World Journal of Surgery

Small institutional studies have shown that adrenalectomy to remove solitary metastases to the adrenal gland is safe and can improve overall survival for selective primary tumors. However, outcomes of adrenal metastasectomy have not been evaluated using large, national databases. All cases of adrenal metastasectomies from 1992 to 2011 were identified in the HCUP-NIS database. The primary endpoint analyzed was death during the same hospitalization. Secondary outcomes included length of stay (LOS), blood loss requiring transfusion, surgical infection, cardiac complications, and respiratory complications. A sub-analysis of 428 patients stratified by primary tumor (where data were available) was also performed. Statistical analysis was performed using chi-square, ANOVA, and logistic regression using Stata software, significance was set at p value of 0.05. A total of 2,057 cases of adrenal metastasectomies were identified. Median age of the patients was 62 ± 13.2 years (49.9 % men, 69.7 % Caucasian). Over the study period, there was a general increase in the number of cases performed and the number performed by minimally invasive approaches. There was also a decrease in LOS and number of deaths. However, age ≥71 years predicted a significantly higher rate of mortality (OR = 6.0, CI 1.3–26.5) when controlled for race, procedure type, year of surgery, and primary tumor in multivariable analysis. This age group had a higher number of cardiac complications (5.4 %, p = 0.005) that potentially contributed to the higher mortality rate. In addition, there was no difference in surgical outcomes when stratified by primary tumor type for the entire cohort of patients. Adrenal metastasectomy is a safe procedure with decreasing same-hospitalization mortality from 1992 to 2011. However, age ≥71 years is a significant risk factor for same-hospitalization mortality. This increased risk should be considered when discussing adrenal metastasectomy in this age population.

Axillary clearance in node-negative breast cancer patients is performed only for staging and prognostic purposes. The sentinel node concept may provide an alternative conservative approach for these patients. This paper reports on the learning experience with lymphatic mapping involving the use of patent blue dye for the identification of sentinel lymph nodes (SLNs), followed by axillary dissection. The histopathology of the SLNs included serial sectioning and immunostaining for cytokeratin and epithelial membrane antigen, the remaining nodes being processed as usual. Of the 70 mapping procedures, 58 were successful; the surgical performance revealed a well defined learning period. The mean diameter of the successfully mapped tumors was 2.4 cm (ranging from in situ carcinoma to 4.8-cm invasive cancer). The mean numbers of SLNs and non-SLNs were 1.3 (range 1–3) and 19 (range 7–42), respectively. There were 36 SLN-positive cases, 21 of which had metastases only to these nodes. There were 19 node-negative cases, and 3 SLNs were falsely negative. Possible causes of the errors during lymphatic mapping are analyzed in the light of experiences published to date. SLN biopsy seems a good approach to enhancing the selectivity of axillary lymphadenectomy, but the limitations of the procedure must be evaluated and carefully considered.

Systematic screening for hepatocellular carcinoma (HCC) in cirrhotic patients by alpha-fetoprotein and ultrasound permits the detection of small asymptomatic tumors. Owing to the small tumor size, more liver resections can now be performed than in the past. These resections are performed in a more economical way in terms of loss of functional parenchyma and in a more appropriate manner with regard to carcinology: surgical techniques of liver segmentectomy and use of intraoperative echography are mandatory. Favorable long-term results obtained in Eastern countries by resecting such lesions are encouraging but remain to be confirmed in the Western hemisphere.

Pneumopericardium occurred in 28 neonates with respiratory distress syndrome at the University of Minnesota Hospitals and St. Paul Children's Hospital from July 1, 1972 through June 30, 1976. All patients developed this complication while on mechanical ventilatory support with positive end-expiratory pressure (2–12 cm water). In 23 patients, pneumopericardium resulted in clinical pericardial tamponade that necessitated cardiac resuscitation. The clinical presentation of pericardial tamponade consisted of muffled, distant heart sounds, hypotension, bradycardia, and hypoxia with cyanosis. The diagnosis was confirmed by chest x-ray. Pneumothorax, pneumomediastinum, and/or pneumoperitoneum were associated with the appearance of pneumopericardium in 93% of the cases. Treatment consisted of: (a) needle pericardial aspiration in 7 patients, of which 5 survived; (b) pericardial tube placement with application of suction in 10 patients, of which 8 survived; (c) no treatment in 16 patients, of which 5 survived. Overall, 13 patients (46%) survived pneumopericardium and 15 patients (54%) died. Complications of treatment developed in 5 patients; 3 developed pneumothorax and 2 developed myocardial lacerations from percutaneous placement of a plastic drainage catheter. Of 5 asymptomatic patients, 2 (40%) died as a result of pneumopericardium. Based on our experience, it is recommended that pneumopericardium be evacuated whenever it is diagnosed. Initially, needle aspiration of the pericardial sac should be performed to manage the acute episode and stabilize the patient, and then a chest catheter of No. 10 Fr. caliber should be placed under direct vision into the pericardial sac and maintained on suction until positive end-expiratory pressure ventilation has been discontinued.