Single-stage sacral coccygectomy and repair using human acellular dermal matrix (AlloDerm) with bilateral gluteus maximus flaps for hernia prophylaxis.

Sacrococcygectomy is often necessary for the ablation of malignancies involving the sacrum and coccyx, and can result in deep posterior peritoneal defects with disruption of the pelvic floor. Such a radical procedure is frequently associated with significant morbidity, including sacral herniation. Numerous techniques for the closure of the surgical defect have been described, with varying degrees of success in avoiding future herniation. We report the first single-stage coccygectomy and partial sacrectomy with closure utilizing human acellular dermal matrix (HADM) (AlloDerm; LifeCell Corporation, Branchburg, NJ) and bilateral gluteus maximus transposition flaps.

Effects of acute and chronic relaxin-3 on food intake and energy expenditure in rats.

The effects of acute and repeated intraparaventricular (iPVN) administration of human relaxin-3 (H3) were examined on food intake, energy expenditure, and the hypothalamo-pituitary thyroid axis in male Wistar rats. An acute high dose iPVN injection of H3 significantly increased food intake 1 h post-administration [0.4+/-0.1 g (vehicle) vs 1.6+/-0.5 g (180 pmol H3), 2.4+/-0.5 g (540 pmol H3) and 2.2+/-0.5 g (1,620 pmol H3), p<0.05 for all doses vs vehicle]. Repeated iPVN H3 injection (180 pmol/twice a day for 7 days) significantly increased cumulative food intake in ad libitum fed animals compared with vehicle [211.8+/-7.1 g (vehicle) vs 261.6+/-6.7 g (ad libitum fed H3), p<0.05]. Plasma leptin was increased in the H3 ad libitum fed group. Plasma thyroid stimulating hormone was significantly decreased after acute and repeated administration of H3. These data suggest H3 may play a role in long-term control of food intake.

Central relaxin-3 administration causes hyperphagia in male Wistar rats.

Relaxin-3 (INSL-7) is a recently discovered member of the insulin superfamily. Relaxin-3 mRNA is expressed in the nucleus incertus of the brainstem, which has projections to the hypothalamus. Relaxin-3 binds with high affinity to the LGR7 receptor and to the previously orphan G protein-coupled receptor GPCR135. GPCR135 mRNA is expressed predominantly in the central nervous system, particularly in the paraventricular nucleus (PVN). The presence of relaxin-3 and these receptors in the PVN led us to investigate the effect of central administration of relaxin-3 on food intake in male Wistar rats. The receptor involved in mediating these effects was also investigated. Intracerebroventricular injections of human relaxin-3 (H3) to satiated rats significantly increased food intake 1 h post administration in the early light phase [0.96 +/- 0.16 g (vehicle) vs. 1.81 +/- 0.21 g (180 pmol H3), P < 0.05] and the early dark phase [2.95 +/- 0.45 g (vehicle) vs. 4.39 +/- 0.39 g (180 pmol H3), P < 0.05]. Intra-PVN H3 administration significantly increased 1-h food intake in satiated rats in the early light phase [0.34 +/- 0.16 g (vehicle) vs. 1.23 +/- 0.30 g (18 pmol H3), P < 0.05] and the early dark phase [4.43 +/- 0.32 g (vehicle) vs. 6.57 +/- 0.42 g (18 pmol H3), P < 0.05]. Feeding behavior increased after intra-PVN H3. Equimolar doses of human relaxin-2, which binds the LGR7 receptor but not GPCR135, did not increase feeding. Hypothalamic neuropeptide Y, proopiomelanocortin, or agouti-related peptide mRNA expression did not change after acute intracerebroventricular H3. These results suggest a novel role for relaxin-3 in appetite regulation.

Carcinosarcoma of the esophagus--pattern of recurrence.

