James M. Nottingham

Maxillofacial injuries and life-threatening hemorrhage: Treatment with transcatheter arterial embolization

BACKGROUND There are many reasons for hypotension in trauma patients with multiple injuries; one uncommon source is facial fractures. The treatment algorithm is volume replacement and local control of the bleeding. A retrospective study was undertaken to evaluate the treatment of patients with life-threatening hemorrhage secondary to facial fractures, and to develop a treatment algorithm. METHODS A retrospective chart review was undertaken to determine the incidence of hemorrhagic shock in patients with facial fractures exclusive of others sources, and the use of transcatheter arterial embolization to control the bleeding was evaluated. RESULTS Over a 4-year period, 7562 patients were treated at Palmetto Richland Memorial Hospital, a Level I trauma center. There were 912 patients with facial injuries, with 11 of these patients presenting with life-threatening hemorrhage secondary to facial fractures. The incidence of life-threatening hemorrhage from facial fracture was 1.2%. The mechanism of injury was blunt in 10 patients and penetrating in 1. The blunt injuries resulted from six motor vehicles crashes, three motorcycle crashes, and one plane crash. The one penetrating injury was a shotgun blast. There were six patients with Le Fort III fractures, two patients with Le Fort II fractures, and three patients with a combination of Le Fort II and III fractures bilaterally. The average volume infused before the embolization was 7 L; this included blood and crystalloid. There were four complications: two minor groin hematomas, one partial necrosis of the tongue, and one facial nerve palsy. There were two deaths, both secondary to concomitant intracranial injury as a result of blunt trauma. CONCLUSION The incidence of severe hemorrhage secondary to facial fractures is rare; however, it can be life threatening. When common modalities of treatment such as pressure, packing, and correction of coagulopathy fail to control the hemorrhage, transcatheter arterial embolization offers a safe alternative to surgical control.

Richter's hernia in the laparoscopic era: four case reports and review of the literature.

Richters hernia can occur at trocar sites after laparoscopic procedures, and 10-mm or larger ports are the usual culprits. Most surgeons now routinely close the fascia of these sites to prevent herniation. The usual presentation is of crampy abdominal pain with nausea and vomiting. Treatment is reduction of the bowel that is incarcerated and then repair of the fascial defect. We describe four cases of Richters hernia after laparoscopy, two that were repaired by open procedure and two that were repaired laparoscopically, and review the literature. A laparoscopic hernia repair is acceptable treatment at the time of diagnosis, especially in the obese patient, as long as the incarcerated bowel is not compromised or frankly ischemic.

Mechanical small bowel obstruction from a loose linear cutter staple after laparoscopic appendectomy.

Laparoscopic linear cutting staplers are commonplace in advanced laparoscopic techniques. Most of the loose staples are probably inert, but we present a case of a mechanical small bowel obstruction after a laparoscopic appendectomy. The etiology of the bowel obstruction was a loose linear cutter staple from the load that fired across the appendiceal stump. We recommend retrieving as many loose staples as possible with the laparoscopic grasper or suction at the termination of the laparoscopy.

The role of adipose tissue-associated macrophages and T lymphocytes in the pathogenesis of inflammatory bowel disease

