Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2017 , Hindawi Publishing Corporation . 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. Flare-Up Diverticulitis in the Terminal Ileum in Short Interval after Conservative Therapy: Report of a Case Tue, 20 Dec 2016 14:33:22 +0000 Diverticulitis in the terminal ileum is uncommon. Past reports suggested that conservative therapy may be feasible to treat terminal ileum diverticulitis without perforation; however, there is no consensus on the therapeutic strategy for small bowel diverticulitis. We present a 37-year-old man who was referred to our hospital for sudden onset of abdominal pain and nausea. He was diagnosed with diverticulitis in the terminal ileum by computed tomography (CT). Tazobactam/piperacillin hydrate (18 g/day) was administered. The antibiotic treatment was maintained for 7 days, and the symptoms disappeared after the treatment. Thirty-eight days after antibiotic therapy, he noticed severe abdominal pain again. He was diagnosed with diverticulitis in terminal ileum which was flare-up of inflammation. He was given antibiotic therapy again. Nine days after antibiotic therapy, laparoscopy assisted right hemicolectomy and resection of 20 cm of terminal ileum were performed. Histopathology report confirmed multiple ileal diverticulitis. He was discharged from our hospital 12 days after the surgery. Colonoscopy was performed two months after the surgery and it revealed no finding suggesting inflammatory bowel disease. Surgical treatment should be taken into account as a potential treatment option to manage the diverticulitis in the terminal ileum even though it is not perforated. Kensuke Nakatani, Takaharu Kato, Shinichiro Okada, Risa Matsumoto, Kazuhiro Nishida, Hiroyasu Komuro, Maki Iida, Shiro Tsujimoto, and Toshiyuki Suganuma Copyright © 2016 Kensuke Nakatani et al. All rights reserved. Abdominal Pain in the Female Patient: A Case of Concurrent Acute Appendicitis and Ruptured Endometrioma Tue, 20 Dec 2016 14:18:11 +0000 General surgeons are often asked to evaluate acute abdominal pain which has an expanded differential diagnosis in women of childbearing age. Acute appendicitis accounts for many surgical emergencies as a common cause of nongynecologic pelvic pain. In some rare instances, acute appendicitis has been shown to occur simultaneously with a variety of gynecologic diseases. We report a case of concurrent acute appendicitis and ruptured ovarian endometrioma. Martine A. Louis, Amanda R. Doubleday, Elizabeth Lin, Ji Yoon Baek, Alda Andoni, and Xiao Hui Wang Copyright © 2016 Martine A. Louis et al. All rights reserved. Delayed Tension Pneumocephalus following Gunshot Wound to the Head: A Case Report and Review of the Literature Thu, 15 Dec 2016 12:12:48 +0000 Tension pneumocephalus is a rare complication of head trauma and neurosurgical procedures, amongst other causes. It is defined by the combination of intracranial air, increased intracranial pressure, and mass effect. Although it often presents soon after surgery, it can also rarely present in a delayed fashion. We present a case of delayed tension pneumocephalus, occurring approximately 16 weeks after bifrontal craniectomy for a self-inflicted gunshot wound. Following a month of rhinorrhea, postnasal drip, and cough, the patient presented with a sensation of expansion in the area of the right forehead. As tension pneumocephalus is an emergency that can be fatal, this patient was treated expediently and avoided severe neurological deficits. The case recounted here is important as a demonstrative example that tension pneumocephalus does not always follow a defined course immediately after trauma or neurosurgery but rather can develop insidiously without obvious signs. Arthur Wang, Elena Solli, Nathan Carberry, Virany Hillard, and Adesh Tandon Copyright © 2016 Arthur Wang et al. All rights reserved. Reconstruction of Abdominal Wall Defects Using a Pedicled Anterolateral Thigh Flap including the Vastus Lateralis Muscle: A Report of Two Cases Thu, 15 Dec 2016 12:10:59 +0000 The purpose of abdominal wall reconstruction is to prevent hernias and protect the abdominal viscera. In cases involving full-thickness defects of the rectus abdominis muscle, the muscle layer should be repaired. We