Early adenoid cystic carcinoma of the upper oesophagus.

A 70-year-old male patient with an early stage primary adenoid cystic carcinoma of the oesophagus is reported. The 1.5 cm protuberant tumour, located in the upper oesophagus and found during examination for heartburn, was radically resected. It was restricted to the submucosa, which strongly suggests that it originated from the oesophageal glands. Microscopically, the tumour showed sparse S100 cells. This finding is in contrast with that in adenoid cystic carcinomas of the salivary glands.

Leiomyosarcoma of large and small veins: clinical findings and results of treatment in six patients.

Vascular leiomyosarcomas are rare malignant tumours originating from the media of the vessel wall. Six patients (five women and one man, aged 44-66 years) have been treated for a vascular leiomyosarcoma located in the inferior vena cava (three patients), the suprarenal, the external iliac and an antecubital vein. In four patients, the tumour was large and extended beyond the vessel wall giving rise to a retroperitoneal mass. In two patients the tumour was confined to the inner wall of respectively a large and small vein, occluding the lumen; the former was in the inferior vena cava and the latter in an antecubital vein. Block resection was performed in all patients. The tumours showed mitotic indices ranging from 6-32 mitoses/10 high power fields. The five patients with retroperitoneal tumours received additional radiotherapy varying from 50.00-70.00 Gy, on the basis of either macroscopic residual tumour or indefinite radicality. One of these five patients developed distant metastases within 2.5 years without local recurrence, the other four had no evidence of recurrence at follow-up, 3-7 years (mean 4.2 years) after surgery. The results illustrate the role of adjuvant radiotherapy in the control of local recurrence, when resection in this type of tumour proves to be either non-radical or totally radical.

The cut-closed-reconnected Roux loop.

BACKGROUND: Motility disturbances in the Roux loop can negatively influence the outcome of reflux gastritis; the uncut Roux loop does not have these disadvantages, but is less suitable for clinical application because of staple dehiscence. The reported "cut-closed-reconnected" Roux loop has the same physiological starting points as the uncut Roux loop, but a difference is an extra closure at the site of the seromuscular level. METHOD: The technique of the cut-closed-reconnected Roux loop is described. RESULTS: After 1 year, the clinical findings in 8 patients were as follows: 1 patient free of symptoms, 4 with gastric pain, 2 patients vomited (1 bilious), and 1 felt fullness. CONCLUSION: Dehiscence of the closure could not be demonstrated by endoscopy, barium contrast roentgenography, and HIDA scan.

Cytomegalovirus infection in the pregnant women.

Cytomegaloviruses (CMV) commonly infect man but overt disease only occurs in few patients; in the vast majority the infection is subclinical. We report on a HIV-negative pregnant woman. She suffered from a life-threatening ulcerating colitis due to CMV infection for which laparotomy was indicated. The case history is presented and suggestions are given for the surgical treatment of gastrointestinal complications such as haemorrhage, toxic colitis and perforation. Although CMV disease usually occurs in immunocompromised patients such as AIDS patients and transplant recipients, one should always keep the possibility of CMV infection in mind. The gastrointestinal tract is one of the sites of infection where the colon and terminal ileum are most frequently involved in complications such as bleeding and perforation. Gastrointestinal complications of CMV infection, although rare, can be life threatening and often require extensive surgery.

Traumatic neuroma giving rise to biliary obstruction after reconstructive surgery for iatrogenic lesions of the biliary tract--a report of three cases.

A traumatic neuroma of the biliary tract, most commonly has been described as an amputation neuroma in the cystic duct stump after cholecystectomy. Traumatic neuroma has less frequently been associated with biliary obstruction, and this combination is very rare after reconstructive surgery of the biliary tract. Three patients who had undergone a reconstructive procedure following accidental injury of the biliary tract during cholecystectomy are described. After many years they presented with jaundice due to an obstructive traumatic neuroma in the common hepatic duct (one patient) and in a previous biliary-digestive anastomosis (two patients). Eighteen cases of traumatic neuroma of the biliary tract causing obstructive jaundice, were found in the literature and analysed. As far as we know, a traumatic neuroma located in a previous biliary-digestive anastomosis has not been reported before.

Pressure and X-ray recording of reflux into the thoracic stomach.

Anastomotic leakage, pulmonary aspiration and reflux-esophagitis might be induced or aggravated by the increased duodenogastric reflux observed in the thoracic stomach. In this study, the effect of respiration on the reflux-promoting pressure gradient in the intrathoracally located stomach was assessed. In nine patients pressure recording was done in the duodenum and the abdominal and thoracic part of the stomach. Intrapleural pressure was determined by recording mouth pressure during inspiratory occlusion. In addition, the course of injected contrast was examined fluoroscopically. The mean end-expiratory pressure gradient in the thoracic part of the stomach was 0.8 cm H2O, increasing up to 6.0 cm H2O and 21.3 cm H2O during normal and forced inspiration, respectively. Fluoroscopic examination showed reflux of contrast that coincided with the downward movement of the diaphragm. From this study, we conclude that reflux into the thoracic stomach is promoted by intraluminal pressure fluctuations induced by voluntary breathing. Performing a pyloroplasty or -myotomy after intrathoracic esophagogastrostomy destroys the integrity of the pyloric sphincter as a barrier to reflux, thus promoting duodenogastric reflux.

