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Incisional herniation after appendectomy through a right lower quadrant muscle-splitting (McBurney) incision is rare, occurring in less than 0.12% of operations for appendicitis. Primary repair of this form of hernia is particularly difficult as a result of the attenuated fascia created by the herniation. By using synthetic mesh, it is possible to effectively repair this type of hernia. Three cases of postoperative incisional herniation treated by different surgical approaches are reviewed.

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OBJECTIVE: To determine whether age is a prognostic factor of breast cancer and should be used to make treatment recommendations, because younger patients are considered to have a poorer prognosis compared with that of older patients and, thus, often receive more aggressive therapy. DESIGN: A large group of patients with operable breast cancer, all of whom were followed up prospectively as part of two multicenter trials. SETTING: Case Western Reserve University, Cleveland, Ohio, was the primary hospital and study center, with 12 participating regional institutions. PATIENTS: All 1353 patients underwent uniform local-regional therapy that consisted of a modified radical mastectomy. Patients who were node negative were followed up, and patients who were node positive received systemic chemoendocrine therapy. MAIN OUTCOME MEASURES: Patients were followed up at regular intervals for either recurrence or death. RESULTS: Patients ranged in age from 22 to 75 years with a median age of 56 years. Younger patients had more estrogen receptor-negative tumors (P < .0001) and a greater number of positive lymph nodes (P < .0001). Of the 241 black patients in the study, a greater percentage were younger compared with white patients (P < .0001). Age was considered in a Cox's multivariate model, together with nodes, tumor diameter, estrogen receptor content, and race. Age was not a significant predictor of either disease-free (P = .33) or overall (P = .30) survival. Using mixture models with covariates, the estimated average hazards (where lambda indicates the force of mortality) of breast cancer deaths per year were similar (P, not significant) for patients 45 years old or younger (lambda = 0.061), older than 45 years but 65 years old or younger (lambda = 0.052), and older than 65 years (lambda = 0.061). CONCLUSIONS: In conclusion, younger patients as a group have more aggressive and advanced breast cancer at presentation compared with older patients. Considered in a multivariate model, together with other variables, age does not provide independent prognostic information and should not be used alone for management decisions.

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In view of current emphasis on identifying prognostic factors for patients with early breast cancer, we studied the importance of tumor size to survival among 1392 patients with primary operable breast cancer who were followed up prospectively. All patients had modified radical mastectomies. Nine hundred seventeen patients had negative nodes and did not receive postoperative adjuvant therapy. Four hundred seventy-five patients had node involvement and received combination chemoendocrine therapy. In a Cox's proportional hazards model, tumor size was a significant predictor of disease-free and overall survival when the number of positive nodes, estrogen receptor status, menopausal status, and race were considered. Among the node-negative group, tumor size explained considerable variation in disease-free and overall survival, varying from a 10-year disease-free and overall survival of 80% and 99% for patients with estrogen receptor-positive tumors measuring 1 cm or less to a 10-year disease-free and overall survival of 51% and 59% for patients with tumors larger than 5 cm.

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Careful patient selection and preparation for ambulatory inguinal herniorrhaphy combined with monitored local anesthesia result in a safe procedure with excellent patient acceptance. Factors contributing to early and late complications are presented, and the common methods of their treatment are reviewed.

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In 1955, the concept that an ulcerogenic islet cell tumor was responsible for a marked ulcer diathesis that led to gastric hyperacidity was proposed by myself and Ellison. Recently is was suggested that this concept marked the beginning of modern gastrointestinal endocrinology. Although these pancreatic ulcerogenic tumors are relatively uncommon, a survey in 1987 stated that inquiries about the tumor were the most common references requested from surgical journals. The original diagnostic triad proposed included a fulminating ulcer diathesis (12-hr secretion 2-3 liters), rapidly recurring ulceration despite adequate medical, surgical, and radiation therapy, and identification of a non-beta islet cell tumor of the pancreas. The non-beta islet cell was considered to be different from the cells producing insulinoma, which up to that time was thought to be the only type of islet cell tumor produced by the pancreas.

