Cm In Transverse Diameter Research Articles

OC-060 PREDICTING FACTORS OF RECURRENCE AFTER TRANSVERSUS ABDOMINIS MUSCLE RELEASE (TAR) FOR COMPLEX INCISIONAL HERNIAS. RETROSPECTIVE ANALYZE OF A COHORT

Abstract Background Transversus Abdominis Muscle Release (TAR) is used to provide adequate coverage for large abdominal wall defects and appears to be more advantageous compared to Anterior Component Separation concerning complications and recurrence rates. The aim of this study was to identify the independent predictors associated with hernia recurrence after TAR in the treatment of complex incisional hernias. Methods This is a retrospective observational study of 191 patients who underwent TAR between November 2014 and December 2021. The main inclusion criteria were adults with large complex incisional hernias larger than 10 cm in transverse diameter. The recurrence rate was determined by clinical examination and by abdominal CT scan. Results At a median of 49.6 months (range 36–75 months) of postoperative follow-up, we reported 19 cases of recurrence (9.94%). Recurrences occurred after a mean period of 12.4 months (range 10–49 months). On multivariate analysis, the development of postoperative hematoma (OR 2.9; CI 1.55–4.10, p = 0.001), and needing surgery for the hematoma (OR 2.1; CI 1.21–3.29, p = 0.004), obesity and chronic pulmonary disease (COPD) were predictors of recurrence after TAR. The area under Curve (AUC) was highly specific for all these independent factors (AUC = 0.842). There was no significant difference in recurrence rate among obesity, smoking, urgent repair, type of mesh fixation, operative time, type of prosthesis, or concomitant procedures. Conclusions In our current study, the development of postoperative hematoma and needing surgery for the hematoma, and obesity were associated with an increased risk of hernia recurrence after RSR.

V-053 USE OF HYBRID LAPAROSCOPIC INTRACORPOREAL RECTUS APONEUROPLASTY (LIRA-TECHNIQUE) IN COMPLEX VENTRAL HERNIAS

Abstract Aim The hybrid approach (HA) to ventral hernias (VH), combining the laparoscopic and open approaches, is not very common at present. The great contribution of this approach is that it combines the advantages of the minimally invasive approach with the advantages of the open approach, making it possible to correct aesthetic defects and major skin and subcutaneous problems. Material & Methods 40-year-old-man with previous surgery for supraumbilical hernia, with placement of a supraaponeurotic mesh with hernia recurrence and chronic infection with a meshoma. Physical examination revealed VH of 5–8cm in transverse diameter and 10cm in vertical diameter. A CT-scan showed a 6.5cm transverse supraumbilical recurrent hernia with a fatty content. Results A laparoscopic approach was performed, revealing an 8×8cm supraumbilical defect in the abdominal cavity with no adhesions. A midline repair was performed according to the principles of the LIRA technique by performing a posterior fascial flap 2cm above the edges of the defect: the midline was reinforced with a loop-suture. An intra-abdominal mesh was placed and fixed with tackers and fibrin glue. In the open procedure, the chronic sinus, meshoma, excess skin and hernial sac were removed. Conclusions The treatment of complex abdominal hernias is a field in constant evolution. The HA aims to solve the skin problems associated with laparoscopic repairs alone. The use of intraperitoneal on-lay meshes combined with the use of open approach for excision of the sac and remaining skin tissue allows a complete and effective treatment of complex hernias.

