[Cutaneous melanoma of the head and neck]. / Melanomas cutaneos de cabeza y cuello.

The clinical records of 20 patients with the diagnosis of cutaneous melanoma of the head and neck treated between 1991 and 2005 were retrospectively reviewed. Advances in diagnostic techniques and treatment have had obvious impact on outcomes in cutaneous melanoma. Cutaneous melanoma of the head of neck is treated with complete surgical resection in early stage disease. Resection margins are determined by the size and depth. Evaluation for regional and distant metastatic disease is necessary in advanced stage disease. Adjuvant therapy may be indicated in regional nodal disease.

[Sinonasal mucosal melanoma]. / Melanomas mucosos nasosinusales.

Mucosal melanomas of the nasal cavity and paranasal sinuses are rare and agresive neoplasms and carries a bad prognosis. The diagnosis may require confirmatory immunohistochemical stains (S-100 protein, HMB-45, vimentin and cytokeratine). The clinical records of 6 patients with the diagnosis of sinonasal melanomas between 1991 and 2005 were retrospectively reviewed. The mean age was 70 years (range 51 to 83 years), there were 2 men and 4 women. Surgery was performed in four patients, adjuvant radiation therapy was used in one patient after local recurrence and chemotherapy in three patients. Three of four patients (75%) had a recurrence after previous treatment (surgery). The actuarial disease-free survival for this group of 6 is 33.3% (2 of 6). Mucosal melanoma of the head and neck remains a difficult disease to treat, with high locoregional recurrence rates and poor prognosis.

[Postseptal orbital cellulitis and sinusitis. Descriptive study of 8 cases and literature review]. / Celulitis orbitaria retroseptal y sinusitis. Presentación de 8 casos y revisión de la literatura.

This is a retrospective study of 8 patients with postseptal orbital cellulitis (stages II-V of Chandler) caused by sinusitis during 1999-2003. The variables analyzed in this study included age, sex, delay in diagnosis, aetiology, imaging studies, microbiology specimens collected and treatment. Delays in diagnosis were frecuent. CT was the best radiologic study. Polymicrobial infections were the rule, including anaerobes. 4 patients of 8 needed surgical drainage. A general guideline for the management of periorbital and orbital cellulitis according to the clinical staging of the process is presented.

[Metastasis to the parotid gland]. / Metastasis en la glandula parótida.

INTRODUCTION: Metastatic disease in the parotid gland has been observed and reported in the literature, and its treatment is controversial. MATERIAL AND METHODS: We review 48 patients with parotid tumors that underwent surgery during 1997-2004. The clinical and histogical features are reviewed. RESULTS: Among these 48, there were 12 cases of metastatic tumors to the parotid (25%). The pathohistological analysis of these tumors revealed that 8 were epidermoid carcinoma (66%), 1 patient was a melanoma (8%), 2 lymphomas below clavicules (16%) and 1 patient with a metastasis of a primary renal cancer. All patients underwent parotidectomy and 10 also cervical neck dissection (6 cases showed cervical metastases). 8 patients received radiotherapy after surgery. CONCLUSIONS: In our study parotid metastases are relatively common in patients submitted for parotid surgery. Often the site of origin of the primary tumor is the facial skin, and the primary tumors most commonly are melanomas or squamous-cell carcinomas, but it is possible distant primary tumors below clavicules.

[Otology manifestations of the Anderson-Fabry disease]. / Manifestaciones otológicas en la enfermedad de Fabry-Anderson.

Anderson-Fabry disease in an inherited X-linked metabolic disorder involving glycosphingolipid metabolism. Few data are available regarding cochlear involvement. Clinical manifestations of Fabry disease appeared on the first decade of life. The prognosis of males with Fabry disease is serious and life expectancy is limited; clinical evolution of heterozygous females is clearly better. We report a family with Fabry disease in several members. The mother, already dead, had two child which have been examined in our department; the male, without a risk of ototoxicity, or acoustic trauma, has progressive hearing loss, tinnitus and dizinness sometimes; the daughter, without a history of deafness, shows unilateral hearing loss on high-tone frequencies. It is important to emphasize these data to those physicians expert in children with Fabry disease because early enzyme replacement therapy intervention should offer increased possibilities of regression of the disease.

