Foreign-body granuloma mimicking an extrahepatically growing liver tumor: Report of a case

We herein describe a 74-year-old woman with a foreign-body granuloma mimicking a liver tumor. Imaging studies revealed a pedunculated left lobe mass in the setting of chronic liver disease. She had a past history of a cholecystectomy as well as a previous gynecological operation. A left lateral segmentectomy was performed because of the possibility of a rupture. The dissected specimen showed a foreign-body granuloma caused by gauze. We believe this case to be a very unique granuloma, which should be kept in mind whenever making a diagnosis of a liver tumor particularly in a patient with chronic liver disease, who has a past history of abdominal surgery.     

Case studies for illustration and discussion: peripheral nerve tumors

This article gives a presentation of a variety of surgical cases of peripheral nerve tumors for illustration and discussion. The first three cases include a schwannoma, a neurofibroma, and a desmoid tumor of the brachial plexus region. Case 4 is that of a patient with a common peroneal ganglion cyst, and case 5 is that of a patient with an angiolipoma of the forearm. Cases 6 through 8 illustrate a plexiform neurofibroma, a malignant peripheral nerve sheath tumor, and a metastatic carcinoma to the brachial plexus region. In case 9, a patient with schwannomatosis was treated for multiple spinal schwannomas.     

Vena cava stenting and portorenal shunt in Budd-Chiari syndrome: combination of the 'modern' and the 'classical'.

We have treated a 33-year-old Budd-Chiari patient (due to antiphospholipid syndrome) with a history of myocardial infarction by placing a vascular stent in the inferior vena cava and performing a portorenal shunt with three objectives: (1) to perform a shunt operation on a Budd-Chiari patient with good hepatic functional reserve, (2) to avoid a thoracotomy and manipulation of the heart in a patient with a cardiac thrombus and a history of myocardial infarction and (3) to avoid a synthetic graft in a patient with antiphospholipid syndrome. Vena cava stenting and portorenal shunt make a useful combination which should be included in the armamentarium of the hepatobiliary surgeon.     

A congenital diverticulum of the small intestine; Meckel's diverticulum or duplication?

A diverticulum of the small intestine is a condition with only a low morbidity. This is generally a Meckel's diverticulum (MD). There is, however, the possibility of another congenital malformation, which can closely resemble a MD but has another etiology, the tubular duplication of the small intestine. In a period of three months six patients were treated with a MD with different clinical presentations and histologic findings and an invaginated duplication of the small intestine in a male adult patient. The diagnosis of a tubular duplication of the small intestine is not often considered when finding a diverticulum of the small intestine and such a malformation is too easily called a Meckel's diverticulum.     

Limb salvage after subtotal supramalleolar amputation by initial shortening followed by tibial lengthening

BACKGROUND: We present a patient with a subtotal traumatic supramalleolar amputation of the leg, which was initially treated by a vascular reconstruction with deliberate bone and soft-tissue shortening. METHODS: To correct the ensuing complex deformity, which consisted of a varus hindfoot, leg length discrepancy and equinus, a staged reconstruction was planned. Initially, the hindfoot varus, in presence of a stiff ankle, was corrected by a supramalleolar osteotomy, followed by a Wagner distraction and finally a correction of the equinus. RESULTS: After a relatively long period of normal functioning, she regained painful minimal ankle function, which necessitated ankle fusion and correction of a pronation deformity. At the most recent follow-up 13 years after the injury, the patient is fully functional and has near normal leg length. CONCLUSION: Although a mangled lower extremity is often a candidate for primary amputation allowing early rehabilitation, in certain cases a good result can be obtained by a creative strategy.     

In vivo turnover study demonstrates diminished clearance of lipoprotein(a) in hemodialysis patients

Lipoprotein(a) (Lp(a)) consists of a low-density lipoprotein-like particle and a covalently linked highly glycosylated protein, called apolipoprotein(a) (apo(a)). Lp(a) derives from the liver but its catabolism is still poorly understood. Plasma concentrations of this highly atherogenic lipoprotein are elevated in hemodialysis (HD) patients, suggesting the kidney to be involved in Lp(a) catabolism. We therefore compared the in vivo turnover rates of both protein components from Lp(a) (i.e. apo(a) and apoB) determined by stable-isotope technology in seven HD patients with those of nine healthy controls. The fractional catabolic rate (FCR) of Lp(a)-apo(a) was significantly lower in HD patients compared with controls (0.164+/-0.114 vs 0.246+/-0.067 days(-1), P=0.042). The same was true for the FCR of Lp(a)-apoB (0.129+/-0.097 vs 0.299+/-0.142 days(-1), P=0.005). This resulted in a much longer residence time of 8.9 days for Lp(a)-apo(a) and 12.9 days for Lp(a)-apoB in HD patients compared with controls (4.4 and 3.9 days, respectively). The production rates of apo(a) and apoB from Lp(a) did not differ significantly between patients and controls and were even lower for patients when compared with controls with similar Lp(a) plasma concentrations. This in vivo turnover study is a further crucial step in understanding the mechanism of Lp(a) catabolism: the loss of renal function in HD patients causes elevated Lp(a) plasma levels because of decreased clearance but not increased production of Lp(a). The prolonged retention time of Lp(a) in HD patients might importantly contribute to the high risk of atherosclerosis in these patients.     

