Puberal gynaecomastia. Review of nine cases

Gynaecomastia is more frequent during the adolescence. In this paper, a retrospective study of nine cases diagnosed and treated on a period of six years is presented. The reports of nine patients are reviewed. The mean age at diagnosis was 10.4 years (range 9-12). In all cases a bilateral mammary hypertrophy was detected, symmetrical in 6 cases (67%) and asymmetric in 3 (33%). After a mean follow-up period of 24 months, surgical treatment was indicated: a subtotal subcutaneous mastectomy was performed in all nine cases. Only two patients developed early complications: one wound infection and one haematoma. The long-term plastic results were satisfactory after a mean follow-up postoperative period of 11 months. The general management of this kind of pathologic process is presented. In the authors experience the elective surgical procedure is the subtotal subcutaneous mastectomy as simple procedure with a very short morbidity and excellent plastic results.     

Luque trolley and convex epiphysiodesis in the management of infantile and juvenile idiopathic scoliosis.

STUDY DESIGN: Retrospective analysis of 5-year follow-up data from patients instrumented with Luque trolley with or without convex epiphysiodesis for management of progressive infantile and juvenile idiopathic scoliosis. OBJECTIVE: To assess results, establish predictors of outcome, and suggest more effective surgical interventions. SUMMARY OF BACKGROUND DATA: Initial results have been reported. There are no long-term follow-up studies. METHODS: Luque trolley instrumentation was used in eight patients with idiopathic scoliosis between 1983 and 1984. Luque trolley with convex epiphysiodesis was used in 18 patients between 1984 and 1990. RESULTS: Changes in Cobb angle from 8-week to 5-year follow-up are as follows. For Luque trolley alone, Cobb angle worsened for all patients. For progressive infantile scoliosis managed with Luque trolley and convex epiphysiodesis, Cobb angle worsened in seven, remained unchanged in four, and improved in two patients. Mean age at operation was 3.1 years (range, 1.5-7.4 years), and instrumented spinal growth was 32% of expected growth. Preoperation Cobb angle was 65 degrees (range, 40-95 degrees). Cobb angle at 5-year follow-up was 32 degrees (range, 0-86 degrees), which is predicted by preoperation apical concave rib-spinal angle (P = 0.002) and upper end vertebral tilt (P = 0.04). For juvenile idiopathic scoliosis managed with Luque trolley and convex epiphysiodesis, Cobb angle worsened in three patients and improved in one. CONCLUSIONS: Luque trolley instrumentation alone does not prevent curve progression. Additional convex epiphysiodesis results in curve resolution in some patients, which suggests a growth effect. Both spine and rib factors predict Cobb angle at 5-year follow-up.     

Ludwig''s Angina. The anaesthetic management of nine cases

We reviewed nine patients with Ludwig's angina who required surgical drainage over a 24-month period. This represents the largest series reported in world literature. All of these patients were managed successfully by a combination of tracheal intubation and early surgical intervention. None required tracheostomy, which is the previously recommended procedure of choice for airway management.     

Transcorporal artificial urinary sphincter cuff placement in cases requiring revision for erosion and urethral atrophy

PURPOSE: A distal cuff location is often required in patients undergoing artificial urinary sphincter reimplantation after previous erosion or in those requiring revision because of urethral atrophy at the original cuff site. Dissecting the urethra at a more distal site increases the risk of urethral injury and erosion, and often the urethral circumference is so small that a 4 cm. cuff is too large. We present a novel technique for distal cuff placement using transcorporal dissection that leaves corporal tunica albuginea on the dorsal surface of the urethra, allowing for its safer mobilization and adding to its bulk. MATERIALS AND METHODS: We reviewed the charts of 31 men who underwent this technique and contacted 26 by telephone. The indications for distal transcorporal cuff placement varied. In 7 men with inadequate urethral coaptation with a 4 cm. proximal cuff at initial implantation a primary transcorporal tandem cuff was implanted distal. In 8 men persistent or recurrent incontinence despite a 4 cm. proximal cuff led to secondary distal reimplantation. Previous artificial urinary sphincter erosion and/or infection in 10 cases, previous urethral surgery at the optimal cuff site in 5 and radiation changes at the optimal cuff site in 1 led to selection of the more distal site and technique. Of the transcorporally placed cuffs 18 were 4 cm. and 13 were 4.5 cm. Preoperatively 5.2 pads were used daily. Of the 31 patients 27 were impotent preoperatively, 1 had normal erections, 1 had partial erections with the MUSE drug delivery system (Vivus, Inc., Menlo Park, California) and 2 had a previously placed penile prosthesis. RESULTS: At a mean followup of 17 months 26 of the 31 patients (84%) had occasional or no stress incontinence requiring 0 to 1 pad daily, 2 with pure urge incontinence used 1 to 2 pads daily and 3 had mixed incontinence requiring 0 to 3 pads daily. Of the 26 men surveyed 25 were very satisfied with the postoperative level of incontinence. Postoperatively erectile function deteriorated in 1 patient and was unchanged in the remainder. There was no erosion or infection of the transcorporally placed cuffs, although 3 were replaced for malfunction. CONCLUSIONS: This technique offers significant advantages in cases of revision. The technique protects the urethra from intraoperative dissection injury and decreases the risk of erosion because the urethra is buttressed at its vulnerable location. In addition, bulk is added to the urethra, allowing for better cuff sizing, which is usually a problem at this location where the urethra is small, thereby, improving continence in revised cases. Our success has recently led us to abandon tandem cuff placement altogether. There is a potential for deteriorating erectile function in potent men who undergo implantation in this fashion.     

