Diaphragmatic hernia after Ivor-Lewis esophagectomy manifested as lower gastrointestinal bleeding.

Diaphragmatic hernia after esophageal resection is a recognized but rare complication. Parahiatal hernias may result from manipulation and extension of the crura during surgery. This can lead to a wide array of symptoms depending on the extent and organ that is herniated. A high index of suspicion is required because there is no one symptom that is specific for herniation. This report represents the first case of a patient presenting with lower gastrointestinal bleed from a parahiatal hernia after esophageal resection.

Basic skin flaps for the general surgeon: a teaching method.

BACKGROUND: Teaching residents the design and creation of skin flaps is challenging because the use of skin flaps is not common enough during the course of a typical residency to provide a broad experience base. METHODS: A 12 x 12-inch board with a 1/8-inch foam rubber covering was designed to provide for the creation of four flaps and one Z-plasty. A lecture and practical exercise were used to teach basic techniques. Performance was measured by preexamination and postexamination, as well as by a resident satisfaction survey. RESULTS: Mean scores improved by 45%. The resident survey revealed an average subjective rating was 4.7 on a scale of 1 to 5. All residents rated this format superior to traditional lecture instruction. Total cost to provide laboratory experience for 16 residents was $50. Materials can be recovered and reused at a cost of $0.40 each. CONCLUSIONS: The materials developed provided an effective, inexpensive nonbiologic model for teaching preoperative skills.

Malignant peripheral nerve sheath tumors of the head and neck: analysis of prognostic factors.

Malignant peripheral nerve sheath tumors of the head and neck region are uncommon and may be associated with neurofibromatosis or occur in a sporadic manner. This is a retrospective review of 17 patients with these tumors who were treated at a single institution. Analysis of clinical and pathologic factors that influenced outcome was performed. There were 9 men and 8 women. Seven patients had a history of neurofibromatosis. Radiotherapy was implicated as a possible etiologic factor in 4 patients. The neck was the most frequently involved site. Overall survival at 5 years was 52%. Survival was improved for women and for patients with low-grade tumors. Age, tumor site, and size had no impact on survival. Survival was worse for patients with neurofibromatosis than for those with the sporadic form of the disease (P = 0.02). Survival was calculated by the method of Kaplan and Meier. The significance of such results was based on results of the log rank test. Local recurrence correlated with tumor size and resection margin status. No local recurrences occurred in those patients who had negative margins of resection and received adjuvant radiotherapy. Tumor grade was predictive of the development of distant metastases. Negative margins of resection are essential for obtaining local control, and the addition of adjuvant radiotherapy may be beneficial in this group. Salvage surgery for local recurrence is possible in some patients.

Malignant tumors of the small intestine: a review of 144 cases.

Cancer of the small intestine represents less than two per cent of all the malignant tumors of the gastrointestinal tract. Because they are infrequent tumors, a review of a tumor registry was performed to analyze response to treatment of the disease and prognostic factors. A retrospective review of patients with primary cancer of the small intestine was performed using the Department of Defense Tumor Registry. The registry was accessed to determine stage, types of cancer, intervention, and patient outcomes. TNM staging and follow-up were available on 144 patients from 1970 to 1996. Median follow-up was 38.9 months. There were 92 (64%) males and 52 (38%) females. The median age was 55.7 years. The types of small intestinal cancer included 68 patients (47%) with adenocarcinoma, 41 patients (28%) with carcinoid, 18 patients (13%) with leiomyosarcoma, and 17 patients (12%) with lymphoma. The overall 5-year survival was 57 per cent and the median survival was 52 months. Survival of patients with adenocarcinoma was not dependent on location within the small bowel. Survival was best for early-stage tumors and when lesions could be completely resected.

Predicting conversion of laparoscopic cholecystectomy for acute cholecystitis.