V-020 LAPAROSCOPIC INTRACORPOREAL RECTUS APONEUROPLASTY: FIRST EXPERIENCE AT HOSPITAL UNIVERSITARIO DE CANARIAS

Abstract We present the case of a 46-year-old-male patient, personal history: Chronic smoking; no previous abdominal surgeries. Height: 1,88 m. Weight: 100 Kg. BMI: 28. Clinical and ultrasound diagnosis of a painful and reducible ventral hernia M3 W1 (EHS Classification) associated with supraumbilical rectal diastasis (RD) of 4 cm transverse diameter T2 D2 H1 (EHS Classification). It is programmed for hernia and RD correction using de Laparoscopic Intracorporeal Rectus Aponeuroplasty (LIRA) technique. Access is laparoscopic at the left anterior axillary line level. Reduced umbilical hernia is identified and sickle cell ligament dissection is performed to identify and treat RD. The size of the umbilical defect and that of the supraumbilical RD are measured and, by means of a mathematical formula, the posterior aponeurosis of both rectal muscle is opened longitudinally parallel to both margins of the defect and the diastasis in order to suture the two flaps in the midline, allowing a tensión-free closure and also avoinding seroma formation and post-op bulging effect. We ended the procedure by placing an intraperitoneal mesh that we fixed covering the defect generated in the posterior aponeurosis. The LIRA technique could be considered an alternative to conventional defect closure (CD) or endoscopic component separation for midline defects smaller than 10 cm in transverse diameter. This is the first case of LIRA published in our latitude. It is a safe, effective and reproducible technique.

1078 Enteric Duplication Cyst in An Adult: Presenting with Diarrhea and Vomiting

Abstract Intestinal duplication cysts are rare disease entirety, most commonly presenting in childhood. The incidence is 1:4,500 births, with a slight male predominance. They can occur anywhere along the alimentary tract, 35% occur in the ileum and 10% in jejunum. Diagnosis can prove challenging as they can present with a vast variation of symptoms and mimic other pathologies. A 29-year-old male presented to A&E following a collapse. He had been suffering of diarrhoea and vomiting with lower abdominal discomfort. The patient was otherwise fit and well and no surgical history. On physical examination his abdomen was generally tender with no peritonism but was tachycardic, tachypneic but normotensive. His blood pressure dropped to 70/56, heart rate 130 and temperature increased to 41.2 degrees. A CT abdomen and pelvis with contrast was subsequently performed while on intensive care. There was a huge fluid-filled structure almost filling the entire pelvis and right side of the abdomen measuring up to 18cm in transverse diameter and 38cm longitudinally. The fluid filled structure appeared to communicate with a loop of small bowel in the right iliac fossa. There was no sign of obstruction. Due to the CT findings and the patient’s clinical status a laparotomy was performed. A large congenital duplication cyst was seen which was adherent to 40cm of the small bowel. The section of bowel was 130cm distal to the DJ flexure. The small bowel including the cyst was resected and hand sewn end-to-end anastomosis performed.

Diagnostic accuracy of pubic symphysis ultrasound in the detection of unstable pelvis in polytrauma patients during e-FAST: the value of FAST-PLUS protocol. A preliminary experience.

Extended focused abdominal sonography for trauma (e-FAST) is part of the primary survey in patients with high-energy trauma. However, it does not identify patients with retroperitoneal haemorrhage associated with significant pelvic trauma. A traumatic diastasis of pubic symphysis, as well as an 'open book' (OB) pelvic injury, is a diagnostic clueto recognize unstable pelvis with higher risk of bleeding. FAST-PLUS (FAST-PL pleural -US ultrasound of symphysis) protocol is an addendum to the e-FAST, which takes into account the study of the pubic symphysis in a single transverse scan after the traditional focused evaluation of the abdomen and thorax. The aim of this study is to determine the value of FAST-PLUS protocol in the evaluation of pubic symphysis injuries and the identification of 'open book' (OB) unstable pelvic fractures. Between January 2018 and December 2019, we retrospectively reviewed 67 polytraumatised patients with clinical suspicion of pelvic instability and with known anteroposterior pelvis compression injuries who underwent e-FAST with an additional transverse scan of the pubic symphysis, named the FAST-PLUS protocol and computed tomography (CT) exam in order to assess the correlation between them in defining the presence or absence of pubic symphyseal widening (SW). A cutoff value of 2.5cm in transverse diameter was used to diagnose OB unstable pelvic injury. The results were analysed using Cohen's test, which uses the Kappa value as the reference index. The analysis carried out to assess the degree of agreement between FAST-PLUS and CT showed 5/67 patients (7.5%) with a critical pubic SW (> 2.5cm transverse diameter) suggestive of unstable OB pelvic injury and 62/67 (92,5%) without any signs of SW at FAST-PLUS. At CT, findings of unstable OB pelvic fracture were confirmed in all patients with positive results at FAST-PLUS. Similarly, all patients with negative results for critical pubic SW (< 2.5cm in transverse diameter) at FAST-PLUS were found to be negative at CT exam. The level of correlation between the two methods was high (Kappa value = 1) CONCLUSION: The FAST-PLUS protocol shows a high correlation with CT exam, which is the gold standard for the detection of unstable pubic SW, as well as OB pelvic injury, in polytraumatised patients. Inclusion of FAST-PLUS in patient management in the shock room may lead to a quicker identification of patients with unstable pelvis and to faster therapeutic work-up.

