Posthysterectomy vaginal cuff fistula: diagnosis and management of an unusual cause of "incontinence"

OBJECTIVES: Connection between the vaginal cuff and the peritoneal cavity after hysterectomy is a rare event that can mimic urinary incontinence. The appropriate evaluation and treatment of these patients is discussed. METHODS: Five patients underwent excision of the vaginal cuff during a 12-month period. All of these patients had a negative workup for urinary incontinence, except for 1 patient who also had stress incontinence and required a vaginal wall sling at the time of cuff excision. RESULTS: All 5 patients are presently free of excess vaginal drainage or significantly improved, with a mean follow-up of 6 months. One patient developed stress incontinence after cuff excision and later required a vaginal wall sling. There have been no perioperative complications and no evidence of recurrent fistula. CONCLUSIONS: Fistula of the vaginal cuff is a diagnosis of exclusion after urinary incontinence has been ruled out. A high index of suspicion is often required to make the diagnosis because these patients often present with symptoms highly suggestive of urinary leakage. Fistula of the vaginal cuff is successfully treated with excision of the vaginal cuff and the fistulous tract (if identified), with minimal morbidity.     

Heterotopic ossification following total knee arthroplasty requiring surgical excision

We present a case of progressive heterotopic ossification (HO) after cementless total knee arthroplasty causing painful stiffness that was treated with surgical excision. The patient had few risk factors associated with HO, including minimal anterior notching and dissection of the distal femoral cortex. The patient did undergo manipulation; however, this occurred after the diagnosis of HO was made. This report documents a rare case of HO following total knee arthroplasty that required surgical excision.     

A case of hydronephrosis caused by arteriosclerotic compression of the renal pelvis

The purpose of this study was to identify possible causes for the low union rate for surgically stabilized os acromiale. Between February 1990 and November 1995, fusion of an os acromiale was attempted in 15 shoulders in 12 patients at our institution. All patients were men. The mean age was 54 years (range 37 to 63 years). All shoulders had an os mesoacromiale considered too large for simple resection. An associated lesion of the rotator cuff ranging from partial-to full-thickness tear was present in all patients. Eleven had an unfused acromial epiphysis in both shoulders. Two different surgical approaches were used. Seven shoulders were approached through an anterior deltoid-off approach, thus potentially devascularizing the os acromiale. Eight shoulders were approached transacromially, preserving the deltoid origin and hence the terminal branches of the thoracoacromial artery. The technique of internal fixation (tension band wiring) was the same for both groups. The mean follow-up was 44 months (range 13 to 72 months). Union, as demonstrated by axial radiographic views, occurred in 3 out of 7 cases with a devascularized os acromiale and in 7 out of 8 shoulders with a perfused os acromiale (P = .017), respectively. Patients with a united os acromiale had a significantly better functional outcome as measured by the Constant score (P = .0169). In conclusion, aiming at a stable fusion of a sizable and hypermobile os acromiale is probably desirable because it enhances the overall functional result. Obtaining consolidation was possible when the vascularity of the acromial epiphysis was respected.     

In vitro activity of SCH 27899 (Ziracin) against Legionella species

PURPOSE: To report the efficacy of topical mitomycin C in preventing local recurrences after incomplete surgical excision of conjunctival squamous cell neoplasia. METHODS: Four patients presented with unilateral conjunctival tumors. Excisional biopsy results revealed conjunctival intraepithelial neoplasia with an intact basement membrane. Neoplastic cells were present in at least one of the surgical borders of the excised conjunctiva in all four cases. Patients were treated with topical mitomycin C 0.02% three times daily for 2 weeks to prevent recurrences. RESULTS: All four patients were free of clinically detectable tumors after a mean follow-up period of 20 months (range, 16-23 months). Side effects included mild discomfort, redness, photophobia, and punctate epithelial keratopathy that subsided on discontinuation of the medication. CONCLUSION: Postoperative topical mitomycin C application may be a useful adjunct to prevent recurrences in patients with incompletely excised conjunctival squamous cell neoplasia.     

