Case Reports in Surgery The latest articles from Hindawi Publishing Corporation © 2016 , Hindawi Publishing Corporation . All rights reserved. Chronic Intussusception Associated with Malrotation in a Child: A Variation of Waugh’s Syndrome? Thu, 29 Sep 2016 13:30:54 +0000 Chronic intussusception is a relatively uncommon disease most commonly observed in older children. Waugh’s syndrome represents a rare entity characterized by intestinal malrotation and acute intussusception. We report a very unusual case of intestinal malrotation associated with chronic intussusception. Clinical presentation, radiological findings, and managing of this association are discussed in the light of the available literature. Nick Zavras, Konstantinos Tsilikas, and George Vaos Copyright © 2016 Nick Zavras et al. All rights reserved. One-Step Posterior and Anterior Combined Approach for L5 Retroperitoneal Schwannoma Eroding a Lumbar Vertebra Tue, 27 Sep 2016 10:00:23 +0000 We report the case of a large lumbar schwannoma eroding the vertebra and originating from spinal canal with invasion of the retroperitoneal space. We also review all the cases in literature reporting lumbar schwannomas eroding the vertebral bodies and invading the retroperitoneal space focusing on the surgical strategies to manage them. Spinal CT-scan revealed a inhomogeneous soft-tissue mass arising from the right L5-S1 neural foramen and its most anterior portion had a clear colliquative aspect. Magnetic resonance image showed a neoplastic lesion with homogeneous low signal in T1WI, heterogeneous signal in T2WI, and strong enhancement in postgadolinium examination. It developed as well in the retroperitoneal space, posteriorly to the iliac vein, up to the psoas muscle with wide erosion of the omolateral conjugate foramen. We performed a one-step combined approach together with the vascular surgeon because the lesion was too huge to allow a complete resection via a posterior approach and furthermore its tight relationship with the psoas muscle and the iliac vessels in the retroperitoneal space should be more safely managed via a retroperitoneal approach. We strongly suggest a 1-step surgery first approaching the dumbbell and the intraspinal schwannomas posteriorly achieving the decompression of the spinal canal and the cleavage of the tumor cutting the root of origin and the vascular supply and valuating the stability of the spine for potential artrodesis procedure. The patient must be then operated on via a retroperitoneal approach achieving the complete en bloc resection of the tumor. Giancarlo D’Andrea, Giovanni Sessa, Veronica Picotti, and Antonino Raco Copyright © 2016 Giancarlo D’Andrea et al. All rights reserved. Stent Graft-in-Stent Graft as a Rescue Technique for Endovascular Treatment of Giant Extracranial Internal Carotid Aneurysm Sun, 25 Sep 2016 09:34:45 +0000 Endovascular treatment of a giant extracranial internal carotid aneurysm by a stent graft implantation was unsuccessful due to a high flow leak directly through the stent graft’s coating. The problem was solved deploying a second stent graft inside the previously implanted one resulting in complete exclusion of the aneurysmal sac and patent carotid lumen preservation. The review of the literature did not provide a case using this endovascular strategy. Follow-up for more than 12 months, using CT angiography, showed confirmed aneurysmal exclusion and carotid patency and no clinical complications have been detected. Adenauer Marinho de Oliveira Góes Junior and Salim Abdon Haber Jeha Copyright © 2016 Adenauer Marinho de Oliveira Góes Junior and Salim Abdon Haber Jeha. All rights reserved. Tracheal Lobular Capillary Haemangioma: A Rare Benign Cause of Recurrent Haemoptysis Sun, 25 Sep 2016 06:48:21 +0000 Lobular capillary haemangioma (LCH), previously known as pyogenic granuloma, is a benign vascular lesion commonly found within the oral and nasal cavity. However, it is rarely encountered within the trachea, where presenting features include recurrent haemoptysis, cough, and wheeze. We here describe a case of a 7 mm tracheal LCH in a 56-year-old