Surviving Boerhaave's syndrome without thoracotomy.

A case of Boerhaave's syndrome managed without thoracotomy is described. The diagnosis was not confirmed for 24 h when a barium swallow revealed free rupture of the esophagus into the left pleural cavity. Although survival has been reported with nonoperative management of contained esophageal perforations, to our knowledge, this is the first report of surviving Boerhaave's syndrome with free pleural rupture, without thoracotomy.

Upper extremity replantation at a regional medical center: a six-year review.

Trauma to the upper extremity can be a cause of significant morbidity and disability to otherwise productive people. Traumatic amputation can be particularly devastating, but many of these extremities can be saved by replanatation of the amputated parts. We reviewed the upper extremity replantations performed at the Medical Center of Central Georgia in the 6-year period from September 1987 to August 1993. A total of 48 replantations in 39 patients (33 male, six female) were studied: 36 fingers, seven thumbs, two transmetacarpals, one wrist, one forearm, and one brachium. Average patient age was 32.7 years, with a range of 4 to 69 years. All seven thumbs, two transmetacarpals, and three proximal replants survived. Viability of replanted fingers was 56 per cent; however, sharp injuries fared better than crush injuries (62% vs 50%). The success rate improved with experience of the surgeon (85% after 1990). Leeches were used effectively for venous congestion in nine of 13 cases (70%). Results were comparable with those of large academic medical institutions. Replantation of traumatic amputations can be performed with reasonable success at a regional medical center if a qualified surgeon and appropriate ancillary care are available. Results improve with experience of the surgeon and careful patient selection. Successful replantation significantly reduces the morbidity of upper extremity amputations and will continue to be important in the management of the trauma patient.

Management of vasospastic disorders of the hand.

Vasospastic disorders of the upper extremity are common and often difficult to treat. Using the proposed classification system (Table 2) allows management based upon pathologic condition, physiologic staging, and response to treatment. Identifying patients in this way also helps in determining which treatments are most appropriate. The basic approach to management includes environmental and behavioral modifications including cessation of tobacco use, protection of hands, and avoidance of situations that trigger the vasospastic response. Pharmacologic therapy may provide good results in a majority of patients. Surgical intervention is reserved for patients with vaso-occlusion, ischemia, and refractory symptoms in spite of attempts at medical management. Surgical options include vascular reconstruction, peripheral sympathectomy, or a combination of techniques. The goal of medical and surgical management is to increase total or nutritional blood flow in the digits.

Multifocal mesenchymal hamartoma of the chest wall in infancy.

The authors report on an infant who had multifocal mesenchymal hamartoma of the right posterior chest wall. The tumors were found incidentally, on a chest radiograph, during routine evaluation for upper respiratory tract infection. Resection of both lesions with chest wall reconstruction was performed, with a good result. Only 46 cases of this unusual tumor have been reported previously, and only two of them were multifocal.

Benign cartilaginous lesions of the upper extremity.

Common and rare benign cartilaginous neoplasms and diseases of multiple cartilaginous lesions are discussed. Particular attention is paid to patient demographics, physical and radiographic findings, pathology, and treatment.

Mesenteric lymphangioma causing bowel obstruction in a child.

Mesenteric lymphangioma was manifested as a bowel obstruction in a child with cerebral palsy. Diagnosis was not confirmed until the time of laparotomy. Mesenteric lymphangioma is rare but should be considered in a child with bowel obstruction and no other known abdominal disease.

Osteogenesis in a rat model: use of bone marrow cells and biodegradable gelatin matrix carrier.

We investigated the use of a biodegradable porcine gelatin matrix (Gelfoam) as a carrier for marrow cells that induce osteogenesis at ectopic sites in rats. Bone marrow cells obtained from the long bones of 6-week-old Sprague-Dawley rats were dissociated enzymatically and the cells reconstituted in rat serum. Twenty million cells in 0.1 mL of serum were then adsorbed into 1-cm3 pieces of gelatin matrix substrate and implanted into ectopic sites in live Sprague-Dawley rats. The implants were retrieved and analyzed histologically for bone and cartilage formation 3, 4, 6, and 8 weeks after implantation. Woven bone was seen as early as 3 weeks and persisted through 8 weeks. No cartilage was observed. Osteoclasts first appeared at 3 weeks, peaking in number at 4 weeks. By 6 and 8 weeks, only small islets of substrate remained, surrounded by dense, woven bone. Control implants, consisting only of serum adsorbed into the carrier, showed no bone formation. We conclude that biodegradable gelatin matrix can serve as a carrier for the osteogenic cells of bone marrow in rats in ectopic sites. Such a system may be further developed to augment bone healing.

Ulnar artery thrombosis: a 6-year experience.

Thrombosis of the ulnar artery can be a cause of significant morbidity. Most often a consequence of blunt trauma to the hypothenar eminence of the hand, it may be attributable to one traumatic event or to repetitive insults. Surgery is often required. We reviewed the presentation and diagnosis of ulnar artery thrombosis and evaluated the effectiveness of treatment by ulnar artery excision with interposition vein grafting. Retrospective chart analysis from 1989 to 1995 at the Medical Center of Central Georgia showed that nine patients (eight male, one female) were treated for ulnar artery thrombosis. Three had associated ulnar artery aneurysms. Eight of the nine were treated with artery excision and interposition vein grafting. Four also received stellate ganglion blocks before surgery. One was treated with stellate ganglion blocks alone. All patients had symptomatic relief and resolution of physical findings. We conclude that ulnar artery thrombosis can be managed with ulnar artery excision and interposition vein grafting when conservative measures fail.