Adductor tenotomy in the management of groin pain in athletes.

This study evaluates the efficacy of adductor longus tenotomy in athletes with chronic tendinopathy refractory to conservative management. In a retrospective case series we report our experience with 109 male athletes who underwent unilateral adductor tenotomy during the period 2000-2005, all of whom responded to a detailed questionnaire. The criterion for tenotomy was chronic adductor origin pain which prevented training or playing (Level 4), limited training or playing (Level 3), or affected performance (Level 2)and which had failed to respond to conservative management including rest, rehabilitation and/or local steroid injection. Level 1 performance is classified as optimal performance with no pain. 99 of the 109 patients (91%) reported improvement. Best results were achieved in patients with maximum discomfort preoperatively (Level 4) with 32 of 38 (84%) patients returning to Level 1 performance. In conclusion, adductor tenotomy in athletes with severely incapacitating pain (Level 3/4) which fails to respond to conservative management offers the best opportunity of returning to competitive sport.

Pyogenic liver abscesses: diminished role for operative treatment.

BACKGROUND: Pyogenic liver abscess is a rare but potentially serious condition. It has traditionally been treated by open drainage; however interventional radiology is now becoming the standard of care. METHODS: All cases of liver abscesses admitted to a tertiary hospital over thirteen years (1995-2007) were retrospectively reviewed. Patient demographics, length of hospital stay, predisposing factors as well as cultured organisms were evaluated. Imaging techniques as well as patient management were also recorded. RESULTS: There were 66 hospital admissions of 61 patients with liver abscesses, 0.032% (66/205,079) of the total hospital admissions for the time period. Mean age was 61 years (range 26-90 years), male (36/61) 59%: female (25/61) 41%. Average hospital stay was 23 days (Range 1-84 days) and there were no deaths. 39 of 61 patients (64%) had a single abscess (90% right lobe). 20 of 61 patients (33%) had undergone a recent intra-abdominal procedure. Escherichia coli (10/61) and Enterococci (8/61) were the most frequent organisms isolated. Radiological intervention was performed in 50 of 61 (82%, 51% ultrasound and 31% CT guided). 9 of 61 (15%) were managed conservatively, while one case was managed surgically and another with endoscopic sphincterotomy and stent placement. CONCLUSIONS: Pyogenic liver abscesses are uncommon, and while associated with significant morbidity and prolonged hospital stay, mortality is now rare. Radiological intervention and anti-microbial therapy are the mainstay of treatment, and operative intervention is now rarely required.

Giant solitary non-parasitic cyst of the liver.

BACKGROUND: Cystic diseases of the liver and intrahepatic biliary tree are uncommon. The majority of cases are detected only when patients become symptomatic, or as an incidental finding on radiological imaging. METHODS: We discuss the case of a 25-yr-old female with a centrally located giant liver cyst causing obstructive jaundice, and briefly discuss the management options in the treatment of this uncommon problem. RESULTS AND CONCLUSIONS: Intervention is recommended in patients with symptomatic simple cysts of the liver. Surgical cystectomy is the treatment of choice for large deep seated cysts.

Gloveport hernioscopy.

It can be difficult to exclude occult, necrotic bowel in incarcerated herniae that reduce prior to emergent surgical exploration without resorting to further abdominal wall incisions. This case illustrates the Gloveport hernioscopy technique to identify necrotic small intestine that had spontaneously reduced in a man with a strangulated umbilical hernia. This minimally invasive technique allowed a multichannel examination of the peritoneal cavity without any further insult to the abdominal wall.

Isolation of lymphocytes from normal adult human liver suitable for phenotypic and functional characterization.