Complete intracorporeal defect closure using unidirectional barbed suture in laparoscopic incisional hernia repair: Preliminary experience with short-term follow-up.

Surgical techniques to close defects in laparoscopic incisional hernia repair vary across the literature. We herein demonstrate our original and standardized surgical technique for laparoscopic incisional hernia repair with complete intracorporeal defect closure using barbed suture. Complete intracorporeal defect closures were indicated for defects less than or equal to 6 cm in transverse diameter. We performed a defect closure with a running suture using barbed suture in a caudal to cranial direction, with tissue bites and inter-suture spacing of 1 cm each. The hernial sac was incorporated into the suturing to reduce possible dead space. After the procedure, intraperitoneal onlay mesh was placed. Seven patients underwent this procedure. The median total operative time was 188 min, and the median time specifically for defect closure was 25 min. There was no seroma, mesh bulge, persisting pain, or hernia recurrence at follow-up. Our proposed technique is simple and can be safely performed with good short-term outcomes.

Innominate Artery Aneurysm: Simulating a Thyroid Nodule.

We report a 69-year-old lady who was referred for the evaluation of a suspected solitary thyroid nodule. The patient noticed a gradually increasing neck swelling of over a year duration along with a history of intermittent dysphagia to solid food without other compressive symptoms. There were no signs and symptoms of hypothyroidism or hyperthyroidism. She had other co-morbidities including Type 2 Diabetes mellitus, Systemic Hypertension and Coronary Artery Disease with no prior history of local trauma. Examination revealed a non-tender soft and non-pulsatile, fluctuant swelling of size 2X 2cm on the right side of the neck just above the sternoclavicular joint [Table/Fig-1]. The swelling moved with deglutition. There was no cervical lymphadenopathy or tracheal deviation. Laboratory investigations revealed a normal Thyroid Stimulating Hormone (TSH) -4.24uIU/ml (Normal-0.8-4.5), Total Thyroxine (T4) of 9.7ug/dl (Normal-4.5-12.5), Free Thyroxine (FT4) – 0.95ng/dl (Normal-0.8-2), with negative anti-thyroid antibodies. The fasting blood glucose was 123mg% (Normal-70-100), Post prandial blood glucose was 185mg% (Normal<140) and Glycated Haemogloin, (HbA1c) of 5.3% (Normal<7%). The lipid profile showed total cholesterol 206 mg% (Normal-<160), LDL–C- 136 mg% (Low Density Lipoproteins) (Normal <100), TG -189 mg% (Trigly cerides) (Normal<150). Ultrasonography of the thyroid did not reveal any thyroid nodule; however the Colour Doppler revealed a focal fusiform dilatation of the right innominate artery measuring 2x2cm in diameter [Table/Fig-2] and no obvious thrombus was detected. Barium swallow showed left ward displacement of the cervical oesophagus [Table/Fig-3] which could be the cause for her dysphagia. Thus, although she was clinically diagnosed to have a thyroid nodule, the Colour Doppler showed a right innominate artery aneurysm. Thus FNAC and thyroid scintigraphy was avoided. [Table/Fig-1]: Clinical image of the patient showing nodule in the right side of the neck (shown in arrow) [Table/Fig-2]: Colour Doppler showed a focal fusiform dilatation of the right innominate artery measuring 2x2 cm in diameter [Table/Fig-3]: Barium swallow showed left ward displacement of the cervical oesophagus (shown in arrow) The vascular lesions in front of the neck such as aneurysm or tortuous artery can sometimes resemble a thyroid nodule [1]. The indexed case was of right innominate artery aneurysm, which was initially suspected to be a solitary thyroid nodule. An innominate artery aneurysm is an uncommon entity which occurs exclusively in middle aged women who are at high risk for atherosclerotic disorders [2]. It may be sometimes difficult to appreciate the pulsatility of the aneurysm because of the overlying connective tissues [3]. When ultrasound shows no obvious thyroid nodules, a Colour Doppler study of the neck is helpful in determining the nature of neck swelling as in our patient [4]. Fine needle aspiration in such a circumstance can be catastrophic with potential lethal complications. There is a previous report of a similar case where scintigraphy was done initially that revealed a cold area in the lower lobe. They subsequently performed an ultrasound that led to the diagnosis and stressed the importance of Colour Doppler Sonography as a compliment to nuclear medicine procedures in that scenario [1,5]. The patients’ clinical picture is suggestive of atherosclerotic disease, which probably played a causal role in the development of aneurysmal disease. The other causes of innominate artery aneurysm are trauma, infection, connective tissue disease, Kawasaki’s disease, and Takayasu’s arteritis [6], Small size innominate artery aneurysm is usually asymptomatic, present either as an incidentally detected neck mass or as a superior mediastinal mass on chest x-ray [7]. Patients with innominate artery aneurysm may presents with symptoms like hoarseness of voice or dysphagia due to compression of localized structures and neurological symptoms due to thrombo-embolism [8]. Ultrasound with Doppler is diagnostic, when lesions are located in the neck region. However, CT scan is indicated in case of mediastinal lesion. Asymptomatic innominate artery aneurysms are usually managed conservatively. Surgery is indicated if the size of aneurysm is more than 3 cm in transverse diameter or in the presence of thrombus or if complicated by thrombo-embolism [9]. In our case surgery was not offered as there was no definite indication. She is currently under regular follow-up without any worsening of symptoms.

