Effects of murine tumors on delayed hypersensitivity to dinitrochlorobenzene. I. Description of anergy caused by transplanted tumors.

In the murine model presented for tumor-associated immune suppression, normal BALB/c mice displayed significant foodpad swelling when sensitized on the flank with 2 mg dinitrochlorobenzene (DNCB) dissolved in dimethyl sulfoxide and challenged in a footpad with 0.05 mg DNCB 10 days later. This reaction in challenged footpads seemed to be a classic delayed hypersensitivity reaction, since it took 24 hours to develop and included an extensive mononuclear infiltrate. The reaction was transmissible from sensitized to normal mice by the transfer of lymphoid cells but not to serum. When sensitized 10 days after tumor inoculation, mice bearing either an allogeneic melanoma or a syngeneic lymphoma or fibrosarcoma did not demonstrate delayed hypersensitivity to DNCB.

Inhibition of leukocyte migration by tumor-associated antigens in soluble extracts of human malignant melanoma.

Direct leukocyte migration inhibition (LMI) assays were performed to investigate whether cell-mediated immune reactions could be detected in response to tumor-associated antigens of human melanoma. The antigens were 3 M KCl-soluble extracts of different fresh melanomas, other cancers, and benign nevus tissue. A total of 48 of the 79 (61%) blood samples from melanoma patients (64 patients) reacted with extracts of melanoma tissue. Since the subjects were usually tested with two or three extracts, 57/134 (42%) tests with melanoma patients' leukocytes were inhibited by KCl extracts of melanoma tissue, whereas only 3/50 (6%) tests with leukocytes of normal donors and 4/27 (15%) with patients having other cancers gave positive results. No positive reactions were obtained when 13 melanoma patients were tested with a 3 M KCl extract of benign nevus tissue. Likewise, only 2/26 (8%) positive tests were obtained from melanoma patients tested with extracts of other cancers. Individuals in all stages of disease had similar incidences of positive reactions to the soluble melanoma extracts, except for patients with stage-1 disease who exhibited a somewhat higher incidence of reactivity. The highest incidence of reactivity was observed in patients before surgical resection of the tumor, and somewhat decreased reactivity was seen 0-14 days post surgery. The results indicate that the direct LMI assay may be used to measure cell immune reactivity against melanoma-associated antigens. Since many of the positive results were obtained with allogeneic extracts, the results also indicate that different melanomas possess common antigens.

Extraadrenal myelolipoma.

A rare case of presacral myelolipoma surgically resected from a 72-year-old woman, who also had megaloblastic anemia and brest carcinoma, is described and compared with mass-forming extramedullary hematopoiesis, and other reported cases of extra-adrenal myelolipoma. Extra-adrenal myelolipoma should be morphologically differentiated from mass-forming extra medullary hematopoiesis. The former is encapsulated or well-circumscribed, is composed of fat cells, and has normal marrow hematopoietic elements. The latter lacks circumscription, and fat is not an integral component of the process. Clinically, myelolipoma is usually asymptomatic, and shows no consistent associated disease process, while mass-forming extramedullary hematopoiesis is usually symptomatic, and is associated with myeloproliferative disorders, hemolytic anemia, or severe skeletal diseases.

Severe complications of intralesional BCG therapy in an unsensitized patient. Case report and clinical implications.

Since the introduction of BCG intralesional immunotherapy for melanoma, severe complications, including death, have been reported after treatment in hypersensitized individuals. This is a case report of BCG dissemination with ulceration, skin necrosis, lymphadenitis, and abscess formation following the first intralesional injection of a minimal dose of BCG in a PPD-negative patient. The case demonstrates that severe complications can occur in patients who are not hypersensitized, anergic, or debilitated or who have been treated multiple times. This patient's complication further suggests that migration of BCG after intralesional therapy may play a role in the regression of uninjected nodules seen in some patients.

Laparoscopic repair of recurrent hernia.

BACKGROUND: Failure rates for recurrent hernioplasties vary from 3% to 30%. To help explain this high incidence of recurrence, we reviewed our 4-year experience using a laparoscopic approach and analyzed the characteristics of the recurrent hernias repaired. METHOD: One hundred fifty-two patients with 173 recurrent hernias and 942 patients with 1,230 primary hernias were laparoscopically repaired using either a transabdominal preperitoneal or a totally extraperitoneal laparoscopic approach. RESULTS: With a median follow-up of 24 months, one recurrence developed in the recurrent and four in the primary group. The incidence of bilateral disease (80% versus 46%), and the complexity of the hernias repaired (28% versus 14%) were significantly increased in the recurrent patients. CONCLUSION: The importance of intrinsic weakness and missed hernias as factors that contribute to the failure of recurrent hernioplasties was supported by our findings. The low early failure rate of our laparoscopic approach suggested that this technique may help in eliminating these causes of failure.

Adult intussusception; case report of recurrent intussusception and review of the literature.

An unusual case of lymphoma is presented in which small bowel intussusception due to a lymphomatous nodule caused an acute abdomen, requiring small bowel resection. Four weeks later a second intussusception caused intestinal obstruction, necessitating a second laparotomy and bowel resection. The high incidence of malignant tumor in adult cases leads us to recommend primary resection without manual reduction in all but rectosigmoid and selected small bowel cases.

