Colonoscopy-assisted 'trephine' sigmoid colostomy.

Fecal diversion is often required to treat complex traumatic, malignant or inflammatory anorectal conditions. In such circumstances, the formation of a proximal, 'trephine' sigmoid colostomy would avoid the need for, and the associated morbidity of, a formal laparotomy. We describe a technique which combines intraoperative colonoscopy with a diverting, 'trephine' sigmoid colostomy, thereby helping the surgeon to identify the correct loop of bowel, to avoid inadvertent maturing of the wrong end of the divided colon, and to exclude intracolonic lesions.

A decade of experience with abdominal aortic aneurysm repair in octogenarians.

BACKGROUND: Should abdominal aortic aneurysms (AAA) be electively repaired in octogenarians? METHODS: This was a retrospective review of patients' charts over a ten-year period starting in January 1995. This study was conducted at St. Francis Hospital, Roslyn, New York, which is a tertiary referral center. All octogenarians who underwent AAA repair (elective and emergent) were included in this study (mean age 82.9 years). A total of 71 such patients were identified. Sixty-two patients had elective surgery and nine patients had emergent repair of the ruptured AAA. It was hypothesized before the study was conducted that AAA could be repaired in octogenarians with acceptable morbidity and mortality in an institution with vast experience in dealing with this disease. RESULTS: The mean aneurysm diameter was 6.73 cm. Twenty patients (28%) received bifurcated grafts, while 51 patients (72%) received tubular grafts. Four patients had coronary artery bypass graft before aneurysm surgery. Forty-four patients (62%) were male and 27 (38%) were female. The thirty day mortality rate after elective AAA repair was 1.4%, whereas after the repair of ruptured aneurysms was 44.4%. CONCLUSIONS: We concluded that the elective repair of abdominal aneurysms in most octogenarians is a safe and life-prolonging procedure if performed in an experienced tertiary center.

Bilateral hydroureter and hydronephrosis causing renal failure due to a procidentia uteri: a case report.

We report a case of complete uterine prolapse that resulted in bilateral hydroureter, hydronephrosis, and renal dysfunction. The nonoperative reduction of the prolapse with a vaginal pessary reversed the obstructive uropathy and ameliorated renal function. The lower urinary tract should be imaged in patients with complete uterine prolapse. If present, obstructive uropathy should be relieved by the reduction of the prolapse before irreversible renal damage occurs.

Intractable obstructive shock as a result of isolated cardiac metastases: a case report.

Cardiac metastases are uncommon and difficult to diagnose clinically; thus, they are most often found only at autopsy. Here we present a case of isolated right atrial cardiac metastasis found 7 weeks after the resection of the primary tumor, which was an adenocarcinoma of the lung. The patient presented with intractable obstructive shock, caused by a ball-valve effect of the atrial lesion that prevented forward blood flow from the right atrium. Computed tomography (CT) scans and echocardiograms failed to detect the lesion, and the patient died 2 weeks later. An autopsy revealed a large, isolated right atrial metastatic adenocarcinoma.

Malignancy in HIV/AIDs: a single hospital experience.

BACKGROUND AND OBJECTIVES: Our hospital serves an area with a significant number of patients seropositive for the human immunodeficiency virus (HIV). Intravenous drug abuse and heterosexual exposure are by far the predominant risk factors for HIV and acquired immunodeficiency syndrome (AIDS). Seven percent of these patients develop malignancies. Our aim was to study the types of tumor, their distribution, and to evaluate the patients' outcome. METHODS: Of 3,578 patients with HIV infection or AIDS treated between 1993 and 1998, 245 had 1 or more malignancies. Information was collected on age, sex, race, predisposing risk factors for AIDS, malignancies, symptoms at presentation, the time of the onset of AIDS, CD4 cell counts, pathology findings, and mortality. RESULTS: Although aspects of our patients resembled those of previously studied groups of patients with AIDS, there also were ways in which our patients differed from those other groups. Of our patients, 21. 6% had non-AIDS-defining (NAD) invasive malignancies. This was considerably higher than the rate in most studies. Twenty-seven patients with such malignancies died during the study. Forty-two other patients had pre-invasive cancers. Among patients having AIDS-defining (AD) malignancies, 55.9% died, a fact that was related to patients' low CD4 cell counts and late presentation. Our 97 patients with Kaposi sarcoma included 22 women, a relatively high number that may be related to the fact that most of our patients were intravenous drug abusers or had become infected by heterosexual transmission of HIV. CONCLUSIONS: AIDS is associated with a high risk of malignancy and an unusual spectrum of tumors. Patients with invasive tumors have advanced disease at the time of initial presentation. Those with AD tumors have a worse prognosis than patients with NAD tumors. The impact of highly active antiretroviral therapy on both AD and NAD tumors needs to be further evaluated.