[Predictive biochemical indicators of a postlaryngectomy pharyngocutaneous fistula: a clinical study]. / Indicadores bioquímicos predictivos de fístula faringocutánea postlaringuectomía: un estudio clínico.

UNLABELLED: The aim of this clinical study was to determinate biochemical predictor indicators of postlaryngectomy pharyngocutaneous fistula. PATIENTS AND METHODS: We have studied 100 patients with T2- 4 a laryngeal and piryform sinus carcinoma who underwent a laryngectomy. All patients were ASA 2-3. We studied serum albumin, protein serum level, cholesterol and lymphocites in each patient. These variables underwent statistical analysis (p < 0.05). RESULTS: 19% of the patients developed a postlaryngectomy pharyngocutaneous fistula, with a long-stay of 25 days vs. 10 days of stay in patients without postlaryngectomy pharyngocutaneous fistula. 7 postlaryngectomy pharyngocutaneous fistula needed surgical repair. Low serum albumin (< 3.5 g/dL) and a low level of serum proteins (< 6.5 g/dL) were predictive indicators of postlaryngectomy pharyngocutaneous fistula (p < 0.05). CONCLUSIONS: Our results suggest that a low-level of serum proteins and albumin are predictive clinical parameters of postlaryngeal pharyngocutaneous fistula.

Loss of heterozygosity and mutation analysis of the p16 (9p21) and p53 (17p13) genes in squamous cell carcinoma of the head and neck.

We analyzed allelic loss at the p53 gene (17p13) and at chromosome region 9p21 in 35 primary head and neck squamous cell carcinomas. Loss of heterozygosity (LOH) at p53 and 9p21 was found in 50 and 75% of informative cases, respectively. LOH at the p53 gene did not increase significantly with tumor stage, but was more frequent in moderately and poorly differentiated tumors than in well-differentiated tumors. LOH plus mutation or homozygous deletion of p53 was limited to advanced stage and poorly differentiated tumors. Allelic loss at 9p21 is frequent in early stage head and neck squamous cell carcinoma and is not significantly associated with LOH at p53. The second exon of the p16/MTS1/CDKN2 gene was found to be homozygously deleted in 1 of 19 cases showing LOH at 9p21, but direct sequencing did not show mutations in the remaining 18 cases. This suggests that p16 plays a limited role in the development of head and neck squamous cell carcinoma.

[Lipid profile and hearing-loss aged-related]. / Perfil lipídico de la sordera ligada al envejecimiento.

OBJECTIVES/HYPOTHESIS: Presbycusis is the most prevalent cause of hearing-loss in the older, but pathogenesis is not well-know. The premise of this study is that hyperlipemia increase risk of age-related hearing-loss. PATIENTS AND METHODS: 180 patient more than 65 years-old were studied. All patients had bilateral hearing-loss and no renal, neurological, thyriod or middle-ear pathology. We explored serum levels of cholesterol, HDL, LDL and triglycerides. We performed tonal audimetry in all patients. RESULTS: The 71% of patients has hypercholesteremia and the highest serum levels were detected in 65-69 years-old men (mean media 5,27). Patients with hypercholesteremia had worse hearing-loss than patients with normal lipid serum levels (p < .05). CONCLUSIONS: Our study sugest that hypercholesteremia are associated to age-related hearing-loss, possibly by an atherosclerosis mechanism.

[Minimally invasive surgery for treating of complicated fronto-ethmoidal sinusitis]. / Cirugía mínimamente invasiva para el tratamiento de la sinusitis fronto-etmoidal complicada.

OBJECTIVES: Functional endoscopic sinus surgery (FESS) is nowadays the "gold standard" for frontal sinus pathologies, but management of acute situations and the aproach and/or the extent of the surgery perfomed in the frontal recess remains controversial nowadays. MATERIAL AND METHODS: We report our experience in 4 patients with orbital celulitis due to frontal sinusitis who underwent combined external surgery (mini-trephination) and endoscopic sinus surgery. RESULTS: All patients managed sinus patency without any complications. CONCLUSIONS: We found this combined sinusotomy as an easy, effective and reproductible technique in order to resolve the difficult surgical management of complicated frontal sinusitis.

Chromosome 3p loss of heterozygosity and mutation analysis of the FHIT and beta-cat genes in squamous cell carcinoma of the head and neck.

