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Parsonage-Turner syndrome (PTS) is a clinical syndrome characterized by rapid onset of upper extremity pain typically followed by varying degrees of weakness and atrophy. In this case, we discuss a 54-year-old female who developed severe right upper extremity pain soon after receiving a shingles vaccine, which was then followed by weakness and atrophy. Thorough medical workup was unrevealing, as it was too early to see electromyography (EMG) changes. Nine months later she presented to the hospital again with a similar presentation of the contralateral upper extremity. EMG findings at that time were supportive of a PTS diagnosis. This report discusses the clinical variability, etiology, and treatment of PTS, as well as some diagnostic complexities and how they were overcome to diagnose this patient.

Background: In assigning risk of infection, the traditional wound classification system has been replaced by the National Nosocomial Infection Surveillance (NNIS) system. NNIS classification is determined by procedure length, wound cleanliness, and ASA status. To date, no prophylactic antibiotic guidelines have been proposed for the NNIS system. Methods: Clean general surgery cases were retrospectively reviewed in our hospital for infection and prophylactic antibiotic use. These cases were then stratified per the NNIS system. Results: One thousand twenty-three clean general surgery cases had 16 (1%) surgical site infections. The infection rate in NNIS class 0, 1, and 2 cases not given prophylactic antibiotics was 1.21%, 3.03%, and 0%, respectively. The infection rate in NNIS class 0, 1, and 2 cases given prophylactic antibiotics was 0.94%, 2.44%, and 6.67%, respectively. Conclusions: No statistically significant decrease in infection rate was demonstrated by us using prophylactic antibiotics, regardless of the NNIS classification in clean general surgery cases.

Abdominal binders are ordered by some surgeons postoperatively for patient comfort and to prevent wound complications. There has been some question as to the compressive effect that an abdominal binder has on pulmonary function. We prospectively randomized 54 patients undergoing a midline laparotomy incision to two groups: a “binder” group and a “no binder” group. Preoperative pulmonary function tests (vital capacity and incentive spirometry) were measured. Postoperatively, pulmonary function tests, pulse oximetry, oxygen requirement, pulmonary and wound complications, pain control, time to ambulation, and hospital length of stay were examined. Vital capacity as a per cent of preoperative values on postoperative Day 1 for the binder and nonbinder groups were 64.7 and 54.6 per cent, respectively, but this was not statistically significant. Average level of pain using the visual analog pain scale on postoperative Days 1 through 3 in the binder versus nonbinder groups was 4 versus 8, 3 vs 6, and 3 versus 7, respectively. Time to ambulation was 18.6 hours in the binder group and 16.7 hours in the nonbinder group. Hospital length of stay in the binder and nonbinder groups was 3.9 days and 3.7 days, respectively. We conclude that abdominal binders in our patients with midline abdominal incisions had no significant effect on postoperative pulmonary function, but seemed to help with pain control.

Background : Preoperative therapy with concurrent cisplatin infusion and accelerated hyperfractionated radiation has the potential to eradicate pools of resistant cells with high-growth fraction that accumulate during standard radiation therapy. Based on preliminary data showing a high complete response rate (necessary for organ preservation) in patients with advanced squamous cell cancer of the head and neck (stages III and IV), we conducted a multi-institutional study using accelerated hyperfractionated radiation to maximize local and regional tumor control without adding toxicity. Pattents and methods : Preoperative radiation was given in 1.8 Gy fractions for 2 weeks followed by 1.2 Gy bid hyperfractionation to 46.7 Gy. Continous infusion of cisplatin 20 mg/m2 was given on days 1 through 4 and 22 through 25. Patients were initially assessed with panendoscopy and were subsequently reassessed with biopsy of primary site (±nodes). Patients with negative primary site biopsy received additional hyperfractionated radiation to 76 Gy with simultaneous carboplatin 25 mg/m2 bid for 12 consecutive days. Patients with residual disease after 47 Gy had resection of primary site and node dissection. Of 69 patients treated, 56 were T3 and T4, and 46 were N1, N2, and N3; 17 patients (25%) were stage III and 50 (72%) were stage IV; in 2 patients (3%) the stage was unknown. Results : Treatment was well tolerated with no grade IV toxicities, but there were 13 patients with grade III toxicities (mucositis, dysphagia, or hematological toxicity). Biopsy specimens were taken from 84% of the patients, and 81% of the primary sites showed pathologic complete response and 49% of the lymph nodes showed a pathologic complete response. Thirty-four patients underwent curative surgery. Eleven required resection of the primary and 23 required neck dissection only. At 2 years (median follow-up 12 months), 44 of 69 patients (64%) have no evidence of disease, 9 are dead of disease, 9 are dead of other causes, and 6 are alive with disease. Surgical toxicities were minimal and primarily limited to fibrosis in 12 patients, edema in 8 patients, tracheoesophageal fistula in 1 patient, and delayed wound healing in 1 patient. Late toxicities included xerostomia in 22 patients, dysphagia in 17, and speech impairment in 9. Conclusions : Preoperative concurrent radiotherapy and chemotherapy provides a high level of organ preservation and local and regional control because of the high complete response rate at the primary site. A planned neck dissection with minimal morbidity ensures local/regional control, as well as providing definitive staging information. A randomized evaluation is suggested for this program.