An Unusual Finding in Setting of Necrotizing Pancreatitis

Purpose: Pancreatic cancer is the fourth common cause of cancer deaths in the U.S. It is a disease with grave prognosis and usually remains undiagnosed till advanced stages. Here we describe a case of a patient with metastatic pancreatic adenocarcinoma that got unmasked by acute gallstone pancreatitis. In this case, the question of gallstones versus underlying carcinoma as the precipitating factor for pancreatitis stays unanswered. The case also questions the imaging modalities available for the diagnosis of pancreatic carcinoma. A 60-year-old female with history of diabetes mellitus and hypertension presented to the hospital with high fever, abdominal distension and vomiting three days post-discharge after a complicated course of necrotizing pancreatitis. Patient's previous admission involved gallstone pancreatitis leading to ARDS with respiratory failure, tracheostomy and ventilator dependence, contrast-induced acute renal failure, and deep venous thrombosis. On exam she was febrile and tachycardic. The abdomen was distended with flank fullness and mildly tender diffusely with hypoactive bowel sounds. Blood work revealed leukocytosis, worsening renal function, and signs of a possible urinary tract infection. The patient was admitted to the intensive care unit for ventilator support, and placed on antibiotics for UTI. A CT scan of the abdomen showed the absence of pancreatic tissue, moderate ascites, and two organizing pseudocysts with the larger measuring 11 cm in transverse diameter impinging on the gastric outlet. The patient was started on parental nutrition due to inability to tolerate tube feeds. She was evaluated for the possibility of drainage of the pancreatic pseudocysts. However, there were no signs of infection, and no acute indication for drainage. Subsequent imaging revealed progressive expansion of the pseudocysts to approximately 15, and later, 17 cm, (Figure 1) with massive ascites and no discrete masses. Paracentesis of the ascitic fluid revealed inflammatory cells with no malignant cells. An endoscopic ultrasound showed a large pseudocyst with layering necrotic material within the cyst, diffuse bulge in the body and fundus of the stomach by the pseudocyst, and no discrete masses. She was not considered a candidate for endoscopic drainage of the pseudocysts and was thought to be a candidate for open drainage. On laparotomy, it was discovered that the patient had widespread carcinomatosis involving the pelvis, umbilicus, omentum, liver, falciform ligament, and stomach. Frozen sections of the omentum and falciform ligament indicated metastatic adenocarcinoma of primary pancreatico-biliary origin.