present 2 cases in which full-thickness lower rectus abdominis muscle defects were reconstructed using vastus lateralis-anterolateral thigh flaps. The pedicled vastus lateralis-anterolateral thigh flap provides skin, fascia, and muscle tissue. Furthermore, it has a long neurovascular pedicle and can reach up to the periumbilical area and cover large defects. We consider that this muscle flap is a good option for repairing full-thickness lower abdominal defects. Kiyoko Fukui, Masaki Fujioka, and Satoko Ishiyama Copyright © 2016 Kiyoko Fukui et al. All rights reserved. De Garengeot’s Hernia: Two Case Reports with Correct Preoperative Identification of the Vermiform Appendix in the Hernia Wed, 14 Dec 2016 09:45:29 +0000 We present two cases of incarcerated de Garengeot’s hernia. This anatomical phenomenon is thought to occur in as few as 0.5% of femoral hernia cases and is a rare cause of acute appendicitis. Risk factors include a long pelvic appendix, abnormal embryological bowel rotation, and a large mobile caecum. In earlier reports operative treatment invariably involves simultaneous appendicectomy and femoral hernia repair. Both patients were correctly diagnosed preoperatively with computed tomography (CT). Both had open femoral hernia repair, one with appendectomy and one with the appendix left in situ. Both patients recovered without complications. Routine diagnostic imaging modalities such as ultrasonography and standard CT have previously shown little success in identifying de Garengeot’s hernia preoperatively. We believe this to be the first documented case of CT with concurrent oral and intravenous contrast being used to confidently and correctly diagnose de Garengeot’s hernia prior to surgery. We hope that this case report adds to the growing literature on this condition, which will ultimately allow for more detailed case-control studies and systematic reviews in order to establish gold-standard diagnostic studies and optimal surgical management in future. Zhaosheng Jin, Muhammad Rafiz Imtiaz, Henry Nnajiuba, Suzette Samlalsingh, and Akinyede Ojo Copyright © 2016 Zhaosheng Jin et al. All rights reserved. Torsion of Hydrosalpinx with Concurrent Acute Cholecystitis: Case Report and Review of Literature Wed, 14 Dec 2016 09:33:59 +0000 Introduction. Isolated torsion of the Fallopian tube is an uncommon cause of acute lower abdominal pain and can occur in women of all age groups. Cholecystitis is a frequent cause of upper abdominal pain. We present an unusual case with the presence of these two distinct pathological entities occurring concurrently in the same patient, causing simultaneously occurring symptoms. To our knowledge, this is the first reported presentation of such a case. Methods. We describe a 34-year-old premenopausal woman who presented with right sided upper and lower abdominal pain and nausea. Abdominal ultrasound (US) revealed acute cholecystitis. Vaginal US was suggestive of right hydrosalpinx. Intravenous antibiotics were administered and consent was obtained for operative intervention. During laparoscopy, the right Fallopian tube with hydrosalpinx was noted to be twisted three times. The right ovary appeared normal. The gall bladder wall was thickened and inflamed. Laparoscopic right salpingectomy and cholecystectomy were performed. Results. Surgical pathology revealed hydrosalpinx with torsion and acute calculous cholecystitis. The patient had an uneventful postoperative course and was discharged home on the first postoperative day. Her symptoms resolved after the procedure. Conclusions. In women with abdominal pain, both gynecologic and nongynecologic etiologies should be considered in the differential diagnoses. Concurrent presence of symptomatic gynecologic and nongynecologic intra-abdominal pathology is rare. Isolated Fallopian tube torsion is rare and is associated most often with hydrosalpinx. Some torqued Fallopian tubes can be salvaged. Laparoscopy is useful in management of both Fallopian tube torsion and cholecystitis. Preeti R. John and Amelia M. Pasley Copyright © 2016 Preeti R. John and Amelia M. Pasley. All rights reserved. A Rare Subcutaneous Manifestation of Metastatic Renal Cell Carcinoma Wed, 14 Dec 2016 06:10:58 +0000 We report a rare case of advanced metastatic renal