woman, which was successfully resected at interventional bronchoscopy using biopsy forceps. Clinicians should be aware of tracheal LCH in the differential diagnosis for recurrent haemoptysis. Metesh Nalin Acharya, Konstantinos Kotidis, and Mahmoud Loubani Copyright © 2016 Metesh Nalin Acharya et al. All rights reserved. A Content Incontinent: Report of Liposomal Bupivacaine Induced Fecal Incontinence Thu, 22 Sep 2016 14:17:23 +0000 Proper surgical management of anal fistula demands sound clinical judgment and extraordinary care to prevent incontinence and adequate postoperative pain control and provide satisfactory resolution to optimize quality of life. Fecal incontinence can be a devastating complication of procedures performed for fistula in ano. We report a unique case in which temporary incontinence (for less than 4 days) followed injection of liposomal bupivacaine for postoperative pain control after draining seton placement for fistula in ano. Patients and physicians should be aware as it may be mistaken for a more serious anatomical and permanent cause of fecal incontinence. Emanuel A. Shapera and Vinay K. Rai Copyright © 2016 Emanuel A. Shapera and Vinay K. Rai. All rights reserved. Gallbladder Volvulus in a Patient with Type I Choledochal Cyst: A Case Report and Review of the Literature Thu, 22 Sep 2016 13:54:29 +0000 Introduction. Gallbladder volvulus is a rare, potentially fatal condition unless diagnosed and treated early. Choledochal cysts are rare congenital malformations of the biliary tree predisposing to different pathologies and posing the risk of degradation into cholangiocarcinoma and gallbladder cancer. Dealing with both diseases at once has not been published yet in the literature. Presentation of Case. We report a case of gallbladder volvulus in an elderly female who happened to have a concomitant type I choledochal cyst. Treatment was achieved with a cholecystectomy and observation and follow-up of the choledochal cyst. Discussion. Prompt diagnosis and surgical management of gallbladder volvulus is important to avoid the morbidity and mortality of gangrenous cholecystitis and biliary peritonitis in a frail old population of patients. Precise clinical diagnosis, supplemented with specific imaging clues, helps in the diagnosis. Management of choledochal cysts is also surgical; however the timing of surgery is still a matter of debate. Conclusion. We describe in this report the first case of gallbladder volvulus in a patient with a choledochal cyst and propose a management algorithm of a very rare biliary tree pathology combination. George Younan, Max Schumm, Fadwa Ali, and Kathleen K. Christians Copyright © 2016 George Younan et al. All rights reserved. Pancreaticopleural Fistula Causing Massive Right Hydrothorax and Respiratory Failure Thu, 22 Sep 2016 12:48:09 +0000 Hydrothorax secondary to a pancreaticopleural fistula (PPF) is a rare complication of acute pancreatitis. In patients with a history of pancreatitis, diagnosis is made by detection of amylase in the pleural exudate. Imaging, particularly magnetic resonance cholangiopancreatography, aids in the detection of pancreatic ductal disruption. Management includes thoracocentesis and pancreatic duct drainage or pancreatic resection procedures. We present a case of massive right hydrothorax secondary to a PPF due to recurrent acute pancreatitis. Due to respiratory failure, urgent thoracocentesis was done. Distal pancreatectomy with splenectomy and cholecystectomy was performed. The patient remains well at one-year follow-up. Esther Ern-Hwei Chan and Vishalkumar Girishchandra Shelat Copyright © 2016 Esther Ern-Hwei Chan and Vishalkumar Girishchandra Shelat. All rights reserved. Massive Preperitoneal Hematoma after a Subcutaneous Injection Wed, 21 Sep 2016 10:39:38 +0000 Preperitoneal hematomas are rare and can develop after surgery or trauma. A 74-year-old woman, receiving systemic anticoagulation, developed a massive preperitoneal hematoma after a subcutaneous injection of teriparatide using a 32-gauge, 4 mm needle. In this patient, there were two factors, the subcutaneous injection of