A case of liver hernia protruded from the central tendon of the right diaphragm

Diaphragmatic hernia is a rare disease. And if the contents of hernia are intestines, the diagnosis is easy. But if those are great omentum or liver, discrimination from the thoracic tumor is difficult. We experienced a case of liver hernia protruded from the central tendon of the right diaphragm. A 6-year-old girl was admitted to our hospital for investigation of an abnormal shadow of the right lower lung filed, pointed out in the chest X-ray examination at school. We diagnosed as a congenital diaphragmatic hernia of the liver. We made a surgical correction and her postoperative course was uneventful.     

Combined resections of the diaphragm and the liver for a locally advanced non-small-cell lung cancer

A 73-year-old man was admitted to our hospital to undergo treatment for right lung cancer (large cell carcinoma) which had directly invaded the liver through the diaphragm, and presented with T3N0M0, stage IIIa disease. A right lower lobectomy was performed with lymph node dissection, combined with a partial resection of the diaphragm and the liver, as well as a reconstruction of the diaphragm using the latissimus dorsi muscle. The patient had an uneventful postoperative course and was free of disease 1 year later at the time when this paper was written.     

Superselective bronchial arterial infusion therapy with cisplatin and epirubicin hydrochloride, mitomycin C-iohexol-Lipiodol emulsion (EMILE) for hilar lung adenocarcinoma: preliminary clinical experience

A case of hilar lung adenocarcinoma was treated by superselective bronchial arterial infusion therapy with cisplatin and epirubicin hydrochloride, mitomycin C-iohexol-Lipiodol emulsion (EMILE) using Tracker -18 infusion catheter. The tumor size was reduced on follow-up CT scans. However, EMILE was also distributed to nontumorous lung tissues around the tumor, and a shrinkage of the right upper lobe and elevations of the right hilus and diaphragm followed. No major complaints and clinical complications during and after the treatment occurred. This therapy was safe and effective for local tumor reduction in a case of hilar lung adenocarcinoma.     

Effect of magnetic stimulation on the contractile activity of the rectum in the dog

A 64-year-old male complained of right hypochondralgia and was admitted to our hospital. A large tumor (10 x 15 x 10 cm) of the right diaphragm was detected involving the middle and lower lobe of the lung. Microscopic and immunohistochemical examinations showed that bronchiolo-alveolar cell carcinoma was interposed in the sarcoma-like lesion, and this tumor was diagnosed as a so-called carcinosarcoma of the lung.     

A patient with generalized actinomycosis

A 36-year-old man was admitted because of haemoptysis and weight loss. Despite elaborate investigations, including multiple biopsies of affected organs (pleura, lung, kidney and liver) no diagnosis was established. The patient refused further diagnostic procedures and left hospital for winti treatment in Surinam. He did not take the prescribed pheneticillin and returned after seven weeks in a very poor condition. The second admission was complicated by septic shock. Despite intensive treatment he died. On autopsy actinomycosis abscesses were found in lung, liver and kidney. Even when suspected, an infection with Actinomyces is difficult to diagnose. Without adequate treatment this infection can lead to life-threatening complications.     

Right hemihepatectomy using a frontal approach--alternative to the conventional procedure

Right hemihepatectomy is an anatomically based major resection technique for primary and metastatic liver cancer. The most dangerous step in the procedure is to mobilize the right liver lobe from the retroperitoneum and the inferior vena cava. Large tumors or those with extension to the diaphragm, adrenal gland, or kidney may be more easily resected if a frontal approach to dividing the liver is followed. After dissection of the hilus, the liver is divided and during this step all vessels draining to the vena cava are separated. Then the right liver lobe is mobilized together with surrounding structures if necessary, but with no significant risk of bleeding. Our experience in four patients operated on for metastases or different primary tumors demonstrated that this frontal approach may be safely used and allows minimal manipulation of the tumor. Intraoperative ultrasound may be helpful in the detection of the middle and right hepatic vein.     

