Axillary Surgical Attitude Changing with Retrospective Application of ACOSOG Z0011 Eligible Criteria: An Institutional Evaluation.

Objective: Sentinel lymph node biopsy (SLNB) represents the gold standard for axillary surgical staging. The aim of this study was to assess the proportion of axillary lymph node dissection (ALND) that could be avoided after retrospective application of the ACOSOG Z0011 criteria and to evaluate the shortterm complications associated with axillary surgery. Materials and Methods: We reviewed breast cancer (BC) patients treated by primary breast-conserving surgery from 2012 to 2015. The percentage of SLNB vs ALND performed before and after the application of the ACOSOG Z0011 criteria was calculated. Complications were analyzed using crosstabs, with p<0.05 considered significant. Results: Two hundred fifty one patients with a median age of 59.3 years were included. BC tumors had a median size of 13 mm and were mostly unifocal (83.9%). There were 30.3% with 1-2 metastatic lymph nodes (MLN). ALND was performed in 44.2%. The patients with 1-2 MLN, had only SLNB in 14.5% of cases. By applying the ACOSOG Z0011 criteria, ALND would have been avoided in 40.2% of patients. At least one postoperative complication was reported after SLNB or ALND for 45.7% and 74.7% of patients respectively. Seroma was the most frequent complication, and occurred in 29.3% of cases after SLNB and in 59.5% after ALND. Conclusion: SNLB is the most commonly used axillary surgical staging procedure in this series (55.8%). With a retrospective application of the ACOSOG Z0011 criteria in our population, ALND could have been avoided for 40.2% patients. Post-operative complications rate was higher after ALND, with a seroma rate at 59.5%.

Efficacy of opioid-free anesthesia in modified radical mastectomy: a cross-sectional observational study.

Introduction: Perioperative management of female patients undergoing breast surgeries differs from other patients due to chronic pain and postoperative nausea and vomiting. The anesthesia could consist of opioid-free general anesthesia (OFA) or non-opioid-free general anesthesia (NOFA). OFA relies on multimodal analgesia preoperatively and postoperatively. However, it is not yet established whether OFA could replace NOFA as a standard regimen for the management of breast surgeries. The aim of this study is to evaluate the efficacy of OFA for breast surgeries in female patients. Materials and methods: Patients undergoing modified radical mastectomy were retrospectively recruited. Two groups were defined: group 1, consisting of treated patients using OFA and group 2, consisting of treated patients using NOFA. Mean time to extubate and mean dose of morphine after recovery were computed. Postoperative morphine and antiemetic use were assessed for up to 24 h. A comparison of the computed data was conducted between both groups. Results: A total of 116 patients were included with a mean age of 53±13 years. Group 1 consisted of 56 (mean age was 54±14 years). Group 2 consisted of 60 patients (mean age was 51±12 years). Demographic parameters and time to extubate did not yield significant differences. We noticed morphine sparing at T0 and T12 with statistically significant differences P=0.043 and P=0.006, respectively. Conclusion: OFA could be considered in modified radical mastectomy management in female patients; nerve block seemed to act as morphine sparing in operative and postoperative settings by providing significantly less time to extubate with less postoperative morphine requirement.

Effectiveness of Carbon Localization for Invasive Breast Cancer: An Institutional Experience.

Introduction: The final oncological and aesthetic results of breast-conserving surgery (BCS) are influenced by the precise localization of breast cancer (BC) tumors and by the quality of the intraoperative margin assessment technique. This study aimed to assess the effectiveness of the carbon localization (CL) technique by determining the success rate of BC identification and the proportion of adequate complete resection of BC lesions. Methods: We conducted a cross-sectional retrospective study of patients treated with primary BCS for invasive BC who underwent CL of their BC lesion at the Jules Bordet Institute between January 2015 and December 2017. Descriptive statistics with categorical and continuous variables were used. The success rate of tumor identification and the rate of adequate excision were calculated using the test of percentages for independent dichotomous data. Results: This study included 542 patients with 564 nonpalpable BC lesions. The median pathological tumor size was 12 mm. Of these, 460 were invasive ductal carcinomas. Most of the tumors were of the luminal subtype. CL was performed using ultrasound guidance in 98.5% of cases. The median delay between CL and surgery was 5 days, with 46% of the patients having CL one day before surgery. The lumpectomy weighed 38 g on average, with a median diameter of the surgical sample at 6 cm and a median volume of 44 cm3 (6-369). One-stage complete resection was successfully performed in 93.4% of cases. In 36% of cases, an intraoperative re-excision was performed, based on intraoperative macroscopic pathological margin evaluation. The tumor was identified in 98.9% of cases in the breast surgical specimen. Conclusion: This study demonstrated high success rates for BC tumor identification (99%) and one-stage complete resection (93.4%) after BCS and CL. These results show that CL is an effective, simple, and inexpensive localization technique for successful excision of BC lesions during BCS.

