Team E: surgery, anesthesiology, colon & rectal surgery, gastroenterology, oncology, otolaryngology--head & neck surgery, and urology.

IN VITRO PROTECTIVE EFFECTS OF AMIFOSTINE ON HUMAN MESENCHYMAL STEM CELLS AND HEMATOPOIETIC PROGENITORS EXPOSED TO RADIATION. Jagadeesh Ramdas, IVID, R. P. Warner, MD, Charles Scher, MD, and Vincent F. La Russa, PhD. Louisiana State University Health Science Center, BMT Laboratory, Tulane University Health Science Center, New Orleans, La.

Amifostine is a phosphorylated aminothiol that affords broad cytoprotection from the myelosuppressive effect of antineoplastics. Mesenchymal stem cells (MSCs) are thought to be multipotent cells residing in the marrow hematopoietic microenvironment with the potential to differentiate into stromal derived lineage's including bone, cartilage, fat, tendon, muscle, and marrow stroma. Evaluate: a) the differential sensitivities of progenitors to radiation for CFU-F derived fibroblast-like cell colonies and CFU-FA derived fibroblasts and adipocyte mixed cell colonies, and b) determine the protective effects of amifostine on hematopoietic and mesenchymal progenitors exposed to radiation. Experimental groups were established for treatment of cryopreserved marrow low density cells (LDC) (1.077-1.0800 g/mL) with: 1) amifostine using concentrations ranging from 0.0025 mM to 2.5 mM, 2) radiation doses ranging from 100 cGY to 400 cGY), and 3) sequential treatment of cells first with amifostine at two different concentrati ons (2.5 mM, 0.25 mM) followed by radiation ranging from 100 cGY to 400 cGY Mesenchymal progenitor derived colonies were established by plating 2.5 x 10 5 marrow LDC in long term marrow culture medium (LTCM) made up of supplemented IMDM including 25% equine serum and 5 x 10-6 M hydrocortisone. Hematopoietic progenitors assays were assessed by methylcellulose based assay. CFUGEMM, BFU-E, and CFU-GM were scored after 14 days incubation and results expressed as M [+ or -] SEM. Radiation at 100 cGY decreased CFU-F by 12% and CFU-FA by 13%. Higher doses of radiation at 200 cGY decreased CFU-F by 36% and CFU-FA by 52% and 400 cGY decreased CFU-F by 50% and CFU-FA by 86%. For hematopoietic progenitors radiation at 100 cGY decreased colony formation of CFU-GEMM only by 5%, and BFU-E were totally radioresistant while CFU-GM were more sensitive and decreased by 74%. Radiation with 200 cGY decreased CFU-GEMM by 72%, BFU-E by 54% and CFU-GM by 84%. Radiation with 400 cGY further decreased CFU-GEMM by 83%, BFU-E by 81% an d CFU-GM by 93%. Pretreatment with amifostine at 0.25 mM protected 100% CFU-F and 86% CFU-FA exposed to 100 cGY radiation, 100% CFU-F and 57% CFU-FA exposed to 200 cGY, and 84% CFU-F and 35% CFU-FA exposed to 400 cGY Pretreatment with amifostine at 2.5 mM protected 100% of CFU-GEMM and 50% CFU-GM exposed to 100 cGY While 97% BFU-E exposed to 200 cGY were protected with 2.5 mM amifostine. These data indicate that mesenchymal progenitor cell subpopulations are differentially sensitive to radiation, as CFU-FA LDSO is 200 cGY while CFU-F LD5O is 400cGY indicating that CFU-F are at least 2 times more radioresistant. Pretreatment with amifostine at 0.25mM protected 100% of CFU-F with lower radiation doses and up to 84% with 400 cGY In contrast, CFU-FA were minimally protected. Amifostine protects both CFU-F and CFU-FA, and hematopoietic progenitors against radiation injury though the level of protection appears to be dependent upon the sensitivities of these progenitor cells to radiation. Hematopoietic progenitors are more sensitive to radiation than mesenchymal progenitors.

5-FLUOROURACILASSOCIATED PERIPHERAL NEUROPATHY. Muhammad Wasif Saif, MD, Richard Wilson, MD, and Jean Grem, MD. National Naval Medical Center, Bethesda, Md.

5-Fluorouracil-associated neurotoxicity is rare and may include an acute form (cerebellar syndrome, encephalopathy) or a delayed form (cerebellar ataxia, subacute multifocal leukoencephalopathy). To date, only 2 cases of peripheral neuropathy have been described following the administration of 5-FU. We report two patients treated on a Phase I trial consisting of oral 5-FU d2, lecucovorin 30mg P0 dl-3, and eniluracil 20mg P0 dl-3 (an inhibitor of dihydropyrimidine dehydrogenase [DPD], the rate limiting enzyme in catabolism of 5-FU) who developed symptoms of unsteady gait and reduced sensation in the legs. This was first appreciated during the 7th cycle in one patient (65 yrs old) when the dose of 5-FU was increased to 65 mg/[m.sup.2] P0 as a single dose on day 2. Prior to that cycle, he had experienced minimal toxicity (grade 1 fatigue). His 5-FU dose was decreased back to 51 mg/[m.sup.2] for cycles 8 & 9; although the patient noted some improvement, he continued to notice unsteady gait. Therefore, the start o f cycle 10 was delayed to permit more thorough neurological evaluation. A second patient (70 years old) reported unsteady gait during his 7th cycle of therapy; this represented his 3rd cycle at a 5-FU dose of 23.4 mg/[m.sup.2] Prior to this cycle, the patient had reported minimal side effects except mild fatigue. An MRI of the brain was negative in both patients. EMG and nerve conduction studies revealed evidence of sensorimotor polyneuropathy in the former and sensory neuropathy in the later patient. Diagnostic evaluation did not support a diagnosis of CNS metastasis and other etiologies such as [B.sub.12] and folate deficiencies, VDRL, connective tissue disorders, diabetes mellitus, or other drug-induced neuropathy were also excluded. Since the first patient had experienced a partial response to therapy, he wished to remain on protocol therapy and the dose of 5-FU was decreased to 33 mg/[m.sup.2]. Similarly, since the second patient had no evidence of disease progression, he wished to remain on study. He re ceived a dose reduction of dose of 5-FU to 18.8 mg/[m.sup.2] for his subsequent cycle. Although pre-treatment DPD was normal, the activity of DPD was markedly suppressed while on eniluracil. The neurological conditions of these patients stabilized after reducing the dosage of 5-FU and no further deterioration was found. Neurologic toxicity has been seen on several 5-FU schedules, but is more pronounced on schedules that include high daily doses or with intensive daily schedules. Modulators such as dThd, PALA, and allopurinol may aggravate neurotoxicity associated with 5-FU. It has been found that 5-FU results in severe and prolonged neurologic toxicity in patients with DPD deficiency. Low activity of DPD may result in reduced 5-FU catabolism, which leads to increased 5-FU binding to thymidylate synthetase and incorporation into RNA. Subacute multiple leukoencephalopathy has been found to be unique to the combination of 5-FU/levamisole therapy since no similar phenomenon has been reported in studies involving 5FU/leucovorin or levamisole alone. Recognizing the rare adverse effect of 5-FU-based regimens as a cause of neurotoxicity is important because the distinction is crucial between this untoward effect of 5-FU and metastatic or paraneoplastic disease, and may aid in decisions for further management and widely different prognostic outcomes.

CHEMOTHERAPY-INDUCED ANEMIA IN INTERMEDIATE-GRADE NON-HODGKIN'S LYMPHOMA (IGNHL) PATIENTS. R. E. Tannous, PharmD, MS, Sanjay Gupta, PhD, MBA, and M. Fridman, PhD. Amgen Inc., Thousand Oaks, Calif.

Chemotherapy-induced anemia rates and associated factors were evaluated from a practice pattern study conducted at twelve community and academic oncology sites from 1993 through 1999. Data on 591 IGNHL patients treated with CHOP chemotherapy were collected retrospectively. Only patients with available baseline chemotherapy hemoglobin (Hb) value were included in the analysis (546 patients). The overall mean drop in Hb from baseline to the lowest value measured during chemotherapy was 2.3 g/dL (95% confidence interval, 2.18, 2.46). Of the 353 patients who had a normal Hb ([greater than or equal to] 12.0 g/dL) at baseline, 28.3% (100 patients) developed moderate to severe anemia ([less than]10 g/dL) during chemotherapy and patients 60 years and older had a significantly higher risk (odds ratio 2.5) of developing anemia. Examining the persistence of anemia throughout the chemotherapy cycles shows that of the 62 patients whose baseline Hb was [less than]10 g/dL, 47.5% of the patients failed to recover to a [greate r than or equal to]10 level during chemotherapy. Anemia treatment data were not available. Similarly, a third of the 131 patients whose baseline Hb was between 10-12 g/dL dropped below the Hb level of 10. In addition, anemia and neutropenia were found to be significantly associated. Patients who developed anemia were also at a higher risk of experiencing febrile- neutropenia (FN). FN was documented in patient charts by their treating physician.

ACUTE LYMPHOBLASTIC LEUKEMIA L3 (ALL-L3) EVOLVING IN A PATIENT WITH CLINICAL REFRACTORY ANEMIA MYELODYSPLASTIC SYNDROME. Roger A. Wood, MD, and Robert Prieto, MD. Wilford Hall Medical Center, Lackland AFB, Tex.

Myelodysplastic syndromes is a clonal hematological disorder known to evolve into acute leukemia in about 15-20% of patients, and usually results in a myeloid lineage malignancy. Transformation to acute lymphoblastic leukemia is an uncommon occurrence with a poorly understood mechanism of evolution. Review of the literature shows several case reports describing this particular event. We report a 69 year old caucasian male with an underlying refractory anemia presumed due to MDS based on clinical behavior. Bone marrow biopsy at the time of diagnosis did not show the typical morphologic characteristics of MDS and cytogenetic analysis was unobtainable, but the clinical nature of his anemia and response to weekly erythropoietin therapy was supportive for a refractory anemia MDS. The patient was maintained on erythropoietin therapy with normalization of his hemoglobin, and he remained in his usual state of health for approximately two years. During routine follow-up, a CBC demonstrated a mild leukocytosis (17,000/ ul), anemia (Hgb 11.8 g/dl), and thrombocytopenia (plt 64,000/ul), and was notable for 22% circulating blasts. Subsequent bone marrow biopsy revealed blasts comprising 88% of the nucleated cells. The blasts were characterized by scant basophilic cytoplasm, round irregular nuclei with prominent nucleoli, and cytoplasmic vacuoles suggestive of acute lymphoblastic leukemia, L3 subtype (Burkitt cell leukemia). Flow cytometry showed expression of CD19, CD20, CD22, and HLA-DR, and lack of CD34, TdT, and surface light chains consistent with a mature B-cell process. Cytogenetic analysis revealed the translocation involving chromosomes 14 and 18 (t( 1 4;1 8)), and the characteristic translocation between chromosomes 8 and 14 (t(8;14)) confirming Burkitt cell leukemia.

MYOCARDIAL INFARCTION: A RARE COMPLICATION OF VINEROLBINE TARTARATE. Anil K. Goli, MD, Harsha Shantaveerappa, MD, Sujatha Goli, MD, Ryland P. Byrd, Jr., MD, and Thomas M. Roy, MD. Department of Pulmonary and Critical Care Medicine, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, Tenn.

A 65-year-old male with squamous cell cancer of the epiglottis had been treated with 33 fraction of radiation treatment. Upon restaging his tumor, he was found to have progressed to stage 4 and he chose to undergo chemotherapy with 55.5 mg of intravenous vinerolbine. Within 4 hrs of treatment he experienced acute shortness of breath that was unresponsive to bronchodilators and corticosteriods. Breathing 100% [FIO.sub.2] by mask, his pH was 7.314, [PaCO.sub.2] was 44.6 torr and [PaO.sub.2] was 53.9 torr. [HgbO.sub.2] saturation was 84.5% with a shunt of 32% and a [PaO.sub.2]/[PAO.sub.2] of .08. The patient was intubated and required an initial [FIO.sub.2] of 90% and PEEP of 12 cm [H.sub.2]O to achieve adequate oxygenation. A new CHE pattern was seen on chest x-ray and serial cardiac enzymes and troponins confirmed myocardial injury. EKG, however, showed only old Q-waves in inferior leads without acute ischemic changes. The clinical picture was consistant with a nontransmural myocardial infarction. With hemodyn amic monitoring, preload and afterload were manipulated to achieve optimal cardiac output, renal perfusion and successful extubation. Vinerolbine tartrate (Navelbine), a mitotic spindle poison, was invented in 1970 as a semisynthetic vinca-alkaloid with broad spectrum anti-tumor activity. Compared with other vinca-alkaloids, vinerolbine has increased lipophilic properties and is approximately 300-400 times more concentrated in heart and lungs than in serum. Its major toxicity is severe granulocytopenia, occurring in 40% of patients. In about 5% of recipients, one of two types of respiratory side effects may occur. One is an acute reaction that appears to be allergic in nature and mimic a hypersensitivity pneumonitis. The other is a subacute reaction attributed to acute endothelium-alveolar damage. Our patient had an acute respiratory reaction that began within hours of his intravenous treatment. He subsequently suffered myocardial insult. To the best of our knowledge this is only the 4th case report of vinero lbine-related myocardial infarction. From our review, it appears that our patient is the first to sustain myocardial injury, a nontransmural myocardial infarction, casually linked to hypoxemia due to the acute lung reaction induced by vinerolbine. We conclude that drug should be used with caution in patients with prior cardiopulmonary disease.