Internal hernia. Report of nine cases

Summary Internal abdominal hernias are rare and develop when one or more viscera protrude through an intraperitoneal orifice while remaining within the peritoneal cavity. This orifice may be normal (Winslow's foramen) or paranormal (peritoneal fossae); these hernias possess a sac and are true hernias. Protrusion may be through a pathologic hole, without a sac, realizing an internal prolapse or procidentia. The clinical diagnosis is always difficult and leads to an urgent operation for intestinal obstruction. The treatment is often simple and the results are generally excellent.     

The role of agger nasi air cells in patients requiring revision endoscopic frontal sinus surgery.

OBJECTIVES: To determine the association of agger nasi air cell disease with frontal rhinosinusitis, assessed by computed tomography (CT), in patients who require revision functional endoscopic sinus surgery (FESS). METHODS: We prospectively collected data on patients undergoing revision FESS at a tertiary care medical center over an 18-month period. Sinus CT scans were graded as per Lund-Mackay. Frontal sinus findings on CT scan were correlated with the presence or absence of disease in agger nasi air cells. RESULTS: Eighty patients underwent revision FESS in an 18-month period. A total of 160 sides were evaluated by sinus CT scan with agger nasi being present in all but 11 sides (93%). One patient did not have a pneumatized frontal sinus on 1 side and so 148 sides were available for study. Frontal sinus disease was present in 119 and absent in 29 sides. The average CT grade of patients with frontal rhinosinusitis was 8.4 while it was only 3.0 in patients without frontal rhinosinusitis (P = 0.000). Agger nasi air cell disease was present in only 3 of 29 (10%) sides in patients without frontal rhinosinusitis and was present in all 119 (100%) sides of patients with frontal rhinosinusitis (P = 0.0000). CONCLUSION: Agger nasi air cells are a common anatomic feature, present in 93% of our patients. Agger nasi air cell disease correlates strongly with frontal sinus disease as assessed by sinus CT scan in patients undergoing revision FESS. In addition, frontal sinus disease correlates with the severity of overall sinus disease as determined by sinus CT scan.     

Chylothorax. Clinical experience in nine cases

Clinical experience in nine cases of chylothorax is presented. In five cases the cause was iatrogenic, in two cases idiopathic and in two cases the chylothorax was secondary to an advanced malignant disease. Iatrogenic chylothorax occurred after mediastinoscopy, thoracic sympathectomy, pneumonectomy, resection of an aneurysm of the thoracic aorta and closure of a patent ductus arteriosus. Only one of these patients needed an operative closure of the thoracic duct. In one of the two cases of a neoplastic origin the chylothorax was caused by a malignant mesothelioma and thoracic duct ligation was needed while in the other case it was due to an inoperable pancreatic carcinoma and was treated by thoracocentesis. In one of the idiopathic cases supradiaphragmatic ligation of the thoracic duct was necessary. It is concluded that in most iatrogenic or traumatic cases chylothorax can be cured by conservative therapy (diet, thoracocentesis); in other cases the operative therapy should be adjusted to the primary disease, and the ligation of the thoracic duct should be performed at a level where it is able to prevent the chylous leak without unnecessarily interfering with the collateral lymphatic circulation. Abundant and prolonged chylous leakage should be always treated operatively to prevent disastrous nutritional and immunological deficiencies.     

The long-term results of the Howse total hip arthroplasty. With particular reference to those requiring revision

We present the results of 506 consecutive Howse hip arthroplasties with a minimum follow-up of 10 years. The mortality within one month of surgery was 0.79%. The early dislocation rate was 1.38%, two hips requiring revision. Nine hips developed deep sepsis (1.78%), eight of which required revision. At 10 years 42 hips (8.3%) had required revision, including 14 with aseptic acetabular loosening and 11 with femoral stem fractures. We feel that as judged by the dislocation rate and the need for subsequent revision, the Howse arthroplasty is an acceptable form of total hip replacement, particularly in the older patient and in those requiring total replacement for femoral neck fractures.     

Intraosseous lipoma. A clinicopathologic study of nine cases.

Intraosseous lipoma is one of the rarest benign primary tumors of the bone. The clinicopathologic features of nine cases of intraosseous lipoma, including one with multiple lesions of the lumbar spinous processes, were studied and analyzed. They represented 2.5% of all primary bone tumors seen in our institutions. They were subdivided into three groups according to their histologic appearances: Group 1, tumors consisting predominantly of viable fat cells; Group 2, tumors showing, in addition, areas of fat necrosis and calcification; and Group 3, lesions with extensive reactive ischemic bone formation and calcification, viable lipocytes and fat necrosis may or may not be visible. Since the tumor is located within the rigid confines of the bony trabeculae, the internal pressure created as it enlarges is believed to be most significant in the morphogenesis of the tumor. The recognition of this spectrum of morphologic features is important, since the secondary changes may predominate and overshadow the original lipomatous component, leading to the possibility of confusing it with other benign bone tumors, cysts, and bone infarction. A combined clinical, radiologic, and pathologic approach should be adopted in the diagnosis of this tumor.     

