Non-surgical biliary drainage: endoscopic conversion of percutaneous transhepatic into endoprosthetic drainage

Percutaneous transhepatic drainage (PTD) is associated with many long-term complications. Therefore a large-diameter endoscopic endoprosthesis is preferentially employed to bridge a malignant obstruction of the biliary tract. Only if the placement of an endoprosthesis fails, must PTD be established. We present a simple method for converting PTD into a large endoprosthesis (14 F) with the aid of endoscopy. We have performed this conversion successfully in 8 patients without complications.

[Clear text-oriented documentation in hand surgery--integrated in the medical routine documentation service]

For reasons of contents and economy, the construction of medical documentation should be integrated into the secretary's routine work. An efficient and inexpensive microcomputer is able to facilitate and accelerate the typing work of a hand surgical section by the use of a modern data processing system. At the same time important data can be stored for documentation without being coded and with hardly any additional effort. The dates can be analysed according to different criteria (e.g. statistics of diagnosis/therapy, the recall of data of patients with certain diagnosis, yearly statistics and so on). Knowledge of data processing is not necessary.

Myxoid leiomyosarcoma

A series of 13 myxoid leiomyosarcomas (LS) is presented. Seven were from genital and six from extragenital sites and most tumours were large. The myxoid matrix in some tumours separated individual tumour cells; occasionally the myxoid areas were trabecular in shape, resulting in a plexiform tumour pattern; in other tumours there were many closely spaced small mucoid pools which produced a pseudoglandular pattern; in one tumour the pools were large and confluent, and macroscopically evident as gelatinous areas. Four patients who were followed up and whose tumours had shown an absent or very low mitotic rate, nevertheless developed recurrences or metastases; hence a low mitotic count was an unreliable prognostic criterion. The myxoid LS studied did not differ in clinical behaviour and prognosis from the more common solid counterparts. Myxoid LS should be included in the differential diagnosis of any myxoid malignant soft tissue tumour.

Verruciform xanthoma of the skin

A case of verruciform xanthoma is described, representing the fourth case of an extraoral lesion and the first case of xanthoma of this type to involve the true skin. The differential diagnosis from other types of xanthoma, and from granular cell tumour, verrucous carcinoma and other lesions is discussed. This lesion is well known to oral pathologists but deserves wider recognition by histopathologists in general.

[Ceruletide--a sensible adjuvant measure in ERCP?]

The gastro-intestinal hormone Ceruletide is used for diagnostic and therapeutic purposes. Apart from other effects, Ceruletid brings about a relaxation of the Sphincter of Oddi. In the present double-blind study, it was examined on 70 patients whether the effect of this drug can facilitate the cannulation of the Papilla Vateri. Using a dosage of 50 ng/kg body weight Ceruletid in i.m. application the examination time required by the most experienced examiner up to the cannulation of the Papilla Vateri was shortened by half with respect to the collective control group treated with placebo. In the case of less experienced examiners, there was no statistically significant difference in the time of sondage between Ceruletid and the administration of a placebo. Clinical parameters as well as chemical parameters in the laboratory did not reveal any abnormalities. Complications or incompatibilities caused by this drug were not observed.

Ductal adenoma of the breast: a lesion which can mimic carcinoma

Twenty-four cases of a solid benign tumour of breast ducts are described, for which we propose the name 'ductal adenoma'. The lesion consists of a single nodule or multiple nodules involving medium size and small ducts, but not major subareolar ducts. It presents as a palpable lump, and is not associated with a nipple discharge. Clinically, radiologically and macroscopically, it can simulate malignancy because of its occurrence in older age groups, frequent microcalcification and the firmness and irregularity of many lesions. Fibrous sclerosis sometimes results in distortion with apparent invasion of surrounding tissue. It can be mistaken for carcinoma both on frozen and paraffin sections. Differentiation into epithelial and myoepithelial cells is the most reliable criterion in the recognition of this lesion as benign. It has microscopic affinities with ductal papilloma, on the one hand, and with salivary-type adenoma, on the other. Ductal adenoma constitutes the third major type of adenoma in the breast, in addition to the already widely recognized nipple adenoma and tubular adenoma.

