Two cases of partial hepatectomy for malignant melanoma.

BACKGROUND: While the liver is a frequent site of metastatic spread for malignant cutaneous as well as malignant ocular melanoma, isolated hepatic metastases without evidence of systemic disease is rare. Hepatic resection has been proposed as a therapeutic and potentially curative procedure in metastatic melanoma patients with isolated hepatic metastases. OBJECTIVE: To report two metastatic melanoma patients with isolated hepatic metastases treated with partial hepatectomy. In addition, the literature is reviewed and the management and efficacy of surgical excision for isolated hepatic disease in the setting of malignant melanoma is discussed. CASE REPORT: A 34-year-old woman with metastatic cutaneous melanoma and a 55-year-old man with metastatic ocular melanoma are presented. Both patients developed isolated hepatic metastases detected during routine surveillance following resection of their primary disease and underwent partial hepatectomy. CONCLUSION: In select cases, partial hepatectomy is an efficacious and potentially curative treatment for metastatic melanoma patients with isolated hepatic metastases.

What is the likelihood of requiring contralateral inguinal hernia repair after unilateral repair?

BACKGROUND: Factors that predispose patients to the development of inguinal hernias will persist after repair. This study aimed to determine the incidence of future contralateral hernia repair. METHODS: We performed a retrospective review of a non-Medicare claims database (1999-2009) to identify patients billed for 2 asynchronous initial inguinal hernia repairs. RESULTS: In this database, 7,050 patients were followed up for a mean of 3.6 years, 272 patients required a contralateral hernia repair. The mean time between hernia repairs was 2.9 years and the same surgeon repaired both hernias in 67.6%. Fifteen patients had incarcerated contralateral hernias (5.5%). Patients who required contralateral repairs were older (62.2 vs 59.6 y; P = .014) and had prostate disease (odds ratio, 1.45; P = .0001). The risk of needing a contralateral inguinal hernia repair at 5 and 10 years of follow-up evaluation was 2.5% and 3.8%, respectively. CONCLUSIONS: Despite a reported 8% to 22% incidence of clinically unsuspected contralateral inguinal hernia, the likelihood of undergoing contralateral repair within 10 years is low at 3.8%.

Proteinuria as a predictor of renal dysfunction in trauma patients receiving intravenous contrast.

Trauma patients have unknown comorbidities, multiple injuries, and incomplete laboratory testing, yet require contrast-enhanced imaging to identify potentially life-threatening problems. Our goal was to characterize contrast-induced nephropathy (CIN) in this population. We retrospectively reviewed characteristics of 402 patients who presented to a Level II trauma center and received contrast-enhanced imaging. CIN was defined as creatinine rise of 0.5 mg/dL or greater or 25 per cent or greater from baseline within 48 hours. CIN occurred in 7.7 per cent and four patients required hemodialysis. Patients with CIN were older, had lower admission hemoglobin, higher Injury Severity Score, and received more blood products. Factors that predicted CIN included: male sex, age older than 46 years, body mass index less than 27 kg/m², glomerular filtration rate less than 109 mL/min/1.73 m², hemoglobin less than 12 mg/dL, hematocrit less than 36 per cent, proteinuria, 2 units or more of fresh-frozen plasma in 48 hours, and alcohol use. Odds ratio for developing CIN with two, five, or six of these factors was 3.39, 6.54, and 8.38, respectively. A match-controlled analysis for Injury Severity Score and age in patients with CIN versus non-CIN patients revealed the strongest predictor of CIN was proteinuria (relative risk, 2.5; confidence interval, 1.1 to 5.8). Although it is difficult to truly differentiate CIN from renal dysfunction related to injury severity in trauma patients, proteinuria may be an important factor in identifying nephropathy in this population.

Laparoscopic drainage of intraabdominal abscess after appendectomy: an alternative to laparotomy in cases not amenable to percutaneous drainage.

PURPOSE: Postoperative abscesses after appendectomy occur in 3% to 20% of cases and are more common in cases of perforated appendicitis. Smaller abscesses are often amenable to antibiotic therapy, but surgical drainage remains the mainstay of treatment for larger collections. Surgical options generally include percutaneous drainage and open laparotomy. Laparoscopic drainage of these abscesses has not been well characterized in the pediatric population. OBJECTIVE: The aim of this study was to describe our experience with laparoscopic drainage of postappendectomy abscesses that were not amenable to percutaneous drainage. METHODS: This study is a retrospective review of all pediatric patients who underwent laparoscopic appendectomy for acute appendicitis at a tertiary pediatric medical center during a 4-year period (2006-2009). The review focuses on patients who developed abscesses after appendectomy, were unable to undergo percutaneous drainage, and were treated with laparoscopic abscess drainage. RESULTS: Twelve patients (7 male and 5 female) underwent laparoscopic drainage of postappendectomy abscesses. The mean age was 8.5 years old (range, 3-14 years). A clinical diagnosis of postoperative abscess was made when fevers, pain, and leukocytosis persisted despite broad-spectrum antibiotics. Computed tomography was performed in all patients. Abscesses ranged between 3 and 11 cm in size. The mean length of time between initial appendectomy and drainage procedure was 10 days. There were no complications specifically related to the laparoscopic drainage procedure. The mean length of the drainage procedure was 77 minutes (range, 30-196 minutes). The mean hospital length of stay after laparoscopic drainage was 6.5 days (range, 3-13 days) with patients maintained on intravenous antibiotics until afebrile and without leukocytosis. CONCLUSION: Laparoscopic drainage is a safe and effective alternative for intraabdominal abscesses that occur after laparoscopic appendectomy. We recommend it as an alternative to open laparotomy when percutaneous drainage is not an option.

Use of an atriocaval shunt in a trauma patient: first reported case in Hawai'i.

BACKGROUND: Traumatic injuries to the retrohepatic vena cava are typically fatal. Emergent access to this area is difficult and patients typically exsanguinate before the injury can be identified and fixed. OBJECTIVE: To report the use of an atriocaval shunt in the repair of an injury to the retrohepatic vena cava from a gunshot wound. CASE REPORT: A 24-year-old man was shot in his right chest suffering a penetrating injury to the liver and inferior vena cava. Surgical repair was performed with the aid of an atriocaval shunt fashioned from a chest tube. He survived and recovered without incident. CONCLUSION: Atriocaval shunting maybe a life-saving option for uncontrolled hemorrhage from injuries to the retrohepatic vena cava.

Solid cervical ectopic thymus in an infant.

Cervical ectopic thymus presenting as a neck mass is rare in a neonate. Just more than 100 cases have been reported in the literature with less than 10% occurring in infants. We report a case of solid cervical ectopic thymus in an asymptomatic 2-month-old boy. We review the literature and discuss the embryology, pathophysiology, diagnosis, and management of an infantile ectopic thymus.