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To investigate whether or not hormone receptor determination gives independent prognostic information for long term survival of patients with carcinoma of the breast, we studied 1,392 patients with early carcinoma of the breast. Patients were part of two prospective, multi-institutional trials, the first begun in 1974 and the second in 1980. Estrogen receptor assays were performed on all primary specimens taken of the carcinoma of the breast. Initial treatment for all patients was a modified radical mastectomy. Nine hundred and seventeen patients had negative axillary nodes and were observed without additional therapy. Four hundred and seventy-five had positive nodes and were randomized to receive combination chemoendocrine adjuvant therapy. One thousand and sixty-three (76.4 per cent) of the patients were found to have estrogen receptor positive (ER+) tumors (greater than or equal to 3 femtomoles per milligram cytosol of protein). The ten year over-all survival rate of 65.9 per cent was significantly better than that of 329 (23.6 per cent) patients with estrogen receptor negative (ER-) tumors (less than 3 femtomoles per milligram cytosol protein), who had a ten year over-all survival rate of 56.0 per cent (p = 0.0001). Higher estrogen receptor values were associated with Caucasian (p = 0.0001) and postmenopausal patients (p = 0.0001). In a proportional hazards regression model, patients with ER+ tumors had a significantly longer over-all survival period (p = 0.0001), but only a marginally improved disease-free survival time (p = 0.07) when compared with patients who had ER- tumors. These results indicate that ER determination does have prognostic value for long term over-all survival of patients with carcinoma of the breast. The greater importance of ER analysis to over-all compared with disease-free survival may be related to more easily managed recurrent disease among the ER+ group.

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With the increased use of prophylactic and broad-spectrum antibiotics, pseudomembranous colitis has emerged as a significant clinical problem. Management with specific anti-Clostridium difficile therapy (vancomycin or metronidazole) has reduced mortality to less than 2%. Nevertheless, the disease may progress to a fulminant toxic colitis or colonic perforation. Additionally, another subset of patients will present with a dramatic clinical picture, suggesting acute peritonitis, eventuating in unnecessary laparotomy. This report reviews both the medical and surgical literature during the past 15 years of patients treated for pseudomembranous colitis. Analysis of this clinical data has provided us with the opportunity to both define the role of surgery in this disorder and illustrate the necessity for a combined medical and surgical cooperative approach in the early management of this iatrogenic disease.

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In 1955, the concept that an ulcerogenic islet cell tumor was responsible for a marked ulcer diathesis that led to gastric hyperacidity was proposed by myself and Ellison. Recently it was suggested that this concept marked the beginning of modern gastrointestinal endocrinology. Although these pancreatic ulcerogenic tumors are relatively uncommon, a survey in 1987 stated that inquiries about the tumor were the most common references requested from surgical journals. The original diagnostic triad proposed included a fulminating ulcer diathesis (12-hr secretion 2-3 liters), rapidly recurring ulceration despite adequate medical, surgical, and radiation therapy identification of a non-beta islet cell tumor of the pancreas. The non-beta islet cell was considered to be different from the cells producing insulinoma, which up to the time was thought to be the only type of islet cell tumor produced by the pancreas.

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A retrospective review of 1,220 cystic fibrosis (CF) patients between 1965 and 1989 identified 60 patients who underwent appendectomy. Ten had appendectomy prior to referral and 16 had an incidental appendectomy (primarily meconium ileus). Among the remaining 34 patients, acute appendicitis was present in 19 (1.8% incidence). "Classic appendicitis"--acute abdominal pain shifting to the right lower quadrant (RLQ), focal RLQ tenderness, and elevated white blood cell (WBC) count--was present in 15. Four additional inflamed appendixes were removed in patients following incorrect preoperative diagnosis. Thirteen of these 19 were perforated. Complications included wound infection (2), pelvic abscess (1), ileal obstruction requiring ileostomy (1), and pelvic hematoma (1). There were no deaths. One patient with acute RLQ pain and tenderness had a normal appendix. Seven patients (mean, 20 years) had chronic, intermittent, focal RLQ pain and tenderness not originating periumbilically with a normal WBC count and temperature. At exploration, these appendixes were enlarged and tensely distended with inspissated mucus. Microscopic examination showed no inflammation. Appendectomy resulted in resolution of symptoms without complications. Four additional patients with intermittent RLQ pain and tenderness and a history of recurrent intussusception presented with ileocolic intussusception. Persistent postreduction symptoms in three and failure of reduction in the fourth necessitated celiotomy at which time tensely distended appendixes were removed. Appendectomy led to resolution of symptoms. Three additional enlarged noninflammed appendixes were incidentally removed in asymptomatic patients undergoing unrelated intraabdominal procedures. Appendiceal disease in CF patients represents a spectrum ranging from simple mucous distention to acute appendicitis with perforation. CF patients with pain secondary to a noninflamed distended appendix represent a distinct syndrome cured by appendectomy.(ABSTRACT TRUNCATED AT 250 WORDS)