Long-term follow-up after colectomy and ileorectal anastomosis in familial adenomatous polyposis coli. Is there still a place for the procedure?

Forty-four patients with familial adenomatous polyposis coli treated with colectomy and ileorectal anastomosis were studied. Mean age at operation was 27 years. The mean follow-up period was 10 years (median 8 years). Three patients (7%) developed rectal cancer 1, 4, and 24 years after the initial operation, respectively. Proctectomy with ileostomy was performed in one patient, and 7 patients underwent a conversion to an ileoanal procedure for an increasing number of rectal polyps in the rectum stump. Although frequent bowel actions and episodes of diarrhea were common findings in patients after colectomy and ileorectal anastomosis, almost all patients (96%) were more or less satisfied with their quality of life after the procedure. On the basis of our results and the results reported in the literature, colectomy with ileorectal anastomosis is still the operation of choice in selected patients with familial adenomatous polyposis coli. An initial ileal pouch - anal anastomosis, or a conversion to such a procedure after colectomy and ileorectal anastomosis is indicated, depending on the number and size of rectal polyps.

[Benign strictures of the bile ducts. Significance of adequate bile duct drainage for the prognosis and course of this disease]. / Gutartige Strikturen der Gallenwege. Die Bedeutung der ausreichenden Gallengang-Drainage für die Prognose und den Verlauf dieser Erkrankung.

Ninety-five patients with benign biliary strictures are presented in this study. All underwent reconstructive biliary surgery, either for proximal biliary strictures (Group A; 38 patients) or for distal biliary strictures (Group B; 57 patients). The type of bypass was individualized according to each patient's mechanical and anatomical characteristics as were assessed in our cholangiographic findings. For group A we used either a proximal to the stricture intrahepatic cholangiojejunostomy between Roux-en-Y jejunal loop and the main right or left hepatic ducts or multiple intrahepatic cholangiojejunostomies between segmental hepatic ducts and a Roux-en-Y jejunal loop. For Group B we chose between a choledocho- or hepaticoduodenostomy and a choledocho- or hepaticojejunostomy. There were three deaths due to sepsis, one in patients of group A and two among those of group B. Long-term results were satisfactory. None of our patients during a mean six year follow-up underwent further surgery for reasons related with either his/her operation or disease.

Primary closure of the perineum and vacuum drainage after abdominoperineal excision.

From retrospective study of the case records of 62 consecutive patients from whom 58 underwent abdominoperineal rectal excision for malignant or inflammatory bowel disease, it was found that management with primary closed perineum and closed pelvic peritoneum with closed vacuum drainage results in 84% primary perineal healing and short hospitalization. Perineal wounds were healed in 93% of patients within one month. Adequate exclusion of three sepsis promoting factors, e.g. dead space, devitalized tissue and micro-organisms should preclude perineal sepsis. The need for precise positioning of a large bore vacuum drain, Ch. 27, through a preoperatively determined stab-wound on the medial side of the thigh is stressed. To guarantee optimal drainage a three-stage procedure is required in a one-team management. The procedure is well tolerated as a palliation; patients with pre-existing massive perineal sepsis should be excluded.

[A mixed form of mucocele of the colon]. / Een gemengde vorm van mucocele van het colon.

The term mucocele is applied to an accumulation of mucus within a lumen lined with mucus-secreting epithelium as well as to the structure resulting from leakage of mucus into surrounding connective tissue. The case report is presented of a patient with a bizarre, mixed type of mucocele after perforation of a hemicolon retained 26 years previously, a clinical picture which could not be traced in the literature.

[Ileo-anal anastomosis with ileum reservoir]. / De ileo-anale anastomose met ileumreservoir.

Ileo-anal anastomosis with an ileal pouch is a reasonable alternative for patients with ulcerative colitis and adenomatous polyposis coli. The type of the reservoir, the length of the rectal cuff and the level of the anastomosis are still topics of discussion. This operation was performed in 41 patients. A modified J-reservoir (B-reservoir) was constructed in 34 patients in an attempt to improve the function of the neorectum. Twenty patients underwent inter-sphincteric freeing of the rectum and subsequent resection without leaving a rectal cuff. Although this procedure is associated with a considerable morbidity, the ultimate result is satisfactory.

[The clinical aspects and treatment of renal angiolipomas in patients with tuberous sclerosis]. / Het klinische beeld en de behandeling van renal angiomyolipomen bij patiënten met tubereuze sclerose.

The incidence of multiple and bilateral renal angiomyolipomas in tuberous sclerosis patients is 40-80%. These benign abundantly vascularised tumours are almost always asymptomatic. Most of the symptomatic renal angiomyolipomas measure more than 4 cm. These lesions are attended by a high risk of spontaneous rupture and massive haemorrhage. In our series of 23 tuberous sclerosis patients with renal angiomyolipomas 4 became symptomatic. Three of them were successfully treated wtih transcatheter selective embolization. Preventive embolization of renal angiomyolipomas appears indicated if these measure more than 4 cm. A fifth patient became symptomatic before the diagnosis of tuberous sclerosis was made. She had a forme fruste. She was also successfully treated by the same method.