INTRAVENOUS IMMUNE GLOBULIN (IVIG) PRECIPITATING ACUTE MYOCARDIAL INFARCTION. Major Erika J. Struble, MD, Major Y Gia Dice, MD. Keesler Medical Center, Keesleer Air Force Base, Miss.

A 48-year-old man had elective sigmoidectomy for recurrent symptomatic diverticulitis. History was remarkable for antiphospholipid antibody syndrome, immune thrombocytopenia purpura (ITP) and heparin induced prophylaxis. Lepirudin, 15mg subcutaneously twice daily, was started for thrombus prophylaxis. On the first post-operative day he experienced worsening thrombocytopenia with platelet counts decreasing from 105K to [less than] 25K, but was asymptomatic without any evidence of bleeding. Laboratory studies and lower extremity Doppler ultrasound were unrevealing. IVIG was initiated for presumptive diagnosis of worsening ITP. Four hours into the infusion he experienced chest discomfort. Electrocardiogram and cardiac enzymes were consistent with an acute inferior myocardial infarction. The patient was treated with increased dose lepirudin, 0.4 mg/kg bolus then 0.15 mg/kg continuous intravenous infusion, and platelet transfusion. He recovered without further complications. Thrombotic events are rarely associated with IVIG therapy, however at least 16 cases of IVIG related thrombosis have been reported. In addition, IVIG has been associated with increased incidence of veno-occlusive disease in transplant patients. Most thrombotic events occur during or immediately after IVIG infusion, however, events occurring several days afterwards are not uncommon. The pathogenesis of IVIG related thrombosis may be related to platelet/endothelial cell activation, increased viscosity, or presence of a procoagulant. IVIG should therefore be used with caution in patients with predisposing factors for thrombus formation, as adverse events are not limited to mild and well-tolerated events.

BLEOMYCIN-INDUCED MYOCARDIAL INFARCTION IN A YOUNG MAN WITH TESTICULAR CANCER. Winston Tan, MD, and Leonel Ochoa, MD. Mayo Clinic Jacksonville, Jacksonville, Fla.

Acute myocardial infarction due to chemotherapy is rare. In a patient with malignancy, several possibilities should be considered, including hypercoagulable state cardiac invasion by the tumor and coronary artery spasm or thrombosis. Chemotherapy-induced myocardial infarction due to vincristine, vinblastine, ifosfarmide, cisplatin, and bleomycin have been reported. These chemotherapeutic agents could cause major vascular disease in large arterial vessels, and even fatal coronary fibrosis was reported due to it. Several case reports of bleomycin-induced myocardial infarction have been reported in literature. They usually present with chest pain with EKG changes consistent with myocardial infarction. Presented is a case of bleomycin-induced acute myocardial infarction diagnosed early and survived treatment with his cancer in remission. A 26-year-old white man, who presented for his first cycle of chemotherapy for mixed germ cell tumor with pulmonary metastasis. Initially, he presented 1 year earlier with germ c ell tumor with invasion of the tunica albuginea. Postsurgery tumor markers were undetectable until the present time when his tumor markers started to go up (alpha fetoprotein 7.5) and CT showed multiple lymphadenopathies and pulmonary nodules. He denies taking any medications, denies any risk factors for coronary artery disease. He has smoked half a pack a day for 9 years. He denies any drug abuse or alcohol abuse. The patient was given day one of PEB without any event. He presented to the emergency room with acute chest pain with EKG changes in the inferior leads (about 36 hours after receiving his day 8 bleomycin). He was immediately started on heparin, and cardiac catheterization revealed complete occlusion of the right coronary artery. He had positive cardiac enzymes, with maximum level of 600 CK-MB. Subsequently PTCA with stent placement of the right coronary artery vessels was done. He recovered completely from his acute coronary syndrome and was subsequently discharged. He completed another 3 cycles of chemotherapy without the bleomycin without any chest pain. The patient has been in remission since then.

DISPARATE SURVIVAL OF COLORECTAL CANCER PATIENTS. K. Gray, MD, W. C. Chapman, MD, Y. Shyr, PhD, A. Jeyakumar, MS, Mark Davidson, Jake Debelak, BS, S. O. Rogers, MD, and S. C. Stain, MD. Departments of Surgery, Meharry Medical College and Vanderbilt University School of Medicine, Nashville, Tenn.

There is increasing evidence of a major disparity in cancer treatment outcomes for black patients. Suggested contributing factors include advanced stage at diagnosis, differences in treatment rendered, access to care, tumor biology or patient co-morbidity. We performed a 10 year retrospective review of all patients with colorectal cancer from the tumor registries of a City hospital and nearby University Hospital to determine stage at the time of diagnosis, primary and adjuvant treatments, and survival. We identified 83 patients at the City Hospital (44 black, 36 white), and 585 patients at the University Medical Center (62 black, 519 white). Differences in tumor stage and treatments were compared by chi square, and median survivals compared by log rank (P [less than] .05 was considered significant). There were significantly more black patients treated at the City hospital. No differences were identified in tumor stage, treatments received between hospitals, or between black and white patients. A marked surviv al difference was noted between hospitals, and between black and white patients treated at both institutions. These survival differences may be due to biologic factors or non-cancer related health conditions, and further study is indicated.

PREOPERATIVE NEOADJUVANT CHEMORADIATION FOR ULTRASOUND-GUIDED UT3-T4 RECTAL CANCERS. Shekar Narayanan, Joaquim Simoes Neto, MD, and Paul R. Williamson, MD. Colon and Rectal Clinic of Orlando, Orlando, Fla.

Advanced rectal cancer is a difficult subset of GI malignancy, prone to local recurrence yielding different standards of care in deciding upon management options. The goal in the use of preoperative chemoradiation for locally advanced rectal cancers is to reduce local recurrence, improve resectability, and to perform sphincter saving procedures. The aim of this study was to determine the effects of preoperative chemoradiation on the local response of advanced rectal tumor, its effect in determining the surgical procedure used, its short and long-term effects on this patient population. The authors conducted a linear prospective review of consecutive patients presenting with T3 or T4 rectal cancers staged by ultrasound. All patients had preoperative neoadjuvant chemoradiation using a minimum of 4140 rads plus an infusional protocol using a 5FU-based regimen. Charts were prospectively analyzed targeting ultrasound-staged pathology, chemoradiation complications, and surgery proposed versus that performed. Patien ts were analyzed as to whether their surgery was performed in a curative way. Pathologic diagnosis was correlated for disease free period and survival curves. Recurrences were computed regarding clinical and ultrasound staging. Eighty consecutive patients presenting with rectal masses were entered into the linear study. Each patient had ultrasound confirmation and staging of the rectal mass followed by biopsy confirmation of adenocarcinoma. Patients had surgical resection 6 weeks after their chemoradiation protocol. Patients who did not fulfill these criteria were excluded. Thirty-six patients were identified. Twenty-nine were male. Mean age was 61.4 years (range, 22 to 86 years); 19.4% of the patients experienced discomfort that caused interruption and break of their treatment; 50% of the tumors were downstaged by their histologic path compared with the original ultrasound staging; 27.8% of patients had no demonstrable lymph node tissue within the section specimen (ie, their lymph nodes had been "sterilized" ); 22.3% of patients were found to have no residual microscopic tumor within their specimen; 8.3% of patients had complications that were thought to be related with local radiation effect. 6/22 (27%) patients had a low anterior resection while preoperative proposal was for abdominoperineal resection. The average follow-up was 27 months (range, 1 to 89 months). Local recurrence was observed in 2.7%. Metastases were observed in 27.8% (16.7% had metastatic disease at the time of laparotomy). The disease free period for this group of patient was 29.1 months (range, 1 to 86 months). No major intraoperative complications were demonstrated in this series. No anastomotic leakage was observed. Every specimen had negative radial and distal margins. We advocate the belief that when performed before the surgical intervention, chemoradiation brings a better local control, a better resectability in the face of a risk of only minor complications for locally advanced rectal cancers. Although some studies report increased lea kage, problems in technical difficulty with this surgery we did not observe this in our experience.

ANOPLASTY: ELEVEN-YEAR EXPERIENCE IN THE TREATMENT OF ANAL FISSURE AND STENOSIS. Cary L. Gentry, MD, Joaquim Simoes Neto, MD, Sergio Larach, MD, Andrea Ferrara, MD, Paul Williamson, MD, Joe Gallagher, MD, and Samuel Dejesus, MD. Colon and Rectal Clinic of Orlando, Orlando, Fla.

The treatment of anal stenosis, also known as anal stricture, and anal fissure has progressed from routine anal dilatation to internal sphincterotomy and anoplasty in the last several decades. The technique used to repair any anal deformity should be tailored to the patient. This retrospective review encompasses an 11-year period, and evaluates the approach we take in the treatment of anal stenosis and fissures. We reviewed all patients who had an anoplasty at our institution from 1989 to 2000. The indication for procedure, related medical and surgical history, type of repair, postoperative morbidity, and long-term outcome were collected for analysis. There were 129 patients included for review and follow-up (65 men and 64 women). The median age was 53.6 years (range, 18 to 85 years). Average follow-up was 10.5 months (1 to 75 months). The most common indication for anoplasty was anal stenosis or anal fissure (82.9%). The most common presenting symptoms were pain, bleeding, and difficult defecation. The types of repairs were as follows: V-Y flap in 44 (34%), Diamond flap 27 (21.5%), House flap 15 (11.7%), Rhomboid 13 (10%), Island 11 (8.4%), and Trapezoid in 2 (1.4%). There were 13 (10%) C or S rotational flaps and 7 Z-plasties performed for anal stenosis. Anoplasty in combination with a lateral internal sphincterotomy was performed in 107 cases. No mortality was observed, and postoperative morbidity was seen in 47 patients (35.7%). Dehiscence was seen in 17%, infection in 6.2%, and impaction, urinary retention, and thrombosed hemorrhoids in [less than]4%. The mean healing time was 4.8 weeks. Two patients had gas incontinence and conservative management improved their symptoms within 5 weeks. Recurrence was seen in 6 (4.7%) patients. The treatment of anal stenosis and anal fissure by the use of advancement or rotational flap anoplasty can be performed with good results. The selection of the type of flap should be tailored to the individual anal deformity. The postoperative healing time is good, the recurrence rat e is low, and the morbidity is acceptable.

NASOGASTRIC TUBE USE IN ELECTIVE COLECTOMY. Walker R. Byars, MD, D. Perrin Roten, MD, Deborah C. McFadden, FNP, and Mark D. Williams, MD. VA Medical Center, Jackson, Miss.

Historically, nasogastric tubes (NGs) have been used after elective colectomy, but as there is very little scientific data to support their use, they are beginning to be used less frequently. We reviewed our experience with the use of NGs after elective colectomies in this Veterans Affairs Medical Center population to try to determine if NGs are needed after elective colectomy in these elderly patients. From 10/1/97 to 12/6/00, 46 male patients ranging in age from 45 - 91 years, with a mean of 67 years, underwent an elective colectomy. Thirty-two patients (70%) had the NG removed in the recovery room (NoNG group) and 14 were managed with a postoperative NG (NG group) until the return of bowel function. The mean operating time was 190 minutes (SD = 72 minutes), 223 minutes (SD = 86 minutes) in the NC group and 175 minutes (SD = 61 minutes) in the NoNG group, not a significant difference. The mean postoperative day for tolerating a regular diet (RD) for the entire group was 7 days (SD = 3 days), 7 days (SD = 4 days) in the NoNG group and 8 days (SD = 4 days) in the NG group, again not a significant difference. The NC group tended to fail management (a return to NPO status after beginning a diet or a reinsertion of the NG) less often as nine of the 32 NoNG patients (28%) failed yet only one of the 14 NC patients (7%) failed. As might be expected, successful management in 36 patients led to a significantly shorter mean RD, 6 days (SD = 2 days) compared to the 10 failures, mean RD = 11 days (SD = 6 days). These data suggest that a postoperative NC should be used after elective colectomy in these elderly patients. Routinely using a postoperative NC could of spared one out of four of these elderly patients the agony of having abdominal distention, vomiting and/or NG reinsertion while fully awake with a fresh laparotomy incision. Not using a postoperative NC did not lead to a significantly shorter time till the successful return to a regular diet. We are continuing to investigate these issues in a prospective, randomized fashion.

EMERCENCY COLONIC RESECTION: PROFILE AND SICNIFICANCE. Gamal Mostafa, MD, Brent D. Matthews, MD, Kent W. Kercher, MD, Ronald F. Sing, DO, FACS, Amy E. Lincourt, PhD, Eric Hearn, RN, and B. Todd Heniford, MD, FACS. Department of Surgery, Carolinas Medical Center, Charlotte, NC.

