Faculty Bibliography

BACKGROUND:Acute cholecystitis is one of the most common surgical problems, yet substantial debate remains over the utility of simple examination, abdominal ultrasound (AUS), or advanced imaging such as hepato-imino diacetic acid (HIDA) scan to support the diagnosis. MATERIALS AND METHODS/METHODS:The preoperative diagnostic workup of patients who underwent cholecystectomy with histologically confirmed acute cholecystitis was reviewed to calculate the sensitivity of AUS, HIDA scan, or both. In addition, the sensitivity of the commonly described ultrasonographic findings was assessed. RESULTS:From 2010 through 2012, 406 patients among 9087 reviewed charts presented to the emergency department with acute upper abdominal pain and met inclusion criteria. 32.5% (N = 132) of patients underwent AUS only, 11.3% (N = 46) underwent HIDA scan only, and 56.2% (N = 228) had both studies performed for workup. 52.7% (N = 214) of patients had histopathologically confirmed acute cholecystitis. The sensitivities of AUS, HIDA, and AUS combined with HIDA for acute cholecystitis were 73.3% (95% confidence interval [CI] = 66.3%-79.5%), 91.7% (95% CI = 86.2%-95.5%), and 97.7% (95% CI = 93.4%-99.5%), respectively. Although of limited sensitivity, AUS findings of sonographic Murphy sign, gallbladder distension, and gallbladder wall thickening were associated with a diagnosis of acute cholecystitis. CONCLUSIONS:The sensitivity of AUS for diagnosing acute cholecystitis in patients with acute upper abdominal pain is limited. The addition of a HIDA scan in the diagnostic workup significantly improves sensitivity and can add valuable information in the appropriate clinical setting.

Jejunal diverticulosis is a rare entity with a reported clinical incidence of 0.5%. However, symptoms relating to its presence are non-specific, which does not only delay diagnosis, but also increases the risk of serious complications approaching 15%. We report a case of perforated jejunal diverticulum presented with a 6-month history of significant weight loss and acute abdominal pain. We discuss clinical presentation in both simple and complex cases, diagnostic pitfalls and management strategies.

Subareolar abscess of the male breast is a rare condition, which can be complicated by a fistula from the areolar skin into a lactiferous duct. In 1951, Zuska et al first characterised this entity in women. Literature on mammillary fistulas in men is scarce and therefore standardisation of treatment does not exist. We present two cases of recurrent subareolar abscesses with draining fistulas. Both patients were successfully treated by complete excision of the lactiferous duct fistula, and continue to do well with no evidence of disease recurrence. When male patients present with a draining subareolar abscess, one should have a high index of suspicion for a mammillary fistula. Failure to identify and surgically excise the fistula may lead to recurrence of the abscess and prolonged morbidity. The most effective management of this uncommon entity includes complete excision of the lactiferous duct fistula.

AIM/OBJECTIVE:The aim of this study is to retrospectively evaluate the use of bioresorbable plating systems in the rigid fixation of paediatric mandible fractures. PATIENTS AND METHODS/METHODS:Our series consists of fifteen paediatric patients (11 male, 4 female, average age 8.13 years) with mandible fractures of varying severity treated with bioresorbable plates over a 54-month period at our institution. Fractures of the ramus, body, parasymphysis, and symphysis were treated by one surgeon with open reduction and internal fixation with 1.5 mm and 2 mm resorbable plates and monocortical screws, using 3 different plating systems, each with differing polymer concentrations of polyglycolic and poly-L-lactic acid. The patients were followed with respect to the following clinical categories: fracture location, postoperative occlusion, maximum interincisal opening (MIO), segmental mobility at the fracture site, and any abnormal swelling at the operative site. RESULTS:Our data shows a stable occlusion and maximum interincisal opening of thirty millimetres or greater was achieved in 14 of 15 patients seen in follow up, with 8 patients having an MIO of 40 mm or greater. No segmental mobility noted at any of the fracture sites. Thirteen patients had no postoperative sequelae or implant related complications. Two patients developed a seroma-like collection at the operative site. Postoperative films starting at 1 year showed significant bony osseous fill where the previous screw sites were located. CONCLUSIONS:In our case series we found that the use of resorbable polyglycolic and poly-L-lactic acid plating systems when combined with a brief postoperative period of intermaxillary fixation is an effective method of internal fixation for mandibular fractures in the paediatric population.

The human body is covered with several million sweat glands. These tiny coiled tubular skin appendages produce the sweat that is our primary source of cooling and hydration of the skin. Numerous studies have been published on their morphology and physiology. Until recently, however, little was known about how glandular skin maintains homeostasis and repairs itself after tissue injury. Here, we provide a brief overview of sweat gland biology, including newly identified reservoirs of stem cells in glandular skin and their activation in response to different types of injuries. Finally, we discuss how the genetics and biology of glandular skin has advanced our knowledge of human disorders associated with altered sweat gland activity.