Renal transplantation in patients above 60 years of age in the modern era: a single center experience with a review of the literature.

A retrospective study was conducted of 797 patients receiving renal transplants from January 1985 to March 1997. Patient and graft survival was compared for patients above and below the age of 60. Sixty-nine patients < or =60 years old received 73 kidneys. Race: 73% Caucasian, 26% Black, 1% Other. Sex: 68% M. Hypertension (19) and PCKD (15) were the most common diagnoses. Mean peak panel reactive antibody (PRA) was 37.7%. Donor age was 2 to 66 years. Mean Cold ischemic time was 28.1 hours. Follow-up was until death or until 8/30/97. Patients <60 years included: 62% Caucasian, 34% Black, 4% Other; 60% male, Mean PRA 39.3. Of the 69 study patients, 27 died: 19 with a functioning graft, 8 within one year of transplantation. Cardiovascular causes (19 patients, 72%) and infection (7 patients, 24%) were most common. Common causes of graft loss were death with a functioning graft (19) and chronic rejection (15); other causes were acute rejection and primary non-function. Univariate analysis of 18 risk factors showed CHF and past history of vascular surgery significantly (p < 0.05) affected time of return to dialysis. Multi variate analysis did not show these independent variables to be significant. Abnormal ejection fraction and presence of q waves on EKG significantly affected time to death (p < 0.05) on uni- and multi-variate analysis. After censoring patients that died with functioning grafts, difference in graft survival between > or =60 and <59 years was not significant (p > 0.2). In this study, 68% of older patients had allografts functioning at 1 year. The fact that older patients succumb over time from natural causes should not keep patients from transplantation. Immunosuppressive agents need to be limited to reduce the incidence of infection. Criteria need to be refined to define those who are at prohibitive risk, who may not be candidates for transplantation.

Syncytial variant of nodular sclerosing Hodgkin lymphoma.

We report the case history of a 31-year old woman with a rare morphologic form of nodular sclerosing Hodgkin disease (NSHD) termed "syncytial variant." Its histologic features mimic metastatic carcinoma, thymoma, melanoma, non-Hodgkin lymphoma and germ-cell tumor. Antigens expressed on Reed-Sternberg cells, the hallmark of Hodgkin disease, and other neoplastic cells were screened to determine the correct diagnosis. This patient demonstrates the importance of using specific immunohistochemical techniques to clarify the diagnosis of NSHD of the "syncytial variant" subtype.

Emergency surgery for generalized peritonitis caused by cytomegalovirus colitis in a patient with AIDS.

Cytomegalovirus infection of the colon is a late and severe complication in human immunodeficiency virus patients. Despite availability of medical treatment, occasional life-saving emergency surgery must be performed. The controversial surgical aspects of treatment are discussed based upon an unusual case of aseptic generalized peritonitis without perforation. The feasibility and value of limited resection are emphasized.

Acute acalculous cholecystitis in young patients without predisposing factors.

We report the atypical presentation of acute acalculous cholecystitis in four young, otherwise healthy patients. These cases emphasize the fact that the traditional concept of this disease as being associated with trauma, major surgery, or other pathology may no longer be true, and an important number of cases may appear de novo in patients without any predisposing factors.

Modern management of postoperative pain.

In the last 10 years there has been an increased awareness of the need for improved pain management, especially in the postoperative period, to a large extent stimulated by the US Agency for Health Care Policy and Research (AHCPR), which published its clinical practice guidelineS for pain management in 1992. Teams of surgeons, nurses and anesthesiologists now are combining modalities for managing pain so as to provide the most comfortable postoperative course possible for their patients.

Kaposi's sarcoma of the parotid gland in acquired immunodeficiency syndrome.

