the need for repeated surgeries. Akmal Hisham, Marzida Abd Latib, and Normala Basiron Copyright © 2017 Akmal Hisham et al. All rights reserved. Treatment of Complete Anal Stricture after Diverting Colostomy for Fournier’s Gangrene Tue, 31 Jan 2017 00:00:00 +0000 Background. Anal stenosis is a rare but serious complication of anorectal surgery. Severe anal stenosis is a challenging condition. Case Presentation. A 70-year-old Japanese man presented with a ten-hour history of continuous anal pain due to incarcerated hemorrhoids. He had a history of reducible internal hemorrhoids and was followed for 10 years. He had a fever and nonreducible internal hemorrhoids surrounding necrotic soft tissues. He was diagnosed as Fournier’s gangrene and treated with debridement and diverting colostomy. He needed temporary continuous renal replacement therapy and was discharged on postoperative day 39. After four months, severe anal stenosis was found on physical examination, and total colonoscopy showed a complete anal stricture. The patient was brought to the operating room and underwent colostomy closure and anoplasty. He recovered without any complications. Conclusion. We present a first patient with a complete anal stricture after diverting colostomy treated with anoplasty and stoma closure. This case reminds us of the assessment of distal bowel conduit and might suggest that anoplasty might be considered in the success of the colostomy closure. Kenji Okumura, Tadao Kubota, Kazuhiro Nishida, Alan Kawarai Lefor, and Ken Mizokami Copyright © 2017 Kenji Okumura et al. All rights reserved. Primary Pure Squamous Cell Carcinoma of the Gallbladder Locally Invading the Liver, Duodenum, and Stomach: A Case Report and Literature Review Sun, 29 Jan 2017 00:00:00 +0000 Primary pure squamous cell carcinoma (SCC) of the gallbladder is an exceptionally rare type of tumor that comprises only 1% of all gallbladder cancer. SCC of the gallbladder portends a worse prognosis than the more common adenocarcinoma variant because of its aggressive invasion to local structures and because it is often diagnosed at an advanced stage. Owing to its rarity, diagnosis and management can be challenging. Herein, we present the case of a 75-year-old female complaining of abdominal pain, nausea, and vomiting. Computed tomography and ultrasonography results of the abdomen were consistent with acute cholecystitis and cholelithiasis. Histologic evaluation of the resected mass revealed a malignant tumor with prominent keratinization, confirming the diagnosis of an invasive primary pure SCC of the gallbladder. Microscopic examination showed direct infiltration to the liver, duodenum, and stomach. This case report describes the hospital course of a patient with SCC of the gallbladder and suggests that gallbladder cancer should be considered as part of the differential diagnosis in elderly patients presenting with acute cholecystitis. In addition, this article will review existing literature to examine the utility of different diagnostic techniques and treatment modalities available in the management of gallbladder cancer. Aldrin C. Alpuerto, Maximo E. Mora, R. Jonathan Robitsek, and Sebastian D. Schubl Copyright © 2017 Aldrin C. Alpuerto et al. All rights reserved. Acute Thrombotic Occlusion of the Popliteal Artery following Knee Dislocation: A Case Report of Management, Local Unit Practice, and a Review of the Literature Thu, 26 Jan 2017 09:26:34 +0000 Arterial complications following traumatic knee injury are relatively rare but mandate timely recognition and treatment to avoid significant comorbidity and medicolegal ramifications. In this report we describe a case of acute thrombotic occlusion of the popliteal artery occurring after knee dislocation, successfully repaired by intimal fixation and a limited venous patch reconstruction. We present a review of local practice in screening vascular injuries following knee dislocation, aligned with a review of the literature and considerations for practice. Anthony Dean Godfrey, Fadi Hindi, Callum Ettles, Mark Pemberton, and Perbinder Grewal Copyright © 2017 Anthony Dean Godfrey et al. All rights reserved. Unusual Complication following a Myomectomy: Colic Migration of a Forgotten Abdominal Swab Thu, 26 Jan 2017 00:00:00 +0000 Surgical sponges are the most common retained foreign bodies following surgery. The morbidity of