Spontaneous extrusion of sacral nerve implant secondary to massive weight loss

Sacral neuromodulation (Interstim, Medtronic, Minneapolis, Minnesota) is a recognized treatment for refractory urgency, frequency, and urge incontinence. Revision rates range from 10–33% mainly for pain over the implantable pulse generator site (IPG) or lead migration [Hassouna et al. J Urol 163:1849-1854, 2000; Schmidt et al. J Urol 162:352–357, 1999; Spinelli et al. J Urol 166:541–545, 2001; Swinn et al. Eur Urol 38:439–443, 2000; Weil et al. Eur Urol 37:161–171, 2000; Evaraert et al. Int Urogynecol J Pelvic Floor Dysfunct 11:231–236, 2000]. We report a case of spontaneous extrusion of the IPG through the subcutaneous fat and skin secondary to marked weight loss after gastric bypass surgery. Continued weight loss resulted in multiple surgical interventions and eventual removal of the device.     

Rib Haemangioma: A Rare Differential for Rib Tumours

Haemangiomas account for approximately 1% of all bone tumours and commonly involve the skull and the vertebrae Dorfman et al. (Human Pathol 2:349–376, 1971). Rare costal originated haemangiomas have been reported as a case report in literature Clements et al. (Am Surgeon 64:1027–1029, 1998), Filosso et al. (J Cardiovasc Surg 36:97–98, 1995). We report a case of 26 years old female presenting with haemangioma of the eighth rib (right). And conclude that haemangiomas should be included in the differential diagnoses of an osteolytic and expansile lesion of the ribs on radiology, especially in asymptomatic or mildly symptomatic patients.     

Sudden death after open gastric bypass surgery

Purpose  Gastric bypass surgery has become a relatively low-risk bariatric surgical intervention in a high-risk patient population (Nguyen et al., Arch Surg, 141:445–449, 2006; Buchwald et al. JAMA, 13:1724–1737, 2004). Surgical interventions in patients suffering from morbid obesity are typically associated with excess morbidity (Parikh et al., Am Surg, 73:959–962, 2007). Though overall mortality after bariatric surgery is <1% is low (Mason et al., Obes Surg, 17:9–14, 2007), some surgical complications such as anastomotic leaks, staple line disruption and bowel obstruction may still impact on postoperative outcome (Parikh et al., Am Surg, 73:959–962, 2007; Mason et al., Obes Surg, 17:9–14, 2007). Early symptoms are often missed, as clinical presentation may be discreet, inexistent or falsely attributed to obesity. Methods  This case report refers to a patient in whom discomfort and agitation associated with a rise in temperature heralded a fulminant septic shock syndrome precipitating his death. Literature on early complications and management after gastric bypass is reviewed. Conclusion  A high level of suspicion should be present in the case of an unexpected postoperative deterioration of the patient’s general condition. Time to treat may be very short (Mason et al., Obes Surg, 17:9–14, 2007). Computed tomography is mandatory to rule out pulmonary embolism and bypass obstruction.     

Laparoscopic Sleeve Gastrectomy is a Safe and Effective Bariatric Procedure for the Lower BMI (35.0–43.0 kg/m<Superscript>2</Superscript>) Population

Background  

The laparoscopic vertical sleeve gastrectomy (LSG) is derived from the biliopancreatic diversion with duodenal switch operation (Marceau et al., Obes Surg 3:29–35, 1993; Hess and Hess, Obes Surg 8:267–82, 1998; Chu et al., Surg Endosc 16:S069, 2002). Later, LSG was advocated as the first step of a two-stage procedure for super-obese patients (Regan et al., Obes Surg 13:861–4, 2003; Cottam et al., Surg Endosc 20:859–63, 2006). However, recent support is mounting that continues to establish LSG as the definitive procedure for surgical treatment of morbid obesity. We will report our experience with the LSG as a primary bariatric procedure and evaluate if this operation is suitable as a stand-alone procedure.     

