Traumatic retropharyngeal haematoma treated by embolization of the thyrocervical trunk.

Trauma involving the retropharyngeal space is relatively infrequent. Upper airway obstruction due to a retropharyngeal haematoma can be life threatening and requires immediate intervention. We present a well-documented case that illustrates the unexpected clinical course of such a haematoma and its management.

Clinico-pathological data and prognostic factors in completely resected AJCC stage I-III liposarcomas.

BACKGROUND: In general, although biological behavior and prognosis of liposarcomas (LPS) are more favorable compared with most other soft tissue sarcomas (STS), prognosis can vary widely depending on tumor characteristics, especially histological subtype and tumor grade. PATIENTS AND METHODS: All consecutive, completely resected stage I-III LPS (as determined by the American Joint Committee on Cancer staging guidelines), treated at the Groningen University Hospital from 1977-2000, were analyzed. RESULTS: A total of 69 patients, 35 males and 34 females, median age 51 (range 11-80) years, were reviewed. After a median follow-up of 71 (range 5-231) months, the overall local recurrence and metastasis rate at five years after diagnosis were 27% and 16%, respectively. Retroperitoneal localization was a significant negative prognostic factor regarding local recurrence; dedifferentiation, grade II-III, and deep location regarding distant metastasis; and dedifferentiation, grade II-III, stage II-III, size >20 cm and non-radical resection regarding survival. CONCLUSIONS: LPS have a relatively mild biologic behavior, with the exception of very large, deeply located, dedifferentiated and/or grade II-III LPS. Radical resection is important for disease-specific survival. LPS have a relatively mild biologic behavior, with the exception of very large, deeply located, dedifferentiated and/or grade II-III LPS.

Simultaneous epstein barr virus and cytomegalovirus infection accompanied by leiomyomatous change in a well-differentiated liposarcoma in a patient with long-term corticosteroid treatment.

Patient. A 59-year-old woman presented with a large tumour of the abdominal wall. She had been taking corticosteroids for severe chronic obstructive pulmonary disease for 15 years. On CT scan the tumour had the characteristics of lipomatous tissue with a dense core.Results. Histology showed a well-differentiated liposarcoma with a core of benign fibroleiomyomatous differentiation. Within the core, a third component was observed, characterized by more pleomorphism and the presence of an inflammatory infiltrate. In this component, immunoperoxidase stains and in situ hybridization demonstrated cytomegalovirus (CMV) and Epstein Barr virus (EBV) infection in large and small cells, respectively.Discussion. Long-term corticosteroid use for pulmonary disease may extend the list of immunosuppressed states associated with the development of leiomyomatous tumours with EBV infection, previously described in AIDS patients and liver transplant recipients. The role of CMV is uncertain.

Severe complications of perianal sepsis in patients with human immunodeficiency virus.

Fifty human immunodeficiency virus (HIV)-infected patients with perianal sepsis were studied. Seven (14 per cent) had serious septic complications, four patients with severe necrotizing gangrene, and three with abscesses in the mediastinum, liver and brain respectively. CD4+ lymphocyte counts were significantly lower in patients with severe septic complications as compared with those with uncomplicated perianal sepsis (P < 0.05). In patients with HIV presenting with rare (metastatic) abscesses, perianal sepsis must always be kept in mind as a possible focus. Although HIV-infected patients have a limited life expectancy perianal fistulas and abscesses should be aggressively treated, because of the high risk of severe complications.

[Surgical treatment of anorectal disorders in 32 HIV-seropositive patients]. / Chirurgische behandeling van anorectale afwijkingen bij 32 HIV-seropositieve patiënten.

OBJECTIVE: To describe the presentation and surgical treatment of anorectal pathology in HIV seropositive patients. DESIGN: Retrospective study. SETTING: Department of surgery, University Medical Centre, Amsterdam, the Netherlands. METHODS: Retrospective review of the records of 32 HIV seropositive patients surgically treated for anorectal pathology in 1985-1992. RESULTS: The 32 patients, homosexual males, had a total of 46 diagnoses for which they underwent 49 surgical interventions. Sixteen patients had an anorectal ulcer (14 in the anal canal, 2 in the distal rectum); 7 were treated by local excision and 9 with additional advancement of the anal mucosa; there were 4 and 2 recurrences, respectively. Ten patients had a perianal abscess; 5 a fistula, 2 of whom initially presented with a metastatic abscess in liver and brain. Eight patients had perianal warts, which in 2 cases showed severe dysplasia and in one an infiltrating carcinoma. Five patients presented primarily with a malignancy (3 with squamous cell carcinoma of the anus, 1 with cloacogenic carcinoma, 1 with non-Hodgkin lymphoma distally in the rectum). Twelve patients died within 6 months after the first operation. CONCLUSION: In choosing therapy for anorectal disorders, the limited survival of HIV seropositive patients, especially those with an advanced stage of AIDS should be considered. Surgical treatment can improve the quality of life in these patients.

Endosonographic TNM staging of extrahepatic bile duct cancer: comparison with pathological staging.