teriparatide and systemic anticoagulation, associated with development of the hematoma. These two factors are especially significant, because they are widely used clinically. Although extremely rare, physicians must consider this potentially life-threatening complication after subcutaneous injections, especially in patients receiving anticoagulation. Hideki Katagiri, Kentaro Yoshikawa, Alan Kawarai Lefor, Tadao Kubota, and Ken Mizokami Copyright © 2016 Hideki Katagiri et al. All rights reserved. Colocutaneous Fistula after Open Inguinal Hernia Repair Wed, 21 Sep 2016 09:25:17 +0000 The plug-and-patch technique is frequently used for the open repair of inguinal hernias; however, serious complications may arise on rare occasions. We present the case of a 69-year-old patient who presented with a colocutaneous fistula with the sigmoid colon 9 years after the repair of a left sliding inguinal hernia with the plug-and-patch technique. The patient underwent sigmoidectomy and excision of the fistulous track. He was discharged on postoperative day 5 and had an uneventful recovery. Although such complications are reported rarely, the surgeon must be aware of them when deciding upon the method of hernia repair. Maria Isaia, Demetris Christou, Panayiotis Kallis, Nikolaos Koronakis, and Panayiotis Hadjicostas Copyright © 2016 Maria Isaia et al. All rights reserved. Neglected Fournier’s Gangrene Caused by Acinetobacter baumannii: A Rare Case Report Tue, 20 Sep 2016 17:19:17 +0000 Fournier’s gangrene, rare but life threatening disease, is characterized by an acute necrotic infection of the scrotum, penis, or perineum. Fournier’s gangrene is a mixed infection caused by both aerobic and anaerobic bacteria. Fournier’s gangrene caused by multidrug resistant Acinetobacter baumannii have been reported rarely. The mainstay of treatment is prompt recognition and a combination of antibiotics with radical debridement. We describe a case of a 56-year-old male patient presenting with neglected Fournier’s gangrene caused by Acinetobacter baumannii. Many treatment modalities including broad-spectrum antibiotics, aggressive debridement, negative pressure wound therapy, diversion colostomy, and partial-thickness skin grafts were applied to save the patient’s life. Arif Emre, Mehmet Sertkaya, Sami Akbulut, Yakup Duman, and Ilhami Taner Kale Copyright © 2016 Arif Emre et al. All rights reserved. Endovascular Aneurysm Repair in HIV Patients with Ruptured Abdominal Aneurysm and Low CD4 Thu, 15 Sep 2016 08:43:05 +0000 We report two HIV infected patients with ruptured abdominal aneurysm by using endovascular aneurysm repair (EVAR) technique. A 59-year-old Thai man had a ruptured abdominal aortic aneurysm and a 57-year-old man had a ruptured iliac artery aneurysm. Both patients had a CD4 level below 200 μ/L indicating a low immune status at admission. They were treated by EVAR. Neither patient had any complications in 3 months postoperatively. EVAR may have a role in HIV patients with ruptured abdominal aneurysm together with very low immunity. Saranat Orrapin, Saritphat Orrapin, Supapong Arworn, Termpong Reanpang, and Kittipan Rerkasem Copyright © 2016 Saranat Orrapin et al. All rights reserved. Intraluminal Bowel Erosion: A Rare Complication of Retained Gallstones after Cholecystectomy Wed, 14 Sep 2016 14:13:53 +0000 Laparoscopic cholecystectomy for acute cholecystitis and cholelithiasis is one of the most common operations performed in the United States. Inadvertent perforation and spillage of gallbladder contents are not uncommon. The potential impact of subsequent retained gallstones is understated. We present the case of an intraperitoneal gallstone retained from a previous cholecystectomy eroding into the bowel and leading to intraluminal mechanical bowel obstruction requiring operative intervention. This case illustrates the potential risks of retained gallstones and reinforces the need to diligently collect any dropped stones at the time of initial operation. Alex B. Blair and Nathaniel McQuay Jr. Copyright © 2016 Alex B. Blair and Nathaniel McQuay Jr. All rights reserved. Spontaneous