Postpartum Budd-Chiari syndrome with prolonged hypercoagulability state

Budd-Chiari syndrome after pregnancy is an extremely rare disease. Reported here is a case of postpartum Budd-Chiari syndrome with unusual features of prolonged hypercoagulability state. The disease occurred 2 weeks after delivery and despite massive anticoagulation treatment the patient developed severe hepatic vein occlusion, renal vein thrombosis, inferior vena cava thrombosis, and femoral artery thrombosis.     

Early detection of a congenital coronary artery fistula in a neonate by Doppler color flow mapping

AIMS: To describe a case of a congenital coronary artery fistula in a neonate with the diagnostic and surgical modalities used to manage this condition. A full-term infant was recently diagnosed with a coronary artery fistula. The patient was a term neonate, born without complications, which then appeared to be cyanotic and had a significant heart murmur. RESULTS: Echocardiography demonstrated a large right coronary fistula measuring 7 mm in diameter entering the right ventricle and a small patent ductus arteriosus (PDA) with a left to right shunt. The patient subsequently had patch closure of the coronary artery fistula and ligation of the PDA. Recovery followed from the procedure without apparent intra-operative or post-operative complications. CONCLUSION: Prompt diagnosis and surgical management of the neonate with a coronary fistula is essential to reduce the morbidity and mortality that may result from this condition.     

Transhepatic artery chemoembolization for liver metastases of primary retroperitoneal endodermal sinus tumor. A case report.

BACKGROUND: Primary retroperitoneal endodermal sinus tumors (EST) are extremely rare and highly malignant. Hepatic metastases from EST are often very difficult to manage and carry a dismal prognosis. Transhepatic artery chemoembolization has been widely applied in primary unresectable hepatoma and had been reported to have antitumor activity for some metastatic tumors. We report a case in which transhepatic artery chemo-embolization was employed to control hepatic metastases from EST. CASE: A 35-year-old woman presented to our service with primary retroperitoneal EST associated with multiple hepatic metastases. The patient underwent aggressive debulking surgery followed by a combination chemotherapy regimen of cisplatin, vinblastine and bleomycin. Transhepatic artery chemoembolization with adriamycin, lipoidol and gelfoam was subsequently employed to treat hepatic metastases. CONCLUSION: The combination of transhepatic artery chemoembolization and systemic chemotherapy after surgical resection of primary retroperitoneal EST was effective in controlling the hepatic disease in this case.     

Robotic Low Anterior Resection and Partial Bladder Resection for Management of Locoregional Endometrial Cancer Recurrence

ObjectiveTo demonstrate a robotic tumor debulking for management of locoregional endometrial cancer recurrence.DesignCase report.SettingTertiary referral center in New Haven, CT.InterventionsA 70-year-old patient with a history of stage IB endometrioid endometrial cancer presented with rectal bleeding 3 years after the completion of treatment. A mass involving the distal sigmoid colon/upper rectum and bilateral distal periureteral masses were visualized on imaging. There was no distant metastatic disease. Colonoscopic biopsies were consistent with endometrial cancer recurrence. Because the patient was symptomatic with rectal bleeding and had no distant metastasis, it was recommended that she undergo surgical resection for management of this locoregional recurrence.The patient was placed in reverse Trendelenburg position with a rightward tilt to mobilize the splenic flexure. Once the cephalad aspect of the descending colon mobilization was completed, the patient was placed in Trendelenburg lithotomy position to expose the pelvis. A robot was docked at this point and the pelvic avascular spaces were delineated. A medial-to-lateral approach was used in mobilization of the sigmoid colon mesentery. The left ureter was identified and the sigmoid branches of inferior mesenteric artery were sealed. The descending/sigmoid colon junction was stapled. After complete mobilization of the sigmoid colon, the tumor-free upper rectum was delineated and stapled.Attention was then turned to the distal peri-ureteral masses. The 2-cm mass on the right, which was densely adherent to the distal right ureter, was completely resected after extensive ureterolysis. The resection of the 4-cm mass on the left which involved both the distal left ureter and the bladder dome required an intentional cystotomy and a partial cystectomy to attain negative margins (Supplemental Figure 1).The procedure was continued with the bowel anastomosis. The anvil was introduced through the vagina and was placed into the proximal limb through an antimesenteric incision. An end-to-end tension-free anastomosis was performed and adequate vascularization was confirmed with intravenous indocyanine green.ConclusionRobotic low anterior resection and partial bladder resection were performed without any complications with negative margins. Robotic tumor debulking should be considered in appropriate patients when managing locoregional recurrence of endometrial cancer [1,2].     