Pulmonary actinomycosis with "balls-in-a hole" appearance diagnosed by examination of bronchial lavage fluid

A 49-year-old man was referred to our hospital because of abnormal chest X-ray findings. Chest X-ray films showed infiltrative opacities in the right lung, and histological findings of a transbronchial biopsy specimen showed non-specific inflammation. The patient was treated with Ofloxacin for one month. After the treatment, chest X-ray films showed that the infiltrative opacities in the right upper lobe had decreased, but that opacities in the right lower lobe had increased, with an air meniscus sign. A chest computed tomography scan at the same time revealed that the remaining opacities contained multiple mass-like lesions within a cavity in the right S6, appearing as "balls in a hole". One year after the first visit, the patient visited the hospital again because of cough and sputum. A chest X-ray film showed that the size of the cavity in the right lower lobe had increased. The histological findings from a fresh transbronchial biopsy specimen revealed a non-specific inflammation again; however, black clots obtained from bronchial lavage fluid after biopsy were histologically identified as sulfur granules, a classic pathological indication of actinomycosis. This confirmed the diagnosis of pulmonary actinomycosis. The patient was treated with penicillin, and the opacities in the right lower lobe subsided.     

Characterization and responsiveness of the Madison 109 lung carcinoma to various antitumor agents

The Madison 109 (M109) tumor was discovered in 1964 in the lung of a BALB/c mouse. This experimental carcinoma is maintained in vivo by sc passage in the right axillary region. When implanted im (5 X 10(5) cells) into the right hind leg of BALB/c mice for testing, the primary progresses with metastases to the lung, spleen, and liver. The metastases to the lung are visible within 3 weeks and result in the death of the host in about 35 days after tumor implant. Implantation of a lung nodule is tumorigenic and lethal. Pyran polymer therapy delayed the appearance of lung metastases, inhibited the growth of the primary tumor, and significantly increased the lifespan of BALB/c mice inoculated with the M109 tumor. No spontaneous regression has been observed and very few "no takes" have occurred in untreated BALB/c mice inoculated with at least 500 M109 cells. Of the 82 agents tested so far, the M109 model has selected active agents such as actinomycin D, adriamycin, daunorubicin, DNA, procarbazine, and pyran polymer. It has not shown sensitivity as tested to several standard therapeutic agents including cytosine arabinoside, BCNU, hydroxyurea, mechlorethamine, melphalan, triethylenemelamine, and vincristine.     

Medical anthropology and infectious disease control

A 46-year-old woman complained four times of chest pains due to repeated right pneumothorax. This was improved by the right thoracic drainage each time. She was diagnosed as having catamenial pneumothorax from the fact that each episode of pneumothorax began with the first day of her menstrual cycle. She was admitted to our hospital in Jan. 1996 and operated on by the obliteration of pleuro-peritoneal fistulas on right diaphragm under video-assisted thoracoscopic surgery (VATS). No other abnormal lesions were found in the right pleural cavity and right lung. In this case, the pathophysiological mechanisms of pneumothorax might have been caused by the air influx from the peritoneal cavity to the right pleural cavity through the fistulas on the right diaphragm. VATS is minimally invasive surgery and very useful for the treatment of pleuro-peritoneal fistulas on the diaphragm. It should be emphasized that hormonal therapy is necessary after VATS of catamenial pneumothorax.     

Traumatic rupture of right diaphragm presenting as pleuropneumonia

We present a case of rupture of the right diaphragm, due to an automobile accident, discovered after a period of eight years and presenting a clinical picture of pleuropneumonia. The radiologic appearances of traumatic hernia of the diaphragm are more difficult to appreciate on the right side because of the presence of the liver and delayed symptoms. This may be dangerous or sometimes fatal.     

Sucking effect of diaphragm and its significance in drainage of abdominal cavity during hepatic surgery

Investigation of the value of the sucking effect of the diaphragm in 44 patients was carried out. The first group consisted of 28 patients who have not undergone hepatic resection. The second group included patients after hepatic resections of various volume in local pathology. The balloon method in modification of this clinic was used for measurement of the value of the sucking effect. In patients of the first group the value of sucking effect was almost two times more under the right cupula of the diaphragm (130.33 + 4.78 mm of water column) in comparison with the left infradiaphragmatic space. It is responsible for presence of the slot between the right half of the liver and the diaphragm, which aggravates the sucking effect. In the second group of patients the value of the sucking effect under the right diaphragmatic cupula was practically the same as in patients of the first group. After right-sided hemihepatectomy the value of the sucking effect under right cupula of the diaphragm has significantly diminished. After resection of the right lobe of the liver as well as after left-sided hemihepatectomy, or without them, the value of sucking effect under left cupula of the diaphragm did not significantly differ. The investigations showed that vacuum-aspiration with vacuum of not less than 150 mm water column should be used for effective drainage of infradiaphragmatic space.     

