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1/26. patients with morbid obesity don't get life-saving bone marrow transplants.

    When the patient, a registered nurse, was surgically treated for morbid obesity she initially lost 54.5 kg. Approximately 2 years after gastric bypass, she received a diagnosis of chronic myelogenous leukemia and subsequently underwent a successful allogenic bone marrow transplant (BMT). When her surgical history was taken at the transplant facility, the significant weight loss and gastric bypass were discussed. She was informed that at 140 kg, she would not have been eligible nor considered a candidate for transplant. A search of the literature and a survey of other facilities confirmed this view as typical. The reasons cited were that the chemotherapy dosage required for the morbidly obese weight level would cause fatal organ damage as opposed to organ-sparing dosages, which would not eradicate all leukemic cancer cells. An additional general view was that the morbidly obese could not survive the rigors of the transplant preoperative regimen. This patient had an uneventful recovery and remains disease-free today, 3 years after BMT and 5 years after gastric bypass, with a sustained total weight loss of 73 kg.
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2/26. Cognitive-behavioral therapy for bulimia nervosa: an illustration.

    Cognitive-behavioral therapy for bulimia nervosa (BN) is a well-developed, theoretically grounded treatment for BN with the strongest empirical support for its efficacy of any form of treatment for BN. The treatment package comprises three distinct phases typically delivered over 20 weeks. Incorporating a variety of specific interventions, these three phases of treatment focus systematically on (i) dietary restraint, (ii) dysfunctional beliefs about body weight and shape, and (iii) reactions to recurrence of symptoms, which are thought to be the primary operative mechanisms that cause and maintain BN symptoms. Case material is presented to illustrate cognitive-behavioral treatment principles.
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3/26. A case of huge ovarian cyst of 21-year-old young woman.

    Huge ovarian tumors are rarely seen in modern surgical practice. As health care education and access to hospitals have improved over the past 30 years, the number of these reports have become almost negligible. However, these huge ovarian tumors still present many challenge, even life-threatening risks due to severe cardiovascular, pulmonary, and circulatory problems, including technical difficulties of surgery, massive hemorrhage, and postoperative complications. A knowledge of the deranged physiology and its management may avert these complications. We present the case of a 21-year-old woman with huge ovarian tumor. The total weight of the tumor was 136 pounds (62 kg). She was treated surgically with good results.
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4/26. Refracture of proximal fifth metatarsal (Jones) fracture after intramedullary screw fixation in athletes.

    This study details six instances of refracture of clinically and radiographically healed fractures of the base of the fifth metatarsal after intramedullary screw fixation. Four professional football players, one college basketball player, and one recreational athlete underwent intramedullary screw fixation of fifth metatarsal fractures. The athletes were released to full activities an average of 8.5 weeks (range, 5.5 to 12) after fixation, when healing was clinically and radiographically documented. Three football players developed refracture within 1 day of return to full activity. The other three athletes refractured at 2.5, 4, and 4.5 months after return to activity. Two football players underwent repeat fixation with larger screws and returned to play in the same season. The college basketball player underwent bone grafting and returned to play in subsequent seasons. The other three athletes underwent nonoperative management and healed uneventfully over 6 to 8 weeks. On the basis of this series, we recommend that 1) screw fixation using a large-diameter screw should be given careful consideration for patients with large body mass for whom early return to activity is important; 2) functional bracing, shoe modification, or an orthosis should be considered for return to play; 3) if refracture occurs, exchange to a larger screw may allow return to play in the same season; and 4) alternative imaging should be considered to help document complete healing.
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5/26. Initial experience with fenoldopam in children.

    fenoldopam is a direct-acting vasodilator that acts at the postsynaptic dopamine 1 receptors in renal, coronary, cerebral, and splanchnic vasculature resulting in arterial dilation and a lowering of the mean arterial pressure (MAP). Preliminary evidence suggests its efficacy in the treatment of hypertensive urgencies and emergencies in adults. We present four children in whom fenoldopam was used to control MAP in various clinical scenarios, including hypertensive emergencies and urgencies, intraoperative reduction of MAP for controlled hypotension, and control of MAP during extracorporeal membrane oxygenation. The possible applications of fenoldopam and suggested dosing regimens in children are reviewed.
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6/26. Intraluminal duodenal obstruction by a gastric band following erosion.

