Großer Flankentumor nach gedeckter Gallenblasenperforation

We report on a 79-year-old woman patient with a tumor with a diameter of 18 cm in the right flank. The medical history of the patient was normal except for a single asymptomatic gallstone, which had been known since 12 years. Sonography and abdominal CT showed an enormous intra-abdominal mass filled with liquid with a permanent union with the gallbladder. We than performed an explorative laparotomy with a tumor resection and a cholecystectomy. The histological examination showed perforation of the gallbladder with a great pseudocyst filled with 1800 ml infected bile and with penetration through the abdominal wall.     

Kinematics of three variations of the Freeman-Samuelson total knee prosthesis

The effect of changes in the articulating surfaces on the kinematics of the Freeman-Samuelson total knee replacement was evaluated. Twenty-two patients (22 knees) (median age, 69 years) were randomized to a standard design with a fixed polyethylene bearing, a design with a mobile bearing, or a new design with a spherical medial femoral condyle with a fixed bearing. The patients were studied with radiostereometry and film-exchangers at 0 degrees nonweightbearing and during active weightbearing extension from 45 degrees to 15 degrees. The center of the tibial tray with a mobile-bearing prosthesis occupied a more anterior position than observed in the designs with a fixed bearing. The medial femoral condyle center had a more posterior position in the standard design than in the design with a spherical medial condyle. From a distally displaced position at 45 degrees, the medial condylar center displaced a mean of 1.8 mm proximally during extension in the standard design and had a constant position in the meniscal design. In the spherical design the medial condyle was displaced proximally at 45 degrees and displaced a mean of 1.6 mm distally during extension. The reduced anteroposterior and proximodistal translations in the meniscal design are compatible with improved congruency between the components. The design with a spherical medial condyle stabilized anteroposterior motions, but showed more pronounced proximodistal displacement medially than did the other two designs.     

The spectrum of double-outlet right atrium including hearts with three atrioventricular valves

Double-outlet right atrium (DORA) is characterized by simultaneous right atrial emptying into both ventricles. Ventriculoatrial septal malalignment is the cardinal morphological feature. Three cases are presented to depict two major types of DORA-DORA with a malaligned atrial septum and DORA with a malaligned ventricular septum. We describe two subtypes of each form of DORA: DORA with a malaligned atrial septum presents with either a common atrioventricular (AV) junction (guarded by a common AV valve) or with a single AV junction (due to the absence of the left AV junction). DORA with a malaligned ventricular septum may be associated with a right ventricle (RV) that is adequate for biventricular repair or a severely hypoplastic RV not compatible with biventricular repair. DORA with a malaligned ventricular septum is closely related to typical straddling of the tricuspid valve. Peculiarly, DORA with a malaligned ventricular septum presents three AV valves at the AV junction and is associated with an abnormal disposition of the AV conduction axis. Clear understanding of the morphology of these lesions is important in preventing a surgical misadventure at the crux of the heart.     

Posttraumatische Deformität am distalen Unterarm nach vorzeitigem Verschluss der ulnaren Wachstumsfuge

We report on a 16-year-old boy with deformity of the forearm with painful functional limitation after a fracture of the distal radius associated with an unapparent lesion of the distal physis of the ulna suffered 4 years earlier. The lesion caused premature growth arrest in the ulna and a bowing of the distal radius with a carpal slip. It was treated with a corrective osteotomy in the radius together with a lengthening of the ulna, with excellent functional results.     

Our experience regarding biologically inactive gastroenteropancreatic neuroendocrine tumors

The Authors present 9 cases of gastro-enteropancreatic neuro-endocrine biologically inactive tumors. In 5 cases the tumor site was appendicular. In 4 patients an appendectomy was performed, in one patient a right hemicolectomy and the patients after a period of 3-9 years are well and disease free. In a patient with a gastric carcinoid and a single hepatic metastasis a total gastrectomy with an hepatic metastasectomy were performed but the patient died 16 months thereafter. In a case localized to the right colon with a single hepatic metastasis a right hemicolectomy was performed with a metastasectomy but the patient died after 12 months. In a case localized to an ileal loop a segmental resection was performed followed by a medical therapy with octreotide and the patient is well and disease free after 3 years. In a case localized to the pancreas with widespread lymphatic metastasis it was performed a simple biliary diversion (coledocho-duodenostomy) followed by medical therapy with octreotide. Surprisingly after 4 years the patient is alive and a TC control shows a decrease of the pancreatic tumor and of the lympho glandular tumefactions.     

