Peritoneography (Herniography) for Detecting Occult Inguinal Hernia in Patients with Inguinodynia

OBJECTIVE: To evaluate the usefulness of peritoneography in patients referred with inguinal pain (inguinodynia) and clinically absent inguinal hernia on physical examination. SUMMARY BACKGROUND DATA: In patients with chronic groin pain, peritoneography is a seldom-used yet available technique that can detect an occult inguinal hernia. The value of peritoneography in the diagnosis of occult inguinal hernia has been previously shown. METHODS: During a 60-month period, 80 consecutive patients with complaints of persistent inguinal pain (inguinodynia) without evidence of hernia on clinical examination were referred for outpatient evaluation by peritoneography. Twenty-nine patients had prior inguinal surgery in the region of their current pain. Peritoneography was performed using a midline or paraumbilical approach. Radiographs were obtained with patients in prone and prone oblique positions with the head elevated 20 degrees to 25 degrees, both with and without provocative maneuvers. All available records were retrospectively reviewed for radiographic findings and outcome. RESULTS: Of the 80 patients undergoing peritoneography, 36 (45%) were diagnosed radiographically to have inguinal hernias that were not detectable clinically. Twenty-seven of these patients subsequently underwent inguinal exploration, and a hernia was confirmed in 24 (89%). Of the patients having prior inguinal surgery in the region of their pain, 12/29 (41%) were diagnosed by peritoneography with a hernia. Two complications (2.5%), both colon perforations that did not require significant intervention, occurred as a result of peritoneography. CONCLUSIONS: Peritoneography is highly reliable for detecting clinically occult inguinal hernia and has a low complication rate. Its usefulness is shown in a prospective consecutive series for detection of occult hernias in patients with chronic inguinal pain. The authors conclude that peritoneography is a safe and useful diagnostic test in the setting of persistent inguinal pain and a negative clinical examination.     

Functional outcome after centralization for radius dysplasia.

Centralization for radius dysplasia purportedly offers a more normal appearance, provides length to a shortened forearm, and improves upper-extremity function. Limited objective outcome data, however, exist to substantiate its use. To better define functional status after centralization, the Jebsen-Taylor hand test and the Disabilities of the Arm, Shoulder, and Hand questionnaire (DASH) were administered to 21 patients (25 wrists) at an average of 20 years after surgery. Jebsen-Taylor scores, a measure of hand function, were significantly altered with an average total score of 48 seconds compared with an average normal score of 30 seconds (62% increase). The DASH questionnaire, a measure of upper-extremity function, showed only a mild disability of 18%. These long-term follow-up data show that hand function remains markedly abnormal while upper-extremity disability is mild. Improved wrist alignment and increased ulna length did not correlate with improved upper-extremity function.     

Discitis associated with pregnancy and spinal anesthesia.

Discitis (inflammation of the intervertebral disk) most commonly develops as a rare complication of bacterial infection or chemical or mechanical irritation during spine surgery (1) with a postoperative incidence of 1%-2.8% (2). It is also a complication of discography-the intradiscal injection of saline or contrast material (3). The incidence of postdiscography discitis is 1%-4% (3); no cases have been reported when prophylactic antibiotics have been used, supporting the theory of bacterial contamination (3). Although it is controversial whether discitis can be caused by an aseptic or infectious process, recent data suggest that persistent discitis is almost always bacterial (4). Honan et al. (5) reported 16 cases of spontaneous discitis and reviewed another 52 patients from the literature. In their series, patients tended to have one or more comorbid conditions, such as diabetes, vertebral fracture, or a preexisting spine injury. Spontaneous discitis has also been associated with advanced age, IV drug abuse, IV access contamination, urinary tract infection, and immunocompromised states (5,6). No cases of infectious discitis associated with pregnancy and spinal anesthesia have been reported in the English literature. Discitis presents as spasmodic pain in the back that may be referred to the hips or groin (7). The pain may radiate to the lower extremities. The erythrocyte sedimentation rate is usually increased. Radiological changes in discitis include narrowing of the intervertebral disk space, vertebral sclerosis, and erosion of the end plates. The best diagnostic measure may be magnetic resonance imaging (MRI) or a combination of bone and gallium scanning (2). The mainstay for discitis treatment is pain control and antibiotics; surgical intervention is usually not required. Complications of discitis include intervertebral fusion, epidural abscess, and paralysis. IMPLICATIONS: This is a case report of a disk infection (discitis) caused by the bacteria, Streptococcus bovis after spinal anesthesia for cesarean delivery. S. bovis rarely causes discitis, and spinal anesthesia for labor and delivery has not been reported as a cause of discitis.     

