Paediatric mycosis fungoides - characteristics, management and outcomes with particular focus on the folliculotropic variant.

BACKGROUND: The literature on paediatric mycosis fungoides (MF) and especially its folliculotropic variant (FMF) is sparse. OBJECTIVES: To describe the clinical manifestations, treatments, outcomes and long-term course of paediatric MF, including FMF. METHODS: A retrospective analysis was conducted of all consecutive MF patients diagnosed at ≤18 years attending two medical centres in 1995-2015. RESULTS: The cohort included 71 patients, all but two of whom had early-stage disease: hypopigmented (55%), folliculotropic (42%) and classical MF (39%), alone or in combination. The head and neck area were involved in 43% of patients with early-stage FMF compared to 12% of the non-FMF group (P = 0.004). There was no difference in the involvement of other body areas between the groups. Pruritus, although mild, was more often recorded among patients with early-stage FMF compared to non-FMF (58% vs. 29%, respectively, P = 0.02). Complete response (CR) was achieved in 60 of the 69 patients with early-stage MF (87%) after an average of 1.8 treatment modalities. NBUVB was the most administered treatment to non-FMF patients with CR rates of 63% vs. 29% of FMF patients (P = 0.04). Systemic/bath PUVA and UVA+NBUVB were the most administered treatments to FMF patients with CR rates of 60% vs. 81% for non-FMF patients (P = 0.17). During a mean follow-up of 9.2 years (range 1-24), stage progression was observed in four (6%) of the patients with early-stage disease, two of whom (all FMF) to advanced stage. CONCLUSIONS: Paediatric MF presents as an early-stage disease with over-representation of hypopigmented and FMF variants. NBUVB and UVA-based therapies yield good response rates in non-FMF and FMF patients, respectively. Disease course is indolent, and even on relatively long follow-up, it has a very low progression rate from early to advanced-stage disease, occurring in patients with FMF. We propose a treatment algorithm for paediatric MF.

Laparoscopic colectomy for transverse colon carcinoma.

BACKGROUND: Laparoscopic resection of transverse colon carcinoma is technically demanding and was excluded from most of the large trials of laparoscopic colectomy. The aim of this study was to assess the safety, feasibility, and outcome of laparoscopic resection of carcinoma of the transverse colon. METHODS: A retrospective review was performed to identify patients who underwent laparoscopic resection of transverse colon carcinoma. These patients were compared to patients who had laparoscopic resection for right and sigmoid colon carcinoma. In addition, they were compared to a historical series of patients who underwent open resection for transverse colon cancer. RESULTS: A total of 22 patients underwent laparoscopic resection for transverse colon carcinoma. Sixty-eight patients operated for right colon cancer and 64 operated for sigmoid colon cancer served as comparison groups. Twenty-four patients were identified for the historical open group. Intraoperative complications occurred in 4.5% of patients with transverse colon cancer compared to 5.9% (P = 1.0) and 7.8% (P = 1.0) of patients with right and sigmoid colon cancer, respectively. The early postoperative complication rate was 45, 50 (P = 1.0), and 37.5% (P = 0.22) in the three groups, respectively. Conversion was required in 1 (5%) patient in the laparoscopic transverse colon group. The conversion rate and late complications were not significantly different in the three groups. There was no significant difference in the number of lymph nodes harvested in the laparoscopic and open groups. Operative time was significantly longer in the laparoscopic transverse colectomy group when compared to all other groups (P = 0.001, 0.008, and <0.001 compared to right, sigmoid, and open transverse colectomy, respectively). CONCLUSIONS: The results of laparoscopic colon resection for transverse colon carcinoma are comparable to the results of laparoscopic resection of right or sigmoid colon cancer and open resection of transverse colon carcinoma. These results suggest that laparoscopic resection of transverse colon carcinoma is safe and feasible.

Laparoscopically assisted reversal of Hartmann's procedure.

BACKGROUND: Restoration of bowel continuity after Hartmann's procedure is a major surgical procedure associated with substantial morbidity and occasional mortality. The authors review their experience with laparoscopically assisted reversal of Hartmann's procedure (LARH) to assess difficulties and potential advantages associated with this procedure. METHODS: A retrospective chart review of a prospectively entered database was performed to identify patients who underwent LARH over a period of 7 years. Data regarding demographic and clinical characteristics, surgical details, and postoperative course were reviewed. Specifically, age, gender, diagnosis at initial operation, American Society of Anesthesiology (ASA) score, comorbidities, operative time, conversion, surgical team, complications, postoperative bowel movements, and hospital stay were assessed. All surgeries were performed by six experienced laparoscopic surgeons. RESULTS: A total of 27 patients, 17 men and 10 women, with mean ages of 58.1 and 62.9 years, respectively, underwent LARH. The procedure was laparoscopically completed for 23 patients. Conversion to laparotomy was required for four patients (14.8%) because of dense adhesions after the initial Hartmann's procedure in three patients and rectal perforation in one patient. The median operative time was 226 min, and the median hospital stay was 6 days. The overall morbidity rate was 33% (9 patients), attributable to colostomy site infection in 5 of the 9 patients. One patient required reoperation because of intraabdominal bleeding. No anastomotic leaks or intraabdominal abscesses were recorded. There was no operative mortality. CONCLUSIONS: Laparoscopically assisted reversal of Hartmann's procedure is technically challenging and time consuming. However, in the hands of experienced laparoscopic surgeons, it is safe and associated with a reasonably low conversion rate. Furthermore, the relatively low morbidity rate, short hospital stay, and earlier return of bowel function may be beneficial to patients.

