Faculty Bibliography

Tuberculous pericarditis is rare in developed nations and is most commonly associated with effusive-constrictive pericarditis. We present the case of a 33-year-old man with a self-inflicted mid-abdominal stab wound. The patient underwent an exploratory laparotomy, revealing a grade IV pancreatic transection and injuries to the portal vein, right renal vein, inferior vena cava and the superior mesenteric vein. Repair of the vessels was performed and a pancreaticojejunostomy with a gastrojejunostomy was created for the pancreatic injury. The patient's hospital course was complicated by tuberculous effusive-constrictive pericarditis requiring emergent median sternotomy with opening of the pericardial sac and eventual expiration. The final cultures from the pericardial fluid demonstrated tuberculosis.

The clinical outcome and complication rates related to the choice of technique and insertion site in the placement of a Greenfield filter (GFF) is still controversial. Moreover, there is no consensus as to which technique and placement site produces the best outcome. This study evaluated the charts of 364 patients who received GFFs during a 5-year period. Seventy-one filters were placed surgically and 293 were placed percutaneously in the operating room by general and vascular surgeons. Seventy-eight were placed using the femoral approach and 296 were placed using the jugular approach. Demographics were recorded as well as preoperative, intraoperative, and postoperative variables. All immediate complications were examined including failure of the GFF to open, suboptimal placement, multiple attempts at placement, abandoned procedures, guidewire related difficulties, hematoma, bleeding, phlegmasia cerulea dolens, pneumothorax, arrhythmia, and death. There was no statistically significant difference between complications derived from surgical placement versus percutaneous placement. There were no statistically significant differences among variables based on jugular versus femoral placement. There was a statistically significant difference in the time required for the percutaneous placement versus the open surgical procedure (33 +/- 28 min, vs 45 +/- 27 min., p<0.05). These findings suggest that the technique and site of the GFF insertion can be left to the discretion of the surgeon based on each patient's profile.

Superior mesenteric artery aneurysms (SMAAs) have been described for the past 100 years, with the first successful treatment being published in 1953 by Drs. M.E. DeBakey and D.A. Cooley. It is now 45 years after this first successful treatment, and we have a case study of SMAA that depicts the typical presentation and treatment of such an aneurysm. Our SMAA was repaired with proximal and distal ligation of the aneurysm, with intestinal viability determined by Doppler probe, fluorescein dye and repeated laparotomy in 24 hours. The patient tolerated the procedure well, and there were no postoperative sequelae. In general, SMAAs have a broad range of treatments, including vessel ligation with or without excision, revascularization with primary anastomosis, and obliterative aneurysmorrhaphy. In the future, these SMAAs and other visceral aneurysms can be treated with transluminally placed endovascular grafts with the combined efforts of the vascular surgeon and the interventional radiologist. Our article provides an overall examination of SMAAs with a review of the literature.

A retrospective study of the Staten Island University Hospital experience with ruptured abdominal aortic aneurysms (AAA) was undertaken. The study covered a 58 month period and included 30 patients. The purpose of the study was to investigate the relationship of ruptured AAA with hematuria. We specifically investigated (1) the incidence of hematuria in patients with ruptured AAA, (2) weather the presence of hematuria in these patients led to a delay in the diagnosis of ruptured AAA, and (3) if the presence of hematuria adversely effected survival as a function of causing a delay in diagnosis. The data revealed an 87% incidence of hematuria in ruptured AAA. Furthermore, gross hematuria was found to cause a statistically significant delay in arriving at the diagnosis of a ruptured AAA. This delay however could not be demonstrated to adversely affect patient survival.

Neutrophils (PMNs) have been implicated in the pathogenesis of gastritis. This study evaluates the magnitude and mode of PMN-mediated damage to gastric mucosal surface cells (GSC) in a system independent of vascular and neural factors. Rabbit GSC were freshly isolated and preloaded with 51Cr. GSC were then incubated for 1 hr or 4 hr with freshly isolated human PMNs at varying effector-to-target cell ratios. Injury to GSC was assessed as percent specific 51Cr released and by electron microscopy. We found minimal GSC injury using nonactivated PMNs. Incubation with PMNs activated with formylmethionyl-leucyl-phenylalanine (FMLP), however, resulted in significant GSC injury at the 20:1 PMN/GSC ratio, 33.2 +/- 1.8% 51Cr release (P < 0.001 compared to nonactivated PMNs). Electron microscopy revealed well-preserved gastric surface cells after exposure to nonstimulated PMNs. GSC exposed to activated PMNs (20:1 PMN/GSC ratio) were severely injured. Proteinase inhibitors and dimethylsulfoxide failed to diminish PMN-mediated GSC injury. Conversely, superoxide dismutase (SOD) inhibited GSC injury by more than 50% (P < 0.001). In addition, glutathione peroxidase inhibited injury by 84% (P < 0.001). These data suggest that neutrophil-mediated injury to gastric surface cells in vitro involves superoxide anion and hypochlorous acid and not neutral trypsinlike proteinases or hydroxyl radicals.

One hundred twenty-two hernias were repaired in 101 male patients through a total extraperitoneal approach. Patients ranged from 18 to 78 years old. All repairs were done with polypropylene mesh. Five patients (5%) required conversion to an open or transabdominal approach. Patients have been followed from 6 to 20 months, with a mean of 12 months. No recurrence has developed to date. Complications included urinary retention, groin hematoma, trocar site infection, and lateral femoral cutaneous nerve neuralgia. Six patients underwent simultaneous extraperitoneal endoscopic pelvic lymph node dissections, and two patients had varicoceles repaired simultaneously. Patients returned to usual activity within 1 week.