Symptomatic post-traumatic cyst of the liver: treatment by laparoscopic surgery.

We report a case of a large post-traumatic liver cyst in a symptomatic patient treated by laparoscopic excision in an ambulatory setting. This rare lesion can be treated safely by this alternative modality on an outpatient basis, with minimal morbidity.

Value of three-dimensional US for optimizing guidance for ablating focal liver tumors.

PURPOSE: To determine if three-dimensional ultrasound (3D US), by nature of its ability to simultaneously evaluate structures in three orthogonal planes and to study relationships of devices to tumor(s) and surrounding anatomic structures from any desired orientation, adds significant additional information to real-time 2D US used for placement of devices for ablation of focal liver tumors. MATERIALS AND METHODS: Sixteen patients underwent focal ablation of 23 liver tumors during two intraoperative cryoablation (CA) procedures, three intraoperative radiofrequency ablation (RFA) procedures, 11 percutaneous ethanol injections (PEI) procedures, and six percutaneous RFA procedures. After satisfactory placement of the ablative device(s) with 2D US guidance, 3D US was used to reevaluate adequacy to device position. Information added by 3D US and resultant alterations in device deployment were tabulated. RESULTS: 3D US added information in 20 of 22 (91%) procedures and caused the operator to readjust the number or position of ablative devices in 10 of 22 (45%) of procedures. Specifically, 3D US improved visualization and confident localization of devices in 13 of 22 (59%) procedures, detected unacceptable device placement in 10 of 22 (45%), and determined that 2D US had incorrectly predicted device orientation to a tumor in three of 22 (14%). CONCLUSIONS: Compared to conventional 2D US, 3D US provides additional relationship information for improved placement and optimal distribution of ablative agents for treatment of focal liver malignancy.

Rectal excision with coloanal anastomosis for superficial distal third rectal cancer: survival and local recurrence.

OBJECTIVE: Appropriate surgical treatment of distal third rectal cancer limited to bowel wall (i.e. T1 or T2) in medically operable patients is controversial. Transanal excision can deprive some patients of accurate pathological staging, prognosis and cure. In contrast abdominoperineal resection has considerable practical and psychosocial problems largely related to a permanent colostomy. We hypothesize that superficial distal rectal tumours can be effectively treated with rectal excision and coloanal anastomosis. SUBJECTS AND METHODS: Prospective oncological study of 80 patients with distal third superficial rectal carcinomas treated by complete rectal excision with coloananl anastomosis from December 1977 to January 1993 was carried out. The resected specimens were examined for depth of spread and number of histologically positive nodes. The actuarial local recurrence and survival rates for superficial node-negative and node-positive tumours were analysed independently. RESULTS: Seventy-eight patients had complete postoperative assessment. Thirty-one percent had received low-dose preoperative neo-adjuvant radiotherapy (3500 rads). Mean follow-up time in all patients was 70 months on average. The lymph node involvement rate for T1 and T2 tumours was 12.5 and 15.6%, respectively. The local recurrence rates for patients with (T1/T2) N0 and (T1/T2) N1 were 1.5 and 16.7%, respectively, and the five year actuarial survival rates were 96.6 and 90%, respectively. The overall local recurrence was 3.8% with five-year actuarial survival of 95.8%. CONCLUSIONS: Lymph node involvement in superficial tumours is not rare. Rectal excision with coloanal anastomosis results in a high cure rate especially for node-positive superficial tumours. This treatment strategy avoids the psychological trauma of colostomy following abdominoperineal resection and the potential risk of undertreatment by local excision.

Factors influencing survival after resection for periampullary neoplasms.

BACKGROUND: The purpose of this study was to determine predictors of survival after resection for periampullary neoplasms. METHODS: Over a 15-year period, 208 patients underwent laparotomy for periampullary neoplasms. Data were analyzed to assess predictors of survival. RESULTS: Pathologic examination showed pancreatic cancer (n = 136; 65%), ampullary cancer (n = 28; 13%), distal common bile duct cancer (n = 10; 5%), duodenal cancer (n = 4; 2%), neuroendocrine tumor (n = 11; 5%), cystadenocarcinoma (n = 4; 2%), cystadenoma (n = 5; 2%), and other (n = 10; 5%). A total of 129 patients underwent pancreatic resection (71 Whipples, 35 total pancreatectomies, 21 distal pancreatectomies, and 2 partial pancreatectomies) whereas 79 patients were found to be unresectable and underwent palliative bypass and/or biopsy. Median survival was 20.4 months for resectable patients versus 4.5 months for unresectable patients (P<0.001). Of the 129 resected patients, factors significantly (P<0.05) favoring long-term survival on univariate analysis included well-differentiated histology, common bile duct or ampullary adenocarcinoma, early stage, tumor diameter <2 cm, negative margins, and absence of lymph node metastases, perineural, or vascular invasion. Age, sex, race, and type of procedure had no influence on survival. On multivariate analysis, only tumor differentiation appeared independently related to survival. Using Kendall's tau analysis, tumor type and grade correlated significantly with all other predictors. CONCLUSIONS: Of all variables studied, tumor type and poor tumor differentiation in periampullary neoplasms appear to be markers that predict a constellation of other adverse findings.

Coloanal anastomosis for distal third rectal cancer: prospective study of oncologic results.