Management of a giant omphalocele with an external skin closure system

Background/Purpose The management of neonates with giant omphalocele remains challenging and multiple strategies have been described. We present the case of a 34-week-old neonate with isolated giant omphalocele managed with an external surgical skin closure system as a component of a staged closure strategy. Case Presentation An Inuit boy of 34 weeks gestation was born by urgent Caesarean delivery at an affiliated obstetrical hospital with a giant ruptured omphalocele and loss of abdominal domain. He was transferred to our institution and a silastic silo was fashioned and placed in the operating room. He returned to the operating room several times and was treated by placement of a combined Gore-Tex (WL Gore and Associates, Flagstaff, Ariz)/silastic inlay mesh. An eschar formed over this temporary closure, and we elected to place a dynamic skin closure device to continue gradual bedside reduction. The initial abdominal wall defect was 8.5 cm in transverse diameter and was reduced to 4.5 cm over 3 weeks. Complete closure was subsequently achieved without the need for skin grafting. Discussion The use of a dynamic reduction skin closure device has not been documented previously in the pediatric population or in the context of a congenital defect. We describe the use of an external surgical skin closure device in the context of the staged closure of a giant neonatal omphalocele and postulate that such a device may prove useful in the treatment of other congenital tissue defects.

A Giant Cavernous Hemangioma of the Heart

Cardiac hemangiomas are exceptionally rare, vascular neoplasms of the heart, with an incidence of 1% to 2% among all detected benign heart tumors. With the availability of the advanced imaging modalities of the heart, asymptomatic cardiac tumors are detected more frequently. These tumors are composed either of capillaries or larger cavernous channels. Herein, we report a rare case of a huge cardiac hemangioma involving both ventricles, which is not amenable to a curative surgical resection.

Current Trends in the Management of Small Abdominal Aortic Aneurysms

Over the past decade, there have been revolutionary changes in the diagnosis and treatment of abdominal aortic aneurysms. Minimally invasive endovascular technologies have decreased length of stay and, more importantly, improved at least the early outcomes compared with conventional open surgical therapy. Several large, randomized, prospective trials have re-evaluated the optimal size to treat abdominal aortic aneurysms. The guidelines and conclusions from these studies, the UK Small Aneurysm Trial and The Veterans Affairs Administration aneurysm Detection And Management Trial recommend intervening on aortic aneurysms when they reach 5.5 cm in transverse diameter. However, these studies do not bear direct relevance to contemporary management of aneurysms with endovascular techniques. Clinical trials are currently underway to assess the optimal size for treating abdominal aortic aneurysms with endovascular stent grafts.

Letters to the Editor

Letters to the Editor

Esophageal Polyps in a HIV Infected Patient with Upper GI Bleeding

To highlight esophageal polyps in the setting of upper GI bleeding in a HIV infected patient. Case Report: 40 y/o male was referred for follow up EGD two months after an episode of massive upper gastrointestinal bleed. Initial upper endoscopy (EGD) had revealed multiple esophageal polyps with ulcerations and the patient was subsequently placed on proton pump inhibitors. Follow up EGD revealed multiple small and large polyps in the esophagus with severe candidal esophagitis. A single large pedunculated polyp (7 cm in length) was seen in the upper esophagus that extended from 15 cm to 22 cm from the gums. Barium esophagogram also revealed the multiple esophageal polyps and the large pedunculated polyp was clearly seen in the proximal esophagus, measuring 2 cm in transverse diameter. Biopsies from the polyp showed candida esophagitis with granulation tissue and ulceration. No dysplasia or malignancy were noted. Viral cultures were negative. The patient was treated with a two week course of oral fluconazole. He was noncompliant with subsequent follow up. Two months later, HIV testing was found to be positive and his CD4 count was 6. He developed respiratory failure and died shortly afterwards at an outside instituition. Discussion: Esophageal polyps in the setting of HIV infection is seen rarely. Primary esophageal lymphomas and inflammatory fibroid polyps of the esophagus have been reported in HIV infected patients and they usually present with dysphagia. Esophageal polyps as a possible cause of upper GI bleeding, as illustrated in our case, is extremely rare. Conclusion: In patients with HIV infection, esophageal polyps should be considered in the setting of upper GI bleeding. [figure 1][figure 2]FigureFigure

Small-Bowel Obstruction in a Phantom Model of ex Vivo Porcine Intestine: Comparison of PACS Stack and Tile Modes for CT Interpretation