Septic Arthritis of Pubic Symphysis in an Elite Athlete Wed, 14 Sep 2016 14:02:44 +0000 Septic arthritis of the pubic symphysis is a potentially severe disease. Athletes are at risk of this form of spontaneous arthritis, as inflammation of the pubic bone due to muscular stress is relatively common. Oedema due to inflammation might predispose to infection through bacteraemia or local bacterial translocation. Suspicion should be raised when an athlete complains of groin pain and has signs of infection (i.e., fever, elevated white blood cell count, and elevated C-reactive protein). Diagnosis is made by imaging showing signs of inflammation combined with positive (blood) cultures. Broad spectrum antibiotics should be started upon suspicion and adjusted according to cultures. An abscess causing clinical deterioration under antibiotic treatment is an indication for invasive intervention (i.e., surgical or image-guided drainage). This is the first case of spontaneous septic arthritis of the pubic symphysis in an athlete requiring surgical and additional image-guided drainage. F. Jasmijn Smits, Herman Frima, Christoph Schaeffeler, and Christoph Sommer Copyright © 2016 F. Jasmijn Smits et al. All rights reserved. Wandering Spleen and Organoaxial Gastric Volvulus after Morgagni Hernia Repair: A Case Report and Review of the Literature Wed, 14 Sep 2016 13:49:58 +0000 Wandering spleen and gastric volvulus are two rare entities that have been described in association with congenital diaphragmatic hernia. The diagnosis is difficult and any delay can result in ischemia and necrosis of both organs. We present a case of a 13-year-old girl, previously operated on for anterior diaphragmatic hernia and intrathoracic gastric volvulus, that presented to our service for a subdiaphragmatic gastric volvulus recurrence associated with a wandering spleen. In this report we reviewed the literature, analyzing the clinical presentation, diagnostic assessment, and treatment options of both conditions, in particular in the case associated with diaphragmatic hernia. Noemi Cantone, Caterina Gulia, Vittorio Miele, Margherita Trinci, and Vito Briganti Copyright © 2016 Noemi Cantone et al. All rights reserved. An Unusual Case of Abdominal Leiomyoma Presenting as a Free Lying Intraperitoneal Mass in an Elderly Gentleman Thu, 08 Sep 2016 17:34:42 +0000 Introduction. Leiomyomas are common benign tumours of female reproductive tract and are rarely seen in extrauterine location. Case Report. We report an interesting case of a free lying abdominal leiomyoma presenting as a painless abdominal lump in an elderly gentleman. Discussion. Primary abdominal leiomyomas are uncommon and require surgical removal if symptomatic. Amrit Nasta, Kunal Nandy, and Yogesh Bansod Copyright © 2016 Amrit Nasta et al. All rights reserved. Organ Preservation in a Case of Retroperitoneal Ganglioneuroma: A Case Report and Review of Literature Wed, 07 Sep 2016 14:04:00 +0000 The retroperitoneum is a closed space harbouring vital organs including the great vessels, kidneys and adrenal glands, ureters, and the ascending and descending colon. Surgical management of retroperitoneal pathologies may need multiorgan resection in order to achieve complete surgical resection while preservation of surrounding organs should be attempted, especially in case of benign tumors. We present a case of 15-year-old girl with an 11 × 6 × 5 cm retroperitoneal ganglioneuroma displacing the right kidney, renal vein, and ureter and abutting the IVC which was excised in toto preserving the right kidney and ureter with careful dissection around the great vessels. We also attempt to review the various surgical options available while dealing with these benign retroperitoneal tumors which are often detected incidentally and usually surround important retroperitoneal organs and vessels. Santosh Kumar, Shivanshu Singh, and Abhishek Chandna Copyright © 2016 Santosh Kumar et al. All rights reserved. Recurrent Midgut Bleeding due to Jejunal Angioleiomyoma Wed, 07 Sep 2016 13:33:34 +0000 Angioleiomyoma being a type of true smooth muscle gastrointestinal tumors can