AIMS: To study the loss of heterozygosity at the short arm of chromosome 3 in primary tumours from patients with squamous cell carcinoma of the head and neck; to determine whether the FHIT gene, mapped to 3p14.2 and the CTNNB1 (beta-cat) gene, mapped to 3p21, are deleted or mutated in these tumours. METHODS: DNA was extracted from fresh tumours. Loss of heterozygosity was assessed by microsatellite analysis of the following markers: D3S1283 and D3S1286 (3p24), D3S966 (3p21), and D3S1300 (3P14.2). Homozygous deletion was determined by radioactive multiplex polymerase chain reaction of exons 5 and 6 of the FHIT gene. The presence of mutations in FHIT exon 5 and beta-cat exon 3 was studied by single strand conformation polymorphism. RESULTS: 50% of informative cases (25/50) showed loss of heterozygosity for at least one of the 3p markers. 3p21 was the region with the highest rate of allelic deletion (63%). No point mutation was found in FHIT exon 5 or beta-cat exon 3. No case showed homozygous deletion for the FHIT (exons 5 and 6) or the beta-cat exon 3. CONCLUSIONS: The short arm of chromosome 3 is often deleted in the head and neck squamous cell carcinomas. In the remaining alleles of the FHIT or beta-cat genes, no evidence was found for point mutations or deletions, documented in other common carcinomas. Inactivation could occur by different mechanisms such as methylation, or other genes (not studied here) could be target of allelic losses in squamous cell carcinoma of the head and neck.

Genetic polymorphism of N-acetyltransferase-2, glutathione S-transferase-M1, and cytochromes P450IIE1 and P450IID6 in the susceptibility to head and neck cancer.

AIMS: To analyse the allele frequencies of DNA polymorphisms at the genes for cytochromes P450IIE1 and P450IID6, N-acetyltransferase-2, and glutathione S-transferase-M1 in patients with head and neck squamous cell carcinoma, in an attempt to define genetic factors involved in the susceptibility to this cancer, which is strongly associated with tobacco consumption. METHODS: Determination of restriction fragment length polymorphism (RFLP) at cytochromes P450IIE1/P450IID6 and NAT2 genes, and the presence of homozygous deletion of the GSTM1 gene, in 200 controls and 75 head and neck cancer patients. Allelic frequencies between the two groups were compared using a chi 2 test, and odds ratio with 95% confidence intervals were calculated. RESULTS: There was no evidence of an association between alleles of CYP2D6 and CYP2E1 and head and neck cancer in our population. Similarly, frequencies of individuals lacking the GSTM1 gene did not differ between controls and patients. However, individuals with the NAT2-SA phenotype were at higher risk of developing head and neck cancer. The frequencies of the most common SA genotype (homozygous for the NAT2*5 allele) were higher in patients than in controls (27% v 15%, respectively). Slow acetylators homozygous for the NAT2*6 allele, the second most common SA allele, were also more common in patients than in controls (11% v 5%, respectively). CONCLUSIONS: Slow NAT2 activity is a risk factor possibly leading to the development of head and neck cancer in response to tobacco carcinogens.

Deletion and methylation of the tumour suppressor gene p16/CDKN2 in primary head and neck squamous cell carcinoma.

AIMS: To study the homozygous deletion and methylation status of the 5' CpG island of the p16 and p15 genes (9p21) in a set of primary advanced head and neck squamous cell carcinomas (SCC) and to test whether inactivation of these genes by these mechanisms contributes to head and neck SCC development. METHODS: DNA was extracted from fresh tumours. Homozygous deletion was determined by the polymerase chain reaction (PCR) followed by hybridisation with the corresponding probe, radioactively labelled by the random priming method. Methylation status of the CpG island of the 5' region of these genes was assessed by digestion with the appropriate restriction enzymes followed by PCR and subsequent hybridisation with the corresponding probe. The presence of point mutations was determined by PCR-SSCP (single strand conformation polymorphism). RESULTS: The p16 and p15 genes were homozygously deleted in 20% and 10% of the tumours, respectively. No point mutations were found at p16 and p15. The 5' CpG island at the p16 gene was methylated in 20% of the cases. CONCLUSIONS: The tumour suppressor gene p16 is inactivated through homozygous deletion or methylation in a significant proportion of cases of head and neck SCC.

