Section on Surgery. (Abstracts of Scientific Posters).

S1-E. PHEOCHROMOCYTOMA IN A PATIENT WITH BECKWITH-WIEDEMANN SYNDROME: THE FIRST REPORTED CASE. Danny Little, MD, John Mark Vermillion, MD, Katrina Baca, MD, Misty Humphries, MD, Laurence Frankel, MD, and Monford Custer, MD. Scott and White Hospital and Texas A&M Health Sciences Center, Temple, TX

Beckwith-Wiedemann Syndrome (BWS) is a rare syndrome, affecting 1 in 13,700 live births. Characterized by developmental anomalies and organ hyperplasia, BWS is particularly worrisome for its association with a subset of embryonic neoplasms. This case represents the first report of a child with BWS developing a pheochromocytoma. A thirteen-year-old girl presented with a one-day history of nonbilious emesis and seizure. PMH included BWS with associated macroglossia and omphalocele. The child was known to have a left adrenal mass, which had been followed by serial ultrasound examinations and found to be stable. Unfortunately, CT and MRI films were difficult to interpret due to Harrington rod interference. IV access was tenuous and necessitated central venous catheter placement on hospital day four. Subsequently, she experienced a perioperative hypertensive crisis, requiring transfer to the pediatric intensive care unit and treatment with labetol drip. A cardiac echocardiogram revealed hypertrophic cardiomyopathy . Urine norepinephrine value was elevated at 1277 mg/24hr (normal, 15-80 mg/24 hr). Urine dopamine value was 354 mg/24 hr (normal 65-400 mg/24 hr). The patient received two weeks of preoperative alpha- and beta-blockade. The child was taken to the operating room and underwent an open left adrenalectomy. An enlarged para-aortic nodule was also discovered at laparotomy. Postoperative course was uneventful. Final pathology confirmed the diagnosis of pheochromocytoma with metastasis to a para-aortic node. Approximately 7.5% of children with BWS will develop a neoplasm, usually during the first eight years of life. Increased risk has been noted in children with hemihypertrophy. Adrenocortical adenomas and Wilm's tumors are most common; however, neuroblastoma, carcinoid, hepatoblastoma, gonadoblastoma, fibroma, and retinoblastoma may also be seen. This case reports a new tumor association with BWS. Children with BWS and adrenal masses must be investigated for the presence of a pheochromocytoma. Furthermore, given t he overall increased risk of neoplastic transformation in these patients, a biannual abdominal ultrasound examination and chest radiograph are warranted.

