ADRENALECTOMY: EXPANDED INDICATIONS FOR THE EXTRAPERITONEAL APPROACH

The adrenal glands can be removed surgically by the anterior transperitoneal approach, or by the extraperitoneal approaches, either posteriorly or posterolaterally. While the extraperitoneal routes have become accepted as the preferred approach to the adrenal glands for small benign cortical adenomas, many authors still recommend the anterior transperitoneal route as the preferred operative approach for phaeochromocytoma, large tumours, adrenal cancers or bilateral hyperplasia. A series of 51 consecutive adrenalectomies performed for a wide range of adrenal disorders is presented, including phaeochromocytoma and large malignant tumours. In 47 cases the tumours were successfully removed through an extraperitoneal approach, with minimal morbidity. The anterior approach had to be employed in only four cases, and in three of these there was pre-operative evidence of tumour invasion into either the major vessels or the liver. The extraperitoneal approach to the adrenal gland is technically simple and can be performed quickly, with a low postoperative morbidity and should be regarded as the routine approach for almost all adrenal procedures.     

Tarsal tunnel syndrome. Causes and results of operative treatment

From 1975 to 1988, operative treatment was performed on 50 feet in 45 patients with tarsal tunnel syndrome. The causes of this syndrome were correlated with operative findings and included ganglia in 18, and a bony prominence from talocalcaneal coalition in 15. Five feet had sustained an injury, tumours were found in three and there was no obvious cause in nine. In most cases in need of operative treatment, there was a space-occupying lesion. Classifying the results according to causes, those with coalition or a tumour fared better, and idiopathic and traumatic cases had a worse outcome. In cases with a definite lesion, an excellent result can be expected from surgical treatment carried out soon after onset of the condition.     

Partial cystectomy for transitional cell carcinoma of the bladder

Partial cystectomy was performed for urothelium-derived bladder carcinoma in 55 patients in the period 1958-78. Ureteral re-implantation was done in 14 cases. The operative mortality was 7.3%. The five-year and ten-year survival rates were, respectively, 47.1 and 35.4%. The series was subdivided according to grade and T-stage of the tumours. The patients with a grade I or II tumour had significantly better survival rates than those with a grade III or IV tumour. T1 tumours had a more favourable outcome than T2 or T3 tumours, though the difference was not statistically significant. The ten-year prognosis was best when the tumour measured less than 1 cm, but tumour size did not otherwise influence the result. The tumour recurred in 32 (58%) of the patients, in 25 of them within 2 years of operation. The attractions of partial cystectomy include avoidance of urinary diversion and possibility of later, more radical surgery. Prophylactic antibiotic treatment is recommended in order to reduce the operative mortality and morbidity.     

Electroencephalography (EEG) after introduction of water soluble contrast media into cerebrospinal fluid (CSF)

Summary Thirty-six patients undergoing Dimer X or Amipaque ventriculography or myelography underwent electroencephalographic investigations. In most cases EEG alterations were found. They ranged from general slowing to seizure potentials. These findings and their causes are discussed.     

Primary tumours of the ribs

Thirty-four primary rib tumours (24 benign, 10 malignant) were surgically treated in 1966-1985. The mean age was higher and the tumour diameter was greater in the patients with malignant, than in those with benign neoplasm. The benign tumours were excised without operative death. At follow-up after a mean of 12.3 years there was no recurrence of benign growth, but in two cases with initial diagnosis of chondroma a regrowth at the same site proved to be chondrosarcoma. Among the cases of malignant tumour there was one operative death from pulmonary embolism, after radical resection of sarcoma. None of the four patients with chondrosarcoma had recurrence 6-13 years after surgery. There was no long-term survival among the patients with other forms of sarcoma or malignant tumour of the reticuloendothelial system.     

