Spigelian hernia: CT findings and clinical relevance.

OBJECTIVE: The purpose of our study was to evaluate the clinical relevance of preoperative CT in distinguishing between the two subtypes of spigelian hernia (SH). MATERIALS AND METHODS: We reviewed retrospectively the CT images of 35 patients. The patients were divided into two groups on the basis of the SH subtype: interstitial SH group (n = 15) and subcutaneous SH group (n = 20). Clinical characteristics of patients and CT findings were analyzed. Bowel ischemia on surgery was also noted. RESULTS: Sixteen right hernias and 19 left hernias were observed. Fifteen interstitial SH (43%) and 20 subcutaneous SH (57%) were found. No type of content showed a statistically significant association with one or other subtype of SH. Nine of the 26 patients presenting with SH with SB content showed signs of SBO on CT. Closed-loop SBO on CT was present in 5 of the 26 patients with SB content. An interstitial SH was observed in all of these 5 patients (p = 0.039). Surgery was performed on 10 patients. Bowel ischemia was found on surgery in 4 patients and showed no statistically significant association with a particular subtype of SH (p = 0.6). CONCLUSION: Our study shows the importance of performing CT in SH. CT provides the diagnosis of SH, shows SH content, and demonstrates the presence of SBO or closed-loop SBO. Moreover, the distinction between the two subtypes of SH on CT appears to be of clinical relevance since closed-loop SBO is statistically associated with interstitial SH and the optimal surgical approach may differ.

Sentinel lymph node biopsy in melanoma: our 8-year clinical experience in a single French institute (2002-2009).

BACKGROUND: Since the introduction of sentinel lymph node biopsy (SLNB), its use as a standard of care for patients with clinically node-negative cutaneous melanoma remains controversial. We wished to evaluate our experience of SLNB for melanoma. METHODS: A single center observational cohort of 203 melanoma patients with a primary cutaneous melanoma (tumour thickness > 1 mm) and without clinical evidence of metastasis was investigated from 2002 to 2009. Head and neck melanoma were excluded. SLN was identified following preoperative lymphoscintigraphy and intraoperative gamma probe interrogation. RESULTS: The SLN identification rate was 97%. The SLN was tumor positive in 44 patients (22%). Positive SLN was significantly associated with primary tumor thickness and microscopic ulceration. The median follow-up was 39.5 (5-97) months. Disease progression was significantly more frequent in SLN positive patients (32% vs 13%, p = 0.002). Five-year DFS and OS of the entire cohort were 79.6% and 84.6%, respectively, with a statistical significant difference between SLN positive (58.7% and 69.7%) and SLN negative (85% and 90.3%) patients (p = 0.0006 and p = 0.0096 respectively). Postoperative complications after SLNB were observed in 12% of patients. CONCLUSION: Our data confirm previous studies and support the clinical usefulness of SLNB as a reliable and accurate staging method in patients with cutaneous melanoma. However, the benefit of additional CLND in patients with positive SLN remains to be demonstrated.

C-reactive protein predicts short-term mortality in patients with cirrhosis.

BACKGROUND & AIMS: We aimed at improving prediction of short-term mortality in cirrhotic inpatients by evaluating C-reactive protein (CRP) as a surrogate marker of systemic inflammatory response syndrome (SIRS). METHODS: One-hundred and forty-eight consecutive cirrhotic patients with Child-Pugh score ≥ B8 and without hepatocellular carcinoma were prospectively included and followed for 182 days. The primary end point was 6-month survival. RESULTS: Main baseline characteristics were as follows: alcoholic liver disease in 88.5%; bacterial infection in 37%; hepatorenal syndrome in 7% of cases. CRP range was 1-240 mg/L (median 26 mg/L); 42 patients (28.4%) had SIRS as defined by ACCP/SCCM-criteria. CRP levels were higher in patients with SIRS (50 vs. 21 mg/L; p<0.0001), infection (46 vs. 27 mg/L; p<0.0001), and alcoholic hepatitis (44 vs. 32 mg/L, p=0.049). Forty-two patients died within the first 6 months of follow-up. Short-term mortality was associated with extrahepatic co-morbidities (p=0.002), high MELD score (p<0.001; AUROC=0.67), renal failure (p=0.008), elevated blood lactates (p<0.001), and high baseline CRP levels (p=0.003; AUROC=0.63; best cut-off value at 29 mg/L). Among patients with baseline CRP ≥ 29 mg/L, 32 still had CRP ≥ 29 mg/L at day 15 (group A). Group A was associated with 6-month mortality in the overall population (p<0.001) and also through sensitivity analyses restricted to patients without infection or alcoholic hepatitis. Multivariate analysis (Cox) adjusted for age identified three predictors of mortality: high MELD score (HR=1.08; 95% CI: 1.03-1.12; p<0.001), extrahepatic co-morbidities (HR=2.51; 95% CI: 1.31-4.84; p=0.006), and CRP level (group A) (HR=2.73; 95% CI: 1.41-5.26; p=0.003). The performance of the three variables taken together for predicting death was 0.80 (AUROC). CONCLUSIONS: In Child-Pugh score ≥ B8 cirrhotic patients, persistent CRP levels ≥ 29 mg/L predicted short-term mortality independently of age, MELD, and co-morbidities, and better than infection or clinically-assessed SIRS.