Minimally invasive treatment of abdominal lymphocele: A review of contemporary options and how to approach them.

Lymphoceles are lymphatic fluid collections resulting from lymphatic vessel disruption after surgery or trauma. They are most often described following retroperitoneal surgeries such as cystectomies, prostatectomies, renal transplants, and gynecologic surgeries. Most lymphoceles are asymptomatic and resolve spontaneously without treatment. If persistent, they can become infected or exert mass effect on adjacent structures causing pain, urinary, or lower limb edema particularly for lymphoceles in the pelvis Symptomatic lymphoceles should be treated to relieve symptoms and prevent functional compromise of vital adjacent structures. Although surgery has been traditionally accepted as the gold standard treatment, advances in imaging and interventional technology allow for less invasive, percutaneous treatment. Available minimally invasive treatment options include percutaneous aspiration, catheter drainage, sclerotherapy, and lymphangiography with lymphatic embolization. A review of these treatment options and a suggested algorithm for managing lymphoceles is presented.

Structure and localization of mouse Pmscl1 and Pmscl2 genes.

Sera from some patients with polymyositis-scleoderma overlap syndrome (PM-SCL) recognize two antigenically unrelated proteins, PMSCL1 and PMSCL2. Complete mouse Pmscl1 and Pmscl2 cDNA sequences, chromosomal localizations, exon/intron structure, and promoter region sequences of the mouse Pmscl2 gene are presented. The PMSCL1 gene was found to overlap significantly with cyclin A2 in both human and mouse. As such, it may be deduced that PMSCL1 sequences map to human chromosome 4q27 and the proximal portion of mouse chromosome (Chr) 3 where human and mouse cyclin A2 genes reside. Analysis of human and mouse PMSCL1 cDNA sequences provides evidence that the PMSCL1 protein is 68 amino acids longer than previously thought. A BAC containing mouse Pmscl2 was localized to distal mouse Chr 4 by FISH. This BAC contains the microsatellite D4Mit310. D4Mit310 colocalizes with a number of genes that map to human 1p36. In fact, a STS (G25404) located 54.6 cR from the top of human chromosome 1 was found to contain PMSCL2 sequence upon BLAST search.

Mapping of the SWAP70 gene to mouse chromosome 7 and human chromosome 11p15.

The protein SWAP-70 was isolated as part of a DNA recombination complex in B lymphocytes, where it is predominantly expressed. In resting B cells, SWAP-70 is found in the cytoplasm; upon B-cell activation, it is transported both into the nucleus and to the cell membrane, where it is associated with the B-cell receptor complex and may play a role in signal transduction. In the nucleus, its involvement in heavy-chain class switch recombination has been suggested. In this report, using restriction fragment length polymorphism, simple sequence length polymorphism, and fluorescence in situ hybridization, we map the chromosomal localization of the mouse and the human genes to syntenic regions of mouse mid Chromosome (Chr) 7 and human Chr 11p15.

Diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis.

AIM: To determine the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and trans-abdominal ultrasound in the detection of choledocholithiasis, and to compare bile duct stone characteristics using endoscopic retrograde cholangiopancreatography (ERCP), MRCP and ultrasound. MATERIALS AND METHODS: Of 191 consecutive patients referred for diagnostic ERCP, choledocholithiasis was diagnosed in 34 patients using direct cholangiography. The latter took the form of ERCP (n = 29), intraoperative cholangiography (n = 3) or percutaneous transhepatic cholangiography (n = 2). All patients underwent MRCP and ultrasound examinations and their findings for choledocholitiasis were compared with those at direct cholangiography. Finally, in the 29 patients with choledocholithiasis diagnosed under ERCP, stone characteristics were compared across the three investigations of ERCP, MRCP and ultrasound. RESULTS: Compared with direct cholangiography, MRCP showed a sensitivity, specificity and diagnostic accuracy of 91%, 98% and 97%, respectively, in the diagnosis of choledocholithiasis. MRCP resulted in three false-negative and three false-positive findings, four of which occurred due to confusion with lesions at the ampulla. Ultrasound showed a sensitivity, specificity and diagnostic accuracy of 38%, 100% and 89%, respectively, in the diagnosis of choledocholithiasis. ERCP revealed a greater number of stones and these were more proximally distributed within the bile ducts when compared to MRCP. CONCLUSIONS: MRCP is highly accurate in the diagnosis of choloedocholithiasis and has the potential to replace diagnostic ERCP. MRCP underestimates the number of bile duct stones present.

The diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis.