lead to serious life-threatening gastrointestinal bleeding. We report a case of 21-year-old male patient with recurrent midgut bleeding. Contrast-enhanced CT revealed highly vascular small bowel neoplasm. The patient underwent laparotomy with bowel resection and recovered uneventfully. Histopathology revealed jejunal angioleiomyoma. Mahir Gachabayov and Petr Mityushin Copyright © 2016 Mahir Gachabayov and Petr Mityushin. All rights reserved. The Application of Vacuum-Assisted Closure Device in the Management of Empyema Necessitans Wed, 31 Aug 2016 13:40:17 +0000 Vacuum-assisted closure (VAC) is gaining popularity in the management of many types of acute and chronic wounds. The use of VAC devices in thoracic surgery is limited, but it appears to be promising in complex cases of empyema thoraces. We report a case of empyema necessitans, in which VAC was used to achieve complete wound healing after open drainage which was communicating with the pleural space. Yasser Aljehani, Zahra Al-Matar, and Samah Nawar Copyright © 2016 Yasser Aljehani et al. All rights reserved. Traumatic Rupture of A Posterior Mediastinal Teratoma following Motor-Vehicle Accident Wed, 31 Aug 2016 07:32:38 +0000 We report a case of a posterior mediastinal mature cystic teratoma with rupture secondary to blunt chest trauma in a 20-year-old male involved in a motor-vehicle accident. Initial treatment was guided by Advanced Trauma Life Support and a tube thoracostomy was performed for presumed hemothorax. The heterogeneous collection within the thoracic cavity was discovered to be the result of a ruptured cystic mass. Pathologic findings confirmed the mass consistent with a mature cystic teratoma. As mediastinal teratomas are most commonly described arising from the anterior mediastinum, the posterior location of the teratoma described in this report is exceedingly rare. Christopher Bell, Fernando Domingo, Ashley D. Miller, Jeremiah S. Smith, and James R. Headrick Jr. Copyright © 2016 Christopher Bell et al. All rights reserved. Successful Deep Inferior Epigastric Perforator Flap Harvest despite Preoperative Therapeutic Subcutaneous Heparin Administration into the Abdominal Pannus Mon, 29 Aug 2016 16:33:58 +0000 Abdominal free flaps for microsurgical breast reconstruction are most commonly harvested based on the deep inferior epigastric vessels that supply skin and fat via perforators through the rectus muscle and sheath. Intact perforator anatomy and connections are vital for subsequent optimal flap perfusion and avoidance of necrosis, be it partial or total. The intraflap vessels are delicate and easily damaged and it is generally advised that patients should avoid heparin injection into the abdominal pannus preoperatively as this may compromise the vascular perforators through direct needle laceration, pressure from bruising, haematoma formation, or perforator thrombosis secondary to external compression. We report three cases of successful deep inferior epigastric perforator (DIEP) flap harvest despite patients injecting therapeutic doses of low molecular weight heparin into their abdomens for thrombosed central venous lines (portacaths™) used for administering primary chemotherapy in breast cancer. Joseph W. Duncumb, Kana Miyagi, Parto Forouhi, and Charles M. Malata Copyright © 2016 Joseph W. Duncumb et al. All rights reserved. Perforated Carcinoma in the Gastric Remnant: A Case of Conservative Treatment Prior to Successful Curative R0 Resection Mon, 29 Aug 2016 12:35:16 +0000 An 80-year-old man who had undergone distal gastrectomy and Billroth-II gastrojejunostomy 38 years previously, for a benign gastric ulcer, was diagnosed with remnant gastric cancer based on upper gastrointestinal endoscopy findings. He presented at our emergency department with acute-onset epigastric pain due to perforated remnant gastric cancer. Conservative medical management was selected, including nasogastric tube insertion, antibiotics, and proton pump inhibitors, because his peritonitis was limited to his epigastrium and his general condition was stable. Twenty-one days after the perforation occurred, curative