Small Bowel Adenocarcinoma – Report of Two Cases and Review of Literature

Although accounting for 90 % of the intestinal surface area, small bowel adenocarcinomas are not common. The majority of these lesions are incidentally detected during laparotomy for intestinal obstruction or perforation. The symptoms associated with these lesions are not very specific and preoperative diagnosis is rare. We report two cases of jejunal adenocarcinomas detected in patients undergoing laparotomy for acute abdomen and review the literature for small bowel adenocarcinomas.     

Paraganglioma of the Cauda Equina Region – Report of two Cases and Review of the Literature

Summary  A paraganglioma of cauda equina region is extremely rare and except for secreting tumour, the pre-operative diagnosis of paraganglioma is very difficult. Two cases of non-functional paragangliomas of the cauda equina region are reported, one was attached to the filum terminale and the other to a rootlet looking very much like a vascular neurinoma. Both were successfully removed by surgery. An extensive review of the literature permits one to find 77 other cases. The clinical, radiological, pathological (ultrastructural and immunohistochemical) features and surgical findings of all theses cases are discussed. Surgery remains the treatment of choice. No effect of radiotherapy on recurrence prevention has ever been demonstrated.     

Malignant Peripheral Nerve Sheath Tumours – Report of 8 Cases and Review of the Literature

Summary  Background. Though Malignant peripheral nerve sheath tumours (MPNST) are a rare entity accounting for 5–10% of soft-tissue sarcomas they are an important differential diagnosis to benign tumours of the peripheral nervous system regarding treatment and prognosis.  Method. We present our experience with eight patients who underwent surgery for MPNST at the Department of Neurosurgery between 10/1990 and 9/1999. The median age was 37 years [range: 13–64], the male/female ratio was 1:1. Two patients suffered from Neurofibromatosis type 1. Paraffin embedded tumour specimens were immunohistochemically stained for S-100, p53 and Ki67/MIB-1.  Findings. The most frequent initial symptoms were local swelling and pain followed by irritation of cranial nerves and spinal ataxia. Four tumours were localised at the head & neck region, three were found in the extremities and one tumour was located on the trunk. All patients underwent surgery with curative intent, but total resection, defined by negative surgical margins, was achieved in only 3 cases. All of these developed local recurrence with a mean disease free survival time of 10,6 months. In five cases, adjuvant radiation was given. During follow up, three patients developed distant metastases located in the lung, liver and subcutaneous tissue. Five out of eight patients died during follow-up with a mean survival time of 11,6 months after diagnosis.  Results of immunohistochemical staining were as followed: S-100 (7/8), p53 (7/8). The Ki67/MIB-1 proliferation index was detectable in all tumour samples, it differed from 10–30%.  Interpretation. MPNST is a rare and fatal diagnosis in neurosurgery with high risk of local recurrence and occurence of distant metastases. Though mulitimodal therapy including surgical resection and adjuvant radiotherapy including brachytherapy is available, the prognosis remains dismal. Modern clinical studies and the development of effective chemotherapy is needed in order to gain control of the disease.     

Posterior-Fossa Haemorrhage After Supratentorial Surgery – Report of Three Cases and Review of the Literature

Summary  We present clinical details of three patients with posterior fossa haemorrhage after supratentorial surgery and discuss possible pathomechanisms of this rare complication. All patients were males of advanced age. Two patients presented with a history of hypertension. In all patients the occurence of haemorrhage was associated with loss/removal of large amounts of cerebrospinal fluid (CSF) either intra-operatively (one patient undergoing aneurysm surgery) or postoperatively (all three patients: drainage of subdural hygromas or chronic subdural haematomas in two, external ventricular drainage in one patient). Treatment consisted in haematoma evacuation and/or external ventricular drainage. Two patients died, one patient recovered completely.  Although haematomas distant from a craniotomy site are a well known entity, a review of the literature identified only 25 published cases of posterior fossa haemorrhage after supratentorial procedures in the CT era. Most often disturbances of coagulation, positioning of the patient and episodes of hypertension have been associated with this complication. Only one author described the occurence of a haemorrhage after drainige of a supratentorial hygroma. We suggest that the loss of large amounts of CSF intra-operatively and postoperatively may lead to parenchymal shifts or a critical increase of transmural venous pressure with subsequent vascular disruption and haemorrhage.     

