Traumatic pseudoaneurysm of the thyrocervical trunk.

A case of a pseudoaneurysm of the thyrocervical trunk after a pocketknife stab wound to zone I of the neck is reported. The patient was evaluated and treated in an emergency department with irrigation of the wound, bandage, and oral antibiotics. A large pseudoaneurysm slowly developed over the next 2 months. When the patient arrived at our hospital, he was immediately admitted and arteriograms were obtained. Arteriograms revealed an active leak of blood into a pseudoaneurysm from the thyrocervical trunk. Surgical treatment consisted of proximal and distal ligation of the thyrocervical trunk. This is the first case of a pseudoaneurysm developing only from the thyrocervical trunk due to a stab wound to zone I of the neck. This case and its complication serve to illustrate and emphasize the rationale for routinely imaging the great vessels after all penetrating trauma to zone I of the neck.

Scar endometriosis manifested as a recurrent inguinal hernia.

A 24-year-old woman was initially found to have a right inguinal hernia that occurred suddenly after heavy lifting. A right direct inguinal hernia was found during the initial operative procedure. The round ligament was excised, the internal ring was closed, and the hernia was repaired with mesh placed on the floor of the inguinal canal. Four months after an uneventful postoperative recovery, the patient returned with pain in the right inguinal area. Over the next 2 months, a deep painful bulge developed. Inguinal exploration revealed an endometrioma rather than recurrent inguinal hernia. A portion of the original hernia incision included part of a previous Pfannenstiel incision made 3 years previously for a cesarean section. Scar endometriosis most probably occurred from peritoneal seeding from the Pfannenstiel incision and mimicked the findings of a recurrent inguinal hernia.

Necrotizing fasciitis developing from a brown recluse spider bite.

A 20-year retrospective case series was analyzed to identify the brown recluse spider bite as a cause of necrotizing fasciitis. Data from 31 consecutive patients with necrotizing fasciitis were analyzed. Of the 31 patients with necrotizing fasciitis a brown recluse spider bite was found to be the initial cause in two patients. Both patients with spider bites delayed in obtaining medical treatment, and secondary infection of the necrotic tissue occurred. One patient was diagnosed by frozen section tissue biopsy, and the second patient was diagnosed by clinical examination. All patients in this series had immediate aggressive operative debridement. Both patients survived with functional limbs. There were no deaths in this large series. Necrotizing fasciitis can be caused by a secondarily infected brown recluse spider bite. Successful treatment of necrotizing fasciitis from any cause is associated with early diagnosis, immediate surgical debridement, and supplemental enteral or parenteral nutrition.

Obstructing giant colonic diverticulum.

We report the second case of an obstructing true colonic diverticulum. Of the 103 cases of giant sigmoid diverticulum found in the literature, 13% have been reported as true giant sigmoid diverticulum, ie, containing all layers of the colonic wall. Our 75-year-old patient had clinical symptoms for only 6 months, and endoscopy revealed an almost totally obstructing mass 20 cm from the anus. Surgical resection of the sigmoid colon with a primary anastomosis resolved all of the patient's obstructive symptoms. A flap-valve mechanism was the cause of this true giant colonic diverticulum. Microscopic examination of the diverticulum wall revealed all normal layers of colon wall.

Cutaneous angiosarcoma in an irradiated breast after breast conservation therapy for cancer: association with chronic breast lymphedema.

The authors report a rare case of cutaneous angiosarcoma arising more than 5 years after excision of a 1.5 cm invasive ductal cancer of the breast. All lymph nodes were negative for metastatic breast cancer in this 68-year-old female. The patient had postoperative therapy consisting of 5040 cGy over a 5 week period using a 6 Megavolt linear accelerator. After radiation therapy to the breast and axillae, the patient developed chronic hard, taut edema of the irradiated right breast. Tamoxifen was administered for 5 years and then stopped. Three months after the cessation of tamoxifen, cutaneous angiosarcoma was found by skin biopsy. A complete mastectomy removed all tumor with clear margins. There are less than 60 cases of radiation associated breast angiosarcoma found in the literature. The presence of chronic lymphedema in the breast after radiation therapy possibly contributes to the development and is an early warning sign for later development of secondary angiosarcoma. The characteristic purple nodules and discoloration of the irradiated skin is the hallmark to suspect the diagnosis. The authors recommend long-term clinical surveillance for this tumor for all patients who have received breast conservative surgical therapy with concomitant radiation therapy for primary breast cancer.

