Lipofibrom des Nervus medianus

The following article presents two new cases of a lipofibroma of the median nerve. This formation is a very rare benign tumor of peripheral nerve tissue. Up to now 30 cases have been reported in the literature and are reviewed in this article and are compared with the two cases reported. Besides the operative treatment, which made the neuropathological diagnosis possible, preoperative diagnosis has been extended by MNT-scans of the involved parts of the nerve. The noninfiltrating character of the tumor could be well recognized on these scans. The signal quality and the anatomical proximity to the median nerve made the diagnosis of a lipofibroma likely. By the postoperative histological reviews the diagnosis was confirmed in classic manner. The immunological marking of the S-100 protein showed a remarkable reduction of this protein in these peripheral nerve tumors. The two cases reported by us recapitulate the clinical history typically and describe symptoms and our treatment for the lipofibroma of the median nerve.     

Pitfalls in intraoperative frozen section histology of mediastinal neoplasms

We evaluated the reliability of intraoperative frozen section histology in 149 mediastinal tumours of which 106 lesions were localized in the anterior, 18 in the central and 25 in the posterior mediastinum. Gross non-resectability was ruled out by preoperative imaging. No preoperative cytological or histological diagnosis was obtained in any case. At thoracotomy, 3 biopsies from 3 different sites of the tumour were processed for frozen section as well as for paraffin histology and immunohistochemistry. In 67 of 73 benign lesions (91%), the intraoperative diagnosis was correct, 5 cases could not be classified by frozen section and 1 case had to be revised. Only 28 of 76 malignant lesions (36.8%) were diagnosed correctly by intraoperative frozen section. In 27 cases (35.5%), no intraoperative classification was possible and in 21 patients (27.6%), the diagnosis was wrong with the consequence of surgical overtreatment for lymphoma misinterpreted as thymic cancer in 3 cases. In patients in whom preoperative investigations suggest borderline resectability, a staged procedure to obtain histology prior to definitive surgery could prevent overtreatment.     

Periventricular intraparenchymal schwannoma

A 60-year-old male presented with a rare case of periventricular schwannoma. Imaging studies revealed a partially calcified, well-enhanced tumor in the periventricular area of the left frontal horn. The preoperative diagnosis was low grade glioma, but postoperative pathological findings revealed that the tumor was schwannoma. Most intraparenchymal schwannomas are benign, so total extirpation is usually curative. However, this uncommon neoplasm is difficult to distinguish from mimics, especially low grade gliomas, with only preoperative radiological findings or intraoperative pathological findings. Based on our experience and analysis of the characteristic radiological and pathological features in previous cases, we suggest that an accurate intraoperative diagnosis is possible. The key element is the combination of correct interpretation of the intraoperative pathology analysis and careful evaluation of the preoperative radiological studies. An appropriate intraoperative judgment is important, because the treatment, including the surgical management, would be totally different for schwannoma and glioma.     

Intraarticular ganglion of the dorsal interosseous scapholunate ligament: a case for arthroscopy

A rare case of an intraarticular ganglion within the dorsal interosseous scapholunate ligament is presented, including preoperative work-up and intraoperative findings. Wrist arthroscopy was crucial in its diagnosis.     

周围神经束间瘤变组织显微切除治疗周围神经脂肪纤维瘤

目的 探讨周围神经脂肪纤维瘤的诊治方法.方法 2005年1月至2010年7月,收治周围神经脂肪纤维瘤患者5例,其中单纯正中神经瘤变3例、正中神经合并尺神经瘤变2例、合并巨指1例,采用周围神经松解、瘤段切除、周围神经束间瘤变组织显微切除等手术治疗.结果 术后随访7～24个月,行瘤段病变切除1例术后出现神经支配区感觉缺失;行周围神经松解2例,术后手指麻木症状消失;行周围神经束间显微切除2例,无明显神经支配区感觉缺失.结论 通过CT、MRI、手术观察以及术后肿瘤病理检查可明确诊断周围神经脂肪纤维瘤,但目前治疗手段有限,周围神经束间瘤变组织显微切除是一种在最大限度保存神经功能的前提下可切除较多瘤变组织的治疗方法.     