Efficacy of multimodality therapy in advanced renal cell carcinoma

OBJECTIVES: The integration of systemic biologic response modifier (BRM) therapy and surgery to treat metastatic renal cell carcinoma (RCC) is an evolving approach. The purpose of this study was to evaluate the efficacy of this form of multimodality therapy in patients with metastatic RCC. METHODS: Between 1988 and 1996, 14 patients at our institution underwent initial BRM therapy followed by surgical resection of primary and metastatic RCC lesions. Patient records were reviewed to determine the response to BRM therapy, progression-free survival rate, and overall survival rate. The mean follow-up for the entire group was 43.5 months. RESULTS: After BRM therapy, 9 patients manifested an objective response and 5 patients had stable disease. All patients were then rendered disease-free by surgical excision of residual or recurrent metastatic lesions and the primary tumor. The cancer-specific survival rate at 3 years was 81.5%. Currently, 7 patients are alive and disease-free (mean follow-up 41.4 months), 3 patients are alive with recurrent disease (mean survival 48.3 months), 3 patients died of metastatic disease (mean survival 27.9 months), and 1 patient died of an unrelated cause 54.4 months after therapy. CONCLUSIONS: The results of this study suggest that adjunctive surgery after BRM therapy can extend the survival of selected patients with metastatic RCC. Aggressive surgical resection of stable or responding lesions after BRM therapy should be considered in the management of these patients.     

Surgical experience with intracardiac myxomas: long-term follow-up

BACKGROUND: Myxomas are the most common benign intracardiac tumors. This report summarizes our 20-year experience with these tumors. METHODS: Sixty-six patients (25 male) with a median age of 39 years (range, 6 to 70 years) underwent surgical excision of primary or recurrent intracardiac myxomas during the years 1976 to 1996. Symptom duration ranged from 2 to 8 months. There were 55 left atrial myxomas, 10 right atrial myxomas, and 1 biatrial myxoma. Three of the patients were in one family. The surgical approach comprised complete wide excision. RESULTS: There were two early deaths. Late follow-up is 89% (57/64) complete. There was one late death, which was not due to a cardiac cause. Echocardiography at a mean follow-up of 66.9 months (range, 7 to 241 months) showed no recurrence of sporadic myxomas. However, 2 of the 3 patients with familial myxomas had recurrence. CONCLUSIONS: Surgical excision of atrial myxoma gives excellent short-term and long-term results leading to eventual cure of nonfamilial myxomas. However, familial myxomas retain a strong tendency to recur even 20 years after excision.     

Anorectal melanoma--an incurable disease?

PURPOSE: This study was designed to describe recurrence and survival rates after operative treatment for anorectal melanoma and to identify predictive factors for recurrence. METHODS: Records of 50 patients with anorectal melanoma from 1939 to 1993 were reviewed. RESULTS: Overall five-year survival and disease-free survival were 22 and 16 percent, respectively. At the time of diagnosis, 26 percent of patients had metastatic disease, and all died within 12 (mean, 6.3) months. Five-year survival and recurrence rates were identical after either abdominoperineal resection (APR) or wide local excision, both with curative intent. Gender, size of tumor, presence of melanin, positive perirectal lymph nodes, or treatment were not predictive of recurrence. Anorectal melanoma was found incidentally after hemorrhoidectomy or polypectomy in five patients. Three other patients underwent an excisional biopsy of a lesion measuring less than 2 cm. Of these eight patients, five underwent APR and three underwent wide local excision with no microscopic residual tumor at pathology. All developed regional or systemic recurrence at a mean of 21 (range, 4-88) months, and all died of their disease at a mean of 29 (range, 5-98) months. CONCLUSION: Prognosis for anorectal melanoma is poor, irrespective of surgical treatment performed. No predictive factors for recurrence were identified in this series. Wide local excision with a negative margin of a least 1 cm is suggested as the treatment of choice. APR should be reserved for tumor not amenable to local excision or for palliative treatment of large obstructive lesion until effective adjuvant therapies are available.     

