Stephen P. Hetz

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.

Biliary dyskinesia: a study of more than 200 patients and review of the literature.

The dlagnosis and treatment of biliary dyskinesia, defined as symptoms of billiary colic in the absence of gallstones, remains controversial and has been the subject of several previous retrospective reviews The diagnosis and treatment of biliary dyskinesia based on the CCK-HIDA scan, and the outcome with cholecystectomy for billiary dyskinesia, are reviewed We add more than 200 cases of cholecystectomy for billary dyskinesia, and compare our results with those of previous reports We retrospectively reviewed 295 patients with biliary dyskinesia who underwent cholecystectomy at three military hospitals between 1988 and 1995 All patients had symptoms consistent with biliary colic and preoperative evaluations that revealed no evidence of cholelithiasis Pathology specimens were reviewed for cholelithiasis and pathologic changes Data were retrieved by chart review and clinic evaluation of new patients Individual follow-up of each patient was attempted Follow-up was achieved m 218 of the 295 patients for a rate of 74% The mean duration of follow-up was 506 days with a range of 22 days to 6 years Two hundred patients (92%) had CCK-HIDA scans with an ejection fraction (EF) <50% Eighteen patients (8%) had an EF >.50% but did have reproducaon of their symptoms with CCK injection In the group with an EF <50%, 94 5% were improved or cured with cholecystectomy In the group with an EF =>50% and pain reproduction, the improved or cured rate was 83 4% CCK-HIDA scans are useful for diagnosing biliary dyskinesia and predicting improvement after cholecystectomy Patients presenting with biliary dyskinesia and an EF<50% on CCK-HIDA scan have 94% improvement or resolution of their symptoms after cholecystectomy CCK-HIDA scans should be employed early m the evaluation of biliary colic with no evidence of cholelithiasis (i.e, with a normal ultrasound scan) When test results are abnormal, cholecystectomy should be performed, since the results in this setting approach those of cholecystectomy for stone disease (>90% cured/improved) In the current climate of cost containment, these excellent results would obviate the need for extensive and expensive medical testing before surgcal therapy is recommended

IMPLICATIONS OF NEW DRY FIBRIN SEALANT TECHNOLOGY FOR TRAUMA SURGERY

Trauma patients have been bleeding to death for thousands of years. The methods used to control hemorrhage (tourniquets, pressure, bandages, and ligatures) have not changed for 2000 years. Technology now exists to amplify the normal clotting system with human proteins, thus providing almost instant hemorrhage control in the face of bleeding. The increasing body of clinical and animal research and safety data regarding new fibrin sealant technologies is compelling. When combined with the evolving concepts of extended trauma resuscitation, acceptance of this technology will finally add a new method of rapid, easy hemostasis to the armamentarium of the surgeon faced with an unstable hemorrhaging patient. Several important issues remain unresolved, such as optimal thrombin and fibrinogen content, amount of material required for hemostasis, long-term effects, distribution of breakdown products, and role of recombinant proteins. These issues are under active investigation. Despite these unanswered questions, the field of absorbable, off-the-shelf, rapidly active hemostatic agents that do not require refrigeration is an exciting area that should yield significant improvements in the care of injured patients.

Femoral venous flow dynamics during intraperitoneal and preperitoneal laparoscopic insufflation

AbstractBackground: Laparoscopic herniorrhaphy may be performed using an intraperitoneal or a preperitoneal approach. Anecdotal and experimental evidence indicates that alterations in lower extremity venous flow, which occur during intraperitoneal laparoscopic insufflation, may be associated with an increased risk of deep vein thrombosis. However, no study has directly compared femoral venous flow during intraperitoneal insufflation with that during preperitoneal insufflation. Method: In eight consecutive patients undergoing laparoscopic herniorrhaphy under general anesthesia, flow through the common femoral vein was evaluated with B-mode and color flow duplex. Pre- and intraperitoneal pressures were standardized to 10 mm Hg, and respiratory tidal volumes were standardized to 10 cc/kg. Flow measurements were taken at end expiration. Flow through the common femoral vein was measured after induction of anesthesia, during intraperitoneal insufflation, during preperitoneal insufflation, and between insufflations to ensure return to baseline. Results: All patients in the study were males. Their mean age was 59 years. Mean flow in the common femoral vein was essentially identical at baseline (138 ml/min) and during preperitoneal insufflation (135 ml/min). Alternatively, mean flow in the common femoral vein was significantly reduced during intraperitoneal insufflation (65 ml/min, p= 0.02). Conclusions: Flow in the common femoral vein is significantly reduced during intraperitoneal insufflation. However, flow in the common femoral vein is not affected by preperitoneal insufflation. These data suggest that laparoscopic preperitoneal inguinal hernia repair may pose as less a risk of thromboembolic complications than laparoscopic intraperitoneal inguinal hernia repair.