Pathologic diagnosis and extent of resection in cases of emergency colonic surgery can lead to significant morbidity. The objectives of this study are to define the distinguishing features between elective and emergency colonic surgery, and to determine the variables affecting morbidity and mortality in emergency cases. The records of all adult patients who underwent colonic resection over a 4-year period were reviewed. Trauma patients were excluded. Cases were categorized as elective or emergency based on presentation and urgency of the procedure. Primary analysis included a comparative study between the two groups in terms of the following variables: demographics, extent of procedure, operative time, blood loss, pathological diagnosis, length of stay, and morbidity and mortality. In a secondary analysis of the emergency group, we defined postoperative complications and death as outcome measures. The effect of three categories of variables (1) clinical presentation, (2) diagnosis, and (3) procedure on the ou tcome was examined. Statistical analysis was performed using t-tests and Chi-square to compare elective and emergency procedures and multiple regression analysis to identify the significant predictors of outcome. A P value [less than] .05 was considered significant. Four hundred eighty-five patients underwent 338 elective and 147 emergency colonic resections. There were 238 males and 247 females, with mean age of 60 (SD = 16.42). Patient demographics were comparable in the emergency and the elective group. Overall, there were 118 complications (24.1%) and 30 deaths (6.1%). The emergency group accounted for 63 (54.7%) and 23 (79.3%) of the total morbidity and mortality for the whole group respectively (P = .001). There was a significant difference in the distribution of pathology between the two groups. Diverticular disease was most common in the emergency group (42.8%, P = .001) while malignancy predominated in the elective group (56.2%, P = .001). Both inflammatory bowel diseases and ischemic colitis had equ al proportions in the emergency group (13%) which was significantly higher than the elective group (6.8% and 2% respectively, P = .03, P = .001). Left colonic resection represented the most common procedure with equal proportions in both groups (49%). There was a significant difference in the percentage of subtotal colectomy between the two groups (elective-6.3% vs emergency-19.2%, P = .001). Stoma was created in a total of 85 emergency (57%) and 15 (4.4%) elective cases (P = .001). Only 3 patients (2%) in the emergency group had laparoscopic procedures compared to 49 patients (14.5%) in the elective group (P = .001). Emergency procedures had a significantly higher intraoperative blood loss (mean 269 cc) compared to elective procedures (mean 203 cc) (P = .01). Obstruction was a strong predictor of morbidity (P = .04, odds ratio 2.5) and mortality (P = .008, odds ratio = 4.1). Emergency subtotal rather than partial colonic resection was a significant predictor of morbidity (P = .007, odds ratio = 3.37) and mor tality (P= .0001, odds ratio = 7.52). Emergency right vs. left colonic resection and resection with or without a stoma did not influence outcome. Patients with diverticular disease were less likely to have complications (P = .008, odds ratio = .19) and had lower mortality (P = 0.01, odds ratio = .35). Emergency colonic surgery has distinctive features. Colonic obstruction and subtotal resection are associated with higher morbidity and mortality. Diverticular disease compares favorably to other pathologies in postoperative outcome.

PRIMARY OAT CELL CANCER OF THE ESOPHACUS. Reginald Smith, MD, and Mukta Panda, MD. University of Tennessee, Chattanooga, Tenn.

Oat cell carcinoma is commonly seen in the lungs. Although rare, it has also been reported in extra pulmonary sites such as the trachea, salivary glands, pancreas, cervix, prostate, and esophagus. Primary oat cell cancer of the esophagus is rare and was first reported in the literature in 1952 by McKeown. Upon literature review, the majority of cases have been reported in Japanese literature, suggesting a geographic bias in prevalence. However, a few but growing number of cases have been reported in Western literature, thus recognizing primary oat cell cancer of the esophagus as a separate new entity. We report one such case and review the clinical, radiologic and pathologic findings encountered. A 52-year-old man with a medical history significant only for hypertension, presented in February 1998 with a 2-month history of odynophagia, nonradiating epigastric pain, and dysphagia for solid foods. He denied any history of weight loss, cough, gastric reflux, dyspnea, or dysphonia. His social history was positive for long-standing alcohol and tobacco abuse. An upper gastrointestinal double-contrast roentgenographic study revealed a mucosal mass involving the thoracic esophagus at the junction of its middle and distal thirds. Endoscopic biopsies of the bulky, circumferential, esophageal mass confirmed undifferentiated oat cell carcinoma with chromograffin positive cells suggesting a neuroendocrine origin. Evaluation for primary lung cancer, as well as metastatic disease, was negative at that time. He initially responded to chemotherapy and adjuvant radiation therapy. However, in January 1999, he had recurrent disease with metastases to para-aortic lymph nodes that failed to respond to salvage chemotherapy. He subsequently had metastatic brain lesions, malignant ascites, and several episodes of bowel obstructions. He died 3 months later. In the United States cancer of the esophagus is a relatively uncommon entity, but the mortality rate is staggering. Since primary oat cell cancer of the esophagus is so rare, there is limited data in regard to epidemiology, etiology, and pathogenesis. There does appear to be a male predilection, with most cases occurring in men between the fifth and seventh decades of life. The majority of tumors are located in the middle or lower thirds of the esophagus. They are thought to be derived from neural crest cells or argyrophil cells (due to their staining characteristics with silver stain) in the esophageal mucosa. Some of these tumors can produce inappropriate hormones, however ectopic endocrine syndromes have not been noted. Most epithelial esophageal neoplasms cause luminal narrowing on gastrointestinal evaluation, in contrast to most oat cell cancers that typically present as bulky, fungating tumors expanding the lumen as in our patient. Except for the site of origin in the esophagus, these tumors are aggressive, and the nature of spread is similar to oat cell cancer of the lung. Most cases reported had rapid progression and succumbed to cancer 4 to 12 months after initial diagnosis. It is unclear from the literature whether these patients were given chemotherapy and their response. Increasing familiarity of the clinical and pathologic findings may lead to recognition of more cases in Western countries. In conclusion, oat cell esophageal carcinoma should be considered in patients presenting with dysphagia, radiating pain to the back, diffuse metastasis, and a bulky middle or lower esophageal mass.

MACROCYTOSIS DURING AZATHIOPRINE OR 6-MERCAPTOPURINE (6-MP) THERAPY FOR CROHN'S DISEASE MAY INDICATE OPTIMAL DOSE TITRATION. Austin Garza, MD, and Charles Sninsky, MD. Vanderbilt University Medical Center, Nashville, Tenn.

Azathioprine (AZA) and 6-mercaptopurine (6-MP) are effective at inducing and maintaining remission in Crohn's disease. However, the high individual differences in oral bioavailability and activity of specific metabolic pathways between patients requires upward dose titration to optimize their therapeutic benefit. Certain investigators report that lymphopenia, leukopenia, or measurement of 6-thioguanine nucleotide (6-TG) levels are possible surrogate markers of optimal dose titration in patients who require dose escalation to induce remission. Our clinical experience supported by reports in the literature led us to postulate that macrocytosis may be a reliable and inexpensive method to optimize dose titration with AZA or 6-MP in patients with normal [B.sub.12] and folate levels with Crohn's disease. A recent study reports that the delta-MCV (DMCV) correlates with 6-TG levels. Although the exact mechanism responsible for the macrocytosis is not understood, it is reasonable to assume that accumulation of certain thiopurine metabolites within erythrocytes accounts for the change in the mean corpuscular volume (MCV). The aim of our study was to perform a retrospective analysis to examine the relationship of macrocytosis or change in MCV during AZA or 6-MP therapy in all Crohn's patients from 1990 to 2000 seen at our medical center. Clinical remission was defined as [less than] 3 bowel movements per day (BM/d), and being weaned from steroids and without disease flare-up. This is a retrospective study examining the medical records of all patients hospitalized and followed in clinic at Vanderbilt University Medical Center with known Crohn's disease, and who were treated with either 6-MP or AZA over the 115 month period from January 1990 through May 2000. 525 patients with Crohn's were seen over this period at VUMC, and 98 were identified as having been treated with 6-MP or AZA. 34 were excluded due to limited follow-tip or the lack of available baseline CBC. Thirty-eight patients, or 59.4%, were successfully treated with 6MP/AZA and met our criteria for remission. 26 patients did not achieve clinical remission as defined above. Overall, this cohort was found to have an overall increase in their MCV from baseline through end of treatment with either AZA or 6-MP with a net DMCV of + 10.7 fL ( + 6.0 fL). Patients found to have achieved a clinical remission had an average of DMCV of 13.2 ft. (+/- 6.2 fL), while non-responders had an average DMCV 7.2 fL (+ 3.3 fL). The DMCV can help guide dosing in immunomodulator therapy in Crohn's disease. This study helps support the limited observations made in both the gastroenterology and transplant community that macrocytosis correlates with the likelihood of a patient being a therapeutic dose of 6-MP or AZA, and achieving clinical remission.

SENTINEL LYMPH NODE METASTASIS IN ANAL MELANOMA: A CASE REPORT. Huey Yuan Tien, MD, Kelly McMasters, MD, PhD, Michael Edwards, MD, and Celia Chao, MD. Department of Surgery, University of Louisville, Louisville, Ky.

Anal melanoma is a rare cancer that occurs in 1% of all melanomas. Due to delayed diagnosis and early metastasis, the prognosis is uniformly poor. Increasingly, sentinel lymph node biopsy has become the preferred staging method for malignant melanoma. We report a thirty-nine-year-old caucasian woman who presented with a history of chronic hemorrhoidal pain. She felt a pedunculated pen-anal tag associated with bleeding. The lesion was biopsied and found to be a six millimeter deep primary anal melanoma. There was no evidence of distant metastatic disease on diagnostic evaluation obtained preoperatively. She underwent wide local excision of the pen-anal site of the primary melanoma, as well as intraoperative lymphatic mapping with both isosulfan blue and radiocolloid. An ipsilateral inguinal sentinel lymphadenectomy identified five nodes, all of which were both "hot" and blue. One node was found to have a one-millimeter metastatic deposit of micrometastasis, which was confirmed with S-100 immunohistochemical st aining. Subsequently, she was treated with adjuvant radiation therapy to the superficial and deep inguinal nodal basins. Additionally, she has received two of four total cycles of biochemotherapy. Sentinel lymph node mapping in this situation is extremely helpful in identifying the nodal basin(s) at risk. Micrometastasis was identified in this setting and appropriate up-staging impacted on treatment outcome.

EXPERIENCE WITH SENTINEL LYMPH NODE (SLN) IN HIGH-RISK MELANOMA PATIENTS. E. George Elias, MD, John L. Zapas, MD, Sandra L. Beam, RN, and Sally D. Brown, RN. Baltimore, Md.

Patients with deeply invasve melanoma who presented with unenlarged regional lymph nodes (LN) were managed by prophylactic lymph node dissection (LND). SLN is considered to be the first LN to receive metastases from the primary site. It is the latest surgical tool in the management of melanoma. Its identification, excision and pathologic examination, done as an outpatient, can detect early metastases. If SLN contains no metastases, no LND is indicated. However, if SLN contains metastases, LND is in order. We are presenting our experience with the first 55 patients. These patients had cutaneous melanoma of [greater than or equal to]1 mm depth of invasion. They all had intradermal injection (at the biopsy site) with 1 millicurie of Tc99m sulfur colloid. In 50 of them, the SLN were identified by gamma camera and probe with an incidence of 91%. Of these 50 patients, 9 had metastases to their SLN (18%) and had LND. Eight of the 9 patients had the SLN as the only positive LN after LND. The primary lesions of these 9 patients with positive SLN were ulcerated in 4 and not ulcerated in 5. The depth of invasion of the primaries of these 9 patients ranged from 1.4 to 3.6 mm. The number of excised SLN varied from 1 to 4. After a median follow-up of 10 months, one of the 9 patients with positive SLN had distant metastases and died. Of the 41 patients with negative SLN, 2 died of causes other than melanoma (one with oat cell cancer and one with renal failure). Another 5 patients had recurrences, one in each: lung, soft tissue, LN basin, LN outside the basin, and one had local recurrence then intransit metastases. Therefore, it seems that SLN eliminated the need for prophylactic LND and unnecessary hospitalization. It identified early LN metastases. However, its effect in improving survival remains to be seen.

METASTATIC GASTROESOPHAGEAL ADENOCARCINOMA TO SKELETAL MUSCLE: A UNIQUE EVENT. Shakaib U. Rehman, MD, Jan N. Basile, MD, and Dennis W. Cope, MD. Medical University of South Carolina, Charleston, SC.

Skeletal muscle is rarely the site of metastatic cancer although there have been a few such cases reported. Esophageal adenocarcinoma metastasis to skeletal muscle has not been reported in the literature before. We are reporting a case of thigh muscle metastasis from adenocarcinoma of the Gastroesophageal junction. A 71-year-old African American male with Stage IV adenocarcinoma of the gastroesophageal junction complained of severe and disabling pain in the right thigh, which was extremely tender to palpation, his pain was unresponsive to NSAIDs and full dose narcotics. Plane x-rays and bone scan was not diagnostic. MRI showed a soft tissue mass involving the thigh muscles, anterior and medial to the right femur. A CT guided biopsy revealed that the thigh mass was metastatic adenocarcinoma consistent with the primary cancer. Radiation therapy was then started on the patient's right thigh, with a good response. Patient was discharged from the hospital in ambulatory condition with out pain. Metastasis to muscle is rare, but physician should be aware of such a possibility, as detection requires specific tests such as magnetic resonance imaging (MRI) and CT guided biopsy. We have discussed the role of such tests as well as the treatment options available to date for such an occurrence.

METASTATIC NEUROENDOCRINE CARCINOMA (SMALL CELL) PRESENTING AS A THYROID NODULE. David M. Hufnagel, DO, and Dennis P. Mong, MD. Brooke Army Medical Center, Fort Sam Houston, Tex.

