Necrotizing fasciitis: a plea for early diagnosis and treatment.

INTRODUCTION: Necrotizing fasciitis is an uncommon infectious entity that poses difficult diagnostic and therapeutic management decisions. PURPOSE: This paper addresses the presentation, evaluation and management of the patient with a necrotizing soft tissue infection. CASE REPORT: A 54-year-old man presented to his physician with pain and swelling of the left anterior chest wall following a presumed insect bite several days prior. He was treated with oral antibiotics but returned to the office three days later with increased swelling, pain, and erythema in the axilla. Necrotizing fasciitis was diagnosed. He was hospitalized and taken to the operating room for debridement of the chest wall. Extensive necrosis of the skin, subcutaneous tissue and muscle was encountered. Muscle debridement extended from the pectoralis major and both obliques anteriorly to the latissimus dorsi and para-spinalis muscles posteriorly. Multiple operative debridements were performed over several days. The patient developed septic shock requiring blood pressure support, and multiple organ system failure requiring hemodialysis, prolonged ventilatory support and eventual tracheostomy. Split-thickness skin grafts were placed during the third operative debridement and concluded on the 15th day of hospitalization. The patient eventually recovered and on the 53rd hospital day was transferred to the rehabilitation service, where he spent the next four weeks recovering movement in the left arm. CONCLUSION: Necrotizing fasciitis is an infectious entity that requires rapid diagnosis, surgical debridement, and tissue coverage if the patient is to survive.

Intussusception in adults: institutional review.

BACKGROUND: Intestinal intussusception in the adult is a rare entity that differs greatly in etiology from its pediatric counterpart. Controversy remains regarding the optimal management of this problem in the adult patient. The purpose of this study was to determine the cause(s) of intussusception and to determine the role of intestinal reduction in the management of intussusception in adults. STUDY DESIGN: A retrospective review performed at The Mount Sinai Medical Center identified 27 patients, 16 years and older, with a diagnosis of intestinal intussusception. Data related to presentation, diagnosis, treatment, and pathology were analyzed. RESULTS: There were 13 males and 14 females. The median age of the group was 52 years with a range of 16 to 90 years. Abdominal pain was the most common presenting complaint. A preoperative diagnosis was suspected in 11 of 27 patients (40%). There were 22 small bowel lesions and 5 colonic lesions. A pathologic cause was identified in 85% of patients with 8 of 22 (36%) small bowel and 4 of 5 (80%) of large bowel lesions being malignant. All small bowel cancers represented metastatic disease and all large bowel malignancies were primary adenocarcinomas. The median age of patients with malignant disease was 60 years; it was 44 years for those with benign disease. Operative treatment consisted of resection alone in 58% of patients and resection after reduction in 42%. Three patients were treated nonoperatively. CONCLUSIONS: Our data support a selective approach to the operative treatment of intussusception in adults. Colonic lesions should not be reduced before resection because they most likely represent a primary adenocarcinoma. Small bowel intussusception should be reduced only in patients in whom a benign diagnosis has been made preoperatively or in patients in whom resection may result in short gut syndrome.

Awareness and attitudes concerning BRCA gene testing.

BACKGROUND: The availability of a commercial test for the breast cancer susceptibility genes, BRCA1 and BRCA2, has generated interest in both the medical community and the general public. METHODS: Patients and family members were approached in the waiting room and asked to fill out an anonymous questionnaire about their awareness of breast cancer genes and breast cancer gene testing, and their desire to be tested. chi2 analysis was used to analyze frequencies between groups. RESULTS: A total of 354 women completed a questionnaire concerning the breast cancer genes BRCA1 and BRCA2. The very young, the very old, and African-Americans were the least informed in terms of awareness of the genes and the availability of testing for the breast cancer susceptibility genes. Jewish people, people with a college education or beyond, people earning more than $30,000 a year, and Caucasians were more aware of the genes and of testing for these genes. Interest in being tested was similar in all groups, except for participants over 60 and those who had only an elementary-school education. CONCLUSIONS: Information concerning the breast cancer susceptibility genes has not reached the general public uniformly. A concerted effort is needed if this information is to be passed on to those people at risk.

