Place of transmetatarsal amputations: a 5-year experience and review of the literature

A series of 30 patients who underwent transmetatarsal amputation over a 5-year period was analysed. The indications for amputation were gangrene, rest pain and ulceration. The mean age was 75 years and the male to female ratio was 3:2. A higher level of amputation was required in 50% of patients. Of a series of factors analysed for their influence upon outcome (age, diabetes, peripheral pulse status, pre-existing infection, smoking habits, previous digital amputation, prior sympathectomy and/or vascular reconstruction), none had any predictive value in terms of wound healing.     

Renal plasmacytoma: Mayo Clinic experience and review of the literature

Extramedullary plasmacytoma arising in the kidney is rare. Only 8 cases have been reported. Recently, we noted the ninth case, the second case seen at the Mayo Clinic. Clinically, the tumor mimics a renal cell carcinoma or a transitional cell carcinoma of the renal pelvis.     

Popliteal artery injury: Royal Perth experience and literature review

BACKGROUND: Popliteal artery injury is uncommon but poses a significant challenge in Australian trauma care. Blunt trauma and knee dislocations appear to be associated with higher amputation rates. The aim of the present study was to review the authors' experience with this condition and discuss the best approach to investigation and management. METHODS: The medical records of all patients with popliteal artery injury (n = 19) who were entered prospectively onto the Royal Perth Hospital Trauma Registry from 1995 to 2003 were reviewed. Their demographic data, investigations, primary operative procedures, fasciotomy, primary and secondary amputation rates and mortality were determined. RESULTS: There were 17 male and two female patients with a median age of 34 years (range 17-62 years). Most patients (84%) were under 40 years in age. Blunt trauma was the commonest cause of popliteal artery injury (68.4%), and 84.6% of the patients had associated skeletal injury. The amputation rate in the present study was 26.3% (5/19). There were no intraoperative or in-hospital deaths. Three of 13 patients (23%) with blunt trauma underwent amputation, compared to two of six (33.3%) with penetrating injury. Two of three amputee patients in the blunt trauma group had dislocated knees. CONCLUSION: Despite technical improvements in management of popliteal artery injury, a high amputation rate is still seen, especially in patients with one or more of the following factors: extensive soft-issue injury, associated skeletal trauma, knee dislocation, and prolonged ischaemia time. Measures to reduce the amputation rate, ranging from more prompt diagnosis to modified surgical treatment techniques, are discussed.     

Malacoplakia: a 25-year experience with a review of the literature

Our experience with 9 cases of genitourinary malacoplakia is reviewed. The bladder was involved in 4 patients, ureter in 2, prostate in 1, testis in 1 and a combination of prostate, bladder, rectum and pelvic adnexae in 1. The female-to-male ratio was 2:1. Escherichia coli was present in 7 of 8 available urine cultures. Of 9 patients 2 had associated immunocompromised conditions. A variety of therapeutic approaches were chosen, depending mainly on location and extent of disease. These varying combinations of medical and surgical therapies produced resolution of disease in 8 of 9 patients. Generally, upper tract involvement requires surgical intervention, while most cases of lower tract involvement can be managed with antibiotics and endoscopic resection. Rare cases of extensive lower tract malacoplakia may require extirpation for cure.     