Cerebral Aneurysms in the Perforating Artery Manifesting Intracerebral and Subarachnoid Haemorrhage – Report of two Cases

BACKGROUND: An arteriosclerotic aneurysm in the perforating artery has been focused on as a causative factor for hypertensive intracerebral haemorrhage. However, its pathogenesis remains unknown, and its existence is still a controversy. CASE DESCRIPTION: A 62-year-old female and a 70-year-old male with a history of hypertension suffered from intracerebral haemorrhage accompanied by subarachnoid haemorrhage. Cerebral angiograms demonstrated an aneurysm arising from the perforating artery at the central location of the haematoma in both cases. The aneurysms were confirmed as the cause of bleeding during microsurgery, and were resected. Histological examination of the surgical specimens revealed that the walls of the aneurysms lacked internal elastic lamina and consisted only of the adventitia. CONCLUSION: These findings demonstrate that the aneurysm in the perforating artery can be a causative factor for hypertensive intracerebral haemorrhage, and indicate that the loss of internal elastic lamina induced by hypertension may contribute to the formation of the aneurysm of the perforating artery.     

“Ambulatory PCNL” (Tubeless PCNL under Regional Anesthesia) – A Preliminary Report of 10 Cases

Aim: We report the technique, safety, outcome and efficacy of “tubeless percutaneous nephrolithotomy (PCNL) performed under regional anesthesia” in selected cases. Methods: Patients satisfying the entry criteria for the regional block (spinal low-dose anesthesia with low-dose Bupivacaine plus Fentanyl) and tubeless procedure were subjected to a tubeless spinal PCNL The patients were followed up the next day for an ultrasonography and an x-ray of the KUB region. Results: All the ten patients were discharged uneventfully the next day (mean hospital stay-40 h). No blood transfusion and postoperative analgesics (mean post op visual analogue pain score was 2.4) were required. The mean time to return of S₁ sensation, motor block and walking were 183,118 and 196.6 min respectively. There was complete stone clearance in all the cases with a mean collection of 14.5 cc was seen on the post op ultrasound. Conclusions: The present cases were reported to highlight that in a select group of patients tubeless PCNL under regional block is technically feasible and viable option. Regional block has the advantage of avoidance of general anesthesia and anaphylaxis due to use of multiple drugs. Tubeless PCNL has the advantage of avoidance of nephrostomy tube related postoperative pain discomfort and urosepsis. This synergistically (spinal + tubeless PCNL) speeds up the recovery, shortens the length of hospitalization and the analgesic requirement.     

Radiotherapy in the Management of Klippel-Trénaunay-Weber Syndrome: Report of Two Cases

Klippel-Trénaunay-Weber syndrome (KTWS) is characterized by combined vascular malformations of capillary, venous, and lymphatic types usually observed during infancy or childhood. In this report, we describe two KTWS patients treated with radiotherapy after long-term conservative treatment or multiple surgical interventions. The first patient, a 15-year-old female, presented with vascular masses located on the right upper extremity. She was treated conservatively for 14 years, and amputation was offered at the age of 14 due to cardiac failure. A course of radiotherapy to a total dose of 40 Gy with conventional daily fractionation was administered as an alternative to the mutilating surgery, and prominent improvement both subjectively and objectively was detected 1 year after radiotherapy. The second patient, a 40-year-old male, suffered from huge vascular masses of both the trunk and lower extremities. Despite multiple surgical interventions and conservative treatment, disease progressed and neurological symptoms occurred due to compression of vertebral structures. He was administered a course of 30 Gy radiotherapy with 1.5 Gy daily fractions to the lower thoracic region and whole abdominal cavity. Six months after radiotherapy, subjective relief described by the patient but without any objective response was detected. Though considered as a benign disease, KTWS can cause life-threatening complications. The response of one of our patients is a hopeful finding for considering radiotherapy as an alternative treatment modality for these patients.     

Laparoscopic Reversal of Hartmann’s Procedure: Report of Two Cases and Literature Review

Reversal of Hartmann’s procedure is considered a major surgical operation, associated with a significant morbidity and mortality.We reviewed current literature to demonstrate whether laparoscopic reversal of a Hartmann’s procedure is safe and feasible, and report here two consecutive cases of Hartmann’s reversal performed laparoscopically     

Thrombotic Obstruction of the Björk-Shiley Aortic Valve Prosthesis. Report of Four Cases

We present four cases of late thrombotic obstruction of the Björk-Shiley aortic valve prosthesis. The incidence of this complication reported in the literature to vary from 0.7% to 5%. In our experience of a total of 623 Björk-Shiley aortic valve replacements, we observed this complication in only 4 patients (0.6%). Two of them had poorly controlled anticoagulation therapy. The clinical presentation was subacute in all four patients. Surgical treatment, thrombectomy and debridement, was performed in all of them. The diagnosis was made upon abrupt and progressive onset of dyspnoea, physical examination data and echocardiographic and radioscopic findings. Angiocardiographic studies were needed in two patients.