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Spontaneous ventral hernia through the rectus abdominis sheath is perhaps the rarest hernia, with eight previously reported cases since 1937. The condition has not been reflected in the popular treatises on hernia. An 83-year-old male patient underwent surgery for intestinal obstruction. A spontaneous Richter's hernia of the small intestine through the posterior rectus abdominis sheath was successfully treated with bowel resection and tissue repair. Hernias of this variety are not well known and thus are rarely suspected. Their successful management is based on accurate emergency diagnosis and surgery, which we recommend as the best chance for a successful outcome. [ABSTRACT FROM AUTHOR]

Primary angiosarcoma of the breast is a rare and aggressive malignancy that is typically seen in premenopausal patients. The tumor's spread occurs predominantly through the bloodstream; involvement of the lymphatics is unusual. We present a case of breast angiosarcoma presenting with enlarged axillary lymph nodes treated with a modified mastectomy and axillary lymph node dissection. Pathology found no tumor in the lymph nodes. Based on this experience and data from the literature, we suggest evaluation of the sentinel nodes prior to potentially morbid standard level 1 and 2 axillary lymph node clearance. [ABSTRACT FROM AUTHOR]

Superficial thrombophlebitis of the thoracoepigastric veins (also known as Mondor's disease) is an uncommon disorder that typically affects middle-aged women and classically involves the chest wall including the breasts. Only one previously published, non-operative case of the disease, describes how the condition can resemble a strangulated Spigelian hernia. Herein we describe another similar case in which the diagnosis was made intra-operatively. The extremely unusual and similar clinical findings we observed demonstrate that Mondor's disease can occur in the Spigelian hernia belt and cause diagnostic confusion. [ABSTRACT FROM AUTHOR]

A 69-year-old male patient underwent excision of hidradenitis suppurativa (HS) affecting both gluteal areas and the perineum. The perineal specimen contained a 1-cm superficially invasive, well-differentiated keratinizing squamous cell carcinoma. The patient was free of recurrence 1 year after surgery. A 66-year-old male patient was diagnosed with massive perineal HS more than 40 years previously. More than 30 abscesses and suppurative sinus tracts were surgically treated over the years. He eventually died of unresectable pelvic squamous carcinoma. Search of the literature and available bibliography revealed 47 retrospective studies of skin carcinoma arising in HS since 1959, including a total of 64 patients together with the two patients treated by our team. Squamous cell carcinoma is a rare but potentially fatal complication of HS. Surgery is the only known treatment method that provides a real chance for cure for both HS and a carcinoma that complicates it. HS must be treated early with complete excision to avoid chronic progression of the disease that can cause cancerous degeneration. A high index of suspicion, early tissue diagnosis, and immediate referral for radical surgery carry the only hope for cure in those whose HS harbors malignancy.

Remote necrotizing soft tissue infection (NSTI) resulting from paronychia is very unusual but potentially lethal. We report a case of a 39-year-old woman affected by this unusual infection. The paronychia completely resolved in less than 2 weeks, however, a NSTI involved the right chest and flank and the left thigh. The patient required intensive care and multiple surgical debridements. This recent experience and literature data suggest that paronychia can cause a remote NSTI that can rapidly spread and become life-threatening. Broad spectrum antibiotics and aggressive surgical debridement are essential to a successful outcome., (Copyright © 2011 Elsevier Inc. All rights reserved.)

Background: The very unusual association between herpes zoster and Ogilvie syndrome has received scant attention in the published literature., Objectives: This review discusses the published experience since 1950 and attempts to increase clinical awareness about the co-existence of both conditions., Case Report: An 84-year-old male patient affected by herpes zoster presented with advanced acute colonic pseudo-obstruction and was successfully treated with colonic diversion., Discussion: Twenty published studies (1950-2008) of 28 patients in whom the two conditions co-existed are reviewed. The review included 22 male and 7 female patients (24%) aged 32-87 years (mean, 61 years). Significant co-morbidities were present in 45% of the patients. The majority of patients were observed and treated conservatively (83%). Two patients died (7%), both suffering from respiratory complications and malignancy., Conclusion: Recognition of the combined syndrome may help to avoid unnecessary surgery. Laparotomy should be reserved as a last resort for when the obstruction cannot be successfully managed by endoscopy. A diverting colostomy can be used to monitor the blood supply and thus provide early warning for an impending abdominal catastrophe., (Published by Elsevier Inc.)

A 64-year-old, otherwise healthy, male patient presented with a malodorous abdominal wall fistula of recent onset. He gave a history of mesh repair of ventral hernia 25 years ago. Computed tomography scan of the abdomen revealed a 15 cm x 15 cm thick-walled cavity inside the abdomen adjacent to bowel loops and the prosthetic mesh. Resection of the mass included a 25-cm segment of small bowel. Histopathology revealed a thick-walled large cavity lined with mucosa, surrounding a large wrinkled sheet of permanent mesh., (Published by Elsevier Inc.)

