Intraoperative magnetic resonance imaging-guided drainage of nonpalpable abscesses.

SUMMARY: Intraoperative magnetic resonance imaging provides the surgeon with powerful, high-resolution, real-time imaging. Procedures may be performed with minimal invasion, with the benefit of reduced tissue damage, improved wound healing, and a better cosmetic result. The authors present a case of a leukemic pediatric patient with a few large, deeply situated, nonpalpable abscesses that were drained successfully with intraoperative magnetic resonance imaging guidance. In this case, this new intraoperative imaging method enabled minimal invasiveness, with fast recovery.

Upper gastrointestinal bleeding due to gastric ulcers in children with gastrostomy tubes.

The authors describe four children with gastrostomy tubes (G-tubes) presenting with upper gastrointestinal bleeding due to gastric ulcers years after G-tube insertion. They review the literature and discuss the possible mechanisms of gastric ulcer formation in these patients.

[Preliminary report of experience with laparoscopic splenectomy in adults and children].

Laparoscopic splenectomy is effective and technically feasible for treating various hematological diseases such as idiopathic thrombocytopenic purpura (ITP), congenital spherocytosis, hemolytic anemia, and Hodgkin's lymphoma. An anterior approach to the vascular pedicle is usually described. However, in this approach to the splenic hilum, the dissection of the splenic artery is frequently difficult. The laparoscopic posterolateral approach involves dissection of the posterolateral attachments to the diaphragm, followed by the dissection and ligation of all splenic branches near the splenic parenchyma. We used it in 9 adults and 4 children: 11 patients had ITP, 1 spherocytosis and 1 Hodgkin's lymphoma. This procedure was completed in 13 patients, but in 2 it had to be converted to open surgery. Mean operating time was 3 hours and mean postoperative stay 3 days. Blood transfusion was not required and there were no postoperative complications. Laparoscopic splenectomy is safe in both adults and children, and the posterolateral approach provides excellent visualization and allows control of the branches of the splenic vein and artery in the splenic hilum.

Congenital aorto-caval fistula in the newborn: a case report.

The authors report a rare case of congenital fistula between the distal aspect of the descending aorta and the inferior vena cava. The clinical features of this aortocaval fistula is being described as well as the preoperative diagnostic workup, the intraoperative findings, and the complicated postoperative course and treatment.

A bizarre bezoar: case report and review of the literature.

A bizarre case of a foreign-body bezoar is presented. A 16-year-old girl swallowed large amounts of toilet paper as a means of dieting. She presented with a palpable abdominal mass, multiple bezoars in the bowel, and paper excretion in the feces before admitting intentional ingestion of toilet-paper balls. Administration of Gastrografin via a nasogastric tube and enemas resulted in gradual excretion of the paper balls.

Congenital hemangiopericytoma/infantile myofibromatosis: radical surgery versus a conservative "wait and see" approach.

Infantile/congenital hemangiopericytoma, although sharing many similar histological features with adult hemangiopericytoma, has a much better prognosis. Nevertheless, most cases described in the literature were pursued by radical surgery with or without adjuvant chemotherapy. We describe a neonate who presented with a huge mass in the right gluteus, 6 x 5 x 4 cm, and a small ventral abdominal mass. The masses were confirmed on biopsy according to light microscopy, immunohistochemistry, and electron microscopy as congenital hemangiopericytoma. They shrank spontaneously within 2 weeks and vanished within 2 months. We present a hypothesis that masses appearing in the neonatal period with this histology and with no life-endangering pressure on vital organs should routinely be dealt with conservatively.

Correct preoperative localization: does it permit a change in operative strategy for primary hyperparathyroidism?