The patient is a 55-year-old non-smoking Hispanic woman who was referred to the endocrinology clinic after a 3 cm thyroid nodule was detected during routine examination. FNA of the nodule was performed and was suspicious for papillary carcinoma. The patient subsequently had uncomplicated total thyroidectomy with excision of an infrathyroidal nodule. Initial pathology of the specimens favored medullary carcinoma with a small coexisting focus of papillary carcinoma. The patient's serum calcitonin and carcinoembryonic antigen (CEA), however, were normal. Two weeks postoperatively, the patient presented with severe right midaxillary chest wall pain and shortness of breath. Physical examination was notable for a tachypneic, afebrile woman in moderate distress. Epigastric tenderness and a positive Murphy's sign were elicited. The remainder of the physical examination was normal. RUQ ultrasound showed an echogenic pancreas with fluid in Morrison's pouch as well a 3 cm cystic lesion in the liver. Follow-up CT scan of the abdomen showed irregular cysts in the left lobe of the liver, as well as a 7 cm mass in the area of the pancreatic head. A 2 cm subcarinal mass and a 3 cm right hilar mass were present on CT of the chest. Bronchoscopy was showed an endobronchial lesion with near complete obstruction of the posterior segment of the right upper lobe. Biopsies of the mass and subcarinal lymph nodes were taken and a CT guided biopsy of the pancreatic lesion was performed. Tissue samples from these sites were consistent with poorly differentiated neuroendocrine carcinoma. With this new clinical information, the thyroid tissue was reexamined and showed the same immunohistochemical profile as the pancreatic and lung lesions. The original report of medullary carcinoma was amended to neuroendocrine carcinoma of undetermined primary. Metastatic neuroendocrine tumors to the thyroid are uncommon but should be suspected especially in cases of medullary thyroid carcinoma where serum CEA and calcitonin are normal. A recent review of th e literature revealed only two other cases of neuroendocrine carcinoma with metastases to the thyroid.

RAPIDLY PROGRESSIVE CARCINOID SYNDROME IN AN IMMUNOSUPPRESSED MAN. Jennifer R. Pederson, MD, Mukta Panda, MD, and Jackson J. Yium, MD. University of Tennessee, Chattanooga, Tenn.

Carcinoid tumors are usually intestinal in origin. They are extremely indolent with slow spread. We report a rapidly deteriorating course of carcinoid syndrome in a man who was receiving immunosuppressive therapy. A 61-year-old man, status postrenal transplantation in 1995 for chronic renal insufficiency, was admitted in September 1999 with complaints of weight loss, diarrhea, anorexia, and early satiety. The patient noted a gradual onset of symptoms since 1996, with worsening over a 6-month period before presentation. He was on immunosuppressive therapy since 1995. His medical history was significant for a Billroth II procedure at age 28 for reported peptic ulcer disease. Physical examination revealed a cachectic white man with redness and telangiectasias of the face and neck. His physical examination was otherwise unremarkable. CBC, electrolytes, and liver function tests were all within normal limits. Ultrasound of the abdomen, CT of the pelvis and colonoscopy in 1996, and panendoscopy in 1999 were normal. Workup was negative for malabsorption, H pylori, Giardia, and C difficile. He was readmitted a month later for right hip fracture. He still bad diarrhea and weight loss but also noted prominent bilateral facial, neck, and arm flushing. Punch biopsy from the skin of the neck was essentially unremarkable. Postoperative CT of the abdomen revealed innumerable hepatic lesions in all lobes of the liver. Ultrasound guided liver biopsy revealed metastatic carcinoid tumors. Subsequent 24-hour urine collection revealed elevated 5-HIAA levels. The patient was treated with sandostatin and antihistamines. He rapidly deteriorated and died within several months of diagnosis. Carcinoid accounts for 30% to 40% of all small intestinal tumors. Over 95% of all GI carcinoids occur in one of 3 sites: the rectum, appendix, or small intestine (usually the ileum). Tumors less than 2 cm are less likely to metastasize. These tumors secrete vasoactive materials responsible for the clinical manifestations of carcinoid syndrome, which is seen only in patients with hepatic metastasis. With advanced disease, treatment is symptomatic and true cure is seldom achieved. Rapid progression of indolent carcinoid has been reported in patients who are immunosuppressed. Since our patient's preliminary extensive GI workup did not reveal an obvious primary, we postulate that our patient may have primary hepatic carcinoid, which rapidly progressed due to his immunosuppressed state. There has been only one case reported in the literature of primary hepatic carcinoid in a renal transplant patient. Furthermore, our patient could also have the MEN I syndrome since he required surgery for peptic ulcer disease at an early age. With the worldwide increase in the incidence of tumors among immunosuppressed patients, physicians should have a low threshold for early thorough workup of suspected tumors.

EFFECTIVENESS OF STEREOTACTIC VACUUM-ASSISTED CORE-NEEDLE BREAST BIOPSY Evan M. Renz, MD, Robert D. Stoffey, DO, Thomas P. Baker, MD, and John P. Schriver, MD. Departments of Surgery, Radiology, and Pathology, William Beaumont Army Medical Center, El Paso, Tex.

The technique of stereotactic vacuum-assisted core-needle breast biopsy became available at our institution in December 1999. We sought to review the results of all stereotactic breast biopsies performed during the first 14 months following implementation to determine the effectiveness and accuracy of the procedure. We performed a retrospective review of the clinical records of all patients who underwent a stereotactic breast biopsy at our hospital between December 1999 and January 2001. Seventyeight female patients undewent a total of 87 stereotactic breast biopsies of mammographically suspicious (BIRAD IV) or highly suspicious (BIRAD V) lesions utilizing an 11-gauge mammotome device between December 1999 and January 2001. These patients ranged from 34 to 83 years of age. Eight patients underwent multiple stereotactic biopsies. The lesions of three patients initially scheduled for stereotactic biopsy proved inaccessible using the stereotactic technique due to inadequate visualization and subsequently underwe nt needle-localized biopsy. Fourteen of 78 patients (17.9%) were reported to have the following abnormal histologic findings: invasive carcinoma in five patients (6.4%), carcinoma in situ in three patients (3.8%) and atypical ductal hyperplasia in six of the 78 patients (7.7%). The women identified with breast cancer using stereotactic biopsy accounted for eight of the 24 total breast cancer cases (33.3%) diagnosed at our institution during the same period. One patient, initially diagnosed with a benign lesion, was later found to have invasive carcinoma on repeat stereotactic biopsy when her follow-up mammogram appeared suspicious. Subsequent needle-localized excision of lesions diagnosed as atypical ductal hyperplasia revealed no evidence of invasive or in situ breast cancer. Later surgical excision also confirmed the diagnosis for each case of ductal carcinoma in situ. The positive predictive value of the procedure was shown to be 100%. During the first 14 months of utilization the stereotactic core-needle breast biopsy procedure proved highly effective in providing accurate evidence of breast cancer in women with mammographically suspicious lesions.

INITIAL EXPERIENCE WITH THE STRETTA PROCEDURE FOR THE TREATMENT OF GASTROESOPHAGEAL REFLUX DISEASE. Leena Khaitan, MD, Stefan Scholz, MD, Jonathan Cohen, MD, Kenneth Sharp, MD, Michael Holzman, MD, and William Richards, MD. Department of Surgery, Vanderbilt University Medical Center, Nashville, Tenn.

Endoscopic radiofrequency energy delivery to the smooth muscle of the gastroesophageal junction has recently been shown to reduce transient lower esophageal sphincter relaxations. The Stretta device (Curon Medical, Sunnyvale, CA) is a balloon-tipped 4-needle catheter which delivers radiofrequency energy (RFE) to the gastroesophageal (GE) junction and is now being used for the endoscopic treatment of gastroesophageal reflux disease (GERD). Data prospectively collected on the first 22 consecutive patients undergoing the Stretta procedure at Vanderbilt University Medical Center between August 2000, and March 2001, is reported. Patient work up included esophageal manometry, ambulatory 24-hour pH testing, completion of a standard GERD-specific quality of life survey (QOLRAD), general quality of life survey (SF12), and endoscopy. Patients with esophagitis on endoscopy did not undergo 24-hour pH testing. Stretta was performed following a standardized protocol. Briefly, after endoscopic visualization of the Z-line, s ubmucosal radiofrequency energy is delivered to the GE junction with a 4-needle catheter and a thermocouple-controlled generator. Data regarding anesthesia, operative procedure and complications were collected. At three-month follow-up, patients completed the QOLRAD and SF12 forms, and complications and medication use were identified. Results are presented as mean +/- SEM. Prior to treatment, patients had a DeMeester score of 31 [+ or -] 6 and normal esophageal peristalsis. LES pressure was 22 [+ or -] 2 mmHg. Of the 22 outpatient procedures, 16 (72%) were done under conscious sedation. Six patients underwent general anesthesia due to comorbidities requiring tighter physiologic control (4) or inadequate sedation (2). Average operative time was 76 [+ or -] 8 minutes for the first three cases. This time was reduced to 50 [+ or -] 2 minutes in the following sessions. All patients under conscious sedation reported moderate pain during the application of RFE. All patients experienced mild postoperative pain for 24 hours, which was sufficiently controlled with over-the-counter pain medication (acetaminophen). No other complaints were specified. Fifteen procedures were performed prior to December 31, 2000 and had 3-month follow up. Two complications were noted. One patient developed pan creatitis on postoperative day (POD) 27, and it appears to be unrelated to the Stretta procedure. One patient presented with nausea and hematemesis on POD 12. Ulcerative esophagitis was confirmed by endoscopy. Five of the thirteen patients (38%) remain on anti-secretory medication (Prilosec 20 mg qd) at three months. In all patients, QOLRAD scores improved (3.8 [+ or -] 0.4 to 5.7 [+ or -] 0.5) as did SF12 physical (PCS, 24.6 [+ or -] 3.2 to 29.8 [+ or -] 3.5) and SF12 mental scores (42.6 +/- 2.2 to 47.6 [+ or -] 2.4). All patients would undergo Stretta again except 1 who would not repeat the procedure due to progressive Alzheimer's disease. This patient had markedly improved QOLRAD (3.2 to 5.3) and PCS (26 to 54) scores post procedure. RFE delivery to the GE junction is a promising new modality in the management of GERD. Stretta can be safely performed in one short session with gastroesophageal endoscopy under conscious sedation in an outpatient setting. It improves GERD symptoms and quality of life scores in patients 3 months post Stretta and eliminates the need for anti-secretory drugs in most.

ONE-DAY GASTRIC EMPTYING PROTOCOL FOR IDENTIFYING GASTROPARESIS AND PREDICTING RESPONSE TO METOCLOPRAMIDE. Amolak Singh, MD, and Steve Harper, MD. University of Missouri Health Sciences Center, Columbia, Mo.

Since 1989, we have employed a simplified, one-day protocol for the determination of gastric emptying, and predicting, whether or not patient will respond to Metoclopramide (MET). Prior to this practice, the gastric emptying studies (GES) required two-day protocol. One day to determine, if the patient had gastroparesis, and second study (on another day) to determine if the patient will benefit from MET. The purpose of this paper is report the advantages with one-day protocol and define what constitute a good response to MET. After an overnight fast, patient is given a radiolabeled scrambled egg meal for gastric emptying study. Serial 5-minute scintiscans are obtained for 60-90 minutes in anterior and posterior projection. The gastric emptying half time (GET) is calculated from the mean geometric gastric counts. The counts are decay corrected and GET is determined using a linear regression analysis. If GET is prolonged ([greater than]100 min), a dose of MET (10mg) is given intravenously and 5 minute images are obtained for additional 30 minutes. The GET is again calculated and compared with the baseline. Of 750 patients 180 (24%) underwent one-day protocol. Only those with gastroparesis (GET[greater than]100 mm) were analyzed. There were 168 patients with mean age of 50.7 years (range 21-93). The GET pre-MET and post-MET were 348 [+ or -] 295 and 103.8 [+ or -] 188 ([less than].00001) minutes respectively. The reduction in mean GET relative to baseline GET was calculated and attempt was made to. establish a threshold that would indicate a good response to MET. In this study 81% of patients has better than 50% reduction in GET. The grading of response to MET and patients with each grade will be reported. We conclude that one-day protocol is effective in identifying patients with gastroparesis and predicting response to metoclopramide. The protocol saves time, money, and reduces radiation exposure to patients. Prompt diagnosis leads to early institution of pro-kinetic therapy. A 50% or more reduction in GET is propo sed as a criterion for predicting a good therapeutic response to metoclopramide.

HIGH-FREQUENCY ELECTRICAL STIMULATION OF THE STOMACH IMPROVES NAUSEA AND VOMITING AND GASTRIC MOTILITY IN GASTROPARETIC PATIENTS. Richard W. McCallum, MD, Zhiyue Lin, MS, Irene Sarosiek, MD, G. S. Raju, MD, Susan C. Shea, MS, and Jameson Forster, MD. Departments of Medicine and Surgery, University of Kansas, Kansas City.