Endobronchial Lipoma Accompanied with Primary Lung Cancer: Report of a Case

A 72-year-old man was found to have an endobronchial lipoma accompanied with primary lung cancer. A left lower lobectomy with a mediastinal lymph node dissection and a sleeve resection of the lingual bronchus with telescoping bronchial anastomosis were done. The pathological staging was T1N2M0, stage IIIA. A histological examination showed well-differentiated squamous cell carcinoma in segment 10, in addition to the presence of mature adipose tissue which was diagnosed to be a benign endobronchial lipoma originating from the lingual bronchus. The postoperative course was uneventful and the patient was discharged 13 days after the operation. However, he had a recurrence in the subcarinal lymph node, and died 8 months after surgery. Received: March 2, 2001 / Accepted: November 20, 2001     

No relationship exists between the correction of the thoracic and the lumbar curves after selective thoracic fusion for adolescent idiopathic scoliosis King type II

In this study we focus on idiopathic scoliosis with a primary thoracic curve and a secondary lumbar curve. We were interested in how the lumbar curve corrects following selective thoracic fusion and whether one can explain or predict the behaviour of the lumbar curve. In the literature it is said that, if the lower level of fusion is properly selected, the lumbar curve spontaneously corrects to balance the thoracic curve after selective thoracic fusion. Most authors have assumed a mechanism whereby improvement of the lumbar curve occurs through counterbalancing the surgical correction of the thoracic curve. The correction of the lumbar curve is said to echo the correction obtained for the thoracic curve. Because of these hypotheses, we postulate there should be a correlation between the correction of the lumbar and the thoracic curves of a scoliosis. To validate this hypothesis, we performed a retrospective study on 27 patients with King type II adolescent idiopathic scoliosis treated by selective thoracic fusion. The mean preoperative Cobb angles were 54 degrees for the thoracic curve and 34 degrees for the lumbar curve. Postoperatively they were 31 degrees and 22 degrees respectively. Using Pearson correlation analysis, we found no significant correlation between the relative corrections of the individual thoracic and lumbar curves. Moreover, there was a decrease in the correlation between the thoracic and lumbar curve after operation (preoperative R=0.787, postoperative R=0.364). These results show that the correction of the lumbar curve is not a reflection of the thoracic correction. The exact mechanism by which the lumbar spine corrects remains to be elucidated.     

New Strategies for Colorectal Cancer Prevention and Treatment

Colorectal cancer (CRC) is the second most common fatal malignancy in the Western world, with more than 150,000 new cases accounting for 55,000 deaths in the United States every year. Surgical resection is an effective treatment for localized disease, achieving a 5-year survival rate of 90%; but chemotherapy and other novel treatments for metastatic disease remain ineffective. There have been significant efforts to identify risk factors associated with the development of CRC and to explore potential preventive therapies. Both genetic and epigenetic factors contribute to the development of colorectal cancer. Specific genetic changes in proto-oncogenes, tumor suppressor genes, and DNA mismatch repair genes have led to a genetic model of CRC. Cooperative genetic aberrations involving APC (adenomatous polyposis coli), beta-catenine, K-ras, and p53 are involved in the multistep adenoma-carcinoma sequence of CRC. Emerging data have implicated cyclooxygenase-2 (COX-2) and prostanoid production in the pathogenesis of colorectal carcinoma. Several reports indicate a close relation between the intake of nonsteroidal antiinflammatory drugs (NSAIDs) and a decreased risk for developing colorectal cancer. Epidemiologic studies indicate a 40% to 50% reduction in mortality due to colorectal cancer in individuals taking NSAIDs (e.g., aspirin). Epigenetic factors including age, diet, angiogenesis, and immune responses also appear to contribute to the development of CRC. Combining knowledge of the genetic and epigenetic events implicated in this disease may allow a broader understanding of the pathogenesis of CRC. These developments may yield benefits in earlier detection and in the design of better antitumor interventions.     