BACKGROUND: A meticulous bilateral neck exploration by an experienced endocrine surgeon offers a high cure rate with low morbidity for patients with primary hyperparathyroidism. The advent of localizing studies raises the possibility of unilateral neck exploration. The cost-effectiveness of preoperative localizing studies and unilateral neck exploration in primary hyperparathyroidism are controversial issues. This study was designed to determine the risks of missing a contralateral pathologic parathyroid gland in patients with preoperative localization that was confirmed at neck exploration. METHODS: Preoperative studies (ultrasonography, nuclear radioactive imaging scan, or both) were performed in 79 patients with primary hyperparathyroidism. In 58 patients a definite localization of an enlarged parathyroid gland was confirmed at operation. All patients underwent a meticulous bilateral neck exploration. RESULTS: Unilateral neck exploration was feasible only in 73.4% of the patients, according to our localizing modalities, and an additional enlarged parathyroid gland on the contralateral side, not detected before operation, was revealed in five patients (8.6%). False-positive rates were 1.7% for ultrasonography and 13% for scan. CONCLUSIONS: These results indicate an unacceptably high surgical failure rate for unilateral neck exploration guided by preoperative localizing studies compared with a bilateral neck exploration by an experienced endocrine surgeon, questioning the cost-effectiveness of preoperative localizing studies.

Pitfalls in the detection of urinary extravasation following major urinary tract reconstructive surgery.

Urinary extravasation may complicate the postoperative course of urinary tract reconstructive surgery. Early diagnosis of extravasation is critical in the postoperative management. In this study we assessed prospectively the various diagnostic techniques employed in the detection and documentation of urinary extravasation in 76 consecutive patients who underwent major urinary tract reconstructive surgery. Assessment included measurements of the volume of the fluid obtained from the drains, analysis of serum to fluid creatinine ratio, detection of intravenously injected indigo dye and traditional radiographic evaluation. Urinary extravasation was detected in 7 patients (9.2%). Increased creatinine ratio had the highest diagnostic accuracy: 97.3%, sensitivity 71.4% and specificity 100%. Various radiological investigations had accuracy of 96%, sensitivity 85.7% and specificity 97.1%. The combined use of these methods detected all cases of urinary extravasation with sensitivity, specificity and total accuracy of 100%. Fluctuations in the volume of fluid in the drains and intravenous injection of indigo dye had lower accuracy, sensitivity and specificity and added very little to the workup. We conclude that radiological investigations and creatinine ratio analysis are highly accurate complementary methods for the early detection and monitoring of urinary extravasation following reconstructive urinary tract surgery.

Intraoperative irrigation with bupivacaine for analgesia after orchiopexy and herniorrhaphy in children.

Effective postoperative analgesia is important, especially in pediatric surgery. The efficacy of intraoperative surgical wound irrigation with bupivacaine for postoperative analgesia was investigated in 90 children undergoing elective inguinoscrotal surgery. We found that this method effectively reduced postoperative pain and narcotic drug requirement. Bupivacaine irrigation was simple and complication-free. We believe that the irrigation of surgical wounds with bupivacaine should be a routine procedure in elective inguinoscrotal surgery in children.

Prenatal diagnosis of congenital gastric outlet obstruction.

A case of gastric outlet obstruction diagnosed prenatally at 22 weeks' gestation is described. The differential diagnosis and the clinical management of this rare condition are discussed, and an updated literature review is presented.

Ureteral substitution using the isolated interposed vermiform appendix in a patient with a single kidney and transitional cell carcinoma of the ureter.

A patient with a single kidney presented with ureteral obstruction caused by a combination of primary transitional cell carcinoma of the ureter and extrinsic involvement of the ureter by a second primary malignant retroperitoneal lymphadenopathy. Due to the complexity of the case, we chose to perform a partial ureterectomy and used a method of ureteral substitution using the interposed vermiform appendix in combination with a psoas hitch. Application of the psoas hitch may allow the use of the appendix in most cases in which ureteral substitution becomes necessary. Antireflux mechanism is easily achieved with the appendix using the split cuff nipple technique. Finally, the use of the appendix allows complete retroperitonealization of the anastomoses to both ureter and bladder. We anticipate that the appendix will be used more commonly in the future as a ureteral substitute as more urologists become more comfortable with it through its use in various reconstructive procedures.