The stereotactic volumetric information: its role in two-step resection of brainstem and thalamic giant tumor. Report of three cases and technical note

BACKGROUND: A compact intracerebral tumoral lesion is usually considered to be completely resectable. Nevertheless, radical resection of a huge lesion located in a critical area may damage the surrounding compressed brain tissue. In cases with a good prognosis, a two-step removal appears to be a safer strategy. METHODS: In three cases, two with huge brain stem lesions and one with a thalamic lesion, a two-step volumetric stereotactic resection was planned. This strategy allowed us to evaluate the amount of tumor to be removed during the first procedure and to have, during the second operation, an exact definition of the reduced mass with regard to the scar tissue and postoperative adhesions. Furthermore, we avoided significant shifting of the cerebral structures during both procedures. RESULTS: There was a very good final recovery in the cases with brain stem lesions and a minimal deficit in the patient with the thalamic lesion. The patient with a mesencephalic lesion remained comatose for almost 2 days after the first procedure, confirming our fears about too radical a one-step resection. CONCLUSIONS: We think that by using current techniques, it is possible to remove a well circumscribed lesion regardless of its position. This is probably easier with giant lesions where a safe trajectory can be planned. In these cases, with lesions located in very critical areas but with a good prognosis, a two-step resection appears to be a good option.     

Ewing’s Sarcoma of the Peritoneum: a Rare Location for Extraskeletal Ewing’s Sarcoma

A 38-year-old male presented to the emergency department with abdominal pain and bulge. He had a history of irritable bowel syndrome for 1 year with complaint of dyspepsia. Physical examination revealed a distended abdomen with a huge palpable mass located in the paraumblical region. Laboratory findings revealed a high white blood cell count with neutrophil predominance. Contrast-enhanced computed tomography (CT) showed a 23-cm, oval-shaped, grossly necrotic, low-attenuation mass with peripherally located dominant vessels. Magnetic resonance imaging (MRI) with diffusion weighted imaging (DWI) suggested a highly malignant tumor with prominent diffusion restriction especially at the periphery of the mass. On surgery, macroscopic examination showed a macrolobulated, hypervascular, reddish brown mass attached to the parietal peritoneum with a stalk. Ewing’s sarcoma (ES) was diagnosed on histopathological examination with small round cells.     

Case Report: Pancreas Graft With a Duodenal Complication Rescued Using Total Duodenectomy

Simultaneous pancreas-kidney (SPK) transplantation is the treatment of choice for type 1 diabetics with end-stage renal disease. Recently patients with type 2 diabetes have been considered for transplantation. Despite that the patient and graft survival rates have improved over the past years, it continues to be a procedure with high surgical complication rates. We herein report a case of a pancreatic graft with a duodenal complication rescued using a total duodenectomy, a procedure that is seldom used. A 57-year-old type 2 diabetic underwent a SPK transplantation with systemic-enteric drainage. He was converted to a Roux en Y at day 7 for a small duodenal fistula without peritonitis. At day 13, with good graft function, he presented with gastrointestinal and abdominal bleeding. At laparotomy he had a congestive duodenum with intraluminal bleeding and an anastomotic fistula. We performed a total duodenectomy with enteric drainage. The patient was discharged home on day 39 with a pancreatic fistula on intramuscular Octretotide that lasted for 3 months. He was never readmitted and has good pancreas and kidney function at 16 months of follow-up. We think this is an option to rescue a pancreas graft with duodenal complications in selected cases.     