Nonoperative management of blunt splenic injury: a 5-year experience

OBJECTIVES: The purpose of this study was to examine the success rate of nonoperative management of blunt splenic injury in an institution using splenic embolization. METHODS: We conducted a retrospective review of all patients admitted to a Level I trauma center with blunt splenic injury. Data review included patient demographics, computed tomographic (CT) scan results, management technique, and patient outcomes. RESULTS: A total of 648 patients with blunt splenic injury were admitted, 280 of whom underwent immediate surgical management. Three hundred sixty-eight underwent planned nonoperative management, and 70 patients were treated with observation, serial abdominal examination, and follow-up abdominal CT scanning. All were hemodynamically stable, with a 100% salvage rate. One hundred sixty-six patients had a negative angiogram, with a nonoperative salvage rate of 94%, and 132 patients underwent embolization, with a nonoperative salvage rate of 90%. Overall salvage rates decreased with increasing injury grade; however, over 80% of grade 4 and 5 injuries were successfully managed nonoperatively. The salvage rate was similar for main coil embolization versus selective or combined embolization techniques. Admission abdominal CT scan correlated with splenic salvage rates. Significant hemoperitoneum, extravasation, and pseudoaneurysm had acceptable salvage rates, whereas arteriovenous fistula had a high failure rate, even after embolization. CONCLUSION: Splenic embolization is a valuable adjunct to splenic salvage in our experience, allowing for the increased use of nonoperative management and higher salvage rates for American Association for the Surgery of Trauma splenic injury grades when compared with prior studies. Main coil embolization has a similar salvage rate when compared with other angiographic techniques. An arteriovenous fistula as a CT finding was predictive of a 40% nonoperative failure rate.     

Renal cell carcinoma metastatic to the stomach: single-centre experience and literature review

OBJECTIVES

To investigate the incidence, clinical presentation and therapy of gastric metastases, an uncommon finding, in a large group of patients with renal cell carcinoma (RCC).

PATIENTS AND METHODS

We systematically searched the computerized RCC database of our institute, covering 2082 patients (1180 men and 902 women) who had surgery between January 1984 and September 2005, to identify those with a synchronous and/or metachronous diagnosis of cancer in gastric biopsies or resection specimens. The histopathological slides of both renal and gastric cancer probes, and the clinical presentation, treatment and outcome of affected patients, were reassessed.

RESULTS

Twelve patients with primary gastric cancer, one with local RCC recurrence affecting the antrum and five with clear cell RCC (three men and two women; mean age 73 years, range 65–83) with haematogenous cancer spread to the stomach were detected. The mean (range) time to gastric metastasis was 6.9 (1.7–13.1) years. There were metastases to other organs, most often the lung, in all patients. Three patients presented with symptoms of gastrointestinal bleeding, which was successfully controlled by local endoscopic therapy. Four patients died from disease at 3–19 months after diagnosis. One patient is still alive with disease after ≈2 years.

CONCLUSIONS

Gastric metastasis in patients with RCC appears to be a late event in the course of the disease. Most patients show concomitant tumour spread to other organs, and the outcome is generally poor. The use of targeted drugs might offer a new perspective for affected patients.     

Analysis of 155 patients with chemical injury: a 5-year experience

From July 1986 to June 1991, 155 patients were treated in our department for various chemical burn injuries. The experience over the 5-year period is reviewed. Among these patients, 109 patients were between 20 and 40 years of age and accounted for 70.3 per cent of all chemical burn patients. It is suggested that chemical burns are very common in people of working age. Chemical burn manifestations were unlike those of thermal injury. The scene of injury, type of chemical agent, age of patients, clinical manifestation and management of the burn surface are discussed. Although the patients were given the same physical therapy, early tangential or full thickness excision and immediate autografting yielded better results than conservative treatment and shortened hospital stay.     

Spigelio hernia: 5-year experience

Spigelian hernia is a rare condition of the abdominal wall; 13 cases occurred in the last five years are here reported. These patients were treated surgically, using direct reconstruction of the abdominal wall in eight cases, while a tension-free hernioplasty was utilized in five cases.     

Pulmonary tuberculosis and coexisting carcinoma: a 10-year experience and review of the literature.

Of 7,986 patients admitted to Mount Wilson State Hospital for Pulmonary Diseases between 1960 and 1970, 72 were proven to have coexisting pulmonary tuberculosis and bronchogenic carcinoma. The patients usually were in the older age group, and usually smoked. There was a high predilection for the tumor to occur in the upper lobes. Active tuberculosis was present in 50 per cent of the patients and tumor and tuberculosis was present in the same area 80 per cent of the time. Cell diagnosis was possible in 60 per cent of the patients without thoracotomy. Diagnosis was usually made late in the course of the disease and therapeutic results were poor. Only 13 patients were operable and only four are presently alive. Earlier recognition is vital to adequate treatment. A plan for earlier recognition based on a high degree of suspicion is presented.     

