Background. Common bile duct (CBD) stones are common. However, they are known to pass spontaneously, which obviates the need for ERCP. Aim. The aim of this study is to identify specific predictors for spontaneous passage of CBD stones. Methods. Data was retrospectively collected for all patients who were hospitalized with clinical, laboratory, or ultrasonographic evidence of choledocholithiasis and who underwent magnetic resonance cholangiopancreatography (MRCP) in Hadassah Medical Center between 2005 and 2011. The patients were classified into 4 groups: group A (positive MRCP and positive ERCP), group B (positive MRCP but negative ERCP), group C (positive MRCP but did not undergo ERCP), and group D (negative MRCP that did not undergo ERCP) for choledocholithiasis. All positive MRCP-groups (A+B+C) were further grouped together into group E. We compared groups A versus B and groups E versus D. Results. Comparing groups A versus B, only gamma-glutamyl transferase predicted spontaneous passage of stones from CBD, as the level was significantly higher in group A (677±12.1) versus group B (362.4±216.2) (P=0.023). Patients with small stone diameter (P=0.001), distal stones (P=0.05), and absence of intrahepatic dilatation (P=0.047) tend to pass their stones spontaneously. Comparing groups D versus E, it was found that male gender (P=0.03), older age (P<0.001), high levels of GGT (P=0.022), high levels of alkaline phosphatase (P=0.011), high levels of total bilirubin (P=0.007), and lower levels of amylase (P<0.001) are predictors for positive MRCP studies for CBD stones. Conclusion. Identification of specific predictors is important to avoid unnecessary invasive endoscopic intervention.

Aims:We analyzed our series of patients with seatbelt signs (bruising) that underwent laparotomy in order to correlate injury pattern with clinical course and outcome.Materials and Methods:Retrospective analysis of patients with seatbelt signs presenting to the level 1 Trauma Unit between 2005 and 2010 was performed. We evaluated the nature of injuries during laparotomy associated with seatbelt signs and their treatment and complications.Results:There were 41 patients, 25 (61%) male, with a median age of 26 years. Median injury severity score (ISS) was 25 (range 6–66) and overall mortality was 10% (four patients). Patients were classified into three groups according to time from injury to surgery. Median time to surgery for the immediate group (n = 12) was 1.05 h, early group (n = 22) was 2.7 h, and delayed group (n = 7) was 19.5 h. Patients in the immediate group tended to have solid organ injuries; whereas, patients in the delayed group had bowel injury. Patients with solid organ injuries were found to be more seriously injured and had higher mortality (P < 0.01) and morbidity compared with patients with the “classic” bowel injury pattern associated with a typical seatbelt sign.Conclusion:Our data suggest that there is a cohort of patients with seatbelt injury who have solid organ injury requiring urgent intervention. Solid organ injuries associated with malpositioned seatbelts lying higher on the abdomen tend to result in hemodynamic instability necessitating immediate surgery. They have more postoperative complications and a greater mortality. Seatbelt signs should be accurately documented after any car crash.

Leiomyoma is the most common benign esophageal neoplasm. Different invasive surgical approaches have been described for management of such lesions. The literature is reviewed and a robotic assisted left thoracoscopic enucleation with the patient in the right side position is described. A 40-year-old male patient, otherwise healthy, found to have a lower midiastinal mass on screening X-ray, is described. Physical examination and blood tests were within normal limits. Diagnostic work-up included: computerized tomography (CT) scanning of the chest and midiastinum that revealed a 40 × 30 mm mass of the distal esophagus, an upper gastrointestinal endoscopy showed a lower protruding esophageal submucosal mass with intact mucosa, a filling defect was apparent on esophagography. Endoscopic ultrasonography (EUS) showed the same findings, biopsies were taken and leimyoma was diagnosed. Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned on his right side. A 30 robotic scope was introduced in the left 7th intercostal space on the posterior axillary line. Two 8-mm robotic trocars were inserted in the left 5th and 9th intercostals spaces on the same line. Operative field was clearly exposed and an additional 5-mm ethicon trocar was inserted. The inferior pulmonary ligament was released, the parietal pleural space opened, proximal and distal control was achieved using Penrose. The muscular layer of the lower esophagus was opened by coagulation hook, the lesion was enucleated without mucosal penetration. Intraoperative endoscopy permitted localization of the lesion and ensured mucosal integrity. The muscular layer was not closed and the chest drain was left. Total operative time was 200 min and blood loss was less than 20 mL. A Gastrograffin swallow on the first post-operative day showed good esophageal clearance and absence of leak, the patient was allowed a liquid diet. He was discharged on the third post-operative day in a good general condition, benign pathology was confirmed.

Background: Achieving complete cytoreduction of peritoneal surface malignancies (PSM) can be challenging. In most cases, delivery of heated intra-peritoneal chemotherapy (HIPEC) is straightforward. However, using the closed technique in some cases may be technically challenging; for example, in patients requiring abdominal closure using a large synthetic mesh. In cases where groin hernias are present, it is imperative to resect the hernia sac, since it may contain tumor deposits. In cases with major inguinal involvement where disease may spread out of the hernia sac or in cases where a hernia repair was performed while disease is present, inguinal perfusion should be considered.Aim: To describe our experience with combined intra-peritoneal and inguinal perfusion of HIPEC following cytoreductive surgery.Patients and Methods: This is a retrospective review of all patients who underwent cytoreductive surgery (CRS) and HIPEC at our institution. A prospectively maintained database containing data of patients treated by CRS and HIPEC (n=122) was reviewed. All patients with macroscopic inguinal involvement by PSM with complete cytoreduction perfused by HIPEC were included.Results: We identified five cases who underwent CRS and combined intraperitoneal and inguinal perfusion after resection of large inguinal tumor deposits (n=4) or after a recent hernia repair with hernial sac involvement by mucinous adenocarcinoma (n=1). All five patients were successfully perfused using an additional outflow catheter placed in the groin.Discussion: In cases of inguinal involvement by PSM, complete cytoreduction should be achieved and perfusion of the involved groin considered as it is feasible and safe.

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