Indications for surgical resection of metastatic ocular melanoma. A case report and review of the literature.

CONCLUSIONS: Ocular melanoma can metastasize to the gallbladder and porta hepatic nodes and mimic pancreatic carcinoma. If one suspects metastatic disease, a complete metastatic work-up must be done prior to surgery to prevent unnecessary surgery. If no distant disease is present or the patient is symptomatic, metastatic disease should be resected. PURPOSE: To review the literature pertaining to the spread of ocular melanoma and to determine if distant disease should be resected. PATIENTS AND METHODS: A 44-yr-old Egyptian male presented to an outside institution with mid-epigastric and right upper quadrant abdominal pain. His past medical history was significant for a left orbital enucleation for uveal melanoma in 1982. On physical examination, there was no supraclavicular adenopathy and no skin lesions were noted. There was a mass in the right upper quadrant. The total bilirubin was 4.8 mg/dL. A computed tomography showed a mass in the head of the pancreas and portal vein involvement could not be determined. RESULTS: The patient was taken to the operating room and a pancreatico-duodenectomy was performed for a cystic mass in the head of the pancreas. Final pathology revealed metastatic melanoma in the gallbladder and an enlarged, cystic lymph node growing into the head of the pancreas replaced with metastatic melanoma. The patient did well post-operatively and was discharged home on the eighth post-operative day.

Complications requiring reoperation following pancreatectomy.

CONCLUSIONS: In this series, the overall reoperative rate following pancreatic surgery is 9%. Complications following pancreatectomy that require reoperation fall into four categories: hemorrhage, infectious, delayed gastric emptying, and anastomotic leak. A delay in the management of these types of complications can be fatal. BACKGROUND: Despite the improvement in the morbidity and mortality rates associated with pancreatic resection, complication still arise that require surgical intervention. This study reviews the pancreatic surgical experience at a major medical center to determine the overall reoperative complication rate. STUDY DESIGN: From 1985 to 1995, 107 patients underwent pancreatic resection. There were 50 pancreaticoduodenectomies, 20 total pancreatectomies, and 37 distal pancreatectomies for 102 periampullary or pancreatic cancers and five for chronic pancreatitis. The operative mortality rate was 6.5% and the morbidity rate was 43%. Ten patients (9%) developed complications that required reoperation. RESULTS: Re-exploration was performed in five patients for hemorrhage. Four patients had bleeding intra-abdominally and one had a suture line bleed. One patient developed a wound infection and fascial necrosis which necessitated reoperation. Three patients were explored for sepsis and one was found to have a pancreatic leak. One patient had persistent gastric outlet obstruction and he required conversion of the gastrojejunostomy to a Roux-en-y anastomosis. The mortality rate for re-exploration was 3/10 (30%).

Intraoperative cardiac tamponade complicating esophagogastrectomy.

BACKGROUND: Thoracoabdominal esophagogastrectomy is associated with a number of potential life-threatening complications. PATIENTS: We describe a patient with intraoperative hypotension in which a number of therapeutic maneuvers eventually led to the diagnosis of cardiac tamponade. RESULTS: Once the diagnosis of tamponade was made, it was successfully treated by the release of intrapericardial blood. CONCLUSIONS: Although rare, tamponade should be considered as a cause of hemodynamic instability whenever intraoperative manipulation of the heart has occurred.

The role of laparoscopy in the management of intussusception in the Peutz-Jeghers syndrome: case report and review of the literature.