Relationship of non-LDL-bound apo(a), urinary apo(a) fragments and plasma Lp(a) in patients with impaired renal function.

BACKGROUND: Plasma lipoprotein (a) [Lp(a)] has been shown to be a risk factor for atherosclerosis in numerous studies. However, the catabolism of this lipoprotein is not very clear. We and others have shown that Lp(a) is excreted into urine in the form of fragments. Lp(a) has also been shown to exist in a low-density non-lipoprotein (LDL)-bound form. Since Lp(a) is increased in all forms of kidney disease with reduced excretory kidney function and decreased excretion of apo(a) fragments could be partially responsible for this increase, we investigated the relationship of non-LDL-bound apo(a), urinary apo(a) fragments and plasma Lp(a) in patients with impaired renal function. METHODS: Plasma Lp(a), non-LDL-bound apo(a) and urinary apo(a) fragments were measured in 55 kidney disease patients (28 males and 27 females) and matched controls. RESULTS: Plasma Lp(a) and non-LDL-bound apo(a) were increased in patients, whereas urinary apo(a) was decreased, especially in patients with a creatinine clearance < 70 ml/min. There was a significant correlation between plasma Lp(a) and non-LDL-bound apo(a) in patients and controls. CONCLUSION: We conclude that decreased urinary apo(a) excretion could be one possible mechanism of increased plasma Lp(a) and non-LDL-bound apo(a) in patients with decreased kidney function.     

Sinonasal Tract Adenoid Cystic Carcinoma Ex-Pleomorphic Adenoma: A Clinicopathologic and Immunophenotypic Study of 9 Cases Combined with a Comprehensive Review of the Literature

Primary sinonasal tract carcinoma ex-pleomorphic adenoma (CEPA) is very uncommon, with adenoid cystic carcinoma (ACC) CEPA exceptional. These tumors are often misclassified. This is a retrospective study. Nine cases of ACC CEPA included 7 females and 2 males, aged 39–64 years (mean, 51.1 years). Patients presented most frequently with obstructive symptoms (n = 5), epistaxis (n = 3), nerve changes or pain (n = 3), present for a mean of 25 months (men: 9.5 versus women: 29.4 months; p = 0.264). The tumors involved the nasal cavity alone (n = 5), nasopharynx (n = 2), or a combination of locations (n = 2) with a mean size of 2.9 cm (females: 3.3; males: 1.7; p = 0.064). Most patients presented at a low clinical stage (n = 7, stage I), with one patient each in stage II and IV, respectively. Histologically, the tumors showed foci of PA associated with areas of ACC. Tumors showed invasion (lymph-vascular: n = 4; perineural: n = 6; bone: n = 6). The neoplastic cells were arranged in tubules, cribriform and solid patterns, with peg-shaped cells arranged around reduplicated basement membrane and glycosaminoglycan material. Mitoses ranged from 0 to 33, with a mean of 8.7 mitoses/10 HPFs. Necrosis (n = 2) and atypical mitotic figures (n = 1) were seen infrequently. Immunohistochemical studies showed positive reactions for cytokeratin, CK5/6, p63, CK7, EMA, SMA, calponin, S100 protein and CD117, several highlighting luminal versus basal cells components. GFAP, CK20 and MSA were non-reactive. p53 and Ki-67 were reactive to a variable degree. Surgery (n = 8), accompanied by radiation therapy (n = 5) was generally employed. Five patients developed a recurrence, all of whom died with disease (mean, 8.4 years), while 4 patients are either alive (n = 2) or had died (n = 2) without evidence of disease (mean, 15.9 years). In summary, ACC CEPA probably arises from the minor mucoserous glands of the upper aerodigestive tract, usually presenting in patients in middle age with obstructive symptoms in a nasal cavity based tumor. Most patients present with low stage disease (stage I and II), although invasive growth is common. Recurrences develop in about a 55 % of patients, who experience a shorter survival (mean, 8.4 years) than patients without recurrences (mean, 15.9 years). The following parameters, when present, suggest an increased incidence of recurrence or dying with disease: bone invasion, lymph-vascular invasion, and perineural invasion.     