Renal Schwannoma: case report and literature review

Schwannomas are tumors arising from the nerve sheath. Renal schwannomas are extremely rare and have nonspecific symptoms and limited radiologic features, and are often diagnosed histologically after surgical excision. We report a case of a left renal schwannoma which, after evaluation by imaging studies, was assumed to be a renal cell carcinoma arising from the left kidney. A brief discussion and literature review of the diagnosis, treatment, and prognosis is presented.     

Renal leiomyoma: Case report and literature review

Renal leiomyomas are rare benign tumours of the kidney originating from muscle cells. They are usually found by an autopsy, whether the patient is asymptomatic or has symptoms (i.e., abdominal/flank pain, hematuria, palpable mass). Today the widespread use of ultrasonography and computed tomography has increased the detection of clinically asymptomatic renal leiomyomas. The differential diagnosis between leiomyomas and other malignant lesions (above all renal cell carcinoma or leiomyosarcoma) is still possible by histological examination. Radiological examinations are not sufficient for the differential diagnosis. Renal leiomyomas have no aggressive behaviour and they usually do not metastasize. The prognosis, after surgery, is excellent without recurrence. We report a case of leiomyoma in a 31-year-old man who presented hematuria and flank pain. We also review the literature and provide a summary of clinical, radiological and histological features of renal leiomyomas.     

Renal vein thrombosis: a 10-year review

PURPOSE: Renal vein thrombosis (RVT) is a rare cause for pediatric surgical consultation. The purpose of this study is to review the Montreal experience in the 1990s with RVT. METHODS: A retrospective chart review was conducted from 1990 through 1999. RESULTS: Twenty-three cases were identified by Duplex ultrasound scan. Mean length of follow-up was 42 months. Eighty-three percent (83%) of cases were diagnosed within the first month of life. In utero thrombosis was suspected in 22% and was associated with caval thrombosis and factor V Leiden. Known risk factors were present in 87%. The "diagnostic triad" of flank mass, gross hematuria, and thrombocytopenia was present in only 13% at the time of diagnosis. Long-term renal function impairment was detected in 100% of those who did not receive heparin, and in 33% of those who did receive heparin. No patient required dialysis. One patient required nephrectomy for recurrent pyelonephritis. CONCLUSIONS: RVT occurs more commonly than anticipated. Because the "classic" triad of signs usually is absent at presentation, the presence of either a flank mass, hematuria, or thrombocytopenia in a patient with risk factors should prompt investigation for RVT. Factor V Leiden is a risk factor for in utero RVT. Anticoagulation improves renal outcome. Patients with RVT require long-term follow-up.     

Alloplastic spermatoceles: a 5-year experience

We implanted 14 alloplastic spermatoceles in 8 patients with congenital absence or atresia of the vas deferens or anejaculation. The surgical technique and results of aspirations are detailed. Five spermatoceles yielded sperm: 2 for prolonged periods (4 1/2 to 11 months) and 1 produced motile sperm considered adequate for artificial insemination.     

Mandibular ameloblastoma: clinical experience and literature review

Background: Ameloblastoma is a locally aggressive odontogenic tumour of the mandible and maxilla that, if neglected, can cause severe facial disfigurement and functional impairment. A thorough understanding of its clinicopathological behaviour is essential to avoid recurrence associated with inadequately treated disease. Currently, wide resection and immediate reconstruction is the treatment of choice in most cases of mandibular ameloblastoma. We present our experience in the management of this disease and review the current status of the literature. Method: Retrospective review of all patients between 1996 and 2006 with histologically confirmed ameloblastoma. A literature review on the current understanding of this disease and its management is then presented. Results: Six patients were identified, ranging between 23 and 54 years old. All were females. Two tumours involved the angle and posterior body of the mandible, one the angle and ramus, one the body and two the anterior mandibular. Four patients underwent mandibular reconstruction with free tissue transfer and two by non‐vascularized bone grafts. All procedures were successful. One patient developed deep vein thrombosis requiring anticoagulation. Another developed a collection at the mandibular surgical site requiring drainage. Satisfactory union was achieved in all cases with no evidence of recurrence. All patients had adequate cosmesis, masticatory efforts and speech. Conclusion: Management of ameloblastoma remains a challenge and requires a thorough understanding of the behaviour of its different clinicopathological variants. We have found segmental mandibulectomy and immediate reconstruction to be an excellent treatment option in our series of patients.     