Hemoductal pancreatitis.

Gastrointestinal tract hemorrhage from rupture of the splenic artery into the pancreatic duct is unusual. This obscure cause of intermittent gastrointestinal tract bleeding should be suspected when the more common causes of bleeding have been ruled out. Duodenoscopy carried out during active hemorrhage may reveal blood coming from the papilla of Vater. Coeliac arteriography will show the pathognomonic findings and confirm the diagnosis. We have treated three patients who had chronic pancreatitis and who developed pseudocyst formation and pseudoaneurysms of the splenic artery. The pseudoaneurysm ruptured into the duct of Wirsung, causing obscure upper-gastrointestinal bleeding. Treatment was distal pancreatectomy and splenectomy, including the pseudoaneurysm and pseudocyst. A review of the literature suggests that three different types of bleeding into the pancreatic duct can occur. The cause of each is described.

Pancreaticoduodenectomy without homologous blood transfusion in an anemic Jehovah's Witness.

Whipple pancreaticoduodenectomy is an accepted procedure for management of periampullary and pancreatic carcinomas and has modern mortality rates of less than 10%. The procedure is associated with significant operative blood loss. Therefore, blood transfusion is an important supportive measure. We report the case of a bleeding ampullary carcinoma in a Jehovah's Witness who refused transfusion of all homologous blood products. Despite a preoperative hemoglobin level of 51 g/L, curative pancreaticoduodenectomy was successfully performed. The success of the procedure can be primarily attributed to careful surgical technique, intraoperative autotransfusion, avoidance of postoperative complications, minimization of perioperative phlebotomies, use of human recombinant erythropoietin, and, possibly, the use of the perfluorocarbon emulsion Fluosol DA-20%. The case illustrates several important principles for the surgical treatment of patients with severe anemia who refuse transfusion of homologous blood products.

Preoperatively assessing and planning blood use for elective vascular surgery.

Few guidelines exist for determining transfusion needs and strategies, namely, the appropriate use of autologous versus homologous blood for elective vascular surgery. To address this deficiency, we have developed and used an algorithm based on an analysis of the procedure, maximum surgical blood ordering schedule, patient status, and patient suitability for autologous alternatives. Data were derived from consecutive major vascular procedures done at our hospital from 1991 to 1992. The algorithm helps the surgeon assess transfusion need and patient suitability for autologous predonation and aids in selecting appropriate transfusion alternatives. Using this algorithm during the past year with 120 patients, we simplified transfusion decisions, reduced homologous blood use (to only 4.2%), and reduced wasting of autologous blood to less than 5% of the units predonated. We believe that the use of this algorithm will aid the vascular surgeon in choosing appropriate alternatives to allogeneic blood transfusion, thereby reducing the patient's exposure to risk. The algorithm should also reduce wasting of autologous blood.

Elective surgery without transfusion: influence of preoperative hemoglobin level and blood loss on mortality.

To clarify the widespread practice of preoperative transfusion to attain a 10 g/dL level of hemoglobin, the relationship between preoperative hemoglobin level, operative blood loss, and mortality was studied by analyzing the results of 113 operations in 107 consecutive Jehovah's Witness patients who underwent major elective surgery. Ninety-three patients had preoperative hemoglobin values greater than 10 g/dL; 20 had preoperative hemoglobin levels between 6 to 10 g/dL. Mortality for preoperative hemoglobin levels greater than 10 g/dL was 3 of 93 (3.2%); for preoperative hemoglobin levels between 6 to 10 g/dL, mortality was 1 of 20 (5%). Mortality was significantly increased with an estimated blood loss of greater than 500 mL, regardless of the preoperative hemoglobin level (p less than 0.025). More importantly, there was no mortality if estimated blood loss was less than 500 mL, regardless of the preoperative hemoglobin level. From these data, we conclude that: (1) Mortality in elective surgery appears to depend more on estimated blood loss than on preoperative hemoglobin levels; and (2) Elective surgery can be done safely in patients with a preoperative hemoglobin level as low as 6 g/dL if estimated blood loss is kept below 500 mL.

Bioavailability of medication delivered via nasogastric tube is decreased in the immediate postoperative period.