Revascularization of traumatic thrombosis of the renal artery

Renal artery thrombosis, although well recognized, remains a rare complication of blunt abdominal trauma. In an effort to resolve the current controversy concerning the appropriate therapy, we have reviewed the available literature. Only those instances when the injury was due to blunt trauma and resulted in complete occlusion of the renal artery, documented by roentgenographic means, were included in this review. Avulsion injuries, incomplete occlusion or branch artery injuries were also excluded. In order to be classified as a surgical success, postoperative documentation of renal function and a patent renal artery were required. Only nine successfully performed vascularization procedures were identified. There were four instances of bilateral obstruction with postoperative serum creatinine levels ranging from 1.77 to 7.1 milligrams per deciliter. All required postoperative dialysis ranging from three days to three months in duration. Thirty-five patients with an unilaterally obstructed renal artery underwent attempted revascularization. Five patients, all with a presumed ischemic time of less than 12 hours, had a successful outcome. Postoperatively, four patients demonstrated either a decrease in size or function of the injured kidney. Thirteen eventually required nephrectomy.     

Outpatient total laparoscopic hysterectomy

STUDY OBJECTIVE: To assess the safety of and patient satisfaction with total laparoscopic hysterectomy as an outpatient procedure. DESIGN: Retrospective case study (Canadian Task Force classification III). SETTING: Tertiary care hospital. PATIENTS: Sixty-six consecutive women. INTERVENTION: Outpatient total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS: Of 66 procedures completed, 6 patients (7.5%) required overnight hospitalization, with 4 of them discharged the next day. Seven (11%) minor postoperative complications occurred. One patient required hospitalization to receive intravenous antibiotics and one for drainage of a cuff hematoma. There were three (4.5%) minor intraoperative complications. One woman developed Clostridium difficile diarrhea as well as deep vein thrombosis and pulmonary embolus. Sixty-three women (95%) were satisfied with the procedure and would recommend it to others. CONCLUSION: Outpatient total laparoscopic hysterectomy is well tolerated, safe, and cost effective.     

Renal biopsy and pregnancy

OBJECTIVE: Our aim was to review our experience with renal biopsy in pregnancy. STUDY DESIGN: We reviewed 18 renal biopsies performed during pregnancy or in the immediate postpartum period at the University of North Carolina. Indications, histopathologic findings, complications, and neonatal outcome were reviewed for each case. RESULTS: Fifteen patients underwent biopsy during the antepartum period and 3 in the postpartum period. Only 5 patients had the classic histopathologic preeclamptic lesion glomeruloendotheliosis confirmed. There were 7 identifiable renal hematomas after biopsy; 2 patients required blood transfusion. There were 4 intrauterine fetal deaths in this series; it is presumed that none were a result of the biopsy. CONCLUSION: Renal biopsy in pregnancy is a morbid procedure and should be considered only if it offers the opportunity to make a diagnosis other than severe preeclampsia in a patient remote from term.     

Synchronous fallopian tube and breast cancers: case report and literature review

A case of fallopian tube cancer was intraoperatively diagnosed in a patient submitted to laparoscopic hysterectomy and bilateral salpingo-oophorectomy because of an ultrasound diagnosis of a probable endometriotic cyst of the right ovary. Postoperatively a complete staging was performed and a synchronous carcinoma of the breast was diagnosed. Consequently the patient completed laparotomic debulking and a left mastectomy. A case of a premenopausal woman with fallopian tube cancer and synchronous breast cancer is reported together with a review of the most recent literature.     

Metachronous metastases from renal cell carcinoma to uterine cervix and vagina: case report and review of literature

BACKGROUND: Although renal cell carcinoma (RCC) is characterized with unpredictable clinical presentation, multiple genital tract metastases are still surprising and mode of spread is obscure. CASE: We report a case of RCC metastases to uterine cervix and vagina 1 year after radical nephrectomy in a 19-year-old virgin. To our knowledge, this case is the second youngest patient with RCC metastasis to vagina, and also third patient with RCC metastasis to uterine cervix. CONCLUSION: Detection of genital lesion may precede diagnosis of RCC. The primary renal tumor was mostly left sided. Retrograde venous extension seems to be the most plausible mode of spread. Limited total experience and variability in therapeutic approach prevent generalizations regarding prognosis, optimal treatment and survival.     

Primary primitive neuroectodermal tumor of the urinary tract.

