Leiomyosarcoma of the colon: a second malignant neoplasm after treatment for a Wilms' tumor.

Leiomyosarcoma of the colon is a rare malignancy. We report the case of a 33-year-old woman with a leiomyosarcoma of the colon occurring as an intussusception 30 years after receiving abdominal irradiation for a Wilms' tumor. A review of the prior and current treatment for Wilms' tumor is discussed, as well as the association between second malignancies and abdominal irradiation. Leiomyosarcoma of the colon usually presents in the fifth and sixth decades of life and is more common in men. The most common symptom is pain. Ninety per cent are diagnosed at surgery for treatment of bleeding, perforation, or obstruction. Surgery remains the primary treatment. Leiomyosarcomas of the gastrointestinal tract are radioresistant, and adjuvant chemotherapy has shown no survival benefit. The overall prognosis is poor, with mean 5-year survival of 28 per cent. General surgeons need to be aware of the possibility of second malignant neoplasms after primary treatment of childhood cancers. Proper reporting is essential to study the long-term effects of early treatment of childhood cancers and in predicting the best treatment outcomes for these patients.

Postpolypectomy colonic hemorrhage.

PURPOSE: This study was undertaken to evaluate the incidence, diagnostic methods, and treatment of hemorrhage occurring after colonoscopic polypectomy. METHODS: A retrospective chart review was conducted of 12,058 patients who underwent colonoscopy at an academic referral center between January 1989 and July 1993. Of these, 6,365 patients required polypectomies or biopsies. RESULTS: After these procedures, 13 patients (0.2 percent) developed lower gastrointestinal hemorrhage requiring hospitalization. All bleeding episodes occurred within 12 days of polypectomy or biopsy (mean = 8 days). Twelve patients (92 percent) underwent technetium-tagged red blood cell scintigraphy, which localized bleeding in four patients (31 percent). In the eight patients with normal scintigrams, hemorrhage did not recur, and no further evaluation was performed. Five patients (38 percent) underwent arteriography. Arteriogram was positive in two of four patients with positive scintigrams, and bleeding was controlled with selective vasopressin infusion. The fifth patient had arteriography without prior diagnostic studies because of massive hemorrhage; the bleeding site was identified and controlled with selective vasopressin infusion. Three patients had lower gastrointestinal endoscopy, with endoscopic identification of bleeding site in two patients, and endoscopic electrocautery controlled the bleeding in one patient. In the 13 patients with hemorrhage, cessation of bleeding occurred with intestinal rest and hydration in nine patients (69 percent), selective vasopressin infusion in three patients (23 percent), and endoscopic electrocautery in one patient (8 percent). Eight patients (62 percent) required blood transfusion with a mean of 4.8 units (excluding one patient on warfarin sodium who required 14 units of blood). No patient required surgical intervention. CONCLUSIONS: Incidence of hemorrhage after colonoscopic polypectomy or biopsy is low, and in our series, hemorrhage resolved without the need for surgical intervention. Management includes initial stabilization followed by diagnostic evaluation. Technetium-tagged red blood cell nuclear scintigraphy identifies ongoing bleeding and identifies patients in whom additional invasive procedures (arteriography lower gastrointestinal tract endoscopy) are warranted.

Intraoperative diagnosis of choledochal cyst in preparation for laparoscopic cholecystectomy.

The initial description of abnormalities of the biliary tree was reported by Vater in 1723. However, it was not until 1959 that Alonzo-Lej and colleagues reported on the full description and classification of choledochal cysts. This report describes a Hispanic female who presented with classic findings consistent with biliary colic. A preoperative ultrasound revealed multiple gallstones and mild dilatation of the common bile duct. At the time of laparoscopy, she was found to have a dilated common bile duct, cystic duct, and gallbladder. Further dissection was discontinued, a cholecystectomy made, and a percutaneous transabdominal cholangiogram through the gallbladder performed, which revealed a type I choledochal cyst (cystic dilatation of the extrahepatic bile ducts). The patient then underwent resection of the extrahepatic biliary tree with a Roux-en-Y hepaticojejunostomy. Her subsequent postoperative course was uneventful. This case illustrates the role of cholangiography using the gallbladder as a conduit in the diagnosis of complex biliary tree anomalies during laparoscopy when the biliary tree cannot be safely accessed.

Overlapping sphincteroplasty for acquired anal incontinence.

Overlapping sphincter repair is the operation of choice for incontinence due to obstetric injuries, trauma, or previous anorectal surgery. We present our experience from 1981 to 1990 using the overlapping sphincter repair for anal incontinence resulting from childbirth in 21 patients (58%), previous anorectal surgery in 7 (19%), trauma in 1 (3%), gynecologic surgery in 1 (3%), multifactorial causes in 1 (3%); the incontinence was idiopathic in 5 (14%). All 36 patients were operated on by one surgeon and had identical care. There were no deaths. Two patients required colostomy for wound sepsis. Two additional patients (with idiopathic incontinence) elected to have a colostomy after failure of sphincter repair. Long-term follow-up was possible in 33 patients (92%). Twenty-four patients (73%) were considered to have good to excellent results. Eliminating those patients with idiopathic anal incontinence improved the results significantly. Twenty-two patients (85%) reported good to excellent results. Twenty-four patients (92%) consider their continence better now than before surgery and 25 patients (96%) would undergo the procedure again. In conclusion, overlapping sphincteroplasty has a definite role in treatment of anal incontinence due to obstetric injury, anorectal surgery, and trauma, but a more limited role in treatment of idiopathic anal incontinence.