Credentialing for transvaginal mesh placement—a case for “added qualification” in competency

Introduction and hypothesis

A process of added qualification of transvaginal mesh (TVM) placement is desirable.

Methods

Through a physician-led partnership of specialty societies, centers of excellence, and industry, a core curriculum encompassing mesh/graft biology, technical skills, and safety can be coupled with current educational endeavors instructing surgeons in the use of TVM. A posttest process can verify a knowledge-based competency in mesh/graft safety. An auditing process after implementation would be optimal.

Results

We recommend implementation of a five-step process in order to accomplish these goals.

Conclusions

It is hoped through these efforts, the ultimate goal of patient safety may be reached.

     

Adenocarcinoma arising from an anal gland—Report of a case

INTRODUCTIONAdenocarcinoma arising from an anal gland is extremely rare. Most anal canal cancers are squamous cell carcinoma, and adenocarcinoma is infrequently diagnosed. Diagnostic criteria and the standard treatment for adenocarcinoma of the anal canal have not been clearly defined, in part because of the rarity of this lesion.PRESENTATION OF CASEAn 84-year-old man who presented with a piece of tissue prolapsing from the anus. An incisional biopsy showed adenocarcinoma, and an abdomino-perineal resection was then performed. Cytokeratin 7 (CK7), cytokeratin 19 (CK19) stained positive in the specimen, suggesting that the tumor developed from an anal gland. The patient was discharged after surgery without any complications.DISCUSSIONExact diagnostic criteria for adenocarcinoma of the anal canal have not been previously described. In the present case, CK7 and CK19 were stained, and the tumor showed positivity for both of these markers, which is compatible with the staining patterns of anal gland origin cancer. Radical resection is recommended rather than local resection, because of the tumor's high recurrence rate. Some authors recommend combined modality treatment with preoperative or postoperative chemoradiotherapy because of the high rate of distant recurrence.CONCLUSIONThe preoperative diagnosis of adenocarcinoma arising from an anal gland is not easily established. However, it may be possible to suspect an anal glandular adenocarcinoma based on a meticulous physical examination, appropriate diagnostic studies and pathological findings on biopsy.     

Combined anterior trans-obturator mesh and sacrospinous ligament fixation in women with severe prolapse—a case series of 30 months follow-up

Introduction and hypothesis  

To study the efficacy and safety of performing anterior mesh (Perigee) with vaginal reconstructive surgeries (sacrospinous ligament fixation) for treatment of advanced prolapse.     

An impending rupture of a celiac artery aneurysm in a patient with Behçet’s disease — Extra-anatomic aorto-common hepatic artery bypass: Report of a case

A celiac artery aneurysm associated with Behçet’s disease is extremely rare. We herein present the case of successful surgical treatment for an impending rupture of a large celiac artery aneurysm with a wide proximal neck in a patient associated with Behçet’s disease. To our knowledge, this is the first report of a procedure involving extra-anatomic aorto-common hepatic artery (CHA) bypass through the retroperitoneal space implanting a 6-mm expanded polytetrafluoroethylene graft. An 18-month postoperative magnetic resonance angiography scan showed a good patency of the aorto-CHA graft without an anastomotic pseudoaneurysm in a closure of aorta and anastomoses.     

Intestinal obstruction caused by colonic metastasis from intrahepatic cholangiocarcinoma 6?years after removal of the primary tumor: report of a case

We report a case of intestinal obstruction caused by metastasis that manifested 6 years after surgery for intrahepatic cholangiocarcinoma (ICC). The patient, a 57-year-old man, had undergone resection of the hepatic left lobe, Spiegel lobe, and extrahepatic bile duct, following which histopathological examination had confirmed the diagnosis of ICC and that the resection margins were free from disease. There had been no signs of recurrence until an increase in the CA19-9 level was detected 6 years later. Colonoscopy revealed an ulcer-like lesion and stenosis at the level of the hepatic flexure. The patient was subsequently admitted to our hospital with abdominal pain and underwent right hemicolectomy with partial resection of hepatic segment V. Based on the immunohistological finding that the expression pattern of cytokeratins and mucins was consistent with ICC origin rather than colon cancer origin, we diagnosed colon metastasis from ICC.     