S2-E. METASTATIC LUNG CANCER PRESENTING AS A BOWEL OBSTRUCTION

John Emory Streitman, MD, and Brian M. Camazine, MD. Temple, TX

Lung cancer metastatic to the gastrointestinal tract is exceptionally rare, ranging from 0.5% to 2.0% of patients with advanced-stage cancer. While no large series exist in the literature, the most commonly reported cases are associated with perforation or melena. We present 2 cases from a single institution of lung cancer metastatic to the small bowel in one case and the colon in the second. In both cases, the patients presented with signs of bowel obstruction, having never had abdominal surgery. The first patient was a 75-year-old Caucasian man with a history of a T1N0M0 poorly differentiated adenocarcinoma of the right upper lobe who underwent right upper lobectomy in February 1998 and presented in April of 2001 with signs and symptoms of a partial small-bowel obstruction. Although the patient had never had an abdominal operation and had no other obvious explanation for his obstructive symptoms, he was initially managed conservatively, as he was deemed a poor operative candidate. Unfortunately, his symptom s continued to worsen, and he was taken to the operating room for laparotomy. He was found to have a 7-cm mass invading transmurally through the terminal ileum into the mesentery and invading the posterior aspect of the right lower anterior abdominal wall. This region was excised en bloc as an extended right hemicolectomy, with abdominal wall resection and primary anastomosis. Pathologically, this tumor was similar to the patient's right upper lobe tumor. The patient's postoperative course was complicated by a wound infection, but he otherwise recovered bowel function and was discharged on postoperative day 25. He has since received adjunctive chemotherapy and continues to do well almost 1 year out. The second patient was a 62-yearold Caucasian man who presented in April 1997 with superior vena cava syndrome. He was admitted and found to have a 2.5-cm mass in the apex of the right lung with mediastinal lymphadenopathy. He underwent mediastinoscopy and was found to have a TIN2MX non-small cell cancer. As part of his initial work-up the patient underwent colonoscopy, which was only remarkable for diverticulosis. He underwent radiation therapy for this tumor. Approximately one year later, in March 1998, he returned with symptoms of partial bowel obstruction and underwent another colonoscopy, as CT scan of the abdomen suggested a large transverse colon lesion that was partially obstructing. At colonoscopy, he was found to have extrinsic compression of the colon with near obstruction. He underwent laparotomy at that time and was found to have a 14-cm mass arising from the exterior aspect of the colon and invading into the lumen, as well as into the spleen. He underwent segmental colectomy with anastomosis and splenectomy. When compared with the patient's prior pathology, this was compatible with metastatic non-small cell carcinoma of the lung. He recovered from this and, following further chemotherapy, underwent right upper lobectomy in September 1998 for a poorly differentiated adenocarcinoma. He continues to do well , and on last evaluation with CT scan of chest, abdomen, and pelvis in January 2002, remained disease free. These cases provide several interesting points for discussion with regard to metastatic lung tumors. In the first case, the patient presented with an early-stage lung cancer, but still had late distant metastasis, while the second patient presented at a much more advanced stage initially. These cases are also unique in showing that patients with a history of malignancy and bowel obstruction without obvious cause must be suspected of having metastatic disease as the etiology of their obstruction. Finally, these cases emphasize that aggressive treatment of metastatic disease can afford long-term survival.

S3-E. THE ROLE OF CHOLESTEROL IN THE ADHERENCE OF HELICOBACTER PYLORI TO GASTRIC CELLS. Ata Atogho, MS-III, Cornell Allen, MS, Amel Ahmed, PhD, and Duane Smoot, MD. GI Division, Department of Medicine, Howard University Hospital, Washington, DC.

Helicobacter pylon is the major cause of peptic ulcers and chronic gastritis. Studies have also linked this bacterium with the occurrence of gastric cancer. The bacteria adhere to gastric cells and produce destruction by different mechanisms. Previous studies have suggested that highly specialized membrane microdomains called lipid rafts are essential for the adherence of viruses. These microdomains have a very distinct lipid composition of glycolipids, sphingolipids, and cholesterol in high concentrations. Cholesterol has been shown to affect the adherence and pathogenicity of HIV-1 in particular. The present study aims to find the correlation between cholesterol in the cell membrane of gastric cells and adherence of H pylon to these cells. We also investigate the association between the use of fetal bovine serum (FBS) and an increase in the cholesterol and the adherence of H pylori cells. The gastric cells (AGS) were treated with different amounts of cholesterol, FBS, and Dulbecco Modified Eagle medium (DME M) for 1, 2, and 3 hours. They were then treated with H pylori, and the adherence of the latter to AGS cells was determined. AGS cells were treated with different concentrations of 2-hydroxy-propylbeta cyclodextrin (THPB) for an hour to deplete the AGS cells of cellular cholesterol and the adherence of H pylori to these cells was also determined. Doubling the amount of cholesterol produced a 50% increase in the adherence of H pylori to AGS cells over a 2-hour period. FBS increased the amount of cholesterol in the cell membrane and doubling the concentrations of FBS produced a 2-fold increase in the adherence of H pylori after two hours. However, we did not show whether the cholesterol explains the increase in adherence due to FBS.

S4-E. IS SCORING SYSTEM A PREDICTIVE FACTOR FOR HOSPITALIZATION STAY LENGTH OF PATIENTS WITH ACUTE PANCREATITIS (AP)? Atilla Soran, MD, Serap Erel, MD, Belma Kocer, MD, O. Yildirim, MD, M. Karabeyoglu, MD, O. Cengiz, MD. Ankara Numune Teaching and Research Hospital, Ankara, Turkey.