Inflammatory bowel diseases (IBDs) are chronic inflammatory disorders of the gastrointestinal tract that affect more than 3 million people worldwide, but the pathological etiology is still unknown. The overall purpose of our investigations was to elucidate the possibility of pathological causes of IBD, and therefore, we determined the difference of inflammatory cytokine profiles in adipose tissue macrophages (ATMs) and T lymphocytes (ATTs) obtained near active lesions of IBD; investigated whether the alteration in ATM activation induces genes involved in collagen formation; and evaluated the effects of fatty acid oxidation inhibitors on factors involved in inflammation and collagen production by ATMs in IBD. Adipose tissues (ATs) were collected near active lesions and also at the margin of resected segments of the bowel from IBD patients with ulcerative colitis (UC) and CD (n=14/group). Normal appearing ATs from control subjects (n=14) who had colon resection for adenocarcinoma were collected as far away from the cancer lesion as possible to rule out possible changes. Compared with inactive disease lesions, ATMs and ATTs from active lesions released more IL-6, IL-4 and IL-13. Treatments of cytokine IL-4 and/or IL-13 to ATMs reduced iNOS expression but increased Arg-I expression which were exacerbated when treated with T cell- and adipocyte-conditioned medium. However, fatty acid oxidation inhibitors prevented the effects of cytokines IL-4 and/or IL-13 on iNOS and Arg-I expressions. This study was the first to show the effect of IL-4 and IL-13 on collagen formation, through iNOS and Arg-I expressions, that was exacerbated in a condition that mimics in vivo condition of active lesions. Moreover, our study was the first to provide potential benefits of fatty acid oxidation inhibitors to ATMs on preventing collagen formation; thus, providing therapeutic implications for individuals with intestinal fibrosis and stricture lesions, although future study should be guaranteed to elucidate the underlying mechanisms.

Human satellite progenitor cells for use in myofascial repair: Isolation and characterization

Current use of prosthetic meshes and implants for myofascial reconstruction has been associated with infectious complications, long-term failure, and dissatisfying cosmetic results. Our laboratory has developed a small animal model for ventral hernia repair, which uses progenitor cells isolated from a skeletal muscle biopsy. In the model, progenitor cells are expanded in vitro, seeded onto a nonimmunogenic, novel aligned scaffold of bovine collagen and placed into the defect as a living adjuvant to the innate repair mechanism. The purpose of the current investigation is to examine the feasibility of translating our current model to humans. As a necessary first step we present our study on the efficacy of isolating satellite cells from 9 human donor biopsies. We were able to successfully translate our progenitor cell isolation and culture protocols to a human model with some modifications. Specifically, we have isolated human satellite muscle cells, expanded them in culture, and manipulated these cells to differentiate into myotubes in vitro. Immunohistochemical analysis allowed the characterization of distinct progenitor cell cycle stages and quantification of approximate cell number. Furthermore, isolated cells were tracked via cytoplasmic nanocrystal labeling and observed using confocal microscopy.

Delayed laparoscopic repair of a traumatic flank hernia: A case report and review of the literature

Highlights • Not all traumatic abdominal wall hernias require laparotomy at time of injury.• Observation is considered to be safe when there is no other indication for surgery.• Many patients managed non-operatively remain asymptomatic.• Delayed laparoscopic repair with mesh reserved for hernias that become symptomatic.

Clinical, ultrasonographic, mammographic, and histologic features of leiomyoma of the breast

Abstract Leiomyomas are benign, smooth muscle tumors classically found in the uterus, esophagus, or small bowel. In very rare instances, they can be found in the breast. We report a case of leiomyoma of the breast in a 68-year-old

Non-traumatic perforation of common hepatic duct: Case report and review of literature HP

Highlights • A rare case of spontaneous perforation of common hepatic duct due to stones impaction.• Because of its rarity, spontaneous biliary perforation requires high index of suspicion.• Impacted stones in the biliary tree need to be extracted to avoid complications.• ERCP and stent placement should be only used as temporizing measures to manage the acute obstructive phase.• Definitive surgical intervention must follow initial biliary decompression to extract the impacted biliary stones.

Lysine Pill-Induced Esophageal Perforation

Department of Surgery, University of South Carolina School of Medicine, Two Medical Park, suite 300, Columbia, SC 29203, USA *Corresponding author James M. Nottingham, MD, FACS Professor of Clinical Surgery Department of Surgery University of South Carolina School of Medicine, Two Medical Park suite 300, Columbia SC 29203, USA Tel. (803)545-5800 Fax: (803)933-9545 E-mail: james.nottingham@uscmed.sc.edu