Splenic trauma following endoscopic retrograde cholangiopancreatography (ERCP).

Endoscopic retrograde cholangiopancreatography (ERCP) is a safe diagnostic and therapeutic procedure. Splenic injury after ERCP is extremely rare and only two cases have been reported in the English literature. A subcapsular splenic hematoma is reported after ERCP and the mechanism of injury and possible preventive measures are discussed.

Gastrointestinal neurofibroma in a patient with von Recklinghausen's disease.

A 47-year-old woman underwent surgery because of a nonhealing gastric ulcer. An interesting pathologic finding followed.

Diverticulitis of the cecum and ascending colon.

Twelve cases of acute solitary diverticulitis of the cecum or ascending colon are reviewed. This is frequently indistinguishable from acute appendicitis preoperatively and is often mistaken for carcinoma at laparotomy. There are subtle clinical features that may help to suggest the diagnosis both before and during surgery. If diagnosed preoperatively, it can be treated effectively with broad spectrum antibiotics without surgical intervention. When diagnosed intraoperatively, hemicolectomy can often be avoided. Appendectomy should be done if resection is not performed.

Unsuspected hepatic abscess associated with biliary tract disease.

Experience at Beth Israel Medical Center with 10 patients who had unsuspected intrahepatic abscesses due to biliary tract disease led to a reevaluation of this entity. Ultrasonography, computerized tomography, and radionuclide imaging techniques have radically altered the approach to the evaluation and management of this disease in the last several years, and rapid diagnosis and treatment have led to a markedly improved prognosis, especially in those patients with calculous disease of the biliary tract.

Primary smooth muscle tumors of venous origin.

Vein tumors are rare, difficult to diagnose, and usually malignant. We have encountered three: a leiomyoma of the jugular vein and leiomyosarcomas of the saphenous vein and inferior vena cava (IVC). The leiomyoma was lost to follow-up, the saphenous vein leiomyosarcoma survived nine years, and the leiomyosarcoma of the IVC is six months without recurrence. Half of venous leiomyosarcomas arise in the IVC, predominately in women over 50 years of age. Surgical excision is the treatment of choice since malignant or benign status cannot be determined operatively. Resection should include a segment of the original vessel. This poses problems in the IVC when the renal veins require sacrifice. Right renal vein interruption mandates nephrectomy. Edema following IVC resection is evaluated. The incidence is lower than anticipated when resection is for tumor if there is no history of phlebitis. The IVC was reconstructed with a composite autograft but this is not now recommended. Despite significant local recurrences or distal metastases, cure or long-term palliation can often be achieved. Radiation and chemotherapy do not improve survival or prevent recurrence.

Common bile duct stones and biliary-intestinal anastomoses.

Six patients with symptoms referable to residual or recurrent common bile duct calculi following biliary tract operations, including a biliary-intestinal diversion, were studied by endoscopic retrograde cholangiography. Two patients were treated by endoscopic papillotomy and the remainder, by surgical procedures which included choledocholithotomy, transduodenal sphincteroplasty and revision of the biliary-intestinal anastomosis. Analysis of this experience suggests that one cannot assume that choledochoduodenostomy or choledochojejunostomy will always mitigate the consequences of retained or recurrent common duct stones. The segment of common bile duct between the biliary-intestinal anastomosis and the papilla of Vater may serve as a blind pouch or sump in a small number of patients undergoing these procedures. In patients with choledocholithiasis, efforts to remove all stones from the ductal system are the principal consideration; and choledochoduodenostomy should be reserved for specific indications, such as obstruction of the distal part of the bile duct.

Bleeding from stapler anastomosis.

Three patients with massive bleeding after stapler-performed intestinal anastomosis are reported on. Two patients required secondary operation for control. The cause was mechanical instrument failure. Periodic in vitro testing is recommended as a preventive measure.

Combined use of percutaneous transhepatic cholangiography (P.T.C.) and endoscopic ampullary cholangiography in the diagnosis of "difficult" jaundice cases.

When bilirubin levels are elevated, visualization of the biliary ducts is only possible by endoscopic transampullary cholangiography or by P.T.C. Cannulation of the biliary tree is difficult under the best of circumstances and when obstruction exists at the caudal end of the ducts, success is frequently precluded. P.T.C. then becomes the modality of choice, since visualization can be achieved in 98% of cases when obstruction exists. These methods are complementary. Each should be used when the other fails. Their dual application and complementary role in "difficult" jaundice cases is elaborated upon in the 16 cases reported in this current series. Their combined use should help elicit the diagnosis in almost all cases of jaundice.