“Hammock” reconstruction of full-thickness excised lower lip: a case report

A number of techniques have been described to reconstruct lower lip defects. A microsurgical total lower lip reconstruction was performed in a 48-year-old female patient affected by a squamous cell carcinoma of the lower lip. The patient underwent a wide lower lip resection and an immediate aesthetic and functional lower lip reconstruction. The lower lip was reconstructed with a composite radial forearm palmaris longus flap. The subcutaneous layer of the residual upper lip was undermined and palmaris longus tendon was transfixed to the paranasal portion of the orbicularis oris muscle, giving to the flap a good aesthetic “hammock” effect and achieving a nearly impairment free function. The use of a forearm free flap for lower lip reconstruction has previously been described, with poor functional results. We have described a different technique to inset and fix the flap using palmaris longus tendon: the suspension vector of the flap and the preservation of the residual orbicularis oris fibers seem to be of great importance to achieve a satisfactory functional recovery. We propose that the radial forearm free flap comprising palmaris longus tendon, inset and fixed with the described technique, may be a good alternative among the surgical options for full-thickness lower lip defects in order to achieve a satisfactory aesthetic and functional reconstruction.     

Acute paralysis following “a bad potato”: A case of botulism

PURPOSE: Intensivists often encounter patients with respiratory failure as a result of neuromuscular disease, however, acute neuro-muscular syndromes are less common. We present a case of food borne Clostridium botulism and discuss the diagnostic and therapeutic considerations. CLINICAL FINDINGS: A 35-yr-old healthy male presented with abdominal pain and blurred vision 12 hr after ingesting a "bad" potato. During the next 17 hr, the patient demonstrated a gradual descending paralysis which ultimately resulted in no cranial nerve function and 0/5 strength in all extremities. Sensation was intact. The patient required intubation and mechanical ventilation. His blood count, biochemical profile, computerized tomography and magnetic resonance imaging of the head were normal. A lumbar puncture revealed no abnormalities. Due to the rapid deterioration and presentation of 'descending' paralysis, botulism was suspected. The patient was treated empirically with botulinum anti-toxin. Samples of blood, stool and gastric contents were cultured for the presence of Clostridium botulinum and its toxin and these tests were positive for botulinum toxin A 12 days later. The patient's neuromuscular function gradually improved over a prolonged period of time. Six and one-half months after his initial presentation, the patient was discharged home after completing an aggressive rehabilitation program. CONCLUSIONS: Botulism is a rare syndrome and presents as an acute, afebrile, descending paralysis beginning with the cranial nerves. If suspected, botulinum anti-toxin should be considered, particularly within the first 24 hr of onset of symptoms. Confirmation of the presence of botulinum requires days therefore the diagnosis and management rely on history and physical examination.     

Repair of parietal hernia by overlapping onlay reinforcement or “gap-bridging” replacement polypropylene mesh: Preliminary results

Summary In an open prospective observational study, all patients presenting with abdominal wall hernias since January 1996 underwent polypropylene mesh repair. The patient population comprised 15 male and 22 female patients (aged 24 to 86 years, median 60.5 years) with 22 primary and 4 recurrent incisional hernias and 8 primary and 3 recurrent umbilical hernias, respectively. Premusculo-fascial mesh onlay followed direct apposition of the myoaponeurotic hernial rim in 24 patients and was fixed tension free bridging the defect with hernial sac interposition in 13 patients. In 2 patients subcutaneous wound sepsis, and in one skin- and subcutaneous slough, necessitated debridement and open wound treatment with subsequent uneventful secondary wound healing. 31 patients followed up for more than 6 months were assessed clinically and sonographically in October 1998 [8 patients after 8 months (range 6–9) and 23 patients after 19 months (range 12–33)]. The main complaint was neuralgiform pain at the mesh periphery in 8 patients. No recurrence was observed.     

Time course of magnetic resonance images in an adolescent patient with Kienböck's disease treated by temporary scaphotrapezoidal joint fixation: a case report

Kienb?ck's disease in a 15-year-old girl was treated successfully by temporary scaphotrapezoidal joint fixation using longitudinal K-wires. Repeated magnetic resonance imaging begun 3 months after surgery showed progressive increases in signal intensity on T1-weighted sequences of the lunate and was almost normal 6 months after surgery. The K-wires used for the temporary joint fixation were removed 6 months after surgery. The signal intensity of the lunate on magnetic resonance images remained normal 2 years after surgery. At that time plain x-ray showed no sign of lunate sclerosis and there was no cystic shadow or sign of advanced collapse. At 2 years after surgery the patient does not complain of wrist pain, can lead a normal daily life, and plays sports without difficulty. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic, Level IV.     

Clinical presentation and surgical management of chronic Achilles tendon disorders — A retrospective observation on a set of consecutive patients being operated by the same orthopedic surgeon

Background

Non-invasive treatment is not always successful in patients with Achilles tendon disorders, and surgical treatment is instituted as the next step. There is sparse knowledge about the diagnoses, pain levels before surgery, surgically confirmed pathologies and postoperative complications in large patient groups.