Laparoscopic adrenalectomy for a giant adrenal teratoma: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Teratomas typically are benign gonadal neoplasms, arising from more than one embryonic germ layer. Extragonadal teratomas are rare and primary adrenal teratomas more so, with few documented cases. We present one such case, diagnosed via CT, resected via laparoscopic adrenalectomy, and confirmed on histology. To the best of our knowledge, this is the first case documented in the Caribbean. CASE PRESENTATION: A 38-year-old obese female with restrictive lung disease presented with right back/flank pain due to a non-functional 10.5 cm right adrenal mass on CT, likely a giant myelolipoma. Further radiologic review suggested this was instead a mature adrenal teratoma. She underwent a laparoscopic adrenalectomy and histology confirmed a mature adrenal teratoma. CLINICAL DISCUSSION: Most adrenal tumours are incidentalomas and are usually benign adenomas. Primary adrenal teratomas account for 1 % of teratomas and 0.13 % of adrenal tumours. They may be mature or immature; the latter carries a greater risk of malignancy. Benign adrenal teratomas are typically non-functional and commonly mistaken for myelolipomas on imaging. Adrenalectomy is required due to the risk of malignant transformation. The laparoscopic approach depends on size, localized tissue invasion and technical considerations, but offers advantages for the patient if possible. CONCLUSIONS: Though uncommon, preoperative radiologic diagnosis of an adrenal teratoma is possible and should be completely resected after a functional workup. A laparoscopic adrenalectomy is preferred once this can be done safely, even when very large, with surgical and oncologic outcomes equivalent to an open approach combined with the known advantages of laparoscopic surgery.

Discordant intestinal malrotation in adult monozygotic twins discovered incidentally during laparoscopic gastric bypass: A case report and review of the literature.

INTRODUCTION AND IMPORTANCE: Intestinal Malrotation is an uncommon entity in the adult population; more so in monozygotic twins, where concordance is expected. In literature, discordant intestinal Malrotation has only been discovered when one twin became symptomatic, and the other was screened. To the best of our knowledge, this is the first documented case of discordant adult type intestinal Malrotation in otherwise asymptomatic monozygotic twins discovered incidentally during Laparoscopic Roux-en-Y Gastric bypass (LRYGB). CASE PRESENTATION: Twins A and B met the NIH criteria for bariatric surgery, neither having symptoms of acute or chronic volvulus or history of intraabdominal surgery. Twin A had a LRYGB performed by a trained bariatric surgeon, noting no anatomic anomalies. 5 months later, Twin B had LRYGB and intestinal Malrotation was diagnosed incidentally. CLINICAL DISCUSSION: Diagnosis of Intestinal Malrotation is rare in adults, usually discovered after becoming symptomatic or during abdominal imaging for another indication. Two cases of discordant intestinal Malrotation in monozygotic twins have been documented, both discovered when one twin became symptomatic due to acute volvulus, suggesting epigenetic phenomena. When discovered incidentally during surgery, patients can safely undergo their intended procedure, but literature suggests prophylactic division of Ladd's bands, while appendectomy is left to the discretion of the surgeon. CONCLUSIONS: Intestinal Malrotation appears to be associated with epigenetic phenomena and if discovered incidentally during surgery, the proposed procedure can be carried out by an experienced surgeon, in addition to division of Ladd's bands and appendectomy.

Complete Genome Sequence of Enterobacter xiangfangensis Pb204, a South African Strain Capable of Synthesizing Gold Nanoparticles.

Enterobacter xiangfangensis Pb204, isolated from acid mine decant from a uranium mine, produces a wide variety of gold nanoparticles (AuNPs), ranging from large triangular plates to small spherical AuNPs. The complete genome sequence of this isolate incorporates an integrative and conjugative element which may be pivotal to AuNP synthesis.

Long-term survival following open versus thoracoscopic lobectomy after preoperative chemotherapy for non-small cell lung cancer.

OBJECTIVES: Video-assisted thoracoscopic (VATS) lobectomy is increasingly accepted for the management of early-stage non-small cell lung cancer (NSCLC), but its role for locally advanced cancers has not been as well characterized. We compared outcomes of patients who received induction therapy followed by lobectomy, via VATS or thoracotomy. METHODS: Perioperative complications and long-term survival of all patients with NSCLC who received induction chemotherapy (ICT) (with or without induction radiation therapy) followed by lobectomy from 1996-2012 were assessed using Kaplan-Meier and Cox proportional hazard analysis. Propensity score-matched comparisons were used to assess the potential impact of selection bias. RESULTS: From 1996 to 2012, 272 patients met inclusion criteria and underwent lobectomy after ICT: 69 (25%) by VATS and 203 (75%) by thoracotomy. An 'intent-to-treat' analysis was performed. Compared with thoracotomy patients, VATS patients had a higher clinical stage, were older, had greater body mass index, and were more likely to have coronary disease and chronic obstructive pulmonary disease. Induction radiation was used more commonly in thoracotomy patients [VATS 28% (n = 19) vs open 72% (n = 146), P < 0.001]. Thirty-day mortality was similar between the VATS [3% (n = 2)] and open [4% (n = 8)] groups (P = 0.69). Seven (10%) of the VATS cases were converted to thoracotomy due to difficulty in dissection from fibrotic tissue and adhesions (n = 5) or bleeding (n = 2); none of these conversions led to perioperative deaths. In univariate analysis, VATS patients had improved 3-year survival compared with thoracotomy (61% vs 43%, P = 0.010). In multivariable analysis, the VATS approach showed a trend towards improved survival, but this did not reach statistical significance (hazard ratio, 0.56; 95% confidence interval, 0.32-1.01; P = 0.053). Moreover, a propensity score-matched analysis balancing patient characteristics demonstrated that the VATS approach had similar survival to an open approach (P = 0.56). CONCLUSIONS: VATS lobectomy in patients treated with induction therapy for locally advanced NSCLC is feasible and effective and does not appear to compromise oncologic outcomes.

Continuous infusion of bupivacaine for pain control after anterior iliac crest bone grafting for alveolar cleft repair in children.

OBJECTIVE: The purpose of this study was (1) to evaluate the analgesic efficacy of continuous infusion bupivacaine, (2) to evaluate the effects of the site-specific catheter infusion on operating room time, narcotic use, ambulatory status, and length of hospitalization, (3) to monitor for adverse outcomes, and (4) to assess patient/family acceptance. DESIGN: Randomized, double-blinded, and prospective study of bupivacaine versus saline for pain control after anterior iliac crest bone grafting for alveolar cleft repair. SETTING: University of Alabama at Birmingham. PATIENTS: A total of 65 pediatric patients with alveolar cleft defects treated between 2006 and 2009. INTERVENTIONS: Anterior iliac crest bone grafting for alveolar cleft repair with assignment to either a bupivacaine or a saline infusion group. MAIN OUTCOME MEASURES: Physical examination, pain ratings, narcotic use, ambulatory status, operating room time, and length of hospital stay. RESULTS: On the blinded physical exam, 71% in the bupivacaine infusion group and 42% in the saline infusion group were assessed as not experiencing pain at the surgical hip site. The experimental group used less narcotics compared with the control group. No significant differences were noted with operating room time, initial ambulatory status, or length of hospitalization (1.09 versus 1.12 days). Satisfaction and acceptance of the catheter treatment was universal. CONCLUSIONS: These results suggest that postoperative infusion of bupivacaine may be efficacious for enhancing pain relief after bone harvest in pediatric patients and may enhance parental perceptions of postoperative care; however, this patient population is difficult to study accurately.