Benign enterogenous cyst of the pancreas.

A 26-year-old woman was evaluated for a mass found by computed tomography (CT). Radiographically, the mass resembled a pancreatic cystadenoma. The patient had had left upper quadrant abdominal pain for several years and low grade fevers and indigestion for 5 months. At surgery, a unilocular cystic mass was found anteriorly and caudally to the tail of the pancreas in the lesser sac. The cystic structure was connected to the pancreas by a tubular structure, which was suture ligated and divided. A review of the literature revealed this cyst to be the fifth reported case of enterogenous cyst of the pancreas. The case is unique, differing from previous reports in that ciliated respiratory epithelium, transitional epithelium, gastric mucosa, a bilayered smooth muscle wall, and a serosal surface were present in the cyst wall.

Advances in general and vascular surgical care of Jehovah's Witnesses.

BACKGROUND: Jehovah's Witnesses are an enlarging religious community in the US and throughout the world. Members of this faith refuse administration of blood during medical or surgical therapy even if death may occur as a consequence. The surgeon is consequently faced with difficulties and moral dilemmas of caring for these patients. PATIENTS AND METHODS: From July 1, 1975 to March 1, 1999, the author performed 132 general and vascular surgical procedures on pediatric and adult patients who were Jehovah's Witnesses. RESULTS: A surgical series of 132 patients who are Jehovah's Witnesses is reported. The series includes general surgical procedures in children and adults. Also, vascular surgical procedures in adults are reported. Thirty-one procedures were of significant magnitude to possibly require a blood transfusion. No patient in this series received a blood transfusion. No patient was refused an indicated surgical procedure. Fourteen complications incurred in this series which included one death. The age range of patients in this surgical series was 9 months to 91 years. There was no difference in the male to female ratio. The spectrum of cases reported represents the entire range of procedures seen in general and vascular surgical practices. CONCLUSIONS: The surgical care of Jehovah's Witnesses has become less of an operative risk over the last decade. There are now significant alternatives to the transfusion of blood, such as erythropoietin, iron dextran, aprotinin and Fluosol-DA 20%. Technological surgical developments and advances, such as the cell saver, argon beam coagulator, acute limited normovolemic hemodilution, autologous whole plasma fibrin gel, and controlled hypotensive anesthesia during anesthesia have contributed substantially to a reduction in the operative loss of blood. The time honored rule of hemoglobin of 10 g/dl and a hematocrit of 30% should not require strict adherence in the postoperative care of most patients. The acceptance of a lower transfusion trigger point of hematocrit of 22% and a hemoglobin of 7 g/dl can significantly reduce transfusion requirements without an increase in morbidity. Ethical considerations are discussed and evaluated when treatment restrictions, such as blood transfusion and other life-preserving therapies are limited by religious beliefs or living wills.

Bilateral breast masses as initial presentation of widely metastatic melanoma.

BACKGROUND AND OBJECTIVES: Malignant melanoma is the most rapidly increasing cancer in the world. Metastatic disease occurs in 20% of patients. Metastatic cancer to the breast is rare, but primary breast cancer is one of the leading causes of death in women. In the present study, a large personal series of breast biopsies is reviewed, and 2 cases of metastatic malignant melanoma to both breasts are reported. METHODS: A personal series of 1,200 breast biopsies from 1975 to 1998 were reviewed. In this series, 2 cases of metastatic melanoma to both breasts were identified. RESULTS: Two female patients, ages 31 and 34 years, were evaluated for bilateral breast masses. Both were treated with simple excision of the breast tumor. Postoperatively, both patients were found to have widespread metastatic disease to the brain, lung, and liver. Despite aggressive treatment with chemotherapy and radiation, the patients died at 6 and 22 months, respectively, after the initial presentation. CONCLUSION: Bilateral breast metastasis from malignant melanoma is rare. Care must be taken to make a correct diagnosis of metastatic melanoma rather than of primary breast cancer. An incorrect diagnosis of anaplastic carcinoma can lead to major surgical procedures that are of no value. The long-term prognosis of patients with bilateral breast metastasis from malignant melanoma is poor.

Vertebral arteriovenous fistula as a result of Swan-Ganz catheter insertion: surgical correction in a symptomatic patient.

