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A 33-year-old African-American woman with a severe manifestation of Poland syndrome developed breast cancer in the ipsilateral breast. She had a severely hypoplastic upper extremity, including symbrachydactyly, and a hypoplastic forearm and upper arm. In addition, she lacked the sternal origin of the pectoralis muscle. She had a very small nipple-areola complex and no axillary hair. This is the first case report of breast cancer developing in the ipsilateral breast of a patient with Poland syndrome.

Patients with bullets in the pericardial sac without obvious myocardial injuries are rare, making it difficult to analyze the natural history and propose management approaches. We present the case of a meandering bullet in the pericardial sac and a review of the literature.

Islet cell tumors of the pancreas usually secrete gastroenteropancreatic peptides causing well-recognized clinical syndromes. Description of these syndromes and the identification of the responsible hormones by radioimmunoassay has led to a better understanding of neuroendocrine regulatory function. More recently, similar tumors have been seen that contain various peptides on immunohistochemical stain but do not secrete these substances sufficiently to cause clinical symptoms. Nonetheless, they have the same malignancy and metastatic rate as most of the functional tumors. Between 1972 and 1996, 44 patients with islet cell tumors have been treated at the Indiana University Medical Center Hospital, and of these 14 have been nonfunctional. Preoperative imaging studies, such as CT scan and endoscopic ultrasound, were able to visualize a lesion but not to make the specific diagnosis, even with fine-needle aspiration. Pancreatic ductal preservation on endoscopic retrograde cholangiopancreatography with CT evidence of a mass should arouse suspicion of an islet cell tumor. Once discovered, all but 1 of the 14 patients has under gone resective therapy, with only 1 postoperative death. Treatment has been aggressive, with 11 of the 13 resected patients undergoing pancreaticoduodenectomy, and 2 others distal pancreatectomy. Four of the seven patients with positive lymph node metastases are dead, while all patients with negative nodes are still alive. Thus far, 10 of the original 14 patients are alive, surviving an average of 32.7 months, with a median survival of 31.1 months. Because these tumors have a better overall prognosis, vigorous attempts at total or subtotal resection should be carried out, since the long-term survival is enhanced by tumor bulk reduction or curative resection when possible.

Although primary repair of penetrating colon injuries in patients with low injury severity is now widely accepted, several "risk factors" continue to be viewed as relative contraindications to this method of management. The purpose of this study was to evaluate the septic complications and leak rate in a series of consecutive penetrating colon injuries managed exclusively with primary repair. The records of 58 consecutive patients with penetrating intra-abdominal colon injuries managed at an urban Level I trauma center from July 1991 to December 1995 were reviewed. Patients were stratified for injury severity using the Penetrating Abdominal Trauma Index (PATI), and the presence of "risk factors" and septic abdominal and wound complications were recorded. All 58 patients were managed with primary repair. There were 48 gunshot wounds (72%), 7 shotgun wounds (12%), and 9 stab wounds (16%) with a mean PATI of 26.7 +/- 15.2 standard deviation. Seven patients (12.1%) developed intra-abdominal abscess, and all were managed by CT-guided percutaneous drainage. Five patients (8.6%) developed bacteremia, and eight patients (13.8%) developed fascial dehiscence. Three patients (5.2%) underwent abdominal re-exploration in the postoperative period, but none of these was related to failure of the colonic repair. There were no clinically apparent leaks or fistulae and no deaths. The presence of "risk factors" appeared to identify more severely injured patients as indicated by a higher mean PATI score and a higher incidence of intra-abdominal abscess, when compared to patients in whom the "risk factor" was absent. Primary repair can safely be used for virtually all penetrating colon injuries, as clinical leaks are rare, even in patients with "risk factors". Intra-abdominal abscess and other septic complications are dependent on the overall severity of the intra-abdominal injuries and probably result from contamination occurring at the time of injury rather than from postoperative leak from the primary repair.

Swelling in the inguinal region of a woman may result from a number of conditions, including inguinal hernia, tumor (lipoma, leiomyoma, sarcoma), cyst, abscess, adenopathy, or hydrocele of the canal of Nuck. It may be difficult to make a specific diagnosis based upon the history and physical examination alone. This report describes a symptomatic woman in whom ultrasound was helpful in diagnosing a hydrocele of the canal of Nuck, which is the female counterpart of a spermatic cord hydrocele in the male. The ultrasound findings are described.

