ABSTRACT
Pedunculated hepatocellular carcinoma (P-HCC) is a rare subtype of HCC. P-HCC may occur in patients without underlying liver cirrhosis and can be present with negative serum tumor markers. With a growing worldwide incidence of nonalcoholic fatty liver disease, non-cirrhotic HCC will likely become more prevalent. We report a patient presenting to the hospital with nonspecific symptoms of weight loss, abdominal discomfort, and early satiety. Abdomen palpation found a large firm mass in the right middle abdomen. Computed tomography imaging showed a large right abdominal mass without evidence of liver attachment. The patient underwent a diagnostic laparotomy where a single 17 cm exophytic mass originating from the left liver lobe was found and resected. Clear margins were attained, and pathology demonstrated HCC. Early diagnosis of HCC is critical to achieving curative treatment, and physicians should keep P-HCC in mind when presented with a similar patient.
ABSTRACT
Foramen of Winslow hernias form 8% of all internal hernias. They present with non-specific findings and are often diagnosed late in disease progression. Delayed diagnosis of the hernia is associated with an estimated mortality of 50%. This rare event has yet to be described in the literature as a follow-up complication to a Ladd's procedure. Here, we present a young male patient with a surgical history of a Ladd's procedure with a chief complaint of an acute-onset, severe abdominal pain accompanied by episodes of emesis. Prompt clinical analysis, imaging and fluid resuscitation was conducted. A computed tomography (CT) scan showed a mesenteroaxial gastric volvulus and air was identified within the Falciform Ligament. Consequently, the patient underwent an exploratory laparotomy and the foramen of Winslow hernia was identified. An excision and anastomosis procedure was performed, and the cecum was fixed in the lower left quadrant. The procedure had no complications and the patient was discharged from the hospital on the fifth post-operative day. The purpose of this case report is to present an unusual patient who experienced a foramen of Winslow hernia involving the small bowel six years following a Ladd's procedure. While a causative relation cannot be made between these two events, we theorize that gastrointestinal hypermobility, being one of the three properties leading to herniation, played a role in both pathologies. Therefore, a vigilant surgeon should keep in mind that intra-abdominal congenital malrotation can put patients at greater risk for future herniation.
ABSTRACT
BACKGROUND: Optimal adjustment of the filling volume of laparoscopic adjustable gastric banding is challenging and commonly performed empirically. Patients with band over-inflation and gastric obstruction arrive at the emergency department complaining of recurrent vomiting. In cases of gastric obstruction, intra-band pressure measurement may assist in determining the amount of fluid that should be removed from the band; however, our investigations have determined that intra-band pressure assessment need not play a role in the treatment of gastric band obstruction. METHODS: In patients coming to the emergency department with gastric band obstruction, we measured intra-band pressure at arrival and following stepped removal of fluid, comparing the initial pressure with post-deflation pressure and measuring the volume of fluid removed. RESULTS: Forty-eight patients participated in the study. Forty-five patients had a low-pressure/high-volume band. Their mean baseline pressure was 54.6 ± 22.3 mmHg. The mean volume of fluid removed from the band was 1.3 ± 0.8 ml. The mean post-deflation pressure was 22.5 ± 16.3 mmHg. Nearly 30 % of patients required as little as 0.5 ml of fluid removal, and 60 % of them were free of symptoms with removal of 1 ml. CONCLUSIONS: Our results indicate that intra-band pressure measurement is of little value for determining the amount of fluid that should be removed for treatment of band obstruction. We suggest the removal of fluid in volumes of 0.5 ml until symptoms are relieved. Only in complicated cases, such as in patients having recurrent obstructions, should additional modalities be employed for further management guidance.
