Successful management of ruptured choledochal cyst by primary cyst excision and biliary reconstruction

One to two percent of patients who have choledochal cysts present with cyst rupture and bile peritonitis. Reported cases have been managed with external drainage of the cyst followed by a second procedure to excise the cyst and reconstruct the biliary tract. The authors report two cases of ruptured choledochal cyst treated with primary cyst excision and biliary drainage. The satisfactory outcome of these patients suggests that this is the preferred management.     

Pulmonary valve cyst in an adult. Case report

A case is described of an asymptomatic woman who had typical findings of mild pulmonic stenosis. Right heart catheterization revealed a 44 mm. Hg gradient across the pulmonary outflow tract, and a filling defect was discovered by angiography. On surgical exploration, the defect was found to be a benign cyst attached to the anterior leaflet of the pulmonary valve.     

Primary splenic pregnancy. Case report

A patient with a primary splenic pregnancy is described.     

Case report: calcification within aneurysmal bone cyst

Aneurysmal bone cyst (ABC) usually affects older children or young adults. The radiological appearance is of a purely osteolytic expansile metaphyseal lesion with thinned out cortex and internal septations. We present a case of ABC in a 5-year-old girl which showed internal calcification and was initially diagnosed as enchondroma. However, pathological examination revealed typical appearance of ABC with large area of dystrophic calcification.     

Epidermoid cyst of the brain stem. Case report

OBJECTIVE: To search for the effect and safety of coral porous hydroxyapatite (CHA) implanted material in orbital rim reconstruction. METHODS: 7 cases of orbital rim reconstruction were treated with CHA which is a plate form mass with an interconnected system of canals of approximately 200 microns in size. It has three types: 1.0 cm x 1.5 cm x 5.0 cm, 0.6 cm x 1.5 cm x 5.0 cm and 0.4 cm x 1.5 cm x 5.0 cm. According to the shape of a contralateral healthy orbit, a rubber putty model was made before the operation. An incision was designed at the upper 1/3 of the face for the elimination of wrinkles or a prolonged incision of lower lid bag plastic surgery was made. After the exposure of the defective part of the orbit, a correctly molded CHA tamponade was inserted. RESULTS: The orbital rim reconstruction in 7 cases with orbital defect was successfully treated with CHA. During a follow-up of 3-12 months (average 6.6 months), there was no extrusion or migration of implant. CONCLUSION CHA is a good material for substitution of bone graft and is much better than autogenous tissue of other artificial materials.     

Granulomatous hypophysitis caused by a ruptured intrasellar Rathke''s cleft cyst: report of a case and review of the literature

STUDY OBJECTIVES: To determine the clinical significance of Candida sp isolated from bronchoscopic samples in patients with suspected pneumonia. DESIGN: A retrospective chart review was performed in all nonneutropenic adult patients with Candida sp isolates from respiratory secretions obtained by bronchoscopy over a 5-year period (1991 to 1995). Potential risk factors, therapeutic decisions, and outcome were recorded. Microbiological findings, chest radiograph reports, and pathologic material were reviewed. Isolates were classified as definite, probable, or indeterminate contamination, or as definite pulmonary candidiasis, on the basis of histologic findings, therapeutic decisions, and outcome. SETTING: A 600-bed teaching hospital with 16 beds in a medical-surgical ICU. PATIENTS: Thirty-seven consecutive patients with positive cultures for Candida sp from respiratory samples obtained by bronchoscopy were evaluated. Thirty-two of these 37 patients (86.5%) received antibiotic therapy prior to sampling, and 23 (62.2%) were intubated. RESULTS: Contamination was classified as definite in 3 patients (8.1%) and probable in 30 others (81.0%). Contamination was indeterminate in two cases (5.4%). Two additional patients (5.4%) received antifungal agents for systemic candidiasis. No cases of pulmonary candidiasis could be demonstrated, although 24 of 28 patients showed protected specimen brush cultures > or = 10(3) cfu/mL. CONCLUSIONS: Nonneutropenic patients with isolation of Candida sp from bronchoscopic samples, even in high concentrations, are unlikely to have invasive candidiasis. Indication for initiation of antifungal therapy should be based on histologic evidence or identification from sterile specimens.     