this condition is illustrated herein with the case of a 36-year-old female patient with a history of myomectomy 5 months before her admission into our unit for enterocutaneous fistula. Although imaging and etiological investigations were made, diagnosis was carried out only by laparotomy. The foreign body found was an abdominal swab that migrated from abdominal cavity to the colon causing several intestinal injuries. The lack of specific clinical signs and the death of the patient raise the necessity of preventing these complications that involve the surgeon liability. Boyodi Tchangai, Fousseni Alassani, and Mazamesso Tchaou Copyright © 2017 Boyodi Tchangai et al. All rights reserved. Unexpected Radiation-Induced Aortic Wall Thickening Requiring Composite Graft Technique during Off-Pump Coronary Artery Bypass Grafting Thu, 19 Jan 2017 11:40:00 +0000 Mediastinal radiation is commonly used to treat Hodgkin’s and non-Hodgkin’s lymphoma, lung and breast cancer. Cardiac complications after radiation therapy are well described, although rare. A large spectrum of injuries can occur, causing long term morbidity among survivors. We describe a case of post-actinic ascending aortic wall thickening that prevented saphenous vein proximal anastomosis and was successfully managed with aortic no-touch off-pump coronary artery bypass grafting (OPCAB), 25 years after radiation therapy for Hodgkin’s lymphoma. Paola Redaelli, Amando Gamba, Antonello Stefano Martino, and Michele Triggiani Copyright © 2017 Paola Redaelli et al. All rights reserved. A Case of Crossed Left Renal Ectopia Identified during Colostomy Reversal Wed, 18 Jan 2017 13:50:14 +0000 Unilateral crossed renal ectopia without fusion is an uncommon anatomic anomaly, which often goes undiagnosed. We report a case of this renal variant discovered incidentally during colostomy reversal after Hartmann’s procedure for diverticular stricture. Rachel NeMoyer, Sumana Narayanan, and Nell Maloney-Patel Copyright © 2017 Rachel NeMoyer et al. All rights reserved. Acute “Pseudoischemic” ECG Abnormalities after Right Pneumonectomy Wed, 18 Jan 2017 08:09:35 +0000 New onset of electrocardiographic (ECG) abnormalities can occur after lung surgery due to the changes in the position of structures and organs in the chest cavity. The most common heart rhythm disorder is atrial fibrillation. So-called “pseudoischemic” ECG changes that mimic classic ECG signs of acute myocardial ischemia are also often noticed. We report the case of a 68-year-old male, with no prior cardiovascular disease, who underwent extensive surgical resection for lung cancer. On a second postoperative day, clinical and electrocardiographic signs of acute myocardial ischemia occurred. According to clinical course, diagnostic procedures, and therapeutic response, we excluded acute coronary syndrome. We concluded that physical lesion of the pericardium, caused by extended pneumonectomy with resection of the pericardium, provoked the symptoms and ECG signs that mimic acute coronary syndrome. Our final diagnosis was postpericardiotomy syndrome after extended pneumonectomy and further treatment with nonsteroidal anti-inflammatory drugs (NSAIDs) was recommended. It is necessary to consider possibility that nature of ECG changes after extended pneumonectomy could be “pseudoischemic.” Nada Vasic, Sanja Dimic-Janjic, Ruza Stevic, Branislava Milenkovic, and Verica Djukanovic Copyright © 2017 Nada Vasic et al. All rights reserved. Pedicle Temporalis Fascial Flap with Axial Scalp Flap Obviates Need of Free Flap in Extensive Scalp Wound Tue, 17 Jan 2017 07:22:21 +0000 Extensive scalp defect with exposed bone is best reconstructed with flaps. Majority of these wounds are now routinely reconstructed with free flaps in many centers. Free flaps however require lengthy operative time and may not be available to all patients, where possible less extensive options should thus be encouraged. A sixty-eight-year-old patient presented to us with a Marjolin’s ulcer on the vertex of the scalp. After wide local excision a defect of about 17 cm and 12 cm was left. The defect was successfully covered with a combination of an ipsilateral pedicle temporalis fascial flap and an axial supraorbital scalp flap with good outcome. In conclusion wide defects of the scalp can be fully covered with a combination of local flaps. The axial scalp flap and the pedicle