Small bowel melanoma: extended survival with surgical management.

Small intestinal melanoma is rare, and primary vs metastatic origin is often unclear. A patient with the longest reported survival (21 years) after resection of a melanoma in the small intestine is presented, and the debate regarding primary small bowel melanoma is reviewed. Multiple resections of neck recurrence (or second primaries) in this patient with prolonged survival validates the aggressive pursuit and excision of localized melanoma when possible.

Total colectomy with mucosal protectomy and ileoanal anastomosis--an important surgical option in the aviator with premalignant disease of the colon.

Total proctocolectomy with cutaneous ileostomy has been the standard therapy for many years for premalignant mucosal diseases of the colon, such as ulcerative colitis and familial polyposis. While this procedure relieves the patient of the risk of malignancy, it leaves him with the problem of the management of the ileostomy as well as exposing him to the risk of damage to the nerve supply of the bladder and genitalia during the dissection. Within the military population, the ileostomy is a particularly devastating problem as it disqualifies the individual from worldwide duty and requires him to meet a Medical Evaluation Board for discharge from the service. Over the last several years, total colectomy with mucosal proctectomy and ileoanal anastomosis (TCMPIA) has emerged as a viable surgical alternative in these conditions. The benefits of this procedure in the military population are multiple. It allows the individual to continue on active duty, fulfilling his desire to pursue his career as well as keeping the position filled for the military. The time and cost of a medical board are avoided, the military's investment in the individual's training is protected, and the need to train a new individual for the position is avoided.

Hepatic artery aneurysm. Report of an unusual case and review of the literature.

Hepatic artery aneurysms are relatively infrequent lesions and may represent significant problems in both diagnosis and management. Indeed, as many as 30 to 50 per cent of cases are completely unsuspected and are discovered only at autopsy. A case of a very large hepatic artery aneurysm (greatest dimension of approximately 35 centimeters) presenting as an asymptomatic epigastric mass is reviewed, with emphasis on preoperative evaluation and operative technique. Selective arteriography was the cornerstone of diagnosis with other investigative modes proving not to be effective. Surgical therapy included obtaining proximal and distal control, meticulous ligation of the numerous feeding vessels, and finally evacuation and partial excision of the aneurysm sac with careful suture ligation obliteration of the orifice of each feeding vessel. Restoration of hepatic artery flow was not attempted and no compromise in liver function was seen in the postoperative period. The literature on hepatic artery aneurysms is reviewed to include typical presentation, diagnostic methods, surgical approach, and common complications. Only through a high index of suspicion and early angiography can this frequently fatal lesion be detected early in its course and subsequently be subjected to successful surgical management.

Hospital and health maintenance organization financial agreements for inpatient services: a case study of the Minneapolis/St. Paul area.

With nearly a quarter of the population enrolled in Health Maintenance Organizations (HMOs) the Mineapolis/St. Paul metropolitan area provides a unique opportunity for studies dealing with the effects of prepaid health plans on the health care marketplace. This study explores one aspect of that market; discounts obtained by HMOs for hospital inpatient service. Using information gathered from structured interviews with the 7 HMOs and 30 hospitals in the Twin Cities area, the study addressed three areas of inquiry: (1) the nature of discount contracts between hospitals and HMOs, (2) the roles played by each party in initiating the contracts, and (3) factors influencing the establishment of the contracts. While each of the HMOs was found to have at least one hospital contract under which they received inpatient services for other than full-billed charges, the amount of the discount was not substantial in the majority of cases. Other factors such as hospital location and ability to provide a full range of services appear to be as important as financial discounts when HMOs select a hospital for inpatient services. It appears that hospitals played the lead role in initiating hospital/HMO contracts during the formative HMO years, but this initiative shifted to the HMOs as they gained market shares and bargaining power. Hospitals and HMOs agree that the most important factor influencing hospital willingness to consider discount contracts was and still is the surplus bed availability in the area. This surplus of beds has been exacerbated by a continued decline in hospital utilization. These conditions coupled with increased HMO market shares has recently resulted in intensified contract negotiations and further discounts for inpatient services.

Mallory-Weiss syndrome in children.

We have described a case of Mallory-Weiss syndrome in a 15-year-old girl, and reviewed five other cases in children. Endoscopy was used to make the diagnosis in each case. All patients were successfully managed using conservative, nonoperative therapy, and no recurrent bleeding has been reported. Mallory-Weiss syndrome should be considered in the differential diagnosis of upper gastrointestinal bleeding in the pediatric patient.