The length of hospital stay (LHS) of patients with acute pancreatitis (AP) depends on the severity of the disease. In this study, our aim was to evaluate the predictive importance of serum amylase and CRP levels, Ranson and APACHE II scores, and computed tomography (CT) grading on the LHS of patients with AP. Fifty-two patients diagnosed with AP from 1998 to 2001 were included in this study. There were 19 (36%) men and 33 (64%) women with an average age of 52.5 years (range, 22-82 years). Serum amylase and CRP levels were measured, and Ranson and APACHE II scores were calculated right after the patients' admissions. Balthazar-scored contrast-enhanced CT results were obtained for 48 (92%) patients. The average Ranson score was 2.83 [+ or -] 1.75 (0-7), average APACHE II score was 7.56 [+ or -] 4.69 (0-23) on admission to the hospital. LHS of 26 patients with mild pancreatitis (<3) was 10.7 days and LHS of 26 patients with severe pancreatitis (> 3) was 30.2 days (P.001) based on the Ranson scoring system. Accor ding to APACHE II score, 25 patients with mild pancreatitis (< 8) stayed in the hospital 13.2 days, and 27 patients with severe pancreatitis (>8) stayed 27.1 days (P = .035). There was a statistically significant relationship between the LHS of patients and these scoring systems. According to Balthazar grade, LHS of 33 patients with mild pancreatitis (A, B, C) was 12.6 days, and that of 15 patients with severe pancreatitis (D, E) was 41.9 days; there was a significant difference between the LHS of mild and severe pancreatitis patients (P = .005). The serum amylase and CRP levels on admission had no effect on the LHS. One third of the patients required a stay in the intensive care unit (ICU), and the average number of days spent in the ICU was 14.8 [+ or -] 21.2 days. Since the average Ranson score of patients in the ICU was 4.07 and the average APACHE II score was 11.4, these patients were included in the severe pancreatitis group. Although the APACHE II score is highly recommended worldwide for the assessmen t of AP severity, our outcomes showed that Ranson score and Balthazar classification were more reliable factors for the prediction of LUS of patients with AP.

S5-E. HOWARD UNIVERSITY HOSPITAL STUDY OF SENTINEL LYMPH NODE BIOPSY COMPARED WITH AXILLARY LYMPH NODE DISSECTIONS IN EARLY STAGE BREAST CANCER (STAGES 0, I, II) WITH NO EVIDENCE OF LYMPH NODE METASTASIS. Mukong Adeso, BS, Robert L. Dewitty, Jr., MD, William E. Matory, MD, Lasalle D. Leffall, Jr., MD, and Haile M. Mezghebe, MD. Division of Surgery, Howard University College of Medicine, Washington, DC.

The purpose of this study was to use cases from Howard University Hospital (HUH) to prove that sentinel lymph node biopsy (SLNB) should be the standard for determining the regional nodal status in patients with clinical stage 0 (florid cancer in situ or the comedo type), stage I, and stage 11 breast cancer and to look into factors that may affect the accuracy of using SLNB in staging, such as patient's age, physician experience, technique used in performing SLNB, location of tumor, and procedure performed before SLNB. Our goal was to determine whether SLNB is more sensitive than axillary lymph node dissection (ALND) in the pathologic staging of clinical stage I, II, and some stage 0 breast cancers. Sentinel nodes are theoretically the first lymph nodes that receive lymphatic fluid from a particular area. SLNB is the procedure of biopsying these lymph nodes, usually no more than 1,2, or 3. There are two techniques used: a blue dye, called Isosulfan Blue, and radioactive technetium 99. Stage 0, stage I and stag e II are considered as early-stage breast cancer. Stage 0 is a noninvasive breast cancer which should have no lymph node metastasis.

S6-E. AN EVALUATION OF SURGICAL MARGIN STATUS AND POSSIBLE PREDICTIVE VARIABLES FOR RESIDUAL DISEASE IN BREAST CANCER PATIENTS. Barry S. Kang, BS, George E. Peoples, MD, and Mary E. Maniscalco-Theberge, MD. Washington, DC.