Carcinosarcoma of the esophagus is a rare malignant neoplasm, predominantly affecting men in their seventh decade of life. While presenting symptoms and anatomic location of squamous cell and carcinosarcoma of the esophagus are similar, the latter often presents as a large intraluminal polypoid mass on barium esophagram. The more favorable prognosis associated with carcinosarcoma versus other esophageal neoplasms has been attributed to early onset of symptoms, resulting in prompt diagnosis, and a lower propensity for tumor invasion. We report the case of an elderly woman presenting with dysphagia who was initially diagnosed with esophageal leyomyosarcoma. Final tumor pathology showed esophageal carcinosarcoma.

Malignant proliferating trichilemmal tumor.

Proliferating trichilemmal tumors are uncommon neoplasms that are usually benign, but characterized by frequent local recurrence. In this report, we describe a patient who sought treatment at our clinic for a right occiput scalp nodule measuring 1 cm in diameter. The subcutaneous lesion was mobile and without overlying skin ulceration. Excisional biopsy of the mass was performed and the pathologic diagnosis returned as malignant, proliferating trichilemmal (pilar) tumor. Resection margins were free of tumor. On further examination the patient had no evidence of metastatic disease. A schedule of routine follow-up visits was arranged to monitor the site for recurrent disease.

Prospective comparison of intraoperative angiography with duplex scanning in evaluating lower-extremity bypass grafts in a community hospital.

The gold standard for intraoperative evaluation of lower-extremity bypass grafts has been angiography. Limitations of this technique include inability to measure flow dynamics, violation of graft integrity, cost, and length of assessment time. The goal of this study was to evaluate duplex scanning as an alternative modality for intraoperative graft assessment. Our study group comprised of 19 consecutive patients undergoing infrainguinal bypass procedures at our institution between March 1999 and March 2000. Intraoperative angiography was compared with duplex scanning by evaluating parameters of assessment time, graft flow velocities, serum creatinine levels, and 30-day graft patency rates. Mean study times were the following: cut-film angiography, 22 +/- 1.8 minutes; real-time fluoroscopy, 17 +/- 2.5 minutes; and duplex imaging, 10.4 +/- 1.1 minutes. As noted duplex imaging times as compared with radiographic modalities were significantly shorter (P < 0.05). There was a substantial cost difference between angiography ($650) and duplex scanning ($350). A 100 per cent correlation of study findings was noted between angiography and duplex scanning. No significant change in pre- versus postoperative creatinine levels was found. We conclude that duplex scanning is an effective modality and provides reliable intraoperative vascular graft assessment data in a community hospital setting. Advantages include a shorter study time, lower cost, flow dynamic data acquisition, and avoidance of mechanical graft trauma.

Intraoperative monitoring of recurrent laryngeal nerve function.

Intraoperative recurrent laryngeal nerve identification is sometimes difficult in reoperative cervical dissection or operation for inflammatory thyroid disorders. Three modalities have been described to intraoperatively assess nerve function: vocal cord visualization with fiberoptic bronchoscopy or direct laryngoscopy, electromyelographic surveillance of arytenoid muscle function, and cord function assessment with an electromyelogram-electrode endotracheal tube. Our study focused on patients requiring cervical dissection for thyroid or parathyroid disease in which intraoperative recurrent laryngeal nerve function was monitored by nerve stimulation with a concentric bipolar probe. Impulses were tracked via a specialized electrode-bearing endotracheal tube with signal transduction to a recording monitor. No operative nerve injuries occurred in the patients of our study group. This surveillance technique's several advantages include use of standard intubation techniques with no increase in operative time, nerve stimulation tracings that are quantifiable and reproducible with production of a permanent record, and less subjectivity due to observer variability. We believe these factors make the electromyelogram-electrode endotracheal tube approach to intraoperative recurrent laryngeal nerve assessment the optimal technique.

Intrapericardial interferon in the management of malignant pericardial effusion.

A patient with pericardial tamponade secondary to malignant pericardial effusion underwent pericardiocentesis followed by intrapericardial instillation of recombinant interferon alfa-2b (INTRON A; Schering-Plough; Kenilworth, NJ). The patient subsequently received a full course of chemotherapy and radiation therapy for her primary malignant tumor and experienced no recurrence of the pericardial effusion.