Effects of acute administration of transdermal estrogen on postmenopausal women with systemic hypertension

Os acromiale, failure of fusion of the secondary centers of ossification of the acromion process, has been noted as a contributing factor in shoulder impingement syndrome and rotator cuff tears. Treatments for symptomatic os acromiale with or without rotator cuff tears have been reported in the literature and range from excision of small fragments to fusion of larger, fragments with internal fixation and bone grafting. Generally, rotator cuff repairs have been performed when possible. We report an acromion splitting approach through an existing os acromiale to gain exposure for the repair of a massive rotator cuff tear. Subsequent to this repair, the acromion was repaired with internal fixation. Good functional use of the patient's upper extremity was obtained and the patient expressed satisfaction with the surgical outcome. The acromion splitting approach is a viable approach in patients with an os acromiale and a coexistent rotator cuff tear.     

Malignant change in the biliary tract after excision of choledochal cyst

BACKGROUND: Choledochal cyst is a rare congenital condition with a high risk of malignant change if untreated. The risk of malignancy after surgical excision of choledochal cyst is not known. METHODS: Forty-eight patients with choledochal cysts managed over a 21-year period were reviewed, to determine the risk of malignant change after cyst excision. Thirty-nine of 48 patients had no carcinoma at first admission; their mean(s.d.) age was 20(18) years. Thirty-seven of 39 patients underwent cyst excision and cholecystectomy followed by hepaticoenterostomy. RESULTS: Cyst excision was incomplete in 28 of the 37 patients because dilated portions of the biliary ducts remained proximally and/or distally. In these 37 patients, no carcinoma has developed in the remnant proximal hepatic duct or the terminal bile duct after mean(s.d.) follow-up of 9.1(6.4) years. In the remaining nine patients, biliary carcinoma was diagnosed at the first visit. Six patients died from recurrence with a mean(s.d.) survival time of 13(11) months, while three patients were alive and free from recurrence 2 months, 1 year and 7 years after operation. CONCLUSION: Malignant change has not been observed after total or subtotal excision of choledochal cysts in this series.     

Diagnostic problems of circumscribed myositis ossificans: presentation of an atypical case

BACKGROUND: Thrombosis of mechanical prosthetic heart valves (TMPHV) is one of the major complications that accounts for the highest morbidity and mortality related to Bileaflet Mechanical Prosthetic Heart Valves (BMPHV). MATERIALS AND METHODS: During the last six years we had ten cases of bileaflet mechanical valve thrombosis. All patients had undergone emergency surgical interventions except one who developed systemic embolization and massive brain insult immediately after admission for surgery and died two months later. We divided the patients in two groups, first group includes five patients who came in acute pulmonary edema and emergency operation was done either to replace the thrombosed BMPHV (in two) or successful thrombectomy was achieved (in three) and all of them have survived. The second group (four patients) presented with cardiogenic shock and required emergency femoro-femoral bypass. Two patients survived after thrombectomy and the other two could not come off bypass after changing the TMPHV and in spite of Intra-aortic balloon pump, they died 24 and 48 hours after the procedure. All patients received intravenous heparin on admission. Preoperative i.v. Streptokinase was given in two cases, of which one required thrombectomy and the other had valve replacement and died 24 hours later. RESULTS: Early diagnosis and operation still had the best results in TMPHV though thrombolytic therapy was successful in few reported early presented cases. All patients who had thrombectomy of the TMPHV have survived without any morbidity. Follow up of survived patients ranged between two months and six years with a mean of 24.1 months. It is worth attempting thrombectomy of the thrombosed BMPHV rather than re-replacement which carries higher morbidity and mortality, because of the longer ischemic arrest during operation which further depletes the energy of the myocardium. CONCLUSIONS: Though this is a small number of patients to make a definite conclusion, thrombectomy was more feasible in CarboMedics Prosthetic Heart Valves, since its in situ rotation that allows reorientation of its leaflets and declotting of valve hinge to be performed.     

