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PURPOSE: The purpose of this study was to evaluate the use of an ultrasound guided femoral nerve (FN) block together with an ultrasound guided lateral femoral cutaneous nerve (LFCN) block in addition to a patient controlled intravenous analgesia (PCIA) pump with piritramide as a strategy for postoperative pain-management after primary hip arthroplasty. METHODS: In a retrospective study, data recorded from 32 patients undergoing primary hip arthroplasty in 2008, before peripheral blocks were used, were compared with data from 38 patients undergoing primary hip arthroplasty in 2011, when an ultrasound guided single shot FN and LFCN block was used. As primary endpoint the total piritramide consumption after 48 hours was analyzed. A score on a visual analog pain scale at rest and during movement was included as a secondary outcome. RESULTS: Patients receiving the peripheral nerve blocks used significantly less piritramide in comparison to the patients who received no peripheral nerve blocks (p < 0.01). Moreover, pain scores at rest and during movement were significantly lower in the group with the peripheral nerve block (p-values respectively < 0.01 and < 0.05). CONCLUSIONS: This retrospective study indicates that a FN block in combination with a LFCN block as supplementary postoperative analgesia after primary hip arthroplasty, can reduce the piritramide consumption. Furthermore, patients receiving the peripheral nerve block report lower pain scores at rest and during movement compared with the patients who did not receive a peripheral block. However, as this is a retrospective study, conclusions have to be drawn cautiously.

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Rubber band ligation (Barron ligation, RBL) is a widely used method for the treatment of symptomatic -haemorrhoids. In general, it is considered as a safe, effective and easily performed way of treating second and third -degree haemorrhoids. Perineal and pelvic sepsis was already known to be a rare, but possible complication after stapled haemorrhoidopexy. However, there have been some reports of severe sepsis after rubber band ligation as well. We -present a patient who was treated twice for haemorrhoids with rubber band ligation and attended the emergency department 10 days later. He was diagnosed with perirectal sepsis and aggressive antibiotic treatment was the first attempt of treatment. Because of further deterioration under medical therapy, our patient required extensive surgery.

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Granular cell tumors (GCT's) are uncommon soft tissue neoplasms most likely of neural or neuroectodermal origin. They can be found in virtually any body site, but they are rarely located in the abdominal wall. We report the case of a patient with a history of breast cancer presenting with a slow-growing, firm and painless nodule in the abdominal wall. After ruling out metastatic origin of the mass by CT scan and MRI, an incisional biopsy was performed. Anatomopathologic findings were congruent with a benign granular cell tumor of the abdominal wall. En-bloc surgical resection with reconstruction of the abdominal wall defect using a prosthetic mesh was performed. Preoperative histopathologic diagnosis of an abdominal wall tumor is important. Broad surgical excision to obtain negative margins should be the therapeutic goal in all cases of GCT as positive margins are highly correlated with recurrence of the lesion.

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Gallstone ileus is a rare complication of cholelithiasis. Only 0,3-0,5% of all patients with gallstones will eventually suffer from this condition. It is well known that there is an increased prevalence of gallstones among patients with Crohn's disease, but gallstone ileus remains even in these patients an unfrequent condition. Because of the rarity of this disease and its presentation as an intestinal (sub)obstruction, mostly without biliary symptoms, diagnosis and surgical treatment are often delayed. We report the case of a 75-year-old woman with a long history of Crohn's disease presenting with intermittent symptoms of intestinal obstruction since several weeks. Symptoms were thought to be due to recurrence of Crohn's disease, but the patient did not respond to steroid therapy. Resection of the diseased ileocolic segment was performed and a large impacted stone was detected proximal of the stenotic segment. With this case report we want to emphasize how easily diagnosis of gallstone ileus can be missed, especially in Crohn's patients and we would like to discuss the different treatment options.

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This case reports an idiopathic gastric rupture in a 3-year-old girl who had an episode of nausea and vomiting after a large meal. Abdominal ultrasound and CT scan revealed free air and fluid in the abdominal cavity, leading to the diagnosis of gastro-intestinal perforation. During emergency surgery, gastric rupture was detected on the anterior wall of the gastric body near the greater curvature and treated by performing a sleeve gastrectomy. The intra-operative course was complicated by a cardiac arrest. The child survived following intensive postoperative care. All articles on spontaneous idiopathic gastric rupture in pre-school age children have only been reported in Japanese and Chinese literature.

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PURPOSE: Description of a very rare case of internal abdominal hernia, namely herniation of the proximal jejunum in the Landzert fossa, through a hole in the mesocolon transversum. MATERIAL AND METHODS: Based on preoperative history, clinical state and radiological findings, the diagnosis of internal hernia was strongly suspected. RESULTS: Suspected diagnosis was confirmed during laparotomy. After reduction of the jejunum and closure of the hernia orifice, the patient recovered promptly. CONCLUSION: The diagnosis of internal herniation should always be considered in every patient who presents with an acute abdomen, signs of (sub)obstruction and non-typical history. The most important diagnostic tool is computer tomography, that is accurate in 77%.