Breast cancer is the second leading cause of mortality in women in the United States with approximately 1 in 8 women developing breast cancer in her lifetime. Breast cancer is locally controlled by surgical excision with negative margins and radiation therapy, or mastectomy. Surgical margin status has been an important topic of recent studies. Positive margins increase the possibility of residual carcinoma and the necessity for re-excision. Close margins vary in their definition, and have an uncertain degree of residual disease prediction. This study examines possible predictors of residual disease in breast cancer patients with close, positive and negative margin status. We retrospectively reviewed the charts of breast cancer patients from January 1999 to July 2001 at Walter Reed Army Medical Center. Data were collected on margin status, biopsy method, surgical procedure, tumor histology and size, lymph node involvement, HER2/neu status, and progesterone and estrogen hormone receptor status. Patients with ne gative margins or patients without residual carcinoma more often underwent open biopsies, suggesting a possible correlation. Similarly, a closed biopsy was suggestive of risk for residual disease. While invasive ductal carcinoma appeared to have a correlation with residual disease in patients with close margins, having an associated presence of DCIS with close or positive margins was more often linked to residual disease. Larger tumor size appeared to have a correlation with residual tumor. In addition, no nodal involvement correlated with a reduced chance of residual disease. It was unclear whether HER2/neu or hormone receptor statuses have any use for residual disease prediction. The margin status of patients in our study was similar to other studies published. Our findings suggest margin status predictors may include the biopsy type, histology, tumor size, and nodal involvement. Further research is needed to prove this hypothesis and identify predictors of residual disease.

S7-E. LEFT-SIDED (SEGMENTAL OR SINISTRAL) PORTAL HYPERTENSION: AN ACUTE DIAGNOSTIC AND THERAPEUTIC CHALLENGE. Eric Valladares, MD, William E. Matory, MD, and LaSalle Leffall, MD, Department of Surgery, Howard University, Washington, DC.

GI bleeding accounts for 2% of all hospital admissions. Acute upper gastrointestinal (UGI) bleeding is a common is most commonly caused by peptic ulcer disease (PUD) (40%), gastroesophageal varices (20%), stress gastritis (10%-20%), and Mallory-Weiss tears (15%-20%). Uncommon causes of UGI bleeding, which includes gastric varices, account for approximately 15%-20% of all cases of UGI bleeding. Left-sided portal hypertension is a rare clinical syndrome that is characterized by isolated gastric varices, normal liver function studies, and splenomegaly. Some or none of the above characteristics may be present with left-sided portal hypertension. Although pancreatitis is the most common cause of splenic vein occlusion, advanced pancreatic cancer can also cause left-sided portal hypertension by invasion and thrombosis of the splenic vein and/or external compression by growth or fibrosis. While isolated asymptomatic (nonbleeding) gastric varices do not warrant surgical intervention, symptomatic (bleeding) gastric va rices warrant appropriate diagnostic evaluation to exclude splenic vein occlusion. Occlusion of the splenic vein may be partial or complete obstruction, and may be caused by intrinsic or extrinsic obstruction. The diagnostic test of choice is mesenteric angiography with venous phase imaging revealing an absence of venous return through the splenic vein. The treatment of choice is open splenectomy. The initial evaluation begins with transabdominal ultrasonography and computerized tomography, but endoscopic ultrasound examination and MRI may also be helpful. A high level of clinical suspicion is the key to making a timely diagnosis. We describe and discuss the pathophysiology, diagnosis, management, treatment, and outcome of symptomatic (bleeding) gastric varices caused by left-sided portal hypertension. We also discuss two cases of advanced pancreatic cancer with symptomatic left-sided portal hypertension demonstrated by actively bleeding gastric varices treated at Howard University Hospital by open splenectom y. We performed a comprehensive literature review of pathophysiology, differential diagnosis, clinical presentation, management and treatment options, and outcome. We present a retrospective review of the medical records and discussion of management of two patients with symptomatic left-sided portal hypertension from advanced pancreatic cancer demonstrated by actively bleeding gastric varices. These two patients were seen and treated successfully at Howard University Hospital with open splenectomy. The discussion will include clinical presentation and diagnostic testing, including endoscopy, ultrasonography, CT scan and mesenteric angiography. Additionally, intra-operative photography demonstrating significant collateral vessels as well as gross and microscopic pathology will be reviewed. We report a case series of two patients with symptomatic (bleeding) gastric varices caused by left-sided portal hypertension as a result of advanced pancreatic cancer. Upper endoscopic evaluation revealed bleeding gastric va rices. The diagnostic evaluation by ultrasonography and CT scan suggested advanced pancreatic cancer with a patent splenic vein.