Restriction of indication for automated percutaneous lumbar discectomy based on computed tomographic discography.

This report details the authors' early experience using the automated percutaneous lumbar discectomy (APLD) procedure, developed by Onik et al., in 97 patients with a disc protrusion. In the evaluation of a herniated disc, we used computed tomography (CT) discography. According to the distribution of the dye inside the disc, five different disc types can be differentiated. With a follow-up after 3-7 months, the short-term outcomes of the first 40 APLD-treated patients varied, depending on the shape of the protruded nuclear material. Patients with a broad dye base on CT discography had better short-term outcomes than patients with a narrow dye base. In the next 57 patients we treated with APLD, this tendency was confirmed. The success rate of a consecutive group of patients with a disc protrusion with a broad dye base, treated with APLD, was 80%. In comparison, the patients with a disc protrusion with a narrow dye base had an overall success rate of only 53%. The difference is statistically significant (P < 0.05). The message of this report is that APLD is a useful invasive treatment for patients with a disc protrusion. The outcome depends, however, on the shape of the protruded nuclear material as shown by CT discography, which makes this examination as a conditio sine qua non before treating patients with a disc protrusion with APLD.     

The efficacy of extracorporeal shock wave lithotripsy on single dense calcified gallstones according to computed tomography

The efficacy and complications of extracorporeal shock wave lithotripsy (ESWL) for single gallstones were compared between 15 patients with a CT-lucent stone and 18 patients with a dense calcified stone. In all of five patients with a stone smaller than 10 mm in diameter, complete or sufficient clearance was observed, regardless of calcification. However, in 28 patients with a stone larger than 11 mm in diameter, the rates of complete or sufficient clearance were lower in those with a dense calcified stone (64%) than in those with a computed tomography (CT) lucent stone (93%). There was no difference in the rate of complications between patients with a CT-lucent stone and those with a dense calcified stone. These results thus suggest that extracorporeal shock wave lithotripsy may be safely employed for patients with a single calcified gallstone.     

Reversed lateral upper arm flap with a vascularised fragment of the humerus for reconstruction of ulna shaft fracture after resection of malignant tumour: A case report

The lateral upper arm flap (LAF) is used for a pedicled flap with the vascular arcade at the elbow. There has been no report, however, with regard to the reverse lateral upper arm flap (R-LAF) with a vascularised humerus as an osteocutaneous flap. We describe the case of a 72-year-old woman with a fracture of the ulna after wide resection of a malignant tumour at the proximal half of the forearm, which was reconstructed with an R-LAF with a vascularised fragment of the distal humerus. The flap has successfully survived and the fracture was healed without any adverse event. The R-LAF with vascularised bone is a useful option for the simultaneous treatment of soft tissue and bone defects.     

Percutaneous major aortopulmonary collateral artery banding using a covered stent in an infant

We report a 6-month-old infant with pulmonary atresia with ventricular septal defect who was successfully treated with a novel technique of percutaneous major aortopulmonary collateral artery (MAPCA) banding with a covered stent. He suffered from heart failure due to a residual MAPCA of 4.5 mm in diameter. A covered stent tied with 2 5–0 size nylon threads was successfully deployed into the MAPCA in a dumbbell shape with a banding diameter of 2.8 mm. Banding covered stent implantation is a useful method to reduce the pulmonary blood flow in patients with MAPCA, which could be a less-invasive alternative to surgery.     

预防性植入合成补片在腹腔镜造口术中的应用

目的探究腹腔镜造口术中预防性应用补片的效果。方法将腹腔镜乙状结肠造口术中预防性地在腹膜外植入大孔径、轻量型补片的病例纳入研究。术后随访至少12个月。结果 2003-2007年共有25例病人接受了乙状结肠造口术。平均年龄为65(31～89)岁,BMI平均为26(21～32),其中15例为女性。术后1例病人发生造口坏死,2例发生轻度切口感染。在所有接受随访的20例中(平均随访时间19个月,11～31个月),有3例(15%)发生了造口旁疝。无术后瘘管形成和造口狭窄,也未发生补片感染和再次手术移除补片的情况。结论在腹腔镜造口术中预防性地在腹膜外植入大网孔、轻量型补片是简单安全的操作,并且能有效降低术后造口旁疝的发生率。     

Vena cava stenting and portorenal shunt in Budd-Chiari syndrome: combination of the 'modern' and the 'classical'.