Thirty-five gastroparetic patients have received high-frequency gastric electrical stimulation (GES) therapy at the University of Kansas Medical Center over the last 3 years. To date, 22 patients (18 F, mean age, 41 years) with severe gastroparesis (16 diabetic, 3 idiopathic and 3 postsurgical) refractory to standard medical therapy have completed a 6month evaluation. Our aim was to assess the role of long term GES on the treatment outcome of severe gastroparetic patients. During the abdominal surgery, one pair of electrodes was placed into the muscularis propria of the stomach along the greater curvature at about 10 cm proximal to the pylorus for electrical stimulation using a commercial pulse generator (Medtronic, Minneapolis, Minn) permanently implanted in the abdomen. GES was initiated within 1 week after surgery for 20 patients and 1 month after surgery for the other 2 patients (pulse width, 330 ins; amplitude, 5 mA; and frequency, 12 cpm). Assessment of severity of nausea and vomiting from 0 (none) to 4 (extremely severe), gastric emptying (GE) test of a solid meal simultaneously with electrogastrogram (EGG) recordings were performed at baseline (before surgery) and at 6 months of GES. In comparison to baseline, nausea and vomiting were significantly reduced after 6 months of GES (nausea. 3.5 +/- 0.2 vs 1.9 [+ or -] 0.3; vomiting, 2.9 [+ or -] 0.3 vs 1.3 [+ or -] 0.3). The mean percent of gastric retention at 4 hours was reduced from 45 [+ or -] 6% at baseline to 32 [+ or -] 8% at 6 months of GES. The postprandial EGG power (amplitude) after 6 months of GES was significantly increased compared with baseline (-0.1 [+ or -] 1.1 dB vs 2.6 [+ or -] 1.2 dB). Tachygastrija (frequency of the gastric slow wave [greater than]4 cpm) was the primary dysrhythmia observed at baseline (19 [+ or -] 23%) and remained similar at 6 months of GES (16 [+ or -] 26%). On average, the patients had gained 4 kg after 6 months of GES (58.8 [+ or -] 9.5 kg vs 62.6 [+ or -] 12.2 kg). Of 22 patients, 12 initially required jejunostomy t ube feeding. Nine of these 12 patients had jejunostomy tubes removed within 6 months of GES. Two patients had the device removed due to pouch infection. In gastroparetic patients receiving GES, there was a highly significant reduction in nausea and vomiting and accompanying improvement in nutritional status. Possible explanations identified are enhanced amplitude of postprandial gastric slow waves and a small acceleration in GE of a solid meal. This therapy is a major advance in the management of upper GI symptoms and gastroparesis.

RENAL CELL CARCINOMA: DO MID-REGION LESIONS NEGATIVELY IMPACT NEPHRON-SPARING SURGERY OUTCOMES? Ben Shenassa, MD, Paul Espy, MD, Koushik Shaw, Raju Thomas, and Rodney Davis, MD. Tulane University Health Sciences Center, New Orleans, La.

Partial nephrectomy is considered effective for renal tumors when preservation of renal function is desired. Size and location of the lesion are criteria for nephron-sparing surgery. This study evaluated the efficacy, feasibility, and complications of partial nephrectomy for renal tumors based on size and location. We retrospectively analyzed the records of 32 consecutive patients (72% male, 28% female) (average age, 60 yrs) who underwent partial nephrectomy of 33 renal units over the past 10 years. Indications for nephron-sparing surgery included solitary kidney (25%), compromised renal function (16%), bilateral tumors (6%), and small exophytic tumors easily amenable to nephron-sparing surgery with normal contralateral kidney. Average follow-up was 28 months. The average size of all lesions was 3.9 cm, while those in the upper pole, mid-region, and lower pole averaged 3.6, 5.1, and 2.8 cm, respectively. When lesions other than RCC were excluded, the average size was 3.4 cm, while those in the upper pole, mid -region, and lower pole averaged 3.9, 4.0, and 2.8 cm, respectively. We compared the perioperative complications, recurrence rate, morbidities, progression of renal insufficiency, and mortality based on lesion location. Of 33 lesions in this series, 7 (22%) were upper pole, 13 (39%) lower pole, and 13 (39%) mid-region. Lesions were classified as follows: 25 RCC (76%), two benign cysts (6%), two AML (6%), two foci of inflammation/fibrosis (6%), one oncocytoma (3%), and I TCC (3%). The average length of hospital stay was six days and average estimated intra-operative blood loss was 622 ml. Neither were statistically significant based on lesion location. The average operation time was 235 minutes, with a statistically significant increase in operation time for lesions at mid-region (269 mm) compared to those at the periphery (211 mm). Increase in postoperative creatinine was insignificant for mid lesions compared to peripheral. Two patients with CRF required temporary hemodialysis and one required permanent hemo clialysis. Two deaths were due to an unknown cause and discontinuance of hemodialysis. Nephron-sparing nephrectomy is an effective procedure for patients even with mid-region lesions. Though they are associated with longer operative times, mid-region lesions do not have a statistically significant increase in pen-operative complications, hospital re-admissions, or long-term renal function compared to nephron-sparing surgery for polar lesions.

EXPERIENCE WITH PRIAPISM IN AN URBAN HOSPITAL: FAILURE OF MEDICAL THERAPY James M. Cummings, MD, John A. Boullier, MD, PhD, and Jason Burrus, MD. University of South Alabama, Mobile, Ala.

Few medical therapies for priapism have been evaluated for efficacy. We reviewed our experience with priapism to determine if conservative methods of treatment have a role. Records for 22 men with 48 episodes of priapism were reviewed from a 6-year period. Etiology of the priapism was sickle cell anemia in 9 (19 episodes), idiopathic in 12 (19 episodes) and traumatic in 2 (10 episodes). Three of the sicklers (4 episodes) were pediatric. In adult sicklers, 2 episodes resolved with hydration and oxygenation alone and 1 other resolved with terbutaline. All other episodes required either aspiration of the corpora or shunting. Two of 4 pediatric sickle cell patient episodes responded to exchange transfusion; others ultimately required aspiration to achieve detumescence. In the idiopathic group, 5 episodes were initially treated with either amyl nitrate or terbutaline with 3 failures. In 14 episodes, aspiration or shunting was selected as the initial form of management with only 3 failures. The failures were in men who had suffered previous episodes of priapism. The men suffering traumatic priapism would initially respond to medical treatment such as terbutaline administered in the emergency room but the priapism in each case returned within 7-10 days. Each ultimately required arteriographic embolization followed by aspiration. Efficient therapy of priapism requires knowledge of its etiology. Traumatic priapism may be temporarily abated by conservative therapy but will ultimately require aggressive intervention. Although conservative therapy is recommended for sickle cell priapism, we found that 80% ultimately need aspiration. In idiopathic priapism, initial medical treatment had only a 40% success rate compared to 78% in the group initially managed by aspiration. We recommend non-traumatic priapism, including men with sickle cell anemia, be treated initially by aspiration. Men with traumatic priapism should get arteriography and embolization of aberrant vessels. Medical therapy for priapism is most often not productiv e.

EFFICACY OF SILDENAFIL IN PATIENTS PREVIOUSLY TREATED FOR ERECTILE DYSFUNCTION. Ahmed Fawzy, MD, Joseph Macaluso, MD, Caren Crotty, MD, Glenn Landry, MD, Frank Cerniglia, MD, Frank Deus, MD, David Debessonet, MD, Nadine Gauthier, RN, and Jules Deutsch, MD. Urologic Institute of New Orleans, New Orleans, La.

With the introduction of successful oral therapy (sildenafil citrate) for treatment of erectile dysfunction (ED), patients receiving other modalities of treatment had great interest to convert to oral therapy. Oral therapy is an easy, convenient mode of treatment. This study aims to assess the efficacy of converting ED patients previously receiving a wide variety of treatment modalities to sildenafil. All ED patients followed a goal-oriented comprehensive disease management protocol. Evaluation included complete H/P examination and administration of the International Index of Erectile Function (IIEF) questionnaire. Male hormonal panel, SMA7, and penile Doppler examination were ordered when clinically indicated. Patients received educational material on ED and all its treatment options. Sexual counseling was initiated when clinically appropriate. Reversible causes of ED were managed for all patients, and they were started on sildenafil 50 mg. At follow-up, efficacy, compliance, and side effects were assessed. IIEF and Erectile Dysfunction Inventory of Treatment Satisfaction (EDITS) questionnaires were administered at all visits. Patients were followed up at 1-, 3-, 6-, and 12-month intervals. Those reporting partial or no response were increased to sildenafil 100 mg. Patients who failed maximum dosages were switched to other treatment options based on patient and partner preference. A total of 34 patients were receiving other modalities of treatment for ED. Successful conversion to sildenafil, as defined by treating physician's clinical assessment and patient satisfaction, was achieved in 71% (mean follow-up 18 mo), with IIEF Q3: (3.4 mean), Q4: (3.1 mean). 29% of patients were successfully switched to other modalities of treatment. The use of oral therapy sildenafil is highly effective in patients previously treated for ED. The use of a goal-oriented, comprehensive treatment approach compliments the success of oral therapy.

INFLUENCE OF PSA SCREENING ON SURVIVAL IN MEN UNDER 55 WITH PROSTATE CANCER. Chad Huckabay, MD, Belur Patel, MD, T. P. Reilly, MD, and K. Scott Coffield, MD. Scott and White Clinic and Hospital/Texas A&M Health Sciences Center, Temple, Tex.

The purpose of this study is to evaluate the importance of PSA testing on prostate cancer in men less than 55 years-of-age in a rural population based medical center in central Texas. All men 55 years and younger with the diagnosis of prostate cancer between 1976 and 1999 were identified from a prostate cancer database at one medical institution, and divided into a pre-PSA group, 1976 to 1987 (group 1) and a post-PSA group, 1988 to 1999 (group 2). Patient characteristics along with tumor stage, histology, initial treatment, and 5 and 10 year survival were collected. Grading was divided into well differentiated to undifferentiated cancers and staged as local, regional or distant disease to equate the differences in pathology staging between the groups. A total of 128 patients under the age of 55 years with prostate cancer were identified and divided into a pre-PSA group (group 1) and a post-PSA group (group 2). Patient characteristics were similar between the two groups with an average age of 53.3 and 52.3 yea rs for groups 1 and 2, respectively. The Kaplan-Meier 5 and 10 year survival for patients in the pre-PSA era was 61% and 42%, respectively, versus 92% and 80% for post-PSA era patients (P[less than].0001). Also, survival curves for localized disease showed a significant survival advantage in the PSA screened population. No significant survival advantage was seen in those with regional or distant disease at diagnosis between the two groups. However, statistically significant more localized disease and lower grade tumors were identified after the introduction of PSA. Treatment modalities were also shown to be significantly different with more patients undergoing radical prostatectomy (RRP) in group 2, while those in group 1 tended to receive external beam radiation therapy (XRT). Stratifying the two groups with regard to initial therapy (ie, XRT or RRP) had no influence on survival. However, there was a greater survival in the RRP cohort. PSA testing may be associated with statistically significant increased su rvival in men less than age 55 with adenocarcinoma of the prostate. In our study, type of definitive local treatment of the disease had no effect on survival. The increased discovery of localized disease in younger men with the diagnosis of prostate cancer discovered secondary to elevated PSA might be responsible for the significantly increased survival.

THE ROLE OF OPEN DONOR NEPHRECTOMY IN THE ERA OF LAPAROSCOPY. V. Seenu Reddy, MD, MBA, Chris Lovell, RN, and William A. Nylander, MD, MBA. Vanderbilt University Medical Center, Nashville, Tenn.

This study reviews the modern-era experience of open donor nephrectomy (ODN) to serve as the standard of comparison for laparoscopic procurement (LN). A review of all living ODNs at an academic renal transplant center was done. Endpoints examined included postoperative length of stay (LOS), complications and total charges. Between January 1994 and January 1999, a single surgeon performed 119 consecutive donor nephrectomies. There were 5 patients with multiple renal arteries, 2 with multiple renal veins and 2 with multiple ureters. Donor organs were placed in 97 (81.5%) adults and 22 (28.5%) pediatric recipients. All kidneys were harvested using a modified lateral decubitus position. Rib resection was avoided in all patients. The average operative time was 148 minutes, with 144 min. for adult recipients and 167 min. for pediatric recipients. There were no cases of vascular or ureteral injury, no pneumothoraces and no wound infections. Two patients (1.7%) received transfusions postoperatively. All donors ate a regular diet by the first postoperative day. The average LOS was 3.7 days, with 3.5 days for donors of adult recipients and 4.6 days for donors for pediatric recipients. The past 40 donors had an average LOS of 2 days. All but one donor was able to drive by 3 weeks post donation. All donors returned to work within 2 months. Charges for all donors averaged $10,651. Adult recipients averaged $10,474, while donor charges for pediatric recipients were $11,417. The major component of the hospital charges (45%) was comprised of operating room (OR) charges. Open donor nephrectomy can be done without complication or rib resection. Donor's LOS is longer for pediatric recipients largely due to family reasons. OR fees are the major portion of charges to the patient. LOS, time to return to work and driving are all shorter in the last 40 cases. ODN may remain superior to LN in terms of optimal graft procurement and function, especially when complication rates and overall charges are considered.

LAPAROSCOPIC-ASSISTED COLECTOMY IN CHILDREN. Manuel Caceres, MD, and Donald C. Liu, MD, PhD. Louisiana State University School of Medicine, Department of Surgery, New Orleans, La.

The use of minimally-invasive techniques for colon resection has recently gained popularity in the adult population for both benign and malignant disease. Its use in children, however, is less well-reported. We present our preliminary series of laparoscopic-assisted colectomy (LAC) in children assessing surgical outcome. LAC was attempted in five children, ages 7-20 years old, for benign disease (Crohn's disease- four, testicular feminization requiring colovaginoplasty - one). Four or five port sites were typically placed for endoscopic colon mobilization and ligation/division (harmonic scalpel/endo-GIA stapling device) of mesenteric vascular arcades. Extra-corporeal anastamosis and specimen retrieval were accomplished via a small McBurney incision in the Crohn's patients. Colovaginoplasty with low anterior anastamosis was performed via a mini-Pfannenstiel/perineal approach. LAC was successful in all five patients. Operative times ranged from 61-182 minutes. Estimated blood loss was [less than]100 ccs in all cases. There were no wound infections or anastomotic leaks complicating the procedure. Regular oral intake was established by post-operative day three in all cases. Parenteral narcotics were uniformly discontinued by post-operative day two and length of hospitalization ranged from two to four days. Laparoscopic-assisted colectomy can be safely performed with minimal morbidity for certain benign diseases in the pediatric population. A randomnized, prospective controlled study is required to assess its value compared to more traditional open procedures.