However, due to a high index of clinical suspicion, mesenteric angiography with venous phase imaging was performed and confirmed the diagnosis of splenic vein occlusion, Both patients underwent successful open splenectomy. Postoperatively, UGI bleeding and transfusion requirements immediately ceased. Intra-operatively, diffusely enlarged collateral vessels around the greater and lesser curvature of the stomach (measuring 3-4 mm) were noted confirming the pathophysiology of the disease. Enlarged splenic collaterals were likely responsible for the false-negative evaluation by duplex and color flow ultrasonography. Perioperative mortality rate was 50%. One patient has been alive with rebleeding for six months. The other patient died 14 days after surgery from sepsis and fulminant liver failure. These two patients underwent splenectomy, for massive UGI bleeding, solely for the purpose of palliative surgery and not for tumor resection. Death of these two patients occurred at 4 months and at 18 days, from unrelated causes of UGI bleeding. Pancreatic cancer carries an extremely poor prognosis and is usually diagnosed at an advanced stage. We describe two patients similar to those previously reported two who developed bleeding gastric varices from left-sided (sinistral) portal hypertension as a result of advanced pancreatic cancer. Upper endoscopic evaluation revealed gastric varices. A high level of suspicion for splenic vein obstruction was present, and mesenteric angiography with venous phase imaging was obtained, even after duplex color flow doppler and CT scan suggested a patent splenic vein. Both patients underwent successful open splenectomy with immediate cessation of UGI bleeding and transfusion requirements and a 50% perioperative mortality rate. A high level of clinical suspicion is necessary to adequately diagnose left-sided portal hypertension. Mesenteric angiography with venous phase imaging is the gold standard for diagnosis. Splenectomy is the treatment of choice for symptomatic bleeding gastric varices a s a result of left-sided (sinistral) portal hypertension. Surgical intervention for patients with advanced carcinoma as the cause of left-sided portal hypertension and bleeding should not undergo surgery for cytoreduction, but solely for splenectomy and cessation of UGI bleeding.

S8-E. SPONTANEOUS BOWEL PERFORATION. Tamra McKenzie MD, William E. Matory, MD, S. Siram, MD, and Ernest Myers MD. Department of Surgery, Trauma, and Surgical Intensive Care and Department of Otolaryngology, Howard University, Washington, DC.

Gastrointestinal tract perforations are common causes of peritonitis that require immediate surgery. Perforations not resulting from external trauma are called spontaneous or nontraumatic. Mortality from nontraumatic small bowel perforations in the United States has been attributed to a low index of suspicion, resulting in delayed diagnosis. Perforations are more frequently found in the stomach and duodenum. In the United States, small-bowel perforations in adults are generally associated with obstruction. Less common causes of spontaneous small-bowel perforations are foreign bodies, Crohn's disease, jejunal diverticulosis, lymphoma, metastatic cancer and chemotherapy, Merkel's diverticulum, steroid ingestion, cocaine abuse, and infections (typhoid ulcers, intestinal tuberculosis, or parasites). Due to its rarity in United States, a surgeon is unlikely to have much experience with this problem. The purpose of this study is to evaluate the epidemiology of spontaneous bowel perforations, length of time between diagnosis and the operating room, and the outcome after diagnosis. The medical records of patients at Howard University Hospital between 1991 and 1996 were reviewed. To qualify, patients were required to have abdominal radiographs, pain for few hours to 2 or 3 days, leukocytosis, abdominal distention and peritoneal signs. Additional features that were noted included demographics, history of abdominal cancer, peptic ulcer disease, previous surgeries and crack/cocaine use. The diagnosis of a perforated viscus was confirmed either at surgery or at autopsy. This study is currently in progress. Thus far 20 charts have been reviewed, revealing that most patients were taken to the operating room within 1 to 2 days of diagnosis, where perforations were confirmed.

