"It just wasn't right down there": Surgical treatment of small bowel evisceration after hysterectomy with indocyanine green angiography, a case report.

This is a case of a 70-year-old female with small bowel evisceration through vaginal cuff dehiscence 14 months after hysterectomy. She presented with a loop of ileum herniated through the vagina. The bowel was irreducible and she was taken to the operating room for exploratory laparotomy, reduction of herniated bowel contents, and repair of vaginal cuff. During surgery, the eviscerated bowel had questionable viability and indocyanine green angiography was used to assess perfusion. After the repair of the vaginal cuff, indocyanine green angiography was performed and the bowel was saved from resection. In the discussion, light is shed upon the rarity of vaginal cuff dehiscence and the few cases of small bowel evisceration after a dehiscence. Possible causes of the evisceration, updates to technique, and recommendations for management are also discussed. The ultimate recommendation is for use of indocyanine green angiography in assessment of intestinal viability during surgical exploration for small bowel evisceration.

A patient with history of bladder cancer presenting with an axillary mass: A rare case of supradiaphragmatic cutaneous bladder cancer metastasis.

This case report documents the rare occurrence of axillary metastasis in a patient with a history of typical urothelial bladder cancer. Bladder cancer rarely metastasizes to supradiaphragmatic cutaneous tissues, and this presentation confers a poorer prognosis as well as an association with atypical variants of bladder cancer. However, this paper suggests that typical pure urothelial bladder cancer may be just as aggressive as its atypical counterpart. In addition, the work-up of axillary masses in a patient with a history of bladder cancer, whether typical or variant, should include metastatic disease as part of the differential diagnosis and guide treatment strategies.

Unusual metastatic patterns of invasive lobular carcinoma of the breast.

Invasive lobular carcinoma of the breast has similar patterns of metastatic disease when compared to invasive ductal carcinoma; however, lobular carcinoma metastasizes to unusual sites more frequently. We present a 65-year-old female with a history of invasive lobular breast carcinoma (T3N3M0) treated with modified radical mastectomy and aromatase-inhibitor therapy who underwent a surveillance PET scan, which showed possible sigmoid cancer. Colonoscopy with biopsy revealed a 3 cm sigmoid adenocarcinoma. The patient underwent a lower anterior resection. Pathology showed an ulcerated, invasive moderately differentiated adenocarcinoma extending into but not through the muscularis propria. However, six of seventeen paracolonic lymph nodes were positive for metastatic breast carcinoma (ER+/PR+), consistent with her lobular primary breast carcinoma; there was no evidence of metastatic colon cancer. This case highlights the unusual metastatic patterns of lobular carcinoma.

Spontaneous rupture of a saccular intrahepatic artery aneurysm.

Hepatic artery aneurysms are the second most common visceral aneurysm but are still relatively uncommon. Over the last century, methods for treating these lesions have evolved substantially. The presented case covers the presentation, diagnosis, and treatment of a 65-year-old woman with an aneurysm of the intrahepatic portion of the hepatic artery. This case demonstrates the variety of techniques available for managing these lesions and the importance of both a thorough knowledge of the available treatments and the flexibility to switch among them when necessary.

Extraluminal amyloidoma of the pelvic cavity causing large bowel obstruction.

AMYLOIDOSIS IS A GROUP OF DIVERSE DISORDERS THAT FALL INTO SEVERAL MAJOR CATEGORIES: primary, secondary, dialysis-associated, and hereditary forms. Clinically, amyloidosis may be categorized as localized or systemic. The gastrointestinal tract is among the most common places for deposition of amyloid, but large, localized amyloid deposits are an uncommon occurrence and rarely cause extraluminal bowel compression resulting in obstruction as was seen in the case presented in this clinical scenario.

Ischemic colitis secondary to ergotamine use: a case study.

A 48-year-old woman with a history of chronic migraines, initially admitted for inpatient management of intractable migraine headaches, developed new onset abdominal pain, hypotension, and diarrhea on hospital day number ten. In our institution's headache unit, patients are treated by a multidisciplinary approach, including individualized drug therapy based on diagnosis and previous response to therapy. Given the patient's hypotension and clinical appearance, she was transferred to the intensive care unit and treated for septic shock and metabolic acidosis. A bedside colonscopy revealed diffuse ischemic colitis. Final pathology after colon resection showed widespread, transmural necrosis of the colonic wall. We review the pathophysiology of ergotamine use and its potential association with ischemic colitis.

Eosinophilic granuloma of the lung and rib.

Langerhans-cell histiocytosis is characterized by abnormal proliferation of Langerhans cells, and frequently associated with cigarette smoking. A 24-year-old man who underwent excisional biopsy of a pulmonary nodule and segmental rib resection was found to have the eosinophilic granuloma variation of Langerhans-cell histiocytosis.

Small Bowel Ischemia in a Sickle Cell Patient.

We report a case of small bowel ischemia secondary to sickle cell disease. Acute bowel ischemia is an uncommon presentation of patients with sickle cell disease. Historically, only a handful of cases have been reported. We also provide a summary of the literature relevant to sickle cell patients with acute bowel ischemia.

Aortoesophageal fistula secondary to reflux esophagitis.

Aortoenteric fistula is a rare cause of massive upper gastrointestinal bleeding and is in the overwhelming majority of cases due to erosion of a suture line of a prosthetic vascular graft into the bowel. We report the case of a massive fatal gastrointestinal hemorrhage from an aortoenteric fistula secondary to erosion from reflux esophagitis. Proper management requires expedient radiographic and endoscopic evaluation, and even with appropriate management mortality remains extremely high.

Percutaneous biopsy in evaluation of lung nodules.

Management of an indeterminate pulmonary nodule is a diagnostic challenge that commonly confronts primary care physicians and specialists. Patients often present with this radiographic finding in the course of an unrelated medical evaluation. We examined our institution's experience with percutaneous biopsy of lung nodules to determine the impact of this procedure on overall patient care. Although significant complications are uncommon, the expedience of percutaneous lung biopsy often supplants a surgical opinion prior to initiation of therapy without added diagnostic benefit or cost-savings. Hence, we caution practitioners to use this technique as an adjunct to diagnosis and not a substitute for multidisciplinary care.

Anterior access to the lumbar spine: laparoscopic versus open.

The purpose of this study is to investigate the potential advantages and complications of a minimally invasive laparoscopic approach for anterior spinal exposure as compared with the open technique and to quantify differences in operative time, blood loss, transfusion requirements, analgesia, and morbidity. A retrospective review was performed on all patients undergoing access for anterior spinal procedures. Demographics, operation-related variables, complications, and estimated cost were analyzed. Categorical data were analyzed using the Fisher's exact test and continuous variables were analyzed with the Mann-Whitney U test. We performed a total of 65 anterior spinal access procedures between February 1997 and April 2001 at our institution. Forty-five operations were performed at the L5-S1 level: 31 using transperitoneal laparoscopic techniques and 14 using an open minilaparotomy. Mean follow-up was 12 months (range 1-50). No significant differences between the groups were found when comparing analgesia requirements, time to resumption of oral intake, length of hospitalization, and complication rates. Statistical analysis showed that laparoscopic procedures were associated with shorter operating room times (P = 0.08) and less intraoperative blood loss (P = 0.029). The laparoscopic approach was estimated to cost $1,374 more than the open technique. Transperitoneal laparoscopic techniques for anterior spinal exposure are comparable to the standard open approach and offer no substantive advantages. The overall cost of laparoscopic spinal surgery is higher compared with conventional open procedures.