Closure versus non-closure of hernia defect during laparoscopic ventral hernia repair with mesh.

PURPOSE: Laparoscopic ventral hernia repair with mesh versus laparoscopic ventral hernia defect closure with mesh reinforcement. The primary end-point was recurrence. METHODS: Retrospective review of patients who underwent laparoscopic ventral hernia repair for small- and medium-sized hernias between July 2000 and September 2011. These patients were divided: (1) repair with mesh alone (non-closure group) and (2) those with hernia defect closure and mesh reinforcement (closure group). The closure group was further divided by technique: percutaneous versus intracorporeal closure of the defect. RESULTS: 128 patients were studied: 93 patients (72.66 %) in the non-closure group and 35 patients (27.34 %) in the closure group. Follow-up was available in 105 patients (82.03 %) at a mean of 797.2 days (range 7-3,286 days). In the non-closure group there were 14 patients (15.05 %) with postoperative complications and 8 patients (22.86 %) in the closure group, four of which were seromas. Fourteen patients (19.18 %) developed recurrent hernias in the non-closure group with an average time to presentation of 23.17 months (range 5.3-75.3). Two patients (6.25 %) developed recurrent hernias in the percutaneous group with an average time to presentation of 12.95 months (range 9.57-16.33). There have been no recurrences in patients whose defect was closed intracorporeally. CONCLUSION: Although our study demonstrated a difference in recurrence rates of 19.18 % in the non-closure group versus 6.25 % in the closure group, the difference did not reach statistical significance. A larger series with longer follow-up may demonstrate clinical significance.

Right lower quadrant abdominal pain due to appendicitis and an incarcerated spigelian hernia.

Spigelian hernias are uncommon and difficult to diagnose because of their location in the aponeurosis in the anterior abdominal wall. When they occur on the right side, the symptoms can include nonspecific abdominal pain mimicking appendicitis. We present an adult with right lower quadrant abdominal pain due to an incarcerated spigelian hernia and acute appendicitis. Early recognition and prompt surgical treatment were important to the successful treatment of our patient.

Gastric adenocarcinoma of Meckel's diverticulum as a cause of colonic obstruction.

A 45-year-old-female patient with no prior surgical history presented with bowel obstruction. At laparotomy, a bulky tumor arising from the ileum, which completely obstructed the sigmoid colon, was found. A left hemicolectomy followed by a transverse colostomy and a Hartman's pouch were performed. Pathological examination of the specimen revealed gastric adenocarcinoma arising from a Meckel's diverticulum in the ileum. Malignant transformation from a Meckel's diverticulum is an uncommon occurrence. This case illustrates that successful management of a symptomatic Meckel's diverticulum, even with malignant transformation, can be achieved by surgical resection.

Small-cell carcinoma of the rectum: report of two cases.

Small-cell carcinoma of the rectum is an infrequent pathologic finding, and its precise incidence is unknown. Its incidence is less than 0.2 percent among all colorectal cancers. This tumor manifests highly aggressive behavior. The treatment of choice is combination chemotherapy similar to that used for small-cell carcinoma of the lung, but in small localized tumors surgery plus chemotherapy is an alternative. We present two cases of small-cell carcinoma of the lower rectum and a review of the literature.

Intestinal volvulus following laparoscopic cholecystectomy.

The introduction of laparoscopic cholecystectomy has revolutionized the surgical management of biliary diseases. As the application of this procedure becomes more popular, a variety of associated complications have emerged. We present a rare case of a patient who developed an intestinal volvulus 3 days following laparoscopic cholecystectomy. The precipitating factors of this complication and review of literature are discussed.

Human immune cells mediate catecholamine secretion from adrenal chromaffin cells.

OBJECTIVES: To determine the ability of human mononuclear cells to produce factors that cause catecholamine secretion from adrenomedullary chromaffin cells; to determine conditions that stimulate mononuclear cells to produce such factors; and to compare these results with catecholamine secretion in response to the cytokines interleukin (IL)-1 and IL-2. DESIGN: Randomized, controlled, prospective study using in vitro conditions. SETTING: University research laboratory. SUBJECTS: Human mononuclear cells and porcine chromaffin cells. INTERVENTIONS: Circulating human mononuclear cells were isolated and cultured overnight in RPMI media. Cell-free media from these cultures (conditioned media) were then tested for the ability to cause epinephrine secretion from porcine chromaffin cells. Mononuclear cells were stimulated with phytohemagglutinin or by mixing cells from two different individuals while suppression was tested with dexamethasone. Catecholamine secretion in response to IL-1 and IL-2 (50 and 500 units/well, respectively), or nicotinic agonist dimethylphenylpiperazinium (10 microM, which mimics the action of acetylcholine), was tested for comparison. MEASUREMENTS AND MAIN RESULTS: Isolated porcine chromaffin cells had stable catecholamine content at the time of secretion measurements, and catecholamine release from cells into the media was measured using electrochemical detection after high-performance liquid chromatography separation. Catecholamine secretion was expressed as a percentage of the total cellular content. Epinephrine secretion due to human conditioned media was 6.9 +/- 1.0% compared with 1.4 +/- 0.6% for control media (p < .05) and 14.6 +/- 3.3% for dimethylphenylpiperazinium (p < .05). Epinephrine secretion with conditioned media from mixed cells (mixed leukocyte reaction) was 16.6 +/- 1.2%, which was higher than the epinephrine secretion caused by media from a single donor (6.9% +/- 1.0, p < .001). Pretreatment with dexamethasone inhibited the formation of bioactive products from mixed mononuclear cell preparations. Cytokines IL-1 and IL-2 did not stimulate chromaffin cell epinephrine secretion above background release with control media incubation. In all cases, norepinephrine secretion was similar to that of epinephrine, and results are included in all figures. CONCLUSIONS: Factors released from human immune cells can mediate epinephrine and norepinephrine release from adrenomedullary cells through a nonneural mechanism. Such immune cell factor release can be modulated by immunostimulation and steroid suppression. Release of such factors in vivo may contribute to increased circulating epinephrine in response to infectious challenge and may be an important factor in the critically ill patient.

Comparative analysis of bedside and operating room tracheostomies in critically ill patients with burns.

The objective of this study was to demonstrate that bedside burn intensive care unit tracheostomy is a safe and cost-effective procedure and has advantages over operating room tracheostomy. The charts of all patients who underwent tracheostomies in the burn unit between January 1990 and September 1993 were reviewed retrospectively. All tracheostomies were performed by residents in their second to fourth postgraduate years. The identical operating room technique was used for all bedside procedures including complete instrument tray, electrocautery, and adequate lighting. Standard tracheostomies were routinely performed at the bedside instead of the operating room in an attempt to deal with an increasing number of critically ill patients with burns requiring operating room surgical procedures. No patient-specific criteria were used to determine whether bedside or operating room tracheostomy would be performed. Charges for bedside intensive care unit and operating room tracheostomy were compared. Group t test and chi-square analysis were used with significance set at p < 0.05. Forty-three tracheostomies were performed in the 45-month period reviewed. Twenty-five tracheostomies performed in the operating room were compared with the 18 tracheostomies performed at the bedside in the burn intensive care unit. No statistical difference existed in age, sex, mean total body surface area percent burned, mean inspired oxygen, mean positive end expiratory pressure, mean pretracheostomy intubated days, presence of inhalation injury, or complication rate between groups. The average combined cost for operating room and anesthesia was $1740 per tracheostomy performed in the operating room. No charge was given to the patient for a bedside tracheostomy apart from the surgeon's fee and tracheostomy tube.(ABSTRACT TRUNCATED AT 250 WORDS)