Re-innervation and neo-innervation are known to take place following hernia repairs in indigenous tissue as well as through polypropylene meshes. However, when pain is an overriding issue dictating mesh explant, the degree of mesh innervation is significantly higher when compared to mesh excised for recurrence. That increase has been confirmed statistically.
Bilateral lower extremity vasospasm associated with severe pain and hyperesthesias in the legs, and digital gangrene in both feet developed in a 50-year-old man with carcinoid syndrome. Nifedipine and chemical lumbar sympathectomy were partially effective in relieving the vasospasm. Electromyographic findings were consistent with ischemic neuropathy. A skin biopsy specimen showed striking dermal fibrosis. Serotonin and other vasoconstrictor substances released from the tumor may be responsible for the vasospasm, the dermal sclerosis, and the ischemic neuropathy. The early use of lumbar sympathec-tomy in patients with lower extremity vasospasm may prevent these irreversible ischemic complications. Cancer 62:1026-1029, 1988. ARCINOID TUMORS are apudomas' originating C from the Kulchitsky cells of the crypts of Lieber-kuhn.' Pearse coined the term APUD for cells with amine precursor uptake and decarb~xylation.~ These endocrine cells are widely distributed in the body and are particularly numerous in the gastrointestinal tract. They synthesize and secrete several biologically active peptides and amines including serotonin, substance P, histamine, prostaglandins, kallikrein, bradykinin, Shy-droxytryptophan, hydroxytryptophol, vasoactive intestinal polypeptide (VIP), catecholamines, calcitonin, corticotropin (ACTH), and growth h ~ r m o n e. " ~ Carcinoid syndrome usually occurs when the hepatic inactivation of the amine is exceeded because of the massive secretion by the primary tumor, or if the tumor involves the liver, which reduces the metabolizing capacity and also permits a direct release of secretory products into the hepatic veins. The systemic manifestations of the syndrome are ~ariable.~ The most frequent symptoms include diarrhea, flushing, those due to valvular disease of the right heart, and asthma.6 More unusual are the manifestations of malnutrition and pellagra due to overconsumption of tryptophan by the tumor.7 From the Divisions of Hematology/Oncology and Vascular Surgery,
Irreversible damage of the nerves and vas musculature due to mesh migration is one of the mechanisms for sexual pain and dysejaculation. Attempts at all cost to preserve elements of the spermatic cord may not be justified in cases of severe pain, especially sexual pain (and/or dysejaculation) and intraoperative finding of cord involvement by the mesh. Vasectomy with mesh removal may well be indicated and be considered not a radical procedure but a conservative measure given the severity of the pain!
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