DNA profile and tumour progression in patients with superfical bladder tumours

Summary 229 patients with Grade 1–2 tumours (WHO), all category Ta or T1 (UICC) and surgically treated, were followed clinically and by flowcytofluorometric DNA-analysis (FCM). The tumours were characterised by their DNA profile. 175 cases were found to be diploid and fiftyfour cases showed aneuploidy. The mean follow-up time with continous FCM analysis was 2.6 years. During this period 19 patients showed tumour progression and 11 of these patients died. No progressive cases were found among 175 patients with repeatedly diploid DNA patterns. Thus tumour progression was exclusively linked to an aneuploid DNA pattern. In these case the degree of ploidy determined the frequency of progression: while 50% of the cases with triploid — hypotetraploid DNA pattern showed progression, only 10% of tumours with a tetraploid amount of DNA were found to be progressive. The degree of ploidy in 33 cases with recurrent aneuploid tumours was in general found to be constant. A fairly high degree of consistency was also found in the number of cells in S-phase, expressing proliferative properties. This indicates that superficial bladder tumours can be well characterised by their DNA profiles, that is the degree of ploidy and the proliferation pattern.     

Extensively Cystic Renal Neoplasms in Adults (Bosniak Classification II or III) – Possible “Common” Histological Diagnoses: Multilocular Cystic Renal Cell Carcinoma,Cystic Nephroma,and Mixed Epithelial and Stromal Tumor of the Kidney

Objective(s): To give an algorithm for resolution of extensively cystic renal neoplasms, preoperatively classified in the Bosniak classification as a category II and III. Methods: From 1991 to 6/2004, 701 patients with 727 renal tumours were surgically treated at our hospital. Extensively cystic tumours were found in 10 cases. Extensively cystic tumours were defined as multicystic tumours without any solid nodules visible neither on CT, nor grossly in the specimen at operation (the Bosniak classification type II or III). Results: Seven multilocular cystic renal cell carcinomas, three mixed epithelial and stromal tumour of the kidney and one cystic nephroma were diagnosed on histology. Conclusion(s): Extensively cystic renal tumours classified as the Bosniak type II or III correspond histologically to the entities mentioned above (multilocular cystic renal cell carcinoma, cystic nephroma, mixed epithelial and stromal tumour of the kidney). These entities cannot be distinguished one from another on preoperative imaging studies. A preoperative biopsy and intra-operative frozen-section analysis do not lead to a correct diagnosis in many cases. Fortunately, the operative strategy is the same for all these tumours. In such cases, the nephron sparing surgery is indicated, whenever technically feasible, as almost all extensively cystic renal tumours have a good prognosis.     

Surgery on pituitary adenomas in patients in a subarctic region

Summary The present series consists of 18 consecutive patients with pituitary adenomas operated on between 1977 and 1979 using the transfrontal route. Ten adenomas were 10, 20 or 30 times the normal maximum size of the pituitary measured according to Di Chiro and Nelson's (2) index (Table 2). Tumours without obvious suprasellar growth were operated on using the trans—sphenoidal route and thus are not included in the present series.Large and giant pituitary adenomas are preferably removed by the transfrontal route and using microsurgical techniques. Really poor vision associated with very large tumours seem to improve but not to normal level. A blind eye stays blind. Less poor vision returns to normal (Table 4). Prolactin values associated with giant prolactinomas are extremely high and may remain raised even after apparently radical extirpation. Isolated tumour-containing sellar crypts associated with these large tumours may be responsible for this observation. Postoperative radiotherapy and bromocriptine administration therefore seem advisable. Further operations may be necessary on patients with extensive posterior or lateral growths. Redundant partially intraosseal tumour fragments may be more easily removed later, possibly owing to the beneficial effects of radiation therapy. It is hoped that large and giant adenomas in the future will pass into history, even in the peripheral parts of the world. The trans—sphenoidal approach is always a better solution than the transfrontal approach whenever it can be carried out, but it requires earlier diagnosis.Presented at the 32. Scandinavian Neurosurgical Society Meeting in Linköping, September 3–6, 1980.     

Primary tumours of the sternum

In 1966-1986, two men and four women (mean age 47.5 years) underwent surgery for primary sternal tumour. Three of the tumours were benign (two condromata, one osteochondroma) and three were malignant (two chrondrosarcomata, one reticulum cell sarcoma). Inflammatory or degenerative lesions impeded differential diagnosis in three additional cases (without tumour). The tumours were treated with radical resection of the affected part of the sternum, including the relevant attached structures. Marlex-mesh reconstruction of the defect was necessary in four cases. There was no operative mortality. One Marlex graft became infected. At follow-up (average 11.1 years, range 9.0-14.7 years), five patients were alive without recurrence of tumour and the sixth had died of unrelated cause.     