Acute interhemispheric subdural hematomas. Report of nine cases

Nine male patients with acute interhemispheric subdural hematoma (ISH) are presented. The etiologic factor was trauma for all patients (traffic accident and falling down). The young adult cases and one child had bad prognosis due to severe clinical findings and high mortality. The asymptomatic patients were treated conservatively. In this report, we discussed etiologic factors, presentation of age groups, whether an ISH progresses to a chronic convexity subdural hematoma (SH), and real mortality rates for ISH with relevant literature knowledge. As a result, ISHs can present in all age groups including shaken babies, severely injured young adults as well as low velocity trauma striken elderly patients (especially those under anticoagulant medication). We believe that an acute ISH does not change to chronic convexity SH; in fact they present as simultaneous acute thin convexity SH and acute ISH. It is also concluded that in contrast to previous literature ISH and acute SH patients of similar neurological status have similar mortality rates.     

Hypothenar hammer syndrome. Retrospective study of nine cases

The hypothenar hammer syndrome is an uncommon lesion of the ulnar artery caused by repetitive trauma to the ulnar portion of the hand. It characteristically occurs in the dominant hand of middle-aged craftsmen, but also in athletes practising various types of sports. We present a retrospective study of nine patients between 1988 and 1999. The follow-up ranged from 1 to 10 years. We recommend surgical treatment, by resection of the involved arterial segment and revascularization either by direct anastomosis or by means of a venous interpositional graft.     

Primary optic nerve sheath meningiomas. Report of nine cases

Between 1979 and 1987 the authors treated nine cases of primary optic nerve sheath meningioma. The definitive treatment for these lesions is surgical resection, although no single best plan for optimal management has been determined. The data indicate that only small anterior tumors may be removed with preservation of useful vision. With posterior circumferential tumors, there have been no cases of tumor removal with preservation of vision. A management strategy directed toward preservation of vision is discussed.     

Lung abscess revisited. A survey of 184 cases.

One hundred eighty-four patients with lung abscess, admitted to the Hospital of the University of Mississippi between 1960 and 1982, were studied with respect to sex (149 men and 35 women), age (mainly fourth to sixth decades), location of abscess(es) (RLL, RUL, and LLL mainly), predisposing factors (aspiration in sensorium disorders, obstruction, gingivo-dental suppuration, immunoincompetence) and nonoperative (89%) and operative (11%) therapy, usually lobectomy. Data from the different decades were compared, but there were few major differences. Mortality rate was 22% in the 1960s, 25% in the 1970s, and 28% in 1980-1982. Major management problems involved massive pulmonary hemorrhage, impaired immune defenses, old-age debility, bronchopleural fistula with empyema, or very large cavity. Anaerobic bacteria predominate and penicillin is the treatment of choice. Incidence of operation is declining, but cases are more often complicated. Prognosis is good in the uncomplicated case.     

Deep sternal wound infection requiring revision surgery: impact on mid-term survival following cardiac surgery.

OBJECTIVE: To assess the impact of deep sternal wound infection on in-hospital mortality and mid-term survival following adult cardiac surgery. METHODS: Prospectively collected data on 4586 consecutive patients who underwent a cardiac surgical procedure via a median sternotomy from 1st January 2001 to 31st December 2005 were analysed. Patients with a deep sternal wound infection (DSWI) were identified in accordance with the Centres for Disease Control and Prevention guidelines. Nineteen variables (patient-related, operative and postoperative) were analysed. Logistic regression analysis was used to calculate a propensity score for each patient. Late survival data were obtained from the UK Central Cardiac Audit Database. Mean follow-up of DSWI patients was 2.28 years. RESULTS: DSWI requiring revision surgery developed in 1.65% (76/4586) patients. Stepwise multivariable logistic regression analysis identified age, diabetes, a smoking history and ventilation time as independent predictors of a DSWI. DSWI patients were more likely to develop renal failure, require reventilation and a tracheostomy postoperatively. Treatment included vacuum assisted closure therapy in 81.5% (62/76) patients and sternectomy with musculocutaneous flap reconstruction in 35.5% (27/76) patients. In-hospital mortality was 9.2% (7/76) in DSWI patients and 3.7% (167/4510) in non-DSWI patients (OR 1.300 (0.434-3.894) p=0.639). Survival with Cox regression analysis with mean propensity score (co-variate) showed freedom from all-cause mortality in DSWI at 1, 2, 3 and 4 years was 91%, 89%, 84% and 79%, respectively compared with 95%, 93%, 90% and 86%, respectively for patients without DSWI ((p=0.082) HR 1.59 95% CI (0.94-2.68)). CONCLUSION: DSWI is not an independent predictor of a higher in-hospital mortality or reduced mid-term survival following cardiac surgery in this population.