total remnant gastrectomy and D2 lymphadenectomy were performed. Adhesion between the lateral segment of the liver and the dissected lesser curvature of the gastric remnant may have contributed to the peritonitis in this case, which was limited to the epigastrium. This is the first report of perforated remnant gastric cancer in which conservative treatment was effective prior to curative resection. The protocol reported here may be of use to other clinicians who may encounter this clinical entity in their practices. Ken Yuu, Hiroshi Kawashima, Sho Toyoda, Satoshi Okumura, Kansuke Yamamoto, Naoto Mizumura, Aya Ito, Hiromitsu Maehira, Atsuo Imagawa, Masao Ogawa, Masayasu Kawasaki, and Masao Kameyama Copyright © 2016 Ken Yuu et al. All rights reserved. Primary Splenic Angiosarcoma Presenting as Idiopathic Thrombocytopenic Purpura: A Case Report and Review of the Literature Mon, 29 Aug 2016 09:55:37 +0000 Angiosarcoma of the spleen is a rare malignancy that arises from vascular endothelial origin. This neoplasm is highly malignant and diagnosis is often delayed due to the vague presentation of clinical symptoms. A case report and concise review of the current diagnostic criteria and surgical treatment are provided to aid in the detection and treatment of this malignancy. We present a case of a 56-year-old female who presented with massive splenomegaly secondary to angiosarcoma of the spleen. The patient suffered from longstanding symptomatic anemia and thrombocytopenia. Diagnosis of a splenic angiosarcoma can be difficult due to the vague presentation and lack of concrete risk factors. Early identification and splenectomy are paramount. However, it is an aggressive malignancy with poor prognosis. We reviewed the literature of the current diagnostic and surgical treatment of primary splenic angiosarcoma. S. Christopher N. Frontario, Anna Goldenberg-Sandau, Darshan Roy, and Roy Sandau Copyright © 2016 S. Christopher N. Frontario et al. All rights reserved. An Unusual Trocar Site Hernia after Prostatectomy Sun, 28 Aug 2016 08:42:41 +0000 Trocar site hernias are rare complications after laparoscopic surgery but most commonly occur at larger trocar sites placed at the umbilicus. With increased utilization of the laparoscopic approach the incidence of trocar site hernia is increasing. We report a case of a trocar site hernia following an otherwise uncomplicated robotic prostatectomy at a 12 mm right lower quadrant port. The vermiform appendix was incarcerated within the trocar site hernia. Subsequent appendectomy and primary repair of the hernia were performed without complication. Ryan K. Schmocker and Jacob A. Greenberg Copyright © 2016 Ryan K. Schmocker and Jacob A. Greenberg. All rights reserved. Malrotated Subhepatic Caecum with Subhepatic Appendicitis: Diagnosis and Management Thu, 25 Aug 2016 13:31:45 +0000 Subhepatically located caecum and appendix is a very rare entity. It occurs due to the anomaly in fetal gut rotation that results in an incomplete rotation and fixation of the intestine. Appendicitis, which is a common surgical emergency, in combination with the abnormal subhepatic location, presents a great challenge in its diagnosis and management. Here, we describe a 42-year-old male with chronic dyspepsia who presented with sepsis and severe pain at his right hypochondriac and epigastric region. The final diagnosis was acute appendicitis of the subhepatic appendix. Our discussion focuses on the diagnostic approach and clinical and surgical management. We hope that our report will increase the awareness among the clinicians and hasten the management of such rare condition to avoid complications. Hock Chin Chong, Feng Yih Chai, Dhayal Balakrishnan, Siti Mohd Desa Asilah, Irene Nur Ibrahim Adila, and Khuzaimah Zahid Syibrah Copyright © 2016 Hock Chin Chong et al. All rights reserved. Successful Resection of Isolated Para-Aortic Lymph Node Recurrence from Advanced Sigmoid Colon Cancer following 156 Courses of FOLFIRI Regimen Thu, 25 Aug 2016 13:02:57 +0000 Isolated para-aortic lymph node (PLN) recurrence from colorectal cancer (CRC) is rare, with no currently