Pancreatic cancer remains a major cause of mortality. Less than 5% of patients survive 5 years. No curative therapy exists for patients not surgically resectable. Although chemotherapeutic and radiation therapeutic approaches can provide palliation, they have not had a significant impact on 5-year survival. Phase II and III studies are evaluating whether newer approaches integrating chemotherapy, radiation therapy, and surgery will improve survival. Evaluation of new agents (e.g., camptothecins, paclitaxel [and related compounds], gemcitabine, and thymydilate synthase inhibitors) alone and in combination with other agents (including platinum-related compounds) continue to be pursued. Novel approaches based on increased knowledge about biology of this disease, including high frequency of ras and p53 mutations or expression of a number of growth factor receptors, are being studied preclinically. Approaches utilizing vaccines, gene therapy, and cyto-kines to enhance the immune response are being developed. Hopefully, new approaches will lead to improved treatment of this often fatal disease. © 1995 Wiley-Liss, Inc.

Purpose : This study was undertaken to assess the efficacy of concurrent cis-platinum and radiation in patients with advanced head and neck cancer and to determine if patients responding to the preoperative regimens may be cured without radical surgery. Methods and Materials : One hundred and one patients with potentially operable Stage III and IV squamous cell carcinoma of the head and neck received 45 Gy at 1.8 Gy fractions and continuous infusion cis-platinum 20 mg/m2 over 24 h on days 1 through 4 and 22 through 25 of the radiation schedule. Three to 4 weeks later, radical surgery of the primary site and neck dissections for patients presenting with cervical adenopathy was undertaken or if a complete response had been achieved, continued with radiation to 72 Gy with another course of concurrent continuous infusion cis-platinum. Result : Complete and partial responses were achieved in 92% of the primary sites and 95% of the nodes. Over 80% of the patients were rendered tumor free at surgery after only the initial course of chemotherapy and radiation. There were no grade 3 or 4 toxicities from chemotherapy and radiation. Ninety-five percent of the patients who initiated treatment completed it. With a median follow-up of 41 months for all patients, 49% of the patients have survived disease free up to 9 years, independent of whether or not their primary tumors were resected or were treated definitively by further chemotherapy sensitized radiation. The disease-specific survival is 78% after 3 years with no local failures thereafter. Conclusion : These findings suggest that continuous infusion cis-platinum administered concurrently with radiotherapy can improve survival in advanced head and neck cancer. Patients responding to the preoperative regimen may be cured without radical surgery, which can be reserved for salvage.

Background: From April 1994 to December 1995 a prospective randomized trial was conducted at our institution comparing outcomes of laparoscopic and open appendectomy. It demonstrated no significant advantage to laparoscopic appendectomy. Our current study evaluates whether surgeon’s habits at our hospital have been influenced by our previously published study. Methods: Charts were reviewed for patients who underwent appendectomy from August 1998 to December 1998. In addition, a formal survey was conducted of all staff surgeons to ascertain their procedure of choice for appendicitis, and the reasons for their preference. Results: Seventy-nine percent of the appendectomies were attempted laparoscopically. The median operative time was longer for laparoscopic appendectomy, and median hospital charges were higher. Survey results showed that most staff surgeons prefer laparoscopic appendectomy. Conclusions: Despite our own published paper supporting open appendectomy over laparoscopic appendectomy, laparoscopic appendectomy has become the standard of care at our institution for the treatment of appendicitis.

