Incidental non-inguinals hernias in totally extra-peritoneal hernia repair.

INTRODUCTION: Totally extra-peritoneal (TEP) inguinal hernia repair allows identification and repair of incidental non-inguinal groin hernias. We assessed the prevalence of incidental hernias during TEP inguinal hernia repair and identified the risk factors for incidental hernias. MATERIALS AND METHODS: Consecutive patients undergoing TEP repair from May 2005 to November 2012 were the study cohort. Inspection for ipsilateral femoral, obturator and rarer varieties of hernia was undertaken during TEP repair. Patient characteristics and operative findings were recorded on a prospectively collected database. RESULTS: A total of 1,532 TEP repairs were undertaken in 1,196 patients. Ninety-three patients were excluded due to incomplete data, leaving 1,103 patients and 1,404 hernias for analyses (1,380 male; 802 unilateral and 301 bilateral repairs; median age, 59 years). Among the 37 incidental hernias identified (2.6% of cases), the most common type of incidental hernia was femoral (n=32, 2.3%) followed by obturator (n=2, 0.1%). Increasing age was associated with an increased risk of incidental hernia, with a significant linear trend (p<0.01). The risk for patients >60 years of age was 4.0% vs 1.4% for those aged <60 years (p<0.01). Incidental hernias were found in 29.2% of females vs 2.2% of males, (p<0.0001). Risk of incidental hernia in those with a recurrent inguinal hernia was 3.0% vs 2.6% for primary repair (p=0.79). CONCLUSIONS: Incidental hernias during TEP inguinal hernia repair were found in 2.6% of cases and, though infrequent, could cause complications if left untreated. The risk of incidental hernia increased with age and was significantly higher in patients aged >60 years and in females.

Pre-eclampsia: a hypothesis for its etiology.

A hypothesis is presented according to which the etiology of pregnancy-induced hypertension can be attributed to increased number of active uterine and arteriolar alpha-adrenergic myometrial receptors from pre-eclamptic patients in comparison with the alpha-adrenergic myometrial and arteriolar receptors from non-pre-eclamptic patients. This condition could result in the increased uterine wall irritability and the decreased uteroplacental blood flow in pre-eclampsia. It is suggested that progesterone fails to induce a reduction in alpha 1-adrenergic receptors in the pre-eclamptic patient. This will require pre-eclamptic patients and matched controls to test the hypothesis.

Benign monoclonal gammopathy: a reassessment of the problem.

Disease associations of clonally restricted serum immunoglobulin (Ig) abnormalities were examined using methods for detecting and characterizing homogeneous Ig that are approximately forty times more sensitive than either cellulose acetate zone electrophoresis or immunoelectrophoresis. Medical records of three hundred five patients with clonally-restricted serum immunoglobulins, including 100 monoclonal gammopathies, and 205 immune complex/oligoclonal patterns were reviewed to obtain the attending physician's discharge diagnosis. Our data confirm lymphoproliferative disorders as the most frequent cause of monoclonal gammopathy (63% of our cases). However, in contrast to earlier reports, we found little evidence to support an association between monoclonal gammopathy and non-reticular malignancy. This does not mean our patients with these disorders had normal serum immunoglobulin patterns; rather, their qualitative abnormalities were, for the most part, not monoclonal. Instead, patients with these diseases had a high incidence of serum immune complexes and their antibody excess sequelae, oligoclonal patterns. Oligoclonal responses are noteworthy because Ig products of the individual clones do not always achieve equivalent serum concentrations, nor are the various clonal products synchronized with respect to the time at which they attain peak concentration. This creates a number of problems for laboratories attempting to characterize such abnormalities; 1) some analytical methods may only be capable of detecting the dominant clone of an oligoclonal pattern, and 2) analysis of a single specimen may yield erroneous results because the unique waxing and waning kinetic pattern of oligoclonal responses may preclude identification of all components at a single time point. We conclude that benign "monoclonal" gammopathies and circulating immune complex/oligoclonal Ig abnormalities occur in the same clinical situations and may be synonymous. The sensitivity of an individual laboratory's analytical methods would then determine which name is applied.

Multiple clonally-restricted immunoglobulins in human sera: disease associations.

Diseases associated with multiple clonally-restricted serum immunoglobulin (Ig) abnormalities present at levels which, in most cases, preclude detection by conventional immunoelectrophoresis, were studied using methods for detection and characterization of homogeneous Ig that are approximately equal to 40 times more sensitive than either cellulose acetate zone electrophoresis or immunoelectrophoresis. Patients with these Ig abnormalities had a high incidence of infectious disease (29% of total cases), malignancy (19%), connective tissue disease (14%) and liver disease (10%). The concentration of individual clonal products was found to wax and wane, but it could not be determined whether these clonally-restricted Ig species represent, wholly or in part, the products of dominant antibody-producing plasma cell clones involved in the patients' response to their disease. We conclude that multiple homogeneous serum Ig abnormalities occur in clinical situations where heightened antigenic stimulation and/or immune reactivity are thought to occur (e.g., infections, malignancies and autoimmunity). Laboratory evaluation of these Ig abnormalities could be useful for diagnostic and/or therapeutic monitoring purposes in situations where the specificity of the clonally-restricted Ig species can be established.

Diffuse parenchymal amyloidosis of lungs and breast. Its association with diffuse plasmacytosis and kappa-chain gammopathy.

A patient had systemic amyloidosis that extensively involved the lungs and breasts. Diffuse parenchymal pulmonary amyloidosis is rare but well described. Involvement of the breast in systemic amyloidosis is, however, most unusual. This patient's amyloidosis was associated with diffuse plasmacytosis and a kappa-chain gammopathy. The plasmacytosis was most prominent in the renal interstitium. Immunoperoxidase staining of the renal infiltrate and breast demonstrated IgG/kappa-staining plasma cells exclusively, suggesting that these cells were a monoclonal proliferation that contributed to the patient's M-protein and possibly to the patient's amyloid deposits.

Postirradiation sarcoma (malignant fibrous histiocytoma) of axilla.

A case is reported of a patient who developed a histologically unusual sarcoma in the axilla and chest wall 8 years after receiving radiation therapy (6500 rad) for carcinoma of the breast. This sarcoma showed light- and electron-microscopic features of a malignant fibrous histiocytoma, a tumor not documented among 24 previously reported cases of postirradiation sarcoma following the diagnosis of breast carcinoma. In addition, the literature is reviewed and discussed regarding postirradiation sarcoma in general following breast carcinoma.

Pancreatic pseudocyst with massive ascites.

The autopsy finding on a patient with pancreatic ascites are discussed in relation to the cause of the ascites. The findings are consistent with the theory that the ascites is due to peritoneal irritation caused by leaking pancreatic secretions.