Splenectomy for breast carcinoma diffusely metastatic to the spleen presenting as severe transfusion-dependent anaemia and thrombocytopaenia.

We report a 48-year-old woman with metastatic infiltrating lobular carcinoma of the breast. Though her metastatic disease remained stable, she was repeatedly admitted for symptomatic anaemia and treated by red blood cell and platelet transfusions with increasing frequency as time elapsed. Abdominal examination and ultrasound revealed splenomegaly (27 cm span). A bone marrow biopsy showed fibrosis and foci of metastatic carcinoma. Splenectomy ameliorated her transfusion-dependent anaemia and thrombocytopaenia. Histopathology revealed multiple foci of metastatic carcinoma and scattered foci of extramedullary haematopoiesis. Differential diagnosis of anaemia and thrombocytopaenia in patients with cancer include bone morrow involvement by cancer cells, iron-deficiency anaemia, microangiopathies and chemotherapy suppression of haematopoiesis. Splenic involvement with cancer is common in patients with multivisceral disease. Many may regard transfusion-dependent severe anaemia and thrombocytopaenia as an end-stage disease in these patients. Nevertheless, palliative splenectomy should be considered in patients with possible hypersplenism who will otherwise survive for a relatively prolonged period of time.

Transversus Abdominis Plane Versus Ilioinguinal and Iliohypogastric Nerve Blocks for Analgesia Following Open Inguinal Herniorrhaphy.

OBJECTIVES: We hypothesized that preoperative (pre-op) ultrasound (US)-guided posterior transversus abdominis plane block (TAP) and US-guided ilioinguinal and iliohypogastric nerve block (ILI+IHG) will produce a comparable analgesia after Lichtenstein patch tension-free method of open inguinal hernia repair in adult men. The genital branch of the genitofemoral nerve will be blocked separately. METHODS: This is a prospective, randomized, controlled, and observer-blinded clinical study. A total of 166 adult men were randomly assigned to one of three groups: a pre-op TAP group, a pre-op ILI+IHG group, and a control group. An intraoperative block of the genital branch of the genitofemoral nerve was performed in all patients in all three groups, followed by postoperative patient-controlled intravenous analgesia with morphine. The pain intensity and morphine consumption immediately after surgery and during the 24 hours after surgery were compared between the groups. RESULTS: A total of 149 patients completed the study protocol. The intensity of pain immediately after surgery and morphine consumption were similar in the two "block" groups; however, they were significantly decreased compared with the control group. During the 24 hours after surgery, morphine consumption in the ILI+IHG group decreased compared with the TAP group, as well as in each "block" group versus the control group. Twenty-four hours after surgery, all evaluated parameters were similar. CONCLUSION: Ultrasound-guided ILI+IHG provided better pain control than US-guided posterior TAP following the Lichtenstein patch tension-free method of open inguinal hernia repair in men during 24 hours after surgery. (ClinicalTrials.gov number: NCT01429480.).

Computed tomographic diagnosis of incarcerated Meckel's diverticulum in a patient with bilateral spigelian hernia.

INTRODUCTION: Spigelian hernia is an uncommon abdominal wall hernia occurring through the linea semilunaris located near the lateral border of the rectus abdominis muscle. CASE REPORT: We report an extremely rare case of incarcerated Meckel's diverticulum within a spigelian hernia diagnosed by multidetector computed tomography.

Small intestine perforation due to metastatic uterine cervix interdigitating dendritic cell sarcoma: a rare manifestation of a rare disease.

Interdigitating Dendritic Cell Sarcoma (IDCS) is an infrequent dendritic cell tumor which mainly affects the lymphatic system. Intestinal metastasis from uterine IDCS is extremely rare. Here we report a case of a 76-year-old female presenting with vaginal bleeding and acute abdomen. The final diagnosis revealed a small bowel perforation due to metastatic involvement from uterine cervix IDCS. In this paper, we report the clinical manifestation, computed tomography and histopathological findings helpful for the accurate diagnosis of this rare tumor.

Smaller staple height for circular stapled gastrojejunostomy in laparoscopic gastric bypass: early results in 1,074 morbidly obese patients.