Carcinoid of the gallbladder. A report of a clinical case treated by video laparoscopic cholecystectomy

The authors report a clinical case of the gallbladder carcinoid tumour treated with laparoscopic cholecystectomy. After a short analysis of the classification, the malignant potentiality and the symptoms of gallbladder carcinoids, they conclude that it is possible to treat carcinoids with laparoscopic cholecystectomy, but only in some selected cases, that is to say in the absence of factors indicative of local invasion and that in the other cases it is preferable the classic surgical treatment of laparotomic resection.     

Long-term control of recurrent cyst of the conus medullaris. Case report

The authors report a case in which decompression of an intramedullary epidermoid cyst was maintained by intermittent drainage via an implanted subcutaneous Ommaya reservoir.     

Results of laparoscopic treatments of ovarian endometriomas: laparoscopic ovarian fenestration and coagulation

OBJECTIVE: To determine the long-term results of laparoscopic fenestration and coagulation of ovarian endometriomas and to compare them with the results of ovarian cystectomy performed by either laparotomy or laparoscopy. DESIGN: Case-control study. SETTING: Two university-affiliated hospitals. PATIENT(S): One hundred fifty-six premenopausal women with ovarian endometriomas of at least 3 cm in diameter (stage 3 and 4 endometriosis, revised American Fertility Society classification). INTERVENTION(S): Laparoscopic ovarian fenestration and coagulation (group 1, 80 patients); laparoscopic ovarian cystectomy (group 2, 23 patients); and ovarian cystectomy by laparotomy and microsurgical technique (group 3, 53 patients). MAIN OUTCOME MEASURE(S): Operative findings, recurrence rate, and cumulative clinical pregnancy rate (PR) over a 36-month follow-up period. RESULT(S): The mean (+/-SD) time to first pregnancy was significantly shorter in group 1 (1.4+/-0.2 years) than in group 2 (2.2+/-0.5 years) or group 3 (2.4+/-0.5 years). The difference between the cumulative clinical PR between the three groups was not statistically significant after 36 months of follow-up. The difference in the recurrence rate among groups 1, 2, and 3 was not statistically significant. CONCLUSION(S): Laparoscopic ovarian fenestration and coagulation of endometriomas leads to faster conception than ovarian cystectomy by laparotomy. Laparoscopic ovarian fenestration and coagulation of endometriomas is associated with cumulative clinical PRs and recurrence rates over 36 months that are similar to those associated with ovarian cystectomy.     

Advanced laparoscopic surgery for the removal of rectovaginal septum endometriotic or adenomyotic nodules