ARTHROSCOPIC POSTERIOR CERVICAL FORAMENOPLASTY. Alfred O. Bonati, MD, Anthony R. Mork, MD, and Craig R. Wolff, MD. Hudson, Fla.

Upper extremity radicular pain due to cervical nerve root compression is common. Open procedures such as anterior diskectomy and fusion are successful but sacrifice cervical motion and may lead to future problems at other levels. Open posterior cervical decompression is also an accepted treatment. A new arthroscopic procedure, foramenoplasty, is an arthroscopic version of the traditional open keyhole laminoforamenotomy. The purpose of this study is to review results of this new technique. Patients with more than 1 year of follow-up were identified who were treated by foramenoplasty for cervical radiculopathy or cervicogenic headache. Twenty-seven patients were identified, and demographic and follow-up data were collected. There were 15 men and 12 women who had 33 foramenoplasties done. Their average age was 49.6 years (range, 29 to 81 years) and the average number of years of pain was 5.5 (range, 1 to 30). Forty-eight percent of the surgeries were revisions of an anterior procedure, and 51% were primary surge ries. Seventeen surgeries were done at C5-6, 10 at C6- 7, 3 at C7-T1, 2 at C3-4, and 1 at C2-3. Thirty-two of the 33 procedures were done for radicular pain, and 1 procedure was done for cervicogenic headache at the C2-3 level. Average follow-up was 15.3 months (range, 13 to 17 months). There were no complications. Twenty-three of 27 patients (85%) obtained excellent or good results, and 17% obtained fair or poor results. Three patients required a revision arthroscopic surgery to resolve persistent pain. Twenty-nine of 33 procedures (88%) were successful in relieving preoperative pain versus 12% unsuccessful. Arthroscopic outpatient foramenoplasty for cervical radicular pain is a technically viable procedure. Short-term follow-up shows that foramenoplasty is safe and effective with results comparable to open surgery. Fusion is not required, recovery is quick, and normal anatomy is minimally altered.

LAPAROSCOPIC REPAIR OF A LARGE SYMPTOMATIC EPIPHRENIC ESOPHAGEAL DIVERTICULUM. Evan M. Renz, MD, Mary V. Parker, MD, and Stephen P. Hetz, MD. Department of Surgery, William Beaumont Army Medical Center, El Paso, Tex.

The diagnosis of symptomatic epiphrenic esophageal diverticula is uncommon. Even less common are published reports regarding the efficacy of laparoscopic repair of this malady. We report the case of a 59-year-old male patient with Parkinsonism diagnosed with a large, symptomatic epiphrenic diverticulum and discuss the surgical treatment performed. The patient presented with a six-month history of worsening dysphagia to both solids and liquids, regurgitation of undigested food, and weight loss. Barium esophagram identified the presence of a large distal esophageal diverticulum. Esophagoscopy confirmed the epiphrenic location of the diverticulum and the absence of other pathology. Laparoscopic transhiatal diverticulectomy was performed utilizing an GIA-type endoscopic stapler. Intraoperative esophagoscopy was performed to confirm resection of the diverticulum without constriction. The patient resumed intake of liquids on postoperative day one after a water-soluble contrast esophagram revealed no extravasation. The patient was discharged on hospital day three. To date, the patient continues to tolerate liquids well, but reports difficulty swallowing solid food despite no evidence of esophageal stricture or increased lower esophageal pressure. We conclude that laparoscopic epiphrenic diverticulectomy is technically feasible and safe and is worthy of further refinement.

SAFETY AND EFFICACY OF LAPAROSCOPIC ADRENALECTOMY FOR PHEOCHROMOCYTOMA. Kent W. Kercher, MD, Brent D. Matthews, MD, Demetrius E. M. Litwin, MD, Yuri Novitsky, MD, Adrian Park, MD, and B. Todd Heniford, MD. Departments of General Surgery, Carolinas Medical Center, Charlotte, NC; University of Massachusetts Medical School, Worcester, Mass; and University of Kentucky, Lexington, Ky.

The value of laparoscopic adrenalectomy for Conn's syndrome, Cushing's disease, and nonfunctioning adrenal masses has been well established. The purpose of this study is to evaluate the clinical outcomes of patients undergoing laparoscopic adrenalectomy for pheochromocytoma and to assess the safety and efficacy of a minimally invasive approach. From January 1995 to March 2000, fifty consecutive patients underwent laparoscopic resection of a pheochromocytoma [49 adrenal (28 left, 21 right), 1 extra-adrenal paraganglioma]. Five patients had multiple endocrine neoplasia (MEN) syndrome. There were 34 females, 16 males. Mean age was 44.6 years (range, 19-79). Mean tumor size was 5.1 cm (range, 2-12.1). Average operative time was 162 minutes (range 95-375) with a mean estimated blood loss of 94 cc (range, 30-500). There were no transfusions. Intra-operative hypertension (systolic blood pressure [greater than] 170 mmHg) occurred in 66% of patients and hypotension (systolic blood pressure [less than] 90 mmHg) in 32% of patients. There were no intra-operative complications and no conversions to open surgery. Mean length of stay was 2.3 days (range, 1-4). There were 4 perioperative morbidities: a wound cellulitis, a urinary tract infection, an episode of pseudomembranous colitis and a deep venous thrombosis with micropulmonary emboli. There were no mortalities or recurrences of endocrinopathy at a mean follow up of 14 months. Laparoscopic resection of pheochromocytomas can be accomplished safely in spite of frequent episodes of hemodynamic variability that are equal to historic open controls. A short hospital stay with expedient recovery, minimal wound complications, and eradication of endocrinopathy favor the minimally invasive approach as the procedure of choice for adrenalectomy in the setting of pheochromocytoma.

PHEOCHROMOCYTOMA PRODUCING VASOACTIVE INTESTINAL PEPTIDE. Stephen L. Smith, MD, A. L. Jackson Slappy, MD, Thomas P. Fox, MD, and James S. Scolapio, MD. Departments of General Surgery, Endocrinology, and Gastroenterology, Mayo Clinic Jacksonville, Jacksonville, Fla.

Verner and Morrison originally described the syndrome of watery diarrhea associated with hypokalemia and achlorhydria (WDHA) in 1958. Here we describe a rare case of an extrapancreatic VIP-producing tumor. The patient was found serendipitously to be hypokalemic and was treated empirically, but no etiology was identified. Over the next 3 years, she had persistent hypokalemia and watery diarrhea. Eventually, a 6.5 cm left adrenal mass was discovered on abdominal CT. She desired non-surgical treatment and was given cholestyramine (Questran Apothecon) and octreotide (Sandostatin Novartis) with some improvement. Despite initial success, her watery diarrhea became refractory to medical treatment, and she became dehydrated and had a total weight loss of approximately 20 kg. Pertinent laboratory values included potassium 2.9 mEq/L (normal, 3.6 to 4.8 mEq/L), bicarbonate 12 mEq/L (normal, 22 to 29 mEq/L), serum VIP 594 pg/mL (normal, 0 to 75 pg/mL), urine dopamine 840 mg/24 hr (normal, 65 to 400 mg/24 hr), and urine v anilliylmandelic acid 17.0 mg/24 hr (normal, 0 to 8.9 mg/24 hr). After appropriate preoperative preparation, the patient had surgical resection of a 6.5 cm left adrenal tumor. The pathologic diagnosis was pheochromocytoma positive for VIP by immunohistochemistry. The patient's diarrhea resolved, and electrolytes and VIP levels returned to normal levels postoperatively. Her follow-up was uneventful.

PHYSICIAN ASSISTED SUICIDE: CAN OPINIONS BE INFLUENCED BY ARGUMENTS? John Mark Vermillion, MD, and Laurence B. McCullough, PhD. Baylor College of Medicine, Houston, Tex.

The majority of Americans are in favor of the practice of physician-assisted suicide (PAS) with most physicians opposed. Our study was aimed to determine if exposure to arguments in opposition to the individual's view might change his or her opinion. To perform a qualitative study, we prepared a questionnaire defining PAS, asking the individual's view and reasons behind it. We presented three arguments from the literature in opposition to the individual's view and asked if the arguments changed the individual's mind or reasoning concerning PAS. We also questioned whether the participants felt comfortable speaking with their physician concerning PAS. Of the 248 questionnaires mailed, we received 87 completed responses within three months of mailing. Fifty-one were in favor of PAS, 20 were opposed, and 16 were undecided. Many respondents stated that the questionnaire caused them to thoughtfully reflect on the issue. Two of those initially in favor of PAS stated that after reading the arguments against PAS they changed their minds and are now opposed to the action. Eighty-one percent of respondents felt comfortable discussing PAS with their physician. Presenting arguments in opposition to an individual's view on PAS causes one to reflect on the issue and can possibly change a person's reasoning or even reverse his stance on the issue. Because an overwhelming majority of individuals feel comfortable discussing the issue with their physician, physicians should be open to discuss the issue honestly with their patients.

PATIENT ATTITUDE TOWARDS CLINICAL TRIAL: A SINGLE INSTITUTION DESCRIPTIVE ANALYSIS. Winston Tan, MD. Mayo Clinic Jacksonville, Jacksonville, Fla.

Only 3% of eligible patients participate in a clinical trial. The National Cancer Institute has approximately 300-400 clinical trials ongoing at any time. What are the reasons why they do not participate in a clinical trial. We examined the attitudes of Texas adult population toward experimental oncology treatment and randomized clinical trials. We conducted a health survey at our outpatient oncology clinic. We posed to them a series of questions evaluating demographics, general health, and personality characteristics. We asked specific questions to characterize the subjects' experience with cancer, their desire for autonomy in medical treatment, their health-related behaviors and preconceived opinions. A total of 42 patients were enrolled in the study. 78.6% were males and the average age was 60.9. The majority were caucasian 85%, and 42% had at least a high school education. The majority think a clinical trial is an organized study (88.6%), 45% thought that patients with no standard treatment should be in a trial, 95% confirm that the physician is their main source of information. 48.7% would enter a clinical trial with an aim for cure. Patients would like to participate in a clinical trial if their physicians inform them of their options. Patients trust their physicians and other health care staff and are willing to participate in research. Besides discussing options, clinical trial should be an option discussed.

EXPERIENCE OF A DEDICATED OUTPATIENT COLON AND RECTAL AMBULATORY SURGERY CENTER. Cary L. Gentry, MD, Andrea Ferrara, MD, Sergio Larach, MD, Paul Williamson, MD, Joseph Gallagher, MD, and Samuel DeJesus, MD. Colon and Rectal Clinic of Orlando, Orlando, Fla.

There have been few ambulatory centers that have been specifically established to treat colon and rectal pathology. We present the data generated from an outpatient surgery center that specializes in colon and rectal surgery. The charts of all patients treated from June 1994 to September 2000 at our ambulatory surgery center were reviewed. The outcome data included complications, inpatient admission from the center, reoperations, and subjective data regarding patient satisfaction. Since 1994, 6,863 outpatient anorectal surgical procedures have been performed. Of these, 4,010 colonoscopies, 617 hemor-rhoidectomies, 234 lateral internal sphincterotomies, and 1,234 other minor anorectal procedures have been performed. In addition, 729 invasive EMGs have been performed in this setting. All surgical procedures were performed in the operating room with a board certified anesthesiologist. Since late 1998, 74% of the colonoscopies were performed with an anesthesiologist. There were 33 patients who required in-hospita l admission (0.5%). Seventeen (0.25%) of these patients were colonic perforations after colonoscopy. Fourteen of these patients required an operation. There were two delayed wound infections and one death. There were no patients who required admission to the hospital for pain management after any surgical procedure. The patient satisfaction was measured as excellent or good in 97.5% of the patient population. An outpatient ambulatory surgical center dedicated to colon and rectal surgery can be successful. The admission rate to the hospital after surgical procedures and the overall morbidity is low. In addition, our experience indicates that patients are satisfied with their treatment in this type of setting.

FAINTING, PALPITATIONS, AND DIZZINESS ARE FREQUENT PATIENT COMPLAINTS. John Streitman, MD, Danny C. Little, MD, and John Mark Vermillion, MD. Baylor College of Medicine, Houston, Tex.

Fainting, palpitations, and dizziness are frequent patient complaints. Diagnosis of unexplained syncope or transient cardiac symptoms often involves electrocardiographic monitoring with an external loop recorder. The monitoring duration for these devices is short, and yield is low. The Reveal monitor offers an alternative. This device functions as a lead-less loop recorder, detecting arrhythmias for tip to 14 months. It is the first and only implantable monitor featuring auto and patient activation capabilities. We report our experience in selection, placement, and results of the Reveal Plus monitor in the veteran population. We retrospectively evaluated our first 21 patients (18 male, 3 female) who had a Reveal monitor implanted. Average age was 63 years (35-81). Prior symptoms included unexplained syncope (78%), palpitations (43%), and transient ischemic attacks (10%). All patients had previous nondiagnostic external loop recorders. All Reveal monitors were placed in the operating room using local anesthesi a. There were no perioperative complications. At this point follow-up has been I to 5 months. Three patients have been diagnosed with cardiac arrhythmias and received pacemakers from information gleaned from the Reveal. Two patients were diagnosed with Prinzmetal's angina (a non FDA recongnized indication). Appropriate medical therapy led to the resolution of their symptoms. The Reveal monitor is a safe and acceptable diagnostic tool in veterans with unexplained syncope or cardiac symptoms that suggest cardiac arrhythmias. When used properly, the Reveal increases diagnostic yield and breaks the cycle of expensive repetitve diagnostic testing. The Reveal provides clues that leads to earlier diagnosis, improved patient management, and reduced diagnostic costs. Surgeons should increase their familiarity with this simple but high yield diagnostic tool.