Differential expression of HSU17714 gene in colorectal cancer and normal colonic mucosa

We describe an infant with severe eventration of the right diaphragm and pulmonary hypoplasia who presented like a newborn with congenital diaphragmatic hernia complicated by persistent pulmonary hypertension. Surgical correction while on extracorporeal life support was unsuccessful due to attachments of the liver which prevented reduction into the abdominal cavity and our inability to distinguish the true defect from complete agencies of the right hemidiaphragm. At autopsy the pulmonary remnant and the fibrous membrane separating it from the liver were identified.     

Penetrating missile embolisation

The present case report is that of a 13-year-old boy, who was admitted to the Emergency Unit at the American University of Beirut Medical Center (AUBMC), with a bullet injury to the right upper quadrant with no exist. Chest X-ray and KUB failed to reveal the bullet and there was no evidence of haemo- or pneumothorax. X-ray of both thighs showed the bullet at the level of the right groin. The bullet penetrated the liver, diaphragm and pericardium. It entered through the left ventricle and embolised through the arterial circulation to the right superficial femoral artery. Included in this report is a review and analysis of patients with missile embolisation, who were treated at the AUBMC over the last 10 years.     

A case of actinomycosis of the fallopian tube (author's transl)

Reported is the rare case of an actinomycosis of the right Fallopian tube. The clinical picture is characterized by a comparatively sudden onset of abdominal pain, obstipation and feaver as well as a markedly increased ESR. Good co-operation between the various clinical disciplines (urology, surgery, internal medicine, gynecology) lead to an exact preoperative localization of the scaring and infiltrating process that is then verified by laparotomy. The right adnexae show massive inflammatory infiltrates and form a conglomerate tumor with the adjacent sigma and appendix. Characteristic actinomycetic druses are found histologically only in the right Fallopian tube. On the left side a florid non-specific salpingitis is antibiotics is withoug complications. Mode of infection, differential diagnosis and prognosis that is dependent on a correct diagnosis at an early stage are discussed.     

Simultaneous bilateral pallidoansotomy for idiopathic dystonia musculorum deformans

Affection of the CNS by actinomycosis is a rare but treatable manifestation of an infection with actinomyces israeli. Neurological involvement includes a meningeal, granulomatous and also pseudotumoral form. We report the case of a patient suffering from an intracerebral actinomycosis abscess. The source of infection was the upper jaw. After a right frontal craniotomy the intracerebral abscess was removed. Postoperatively the patient received initially a combined antiedemateous and antibiotic therapy with 12 mg dexamethasone and 6 g cefotaxime and 3 g amoxicilline. After 4 weeks of treatment with improving neurological deficits dexamthasone therapy was reduced followed by an exclusive antibiotic therapy for another 4 weeks. During this time the patient recovered completely.     

Extracerebral metastases of a glioblastoma, in the absence of surgery

A 50 y.o. male presented with a right parietal tumor which was a glioblastoma on stereotactic biopsy. He was treated by radiation and steroids, with clinical improvement. Four months later, he presented with a left preauricular mass and cervical lymphadenopathy. CT scan showed destruction of the left mastoid and filling of the left tympanic cavity. One month later, he suffered progressive dyspnea. Chest X ray showed a mediastinal mass on the right side and numerous bilateral interstitial opacities in the lungs. A bronchial biopsy was inconclusive. His general condition worsened, and he died. Postmortem showed continuous neoplastic infiltration of the left part of the base of skull, extending into the neck. Numerous metastases were present in mediastinal lymph nodes, lung parenchyma, pleura and pleural aspect of the diaphragm. There were no subdiaphragmatic metastases. Neuropathological examination confirmed a poorly differentiated highly malignant glioblastoma with severe necrosis involving the internal part of the parietal lobe extending to the dura mater of the convexity and falx cerebri with invasion of the superior longitudinal sinus which was entirely occluded. The biopsy scar was not infiltrated. Visceral tumors were morphologically identical to the brain tumor. They were strongly GFAP positive and cytokeratin negative. Extraneural metastases of glioblastoma in the absence of surgery are uncommon in adults. Involvement of the dura mater and/or superior longitudinal sinus is an almost constant feature. In our case, this may have led to invasion of the base of skull and secondary regional, lymphatic, and hematogenous spread.     