validated treatments. Few reports have described the successful resection of isolated PLN involvement from CRC following chemotherapy. We report the case of a 63-year-old man who underwent sigmoidectomy for sigmoid colon cancer at our hospital. Pathological examination demonstrated advanced sigmoid colon cancer with metastatic involvement in both of the tested PLNs. Palliative chemotherapy was initiated four weeks after surgical resection, with administration of the FOLFIRI regimen. Four years after the operation, computed tomography (CT) revealed an enlarged PLN below the left renal vein. As PLN enlarged to 15 mm in the minor axis on a CT scan in 2014 after receiving a total of 156 courses of the FOLFIRI regimen, we considered the enlarged PLN to represent an isolated metastasis. Accordingly, lymph node resection was performed with microscopically negative margins. The patient maintained a good quality of life without any side effects throughout the whole course of his treatment and remains disease-free at 24 months without chemotherapy after resection of the isolated PLN. Curative resection following chemotherapy may improve survival of carefully selected advanced CRC patients with locoregional recurrence, such as isolated PLN involvement. Kaoru Takeshima, Kazuo Yamafuji, Atsunori Asami, Hideo Baba, Nobuhiko Okamoto, Hidena Takahashi, Chisato Takagi, and Kiyoshi Kubochi Copyright © 2016 Kaoru Takeshima et al. All rights reserved. Laparoscopic Management of a Very Rare Case: Cystic Artery Pseudoaneurysm Secondary to Acute Cholecystitis Mon, 22 Aug 2016 09:13:15 +0000 Pseudoaneurysm of a cystic artery is a rare entity that commonly occurs secondary to biliary procedures. Most of the cases in literature are consisted of ruptured aneurysms and to our knowledge, except our case, there were only 3 cases with unruptured aneurysms, which incidentally were detected by radiological methods. When cystic artery pseudoaneurysm is present with acute cholecystitis, most of the reports in literature suggested open cholecystectomy with the ligation of the cystic artery as a main treatment option. In this paper we present a case of acute cholecystitis with unruptured cystic artery pseudoaneurysm that incidentally was detected by computed tomography (CT). Cystic artery pseudoaneurysm was handled laparoscopically with simultaneous cholecystectomy. Due to high risk of rupture, surgeons have evaded laparoscopic approach to acute cholecystitis, which accompanied cystic artery pseudoaneurysm. However herein, we proved that laparoscopic management of cystic artery pseudoaneurysm with simultaneous cholecystectomy is feasible and reliable method. Deniz Alis, Sina Ferahman, Süleyman Demiryas, Cesur Samanci, and Fethi Emre Ustabasioglu Copyright © 2016 Deniz Alis et al. All rights reserved. Management and Reconstruction of a Gastroesophageal Junction Adenocarcinoma Patient Three Years after Pancreaticoduodenectomy: A Surgical Puzzle Thu, 18 Aug 2016 16:03:05 +0000 Introduction. With the improving survival of cancer patients, the development of a secondary primary cancer is an increasingly common phenomenon. Extensive surgery during initial treatment may pose significant challenges to surgeons managing the second primary cancer. Case Presentation. A 69-year-old male, who had a pancreaticoduodenectomy three years ago for pancreatic head adenocarcinoma, underwent an uneventful extended total gastrectomy for gastroesophageal junctional adenocarcinoma. The reconstruction controversies and considerations are highlighted. Discussion. Genetic, environmental, and lifestyle factors are common for several gastrointestinal malignancies. However, the occurrence of a second unfavorable cancer such as gastroesophageal adenocarcinoma after pancreatic head cancer treatment is extremely uncommon. This clinical scenario possesses numerous difficulties for the surgeon, since surgical resection is the mainstay of treatment for both malignancies. Gastrointestinal reconstruction becomes challenging and requires careful planning and meticulous surgical technique along with sound intraoperative judgement. Dionysios