We have treated a 33-year-old Budd-Chiari patient (due to antiphospholipid syndrome) with a history of myocardial infarction by placing a vascular stent in the inferior vena cava and performing a portorenal shunt with three objectives: (1) to perform a shunt operation on a Budd-Chiari patient with good hepatic functional reserve, (2) to avoid a thoracotomy and manipulation of the heart in a patient with a cardiac thrombus and a history of myocardial infarction and (3) to avoid a synthetic graft in a patient with antiphospholipid syndrome. Vena cava stenting and portorenal shunt make a useful combination which should be included in the armamentarium of the hepatobiliary surgeon.     

Total hip arthroplasty with a cemented, polished, collared femoral stem and a cementless acetabular component. A follow-up study at a minimum of ten years

BACKGROUND: Recent studies have suggested that cemented femoral components with a polished surface may provide superior long-term fixation when compared with femoral components with a roughened surface. The purpose of this study was to evaluate the results of total hip arthroplasty with a cemented femoral component with a polished surface finish and compare them with the results of total hip arthroplasty performed with a similar design of cemented femoral component with a rougher surface finish. METHODS: We retrospectively reviewed a consecutive group of 132 patients (149 hips) in whom primary total hip arthroplasty had been performed by one surgeon using a cemented collared femoral component with a polished (0.1-microm Ra) surface finish and a cementless acetabular component. Ninety-eight patients (115 hips) were followed for a minimum of ten years. We compared the survivorship of this prosthesis with that of a femoral component of similar design but with rougher surfaces (matte or grit-blasted). RESULTS: No polished stems were revised because of aseptic loosening or demonstrated radiographic evidence of loosening; however, eight hips (5.4%) with a polished stem demonstrated osteolysis distal to the greater or lesser tro-chanter. In contrast, six stems (2.0%) with a matte surface finish of 0.8-microm Ra were revised because of aseptic loosening, and an additional five stems were seen to be loose radiographically. Eleven stems (9.2%) with a grit-blasted surface finish of 2.1-microm Ra were revised because of aseptic loosening, and an additional four stems were seen to be loose radiographically. The difference in the prevalence of revision due to aseptic loosening between the group with the 0.1-microm Ra surface and the group with the 2.1-microm Ra surface was significant (p = 0.001), as was the difference between the prevalence of revision due to aseptic loosening between the group with the 0.8-microm Ra surface and the group with the 2.1-microm Ra surface (p = 0.001). No cups were revised because of aseptic loosening, and one hip had radiographic signs of acetabular loosening. CONCLUSIONS: This study demonstrated excellent durability of a prosthesis consisting of a cemented, collared, polished femoral component and a cementless acetabular component. While no hips were revised because of aseptic loosening, distal femoral osteolysis was observed in eight hips (5.4%), a higher prevalence than has been reported by others after similar durations of follow-up of tapered, collarless, polished femoral components.     

Tracheal reconstruction with a prefabricated deltopectoral flap combined with costal cartilage graft and palatal mucosal graft

We have created an alternative method for tracheal reconstruction. Our new surgical procedure using a deltopectoral flap combined with a costal cartilage graft and mucosal graft for tracheal reconstruction allows us to achieve reconstruction of the tracheal mucosa, the tracheal cartilage, and the covering skin with adequate subcutaneous tissue. In one case, a tracheostenosis was reconstructed with a deltopectoral flap combined with a costal cartilage graft. In the other case, a tracheal defect was reconstructed with a deltopectoral flap combined with a costal cartilage graft and palatal mucosal graft. Although the operation is a multistage procedure, our method provides satisfactory clinical results. Thus, we believe that our method is useful for the surgical treatment of large tracheal defects.     