Repair of anterior base of skull with free latissimus dorsi flap

Summary After craniofacial resection for ethmoid and nasal cancer the resulting defect in the anterior base of skull often is a problem because of liquorrhoea, followed by meningitis and brain herniation. Two approaches were used for surgery of ethmoid and nasal cancer involving the anterior base of skull — the transfrontal and the transethmoidal. The neurosurgeon performs the transfrontal approach, an additional lateral rhinotomy and ethmoidectomy is made by the ENT-surgeon. Seven patients underwent radical operation with immediate repair of the skull base defect performed in four and delayed repair in three cases with a microvascular latissimus dorsi muscle flap. The flap was tailored as a pure muscle transplant if only the base of skull had to be repaired and the surgical cavity had to be obliterated. In three cases a skin paddle was left on the muscle to perform closure of the orbit and of the hard palate.The aim of reconstruction is a good functional and cosmetic result and reduction of postoperative problems — such as brain herniation, CSF-leakage and meningitis — by obliteration of surgical cavities. Furthermore crusting of large cavities and disorders of phonation are reduced. The disadvantage of limited direct postoperative tumour control by nasal endoscopy however is justified by an increase of quality of life.     

Role of transsphenoidal operation in the management of pituitary adenomas with suprasellar extension

Summary 59 consecutive patients with suprasellar extending pituitary adenomas were operated on by the transsphenoidal approach. The suprasellar tumour extension was in 30 cases stage A (Hardy-Wilson), in 18 stage B and in 11 stage C. 14 patients were above 65 years of age and in this latter group 9 cases had large tumours (B or C). 78% of endocrinologically active tumours did not reach the chiasm (stage A) whereas 72% of functionless adenomas compressed the chiasm or grossly the third ventricle. Visual field defects and loss of visual acuity was both present in roughly 90% of stage B and C tumours. Radical surgical removal with regard to suprasellar extension was possible in all but 6 cases. Four of these patients had tumour remnants large enough to require removal by a second intracranial operation. No patient developed visual deterioration post-operatively. Pre-operative visual dysfunction was normalized or markedly improved in more than 90% of the cases. Failure to normalize vision was closely linked to the presence of pale optic discs. Pre-operative hypersecretion was normalized in 70% of the cases. Addition of permanent pituitary insufficiency occurred in three patients.     

Differential surgical treatment of ileus of the large intestine

This is a report about 191 patients with colonic obstruction who were operatively treated between 1984 and 1988. A resection of the tumour was carried out in 106 cases while the other patients underwent palliative surgical treatment for various reasons. - A traditional surgical concept proved to be most satisfactory despite the modern forms of treatment such as primary subtotal colectomy, intraoperative lavage of the colon with resection and primary anastomosis, the internal bypass or preoperative laser dilatation. According to this concept tumours of the right half of the colon are primarily resected in the form of a right hemicolectomy; tumours of the left flexure undergo a two stage and those distal to the left flexure a three stage procedure. These principles were consistently applied in our patients and this resulted in an operative mortality of 0% after excluding patients who had a primary septic condition. In contrast, the operative mortality in the patients who were septic because of a colonic perforation (n = 23) was 47.8%. The worst prognosis could be found in cases with a perforation away from the tumour in the oral overdistended bowel such as coecum and ascending (n = 12). Here, the mortality was even 75% while true tumour perforations - which were usually sealed off - had a mortality of only 10% (n = 10). The main problem in the treatment of colonic obstruction, therefore, seems to be the patients who have a concomitant septic condition.     

DNA aberrations of bladder mucosa in patients with transitional cell carcinomas

DNA aberrations in bladder mucosa have been investigated in altogether 26 patients with aneuploid WHO grade 2 and 3 tumours (transitional cell carcinomas; TCC). In about 1/4 of the patients aneuploid cells were found only in the tumour. Hypotetraploid tumours showed the lowest frequency of involvement of the normal appearing mucosa of the trigone (43%). In hypertriploid tumours the corresponding value was 71%. In altogether 14 of the patients, the same type of aneuploid cells was found in the normal appearing mucosa as in the tumour. This indicates frequent involvement of the whole bladder mucosa in the tumour disease. In about 1/4 of the cases other types of ploidy aberrations were found in the normal appearing mucosa than in the tumour. This is indicative of preneoplastic changes in the mucosa, of which only one type of aberrations is associated with tumour growth. In some cases with multiple tumours of the bladder, all the tumours had the same aneuploid stemline, while in other cases the tumours were of different aneuploid stemlines. This is conformal with other reports of atypia in the surrounding mucosa in TCC and with the concept that recurrence of high grade tumours is the consequence of neoplastic involvement of the whole bladder.     