Segmental dilatation of the ileum: an uncommon cause of neonatal intestinal obstruction.

Two cases of congenital segmental dilatation of the ileum are reported. In both cases additional abnormal segments of bowel were not diagnosed during the initial laparotomy, and further surgical exploration was required. Consideration of this entity in the differential diagnosis of neonatal intestinal obstruction may enable definition of the optimal site for bowel resection and anastomosis.

Analysis of peripheral blood lymphocyte cell surface density of functional and activation associated markers in young and old hemodialysis patients.

Aging has been associated with specific shifts in various peripheral blood immune competent cell subsets. As part of pre-transplant immune profile evaluation possible parallel age-related changes in mean T-cell surface density of several cluster differentiation and activation linked antigens were into 2 groups: group 1-114 patients 40 years old or younger and group 2-36 patients 55 years old or older. Peripheral blood CD3+, DR+, CD3+DR+, CD4+, CD4+DR+, CD8+, CD8+DR+, CD56+, CD8+CD56+, CD3+IL-2-R+ and CD3+TR+ (interleukin-2 and transferrin receptors bearing CD3+ cells respectively), all mononuclear cells expressing IL-2-R and TR, and CD4+CD45+ cell subsets were analyzed and enumerated by 2-color flow cytometry. Subset relative levels as well as absolute counts were recorded. Cell surface density computation was performed using a computerized mathematical model based on fluorescence intensity vector analysis and cell size score determination based on light scatter pattern from raw data obtained by flow cytometry studies. Younger age was significantly associated with higher absolute cell count of CD3+ (p < 0.001), DR+ (p < 0.05), CD4+ (p < 0.01), CD8+ (p < 0.005), CD3+IL-2-R+ (p < 0.05), CD3+TR+ (p < 0.03) and IL-2-R+ (p < 0.05). Older patients had a slightly higher mean absolute count of CD4+CD45+ subset (p not significant) and significantly higher mean count for CD8+CD56+ cell subset (p < 0.001). When cell subset levels were compared between the 2 groups as the relative fraction of cells expressing a given marker out of all mononuclear cells gated out by flow cytometry, younger age was significantly associated with higher levels of CD3+ (p < 0.005), CD8+ (p < 0.001), CD4+DR+ (p < 0.004), CD3-TR+ (p < 0.05) and CD8+IL-2-R+ (p < 0.05). In contrast, slightly higher subset levels of CD56+ (p not significant), and significantly elevated levels of CD8+CD56+ (p < 0.0019) and CD4+CD45+ (p < 0.004) were observed in the older patients. Cell surface density analysis showed that younger patients had higher mean density per cell of CD3 (p < 0.05), CD8 (p < 0.001), IL-2-R on CD3+ cells (p < 0.05) and TR on CD3+ cells (p < 0.05). Mean cell surface density of CD56 on all CD56+ cells as well as on CD8+ cells was higher in older individuals (p < 0.001 and p < 0.003, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)

Bladder neck closure with an Indiana stoma outlet as a technique for continent vesicostomy.

A continent vesicostomy was performed upon two patients. The opened right colonic segment was used to augment the bladder and the ileocecal portion to create a continent abdominal stoma according to the technique used in the Indiana pouch. One patient had complete obstruction of the urethra 1 centimeter distal to bladder neck. The second patient was a paraplegic with an contractile bladder and complete outlet incontinence who was reluctant to perform transurethral self-catheterization. After postoperative follow-up evaluation of 36 and 22 months, respectively, both patients are completely continent day and night on self-catheterization every six hours with preserved function of the upper part of the tract.

A direct approach to the left and middle hepatic veins during left-sided hepatectomy.

A direct surgical approach to the MHV during left-sided hepatectomy is anatomically feasible. The procedure should be applied with appropriate safety measures. Prior verification of the precise anatomic relationship of the hepatic veins is necessary and the MHV should be isolated and secured by the described stepwise technique.

Is it justified to avoid radical cystoprostatectomy in elderly patients with invasive transitional cell carcinoma of the bladder?

