William L. Weaver

Debilitating lymphedema of the upper extremity after treatment of breast cancer.

Lymphedema after mastectomy occurs with a frequency as high as 30%. The incidence increases with more radical surgical dissection, as was often seen with radical mastectomies in the late 1800s. This is one aspect of breast surgery that has been greatly neglected. Surgery has often been deemed a success if the malignancy is eradicated. Patients may complain of symptoms as minor as arm heaviness to major ones such as massive chronic swelling, as was the case with our patient. The patient presented here had increasing lymphedema during a 14-year period after modified radical mastectomy and radiation therapy for advanced breast cancer. This condition had progressed to incapacitation of the extremity and a patient who as a result had become an invalid. The massively edematous extremity revealed no signs of recurrent disease or malignant degeneration. She underwent surgical intervention and physical therapy as procedures of choice to restore function.

Unusual complications of long-term percutaneous gastrostomy tubes

Percutaneous endoscopic gastrostomy (PEG) has been popular since it was introduced in 1980. Gastrostomy tubes left in place for long periods often result in unusual complications. Complications may also result from simply replacing a long-term indwelling tube. Five patients who had gastrostomy tubes in place for as long as 4 years are presented and their complications reviewed. Various methods used in treating these complications are discussed, and suggestions for their prevention are given. Gastrointestinal erosion and jejunal perforation following migration of the gastrostomy tube, persistent abdominal wall sinus tracts, and separation of the flange head with small bowel obstruction were encountered. Reinsertion of a gastrostomy tube through a tract prior to adequate maturation was also noted to lead to complications. Complications may result from gastrostomy tubes left in place for extended periods of time and during replacement procedures. Awareness of such complications along with education of caregivers and timely intervention by the endoscopist may prevent such occurrences. In some cases one can only hope to minimize morbidity.

Using Augmented Reality as a Clinical Support Tool to Assist Combat Medics in the Treatment of Tension Pneumothoraces

This study was to extrapolate potential roles of augmented reality goggles as a clinical support tool assisting in the reduction of preventable causes of death on the battlefield. Our pilot study was designed to improve medic performance in accurately placing a large bore catheter to release tension pneumothorax (prehospital setting) while using augmented reality goggles. Thirty-four preclinical medical students recruited from Morehouse School of Medicine performed needle decompressions on human cadaver models after hearing a brief training lecture on tension pneumothorax management. Clinical vignettes identifying cadavers as having life-threatening tension pneumothoraces as a consequence of improvised explosive device attacks were used. Study group (n = 13) performed needle decompression using augmented reality goggles whereas the control group (n = 21) relied solely on memory from the lecture. The two groups were compared according to their ability to accurately complete the steps required to decompress a tension pneumothorax. The medical students using augmented reality goggle support were able to treat the tension pneumothorax on the human cadaver models more accurately than the students relying on their memory (p < 0.008). Although the augmented reality group required more time to complete the needle decompression intervention (p = 0.0684), this did not reach statistical significance.

Squamous cell carcinoma at herniorrhaphy and unilateral renal agenesis

Unilateral renal agenesis occurs infrequently. However, it has been associated with malignancies at multiple primary sites, anomalies of the genitourinary system, and supernumerary limbs. We present the case of a 60-year-old man with an incarcerated left inguinal hernia and renal insufficiency. At herniorrhaphy, he had squamous cell carcinoma in the hernia sac. A postoperative evaluation revealed unilateral renal agenesis, stage IV squamous cell carcinoma of the urinary bladder, and urolithiasis. The clinician should consider the genitourinary system as a primary site when patients present with the unusual finding of squamous cell carcinoma in the abdominal cavity and unilateral renal agenesis.