Parotid gland enlargement is common in patients infected with the human immunodeficiency virus. Although parotitis is the usual histopathological feature in such cases, patients with acquired immunodeficiency syndrome are at high risk of developing both lymphoma and Kaposi's sarcoma of the parotid gland. Human immunodeficiency virus, however, is not detected within the parotid parenchyma even in the presence of Kaposi's sarcoma. The pathway of the virus' entry into the saliva remains unknown.

Acute appendicitis in minority communities: an epidemiologic study.

This study examines the incidence and epidemiological factors of acute appendicitis in various ethnic groups in an urban minority community. The charts of 278 consecutive patients who underwent appendectomy at The Bronx-Lebanon Hospital Center, Bronx, New York, between January 1988 and December 1990 were reviewed. Thirty-eight patients who underwent incidental appendectomy and one patient who had an interval appendectomy were excluded. The remaining 239 patients, all of whom had acute appendicitis, constituted the study population. The incidence of appendicitis for each ethnic group was calculated as a percentage of the total emergency surgical admissions for that group. Acute appendicitis constituted 3.1% of all emergency admissions to the surgical service over the period studied and represented 4.5% of surgical service admissions from the emergency department in Hispanics, 1.9% in African Americans, 1.5% in whites, and 21% in Asians. These differences were statistically significant except some comparisons involving whites. There were no significant differences in the pathological findings regarding the diseased appendix in different racial groups. These results indicate that acute appendicitis is responsible for a higher incidence of emergency admissions among Hispanics than among African Americans. This finding was statistically significant. High white blood cell counts indicated inflammation of the appendix, but had no predictive value for the type of pathology. Surgical findings were similar in all groups.

Preoperative diagnosis of gallbladder perforation by cholescintigraphy.

Perforation of the gallbladder in patients with chronic cholecystitis is rarely diagnosed preoperatively. We describe a case in which early cholescintigraphy permitted preoperative diagnosis and, therefore, prompt laparotomy.

Primary non-Hodgkin lymphoma presenting as ileocolic intussusception.

We report the case of an HIV-seropositive patient with non-Hodgkin lymphoma of the small intestine who presented with an ileocolic intussusception. This lesion fulfilled the diagnostic criteria for primary gastrointestinal lymphoma. Such a neoplasm in an immuno-compromised patient is usually more aggressive and less responsive to treatment than in an HIV-seronegative patient.

Chemical pleurodesis for spontaneous pneumothorax in a patient with AIDS.

Persistent air leak and failure of the lung to expand completely after closed thoracostomy complicate the course of spontaneous pneumothorax in patients with AIDS. In such cases, attempts to discontinue chest tube drainage may fail. The following is a case of a patient with AIDS and spontaneous pneumothorax who responded to chemical pleurodesis with tetracycline.

Intramural abscess of the duodenum resulting from perforated peptic ulcer.

Even in this age of effective medical treatment for peptic ulcers, their complications remain the same. Many require prompt surgical intervention. We present an unusual case of postbulbar duodenal ulcer complicated by intramural perforation and abscess formation. Such complications have a high mortality rate because of frequent delays in diagnosis and treatment caused by a lack of peritoneal signs or other specific clinical findings.

Sarcoidosis presenting as obstructive jaundice.

Sarcoidosis is an uncommon disorder characterized by a multi-systemic granulomatous disease of undetermined etiology and pathogenesis. The diagnosis is established by the presence of a compatible clinical illness and by histologic demonstration of noncaseating epithelioid cell granulomas in the affected organs. Accurate diagnosis requires a thorough evaluation to exclude infectious and neoplastic diseases that can mimic sarcoidosis. Although all organs and systems can be affected, the lungs and intrathoracic lymph glands are the most common sites of involvement. We describe an unusual case of extrapulmonary sarcoidosis presenting as obstructive jaundice.

Perforated solitary jejunal diverticulum.

We report a case of perforated solitary jejunal diverticulum in an 80-year-old woman. Jejunal diverticulosis occurs in 0.07% to 2.0% of the population. Jejunal diverticulitis with perforation is rare and is associated with high mortality. Treatment is surgical resection of the involved segment. Several theories to explain the pathogenesis of jejunal diverticula may relate to manometric or histologic abnormalities of the small bowel.