Ectopic supernumerary kidney, a cause of para-aortic mass: case report and review.

Ectopic supernumerary kidney is a rare congenital urinary tract abnormality. Because of the scarcity of published cases and atypical presenting symptomatology this entity frequently causes a diagnostic as well as therapeutic dilemma. We report a case of an unusually symptomatic supernumerary kidney that presented as back pain. Noncontrast CT scan showed a suspicious left-sided para-aortic mass, which prompted a percutaneous biopsy. Intravenous contrast CT scan revealed an anatomically and functionally free supernumerary kidney. The approach to diagnosis as well as management of supernumerary kidneys is discussed herein.

Balloon blunt-tip trocar for laparoscopic cholecystectomy: improvement over the traditional Hasson and Veress needle methods.

BACKGROUND AND PURPOSE: Laparoscopic cholecystectomy (LC) is a routine procedure for most general surgeons, yet the technical aspects of gaining access to the peritoneal cavity continue to be quite diverse. We describe a prospective review of 180 LCs using three access techniques: open balloon blunt-tip trocar (BBTT), open Hasson (HA), and closed Veress needle (VN). We favor the BBTT because it is designed to avoid all sharp instrumentation and offers superior seal and mobility, as well as expeditious and easy abdominal access. PATIENTS AND METHODS: The techniques and devices were evaluated prospectively with regard to simplicity of access, leakage of carbon dioxide, access time, and complications. All patients underwent LC by one of two Board-certified surgeons. RESULTS: The mean time to insertion of the laparoscope for the BBTT (3.5 +/- 0.99 minutes) was significantly less than the insertion time for the VN technique (5.2 +/- 0.9 minutes, P < 0.05). The insertion time for the BBTT was also less than for the standard HA approach (4.25 +/- 1.0 minutes; P < 0.05). There were no visceral or vascular injuries noted, but CO2 leakage and subcutaneous insufflation of gas experienced in the standard HA and VN groups resulted in lengthened operative times. One patient in the BBTT group experienced a postoperative port-site herniation, which was repaired primarily without consequence. CONCLUSION: The BBTT is an established, safe alternative to blind access for LC. Our technique is simple and rapid and avoids most of the technical difficulties encountered by other open access devices. We believe this method provides surgeons with an option that is efficient and easier to perform than most other conventional open-access laparoscopic techniques.

Palliative treatment of recurrent obstructing gastric cancer. A case report of successful treatment with three self-expanding metallic stents.

Patients with advanced or recurrent gastric cancer affecting the upper and lower gastrointestinal tract usually experience obstructive symptoms, causing a severe compromise in their quality of life. Surgery may not be feasible because of the patient's precarious medical condition and multilevel tumor infiltration. When faced with these circumstances, surgeons have few options. Parenteral nutrition and comfort measures are utilized when surgical bypass is not a tenable option. We herein describe a unique case of multilevel upper and lower gastrointestinal obstruction secondary to recurrent gastric cancer. The patient was treated palliatively through a combined surgical, radiological, and endoscopic approach by implanting a series of self-expanding metallic stents. To our knowledge, there are no previous reports of successful management of simultaneous strictures of the upper and lower gastrointestinal tract using this technique.

Carcinoma of the breast during pregnancy: a review and update on treatment options.

Gestational breast cancer is occurring with increasing incidence because more women are delaying childbirth into their thirties and forties. Although breast cancer during pregnancy or within the first year postpartum is occurring more often, there is still some confusion regarding its treatment. Although breast conservation therapy has evolved as the major treatment in breast cancer, it has been thought that pregnancy was a contraindication for this type of breast cancer therapy due to risks imposed on the fetus by chemotherapy and radiation. However, recent studies have shown that the use of chemotherapeutics during the second and third trimesters is possible. Also, if chemotherapy is initiated after a lumpectomy, radiation can be withheld until after the birth of the baby when the cancer is detected in the second or third trimester.

Thoracoscopy in acquired immunodeficiency syndrome.

OBJECTIVE: The role of thoracic surgery in patients with acquired immunodeficiency syndrome (AIDS) continues to evolve. This review seeks to evaluate the outcome, morbidity, and mortality associated with video-assisted thoracoscopic surgery for empyema and pneumothorax in patients with AIDS. METHODS: A retrospective review was conducted of patients with AIDS in whom video-assisted thoracoscopic surgery was performed for empyema (group 1) or intractable pneumothorax (group 2). RESULTS: Twenty patients with AIDS (95% male, mean age 37.4 years, mean CD4 count 76 cells/ml3) underwent thoracoscopy. Surgery was performed for empyema (group 1) in 11 (55%) and intractable pneumothorax (group 2) in nine (45%). Three patients (15%) died within 30 days of the operation. At mean follow-up (29 months), overall survival was 55%. For those who survived the hospitalization and died within the follow-up period (35.3%), mean survival time was 8.2 months (range 1 month to 27 months). In group 1, surgical procedures were performed after 8 days of chest tube drainage and included pleural debridement and mechanical pleurodesis (n = 11) along with lung biopsy (n = 6). Survivals at 30 days and 29 months' follow-up were 90.9% and 45.4%, respectively. In group 2, significantly depressed CD4 counts (average 33.2 cells/ml3) were noted along with a more prolonged preoperative hospitalization (18.5 days) with 14.2 days spent with a chest tube before the operation. In this group, operative procedures included mechanical pleurodesis and talc poudrage (n = 9), bleb resection (n = 7), and lung biopsy (n = 1). Two deaths (22%) occurred within 30 days of the operation and survival at 29 months' follow-up was 66%. CONCLUSION: Video-assisted thoracoscopic surgery performed in patients with AIDS for the treatment of empyema and intractable pneumothorax is effective, can be performed with little operative morbidity and mortality, and is associated with acceptable long-term survival. Video-assisted thoracoscopic surgery is best performed soon after the diagnosis of intractable pneumothorax or empyema has been established.