Dellaportas, James A. Gossage, and Andrew R. Davies Copyright © 2016 Dionysios Dellaportas et al. All rights reserved. Diagnostic Dilemma in Appendiceal Mucormycosis: A Rare Case Report Thu, 18 Aug 2016 13:02:24 +0000 Appendiceal mucormycosis is a rare life-threatening infection seen in immunocompromised patients. It is usually seen in chemotherapy induced neutropenia in patients with hematological malignancies. Clinically, the symptoms and signs may be masked due to ongoing corticosteroids. The condition may mimic bacterial appendicitis and the less serious condition, typhlitis. The disease demands prompt surgical debulking and aggressive antifungal treatment. However, surgery is delayed due to the poor performance status and severe neutropenia. This may lead to perforative peritonitis and further dissemination. The survival rates of such disease are dismal. Unfortunately, the diagnosis may be confirmed only on histological examination of the surgically excised tissue. Very few cases have been reported so far. We present here once such a fatal case of appendiceal mucormycosis in a 14-year-old boy who was immunosuppressed due to intensive induction therapy for Acute Myeloblastic Leukemia. Sali Priyanka Akhilesh, Yadav Kamal Sunder, Pande Prasad, George Mary Asha, Agarwal Mohan, and Mehta Hitesh Copyright © 2016 Sali Priyanka Akhilesh et al. All rights reserved. A Rare Case of Mixed Neuroendocrine Tumor and Adenocarcinoma of the Pancreas Wed, 17 Aug 2016 16:45:43 +0000 Introduction. Neuroendocrine carcinoma (NEC) of pancreas is a rare tumor with aggressive progression and poor prognosis. Its coexistence with adenocarcinoma poses significant clinical problems and has not been addressed in the literature. Methods. We describe a case of a 51-year-old male who underwent pancreatoduodenectomy due to pancreatic head tumor  cm. Histological examination of the specimen revealed a mixed neoplasm: (1) a well differentiated adenocarcinoma, neoplastic blasts of which are extended focally to the submucosa without invading the muscular layer, and (2) a low differentiated NEC consisting of solid clusters and pagetoid formations. All 18 lymph nodes of the specimen were free of neoplastic disease and the surgical margins of the specimen were tumor-free. No adjuvant treatment was administered and two months after the operation the patient developed liver metastasis. FNA cytology of the hepatic lesions revealed low grade carcinoma with neuroendocrine characteristics. Five lines of chemotherapy were administered: VP + CDDP, paclitaxel + ifosfamide + Mesna + CDDP, Folfox + Avastin, Folfiri + Avastin, and CAV. During his treatment he revealed PD and succumbed to his disease 13 months after the operation. Conclusion. Coexistence of NEC with adenocarcinoma of the pancreas is a very rare entity presenting significant challenges regarding its adjuvant treatment and the treatment of distant relapse. Sofia Xenaki, Konstantinos Lasithiotakis, Alexandros Andreou, Sofia Aggelaki, Maria Tzardi, Anna Daskalaki, George Chalkiadakis, and Emmanuel Chrysos Copyright © 2016 Sofia Xenaki et al. All rights reserved. Squamous Cell Cancer Arising in an African American Male Cheek from Discoid Lupus: A Rare Case and Review of the Literature Wed, 17 Aug 2016 13:52:51 +0000 A 50-year-old African American male with Discoid Lupus Erythematosus (DLE) presented to the dermatology clinic for a rapidly enlarging left cheek mass. The mass failed to resolve with conservative measures. A biopsy revealed poorly differentiated Squamous Cell Carcinoma (SCC). He was referred to Head and Neck Surgery and successfully underwent a resection with free flap reconstruction. Postoperatively he did well. Squamous cell skin carcinomas arising from lesions of Discoid Lupus are rare and aggressive tumors with greater likelihood of metastases. Cases have been reported among patients with different clinical characteristics; we present a rare case arising in an African American male on the face and involving the ear. Emanuel A. Shapera and Paul D. Kim Copyright © 2016 Emanuel A. Shapera and Paul D. Kim. All rights reserved.