Breast abscess after intravenous methamphetamine injection into the breast

Intravenous drug use is a problem plaguing our society. We present a case of a young female who injected methamphetamine into her mammary vein, resulting in the formation of a breast abscess. This case demonstrates a rare but dangerous complication of intravenous drug use and a possible differential diagnosis in a patient presenting with a breast abscess.     

Repair of a recurrent rectovaginal fistula using gluteal-fold flap: Report of a case

Various surgical procedures have been reported for the repair of a rectovaginal fistula, but a failure of the initial repair leads to difficulty in the second and later operations. This report presents the case of a 58-year-old woman with a recurrent rectovaginal fistula after a low anterior resection for rectal cancer who achieved a good outcome following a repair using a gluteal-fold flap. We therefore conclude that the transfer of a well-vascularized gluteal-fold flap may be a safe and reliable method to repair a rectovaginal fistula with a large diameter following repeated recurrence.     

Our experience regarding biologically inactive gastroenteropancreatic neuroendocrine tumors

The Authors present 9 cases of gastro-enteropancreatic neuro-endocrine biologically inactive tumors. In 5 cases the tumor site was appendicular. In 4 patients an appendectomy was performed, in one patient a right hemicolectomy and the patients after a period of 3-9 years are well and disease free. In a patient with a gastric carcinoid and a single hepatic metastasis a total gastrectomy with an hepatic metastasectomy were performed but the patient died 16 months thereafter. In a case localized to the right colon with a single hepatic metastasis a right hemicolectomy was performed with a metastasectomy but the patient died after 12 months. In a case localized to an ileal loop a segmental resection was performed followed by a medical therapy with octreotide and the patient is well and disease free after 3 years. In a case localized to the pancreas with widespread lymphatic metastasis it was performed a simple biliary diversion (coledocho-duodenostomy) followed by medical therapy with octreotide. Surprisingly after 4 years the patient is alive and a TC control shows a decrease of the pancreatic tumor and of the lympho glandular tumefactions.     

Extensive mobile thrombus of the internal carotid artery: a case report, treatment options, and a review of the literature

The presence of a carotid stenosis, a floating thrombus, and a patient with clinical and CT evidence of a stroke represents a significant therapeutic dilemma to the clinician. The evidence of a stroke precludes any active treatment of the carotid stenosis safely, while the floating thrombus demands immediate attention. We recently were involved with just such a patient and chose a conservative approach of anticoagulation followed by operative intervention several weeks later.     

Failed gastroplasty for morbid obesity. Revised gastroplasty versus Roux-Y gastric bypass

Forty-six percent of 122 gastroplasties for morbid obesity failed. This included a failure rate of 71 percent for a single staple line without stomal reinforcement, 37 percent for a double staple line and a central stoma reinforced with 2-0 polypropylene, and 42 percent for the Gomez gastroplasty. Revisional procedures were performed in 44 patients. Ten underwent revision of a failed gastroplasty using a gastrogastrostomy and 34 had conversion to a Roux-Y gastric bypass. Patients who had revisional gastroplasty as a second procedure had a significantly higher failure and complication rate than those converted to gastric bypass. Four of these 10 patients were subsequently converted to gastric bypass as their third weight reduction procedure. Conversion of a failed gastroplasty to a Roux-Y gastric bypass is a difficult procedure that carried a significantly higher complication rate in our study than that of a group of 46 patients who underwent a primary gastric bypass procedure. Of 26 patients followed for more than 1 year after conversion to Roux-Y gastric bypass, the average weight loss was 66 +/- 18 percent of their excess body weight. This was comparable to 16 patients who had undergone a primary gastric bypass more than 1 year previously and had lost 69 +/- 17 percent of their excess body weight.     

Mixed meningeal and brain plasma-cell granuloma: an example of an unusual evolution

Summary We report a study of a 22-year-old woman with a plasma-cell granuloma (PCG), a rare intracranial lesion characterized by a non-neoplastic polyclonal proliferation of plasma cells and other mononuclear cells. She presented after a generalized seizure and CT-scan and magnetic resonance images demonstrated a left temporo-basal tumour mass involving both the meningeal layers and the brain parenchyma. Histopathological examination of a biopsy led to the diagnosis of a typical PCG. After a short course of steroid administration, the clinical and radiological features improved and complete regression of the lesion was shown after one year and persisted at four-year follow-up. This dramatic regression of an intracranial PCG shows that neither surgical removal nor radiation therapy is required to treat a broad skull base PCG.     