Laparoendoscopic diagnosis of eosinophilic enteritis.

As the popularity of laparoscopic cholecystectomy continues to grow, evaluation of patients with documented cholelithiasis and concomitant vague abdominal complaints becomes less rigorous. We present the case of a patient with chronic cholecystitis documented by history and ultrasonography, incidentally noted on laboratory examination to have peripheral blood eosinophilia. At the time of laparoscopy, an inflamed segment of jejunum was discovered. Limited laparotomy and wedge biopsy revealed active eosinophilic enteritis.

Lymphoma of the extrahepatic biliary ducts in acquired immunodeficiency syndrome.

Gastrointestinal neoplasia in acquired immunodeficiency syndrome (AIDS) frequently presents as a non-Hodgkin's lymphoma or Kaposi's sarcoma, at sites including the oral cavity, esophagus, small bowel, and mesenteries. Primary lymphoma of the biliary ducts, even in the setting of AIDS, is rare. This patient, an older male with no preoperatively known AIDS risk factors, presented with painless jaundice and radiographic findings of focal hepatic duct stenosis, suggesting either a Klatskin tumor or sclerosing cholangitis. Only after the pathologic diagnosis of a malignant large cell lymphoma from the en bloc tumor specimen was his human immunodeficiency virus status ascertained and noted to be positive.

Recombinant interferon alpha-2b in the management of malignant pleural effusions.

Twenty-one patients with malignant pleural effusion (MPE) were prospectively entered into a nonrandomized, single-armed study to evaluate the efficacy and safety of recombinant interferon (IFN) alpha-2b (INTRON A; Schering-Plough; Kenilworth, NJ) as an intrapleural palliative agent. From March 1989 through February 1993 (48 months), 21 patients were entered into the study. No symptomatic effusion recurred and no substantial side effects were associated with treatment. This suggests recombinant IFN alpha-2b represents a safe and effective intrapleural agent for the palliation of MPE.

Thoracoscopic assisted pneumonectomy.

A lung carcinoma with tumor involving more than one lobe or in close proximity to the mainstem bronchus often requires pneumonectomy for surgical cure. Inflammation, bulky tumors, and dense adhesions limit the operative field of vision and may result in the abandonment of procedures with potential for complete extirpation. This case illustrates the utility of thoracoscopy in visualization of the hilum and other neurovascular structures in a patient with a proximal tumor and dense intrathoracic adhesions. Successful resection was made possible by use of combined open and thoracoscopic modalities.

Bowel obstruction in pregnancy.

Intestinal obstruction during pregnancy and in the puerperium is an uncommon complication, although cases are probably underreported. Fortunately, the mortality rate has improved over the decades. Overall, it was greater than 60% in 1900. By the 1930s, maternal mortality had dropped to 21% and fetal mortality decreased to 50%. Modern rates of maternal mortality have shown continued improvement, with Goldthorp reporting an incidence of 12% in 1966. Over the last 30 years the maternal mortality rate has decreased to approximately 6%, as noted in various series published in the English literature. Fetal mortality rates, however, have remained significantly high. They have remained constant at between 20% and 26%. Furthermore, only one third of patients with prenatal bowel obstruction complete term pregnancies after operative resolution of their obstruction. These findings emphasize the importance of remembering that two patients are at risk when intestinal obstruction complicates pregnancy. The delay from presentation to admission and from admission to definitive management continues to be a significant cause of morbidity and mortality. A high index of suspicion is mandated in this patient population, especially in those women presenting with a history of previous abdominal or pelvic surgery. The high incidence of necrotic bowel found in this subset of patients demonstrates the need for aggressive surgical intervention. Only through diligent and urgent intervention can the morbidity and mortality be decreased. The diagnosis and treatment of a pregnant patient suspected of having a bowel obstruction should be no different from those given to a nonpregnant one.

