Inflammation and infarction of adipose tissue: implications in bariatric surgery.

Fat necrosis occurs more frequently in patients who have obesity and diabetes mellitus and is linked to worsening of diabetes. Little evidence is available about surgical complications that are related to inflammation and necrosis of adipose tissue. We report two cases of young women with diabetes who underwent bariatric surgery and had complications resulting from extensive inflammation and necrosis of adipose tissue. The first patient was diagnosed with omental infarction, which is a type of fat necrosis that is rarely associated with obesity and bariatric surgery. The second patient had an intraoperative finding of mesenteric panniculitis, which resulted in an intra-operative change in the choice of bariatric surgery to do a sleeve gastrectomy instead of a gastric bypass. Surgeons who perform surgery on bariatric patients must be aware of complications related to excessive amount of adipose tissue.

Giant-cell tumour of the tendon sheath in the foot and ankle.

Giant-cell tumour of the tendon sheath (GCT-TS) is a benign solitary tumour which usually arises in the limbs. It occurs most often in the hand where local recurrence after excision has been reported in up to 45% of cases. It is less common in the foot where the biological behaviour and risk of local recurrence have not been defined. We have studied 17 cases of GCT-TS of the foot and ankle in which treatment was by excision. Fifteen presented as a solitary, painless, slow-growing soft-tissue swelling. One lesion was associated with sensory deficit of a digital nerve and one with pain on walking. Thirteen cases originated from the periarticular tendon-sheath complex of the small joints of the toes and four from the capsule or long tendons of the ankle. A correct preoperative diagnosis was made in only three cases. MRI proved to be the most useful preoperative investigation as GCT-TS has a characteristic appearance which allows planned local excision to be carried out. None of the patients with histologically confirmed GCT-TS required further surgery. There was no local recurrence in 15 patients who were available for follow-up at a mean of 85 months.

Coding errors: a comparative analysis of hospital and prospectively collected departmental data.

OBJECTIVES: To assess the accuracy of a hospital coding database at a busy tertiary referral urological unit. METHODS: Prospectively collected departmental coding data for all urological patients attending the Churchill Hospital, Oxford between 1 May 1999 and 30 April 2000 were compared with the coding data entered by hospital coding clerks on the Oxford Radcliffe NHS Trust database. RESULTS: There were significant discrepancies between the number of patients on the hospital and the departmental database (639 vs 1109). There were gross procedural coding errors in 74 cases. CONCLUSION: Hospital-coded data in this study were incomplete and inaccurate. This has important implications when considering the validity of hospital-trust databases when used as a source for medical research, clinical audit and as a representation of a consultants' clinical workload.

Posterior cranial fossa venous extradural haematoma: an uncommon form of intracranial injury.

Extradural haematomas are commonly associated with direct trauma to the temporal bones of the cranium resulting in damage to the middle meningeal artery or its branches. A case is presented of an occipital skull fracture with venous sinus bleeding that resulted in a posterior cranial fossa extradural haematoma. Bleeding in this area, if unrecognised, may lead rapidly to respiratory arrest secondary to brainstem compression. The presence of significant trauma to the occiput should alert the attending clinician to the possibility of this uncommon but potentially fatal condition.

Assessment of the role of GM-CSF in the cellular transformation and the development of erosive lesions around orthopaedic implants.

Granulocyte-macrophage colony stimulating factor (GM-CSF) is a hematopoietic growth factor with a regulatory effect on the transformation of immature macrophages into multinucleated giant cells (MNGC) that exhibit phenotypic and functional characteristics of osteoclasts (OC). The authors analyzed the bone implant interface membranes harvested from 15 patients with failed total joint replacements for the production and tissue distribution of GM-CSF and interleukin-1 (IL-1). Immunohistology and liquid culture were employed to assess the contribution of these factors in the recruitment of macrophages and the development of bone resorbing MNGC at these sites. This process has been implicated in osteoclastic bone resorption, bone, and bone marrow necrosis adjacent to orthopaedic implants. Histologic assessment of the interface indicated the presence of granuloma and a variable number of MNGC in 11 cases. Four cases showed sites of intramembranous formation of osteoid and mineralized bone that was accompanied by normal bone marrow in two cases. Granulocyte-macrophage colony stimulating factor was expressed by a distinct subset of phagocytic macrophages in the lining layer on the implant side. interleukin-1-positive cells outnumbered those stained for GM-CSF. Stimulation of cultured cells with prosthetic metal particulate material showed marked similarity in the expression of these cytokines to cultures treated with lipopolysaccharide (LPS) or phytohemagglutinin (PHA). The induction of GM-CSF production in the lining layer where small MNGC develop indicates that these cells differentiate locally following the phagocytosis of particulate wear debris. In conclusion, GM-CSF promotes the proliferation and early stages of fusion and development of MNGC responsible for osteolysis at these sites. These results also highlight the capacity of the interface to display both osteogenic and inflammatory characteristics. Collectively, the findings suggest that the local bone marrow could participate in the development of the interface as a source of myeloid cells in addition to the capacity of marrow stroma to generate various osteogenic cells essential for the ingrowth of bone into prosthetic implants.