Traction-induced aneurysm of an accessory left hepatic artery: a potentially fatal but synchronously treatable complication of a large hiatus hernia.

A 59-year-old man presented to our surgical clinic with a long-standing history of heart burn, and upper abdominal pain. Gastroscopy showed a large sliding hiatus hernia associated with severe reflux oesophagitis. Oesophageal pH manometry revealed a high DeMeester score of 36.03. A computed tomography (CT) scan was performed for preoperative hiatal hernia repair planning. This showed the incidental finding of an accessory left hepatic artery (ALHA) and an aneurysm of this accessory artery. The aneurysm occurred at the point where the ALHA traversed the diaphragmatic crus and was only present in association with the hiatus hernia. These observations suggest that the aetiology of the aneurysm was due to traction during development of the hiatus hernia. The patient went onto have a laparoscopic hiatus hernia repair and Toupet fundoplication with ligation of the accessory left hepatic artery and made an excellent recovery. ALHAs are not uncommon, occurring in around 15% of the general population, with aneurysms of the hepatic arteries accounting for about 20% of cases of visceral artery aneurysms. The case presented herein highlights the importance of performing an arterial phase CT when planning surgery for large hiatus hernias to detect more cases like this one. This would allow early detection and concurrent treatment of an associated aneurysm with repair of the hiatus hernia, to prevent aneurysmal complications later on.

Bronchoesophageal fistula in a patient with non-Hodgkin's lymphoma.

Bronchoesophageal fistula secondary to lymphoma is a very rare condition, usually associated with chemo-radiotherapy. We report a case of a patient with a non-Hodgkin's lymphoma (NHL) who, after chemotherapy, developed an oesophago-tracheal fistula. Initially it was treated conservatively but due to the lack of response, a stent was inserted. After nearly one year without success, surgery was considered. Right thoracotomy oesophagectomy and closure of the tracheal defect with an intercostal muscle flap and pericardial patch was performed. This was followed by laparoscopic creation of a gastric tube, which was successfully anastomosed to the cervical oesophagus through a cervicotomy. Unlike oesophageal cancer, NHL can have a good prognosis, so curative treatment of the fistula can be considered. Conservative treatment must always be the first option, leaving stenting or surgery for when the problem persists.

Bronchoesophageal fistula in a patient with non-Hodgkin's lymphoma

Bronchoesophageal fistula secondary to lymphoma is a very rare condition, usually associated with chemo-radiotherapy. We report a case of a patient with a non-Hodgkin's lymphoma (NHL) who, after chemotherapy, developed an oesophago-tracheal fistula. Initially it was treated conservatively but due to the lack of response, a stent was inserted. After nearly one year without success, surgery was considered. Right thoracotomy oesophagectomy and closure of the tracheal defect with an intercostal muscle flap and pericardial patch was performed. This was followed by laparoscopic creation of a gastric tube, which was successfully anastomosed to the cervical oesophagus through a cervicotomy. Unlike oesophageal cancer, NHL can have a good prognosis, so curative treatment of the fistula can be considered. Conservative treatment must always be the first option, leaving stenting or surgery for when the problem persists (AU)

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Ghrelin does not stimulate food intake in patients with surgical procedures involving vagotomy.

CONTEXT: Patients with gastric or esophageal surgery and transection of the vagus nerve may suffer from appetite and weight loss but without dysphagia or mechanical obstruction to eating. The gastric hormone ghrelin stimulates food intake and GH release in rodents and man. However, rodents with vagotomy are not sensitive to the feeding effects of ghrelin. OBJECTIVE: The objective of the study was to determine whether humans with vagotomy are sensitive to ghrelin. STUDY DESIGN: The design was a double-blind, randomized, placebo-controlled trial. SETTING: This was a hospital-based study. PATIENTS: Six men and one woman who all had a previous complete truncal vagotomy with lower esophageal or gastric surgery entered and completed the study. INTERVENTION: Each patient received 120-min infusions of saline, 1 pmol/kg.min ghrelin, and 5 pmol/kg.min ghrelin on 3 separate days. After 90 min, a buffet meal was served. MAIN OUTCOME MEASURE: Energy intake at the buffet meal was measured. RESULTS: Ghrelin-stimulated GH release in a dose-dependent manner was measured, confirming bioactivity. However, no change in energy intake was observed with either dose of ghrelin [energy intake (kilojoules): saline 2805 +/- 812; ghrelin 1 pmol/kg.min, 2486 +/- 767; ghrelin 5 pmol/kg.min, 2382 +/- 543; P = not significant]. CONCLUSIONS: Ghrelin is unlikely to be an effective appetite-stimulatory treatment for patients with vagotomy and esophageal or gastric surgery. Our results suggest that an intact vagus nerve may be required for exogenous ghrelin to increase appetite and food intake in man.