AIM: To determine the diagnostic accuracy of magnetic resonance cholangiopancreatography (MRCP) and ultrasound (US) in the diagnosis of choledocholithiasis in a large group of patients with bile duct stones confirmed at direct cholangiography. Also, to compare bile duct stones confirmed at direct cholangiography. Also, to compare bile duct stone characteristics using the three different investigations, endoscopic retrograde cholangiopancreatography (ERCP), MRCP and US. MATERIALS AND METHODS: 191 patients (M:F, 76:115; mean age, 66 years; range, 24-92 years) were investigated by direct cholangiography, MRCP and US. Their final diagnosis as determined at direct cholangiography were choledocholithiasis (n = 34), strictures (n = 47) and normal ducts (n = 110). The direct cholangiographic methods used for diagnosis of choledocholithiasis were ERCP (n = 29), intraoperative cholangiography (n = 3) and percutaneous transhepatic cholangiography (n = 2). The bile duct stone characteristics were compared using ERCP, MRCP and US in the 29 patients in whom stones were exclusively diagnosed by ERCP. RESULTS: Compared with the final diagnosis, MRCP had a sensitivity, specificity and diagnostic accuracy of 91%, 98% and 97%, respectively, in the diagnosis of choledocholithiasis. MRCP resulted in three false-negative and three false-positive findings, four of which occurred due to confusion with lesions at the ampulla. US had a sensitivity, specificity and diagnostic accuracy of 38%, 100% and 89%, respectively, in the diagnosis of choledocholithiasis. ERCP diagnosed more stones and the stones were more proximally distributed within the bile duct at ERCP when compared with MRCP. CONCLUSION: MRCP has a high diagnostic accuracy (97%), similar to that at direct cholangiography, in the diagnosis of choloedocholithiasis. It has the potential to replace diagnostic ERCP and select patients with choledocholithiasis for therapeutic ERCP.

Recurrent TIPS failure associated with biliary fistulae: treatment with PTFE-covered stents.

PURPOSE: To evaluate the efficacy of covered stents for the treatment of transjugular intrahepatic portosystemic shunt (TIPS) obstruction in human subjects with identified or suspected biliary fistulae. METHODS: Five patients were treated for early failure of TIPS revisions. All had mid-shunt thrombus, and four of these had demonstrable biliary fistulae. Three patients also propagated thrombus into the native portal venous system and required thrombolysis. TIPS were revised in four patients using a custom-made polytetrafluoroethylene (PTFE)-covered Wallstent, and in one patient using a custom-made PTFE-covered Gianturco Z-stent. RESULTS: All identified biliary fistulae were successfully sealed. All five patients maintained patency and function of the TIPS during follow-up ranging from 2 days to 21 months (mean 8.4 months). No patient has required additional revision. Thrombosis of the native portal venous system was treated with partial success by mechanical thrombolysis. CONCLUSION: Early and recurrent failure of TIPS with mid-shunt thrombosis, which may be associated with biliary fistulae, can be successfully treated using covered stents. Stent-graft revision appears to be safe, effective, and potentially durable.

Comparative analysis of smooth muscle isoactin gene expression in normal and neoplastic tissues.

Monoclonal antibodies derived from the actin multigene family are routinely used as an adjunct to morphologic diagnoses of smooth muscle tumors. Northern blot analysis was performed on 60 surgical resections utilizing isoactin-specific cDNAs. A comparison of this analysis to immunohistochemical studies demonstrated that actin-specific monoclonal antibodies represent reliable markers of the smooth muscle lineage. Smooth muscle neoplasms showed a unique pattern of gamma-smooth muscle isoactin gene expression, providing a potentially valuable molecular adjunct to the morphologic diagnosis of uterine smooth muscle tumors.

Percutaneous endoluminal placement of stent-grafts for the treatment of isolated iliac artery aneurysms.

PURPOSE: To evaluate the feasibility of stent-grafts for treatment of isolated iliac artery aneurysms (IAAs). MATERIALS AND METHODS: Nine IAAs in eight patients were treated with transluminally placed endovascular stent-grafts. All patients were men (median age, 72 years). In three, the aneurysm involved both the common and internal iliac arteries. In one, common and external iliac arteries were involved. The other aneurysms involved only the common iliac artery. Two aneurysms were treated with balloon-expandable stents covered with polytetrafluoroethylene (PTFE) graft material, three were treated with self-expanding Z-stents covered with a woven polyester graft, and four were treated with self-expanding Z-stents covered with PTFE. RESULTS: Transluminal placement of the stents was successful in all patients with thrombosis of the aneurysms. There were no distal thromboembolic events, deaths, or infections. The median follow-up period was 8.5 months. CONCLUSION: Initial results suggest that transluminal stent-graft placement for treating isolated IAAs is a safe and effective alternative to surgery in selected patients. Long-term follow-up data are needed before this approach can be recommended for the primary treatment of IAAs.

Endovascular stent-grafting after arch aneurysm repair using the "elephant trunk".