Lipoprotein(a) stimulates growth of human mesangial cells and induces activation of phospholipase C via pertussis toxin-sensitive G proteins

BACKGROUND: Renal disease is commonly associated with hyperlipidemia and correlates with glomerular accumulation of atherogenic lipoproteins, for example, lipoprotein(a) [Lp(a)], and mesangial hypercellularity. Specific binding of Lp(a) to mesangial cells and induction of c-myc and c-fos expression has been demonstrated. Therefore, in this study, we investigated a possible growth stimulatory effect and mode of action of Lp(a) in human mesangial cells. METHODS: Lp(a) was purified from the regenerate fluid of a dextran sulfate column-based low-density lipoprotein apheresis system. Human mesangial cells were isolated by a sequential sieving technique from patients undergoing tumor nephrectomy. DNA synthesis was measured by [3H]-thymidine incorporation. The intracellular calcium concentration ([Ca2+]i) was determined by Fura 2-fluorescence, and inositol 1,4,5-trisphosphate (1,4,5-IP3) concentration was measured by a radioreceptor assay. RESULTS: The data show that Lp(a) bound to the cells with a Kd of 17.0 micrograms/ml and increased DNA synthesis and cell proliferation. Lp(a) caused a rapid increase in 1,4,5-IP3 and [Ca2+]i via a pertussis toxin-sensitive mechanism. The phospholipase C (PLC) inhibitor U73122 abolished Lp(a)-induced cell proliferation. In contrast, vasopressin-induced increase in 1,4,5-IP3 and [Ca2+]i was pertussis toxin insensitive. CONCLUSION: This study revealed that Lp(a) stimulates growth of human mesangial cells. Lp(a)-induced signaling involves binding to a receptor and stimulation of PLC via Gi proteins. Stimulation of PLC appears to be essential for the growth stimulatory effect of Lp(a). Whether these effects of Lp(a) contribute to the pathophysiology of renal disease needs to be determined.     

Gastrointestinal stromal tumor of the stomach in a child with a 3-year follow-up period-Case report

We report a case of a nine-year-old boy with a 4-week history of general fatigue, loss of appetite, vomits and hematemesis. Laboratory evaluation revealed a hemoglobin level of 4.4 g/dl. After a transfusion of packed red blood cells the patient underwent an esophagogastroduodenoscopy, which showed a smooth, rounded 6–8 cm submucosal lesion with a central depression with ulceration and active bleeding in the cardia extending to the fundus.Computed tomography (CT) of the chest, abdomen and pelvis showed a large mass originating from the gastric wall but not infiltrating surrounding organs, approximately 8.0 cm × 7.0 cm × 5 cm. Despite the tumor size, no metastases were diagnosed. The patient underwent a total gastrectomy in an en-bloc resection including the distal part of the esophagus (3 cm) and omentum with oncologic margins. Reconstruction was performed with a mediastinal end-to-side esophago-jejunal anastomosis. Immunehistochemic confirmed GIST. He remains well without evidence of disease after 36 months of follow-up with a multiprofessional team.     

Hamartochondroma arising from a tracheal bronchus

Tracheal bronchus is a congenital abnormality rarely described in the literature. It is mostly completely asymptomatic. This condition may rarely be associated with inflammatory diseases. Exceptional are those cases in which the condition is associated with malignancy. We describe a case of a 45-year-old man in whom a 3-month history of non-productive cough and chest pain led to a diagnosis of a solitary pulmonary nodule associated with a tracheal bronchus. The histopathological examination after VATS enucleation showed the presence of a hamartochondroma. To the best of our knowledge this is the first case in which a hamartochondroma has been found to be associated with a tracheal bronchus.     

A technique for lateral retinacular release

The following article does not intend to present indications or contraindications for lateral retinacular release as a therapeutic measure; it presents a simple, effective method of doing a complete lateral retinacular release with a minimal degree of effort for the surgeon, if he or she decides on release as a therapeutic measure. A carefully designed scissors that allows a complete release of the lateral retinaculum in a matter of moments is described, as well as a basic technique for a complete release. This method has given the author satisfactory release in all cases, with a minimal degree of complications. The instrumentation is basic, effective, and readily available.     

Calculocutaneous sinus

Extrusion of a urinary calculus is a rare occurrence, and to date only 7 cases have been previously documented. Three patients are described, all of whom had a persistent discharging calculocutaneous sinus as a manifestation of the extruded calculus. The 3 cases had similar features of presentation with a perinephric abscess, a staghorn calculus within a nonfunctioning kidney, and a classic radiologic feature of a portion of calculus clearly distinct from the main bulk of the stone.     

Candida albicans spondylodiscitis

Candida spondylodiscitis is a rare complication of a haematogenous dissemination of a candida infection, that usually affects immunocompromised patients. We present a case of a Candida albicans spondylodiscitis in a patient in whom a bacterial origin was suspected because of the antecedent of a Staphylococcus aureus bacteriaemia. After unfavourable evolution with initial antibiotic treatment, the correct diagnosis was reached after culture of the material obtained from surgical debridement. The clinical, diagnostic features, and the literature are reviewed.