术前及术中超声在最大径≤1.5 cm小肾肿瘤中的临床应用研究

目的探讨术前及术中超声在最大径≤1.5 cm的小肾肿瘤中的临床应用价值。 方法回顾性分析我院2018年9月至2022年3月期间42例经手术切除且病理证实最大径≤1.5 cm肾肿瘤患者的超声资料。所有患者均行术前常规超声及超声造影(CEUS)检查,其中8例内生型肿瘤病例因术中无法准确定位,行术中超声检查。 结果42例小肾肿瘤患者中8例(19.1%)为术前CEUS检出,而术前常规超声未检出(P＝0.005)。术中超声则全部检出了术前漏诊病灶,清晰显示出肿瘤边界、形态及血供情况。其中7例诊断考虑为恶性肿瘤的患者行术中超声辅助肾部分切除术,术后病理证实1例为透明细胞乳头状细胞癌,5例为透明细胞癌,1例为嫌色细胞癌,病灶切缘均为肿瘤阴性,术后随访6个月未发现疾病复发或转移。 结论对于最大径≤1.5 cm的小肾肿瘤,术前超声存在一定漏诊率,CEUS则可显著降低漏诊率,而术中超声则能全部检出内生型肿瘤。术中超声对于引导完全剔除肿瘤、保护瘤体包膜完整、充分保留残存肾单位具有重要价值。     

Surgical therapy of insulinoma

From 12 Patients surgically explored because of suspected insulinoma, the diagnosis was correct in 11. In 8 patients there was a solitary insulinoma, which was diagnosed in every case by preoperative ultrasonography, computed tomography or angiography. In one patient with three adenomas, only one was diagnosed preoperatively, the second by palpation and the third by intraoperative sonography. One patient had a diffuse hyperplasia. The intraoperative frozen section was correct in 9 from 11 patients. The preoperative localisation of insulinoma assisted in the intraoperative identification. The intraoperative pancreatico sonography is an useful help in localisation of insulinoma. For treatment the enucleation of tumor is preferable.     

Anesthetic Management of Renal Cell Carcinoma With Inferior Vena Caval Extension

We present a case of a patient with renal cell carcinoma extending into the inferior vena cava. Preoperative diagnosis was facilitated by transthoracic and transesophageal echocardiography (TEE), and inferior venacavography. Intraoperatively, monitoring with continuous TEE was used. Preparation was made for cardiopulmonary bypass but surgery was successfully completed using extracorporeal venous shunting. We discuss the important aspects of preoperative diagnosis and the intraoperative anesthetic management of this case.     

Submucous lipofibroma of the ileum

A case of submucous lipofibroma of the ileum associated with intussusception was reported. The history, symptomatology and physical findings were typical of those found in similar cases. The patient recovered after surgical resection of the involved bowel and an end-to-end anastomosis.     

Lipofibroma of the median nerve.

Tumors arising within the median nerve in the region of the distal forearm, wrist, and palm are rare and their exact pathological nature has not been well clarified. One case is reported in a 47-year-old woman, in whom a mass of 3 years' duration was located in the thenar eminence of the right hand without causing any sensory or motor deficit. The tumor was surgically excised, and the continuity of the nerve branches was preserved. The diagnosis of lipofibroma of the median nerve is recommended for this entity. Other pathological lesions of the median nerve are mentioned.     

Extralobar pulmonary sequestration showing high CA 19-19 levels

We report a case of 40 year-old woman with left thoracic pain who was diagnosed as having a cystic mass located posteriorly at the basis of the left pleural cavity. The preoperative serum CA 19-9 level was increased (2 900 IU/mL). Further investigations did not find neoplastic lesions in the gastrointestinal tract. The intraoperative finding of an anomalous systemic arterial supply to the mass suggested the diagnosis of extralobar sequestration, confirmed at the histopathological examination. The association between pulmonary sequestration and increased tumor markers levels is overlooked in western literature, but it is often reported by many Japanese authors. This case report would underline the practical usefulness for preoperative diagnosis of pulmonary sequestration, when the CT-scan does not demonstrated an anomalous systemic vessel. The common embryogenic origin of both respiratory and digestive apparatus can explain the increased levels of tumor markers such as CA 19-9 and carcinoembryonic antigen in bronchogenic cyst, intestinal duplication and pulmonary sequestration.     

