Hair-thread tourniquet syndrome.

We report a case of hair-thread tourniquet syndrome involving the labia majora of a 14-year-old autistic child. 'Hair-thread tourniquet' refers to the process whereby a thread of hair leads to the ischaemic strangulation of an appendage or other piece of tissue. Uncommonly recognized, this syndrome has gradually gained recognition since its first description in 1612. As it remains infrequent, many have attributed its aetiology to abuse or socio-cultural practices. We review the published literature on this infrequent but important paediatric condition.

Laparoscopic transperitoneal clipping of the inferior mesenteric artery for the management of type II endoleak after endovascular repair of an aneurysm.

We report the case of a high risk patient with an abdominal infrarenal aortic aneurysm (AAA) who was treated by endovascular technique and the subsequent management of a type II endoleak by the laparoscopic approach. In this case, a 74-year-old woman with a 6-cm infrarenal AAA underwent endovascular repair using a bifurcated stent-graft device. Surveillance CT scan showed a persistent type II endoleak at 1 week and 3 months after the operation. Angiography confirmed retrograde flow from the inferior mesenteric artery (IMA). Attempted transarterial embolization of the IMA via the superior mesenteric artery was not successful. Laparoscopic transperitoneal IMA clipping was performed. Subsequent aortic duplex scan and CT scan confirmed complete elimination of the type II endoleak. We conclude that a combination of endovascular and laparoscopic procedures can be used to manage AAA successfully.

CT in acute mesenteric ischaemia.

Enhanced computed tomography (CT) is frequently performed for possible bowel ischaemia. It has the distinct advantage of possible detection of the causes of ischaemia. Radiologists therefore need to be familiar with the spectrum of diagnostic CT signs. We present the CT imaging findings in surgically proven cases of small bowel ischaemia. In addition to signs pertaining to the underlying aetiological pathology, bowel dilatation, bowel wall thickening, mural gas, occlusion of mesenteric vessels, ascites and infarct of other abdominal organs were observed.

Gastric rupture after Heimlich maneuver and cardiopulmonary resuscitation.

Choking is a common emergency problem. The Heimlich maneuver is unquestionably effective in relieving airway obstruction. Serious and life-threatening complications may arise, however, if the maneuver is applied incorrectly. Two cases of gastric rupture after Heimlich maneuver are reported. Lay public, paramedics and the medical professionals should be educated with the correct technique of Heimlich maneuver and its potential complications. All patients receiving Heimlich maneuver should be examined by an experienced physician.

Thoracoscopic esophageal mobilization for pharyngolaryngoesophagectomy.

BACKGROUND: Pharyngolaryngoesophagectomy (PLE) for hypopharyngeal cancers and tumors of the cervical esophagus is a procedure of significant morbidity and mortality. Conventional esophageal mobilization is performed with the transhiatal dissection technique. Thoracoscopic esophageal mobilization is tested as an alternative to determine whether surgical outcome can be improved. METHODS: From 1994 to 1998, thoracoscopic mobilization was carried out in 30 consecutive patients who underwent PLE (PLE-TS). This was compared to a historical cohort of 30 patients who had PLE with transhiatal mobilization (PLE-TH). RESULTS: In PLE-TS, thoracoscopic esophageal mobilization was successful in 28 patients (93%). Median blood loss was 700 mL (range, 164 to 3,000 mL) compared to 1,000 mL (range, 400 to 2,200 mL) in group PLE-TH, p = 0.21. Thoracoscopy time was 90 minutes (range, 60 to 180 minutes). Total operating time were 392 minutes (range, 180 to 570 minutes) and 300 minutes (range, 150 to 550 minutes) in PLE-TS and PLE-TH, respectively (p = 0.03). Major pulmonary complications occurred in 7 (23%) and 8 (27%) patients in PLE-TS and PLE-TH, respectively (p = 0.77). Cardiac complications occurred in 7 (23%) and 5 (17%) patients in PLE-TS and PLE-TH, respectively (p = 0.52). Thirty-day mortality rates were 3.3% and 10% (p = 0.6) and hospital mortality rates were 13% and 17%, (p = 1.0). CONCLUSIONS: Thoracoscopy was safe and feasible. Morbidity and mortality after PLE was not significantly reduced. The theoretical advantage offered by thoracoscopy may be offset by the lengthened time of one-lung anesthesia.

Esophageal small cell carcinomas: clinicopathologic parameters, p53 overexpression, proliferation marker, and their impact on pathogenesis.