Purpose To determine whether a course of hyperfractionated radiation therapy concomitant with escalated radiosensitizing platinum compounds can be administered with acceptable morbidity and achieve a high rate of loco-regional control for Stage III and IV head and neck cancer and whether the patients can be tumor free at the primary site after initial therapy and cured by the additional chemoradiation without radical resection of the primary tumor. Methods and materials Patients with Stage III/IV head and neck cancer were treated in this multicenter Phase II Study with 1.8 Gy fraction radiotherapy for 2 weeks, with escalation to 1.2 Gy b.i.d. hyperfractionation to 46.8 Gy. Concomitant continuous infusion cisplantinum (CDDP) 20 mg per meter square on day 1 to 4 and 22 to 25 was given. Reassessment by biopsy of primary and nodes was done. Patients with a complete response continued with hyperfractionated radiotherapy to 75.6 Gy with simultaneous carboplatinum (Carbo), 25 mg per meter square b.i.d. for 12 consecutive treatment days. Patients with residual disease at 46.8 Gy required curative surgery. Seventy-four patients were treated at the three institutions; 20 were Stage III and 54 were Stage IV. All patients had daily mouth care, nutritional, and psychosocial support. Results This regime was well tolerated. Eighty-five percent of toxicities were Grade 1 or 2 and there was only one Grade 4 hematologic toxicity. Late toxicities included xerostomia in 25 patients, dysphasia in 18, and mild speech impediment in 11. Biopsies of primary site were done after the first course of treatment in 59 patients. Neck dissections were performed in 35 patients. Forty-four of 59 (75%) primary sites and 16 of 35 (46%) lymph nodes had pathologically complete response (CR). Of the 74 patients, only 12 required surgical resection of the primary site. Thirty-five of the 50 node positive patients had neck dissections, 16 of these were CRs at surgery. At 4 years (median follow-up of 26 months), disease-specific survival is 63%. The actuarial survival for all patients is 51%. Patients with pathological CR after initial treatment have disease specific survival of 73% at 4 years vs. 48% of patients with partial response (PR) only. Conclusion This study, developed on the basis of radiobiological and cell kinetic precepts, produced results that compare favorably with other reports of management of patients with advanced head and neck cancer. In comparison with our previous study, these results are comparable, not impressively better. The associated morbidity was somewhat worse.

To compare open appendectomy (OA) with laparoscopic appendectomy (LA) for length of the operation, complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges.Prospective randomized clinical trial of patients with acute appendicitis.Tertiary care, urban teaching hospital.A population-based sample of patients (agedor = 12 years; weight,49.7 kg) admitted to a surgical teaching service with a clinical diagnosis of acute appendicitis. Patients were prospectively randomized to either OA or LA during a 20-month period (from April 1, 1994, to December 31, 1995). Fifty-seven patients were initially enrolled in the study; 7 did not complete the study because of a protocol violation. All remaining patients completed the study, including postdischarge follow-up.Two (7.4%) of the 27 patients in the LA group required conversion to OA because of technical difficulties. One patient (in the OA group) underwent a second surgical procedure for drainage of a pelvic abscess. Three patients (in the LA group) required second surgical procedures. For analysis, no crossovers were allowed and all patients remained in their originally randomized group.Length of the operation, intraoperative and postoperative complications, postoperative pain control, length of hospitalization, postdischarge recovery time, and hospital charges.Fifty patients (19 women and 31 men) were examined. Twenty-seven patients underwent LA, 2 requiring conversion to an OA. Twenty-three patients underwent an OA. Patient demographics were similar between groups. Statistical differences between the 2 groups were found for (1) length of the operation (median, 81.7 vs 66.8 minutes, LA vs OA groups: P.002), (2) operating room charges (median, $3191 vs $1514, LA vs OA group; P.001), and (3) total hospital charges (median, $5430 vs $3673, LA vs OA group; P.001). No statistical differences between the 2 groups were found for (1) length of hospitalization (median, 1.1 vs 1.2 days, LA vs OA group), (2) pain control (mean, 4 vs 3.7 of 10 [0 indicates least pain; 10, most pain], LA vs OA group), (3) recovery time (time necessary before returning to work or school) (median, 14.0 days for both groups), and (4) complications (5 vs 1, LA vs OA group).Laparoscopic appendectomies and OAs are comparable for complications, postoperative pain control, length of hospitalization, and recovery time. Patients who underwent an OA had a shorter operative time and lower operating room and hospital charges. Laparoscopic appendectomy does not offer any proved benefits compared with the open approach for the routine patient with acute appendicitis.

The primary objective of this study was to determine the response rate of patients with metastatic colorectal cancer to combined therapy with 5-fluorouracil (5-FU), leucovorin, and intravenous azidothymidine (AZT), a thymidine nucleoside analog. By itself, AZT has limited antineoplastic efficacy. However, experimental studies indicate that 5-FU enhances the antitumor activity of AZT by inhibiting synthesis of normal thymidine nucleotides with which AZT competes for incorporation into nucleic acids. A phase I study defined the maximum tolerated dose of AZT as 7 g/m2 with hypotension during the infusion being the dose-limiting toxicity. A phase II study was performed with oral leucovorin (100 mg p.o. hourly for 4 h prior to 5-FU and 4 h and 8 h after 5-FU), bolus 5-FU (400 mg/m2) followed 1 h later by a 2-h infusion of AZT (7 g/m2). Treatment was given weekly for 4 weeks followed by a 1-week break, which constituted a cycle of therapy. Responses were evaluated after every two cycles. Patients continued on therapy as long as they tolerated treatment and did not have progressive disease. Of 15 evaluable patients who had received no chemotherapy there was 1 complete response and 4 partial responses (a 33% response rate), whereas only 1 of 6 patients who had received prior adjuvant chemotherapy had a partial response (17%). An additional 10 patients had stable disease lasting 2–14 months. Therapy was well tolerated with the only one instance each of grade 3 nausea and vomiting, diarrhea, anemia, and hypotension. Approximately 50% of treatments were accompanied by mild hypotension, which was easily corrected by increasing the rate of normal saline infusion. There was no difficulty administering this regimen in the outpatient setting. While the overall response rate (29%) is comparable to that seen with combinations of 5-FU and leucovorin alone, in most reported series a considerably higher dose of 5-FU was utilized than in this study. Since patients in the present study experienced relatively little 5-FU toxicity, increasing the dose of 5-FU in this regimen would appear to be feasible and might result in a higher response rate.