temporalis fascial flap where applicable provide an easy and less demanding option in covering such wounds. These flaps are reliable with good blood supply and have got less donor side morbidity. F. W. Nangole and S. O. Khainga Copyright © 2017 F. W. Nangole and S. O. Khainga. All rights reserved. Utility of the CT Scan in Diagnosing Midgut Volvulus in Patients with Chronic Abdominal Pain Sun, 15 Jan 2017 00:00:00 +0000 Symptomatic intestinal malrotation first presenting in the adults is rare. Midgut volvulus is the most common complication of malrotation in the adults. Because of more differential diagnosis, Computed Tomography (CT) scan can play an important role in the evaluation of patients with this abnormality. The whirl pattern around the superior mesenteric artery found on CT scan in patients with midgut volvulus is pathognomonic and diagnostic. We describe a case of intestinal malrotation complicated by midgut volvulus in an adult patient. The preoperative CT findings were pathognomonic. Ehsan Shahverdi, Mehdi Morshedi, Maryam Allahverdi Khani, Mohammad Baradaran Jamili, and Fatemeh Shafizadeh Barmi Copyright © 2017 Ehsan Shahverdi et al. All rights reserved. Anterior-to-Posterior Migration of a Lumbar Disc Sequestration: Surgical Remarks and Technical Notes about a Tailored Microsurgical Discectomy Tue, 10 Jan 2017 09:57:37 +0000 Extrusion of disc material within the spinal canal complicates up to 28.6% of lumbar disc herniations. Due to the anatomical “corridors” created by the anterior midline septum and lateral membranes, relocation occurs with an anterior and anterolateral axial topography. Posterior migration is an extremely rare condition and anterior-to-posterior circumferential migration is an even rarer condition. Its radiological feature can be enigmatic and since, in more than 50% of cases, clinical onset is a hyperacute cauda equina syndrome, it may imply a difficult surgical decision in emergency settings. Surgery is the gold standard but when dealing with such huge sequestrations, standard microdiscectomy must be properly modified in order to minimize the risk of surgical trauma or traction on the nerve roots. Alessandro Frati, Alessandro Pesce, Mauro Palmieri, Tommaso Vangelista, Riccardo Caruso, Maurizio Salvati, and Antonino Raco Copyright © 2017 Alessandro Frati et al. All rights reserved. Thoracoscopic Surgery for Glomus Tumor: An Uncommon Mediastinal Neoplasm and Iatrogenic Tracheal Rupture Wed, 04 Jan 2017 10:06:33 +0000 Mediastinal glomus tumors are rarely recognized, and only seven cases have been reported in the literature. Here, we describe a rare mediastinal glomus tumor and review the characteristics of this rare clinical case. The patient was a 50-year-old female who presented with coughing for 3 months. Her chest computed tomography scan demonstrated a localized tumor in the posterior superior mediastinum. Intraoperatively, we found a longitudinal rupture of the membranous trachea above the carina. We completely resected the tumor and repaired the tracheal rupture under a thoracoscopy using a pedicled muscle flap. The tissue was diagnosed as a mediastinal glomus tumor according to its histological and immunophenotypic characteristics. Zhongjie Fang, Dehua Ma, Baofu Chen, and Huarong Luo Copyright © 2017 Zhongjie Fang et al. All rights reserved. Rare Type Cranial Postauricular Pilonidal Sinus: A Case Report and Brief Review of Literature Tue, 03 Jan 2017 00:00:00 +0000 A pilonidal sinus is a chronic inflammatory process, the etiology of which is still not fully elucidated. It frequently presents at the sacrococcygeal region (typical) and rarely at extrasacrococcygeal (atypical) locations, including the interdigital, axillary, inguinal, and umbilical regions, as well as the neck, face, and scalp. A 46-year-old man presented with a thirty-year history of a slowly growing nodule on the postauricular area of the scalp. The lesion was excised and diagnosed as a pilonidal sinus based on the clinical and histological findings. The purpose of this review is to report the unusual occurrence of a pilonidal sinus on the scalp and to review the literature regarding this particular location of occurrence. Sebahattin Destek, Vahit Onur Gul, and Serkan Ahioglu Copyright © 2017 Sebahattin Destek et al. All rights reserved. Colorectal Cancer Metastasis to the Thymus Gland: Rare Presentation