Laparoscopic repair of a large symptomatic epiphrenic esophageal diverticulum

PURPOSE The diagnosis of symptomatic epiphrenic esophageal diverticula is uncommon. Even less common are published reports regarding the efficacy of laparoscopic repair of this malady. METHODS We report the case of a 59-year-old male patient with Parkinsonism found to have a large, symptomatic epiphrenic diverticulum and discuss the surgical treatment performed. The patient presented with a 6-month history of worsening dysphagia to both solids and liquids, regurgitation of undigested food, and weight loss. Barium esophagram identified the presence of a large distal esophageal diverticulum. Esophagoscopy confirmed the epiphrenic location of the diverticulum and the absence of other pathology. Laparoscopic transhiatal diverticulectomy was performed utilizing a gastrointestinal endoscopic stapler. Intraoperative esophagoscopy was performed to confirm resection of the diverticulum without constriction of the lumen. RESULTS The patient resumed intake of liquids on postoperative day 1 after a water-soluble contrast esophagram revealed no extravasation. The patient was discharged on hospital day 3. He reported residual dysphagia to solids postoperatively, which appeared to resolve after pneumatic dilation. CONCLUSIONS We conclude that laparoscopic epiphrenic diverticulectomy is technically feasible and safe. The comorbidity of Parkinsonism adds complexity to the diagnosis and treatment of this uncommon disorder.

Thoracoscopic pleurodesis with minocycline vs talc in the porcine model

AbstractBackground: Eighteen adult pigs (Sus scrofa) underwent thoracoscopy and were placed into one of three groups: no sclerosant, talc pleurodesis, or minocycline pleurodesis. Methods: Animals were then sacrificed at matched time intervals. Gross inspection of the pleural cavity estimated percentage of pleural symphysis (>25% was considered substantial) and allowed assignment of a pleurodesis score based on a scale described by Bresticker. Microscopic examination evaluated degree of fibrosis as mild, moderate, or severe. Results: The talc group had significantly better pleurodesis than the minocycline group as determined by (1) the proportion of animals with substantial surface pleural symphysis (5/6 vs 1/6, p < 0.01), (2) a higher pleurodesis score (3 vs 1.3, p < 0.05), and (3) the proportion of animals with moderate fibrosis (5/6 vs 0/6, p < 0.01). Conclusions: The authors conclude that instillation of aerosolized talc produces significantly better fibrosis and pleural symphysis than atomized minocycline in this animal model.

Complicated war trauma and care of the wounded – the Israeli experience in medical care and humanitarian support of Syrian refugees

Namatame, Norifumi, guest editor. 2013. “After Fukushima: The Right to Know.” Asian Perspective 37 (4) October–December: 473–474. http://journals.rienner.com/doi/abs/10.5555/0258-918437.4.473?code=lrpi-site. Ruff, Tilman, guest editor. 2015. “Nuclear Power in East Asia: The Costs and Benefits.” Asian Perspective 39 (4) October–December: 555–752. http://journals.rienner.com/toc/aspr/39/4. 2017. “2011 Japan Earthquake – Tsunami Fast Facts. CNN Library. Updated 1353 GMT (2153 HKT) March 5. http://edition.cnn.com/2013/07/17/world/asia/japan-earthquake–tsunami-fast-facts/ index.html.

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

Pediatric bilateral spontaneous pneumothoraces in monozygotic twins

Primary spontaneous pneumothorax from subpleural bleb disease is an uncommon occurrence in pediatric patients. This is a rare case of monozygotic twins presenting at alternating intervals with a single-sided spontaneous pneumothorax, only to have it surgically corrected, and to present later with a subsequent contralateral pneumothorax. A review of familial spontaneous pneumothoraces occurring in children was queried for congenital or genetic syndromes. We concluded that a vast majority of pneumothoraces in children, like adults, are not spontaneous and not familial linked. While they are rare, some congenital syndromes have been identified. The HLA haplotype A2 B40, the gene encoding folliculin, Alph-1-antitrypsin, Marfan’s syndrome, Ehlers–Danlos syndrome and Birt–Hogg–Dube syndrome have all been associated with familial spontaneous pneumothoraces. Physicians need to counsel family members to ensure appropriate observation and expedited treatment is not delayed.