Synchronous bleeding of liver adenomatosis and possible relation to acoustic trauma.

BACKGROUND: Solitary hepatic adenoma is a rare tumour but adenomatosis of the liver is even less common; it has been defined arbitrarily as more than four adenomas within otherwise normal hepatic parenchyma. Usually asymptomatic, the main clinical presentation is abdominal pain secondary to bleeding from the tumour. CASE OUTLINE: A 40-year-old woman admitted for abdominal pain and operated within a few hours due to circulatory instability was found to have synchronous bleeding from three out of four liver cell adenomas. The onset of pain followed shortly after exposure to particularly loud music. The three bleeding tumours were enucleated. The fourth lesion was left in situ; during outpatient follow-up it decreased in size and eventually disappeared. DISCUSSION: Although rupture with bleeding is a well-known presentation of liver cell adenomas, synchronous bleeding from more than one tumour is exceedingly uncommon and this may be the first reported case. Enucleation of the tumour is easy to perform even during active bleeding. Small asymptomatic tumours may be followed without surgical intervention.

The laparoscopic second look for ischemic bowel disease.

BACKGROUND: Survival after acute vascular ischemia depends on a second look laparotomy to detect extending bowel compromise and to verify the integrity of the anastomosis. In a series of five consecutive patients with acute ischemic bowel disease, we used laparoscopic technique to determine if a formal laparotomy could be avoided. METHODS: following the resection of ischemic bowel in five consecutive patients, two laparoscopic trocars were inserted in the lower abdominal quadrants and covered by sterile gloves. Forty-eight to 72 h following the primary operation, the abdomen was inflated via a trocar and secondary assessment done by laparoscopy. RESULTS: In all patients, the integrity of the anastomosis and viability of the remaining bowel was accurately assessed by laparoscopy. CONCLUSIONS: Using minimally invasive techniques, a second look laparotomy was avoided in 5 patients with ischemic bowel disease.

A novel polymorphism in intron 6 of the human p53 gene: a possible association with cancer predisposition and susceptibility.

We present a novel polymorphic 8-bp sequence in intron 6 of the p53 gene that maps between bp 55 and 62 of the 3' end of exon 6. Of normal blood samples, 32% were heterozygotic for this polymorphism and display a NN' genotype, whereas 68% of the population is homozygotic for the N genotype. The rare homozygotic genotype N' was detected only in four blood samples of cancer patients. Peripheral blood of gastrointestinal (GI) and breast tumor patients demonstrated a higher incidence of heterozygosity (50%) than that of normal individuals. Analysis of the distribution of this polymorphism in tumor samples showed loss of heterozygosity (LOH). This LOH during tumor progression could exhibit preference to each one of the polymorphic alleles. The rare presentation of one allele and the increased incidence of heterozygosity in carcinoma patients may suggest an association between this polymorphism with cancer predisposition and susceptibility. The fact that genetic alterations occurring in noncoding regions may play a role in tumor development only further increases the extent of involvement of p53 in carcinogenesis.

p53 mutations in matched primary and metastatic human tumors.

Mutations in the p53 tumor suppressor gene have been found to be the most frequent genetic alterations in human malignancies. To further examine the idea that neoplastic progression is associated with mutations in the p53 gene, we analyzed matched primary and metastatic tumor samples. The samples included 15 pairs of breast cancer and metastases to lymph nodes, four pairs of gastrointestinal adenocarcinomas and metastases to liver, one colon adenocarcinoma and metastasis to a lymph node, and one lung carcinoma and metastasis in the pleura. Genomic DNA or cDNA from each tumor sample was amplified by the polymerase chain reaction and labeled by using one biotinylated primer. The DNA strands were separated with magnetic streptavidin beads and sequenced directly. p53 mutations were detected in 11 of 21 patients (52%) in either primary tumors, metastases, or both. In six of these patients the primary tumor and matched metastasis shared the same single mutation. In the other patients an additional mutation in the primary tumor only or a mutation in the metastasis only was observed. Our data suggest that tumor development and progression toward metastasis involves structural alterations in the p53 gene that occur early in carcinogenesis. In some cases, genetic changes in metastatic spreading may also include the appearance of a mutation in a metastasis derived from a primary tumor expressing wild-type p53, a selection of metastatic cells with a single mutation from a primary tumor expressing two different mutations, or loss of heterozygosity.

A comparison between digitally-guided fine needle aspiration and ultrasound-guided transperineal core needle biopsy of the prostate for the detection of prostate cancer.

OBJECTIVE: To prospectively examine the accuracy of fine needle aspiration (FNA) for the detection of prostate cancer. Ultrasound-guided core needle biopsy of the prostate was used as the standard to which the FNA results were compared. PATIENTS AND METHODS: One-hundred patients who had been referred for urological evaluation were suspected of having prostate cancer on the basis of digital rectal examination (DRE) and/or transrectal ultrasound (TRUS). All were further evaluated by digitally guided transrectal FNA and by TRUS-guided transperineal core needle biopsy. RESULTS: Prostate cancer was identified in 54 patients by core needle biopsy and in 45 by FNA. The sensitivity of FNA was 81% and both specificity and positive predictive value were 98%. CONCLUSION: FNA is easily performed, has negligible morbidity and offers prompt results. These data suggest that FNA is a reasonable initial diagnostic procedure for the detection of prostate cancer. Core needle biopsy may be reserved for patients with negative cytology who are clinically suspected of having prostate cancer. In selected patients, FNA may be used as an alternative to core needle biopsy for diagnosis, treatment planning and follow-up.

Colocutaneous fistula--a rare complication of percutaneous endoscopic gastrostomy.