BACKGROUND AND OBJECTIVES: Laparoscopic cholecystectomy can be safely performed in patients with acute cholecystitis. However, the rate of conversion to open cholecystectomy remains higher when compared with patients with chronic cholecystitis. Preoperative clinical or laboratory parameters that could predict the need for conversion may assist the surgeon in preoperative or intraoperative decision making. This could have cost-saving implications. METHODS: A retrospective review of 46 patients undergoing laparoscopic cholecystectomy for acute cholecystitis was performed. Records were assessed for preoperative clinical, laboratory and radiographic parameters on admission. Temperature and laboratory parameters were also recorded prior to surgery after an initial period of hospitalization that included intravenous antibiotics. The effect of admission and preoperative parameters as well as the trend in these parameters prior to surgery upon the rate of conversion to open cholecystectomy was assessed. RESULTS: Ten patients (22%) required conversion to open cholecystectomy. Conversion was required more often in males (43%) when compared with females (4%) (p=0.003). Conversion rate was 30% in patients with increased wall thickness by ultrasound compared with 12% for patients without wall thickening (p=ns). No admission or preoperative laboratory values predicted conversion. The trend in the patient's temperature (p=0.0003) and serum LDH value (p=0.043) predicted the need for conversion to open surgery. CONCLUSIONS: Preoperative prediction of the need for open cholecystectomy remains elusive. Male patients and patients with rising temperature and LDH levels while on intravenous antibiotics require conversion at increased frequency. However, the benefits of laparoscopic cholecystectomy warrant an attempt at laparoscopic removal in most patients with acute cholecystitis.

Head and neck mucosal melanoma: a 32-year review.

Because mucosal melanoma of the head or neck is uncommon, retrospective data are of value in defining its natural history, response to treatment, and patterns of recurrence. We analyzed the medical records of 28 patients who had been treated for a mucosal melanoma of the head or neck between 1961 and 1993. We found that their cumulative 5-year survival rate was 20%. Patients who had primary tumors of the nasal cavity had significantly better 5-year survival than other patients. Early stage at presentation was another predictor of a more favorable outcome. Only 2 of the 17 patients (12%) who underwent surgery died with local disease. However, 13 of these 17 surgical patients (76%) eventually died of distant metastases. There were 3 long-term (> 5 yr) survivors: 2 who were treated by surgery alone, and 1 who was treated with surgery and radiation therapy. We found that aggressive resection of the primary tumor and of any local recurrence can achieve local control in most patients with mucosal melanoma of the head or neck. Distant metastasis is the limiting factor for long-term survival.

Sarcoma of the breast: implications of the extent of local therapy.

Although the majority of breast neoplasms will be of epithelial origin, tumors of the stromal elements of the breast may occur. A retrospective review of the medical records and tumor registry data of 25 patients with breast sarcoma treated at Roswell Park Cancer Institute from 1964 to 1995 was performed. There were 24 females and 1 male, with a median age of 55 years. Delay in seeking medical attention was common. Angiosarcoma was the most common histologic type of breast sarcoma (n = 10). Mastectomy was the predominant form of local therapy (21 patients). Overall survival was 61 per cent at 5 years and 36 per cent at 10 years. There was no difference in survival or local control rates for those patients treated with local excision when compared with patients treated with mastectomy. Sarcoma is an unusual form of breast tumor. Survival and local control are similar when comparing local excision and mastectomy. When local excision is performed, attention must be directed to achieving clear margins of resection. The benefit of adjuvant therapy remains undefined.

Intrathyroid cysts of thyroglossal duct origin.

Thyroglossal duct cysts develop from a persistent portion of the thyroglossal tract and have been described as occurring anywhere from the base of the tongue to the manubrium. We present two patients who presented with a cystic thyroid nodule due to an intrathyroid thyroglossal duct cyst. A fine-needle aspiration biopsy was performed, which revealed benign squamous cells. Upon exploration, the first patient was found to have a 2-cm cyst within the thyroid isthmus, and in the second patient, a 1-cm cyst was found in the right thyroid lobe. Pathologic analysis revealed the cyst to be lined by a squamous epithelium consistent with a thyroglossal duct cyst. The lesions were completely surrounded by normal thyroid tissue. There was no evidence of a remnant of the thyroglossal duct extending from the thyroid in the region of the cyst. Both patients were treated by thyroid lobectomy and isthmusectomy and have remained without evidence of recurrence. Intrathyroid thyroglossal duct cysts should be included in the differential of patients with cystic thyroid lesions. Fine-needle aspiration revealing benign squamous cells is usually diagnostic and may detect an occult carcinoma arising within the cyst. Surgical resection is curative and should include a Sistrunk procedure if a thyroglossal duct tract is present.

Prognostic factors for adenocarcinoma of the gallbladder: an analysis of 162 cases.