A 68-year-old woman with severe chronic obstructive pulmonary disease, aortic valvular insufficiency, and diffuse thoracic aortic aneurysm underwent aortic valve replacement and separate Dacron graft replacement of the ascending aortic and arch aneurysms using the elephant trunk technique. She was discharged on the tenth postoperative day. Five months later, she underwent endovascular stent-graft repair of the descending thoracic aortic aneurysm. She recovered uneventfully, and was discharged on the third postoperative day. Follow-up computed tomography at 6 months demonstrated exclusion of all flow into the descending thoracic aortic aneurysm. The elephant trunk technique followed by endovascular stent-grafting of the descending thoracic component is a potential therapeutic option in selected high-risk patients with diffuse aortic aneurysmal disease.

The secretory phospholipase A2 gene is a candidate for the Mom1 locus, a major modifier of ApcMin-induced intestinal neoplasia.

Mutations in the APC gene are responsible for various familial and sporadic colorectal cancers. Min mice carry a dominant mutation in the homolog of the Apc gene and develop multiple adenomas throughout their small and large intestine. Quantitative trait loci studies have identified a locus, Mom1, which maps to the distal region of chromosome 4, that dramatically modifies Min-induced tumor number. We report here the identification of a candidate gene for Mom1. The gene for secretory type II phospholipase A2 (Pla2s) maps to the same region that contains Mom1 and displays 100% concordance between allele type and tumor susceptibility. Expression and sequence analysis revealed that Mom1 susceptible strains are most likely null for Pla2s activity. Our results indicate that Pla2s acts as a novel gene that modifies polyp number by altering the cellular microenvironment within the intestinal crypt.

An unusual round cell tumor of the tibia with granular cells.

We present the clinical, radiographic and histopathologic findings of an unusual tumor that originated in the diaphysis of the tibia in a 10-year-old boy. Clinical symptoms had been present for approximately 2 years and radiographic abnormalities for > or = 8 months before biopsy and subsequent resection of the neoplasm. The child is doing well 4 1/2 years later. Microscopically, the tumor was not typical of any bone tumor with which we are familiar. It was a round-cell tumor with extensive fibrosis, prominent cytoplasmic granularity, and isolated immunoreactivity for vimentin, epithelial membrane antigen, and antichymotrypsin. Ultrastructural examination uncovered the presence of both well-formed desmosomes and cell-associated basement membrane material in addition to abundant phagolysosomes. Classification of this tumor is a challenge; the differential diagnosis includes atypical adamantinoma, atypical Ewing's sarcoma, and small-cell osteosarcoma. We favor the former interpretation, although we raise the possibility that it may be a unique lesion.

A high-resolution linkage map of the lethal spotting locus: a mouse model for Hirschsprung disease.

Mice homozygous for the lethal spotting (ls) mutation exhibit aganglionic megacolon and a white spotted coat owing to a lack of neural crest-derived enteric ganglia and melanocytes. The ls mutation disrupts the migration, differentiation, or survival of these neural crest lineages during mammalian development. A human congenital disorder, Hirschsprung disease (HSCR), is also characterized by aganglionic megacolon of the distal bowel and can be accompanied by hypopigmentation of the skin. HSCR has been attributed to multiple loci acting independently or in combination. The ls mouse serves as one animal model for HSCR, and the ls gene may represent one of the loci responsible for some cases of HSCR in humans. This study uses 753 N2 progeny from a combination of three intersubspecific backcrosses to define the molecular genetic linkage map of the ls region and to provide resources necessary for positional cloning. Similar to some cases of HSCR, the ls mutation acts semidominantly, its phenotypic effects dependent upon the presence of modifier genes segregating in the crosses. We have now localized the ls mutation to a 0.8-cM region between the D2Mit113 and D2Mit73/D2Mit174 loci. Three genes, endothelin-3 (Edn3), guanine nucleotide-binding protein alpha-stimulating polypeptide 1 (Gnas), and phosphoenolpyruvate carboxykinase (Pck1) were assessed as candidates for the ls mutation. Only Edn3 and Gnas did not recombine with the ls mutation. Mutational analysis of the Edn3 and Gnas genes will determine whether either gene is responsible for the neural crest deficiencies observed in ls/ls mice.

Transluminal placement of endovascular stent-grafts for the treatment of descending thoracic aortic aneurysms.