A unified approach to recurrent laparoscopic hernia repairs.

BACKGROUND: The problem of recurrence after laparoscopic hernia repair is relatively new, and the best way to handle it remains uncertain. The question of whether an open approach, a laparoscopic approach, or some combination of techniques should be preferred has not yet been resolved. The purpose of this study was to determine if the laparoscopic approach could deal with the problem safely and successfully. METHODS: A retrospective review was done of the cases performed at the Center for Hernia Repair by one surgeon between July 1991 and September 1999. Laparoscopic hernioplasties for hernias that had previously been repaired laparoscopically were analyzed. All remedial repairs were begun using a transabdominal approach. RESULTS: Seventeen of 1960 hernias repaired were for failed laparoscopic repairs. Ten were repaired totally laparoscopically and two via an open approach with mesh, while five required a small anterior counterincision. There were no serious complications and one recurrence. CONCLUSION: The laparoscopic transabdominal approach to failed laparoscopic repairs is feasible, safe, and reliable when used in combination with a modified anterior approach when appropriate.

Causes of small bowel obstruction after laparoscopic gastric bypass.

BACKGROUND: Small bowel obstruction after laparoscopic Roux-en-Y gastric bypass is not a rare complication, occurring in approximately 3% of patients. The goal of this study was to review the causes and timing of small bowel obstruction as an aid to diagnosis, treatment, and prevention. METHODS: The records of consecutive patients who underwent laparoscopic Roux-en-Y gastric bypass at the authors' center from 4/99 to 7/03 were retrospectively reviewed. All the patients had a laparoscopic handsewn gastrojejunostomy and a stapled jejunojejunostomy. The Roux limb was placed retrocolically in the first 405 patients and antecolically in the next 1,310 patients. RESULTS: Altogether, 1,715 patients underwent a total laparoscopic Roux-en-Y gastric bypass at the authors' bariatric center. In 51 patients, 55 small bowel obstructions occurred (3%) during a median follow-up period of 21 months (range, 1-52 months). Small bowel obstruction developed in 27 (7%) of the retrocolic patients, as compared with 24 (2%) of the antecolic patients (p < 0.001, chi-square). The causes of small bowel obstruction were adhesive bands (n = 14), obstruction at the jejunojejunostomy from kinking or narrowing (n = 13), internal hernia or external compression at the transverse mesocolon (n = 11), internal hernia through the jejunal mesentery (n = 8) incarcerated abdominal wall hernia (n = 4), and other (n = 5). For patients in whom small bowel obstruction developed in the first 3 weeks after their bypass surgery bowel resection was required in 19 of 24 patients, as compared with 6 of 31 patients in whom obstruction develop after 3 weeks (p < 0.001, chi-square). CONCLUSIONS: Early small bowel obstructions tend to result from technical problems with the Roux limb and require revision of the bypass or small bowel resection significantly more often than late obstructions. The latter group of obstructions usually result from adhesions or hernias, which could be handled laparoscopically without bowel resection. The position of the Roux limb (retrocolic vs antecolic) appeared to influence the incidence of small bowel obstruction. In the current series, changing the position of the jejunal bypass limb from retrocolic to antecolic significantly decreased the overall incidence of small bowel obstruction because it eliminated one of the most common sites for obstruction: the mesocolon.

The use of a moldable plastic splint to minimize early postoperative thrombosis of an internal arteriovenous fistula in the high-risk renal dialysis patient.

An inexpensive moldable plastic wrist splint was developed to protect the site of an internal arteriovenous fistula from accidental thrombosis in the early postoperative period. This splint, or fistula guard, is easily constructed and has been successfully used in a series of 11 high-risk patients without reported discomfort by the wearer.

Laparoscopic repair of spigelian hernias.

Spigelian hernias can be difficult to diagnose and localize before surgical exploration. Four patients with abdominal wall hernias underwent laparoscopic diagnosis and repair of their spigelian hernias. The laparoscopic approach affords an accurate appraisal of the defect and a direct means of repair. Extensive dissection was avoided, and recovery was prompt.

Double-buttress laparoscopic herniorrhaphy.

To determine if laparoscopic inguinal herniorrhaphy can be performed safely in unselected patients, the authors' first 100 consecutive laparoscopic inguinal hernia repairs were reviewed. All patients with inguinal hernias who were candidates for general anesthetic were accepted for the study. Their ages ranged from 18 to 84 years. One hundred and six hernias were laparoscopically repaired in 95 males and 4 females. One male patient required an open hernia repair. The first 14 patients were repaired with a preperitoneal patch and plug technique, and the next 85 with the double-buttress transabdominal preperitoneal approach. Two pieces of polypropylene mesh were stapled to the transversalis fascia, ileopubic tract, and Cooper's ligament after the preperitoneal dissection of the hernia was completed. The first piece was placed over the indirect space, with a slit for the cord medially, and the second piece was placed over the entire direct and indirect area. Patients have been followed from 8-18 months. To date, no recurrence has developed. Complications have included seroma, inferior epigastric bleeding, trocar hernia, and neuralgia. Patients have returned to work and normal activity in 2 days to 2 weeks, with an average of 1 week.