Factors influencing the decision-making process for breast surgery in women likely to face breast cancer: a cross-sectional study.

Breast cancer (BC) is one of the main neoplasia affecting women worldwide. Breast conserving surgery (BCS) or modified radical mastectomy (Mx) are both applicable with no difference between patients treated by these surgeries in terms of quality of life, local recurrence rate, and overall survival. The surgical decision today favors the surgeon-patient dialog, in which the patient is involved in the therapeutic decision. Several factors influence the decision-making process. This study aims to investigate these factors in Lebanese women likely to face BC and before being operated on, unlike other studies that targeted patients who had already been operated on. Methods: The authors conducted a study to investigate the factors influencing the choice of breast surgery. To be eligible for this study, participants had to be Lebanese women, with no age limit and willing to participate voluntarily. A questionnaire form was used to collect data related to patient demographics, health, surgery, and relevant factors. Data analysis was performed by statistical tests using IBM SPSS Statistics software (version 25) and Microsoft Excel spreadsheet (Microsoft 365). Significant factors (defined as P<0.05) were than used to determine the factors that influenced women's decision-making. Results: Data from 380 participants were analyzed. The majority of participants were young (41.58% were between 19 and 30 years old), living in Lebanon (93.3%), and had a bachelor's degree or higher (83.95%). Almost half of the women (55.26%) are married and have children (48.95%). Among the participants, 97.89% had no personal history of BC, and 95.79% had not undergone any breast surgery. The majority of participants indicated that their primary care physician and surgeon influenced their decision on the type of surgery they take (56.32 and 61.58%, respectively). Only 18.16% of respondents said they had no preference for Mx over BCS. While the others listed their reasons and concerns for choosing Mx, including: concern about recurrence (40.26%), concern about residual cancer (31.05%). 17.89% of the participants justify the reason for choosing Mx rather than BCS, by the fact that they lack information on BCS. Most of the participants confirmed the importance of clarifying all information about BC and treatment options before being affected by a malignancy (71.84%) of which 92.28% preferred to participate in the next online lectures about this topic. The assumption of equal variance is assumed. Indeed, according to the Levene Test (F=1.354; P<0.05), there is a significant difference between the age categories of the group that prefers Mx (2.08) and the group that does not prefer Mx over BCS (1.77). Based on an independent samples t-test (t(380)=2.200; P<0.05). On the other hand, the preference of Mx over BCS is statistically dependent on the choice of contralateral prophylactic mastectomy. Indeed, according to the χ2-test, the relationship between the two variables is significant (χ2 (2)=8.345; P<0.05). The 'Phi' statistic measures the intensity of the relationship between the two variables in question (φ=0.148); therefore, the relationship between the preference of Mx rather than BCS and the asking of contralateral prophylactic Mx is strong and significant (P<0.05). However, there was no statistically significant dependence between the preference of Mx and the other factors studied (P>0.05). Conclusion: BC poses a problem for affected women, especially when they are asked to choose between a Mx or a BCS. Several complex factors affect and influence their decision and lead them to decide. Understanding these factors helps us to properly help these women choose. In this study, the authors demonstrated all the factors that can influence the choice of Lebanese women prospectively, and we stressed the need to explain all the modalities before being diagnosed.

Primary invasive ductal carcinoma of axillary accessory breast.

Primary accessory breast cancer is an extremely rare pathology, representing less than 1 % of all breast cancers, and it is found in more than 90 % of cases in the axilla. The diagnosis of accessory axillary breast cancer (AABC) is often late and at an advanced stage with an average delay of 40.5 months. Histological sampling and immunohistochemical results confirm the diagnosis. Most patients are diagnosed with stage II disease or higher, so it is considered to have a poor prognosis. There is no specific management for AABC; it follows the guidelines for orthotopic pectoral breast cancer. We therefore report the case of a 50-year-old woman diagnosed with grade II invasive ductal carcinoma found in accessory axillary breast, treated by wide local resection and sentinel lymph node dissection.