A case of a vertebral arteriovenous fistula is reported after being caused by insertion of a Swan-Ganz catheter into the vertebral artery prior to cardiac surgery. The patient's clinical symptoms which precipitated re-admission consisted of multiple episodes of diaphoresis and dizziness. A right carotid bruit was detected in the neck. Four vessel cerebral arteriograms could not accurately identify the origin of the fistula. The proximal carotid artery was considered by several radiologists to be the arterial source of the fistula. During the surgical procedure, a tortuous right vertebral artery was found to be the source of the fistula. Surgical correction of the fistula was successful with preservation of the vertebral artery. Recommendations from a review of the literature are made for the current treatment of this rare complication from an insertion of a Swan-Ganz catheter.

Splenic artery tortuosity simulating a splenic artery aneurysm.

Splenic artery aneurysms (SAAs) are most commonly identified on x-ray film by the presence of concentric calcifications in the left-upper abdominal quadrant. Not all calcifications are SAAs. In patients with suspicious left-upper abdominal quadrant calcifications, definitive imaging is necessary to confirm the diagnosis of SAA. This unique case report shows a calcified tortuous splenic artery that simulates the characteristic concentric aneurysmal calcifications of SAA.

Geriatric acute perforated appendicitis: atypical symptoms lead to a difficult diagnosis.

A geriatric man was admitted to the hospital with left-sided chest pain and subsequently had a full cardiac evaluation by a cardiologist. The workup revealed no cardiac abnormalities, and the patient was discharged on the second hospital day. He returned within 48 hours for recurrence of the left-sided chest pain and the interval development of epigastric and left upper quadrant abdominal pain. He was admitted to the hospital for evaluation and serial examinations. Mild diffuse abdominal tenderness developed overnight, and computed tomography of the abdomen revealed a perforated appendix with suppuration. An appendectomy was done immediately. The diagnosis of appendicitis in the geriatric patient is occasionally difficult because of atypical and sometimes misleading physical findings.

Migration of wire mesh into the intestinal lumen causing an intestinal obstruction 30 years after repair of a ventral hernia.

Wire mesh repair of abdominal wall hernias was abandoned almost four decades ago. Recently, a woman who had a wire mesh repair of an incisional hernia in 1964 came to the emergency room with a complete small bowel obstruction. The obstruction was caused by a segment of wire mesh that broke off from the abdominal wall and migrated into the small bowel lumen. During the preceding 2 years, she had been evaluated by two different gastroenterologists for chronic anemia, but they failed to obtain an evaluation of the small intestine. This case report shows that abdominal foreign bodies may migrate into the intestinal tract. I recommend that an evaluation of chronic anemia in the geriatric patient include evaluation of the small intestine.

Primary aortic intimal sarcoma of the endothelial cell type with long-term survival.

Primary tumors of the aorta are rare and are difficult to diagnose preoperatively. These tumors are malignant and ultimately fatal. A patient had initial evidence of aortoiliac obstructive disease. Aortic endarterectomy produced an excellent postoperative clinical result until the pathology report from the endarterectomy specimen revealed aortic sarcoma. The patient refused a second operation for en bloc aortic resection. One year later with recurrent symptoms, the patient underwent en bloc resection of the aorta and common iliac vessels until clear margins were obtained. The tumor was found to be intimal aortic sarcoma of endothelial cell origin. The only metastasis was to bone, and it was controlled with radiation and chemotherapy. The patient lived a total of 8 years from the time of initial diagnosis. Abdominal aortic intimal sarcoma of the endothelial cell type is a rare variety of aortic sarcoma that can be managed successfully if diagnosed early. This specific type of tumor has a longer survival period and better prognosis than other types of aortic sarcoma when managed with aggressive surgical resection, radiation, and chemotherapy.

Necrotizing fasciitis: improved survival with early recognition by tissue biopsy and aggressive surgical treatment.

