Intestinal perforation of pedunculated hepatocellular carcinoma [rare among rarities]

Pedunculated type is a rare macroscopical form of hepatocellular carcinoma. 47 years old male complained from vague abdominal pain, anorexia, weight loss and malena during the last few months. Abdominal ultrasound and spiral CT scan revealed a vascular mass 17x13 cm. in diameter occupying the whole right side of the abdomen. On exploration the mass was perforated into a segment of ileum due to direct invasion and attached to the liver by vascular pedicle. The mass was completely excised with segment of ileum followed by end-end anastomosis. Immunohistochemical study shows that the tumor was stained by alpha-fetoprotein staining confirming the diagnosis of pedunculated hepatocellular carcinoma. Pedunculated hepatocellular carcinoma should be kept in mind in any differential diagnosis of large intraperitoneal mass even if it is not related to the liver by imagining study

Is enucleation sufficient treatment for solitary insulinoma?

Enucleation is the traditional surgical procedure for removal of sporadic insulinoma, but this may associated with recurrence. This is a case report of thirty-five years old woman, who underwent enucleation for solitary insulinoma at the head of pancreases three years ago. Recently, she was complaining from recurrent attacks of hunger pain, dizziness, sweating, convulsion, behavioral changes and loss of consciousness. Endoluminal ultrasound revealed that there are bilobed mass or probably two masses related to the head/neck region of the pancreas about 1.5 cm in diameter. So the diagnosis of recurrent insulinoma was made and she was treated by complete resection with 1cm safety margin by harmonic scalpel guided by intraoperative ultrasound. The recurrent insulinoma reported in this article and others may give attention to change the strategy of treating solitary insulinoma by local resection with good safety margin rather than by enucleation to prevent recurrence