Sigmoid volvulus is a rare surgical complication occurring in pregnancy and puerperium. Only 84 cases of sigmoid volvulus in pregnancy have been reported in the English literature so far. We have reviewed the available literature on this subject and present another case recently managed at our institution. The available literature suggests that over the years, there has been an improvement in the maternal and fetal outcome for this critical condition, but delay in presentation and a further delay in diagnosis remain a challenge for the treating physicians. Our patient was a 30-week pregnant lady, who presented late with 6 days history of abdominal pain, distension and absolute constipation. She had evidence of multi-organ dysfunction at presentation due to complicated sigmoid volvulus. She was resuscitated and surgical exploration revealed gangrenous large bowel. Bowel resection with diverting ileostomy was performed, but she succumbed to the septic shock due to late presentation. Acute surgical pathology may be overlooked in pregnant patients due to reluctance in radiological workup and a high index of suspicion is essential for enhanced outcome. There is a need to increase the awareness amongst the obstetricians and general practitioners. Early diagnosis and referral and timely surgical intervention could significantly improve the outcome of this surgical and obstetric catastrophe.

BackgroundMelanomas within the alimentary tract are usually metastatic in origin. On the other hand, primary melanomas of the gastrointestinal tract are relatively uncommon. There are several published reports of melanomas occurring in the esophagus, stomach, small bowel, and anorectum. The occurrence of primary melanoma of the colon has, however, only been rarely reported. The optimum modus operandi for the management of primary colonic melanoma remains nebulous due to the limited number of reports in literature.MethodsA comprehensive search of Medline, Cochrane and Highwire was performed using the following keywords: 'melanoma', 'malignant melanoma', 'primary melanoma', 'colon', 'gastrointestinal tract', 'alimentary tract', 'digestive tract', and 'large bowel'. All patients with primary melanoma localized to the colon were included in the review. Patients with metastatic melanomas to the gastrointestinal (GI) tract and primary melanomas localized to the GI tract in anatomic locations other than colon were excluded.ResultsThere have been only 12 reported cases of primary melanoma of the colon to date. The average age of patients on presentation was 60.4 years without any significant gender predilection. Right colon (33%) and cecum (33%) were the most common sites for the occurrence of primary colonic melanoma while abdominal pain (58%) and weight loss (50%) were the most common presenting complaints. Colonoscopy is the most reliable diagnostic investigation and offers the additional advantage of obtaining tissue for diagnosis. S-100 and HMB-45 are highly sensitive and specific for the diagnosis of this malignancy. For primary colonic melanomas that have not metastasized to any distant parts of the body, surgical resection with wide margins appears to be the treatment of choice. Although the management was individualized in every case, most of the authors preferred traditional hemicolectomy as the favored surgical approach. Chemotherapeutic agents including interferons, cytokines, biological agents and radiation therapy for brain metastases have been reported as adjuvant and palliative options while considering malignant melanomas in general. The average recurrence-free interval was 2.59 years. Nine of the 12 reports documented follow-up in their patients. Two of these 9 (22.2%) patients died.ConclusionsPrimary melanoma of the colon is a rare clinical entity. Whenever a seemingly primary melanoma is detected in an atypical location such as the colon, it is prudent to conduct a thorough clinical investigation to consider the possibility of metastatic disease. Further studies are needed to document the long term follow-up, survival advantage and safety of the management approaches employed in patients with primary colonic melanoma. Based on current data, surgical resection appears to be appropriate management for primary colonic melanomas; unless the disease has metastasized to distant sites where surgery may have a limited palliative role.

Hypothesis: Radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) can be performed by percutaneous or surgical approach. Tumor size is an important consideration while deciding the treatment approach. Design: Case series with prospective data collection. Setting: A tertiary referral center. Patients: A total of 228 patients who underwent RFA of small (Յ3 cm; n=155) and medium (3.1-5 cm; n=73) HCC by percutaneous or surgical approach. Main Outcome Measures: Complete ablation rate, post-RFA complications, treatment-related mortality, and overall and disease-free survival. Results: In patients with small HCC, the complete ablation rate was 95% with both approaches (PϾ.99). Complication rate (PϽ.001) and hospital stay (PϽ.001) were higher with the surgical approach. One-year and 3-year survival rates were 91% and 71%, respectively, in the percutaneous group, and 89% and 57%, respectively, in the surgical group (P =.30). In patients with medium HCC, the complete ablation rate was similar between the surgical and the percutaneous groups (92% vs 95%; P=.48), and the complication rate was also comparable (P=.17). The 1-year and 3-year survival rates were 92% and 68%, respectively, in the surgical group, significantly superior to the corresponding rates of 81% and 42% in the percutaneous group (P =.03). Conclusions: In patients with small HCC, the percutaneous approach achieved similar tumor control with lower morbidity compared with the surgical approach and should be the preferred approach provided that tumor location is suitable. For medium HCC, the surgical approach seems to achieve better overall survival and may be a preferred option.

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