Proximal carpal row dislocation: a case report

Carpal dislocations commonly occur as the result of high-energy axial loading of the forearm with the wrist extended. There exists several variants of carpal dislocations with the most commonly observed being those about the lunate. Perilunate dislocations and fracture dislocations were first characterized by Mayfield in 1980 and represent a spectrum of traumatic carpal dislocation beginning radial and progressing to the ulnar side of the wrist (Mayfield et al. J Hand Surg [Am] 5:226–241, 1980). The path of energy takes a predictable pattern around the lunate from the scapho-lunate ligament, into the mid-carpal joint and then to the luno-triquetral joint. The final stage is volar dislocation of the lunate into the carpal canal. These complex fracture dislocations are unstable and require operative fixation through open reduction and with internal fixation (Herzberg et al. J Hand Surg [Am] 18:768–779, 1993; Adkison and Chapman Clin Orthop Rel Res 164:199–207, 1982). Other types of carpal dislocations have been described; however, these are much less frequently encountered (Green and O’Brien Clin Orthop Rel Res 149:55–72, 1980; Irwin et al. J Hand Surg [Br] 20B:746–749, 1995; Rosado J Bone Joint Surg 48B:504–506, 1966). These also include mid-carpal instability and longitudinal (axial) instability and have been described extensively in the literature (Norbeck et al. J Hand Surg 12A:509–514, 1987; Primiano and Reef J Bone Joint Surg 56A:328–332, 1974; Garcia-Elias et al. J Hand Surg 14A:446–457, 1989; Taleisnik Hand Clinics 3:51–68, 1987). Carpal instabilities can be characterized as dissociative which disrupt joints within a carpal row, or as non-dissociative which have dislocations or subluxations between carpal rows (Dobyns and Cooney 1998). We report a case of complex carpal injury non-dissociative involving dislocation of the entire proximal carpal row volarly. To our knowledge such a variation of complex carpal dislocation has not been reported. This injury represents yet another possible variant encountered when treating high-energy injuries to the wrist.     

A rare radiological appearance of lumbar tuberculous vertebral osteomyelitis

Spinal tuberculosis (TB), or Pott disease, has classically been recognized as a source of spinal deformities in unindustrialized countries. However, in industrialized countries with more access to sensitive imaging studies, Pott disease may be identified earlier as vertebral osteomyelitis with local complications, such as psoas abscess. In industrialized countries, persons at risk for Pott disease include the immunosuppressed, African Americans and those with a history of prior exposure to TB (Maron et al. Spine 31(16):E561–E564, 2006). This report describes an unusual case with a very interesting radiological appearance of spinal TB. A 30-year-old man presented with dull, progressive back pain. Radiological control showed complete destruction of the L4 vertebral body and partial destruction of the L3, as well as extensive bilateral paraspinal soft tissue infection. The patient underwent open biopsy, complete abscess drainage, lumbar spine stabilization and antituberculous chemotherapy.     

Concurrent Chiari decompression and spinal cord untethering in children: feasibility in a small case series

Background and purpose  

We describe the rationale and safety of concurrent decompression of Chiari type 1 malformation (CM1) and untethering of the spinal cord. Spinal cord traction is considered one of the pathogenic mechanisms involved in the development of CM, and 14% of patients with CM1 have tethered cord syndrome (Milhorat et al., Surg Neurol 7:20–35, 2009; Roth, Neuroradiology 21:133–138, 1981; Royo-Salvador, Rev Neurol 24:937–959, 1996; Royo-Salvador et al., Acta Neurochir 147:515–523, 2005). Therefore, intraspinal anomalies that require intervention are commonly treated before surgical decompression of Chiari malformation (Cheng et al., Neurologist 8:357–362, 2002; Menezes, Pediatr Neurosurg 23:260–269, 1995; Milhorat et al., Surg Neurol 7:20–35, 2009; Royo-Salvador et al., Acta Neurochir 147:515–523, 2005; Schijman and Steinbok, Childs Nerv Syst 20:341–348, 2004; Yamada et al., Neurol Res 26:719–721, 2004). However, in the interval between the spinal cord untethering and the decompression surgery, patients may continue to suffer from the untreated symptoms of CM. In a series of four patients with concurrent severe and progressive symptoms referable to both conditions, we performed both surgeries simultaneously.     