Background: Graft survival following renal retransplantation has been inferior to that following primary allografting, particularly in African Americans (AAs) receiving deceased-donor (DD) kidneys., Methods: Among 166 AA DD renal allograft recipients transplanted from July 2001 through July 2007, we compared the outcomes of 26 (16%) receiving a second graft with those of 140 primary cases. All patients received either thymoglobulin (ATG) or an IL-2 receptor antagonist for induction, and were maintained on either tacrolimus or sirolimus + mycophenolate mofetil +/- prednisone., Results: When compared with primary transplants, regrafts received kidneys from older donors, were younger, more sensitized, more likely to receive ATG and to be maintained on prednisone, received more doses of ATG, and were less likely diabetic. There was no difference between primary and retransplant groups in overall patient or graft survival; incidence of acute rejection, CMV infection, BK nephropathy, or new-onset diabetes mellitus; and serum creatinine at 1 year., Conclusion: AA renal allograft recipients can undergo a second DD transplant with intermediate-term outcomes comparable to that of a primary graft, despite the presence of multiple immunologic and non-immunologic high-risk factors, by extending the course of ATG induction and continuing prednisone therapy in the vast majority of cases.

Sternal osteomyelitis secondary to minor trauma occurs rarely. Only a handful of cases have been reported. A 24-year-old male patient who had history of intravenous drug abuse and recent minor sternal trauma presented with signs and symptoms of sternal infection. Imaging studies suggested osteomyelitis and the patient underwent sternal resection, with a successful outcome. Sternal osteomyelitis should be suspected in immunocompromised patients, including intravenous drug abusers presenting with sternal inflammatory symptoms. Increased awareness, rapid diagnosis, and appropriate empiric antibiotic and radical surgical treatments can successfully manage life-threatening osteomyelitis of the sternum.

The relative importance of donor and recipient risk factors in predicting outcomes in African-American (AA) renal allograft recipients receiving contemporary immunosuppression, including early steroid withdrawal, has not been previously examined. We assessed the impact of 21 risk factors on five primary outcomes in 132 deceased-donor AA renal allograft recipients transplanted from July 2001 to August 2006 with follow-up 6-67 (mean 35 +/- 17) months by univariate and multivariate analysis. Thymoglobulin or basiliximab was given for induction, and mycophenolate mofetil with either tacrolimus or sirolimus (SRL) +/- prednisone for maintenance. Non-compliance accounted for 26% of graft loss (GL) and 19% of acute rejection (AR) episodes, and was more prevalent in patients who were HCV+ and those on prednisone. Delayed graft function remained a significant predictor of GL, but not via increased AR, and donor ethnicity emerged as an important predictor of patient death. De novo use of SRL resulted in increased AR, and only increased recipient age significantly predicted new-onset diabetes mellitus. Our preliminary results suggest the need for improvements in patient education, pre-transplant psychosocial assessment, and late post-transplant psychosocial support and can be utilized to help guide donor/recipient selection and tailor immunosuppressive management to optimize outcomes in this challenging group of patients.

Informed consent is increasingly being standardized. We sought to evaluate variability in the amount and quality of information desired by patients in choosing whether to undergo elective surgical hernia repair, a prototypical low- to moderate-risk common procedure. Consecutive stable outpatients were asked to assume that they were considering hernia repair and interviewed with a standard questionnaire that asked them to rate their interest in learning about the natural history, pathology, and management of inguinal hernia as well as herniorrhaphy complications and postoperative recovery. Ninety-eight consecutive patients exhibited substantial interpersonal variability in their level of interest in receiving information. Although interest in some types of information tended to correlate with interest in other types of information, patients' degree of interest in receiving information about anesthesia during the procedure was independent of other variables. Education and previous exposure to individuals with hernias also affected interest in receiving potentially important information before deciding whether to consent to hernia surgery. Patients may vary with regard to the information they want to receive when deciding whether to consent to an invasive procedure. It may be preferable to individualize the consent process to patients' preferences rather than adhering to standardized content.

Circulating mitochondrial DNA (mtDNA) affected by mutations have been detected in melanoma, prostate cancer, and digestive neoplasms involving the pancreas, liver, and the colon. We sought to detect such mutations in women with breast cancer to assess if the method could be used to aid in the diagnosis of breast cancer. Blood was collected and mtDNA extracted; 27 samples included 14 patients who had breast cancer and 13 healthy controls. White blood cells and serum were separated. The mitochondrial D-loop region was amplified using PCR followed by automated DNA sequencing. The collected data was analyzed with computer software to detect both polymorphisms and mutations. mtDNA sequencing was successful in 93% of the samples (n=23). No mutations were found in any of the study groups. Polymorphisms were detected in all specimens, three of which had not been previously reported. The method used did not detect mtDNA mutations in the blood of women with breast cancer, but was extremely sensitive in polymorphism detection.