Effects of 5-year treatment with elcatonin and alfacalcidol on lumbar bone mineral density and the incidence of vertebral fractures in postmenopausal women with osteoporosis: a retrospective study

 The purpose of this retrospective study was to compare the effects of long-term treatment (5 years) with elcatonin and alfacalcidol on bone mineral density (BMD) and the incidence of vertebral fractures in postmenopausal women with osteoporosis. Fifty-six osteoporotic women, more than 5 years after menopause and 58–79 years of age, were enrolled in the study and allocated to an elcatonin treatment group (20 units IM, weekly; n = 30) or an alfacalcidol treatment group (1 μg/day, daily; n = 26). BMD of the lumbar spine (L2-L4) was measured by dual energy X-ray absorptiometry at baseline and every year for 5 years. There were no significant differences in age, body mass index, years since menopause, BMD, or number of prevalent vertebral fractures at baseline between the two groups. One-way analysis of variance with repeated measurements showed no significant longitudinal changes in BMD in either group, suggesting that both treatments sustained the BMD over 5 years. Two-way analysis of variance with repeated measurements also showed no significant differences in longitudinal changes in BMD between the two groups, suggesting that the effects of the two treatments on BMD were similar. However, the number of incident vertebral fractures per patient was significantly lower in the alfacalcidol treatment group than in the elcatonin treatment group (0.80 ± 1.19 and 2.08 ± 2.73, respectively; P < 0.05). These findings indicate that both treatments appeared to sustain lumbar BMD similarly over a 5-year period in postmenopausal women with osteoporosis, but alfacalcidol treatment may be superior to elcatonin treatment regarding the incidence of vertebral fractures. Further study with prospective observations are needed to confirm the results of the present study. Received: April 2, 2002 / Accepted: July 13, 2002 Offprint requests to: J. Iwamoto     

Minimally invasive approach to Boerhaave’s syndrome

Background: Boerhaave's syndrome requires urgent thoracotomy, laparotomy, or both for esophageal repair and pleuromediastinal debridement. Minimally invasive techniques may be suitable alternatives. Material and methods: Over a period of 12 months, three patients with spontaneous esophageal perforations after forceful vomiting were treated by a combination of minimally invasive techniques including laparoscopy, thoracoscopy, mediastinoscopy, and endoscopic stenting. Results: Esophageal repair was performed transhiatally via laparoscopy using primary suture, primary suture reinforced by a fundic patch, and fundic patch alone in one patient each. One patient had a second perforation of the proximal esophagus, which was sutured through a cervical incision. This patient successfully underwent secondary endoscopic stenting for a persistent esophageal fistula. Mediastinal debridement was performed transhiatally and also by means of a mediastinoscope introduced via the cervical incision in one patient. One patient required secondary thoracoscopic debridement of a pleural empyema but died of sepsis after 1 month. The two other patients recovered and were discharged from the hospital after 2 and 8 weeks, respectively. Conlusions: Boerhaave's syndrome is amenable to minimally invasive techniques. Avoidance of a formal thoracotomy with its resulting morbidity could be of considerable benefit to these critically ill patients.     

Vesicoureteral reflux: A new treatment algorithm

Vesicoureteral reflux (VUR) affects about 1% of all children and carries an increased risk of pyelonephritis and long-term renal impairment. There are several approaches to the treatment of VUR: antibiotic prophylaxis (conservative treatment), open surgery, and endoscopic treatment. For many patients, endoscopic treatment cures VUR with a single procedure, eliminating the need for long-term antibiotic treatment and avoiding the trauma of a major surgical procedure. The choice of material for endoscopic treatment is of key importance, and, until recently, all available materials were associated with concerns regarding safety and efficacy. Emerging data demonstrate that dextranomer/hyaluronic acid (Dx/HA) copolymer has good long-term safety and efficacy in treating VUR. A new treatment algorithm is, therefore, proposed, recommending that most children with persistent VUR (longer than 1 year) be offered endoscopic treatment with Dx/HA copolymer as an alternative to prolonged antibiotic prophylaxis or open surgery.