Gastrinoma excision for cure. A prospective analysis.

The role of surgery in the treatment of gastrinoma is unclear. The purpose of this study was to determine prospectively the surgical cure rate using a controlled clinical trial. Eleven patients who fit the entry criteria underwent abdominal exploration and attempted tumor resection for cure. A historical control group was used for comparison. Cure was defined as: (1) normal serum gastrin level, (2) no response to intravenous secretin, (3) no symptoms when antisecretory medications are stopped, and (4) no tumor recurrence on follow-up examination. Tumors found in both groups tended to be small (1.5 cm vs. 2.2 cm), multiple (71% vs. 40%), and in lymph nodes (70% vs. 70%). All tumors identified were located anatomically within the gastrinoma triangle. Tumors were found in 10 of 11 patients (91%) in the study group, and significantly more patients had their tumors excised for cure as compared to controls (82% vs. 27%, p less than 0.05). The current prospective cure rate for gastrinoma is higher than previously appreciated and tumors within lymph nodes do not preclude curative resection.     

Safety and efficacy of laparoscopic cholecystectomy. A prospective analysis of 100 initial patients.

Laparoscopic cholecystectomy quickly emerged as an alternative to open cholecystectomy. However its safety, efficacy, and morbidity have yet to be fully evaluated. During the first 6 months of 1990, we performed 100 consecutive laparoscopic cholecystectomies with no deaths and a morbidity rate of 8% (8 of 100 patients; 4 major, 4 minor). There were 81 women and 19 men, with a mean age of 46.1 years (range, 17 to 84 years). All patients had a preoperative history consistent with symptomatic biliary tract disease, and most had proved gallstones by sonography. This included four patients with acute cholecystitis. Mean operating time improved significantly from month 1 to month 6 (122 +/- 45.4 minutes versus 78.5 +/- 30 minutes, respectively), indicating a rapid learning curve. Mean hospital stay was 27.6 hours, reflecting a policy of overnight stay. Postoperative narcotic requirements were limited to oral or no medications in more than 70% of patients. A regular diet was tolerated by 83% of the patients by the morning following the procedure. Median time of return to full activity was 12.8 +/- 6.8 days after operation. In addition analysis of the hospital costs of these 100 cases demonstrates a modest cost advantage over standard open cholecystectomy (n = 58) (mean, $3620.25 +/- $1005.00 versus $4251.76 +/- $988.00). There was one minor bile duct injury requiring laparotomy and t-tube insertion, two postoperative bile collections, and one clinical diagnosis of a retained stone that passed spontaneously. Four patients required conversion to open cholecystectomy because of technical difficulties with the dissection. Although there is a significant learning curve, laparoscopic cholecystectomy is a safe and effective procedure that can be performed with minimal risk. Laparoscopic cholecystectomy should be performed by surgeons who are trained in biliary surgery and knowledgeable in biliary anatomy, and, as with all operations, it should be performed with meticulous attention to technique.     

Functional results following fistulectomy with primary muscle suture in high anal fistula. A prospective clinical and manometric study

A prospective study was carried out on 46 patients with anal fistula to evaluate clinical aspects and anal manometry. In 26 patients a high fistula was diagnosed (type II, n = 20; type III, n = 6). In those cases the sphincter-saving technique with primarily muscle suturing was used. 70% (n = 14) of type II and 100% (n = 6) of type III had been operated on before. Out of 26 five patients (19.2%) with high anal fistula developed incontinence in the case of watery stools postoperatively, 4 of those only once in a while. There was no complaint about incontinence for solid stool at all.     

A case of primary psoas abscess presenting as buttock abscess

Buttock abscess is a rare clinical manifestation from unusual extrapelvic extension of psoas abscess. A 48-year-old woman presented with painful swelling of the buttock with a sense of local heat. Magnetic resonance imaging revealed a large subfascial abscess over the glutei muscles and was traced into the intraabdominal cavity over the iliac wing to the psoas muscle. Both the psoas abscess and the buttock abscess were evacuated via separate approaches. Empirical antibiotic therapy was delivered for 3 weeks. After 6 months, no evidence of recurrence was found. Psoas abscess could be included in the differential diagnosis of buttock abscess.     