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PURPOSE: Bexarotene (Targretin; Ligand Pharmaceuticals, Inc, San Diego, CA) is a retinoid-X-receptor (RXR)-selective retinoid with preclinical antitumor activity in squamous cell cancers. In this phase I/II trial, we combined bexarotene with cisplatin and vinorelbine in the treatment of patients with non-small-cell lung cancer (NSCLC). PATIENTS AND METHODS: Forty-three patients who had stage IIIB NSCLC with pleural effusion or stage IV NSCLC and had received no prior therapy received bexarotene in combination with cisplatin (100 mg/m2) and vinorelbine (alternating doses of 30 mg/m2 and 15 mg/m2). In the phase I portion, the daily dose of bexarotene was escalated in cohorts of three patients from 150 mg/m2 to 600 mg/m2, beginning 1 week before the start of the cisplatin-vinorelbine regimen. Once the maximum-tolerated dose (MTD) of bexarotene was determined, the study entered the phase II portion. Response rate was the primary end point; median survival time and 1-year survival rate were secondary end points. RESULTS: In the phase I portion, the daily MTD of bexarotene was determined to be 400 mg/m2. Eight of 43 patients exhibited major responses. Seven (25%) of the 28 patients in the phase II portion responded to treatment. The median survival time in the phase II portion was 14 months; nine (32%) of the 28 patients were still alive at a minimum follow-up of 2 years. One-year and projected 3-year survival rates were 61% and 30%, respectively. The most common grade 3 and 4 adverse events were hyperlipemia, leukopenia, nausea, vomiting, pneumonia, dyspnea, anemia, and asthenia. Grade 3 and 4 laboratory abnormalities with incidences greater than 5% were decreased hemoglobin levels and WBC, absolute neutrophil, and absolute lymphocyte counts and increased prothrombin time and creatinine and amylase levels. Of the two cases of pancreatitis, one required hospitalization and both were associated with increased triglyceride levels. There was one death secondary to renal insufficiency unrelated to bexarotene treatment. CONCLUSION: In patients with advanced NSCLC, bexarotene with cisplatin and vinorelbine yielded acceptable phase II response rates (25%) and was associated with better-than-expected survival (14-month median survival time; 61% 1-year, 32% 2-year, and 30% projected 3-year survival rates). The regimen should be studied in larger clinical trials.

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BACKGROUND: Thymidine incorporation studies performed in animal tumour models, revealed major differences in endothelial cell proliferation when tumour tissue was compared with normal tissue. The fraction of proliferating endothelial cells is reported to be increased by a factor of 30 to 40 in tumour tissue. PATIENTS AND METHODS: To make it possible to analyze the endothelial cell proliferation in human tumours, an immunohistochemical double staining technique comprising CD31, an endothelial cell marker, and Ki-67, a proliferation marker, was developed. Endothelial cell proliferation was analysed in 21 primary human colorectal adenocarcinomas and in the adjacent mucosa. RESULTS: Proliferating endothelial cells were found throughout the entire carcinoma. The mean overall endothelial cell labeling index (ECLI) was 9.9% (range, 5.4-18.0), and the labeling index of endothelial cells in areas of intense neovascularisation was even higher. Mean ECLI in the vascular hot spots was 21.0% (range, 6.8-35.0), and the mean tumour cell labeling index (TCLI) in the maximally Ki-67 immunostained areas was 78.3% (range 47.0-89.7). In 14 of 21 carcinomas, these areas were predominantly found at the luminal margin of the tumour, as were the vascular hot spots. A significant positive correlation was found between tumour vascularity, measured in the vascular hot spots, and tumour cell proliferation, measured in the maximally Ki-67 immunostained areas (p < 0.05). To analyse this relation in more detail, microvessel density (MVD), TCLI and ECLI were determined per x400 microscopic field by scanning in sequence from the luminal tumour margin to the invasive tumour base. In all tumours, the pattern of the MVD per x400 field, from the luminal margin to the tumour base, was similar to that of the TCLI and ECLI. CONCLUSIONS: These findings confirm that the fraction of cycling endothelial cells is higher in human colorectal carcinoma than in the adjacent mucosa which suggests that endothelial cells are proliferating in most of the individual capillaries in tumour tissue. Regional differences in MVD correlate with differences in tumour cell proliferation in these tumours.

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A short survey of the recent advances in the treatment of gallstones is followed by a video-report of the laparoscopic cholecystectomy: the last acquisition in surgical practice. Since the excellent results the authors prefer the endoscopic way to the open cholecystectomy in the treatment of non-complicated symptomatic gallstone disease. This procedure can be considered as the "first choice", so far as indications are severed, and operation is performed by a surgeon credentialed in general biliary surgery.

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An unusual complication of myomatous uterus in pregnancy is presented. It shows spontaneous perforation of a myoma after red degeneration, presenting as an acute abdomen. To our knowledge spontaneous perforation of a necrotising leiomyoma has not been reported earlier. A review of the literature is given.

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