Agenesis of the gallbladder found at laparoscopy in an adult patient with cardiac congenital malformation

We report a case of gallbladder agenesis in a 30-year-old woman affected by a cardiac congenital malformation who had been operated on at the age of 12. The patient was sent for laparoscopic cholecystectomy due to a preoperative diagnosis of cholelithiasis using clinical and instrumental examinations such as ultrasonography and cholangiography. During laparoscopy, the gallbladder was not found, and laparotomy with intraoperative cholangiography and ultrasonography was performed which also resulted negative. The preoperative possibility of a diagnosis of gallbladder agenesis, the association with other malformations and the steps to be taken to discover agenesis of the gallbladder are discussed.     

Intraoperative echocardiographic diagnosis of previously unrecognized cor triatriatum.

Cor triatriatum is a congenital heart defect resulting in abnormal septation of the left atrium by a fibromuscular membrane. Echocardiography has improved the preoperative diagnosis of this rare congenital heart defect. We report a case where transesophageal echocardiography proved useful in the intraoperative diagnosis of a previously undetected cor triatriatum.     

甲状腺乳头状微小癌36例临床分析

目的总结甲状腺乳头状微小癌的诊治体会。方法回顾性分析1996年1月至2005年12月经手术和病理诊实的36例甲状腺乳头状微小癌的临床资料。结果36例甲状腺乳头状微小癌,术前诊断9例（25％）,术中冰冻切片诊断22例（61．1％）,所有病例经石腊切片确诊,与良性结节并存20例。随访5个月至8年,无手术并发症,无手术死亡,复发1例。结论重视术前彩超及术中冰冻切片可减少本病的漏诊,甲状腺微小癌的外科治疗应根据病例的具体情况而定。     

Intraneural lipofibroma of the median nerve

A case of an intraneural lipofibroma of the median nerve is described. The patient was first seen with an enlarging mass on the flexor side of the wrist and in the palm. After interfascicular dissection of the tumor there was a permanent loss in sensibility and motor function. In most cases decompression of the nerve will suffice; resection by means of interfascicular dissection is rarely justified.     

下消化道出血的诊断及术中定位方法(附22例报告)

目的 探讨原因不明的下消化道出血的术产主中定位该当。方法 采用选择性腹腔动脉造影对２２例原因不明的肠道出血病例进行术前诊断,并在选择性腹腔动脉诊断的基础上,进一步地出血分支动脉行超选插管,入一小段导引钢丝作为手术定位标记及妥急性出血期因。结果 ２２例病人术前全部得到定性及;定位诊断,并置标记物,其中小肠恶性肿瘤８例、肠道血管畸形１４例,术中均准确找到标记物,从而获得满意的治疗效果。结论 选择性腹腔     

Arthroscopic evaluation of the subtalar joint: does sinus tarsi syndrome exist?

This is a retrospective review of 49 subtalar arthroscopies performed between 1989 and 1996. Patients were evaluated in the following areas: (1) preoperative diagnosis, (2) preoperative tests and clinical evaluation, (3) intraoperative findings, (4) postoperative diagnosis,(5) complications, and (6) clinical outcome. Particular attention was paid to the accuracy of the preoperative diagnosis, subtalar instability, intraoperative findings in sinus tarsi syndrome, and clinical outcome. Overall, this study demonstrated a success rate of 94% good and excellent results in the treatment of various types of subtalar pathologic conditions with arthroscopic techniques. The Workers' Compensation cases reported 90% good and excellent results. The complication rate was low, with five minor complications reported. The most common complication was a transient neuropraxia involving branches of the superficial peroneal nerve. Of the 14 feet that had a preoperative diagnosis of sinus tarsi syndrome, all the diagnoses were changed at the time of arthroscopy. The postoperative diagnoses included 10 interosseous ligament tears, two cases of arthrofibrosis, and two degenerative joints. Based on these findings, "sinus tarsi syndrome" seems to be an inaccurate term that should be replaced with a specific diagnosis. Arthroscopy is the tool that will allow the orthopaedic surgeon to make a more accurate diagnosis.     

Intraoperative pancreas puncture cytology

In the case of 10 to 15% of surgical patients with a pancreatic disorder an intraoperative diagnosis had to be made when a preoperative diagnosis had not yielded a definite result. Fine needle aspiration biopsy ( FNAB ) of the pancreas provided the basis for intraoperative differentiation of malignant and benign pancreatic processes. 244 pancreatic biopsies were carried out in 100 patients. It was possible to make a statement in 99% of the cases, with 65 malignant and 35 benign changes. In 83% the cytological diagnosis was correct; the method yielded incorrect-negative results in 7% of the cases. In 9% the presence of tumour cells was only suspected. There were no incorrect positive cancer diagnoses. FNAB caused no postoperative complications. Intraoperative bleeding after FBAB had to be stopped with a suture in one case. Transitory, asymptomatic hyperamylasemy must be expected in 25% of the patients after FNAB . This diagnostic technique is recommended in preference to the histological tissue removal methods because of its low risk factor. At least 2 biopsies of the suspect area with 2 smears are required, as a training in this diagnostic technique.     

