An unusual complication of a biliary stent-small bowel perforation of an incarcerated hernia sac.

We present a case of small bowel perforation after migration of an endoscopically inserted biliary stent inside an incarcerated hernia sac. A review of the literature revealed no other report of stent morbidity associated with hernias. The management and implications are discussed.

Resection of metastatic renal cell carcinoma.

PURPOSE: Resection of solitary metastases from renal cell carcinoma (RCC) is associated with a 5-year survival rate of 35% to 50%. Selection criteria are not well defined. PATIENTS AND METHODS: We retrospectively analyzed our experience with 278 patients with recurrent RCC from 1980 to 1993. RESULTS: One hundred forty-one of 278 patients underwent a curative metastectomy for their first recurrence (44% 5-year overall survival [OS] rate), 70 patients underwent noncurative surgery (14% 5-year OS rate), and 67 patients were treated nonsurgically (11% 5-year OS rate). Favorable features for survival were a disease-free interval (DFI) greater than 12 months versus 12 months or less (55% v 9% 5-year OS rate; P < .0001), solitary versus multiple sites of metastases (54% v 29% 5-year OS rate; P < .001), and age younger than 60 years (49% v 35% 5-year OS rate; P < .05). Among 94 patients with a solitary metastasis, lung (n = 50; 54% 5-year OS rate) was more favorable than brain (n = 11; 18% 5-year OS rate; P < .05). Survival rates after curative resection of second and third metastases were not different compared with initial metastectomy (46% and 44%, respectively, v 43% 5-year OS rates; P = nonsignificant). Favorable predictors of survival by multivariate analysis included a single site of first recurrence, curative resection of first metastasis, a long DFI, a solitary site of first metastasis, and a metachronous presentation with recurrence. CONCLUSION: Selected patients with recurrent RCC who can undergo a curative resection of their disease have a good opportunity for long-term survival, particularly those with a single site of recurrence and/or a long DFI.

The protective effect of L-arginine on ischemia-reperfusion injury in rat skin flaps.

The objective of this study was to examine whether the administration of L-arginine, a precursor of nitric oxide and substrate of nitric oxide synthase, prior to reperfusion could lead to decrease in neutrophil-mediated tissue injury and improved flap survival. Epigastric island skin flaps were elevated in 70 rats and rendered ischemic. Thirty minutes prior to reperfusion, the rats were treated with intraperitoneal saline (n = 15), L-arginine (n = 15), D-arginine (n = 15), or N omega-nitro-L-arginine methylester plus L-arginine in equimolar amounts (n = 15). Flap survival at 7 days and neutrophil counts at 24 hours were evaluated. Flap necrosis as expected in the sham group of animals (n = 10) was 0.0 percent, while the control (saline-treated) animals had 59.6 percent necrosis. Animals treated with L-arginine demonstrated a significant decrease in flap necrosis to 12.7 percent. This protective effect was almost completely negated by N omega-nitrol-L-arginine methylester, which significantly increased flap necrosis to 49.3 percent and was much less pronounced with D-arginine (28.6 percent). Neutrophil counts were significantly decreased in flaps from L-arginine-treated and sham animals versus both saline and N omega-nitro-L-arginine methylester-treated groups. We conclude that administration of L-arginine prior to reperfusion can significantly reduce the extent of flap necrosis and flap neutrophil counts due to ischemia-reperfusion injury. This protective effect is completely negated by nitric oxide synthase inhibition. Since L-arginine reduces the number of neutrophils within the flap and the extent of flap necrosis only in the presence of active nitric oxide synthase, we hypothesize that this protective effect of L-arginine on ischemia-reperfusion injury is secondary to a nitric oxide-mediated suppression of neutrophil-mediated injury.

The radial forearm fasciocutaneous free-tissue transfer for tracheostomy reconstruction.

Wide resection of parastomal tissues after stomal recurrence significantly benefits patient survival. The defect thus created often requires coverage with a flap that provides (1) well-vascularized skin and soft tissue for uncomplicated wound closure and (2) pliable skin that can be inset easily around the often-shortened tracheal remnant. The radial forearm fasciocutaneous flap is ideal for these types of reconstructive problems. It should therefore be included on the reconstructive ladder for tracheostomy reconstruction both as a first choice and as a backup flap.

Fat necrosis following breast reduction.

Between 1984 and 1992, 300 patients underwent breast reduction in our unit. Three patients during the follow-up period were found to have a palpable mass in their breast. Excision biopsy revealed fat necrosis of the breast. The clinical, radiological and pathological features of fat necrosis of the breast are described.

The management of decubitus ulcers by musculocutaneous flaps: a five-year experience.

Large decubitus ulcers can be treated by using many methods, including musculocutaneous flaps. Musculocutaneous flaps provide reliable, well-vascularized cover and often can be revised in patients with secondary recurrence. We have treated 30 patients with large decubitus ulcers during a 5-year period by using musculocutaneous advancement flaps of the gluteus maximus, the hamstring muscle, and the tensor fasciae latae. There were two complications treated by debridement with flap advancement in 1 patient and the use of another flap in the second patient. Four patients developed a recurrent ulcer, which was treated by reelevation and advancement of the original flap in all patients. The general management and overall results are presented.