Proctitis cystica profunda in paraplegics. Report of three cases.

Proctitis cystica profunda is a benign disease of the rectal mucosa that can be mistaken for rectal carcinoma both grossly and microscopically. Symptoms may consist of blood or mucus in the stool, diarrhea, tenesmus, or rectal pain. The disease has never been reported in a paraplegic population before, but the proposed etiology makes this group seem to be at high risk. We report three cases in our paraplegic population and discuss the nature of the disease as well as its treatment.

Technique for placement of a totally implantable venous access device.

A totally implantable venous access system is described which greatly improved the ability to gain long-term venous access in selected patients. The external jugular approach has been demonstrated to be a safe and simple technique. The only major problem associated with the implantable venous access system was the development of one-way catheter occlusions. A number of methods for restoring catheter patency have been advocated. The use of streptokinase appears to be the most reliable and was found effective in this study. Importantly, however, catheter sepsis has been virtually eliminated with this totally implantable system.

New surgical approach to minimize radiation-associated small bowel injury in patients with pelvic malignancies requiring surgery and high-dose irradiation. A preliminary report.

Complications associated with small bowel intolerance to radiation therapy at doses higher than 4500 to 5000 cGy have been the limiting factor in delivering pelvic radiation either as an adjuvant to surgery or alone in the treatment of pelvic malignancies. Despite numerous surgical, medical, and radiation therapy technical measures to minimize small bowel injury, none have been uniformly successful in eliminating this problem. With the availability of a new synthetic absorbable mesh, a pelvic sling can be placed at the time of exploration or definitive surgery aimed at suspending the small bowel out of the pelvis. Preliminary work in animal models has shown the mesh sling to be well-tolerated and successful. Barium-contrast simulation studies of seven patients with pelvic malignancies requiring resectional surgery and postoperative radiation therapy in whom the mesh sling was placed at the time of surgery demonstrate total exclusion of the small bowel from the pelvic radiation treatment field. All patients have been followed for at least 4 months since mesh placement, and to date no complications have occurred. It is possible that this technique of bowel exclusion will permit the delivery of larger doses of radiation therapy in patients with pelvic malignancies aiming at more effective local and regional control of cancer without increased complications from radiation-associated small bowel injury.

Superficial lymph node infarction.

Superficial lymph node necrosis is an unusual pathologic diagnosis encountered in clinical practice. When seen it is usually indicative of involvement of the affected lymph nodes with either metastatic cancer or lymphoma. Occasionally it has been associated with hypersensitivity phenomena with arteriolar involvement. The underlying etiology in all of these instances is extensive occlusion of the rich vascular supply to the node. Rarely cases are seen where no clear-cut etiology can be found. Ten such cases have been reported in the medical literature including the case published in this report. Its occurrence, however, may be more common than previously recognized. Preoperatively it is usually not possible to distinguish this entity from the other diagnoses for which it is generally mistaken. These other diagnoses most commonly include femoral hernia and mass in the axillary tail of the breast. The patient reported here is unusual in regard to the size of the lesion encountered. In other published reports very few lymph nodes were involved. In this case extensive involvement of a large mass of nodes was noted. Once the diagnosis is made limited work-up as well as further close observation is important since it may herald the occurrence of a lymphoproliferative disorder.

The closure of abdominal wounds in cancer patients.

A total of 102 abdominal surgical wounds in cancer patients were closed with absorbable suture material. The object of the study was to evaluate whether patients with cancer having possible wound healing impairments could be closed with absorbable sutures, thereby omitting the difficulties involved with retention sutures or nonabsorbable material. Polyglycolic acid sutures were used in the fascia in all of these patients, and they were studied regarding the incidence of wound infection, wound dehiscence, and incisional hernias. There were no instances of wound dehiscence in the entire series. A wound infection rate of 14.8% was encountered. The incidence of incisional hernia following either infection or primary healing was noted to be markedly decreased. The rate of wound dehiscence and wound hernia was sufficiently low to lead us to recommend this type of abdominal wound closure in all cancer patients.

Near-fatal hemorrhage following gastrografin studies.

The use of upper gastrointestinal studies followed by gastric drainage and observation is recommended for the evaluation and treatment of stomal dysfunction due to edema or gastric atony. Gastrografin though, may be precipitated out and can cause gastrointestinal bleeding if left in the gastric remenant. This agent should be used with proper precautions in the evaluation of postoperative gastric retention.

A new variant of intra-abdominal hernia.

A new variant of intra-abdominal hernia is presented. Available evidence suggests that this type of intra-abdominal hernia may be more prevalent than previously reported. Patients suffering from crampy, intermittent abdominal pain whose routine radiographic gastrointestinal studies are unrevealing often are labeled as having psychogenic disorders. Three cases are present giving similar histories and routine findings in which mesenteric arteriography coupled with careful small bowel series has revealed a surgically curable lesion. Such patients should have judicious mesenteric angiography coupled with routine radiographic gastrointestinal studies in search of small intramesenteric herniae which are readily correctible.

The anterior approach to percutaneous liver biopsy.

Anterior subcostal percutaneous liver biopsy using the Tru-cut disposable needle is safe and simple; there were no major complications in our experience. It avoids completely the known thoracic complications of the posterior or lateral approach to percutaneous liver biopsy and has the added benefit of making any of the remaining complications easier to manage.