Primary primitive neuroectodermal tumor (PNET) of the urinary tract is a rare disease with aggressive behavior and poor prognosis. We analyzed 851 cases of urinary tract malignancies in our hospital between 1984 and 2004. Only three (0.035%) cases with PNET of the urinary tract were identified. Presenting symptoms included flank pain and hematuria. The first case was a 44-year-old man with left renal PNET who underwent hand-assisted laparoscopic radical nephrectomy and adjuvant chemotherapy. There was no recurrent tumor at the 4-year follow-up. The second case was a 75-year-old woman with right renal PNET with inferior vena cava (IVC) thrombosis extending to the right atrium. The patient underwent right radical nephroureterectomy and IVC thrombectomy with cardiopulmonary bypass. She died of metastatic disease 7 months later. The third case was a 45-year-old man with left ureteral PNET. Left ureteral segmental resection and partial cystectomy were performed. Tumor recurrence was noted 7 years later. The patient died of disseminated disease 1 year after the discovery of recurrence. Urinary tract PNET appears to be an aggressive malignancy. Long-term survival is possible if complete resection is performed at an early stage.     

Feasibility of laparoscopic debulking with electrosurgical loop excision procedure and argon beam coagulator at recurrence in patients with previous laparotomy debulking

OBJECTIVES: Our purpose is to assess the feasibility and success of laparoscopic ovarian debulking with electrosurgical loop excision procedure (LEEP) and argon beam coagulator (ABC). METHODS: Thirty-six consecutive asymptomatic patients with chemosensitive stage III or IV ovarian cancer who had undergone prior laparotomy debulking and chemotherapy, underwent laparoscopic debulking at the time of elevated CA 125. Preoperative abdominal/pelvic computed tomography was negative. Operative laparoscopy was performed through an open technique in the left upper quadrant. Tumors were debulked laparoscopically by using the LEEP and the ABC. RESULTS: Of 36 patients, 34 (94%) underwent successful laparoscopic debulking without requiring laparotomy. Of 34 patients, 32 (94%) had all visible disease resected at laparoscopy; 6% had surgical complications. Median time for surgery was 2.6 hours, median blood loss 70 mL, and median hospital stay 1 day. Seventy-four percent had a complete response after laparoscopic debulking and chemotherapy with a median progression free survival of 1.1 years. CONCLUSION: We present the first report of laparoscopic ovarian debulking using LEEP and ABC after elevation of CA 125 in chemosensitive, asymptomatic patients who had undergone prior laparotomy debulking. Laparoscopic debulking appears feasible (94%), successful (94%), and safe (6% complications). Prospective randomized trials are needed to determine the optimal management of asymptomatic, chemosensitive patients with elevated CA 125.     

Continuous Intraoperative Intraperitoneal Hyperthermic Chemoperfusion (CIIPHCP) in the treatment of advanced stage and recurrent granulosa cell tumors. Report of two cases

BACKGROUND: Treatment of advanced stages and recurrent ovarian granulosa cell tumors, has not been established yet. The effectiveness of radiation therapy could not be proven. Systemic chemotherapy has shown promising results, but with severe side effects and high incidence of relapse. CASE REPORTS: We report of one patient with advanced stage III C, and one patient with bulky recurrent ovarian granulosa cell tumors. Both patients were treated with a combination of surgical debulking, Continuous Intraoperative Intraperitoneal Hyperthermic Chemoperfusion (CIIPHCP) with Cisplatin and one of them with adjuvant systemic chemotherapy. CONCLUSION: CIIPHCP appears to offer a promising procedure in addition to surgical debulking and systemic chemotherapy for treatment of advanced or recurrent ovarian granulosa cell tumors. The present report is the first concerning the question of adding Intraoperative Hyperthermic Chemoperfusion in the treatment of advanced or recurrent ovarian granulosa cell tumors.     

Umbilical artery regression: a rare complication of intravascular fetal transfusion

Background: Intravascular fetal transfusion is an important therapeutic advance but is associated with several complications. Regression of an umbilical artery associated with transfusion is rare.Case: A case of red blood cell alloimmunization managed by serial transfusions was complicated by functional loss of an umbilical artery during pregnancy. Refractory fetal bradycardia occurred during the last transfusion procedure, requiring emergency preterm cesarean delivery. Coagulative necrosis, thrombosis, and focal calcification of one umbilical artery was confirmed after delivery.Conclusion: Umbilical artery regression associated with transfusion therapy is rare and may complicate subsequent fetal transfusions.     

Successful living-related renal transplantation in a 2-year-old girl weighing less than 10 kilograms.

The success of renal transplantation for infants weighing less than 10 kg is very limited because of graft thrombosis. We report a successful living-related renal transplant in a 2-year-old girl weighing 9.5 kg. Chronic renal failure was diagnosed 1 month before the transplantation. Laparoscopic donor nephrectomy was performed to retrieve the left kidney of her father, a 36-year-old man weighing 70 kg, and the recipient operation was conducted via a right retroperitoneal approach. The right native kidney of the recipient was removed to accommodate the graft kidney during the transplant surgery. The graft renal artery, renal vein, and ureter were anastomosed to the recipient abdominal aorta, inferior vena cava, and bladder, respectively. The abdominal fascial defect was closed with absorbable mesh grafting, and the skin was closed primarily. With intensive fluid therapy and monitoring after reperfusion of the graft kidney, the patient recovered uneventfully and was discharged with an FK506-based immunosuppressive regimen 2 weeks after the operation. Renal function was good, and serum creatinine was 0.5 mg/dL 6 months after the operation.     