Epidermoid cysts of testis

Two cases of epidermoid cyst of testis are reported. The histogenesis is discussed, together with the histogenesis of identical cysts of the ovary and the spleen, and, for the gonadal lesions, a teratoid origin is considered the most likely developmental derivation. The prognosis is excellent after limited excision or orchidectomy.

[Therapeutic regional anesthesia following an accidental intra-arterial injection. A case report on anesthesiologic care following incorrect injection of Reparil (sodium escinate)]

Symptomatology and therapeutic measures after accidental brachial intra-arterial injection of sodium escinate were explained by means of a case report. We obtained long-acting analgesia and sympathicolysis in the upper extremity by an anaesthesia of the ganglion stellatum followed by repeated interscalene plexus brachialis blockade. Even in very severe cases of accidental intra-arterial drug injection surgical procedures should be accompanied with therapeutic regional anaesthesia technics.

Pleomorphic lipoma: a tumour simulating liposarcoma

Pleomorphic lipoma or giant-cell lipoma is a recently recognized entity affecting predominantly elderly and middle-aged men. The neck, shoulder region and back are the sites of predilection. The clinical setting is similar to that seen with spindle-cell lipoma. The lesion is characterized by an intricate mixture of mature fibrous tissue, adipose tissue and myxoid tissue interspersed with cellular foci. Most characteristic of the latter are a variety of giant cells and especially the 'floret' giant-cells, so named because of the arrangement of their nuclei which is reminiscent of the petals of a flower. The pleomorphism of the lesion frequently leads to misdiagnosis as liposarcoma. Criteria for the differentiation from the various types of liposarcoma are discussed. The possible relationship of pleomorphic lipoma to some of the 'atypical lipomas' described in the recent literature is analysed. The pleomorphic lipoma is a benign lesion of subcutaneous tissue which must be sharply differentiated from sarcomas. Some of the liposarcomas alleged in the literature to have originated within a pre-existing lipoma possibly represented pleomorphic lipomas. Pleomorphic lipoma is an entity which must be added to the growing number of pseudosarcomatous lesions of soft tissue.

Tenosynovial fibroma

Tenosynovial fibroma or angiofibroma of tendon sheath is a distinctive clinicopathological entity occurring mainly in young and middle-aged men and affecting dominantly the distal extremities. Fingers, hands and wrists are the site of 80 per cent of cases. Palmar aspects of hands and plantar aspects of foot are preferentially involved. The trunk and neck are seldom affected. They are generally small, firm, sometimes painful lesions attached to tendon sheath and/or tendon. The lesion must be distinguished from a variety of benign lesions including nodular fasciitis, angiomyoma and giant-cell tumour of tendon sheath. It can also be confused with sarcoma, including synovial sarcoma, because of the presence in it of characteristic slit-like spaces which have been identified as vascular rather than synovial spaces by virtue of the Factor VIII content of their lining cells.

[Malignant fibrous histiocytoma of soft tissue. Pathology and radiology of an unusual sarcoma]

Four cases of malignant fibrous histiocytomas are reported. An attempt is made to determine some characteristic roentgenologic features of this disease. There is no pathognomonic radiologic sign; however, angiographic documentation of hypervascularization together with neovascularity and absorption values of about 35 HE in computed tomography suggest a predominantly fibrous sarcoma. Differential diagnosis on abscess formation, tumours of the fat tissue and primary vascular neoplasms should be performed and these conditions ruled out if not applicable.

Pilar tumour: a distinctive type of trichilemmoma

A series of pilar tumours is presented. Although they are predominantly tumours of the elderly female, they occur also in men and in middle age. Some 90 per cent occur on the scalp or nape of neck; about 10 per cent affect other areas. Most tumours outside the scalp involve the trunk; they are rare on the extremities. Evidence is presented that most arise from pre-existing pilar cysts. Two tumours recurred, but were cured by re-excision. Four tumours exhibited histological and/or cytological criteria of malignancy. Two of these were interpreted as in situ carcinomas, and two as combined invasive and in situ carcinomas. None is known to have metastasized or to have behaved aggressively. The prognosis of pilar tumours in excellent whatever the histological appearance. The nature of the lesion and the problems of nomenclature associated with it are discussed.