BACKGROUND: Although radical cystectomy is accepted by most urologists as the treatment of choice for invasive carcinoma of the bladder and age alone is not considered a contraindication for radical surgery, many consider radical major operations to be unsuitable for elderly patients. METHODS: The authors compared the results of radical cystectomy in 42 elderly patients to those in patients 69 years old or younger and to a group of 21 elderly patients, matched by stage of disease and severity of medical problems, who received alternative treatment. RESULTS: The overall operative mortality rate was 6.3% (seven patients). Three (4.3%) postoperative deaths in the younger group and four (9.5%) deaths among elderly patients were recorded. The operative morbidity and mortality did not differ significantly between those two groups (P = 0.1). Among the patients who received alternative therapy, 13 (61.9%) died within the first 6 months, and only 3 survived more than 12 months. Morbidity was encountered in 97% of these patients. CONCLUSIONS: The authors showed that radical cystectomy is a relatively safe procedure for elderly patients. The elderly patient who is thought to be unsuitable for surgery not only is deprived of his right to definite curative therapy but also is exposed to higher morbidity and mortality and worse quality of life than are those who undergo operations. The authors conclude that it is unjustified to avoid radical cystectomy in the elderly population on the basis of age alone.

Quantitative changes in platelet counts following major urological pelvic surgery.

Postperative quantitative changes in platelet counts have been reported following various extensive surgical procedures. It is generally accepted that reactive thrombocytosis at levels less than 1,000,000/mm3 is a benign condition and is not associated with increased risk of postoperative thrombohemorrhagic complications. The role of prophylactic treatment with platelet inhibitors in these situations is controversial. We assessed retrospectively the timing and the extent of postoperative thrombocytosis in 85 consecutive patients following major urological pelvic surgery and evaluated its possible clinical significance to hemorrhagic and thromboembolic complications, in view of the coincidence of multiple potential risk factors for thromboembolism in these patients. 73 (85.9%) patients demonstrated marked postoperative changes of platelet counts. In 12 patients (14.1%) we found only minor fluctuations in platelet counts throughout the postoperative period. Two distinct groups of 26 and 47 patients respectively could be identified among these 73 patients, who differed in the rate and extent of changes in platelet counts. Those fluctuations were characterized by an early decrease in platelet levels (mean percentage change of 40 and 60% in groups I and II respectively). This was followed by a gradual increase leading to delayed thrombocytosis (mean percentage change of 225 and 305% in groups I and II respectively). Thromboembolic complications were diagnosed in 5 patients. The occurrence of thromboembolism preceded any significant increase in platelet counts in all 5 patients. There was no correlation between the timing of thromboembolic complications and timing and extent of the change in platelet count. We conclude that reactive thrombocytosis following major urological pelvic surgery is a frequent innocuous finding and is not associated with hemorrhagic or thromboembolic complications.(ABSTRACT TRUNCATED AT 250 WORDS)

Non-autonomy of parathyroid hormone secretion in acute primary hyperparathyroidism.

A patient with acute primary hyperparathyroidism treated with mithramycin preoperatively, underwent neck exploration and two enlarged parathyroid glands were excised: one huge adenoma (6g) and another smaller gland. Mithramycin was administered preoperatively to lower life-threatening hypercalcaemia, and parathyroid slices from the huge adenoma removed at surgery were submitted in vitro to various calcium concentrations in the media to determine the influence of calcium on parathyroid adenoma secretory pattern in acute primary hyperparathyroidism. Mithramycin induced a significant decline in calcium levels and significant elevations of calciotrophic hormones (intact PTH, mid-region specific PTH, calcitonin and calcitriol). Significant suppression in PTH output in vitro was achieved by increasing calcium levels in the media. These results exclude autonomous PTH secretion (non-calcium dependent) as a possible aetiology of acute primary hyperparathyroidism. We suggest that a sudden increase in the set-point of the diseased parathyroid cells in the presence of a huge cell mass accounts, in large part, for both the marked hypercalcaemia and elevated PTH levels in this patient.