OBJECTIVE: To evaluate the clinicopathologic features and the roles of p53 and MIB-1 in esophageal small cell carcinoma. METHOD: Twenty patients (14 men and 6 women) with esophageal small cell carcinoma treated in our hospital from 1982 through 1996 were studied. The clinicopathologic features, treatment received, and survival data of these patients were documented. Representative tissue was collected from each tumor, and immunohistochemical preparations for p53 protein and MIB-1 were made. RESULTS: Small cell carcinoma accounted for 1.3% of all esophageal malignant tumors. The median age of patients at presentation was 60 years. On gross examination, the tumors were large ulcerative lesions (median length, 7.5 cm). In 17 patients in whom p53 immunohistochemical study was performed, p53 protein was detected in 65% (9 of 17). All stage IV tumors were negative for p53 expression. The median tumor cell MIB-1 score was high at 855 (range, 810-964) positive cells per 1000. Overall median survival was 3.4 months. In patients who underwent chemotherapy, there was significant response. CONCLUSIONS: Esophageal small cell carcinoma is an aggressive tumor. Overexpression of p53 is associated with early stages of carcinogenesis. The high proliferative index, as defined by the MIB-1 immunohistochemical method, may be related to aggressive behavior and high sensitivity to chemotherapy and radiotherapy.

The clinicopathological significance of p21 and p53 expression in esophageal squamous cell carcinoma: an analysis of 153 patients.

OBJECTIVE: The p21 gene is thought to play a central role in tumor suppression. The aim of this study was to examine the clinicopathological role of p21 and p53 in esophageal squamous cell carcinomas. METHODS: The expression of p21 and p53 proteins in 153 Chinese patients (131 men, 22 women) with resected esophageal squamous cell carcinomas was investigated by the immunohistochemical method. Correlation between p21 and p53 expression and clinicopathological features was examined. RESULTS: The expression of p21 and p53 was detected in 70% and 64% of the tumors, respectively. The staining of p21 and p53 was also found in squamous carcinoma in situ, dysplasia, and nontumor epithelium. p21 expression was often weak in the suprabasal cells and found in better differentiated tumors. There was no significant correlation between the expression of p21 and the abnormal accumulation of p53. The prognosis of the patients depended on the size, stage, and p21 expression of the lesion. In stage III lesions with tumor diameter < or = 7.5 cm (n = 93), patients with loss of p21 expression had better survival. The survival rates of patients were worse if they had expression of both p21 and p53. CONCLUSIONS: Thus, p21 and p53 had prognostic value for esophageal squamous cell carcinomas. Loss of p21 expression was shown without p53 alternations, indicating that other mechanisms are also involved in turning off the gene. The pattern of p21 and p53 expression predicts an aggressive clinical course of esophageal squamous cell carcinomas.

Helicobacter pylori status and endoscopy follow-up of patients having a history of perforated duodenal ulcer.

BACKGROUND: The aim of this study was to determine whether the recurrence of symptoms or ulcer disease in patients with a history of perforated duodenal ulcer is related to Helicobacter pylori infection. METHODS: One hundred sixty-three consecutive patients with history of perforated duodenal ulcer unrelated to nonsteroidal anti-inflammatory drugs underwent upper endoscopy. Any recurrent symptoms or complications were documented. Regardless of the endoscopic findings, three antral biopsy specimens were taken for histologic examination and a rapid urease test. RESULTS: There was a preponderance of men (male/female = 5.3:1). The mean age was 55.9 years. Sixty-seven (41.1%) patients gave a history of recurrent epigastric pain, seven of whom also had a history of bleeding ulcer. Upper endoscopy was performed at a mean of 74.5 +/- 7.1 months after operation. Positive endoscopic findings were noted in 68 (41.7%) patients; H. pylori was found in the biopsy specimens from 77 (47.2%) patients. Recurrent duodenal ulcer was found in 29 (17.8%) patients and was significantly related to male gender, recurrent epigastric pain, bleeding ulcer, longer interval from previous operation, and positive H. pylori status. Positive H. pylori status and male gender were independent factors associated with recurrent duodenal ulcer. CONCLUSIONS: Recurrent ulcer disease in patients with a history of perforated duodenal ulcer is related to H. pylori infection.

Laparoscopic insufflation with room air causes exaggerated interleukin-6 response.

