Pneumoperitoneum.

Pneumoperitoneum results from perforation of the gastrointestinal tract in the majority of instances and the necessity of operative treatment is implied. In patients where peritonitis is not a problem, nonoperative treatment is successful. Surgical treatment is not required for those in whom the condition results from barotrauma. The decision to enjoin or withhold operative intervention in individual cases is judgmental.

Hemicorporectomy: a collective review.

Hemicorporectomy or translumbar amputation has been described as the most revolutionary of all operative procedures. Frederick E. Kredel, who first voiced the concept of the operation in 1950, referred to it as halfectomy. Demonstration of his cadaver studies established the feasibility of the operation. Amputation is effected through the lower lumbar area of the body. Necessary life functions are preserved in the upper torso. Kredel envisioned hemicorporectomy as a curative operation for locally advanced cancer, limited to the pelvis, not encompassable by standard operative intervention. Additional indications are intractable decubitus ulcers with malignant change, particularly in paraplegics; pelvic organs, and bone infection with nonhealing fistulae; and crushing trauma to the pelvis. The first hemicorporectomy operation was reported in 1960. Thirty-four operations have been recorded in the world literature. Two heretofore unreported cases are added, raising the total to 36. Review of these 36 cases confirms the conviction that hemicorporectomy is a humane and ethical alternative to the suffering encumbered by advancing, painful, malodorous malignant disease not treatable by conventional means. While cure rates are not substantial, the best results are reported in paraplegics with intractable decubitus ulcers with or without malignancy. Rehabilitation is prolonged and costly. Most survivors have been restored to preoperative occupations or other gainful employment.

Liver tumor in long-term user of oral contraceptives.

Oral contraceptives are implicated in the development of some liver tumors. Paralleling the widespread use of these drugs has been an increase in reported cases of hepatic cell adenomas. Large, multiple tumors, often manifested by spontaneous rupture and hemoperitoneum, have been associated with prolonged use of oral contraceptives. When use of oral contraceptives is discontinued, the hepatic cell adenoma regresses.

PIP: A 36 year old obese and hypertensive woman visited her family physician because she felt dizzy and generally weak for 3 days. Even though she had been advised to stop taking the combined oral contraceptive (OC) containing 50 ug ethinyl estradiol and .5 mg norgestrel, at the time she consulted the physician she had been using it for 6 years. Upon admission to a South Carolina hospital, she stopped taking the OC. After appropriate treatment, her condition soon stabilized. The next day, however, she had a fever of 39.44 degrees Celsius, abdominal pain, generalized abdominal tenderness, and rebound tenderness. These symptoms continued through a 2nd day and a laparotomy was warranted. A 15x10 cm hepatic cell adenoma on the right lobe of the liver caused hemorrhaging in the peritoneal cavity. In addition, a 5-6 cm mass was found on the inferior surface of the left lobe. A liver spleen scan 3 weeks following surgery indicated diminished activity at the tumor site on the right lobe. 1 1/2 years later, physicians excised the now reduced tumor (4x2 1/2 cm) on the left lobe and the right lobe adenoma had necrotized and regressed. 15 months following excision of the left lobe tumor, a needle liver biopsy showed a mild, fatty change in the liver. No further liver problems have developed. Research demonstrates that prolonged use of OCs predisposes women to the development of hepatic cell adenoma, and large multiple tumors are associated with especially lengthy use. Research also indicates that when OC use stops, these tumors regress, but can reoccur if OC use or any estrogen therapy is reinstituted or if pregnancy occurs.

Mesenteric artery aneurysms.

In this case of atherosclerotic aneurysm involving the main superior mesenteric artery and an aberrant artery from the aorta, characteristic eggshell calcifications were visible on preoperative x-ray films of the abdomen. The aneurysm was excised. Flow through the superior mesenteric artery was maintained by lateral suture of the artery at the site of excision of the aneurysm.

Parathyroid cyst.

Although parathyroid cyst has been infrequently reported until the past decade, its presumed rarity is attributed to nonrecognition. First reported in 1905, only 58 cases of parathyroid cyst had been documented in the world literature by 1967. Since then, however, substantial literature about this entity has been accumulating. The three cases we are reporting bring the cumulative total to 149. All three have been examined histologically and treated by aspiration or surgical excision. There is confusion clinically with thyroid cysts, and assay of fluid aspirate for parathormone and thyroxine may not accurately distinguish the origin of the cyst. Tissue diagnosis is confirmatory. Parathyroid cysts may be developmental, arising from vestigial remnants of the third and fourth branchial clefts; or coalescence of microcysts with associated hypersecretion may enlarge into macrocysts; or an adenoma may degenerate into a pseudocyst. Hyperparathyroidism, if present, is associated with only the last two.