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Unregulated increases in intracellular calcium levels with subsequent cytoskeletal disruption have been implicated in tissue injury caused by oxygen free radicals (OFRs). The purpose of these experiments was to study the kinetics of free intracellular calcium in endothelial cells on exposure to exogenous OFRs and investigate the mechanisms of this altered homeostasis. Monolayers of endothelial cells were labeled with a calcium-sensitive probe and exposed to exogenous OFRs generated with hypoxanthine and xanthine oxidase. Intracellular calcium changes were monitored dynamically by continuous measurement of fluorescence with a spectrofluorometer. A sustained rise in intracellular Ca++ levels reaching a peak at 5 minutes was observed. This effect was blocked by superoxide dismutase and catalase. Removal of calcium from the medium or chelating the extracellular calcium with ethyleneglycoldiamine tetraacetate significantly blunted the response to OFRs (p less than 0.05). Preincubation of the cells with verapamil did not alter the observed increase in Ca++i. Addition of another divalent cation (Mn++) to the medium partially blocked the rise in calcium levels (p less than 0.05). Membrane potential measurements assessed fluorometrically, with the fluorescent probe bisoxonol, demonstrate a transient hyperpolarization of the plasma membrane on exposure to OFRs, temporally associated with the rise in [Ca++]i. In summary, OFRs cause an increase of intracellular calcium in endothelial cells. This response is dependent on extracellular calcium and independent of voltage-sensitive calcium channels. The increase can be partially inhibited by other divalent cations. These results suggest that the transformation of the plasma membrane components (lipid peroxidation and cross-linking of proteins) caused by OFRs may produce cation ionophores.

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A prospective, randomized double-blind study was undertaken to compare the efficacy of three prophylactic regimens (oral neomycin and erythromycin, intravenous cefoxitin, and a combination of both oral and intravenous antibiotics) in patients undergoing elective colorectal surgery. One hundred sixty-nine patients were randomized and 146 patients were evaluable. Septic complications occurred in 11.4 per cent of patients receiving oral antibiotics only, in 11.7 per cent of patients receiving intravenous cefoxitin alone, and in 7.8 per cent of patients receiving both oral and intravenous antibiotics. These differences were not statistically different. The greatest number of septic complications occurred in those patients with anastomotic disruptions. Two patients died (1.3%), both of whom had major anastomotic failures. There was no advantage between any of the groups in the incidence of wound infection (3.9-6.8%). Thus, no advantage could be identified in this study in the combination of oral and intravenous antibiotics in elective colorectal surgery.

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Jaundice due to metastatic tumor involving the extra-hepatic bile ducts is uncommon, and thus, the management of this problem is not standardized. Retrospective analysis of all patients admitted to University Hospitals of Cleveland with malignant biliary obstruction was thus undertaken to identify the incidence, origin, management, and outcome of these metastatic tumors. During a 5-year period, 56 patients with jaundice secondary to biliary, pancreatic, ampullary, or metastatic tumors were identified. Of these, 12 (21%) represented a distant malignant process metastatic to the porta hepatis. Sites of origin were diverse: lymphoma, 2; breast, 3; colon, 2; and 1 each with Hodgkin's, lung, ovary endometrium, and melanoma. Patients ranged in age from 31 to 90 years (mean: 60). Surgical intervention was undertaken in only two patients (cholecystojejunostomy, 1; transhepatic U-tube stenting, 1). The remainder were managed as follows: no procedure, 3 (25%); percutaneous stenting, 5 (42%); and radiation only, 2 (17%). Mortality was as follows: 5 of 12 (42%) died within 30 days and 8 of 12 (67%) within 60 days. The only survivors beyond 60 days were the patients with Hodgkin's (1 of 1), lymphoma (1 of 2), breast (1 of 3) and melanoma (1 of 1). Ten of the patients had obvious extensive metastatic disease, which would explain the poor outcome. Analysis of this data indicates that overall survival is dismal and palliative, nonoperative methods to manage the jaundice should be considered.

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A patient with pseudomembranous colitis is described in whom a percutaneous cecostomy was performed using computed tomographic guidance. Several lines of evidence indicate the safety of this approach, and clinical circumstances are suggested in which the procedure may have potential therapeutic benefit.

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