Edward S. Kondi

New surgical approach to minimize radiation‐associated small bowel injury in patients with pelvic malignancies requiring surgery and high‐dose irradiation. A preliminary report

Complications associated with small bowel intolerance to radiation therapy at doses higher than 4500 to 5000 cGy have been the limiting factor in delivering pelvic radiation either as an adjuvant to surgery or alone in the treatment of pelvic malignancies. Despite numerous surgical, medical, and radiation therapy technical measures to minimize small bowel injury, none have been uniformly successful in eliminating this problem. With the availability of a new synthetic absorbable mesh, a pelvic sling can be placed at the time of exploration or definitive surgery aimed at suspending the small bowel out of the pelvis. Preliminary work in animal models has shown the mesh sling to be well‐tolerated and successful. Barium‐contrast simulation studies of seven patients with pelvic malignancies requiring resectional surgery and postoperative radiation therapy in whom the mesh sling was placed at the time of surgery demonstrate total exclusion of the small bowel from the pelvic radiation treatment field. All patients have been followed for at least 4 months since mesh placement, and to date no complications have occurred. It is possible that this technique of bowel exclusion will permit the delivery of larger doses of radiation therapy in patients with pelvic malignancies aiming at more effective local and regional control of cancer without increased complications from radiation‐associated small bowel injury.

The high cost of treating a psychiatric disorder as a medical/surgical illness.

There are numerous patients who primarily have psychiatric disorders, but repeatedly seek attention for bodily concerns, undergo multiple clinical procedures, and consume valuable medical resources. Although it seems logical to expect that the medical/surgical treatment of these patients would be both expensive and ineffective, there is little documentation of this in the literature. Consequently, we describe a patient who incurred

Diffuse eosinophilic granuloma of bone.A dramatic response to velban therapy

46,000 in medical charges in 1982, and whose estimated lifetime bills total one-half million dollars.

Near-Fatal Hemorrhage Following Gastrografin Studies

A patient with diffuse osseous infiltration by eosinophilic granuloma was treated with intravenous Velban once each week. Generalized bone pain rapidly diminished. Within 5 months, significant sclerosis and recalcification of all bony lesions was observed, and maintenance therapy with Velban has produced a prolonged, complete remission. This unusual response justifies consideration of this therapy in other patients with diffuse eosinophilic granuloma of bone and other related variants of the disease, histocytosis‐X.

A new variant of intra-abdominal hernia.

The use of upper gastrointestinal studies followed by gastric drainage and observation is recommended for the evaluation and treatment of stomal dysfunction due to edema or gastric atony. Gastrografin though, may be precipitated out and can cause gastrointestinal bleeding if left in the gastric remenant. This agent should be used with proper precautions in the evaluation of postoperative gastric retention.

Prolonged survival in a patient with hepatic malignant melanoma treated by intra-arterial bleomycin and oral hydroxyurea

A new variant of intra-abdominal hernia is presented. Available evidence suggests that this type of intra-abdominal hernia may be more prevalent than previously reported. Patients suffering from crampy, intermittent abdominal pain whose routine dadiographic gastrointestinal studies are unrevealing often are labeled as having psychogenic disorders. Three cases are presented giving similar histories and routine findings in which mesenteric arteriography copled with careful small bowel series has revealed a surgically curable lesion. Such patients should have judicious mesenteric angiography coupled with routine radiographic gastrointestinal studies in search of small intramesenteric herniae which are readily correctible.

Proctitis cystica profunda in paraplegics

Abstract A case is reported of hepatic metastasis of malignant melanoma six years after enucleation of the right eye in an elderly patient. A fourteen month objective response to the administration of intra-arterial bleomycin and oral hydroxyurea is presented. The response rate that can be expected in large numbers of patients must await further study.

Gastric outlet obstruction as a consequence of a duodenal web masquerading as gastrinoma in an adult

Proctitis cystica profunda is a benign disease of the rectal mucosa that can be mistaken for rectal carcinoma both grossly and microscopically. Symptoms may consist of blood or mucus in the stool, diarrhea, tenesmus, or rectal pain. The disease has never been reported in a paraplegic population before, but the proposed etiology makes this group seem to be at high risk. We report three cases in our paraplegic population and discuss the nature of the disease as well as its treatment.

Small bowel exclusion from the pelvis by a polyglycolic acid mesh sling

We present the case of a 24-year-old man with recurrent peptic ulcers and hypergastrinemia, in whom a multidisciplinary investigation for gastrinoma revealed a duodenal web. The affected duodenal segment was excised, and a gastroduodenostomy with highly selective vagotomy was performed. Postoperative serum gastrin levels returned to the normal range over the next 6 weeks. Congenital duodenal anomalies are unusual causes of gastric outlet obstruction in adults. Chronic gastric outlet obstruction secondary to an adult duodenal web can induce neurohumoral changes in gastric function, which enhance both acid output and gastrin secretion. This case reminds clinicians to consider congenital anomalies in adults presenting with recurrent peptic ulcers and hypergastrinemia.