A 15-year-old girl with known Peutz-Jeghers syndrome and with nausea and vomiting of all ingested food was transferred from an outside institution. Physical examination revealed a palpable upper abdominal mobile mass. Upper gastrointestinal series revealed a stacked coin appearance consistent with small bowel intussusception. An abdominal computed tomographic scan showed a left upper quadrant sausage-shaped mass with invagination of bowel into bowel suggestive of small bowel intussusception. The patient was taken to the operating room for a combined upper endoscopy and laparoscopy. Laparoscopy confirmed the radiologic findings and a jejuno-jejunal intussusception was identified and reduced laparoscopically. The endoscope could not be passed to the level of the polyp, thus, this loop of small bowel was resected laparoscopically. The final pathologic diagnosis was multiple hamartomas. We conclude that laparoscopy is a safe and effective method of managing intussusception in the Peutz-Jegher syndrome because the pathologic lead point is a benign hamartoma. A combined endoscopic and laparoscopic approach can be used to treat proximal small bowel intussusception and this could possibly eliminate the need for laparotomy and reduce the post-operative complications associated with multiple reoperations in this patient population.

The efficacy of neoadjuvant chemotherapy compared to postoperative therapy in the treatment of locally advanced breast cancer.

The current approach to the treatment of locally advanced breast cancer is sequential chemotherapy, surgery and/or radiation, and consolidation chemotherapy. Although significant tumor response is seen with this regimen, there are few studies that compare this approach to postoperative chemotherapy. The purpose of this study was to compare the disease-free and overall survival of patients with locally advanced breast cancer treated with neoadjuvant chemotherapy and surgery to patients treated with surgery followed by adjuvant chemotherapy. Ninety-four patients with stage IIB, IIIA, and IIIB breast cancer were treated with a standardized chemotherapy regimen. The first group, 60 patients who were followed prospectively, was treated with neoadjuvant chemotherapy (NCT) consisting of vincristine, prednisone, cytoxan, methotrexate, and 5-FU (CVFMP) followed by surgery and consolidation chemotherapy with adriamycin. The second group, 34 patients evaluated retrospectively, had surgery followed by postoperative chemotherapy (PCT) with CVFMP followed by adriamycin. Overall median follow-up was 38 months. In the NCT group, 45/60 (75%) patients had a clinical response to induction therapy and the median reduction in tumor size was 50%. The rates of local recurrence, distant recurrence, and death from disease were similar in the two groups. The time to local recurrence was similar for the two groups. However, the median time to distant recurrence was shorter in the NCT group (19 month vs. 31 months, p = NS). Overall median survival among the NCT patients was shorter than for the PCT group (30 vs. 47 months, p = NS). The current study suggests that postoperative therapy is comparable to a neoadjuvant regimen in patients with locally advanced breast cancer with regard to local recurrence, distant recurrence, and overall survival.

Patterns of symptomatology and patterns of torture and trauma experiences in resettled refugees.

OBJECTIVES: The purpose of this study was: (i) to examine the incidence of psychological and medical symptomatology, torture and related trauma in a sample of 191 refugee clients of the Service for the Treatment and Rehabilitation of Torture and Trauma Survivors (STARTTS) in New South Wales (NSW), Australia; and (ii) to identify patterns of current symptoms, patterns of torture and trauma experiences and the relationships between symptoms and experiences. METHOD: Analysis of STARTTS client records permitted the coding of the presence/absence of 41 medical and psychological symptoms and of 33 torture and trauma experiences. Principal components analyses were used to identify patterns of current symptoms and patterns of torture and trauma experiences. Multiple regression analysis was used to identify relationships between current symptoms and traumatic events in the country of origin or en route to Australia. RESULTS: Six factors were extracted for both the symptoms and trauma experiences; the first symptom factor was labelled 'core posttraumatic stress disorder (PTSD)'. Regression analysis showed that threats and humiliation, and being forced to watch others being tortured best predicted scores on this factor. CONCLUSIONS: Although core PTSD is the dominant factor in symptomatology, comorbidity is high, with another three symptom factors emerging as meaningful. However, client reports of threats and humiliation or forced viewing of others being tortured should alert clinicians to the likely development of core PTSD, if it has not already occurred. Other implications of these findings for treatment and service development are discussed.

Breast carcinoma associated with pregnancy and lactation.