BACKGROUND: The usual treatment for thoracic aortic aneurysms is surgical replacement with a prosthetic graft, but the associated morbidity and mortality are considerable. We studied the use of transluminally placed endovascular stent-graft devices as an alternative to surgical repair. METHODS: We evaluated the feasibility, safety, and effectiveness of transluminally placed stent-graft to treat descending thoracic aortic aneurysms in 13 patients over a 24-month period. Atherosclerotic, anastomotic, and post-traumatic true or false aneurysms and aortic dissections were treated. The mean diameter of the aneurysms was 6.1 cm (range, 5 to 8). The endovascular stent-grafts were custom-designed for each patient and were constructed of self-expanding stainless-steel stents covered with woven Dacron grafts. RESULTS: Endovascular placement of the stent-graft prosthesis was successful in all patients. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent-graft in 12 patients, and partial thrombosis in 1. Two patients initially had small, residual patent proximal tracts into the aneurysm sac, but both tracts thrombosed within two months after the procedure. In four patients, two prostheses were required to bridge the aneurysm adequately. There have been no deaths or instances of paraplegia, stroke, distal embolization, or infection during an average follow-up of 11.6 months. One patient with an extensive chronic aortic dissection required open surgical graft replacement four months later because of progressive dilatation of the arch. CONCLUSIONS: These preliminary results demonstrate that endovascular stent-graft repair is safe in highly selected patients with descending thoracic aortic aneurysms. This new method of treatment will, however, require careful long-term evaluation.

A mechanically detachable coil for the treatment of aneurysms and occlusion of blood vessels.

PURPOSE: To evaluate mechanically detachable coil designs capable of controlled and instantaneous release within an aneurysm or vascular space. METHODS: Three mechanically detachable coil designs, clamped ball, looped ribbon, and interlocking cylinder, were evaluated using in vitro and in vivo testing to study reliability of coil release, retractability, and coil behavior in a microcatheters. In vitro tests were performed using a glass side-wall aneurysm model and conventional microcatheters. In vivo experiments in rabbits included aneurysm models (side-wall and bifurcation) and arterial occlusions (carotid and renal). RESULTS: All three designs deployed coils easily and were able to retract coils after partial deployment. Motion was seen in previously released coils and in the catheter when using the clamped ball and looped ribbon designs. The interlocking cylinder design did not cause similar motion. When compared with the other two designs, the interlocking cylinder had significantly greater separation forces between coil pusher and coil while in the catheter. Frictional forces within the catheter were lower for the interlocking cylinder mechanically detachable coil design than for a commercially available conventional coil and coil pusher system. During in vivo testing, the mechanically detachable coil design operated smoothly in the catheter, providing good release and retraction in aneurysms and straight vessels. CONCLUSION: The interlocking cylinder mechanically detachable coil design is superior to the other two tested designs. The mechanically detachable coil was reliably delivered and detached in in vivo testing for the treatment of aneurysms and for the occlusion of blood vessels.

Differential isoactin gene expression in the sphincteric and nonsphincteric gastrointestinal smooth muscles of the opossum.

The sphincteric smooth muscle tissues of the gastrointestinal tract have been shown to possess mechanical properties distinct from the surrounding nonsphincteric smooth muscle tissues. Little is currently known regarding the molecular basis of this differential smooth muscle development and function. Actin is an important contractile protein whose expression has been linked to the normal development and function of smooth muscle tissues. The purpose of this study was to characterize isoactin gene expression in the sphincteric versus nonsphincteric smooth muscle tissues of the gastrointestinal tract. Northern blot analysis was performed on manometrically identified sphincteric and the flanking nonsphincteric smooth muscle tissues of the adult opossum. Quantitative analysis revealed a distinct pattern of isoactin gene expression in the sphincteric versus nonsphincteric smooth muscle tissues of the gut. The sphincteric smooth muscle tissues expressed significantly lower total quantities of isoactin mRNA than their surrounding nonsphincteric smooth muscle tissues. It is hypothesized that these differential patterns of isoactin gene expression may play a significant role in establishing the myogenic potential of the functionally distinct sphincteric and nonsphincteric smooth muscle tissues of the gut.

Plate fixation of femoral shaft fractures in multiply injured children.

A study was done of twelve patients (seven boys and five girls) who, because of multiple injuries or a head injury, had been managed with compression plating of a unilateral or bilateral femoral-shaft fracture at a level-I trauma center from 1986 through 1990. The patients had a total of fifteen fractures. The average age at the time of the injuries was eight years (range, five years to nine years and eleven months). There were nine closed fractures and six open fractures; three of the open fractures were Grade I; two, Grade II; and one, Grade IIIA, according to the criteria of Gustilo et al. Each patient had an average of three associated injuries. All fifteen fractures had healed clinically and radiographically at an average of eight weeks (range, six to twelve weeks) after the operation. There were no infections. Anatomical alignment was obtained in fourteen limbs. One fracture healed with 13 degrees of anterior angulation. The compression plates were removed at an average of ten months (range, three to twenty-four months) after the index operation. At the latest follow-up evaluation (average, twenty-six months; range, eleven to fifty-seven months), no patient had restriction of activities due to the femoral fracture. Scanograms revealed overgrowth of the injured femur averaging 0.9 centimeter (range, 0.3 to 1.4 centimeters) in seven patients who had an uninjured contralateral femur. We believe that plate fixation of the femur is a good treatment option for children who have a femoral shaft fracture and a major head injury or multiple injuries, or both.