Extra-Gastrointestinal Stromal Tumor (EGIST) in the Pelvis Mimicking Retroperitoneal Sarcoma.

Extra-gastrointestinal stromal tumors (EGISTs) are rare mesenchymal tumors accounting for less than 1% of total gastrointestinal tumors. They tend to be aggressive and have a poor prognosis. Unfortunately, there is a lack of data or controversial data due to its scarcity. Therefore, we report a case of pelvic EGIST misdiagnosed as retroperitoneal sarcoma. We opted for surgical management followed by adjuvant oral chemotherapy with imatinib.

Persistent Left Superior Vena Cava Associated with Right Aberrant Subclavian Artery Detected during Totally Implantable Vascular Access Device Insertion.

Introduction Persistent left superior vena cava (PLSVC) is a rare vascular malformation, with several cases reported in the English literature. The diagnosis is made incidentally, during cardiovascular imaging or when a catheter is placed in the left jugular or subclavian vein. They are without associated hemodynamic alterations, except if they have left atrial drainage or an associated dilation of the coronary sinus. If necessary, long-term PSLVC catheterization with right atrial drainage is safe. Case Presentation We report the case of 40-year-old man, admitted for placement of totally implantable vascular access device (TIVAD) on the same day of his first chemotherapy. A disease localized to the right neck made it impossible to puncture on the right. During the puncture of the left internal jugular vein, the diagnosis of PLSVC was made. Postoperative investigations confirmed the diagnosis and showed the presence of the right superior vena cava to which it was connected by the left brachiocephalic vein. They also confirmed the drainage of PLSVC into the coronary sinus. In addition, they demonstrated the presence of an associated right aberrant subclavian artery of direct aortic origin. Chemotherapy was administered safely and the port was removed 9 months after insertion without any problem. Conclusion This is one of the rare cases reported in the English literature of PLSVC diagnosed during TIVAD insertion and the first to report an associated vascular malformation. We publish it to encourage physicians to think about this differential diagnosis and to carefully perform the appropriate investigations before using the port.

Primary Breast Tuberculosis Mastitis Manifested as Nonhealing Abscess.

Primary breast tuberculosis (TB) is a rare extrapulmonary TB mainly affecting young women of childbearing age from endemic countries. Its incidence is increasing in immunocompromised and HIV-infected people and with the emergence of drug-resistant strains of Mycobacterium tuberculosis (MTB). There are no specific clinical signs suggestive of this disease, it often presents as a hard mass or breast abscess. There is an overlap of features with other inflammatory, infectious, benign lesions, fat necrosis and malignant neoplasms of the breast. The detection of MTB remains the gold standard for diagnosis. Several other diagnostic modalities are used, with varying lack of sensitivity and specificity, and with a range of false negatives. A quarter of cases were treated solely on the basis of clinical, imaging or histological suspicion, without confirmation of the diagnosis. Therefore, we report the case of a young Vietnamese woman, presented for a nonhealing breast abscess, and diagnosed with breast TB based on the patient's ethnicity, histological findings, lack of clinical response to conventional antibiotic therapy, and a good clinical response to anti-TB treatment.

Incidental finding of solitary fibrous tumor of male breast: case report and review of literature.

Solitary fibrous tumor (SFT) of the breast is a rare mesenchymal tumor composed of spindle-shaped tumor cells with collagen and large blood vessels in the shape of a "staghorn". It is discovered anywhere in the human body, usually incidentally or through nonspecific symptoms. A combination of clinical, histological, and immunohistochemical features is required to establish a diagnosis. There are no proper guidelines for the treatment of SFTs because of their rarity; however, wide surgical excision remains the "gold standard". A multidisciplinary team approach is recommended. They are mostly benign with a 5-year survival rate of 89%. Following a PubMed-indexed English literature review, only six publications presenting nine cases of breast SFT in a male patient were found. The following is the case of a 73-year-old man who presented with dry cough. A SFT in the right breast was discovered incidentally during the investigative work up, and the patient was referred to our Breast Clinic at the Jules Bordet Institute, Brussels, Belgium, for appropriate treatment. The patient's presentation, imaging, and histological sample all supported the diagnosis, and he underwent uneventful surgical resection. Here, we present the first case of an incidental finding of a SFT of the male breast, with its diagnosis and therapeutic challenges.