To compare computed tomographic (CT) image interpretation with picture archiving and communication systems (PACS) stack and tile modes for speed and accuracy of transition zone localization in small-bowel obstruction by using ex vivo porcine specimens. Twenty-five small-bowel obstruction phantom models made of ex vivo porcine intestines from a slaughterhouse were imaged at CT. One was used for observer training, and 24 were used for experimentation. At 20-cm intervals throughout the intestines, metallic markers were placed in the mesenteries immediately adjacent to bowel. One obstruction was made in each intestine, midway between markers, by ligating intestine with a 3-0 silk suture to simulate mechanical small-bowel obstruction. The lumen proximal to the ligation site was distended with air and a soybean oil-iodized oil mixture until at least two-thirds of the proximal intestine exceeded 2.0 cm in transverse diameter. Dilated segments were 310-550 cm in length. Soybean oil and a mixture of soybean and iodized oil were used to simulate differences in attenuation among bowel wall, intraluminal fluid, and extraluminal abdominal fat. Four experienced abdominal radiologists independently determined the transition zone by using stack mode (cine viewing of stacked images) and, at least 2 weeks later, tile mode (side-by-side image display). Accuracy and degree of error in counting markers were evaluated, and speed of interpretation was recorded. Statistical analysis was performed with the McNemar and Wilcoxon signed rank tests. For all observers, accuracy of transition zone localization tended to be better with stack mode (63%-83% [15-20 phantoms]) than with tile mode (50%-63% [12-15 phantoms]), but the differences were not significant. For each observer, mean counting error was lower in stack mode (range, 0.96-2.48) than in tile mode (range, 1.74-3.22), with significance for three observers (P < .01, P < .01, and P = .04). Interpretation was significantly faster with stack mode by a factor of two to three for all observers (P < .01). Stack mode evaluation for identification of the transition zone in obstructed small bowel is faster than evaluation with tile mode. Accuracy is not significantly different between modes, although there is a tendency toward better results with stack mode.

Post-traumatic massive abdominal wall defect — A challenge

Blast trauma due to fragmentation devices can be devastating. The management of complex and multiple injuries, particularly when associated with intra-abdominal injuries and complicated by abdominal wall defect is a test of endurance for both patient and the surgeon. The reconstructive goals for the abdominal wall defect in such cases are to preserve life by providing a speedy cover to exposed abdominal viscera, protect the abdominal contents and provide functional support. Full thickness abdominal wall defects exceeding 6 cm in transverse diameter have been categorized as massive [1]. Their closure requires import of autogenous tissue in the form of vascularised flaps. Reconstruction by local or regional flaps may not be feasible in the acute stage on account of involvement of donor areas and the resultant defect at the donor site. We report a case of staged reconstruction of a massive abdominal wall defect following blast trauma from a land mine explosion by tissue expansion and prosthetic mesh.

Stanford V Regimen plus Consolidative Radiotherapy Is an Effective Therapeutic Program for Bulky or Advanced-Stage Hodgkin’s Disease

Since September 1996, 48 untreated patients with bulky or advanced-stage Hodgkin’s disease received the 12-week Stanford V chemotherapy regimen followed by consolidation radiotherapy at a dose of 36 Gy to bulky mediastinal disease and 30.6 Gy to the initial sites of disease ≧3 cm in transverse diameter. After the combined therapy, 46 of 48 (96%) achieved complete remissions. With a median follow-up of 48 months, the 5-year overall survival was 95% and freedom from progression 86%.There were no treatment-related deaths. All but one premenopausal female patient (who received pelvic and inguinal irradiation) recovered normal menses. Until now no case of secondary leukemia or myelodysplasia was observed. Our results confirm that the Stanford V regimen with consolidation radiotherapy is safe and effective in patients with bulky or advanced-stage Hodgkin’s disease, achieving very high remission and overall 5-year survival rates. Longer follow-up is necessary to evaluate the extent of all complications.

