Primary neoplasms of the small bowel.

Primary neoplasms of the small bowel are unusual and constitute 1-5% of all gastrointestinal tract neoplasms. Preoperative diagnostic difficulties, frequent dissemination at the time of the diagnosis, and poor prognosis are characteristic of this pathology. During a period of 26 years we treated 61 patients with tumors of the small bowel, 44 malignant and 18 benign (1 patient had both). The most common symptoms were abdominal pain (62%), weight loss (41%), and gastro-intestinal bleeding (31%). More than half of the patients were treated as emergencies and among the remaining, the most useful diagnostic test was the small intestinal barium study. Seventeen patients were operated on for intestinal obstruction, 6 of them due to intussusception of the tumor, while 8 other patients presented with perforation and 7 with massive gastrointestinal bleeding. Leiomyoma was the most frequent benign lesion. Among malignancies lymphoma was encountered in 38.6%, followed by adenocarcinoma (29.6%) and leiomyosarcoma (22.8%). Lymphoma was predominant among Sephardic Jews. Curative procedures were attempted in all but one of the benign cases and in 21 of the malignant cases. At the time of surgery metastases were present in 23 patients. The postoperative mortality was high (20% and 14% in the benign and malignant groups, respectively) most probably due to the high incidence of emergency surgery in a high risk population. The prognosis of the malignant tumors was poor with a 5-year survival of 18%. Their disappointing course seems to be related to late diagnosis because of nonspecific symptoms and difficulty in bringing the tumor to the fore. Hopefully, a greater awareness will lead to an earlier diagnosis and improve the prognosis.

Localized fibrous mesothelioma of the mediastinum devoid of pleural connections.

Localized fibrous mesothelioma of the pleura is an uncommon neoplasm. Very rarely (there have been three previous cases) it may occur as an isolated mediastinal tumour. Such a tumour was present for at least 3 years in a 47 year old man, causing shortness of breath and superior vena cava syndrome. A mass weighing over 600 g was completely resected through a median sternotomy. The pertinent literature is reviewed.

Choledochoduodenostomy for benign and malignant biliary tract diseases.

Although nonsurgical alternative treatments for primary or retained common bile duct stones--such as dissolution of gallstones with deoxycholic acids and, especially endoscopic papillotomy--have become available, choledochoduodenostomy (CDS) has been used with increasing frequency over the past decade, with extension of the indications for its use. We report our experience with side-to-side CDS in 116 patients with benign (65 patients) and malignant (46 patients) biliary diseases. Even though the mean age of our patients with benign disease--patients who underwent urgent operations because of obstructive jaundice (74%), liver damage (approximately 60%), and other biliary complications--was 66.8 years, the perioperative mortality was 3.07% and the long-term follow-up results were excellent with no biliary complications. In regard to the controversy about the use of CDS in malignant biliary obstructions, our experience shows that none of the 42 patients had any complication due to malignant invasion of the stoma, and only one patient had ascending cholangitis; the perioperative mortality in this group was 8.6%. In our opinion, CDS is a relatively safe, definitive procedure for treatment of benign and malignant biliary diseases, with good long-term results in high-risk, aged patients.