BACKGROUND: Anastomotic leaks, stenosis, and bleeding from the gastrojejunal anastomosis (GJA) after gastric bypass may carry high morbidity and mortality. To date, the standard operation with the circular stapler (CS) used the 25 mm with a staple height of 4.8 mm. We present herein our experience with the 3.5-mm staple height. METHODS: A total of 1,074 morbidly obese patients who underwent fully stapled laparoscopic Roux-en-Y Gastric Bypass over a period of 18 months were included in the study. Mean body mass index was 41.9 (range 28.6-70.7). Mean age was 40.9 years (range 15-74 years). Mean operating time was 73 min (range 43-210 min) and the mean length of stay was 4.2 days (range 1-25 days). The 30-day complication rate associated with GJA was prospectively analyzed. RESULTS: Twenty patients (1.86%) developed postoperative bleeding. Four developed GJA bleeding (0.37%). One leak was recorded from the vertical staple line of the gastric pouch, but no leaks from the GJA were seen. Conversion to open approach was required in two patients (0.18%). Reoperation and readmission rates were 1.7% and 1.8%, respectively. Perioperative complications were observed in 34 patients (3.1%). One case of clinical GJA stenosis was detected in a mean follow-up of 10.5 months (range 5-20 months). There was no mortality in our series. CONCLUSION: Compared to our previous experience with 4.8 mm CS, creating the GJA using a smaller staple height significantly reduced the bleeding rate and seems to be a safe technique that potentially reduces other complications related to the GJA as reported in the literature.

Isolated spontaneous dissection of the celiac trunk in a patient with bicuspid aortic valve.

Isolated spontaneous dissection of celiac trunk is a rare entity. The spontaneous dissection of the visceral artery occurs without aortic dissection. The most consistent presenting symptom is acute onset abdominal pain. Complications consist of ischemia, aneurysm formation, and rupture. We report an exceptional case of an isolated spontaneous dissection of the celiac trunk which occurred in a 49 year old male with a previously undiagnosed bicuspid aortic valve (BAV). We also describe the classical appearance in different imaging modalities with a particular emphasis on multidetector computed tomography, and discuss the clinical manifestation and its relationship to BAV.

[Evaluation of the impact of a clinical pharmacist on the quality and cost of pharmacotherapy in a general surgical department, the Hillel-Yaffe Medical Center].

BACKGROUND: Clinical pharmacy could be defined as an umbrella of services aimed at maximizing the pharmacotherapeutic effect, minimizing the risk for developing adverse drug effects and reducing drug expenditures for the health care system. Clinical pharmacists, in Israel and abroad, have been practicing in different health care settings aiming to implement the principles mentioned above. Most of the articles previously published reviewed the role of the clinical pharmacist in internal medicine wards or in intensive care units. This article focuses on the role of the clinical pharmacist in a general surgery department and the influence of this service on the quality and cost of pharmacotherapy and on intravenous antibiotic therapy in particular. AIMS: Improving the quality of pharmacotherapy while optimally using economic resources in a general surgery ward. METHODS: During September 1999 to August 2000, the clinical pharmacist joined physician rounds in the surgical ward. During the rounds he advised physicians about clinical and economical aspects of drug treatment, and collected data on his activity on a specific designated form. The data was processed on a central computerized database, and analyzed to determine the influence of the clinical pharmacist on clinical and economical outcomes. RESULTS: At the end of the study period the following were found: The pharmacist made 219 interventions. These included adverse drug effects, which were identified and/or prevented. When considering the economic data, a substantial reduction of 56% in intravenous antibiotic therapy was noted (direct saving of about 140,000 NIS). Such savings were accompanied by changes in the prescribing patterns in the department, which were translated into increased rate of oral antibiotic prescribing and reduction in the use of certain i.v. antibiotics while undamaging the quality of the pharmacotherapeutic effect. CONCLUSION: The results of this study indicate that participation of a clinical pharmacist during physicians rounds improved the quality of the pharmacotherapy, assisted in changing clinicians prescribing habits, and at the same time significantly reduced the direct expenditures on medications in general and of intravenous antibiotic therapy in particular.