BackgroundImplantation of a gastric stimulator is a feasible surgical therapy for patients with therapy refractory gastroparesis. In addition it seems to be a promising alternative for treating morbid obesity. We present for the first time the surgical emergency of small bowel obstruction due to strangulation by gastric stimulator electrodes.Case presentationA 59-year-old Caucasian female had undergone implantation of a gastric stimulator to cope with the symptoms of a partial gastroparesis. Eight years after the operation, the patient began to present repeatedly to different hospitals because of abdominal pain and nausea. Symptoms and imaging indicated ileus, which could always be treated conservatively. The underlying pathology could not ultimately be determined and the symptoms were eventually considered gastroparesis-related. After two years the patient was finally referred in circulatory shock due to peritonitis with underlying small bowel obstruction. Emergency laparotomy revealed small bowel strangulation by the gastric stimulator electrodes.ConclusionRepeated presentation of a patient with an unfamiliar treatment modality must raise suspicion of unusual complications. Specialist surgeons treating with innovative methods should provide proper information that is accessible to everyone who might have to treat possible complications.

BackgroundIn the treatment of spinal cord tumors, complete tumor resection with complete reconstruction of the spine represents the ideal goal. However, for the treatment of heavily calcified spinal meningioma, en-bloc resection of the tumor together with the involved dura at the tumor base through laminectomy is quite difficult. Conventional laminectomy is not wide enough to allow full exposure of such tumors, and postoperative dural defects can cause serious complications.Case presentationA 58-year-old Japanese woman presented with a 3-month history of progressive muscle weakness and numbness of the lower extremities. Magnetic resonance imaging (MRI) and computed tomography showed a calcified spinal cord tumor with dural tail sign at the T10-T11 level, severely compressing the spinal cord anterolaterally. The patient underwent en-bloc resection of the tumor with the inner layer of the dura and preservation of the outer layer of the dura through recapping T-saw laminoplasty of T10-T11, including bilateral facet joints. The tumor was histologically diagnosed as meningioma. Postoperatively, the patient achieved complete recovery of neurological functions. Bone union after laminoplasty was obtained within 6 months. Follow-up MRI at 5 years postoperatively demonstrated no recurrence of the tumor.ConclusionResection of spinal meningioma with only the inner layer of dura can minimize postoperative complications, including spinal fluid leakage. Recapping T-saw laminoplasty provides extensive exposure for tumor removal. The combination of these techniques may offer an ideal surgical option for complete resection of spinal meningioma with complete preservation of the posterior spinal elements.

BackgroundEndovascular aneurysm repair has revolutionized the therapeutic strategy for abdominal aortic aneurysm. However, hostile proximal aneurysmal neck and tortuosity of access vessels remain challenges in selecting optimal stent-grafts in abdominal aortic aneurysms with difficult anatomy.Case presentationA 65-year-old woman complained of intermittent abdominal pain for one week. Computed tomography angiogram demonstrated a tortuous infrarenal abdominal aortic aneurysm with a tapered neck and a 136° of infrarenal angulation. Aneurysmal dilatation and severe calcification of bilateral iliac arteries and tortuous aortoiliac access were also showed. Endovascular approach using Endurant stent-graft was attempted at an outside hospital, but failed because of the significant tortuosity of the abdominal aorta and iliac arteries. Since the patient refused to have open aneurysm repair, he was transferred to our hospital for further evaluation and possible EVAR with a different approach. EVAR was performed successfully using Gore Excluder stent-grafts (W.L. Gore & Associates, Flagstaff, AZ, USA). During the procedure, cannulation of the contralateral limb was unable to be achieved because of the tortuous aortoiliac course. Therefore, a snare was inserted from right radial artery, through the contralateral gate, to grasp the wire from left femoral artery. Two iliac stent-grafts were sequentially deployed with the lower end distal to the opening of the left internal iliac artery. Angiography confirmed complete sealing of the aneurysm with patency of bilateral renal arteries and external iliac arteries. The postoperative courses were uneventful and follow-up computed tomography angiogram at 6 months demonstrated patent bilateral femoral and renal arteries without endoleaks or stent migration.ConclusionAlthough endovascular repair of aortic aneurysm with hostile neck and tortuous access is rather challenging, choosing flexible stent-grafts and suitable techniques is able to achieve an encouraging outcome.