The most common malignancy concurrent with pregnancy is breast cancer. Since an increasing number of women are electing to postpone pregnancy to their late thirties and forties, the incidence of breast cancer concurrent with pregnancy is increasing. This article critically reviews the incidence, unique diagnostic and therapeutic considerations, the natural history and ultimate prognosis of breast carcinoma associated with pregnancy and lactation.

Loss of heterozygosity and homozygous deletion of the tpr locus in human gastric cancer.

BACKGROUND: Despite being one of the world's most common neoplasias, there is little information on the molecular events that lead to gastric cancer. Molecular studies have shown that inactivation of tumor suppressor genes by mutation and/or allelic loss is an important genetic alteration in the multistep process of tumorigenesis. METHODS: In an attempt to identify a putative tumor suppressor gene involved in the carcinogenesis of gastric cancer, we performed Southern blot analysis using the tpr probe for 44 patients with gastric cancer, using tumor tissue and normal tissue from the same specimen. RESULTS: Of the 44 samples, 7 (16%) were informative, heterozygous cases for the tpr probe. Three of the informative cases showed a loss of heterozygosity and 3 cases showed homozygous deletion for the tpr probe (6 of 7; 85%). CONCLUSIONS: These findings suggest that tpr gene plays a role in gastric tumorigenesis, and this may be due to a tumor suppressor effect for the tpr gene.

Salvage therapy for pelvic recurrence following curative rectal cancer resection.

INTRODUCTION: Pelvic recurrence is a significant problem following curative resection for rectal cancer. Although treatment options include surgery, chemotherapy, radiotherapy, or any combination of these, the role of surgery remains controversial in management of these patients. PURPOSE: In this study, we have attempted to define the patient with pelvic recurrence following curative rectal surgery who may benefit from reresection. METHODS: A review of the prospective colorectal database at Memorial Sloan Kettering Cancer Center (MSKCC) between 1983 and 1991 identified 25 patients who had pelvic recurrence following a curative resection for rectal cancer and 52 patients who had their initial rectal surgery at an outside institution (OI) and their pelvic recurrence treated at MSKCC. Survival was calculated from time of recurrence by the Kaplan-Meier method, and survival comparisons were made by log-rank analysis. There were no differences between the two groups related to age, gender, type of initial surgery, stage, or use of adjuvant therapy. RESULTS: For the MSKCC group, median time to initial recurrence was 18 months, and median survival was 40 months. Recurrence was symptomatic in 17 patients and asymptomatic in 8 patients. Pain and bleeding accounted for more than one-half of symptomatic recurrences. Of the 17 symptomatic recurrences, 11 (65 percent) had relief of preoperative symptoms. There were no clinical or pathologic factors identified of the primary tumor or recurrence that predicted improved survival following salvage therapy. It was not possible to preoperatively determine which patients could undergo curative reresection. For the OI group, median time to recurrence was 13.7 months, and median survival from time of initial recurrence was 31 months. Curative reresection was the only factor that predicted for improved survival compared with noncurative treatment (P = 0.02). A comparison of the two groups revealed that pelvic recurrence was more likely to be reresected for cure in the OI group vs. the MSKCC group (34/51 vs. 9/25; P < 0.02). There was no survival difference between the two groups when comparing curative with noncurative management of these patients. CONCLUSIONS: Symptoms from recurrent rectal cancer can be palliated with surgery. The only patients who had a survival benefit were those patients in the OI group whose disease could be completely resected. These differences in reresection rates may be attributable to the presence or absence of available planes for dissection around the recurrence in the OI group, as determined by the method of initial curative resection.

Malignant small bowel neoplasms: histopathologic determinants of recurrence and survival.