Access-Port Fixation on the Left Pectoral Fascia in Laparoscopic Adjustable Gastric Banding

Access-port (AP) complications after laparoscopic adjustable gastric banding (LAGB) are often seen but seldom reported in literature. AP complications requiring additional surgery is reported in 3.6% to 24% of LAGB patients (Susmallian et al. Obes. Surg, 4:128–131, 2003; Peterli et al. Obes. Surg., 12(6):851–856, 2002; Busetto et al. Obes. Surg., 12:83–92, 2002; Mittermair et al. Obes. Surg., 19:446–450, 2009; Holeczy et al. Obes. Surg., 9:453–455, 1999; Bueter et al. Arch. Surg., 393:199–205, 2008; Launay-Savary et al. Obes Surg, 18:1406–1410, 2008; Balsiger et al. J. Gastrointest. Surg., 11:1470–1477, 2007; Szold and Abu-Abeid Surg. Endosc., 16:230–233, 2002). We evaluated the effect of fixing the AP on the pectoral fascia using the Velocity™ Injection Port on complication and re-operation rate. From January 2005 till October 2007, 619 LAGB procedures were performed using the SAGB QuickClose™. All procedures were performed by three dedicated surgeons using the pars flaccida technique. APs were placed on the fascia of the pectoral muscle using an infra-mammary incision. The AP device was fixed on the fascia using the Velocity™ Injection Port and Applier. Data was obtained retrospectively and records of 619 consecutive patients were reviewed for access-port complications. Sixty-eight AP complications were observed. Complications could be divided in four categories. Discomfort was reported in 30 patients, seven needing additional surgery. Infection contributed to 11 patients needing surgical removal of the device. Fourteen Patients with superficial infection were treated conservatively. Nine patients had inaccessible APs. Ultrasound-guided access was required in three patients. The remainder needed surgical relocation of the AP. Leakage of the tube was observed in four patients all of which needed revisional surgery. Our experience shows that fixation of the AP on the left pectoral fascia using the Velocity™ leads to a readily accessible AP with good anaesthetic and aesthetic results. In our series, 68 (11%) complications were recorded, of which 28 (4.5%) needed additional surgery.     

Alendronate-related femoral diaphysis fracture—what should be done to predict and prevent subsequent fracture of the contralateral side?

Introduction  

Atypical fractures of the femoral diaphysis have recently been associated with alendronate therapy (Neviaser et al. J Orthop Trauma 22(5):346–350, 2008; Kwek et al. Injury 39:224–231, 2008; Lenart et al. N Engl J Med 358:1304–1306, 2008).     

Laparoscopic TME in rectal cancer – electronic supplementary: op-video

Background  

Laparoscopic total mesorectal excision (TME) for rectal cancer has been proved in various studies. The minimal invasive procedure is feasible and safe which was demonstrated in many studies. However, the results of prospective, randomized studies providing valuable evidence are still not available. Compared to conventional surgery, the laparoscopic technique has short-term advantages including less pain, shorter duration of postoperative ileus, less fatigue, better pulmonary function, and less blood loss (Leung et al., Lancet 363:1187–1192, 2004; Braga et al., Dis Colon Rectum 48:217–223, 2005; Jayne et al., J Clin Oncol 25:3061–3068, 2007; Agha et al., Surg Endosc 22:2229–2237, 2008).     

Human NOTES Cholecystectomy: Transgastric Hybrid Technique

Background  Natural orifice translumenal endoscopic surgery (NOTES) is an emerging field in minimally invasive surgery that is driving the development of new technology and techniques. There are several proposed benefits to the NOTES approach, including potentially decreased abdominal pain, wound infections, and hernia formation Ko and Kalloo (Chin J Dig Dis 7:67–70, 2006); Wagh et al. (Clin Gastroenterol Hepatol 3(9):892–896, 2005); ASGE/SAGES Working Group on Natural Orifice Transluminal Endoscopic Surgery (Gastrointest Endosc 63(2):199–203, 2006); and Pearl and Ponsky (J GI Surg 12:1293–1300, 2008). Cholecystectomy has been one of the most commonly performed NOTES procedures to date, with the majority being performed through the transvaginal approach Marescaux et al. (Arch Surg 142:823–826, 2007); Zorron et al. (Surg Endosc 22:542–547, 2008); and Ramos et al. (Endoscopy 40:572–575, 2008). Transgastric approaches for cholecystectomy have been shown to be technically feasible in animal models and in several unpublished human patients Sumiyama et al. (Gastrointest Endosc 65(7):1028–1034, 2007). This video demonstrates the technique by which we perform transgastric NOTES hybrid cholecystectomy in human patients. Method  Patients with symptomatic gallstone disease are enrolled under an IRB approved protocol. A diagnostic EGD is performed to confirm normal anatomy. Peritoneal access is gained using a needle-knife cautery and balloon dilation under laparoscopic visualization. Dissection of the critical view of safety is performed endoscopically. The cystic duct and artery are clipped laparoscopically and the gallbladder is dissected off of the liver. The gastrotomy is closed intralumenally and over-sewed laparoscopically. The gallbladder is extracted out the mouth. Results  This technique was used to successfully perform four NOTES hybrid transgastric cholecystectomies without operative complications. Conclusions  NOTES hybrid transgastric cholecystectomy can be performed safely in human patients. This procedure is still technically challenging given the current instrumentation that is available. In order to perform a pure NOTES transgastric cholecystectomy, a safe blind access method, improved retraction, endoscopic hemostatic clips, and reliable closure methods need to be developed. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. Presented at SSAT/DDW, May 2008, San Diego, CA.     