Murine and human studies have demonstrated that the normal liver contains significant numbers of resident lymphocytes that have functions distinct from those found in blood and other organs. To characterize these cells requires the isolation of viable lymphocytes that can be analysed by flow cytometry and in functional assays. The techniques classically used to isolate single cell suspensions of hepatic lymphocytes for phenotypic and functional studies involve mechanical and/or enzymatic dissociation of liver tissue. The aim of this study was to determine the effect of these procedures on surface molecule expression and lymphocyte function and to optimise an isolation technique that minimises these effects. Mechanical homogenisation of liver tissue alone resulted in low viable lymphocyte yields but these were improved by the combined use of mechanical and enzymatic techniques. A mean yield of 2.3 x 10(6) lymphocytes with a mean viability was 88.8% was obtained from 200 mg wedge biopsy samples of normal adult human liver using a combination of gentle mechanical dissociation followed by digestion with collagenase type IV and DNase I. These cells were suitable for phenotypic characterisation by flow cytometry. They also retained their ability to grow in vitro, to respond to cytokines and activation stimuli, to mediate cytotoxic killing of target cells, and to produce inflammatory and regulatory cytokines.

Delayed correction of portal hypertension after portal vein conduit arterialization in liver transplantation.

A 55-year-old woman underwent orthotopic liver transplantation for autoimmune chronic active hepatitis. Extensive portal and superior mesenteric venous thrombosis precluded standard portal venous reconstruction and necessitated use of a venous conduit from the recipient splenic vein of the donor liver. Flow through this conduit was poor, however, and to prevent subsequent portal venous thrombosis and graft loss, the conduit was arterialized by end-to-side anastomosis with the recipient hepatic artery. This ensured graft survival but resulted in prehepatic portal hypertension, which required ligation of the arterioportal fistula for 4 months. The patient had a satisfactory outcome.

Relationship of nuclear DNA content to clinical and pathologic findings in patients with primary hepatic malignancy.

BACKGROUND: Nuclear DNA content of a variety of tumors has proven valuable as a prognostic indicator. The purpose of this study was to analyze patterns of DNA content in primary hepatocellular carcinoma and to correlate ploidy status with patient survival. METHODS: The relationship of nuclear DNA content to host and tumor characteristics was analyzed in 46 patients with primary hepatic malignancy who had undergone resection with curative intent between 1975 and 1985. RESULTS: Flow cytometric measurement of tumor DNA content revealed a diploid pattern in 33%, tetraploid or polyploid in 30%, and aneuploid in 37% of cases. There was no significant correlation between tumor DNA content and demographic or pathologic findings in the patients studied. Moreover, there was no difference in survival between patients with diploid versus nondiploid tumors. CONCLUSIONS: These findings suggest that tumor DNA content has no prognostic value in patients with primary hepatic malignancy.

Cytoreductive hepatic surgery for neuroendocrine tumors.

We retrospectively reviewed 37 patients who underwent hepatic resection between 1970 and 1989 to evaluate the role of cytoreductive hepatic surgery in patients with metastatic neuroendocrine tumors (carcinoid, 24; islet cell, 13). Seventeen resections were curative (no gross residual tumor); nine patients had symptomatic endocrinopathies and seven patients had symptoms caused by the primary tumor. Eight of nine patients with symptomatic endorcrinopathies obtained complete relief of symptoms; five are alive with no evidence of disease at 2 to 82 months (mean, 26 months). Six of seven patients with symptoms caused by the primary tumor obtained complete relief; five are alive with no evidence of disease at 5 to 28 months (mean, 14 months). One symptom-free patient underwent curative hepatic resection 5 years after abdominoperineal resection for a rectal carcinoid. Twenty resections were palliative (gross residual tumor); 16 patients had symptomatic endocrinopathies and 4 patients had symptoms caused by the primary tumor. Eight of 16 patients with symptomatic endocrinopathies obtained complete relief; five are alive at 2 to 30 months (mean, 11 months), with a mean duration of complete relief of 6 months (3 to 12 months). All four patients who underwent resection for symptoms caused by the primary tumor obtained complete relief; two are alive and symptom free at 10 and 101 months. Our experience suggests that curative surgery should be considered in all patients with completely resectable metastatic disease and that palliative surgery, despite the short duration of complete relief, should be considered in selected patients because it delays and may reduce the subsequent need for medical therapy.