Bilateral gonadoblastoma/dysgerminoma in a 46 XY individual: case report with hormonal studies

A case of bilateral gonadoblastoma/dysgerminoma in a 46 XY phenotypical female is presented. Increased circulating beta human chorionic gonadotropin (beta-HCG) and testosterone together with a decreased concentration of follicle stimulating hormone (FSH) reflected the activities of these tumours. The patient is alive and well three years later, after treatment by surgery and cobalt therapy.

[Gastrointestinal hemorrhage]

More than 90% of all acute gastrointestinal bleeding is localized in the upper gastrointestinal tract. Manifestation of bleeding elucidates a life-threatening situation. An immediate planned approach with rapid resuscitation from shock, localization of the source of bleeding, estimation of the intensity of bleeding, and local control is necessary. The outcome is influenced more by patient factors and type of bleeding than by therapy. If local control of the source of bleeding is not feasible, a definitive procedure must be employed rapidly.

Ectopic vestigial lesions of the neck and shoulders

A series of five vestigial lesions of the shoulder and back is reported. Their derivation is discussed and in four cases a branchial rather than a bronchial origin is favoured. The fifth case is held to represent skin involvement by thyroglossal duct elements.

Early post-operative endoscopy of the operated intestine

Endoscopy in the early post-operative stage after an intestinal operation is seldom indicated, in contrast to control endoscopy carried out at a later stage. Experiments with animals show that endoscopy of intestinal anastomoses may be performed as early as 24 hours after an operation, if carried out carefully by an experienced endoscopist. During this early post-operative period, endoscopy is indicated only when complications arise. The most important application is the endoscopic insertion of an intestinal tube in cases of post-operative ileus. However, coloscopic suction in meteorism of the colon, and the introduction of tubes through swollen anastomoses are also possible. Bleeding of an anastomosis in the early post-operative stage is rare, whereas bleeding due to teleangiectatic granulomas in the later post-operative stage is more common. Both cases are indications for endoscopic hemostasis. Nevertheless, it must be emphasized that intestinal endoscopy in the early post-operative stage should be carried out only in exceptional cases, and then only by an experienced surgical endoscopist.

Sweat-gland carcinomas: prognosis related to histological type

A series of 10 sweat-gland carcinomas is reported. The ages of the patients at presentation ranged from 12 to 79 years. Three of the tumours had shown long latent periods with a mass present for up to 20 years. Prognosis proved to be related to the histological subtype. Thus, two papillary syringocystadeno-carcinomas, one recurring cylindroma, one hybrid cylindroma/adenoid cystic carcinoma and two mucoid carcinomas were apparently all cured by surgery. Two mucoepidermoid carcinomas and one histologically malignant chondroid syringoma were not only histologically, but also clinically, malignant. The last case, a chondroid syringoma of benign histology, proved nevertheless to be malignant clinically.

Female adnexal tumour of probable Wolffian origin

Two further cases of 'female adnexal tumour of probable Wolffian origin' are described Both were retroperitoneal and presented a unique histology of uniformly close-packed bland spaces. solid islands, cords, and diffuse areas. A small hamartoma in a female fetus, part of which resembled the tumours, was traced to an area of near apposition with some paroophoron canals, providing further evidence of a Wolffian origin. The literature of this and some other putative Wolffian tumours is briefly reviewed, and the relation to rete adenomas is discussed.

Postmastectomy lymphangiosarcoma: a reappraisal of the concept--a critical review and report of an illustrative case

The syndrome of postmastectomy lymphangiosarcoma (LAS) has been universally accepted since it was first outlined by Stewart & Treves (1948), except for a small number of authors who concluded that the neoplasms arising in the chronic lymphoedematous arms were in fact due to retrograde spread from the original breast carcinoma (Laffargue, Pinet & le Go 1960, Giannardi, Pelù & Zampi 1960, Giannardi & Pelù 1961, Delarue 1962, Salm 1963, Laugier, Olmos, Hunziker & Orusco 1973), but their views have been largely ignored. A case is reported in whom neoplastic arm lesions appeared 27 years after mastectomy and were due, in our opinion, to recent metastases from a new primary Carcinoma of the lung. The validity of the entire concept of LAS is re-examined.