This report describes a liver hemangioma causing obstructive jaundice, an extremely rare condition that has been reported on 3 previous occasions. A hemangioma can compress the major bile ducts and require partial hepatectomy for a successful outcome.

Background: Only four centers have reported their results with renal transplantation in human immunodeficiency virus (HIV)+ recipients on highly active antiretroviral therapy, and acute rejection (AR) rates have consistently ranged from 43% to 67%., Methods: We examined the outcomes of eight adult HIV+ primary renal allograft recipients with median 15 (range 8-47) months follow-up with multiple other high-risk factors, including African American ethnicity, hepatitis C virus (HCV) positivity, long waiting times, prior sensitization, paucity of live donors, and delayed graft function. Our immunosuppressive protocol consisted of an anti-interleukin-2 receptor antibody for induction, and mycophenolate mofetil, cyclosporin A, and prednisone for maintenance. Initial and 3- to 6-month cyclosporin A trough level targets were 250 to 300 and 225 to 275 ng/mL, respectively, and mycophenolate mofetil dose was adjusted according to 2 to 4 week surveillance and subsequent as needed mycophenolic acid predose concentrations during the first 6 months., Results: Patient and graft survival were 100% and 88%, respectively, with an AR rate of 13% and excellent renal function. No patients developed new-onset diabetes, opportunistic or other serious infections, malignancy, or progression of hepatitis C virus-related liver disease. Excellent suppression of HIV replication with maintenance of CD4 counts was noted in all cases., Conclusions: Our findings suggest that HIV+ patients on highly active antiretroviral therapy can undergo successful renal transplantation with a low incidence of both AR and AIDS-associated and non-AIDS associated infections, despite associated risk factors for poorer outcome. Our encouraging but preliminary results with this protocol will need to be verified in larger numbers of HIV+ renal allograft recipients with longer follow-up.

Background: Prior studies have yielded conflicting results concerning the impact of HCV on renal transplant outcomes., Methods: We examined outcomes in comparable groups of predominantly African American hepatitis C virus (HCV)-positive (n = 34) and HCV-negative (n = 111) kidney transplant patients receiving contemporary immunosuppression., Results: There was no difference in patient survival or acute rejection, but new-onset diabetes (NODM) was increased and graft survival decreased in the HCV-positive group, with increased graft loss secondary to noncompliance and Type I MPGN. The incidence of NODM among patients undergoing early corticosteroid withdrawal was 11% in both groups, while among those on prednisone, it was 47% in HCV-positive versus 25% in HCV-negative recipients., Conclusions: Deceased-donor HCV-positive renal allograft recipients have equivalent patient but decreased graft survival. Noncompliance and Type I MPGN play a role in producing this negative effect on graft outcome. Steroids may be required for HCV to exert its diabetogenicity in kidney transplant patients.

Malignant neoplasms arising in burn scars are well known but rarely encountered. We discuss personal experience with two patients, both female, who were diagnosed with advanced breast cancer many years after severe thermal injury to their breasts. Our experience, similar to the scant previously published data, reinforces that burn scars demand a high index of suspicion for the presence of an underlying malignant neoplasm. The literature and our study suggest that breast cancer may occur after severe thermal injury. Breast lesions in this or a similar clinical scenario should be considered malignant until proven otherwise, and a tissue diagnosis must be pursued without delay.

Acute appendicitis in a hernia sac occurs exceptionally. An 80-year-old male patient underwent emergency surgery for an incarcerated right inguinal hernia found to contain a gangrenous appendix. His brief improvement after an emergency herniotomy with appendectomy was followed by intestinal obstruction caused by advanced colon cancer. The unique features and individualized management of the four published types of Amyand hernia are reviewed. Rather than simply being an anatomical curiosity, Amyand hernias require individualized attention to decide how to manage both the appendix and the hernia. Clinical scrutiny, a high index of suspicion for surgical comorbidities, and a common sense approach may improve outcomes.