A report of an unexpected complication of PORT-A-CATH insertion.

INTRODUCTION: Vascular access is essential in the management of patients, and sometimes poses a problem, especially in patients requiring chronic treatment. Surgical insertion of the port-a-cath solved this problem by providing easy access, but unfortunately, it's associated with some complications. CASE PRESENTATION: We present a case of 32 year-old woman, diagnosed with advanced breast cancer, admitted for insertion of a port-a-cath for neoadjuvant chemotherapy. A few hours after the operation, the patient developed hoarseness and a cough. A flexible laryngoscope showed the left vocal cord which was fixed in the middle position and did not move, while the other maintained normal motility. The patient was treated conservatively. CONCLUSION: This case demonstrated a rare and unexpected complication of the insertion of a port-a-cath, which is the result of an injury to the recurrent laryngeal nerve. We are reporting this case to encourage physicians to take note of this complication and know how to manage it.

Duodenal teratoma: Rare case of extragonadal germ cell tumors and review of literature.

INTRODUCTION: Duodenal teratoma is a rare condition with only four cases reported in the English literature. Radiological imaging and tissue sample are necessary for diagnosis in addition to tumor markers. The most effective treatment is still complete excision with safety margins. CASE PRESENTATION: We report a case of 26 years-old-man, in whom epigastric pain, decreased appetite, and postprandial bilious vomiting had been prevalent for 5-6 months and had exacerbated prior to the emergency room. Enhanced abdominal computed tomography revealed a 10 × 15cm heterogeneous solid mass with cystic component in the third duodenum segment. The inferior veina cava and aorta were both compressed, although there was no sign of lymphadenopathy or ascites. An ulcerating non-bleeding lesion at the D2-D3 junction of the duodenum was discovered during a gastroduodenoscopy. Biopsies and immunohistochemical investigations revealed findings that were consistent with a mixed non-seminomatous germ cell tumor. A PET-CT scan was performed, which revealed FDG uptake by the duodenal lesion but no evidence of metastatic lesions. A distal duodenal segmentectomy is performed, and then a duodeno-jejunal anastomosis is used to restore continuity. The final diagnosis was teratomatous tumor of the duodenum without malignant changes. CONCLUSION: This is the second adult case of main duodenal teratoma that has been reported. We publish it to encourage surgeons to think about this differential diagnosis and carefully plan surgery using a multidisciplinary approach.

A Novel Technique for the Treatment of a Case of Verneuil's Disease of Perineum and Axillary Regions.

Hidradenitis suppurativa (HS) is a chronic inflammatory disease involving apocrine glands of the skin. It carries out an important burden on the daily life of the patient. Unfortunately, it presents a major concern for medical care management in the absence of clear guidelines for proper medical and surgical treatment. Hence, we report a case of concomitant axillary and perianal HS. We opted for surgical management using a novel technique, which proved efficacy for a year of follow-up recurrence free.

Retrograde intussusception causing small bowel obstruction in a 35 year old Female patient following a Roux en Y Bypass. Case report.

INTRODUCTION: Intestinal intussusception is an uncommon entity when preceded by Roux en Y gastric bypass. Retrograde intussusception is an enigmatic phenomenon characterized by reversely intussuscepted intestinal loop that may involve any piece of the Roux en Y limbs. Computed Tomography is gold standard for diagnosis. Surgical management is highly debatable. CASE PRESENTATION: A 35 years old female known for morbid obesity, post roux en Y gastric bypass since 5 years with 100 % excess weight loss presenting for on-off episodes of small bowel obstruction symptoms. She was diagnosed laparoscopically for retrograde intussusception that was reduced easily with closure of Peterson's pouch due to high suspicion of an internal hernia. She did well postoperatively and followed up adequately with no recurrence of her symptoms. CONCLUSION: Retrograde intussusception remains an interesting uncommon phenomenon in the horizon of the roux en Y gastric bypass surgeries. Several surgical options were discussed in the last 12 years and they are still debatable.

A non-klatskin tumor: A case report and review of intrabiliary hydatid cyst rupture.