INTRODUCTION: Small bowel neoplasms account for only a small percentage of gastrointestinal tumors, but their prognosis is one of the worst. PURPOSE: This study examines the histopathology, treatment, recurrence, and overall survival of a group of patients with primary small bowel tumors. METHODS: From 1970 to 1991, a retrospective review identified 73 patients with primary small bowel tumors. Four histologic groups were identified: 1) group 1, adenocarcinoma, 29 patients; group 2, lymphoma, 18 patients; group 3, sarcoma, 8 patients; and group 4, carcinoid, 18 patients. There were 44 men and 29 women. The median age was 57 years (range, 26 to 90). Median follow-up was 15 months. Survival analysis was by the Mantel-Cox and Breslow methods. RESULTS: The most common, by type, was group 1, duodenum; group 2, jejunum; group 3, jejunum; and group 4, ileum. The preoperative diagnosis was made in only 14 patients. The median survival for adenocarcinomas and lymphomas was 13 months, 18 months for sarcomas, and 36 months for carcinoids. Curative resection could be achieved in 48 (65%) of 73 patients, and the median survival was significantly longer for this group (26 months vs. 11 months, p < 0.05). Of the 48 curative resections, 20 patients (42%) recurred: group 1, 8/19 (42%); group 2, 4/12 (33%); group 3, 4/13 (31%); group 4, 4/4 (100%). The median time to recurrence was 17 months, and the median survival after recurrence was 20 months. Adjuvant chemotherapy-radiation therapy did not alter survival in any group. CONCLUSIONS: The preoperative diagnosis of small bowel tumors rarely is made because symptoms are vague and nonspecific. Surgical resection for cure results in improved survival. Recurrence is common and survival after recurrence is poor. Other treatment methods have no role in the management of these patients.

The use of spiral computed tomography in the evaluation of vessel encasement for pancreatic cancer.

CONCLUSIONS: Spiral CT allows for a noninvasive evaluation of the mesenteric arterial and venous vessels. This test can be performed quicker, with less expense, and with a reduced radiation and contrast load than angiography. Comparison studies of angiography and spiral CT are needed in patients with pancreatic cancer to determine the best method of evaluating possible vessel involvement. BACKGROUND: Preoperative imaging of patients with pancreatic cancer is crucial in determining resectability and planning management. Computed tomography (CT) remains the diagnostic procedure of choice for the evaluation of the primary tumor and angiography is the gold standard to evaluate vessel encasement. This case evaluates the usefulness of spiral computed tomography in determining vessel encasement. METHODS: A 53-yr-old female presented with vague abdominal complaints and evaluation revealed a mass in the pancreas. CT suggested portal vein involvement and collateralization was noted in the upper abdomen. Spiral CT revealed normal arterial anatomy and near complete obstruction of the portal vein at the superior mesenteric vein (SMV) splenic vein (SV) confluence. RESULTS: Operative findings confirmed the involvement of the portal vein at the confluence of the SMV and SV. Pancreatico-duodenectomy with portal vein resection and primary anastomosis was performed. The patient's postoperative course was uneventful and she was discharged home on the 13th postoperative day.

Surgical antibiotic prophylaxis and Clostridium difficile toxin positivity.

OBJECTIVE: To examine a possible relationship between prophylactic antibiotic therapy (PAT) and the development of Clostridium difficile toxin (CDT) positivity. DESIGN: Retrospective case-control study. SETTING: Tertiary care medical center in New York, NY. PATIENTS: A total of 357 patients, admitted from November 1992 to April 1994, with positive. CDT assays. Of these, 23 patients (6%) received only PAT for elective surgical procedures. Thirty-nine patients were matched as controls for age, sex, and surgical procedure. MAIN OUTCOME MEASURES: Both CDT positivity and inappropriate use of PAT. RESULTS: Appropriate PAT was used in 26 (42%) of 62 patients (17% cases, 56% controls). The Mantel-Haenszel estimator for the summary odds ratio for the development of CDT positivity from inappropriate use of PAT was 5.1 (95% confidence interval, 1.10 to 23.64). Main duration between the operation and the final antibiotic dose was significantly longer in the CDT-positive group compared with the control group (3.1 vs 1.7 days, P < .05). The length of hospital stay was significantly longer in the CDT-positive group compared with the control group (16.5 vs 10.2 days, P < .05). CONCLUSIONS: The prolonged use of PAT in elective surgical cases increases the risk of developing CDT positivity. The appropriate use of PAT could significantly reduce health costs by eliminating unnecessary doses of antibiotics, by decreasing the rate of CDT positivity, and by shortening the hospital stay. Restrictive policies may need to be implemented to prevent further antibiotic misuse.