Surgery of tumours of the lateral ventricle

Summary Tumours of the lateral ventricle in most cases enlarge significantly before signs and symptoms are exhibited.In the years between 1980 and 1991 we encountered 55 patients of all age groups with tumours of the lateral ventricle. All were diagnosed either by CT or MRI, and in lesions with good enhancement on CT additional angiography was performed. All 55 tumours were operated upon using microsurgical techniques. The approach was chosen according to the location of the tumour, preferably transcortical. In selected cases large tumours were removed in a twostage operation. Only in one frontal horn and Cella media tumour an interhemispheric transcallosal approach was used. Postoperative or surgically related mortality was experienced in 3 cases. Life expectancy and morbidity were dependent upon histology.Invited Lecture presented at the European Congress, Moscow, June 23–29, 1991.     

Carotid body tumours: the University of Alberta Hospital experience

At the University of Alberta Hospital between 1950 and 1988, 17 patients who had a diagnosis of carotid body tumour were seen; 15 of them were followed up for an average of 8 years (range from 1 to 38 years). In 14 patients the tumour was removed surgically. There were no operative deaths and no strokes occurred. The most frequent complication was cranial nerve deficit. Of the 15 patients followed up, 10 (67%) manifested a deficit of the facial, vagus or hypoglossal nerve. The primary tumour was diagnosed histologically as a benign neoplasm in all 14 patients operated on, but in 3 distant metastases developed or there was invasive local recurrence. Patients with malignant tumour were significantly (p less than or equal to 0.01) younger than those with a benign tumour. Carotid body tumours can be managed safely with respect to stroke complications, but cranial nerve injuries continue to be a problem. Malignant tumours are difficult to distinguish from benign tumours except that they tend to occur in younger patients. Prompt surgery and close follow-up is particularly important in patients with carotid body tumour.     

Intracranial epidermoid tumours: thirty-seven years of diagnosis and treatment

The clinical, operative and pathological characteristics of 102 consecutive cases of intracranial epidermoid tumours are reported. These cases constituted 1.1% of all intracranial tumours and 13.5% of congenital neoplasma admitted to our service in the period 1951-88. Of 91 (89.2%) intradural tumours, 74 (72.5%) were in the subarachnoid cisterns, especially in the cerebellopontine angle cistern (31 cases). The tumours were solid in 69 cases (67.6%) and cystic in 26 (25.5%); the remaining 7 cases were not recorded. There were no specific clinical features with which to identify the nature and extent of the tumour. Diagnosis and treatment are described, with an evaluation of CT and MRI. Before 1981, total removal rate of tumour was 29.3%; after that date it was 72.7% with the aid of microsurgery. The overall surgical mortality rate was 4.9% (5 cases), but there were no deaths in the microsurgical group. Follow-up for a period of 0.5-37 years (mean 13 years) was carried out in 68 patients (70.1%). Among 24 patients with incomplete removal, recurrence of tumour was verified in 4 cases; 3 underwent reoperation with excellent or good results. One patient refused operation and died. All the remaining 20 cases, save 3 who died of other diseases, returned to their normal activities without recurrent manifestations. The results suggest that the primary treatment of epidermoid tumours should be surgical removal including the contents and capsule of a tumour. With the aid of microsurgical technique, complete removal is possible. Patients with incomplete removal can also obtain a long-term favourable result.     

Endoscopic ultrasonography allowing expectant management of pancreatic haemangioma

Pancreatic haemangiomas are rare benign tumours that can affect both adults and children. They have an unknown incidence and only 15 adult cases have been reported, all from histological examination. Patients present with vague symptoms relating to tumour mass or they are detected incidentally. Cross-sectional imaging is the mainstay of investigation and may reveal arterially enhancing cystic lesions but in the case presented here, it was non-diagnostic. The use of endoscopic ultrasonography confirmed the nature of the benign lesion, allowing a conservative approach as opposed to operative resection.     

