The data show that asymptomatic patients with family history of HDGC and CDH1 mutation have high probability of having signet ring cell adenocarcinoma of the stomach that is not able to be diagnosed on endoscopy; when symptoms arise, the diagnosis can be made by endoscopy, but they have metastases and decreased survival. Surveillance endoscopy is of limited value, and prophylactic gastrectomy (PG) is recommended for patients with family history of HDGC and CDH1 mutations.

As the technique of autologous fat grafting is being refined and perfected, its clinical applications are expanding. The use of autologous fat grafting for primary breast augmentation is controversial due to a lack of clarity regarding its safety and efficacy. Most notably, concerns about interference with the detection of breast cancer have been raised, but these have not been clearly addressed in the literature. To help surgeons gain further insight, the authors conducted a systematic review of the literature, carefully comparing technique, clinical outcome, radiologic impact, and complications in all available data on this subject. Although an optimal method of autologous fat grafting for primary breast augmentation is yet to be standardized, further strong evidence-based studies are necessary to confirm the findings of this approach.

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Case Presentation and EvolutionA 57-year-old male presented with left-sided abdominal pain. A thorough history revealed only frequent headaches worsening over the past 5 years and the recent onset of tremor. Physical examination and laboratory values where unremarkable. A computed tomography (CT) scan of the abdomen showed an 11 9 7 9 9.6 cm heterogeneous, markedly hypervascular mass located in the left paraaortic retroperitoneum and exhibiting massively enlarged tumor vessels measuring up to 18 mm ( Fig. 1a-c). Although there was a tissue plane separating the mass from the pancreas and left kidney, hydronephrosis was noted and subsequently resolved after placement of a ureteral stent. Plasma-free metanephrines were elevated at 385 pg/ml (normal, \205 pg/ml), and plasma-free normetanephrines were 339 pg/ml (normal, \148 pg/ml). Phenoxybenzamine, 10 mg twice daily, was initiated and continued for 4 weeks prior to surgery. Aiming to minimize blood loss and facilitate resection, preoperative embolization and coiling of three major feeding vessels arising from the left renal artery was performed (Fig. 2). In anticipation of potential catecholamine crisis, an anesthesiology team was present with the patient intubated, under full venous access and direct arterial monitoring. The patient remained hemodynamically stable throughout the embolization and overnight in the intensive care unit.At surgery, a bilateral subcostal incision was made with extension to the left. There was no evidence of metastatic disease. The mass was exposed by entering the lesser sac through the gastrocolic ligament and by mobilizing the splenic flexure and left colon medially. The mass was located along the inferior edge of the pancreas between the aorta and the left renal hilum but was not adherent to surrounding structures. Upon manipulation of the mass, there was moderate elevation in the blood pressure that was controlled with vasodilators. The patient's blood pressure remained stable after the tumor was removed. The patient was discharged on the fifth postoperative day and has remained asymptomatic.The specimen was firm, tan-red, and measured 12.5 9 10 9 6 cm (Fig. 3). Sectioning revealed a multilobular, heterogeneous tumor mass with foci of necrosis and hemorrhage. Microscopically, the tumor consisted of nests of ovoid to slightly spindled cells with pale cytoplasm arranged in fibrovascular stroma (Zellballen pattern; Fig. 4a). Occasional nuclear enlargement with hyperchromasia and atypia was present, but the mitoptic index was extremely low (Fig. 4b). Chromogranin A (Fig. 4c) and synaptophysin stains were both positive in the tumor cells, confirming the diagnosis of extra-adrenal retroperitoneal paraganglioma. Ki-67 (mib1) stain showed marked B1% cells, supporting a low proliferation rate.

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ObjectiveThe objective of this study is to evaluate the effectiveness of rfVIIa in reducing blood product requirements and re-operation for postoperative bleeding after major abdominal surgery.BackgroundHemorrhage is a significant complication after major gastrointestinal and abdominal surgery. Clinically significant bleeding can lead to shock, transfusion of blood products, and re-operation. Recent reports suggest that activated rfVIIa may be effective in correcting coagulopathy and decreasing the need for re-operation.MethodsThis study was a retrospective review over a 4-year period of 17 consecutive bleeding postoperative patients who received rfVIIa to control hemorrhage and avoid re-operation. Outcome measures were blood and clotting factor transfusions, deaths, thromboembolic complications, and number of re-operations for bleeding.ResultsSeventeen patients with postoperative hemorrhage following major abdominal gastrointestinal surgery (nine pancreas, four sarcoma, two gastric, one carcinoid, and one fistula) were treated with rfVIIa. In these 17 patients, rfVIIa was administered for 18 episodes of bleeding (dose 2,400-9,600 mcg, 29.8-100.8 mcg/kg). Transfusion requirement of pRBC and FFP were each significantly less than pre-rfVIIa. Out of the 18 episodes, bleeding was controlled in 17 (94%) without surgery, and only one patient returned to the operating room for hemorrhage. There were no deaths and two thrombotic complications. Coagulopathy was corrected by rfVIIa from 1.37 to 0.96 (p < 0.0001).ConclusionUse of rfVIIa in resuscitation for hemorrhage after non-traumatic major abdominal and gastrointestinal surgery can correct dilutional coagulopathy, reducing blood product requirements and need for re-operation.

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