Yersinia enterocolitis.

Human infection with Yersinia enterocolitica is being seen with increasing frequency. This disease has importance to the pediatric surgeon as it may mimic acute appendicitis in patients in the pediatric age group. Clinical suspicion should be high in the patient with right lower-quadrant symptoms suggestive of appendicitis with an inordinate amount of diarrhea. Serologic and microbiologic evidence should be sought, and tissues removed at the time of a negative exploration for appendicitis should be cultured for Yersinia enterocolitica. In general, the disease is associated with an excellent clinical response to simple antibiotic therapy and a good prognosis, but fatal cases have been reported, especially in older patients.     

Palliative care and active disease management are synergistic in modern surgical oncology

Palliative care has long been described in medical literature but only recently is being discussed in the surgical domain. Mounting evidence suggests that early integration of palliative care improves patient outcomes and this is especially true of oncology patients. Thus, the pendulum is swinging toward recognizing that palliative care and active disease management are not mutually exclusive but rather synergistic in modern surgical oncology. Here we use a patient vignette to demonstrate the new challenges and possibilities in modern surgical oncology, we then discuss the historic perspective of palliative care and describe how the paradigm is shifting. Finally, we introduce a model that may be beneficial in conceptualizing this new way of thinking about and integrating palliative care into surgical oncology.     

Mycobacterium tuberculosis infection and laboratory diagnosis in solid-organ transplant recipients

Tuberculosis (TB) is an unusual infection in transplant recipients. We evaluated (i) the frequency of TB, (ii) the duration to develop the TB infection, and (iii) clinical consequences, in 380 solid-organ recipients from January 1995 to December 2000. A total of 10 (2.63%) patients (eight renal, two liver transplant recipients) were found to have post-transplantation TB. The frequency of TB in this patient population is 8.5-fold higher than the prevalance in the general Turkish population. Tuberculosis developed within 2-33 months after transplantation, with a median of 15 months. In all of these 10 patients, Mycobacterium tuberculosis (MTB) was isolated from the culture. All the patients continued to have low dose immunosuppressive treatment, and also quadriple antituberculosis treatment [isoniazid (INH), rifampin (RIF), pyrazinamide (PRZ) and ethambutol (ETB)] has been given. The two recipients had died of disseminated form of TB. Relapse was detected in one patient 6 months after the completion of the treatment. As post-transplant TB infection develops mostly within the first year after transplantation, clinicians should be more careful for early and fast diagnosis and treatment should be started immediately.     

Primary chemotherapy in the treatment of children with bladder--prostate tumors in the Intergroup Rhabdomyosarcoma Study (IRS-II)

Twenty-nine children (24, male; 5, female) with non-disseminated rhabdomyosarcomas of the bladder or prostate were treated (1978-1980) by a primary chemotherapy regimen consisting of vincristine, actinomycin D, and cyclophosphamide ("Pulse" VAC), with or without local radiotherapy. During the initial 20 wk of chemotherapy, nine children achieved a Clinical Complete Response (CCR). Three of these are without evidence of disease (NED) and have functional bladders, two following partial cystectomy. Four who achieved a CCR subsequently relapsed or remained biopsy positive, but are at present NED following radiotherapy and anterior exenteration. Two patients who achieved CCR status relapsed and have died of disease. Twelve patients had a Clinical Partial Response (CPR) in less than 20 wk and two others in less than 40 wk. Seven of these are NED with intact bladders following chemotherapy-radiotherapy; and an additional patient is NED following partial cystectomy. Four patients in the CPR group have been treated by exenteration following failure to achieve complete response, and are NED. One patient has died, and one has progressive disease. Six patients had an inadequate response to chemotherapy (NR). Anterior exenteration was carried out in three, and two of these have survived. The overall results in these 29 patients are: (A) alive and disease-free with functional bladders, 11; (B) alive and disease-free following anterior exenteration, 10; and (C) dead or death from tumor anticipated, 8. The function of retained bladders (11) has been satisfactory.     