Good outcome from surgery for ampullary tumour

BACKGROUND: Ampulla of Vater tumours are rare but usually resectable. There is debate as to the better surgical approach between the standard radical procedure, which provides adequate resection margins, and local resection, which may carry a lower mortality. This study reports the 16-year experience of a specialist unit with these tumours, and compares our results with that of recently published series. METHOD: A retrospective review of patients admitted with an ampullary tumour to the Hepatobiliary and Pancreatic Surgery Unit, Royal Adelaide Hospital, Adelaide, Australia, between January 1981 and April 1997. RESULTS: Twenty-five patients (13 men, 12 women) of median age 65 years were admitted with an ampullary tumour to the unit during this period. The most common presentation was obstructive jaundice. Multiple endoscopic biopsy was found to be very reliable in distinguishing between benign and malignant tumours. Five patients, all male, had benign neoplasms: three adenomas, one carcinoid and one gangliocytic paraganglioma. Transduodenal local excision was performed in four patients. One patient had a Whipple procedure resulting in the only in-hospital death at 3 months. Twenty patients had adenocarcinoma, of which 13 patients had a pancreaticoduodenectomy, two local excisions, two palliative bypasses, two were unfit for surgery and one declined surgery. The resectability rate was 88%, with no operative mortalities. The 5-year actuarial survival of patients who underwent radical resection was 49%. CONCLUSIONS: Proximal pancreaticoduodenectomy, preferably a pylorus-preserving procedure, is safe and effective in the treatment of ampullary carcinoma, with low operative mortality and good long-term survival. Local resection is only recommended for small benign tumours and for patients who may be unfit for radical surgery.     

Transcranial Transsphenoidal Approach for Tuberculum Sellae Meningiomas

Summary  Objective. A series of 21 patients with tuberculum sellae meningioma who received surgical treatment is reported.  Patients and Methods. All 9 females and 12 males (mean age 49 years) presented visual disturbances of varying degrees in either one or both eyes. Eighteen of the tumours were less than 3 cm in size, and 3 were larger. Tumour resection of uniform surgical technique was performed in all cases. Following a bicoronal scalp incision, bifrontal craniotomy combined with removal of the orbital rim bilaterally was performed. The frontal dura was opened bilaterally, and the most anterior portion of the superior sagittal sinus was transected. Bifrontal retraction and arachnoid dissection along the proximal olfactory tracts brought the tumour into view. Additional dissection of the interhemispheric fissure extended the operative field to the anterior communicating artery. The anterior skull base was drilled out to resect the basal part of the tumour. In all cases, the optic canal and sphenoid sinus, and additionally in some cases the ethmoid sinus were opened. The tumour uniformly extended inferomedially to the optic nerve, and direct visualization of this portion of the tumour was possible with our approach. The opened paranasal sinuses were reconstructed with adipose tissue harvested from the patient's abdomen and the pericranial flap.  Results. In all patients, total or almost total resection of the tumour was accomplished. Postoperatively, visual function was improved in 11 patients, was unchanged in 8, and worsened in 2. There were no operative deaths. Cerebrospinal fluid leakage was occurred in two patients but could be conservatively managed. In a mean 3-year follow-up, tumour recurrence was observed in only one patient who presented a malignant histology.  Conclusions. We are confident that our surgical approach has great clinical value in surgical resection of tuberculum sellae meningioma. The good accessibility to a tumour extending inferomedially to the optic nerve should, in particular, be stressed.     

Bilharziasis in malignant tumours of the urinary bladder

In a review of 2248 cystoscopic examinations conducted over 10 years, malignant tumours of the urinary bladder were found in 172 patients. In 128 of these the condition was associated with bilharziasis. The lateral wall of the bladder was the commonest site (52.3%). Squamous cell carcinoma occurred in 78.1%. Forty-nine patients refused surgery and eight were found to have advanced inoperable tumours. Seventy-one patients had a total cystectomy. There were no operative deaths but post-operative complications occurred in nine cases. Eight patients died within 2 years but 21 were well and tumour-free at 5 years. It was concluded that there is a marked association between bilharziasis and bladder cancer. When the tumour is operable, cystectomy is the treatment of choice.