S9-E. INTRAOPERATWE ULTRASONOGRAPHY FOR PLACEMENT OF INFERIOR VENA CAVA FILTER. Jon David Fuller, MD, and Robert Feltitman MD, FACS. VA Hospital, Temple, TX.

Some form of radiographic guidance is recommended to aid in the correct placement of NC filters. Fluoroscopy and intravenous ultrasonography are often used for such confirmation; however, intraoperative ultrasonography can also be used to confirm placement in patients undergoing abdominal procedures for other reasons. This case report from the VA Hopital in Temple, Texas involves placement of IVC filter using intraoperative ultrasonography for guidance. Our patient required exploratory laparotomy for bowel obstruction, and also required NC filter placement. We present our experience using intraoperative ultrasonography for placement of NC filter. Video of intraoperative ultrasonography will be included in the presentation. Intraoperative ultrasonography can be used for IVC filter placement in patients undergoing abdominal procedures for other reasons.

S10-E. ACUTE SUPPURATIVE THYROIDITIS ASSOCIATED WITH THYROTOXICOSIS DUE TO PASTURELLA MULTOCIDA. Sarah A. McLaughlin, MD, and Stephen L. Smith, MD. Jacksonville, FL

Acute suppurative thyroiditis (AST) is an uncommon condition of the thyroid gland, but has been documented in the English literature. Organisms of the staphylococcal or streptococcal species are usually reported as the causative agents. Aspergillus, Brucella, Klebsiella, Eikenella, Salmonella, and Acinetobacter species have also been shown to cause AST in immunocompetent patients. Rarely, AST has been associated with transient hyperthyroidism; however, this combination can be difficult to demonstrate. We herein report the first case of AST due to Pasturella multocida associated with thyrotoxicosis. Our patient, a 50-year-old, previously healthy African American woman, presented with an enlarged, tender thyroid gland, as well as signs and symptoms of thyrotoxicosis and sepsis. Both blood cultures and thyroid aspirates were positive for P multocida. Her thyroid function studies were consistent with thyrotoxicosis, as her TSH leval was < 0.1 mIU/L, and free T4 and free T3 levels were 5.88 ng/dL and 9.0 pg/mL, re spectively. After one month of agressive medical management with PTU, SSKI, propranolol, prednisone, and antibiotics, she remained symptomatic, with elevated fT3 and fT4 levels and undetectable TSH levels. As a result, the patient underwent a near-total thyroidectomy for symptomatic relief and clinical cure. A contributing factor to this patient's disease severity may have been her undiagnosed diabetes mellitus. Not only is this case interesting from the infectious disease standpoint, as the thyroid gland is relatively resistant to infection, but it also emphasizes the rare association of AST with thyrotoxicosis and elucidates the role of thyroidectomy in patients with suppurative thyrotoxicosis who have failed to improve with medical therapies.

S11-E. FRAGMENTATION MALFUNCTION OF A GIANTURGO-ROEHM BIRD'S NEST VENA CAVAL FILTER. James T. Evans, MD, and Sang Kim, MD. University of New York at Buffalo, Buffalo, NY

Based upon an English language literature search, this is believed to be the first reported malfunction of a Gianturco-Roehm bird's nest vena caval filter involving actual fragmentation in an English language publication. Vena caval interruption has always been associated with complications. The use of the Gianturco-Roehm bird's nest vena caval filter is especially important in a patient with a large vena cava (> 28-30 mm). A 78-year-old woman with a medical history of NIDDM, HTN, dementia, pulmonary hypertension, and diverticulosis was admitted for acute lower GI bleeding. Transfusion therapy was successful in treating the lower GI bleed; however, the patient developed an acute myocardial infarction related to the hypotension. While hospitalized, the patient developed a swollen lower extremity, and DVT was confirmed by duplex scan. A caval interruption was deemed necessary, as the patient was not a candidate for anticoagulation. The patient had a vena cava that measured 40 x 38 mm; therefore, the bird's nest filter was selected as most appropriate. The patient was taken to the OR and a right jugular cutdown was utilized to insert the filter. The manufacturer's guidelines for jugular insertion were followed. The filter was fluoroscopically confirmed to be in good position with engagement of all hooks, the guidewire was disengaged by squeezing the handle, and the wire and filter catheter were removed. The introducer sheath was then removed. Postoperatively, a chest x-ray film revealed a portion of the caval filter to be in the internal jugular vein. The possible mechanism for fragmentation malfunction of a Gianturco-Roehm bird's nest vena caval filter is difficult to define with certainty. Possible mechanisms include actual manufacturer abnormal construction, fracture at the time of separation from insertion wire, or entanglement of the filter with introducer sheath at the time of removal. The last possibility seems most likely. All practitioners performing caval filter insertion should be aware of this potential complication.