Laparoscopic repair of ureteral injuries

STUDY OBJECTIVE: To assess the outcome of laparoscopic repair of pelvic ureter injuries. DESIGN: Retrospective case series (Canadian Task Force classification II-2). SETTING: Large urban tertiary care medical center. PATIENTS: Four women who had pelvic ureter injuries and laparoscopic repair during laparoscopic gynecologic procedures. INTERVENTION: Laparoscopic ureteroureterostomy. MEASUREMENTS AND MAIN RESULTS: All injuries were identified immediately and repaired laparoscopically. No patient required repeat surgery. On assessment by physical examination, serum creatinine, and intravenous urogram, no patient had evidence of renal insufficiency. One woman had a narrowing at the site of ureteroureterostomy 6 weeks after repair; it was resolved on urogram 8 months after the injury. CONCLUSION: Laparoscopic ureteroureterostomy is feasible in some cases of ureteral injury. Experience with laparoscopic suturing is necessary to perform this procedure.     

腹腔镜探查在晚期卵巢癌初始手术中的应用价值

晚期卵巢癌的初始治疗是个体化的决策过程。先通过腹腔镜探查查明腹腔内病灶的播散情况和严重程度,以帮助临床医生判断达到满意肿瘤细胞减灭术的可能性,从而决定是否进行开腹细胞减灭手术。然而,尽管具有理论的可行性和文献的支持,腹腔镜探查术在晚期卵巢癌中的临床应用却存在一定的局限性,其临床价值有待进一步研究。     

Assessment of the renal circulation during pregnancy with color Doppler ultrasonography.

OBJECTIVES: A non-invasive method of assessing the renal vasculature during pregnancy would be useful in the management of patients with renal dysfunction resulting from preeclampsia or chronic renal disease. The objectives of this study were to determine (1) whether color ultrasonography during pregnancy facilitates Doppler interrogation of renal and intrarenal arteries, allowing (2) the assessment of differences between waveforms from nonpregnant and pregnant women and (3) the analysis of waveform variability throughout the kidney and between the right and left kidneys. STUDY DESIGN: In a cross-sectional study renal and intrarenal artery flow waveforms were obtained from women in early (12 to 19 weeks; n = 8), mid (20 to 29 weeks; n = 11), and late (30 to 37 weeks; n = 14) pregnancy with eight age-matched, nonpregnant women acting as controls. Waveforms were analyzed for pulsatility index, resistive index, and systolic/diastolic ratio. RESULTS: Left or right renal and upper- and lower-pole interlobar artery waveforms were obtained from all women. The mean pulsatility index values for the nonpregnant women were not significantly different from those women in early, mid, or late pregnancy. In the nonpregnant women, the left renal artery pulsatility index (1.13 +/- 0.13) was greater than the left lower interlobular artery pulsatility index (0.91 +/- 0.08; p < 0.05). During pregnancy renal and interlobar artery pulsatility index values were greater than those for the corresponding interlobular arteries, but the differences were not significant. Mean renal and intrarenal artery pulsatility index values were greater on the right, but the difference was significant only for the lower interlobular artery in midpregnancy. CONCLUSIONS: Pregnancy does not significantly affect renal and intrarenal artery flow waveforms, nor are there significant differences between waveforms from the renal and interlobar arteries.     

Doppler flowmetry in a case of single umbilical artery

A case of sonographic diagnosis of single umbilical artery associated with hypoplastic left heart syndrome and left renal agenesis is reported. Umbilical artery Doppler waveforms are presented and discussed for the first time.     

The internal jugular vein thrombosis during pregnancy with decreased level of protein S

The study presents a rare case of internal jugular vein thrombosis during pregnancy. The patient's only complaints were headaches which increased after conception. In the 11th week of pregnancy thrombosis of the internal left jugular vein was diagnosed. Since then, patient had been treated with low molecular weight heparin. Further course pregnancy, delivery and puerperium were not complicated. The decreased level of protein S was responsible for the internal jugular vein thrombosis in this case.     

Occlusion of the ulnar artery in a patient with severe ovarian hyperstimulation syndrome

A patient with ovarian hyperstimulation syndrome, without additional predisposing risk factors for thrombosis suffered thrombotic occlusion of the distal left ulnar artery. Treatment with therapeutic heparinization was successful.