Primary adenocarcinoma of the appendix should be treated by right hemicolectomy, even if it is a secondary procedure. Surveillance for synchronous or metachronous tumors, especially in the gastrointestinal tract, is warranted.

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Widely invasive HCC with TNM stage III-IV is aggressive, with low probability of recurrence-free survival. Males have worse outcomes than females. Minimally invasive HCC appears to be considerably less aggressive. Radioactive iodine scan performs poorly in detecting distant disease. Although the TERT gene is mutated in HCC, the role of this mutation remains to be demonstrated.

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Iatrogenic colonic perforation is one of the most serious potential complications of colonoscopy. Standard management is surgical repair. No prospective data exist to clearly define the indications for laparoscopic repair. We report the largest case series to date of laparoscopic repair of colonoscopic perforations. A retrospective review was performed of all patients undergoing either exploratory laparoscopy with conversion to open repair, or laparoscopic repair of colonoscopic perforation. Exploratory laparoscopy for the attempted repair of colonoscopic perforations was performed in 11 patients at our institution. The mean colonic perforation size was 2.7 cm. Three cases were converted immediately to open laparotomy. A fourth patient that underwent primary laparoscopic repair of a 4-cm tear developed a leak at the repair site, necessitating reoperation. A fifth patient in whom exploratory laparoscopy was unrevealing underwent separate laparotomy for continued sepsis. Six patients underwent successful laparoscopic repair. Most perforations secondary to colonoscopy warrant rapid exploratory laparoscopy. Extensive inflammation or fecal soilage may require colonic diversion. Inability to laparoscopically localize the area of perforation or doubt regarding the security of the repair should prompt conversion to laparotomy. Laparoscopic repair of colonic perforations in experienced hands is a viable alternative to the open approach.

Laparoscopic-assisted surgery is safe, effective, and applicable to many of the standard colorectal procedures. Observed benefits include less postoperative pain and shorter hospital stay.

To investigate the clinical presentation, laboratory findings, and pathologic characteristics of patients with corticotropin (ACTH)-independent macronodular adrenal hyperplasia.Design: Retrospective review.Setting: Academic medical center.Patients: All patients with bilateral adrenocortical nodules associated with ACTH-independent hypercortisolism without clinicopathologic features of primary pigmented nodular adrenocortical disease with atrophic internodular adrenal cortex.Main Outcome Measures: Compare and contrast our findings with those previously reported; assess response to adrenalectomy.Results: Nine patients met the criteria for cortico-tropin-independent macronodular adrenal hyperplasia. All patients had biochemical evidence of Cushing syndrome, although repetitive testing was frequently required. As a result, the diagnosis was delayed from 1 to 20 years. In all patients, both the low-and highdose dexamethasone suppression tests failed to suppress cortisol secretion. No patient had elevated ACTH levels, and following curative bilateral adrenalectomy, no patient subsequently developed Nelson syndrome, with follow-up ranging from 1 to 8.5 years. Unique histologic features were identified in all cases.