Surgical Correction of Complete Rupture of the Anterior Papillary Muscle

A 59-year-old patient with postinfarction complete rupture of the anterior papillary muscle and massive mitral regurgitation is described. The diagnosis was suspected clinically and confirmed by echocardiography and cardiac catheterization. Two months after the acute episode, the patient underwent a valve-conserving procedure by reattachment of the papillary muscle to the left ventricular wall. The patient is well and asymptomatic 3 years after operation with evidence of good anatomical and functional correction of the mitral valve lesion. This type of repair should be possible in selected patients with this lesion.     

Patient preference for time-saving telehealth postoperative visits after routine surgery in an urban setting

Background

Focusing on high-value delivery of health care, we describe our implementation of telephone postoperative visits as alternatives to in-person follow-up after routine, low-risk surgery in an urban setting. Our pilot program assessed telephone postoperative visit feasibility as well as patient satisfaction and clinical outcomes.

Successful creation of arteriovenous fistulas in nonuremic patients with heparin and aspirin therapy

From November 1977 through June 1979, 26 of 28 nonuremic patients had forearm arteriovenous fistulas successfully created for dialysis, lymphapheresis or vascular access. To improve patency, aspirin and heparin therapy was begun the night before operation and continued postoperatively in all except one patient. No major change in coagulation parameters resulted from this treatment. Twenty-five radial artery to cephalic vein fistulas were created in 23 patients, brachial artery to basilic vein fistulas in 3 patients, and 8 mm polytetrafluoroethylene brachial artery to basilic vein loop grafts in two patients. Early fistula failures (within 11 days) required thrombectomy once in four patients and twice in another patient. A sixth patient was not given heparin or aspirin and required multiple thrombectomies before the graft was removed because of infection. One other patient refused further surgery after two unsuccessful attempts to create an arteriovenous fistula. In the remaining 26 patients, the fistulas have been successfully maintained, and in 18 patients more than 214 dialysis or lymphapheresis treatments have been performed without problems. The successful establishment of arteriovenous fistulas in nonuremic patients has been achieved by giving aspirin and low dose heparin therapy, which appears to be an integral step in maintaining patency.     

In vitro technique for isolating prostatic cells from blood.

An in vitro technique for isolating prostatic cells from blood has been applied to the study of circulating prostatic cells during a transurethral resection of the prostate. Our findings indicate that prostatic cells that are added to the blood in vitro can be isolated by the technique described and that cells resembling prostatic cells can be isolated from the blood of the patient undergoing transurethral resection of the prostate. Furthermore, the results of our study suggest that (i) in selected patients, needle biopsy of the prostate should be carried out prior to transurethral resection of the prostate and that (ii) patients who have multifocal adenocarcinoma diagnosed at the time of transurethral resection of the prostate may not be suitable candidates for future prostatectomy.     

Sacrifice of the unsatisfactory hand.

A hand which compares unfavorably with a prosthesis in function, comfort, and appearance may be better amputated. This decision must be made conjointly by the surgeon and the patient. Contributory factors are severe tissue loss, pain, appearance, infection, functional requirements, sexual reasons, psychological makeup of the patient, economics, safety, the time elapsed since injury, the patient's body image and his desires, and the surgeon's opinion. Fifteen patients elected hand amputation for various combinations of these factors. Eleven were fitted with a prosthesis at the time of operation and three within 3 weeks. All patients expressed satisfaction with their decision and 12 were successful users of the prosthesis.     

Management of immature teratoma of the ovary in children by conservative resection and chemotherapy

Six patients with immature teratoma of the ovary were treated with surgery and chemotherapy. Surgical management consisted of unilateral salpingooophorectomy, biopsy and conservation of the contralateral ovary, and biopsy of peritoneal implants. Triple-agent chemotherapy with vincristine, actinomycin D, and cyclophosphamide was given to four patients and appeared to be beneficial. Radiation therapy was not employed. Local resection of teratomatous recurrences was frequently necessary. Thorough sampling of this tumor is mandatory for establishment of an exact pathologic diagnosis. All six patients are surviving in good health at 1–8-yr follow-up. The prognosis of immature teratoma in the child or adolescent appears more favorable than previously appreciated.     