Laparoscopic resection of two liver hemangiomata.

New laparoscopic instrumentation coupled with standard surgical techniques allows one to perform procedures previously thought impossible via the laparoscope. This report reviews the natural history, the indications for resection, and the technique of laparoscopic resection of hepatic hemangiomata. Two women, 24 and 62 years of age, were first seen with abdominal pain. A diagnosis of hemangioma was made in each case, and both lesions were removed laparoscopically. Operative blood loss was 200 cc in each case, and neither patient required transfusion. Diets were started on the first postoperative day (POD), and the patients were discharged on the second and fourth PODs without narcotic analgesia. If the size and location of the tumor are favorable, laparoscopic resection of liver hemangiomata can be performed safely. Blood loss comparable to that of open procedures and a quicker recovery support an endosurgical approach to resection of liver hemangiomata in selected cases.

Hybrid genes over-express pertactin from Bordetella pertussis.

Pertactin is a surface adhesin of Bordetella pertussis which is produced in small quantities when expressed from the native prn promoter. Hybrid genes were constructed in which the prn promoter was replaced by either the fha or tox promoter. Recombinant B. pertussis strains containing chromosomally integrated hybrid tox promoter/prn (toxpprn) or fha promoter/prn (fhapprn) genes expressed pertactin at approximately 5- and 8-fold the wild-type level, respectively. The pertactin was correctly processed and secreted and was biochemically and antigenically comparable to its wild-type counterpart, as determined by N-terminal sequence analysis, immunoblotting, peptide mapping, circular dichroism and antigenicity studies. In an adherence assay, a strain over-expressing pertactin was no more adherent than the wild-type strain, but a pertactin-deficient strain was less adherent.

One hundred consecutive hepatic resections. Blood loss, transfusion, and operative technique.

BACKGROUND: Hepatic resection is prone to significant blood loss. Adverse effects of blood loss and transfusion mandate improvements in surgical techniques to reduce blood loss and transfusion requirements. METHODS: One hundred hepatic resections were carried out using a standard surgical technique that includes control of the hilar structures, extrahepatic control of the hepatic veins, and use of the Pringle maneuver. Low central venous pressure and Trendelenburg positioning were used during parenchymal transection. Data were collected retrospectively in the first 36 patients, whereas data were collected prospectively in the remaining 64 patients. RESULTS: Hospital mortality was 3%. Median blood loss was 450, 700, 1000, 1100, and 1500 mL for segmental, nonanatomic, lobar, extended right, and extended left resections, respectively. Major resections were more likely than minor resections to be transfused with albumin (P = .008), fresh frozen plasma (P = .009), and packed red blood cells or whole blood (P = .04). Overall transfusion of packed red blood cells or whole blood occurred in 59 of 100 patients. In the 64 patients who were followed up prospectively, the predeposit of autologous blood decreased the need for homologous transfusions from 56% to 38%. A further reduction in the transfusion rate of 25% could have been possible if all patients in the prospective group had donated 2 U of autologous blood. Patients who predeposited blood were more likely to receive transfusions and to have had a transfusion more than 24 hours after surgery than were patients who did not donate blood. CONCLUSIONS: The surgical techniques used results in acceptable blood loss and transfusion requirements for hepatic resection. This approach is safe, cost-effective, reproducible, and applicable for widespread use.

Limbic encephalitis secondary to malignant thymoma.

A 56-year-old woman presented with memory loss and an enlarging mediastinal mass on chest roentgenogram. Physical findings were normal except for an altered mental status examination consistent with dementia. Further radiologic assessment was nondiagnostic. Surgical resection of a malignant thymoma resulted in clinical improvement. Treatment for limbic encephalitis should be directed at the underlying disease, and symptoms may improve if the tumor is eradicated.