<Emphasis Type="Italic">Actinomyces meyeri</Emphasis> osteomyelitis of the symphysis pubis following pubovaginal sling

Previous reports of pubic osteomyelitis associated with bone anchors describe symptoms presenting 10 days to 12 months postoperatively with typical pathogens including Streptococcus, Staphylococcus, Citrobacter, and Pseudomonas (Fitzgerald et al., Int Urogynecol J 10:346–348, 1999 Enzler et al., J Bone Jt Surg Am 81-A(12):1736–1740, 1999; Graham and Dmochowski, J Urol 168:2055–2058, 2004; Fialkow et al., Urology 64(6):1127–1132, 2004; Matkov et al., J Urol 160(4):1427, 1998). This case illustrates the potential for protracted symptoms and delayed diagnosis of pubic osteomyelitis with the fastidious pathogen of Actinomyces meyeri.     

Psychosocial Evaluation for Bariatric Surgery: The Boston Interview and Opportunities for Intervention

The process of psychosocial evaluation for weight loss surgery (WLS) is one that goes beyond serving the function of information-gathering (Bauchowitz et al. in Surg Obes Relat Dis 3:554–558, 2007; Friedman et al. in Surg Obes Relat Dis 3:376–382, 2007; Lanyon and Maxwell in Obes Surg 17:321–328, 2007; Sogg and Mori in Obes Surg 14:370–380, 2004; Sogg and Mori in Surg Obes Relat Dis 4:455–463, 2008). This process offers myriad opportunities for delivering significant and powerful interventions that can enhance the patient’s success in the WLS process. A discussion of the unique opportunities for psychosocial intervention afforded by the pre-surgical evaluation process is presented, using The Boston Interview for Bariatric Surgery (Sogg and Mori in Surg Obes Relat Dis 4:455–463, 2008) as the organizing framework.     

Ileal Ganglioneuromatosis with Adenocarcinoma in a Patient with Multiple Neurofibromatosis

Von Recklinghausen’s disease or type 1 neurofibromatosis is an autosomal dominant disease characterized by mucocutaneous neurofibromas, café-au-lait spots and involves many organs including gastrointestinal tract. Gastrointestinal involvement in neurofibromatosis is uncommon and is seen 25% patients and nearly 5% of them are only symptomatic (Shekitka and Sobin, Am J Surg Pathol 18:250–257, 1994; Tomita et al., Int J Colorectal Dis 21: 89–91, 2006).     

Microscope and endoscopic pituitary surgery

Having just celebrated the centenary of the first transsphenoidal pituitary operation by (Schloffer in Austria in Beitr Klin Chir 50:767–817, 1906), and this year the quarter centenary of the first published report of a therapeutic use of the neuroendoscope (for colloid cysts of the third ventricle) (Powell et al. in Neurosurgery 13:234–237, 1983), it is time to consider the relative merits of microscopic and endoscopic approaches for pituitary surgery. Although transsphenoidal endoscopic surgery has only been utilised by pioneers such as Jho since the mid-1990s (Jho et al., 1996), there is no doubt that it has already gained an important place in the neurosurgical armamentarium, but there is both confusion and propaganda about which method of surgery has most to offer, and indeed whether or not there is any real difference at all.     