BACKGROUND: Necrotizing fasciitis is a soft tissue gangrenous infection that is optimally treated by early diagnosis, radical surgical debridement of all involved necrotic tissue, broad spectrum antibiotics, and aggressive nutritional support. The early clinical diagnosis of an area of necrotizing fasciitis is difficult and frequently unreliable. We are reporting a series of cases in which an early, accurate diagnosis of necrotizing fasciitis was established by a frozen section tissue biopsy obtained at the bedside. METHODS: Over a 15-year period, a consecutive series of 43 patients had a bedside biopsy under local anesthesia with immediate frozen section evaluation. All patients were seen in the hospital or emergency room for treatment of an inflammatory process. RESULTS: These 43 patients had bedside biopsy and frozen section evaluation of an inflammatory process. Twelve patients were found to have necrotizing fasciitis. These patients were treated with immediate surgical debridement of all gross necrotic tissue, broad spectrum antibiotics, and adequate nutritional support. All of them survived. No cases of infectious gangrene occurred in the group of patients whose biopsy did not reveal necrotizing fasciitis. CONCLUSION: Frozen section tissue biopsy is a useful adjunct in establishing an early, accurate diagnosis of infectious gangrene.

Interstitial granulomatous dermatitis with arthritis.

BACKGROUND: Interstitial granulomatous dermatitis with arthritis is an uncommon systemic disorder involving the cutaneous and musculoskeletal systems. The eruption may mimic other dermatoses including granuloma annulare, erythema chronicum migrans, and the inflammatory stage of morphea. Key histopathologic characteristics, along with clinical correlation, allow accurate diagnosis. OBJECTIVE: We describe the clinical, serologic, and histologic features in three patients with interstitial granulomatous dermatitis with arthritis. METHODS: Skin biopsy specimens were examined and correlated with the clinical and laboratory findings. RESULTS: Erythematous, annular, indurated plaques on the extremities were present in two women. An erythematous, papular eruption on the head and neck was present in a third patient. All patients had myalgia and migratory polyarthralgias of the extremities along with various serologic abnormalities. Histologic examination revealed a dense lymphohistiocytic interstitial infiltrate involving primarily the reticular dermis. Foci of necrobiotic collagen were present. Vasculitis was absent. CONCLUSION: Interstitial granulomatous dermatitis with arthritis is unique multisystem disease with variable cutaneous expression. Abnormal serologic findings indicate a possible connection to collagen vascular disease.

Necrotizing fasciitis in a renal transplant patient.

We have described a 28-year-old diabetic woman who had necrotizing fasciitis of the perineum three years after receiving a living related renal transplant. The diagnosis of necrotizing fasciitis was made early and she was referred to a tertiary care center where she received radical perineal debridement and aggressive medical and surgical follow-up. Necrotizing fasciitis in a transplant patient is rare; review of the literature shows few cases and no survivors. Our patient has returned to a normal life despite continuation of all immunosuppressive therapy throughout the entire hospital course. In addition, she had a good cosmetic result despite the large necrotic perineal infection. Her survival can be attributed to early diagnosis and referral, immediate and extensive debridement, and aggressive protein replacement.

Inhibition of macrophage- and neutrophil-mediated cytotoxicity by verapamil.

Peripheral blood monocyte-derived macrophages and polymorphonuclear leukocytes (PMNs) obtained from normal donors kill tumor cells in vitro. However, if verapamil is added to the macrophages or neutrophil tumor cell suspensions in microgram concentrations (0.1 microgram to 0.1 mg), there is marked inhibition of tumor cell killing. The inhibitory effect for the macrophages resulted from an effect of verapamil on both the effector and target cells. When either the effector cells or target cells were preincubated with verapamil, they became resistant to the effects of the cytotoxic macrophages. Cytotoxicity was also inhibited when 0.1 mg of verapamil was added to the macrophages monolayers either at the time of addition of the tumor cells or 15-30 min after addition of the tumor cells, whereas no inhibition of cytotoxicity occurred when verapamil was added more than 30 min after the initiation of the cytotoxic reaction. For the neutrophils it was observed that the inhibitory activity resulted from an effect of verapamil on the effector cells rather than the target cells. When the effector cells were preincubated with verapamil they became incapable of killing the tumor cells, whereas preincubation of the target cells with verapamil had no effect on their ability to be killed by the neutrophils. Cytotoxicity was also inhibited when 0.1 mg of verapamil was added to the neutrophil monolayers either at the time of addition of the tumor cells or 15-60 min after addition of the tumor cells, whereas no inhibition of cytotoxicity occurred when verapamil was added more than 60 min after the initiation of the cytotoxic reaction.

Pillars in the colon. Crohn's colitis with unusual endoscopic and morphologic appearances: report of a case.

A case of Crohn's colitis with unusual endoscopic and morphologic appearances is reported. The colitis was asymptomatic and discovered incidentally. Histologic confirmation was obtained following segmental colectomy.