BACKGROUND: The gut is a central organ in the postoperative stress reaction. We previously reported that measuring gut-mucosal cytokines may more accurately reflect the response to operative stress. Additionally, we have shown that the gut demonstrates a blunted cytokine response after laparoscopy as compared with laparotomy. METHODS: To further investigate whether this differential response is caused by exposure of the peritoneal cavity to general atmospheric air during laparotomy, 80 A/J mice were randomized equally into four groups: CD (carbon dioxide [CO2] pneumoperitoneum), RA (room air pneumoperitoneum), AP (anesthesia and port insertion only), and PC (pure control, no intervention). Pneumoperitoneum was established and maintained at 3 mmHg for 60 min. All the mice were killed 4 h after the intervention. Jejunal mucosa and serum samples were collected and analyzed for interleukin-6 (IL-6) levels. Results were analyzed by analysis of variance (ANOVA). RESULTS: Gut-mucosal IL-6 in the RA group was significantly higher than in all other groups: RA, 1,354.5 +/- 117.9* vs. CD, 964.3 +/- 114.0 vs. AP, 960.2 +/- 86.2 vs. PC, 908.0 +/- 83.6; *p < 0.05. The CD group did not show a significant increase in gut-mucosal IL-6 as compared with the AP and PC groups. Similarly, RA resulted in significant increases in serum IL-6 as compared with AP and PC, whereas CD showed no significant difference: RA, 161.3 +/- 66.2* vs. 95.1 +/- 1 vs. AP, 10.6 +/- 5.3 vs. PC, undetectable; *p < 0.05. There was no difference in serum IL-6 level between CD or any of the other groups. CONCLUSIONS: Exposure of the peritoneal cavity to atmospheric air, independently of the trauma of abdominal access, causes an exaggerated serum and gut mucosal IL-6 response 4 h after intervention. The beneficial effect of CO2 laparoscopy may be caused by the exclusion of general atmospheric air from the peritoneal cavity.

Esophageal carcinoma in a patient with bleeding esophageal varices.

More than 20 cases of esophageal carcinoma have been reported to develop after endoscopic injection sclerotherapy (EIS), and this technique is implicated in the pathogenesis of esophageal cancer. We report a case of esophageal carcinoma presenting as a superficial ulcer in a patient with esophageal varices with no prior EIS. Whether the development of esophageal carcinoma in patients with previous EIS is coincidental or consequential is controversial. Such carcinoma might have already existed before EIS in some reported cases. A causal relationship between EIS and esophageal carcinoma cannot be established without further clarification by a well-designed study.

Minimal increase in gut-mucosal interleukin-6 during laparoscopy.

BACKGROUND: The gut clearly plays a significant role in postoperative recovery. Other investigators have shown an increase in gut-mucosal cytokines in septicemia and burn models. We tested the effects of laparotomy and laparoscopy on gut-mucosal IL-6 production. METHODS: A/J mice were randomized to three groups: control, laparotomy plus bowel manipulation (OBM), and laparoscopy plus bowel manipulation (LBM). Serum and gut-mucosal samples obtained at 4 and 8 h after surgery were analyzed for IL-6. RESULTS: We found that OBM is associated with increased serum and gut-mucosal IL-6 at both 4 and 8 h after surgery. In contrast, LBM showed a blunted response in serum IL-6 and no change in gut-mucosal IL-6 at both time intervals. CONCLUSIONS: We conclude that laparoscopy minimizes trauma to the peritoneal environment, thereby decreasing the gut's inflammatory response to operation. This differential response of the gut may partially explain the preservation of gut function following laparoscopy.

Pancreatic insulinomas. A 15-year experience.

OBJECTIVE: To describe our experience in the management of patients with pancreatic insulinomas, emphasizing the need for preoperative localization and the outcome of surgical treatment. DESIGN: A case series. SETTING: A university hospital in Hong Kong. PATIENTS: From 1981 to 1995, 27 patients with pancreatic insulinomas were surgically treated; the mean follow-up was 25.4 months. MAIN OUTCOME MEASURES: Postoperative morbidity and euglycemia during the follow-up period. RESULTS: The accuracy of tumor localization by ultrasonography, computed tomography, and angiography was 33%, 44%, and 52%, respectively. Venous sampling for an insulin assay regionalized 90% of the tumors. In 24 patients with solitary tumors, most lesions detected or missed by preoperative localization could be either seen (n = 14) or palpated (n = 22). Intraoperative ultrasonography (n = 17) has been routinely performed since 1987; nonpalpable tumors were imaged in 2 of 15 patients with solitary tumors. Eight solitary occult tumors were detected by palpation alone or a combination of palpation and intraoperative ultrasonography. Operative mortality occurred in 1 (3.7%) of the 27 patients, while major morbidity developed in 9 (33%) of the patients. Euglycemia was achieved in 25 patients. Surgery cured all patients with benign insulinomas, whereas the cure rate for patients with malignant neoplasms was only 33%. The type of surgical treatment or correct preoperative localization did not affect the outcome of surgery. CONCLUSIONS: Pancreatic insulinomas can be readily localized intraoperatively despite failed preoperative localization studies. Surgical treatment cured benign adenomas but was associated with notable morbidity.