S12-E. CECAL CONGENITAL DIVERTICULITIS MIMICS ACUTE APPENDICITIS. Juan A. Ortiz, MD, and Scott Gering, MD. Department of Surgery, William Beaumont Army Medical Center, El Paso, TX.

This is the case of a 29-year--old Mexican American man who presented to William Beaumont Army Medical Center with a several-hour history of anorexia and right lower quadrant pain. Physical examination showed a low-grade fever, with focal tenderness at McBurney's point. Laboratory evaluation demonstrated mild leukocytosis. The patient was taken emergently to the operating room with a presumptive diagnosis of acute appendicitis. At surgery, a normal appendix was found. Exploration of the abdomen through the right lower quadrant incision revealed a large inflammatory mass in the region of the cecum. Given the inadequate exposure and unclear diagnosis, a lower midline incision was made. The inflammatory mass extended from the cecum. An ileocecectomy with primary anastomosis was performed. Pathologic examination demonstrated a true congenital cecal diverticulum with dense inflammatory changes. True congenital diverticula of the large bowel have a reported incidence of 1% to 2% of the population. They are typicall y found in the cecum, and they occur with higher frequency among Pacific Islanders. In contrast to acquired diverticula, true congenital diverticula involve all layers of the bowel wall. Rarely, they can present with symptoms of abdominal pain, bleeding, perforation, or infection. Congenital cecal diverticulitis is often misdiagnosed as acute appendicitis, especially in the younger population. For the incidentally found congenital cecal diverticulum, diverticulectomy with stump inversion is recommended. When a diverticular abscess is identified, percutaneous drainage and intravenous antibiotic therapy are indicated, with definitive surgery after resolution of the infection. In many cases, as in this one, a right hemicolectomy or ileocecectomy is performed, given the uncertainty of the diagnosis at the time of surgery.

S13-E. OUTCOME OF DBM USE WITHIN INTERBODY FUSION CAGES: AN ADEQUATE AUTOGRAFT SUBSTITUTE? Keith Maxwell, MD, and Gwen Gimmestad. Southeastern Sports Medicine, Asheville, NC, and Spine-Tech, Minneapolis, MN.

