John D. Horton

Presentation and management of Morgagni hernias in adults: a review of 298 cases

BackgroundMorgagni hernias are a very rare form of diaphragmatic hernias. No robust studies have been performed to show the true natural history of this disease process. This study aimed to summarize clinically relevant data with respect to Morgagni hernias in adults. These data should help surgeons workup, diagnose, and treat Morgagni hernias in adult patients.MethodsA literature search was performed using PubMed, Google scholar, and the following key words: Morgagni, Larrey, retrosternal, retrocostoxiphal, retrochondrosternal, parasternal, substernal, anterior diaphragmatic, and subcostosternal. All case reports and series after 1951 that pertained to adults were included in the review. The following data points were queried: age, sex, presentation, studies used during workup, laterality, surgical approach, hernia sac management, specific laparoscopic techniques, and follow-up evaluation.ResultsThese criteria were met by 135 articles representing 298 patients. Based on the data provided, several conclusions regarding this disease process can be drawn. Most patients (72%) present with symptoms related to their hernia. Pulmonary complaints are the most common symptoms (36%). Men present earlier in life than women. Thoracotomy is the most widely used surgical approach (49%). However, laparoscopic repair has gained popularity since its first report in 1992. Laparoscopic surgeons usually repair the defect with mesh (64%) and do not remove the hernia sac (69%). Laparoscopic repair can be performed with a low complication rate (5%) and a short hospital stay (3 days). Outcomes of other surgical approaches also are reported.ConclusionsUsing modern surgical techniques including laparoscopy, repair of Morgagni hernia can be performed safely with a short hospital stay and with little morbidity or mortality.

Budd^Chiari syndrome: illustrated review of current management

Budd–Chiari syndrome (BCS) is characterized by hepatic venous outflow obstruction at any level from the small hepatic veins to the atriocaval junction. BCS is a complex disease with a wide spectrum of aetiologies and presentations. This article reviews the current literature with respect to presentation, management and prognosis of the disease. Medical, interventional and surgical management of BCS is discussed. Particular attention is paid to interventional and surgical aspects of management. The review is augmented by images, which provide a clinical corollary to the text.

Kaposiform hemangioendothelioma: a rare cause of spontaneous hemothorax in infancy. Review of the literature.

Kaposiform hemangioendothelioma is a rare vascular tumor found almost exclusively in early childhood often associated with a life-threatening thrombocytopenia and consumptive coagulopathy known as Kasabach-Merritt phenomenon. The natural history of these lesions and treatment remains controversial. We portray a case of a spontaneous hemothorax in a 2-month-old female infant and review of 153 reported cases in attempts to better delineate the available treatment options.

Use of Recombinant Factor VIIa in Operation Iraqi Freedom and Operation Enduring Freedom: Survey of Army Surgeons

Military physicians are using recombinant factor VIIa (rFVIIa) in Iraq and Afghanistan to help stop life-threatening hemorrhage in trauma patients. We constructed a questionnaire and surveyed Army general surgeons deployed to Iraq and/or Afghanistan about their predeployment experience, deployment experience, and projected postdeployment practice regarding rFVIIa usage. Most surgeons had rFVIIa available during their deployment (65%). The drug was used with varying frequency and subjective therapeutic effect. A majority of surgeons (79%) were unaware of any guideline or policy governing the use of rFVIIa. Seventy percent of respondents would use the drug in their future practice. Deployed surgeons generally have positive attitudes regarding the use of rFVIIa, but greater guidance and outcome measures are needed.

Perirectal Abscess Infections Related to MRSA: A Prevalent and Underrecognized Pathogen

BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is not a commonly recognized pathogen isolated from perirectal abscesses. Complex perirectal abscesses of MRSA origin may present a significant challenge to the physician and result in treatment failure. The aim of our study was to determine the prevalence of MRSA in our patient population with perirectal abscesses and whether antibiotics coverage, if given, was adequate. METHODS We conducted a retrospective study of all adult patients who presented with a perirectal abscess. The bacteriology of the cultures taken from more than 100 patients during an 8-year period was examined. The prevalence of MRSA was specifically analyzed, and the sensitivities of the organisms isolated were then compared with any antibiotics prescribed to determine the adequacy of coverage. RESULTS In all, 124 patients were treated for perirectal abscess during the 8-year period. Fifty-nine percent of patients were taken to the operating room for incision and drainage, 52% of the patients had cultures taken of the abscess, and 35% of patients were given antibiotics coupled with incision and drainage. The antibiotics offered adequate coverage when compared with the sensitivities of the organisms 73% of the time. The prevalence of MRSA in our patient population was 19%, and when this organism was cultured, the patient only received adequate coverage 33% of the time. CONCLUSION The presence of MRSA in perirectal abscesses is underrecognized. Recent data has shown that incision and drainage combined with antibiotics offers a superior outcome in soft tissue abscesses caused by this organism. If cultures are not routinely taken at the time of incision and drainage, the institutional incidents of MRSA will remain unknown. Physicians must recognize that MRSA is a potential organism present in perirectal abscesses when considering antimicrobial therapy for complex abscesses.

High-Grade Primary Pulmonary B Cell Lymphoma Presenting as a Necrotic Mass

High-grade primary pulmonary B cell lymphoma is a rare, aggressive lung malignancy, accounting for less than 0.2% of all primary lung cancers.[1][1] It often presents as a solitary mass with associated systemic symptoms, most commonly in immunosuppressed patients. We present a case of this unusual

Elective Inguinal Hernia Repair During Operation Iraqi Freedom

OBJECTIVE While there have been many publications regarding trauma care in the deployed environment, there is little discussion on the management of the more mundane maladies. This article examines the role of elective surgical intervention for inguinal hernia repairs within theater. Current U.S. policy transports service members out of theater for elective repair and convalescence. In these times of limited man power, this can represent a significant loss of the fighting strength. METHODS Between January 2006 and July 2006, military surgeons at the 47th Combat Support Hospital in Iraq repaired 11 inguinal hernias. All patients were encouraged to resume normal duty and physical training as soon as possible. A post-procedure questionnaire was completed 6-12 months after surgery. RESULTS Four repairs were completed with the Prolene Hernia System (PHS; Ethicon, West Somerville, NJ) and seven repairs using the plug and patch method (C. R. Bard, Inc., Murray Hill, NJ). Ten patients were available for follow-up. There were no wound infections, nerve injuries, or recurrences. Patients returned to full duty within 3 days to 6 weeks. CONCLUSIONS Based on our experience and the feedback from our patients, no complications were noted in this small population of elective hernia repairs. Further prospective trials with long term follow-up are needed to confirm these initial findings.