LUNG RESECTION FOR MEDICALLY-REFRACTORY PULMONARY INFECTIONS IN CHILDREN. Manuel Caceres, MD, and Donald C. Liu, MD, PhD. Louisiana State University School of Medicine, Department of Surgery, New Orleans, La.

As a result of advances in medical management, lung resection in patients with recurrent pulmonary infections has become nearly obsolete. We report our series of 12 children with recurrent pulmonary infections refractory to conventional medically therapy in whom pulmonary resection was performed. The charts of twelve patients (six males and six females: age range- 7 days to 20 years) who underwent pulmonary resection for severe recurrent pneumonia between January 1996 and January 2001 were reviewed. All patients had received intensive medical therapy since birth or for longer than 6 months prior to surgery. Three (25%) were immunosuppressed and four (33%) were neurologically impaired with severe aspiration risk. Pre-operatively, six had saccular bronchiectasis and three stage II/III empyema. Three (25%) had preexisting primary congenital lung anomaly discovered on pathology. In seven, surgery was urgently performed because of progressively worsening symptoms on maximal medical therapy, including ventilatory s upport. All twelve underwent lung resection (pneumonectomy-two, lobectomy-nine, and segmentectomy-one). 10/12 (83%) have remained asymptomatic without clinical evidence of disease (follow up: range- 3 - 42 mo.). One has developed recurrent pneumonia. One child expired from ARDS after pneumonectomy. In summary, lung resection in children with medically-refractory pneumonia provided relief of symptoms in 83% of affected children with 8% mortality in the small series presented. The authors believe lung resection can be safely performed and is often necessary in this special subgroup of patients.

RESECTION OF LEIOMYOSARCOMA OF THE INFERIOR VENA CAVA WITH PROSTHETIC RECONSTRUCTION: REPORT OF TWO CASES. Darrin L. Willingham, MD, Mark E. Freeman, MD, J. Kirk Martin, Jr., MD, and Christopher B. Hughes, MD. Mayo Clinic Jacksonville, Jacksonville, Fla.

Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare entity and, when found, is usually indicative of advanced disease. We present two cases involving surgical resection of infrahepatic IVC leiomyosarcoma repaired with prosthetic IVC replacement and patch closure respectively. Both of our patients presented with vague complaints of progressive right upper abdominal pain, indeterminate physical examination, and findings of neoplasm on abdominal computed tomography (CT).

Case 1. A 50-year-old woman, in otherwise good health, was referred to us with a 12 month history of right upper quadrant (RUQ) "ache." She had a medical work-up ultimately leading to abdominal CT which revealed a large RUQ mass, initially diagnosed as a primary liver tumor, with a core biopsy consistent with smooth muscle neoplasm. Repeat CT at our institution showed a large infrahepatic mass arising from the PVC. She underwent surgical resection and replacement of the infrahepatic to suprarenal segment of the IVC with a 14 mm ring GoreTex graft. She tolerated this procedure well and has had resolution of her abdominal pain and no report of caval obstructive symptoms to date.

Case 2. A 52-year-old woman presented with an 18 month history of intermittent right upper abdomen and low lateral chest pain. She had a prior surgical history of laparoscopic cholecystectomy, but given her symptoms, an abdominal CT was obtained. A lobulated mass was found arising between the IVC and portal vein and read as consistent with primary retroperitoneal sarcoma. This lesion was treated with surgical resection of the mass, including the anterior caval wall, and subsequent GoreTex patch closure reconstruction with reimplantation of the right renal vein. She has done very well postoperatively.

Leiomyosarcoma of the IVC can be successfully treated with resection of the involved IVC and prosthetic reconstruction to achieve palliation or even potentially cure.

USE OF A COLLAGEN-BASED COMPOSITE WITH AUTOLOGOUS PLASMA AS AN ADJUNCT FOR CONTROL OF RAW SURFACE BLEEDING: RESULTS OF A RANDOMIZED CONTROLLED TRIAL. L. J. Wudel, Jr., MD, C. Hannon, J. P. Debelak, MS, J. Smith, MD, C. W. Pinson, MD, MBA, W. Merrill, MD, D. Weikert, MD, and W.C. Chapman, MD. Vanderbilt University Medical Center, Nashville, Tenn.

Many methods have been utilized as adjuncts for diffuse surgical bleeding including manual compression, oxidized cellulose, gelfoam with and without topical thrombin, and fibrin sealants produced with pooled human plasma. The current trial evaluated a novel collagenbased composite (CoStasisTM) with autologous plasma obtained from a 20 ml patient blood sample at the time of operation compared to a collagen sponge (InstatTM) with manual compression. There were four surgical subgroups (general, cardiac, hepatic, and orthopedic) evaluated in this trial. In this randomized controlled trial, 82 patients (mean age: 55, gender: 53M, 29F) were randomly assigned to either investigational treatment (n = 44) or control (n = 38). Of the 82 patients, 11 (13.4%) had known coagulopathy prior to surgical intervention. Bleeding was monitored by visual inspection of the surgical site for 10 minutes following intervention. The median times (success rates) required to achieve controlled bleeding (ie, capillary Qozing) and to achi eve complete hemostasis were compared between treatment groups. The median time to controlled bleeding was 42% longer (169 sec vs 98 sec, P [less than] .001) for control subjects vs experimental subjects and these differences were statistically significant within each subgroup. Mean time to achieve complete hemostasis was 34% longer (200 sec vs 132 sec, P [less than] .001) for control vs experimental groups. Complete hemostasis within 10 minutes was achieved at only 27/42 (64%) sites in the control group versus 43/48 (90%) sites in the experimental group. This randomized controlled trial suggests that an autologous plasma-based hemostatic agent may be a useful adjunct to control diffuse raw surface bleeding. This work was supported in part by Cohesion Technologies, Palo Alto, CA. Results of hepatic and orthopedic subgroups have also been reported as part of larger multicenter results.

A CASE REPORT OF INTRAOPERATIVE CORONARY THROMBOSIS IN ASSOCIATION WITH LOW-DOSE APROTININ ADMINISTRATION. Mark E. Freeman, MD, Sanford J. Finck, MD, Neil G. Feinglass, MD, and Timothy S. Shine, MD. Mayo Clinic Jacksonville, Department of Surgery and Anesthesia, Jacksonville, Fla.

The use of the serine protease inhibitor, aprotinin, has been advocated by many for coronary artery bypass graft surgery (CABG) to decrease blood requirements and prevent postoperative blood loss. Aprotinin is known to inhibit both kallikrein and plasmin, as well as preserve platelet receptors GpIb and Gp IIb - IIIa for endothelial adhesion. Aprotinin is also known to inhibit the coagulation factors XIIa, XIa, IXa, and VIIIa, resulting in an artificial prolongation of the measurement of the intrinsic clotting system such as the activated clotting time (ACT). A 75-year-old woman underwent reoperative CABG consisting of two saphenous vein grafts. A test dose of aprotinin consisting of 2 x 106 KIU IV was given over 30 minutes with no reaction, and a continuous infusion was then begun at 2.5 x 105 KIU/hr. The patient's ACT was kept between 550 to 701 throughout the procedure. Surgery proceeded uneventfully, however during closure the patient abruptly went into a low-output syndrome. Upon exploration it was found that both vein grafts had developed proximal thrombotic occlusions that propagated distally over a matter of seconds. An intra-aortic balloon pump was placed, thrombectomy of both grafts was performed and the patient immediately improved. Pathological evaluation of the clots revealed white thrombi with a predominance of neutrophils. The intraaortic balloon pump was removed 48 hours later, and she was discharged home on postoperative day nine. Intraoperative coronary artery thrombosis has been linked with the use of aprotinin in several reported cases, although this is a controversial association. In theory, inhibition of fibrinolysis in a low flow state may lead to an increased incidence of thrombosis. Recent reports have shown that aprotinin may artificially increase the ACT, which would require maintaining levels over 1,000 seconds while using high dose aprotinin. While the ACT in our case was between 550 to 701, the ACT requirements for low dose aprotinin remain debatable. This case adds to the growing evi dence that even low dose aprotinin may be pro-thrombotic. Therefore, ACT levels in association with low dose aprotinin should also be maintained at a level greater than 1,000 seconds.

FALSE PROLONGATION OF THE PROTHROMBIN AND ACTIVATED PARTIAL THROMBOPLASTIN TIMES SECONDARY TO INCREASED HEMATOCRIT. Join Y. Luh, MD, Derrick W. Spell, MD, and J. David Bessman, MD. Department of Internal Medicine, Division of Hematology/Oncology, The University of Texas Medical Branch at Galveston.

A 62-year-old man with a past medical history of poorly controlled hypertension and heavy tobacco use was admitted to the neurosurgery service with a hemorrhagic CVA. Initial laboratory evaluation revealed a prothrombin time (PT) of 26.0 seconds and an activated partial thromboplastin time (aPTT) of 42 seconds. The hematology service was consulted regarding the patient's coagulopathy. It was noted that the hematocrit was 58.3 percent. The PT and aPTT were repeated using a tube containing an amount of citrated anticoagulant calculated for a blood sample with a hematocrit of 58.3 percent. The repeat values revealed a PT of 12.8 seconds and an aPTT of 24 seconds. The cause of the patient's elevated hematocrit was secondary erythrocytosis due to hypoxemia and chronic obstructive pulmonary disease. The PT and aPTT are performed on a blood specimen from a standard tube containing an amount of citrated anticoagulant pre-measured for a hematocrit of about 40 to 45 percent, the most common normal values. When the hema tocrit is elevated, especially above 55 percent, there is disproportionately less plasma in the blood sample. Therefore, the pre-measured anticoagulant in a standard blue top tube is excessive and the specimen is artifactually over-anticoagulated. This is the etiology of the abnormal PT and aPTT. This clinical pearl is well-known among many hematologists and is described in several hematology textbooks. However, it is not reported in major internal medicine and surgery textbooks. Physicians in both primary care and surgery should be aware of this cause of a falsely prolonged PT and aPTT.

POISON, NOT JUST FOR RATS. John Mark Vermillion, MD, and Vijay Mehta, MD. Temple, Tex.

MULTI-CENTER CLINICAL EXPERIENCE WITH PERCUTANEOUS TRANSHEPATIC DEPLOYMENT (PTD) AND ENDOSCOPIC RETROGRADE DEPLOYMENT (ERD) OF AN ePTFE LINED NITINOL BILIARY SELFEXPANDING METAL STENT (SEMS). J. Cunningham, R. Uflacker (Charleston, SC), P. Rossi, M. Bezzi (Rome, Italy), R. Schofl, M. Schoder, J. Lammer (Wein, Austria), and D. Lichtenstein (Boston, MA). Department of Medicine, Division of Gastroenterology/Hepatology, Digestive Disease Center, Medical University of South Carolina, Charleston, SC.

A 73-year-old male on chronic anticoagulation was transferred to our institution for a four day history of intermittent abdominal pain associated with anorexia and hematuria. He had recently been prescribed an unknown antibiotic for URI symptoms. Upon presentation, he had a benign abdomen, normal WBC, and INR of 11. CT scan of his abdomen showed inflammation around his sigmoid colon with no bowel wall thickening. Gastrografin enema was normal. His anticoagulation was reversed and an NGT was placed. On hospital day 5, he developed a tender abdomen with increased WBC. CT scan demonstrated thickened small bowel and free intra-abdominal fluid. He was taken to the OR where a transmural hematoma of his mid-jejunum associated with local ischemia and a proximal small bowel obstruction was found. The affected areas were resected. The patient required two additional abdominal explorations for associated problems, went into DIG, and eventually succumbed to his disease process. Transmural small bowel hematoma was first d escribed in 1838 and first attributed to anticoagulation therapy in 1952. The hematoma results from hemorrhage into the submucosal layer with transmural tracking. Signs and symptoms include abdominal pain, nausea & vomiting, fever, GI bleed, and hematuria (in decreasing order). The most reliable indicators are a history of anticoagulacion, a supra-therapeutic coagulation profile, and a bowel-obstruction picture. The diagnosis is best confirmed by a CT scan which demonstrates bowel wall thickening, a proximal obstruction, and occasionally hemoperitoneum. Initial treatment measures are reversal of anticoagulation, NGT decompression, and resuscitation with IVF. In most cases, the hematoma will be absorbed and the patient's symptoms will resolve. If the patient's clinical condition declines, surgery is indicated. Only approximately three percent of resected specimens show evidence of necrosis. This rare entity should be suspected in someone who presents with symptoms suggestive of bowel obstruction with suprather apeutic anticoagulation; once recognized aggressive nonoperative management should be stressed.