Magnesium deficiency in patients with chronic pancreatitis identified by an intravenous loading test.

Magnesium deficiency is a common clinical condition that may exist despite a normal serum magnesium concentration. Patients with chronic pancreatitis could develop magnesium deficiency due to either malabsorption, diabetes mellitus, or chronic alcoholism. Since serum levels of magnesium are a poor indicator of magnesium deficiency, the retention of a low-dose intravenous magnesium load (0.1 mmol/kg body weight) was determined in 13 patients with chronic pancreatitis (10 due to alcoholism) and eight healthy controls. Percentage magnesium retention was greater in patients with chronic pancreatitis than controls (59.8+/-37.3% S.D. versus 22.0+/-38.2% S. D.: P=0.038), and 10 of 13 patients showed evidence of magnesium deficiency. Routine evaluation of magnesium status could allow appropriate supplementation and conceivably symptomatic improvement in patients with severe chronic pancreatitis.

Fibrolamellar hepatocellular carcinoma: results of partial liver resection.

AIM: To assess the results of partial hepatic resection in the treatment of fibrolamellar hepatocellular carcinoma. PATIENTS AND RESULTS: We present six cases of Fibrolamellar hepatocellular carcinoma treated by partial hepatic resection. There were five females and one male with a mean age of 20 (2.6) yr. Five patients were stage IVA and 1 IVB based on the Union International Against Cancer Classification. Two patients, due to recurrent disease, needed further pulmonary resection and a hilar lymphadenectomy. All six cases underwent major resection, three with vascular reconstruction. No operative mortality was recorded; half of the patients displayed some degree of morbidity. One patient died six months after the operation and the rest are alive at 78, 41, 24, 12 and 9 months. We believe that even in advanced cases, an aggressive surgical policy even with vascular reconstruction is justified in patients with fibrolamellar hepatocellular carcinoma.

[Biliary cystadenoma]. / Cistoadenoma biliar.

We report a case of biliary cystadenoma in a 40 years female who presented with an epigastric abdominal mass. The preoperative diagnosis was made by means of US, CT and MRI. Lack of calcifications and the serological tests ruled out hydatid disease. Total excision by shelling out the lesion from the liver parenchyma was performed. We recommend complete surgical removal as the treatment of choice due to the malignant potential and the high recurrence rate after partial resections.

[The coexistence of rheumatoid arthritis, ankylosing spondylitis and intestinal necrotizing vasculitis]. / Coexistencia de artritis reumatoide, espondilitis anquilosante y vasculitis necrotizante intestinal.

We present the case of a 44-year-old male with ankylosing spondylitis and seropositive rheumatoid arthritis whose evolution was complicated by an intestinal necrotizing vasculitis type nodose panarteritis with fatal consequences. We discuss this exceptional association and its clinicopathological characteristics.

[Emphysematous cholecystitis: percutaneous treatment]. / Colecistitis enfisematosa: tratamiento percutáneo.

We present two patients with emphysematous cholecystitis treated successfully by means of percutaneous cholecystostomy. We emphasize the high mortality rate of the disease, and the good response achieved with the percutaneous technique, as well as the low complication rate of the procedure.

[Peritoneal pseudomyxoma secondary to mucinous cystadenocarcinoma of the appendix]. / Seudomixoma peritoneal secundario a cistadenocarcinoma mucinoso del apéndice.

A new case is presented of peritoneal pseudomyxoma secondary to a mucinous cystadenocarcinoma of the appendix discovered in the course of repair of a strangulated umbilical hernia. This is an uncommon entity which is only exceptionally diagnosed before operation and has a controversial treatment. The evolution and prognosis are unpredictable and are directly related to the degree of cellular differentiation.