Metastatic right ventricular mass with intracavitary obliteration.

Metastatic cardiac tumors are more common than the primary cardiac tumors. Cervical cancer metastasizing outside of the pelvis is commonly spread to the lungs, liver, bones and lymph nodes than to the heart. Right-sided metastasis to the heart is more common than to the left side. Intramural spread is more common than intracavitary growth of metastatic cardiac tumors leading to delayed clinical presentation. Intracavitary mass can be confused with intracavitary thrombus which can be seen in the setting of pulmonary embolism. Transthoracic echocardiography plays a major role in the decision making and management of pulmonary embolism, and this modality can also be used to diagnose cardiac masses. Other modalities like TEE, cardiac CT, cardiac MRI and PET-CT scan have further utility in delineating these masses. This may help to plan appropriate management of the right ventricular mass particularly in cases where the patient history and CT pulmonary angiography results favor the diagnosis of pulmonary embolism. We present the case of a 49-year-old woman with a history of supracervical hysterectomy and salpingo-oophorectomy on oral estrogen therapy who was admitted with complaints of pleuritic chest pain and respiratory insufficiency after a long flight. Initial work-up showed sub-segmental pulmonary embolus in the right posterior lower lobe pulmonary artery, and the patient was managed on intravenous heparin. Lack of appropriate response to standard therapy led to further evaluation. Multimodality imaging and biopsies revealed a large right intracavitary ventricular metastatic squamous cell tumor, with the cervix as the primary source.

Transumbilical laparoscopically assisted appendectomy: an alternative minimally invasive technique in pediatric patients.

INTRODUCTION: Transumbilical laparoscopically assisted appendectomy (TULAA) has been reported in the literature as an alternative to traditional three-port laparoscopic appendectomy (LA). Our study compares outcomes between LA and the one-trocar transumbilical technique in a single institution over a concurrent time frame for all cases of pediatric appendicitis. METHODS: An Institutional Review Board-approved retrospective chart review of all appendectomies from July 2007 through June 2009 was performed. All appendectomies were performed either laparoscopically or transumbilically. One surgeon predominantly used the TULAA method, whereas the other 2 surgeons used strictly the LA method. No cases were converted to open. Categorization of specimens as normal, acute, or ruptured was based on pathology reports. Outcomes analyzed for each group included surgical duration, cost, length of stay, fever (>101.5F), wound infection, ileus, and postoperative abdominal-pelvic abscess. RESULTS: A total of 131 appendectomies were performed by 3 surgeons, 83 were LA and 48 were TULAA. For all stages of appendicitis, outcomes differed significantly only for operating room cost, with the TULAA being significantly less expensive. All other outcomes were similar between the two techniques. CONCLUSION: Our study suggests that TULAA is a reasonable alternative to the standard minimally invasive technique for appendicitis in both acute and ruptured situations. All analyzed complications were similar between the groups, suggesting that TULAA is an acceptable surgical method in pediatric patients for all stages of appendicitis.

Laparoscopic Ladd's procedure: treatment of choice for midgut malrotation in infants and children.

INTRODUCTION: Rotational anomalies of the midgut encompass a broad spectrum of incomplete rotational events with malfixation of the intestines during fetal development. Ladd's procedure, as a correction of these anomalies, has traditionally been performed by laparotomy. In our institution, the laparoscopic Ladd's (LL) procedure was introduced in May 2004 and soon became the standard approach. MATERIALS AND METHODS: A retrospective analysis of all Ladd's procedures in children in our institution between September 1998 and June 2008 was performed. Outcomes between the open (OL) and LL procedures were compared. RESULTS: A total of 156 children underwent Ladd's procedure during the study period. There were 120 open and 36 laparoscopic procedures. Overall, 75% of patients in each group were symptomatic, most commonly with emesis and pain. Duration of surgery was similar in both groups. Time to starting feeds, and amount of time to attain full feeding, was significantly less in the LL group. Postoperative length of stay was significantly less in the patients having LL. Conversion rate to OL from LL was 8.3%. CONCLUSIONS: LL can be performed safely in selected patients with no increase in complications. Short-term results are superior to OL and can be achieved without any increase in operative duration.