Renal angiomyolipoma: 6 case reports and literature review

We report 6 cases of renal angiomyolipomas and review the pertinent literature concerning this disease. One case involved the rare association of tuberous sclerosis and pregnancy. Another patient without tuberous sclerosis had renal cell carcinoma and later suffered a contralateral angiomyolipoma. The pathological conditions of renal angiomyolipomas with and without tuberous sclerosis are discussed. Since angiomyolipomas present with multiple clinical similarities to renal cell carcinoma, the primary task for the clinician is to differentiate this hamartoma from carcinoma. The distinguishing characteristics and the clinical management of renal angiomyolipomas are discussed.     

Renal cell carcinoma: case report and literature review

Renal cell carcinoma arising from epithelial cells of the renal tubule is a highly aggressive and malignant tumor in all ages. Less than 2% of cases occur in childhood, relatively in older age group. Only a few pediatric series have been presented in the English literature. Tumor is presented with characteristic findings of flank pain, gross hematuria, and palpable mass. Although one half of the patients have metastasis at the time of diagnosis, most cases are currently being incidentally detected using improved imaging techniques. The overall prognosis in children appears to be similar to that in adults. Tumor stage and complete surgical resection have been reported as the most meaningful prognostic factors for the outcome. The incidence of metastatic disease is same as in adults. The effect of chemotherapy and immunotherapy, either preoperatively or postoperatively, is unclear. Cure is the most likely consequence in localized and completely resected tumors. Here, we present an 8-year-old boy with renal cell carcinoma demonstrating only hematuria without any pathological physical examination findings. The mass was described by abdominal ultrasonography and computed tomography in the left kidney. After the left nephroureterectomy, the patient was given no therapy.     

Renal transplantation from non-heart-beating donors: a single-center 10-year experience

BACKGROUND: Reluctance to accept non-heart-beating donors (NHBD) as a source of kidneys, is due to medical, ethical, and logistical reasons. Evidence suggest that the short-term graft survival is similar to that of kidneys obtained from heart-beating donors (HBD). However, few studies, with long-term follow-up are available. We conducted a single-center study of kidneys obtained from NHBD, in a 14-year period. METHODS: We studied 100 patients transplanted with kidneys between 1989 and 2004, using NHBD, supported by heart compression and mechanical ventilation (n = 24), intravascular in situ cooling (n = 59), or cardiorespiratory resuscitation plus manual abdominal counterpulsation without cooling (n = 17), the last technique being used from 1998. The median follow-up was 51 +/- 51 months (range, 1 to 170). The outcomes of these procedures were compared to those of 1025 transplantations of kidneys from HBD performed during the same period. RESULTS: The characteristics of the recipients did not differ significantly between the two groups. Kidneys from NHBD showed a significantly higher rate of delayed graft function (DGF; 84% vs 26%; (P < .001), furthermore, the primary nonfunction (PNF) incidence was significantly higher with NHBD vs HBD (16% vs 10%; P < .001). The incidence of acute rejection episodes (ARE) within 3 months and at 1 year did not differ between the groups of donors; however, more NHBD kidneys were lost from ARE. The short-term (3-month and 1 year) and long-term (5 and 10 years) renal function, determined by the serum creatinine levels, and patient and graft survival were not different for kidneys obtained from NHBD. CONCLUSIONS: The incidences of PNF and DGF were significantly higher with NHBD, which produced poorer renal function at the time of hospital discharge. One-, 5-, and 10-year graft survivals and renal function did not differ between NHBD and HBD grafts. In our series, PNF was the main barrier to the use of NHBD.