Acute aortic occlusion as a result of extrinsic compression from peritoneal encapsulation.

Acute aortic occlusion frequently occurs with catastrophic visceral, spinal, or lower extremity ischemia and is most often caused by embolic or thrombotic events in older individuals with known cardiovascular disorders. This case describes the rapid development of the clinical signs of acute aortic occlusion in a young and completely healthy individual. Aortic occlusion was produced by extrinsic compression of the juxtarenal aorta from a closed-loop small intestinal obstruction contained within a peritoneal encapsulation, an extremely rare intraabdominal developmental anomaly.

Influence of site of origin and mucin production on survival in ampullary carcinoma.

We studied a series of 26 cases of carcinoma of the ampulla of Vater. There were 24 adenocarcinomas and two neuroendocrine tumors. Histologically the carcinomas could be divided into tumors arising from periampullary duodenal mucosa and those arising within the ampulla. True ampullary tumors had a significantly better 5-year survival rate (p = 0.028) than periampullary tumors. The type of mucin produced was investigated histochemically. Patients with true ampullary tumors producing predominantly sialomucins had a better prognosis than those with tumors secreting sulphated mucins (p = 0.045), but the numbers were small. We hypothesize that the most favorable type of ampullary carcinoma arises from biliary-type epithelium within the ampulla.

Survival in 1001 patients with carcinoma of the pancreas.

Among 1001 patients with carcinoma of the pancreas, 23 of 912 patients with exocrine carcinomas, 10 of 46 with ampullary carcinomas, and 21 of 43 with malignant islet cell tumors survived 3 years. Of the survivors with exocrine cancers, there were nine of 97 patients who had curative operation, two had had palliative resections only, and one was an incidental microfocal carcinoma; in the remaining 11 patients a histologic origin in the pancreas was not established. Preoperatively suspected and histologically proven 3-year survivors included six patients with ductal adenocarcinomas, three patients with mucinous cystadenocarcinomas, one patient with acinic cell carcinoma, and one patient with microadenocarcinoma. Only two patients can be considered cured. Tumor size and lymph node status did not correlate with survival. Cystadenocarcinomas comprised 1% of cases but one third of 3-year survivors. Long-term survival in histologically confirmed pancreatic carcinoma is a rare event that cannot be predicted in the individual case.

The hematologic characteristics of sickle cell anemia bearing the Bantu haplotype: the relationship between G gamma and HbF level.

Previous work has demonstrated that the HbS gene has appeared and expanded three times in Africa in three separate geographic locations and that these three distinct mutational events can be identified by linked DNA polymorphic sites (haplotypes) surrounding the abnormal gene. We have reported that the Senegalese and Beninian haplotypes differ in G gamma expression, mean percentage of HbF, and percentage of dense cells. We now report on the third haplotype, the Bantu, and find that it has intermediate features, namely, the high mean percentage of HbF and low percentage of dense cells associated with the Senegalese haplotype, but with a low percentage of G gamma expression similar to the Beninian haplotype. The distribution of percent HbF is quite different from Senegal haplotype-bearing sickle cell anemia patients since it covers a much wider range. The low G gamma expression is also different from the Beninians since it contains a significant and unique cluster of individuals with lower than 38% G gamma. Interestingly, among the Bantu there is a strong correlation between HbF levels and G gamma expression, which is not seen with the other haplotypes. These findings open the possibility that among the Bantu haplotype-bearing individuals two chromosomal types exist that define different levels of G gamma and HbF expression. Further structural exploration of these two potential subhaplotypes is needed.

Varicose ulcer of the upper extremity.

Serious complications of local venous hypertension occur rarely in the upper extremity. These are most frequently the result of a dysfunctional arteriovenous fistula and may produce changes indistinguishable from those of chronic lower-extremity venous insufficiency. A combination of arterial and venous contrast imaging is essential for identifying major venous outflow obstruction and for planning appropriate surgical therapy.