To assess the efficacy of laparoscopic cholecystectomy for the treatment of acute gallstone pancreatitis.The charts of patients who underwent laparoscopic cholecystectomy between July 1990 and March 1993 were reviewed. Data gleaned included age, duration of symptoms, physical exam, laboratory analysis, imaging studies, and postoperative course.The diagnosis of gallstone pancreatitis was present in 29 of 510 patients (5.7%). The 20 females and nine males ranged in age from 13 to 81 years with an average of 47 years. Twenty-six patients exhibited three or fewer of Ranson's criteria, and three had four criteria. All 29 patients underwent laparoscopic cholecystectomy without complications. Endoscopic retrograde cholangiogram (ERC) was done before operation in four patients, all normal studies. Laparoscopic cholangiography was successful in 18 of the 22 patients in whom it was attempted. Common bile duct (CBD) stones were identified in three patients. Two had all stones cleared via the transcystic approach. The other had several stones removed from the CBD, but some stones were left in the hepatic duct. Postoperative ERC removed the remaining stones. Twenty-two of the 29 (76%) patients were discharged within 2 days of the operation, six were home by Day 6, and the last patient was discharged on Day 16. Twenty-six patients were well in follow-up. Two patients returned 1 month after operation with an elevated serum amylase and lipase that promptly resolved. One patient was lost to follow-up.Laparoscopic cholecystectomy is effective for patients with acute gallstone pancreatitis and can be accomplished safely. Laparoscopic cholangiography can be performed, can visualize the anatomy, and can address common bile duct stones. In most cases these patients can be successfully managed without ERC.

Clinical and biochemical evaluation of patients with hypercalcemia are today extremely accurate in identifying those with primary hyperparathyroidism. Neck exploration by an experienced parathyroid surgeon is equally likely to identify correctly the diseased gland or glands. It has been suggested that recently devised localization techniques may allow the surgeon to limit the extent of the procedure to one side of the neck. The present retrospective study was undertaken to determine the reliability with which two such imaging procedures, ultrasonography (US) and thallium-technetium subtraction scanning (TTSS) localize these lesions by specific site or side. The identity of each patient undergoing parathyroidectomy at a metropolitan medical center was determined by review of the operating room log. From the records of each subject were noted the results of any imaging studies done, the location of lesions found at surgery, and the histologic diagnosis. Accuracy and positive predictive value of US and TTSS were then calculated on the basis of precise and lateralizing localization. Seventy-four patients underwent primary neck exploration during the study period. In 69 patients US, TTSS, or both were performed preoperatively, and among these, data were complete in 65. Ultrasound correctly localized the site of a lesion in 31 of 63 subjects, and TTSS in 25 of 45. Ultrasound correctly localized the side on which the lesion lay in 35 of 62 subjects, and TTSS in 27 of 45. In 29 of 42, one or both studies correctly identified the side on which the lesion lay. In only one of 13 subjects with hyperplasia were all four glands correctly identified as hyperplastic.(ABSTRACT TRUNCATED AT 250 WORDS)

While nonoperative management of blunt hepatic trauma has become the standard of care in children, its use in the adult population is not as well accepted. The purpose of this study was for the authors to review their experience with operative and nonoperative management of adults with blunt hepatic trauma at an urban trauma center. During the past 7 years, 56 adults were found on abdominopelvic computerized tomography or at exploratory laparotomy to have sustained blunt hepatic trauma. Nonoperative management was considered in patients who were hemodynamically stable; had no signs of peritoneal irritation; and had no other intra-abdominal injuries that might require surgical repair. Of the 56 patients, 20 were admitted to the surgical intensive care unit for careful observation. One patient required the administration of blood products and a second underwent laparotomy within 12 hours of presentation for progressive abdominal pain. This patient had a 4-cm liver laceration easily controlled with electrocautery. This review supports the judicious application of nonoperative management in the hemodynamically stable adult with blunt hepatic trauma who is without signs of significant peritoneal irritation or other intra-abdominal injuries that would require surgical repair.

Autotransfusion is a potentially valuable tool in the resuscitation of hypovolemic trauma patients; its acceptance in this setting has been limited by fears of the induction of coagulopathic and septic complications. It has been inferred that the addition of a cell washing step would obviate these concerns but at the cost of speed. To assess the validity of these concerns, we have retrospectively compared two autotransfusion devices: one without (the modified Bentley device) and one with (the Baylor Rapid Autologous Transfusion system) a cell washing step, over a 48-month period. In the Bentley group (n = 13), the mean estimated blood loss was 8,423 ml and the mean amount of blood autotransfused was 1,826 ml. Overall, the device returned 0.54 units of whole blood for every unit of banked blood used. Sixty-two per cent of these severely injured individuals died. Among survivors, there was a 20 per cent incidence of significant complications. In the BRAT group (n = 13), the mean estimated blood loss was 11,177 ml and the mean amount of blood autotransfused was 3,681 ml. Overall, the device returned 0.82 units of washed, packed red blood cells for every unit of banked blood used. Overall mortality was 26 per cent, and 30 per cent of survivors had complications. While we have been unable to demonstrate an advantage of the cell washing step, there is no evidence that this step in this unit limited the rate or volume of autologous blood replacement.

