This case report describes a 75 year-old woman who presents with a post-traumatic thoracic aortic pseudoaneurysm (TAPA), approximately 40 years later. Due to the rarity of this condition, no standardized approach exists. We describe the successful treatment of this disease with Carotid-Subclavian bypass followed by thoracic endovascular vascular aortic repair (TEVAR) of the pseudoaneurysm.

Patients who have multivessel coronary artery stenosis on catheterization are good candidates for Coronary Artery Bypass Graft because stenting is less efficacious in reducing mortality when involving more than two coronary vessels. We present a patient who complains of chest pain status post coronary artery bypass graft using the left internal mammary artery over 10 years prior. The patient is diagnosed with coronary-subclavian steal syndrome via Doppler ultrasound and catheterization. The patient is treated surgically via carotid distal subclavian/axillary bypass grafting due to extensive stenosis of the subclavian graft.

The prevalence of melanoma is on the rise in western society especially as the younger generation ages. Although considered a malignancy of the skin, melanoma can spread to multiple systems throughout the body due to the location of melanocytes in multiple organ systems. Therefore, it is essential for physicians to detect malignant melanoma at the earliest stage in order to decrease the risk of metastasis. We describe a case of a 69-year-old gentleman with a significant past medical history of stage 1a melanoma diagnosed 5 years ago, who presents with multiple nodal masses. The patient is diagnosed with metastatic melanoma after discovery of enhancing lesions on CT imaging of the head, neck, and abdomen confirmed via biopsy of the supraclavicular node. Although the stage 1a melanoma has a low rate of recurrence and metastasis, it is paramount that physicians continue to due serial, thorough dermatologic exams even after successful excision of the primary tumor.

The worst fear for any cancer patient to hear is the word metastasis. Melanoma is highly associated with metastasis and the higher the staging, the less likely the patient is to survive. We discuss a 46-year-old gentleman who presents with recurrent pleural effusions and shortness of breath with a previous diagnosis of metastatic melanoma. He had an initial lesion on his deltoid, which was excised with wide margins but was found to have an enlarged lymph node that was confirmed by pathology to be metastatic melanoma. Further diagnostic workup came back normal. Nodular melanoma has a worse prognosis due to lesions having already metastasized by the time of diagnosis. Due to the aggressive behavior, many suggest adjuvant chemotherapy with surgical excision of any lesions.

Background: Between 6 to 12% of people with cholelithiasis also have choledocholithiasis. Pimary bile duct closure and T-tube drainage are two options available for closure of choledochotomy after common bile duct exploration. The aim of this meta-analysis was to analyze the outcomes of primary choledochorrhaphy versus T-tube drainage after common bile duct exploration for choledocholithiasis.

Methods: A systematic literature search was conducted using Embase, MEDLINE, Cochrane, and PubMed databases on all randomized controlled trials (RCT), published between January 1980 and September 2012, reporting perioperative outcomes after primary choledochorrhaphy versus T-tube drainage after common bile duct exploration.

Results: Eight RCTs were included comprising of 619 patients. Primary choledochorrhaphy was found to reduce the length of stay (weighted mean difference 95% confidence interval (CI), -1.09 [- 1.59 to – 0.60]; p < 0.0001), overall complications (odds ratio (OR) 95% CI, 0.47 [0.28, 0.80]; p = 0.005), positive bile culture (OR 95% CI, 0.58 [0.10, 0.45]; p < 0.0001) compared to T-tube drainage. Whereas no significant differences were found in retained bile duct stones (OR 95% CI, 0.60 [0.23, 1.57]; p = 0.30), mortality (OR 95% CI, 0.44 [0.10, 1.81]; p = 0.25), biliary leak (OR 95% CI, 0.58 [0.23, 1.42]; p = 0.23) and subhepatic collection (OR 95% CI, 1.06 [0.30, 3.68]; p = 0.93).

Conclusion: Primary choledochorrhaphy should be the method of choice after choledochotomy for common bile duct exploration as it is associated with reduced length of stay and overall complications compared to T-tube drainage.

Background: Pancreatogastrostomy (PG) and pancreatojejunostomy (PJ) are both options for reconstruction following pancreaticoduodenectomy (PD). Pancreatic fluid leakage from the pancreatoenteric anastomoses (POPF – post operative pancreatic fistula), delayed gastric emptying, biliary leak, fluid collection, morbidity and perioperative mortality are all complications associated with both methods of reconstruction. The aim of this meta- analysis is to analyze the overall patient benefit in utilizing PJ versus PG.

Methods: Theprimaryend-pointwastheincidenceofPOPFformationfollowingPD while using both PG and PJ. Secondary outcomes examined were the incidence of perioperative mortality, delayed gastric emptying (DGE), biliary leak (BL), fluid collection (FC), and overall morbidity.

Results: Five trials involving 669 patients were included in the meta analysis. Reconstruction utilizing PG was found to decrease the incidence of POPF (n= 669 OR 0.7 (0.45, 1.10) 95% CI p = 0.13). Gastric emptying was less delayed with PG in four studies (n= 520 OR 0.77(0.47, 1.26) 95% CI p = 0.29). Four studies involved comprising 524 patients showed decreased incidence of FC with PG (OR 0.51(0.31, 0.83) 95% CI p = 0.006) and no significant difference in incidence of perioperative mortality (1.07(0.43, 2.66) 95% CI p = 0.88). Four studies with 553 patients both showed decreased incidence of overall morbidity (OR 0.79(0.56, 1.12) 95% CI p = 0.18) and biliary leak (OR (0.22, 1.35) 95% CI p = 0.19).

Conclusions: Despitethecontroversyregardingreconstitutionofpancreaticoentericflow following pancreaticoduodenectomy, the data obtained does not support the notion that either method of reconstruction possesses significantly superior ability to decrease incidence of POPF and other secondary complications.

Breast cancer is a concern for many women because of the potential for distant metastasis. More common sites of metastasis are the lungs, bones, and liver especially with more aggressive types of breast cancer. We report an 87 year-old woman previously diagnosed with breast carcinoma complaining of gastric symptoms and new left breast mass diagnosed with linitis plastica of breast origin after gastroscopy. Metastasis to the stomach has a very rare incidence for breast cancer patients and depending on whether the cancer has positive hormone receptors, treatment usually includes chemotherapy with hormonal treatment.