Boerhaave's syndrome secondary to an incarcerated inguinal hernia: A case report.

INTRODUCTION: Boerhaave's syndrome is defined as the spontaneous perforation of the esophagus. Although it has been reported in association with different gastrointestinal pathologies, there are no previous reports in association with an incarcerated inguinal hernia containing ischemic small bowel. PRESENTATION OF CASE: We present an unusual case of a gentleman who presented with severe chest pain after a 24-h period of emesis. He was found to have developed an esophageal perforation presumed secondary to an incarcerated inguinal hernia causing small bowel obstruction. The patient underwent a thoracotomy to repair the perforated esophagus followed by a groin exploration, small bowel resection and repair of the inguinal hernia. DISCUSSION: Boerhaave's syndrome is well known to be a postemetic phenomenon in association with upper gastrointestinal obstruction. However, to our knowledge, this is the first reported case of esophageal perforation secondary to strangulated bowel in an inguinal hernia. In similar situations, we recommend the surgical correction of the esophageal perforation, followed by exploration and resection of any ischemic small bowel. CONCLUSION: Here we present a patient who was diagnosed with a perforated esophagus after forceful emesis secondary to an incarcerated inguinal hernia containing ischemic bowel.

The management of hepatobiliary cystadenomas: lessons learned.

BACKGROUND: Mucinous cystic neoplasms of the liver (hepatobiliary cystadenomas) are rare neoplastic lesions. Such cysts are often incorrectly diagnosed and managed, and carry a risk of malignancy. The objective of this study was to review the surgical experience with these lesions over 15 years. METHODS: A retrospective chart review identified consecutive patients undergoing surgery for liver cystadenomas from 1997-2011. Clinical data were collected and summarized. RESULTS: Thirteen patients (mean age 51 years, 12/13 females) with cysts 4.6-18.1 cm were identified. Most cysts were located in the left lobe/centrally (11/12) and had septations (8/13). Mural nodularity was infrequent (3/13). Nine patients had liver resection/enucleation, whereas four had unroofing. Frozen section analysis had a high false-negative rate (4/6). All patients had cystadenomas, of which two had foci of invasive carcinoma (cystadenocarcinoma) within mural nodules. There was no 90-day mortality. All but one patient (myocardial infarction) were alive at a median follow-up of 23.1 months. No patient with unroofing has developed malignancy to date. CONCLUSIONS: Non-invasive hepatobiliary cystadenomas present as large central/left-sided cysts in young or middle-aged women. Associated malignancy was relatively uncommon and found within mural nodules. Intra-operative frozen section analysis was ineffective at ruling out cystadenomas. Complete excision is recommended, but close follow-up might be considered in patients with a prohibitive technical or medical risk, in the absence of nodularity on high-quality imaging.

Obstructive jaundice: a rare complication of laparoscopic greater curvature plication.

Laparoscopic greater curvature plication (LGCP) is relatively a new procedure. We report a novel complication of obstructive jaundice in a 24-year-old patient post LGCP. This was secondary to gastric mucosa prolapse with obstruction of the ampulla of Vater. A literature review revealed no previous reports of similar complication.

Evaluating agreement regarding the resectability of colorectal liver metastases: a national case-based survey of hepatic surgeons.

BACKGROUND: The resectability of colorectal liver metastases is in part largely based on the surgeon's assessment of cross-sectional imaging. This process, while guided by principles, is subjective. The objective of the present study was to assess agreement between hepatic surgeons regarding the resectability of colorectal liver metastases. METHODS: Forty-six hepatic surgeons across Canada were invited. A patient with biologically favourable disease was presented after having received neoadjuvant chemotherapy. The scenario was matched with 10 different scrollable abdominal CT scans representing a maximum response after six cycles of chemotherapy. Surgeons were asked to offer an opinion on resectability of liver metastases, and whether they would use adjunct modalities to hepatic resection. RESULTS: Twenty-six surgeons participated. Twenty responses were complete. The median number of scenarios deemed resectable was 6/10 (range 3-8). Two control scenarios demonstrated perfect agreement. Agreement on resectability was poor for 4/8 test scenarios, of which one scenario demonstrated complete disagreement. Among resectable cases, the pattern of use of adjunct modalities was variable. A median ratio of 0.87 adjunct modality per resectable scenario per surgeon was used (range 0.25-1.75). CONCLUSION: A significant lack of agreement was identified among surgeons on the resectability and use of adjunct modalities in the treatment of colorectal liver metastases.

Outpatient laparoscopic adrenalectomy: a Canadian experience.

BACKGROUND: We report our experience at The Ottawa Hospital with outpatient laparoscopic adrenalectomy. METHODS: We report a single surgeon experience. Seventeen consecutive outpatient laparoscopic adrenalectomy were performed between 1994 and 2006. Specific selection criteria were applied. Postoperatively patients were monitored and assessed before discharge. Full discharge instructions were provided. A prescription for analgesic was given. A call back system was put in place. The first postoperative office visit was scheduled within 7 days of surgery. RESULTS: Twelve of 17 patients were females. The mean age was 52.4 years. Our average operating room time was 130 minutes with no conversions. The average stay was about 5.5 hours. Three patients had a 23-hour stay. One admitted with atelectasis. Tumor size ranged from 1 to 5.8 cm. There were no reoperations, late admissions up to 30 days, and no deaths. One patient required admission. Thirteen of 17 patients were contacted by phone after discharge. At our hospital we found a cost saving of C$1478 is made per case. CONCLUSIONS: Laparoscopic adrenalectomy can be safely performed as an outpatient procedure. Strict selection criteria should be applied. Call back systems should be instituted. There is a cost benefit associated with this outpatient procedure.

Surgical management of colorectal liver metastases.

Colorectal cancer is the third most commonly diagnosed cancer with approximately half of the patients developing liver metastases during the course of their disease. Modern multimodal therapies have improved the overall survival. Liver resection remains the most important modality in the treatment of colorectal liver metastases. The evolution of the criteria for resectability has resulted in more patients being offered a hepatectomy. This is further augmented with the utilization of adjuncts to liver resection, including portal vein embolization and local ablative techniques. Two-stage hepatectomy is also being used to increase resectability. Overall survival is improved by the deployment of new chemotherapeutic agents and the use of combination chemotherapy. Neoadjuvant chemotherapy is a promising development in the treatment of colorectal liver metastases. Patients with colorectal liver metastases can achieve long-term survival. A multidisciplinary approach is essential in the management of these patients.