A 3-mm cecal ulcer without any adjacent polypoid structure was detected in a 66-year-old asymptomatic man undergoing screening colonoscopy. Biopsies demonstrated carcinoma in-situ. The literature on tiny colonic carcinomas and carcinoma in-situ in the absence of any polyp is reviewed in this article.

Pancreaticoduodenectomy has been decried as a means of managing combined pancreatic and duodenal trauma. In order to test this harsh assessment, we have reviewed our experience with this procedure in this setting. Six young males with a mean injury severity score of 15.4 underwent pancreaticoduodenectomy for trauma. Four patients sustained penetrating trauma and two patients suffered blunt injuries; each was felt by clinical assessment to have pancreatic ductal disruption combined with significant duodenal injury. Four patients underwent pancreaticoduodenectomy primarily, while two patients underwent initial drainage and diverticulization. The four patients undergoing immediate resection had a mean hospital stay of 28 days (18-42 days) and did not require further surgical intervention. All are alive and well six months to nine years later. The two patients with drainage and repair of their injuries had a mean hospital stay of 115 days (84-147 days) and required additional laparotomies for pancreatic leaks, enterocutaneous fistulae, or drainage of abscesses. Pancreaticoduodenectomy was ultimately performed in each case, and both have survived. Pancreaticoduodenectomy continues to have a role in the management of combined pancreatic and duodenal injuries.

The indications for thoracic aortography in the blunt chest trauma patient remain controversial. Clinical and radiographic findings in 102 patients seen at a Level I Trauma Center over a five-year period were reviewed to evaluate criteria predictive of major thoracic vascular injury. Five patients had positive aortograms. There was no significant correlation with Revised Trauma Score, symptoms, or associated thoracic injuries, although patients with aortic rupture did have a higher incidence of extrathoracic injuries (P less than 0.001). A blinded review of admitting chest radiographs for five major findings (widened mediastinum, aortic arch abnormalities, aortopulmonary window opacification, left apical capping, and right apical capping) revealed a significant difference between patients with and without aortic injury (0.98 +/- 1.24 findings in the negative aortogram group and 3.00 +/- 0.71 findings in the positive aortogram group) (P less than 0.001). All patients with aortic rupture had at least two major positive findings on admitting chest radiographs. Admission chest x-ray evidence of at least one major abnormality is a safe method of screening blunt chest trauma patients for thoracic aortography.

Tubes of canine gastric corpus were constructed so that the mucosa was exposed chronically to jejunal contents, pancreatic juice, or bile. Biopsies of these mucosae obtained 4 to 24 months later were compared with each other and with the normal stomach for parietal cell numbers, mucus cell numbers, inflammation, glandular disorder, and surface-cell hyperplasia. All three preparations showed marked gastrititis, but whole jejunal contents caused more severe changes than did either pancreatic juice or bile, which were approximately equal.

The formation of a temporary distal arteriovenous fistula (dAVF) has been used clinically to palliate patients with symptomatic venous hypertension. This study tested the efficacy of a temporary dAVF for the treatment of venous hypertension in an experimental model. Twenty-four New Zealand white rabbits were divided into two experimental groups. Group I rabbits (n = 12) underwent standardized ligation of the iliac and femoral venous systems. Group II rabbits (n = 12) underwent standardized ligation of the iliac and femoral venous systems with the formation of a temporary dAVF. Venous obstruction was documented with venography, and venous hypertension was documented with femoral venous pressure measurements. Venous pressure, resistance, blood flow, vein circumference, vein cross-sectional area, vein wall thickness, and venography were compared between four rabbits from each group at 2, 4, and 8 weeks. The effect of differences in baseline venous pressures was eliminated by subtracting the venous pressure in the unobstructed rabbit limb from the pressure in the obstructed rabbit leg. Group II rabbits had a lower standardized venous pressure (4.4 +/- 2.2 versus 9.5 +/- 4.2 mm Hg, p less than 0.01) and venous outflow resistance (0.16 +/- 0.08 versus 0.36 +/- 0.18, p less than 0.05) than did group I rabbits. Group II rabbits also had a larger superficial femoral vein circumference (3.46 +/- 0.67 versus 2.57 +/- 0.08 mm, p less than 0.05) and cross-sectional area (0.66 +/- 0.31 versus 0.31 +/- 0.09 mm2, p less than 0.01) than did group I rabbits. The improvement persisted throughout the 6-week study, which suggested an improved venous outflow.