BACKGROUND: A study was performed to determine bioavailability of medication delivered via nasogastric tube in patients after abdominal surgery. METHODS: Acetaminophen (20 mg/kg) was administered to each patient per os at least 48 hours prior to abdominal surgery and via nasogastric tube 3 hours postoperatively. The nasogastric tube was clamped for 30 minutes after drug administration, prior to resuming suction. Serum levels of acetaminophen were measured 0, 40, and 90 minutes after each dose. RESULTS: Acetaminophen levels were significantly lower (P < 0.001) when the drug was administered via nasogastric tube postoperatively. CONCLUSIONS: Decreased bioavailability of medications delivered via nasogastric tube may have important clinical implications and should be taken into consideration during the postoperative period.

Colon operations without wound infection. Principles and techniques in 101 cases.

A total of 101 consecutive elective colon operations were performed with no postoperative wound infection. Patients with a wide variety of diagnoses and procedures were included in the series. Many factors contribute to the formation of postoperative wound infections. A comprehensive approach with attention to preoperative nutritional assessment, bowel preparation, wound protection, sterile technique, closure of the incision, and systemic prophylactic antibiotics contributed to the overall good results.

A survey of preferred approach to inguinal hernia repair: laparoscopic or inguinal incision?

The recent interest in laparoscopic surgery has raised some concerns that large numbers of surgeons were recommending this "minimally invasive" approach in procedures such as inguinal herniorrhaphy before the availability of adequate data regarding safety and benefits. To determine current experience and preference levels for laparoscopic inguinal herniorrhaphy (LH), we conducted a mail survey of New Jersey surgeons. Of 531 respondents, 430 (81%) preferred a traditional inguinal incision approach over a laparoscopic approach (8%). Of 344 general surgeon respondents, 227 (66%) had experience with laparoscopic cholecystectomy, but only 56 (16%) had experience with LH. This latter group had performed only an average of 9.2 laparoscopic herniorrhaphies, with a median of five cases. Most of these 56 surgeons with LH experience indicated a preference for inguinal incision herniorrhaphy although 19 surgeons who had performed 10 or more LH cases showed a slight preference for LH (11 to 8). The primary reasons for choosing LH included "less pain" and "quicker recovery." The primary reasons for choosing inguinal incision herniorrhaphy included having a "better known procedure" and avoiding general anesthesia. Our survey indicates that the laparoscopic approach to inguinal hernia repair has currently accumulated few proponents in the surgical community since many surgeons are waiting for more data on the procedure.

Erythropoetin accelerates hematocrit recovery in post-surgical anemia.

UNLABELLED: We evaluated the role of recombinant human erythropoietin (RHE) for treatment of severe postsurgical anemia (Hct < 25%) in 40 Jehovah's Witness (JW) patients refusing transfusion. Twenty patients (group E) received RHE either at a loading dose of 300 U/kg iv 3 times/week for 1 week followed by 150 U/kg 3 times/week in accordance with an IRB approved protocol (N = 13), or at a dose of 100 U/kg 3 times/week for humanitarian reasons (N = 7). This group was compared to 20 similar JW patients who did not receive RHE (group C). All patients received iron restoration and nutritional support. Non-parametric analysis (Mann-Whitney) was used because of sample size. Entry hematocrit was similar for both groups: H(E)(0) = 15.8% +/- 1.1 SEM (8.5-23.4) vs HC (0) = 12.8% +/- 0.9 SEM (7.3-20.6), P = 0.09. After one week, hematocrit was significantly higher in group E (H(E)(1)) = 19.3 +/- 1.1 vs HC(1) = 12.5% +/- 0.9, P < 0.0005) as was the increase in hematocrit for group E (3.6% +/- 0.9 for E vs -0.4% +/- 0.8 for C, P < 0.005). Hematocrit change in Week 2 showed an increase for both groups (2.9 +/- 0.6 for E vs 4.9% +/- 1.2 for C, P = 0.12). CONCLUSIONS: Hct recovery shows a 1-week lag in severely anemic postsurgical patients treated without RHE. Exogenous RHE appears to accelerate hematocrit recovery in the first week. Use of RHE in the immediate postoperative period may help avoid or reduce homologous blood transfusion.