Robert S. Hollabaugh

Fournier's gangrene : Therapeutic impact of hyperbaric oxygen

&NA; Many controversial issues exist surrounding the disease pathogenesis and optimal management of Founiers gangrene. In Fourniers original descriptions, the disease arose in healthy subjects without an obvious cause. Most contemporary studies, however, are able to identify definite urologic or colorectal etiologies in a majority of cases. To investigate disease presentation, treatment modalities, and overall mortality, a retrospective analysis of Fourniers gangrene from a single institution is presented. Since 1990, 26 cases of Fourniers gangrene have been diagnosed at the University of Tennessee. An evaluation of intercurrent disease revealed that 38 percent of the patients had diabetes mellitus, 35 percent manifested ethanol abuse, and 12 percent were systemically immunosuppressed. Fifteen patients (58 percent) presented with identifiable etiologies for their disease: 31 percent (8) urethral disease or trauma, 19 percent (5) colorectal disease, and 8 percent (2) penile prostheses. Management in all cases involved prompt surgical debridement with initiation of broad‐spectrum antibiotics. Multiple debridements, orchiectomy, urinary diversion, and fecal diversion were performed as clinically indicated. Fourteen patients received hyperbaric oxygen as adjuvant therapy. Statistically significant results were noted with mortality rates of 7 percent in the group receiving hyperbaric oxygen (n = 14) versus 42 percent in the group not receiving hyperbaric oxygen (n = 12). Overall mortality was 23 percent. Controversy still surrounds disease pathogenesis in Fourniers gangrene, particularly in regard to etiology. Our study corroborates current trends in that a clear focus of origin was identified in a majority of the cases. Although a grim prognosis usually accompanies the diagnosis, this study shows significant improvement combining traditional surgical and antibiotic regimens with hyperbaric oxygen therapy. (Plast. Reconstr. Surg. 101: 94, 1998.)

The management of gastroschisis

Summary A striking improvement in the results of infants with gastroschisis has occurred in recent years. The overall survival of 47 patients in a 25-yr period was 53%. In the first 20 years of this experience, only six of 20 lived (30%). In the past 5 yr, 19 of 27 have survived (70%). Two methods have given very satisfactory results. The skin-closure technique involves a major postoperative problem of respiratory support and a lesser problem of impaired wound healing. Furthermore, later hospitalizations for staged repairs of the ventral hernias are required. Despite these problems, there have been only two deaths in the 13 patients handled in this fashion in the last 5 yr. The silo technique is much simpler from the standpoint of the initial procedure and has the great advantage of avoiding significant postoperative respiratory embarrassment. Early technical problems with the material used. separation or tearing of the silo, and infection have largely been solved and the recent results have been very satisfactory. Although the recent experience with both techniques has been comparable in terms of mortality, the much reduced morbidity with the silo technique recommends it as the preferred method.

The prostate anesthetic block for outpatient prostate surgery.

Abstract With the emergence of minimally invasive techniques for the treatment of benign prostate hyperplasia and the need to reduce health care costs, a simple and effective prostate anesthetic block may allow more procedures to be done in an outpatient or office setting. As based on neuroanatomy studies of the prostate, the perineal approach appeared to be the best way to anesthetize the prostate. This technique was used in 43 patients who underwent interstitial laser coagulation an outpatient or office setting. The perineal prostatic block was effective for pain control whether lidocaine or lidocaine/bupivacaine was used as determined by visual analog scale, linear pain scale, or global pain questionnaire. The use of intravenous (i.v.) sedation did not influence the efficacy of the prostate anesthetic block. Thus, the perineal prostate anesthetic block may be employed in patients undergoing minimally invasive surgery for benign prostatic hyperplasia in the outpatient/office location.

Cryosurgical Ablation of the Prostate for Localized Adenocarcinoma: A Preliminary Experience

PURPOSE Cryosurgical ablation of the prostate has recently become recognized as a therapeutic option in the treatment of localized adenocarcinoma of the prostate. To assess the efficacy of cryoablation in this disease process several centers have instituted treatment protocols. MATERIALS AND METHODS Our overall series includes 117 ultrasound guided percutaneous transperineal cryoablations performed on 104 patients with localized adenocarcinoma of the prostate. Followup consisted of digital rectal examinations and measurement of prostate specific antigen levels at 3-month intervals after cryosurgery. Additionally, prostate biopsies were obtained 3 to 6 months postoperatively. RESULTS Of 63 patients who underwent initial cryosurgery and followup biopsy 47 (75%) had negative findings. Of the 16 patients with positive biopsies 10 consented to undergo a second cryosurgical ablation, and 7 of these patients subsequently had negative followup biopsies. Therefore, our disease-free rate at 3 months after 1 or 2 cryosurgical procedures was 95%. A total of 46 protocol patients in our series completed 12 months of evaluation and 40 (87%) had no evidence of disease. This same cohort showed only minimal disease progression, with disease-free rates of 96, 93, 87 and 87% at 3, 6, 9 and 12 months, respectively. Major complications were infrequent. CONCLUSIONS At 1-year followup our clinical experience shows cryoablation of the prostate to be an effective therapy in select cases of prostatic adenocarcinoma. Long-term efficacy is still in question but, based on current disease-free rates, this therepeutic modality merits continued clinical investigation.