Endosonography was performed preoperatively in 33 patients with common bile duct carcinoma and in 43 patients with carcinoma of the common hepatic duct and its bifurcation. The results were correlated with the histology of resected specimens according to the new (1987) TNM (tumor, node, metastasis) classification. Endosonography was accurate in the evaluation of the depth of tumor infiltration. Overall accuracy for common bile duct carcinoma and common hepatic duct carcinoma was 82.8% and 85%, respectively. Endosonography was helpful in diagnosing regional lymph node metastases but not accurate in diagnosing nonmetastatic lymph nodes. With common bile duct carcinoma, the incidence of lymph node metastasis increased with progressive depth of tumor infiltration. No such correlation was found in common hepatic duct carcinomas. In the staging of distant metastasis, this technique was limited by the low-penetration depth of ultrasonography. Thus, additional transcutaneous ultrasonography or computed tomography was necessary for complete staging. The routine use of the biopsy channel for endosonographically guided aspiration puncture will further enhance the diagnostic value of endosonography in the future.

Endosonography of peri-anal and peri-colorectal fistula and/or abscess in Crohn's disease.

Transcolorectal endosonography (ES) was performed in 36 patients with Crohn's disease suspected clinically to have a fistula or abscess. A hypoechoic or anechoic duct-like lesion immediately adjacent to the anorectal lumen compatible with a fistula was found in 32 patients. A communication between the fistulous tract and adjacent structures such as the skin, anal canal, or vagina was detected in all 32 patients. An anechoic cavity adjacent to or communicating with the fistula was visualized in 29 of the 36 patients. A fistula was visualized in the remaining seven patients with no evidence of an abscess. This anechoic cavity compatible with an abscess was surgically confirmed in 14 of 17 patients. We judged the extent and configuration of the abnormalities to be more clearly visualized by ES when results were compared with fistulography in five patients. There were no ES complications, and we conclude that ES is the preferred diagnostic procedure in patients with peri-rectal pathology because of the low risk of bacterial dissemination and low incidence of patient discomfort. Utilizing ES after non-surgical treatment was successful in 19 patients for documentation of the response to therapy.

Ampullopancreatic carcinoma: preoperative TNM classification with endosonography.

Endosonography (ES) was used for the preoperative TNM (1987) staging of tumors in 43 patients with pancreatic cancer and 24 patients with ampullary carcinomas. These results were correlated with the histologic findings of resected specimens. Early-stage tumors could be distinguished from advanced stages of cancer with ES. Detailed images of ductular and parenchymal abnormalities allowed distinction between pancreatic and ampullary carcinomas based on anatomic location. The overall accuracy of ES in the assessment of tumor classification in pancreatic and ampullary carcinoma was 92% and 88%, respectively. In diagnosing regional lymph nodes in pancreatic and ampullary tumors the accuracy of ES was 74% and 54%, respectively. For diagnosing metastatic lymph nodes in pancreatic and ampullary carcinoma the accuracy of ES was 91% and 80%, respectively. The prevalence of lymph node metastases in T1 pancreatic cancers and T1 ampullary carcinomas was 40% and 0%, respectively. Discrimination between inflammation and metastases was difficult with ES. ES was not accurate in assessing distant metastases because of the limited penetration depth of ultrasound.

Preoperative TNM classification of proximal extrahepatic bile duct carcinoma by endosonography.

ES was performed preoperatively in 39 patients with a proximal bile duct carcinoma. The results were correlated with the histologic findings of resected specimens or intraoperative excision according to the new (1987) TNM classification. ES was accurate in assessing the depth of tumor infiltration. The overall accuracy of ES was 83.8%. Overstaging of T2 carcinoma occurred in three of ten patients (30%) and understaging of T3 carcinoma occurred in 3 of 27 patients (11%). ES was helpful in diagnosing lymph node metastasis (accuracy, 92.9%) but not accurate in defining nonmetastatic lymph nodes (accuracy, 18.8%). Difficulties occurred in distinguishing inflammatory lymph nodes and micrometastatic lymph node involvement. ES was not accurate in diagnosing hepatic metastases and peritoneal dissemination because of the limited penetration depth of ultrasound. The incidence of lymph node metastasis of advanced stage carcinoma was approximately 40%. Technical improvements, such as reduction of the diameter of the echoprobe, easy handling of ES-guided cytologic puncture, and the routine use of a catheter echoprobe during ERCP will further enhance the accuracy of ES.

Flumazenil used for reversal of midazolam-induced sedation in endoscopy outpatients.

A double-blind, placebo-controlled randomized clinical study was performed in 69 outpatients scheduled for endoscopy and sedated with midazolam to assess the efficacy, safety, and usefulness of flumazenil in reversing the effects of midazolam-induced sedation. Midazolam was administered intravenously before endoscopy up to a maximum dose of 15 mg. After endoscopy either flumazenil or placebo was injected. Vital signs and psychomotoric tests were assessed before injection of midazolam, before injection of flumazenil or placebo, and 5, 15, 30, 60, 240, and 360 min afterward. Thirty-six patients received flumazenil, 33 placebo. All parameters returned to pre-sedation levels within 5 min in all patients in the flumazenil group, with significant differences as compared with placebo after 5, 15, 30, and 60 min. Flumazenil was well tolerated. No rebound sedation was observed. Flumazenil is a safe and effective benzodiazepine antagonist. The combination of midazolam with flumazenil makes it possible to reduce the recovery period and is useful in outpatient endoscopy.