Laparoscopic repair of recurrent groin hernias.

Between November 1991 and May 1993, 54 recurrent groin hernias were laparoscopically repaired in 50 patients. Forty-eight were men and two were women. Forty-six recurrent hernias were unilateral and four bilateral. Twenty-five were direct, 19 indirect, 10 pantaloon, and two had a femoral component. In only 10 patients was the contralateral side normal. In 27 patients, the other side had been previously repaired, and in 13 they had a new contralateral hernia. A transabdominal preperitoneal technique was used to dissect and repair the entire floor in all patients. A single sheet of polypropylene mesh was used in the repair of the women patients, and a double-buttress technique with the first sheet slitted for the cord was used for the men. Patients were examined every 3 months for the first year and at 6-month intervals thereafter. Follow-up ranged from 1 to 18 months with a mean of 8 months. No patient was lost to follow-up, and no recurrence was observed. Patients returned to normal activity in an average of 1 week. Seroma, which resolved spontaneously, was the most common complication. The overall short-term results suggested that a laparoscopic mesh buttressed repair of recurrent groin hernias is technically feasible and can eliminate early rerecurrence of the hernia so commonly seen after repair of recurrent hernias.

Laparoscopic hernioplasty: why does it work?

BACKGROUND: To understand how laparoscopic hernioplasty prevents early recurrence of hernia, we reviewed our first 1,000 patients. We analyzed the patients by age, sex, and hernia type and by whether their hernia was primary or recurrent. METHODS: The 1,000 patients had 1,336 hernias repaired by the transabdominal preperitoneal or the totally extraperitoneal approach. One thousand one hundred seventy-three hernias were primary and 163 were recurrent. The type of hernia found varied with the patient's age (p < 0.001), and with whether the hernia was primary or recurrent (p < 0.001); 14% of primary and 27% of recurrent hernias were complex, a surprisingly high incidence compared to historical controls. RESULTS: With a median follow-up of 2 years, five hernias have recurred and all were due to technical errors. CONCLUSIONS: The laparoscopic repair's success may partially be due to its unique ability to diagnose previously overlooked complex elements. The defects are repaired without creating tension and the groin is reinforced with mesh, eliminating inherent weakness.

Laparoscopic herniorrhaphy. Transabdominal preperitoneal floor repair.

The purpose of this study was to evaluate the results of a laparoscopic transabdominal preperitoneal (TAPP) approach to inguinal hernia repair which dissected the entire inguinal floor and repaired the indirect, direct, and femoral areas in all patients without tension. In our series, 183 patients had 205 hernia repairs and were followed for more than 6 months. Of this group, 128 hernias were indirect, 55 direct, 22 pantaloon, 26 recurrent, and 22 bilateral. All 12 females and the first 11 males had a single-buttress repair with polypropylene mesh. The other 160 male patients had a double-buttress repair. With median follow-up of 12 months, ranging from 6 to 21 months, no recurrences were found. Patients returned to normal activity in an average of 1 week. Dissection and buttressing of the entire inguinal floor with mesh appeared to solve the problem of early recurrence first seen in laparoscopic herniorrhaphy.

Laparoscopic repair of recurrent hernias.

The purpose of this study was to evaluate the results of a laparoscopic approach to recurrent inguinal hernia repair which dissected the entire inguinal floor and repaired all potential areas of recurrence without producing tension. Both a transabdominal preperitoneal and a totally extraperitoneal laparoscopic approach were utilized. Ninety recurrent hernias were repaired in 81 patients. The patients had 26 indirect, 36 direct, and 26 pantaloon recurrent hernias of which eight had a femoral component. In all but one patient the primary operations were open anterior repairs. The median follow-up was 14 months, ranging from 1 to 28 months. Patients returned to normal activities in an average of 1 week. The only recurrence observed was in the one patient whose primary repair was laparoscopic. When the entire inguinal floor of the recurrent hernia was redissected and buttressed with mesh, early recurrence was eliminated and recovery was shortened.

Laparoscopic hernioplasty. TAPP vs TEP.

This study compares the results of two laparoscopic hernioplasties: the transabdominal preperitoneal (TAPP) and the totally extraperitoneal (TEP). Over a 43-month period 1,115 laparoscopic hernioplasties, 733 TAPP and 382 TEP, were performed in 866 patients. There were 11 major complications in the TAPP group (2 recurrences, 6 trocar hernias, 1 small-bowel obstruction, 1 trocar, and 1 dissection injury of the small bowel) compared to 1 recurrence and no intraperitoneal complications in the TEP group. Five TEP procedures required conversion to the TAPP approach, resulting in one umbilical hernia. The median time to return to work did not vary with the approach, but was prolonged in patients compensated for time off, 16 vs 8 days for noncompensated patients. Results suggested that both techniques shortened recovery and eliminated most early failures, but the totally extraperitoneal approach reduced the potential for intraperitoneal complications and may be the procedure of choice in most situations.