Hemangiopericytoma: an unusual cause of upper gastrointestinal hemorrhage.

Hemangiopericytomas, first described in 1942, are rare, highly vascular neoplasms that arise from capillary pericytes. They are seen most commonly as a painless mass arising from the lower extremity but can also originate in the pelvic retroperitoneum and on the head, neck, chest, and abdomen. An unusual case is reported here of a patient presenting with recurrent massive upper gastrointestinal (GI) bleeding in whom a large hemangiopericytoma was found arising in the perisplenic soft tissues. Precedence exists in the literature for the association of hemangiopericytoma with GI bleeding. In prior reports, however, a mural origin of the tumor and subsequent bleeding into the GI lumen was demonstrated. In the case presented here, marked dilatation of the gastric and splenic vessels was noted, but there was no direct pathologic involvement of the stomach wall. It is proposed that superficial gastric erosions combined with the tumor-associated increased vascularity within the stomach wall led to recurrent major bleeding. Diagnosis of these tumors roentgenographically is nonspecific, but angiography is helpful. Morphological characteristics allow accurate histopathological diagnosis and provide prognostic information. The treatment of choice remains wide surgical excision, with the addition of radiation or chemotherapy in selected cases.

Accessory bile duct and laparoscopic cholangiography: report of three cases.

Laparoscopic cholangiography can be useful in identifying an accessory bile duct. Failure to identify an accessory bile duct during laparoscopic cholangiography may lead to complications and prolonged hospitalizations. At times, the accessory duct can be clearly seen filling with contrast; at other times, the only clue to the possible presence of an accessory duct is opacification of the gallbladder. If the cystic duct has been clipped on the gallbladder side of the cholangiocatheter, the only way for the gallbladder to fill is through an accessory duct. If the actual accessory duct cannot be demonstrated and ligated, then drains should be placed in the gallbladder bed. The three cases presented here illustrate these points.

Common duct stone push-through.

Most common duct stones are located below the junction of the cystic duct and the common bile duct. We describe a technique of trans-cystic-duct manipulation of stones through the ampulla of Vater and into the duodenum which we have termed common duct stone push-through (CDSPT). A balloon catheter is inflated above the stone and pushed into the duodenum several times. Successful manipulation of the stone into the duodenum is confirmed by repeat cholangiography. Stones were successfully manipulated by CDSPT in seven patients over a brief period starting June 1988.

Dollars and cents: minicholecystectomy and early discharge.

We present minicholecystectomy as a means of cost containment and discharge from the hospital 24 to 48 hours later. Among 450 patients undergoing this form of cholecystectomy through a 4 cm incision, only 49 stayed longer than an average of 1.2 days; all of those patients had preexisting surgical problems, some of which were corrected concurrently. Forty-two patients were admitted on the morning of the day of operation and stayed an average of 1.07 days. The mortality was 1/450 (0.2%); the complication rate was 3.1%. We have found the shorter and earlier procedure an excellent and safe means of cost containment and recommend that earlier discharge be considered for other procedures as well.

Removal of a common duct stone with a "filet" T-tube.

In a patient who had had cholecystectomy, a common duct stone was removed with a filet T-tube, the open limbs of the tube closing around the stone so that it could be pulled out along the track of the T-tube stem. The maneuver was successfully repeated in a dog. The use of the filet tube is recommended when a T-tube is to be placed in the common duct.