of Colorectal Cancer as Anterior Mediastinal Mass Mon, 02 Jan 2017 08:19:05 +0000 Despite improved screening modalities, 15–25% of newly diagnosed colorectal cancers are metastatic at the time of diagnosis. The vast majority of these cases present as hepatic metastasis; however, 22% present with concomitant extrahepatic disease. The thymus gland is an uncommon site of metastasis for any primary malignancy, particularly, colorectal cancer given its vascular and lymphatic drainage. This case report details our experience with a rare case of colorectal cancer metastasis to the thymus gland presenting as a symptomatic mediastinal mass. H. Charles Peters, Xiuli Liu, Atif Iqbal, Lisa A. Cunningham, and Sanda A. Tan Copyright © 2017 H. Charles Peters et al. All rights reserved. Skeletal Muscle Metastasis of a GIST: A Case Report and Review of the Literature Sun, 25 Dec 2016 14:22:06 +0000 Gastrointestinal stromal tumors (GISTs) are the most common malignant mesenchymal tumors of the gastrointestinal tract. The most common sites of metastasis are the liver and the peritoneum, whereas metastasis to soft tissue is rare. The authors present the case of a 78-year-old male with a soft tissue metastasis of a GIST and the current literature is reviewed. Olga D. Savvidou, George D. Chloros, Georgios D. Agrogiannis, Penelope Korkolopoulou, Georgios N. Panagopoulos, and Panayiotis J. Papagelopoulos Copyright © 2016 Olga D. Savvidou et al. All rights reserved. Laparoendoscopic Rendezvous for Concomitant Cholecystocholedocholithiasis: A Successful Modality Even in the Most Difficult Presentations Including Pregnancy Sun, 25 Dec 2016 12:15:51 +0000 Background. Laparoendoscopic rendezvous (LERV) technique is emerging as an attractive treatment option for concomitant cholecystocholedocholithiasis. In this paper, we report our experience in performing the LERV technique in patients with unusual presentations in terms of anatomical difficulty, pregnancy, multiple comorbid diseases, and postlaparotomy. We aim to highlight the effectiveness of the LERV technique in some clinical situations where conventional methods would fail or carry high risks in adequately managing concomitant cholecystocholedocholithiasis. Methods. Four patients diagnosed to have concomitant cholecystocholedocholithiasis with associated difficult presentation or comorbid diseases were treated using the LERV technique. One patient presented with difficult anatomy where ERCP failed at initial attempts. Another patient was pregnant (first trimester). A third patient had complex comorbid diseases (bronchial asthma, hypertension, congestive heart failure, and end-stage renal disease on regular hemodialysis). A fourth patient had previous laparotomy and sigmoidectomy for diverticular disease and had severe hospital phobia. Results. All patients tolerated the LERV technique very well; no intraoperative occurrence was reported. The mean operative time was minutes; mean time of the endoscopic part was minutes. The mean blood loss was  mL (range 20–85). Residual stone, postoperative complications, postoperative morbidity, and postoperative mortality were 0 (0%). Postoperative short hospital stay was reported in all patients, average 3 days (range 2–4). Conclusion. LERV procedure is a safe and effective treatment option for the management of concomitant cholecystocholedocholithiasis, even in difficult situations where other methods would fail or carry high risks, or in patients presenting with severe comorbid diseases or pregnancy. This procedure may emerge as an attractive alternative option for high-risk patients. A patient’s wishes may also influence the selection of this procedure. More scientific studies recruiting more patients should be done in order to standardize the LERV procedure. Bader Hamza Shirah, Zaher Abdulaziz Mikwar, Akram Neyaz Ahmad, and Yaser Mohammed Dahlan Copyright © 2016 Bader Hamza Shirah et al. All rights reserved. Ancient Schwannoma of the Cauda Equina: Our Experience and Review of the Literature Thu, 22 Dec 2016 08:19:29 +0000 Ancient schwannomas (AS) are exceedingly rare variant of common schwannomas (CS). Only two cases involving the cauda equina region have been previously reported in literature. AS are typically associated with a higher histological degree of degenerative changes (Antoni B areas). It is of peculiar importance, according to our