Evaluation of patterns of human antral and pyloric motility with an antral wall motion detector

We have examined the hypothesis that isolated pyloric pressure waves occur in the absence of even low-amplitude antral contractions. Antropyloroduodenal motility was recorded in seven healthy adult volunteers. A sleeve/side-hole manometric assembly was positioned across the pylorus with the aid of measurements of transmucosal potential difference. A new sensor consisting of an elliptical wire transducer 2.5 cm long and 1.5 cm in transverse diameter was incorporated into the assembly above the sleeve. This sensor was designed to detect nonlumen-occluding antral contractions. Motility was studied for 45 min under each of three conditions: 1) fasting, 2) after ingestion of a 100-g beef burger, and 3) during and after a 15-min intraduodenal infusion of 25% dextrose at a rate of 4 ml/min. Overall, only 51% of antral transducer deflections were associated with a change in antral side-hole pressures. Eighty-nine percent of antral side-hole pressure waves were associated with an indication of antral wall motion. Of the pressure waves recorded by the sleeve classified as isolated pyloric pressure waves, none was associated with antral transducer deflection during fasting, 1.1% after intraduodenal dextrose, and 18% after the solid meal. Antral contractions were detected by the wall motion detector with greater sensitivity than antral side holes, possibly reflecting the occurrence of nonlumen-occluding antral contractions. With some exceptions during solid gastric emptying, manometrically defined isolated pyloric pressure waves appear to represent truly localized contraction.

The Sliding Plication Gluteus Maximus Musculocutaneous Flap for Reconstruction of Sacrococcygeal Wounds

The technique of the sliding gluteus maximus muscle flap as originally described has allowed closure of defects up to 20 cm in transverse diameter. However, this requires extensive dissection and mobilization of the musculocutaneous units. A modification of the original flap is described. In this technique, there is no subcutaneous dissection. The dissection is limited to the submuscular plane of the lower portions of the muscle origin. These modifications lessen the amount of dissection and blood loss and shorten the operative time. This had permitted closure of sacrococcygeal defects up to 12 cm in transverse diameter. Twenty-two patients with a variety of sacrococcygeal defects were successfully reconstructed with this technique.

Increased prevalence of cholelithiasis in patients with abdominal aortic aneurysm: sonographic evaluation.

We performed a prospective study to determine the prevalence of cholelithiasis in patients with abdominal aortic aneurysm. Over an 18-month period, the gallbladder and the abdominal aorta were evaluated routinely in all consecutive patients referred to us for sonography of the abdomen and retroperitoneum. The patients were divided into two groups: those with an abdominal aortic aneurysm (aorta greater than 3 cm in transverse diameter) (n = 96) and those whose aorta measured less than 3 cm in transverse diameter (n = 538), who served as control subjects. Cholelithiasis was found in 50% of patients with and 26% of patients without aneurysm (p less than .0001). A stepwise logistic regression analysis found age alone to be predictive of cholelithiasis (p = .030). However, age was not predictive of cholelithiasis when included with abdominal aortic aneurysm in a multivariate model. Diabetes mellitus and gender were not predictive of cholelithiasis. We found cholelithiasis in approximately half of the patients who had abdominal aortic aneurysms. This is almost double the prevalence in the general elderly population. A pathophysiologic explanation for this observation remains to be found.

Clinical Stage II Non‐seminomatous Germ Cell Testicular Tumours. Results of Management by Primary Chemotherapy

Between 1977 and 1984, 92 patients with clinical Stage II non-seminomatous germ-cell testicular tumours were treated by primary chemotherapy, with surgery reserved for the excision of persisting masses. Eighty patients (87%) are alive and disease-free: 96% for Stages IIA and IIB and 74% for Stage IIC. Of 43 Stage IIA, B and C patients treated with bleomycin, etoposide and cisplatin (BEP), 40 (93%) are disease-free. For the whole group there was a significant difference between the outcome of treatment in patients with retroperitoneal masses greater than 8 cm in transverse diameter compared with those in whom masses were less than 8 cm, the disease-free rates being 54 and 97% respectively. Primary histology did not influence the outcome of treatment. However, whereas 51% of patients with teratocarcinoma had masses resected after chemotherapy, only 26% of embryonal carcinoma patients came to surgery. The results obtained in this series are as good as those obtained when lymph node dissection is employed as the initial form of treatment. The avoidance of surgery with preservation of ejaculatory function in 78% of Stage IIA and IIB patients argues in favour, of an initially non-surgical approach to management.