Experience with the advanced breast biopsy instrumentation system.

OBJECTIVES: To report early experience with the advanced breast biopsy instrumentation (ABBI) system and to compare the results with those of other published studies. DESIGN: A nonrandomized case series. SETTING: An outpatient breast diagnostic centre at a large urban community hospital. PATIENTS: Thirty-four women; 27 had suspicious calcifications, 2 had a nonpalpable mass and 5 had both. INTERVENTION: The ABBI procedure to excise a breast lesion or obtain a representative sample for histologic examination. MAIN OUTCOME MEASURES: Success of the procedure with respect to diagnosis, sample quality, technical problems, margins of tumour free tissue and patient satisfaction. RESULTS: Malignant tissue was diagnosed in 7 women (21%) and atypical ductal hyperplasia in 2 (6%). In all cancers, the obtained samples had malignant cells present at the margins or less than 1 mm away. Technical problems were encountered in 32% of cases. Manual extraction of the specimen was required in 21% of cases. CONCLUSIONS: The preliminary data correlate well with those of other published results. Although it is possible that a small number of cases and a relatively high proportion of technical difficulties may represent a normal learning curve, there is a definite need for improvement of some ABBI components. ABBI does not appear to provide adequate margins of uninvolved tissue in patients with cancer and thus should not be used with curative intent. ABBI provides excellent quality samples for pathological study and good patient satisfaction. There are not yet enough data for meaningful comparison of ABBI with stereotactic core biopsy and excisional biopsy with needle localization.

Gastrocolic fistula secondary to primary gastric lymphoma.

Gastrocolic fistula in primary non-Hodgkin's lymphoma (NHL) of the stomach is rare; in a review of the literature we found only four cases, all in association with disseminated (stage IV) disease. We describe the first case of a gastrocolic fistula in a patient with stage IE lymphoma. The diagnosis was suggested by feculent vomiting, and the fistula was located using barium enema and CT scan. Therapy consisted of local resection followed by combination chemotherapy.

Coping styles in identifiers and nonidentifiers of a breast lump as a problem.

One hundred patients referred to a teaching hospital breast clinic for as yet undiagnosed breast masses were interviewed during their first visits and prior to assessment by a surgeon. Baseline measures of mental state and coping style were obtained. Despite the purpose of their visits, 74 of the patients were "nonidentifiers" of the breast lump as a problem on their initial contact with the clinic. All patients who were non-identifiers also used denial as a coping mechanism. Nonidentifiers used more than three times the number of avoidant coping mechanisms than "identifiers." Patients with a family history of breast cancer were more likely to be identifiers than those without a family history.

Is age alone a contraindication to major cancer surgery?

The question of whether major cancer operations are worthwhile in elderly patients is becoming more important, as we are faced with a progressively aging population. From Jan. 1, 1978 to Dec. 31, 1983, 268 elderly patients underwent major operations for esophageal, gastric, intestinal, pancreatic and retroperitoneal cancer. The patients were divided into three age groups: group A, 65 to 74 years (163 patients), group B, 75 to 84 years (81 patients) and group C, 85 to 92 years (24 patients). The overall operative mortality was 11.2%, 8.6% in group A, 13.6% in group B and 20.8% in group C. The higher rates in groups B and C resulted from two major factors: (a) the presence of serious cardiopulmonary disease preoperatively and (b) the development of one or more serious complications postoperatively. When these two factors were compensated for, the rates became comparable at 6.1%, 6.6% and 8.3%, respectively. The effect of preexisting cardiorespiratory compromise was approximately equal in each group. The effect of postoperative surgical complications became more pronounced with advancing age. Most patients enjoyed substantial palliation of symptoms. The average length of hospital stay was not unduly prolonged. Major cancer surgery can be safe and beneficial for elderly patients, but concerted attempts must be made to improve their status preoperatively. The minimum effective operation should be performed and postoperative care should be intensified.

Device for the secure fixation of the U tube.

A yoke constructed from a segment of chest tube provides secure U-tube fixation during the early postoperative period. The complications of U-tube dislodgement and bile leakage are thus avoided.

Biliobronchial fistula following pyogenic liver abscess.

A 65-year-old man with malaise, chills and fever was found to have a pyogenic liver abscess. A fistula from the abscess to the bronchial tree was confirmed by bronchoscopy and thoracotomy. In spite of adequate drainage of the abscess, respiratory function deteriorated and the patient died 1 month after operation. Biliobronchial fistula resulting from a pyogenic liver abscess is rare and has not recently been reported in the English or French literature. Reports dating back to the first published case in 1857 are reviewed. Early supradiaphragmatic excision of the fistulous tract and drainage of the hepatic abscess are recommended.

Percutaneous catheter drainage of liver abscess: an alternative to open drainage?

Percutaneous catheter drainage is still a new concept. Only 4 cases have been reported thus far and this paper reports 2 further cases. The technique of percutaneous catheterization of a liver abscess under CAT scan control is described, and the management of the catheter by a closed irrigation system is set out. Unless there is another compelling reason to do a laparotomy, we feel that this procedure is well worth a trial in view of the high mortality still associated with open drainage. Further experience may well prove percutaneous catheter drainage to be the procedure of choice for liver abscess.

Early surgical management of acute cholecystitis.

Between 1971 and 1977, 361 patients underwent early elective cholecystecomy for acute cholecystitis, and the complications and mortality were studied according to the length of time from admission to operation. A substantially greater proportion of the complications, and the only deaths, occurred in the patients operated upon more than 7 days after admission. The mortality rate was 0.6%. Nine additional high-risk patients underwent cholecystostomy. There were four postoperative deaths in this group, all related to the debilitating underlying conditions. The mortality for the entire series was 1.6%. These results compare favourably with those following delayed elective operations for acute cholecystitis. Early elective operation, using cholecystectomy when possible and cholecystostomy when necessary, is recommended for general use in experienced hands. This practice is safe and sound particularly when the diagnosis is made more certain preoperatively by the use of intravenous cholangiography.

Evaluation of intraoperative biopsy of the pancreas.

The authors carried out a retrospective review of intraoperative biopsy of the head of pancreas in 47 patients. Vim-Silverman needle biopsy (32 patients), or wedge biopsy (9 patients), or both (5 patients) were used. The correct diagnosis in the 34 patients with carcinoma was made in 76% by paraffin section and in 65% by frozen section. Diagnositic accuracy was 77% with needle biopsy and 38% with wedge biopsy. Complications occurred in six patients and consisted of pancreatitis, fistula and hemorrhage. Two patients required reoperation because of hemorrhage. The case of one patient who died of a pancreaticoperitoneal leak at the biopsy site is described in detail. The overall complication rate was 15%. These results indicate that wedge biopsy carries significant risks and frequently does not detect carcinoma. Needle biopsy is relatively safe and is more likely to provide an accurate diagnosis of carcinoma.

Umbilical pilonidal sinus.

A rare case of umbilical pilonidal sinus is reported--the only documented case of barber's pilonidal of the umbilicus. Possible mechanisms of formation are described. It is suggested that this possibility should be considered in cases of resistant or recurrent omphalitis. Definitive treatment consists of sinus excision with cosmetic umbilical reconstruction. Total omphalectomy is probably only justified for recurrence.