opinion, to outline that, because of their extremely slow growth (which explains the increase of the degenerative changes in respect to the CS) and their typical soft consistency in respect to their standard counterparts, AS usually imply an even better prognosis. Venceslao Wierzbicki, Alessandro Pesce, Luigi Marrocco, Emanuele Piccione, Alessandro Frati, and Riccardo Caruso Copyright © 2016 Venceslao Wierzbicki et al. All rights reserved. Unusual Presentation of Tuberculous Thyroid Abscess in a Background of Hashimoto’s Thyroiditis in a Chronic Hepatitis B Carrier Thu, 22 Dec 2016 05:58:46 +0000 Tuberculosis of thyroid gland is a very rare disease. It has variable presentations and may be sometimes associated with autoimmune thyroiditis. We report a case of 45-year-old male, with left sided painless neck swelling, with a purulent discharging sinus over it associated with night sweats and loss of appetite. Thyroid imaging disclosed heterogeneous enhancement of left lobe of thyroid gland with internal vascularity and coarse calcifications. Core needle biopsy revealed caseous necrosis and AFB positivity. Patient had thyroid peroxidase antibody and thyroglobulin antibody positivity and the rest of thyroid function tests were normal. Patient had positive Mantoux test, hepatitis B surface Ag, and low viral DNA. The patient was diagnosed as being a case of tuberculous abscess of thyroid gland and was put on antitubercular therapy for 2 months. Patient subsequently underwent left hemithyroidectomy when there was no response. Histopathological examination revealed tuberculosis of thyroid gland. A final diagnosis of tuberculous abscess of thyroid gland in a background of Hashimoto’s thyroiditis in a chronic HBV carrier was made. Therefore, although rare tuberculosis of thyroid should be kept in mind as a differential diagnosis of thyroid swelling. Sakthivel Chinnakkulam Kandhasamy, Sunil Kumar, Anubhav Sangwan, Neelam Sahani, Gopalakrishnan Gunasekaran, Sunil Kumar Meena, and Swapnil Singh Kushwaha Copyright © 2016 Sakthivel Chinnakkulam Kandhasamy et al. All rights reserved. Blowhole Colostomy for Clostridium difficile-Associated Toxic Megacolon Wed, 21 Dec 2016 14:35:30 +0000 We present the case of a 58-year-old man who underwent urgent blowhole colostomy for toxic megacolon (TM) secondary to Clostridium difficile infection (CDI). This infection occurred under antibiotic coverage with amoxicillin-clavulanic acid, four days after laparoscopic sigmoidectomy in our hospital. Although prospective clinical research regarding the surgical management of TM is lacking, decompressive procedures like blowhole colostomy are reported to carry a high risk of postoperative morbidity and mortality and are widely regarded as obsolete. Subtotal or total colectomy with end ileostomy is currently considered the procedure of choice. After presenting our case, we discuss the literature available on the subject to argue that the scarce evidence on the optimal surgical treatment for TM is primarily based on TM associated with inflammatory bowel diseases (IBD) and that there might be a rationale for considering minimally invasive procedures like blowhole colostomy for CDI-associated TM. Jeroen Kerstens, Ian Diebels, Charles de Gheldere, and Patrick Vanclooster Copyright © 2016 Jeroen Kerstens et al. All rights reserved. A Case Report of Bilateral Adrenal Sarcomatoid Carcinoma Tue, 20 Dec 2016 15:36:13 +0000 Adrenocortical carcinoma (ACC) is a rare and aggressive malignancy. Sarcomatoid adrenal carcinoma is even more aggressive type of ACC. Bilateral malignant adrenal tumors are extremely rare except for those that represent metastasis from an extra-adrenal organ. Here we report a 53-year-old woman who presented with abdominal pain and weight loss. Abdominal computed tomography revealed bilateral adrenal masses and a mass in her liver. Surgical specimens showed pleomorphic tumor cells with epithelial and spindle cell morphology and immunohistochemical staining was compatible with sarcomatoid carcinoma. Sarcomatoid adrenal carcinoma should be kept in mind during the management of bilateral adrenal masses. Ozlem Turhan Iyidir, Ethem Turgay Cerit, Çiğdem Özkan, Eroğlu Altınova, Ali Rıza Çimen, Sinan Sözen, Mustafa Kerem, Müjde Aktürk, Leyla Memiş, Baloş Törüner, Nuri Çakır, and Metin Arslan Copyright © 2016 Ozlem Turhan Iyidir et al. All rights reserved.