INTRODUCTION: A 64-year-old lady was diagnosed with having a klatskin type 3A tumor based on imaging, however, an alternative diagnosis was achieved during surgery. PRESENTATION OF CASE: We present a case of a 64-year-old lady who presented for new-onset jaundice and was diagnosed with type 3A klatskin tumor based on MRCP findings. During surgery, it was revealed that the obstruction was caused by a frank intrabiliary hydatid cyst perforation. Choledocoscopy with irrigation, cholangiography, and removal of the mother cyst were performed, and an end-to-end biliary anastomosis over a t-tube was then done. The patient tolerated the intervention and recovered well. DISCUSSION: Hydatid cyst disease of the liver usually follows a benign course, however, intrabiliary rupture is one of the common complications associated with this disease. Intrabiliary rupture is classified into either frank or occult. Frank perforation, which is more common, is when hydatid material passes into the biliary ducts, and it may cause biliary obstruction and cholangitis with a high mortality rate. Occult perforation is when the hydatid cyst becomes infected itself, which usually leads to a silent presentation, and may only cause signs of suppuration. Diagnosis is usually achieved by imaging and relevant history. Treatment consists of medical and surgical intervention. Intraoperative cholangiography, choledocoscopy, and t-tube drainage are recommended during surgery for frank rupture. CONCLUSION: Intrabiliary hydatid cyst perforation can mimic cholangiocarcinoma and must be considered as an alternative diagnosis in these patients prior to surgery.

Laparoscopic ileo-cecectomy for ileo-ceco-colic double intussusception due to a cecal adenoma harboring multifocal high grade dysplasia in a 24 years old male: A case report.

INTRODUCTION: Intestinal Intussusception is defined as invagination of the intussusceptum into the intussuscepien, and is responsible of 1% of all bowel obstructions. It is rare in adults and common in children. It is mostly due to organic causes in adults that form lead points. Enteroenteric intussusception is the most common type. Signs and symptoms are more classic in children but nonspecific in adults. Usually diagnosis is made intraoperatively, while abdomino-pelvic CT scan is the best preoperative imaging modality. Intestinal Intussusception in adults, especially when the colon is involved, is best treated by surgical resection. CASE PRESENTATION: A 24 years old previously healthy male with no surgical or documented familial history presenting for severe crampy abdominal pain and distention, obstipation and palpable right lower quadrant abdominal mass. Abdominal Multi-slice CT diagnosed an ileo-colic intussusception without signs of bowel suffering. Laparoscopic ileo-cecetomy. Final Pathology showed a 4 cm cecal tubular adenomatous polyp with multifocal high grade dysplasia. CONCLUSION: Intestinal intussusception in adults is an interesting rare entity that have the interest of general surgeons. Malignant lesions can be lead-points and they form a great counterpart among other colonic lesions. Minimally invasive laparoscopic surgery is gaining interest in management, and surgical resection remains the gold standard while reduction before surgery is debatable and can be considered in selected cases.

Splenoptosis in young female, case report.

BACKGROUND: Splenoptosis is an uncommon disorder defined as the dislodgment of the spleen from its anatomical location in the left hypochondrium to another location in the intraabdominal cavity. This migration is the result of laxity or absence of the ligaments that fix the spleen to surrounding structures. Splenoptosis is either diagnosed after it causes symptoms, or incidentally using different imaging modalities. Surgery is the definite treatment either by splenopexy or splenectomy. CASE PRESENTATION: In the case presented here, we discuss a 17 years old female patient who presented to our institution for acute onset of abdominal pain, mainly suprapubic, occurring for 4 days. Ultrasound showed a suspicious right pelvic mass, which was found to be a wandering spleen with pedicle torsion. The patient was treated surgically by splenectomy. CONCLUSION: We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of unspecific abdominal pain.

Bilateral inguinal masses or hernias in a female teenager with delayed menarche: Think of Complete Androgen Insensitivity Syndrome (CAIS), a case report.