Percutaneous transluminal dilatation: the treatment of choice for renal artery stenosis causing hypertension

During the last 3 yr a large number of patients with renal artery stenosis have undergone attempted treatment of their stenosis by the technique termed percutaneous transluminal angioplasty or dilatation (PTD) using the balloon tipped catheter developed by Gruntiz. A number of publications have documented that this technique is reasonably safe and effective in renal artery lesions due to fibromuscular disease (FMD), atherosclerosis (AS), or prior surgery such as renal artery bypass or transplantation. Although initially many of the patients that were treated were felt to be poor surgical risks, many patients have now been treated who were excellent candidates for renal artery bypass. The cumulative experience argues that PTD should be the first treatment tried in any patient with significant renal artery stenosis causing hypertension. It should be noted that the cumulative experience is not based on any controlled trial and therefore may well be biased. Nevertheless, I will present this argument based on the published data and our own experience at Indiana University. This argument pertains to any patient with incomplete renal artery occlusion who has a functionally significant stenosis (determined by renal vein renin sampling) and who is a good surgical candidate. Those patients who are at high risk for major surgery will obviously be best treated by PTD or medical management. The argument has four major points: safety, effectiveness, cost analysis, and availability.     

Long-term survival of patients with multiple myeloma and acute renal failure at presentation

Eight patients presented with simultaneous multiple myeloma and acute renal failure requiring hemodialysis. Patients had no known pre-existing renal disease nor exposure to nephrotoxic agents or x-ray contrast dye. Renal failure was attributed to light chain nephropathy in all cases. In 4 of these patients the diagnosis of myeloma was initially unsuspected. Renal biopsies in 3 of these patients, and post-mortem material in a fourth revealed the changes of "myeloma kidney." No patient regained renal function and all required chronic hemodialysis. Among these eight patients, three survived for periods greater than 21 months.     

Cancer of the anterior floor of the mouth: Selective choice of treatment and analysis of failures

From 1971 through 1975, 104 patients with squamous carcinoma of the anterior and anterolateral floor of the mouth underwent surgery, irradiation therapy or a combination of both with the purpose of eliminating their tumors. No patient had received treatment before, and this effort was considered primary and definitive. Fifty-five patients were free of cancer at the time of this analysis, 21 had died of intercurrent disease or new primary tumors, 1 patient was alive although suffering from another primary cancer, and in 27 patients the treatment failed and they died of recurrent carcinoma of the head and neck or with distant metastases. The ultimate determinate rate of control for all stages of disease was 66 percent. A rational approach to the problem of selecting a particular form of treatment for patients with cancer of the anterior floor of the mouth in different clinical manifestations is presented.     

Surgical treatment of renovascular hypertension in children.

In fourteen children with renovascular hypertension the most prevalent lesion was fibromuscular dysplasia (nine patients). Nephrectomy was performed in four patients prior to the adoption of reconstructive vascular techniques. Revascularization of a variety of lesions was employed with autogenous arterial grafts, which gave excellent results over a long follow-up period in ten patients. Ex vivo microvascular repair was used in one patient rather than nephrectomy for management of branch artery lesions. These results indicate that careful and precise arterial repairs will yield a high cure rate in children with renovascular hypertension without the sacrifice of renal parenchyma.     

Rupture of herniated small intestine from blunt abdominal injury: a report of 2 cases

Two cases of perforation of the small bowel following blunt abdominal injury in patients with an abdominal hernia are presented. In one case the bowel was present in a large incisional hernia and the injuring force caused transection of the bowel at three different sites. The bowel was resected and the hernia was repaired at the same time. The patient died of associated chest injuries. In the second case, the bowel was caught in an inguinal hernia; although the injuring force was relatively mild it resulted in two perforations in the herniated terminal ileum. The patient survived following closure of the perforations and simultaneous repair of the hernia.     