A reasonable mechanism for visible light-induced skin rejuvenation

In recent years, much research has been done in the field of non-ablative skin rejuvenation. This comes as a response to the continuous demand for a simple method of treating rhytides, UV exposure, and acne scars. Numerous researches involve visible light-pulsed systems (20–30 J/cm²). The mechanism of action is believed to be a selective heat-induced denaturalization of dermal collagen that leads to subsequent reactive synthesis (Bitter Jr., Dermatol. Surg., 26:836–843, 2000; Fitzpatrick et al., Arch. Dermatol., 132:395–402, 1996; Kauvar and Geronemus, Dermatol. Clin., 15:459–467, 1997; Negishi et al., Lasers Surg. Med., 30:298–305, 2002; Goldberg and Cutler, Lasers Surg. Med., 26:196–200, 2000; Hernandez-Perez and Ibeitt, Dermatol. Surg., 28:651–655, 2002). In this study, we suggest a different mechanism for photorejuvenation based on light-induced reactive oxygen species (ROS) formation. We irradiated collagen in vitro with a broadband of visible light (400–800 nm, 24–72 J/cm²) and used the spin trapping coupled with electron paramagnetic resonance spectroscopy to detect ROS. Irradiated collagen resulted in hydroxyl radicals formation. We propose, as a new concept, that visible light at the energy doses used for skin rejuvenation (20–30 J/cm²) produces high amounts of ROS, which destroy old collagen fibers, encouraging the formation of new ones. On the other hand, at inner depths of the skin, where the light intensity is much weaker, low amounts of ROS are formed, which are well known to stimulate fibroblast proliferation.     

Intramural Metastatic Squamous Cell Carcinoma of Stomach

Intramural metastasis to the stomach (IMMS) from carcinoma esophagus, excluding direct invasion and spread to the stomach, is relatively uncommon. Diagnosis of IMMS is based on histological criteria, and it is associated with poor prognosis (Takubo et al. Cancer 65:1816–1819, 1990]. We report two patients of SCC oesophagus in whom intramural metastasis to stomach has occurred.     

Kimura disease: a brief clinical report

Kimura disease (KD) is an uncommon idiopathic inflammatory disease (Khoo and Chan, Cutis 70(1):57–61, 2002). This chronic inflammatory soft tissue disease is characterized by lymphoid and angiomatous tissue proliferation with lymphadenopathy, eosinophilia, and elevated serum IgE levels (Khoo and Chan, Cutis 70(1):57–61, 2002). Lesions are usually located on the head and neck area (Kung et al., Pathology 16:39–44, 1984), and the disease is more common among Asians. In this study, we present a patient with a diffuse mass on his left side of the face from the parotid area to the temporal fossa, who is also suffering from nephrotic syndrome. A review of the literature is presented.     

Primary mucinous carcinoma (PMC) of the skin—a case report

Primary mucinous carcinoma of the skin is a rare malignant adnexal neoplasm. It was first described by Lennox et al. in 1952. It is uncertain whether it is of apocrine or eccrine origin (Wright and Font, Cancer 44:1757–1768, 2; Mendoza and Helwig, Arch Dermatol 103:68–78, 3). Showing morphological similarity to mucinous carcinoma of the breast, it may be difficult to distinguish it from a cutaneous metastatic deposit of mucinous adenocarcinoma from a visceral primary lesion. Hence, it deserves attention not only for its scarcity but also for the challenge in determining its precise diagnosis and hence, planning its management. We present a case of primary mucinous carcinoma of the skin.     

A novel technique of interlocking screw placement after missing a screw hole

Interlocking nailing has become the common method of treatment of most diaphyseal fractures of long bones today (Brumback et al. in J Bone Joint Surg A 70:1453–1462, 1988; Winquist et al. in J Bone Joint Surg [Am] 66:529–539, 1984). Interlocking screws at the end of the nail that is free of the jig is usually done free hand, by perfect circle technique. Recently, computer-guided interlocking of the nail at the far end of the jig has been introduced, and this technique decreases the radiation and the time for locking at the far end. In fact, it completely avoids radiation while locking at the distal end of the nail (Tornetta et al. in Distal locking using an electromagnetic field guided computer based real time system, San Diego, CA, 2009). Trying to drill without obtaining perfect circles is one of the common causes of missing a screw hole during interlocking nailing, and this is mostly due to inexperience, making small skin incisions, thick fascia causing walking of the drill bit while drilling or being overconfident (Brumback in Tech Orthop 16:342–348, 2001). Further localization of the correct hole is often made difficult by the drill bit trying to re-enter the previously drilled hole. We describe a technique to aid in finding the appropriate screw hole after missing a hole.