INTRODUCTION: Complete Androgen Insensitivity Syndrome (CAIS) is a rare sexual development disorder with X-linked recessive inheritance. It is prevalent in 1:20400 to 1:99000 of female phenotypes, yet characterized by an XY genotype. Cases of CAIS usually present with primary amenorrhea together with unilateral/bilateral inguinal hernias. CASE PRESENTATION: A previously healthy 19 year old sexually inactive girl presents to our clinics for delay in menarche and bilateral palpable inguinal masses 3 years ago. She has normal female habitus, tanner stage 3 and external female genetalia with sparse pubic hair. She has a family history of 2 aunts (mother side) having infertility with Bilateral inguinal hernias surgery. Hormonal tests showed male range testosterone levels. MRI showed bilateral inguinal masses with Mullerian structures agenesis and a misdiagnosis of Mayer-Rokitansky-Küster-Hauser syndrome (MRHKS) was interpreted. While karyotype showed XY genotype. She is then planned for bilateral orchiectomy. Final pathology of the 2 specimens taken showed testicular tissue correlating with CAIS. DISCUSSION: CAIS patients presents with near normal female external genetalia, absence of Mullerian structures, taller status than regular females and testosterone levels equal or higher than male levels. Different imaging types together with karyotyping are crucial in diagnosing and differentiating CAIS from other entities such as MRHKS and Swyer syndrome. Treatment debates include prepubertal or postpubertal gonadectomy correlating with the age related malignancy rate and site of testis followed by Hormonal replacement therapy. CAIS management needs a multidisciplinary approach and decisions by the patient or his family sometimes. CONCLUSION: CAIS must be suspected in any case of young females with bilateral inguinal hernias as in our case, and precise diagnostics tests such as MRI and Karyotyping must be done followed by biopsy or excision for diagnosis and then adequate treatment. Hormonal therapy must be continued after gonadectomy that is best to be postpubertal.

Prepyloric gastric inflammatory fibroid polyp presenting as chronic epigastric discomfort in a 5th decade aged female: A case report.

INTRODUCTION: Inflammatory fibroid polyps is a rare entity that mostly occur in the stomach. Gastric type is usually asymptomatic or may show nonspecific symptoms. Diagnosis is mainly postoperative with limited roles of usual diagnostic techniques. PRESENTATION OF CASE: A 42 years old healthy female presenting with chronic symptoms for epigastric discomfort and mild nausea. Labs showed mild anemia. A gastric lesion was detected by Endoscopy and being studied by echo-endoscopy and needle aspirate. Gastric Inflammatory fibroid polyp was diagnosed after distal gastrectomy by histopathology and immunohistochemistry. CONCLUSION: Gastric inflammatory fibroid polyp is a preoperative diagnostic challenge of unclear pathogenesis. Histopathology and immunohistochemistry are the gold standard. Studies around this exact pathology are required for better management and prevention.

Recurrent giant retroperitoneal liposarcoma with 10 years follow up. Case report and review of literature.

INTRODUCTION: This case is of a patient with a recurrent giant retroperitoneal liposarcoma, followed-up and operated multiple times over 10 years. We report this case because of its rarity and review all previous articles reporting "Giant Retroperitoneal Liposarcoma" in the English literature. CASE DESCRIPTION: A 70 years old man presented to our clinic for dizziness and fatigue. He was incidentally found to have a large retroperitoneal mass filling all the length of the abdominal cavity and shifting all intraabdominal viscera and kidney to the left side. En bloc excision of a 50 × 30 × 18 cm, 9 kg tumor was performed. Final pathology revealed a well-differentiated liposarcoma. Five years later, the patient was reoperated for recurrence and a well-differentiated liposarcoma was excised in 2 pieces (the biggest measuring 14 × 11 × 7 cm) along with the appendix. Four years later the patient was operated on again for a second recurrence, and again a well-differentiated liposarcoma (16 × 10 × 7 cm) extending into the right inguinal canal was excised. One year thereafter, the patient was diagnosed with a third recurrence (22 × 12 cm). DISCUSSION: Retroperitoneal Liposarcomas are rare tumors, presenting with different histological differentiation. They are diagnosed using multiple imaging modality, mainly CT scan, and it is confirmed by percutaneous large core needle biopsy. R0 Surgical excision remains the proper treatment for non-metastatic tumors, which may necessicate multiorgan resection. They rarely grow to reach a large size and be labled as "Giant Retroperitoneal Liposarcoma".

Left gastric artery pseudo-aneurysm post sleeve gastrectomy: A case report.

INTRODUCTION: Bleeding in the context of sleeve gastrectomy could be caused by a variety of diseases however pseudo-aneurysm is an overlooked complication. CASE: For instance, we present case of a 25 year-old Lebanese woman that undergone sleeve gastrectomy and presented 3 weeks later with a bleeding left gastric artery pseudo-aneurysm. CONCLUSION: Angiography followed by embolization is best for diagnosing and treating the pseudo-aneurysm by coiling. Serious outcomes could arise from such a complication. Hence, accurate diagnosis and treatment using the appropriate methods is essential to avoid life-threatening events.