Restoration of sensibility to anesthetic scarred digits with free vascularized nerve grafts from the dorsum of the foot

Five cases of segmental vascularized nerve grafts that bridge scarred beds for digital sensory nerve reconstruction where previous nonvascularized nerve grafts have failed are reported. Average follow-up in this study was 27 4/5 months. Three patients were men and two were women. Average age was 35 1/2 years. The thumb was the recipient digit in one patient; the index finger in two patients; and the long finger in two patients (primary opposing digit). Three digits had suffered amputation and two had crush lacerations. Average graft length was 6.6 mm. Pin prick, touch, and vibratory sensation were restored in all patients (slightly impaired in one). Average moving two-point discrimination was 7.2 mm; average static two-point discrimination was 9.5 mm. Von Frey monofilament cutaneous pressure averaged 4.03 gm. Donor morbidity was negligible except for a neuroma in one patient and slight superficial skin loss in another.     

Thoracoscopy for diagnosis of intrathoracic lesions in children

Disenchantment with available techniques for specific diagnosis of intrathoracic pulmonary lesions in children has led us to explore the usefulness of thoracoscopy. We have performed this technique in nine patients ranging in age from 17 mo to 16 yr. The procedure is performed under intravenous anesthesia with the patient spontaneously breathing oxygen. A fiberoptic rod lens system is employed for the direct observation and biopsy of pulmonary parenchymal or chest wall lesions. Adequate tissue has been obtained in each case to allow a specific diagnosis. There has been no mortality from this procedure and only minor morbidity. We believe that this technique offers a rapid and simple method for the diagnosis of diffuse or localized disease of pulmonary parenchyma or chest wall in children.     

Closed tendon sheath irrigation for pyogenic flexor tenosynovitis

Twenty patients with pyogenic flexor tenosynovitis were treated by through-and-through saline irrigation using an indwelling catheter and small Penrose drain. The treatment lasted for 48 hours. All patients were discharged from the hospital within 4 days. Eighteen patients had regained complete active and passive motion by 1 week after operation. One patient had a slight residual flexor tendon adherence and one gained motion after operation. This technique provides rapid, complete return of function with minimal inconvenience to the patient.     

A comparative immunologic study of IgA nephropathy

A conglutinin binding assay has been used to detect circulating immune complexes (CIC) containing IgA, IgG, or IgM in sera from patients with IgA nephropathy. IgA class CIC were detected in 40.7% of patient. IgG class CIC were detected only in patients with glomercular IgG deposits. IgM class CIC were detected more often in patients with glomerular IgM deposits than in patients without glomerular IgM deposits. These results demonstrate an association between the immunoglobulin in CIC and those in glomerular deposits. CIC were not detected in sera from most patients with IgA nephropathy by a Clq binding assay, however, since this assay does not detect IgA class CIC. Immunoelectronmicroscopic studies of IgA nephropathy have shown that C3 deposits are localized to the same areas as IgA deposits. In conclusion, we suggest that mesangial IgA deposits are composed of immune complexes and may be derived from CIC.     

Sacrococcygeal teratoma: A 33-year experience

During the years 1941 through 1973, 48 patients, 16 males and 32 females, with sacrococcygeal teratoma were seen at the Childrens Hospital of Los Angeles. Forty-four patients have been followed, three are lost to follow-up, and one patient died 2 wk after excision of teratoma.Of the 44 patients with follow-up, 26 had teratoma with mature tissues only, all these patients are living. Six patients had tumor containing mature and embryonic tissues. Of these, five are living and one died with metastases of malignant teratoma 1 yr after excision of the primary tumor. Of the remaining 12 patients, 11 have died during the first 4 yr of life due to malignant teratoma and only one is living without recurrence 15 yr after excision of teratoma containing frankly neoplastic tissues. Recurrence and/or metastasis of malignant sacrococcygeal teratoma was lethal in all instances.