Background: Subxiphoid incisional hernias are notoriously difficult to repair and are prone to recurrence. The few reports on subxiphoid hernia published over the last two decades have not fully addressed the etiology, pathology, treatment, and outcome of this problem. This review was performed to analyze the published experience and increase the understanding of these difficult hernias., Methods: We reviewed the extensive literature, including the Medline and Current Contents computerized database searches, and searched the available bibliographies., Results: Seven retrospective studies of a total of 113 patients who had clinical subxiphoid hernias after median sternotomy were found. An additional surgical technique describing a modified median sternotomy preventing the hernia, and a single review article on selected technical considerations of subxiphoid ventral repair were also found., Conclusions: The incidence of subxiphoid hernia after median sternotomy can be possibly reduced by paraxiphoid extension of the sternotomy, reinforcement near the xiphoid end of the incision, or by optimizing closure of the distal sternotomy and the linea alba. Abdominal wall reinforcement by open-mesh closure or laparoscopic transperitoneal prosthetic repair can effectively deal with the defect. Long-term outcome analyses are not yet available.

Background: There is a paucity of data regarding the use of early corticosteroid withdrawal (ESW) in African-American renal allograft recipients, and very few reports with >or=1 year follow-up in all patients., Methods: We examined the outcomes of 57 African-American renal allograft recipients with minimum follow-up 12 months who did not receive maintenance steroids after day 4 posttransplant. All patients received thymoglobulin induction, mycophenolate mofetil, and initial tacrolimus (n = 48) or sirolimus (n = 9)., Results: Patient and graft survival were 98% and 96% at 1 year, and 95% and 89% over the entire follow-up period (mean, 23 +/- 8 months). Incidence of acute rejection and cytomegalovirus infection were 18% and 7%, respectively, with mean serum creatinine 1.6 +/- 0.5 and 1.7 +/- 0.9 mg/dL at 6 and 12 months. Of patients with functioning grafts, 84% remained steroid free at 1 year, of which 11 (24%) were also calcineurin inhibitor free. Twenty-seven patients underwent surveillance biopsy at 1 month and 28 at 12 months, with 15 surveyed at both time points. There were significant increases in only 2 of the 6 1997 Banff chronic allograft nephropathy (CAN) category scores in this subgroup, with all mean values remaining <1 (mild in severity) at 1 year. Overall, from 82% to 96% of the 12-month scores were

Background: Healing of median sternotomy requires reliable sternal fixation. Although both single and double wire kits are commercially available, no experimental study has compared the two closures in a human cadaveric model. We used a recently described human experimental cadaveric model to compare the stability of the closures., Methods: Sixteen fresh adult human cadaveric sternal plates with adjacent ribs were fixed with custom designed spiked stainless steel clamps and attached to a biomechanical testing device. Single No. 5 peristernal and double peristernal closures were tested. The stability of the unions was tested using perpendicular, repetitive force loads increasing from 0 to 800 Newtons at a rate of 0.5 mm/second., Results: The two study groups did not differ in age or sex. No clamp failures or damage to the specimens occurred. The double peristernal closure exhibited a significantly lower permanent displacement than the single wire group, suggesting a superior strength and stability of that closure., Conclusions: To the extent to which this human cadaveric model resembles in vivo median sternotomy, these data suggest that the biomechanical stability of the peristernal double wire closure may exceed that of single wires.

Multiperforated atrial septal aneurysm (ASA) with left-to-right shunt and elevated pulmonary arterial pressure is rare. We present an adult patient with this unusual anomaly combined with a single coronary ostium emerging from the right sinus of Valsalva. The ASA was excised and the defect repaired successfully.

Objective: To examine the outcome of technical variant liver transplant techniques relative to whole organ liver transplantation in pediatric liver transplant recipients., Background: Technical variant liver transplant techniques comprising split, reduced, and live-donor liver transplantation evolved to address the need for timely and size appropriate grafts for pediatric recipients., Methods: Analysis of data from the Studies of Pediatric Liver Transplantation (SPLIT) registry, a multicenter database of 44 North American pediatric liver transplant programs. The outcome (morbidity and mortality) of each of the technical variants were compared with that of whole organ recipients., Results: Data were available on 2192 transplant recipients (1183 whole, 261 split, 388 reduced, and 360 live donor). Recipients of all technical variant graft type were significantly younger than whole organ recipients, but on average spent 2.3 months less on the waiting list. Thirty-day post-transplant morbidity was increased for each type of technical variant relative to whole organ (45.1% whole, 66.7% split, 65.5% reduced, 51.9% live-donor). Biliary complications (30 day: 7.5% whole, 18.8% split, 16% reduced, 17.5% live-donor) and portal vein thrombosis (30 day: 3.6% whole, 8% split, 8% reduced, 7.5% live-donor) were more common in all technical variant types. Graft type was an independent predictor of graft loss (death or retransplantation) in a multivariate analysis. Split and reduced (relative risk = 1.74 and 1.77, respectively) grafts had a worse outcome when compared with whole organ recipients., Conclusions: Technical variant techniques expand the pediatric donor pool and reduce time from listing to transplant, but they are associated with increased morbidity and mortality.