cell carcinoma which initially presented to the clinic with back and forehead lumps. Ultrasound imaging of the lumps and later of the abdomen picked up a right renal tumour which led to further computed tomography and bone scans. The bone scan confirmed that the forehead lump was a calvarial metastasis and such a presentation for metastatic RCC is very rare which bears a significantly poorer prognosis. Darren Yak Leong Chan and Wei Jin Chua Copyright © 2016 Darren Yak Leong Chan and Wei Jin Chua. All rights reserved. Migration of a Broken Kirschner Wire after Surgical Treatment of Acromioclavicular Joint Dislocation Mon, 12 Dec 2016 15:04:24 +0000 Kirschner wire (K-wire) is one of the commonly used implants in orthopaedics practice. Migration of the wire is one of the most frequently reported complications after fixation by the K-wire. In particular, it has been reported that a greater range of motion in the shoulder, negative intrathoracic pressure associated with respiration, gravitational force, and muscular activities may cause migration from the upper extremities. In general, thin and long foreign bodies with smooth surfaces that are localized within the tendon sheath and at an upper extremity can migrate more readily and can reach longer distances. Here, we present a patient with long-term migration of a broken K-wire who underwent fixation for acromioclavicular joint dislocation 5 years ago. Sabri Batın, Fırat Ozan, Kaan Gürbüz, Erdal Uzun, Cemil Kayalı, and Taşkın Altay Copyright © 2016 Sabri Batın et al. All rights reserved. Primary Osteosarcoma of the Bone with Rhabdoid Features: A Rare, Previously Undescribed Primary Malignant Tumor of Bone Mon, 12 Dec 2016 14:13:30 +0000 Primary osteosarcoma of the bone with rhabdoid features is a rare malignant tumor of bone, not previously described in the literature. Here we report a 69-year-old female who originally presented with a right femur pathologic fracture. Radiographs of the injury showed an aggressive-appearing lesion of the distal femur. Initial biopsy was done, which was not diagnostic; additional advanced imaging studies were performed, which failed to show any other site within the body with detectable disease process. Accordingly, the patient underwent radical resection of the distal femur and reconstruction with endoprosthesis. Histopathology obtained from the operative specimen showed osteosarcoma with rhabdoid features. Two months after surgery, the patient is symptom-free and doing well; she is currently pending adjuvant chemotherapy. Although rhabdoid features have been described in extraskeletal osteosarcoma, this appears to be the first mention of osteosarcoma of bone with rhabdoid features in the literature. Max Seiter, Motasem Al Maaieh, Andrew Rosenberg, and Sheila Conway Copyright © 2016 Max Seiter et al. All rights reserved. A Case of an Epithelioid Hemangioendothelioma Arising from the Innominate Vein Mimicking Cervical Metastatic Lymphadenopathy Mon, 12 Dec 2016 12:41:06 +0000 Background. Epithelioid hemangioendothelioma (EHE) is a rare tumor usually presenting in soft tissue. EHE is a vascular malignancy of intermediate clinical behavior, with a histologic appearance of endothelial cells growing in nests or cords. Although EHE often originates from a vessel, it is relatively rare for a primary vascular EHE to originate from a large vein or artery. Occurrence in the mediastinum is exceptionally rare. There are no known associations with other malignancies. Case Presentation. We present a case of mediastinal invasive EHE in a 39-year-old female with concurrent papillary thyroid cancer. She initially presented with a thyroid mass found by her primary care provider, with preoperative imaging concerning for extension into the superior mediastinum. Operative exploration revealed a mediastinal mass distinct from her thyroid carcinoma with invasion into the great vessels, requiring off-pump interposition graft bypass for en bloc resection. Final pathology confirmed pT3N1b multifocal papillary thyroid carcinoma with a separate grade 1 pT1b EHE. Review of the literature describes the demographics, updated pathologic outcomes, histologic findings, and reported incidence of EHE. Conclusions. This is the first reported case of thyroid malignancy