The relationship between developmental dysplasia of the hip and congenital muscular torticollis

Multiple studies report a correlation between congenital muscular torticollis (CMT) and developmental dysplasia of the hip (DDH) at a rate between 2% and 29%. Most of these studies were completed before the routine use of hip ultrasound. This study assesses the incidence of DDH in a referral population with CMT and the incidence of CMT in a referral population with DDH. We retrospectively reviewed 186 patients referred with a primary diagnosis of DDH and 109 patients referred with a primary diagnosis of CMT between 1995 and 2004. All patients were screened for DDH with ultrasound if they were younger than 4 months and plain radiographs in older children. Among the patients with a primary diagnosis of DDH, 5.9% were subsequently diagnosed with CMT. However, infants who were less than 1 month old when diagnosed with DDH had a 9% risk of subsequent development of CMT. Among the patients primarily diagnosed with CMT, 3.7% were subsequently diagnosed with DDH. Among the patients with DDH, there was a 7.9% coexistence of CMT, regardless of which was diagnosed first, and among the patients with CMT, there was a 12.5% coexistence of DDH. Boys with DDH were 4.97 times more likely than girls to have both DDH and CMT regardless of which diagnosis preceded the other. Our results confirm that patients with CMT should be screened for DDH, and infants, especially boys, treated for DDH should be followed for the development of CMT.     

Creation of an ileocolic bladder after cystectomy

A divided segment of ileum and colon is used to create a neobladder after cystectomy with a cecourethral anastomosis to provide volitional voiding with continence. Such a bladder provides for good sensation with a large low pressure reservoir and an antireflux ureteral anastomosis. The standard nerve-sparing cystoprostatectomy is performed and no segment of the bladder or prostate is left to compromise the cancer operation. In female or male patients with diffuse carcinoma in situ a similar reservoir with a plicated ileocutaneous anastomosis also can provide continence with intermittent catheterization. Four patients with a urethral anastomosis have day and nighttime continence, and 2 with a cutaneous stoma have 4 to 5-hour dry intervals. Ultimately, it is possible for a patient to void with good urinary control and to have sexual function after cystectomy.     

The meatal problem with TUR prostate: the value of post-operative self-dilatation

In a preliminary retrospective study, we found that 37% of patients about to undergo a transurethral resection of the prostate had an external meatus too small to admit a 26 F resectoscope sheath. In a prospective study, a formal meatotomy was compared with an Otis urethrotomy for patients with a narrow meatus. This study was stopped because 71% of cases having a meatotomy developed strictures compared with 29% having an internal urethrotomy. In a further study of 59 patients, regular self-dilatation of the cut meatus with a plastic spigot was compared with internal urethrotomy of the meatus alone. Seven per cent of cases having self-dilatation developed strictures compared with 34% having internal urethrotomy. It was concluded that in those patients with a narrow external meatus meatotomy should not be carried out, but self-dilatation following internal urethrotomy greatly reduces the incidence of meatal strictures.     

Salivary Oncocytic Cystadenoma with Intraluminal Crystalloids: a Case Report with Review of the Literature

Oncocytic cystadenoma is a rare benign tumor of major salivary glands that in rare occasions may present histologically with intraluminal crystalloids. We report a case of 53-year-old man with a progressively enlarging lump in the left submandibular region. Ultrasound examination revealed a cystic mass with an intraluminal fluid collection. The tumor was surgically removed. Histologic examination yielded a diagnosis of oncocytic cystadenoma with a high concentration of intraluminal crystalloids. The microscopic features of the crystalloids were compatible with nontyrosine (alpha-amylase) crystalloids. When compared with previously published cases in the literature, this is the first report of oncocytic cystadenoma with intraluminal crystalloids arising in the submandibular gland, and the second reported case of the nontyrosine type of crystalloids occurring in association with this tumor. The nontyrosine crystalloids may be highly characteristic to salivary gland tumors with oncocytic differentiation.