One-stage surgery of high trans- and supra-sphincter anal fistula using primary fistulectomy and occlusion of the internal fistula ostium. A prospective study of 169 patients

In a prospective study on 169 patients with a so-called high fistula-in-ano (147 transsphincteric, 22 suprasphincteric) the value of a sphincter-saving operation technique was assessed. This technique consists of one-stage fistulectomy as well as of drainage of the intersphincteric space by internal sphincterotomy. The site of the former primary orifice of the fistula is adapted by multiple peranally performed single stitches. The perianal part of the wound is left to heal by second intention. Post-operatively, 19 cases of suture leakage occurred (9.5% with the transsphincteric and 23% with the suprasphincteric fistula, resp.). 32 patients (19%) had to have repeated surgery because of recurrent abscess or fistula or because of suture leakage (mean follow-up 3.2 years). Anal manometry was carried out preoperatively as well as postoperatively. It revealed a decrease in anal resting and squeezing pressure of 10 to 40% with a mean about 30%. Of the patients who had not been operated on previously, an impairment of continence developed in 15% postoperatively. This percentage rose up to 40% according to the rising number of previous fistula operations. The main problem in these cases was soiling. Total anorectal incontinence for formed stool did not occur.     

Taurolidine instillation as therapy for empyema thoracis. A prospective study of 50 patients

Fifty patients with chronic empyema thoracis, without bronchopleural fistula, were treated by drainage and twice-daily instillations of 2% taurolidine (Taurolin; Continental Ethicals) for 14 days. No antibiotics were used. Forty-three patients completed the treatment and 7 were withdrawn from the trial, 3 because of evidence of bronchopleural fistula and 1 each because of pain during instillation, associated chest-wall cellulitis, an unexplained, acute epilepsy-like episode during instillation, and inadvertent administration of antibiotics. All 43 patients who completed the trial showed an excellent clinical response with control of the local and systemic toxic effects of sepsis. A rapid falling-off in the volume and purulence of pleural drainage fluid was noted. Twenty-four of the 43 patients (55,8%) were rendered bacteriologically sterile by the treatment. Instillation of 2% taurolidine was therefore an effective form of monotherapy in cases of chronic empyema thoracis without bronchopleural fistula.     

A prospective analysis of staging laparoscopy in patients with primary and secondary hepatobiliary malignancies

Laparoscopy and laparoscopic ultrasound are used widely in cancer staging and are perceived to prevent unnecessary open exploration in many patients. The aim of this study was to analyze the impact of staging laparoscopy in improving resectability in patients with primary and secondary hepatobiliary malignancies. Over a 10-month period (November 1, 1997 to August 31, 1998), 186 patients with primary and secondary hepatobiliary cancers were submitted to operation for potentially curative resection. One hundred four patients staged laparoscopically (LAP) before laparotomy were compared prospectively to 82 patients undergoing exploration without laparoscopy (NO LAP). Assignment to each group was not random but was based on surgeon practice. Demographic data, diagnoses, the extent of preoperative evaluation, and the percentage of patients resected were similar in the two groups. Laparoscopy identified 26 (67%) of 39 patients with unresectable disease. In the NO LAP group, 28 patients (34%) had unresectable disease discovered at laparotomy. In patients with unresectable disease and submitted to biopsy only, the operating times were similar in the two groups (LAP 83 ±22 minutes vs. NO LAP 91 ±33 minutes; P = 0.4). However, laparoscopic staging significantly reduced the length of hospital stay (LAP 2.2 ±2 days vs. NO LAP 8.5 ±8.6 days; P = 0.006). Likewise, total hospital charges, normalized to 100 in the NO LAP patients, were significantly lower in the LAP group (LAP 54 ±42 vs. NO LAP 100 ±84; P = 0.02). Staging laparoscopy identified the majority of patients with unresectable hepatobiliary malignancies, significantly improved resectability, and reduced the number of days in the hospital and the total charges. The yield of laparoscopy was greatest for detecting peritoneal metastases (9 of 10), additional hepatic tumors (10 of 12), and unsuspected advanced cirrhosis (5 of 5) but often failed to identify nonresectability because of lymph node metastases, vascular involvement, or extensive biliary involvement. Eighty-three percent of patients subjected to laparotomy after laparoscopy underwent a potentially curative resection compared to 66% of those who were not staged laparoscopically. Supported in part by grants R01 CA76416 (Dr. Fong) and R01CA/DK80982 (Dr. Fong) from the National Institutes of Health. Presented at the Fortieth Annual Meeting of The Society for Surgery of the Alimentary Tract, Orlando, Fla., May 16–19, 1999.     

