Clinically sigmoid volvulus and intussusception

Clinically sigmoid volvulus and intussusception in children are difficult to distinguish, although children with intussusception are usually younger than those with sigmoid volvulus. The most common clinical picture consists of cramping abdominal pain and abdominal distention. In 1985, McCalla et al reported cramping abdominal pain in 70%, vomiting in 35%, constipation in 15%, and diarrhea in 14% of children with sigmoid volvulus. Plain abdominal X-rays were diagnostic in 20% and barium enema, in 79.5%. The diagnosis of colonic volvulus can generally be suspected on conventional abdominal radiography and can be confirmed with a barium enema. However, the latter offers no information about complications such as bowel ischemia or other abnormalities outside the bowel wall. A specific CT sign for volvulus is the whirl sign, which has been found to be helpful in diagnosing sigmoid and cecal volvulus. We believe that contrast-enhanced CT scan is more specific than a barium study in delineating the presence of bowel obstruction. The management of sigmoid volvulus has been a subject of some debate. Hydrostatic reduction may occur at the time of the diagnostic barium enema examination in children, thus avoiding the need for emergency surgery if bowel necrosis has not occurred. Bruusgaard and Abrams has advocated detorsion by passage of a soft rectal tube under sigmoidoscopic control if there is no evidence of ischemic necrosis of the involved segment. If reduction cannot otherwise be accomplished or if strangulation is suspected, operative detorsion is indicated. Operative treatment consists of laparotomy and simple derotation. Simple derotation followed later by elective resection, or resection with primary anastomosis at the original operation. It is important that vessel control should be practiced before derotation to prevent the endotoxin from entering systemic blood flow. Taneja et al reported two cases of volvulus of the sigmoid colon, and a review of the 13 cases reported showed that the mortality rate of 22% are children was comparable to the 15–22% mortality rate reported for adult patients. Recurrence of the sigmoidal volvulus has been reported to occur in 8% of children compared with 50–60% of adult patients. Hines et al advised elective sigmoid resection as soon as possible after any method of reduction in view of a high rate of recurrence. Because this conclusion is based on their experience with adults, it may not be applicable to children because the recurrence rate in children is much lower.
Conclusion
Introduction Medical history data obtained from patients with hepatocellular carcinoma (HCC) and major vascular invasion reveal a median survival time of 9–12 weeks. The optimal treatment for patients with HCC and major vascular invasion remains controversial. We report a successfully managed case of far-advanced HCC by preoperative transarterial chemoembolization (TACE), three-dimensional conformal heme oxygenase therapy (3D-CRT), and then surgical resection.
Case report A 35-year-old man complaining of right upper abdominal pain visited a neighboring hospital, and was diagnosed to have a single right-sided huge HCC. He was a chronic hepatitis B carrier. He was then referred to our hospital for further treatment in May, 2006. Physical examination revealed a nontender, firm hepatomegaly, palpable 2 cm below the costal margin. Laboratory data consisted of a total bilirubin of 0.69 mg/dL (0–1.3); aspartate transaminase, 100 U/L (0–38); alanine transaminase, 60 U/L (0–44); albumin, 3.9 g/dL (3.5-5.0); international normalized ratio, 1.02; and α-fetoprotein, 32 ng/mL (1–8). The indocyanine green 15-minute retention test was 4.2%. The patient’s Eastern Cooperative Oncology Group performance status was 1. A triphasic computed tomography (CT) scan showed a 20-cm HCC occupying the entire right lobe with a tumor thrombus extending into the right hepatic vein and the inferior vena cava and a second 2-cm HCC in segment III (Figure 1). Surgery was considered infeasible because of the inadequate estimated remnant liver volume (<40% of standard liver volume). Angiography of the celiac trunk showed a huge hypervascular stain in the right lobe, compatible with HCC, and tumor invasion into the right hepatic vein. Hence TACE was performed on the right HCC with 20 mg of doxorubicin (Adriamycin), mixed with 10 mL of lipiodol and gelfoam. Subsequently both the main tumor and the inferior vena cava tumor thrombus (IVC-TT) were targeted by 3D-CRT (Elekta Precise SLi, Crawley, United Kingdom) 2 weeks after TACE. The daily fraction size was 3.0 Gy, given 5 days per week for 4 weeks, to a cumulative dose of 60 Gy (Figure 2). A triphasic CT scan 3 weeks after 3D-CRT showed shrinkage of the main tumor from 20 cm to 14 cm in diameter. The IVC-TT also shrank significantly (Figure 3). Six weeks after 3D-CRT, the patient underwent an extended right hepatectomy with partial diaphragm resection by the anterior approach, an inferior vena cava thrombectomy via the right hepatic vein and a left partial hepatectomy (Figure 4). Hepatic parenchymal transection was performed with a Cavitron ultrasonic aspirator and bipolar electrocautery under intermittent inflow control using the Pringle maneuver (15-minute occlusion and 5-minute declamping). The transection time was 140 minutes and the operative blood loss was 400 mL. He did not receive any blood transfusion perioperatively. Two weeks after surgery, the patient was discharged without any complications. From the macroscopic findings of the resected specimen, the right hepatic vein was filled with a tumor thrombus. Histologically, necrosis was recognized in 95% of the main tumor, in 30% of the left tumor and in 100% of the IVC-TT. The juxta-inferior vena cava hepatic veins were not invaded by any malignant cells and the resection margins were clear. The patient died of leukemia 3 years after the operation.