Although the percutaneous endoscopic gastrostomy technique for feeding is a fairly common procedure now, we have not come across a complication such as described below, a probable migration of the tube from the stomach to the colon, without any objective proof for this.

Laparoscopic endocorporeal mobilization followed by extracorporeal sutureless anastomosis for the treatment of carcinoma of the left colon.

Surgery has become progressively more reliant on technology. The technique of colonic anastomosis utilizing the biofragmentable anastomotic ring (BAR) is one such example. The benefits of therapeutic laparoscopy have been applied to the arena of colorectal surgery. A case is presented that combines these two modalities in a patient with colon cancer, laparoscopic mobilization of the large bowel, exteriorized resection, and BAR anastomosis.

[Laparoscopic cholecystectomy].

80 patients underwent laparoscopic cholecystectomy, of whom 64 were females and 16 males (age range 20-70 years) and 15 had undergone previous abdominal operations. 3 of the 80 operations were converted to open cholecystectomy. In 11, preoperative ERCP was performed, in 2 of whom common bile duct stones were detected. In 7 intraoperative cholangiography was performed. The average hospital stay was 2.2 days. Based on this and other studies, laparoscopic cholecystectomy seems to be the operation of choice for symptomatic cholelithiasis.

The feasibility of an ambulatory surgery service for military personnel.

In the past, ambulatory surgery has been considered unsuitable for military personnel. In this pilot study, 69 members of the Israel Defense Forces underwent a variety of surgical procedures on an ambulatory basis in a central, university-affiliated general hospital. The waiting time for surgery was considerably reduced. The patients, the army, and the hospital staff were satisfied with the service. Although further study is needed, ambulatory surgery appears to be a suitable and advantageous modality for military personnel.

Carotid endarterectomy under local anesthesia supplemented with neuroleptic analgesia.

Surgical treatment of the carotid artery is being performed increasingly under local rather than general anesthesia. The advantage of local anesthesia is that neurologic function can be continuously assessed while the carotid arteries are cross-clamped, and unnecessary shunting can, thus, be avoided, with resulting sedation, analgesia, alpha blockade and blood pressure stability. The main objection to the use of local anesthesia is the anxiety of the patient. We overcame this difficulty in a series of 42 patients by supplementing the local anesthetic with neuroleptic analgesia. The possible disadvantages of neuroleptic administration are apnea and prolonged sedation. Only one of the patients we studied required an intraluminal shunt. One patient died of cardiac disease and one suffered an early postoperative stroke, which subsequently resolved. We believe that local anesthesia, supplemented by neuroleptic sedation and analgesia to overcome patient anxiety, should be more widely used for carotid endarterectomy.

Transcatheter occlusion of inferior mesenteric arteriovenous fistula: a case report.

Transcatheter embolization of the inferior mesenteric artery with steel coils was performed for the control of massive lower gastrointestinal bleeding and sepsis. The bleeding and sepsis was caused by a very large arteriovenous fistula of the inferior mesenteric vessels. This iatrogenic lesion developed and became symptomatic just 5 weeks after an anterior resection of the rectum was performed. Following embolization, the patient made a speedy recovery from the sepsis and no recurrent bleeding was noted.

Vertical banded gastroplasty for the treatment of morbid obesity.

We report the technique and results of vertical banded gastroplasty in 86 morbidly obese patients. At 12 months, the patients had lost a mean of 57% of their excess body weight; 36 months, they had lost 70%. The most severe early complication was perforation of the esophagus. Other complications included disruption of the vertical staple line in three cases and migration of the mesh band. We were able to achieve satisfactory weight reduction in all patients over a period of 36 months. In view of the good results, reduced morbidity, and absence of mortality, we feel that vertical banded gastroplasty is the surgical treatment of choice for morbid obesity at present.

Selective operative cholangiography.

This is a study of 505 patients who underwent surgical treatment of the gallbladder. Of this group, 343 were operated upon without operative cholangiography with an incidence of retained stones of 0.03 per cent. One hundred and ten underwent operative cholangiography according to five indications. These are: stones in the common duct on ultrasound or roentgenography; obstructive jaundice; dilation of the common duct greater than 1.2 centimeters; previous cholangitis, and preoperative pancreatitis. The advantages of selective operative cholangiography versus routine cholangiography are discussed in detail. We concluded that the selective operative cholangiography should be the preferred procedure.

The everted rectal stump technique for the application of the distal pursestring suture in the construction of stapled anastomoses.

The everted rectal stump technique for the application of the distal pursestring suture was used successfully in three patients to perform a low stapled reconstructive anastomosis in the treatment of carcinoma of the rectum. Two of the patients were Dukes' Stage B and one patient was classified as Dukes' Stage C. The postoperative course was uneventful. There were no complications and all three were free of tenesmus and cutaneous irritation and were continent of flatus and feces, with one to three movements per day.

Pseudoaneurysm of the dorsalis pedis artery.

Two cases of post-traumatic pseudoaneurysm of the dorsalis pedis artery are presented. Both were managed by resection and vascular reconstruction with a successful result. It is suggested that this, rather than resection and ligation, is the preferred treatment in these cases.

Coumadin-induced skin necrosis.

Two women developed coumadin-induced skin necrosis. A 16-year-old woman sustained necrosis on the leg after a single dose of the drug, and a 59-year-old woman developed gangrene of most of her left breast.

Surgical treatment of primary hyperhidrosis. A report of 42 cases.

Forty-two patients suffering from primary hyperhidrosis underwent upper dorsal sympathectomy using the supraclavicular approach. The postoperative course and results were devoid of complications. All the patients except one were satisfied with the results of surgery, which greatly improved the quality of their lives.