Mediastinal mass and radiolucent esophageal foreign body

The diagnosis of radiolucent esophageal foreign bodies can be difficult, particularly in patients with predominant respiratory symptoms. The consequences of the impaction of a foreign body in the esophagus are serious, and esophageal stenosis, perforation, acquired tracheoesophageal fistulas are among the complications already reported. An unusual complication of a nondiagnosed radiolucent plastic coin that remained impacted for 11 months on the posterior esophageal wall of a 20-month-old child, who presented only with respiratory symptoms, is reported. The foreign body eroded through the esophageal wall, causing an intramural abscess that was initially interpreted as a mediastinal mass, and the patient was operated on with the diagnosis of a foregut duplication. Literature on this situation was reviewed, and the problems associated with the diagnosis and treatment of children with radiolucent esophageal foreign bodies are discussed.

Surgery for developmental and growth failure in childhood granulomatous enteritis.

Summary In children with granulomatous enterocolitis, growth failure and maturation arrest are found with alarming frequency. Nine patients without physical retardation were managed medically and did well. Thirteen patients with developmental standstill were treated by resection. All 13 experienced a striking growth spurt and 1 yr later had a mean weight gain of 40% of preoperative weight. Pubertal changes were rapidly completed in all. Growth retardation is the most important complication of regional enteritis of childhood, and represents advanced disease. Patients developmentally mature may be treated medically safely. Once growth and maturation have been arrested, the child is beyond the help of medical therapy. Resection of the diseased bowel is required for restoration of normal physical and sexual development, and is remarkably effective.

Can prostate-specific antigen reverse transcriptase-polymerase chain reaction be used as a prospective test to diagnose prostate cancer ?

The present study addressed the question as to whether prostate-specific antigen reverse transcriptase-polymerase chain reaction (PSA RT-PCR) could be used to identify prospectively men who have prostate cancer and to help determine which patients with an initially negative biopsy would benefit from rebiopsy. PSA RT-PCR was performed prospectively on 90 patients who were to have a prostate biopsy because of an elevated PSA level, an abnormal digital rectal examination, or both. PSA RT-PCR was performed, and the sensitivity of the test was enhanced by hybridization of the PCR with a32p-labeled PSA cl)NA probe (exons 3–5). Of the 90 men, 36 (40%) had prostate cancer on biopsy. Of these 36 men, 5 (13.9%) had a positive PSA RT-PCR finding, whereas 31 (84.1%) tested negative. Of 54 men with negative biopsies, 8 (14.8%) had a positive PSA RT-PCR result. The sensitivity of PSA RT-PCR for the detection of biopsy-proven prostate cancer was 13.9% and the specificity was 85.2%. Only 3 of 12 (25%) patients with advanced disease had a positive test result. The sensitivity of PSA RT-PCR for the detection of biopsy-proven prostate adenocarcinoma in men suspected of having prostate cancer is poor. Indeed, men without biopsy-proven prostate cancer are just as likely to have a positive result in the PSA RT-PCR as are men with cancer. Whether these men with negative prostate biopsies and positive PSA RT-PCR findings may eventually develop prostate cancer remains to be determined. At this time, PSA RT-PCR for the prospective detection of prostate cancer should be considered investigational.

Persistent Müllerian duct syndrome

Persistent müllerian syndrome is rare. A case of phenotypically normal male with persistent müllerian structures that consisted of a bicornuate uterus, fallopian tubes, and upper third of the vagina is reported. These unusual structures were found in association with bilateral cryptorchidism and a right inguinal hernia, and were diagnosed while repairing the hernia in the neonatal period. The uterus and fallopian tubes were removed via laparotomy when the child was eighteen months old; at the same time a bilateral orchiopexy was performed. To avoid damage to the vas deferens, which lay in closely to the müllerian structures and could not be separated from the vaginal wall, a small segment of the upper third of the vagina was retained. The testicles, although normal on pathologic examination, have shown poor response to hormonal stimulation with human chorionic gonadotropin. Long-term follow-up for these patients is necessary because they have an increased risk of testicular tumors developing.

Tracheal hamartoma: Report of a child with a neck mass

Tracheal hamartoma represents an oddity in children. Only one case was found in the English literature as a distal tracheal intraluminal lesion causing obstructive symptoms. All other reported cases were in older patients, who were presumed to have asthma or chronic obstructive pulmonary disease. The authors report on a 21-month-old girl who presented with an anterior neck mass fixed to the trachea. Imaging studies showed a lesion (2.5 x 2.3 x 1.7 cm) anterior to the right lobe of the thyroid, extending to the trachea posteriorly and down to the thoracic inlet inferiorly. The mass had a mixture of soft tissue densities with a focus of calcification. Results of thyroid studies were normal, and there was no adenopathy. Neck exploration showed a white, firm, lobulated mass fixed to the trachea, which was resected completely. The postoperative course was unremarkable. Histological studies showed a mixture of mature cartilage, fat, fibroconnective tissue, and spindle cells with myxoid degeneration, consistent with tracheal hamartoma. Based on a literature search, this is the first reported case of extraluminal tracheal hamartoma presenting as a neck mass in a pediatric patient.

Management of the brown recluse spider bite

The objectives in the treatment of the brown recluse spider bite are to prevent skin necrosis and the need for reconstructive surgery. A simple technique that consists of curetting the subcutaneous tissue in the necrotic area of the lesion, to prevent the local destructive actions of the toxin, is described. From 1981 to 1987, 18 patients were treated with this technique. The wounds were generally curetted under local anesthesia in an outpatient setting. In all but one case, the erythema, edema, and pain resolved significantly in 24 to 48 hours, and the wounds healed primarily with minimal scarring. We consider curettage the treatment of choice for brown recluse spider bites when the lesions are noted in relatively early stages. It can be performed as an outpatient procedure; it controls the symptoms and prevents further necrosis, with excellent cosmetic results.