Psoas abscess as the initial presentation of bladder cancer

A 43-year-old man presented with left leg pain and an abdominal mass. Sonography and cystoscopy showed a bladder tumour obstructing the left ureteral orifice. The left kidney became nonfunctional. Computerized tomography suggested psoas abscess. Nephrectomy was done. Tumoral cells identified at cytological examination of psoas abscess but they were not found in the pyonephrotic kidney's pus. The patient declined further therapy and died 3 months postoperatively. This is the first case of bladder cancer presenting initially with psoas abscess.     

Breast abscess as the initial manifestation of primary pure squamous cell carcinoma: a rare presentation and literature review

Primary squamous cell carcinoma of the breast is a very rare tumor accounting for less than 0.4% of all breast cancers. Fewer than 100 cases have been reported in the literature so far. The diagnosis requires strict pathologic criteria to be fulfilled. Due to the rarity of this tumor the optimal treatment and prognosis are both unclear. Breast abscess as the initial presentation of a primary squamous cell breast carcinoma is an extremely rare clinical entity. In this study, we describe a case of a 61-year-old postmenopausal woman who presented with typical manifestations of a breast abscess and was diagnosed with a pure primary squamous cell breast carcinoma. Diagnostic evaluation and management of the patient are discussed along with a review of the literature. Despite its rarity, the possibility of a primary pure squamous cell breast carcinoma should always be considered in the differential diagnosis in postmenopausal patients presenting with manifestations of a breast abscess, especially in those who respond poorly to the initial treatment. Physicians should be aware of this rare malignancy in order to avoid delays in diagnosis and treatment.     

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目的 观察和评估瘘管隧道法切除一期缝合术治疗肛瘘的临床疗效。方法 将1994例肛瘘病人随机分成：瘘管隧道法切除一期缝合术组（TRFS组，68例），肛瘘切除缝合术组（FS组，64例）和肛瘘切除术组（F组，62例）。观察三组病例创面愈合时间，术后伤口感染情况，监测术后疤痕大小，肛门变形情况和肛门括约肌功能，，随访术后2年内的复发情况。结果 TRFS组和FS组术后创面愈合时间较F组明显缩短（P＜0．05），术后的疤痕小（P＜0．05），FS组术后伤口感染率和复发率较其它两组高（P＜0．05），TRFS组和FS组术后肛门变形的病例很少（P＜0．05），TRFS组和FS组术后均未出现肛门括约肌损伤引起大便失禁的病例。结论 瘘管隧道法切除一期缝合术既能达到根治肛瘘的目的，又最大限度地保护了肛门括约肌的功能，创面愈合时间短，术后疤痕小，手术复发率低，是治疗肛瘘的首选方法。     

Long-term follow-up of elderly patients randomized to primary tamoxifen or wedge mastectomy as initial therapy for operable breast cancer

One hundred and thirty-one fit elderly patients (> 70 years) presenting with operable breast cancer (< 5 cm) between 1982 and 1987 were randomized to receive primary tamoxifen 20 mg b.d. (n = 66) or wedge mastectomy (n = 65) as sole initial therapy, unselected by oestrogen receptor status. Outcome measures were comparison of loco-regional control, metastasis and overall survival. With median follow-up of 145 months there is no statistical difference in breast cancer specific survival or rate of metastasis. Local control, however, has been significantly better with surgery - 38% of mastectomy patients having developed local recurrence by 10 years compared to 81% with local progression on primary tamoxifen (P < 0.0001 Wilcoxon-Gehan statistic). Of the latter 50% have since required mastectomy in order to achieve local control. In conclusion, primary tamoxifen or wedge mastectomy are comparable treatments in terms of metastasis and overall survival but a high local failure rate on tamoxifen suggests that optimal management of the fit elderly should include surgery.     