Microvasculature of the pancreas, liver, and kidney in cerulein-induced pancreatitis.

Edematous pancreatitis was induced in 12 male Sprague-Dawley rats using supramaximal doses of the cholecystokinin analogue cerulein (5 micrograms/kg per hour). The microvasculature of the pancreas, liver, and kidney was examined using scanning electron microscopy of microvascular corrosion casts in 12 test animals and four controls at intervals of 30 minutes, 1 hour, 2 hours, and 4 hours. Distortion of the pancreatic and hepatic microvasculature was seen as early as 30 minutes and progressed during the study period. The renal vasculature remained normal throughout. Light microscopic analysis revealed no morphologic abnormalities in the walls of the pancreatic, hepatic, or renal microvasculature. This study demonstrates that cerulein-induced pancreatitis is associated with marked distortion of the pancreatic and hepatic microvasculature; the abnormalities start early in the disease and progress during the study period.

Radical resection for carcinoma of the ampulla of Vater.

One hundred four consecutive patients who underwent radical resection for ampullary cancer between 1965 and 1989 were retrospectively reviewed. Frequent clinical findings included jaundice (67%), significant (greater than 10%) weight loss (42%), and anemia (27%). Eighty-seven patients (84%) underwent a subtotal pancreatectomy, and 17 patients (16%) underwent a total pancreatectomy. The postoperative mortality was 5.7% (six patients), and reoperation for postoperative complications was required in six patients. The 5- and 10-year survival rates were 34% and 25%, respectively. Eight patients died of tumor recurrence more than 5 years after resection. Patient survival was significantly impaired by microscopic lymphatic invasion, regional nodal metastasis, tumor grade, and the epithelium of origin. In a multivariate analysis, only microscopic lymphatic invasion significantly reduced patient survival. Radical resection for ampullary cancer can be performed with a low morbidity and mortality and should remain the procedure of choice for ampullary carcinoma.

Gilmore's groin repair in athletes.

Incapacitating groin pain is a frequent problem among athletes and its etiology may be multifactorial. A specific clinical syndrome relating to injury to the lower abdominal wall has been described and successfully treated by O. J. Gilmore. This paper presents our results of 100 consecutive groin repairs in 85 young athletes using a diagnostic and therapeutic strategy similar to Gilmore's. Ninety-six percent of our patients returned to competitive sport within 15 weeks; we suggest that this is an appropriate therapeutic intervention for athletes who develop chronic incapacitating groin pain.

The role of CT in the management of carcinoma of the oesophagus and cardia.

The role of computed tomography in assessing tumour spread and tumour resectability was evaluated in 50 patients with oesophageal carcinoma (17 middle third, 33 lower third). CT accurately identified all patients with tumour confined to the oesophagus (Stage I or II) but was limited in its ability to assess direct organ invasion (Stage III) with an overall accuracy for evaluating middle third lesions of 82% (aorta 70%, tracheobronchial tree 94%, other mediastinal structures 82%) compared to an overall accuracy for lower third lesions of 97% (aorta 97%, pancreas 100%, diaphragm 97%). Tumours deemed resectable on CT were always resectable at operation but two of seven middle third tumours and one of twelve lower third lesions deemed unresectable underwent curative resection. Preoperative CT evaluation of oesophageal tumours is useful in that it may reliably identify tumour lesions confined to the oesophagus and reliably identify distant metastases. Because of its limitations however in the assessment of organ invasion, particularly by middle third lesions, this study suggests that patients with oesophageal tumours with no evidence of distant metastases, who are otherwise fit to undergo tumour resection, should not be denied surgery on the sole basis of positive organ invasion on CT particularly if that organ is the aorta.