Carcinoma of the gallbladder is a rare neoplasm and is associated with a dismal prognosis. To analyze the natural history of this disease and prognostic factors, a large tumor registry database was accessed. During the period 1972 to 1995, 214 patients were entered. Adequate follow-up was available on 162 patients, and this group forms the basis of this review. There were 54 males and 108 females with a median age of 62 years. Median follow-up was 7 months. Right upper quadrant abdominal pain was the most frequent presenting symptom. Fifteen patients had an incidental finding of carcinoma after cholecystectomy. Overall, 5-year survival was 25 per cent, with a median survival time of 9.7 months. Survival was improved for patients with local disease compared with those with regional or metastatic disease. One hundred nine patients underwent surgical therapy. Complete resection was possible in 36 patients, whereas 44 patients had residual disease. Median survival time for patients with no residual disease was 67.2 months, whereas those for patients with microscopic residual tumor and gross residual tumor were 8.9 and 3.8 months, respectively (P < 0.000001). Gallbladder cancer is often diagnosed at an advanced stage and is associated with a poor prognosis. In patients with localized disease, surgical treatment provides the opportunity for long-term survival only when a complete resection can be performed. Prognosis for patients with microscopic residual and gross residual disease is similar.

Intraoperative endoscopy in the management of patients with colorectal disease.

Preoperative colonoscopy is recommended in the evaluation of patients with lower gastrointestinal malignancies. The purpose of this study was to investigate the indications and impact on patient management in patients undergoing intraoperative endoscopy. This is a retrospective review of patient charts from February 1972 to July 1994 of 69 intraoperative endoscopic procedures performed in 54 patients during 54 operative sessions. The results of intraoperative endoscopy affected patient management in 29 of the 54 operative sessions (54%). This included 9 cases (17%) in which the planned surgical procedure was altered. There were no complications related to the endoscopies and 99% were completed successfully. Intraoperative endoscopy can provide important information that can alter the surgical management of patients with colorectal disease. This technique should be considered when intraoperative palpation fails to identify synchronous lesions identified on preoperative studies or in cases where the preoperative study is suboptimal.

Surgery as a single modality therapy for squamous cell carcinoma of the oral tongue.

PURPOSE: The treatment of squamous cell cancer of the oral tongue remains a challenging clinical problem. The efficacy of primary treatment with surgery versus radiation therapy for early stage disease and an adequate treatment paradigm for the clinically negative neck continues to be the subject of clinical debate. We have reviewed our experience in the treatment of oral tongue cancer with surgery as a single definitive treatment modality. PATIENTS AND METHODS: From 1971 to 1993, 79 patients with squamous cell carcinoma of the oral tongue were treated with surgery alone at Roswell Park Cancer Institute. RESULTS: Clinically, 69% of the patients presented with stage I/II disease and 31% presented with stage III/IV. Survival by pathological stage I to IV was 89%, 95%, 76%, and 65%, respectively. Surgical therapy ranged from partial to total glossectomy. There were no patients with positive margins. Local recurrence was observed in 15% of patients with close margins (< 1 cm) and 9% of patients with adequate margins (> or = 1 cm). The incidence of pathological node positive (N+) disease was 6%, 36%, 50%, and 67% for T1, T2, T3, and T4 tumors, respectively. Twenty-five percent of patients undergoing elective neck dissection were pathological N+. All pathological confirmed nodal disease was at level I or II. Of the 43 patients with clinical N0 disease, 16% subsequently developed regional recurrence, all of which were surgically salvaged. CONCLUSION: Locoregional control in patients with squamous cell carcinoma of the oral tongue can be achieved with primary surgical therapy. Adequate margins are crucial to local control. Salvage neck dissection may result in long-term survival for patients with regional relapse. Because of the high rate of occult disease (41%), we currently recommend prophylactic treatment of regional lymphatics for primary clinical disease of T2 or greater.

The utility of ultrasonography in the evaluation of groin masses: a case report.

Surgeons are often faced with the evaluation and management of groin masses. In most cases, an accurate history and physical examination will establish a diagnosis. Ultrasonography is being increasingly used in the evaluation of surgical problems. A case is presented in which bedside ultrasound was utilized in the evaluation of a large, symptomatic left inguinal mass found to be a synovial cyst on exploration. The differential diagnosis of cystic groin lesions and the impact of ultrasonography on diagnosis is reviewed with emphasis on synovial cysts. Surgeon-directed ultrasonography is an asset in the diagnosis of some patients with groin masses and may assist in the identification of those lesions requiring prompt operative intervention.

Occult thyroid carcinoma manifested as a cystic neck mass.

Papillary carcinoma of the thyroid is occasionally manifested by palpable cervical adenopathy and an occult primary lesion. Isolated cystic metastases as the presenting sign are an uncommon finding. In the case reported, a cystic lesion in the patient's neck laterally proved to be an occult papillary carcinoma.

Advanced cutaneous squamous cell carcinoma of the trunk and extremity: analysis of prognostic factors.