Flap of the musculus latissimus dorsi to prevent alveolar air leakage from sectional plane of the lung after resection of metastatic pulmonary and chest wall tumor

Alveolar air leakage after pulmonary resection usually heals with adequate pleural drainage, but must be more actively treated if leakage may be severe. If left untreated, the postresection space can lead to empyema. We used a muscle flap to prevent alveolar air leakage from a large sectional plane of the lung resected because of metastases in the lung and chest wall. A 48-year-old man complained of pain and a mass on the right side of his back. He had undergone resection and chemotherapy for clear cell sarcoma that originated on the back of the left hand when 43 years of age, wedge resection of the right lower lobe of the lung for a metastatic pulmonary tumor at 46 years, and lobectomy of the same lobe for a recurrence of the metastatic pulmonary tumor at 47 years. The diagnosis was of a metastatic tumor to the right chest wall with peripheral pulmonary tumors of the right upper and middle lobes. Resection of the chest wall and the lung including the tumors was done. Much air leakage from the extensive sectional plane of the right upper and middle lobes was seen intraoperatively, and this plane was therefore covered with a flap of the musculus latissimus dorsi. Chest tubes were removed on day 7 postoperatively when air leakage was no longer seen. Subcutaneous emphysema, which appeared on day 14 postoperatively, required redrainage of the pleural air space, but pleurodesis was effective. Use of a muscle flap was simple and effective for covering of a sectional plane of the lung, and should be considered when alveolar air leakage may be extensive.     

A case of advanced gastric cancer with liver and lung metastasis effectively treated by combined chemo-immunotherapy of MMC, 5'-DFUR, OK-432

A sixty-eight-year-old male patient was diagnosed as having inoperable advanced gastric cancer with liver and lung metastasis. The patient was treated by combined chemo-immunotherapy of MMC 10 mg/M, 5'-DFUR 800 mg/day and OK-432 5 KE/2 W. Six months after commencing chemotherapy, CT-scan and upper GI series revealed that metasized liver tumors and stomach lesion were remarkably decreased in size and no cancer cell was confirmed by endoscopic biopsy. Further, the metastatic lung tumor has disappeared on chest X-ray. The patient had been well without any evidence of tumor re-progression for over one year, but from July the liver tumor began to metastasize again and the patient eventually died of liver metastasis on Jan. 1, 1993.     

Blunt traumatic rupture of the diaphragm: sonographic diagnosis

Ultrasonographic features of seven patients with diaphragmatic rupture due to blunt trauma were analyzed. The ruptures occurred at the left hemidiaphragm in four patients and at the right in three. Direct ultrasonographic findings were as follows: disrupted diaphragm in four patients; nonvisualized diaphragm in three patients; floating diaphragm in two patients; and herniation of the liver or bowel loops through the diaphragmatic defect in three patients. Indirect sonographic findings included pleural effusion or subphrenic fluid collection in five patients and splenic laceration in one. Although the number of patients was limited, ultrasonography was very useful for the diagnosis of diaphragmatic rupture.     

Thoracoscopic transdiaphragmatic microwave coagulation therapy for a liver tumor

BACKGROUND: Microwave coagulation therapy (MCT) for hepatocellular carcinoma, which induces tumor coagulonecrosis, is now recognized as an efficient treatment. However, when a tumor is located just below the top of the diaphragmatic dome, laparotomical MCT requires a large incision, and percutaneous MCT is sometimes impossible. PATIENTS AND METHODS: The patients were four men and two women. There were four cases of hepatocellular carcinoma and two cases of liver metastasis from colorectal cancer. All tumors were located below the top of the diaphragmatic dome. Thoracoscopic transdiaphragmatic MCT (TTMCT) was performed under general anesthesia using an endotracheal double-lumen tube. Identification of the tumor site in the liver was performed using an ultrasonic probe under thoracoscopic observation. After the diaphragm above the tumor was opened, a needle electrode to transmit microwaves was inserted directly into the tumor. Microwave irradiation was repeated to coagulate the entire lesion. After completion of TTMCT, the diaphragm was closed thoracoscopically. RESULTS: TTMCT was successfully administered to cancerous lesions in all six patients. The postoperative course was uneventful, and the average postoperative hospitalization period was 10.5 days. None of the patients has shown any recurrence during a follow-up period of 4-23 months. CONCLUSIONS: TTMCT was performed without any difficulty using the thoracoscopic surgical technique, and its therapeutic outcome was satisfactory. This is effective for tumors located just below the top of the diaphragmatic dome.