Roberto E. Kusminsky

Laparoscopic radical nephrectomy with intra-abdominal manipulation

SummaryA technique of performing a laparoscopically guided radical nephrectomy using a Pfannenstiel incision is described. We believe that this minimally invasive approach can ease the transition between the standard open method and pure laparoscopic trocar surgery and is applicable to a variety of intra-abdominal problems. Results in this series were comparable to those of a standard radical nephrectomy with the advantages of an improvement in access morbidity (post-operative comfort and respiratory compromise) and consequently decreased hospitalization time.

Leiomyomas of the rectum and anal canal: report of six cases and review of the literature.

Summary and ConclusionsSince 1872, 168 rectal leiomyomas have been reported in the world literature. Their incidence, therefore, is very low. It is estimated that one leiomyoma may be seen for every 2,000 or more rectal tumors. Those leiomyomas located in the anal canal and sphincter are the rarest. A case is reported here that appears to be the eleventh in such a location. The incidence of these lesions is highest between the ages of 40 and 59 years. Most patients have a combination of symptoms rather than a single one, the most frequent of these being the presence of a mass, bleeding, and constipation. Almost always, the chain of events that leads to the diagnosis starts when the tumor is discovered by digital examination of the rectum. The lack of reliable criteria of malignancy and the marked tendency to recur shown by these tumors are the two main problems the surgeon faces when selecting the operative procedure to be used. We believe that those tumors with an original size of 5 cm or more in largest diameter are the ones that have shown the highest tendency to recur, mostly as sarcomas. Therefore it is thought that these lesions should be treated radically from the beginning, especially when they recur. More adequate follow-up studies are needed.

Blunt pelviperineal injuries

The combination of blunt pelvic and perineal injuries is relatively uncommon but carries with it a high morbidity and mortality. A colostomy with distal wash-out plays a significant role in the prophylaxis of septic complications, even in the absence of recognizable colorectal trauma. Among 14 patients with this type of injury, there were six deaths (42 per cent). Three patients died initially because of hemorrhage, and three late deaths were due to sepsis. Two of these patients had no colostomy, and one had a diversion without wash-out. The indications for proximal diversion should be broadened to include an expanded view of the perincum, herein presented.

Prophylactic inferior vena cava clipping in colonic surgery

Incidental prophylactic inferior vena cava clipping (IVCC) has been used in 30 patients undergoing colonic operations. The results obtained compare quite favorably with other methods of preventing postoperative pulmonary embolism (PE). This procedure would be justified in patients with a postoperative PE risk greater than 5 to 10 per cent. Practical criteria to identify this group of patients are presented, and the value of utilizing a risk profile is emphasized. There is no mortality from the procedure itself, and the morbidity was limited to lower-extremity edema in three patients who otherwise could have been expected to develop PE. The edema lasted two months in one patient and cleared rapidly in the other two. Attesting to the procedures effectiveness, there were no cases of recurrent PE. Caval partition is an appealing mode of prophylaxis in high-risk patients because of its safety, efficacy, and permanence.

Identification of the Sentinel Node by Ultrasonography in Patients with Breast Cancer

BackgroundIdentification of the sentinel node (SN) in patients with breast cancer is done by tracking a radioactive tracer, a vital dye, or both, as the marker(s) reach the axilla. Replacing this method with ultrasonographic (US) recognition of the SN could eventually spare patients the need for systemic anesthesia, permit minimally invasive outpatient biopsy of the node, and allow the formulation of a precise therapeutic plan before a definitive surgical procedure.MethodsEighty-eight axillae of 84 patients with a histologic diagnosis of breast cancer were studied by injecting the subareolar area of the affected breast(s) with technetium 99 and an iron preparation before the planned surgical procedure and SN biopsy. An axillary US scan was performed in all patients before the injection of the markers. After induction of anesthesia, the SN was identified, needle-localized, and extracted under US guidance. Confirmation that the SN was retrieved was established by concordance with the audible gamma signal, unless there was none. All extracted nodes had iron stains performed.ResultsAll except three of the SNs were identified with US after the iron marker was injected, and all except six were identified by their radioactive signal. One of the SNs undetected on US was identified by its radioactive tracer, and the other two, although seen on US, had neither a gamma signal nor concordant iron deposits. All other SNs identified with US had a concordant audible signal when there was one, and all had concordant iron deposits on microscopy. Of the six SNs without a gamma signal, three without preincision activity were identified with US; three with neither a preincision nor an ex vivo signal were seen with US, but two of these were the SNs without a concordant iron deposit.ConclusionsUsing an iron preparation, the SN in patients with breast cancer can be identified with US with an accuracy equal to and perhaps better than that achieved with a radioactive tracer. These findings may change the current diagnostic model and affect the therapeutic algorithm of breast cancer patients.

Can we cure breast cancer

0002-9610/

Blunt pelviperineal injuries: An expanded role for the diverting colostomy

see front matter 2015 http://dx.doi.org/10.1016/j.amjsurg.20 The structured surgical treatment of breast cancer began in 1882, when William Halstead, a professor of surgery and one of the founding members of the Johns Hopkins Hospital, developed and performed a radical mastectomy, in which the breast, the underlying muscles, and the axillary lymph nodes were removed. Halstead, an influential and well-known surgeon, theorized that breast cancer was a disease confined to just one area, which spread, he thought, in a predictable manner along the lymphatic channels draining the tumor. And so, he believed, removing the tumor with a wide margin of tissue would offer patients the opportunity of cure. Radiation treatments were initiated in 1896 by Emil Herman Grubbe, a physician from Chicago, who assembled the first ever X-ray machine and treated a patient with recurrent breast cancer. That was just a few months after X-rays were discovered by Wilhelm Roentgen, a Professor of Physics in Worzburg, Bavaria. Grubbe ended up having approximately 90 operations for multiple cancers because of his exposure to X-rays. Eventually he lost his forearm and hand, and most of his nose, upper jaw, and lip to radiation-induced tumors, and lived as a recluse until his death at age 85. The original radiotherapy initiated by Grubbe improved significantly with 2 simultaneous advances. One of these took place in the late 1930s, when scientists Glenn Seaborg and John Livingood at the University of California discovered the radioactive isotope of cobalt, a metal used for centuries to color porcelain, glass, tile, and pottery. This radioactive element