    BACKGROUND: duodenal obstruction occurred 4 years following gastric banding for morbid obesity, which had had a good result. METHOD: A 56-year-old female with a history of gastric banding presented with duodenal obstruction. RESULT: Physical and radiological examination was able to give the diagnosis. At surgery, the gastric band in the distal duodenum was removed. She was discharged on postoperative day 4, with no complication. At 6 months following discharge, her nausea and vomiting have not recurred. CONCLUSION: Following gastric banding, band erosion through the gastric wall and internalization into the lumen can cause small bowel obstruction.
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7/26. rhabdomyolysis following total hip arthroplasty.

    We report six cases of contralateral limb involvement during total hip arthroplasty including swelling of the gluteal muscle compartments, rhabdomyolysis, myoglobinuria, and sciatic nerve palsy. The risk factors for such complications include obesity, prolonged operative time, and positioning in the lateral decubitus position. The laboratory and clinical findings are consistent with a gluteal muscle crush-injury with consequent compartment syndrome. The patients should be treated conservatively as symptoms can be expected to resolve.
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8/26. somatostatin analogue SMS 201-995 long term therapy for vipoma.

    The definitive treatment of a pancreatic tumour secreting vasoactive intestinal polypeptide is surgical removal of the tumour, but when curative resection is not possible symptomatic treatment of the endocrine hyperfunction is important. Streptozotocin, although effective for palliation, can involve unpleasant side effects. We report the long term use of subcutaneous somatostatin analogue SMS 201-995 in an elderly man presenting with severe watery diarrhoea and anaemia due to a pancreatic vipoma. Good symptomatic improvement has been achieved with no side effects over a period of 24 months. We suggest there is a use for subcutaneous SMS 201-995 in elderly patients with inoperable pancreatic gut hormone producing tumours with metastases and in those where surgery would carry a high operative risk.
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9/26. Surgical treatment of regional adiposity. lipectomy versus surgically induced weight loss.

    Recognition of abdominal fat distribution as a significant risk factor raised the question whether surgical treatment of regional adiposity might be feasible or desirable. This is a review of cosmetic and therapeutic lipectomy in man and experimental lipectomy in rodents examining morphologic and metabolic aspects as well as conditions for growth and regrowth of adipose tissue. Potentially detrimental metabolic effects of lipectomy are discussed in the context of the "metabolic sink" hypothesis. Data are also presented on the distribution of weight loss after gastrointestinal surgery for morbid obesity. An obesity-related "elephantiasis" syndrome in superobese men is described. "Giant lipectomy" in one such case, removing a record 50 kg during one operation, with pre- and postoperative determination of body fat is reported. It is concluded that lipectomy is not a treatment for obesity with very rare exceptions. Regrowth of adipose tissue is possible under special circumstances. Surgically induced massive weight loss does not seem to cause preferential regional weight loss, though risk-reducing beneficial metabolic effects are achieved after gastrointestinal obesity surgery.
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10/26. Surgical complications of the Garren-Edwards Gastric Bubble.

    A retrospective review of our initial experience with the Garren-Edwards Gastric Bubble (American Edwards laboratories) was undertaken to study its surgical complications. Between 22 February and 30 August 1986, 250 patients had 275 gastric bubbles endoscopically inserted as an adjuvant treatment for morbid obesity. Profiles of the first 104 patients revealed a mean weight of 113.0 kilograms (74 per cent above ideal body weight) and a mean weight loss of 10.1 kilograms (0.76 kilogram per week) followed by a gain of 0.48 kilogram from the period of peak weight loss at 13.7 weeks to removal at 19.4 weeks. Thirty-three per cent had endoscopic removal and the remainder passed per rectum. Ninety-two had undergone previous abdominal operation. Five instances of obstruction of the upper part of the gastrointestinal tract (mean 18.3 weeks after insertion) required three operative removals, one endoscopic retrieval from the second portion of the duodenum and one hypaque small intestinal series with oral mineral oil to induce spontaneous passage. Four of the five patients had prior abdominal operations--cholecystectomy in one instance, appendectomy in one, cholecystectomy and appendectomy in one and exploratory laparotomy for multiple stab wounds in one. One (multiple stab wounds) had adhesions at the point of the obstruction. The patient who underwent endoscopic retrieval had premature deflation at 6.7 weeks presumably due to a defective bubble. The weight gain after peak weight loss at 13.7 weeks likely represents spontaneous bubble deflation. Prior abdominal surgical treatment appears to be a significant risk factor for the development of obstruction after bubble deflation. In addition, two of five patients have been lost to follow-up study after insertion. Proper patient selection and careful monitoring may be crucial in reducing the morbidity associated with the Garren-Edwards Gastric Bubble.
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