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Primary intracranial malignant lymphoma is rate in clinic. But the incidence tends to be increasing recently. In its relatively short course, children and the slightly more woman headache vomiting IICP (increased intracranial pressure) and corresponding neurofunctional disorders due to various location of the tumors are the main clinical manifestation. Even high density which obviously increased after contrast and peripheral edema may be seen in CT scanning. MRI examination shows lowereal signals in T1 phase. But enhanced signals in T2 phase. Histologically the tumor mass is grayish in color often with a blussed borders (those located in brain surface often have rough borders) to the naked eye. Undermicroscope tumor cell may be seen around blood vessels with decreased cytosol, pathologic rayokinesis and somtimes focal hemorrhage necrosis. All patients in the 40 cases of our study group were connfirmed by surgical excision and patholog examination. Three patients died within half a year after resection. The others showed a survival period ranging from 4 to 20 months after postoperative irradiation solely or combined chemotherapy. Nine patients failed in total resection. Patients undergone postoperative irradiation but without following chemotherapy, only survived 4 to 9.7 months. Thus it can be seen that prolongation of the survival period of primary intracranial malignant lymphoma depends upon possibly early excision combined irradiation and effective chemotherapy.     

Psychiatric outcome of temporal lobectomy for epilepsy: incidence and treatment of psychiatric complications

PURPOSE: To determine the incidence of psychiatric disorders before and after surgical treatment for partial epilepsy and to document the effectiveness of their treatment. METHODS: Fifty consecutive patients treated surgically for focal epilepsy (44 temporal and six frontal) were evaluated by established neuropsychiatric methods before surgery and over a mean period of 2 years after surgery. The patients with interictal dysphoric disorders, with or without psychotic episodes, were treated with tricyclic antidepressant medication alone or combined with serotonin selective reuptake inhibitors and, if necessary, with the addition of risperidone. RESULTS: Before surgery, 25 (57%) of the 44 patients with temporal lobe epilepsy had dysphoric disorders. After surgery, 17 (39%) of the 44 patients experienced either de novo psychiatric complications (six psychotic episodes, six dysphoric disorders, and two depressive episodes) or exacerbation of preoperative dysphoric disorder (three patients). Eight previously intact patients of the 19 (42%) developed dysphoric disorders after surgery that were significantly related to recurrence of seizures. All psychiatric complications occurred in the first 2 months after surgery, except for the six patients intact before surgery, who had a recurrence of seizures. A significant predictor of ultimate excellent psychiatric outcome was complete absence of seizures after surgery. All postoperative psychiatric complications remitted on treatment with psychotropic medication in the compliant patients. CONCLUSIONS: An exceptional psychiatric morbidity is associated with the months after temporal lobectomy. Possible pathogenetic mechanisms are discussed. Antidepressant drugs are very effective in treating the psychiatric disorders of chronic epilepsy; their use in conjunction with the surgical treatment of epilepsy appears to be crucial for the overall positive outcome of a significant number of patients.     

Salvage of failed amputation about the hip in peripheral vascular disease by open wound care and nutritional support

Five consecutive patients with wound and/or plastic surgical flap failure after hip disarticulation or amputation at the lesser trochanteric transfemoral level were treated with local tissue debridement, open wound management, culture-specific antibiotic therapy, and nutritional supplementation. All of the patients underwent amputation about the hip as a result of ischemic necrosis of the lower extremity. Four of the five patients were able to achieve wound healing by second intention. The fifth patient died 2 months after the surgery. None of the patients required revision surgery. One patient underwent split-thickness skin grafting to minimize the need for continued wound care. Local wound management combined with nutritional support and culture-specific antibiotic therapy is an acceptable alternative to major amputation stump revision in patients with potentially high morbidity who fail to heal after amputation about the hip.     

Primary pterygium surgery using the inferior conjunctival transposition flap

The authors investigated a surgical method for primary pterygium without adjunctive therapy and devised a technique called the inferior conjunctival transposition flap. The procedure was performed by making a flap of the inferior conjunctiva after excision of the pterygium, and transpositioning it to make a covering for the bare sclera and donor site and a barrier to pterygium tissue. This method has been used on 54 eyes of 50 patients (mean age 47 years, range 18 to 69 years) with primary pterygium. All of these patients were treated by one surgeon. During a follow-up period of 12 to 26 months (mean 20 months), the pterygium recurred in 3 (5.6%) of the 54 eyes. In all other cases good anatomic and cosmetic results were achieved without any serious complications. The authors concluded that the inferior conjunctival transposition flap is an encouraging technique for the treatment of primary pterygium.     