with separate and concurrent EHE. Surgeons should remain aware of this entity given its variable behavior. Although initially described as an indolent neoplasm, tumors with poor prognostic factors have been shown to be locally aggressive. Jason B. Brill, Isaac E. Schwartz, Lindsey M. Prescher, and Theodore C. Pratt Copyright © 2016 Jason B. Brill et al. All rights reserved. Adrenal Collision Tumor: Coexistence of Pigmented Adrenal Cortical Oncocytoma and Ganglioneuroma Thu, 08 Dec 2016 12:01:52 +0000 Background. Adrenal collision tumors (ACTs), in which distinct tumors coexist without intermingling in the same adrenal gland, are rare and their actual prevalence is unknown. ACTs commonly consist of adrenal cortical adenoma, pheochromocytoma, or metastatic malignant tumor. Case Report. A 32-year-old woman who had been experiencing gastric discomfort for one month was referred to our hospital with abnormal imaging findings. The physical examination and the laboratory data including endocrine studies were unremarkable. Abdomen computed tomography (CT) and magnetic resonance imaging (MRI) showed two adjacent masses in the left suprarenal fossa, and a laparoscopic left adrenalectomy was done. Histological and immunohistochemical (IHC) examinations revealed two distinct tumors: a pigmented adrenal cortical oncocytoma (ACO) and a ganglioneuroma, respectively. Conclusion. Both tumors are rare in the adrenal gland and exist as ACTs only exceptionally rarely. This is the first reported case of coexisting oncocytoma and ganglioneuroma in the same adrenal gland to our knowledge. Hye Seung Lee, Yoo Jin Choi, Chungyeul Kim, and Baek-Hui Kim Copyright © 2016 Hye Seung Lee et al. All rights reserved. Management of Giant Gastric Ulcer Perforation: Report of a Case and Review of the Literature Tue, 06 Dec 2016 08:32:21 +0000 Giant gastric ulcer (GGU) is defined as an ulcer more than 3 cm in diameter. Now infrequent in clinical practice, in the pre-H2 receptor antagonist (H2RA) era, the incidence of GGU varied between 12 and 24% of all gastric ulcers. Proton pump inhibitors reportedly achieve better healing rates and symptom relief in comparison to H2RA. The GGU is associated with high incidence of serious complications such as hemorrhage. A perforated GGU though rare (<2%) offers serious challenges in management. We report one such case wherein the role of multidetector CT scan (MDCT) for diagnosis and treatment planning, surgical options for GGU perforations, and factors affecting outcome are discussed. Nitin Vashistha, Dinesh Singhal, Gurpreet Makkar, Suneel Chakravarty, and Vivek Raj Copyright © 2016 Nitin Vashistha et al. All rights reserved. Intestinal Obstruction Caused by Ileocolic and Colocolic Intussusception in an Adult Patient with Cecal Lipoma Sun, 04 Dec 2016 09:04:05 +0000 Introduction. Intussusception is a rare clinical entity in adults (<1% of intestinal obstructions). Colonic intussusception is even rarer, particularly when caused by lipomas. Case Presentation. A 47-year-old woman presented to our emergency department complaining of abdominal pain with vomiting and diarrhoea. X-ray and CT showed bowel obstruction due to ileocolonic and colocolonic intussusception; a giant colonic lipoma (9 × 4 × 4 cm) was recognizable immediately distally to the splenic flexure of the colon. The patient underwent emergency laparotomy and right hemicolectomy. Assessment of the resected specimen confirmed the diagnosis of giant colonic polypoid lesion near to the ileocecal valve, causing a 12 cm long intussusception with moderate ischemic damage. Conclusion. Colonic obstruction due to intussusception caused by lipomas is a very rare condition that needs urgent treatment. CT is the radiologic modality of choice for diagnosis (sensitivity 80%, specificity near 100%); since the majority of colonic intussusceptions are caused by primary adenocarcinoma, if the etiology is uncertain, the lesion must be interpreted as malignant and extensive resection is recommended. At present, surgery is the treatment of choice and determines an excellent outcome. Tiziana Casiraghi, Alessandro Masetto, Massimo Beltramo, Mauro Girlando, and Camillo Di Bella Copyright © 2016 Tiziana Casiraghi et al. 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.