The use of autograft within cages remains the gold standard for use in the treatment of degenerative disk disease. However, harvesting from the iliac crest requires a second procedure, which can lead to extended pain and complications. New technologies have emerged in hope of finding an adequate replacement for autograft, which would eliminate the necessity of harvesting and still maintain the high rates of fusion. Demineralized bone matrix is often used in conjunction with autograft to add an osteoconductive element and increase the chances of fusion; however the use of DBMs as autograft replacements within cages has not been studied. With the emergence of BMPs, which are costly and have yet to be proven superior to autograft, it is of interest to determine the effectiveness of DBMs as autograft replacements with IF cages. A cohort of 51 consecutive patients was reviewed. These patients were all treated for degenerative disc disease using BAK interbody fusion cages filled with demineralized bone matrix in on e- or two-level procedures. A combination of Grafton and ProOsteon (gel form) was used. A total of 20 cc of the Grafton/ProOsteon mixture (10 cc each) filled each cage. A chart review, including patient history, demographics, surgical details, complications, and fusion status was completed for each patient. In addition, patients were contacted via telephone to determine surgical outcome and overall satisfaction. This patient population consisted of 24 men (47%), 27 women (53%), and 24 smokers (47%) with a mean patient age of 44 years (range, 24-67 years). Six percent of the patients were receiving worker's compensation. All patients were at least one-year post-index. Mean time from surgery was 2.72 years. Operative levels included L34 (2), L4-5 (21), and LS-S1 (37), with 42 (82%) one-level procedures and 9 (18%) twolevel procedures. Mean estimated blood loss, length of surgery, and length of hospitalization were 156 cc (range, 15-1,250 cc), 145 minutes (range, 120-240 minutes), and 2.5 days (range, 0-10 days) , respectively. Back and leg pain scores both improved significantly following surgery (P < .001) from mean scores of 85.3 and 78.9 to 40.8 and 41.2, respectively. Fusion occurred in 45 patients (96%), 4 patients could not be assessed, 1 patient remained unfused, and 1 patient developed pseudoarthrosis. Mean time to fusion was 12 months. No correlations were detected between smoking status and time to fusion or change in back and leg pain. All reported compensation patients returned to work (full or part time) following surgery. Results of the initial telephone survey indicated that 84% of the patients would recommend this surgery and 72% agree that surgery met their expectations or that it has helped enough that they would go through it again for the same outcome. Intraoperative complications included 2 left iliac vein lacerations (4%). There were 14 postoperative complications (26%) resulting in 3 revisions (6%). DBMs appear to effectively promote bone formation within interbody fusion cages. Resulting fusi on rates from this study are comparable to autograft and BMP rates in the literature. Complications related to the cage/DBM construct are similar to complications often noted with cage/autograft constructs. Demineralized bone graft appears to be an effective replacement for autograft within cages, providing an osteoconductive element that results in comparable fusion rates. Results from this study indicate that DBMs may be less expensive, equally effective alternatives to BMPs.

S14-E. LONG-TERM SURVIVAL OF PATIENTS WITH CUTANEOUS MELANOMA MANAGED BY AUTOLOGOUS TUMOR VACCINE. E. George Elias, MD. Section of Surgical Oncology, Department of Surgery, Franklin Square Hospital Center, Baltimore, MD.

The first patient is a 67-year-old white woman who was diagnosed in 1973 with cutaneous melanoma of her left thigh (Clark III, Breslow 0.9 mm). She underwent wide excision and skin graft. She did well until 1981, when she developed metastases to her left groin lymph nodes (LN) and was referred to us. She underwent radical groin dissection. The pathology revealed 4 of 27 LN contained metastases: 3 from the inguinofemoral and 1 from the iliac LNs. Postoperatively, she received autologous tumor vaccine, obtained from her groin LN. She did well until 1986, when she started to lose weight and had an elevated serum LDH level. Work-up revealed a pelvic mass. She underwent exploratory surgery and was found to have metastatic melanoma to her right ovary. She underwent bilateral oopherectomy and splenectomy (for enlarged spleen). Postoperatively, her LDH level returned to normal, and she received a second treatment with autologous tumor vaccine obtained from her ovary. She is alive free of disease 21 years since her fi rst vaccination. The second patient is a 38-yearold white man who was diagnosed in 1987 with cutaneous melanoma of his left thigh (Clark IV, Breslow 1.0 mm). This was widely excised. In 1988, he developed metastases to his left groin and underwent inguinofemoral LN dissection. The pathologic examination revealed that 1 of 15 LNs contained metastases. Later that year, he developed distant metastases in the subcutaneous tissue of his left anterior chest wall, and this was excised. He was then referred to us. The work-up revealed a 4.3-cm mass (matted LNs) in the left iliac area, and this was resected. In 1990, treatment with autologous tumor vaccine from the iliac mass was started. However, shortly after initiating the vaccination, he became anemic and was found to have small-bowel metastases. He underwent exploratory surgery, and 2 metastasic masses were resected from his jejunum. He went on to finish his first set of vaccines, followed by a second set that was obtained from the small-bowel tumor. This ended i n February 1991. It is presently 12 years since the initial vaccination, and he is alive and free of disease. These two cases present several aspects of the prognosis, diagnosis of recurrences, the role of surgery and active immunotherapy in this unpredictable disease.