The treatment of symptomatic os acromiale

During a four-year period, fourteen individuals (fifteen shoulders) who had been seen at the shoulder service of our institution because of pain in the shoulder had a radiographic finding of an os acromiale. On clinical examination, the pain appeared to be due to an unstable os acromiale because the patients had point tenderness over the acromion and pain on forward elevation of the shoulder. The diagnosis of an os acromiale was confirmed on radiographs, magnetic resonance images, or a bone scan. Eight patients had an associated tear of the rotator cuff. The os acromiale was located in the pre-acromion in one shoulder, the meso-acromion in eleven shoulders, and the meta-acromion in three shoulders. At the operation, the anterior aspect of the acromion was found to be unstable in all shoulders. Eleven patients (twelve shoulders) had open reduction of the os acromiale and insertion of an autogenous iliac-crest bone graft. Of those patients, four (five shoulders) had open reduction and internal fixation with a tension-band procedure with use of pins and wires. Only one of those shoulders had a solid osseous union, and the other four shoulders had a non-union that was due to a disruption of the fixation. The remaining seven patients (seven shoulders) had open reduction and internal fixation with use of cannulated screws and a tension-band construct; a solid osseous union was achieved in all but one of them. One patient had excision of the pre-acromion, which relieved the pain. Two patients who had had failed open reduction and internal fixation had excision of a grossly unstable os acromiale in the meso-acromion; both patients had pain and weakness after this procedure. Of the twelve shoulders that had open reduction and bone-grafting, seven had union of the os acromiale; the average time to radiographic and clinical union was nine weeks (range, seven to twenty weeks). We concluded that, although it is rare, symptomatic unstable os acromiale does occur and can be effectively treated with use of autogenous bone-grafting and internal fixation with a rigid tension-band construct and cannulated screws.     

Angiofibroma. Changes in staging and treatment

OBJECTIVE: To identify specific preoperative tumor characteristics and potential surgical decisions that ultimately place a patient at a greater risk for tumor recurrence. DESIGN: The clinical presentation, management, and prognosis of 23 consecutive cases of juvenile nasopharyngeal angiofibroma were reviewed retrospectively from January 1, 1977, to June 30, 1993. A minimum follow-up of 12 months was necessary for study inclusion. SETTING: A single, tertiary care pediatric facility. INTERVENTIONS: All available preoperative imaging studies were reevaluated to ensure consistency in reporting. Preoperative computed tomography was performed in 21 patients, but only 18 scans were available for review. Preoperative angiography with embolization was performed in 21 of 23 patients. Surgical excision was the primary mode of treatment in 22 of 23 patients, and complete surgical excision was possible in 21 of 23 patients. MAIN OUTCOME MEASURES: The rate of recurrence was examined with respect to time of presentations, initial tumor stage, intraoperative blood loss, and surgical approach. RESULTS: When compared with patients without a recurrent tumor, there was no difference in age at presentation, primary symptom, or duration of symptoms before diagnosis. Preoperative tumor stage was found to be the primary factor affecting tumor recurrence. A recurrence rate of 21.7% (five of 23 patients) was identified after an average 6-year follow-up. A trend toward use of the midfacial degloving approach for surgical exposure was identified and was not associated with an increased risk of recurrence. All patients were ultimately cured of their tumor without the need for open craniotomy despite a 32% incidence of stage IIIA and IIIB tumors. No deaths were reported during the study. CONCLUSIONS: Juvenile nasopharyngeal angiofibromas are benign tumors occurring almost exclusively in adolescent males. Recent advances in radiographic imaging techniques allow for more accurate preoperative staging, especially in regard to skull base involvement. Recognition of the extent of the tumor before surgical extirpation reduces the risk of recurrence.     