Conventional palliation for malignant biliary obstruction includes placement of plastic stents or open mesh SEMS. Both are associated with a significant occlusion rate. Covered SEMS may be less likely to occlude due to tumor ingrowth, but early experience has demonstrated a significant problem with migration. We are reporting the initial human experience with both PTD and ERD of a prototype membrane covered SEMS (W. L. Gore & Associates, Inc., Flagstaff, AZ) Two European and two US centers are participating in a prospective trial of a new covered SEMS with variable lengths and diameter (8 or 10 mm) in patients with malignant biliary obstruction who are non surgical candidates. All deploying centers have IRB approval. Conventional percutaneous and endoscopic techniques are used. Forty-two patients have been enrolled, M:21, F:21, mean age 66.3 years. PTD in 29 pts (33 stents) and ERD in 13 (14 stents). 38 patients were palliated with a single stent, 3 with two and one with three stents. One patient had an unkno wn number of stents. Tumor level was Bismuth I in 28, II in 9, VI in 2 and unknown in 3. Tumor staging was T- IV in 29, T- III in 7, T- II in 2 and unknown T stage in 4. Initial stent release was successful in all patients with final stent position being satisfactory in 40/42 cases, 95% (PTD 27/29 and ERD 13/13). Follow up to date: one month 31, 3 months 15, 6 months 3. Mean serum bilirubin level at baseline (mgm/dL) was 9.2 (range 0.7-37.0), at 1 month 1.7 (range 0.5-7.3) and 3 months 0.7 (range 0.5-1.5). There have been two tumor overgrowths in the percutaneous group and no migrations to date in either group. A new prototype ePTFE nitinol lined SEMs can be deployed with a high degree of accuracy using either PTD or ERD. Early stent migration has not occurred to date.

DOUBLE GALLBLADDER. J. Andres Gonzalez, MD, I. Wiener, MD, T. Jayakumar, MD, R. Fisher, MD, and J. A. Dunn, MD. East Tennessee State University, Johnson City, Tenn; and Rosewood Medical Center, Houston, Tex.

The incidence of double gallbladder is extremely rare and lacks characteristic symptoms. It occurs in only 1:3,000-4,000 persons and a number of variants exist. We present a case of double gallbladder in a patient presenting with right upper quadrant pain, normal liver function studiese, cholelithiasis detected by ultrasound, nad a positive oral cholecystogram. The duplicated gallbladder was not detected by either preoperative study. The patient underwent laparoscopy and a duplicated gallbladder was discovered arising from the left hepatic duct. The case was converted to an open procedure and an intraoperative cholangiogram was performed to delineate the ductal anatomy and both gallbladders were removed without incidence. The presence of a double gallbladder is rare and can pose a unique dilemma. For example, a normal gallbladder may be visualized on ultrasound, but inflamed, aberrant gallbladder overlooked. Likewise, visualization studies, such as cholecystogram or nuclear imaging study may also visualize a normal gallbladder. Thus, the acutely inflamed gallbladder may be missed or left behind if not appreciated. In cases where a double gallbladder is found, it is imperative to perform a cholangiogram to clearly define the ductal anatomy. Fully understanding the potential for aberrant gallbladder anatomy, which can occur up to 20% of the time, is the best way to avoid surgical surprises. Hyperbaric oxygen therapy (HBO) is a medical treatment involving the delivery of 100 percent oxygen at pressures greater than atmospheric (sea level) pressure to patients with a variety of diseases. The resultant hyperoxia has a number of beneficial effects that can be utilized by the otolaryngologist as an effective adjunctive therapy for specific conditions such as osteoradionecrosis, necrotizing soft-tissue infections, and compromised skin flaps and grafts involved in reconstructive procedures. Hyperbaric therapy has been used for over a century, but only recently has there been a clarification of the mechanism of action and an understanding of its therapeutic effects. This review examines the beneficial biochemical, cellular, and physiologic effects of hyperbaric oxygen therapy, and discusses the specific indications currently considered appropriate for treatment. Contraindications and complications of this somewhat controversial therapy are reviewed and future endeavors are highlighted.

FOCUSING ON A JAUNDICED EYE ONE MORE TIME. Cesar V. Reyes, MD, Noel I. Rubio, MD, Arner Abboud, MD, and Nasrin Azad, MD. Medical Service and Pathology Laboratory Medicine Service, Veterans Affairs Hospital, Hines, Ill.

Sometimes jaundice is a difficult diagnosis. An illustrative case of cholestatic hepatitis is herein described to debate all the aspects of its differential diagnosis. A 48-year-old man, diabetic on glipizide, with monogamous life, was admitted for obstructive painless jaundice. Pertinent laboratory data were alkaline phosphatase 1,557 to 1,710 U/L, total bilirubin 10.2 to 18.2 mg/dL, gamma-glutamyl transferase 1255 to 1317 U/L, alanine aminotransferase 532 to 609 U/L, and aspartate aminotransferase 343 to 417 U/L. Hepatitis B surface Ag, hepatitis B surface Ab, hepatitis B core Ab, hepatitis A IgM, and hepatitis C profiles were all negative. Computed tomography, ultrasound, and ERCP showed mild hepatomegaly, early intra-hepatic ductal dilatation, prominent gastric mucosal rugae, and no evidence of stone and tumor. Esophagogastroduodenoscopy visualized the large gastric mucosal folds and on biopsy disclosed chronic active diffuse and erosive gastritis associated with Helicobacter pylori. Liver biopsy revealed chronic active cholestatic hepatitis of undetermined etiology with focal epithelioid cell reaction and negative stains for fungus, Mycobacterium, and hepatitis virus B and C. Alpha-1-antitrypsin, anti-mitochondrial, anti-parietal, anti-smooth muscle and anti-nuclear antigen studies were also negative. Withdrawn on admission, glipizide rechallenge was well tolerated. Slightly improved, the patient left the hospital against medical advice and was noncompliant with follow-up clinic appointment. He was readmitted 2 weeks later with the same symptoms, plus striking pruritic maculopapular rashes on the palms and soles of secondary syphilis. Serologic tests (RPR and Treponema pallidum micro hemagglutination assay) confirmed the diagnosis. With massive doses of intravenous penicillin, he promptly improved and the abnormal liver function tests normalized. Follow-up was essentially unremarkable. The diagnostic enigma of acute cholestatic hepatitis became clear when characteristic palmar and solar rashes of secondary syphilis appeared.

PSEUDOHYPERBILIRUBINEMIA (CONJUGATED) DUE TO SULFASALAZINE THERAPY Ellen R. Rand, MD, and Peter W. Wong, MD. Brooke Army Medical Center, Fort Sam Houston, Tex.

Sulfasalazine is used in the treatment of inflammatory bowel disease, ankylosing spondylitis, and rheumatoid arthritis. To detect liver disease in patients with inflammatory bowel disease, liver function tests are routinely ordered. We describe a case of a 34-year-old man with ulcerative colitis on sulfasalazine therapy for 4 years. He does not have a history of liver disease or jaundice. His screening liver function tests (LFT) showed an asymptomatic, conjugated hyperbilirubinemia of 4.7 mg/dL, with a total bilirubin of only 0.6 mg/dL. Repeat of LFT again revealed a conjugated hyperbilirubinemia of 7.0 mg/dL and normal total bilirubin of 0.6 mg/dL. After switching from sulfasalazine to mesalamine, the patient's conjugated bilirubin was 0.2 mg/dL within 7 days. The common laboratory assay for bilirubin analysis is based on the Jendrassik and Goff method. Sulfasalazine has been shown to bind to the assay components in vitro. Sulfasalazine thus interferes with the spectrophotometric analysis, such that a signif icant in vitro elevation of conjugated bilirubin is observed. The total bilirubin level is unaffected by this assay. This report is of significance to clinicians who use sulfasalazine in their clinical practice. Elevation of conjugated bilirubin without jaundice or elevated total bilirubin may simply be due to biochemical interaction of sulfasalazine in the serum sample with the laboratory assay method. Therefore, a patient successfully managed with sulfasalazine therapy can avoid an unnecessary change to other pharmacologic agents.

METASTATIC BREAST CARCINOMA MIMICKING MACRONODULAR CIRRHOSIS WITH PORTAL HYPERTENSION AND FULMINANT HEPATIC FAILURE. Gene Wallace, MD, and Peter I. Skidmore, MD. Brooke Army Medical Center, Fort Sam Houston, Tex.

A 42-year-old woman presented with new onset ascites and hepatic failure of undetermined etiology A year earlier, she had been diagnosed with poorly differentiated infiltrating intraductal carcinoma of the breast. She was treated with left modified radical mastectomy, 8 cycles of chemotherapy, and 8 weeks of radiation therapy. She was determined to be disease free and started on tamoxifen therapy. The patient was in her usual state of health until she presented with a 3-week history of fatigue, malaise, abdominal swelling, and jaundice. Admission vital signs were BP 135/68, mm Hg, pulse rate 102/mm, respiratory rate 18/mm, temperature 98.2[degrees]F, weight 72.22 kg. On physical examination, the patient appeared jaundiced. Cardiovascular examination revealed a regular rhythm, mild tachycardia, and a 3/6 systolic flow murmur. Abdomen was noted to have marked distention, normoactive bowel sounds, positive fluid wave and mild diffuse tenderness. Left breast was absent, right breast had no evidence of nipple retr action, dimpling, masses, or adenopathy. Initial laboratory data were significant for total bilirubin 10.7, AST 705, ALT 250, AP 336,GGT 260, LDH 1026, PT 20.5, PTT 81.7, Ammonia 36, WBC 8.0, Hct 35.7, Plts 71,000, CA125 1,186, and CA27-29 1,007. Abdominal CT displayed ascites and a small, hypoperfused liver. The diagnosis of Budd-Chiari was entertained. A limited ultrasound of the abdomen revealed a small liver with relative sparing of the left hepatic and caudate lobes consistent with macronodular cirrhosis. Hepatofugal blood flow was present within the main portal vein and esophageal varices were noted. The hepatic vein was patent, with no evidence of thrombosis. Liver biopsy was obtained by transjugular approach. Intrahepatic pressure measurement revealed portal hypertension and pathology showed near-complete replacement of the liver by metastatic adenocarcinoma with morphologic features consistent with breast origin. The liver is frequently involved in metastatic carcinoma, but presentation with portal h ypertension and hepatic failure is highly unusual. We report the eleventh case of metastatic breast cancer presenting as portal hypertension and only the second with fulminant hepatic failure.

ABDOMINAL CAVITY PRIMARY EFFUSION LYMPHOMA ASSOCIATED WITH HEPATITIS C VIRUS. Cesar V. Reyes, MD, Gladell P. Paner, MD, and JoAnne Jensen, SCT (ASCP) GMIAC. Cytology Section, Veterans Affairs Hospital, Hines, Ill.

Primary effusion lymphoma or body cavity-based lymphoma is a recently described rare subset of non-Hodgkin's lymphoma occurring within body cavities as lymphomatous effusion without any identifiable contiguous tumor mass and lymph nodal tumor. Involvement may be exclusively or predominantly pleural, abdominal, pericardial, or artificial cavities. Association with the human immunodeficiency virus (HIV), Kaposi's sarcoma-associated Herpes virus (KSHV/HHV-8), Epstein-Barr virus, and hepatitis C virus has been reported. We describe a case of an exclusively peritoneal cavity primary effusion lymphoma in an HIV-seronegative, 58-year-old man with hepatitis C virus-related liver cirrhosis. Cytologic, immunophenotypic, and DNA analysis of the tumor cells revealed a large B-cell non-Hodgkin's lymphoma with striking starry-sky pattern in cell block preparation. Epstein-Barr virus was not detected on immunostaining. Viral evaluation in the serum revealed positive hepatitis C virus, negative hepatitis surface antigen and hepatitis B core antigen, and in the neoplastic cells, negative KSHV/HHV8. Correlation with extended computed tomography proved the absence of mediastinal, abdominal, pelvic, and scrotal lymphadenopathy and mass lesions. The patient died 5 months after diagnosis despite intensive chemotherapy. Our case supports the hypothesis of a possible etiologic role of hepatitis C virus in the pathogenesis of primary effusion lymphoma.

HYPERBARIC OXYGEN THERAPY IN OTOLARYNGOLOGY. LCDR Kirby J. Scott, MC, USN. Chesapeake, Va.

Hyperbaric oxygen therapy (HBO) is a medical treatment involving the delivery of 100% oxygen at pressures greater than atmospheric (sea level) pressure to patients with a variety of diseases. The resultant hyperoxia has a number of beneficial effects that can be used by the otolaryngologist as an effective adjunctive therapy for specific conditions such as osteoradionecrosis, necrotizing soft tissue infections, and compromised skin flaps and grafts involved in reconstructive procedures. HBO has been used for over a century, but only recently has there been a clarification of the mechanism of action and an understanding of its therapeutic effects. This review examines the beneficial biochemical, cellular, and physiologic effects of HBO and discusses the specific indications currently considered appropriate for treatment Contraindications and complications of this somewhat controversial therapy are reviewed and future endeavors are highlighted.

A CASE OF NF II... NOT! VESTIBULAR PRESENTATION OF BILATERAL INTERNAL AUDITORY CANAL MASSES AS A MANIFESTATION OF NEUROSARCOIDOSIS. Mark Packer, MD, and Charles A. Syms, MD. San Antonio, Tex.

Neurosarcoidosis is a clinical manifestation of the systemic granulomatous disease within the CNS in 2-6% of those afflicted with sarcoidosis. This granulomatous inflammation has been reported in all regions of the brain. 48% of cases with CNS involvement present with neurological complaints. Of CNS lesions, cranial neuropathies are common with an order of prevalence from CN VII, II, IX/X, VIII, V. Isolated neuropathies, and focal granulomas are rarely reported. The vestibulocochlear nerve has been shown to play a role in approximately 20% of neurosarcoid cases. In the world literature to date, there have been 67 reported cases of CN VIII involvement, mostly combined with systemic disease, other cranial neuropathies, rarely as mass lesions, and all with clinical hearing loss. We report here the first case to our knowledge of neurosarcoidosis presenting with solely vestibular complaints, and with bilateral enhancing intracanalicular IAC masses. The literature is reviewed and the diagnostic dilemma considered.