In the pelvis, three different forms of endometriosis (Donnez et al, 1992) must be considered: (1) peritoneal, (2) ovarian, (3) rectovaginal septum. By evaluation of the mitotic activity and the stromal vascularization, we have recently suggested (Nisolle et al, 1993) that peritoneal red lesions were the most aggressive form of the disease and progress to the so-called typical or black lesion, which must be considered as an enclosed implant surrounded by fibrosis. This type of infiltration must be clearly differentiated from the rectovaginal endometriotic nodule. Koninckx (1993) recently described three types of deep-infiltrating endometriosis: deep-infiltrating endometriosis of type I is a rather large lesion in the peritoneal cavity, infiltrating conically with the deeper parts becoming progressively smaller. It has been suggested that this type of endometriosis is caused by infiltration. In type II lesions, the main feature is that bowel is retracted over the lesion which thus becomes deeply situated in the rectovaginal septum although not actually infiltrating it. Type III lesions are the deepest and most severe. They are spherically shaped, situated deep in the rectovaginal septum, often only visible as a small typical lesion at laparoscopy or often not visible at all. This lesion is often more palpable than visible and is acutely tender if the patient is examined at the time of menstruation, and gives rise to severe dyspareunia. In our experience there are two different types of 'deep-infiltrating endometriosis': 1. True deep-infiltrating endometriosis caused by the invasion of a very active peritoneal lesion deep in the retroperitoneal space. In cases of lateral peritoneal invasion, uterosacral ligaments can be involved as well as the anterior wall of the rectosigmoid bowel junction resulting in a retraction, adhesions and secondary obliteration of the cul-de-sac. 2. Pseudo deep-infiltrating endometriosis or adenomyosis of the rectovaginal septum. This lesion originates from the rectovaginal septum tissue and consists essentially of smooth muscle with active glandular epithelium and scanty stroma. In our study, the rectovaginal nodule was histologically similar to an adenomyoma (Zaloudek and Norris, 1987). It was a circumscribed, nodular aggregate of smooth muscle, endometrial glands and endometrial stroma. As in the 'adenomyoma', secretory changes were frequently absent in 'endometriotic' rectovaginal nodules. The invasion of the muscle by a very active glandular epithelium, without stroma, proved that the stroma is not necessary for invasion in this particular type of pathology called adenomyosis. In some instances, it can be seen that the vaginal pluristratified epithelium was replaced by a glandular epithelium. The fact that ciliated cells were present and the co-expression of both vimentin and cytokeratin (Donnez and Nisolle, personal communication) proved the Mullerian origin of the nodule, where certain histological characteristics are completely different to those observed in peritoneal lesions (Nisolle et al, 1990). In our series, deep fibrotic tissue assumed to contain endometriosis was excised or vaporized from the anterior rectum with the aid of multiple rectovaginal examinations. Cul-de-sac dissection was followed by excision of deep fibrotic endometriosis, without cul-de-sac reconstruction. In three cases, the bowel lumen was entered. A comprehensive laparoscopic procedure, while not eradicating all the endometriosis, may result in considerable pain relief or a desired pregnancy.(ABSTRACT TRUNCATED AT 400 WORDS)     

Bilateral lutein cyst in normal single-child pregnancy

A rare case of bilateral multiple lutein cysts in pregnancy is reported. They do not require a radical operation because of spontaneous regression after delivery.     

Necrotizing fasciitis following laparoscopic surgery. Case report and review of the literature

Necrotizing fasciitis is a rare and potentially fatal infection characterized by rapid and progressive involvement of the fascia and subcutaneous tissues. Early diagnosis, aggressive initial debridement followed by planned redebridements in conjunction with nutritional support and antibiotics remain the mainstay of therapy. We present a case of necrotizing fasciitis of the abdominal wall following a laparoscopically assisted vaginal hysterectomy. Literature is reviewed and discussed with reference to this catastrophic infection in the age of laparoscopic surgery.     

Eight cases of pyelo-ureteral junction syndrome treated by laparoscopic surgery

From may 1994 to may 1995, eight consecutive patients with symptomatic congenital ureteropelvic junction syndrome (UPJS) were treated by pyeloplasty as described by Anderson, Hynes and Küss by laparoscopic surgery. Three patients had a lower pole artery crossing the anterior surface of the junction and two had a giant renal pelvis. The mean operating time was 120 minutes (min: 90 min; max: 147 min) and the mean hospital stay in the absence of complications (one case) was 3.5 days (min: 1.5 day; max: 8 days). This one complication was due to a postoperative fistula resulting from a technical error requiring an additional fortnight in hospital. All the patients are evaluable at three months. All are asymptomatic and the radiological results showed frank improvement in seven out of eight cases, while the dynamic appearance was improved in the other case. UPJS can be treated by laparoscopic surgery according to proven surgical principles, provided it is performed in a perfectly equipped operating room, by a surgeon and operating team experienced in this type of surgery.     

Torsion of uterine fibroma associated with incarcerated inguinal hernia in pregnancy. Case report

The incidence of inguinal hernias in pregnancy is 1:1000 about. Much more frequent are uterine leiomyomas, reported in 0.5-2.6% cases. We describe a rare case of a 31 old woman at the 20th week of pregnancy affected with a torsion of uterine leiomyoma associated with right inguinal incarcerated hernia, operated urgently (myomectomy and Bassini inguinal plastic).