Bactericidal antimicrobial cover in primary suture of perianal or pilonidal abscess. A prospective, randomized, double-blind clinical trial

The effect of 1-day treatment vs. 4-day treatment with metronidazole and ampicillin in association with primary closure of perianal and pilonidal abscesses was evaluated in a double-blind clinical trial. The patients were randomly allocated to 1-day (group I) or 4-day (group II) antibiotic regimen. No clinical signs of sepsis appeared in any patient. Primary healing, without fistula formation was achieved in all 17 perianal abscesses in the 1-day therapy group and in 14 of 15 in the 4-day group (non-significant difference). Excision with primary suture of pilonidal abscess resulted in primary healing in 20 of 26 cases in group I and 20 of 30 in group II (non-significant difference). Healing with formation of a new sinus or secondary healing occurred in four and two cases, respectively, in the 1-day therapy group, and in two and nine of the 4-day group. One-day administration of metronidazole/ampicillin is as effective as 4-day treatment in primary closure of perianal and pilonidal abscess. The procedure appears to be safe in both groups, but more efficacious in perianal abscess.     

Interferon as adjuvant therapy with initial radiotherapy of patients with anaplastic gliomas

In a group of nine patients with anaplastic gliomas, survival following surgery and treatment with interferon and radiotherapy was comparable to survival for a matched group of patients treated with BCNU and radiotherapy following surgery.     

Balamuthia mandrillaris brain abscess successfully treated with complete surgical excision and prolonged combination antimicrobial therapy

Amoebic encephalitis is an uncommon and usually fatal condition. This case describes successful treatment of a Balamuthia mandrillaris brain abscess using prolonged antimicrobial agents with complete excision. It illustrates the risk of dissemination from cutaneous to cerebral amoebic lesions, potential progression with corticosteroid therapy, and the prospect for curative excision.     

Retroperitoneal iliac fossa abscess presenting as primary disease of the genitourinary tract.

An iliac fossa abscess is a clinical entity that has not been described in the urologic literature. Three patients presenting with urologic symptoms were evaluated and found to have iliac fossa abscesses. It is important for the urologist to be aware of the existence, diagnosis and treatment of this entity.     

A case of primary interhemispheric subdural abscess

A rare case of primary interhemispheric subdural abscess is reported. This 13 year old boy, who had had high fever for 2 days, was brought into the hospital by an ambulance. He was disoriented and mild stiffness of the neck was noted. A Jacksonian seizure that began in the left leg occurred immediately after admission. The initial CT scan showed no apparent abnormality. His clinical signs and spinal fluid findings showing slight monocytic response and normal sugar content suggested viral meningo-encephalitis. The patient was given steroid and glyceol to control the intracranial pressure and antibiotics was also given. The convulsions disappeared with anticonvulsants and the patient became afebrile on the 7th hospital day. He was discharged on the 53rd hospital day without any neurological deficit. But, he was re-admitted because of recurrence of the convulsion 29 days after the discharge. The CT scan revealed an interhemispheric (rt parafalcial) abscess and the drainage of abscess was performed through a craniotomy. The post-operative course was satisfactory and he was discharged on 33rd post-operative day. It is easy to diagnose the primary interhemispheric subdural abscess on CT scan at the advanced stage. However, it may be difficult to make definite diagnosis at its acute phase and it is important not to miss some characteristic clinical features of the interhemispheric abscess that can be safely cured by appropriate surgical treatment.