The authors review their experience with 59 consecutive patients undergoing common duct exploration for calculous biliary tract disease, 33 of whom underwent operative choledochoscopy. It is shown that choledochoscopy is not associated with an increase in the amount of time required to perform cholecystectomy and common duct exploration. It is similarly shown that there is no increase in the incidence of postoperative complications occurring in conjunction with the use of the choledochoscope. Because of the safety of the technique and the subjective satisfaction afforded by its use, the authors, now include choledochoscopy as a routine measure in common duct exploration.

Blood shed into a closed peritoneal cavity is incoagulable. We have investigated this poorly understood phenomenon in animal experiments. Nonthrombogenic femoral vein-peritoneal cavity shunts were established in five dogs and 10 ml/kg blood admixed with 125I-dog fibrinogen was rapidly drained into the peritoneal cavity. After 1 hr the peritoneal cavity was entered and incoagulable blood aspirated; 125I-fibrinogen Mr distribution was assessed by AGPC, demonstrating complete degradation of fibrinogen into core fragments D and E with no evidence of soluble fibrin complexes or crosslinked fibrin fragments. Peritoneal cavity clotting factors II, V, and VIII and platelets were sharply reduced compared to venous control samples. Plasminogen and antiplasmin levels in peritoneal cavity blood showed mean declines of 17% and 15%, respectively. By comparison, incubation of dog blood with 1 to 2 X 10(3) U/ml urokinase for 1 hr in vitro was insufficient to degrade 125I-dog fibrinogen to core fragments D and E, although plasminogen and antiplasmin were reduced by 66% and 100%, respectively. Pretreatment of dogs with epsilon ACA (0.13 gm/kg, N = 4) resulted in massive intraperitoneal cavity clotting, and aspirated fluid blood contained only small quantities of radiolabel. Heparin treatment (300 U/kg bolus, 150 U/kg/hr infusion; N = 4) eliminated the peritoneal cavity lytic response; analytical gel permeation chromatography consistently demonstrated intact fibrinogen only. Therefore it is apparent that blood in a closed peritoneal cavity undergoes limited clotting followed by brisk plasmin-mediated fibrinolysis as opposed to fibrinogenolysis. The closed peritoneal cavity fibrinolytic response to clotting blood represents a striking example of the efficiency of the "tissue-type" plasminogen activator.

A glycogen-rich clear cell carcinoma arose in the breast of a 49-year-old woman. Light microscopic examination of the neoplasm revealed both intraductal papillary growth and stromal invasion. Electron microscopic examination demonstrated neoplastic cells that contained massive quantities of nonmembrane-bound particulate glycogen and that formed numerous acini. Apically, these cells formed microvilli; laterally they formed tight junctions and desmosomes. Morphologic features of this neoplasm are similar to those of the fetal breast and to some other clear cell carcinomas arising elsewhere in the body.

The effect of endotoxin upon oxygen consumption in a peripheral vascular bed was assessed in a canine hind-limb preparation. The left iliac vessels in 12 adult male mongrel dogs were isolated, the artery cannulated proximally and distally such that arterial inflow could be routed through a roller pump, and a nonocclusive catheter placed in the vein. Oxygen consumption was then calculated as the product of flow rate and and arteriovenous oxygen content difference at a series of flow rates before and after the systemic administration of endotoxin (3 mg/kg) or saline solution. At each flow rate, oxygen consumption by the extremities of endotoxic animals was significantly greater (P0.01) than that measured in control animals. This finding mitigates the hypothesis that endotoxin has a direct effect on cells reducing tissue oxygen consumption.

The consequences of exposure of the intact stomach to intestinal contents were examined in six dogs. Diversion of duodenal contents through the stomach lead to the following changes: histologic gastritis in both antrum and corpus, increase in resting and postprandial serum gastrin levels, increased parietal cell density in four of six animals, and enhanced maximal acid secretory capacity in three of six animals. No significant changes were seen in insulin-stimulated acid secretion, insulin-stimulated pepsin secretion, antral gastrin levels, or G cell numbers. We conclude that chronic exposure of the intact stomach to duodenal contents results in gastritis and an amplified gastrin response to food. Parietal cell numbers and maximal acid secretory capacity are increased in some animals.