Surgical treatment of carpal hygroma in cattle: 17 cases (1990-1994)

This retrospective study describes the case reports of 17 cattle suffering from precarpal hygroma, admitted to the clinic for food animals and horses, University of Berne, between 1990 and 1994. The following criteria were evaluated: sex, age, and bodyweight, case history, clinical findings at admission, surgical technique, aftercare, and short- and long-term results. The hygroma was congenital in 3 cases and acquired at the age of 2 to 84 months in 14 cases. Characteristic clinical findings at admission were a non painful, fluctuating, well delineated swelling of the precarpal area with a maximal diameter of 6 to 20 cm, which did not provoke any lameness. Treatment consisted of surgical excision of the bursa. Surgery was performed under general anesthesia with the animal in lateral recumbency and the affected limb positioned uppermost. After placing a tourniquet proximal to the carpal joint, routine preparation and draping of the surgical field, the bursa was resected completely, a penrose drain introduced, and primary wound closure attempted. Aftercare consisted of parenteral antimicrobial treatment and immobilisation of the affected limb with a full-limb splint bandage to prevent wound dehiscence and seroma formation. Primary wound healing was achieved in all cases. At the time of long-term follow-up evaluation, 4 to 48 months after surgery, telephone conversation with the owners revealed uncomplicated healing in 16 cases. In one case, recurrence of the hygroma had occurred a few weeks after surgical excision had been performed.     

Disorders associated with clinically severe obesity: significant improvement after surgical weight reduction

BACKGROUND: Surgical treatment for patients with clinically severe obesity mainly aims to reduce morbidity. METHODS: Sixty-two patients were examined for disorders associated with morbid obesity before and after surgical weight reduction by vertical banded gastroplasty. All patients were followed-up for 12 to 48 months. RESULTS: At the end of the first postoperative year, 84% of the patients had lost at least 50% of their excess weight. Of the 218 weight-related pathologic conditions existing before the operation, 131 (60%) were completely cured, 50 (23%) showed significant improvement, and only 37 (17%) remained unchanged. The same percentages were obtained for patients followed tip for 24, 36, and 48 postoperative months. CONCLUSIONS: Surgical treatment of clinically severe obesity has a significant effect on the health of the patients by eliminating the associated disorders.     

Video-assisted minimal access in excision of left atrial myxoma

BACKGROUND: Minimal access surgery with video-assisted endoscopy has been applied to the correction of intracardiac lesions. We report our experience using this technique in surgical excision of left atrial myxoma in 3 patients. METHODS: From November 1995 to March 1997, 3 female patients, ages 45 to 80 years (mean, 62.7 years), received emergency operations for excision of left atrial myxoma. These operations were performed through a right anterior submammary minithoracotomy or right parasternal incision with the assistance of endoscopy during femoro-femoral cardiopulmonary bypass. The myocardium was protected by continuous coronary perfusion with fibrillatory arrest or cardioplegic arrest with aortic cross-clamping. RESULTS: All the tumors were excised completely through the right atrial approach. The bypass time was 92 to 148 minutes (mean, 111 minutes). The operation time was 3.2 to 4.4 hours (mean, 3.7 hours). There were no hospital deaths. Follow-up, which ranged from 6 to 19 months (mean, 10.5 months), was complete in all patients. Transthoracic echocardiographic examination showed good ventricular function without any residual tumors. Patients were found to be in New York Heart Association functional class I or II. They were satisfied with the good cosmetic healing of the incision. CONCLUSIONS: Our experience demonstrates that minimal access surgery is a technically feasible, safe, and effective procedure in surgical excision of left atrial myxoma.     

Fibrolamellar hepatocellular carcinoma: results of partial liver resection

AIM: To assess the results of partial hepatic resection in the treatment of fibrolamellar hepatocellular carcinoma. PATIENTS AND RESULTS: We present six cases of Fibrolamellar hepatocellular carcinoma treated by partial hepatic resection. There were five females and one male with a mean age of 20 (2.6) yr. Five patients were stage IVA and 1 IVB based on the Union International Against Cancer Classification. Two patients, due to recurrent disease, needed further pulmonary resection and a hilar lymphadenectomy. All six cases underwent major resection, three with vascular reconstruction. No operative mortality was recorded; half of the patients displayed some degree of morbidity. One patient died six months after the operation and the rest are alive at 78, 41, 24, 12 and 9 months. We believe that even in advanced cases, an aggressive surgical policy even with vascular reconstruction is justified in patients with fibrolamellar hepatocellular carcinoma.