BackgroundCecal volvulus is relatively rare. Moreover, to the best of our knowledge, a case of cecal volvulus caused by endometriosis has not yet been reported.Case presentationA 41-year-old woman was admitted to our hospital with a 14-day history of subacute intermittent right lower quadrant abdominal pain. Simple abdominal radiography and abdominal computed tomography findings were suggestive of sigmoid volvulus, and she underwent an emergency colonoscopy. Following colonoscopic reduction, the patient’s symptoms resolved quickly, and elective laparoscopic surgery was scheduled 2 weeks after admission. Intraoperative examination revealed a significantly distended cecum and ascending colon, which was twisted around a short rope-like adhesion that connected the cecum and the mesentery of the transverse colon, whereas the sigmoid colon was neither twisted nor extended. We laparoscopically performed an ileocecal resection. The postsurgery histopathological examination revealed the presence of endometrial tissue in the short rope-like adhesion. This finding confirmed that cecal volvulus in this patient was caused by endometriosis.ConclusionCecal volvulus should be considered in relatively young women who present with atypical right lower abdominal pain. Whenever possible, secondary factors should be evaluated preoperatively, especially in relatively young patients.

BackgroundGorham’s disease is a rare osteolytic disorder characterized by progressive resorption of bone and replacement of osseous matrix by a proliferative non-neoplastic vascular or lymphatic tissue. A standardized treatment protocol has not yet been defined due to the unpredictable natural history of the disease and variable clinical presentations. No single treatment has proven to be superior in arresting the course of the disease. Trials have included surgery, radiation and medical therapies using drugs such as calcium salts, vitamin D supplements and hormones. We report on our advantageous experience in the management of this osteolyic disorder in a case when it affected only the skull vault. A brief review of pertinent literature about Gorham’s disease with skull involvement is provided.Case presentationA 25-year-old Caucasian male presented with a skull depression over the left fronto-temporal region. He noticed progressive enlargement of the skull defect associated with local pain and mild headache. Physical examination revealed a tender palpable depression of the fronto-temporal convexity. Conventional X-ray of the skull showed widespread loss of bone substance. Subsequent CT scans showed features of patchy erosions indicative of an underlying osteolysis. MRI also revealed marginal enhancement at the site of the defect. The patient was in need of a pathological diagnosis as well as complex reconstruction of the afflicted area. A density graded CT scan was done to determine the variable degrees of osteolysis and a custom made allograft was designed for cranioplasty preoperatively to allow for a single step excisional craniectomy with synchronous skull repair. Gorham’s disease was diagnosed based on histopathological examination. No neurological deficit or wound complications were reported postoperatively. Over a two-year follow up period, the patient had no evidence of local recurrence or other systemic involvement.ConclusionsA single step excisional craniectomy and cranioplasty can be an effective treatment for patients with Gorham’s disease affecting the skull vault only. Preoperative planning by a density graded CT aids to design a synthetic bone flap and is beneficial in skull reconstruction. Systemic involvement is variable in this patient’s population.

BackgroundSitus inversus totalis is a relatively rare condition and is an autosomal recessive congenital defect in which an abdominal and/or thoracic organ is positioned as a “mirror image” of the normal position in the sagittal plane. We report our experience of laparoscopic-assisted total gastrectomy with lymph node dissection performed for gastric cancer in a patient with situs inversus totalis.Case presentationA 58-year-old male was diagnosed with cT1bN0N0 gastric cancer. There were no vascular anomalies on abdominal angiographic computed tomography with three-dimensional reconstruction. laparoscopic-assisted total gastrectomy was performed with D1+ lymph node dissection, in accordance with the Japanese Gastric Cancer Treatment Guidelines. There were no intraoperative issues, and no postoperative complications.ConclusionsThis was the first report describing laparoscopic-assisted total gastrectomy with the standard typical lymph node dissection in the English literature. We emphasize that the position of trocars and the standing side of the primary surgeon during the lymph node dissection are critical.