腹腔镜联合术中胆管造影、括约肌切开术序贯诊治胆结石病106例

目的 探讨腹腔镜胆囊切除术(laparoscopic cholecystectomy，LC)联合术中胆管造影(intraoperative cholangiography，IOC)、术中括约肌切开术(intraoperative endoscopic sphincterotomy，IOEST)序贯诊治胆结石病的价值。方法回顾分析序贯诊治106例胆结石病的临床效果。结果64例(60．4％，64／106)术前诊断胆囊结石，经IOC发现有胆总管结石；序贯治疗手术成功率为93．4％(99／106)，98例胆总管结石被取净。术后并发症：水肿型急性胰腺炎6例(6．1％)、十二指肠穿孔1例(0．9％，1／106)、胆漏1例(0．9％，1／106)、气胸1例(0．9％，1／106)、漏诊十二指肠乳头癌1例(0．9％，1／106)、胃潴留2例(1．8％，2／106)。术后平均住院时间3．7d。结论LC联合IOC、IOEST能一次性微创诊治胆囊结石合并胆总管结石。     

Life-threatening coronary ischemia in the operating room: analysis of annual survey from 1999 to 2001 conducted by Japanese Society of Anesthesiologists

In Japan, the incidence of cardiac morbidity among patients with ischemic heart diseases has been reported to be 13.2-16.4%, and that of perioperative myocardial infarction in these patients about 1%. We investigated the perioperative morbidity and mortality due to coronary ischemia by using data from an annual survey concerning anesthesia-related critical incidents, conducted by the Committee on Operating Room Safety, Japanese Society of Anesthesiologists. In this survey, coronary ischemia was divided into intraoperative pathological events (coronary ischemia as intraoperative event) and preoperative complication (coronary ischemia as preoperative complication). The former consists of coronary ischemia which developed in patients without preoperative diagnosis of ischemic heart diseases or which was induced by surgical and/or anesthetic procedures. The latter was coronary ischemia developed in patients with preoperative diagnosis of ischemic heart diseases. From January 1, 1999, to December 31, 2001, 3,020,021 patients were registered from certified training hospitals of Japanese Society of the Anesthesiologists in the survey. Among them 1,918 episodes of intraoperative cardiac arrest and 2,054 deaths (within 7th postoperative days) were reported. Of these 7.5% and 6.3% of cardiac arrests were due to coronary ischemia as intraoperative event and as preoperative complication, respectively. Death was due to coronary ischemia as intraoperative event in 4.0% and as preoperative complication in 5.1%. The occurrence of critical incidents (cardiac arrest and the other life-threatening events) due to both types of coronary ischemia depended on ASA-PS. The percentage of coronary ischemia as preoperative complication was higher in emergency patients than in elective patients. The percentage of coronary ischemia as intraoperative event was almost the same between emergency and elective patients. Both types of coronary ischemia developed most frequently in cardiac/aortic surgeries, followed by thoracotomy with or without laparotomy. The number of critical incidents due to coronary ischemia as preoperative complication was the largest in emergency cardiac/aortic surgeries, followed by elective non-cardiac surgeries. The number of critical incidents due to coronary ischemia as intraoperative event was the largest in elective non-cardiac, especially open abdominal, surgeries in patients with ASA-PS 1(E) + 2(E). Among the patients with ASA-PS 1(E) + 2(E) who underwent non-cardiac surgeries 13.9% of deaths were due to coronary ischemia as preoperative complication and 12.5% as intraoperative event. It should be noted that many critical incidents due to coronary ischemia as intraoperative event during laparotomy developed in patients anesthetized by inhalation anesthesia combined with epidural, spinal or conduction block. Prognosis of cardiac arrest due to coronary ischemia as preoperative complication was the worst: 47.1% of these patients died. The best prognosis was found in critical incidents other than cardiac arrest due to coronary ischemia as intraoperative event with mortality of 12.3%. The results show that quality improvement from the standpoint of intraoperative coronary ischemia is required.