BACKGROUND: Patients with squamous cell carcinoma (SCC) of the skin may exhibit locally advanced or metastatic disease and present a challenging management problem. METHODS: A retrospective review of 40 patients with advanced SCC of the trunk or extremity managed at Roswell Park Cancer Institute from 1982 through 1992 was performed to identify clinical and pathologic factors that influenced outcome. RESULTS: There were 27 males and 13 females with a median age of 61 years. Median follow-up was 24 months. Surgical resection to control the primary tumor was often extensive. Amputation was required in nine patients, hemipelvectomy in three patients, and hemicorporectomy in one patient. Median survival was 28 months, and 5-year survival was 43%. Univariate analysis identified stage (P = 0.04), size (P = 0.0001), type of surgical procedure (P = 0.009), and margins of resection (P = 0.005) as having prognostic significance. On multivariate analysis, stage (P = 0.04) and size (P = 0.02) were found to be significant. CONCLUSIONS: Optimum treatment for advanced SCC of the trunk and extremity involves surgical resection with uninvolved margins. The role of elective node dissection remains undefined. Investigation is needed to define the role of neoadjuvant therapy that may improve functional and cosmetic results.

The management of infectious and noninfectious anorectal complications in patients with leukemia.

BACKGROUND: Infectious and noninfectious anorectal complications may occur in patients undergoing therapy for leukemia. Controversy surrounds the treatment of this problem in immunocompromised patients. STUDY DESIGN: A retrospective review of the medical records of 83 patients with acute or chronic leukemia in whom anorectal disease developed during inpatient therapy for leukemia was performed to determine the initial signs and symptoms, treatment, and outcomes. RESULTS: During a 12-year period, 92 patients with anorectal complications were treated. This series included 25 patients with perirectal abscesses, 22 patients with anal fissures, 18 patients with symptomatic external hemorrhoids, 12 patients with perianal ulcerations, 12 patients with symptomatic internal hemorrhoids, and three patients with fistulas in ano. Overall, 79 (86 percent) of the 92 anorectal complications resolved in 68 of the 83 patients. Increasing periods of neutropenia did not adversely affect the resolution of anorectal disease. Thirteen patients (16 percent) required surgical intervention, most commonly secondary to a perirectal abscess. Incision and drainage was necessary in ten (40 percent) of 25 patients with perirectal abscess, which included five patients with fluctuation and five patients in whom infection failed to respond to medical therapy. CONCLUSIONS: Noninfectious anorectal complications in patients with leukemia respond to nonoperative intervention and rarely progress to a life-threatening infection. Nonoperative intervention in the form of systemic antibiotics and sitz baths is successful in the treatment of infectious anorectal complications. Incision and drainage should be performed when fluctuation is present and in patients whose complications fail to respond to medical therapy.

Role of sentinel node biopsy in the management of malignant melanoma.

The use of elective lymph node dissection for intermediate-thickness melanoma has remained controversial. The technique of sentinel node biopsy (intraoperative lymphatic mapping and selective lymphadenectomy) has been developed in an attempt to identify patients who may benefit from an elective node dissection while sparing patients without occult metastases the morbidity of an elective lymphadenectomy. Current methods of performing a sentinel node biopsy include both a dye and radiolabeled technique. Although the accuracy of sentinel node biopsy for identifying nodes at risk for occult metastases has been demonstrated, a survival benefit from dissection of nodal basins that contain occult metastases remains to be determined. This article reviews the basis for, technical considerations of, and surgical results with selective lymphadenectomy in an attempt to clarify the role of this modality in the management of patients with cutaneous melanoma.

Pneumatosis intestinalis and portal venous air associated with needle catheter jejunostomy.

Pneumatosis intestinalis is an unusual postoperative complication. In some cases, immediate surgical intervention may be necessary. This report describes pneumatosis intestinalis with portal venous air attributed to enteral nutritional support via needle catheter jejunostomy. The etiology, radiographic findings, and management of this problem are reviewed.

Thoracoscopic management of spontaneous pneumothorax allows prompt return to aviation duties.

Primary spontaneous pneumothorax, a disease of young adults, is occasionally encountered in aviation personnel. Surgical intervention is often recommended after the first episode for those patients involved in aviation or diving duties due to the increased risk of recurrence secondary to barotrauma. Thoracoscopic surgery can be used effectively to resect the causative blebs or bullae and to perform a mechanical pleurodeisis. When compared to the traditional open technique, post-operative recovery time is less with this approach and allows more rapid return to aviation duties. Thoracoscopic surgery should be considered in all cases of spontaneous pneumothorax encountered in aviators.