PURPOSE: Jeopardizing cure and risking high local recurrence have served as arguments against sphincter-saving resection for patients with distal third rectal cancer. This prospective study examines and compares the local recurrence and survival rates in patients with distal third rectal cancer treated by either coloanal anastomosis or abdominoperineal resection. METHODS: Between 1977 and 1993, 174 patients underwent coloanal anastomoses and 38 patients underwent abdominoperineal resection. All tumors were located 4 to 7 cm from the anal verge. One hundred ninety-three patients (91 percent) underwent rectal excision with a curative intent. Mean follow-up was 66 months after sphincter-saving resection and 65 months after abdominoperineal resection. RESULTS: Mean anastomotic height from the anal verge was 2.3 cm after sphincter-saving resection. Overall local recurrence rate was 7.9 percent after sphincter-saving resection and 12.9 percent after abdominoperineal resection. The five-year actuarial survival rate was 78 percent after sphincter-saving resection and 74 percent after abdominoperineal resection. CONCLUSION: Local recurrence and survival are not compromised in patients with distal third rectal cancer when treated by sphincter-saving resection, provided that oncologic principles are not violated. Coloanal anastomosis can be performed with an acceptable morbidity.

Continent perineal colostomy after abdominoperineal resection: outcome after 63 cases.

PURPOSE: For patients with distal rectal or anal tumors, quality of life can be compromised after abdominoperineal resection and iliac colostomy. This study examines our experience with a continent perineal colostomy constructed from a colonic smooth-muscle cuff wrap. METHODS: Between 1987 and 1996, 63 patients with distal rectal or anal tumors (0-5 cm from the anal verge) underwent abdominoperineal resection and construction of a colonic smooth-muscle cuff at the site of the perineal colostomy. Postoperatively, all patients required colonic irrigations daily or every two days. The complications, continence at 6 and 12 months, and degree of satisfaction were prospectively evaluated using a standard questionnaire. RESULTS: Early complications included partial perineal dehiscence in 14 (22.5 percent) patients, pelvic abscess in 2 (3 percent) patients, and colostomy necrosis in 1 (1.6 percent) patient. Late complications were colostomy stricture in 7 (11.8 percent) patients, perineal sinus tract in 4 (6.7 percent) patients, and mucosal prolapse in 12 (20 percent) patients. Satisfactory continence (complete continence to stool and incontinence to gas) at 6 and 12 months was achieved in 30 (55.6 percent) and 27 (59 percent) patients, respectively. Patient satisfaction was noted in 85 percent. CONCLUSION: Continent perineal colostomy can serve as an alternative to conventional iliac colostomy. Most patients were satisfied. The modest complication rate can be minimized with patient selection.

Fournier's gangrene: an unusual presentation for rectal carcinoma.

We report a case of a large perforated adenocarcinoma of the rectum manifesting as an ischiorectal abscess progressing to Fournier's gangrene in an insulin-dependent diabetic man. Recognition and management of this rare syndrome in the setting of a common disease is discussed.

Late clinical outcome in a randomized prospective comparison of colonic J pouch and straight coloanal anastomosis.

BACKGROUND: Functional outcome after rectal excision with coloanal anastomosis is improved by construction of a colonic J pouch. Present prospective randomized studies lack follow-up beyond 1 year. The aim of this study was to assess the clinical outcome at both short- and long-term follow-up. METHODS: Forty patients with low rectal cancer were randomized prospectively to either J colonic pouch-anal anastomosis or a straight coloanal anastomosis. Clinical assessments were performed 3, 12 and 24 months after colostomy closure using a standard questionnaire and physical examination. RESULTS: There was no significant difference in the complication rate between the two groups. There was a significant (P < 0.01) improvement in frequency of defaecation at 3, 12 and 24 months for patients with a reservoir. Similarly, fragmentation (clustering of stools) was significantly less at 3 and 12 months (P < 0.01) in the reservoir group, and incontinence occurred less frequently in the first year (P = 0.09). By 24 months no patient in either group suffered from major or minor incontinence. CONCLUSION: The functional improvement gained from a colonic reservoir in coloanal anastomosis continues to benefit the patient for at least 2 years.

Diagnosis and staging of pancreatic neoplasms.

The relative value of current approaches to the diagnosis and staging of pancreatic cancer is discussed. A rational sequence of testing is recommended based on the clinical presentation of the patient and the local institutional expertise and facilities that are available.

An unusual variant of popliteal artery entrapment.

A 43-year-old woman presented with incapacitating exertional pain in the right foot, ankle, and lower calf of 1 years' duration following a minor ankle sprain. Evaluation by several physicians had been inconclusive. Physical examination identified normal pedal pulses at rest but obliteration of pulses with active plantar flexion. Segmental pressures were normal at rest and duplex scanning showed occlusion of the popliteal artery with active plantar flexion. The findings were confirmed by arteriography despite a normal course of the popliteal artery. Magnetic resonance imaging (MRI) showed no muscular abnormality. At exploration entrapment was noted to be the result of compression by branches of the sural nerve and vein as they coursed medially inserting into the medial head of the gastrocnemius muscle. Division of the neurovascular bundle resulted in complete resolution of symptoms and arterial compression on duplex examination postoperatively. This case was unusual because of the patient's age, sex, and the pathologic findings that had not been previously reported. In this case MRI was not useful in demonstrating a muscular or neurovascular bundle abnormality, supporting the use of duplex scanning as the noninvasive diagnostic modality of choice.