Hypothesis Prophylactic antibiotic treatment in elective laparoscopic cholecystectomy does not lower the already low infection rate associated with this procedure. Design and Setting Prospective double-blind randomized trial at a community-based training hospital. Patients Four hundred fifty patients undergoing elective laparoscopic cholecystectomy were randomized into 1 of 3 treatment arms: (1) preoperative cefotetan disodium, 1 g intravenously; (2) preoperative cefazolin, 1 g intravenously; and (3) intravenous placebo. There were no demographic differences between groups in age, smoking history, American Society of Anesthesiologists score, infection risk class, time of antibiotic administration prior to surgery, and type of skin preparation. Interventions Laparoscopic cholecystectomy was attempted in all cases; however, 10 patients required conversion to an open cholecystectomy and they were included in the statistical analysis. Preoperatively, all patients were randomized in a blinded manner and received cefotetan, cefazolin, or placebo intravenously. Results There were 10 postoperative infections. In the cefotetan group, there were 3 cases of superficial surgical site infections. In the cefazolin group, there were 2 superficial surgical site infections—1 pneumonia and 1 rhinosinusitis. In the placebo group, there were 2 superficial surgical site infections and 1 urinary tract infection. The overall infection rate in this series was 2.4%. Follow-up was performed at routine postoperative visits and by telephone contact. Data were evaluated using the χ 2 test and analysis of variance with Duncan post hoc test ( P Conclusion Based on our data, use of prophylactic antibiotics does not decrease the rate of wound infections in elective laparoscopic cholecystectomy.

Objective: To determine if preemptive local anesthesia yields better postoperative pain control than infiltration of local anesthetic at the time of wound closure. Design: Prospective, randomized trial. Setting: Private community teaching hospital. Patients: Two-hundred consecutive patients undergoing elective laparotomy were enrolled in the study between September 1993 and April 1995. Eighty-eight patients were excluded from the study for violation of protocol, leaving a total of 112 patients to be evaluated. Patients were divided into 2 groups: preincisional (n=52) and postincisional (n=60). Interventions: Patients in the preincisional group received 40 mL of 0.25% bupivacaine (Marcaine) 5 minutes before the incision; patients in the postincisional group received 40 mL of 0.25% bupivacaine immediately after approximation of the fascia and before closure of the skin. Main Outcome Measures: The control of the longterm (3-day) postoperative pain in relationship to timing of local anesthetic given. Results: Study groups were comparable for age, weight, sex, operative time, and length of incision. No significant difference in the amount of morphine used or subjective evaluation of pain was noted between the preincisional and the postincisional groups. Conclusions: Based on the theory of "dorsal horn hypersensitivity," several clinical trials have shown significant improvement in pain control with preincisional infiltration of local anesthetic. Our results indicate that pain was no better controlled with preincisional infiltration than with postincisional infiltration of bupivacaine, raising the question of the benefit of preemptive anesthesia at the local level in long-term postoperative care. Arch Surg. 1997;132:766-769

Effective methods for performing abdominal aortic aneurysmectomy associated with congenital pelvic kidney are presented. The embryology and surgical anatomy of these lesions are reviewed. Ordinarily, successful aortic reconstruction can be performed with low risk to the pelvic kidney by use of readily available in situ cold perfusion. Two illustrative case reports applying this method are presented. The recently reported technique of double proximal clamping of the aorta was also employed in one case. This technique allows lumbar collaterals within the aneurysm to perfuse the kidney during construction of the proximal aortic anastomosis, thereby minimizing absolute renal ischemic time. Both in situ cold perfusion and double proximal clamping are effective methods for renal preservation that do not rely on complex extraanatomic techniques. A review of the literature with a discussion of the advantages and disadvantages of previously reported methods of renal preservation is presented. (J Vasc Surg 1989;9:404–9.)