Is mechanical bowel preparation mandatory for left-sided colonic anastomosis? Results of a prospective randomized trial.

BACKGROUND: Preoperative mechanical bowel preparation is aimed to reduce the risk of infectious complications, and its utility is a dogma in left-sided large bowel anastomosis. The aim of this study was to specifically assess whether colocolonic and colorectal anastomoses may be safely performed without preoperative mechanical bowel preparation. METHODS: Patients undergoing elective colon and rectal surgery with primary colocolonic or colorectal anastomosis were prospectively randomized into two groups. The "prep" group had mechanical bowel preparation prior to surgery, while the "non-prep" group had surgery without pre-operative mechanical bowel preparation. RESULTS: Two hundred forty-nine patients were included in the study, 120 in the prep group and 129 in the nonprep group. Demographic characteristics, indications for surgery, and type of surgical procedure did not significantly differ between the two groups. There was no difference in the rate of surgical infectious complications between the two groups. Overall infectious complication rate was 12.5% in the prep group and 13.2% in the non-prep group. Wound infection, anastomotic leak, and intra-abdominal abscess occurred in 6.6%, 4.2%, and 1.6% of patients in the prep group and in 10.0%, 2.3%, and 0.7% of patients in the nonprep group, respectively (p=NS). CONCLUSIONS: These results suggest that elective left-sided anastomosis may be safely performed without mechanical preparation. Multicenter studies to test the reproducibility of these results are required, to support a change in this time-honored practice.

Preperitoneal bupivacaine attenuates pain following laparoscopic inguinal hernia repair.

BACKGROUND: Laparoscopic preperitoneal inguinal hernia repair is associated with a short hospital stay and an early return to normal activity. Therefore, early postoperative pain control is important. The aim of this study was to evaluate the effect of preperitoneal Bupivacaine instilled into the preperitoneal cavity on pain following laparoscopic mesh repair of inguinal hernia. METHODS: After institutional review board approval, 44 patients undergoing elective laparoscopic inguinal hernia repair were prospectively randomized into two groups. Upon completion of the Prolene mesh repair, group A received 80 mg of Bupivacaine in 25 cc of saline installed into the preperitoneal space, whereas group B received normal saline installed into the preperitoneal space. Pain was assessed using a visual analog scale at fixed time intervals; the amount of analgesics required was also recorded. RESULTS: Twenty-two patients were included in each group. The demographic characteristics and type of surgery (unilateral vs bilateral) did not significantly differ between the two groups. The average pain levels were significantly attenuated in group A compared to group B at 1 (4.0 vs 5.0, respectively; p = 0.0038), 2 (4.0 vs 5.9, respectively; p = 0.0015), and 4 (4.3 vs 5.8, respectively; p = 0.0038) h after surgery. Furthermore, the analgesic intake was significantly decreased in group A compared to group B. CONCLUSION: Preperitoneal Bupivacaine attenuates pain following laparoscopic inguinal hernia repair and should be considered in these cases.

Laparoscopic management of surgical complications after a recent laparotomy.

BACKGROUND: The use of laparoscopy in the scarred abdomen is now well established. However, recent laparotomy and the presence of a fresh abdominal wound usually preclude laparoscopic intervention. Thus, early postlaparotomy complications, which mandate surgical interventions, are usually treated by a second laparotomy. We report our experience with the use of laparoscopy for the treatment of postoperative complications, after open abdominal procedures. METHODS: Fourteen patients were operated for a variety of conditions, and postoperative complications, such as bowel obstruction, intraabdominal infection, or anastomotic insufficiency, were handled laparoscopically. RESULTS: Eleven patients recovered from the acute condition. One patient died from sepsis, one retroperitoneal abscess was missed and later drained percutaneously, and one conversion to open surgery was necessary because of adhesions and lack of working space. CONCLUSIONS: We conclude that a recent laparotomy is not a contraindication for laparoscopic management of acute abdominal conditions. Postlaparotomy complications can be successfully treated by laparoscopy. Avoiding the reopening of the abdominal wound and a second laparotomy may reduce the additional surgical trauma, and thus result in easier recovery.

Laparoscopic distal pancreatectomy.

BACKGROUND: Advanced laparoscopic techniques have been adapted to various surgical pathologies, including pancreatic tumors, with the potential benefits of attenuated surgical trauma, faster recovery, and improved cosmesis. Laparoscopic pancreatic surgery is technically demanding, and thus has not yet gained widespread acceptance. The aim of this study was to review our preliminary experience with laparoscopic distal pancreatectomy for benign and malignant pancreatic pathologies. METHODS: A retrospective chart review of consecutive patients with benign and malignant pancreatic tumors who underwent laparoscopic distal pancreatectomy in a university-affiliated department of surgery between 1997 and 2003 was performed. Data relative to demographic and clinical characteristics, indications for surgery, surgical procedure, and postoperative course were recorded. RESULTS: Laparoscopic distal pancreatectomy was attempted for 12 patients with benign (n = 8) and malignant (n = 4) pancreatic tumors and successfully completed laparoscopically in 75%, of these cases. Six early postoperative complications (two abscesses, two instances of diabetes mellitus, two pancreatic leaks) developed in three patients. The spleen was successfully preserved in 58% of the cases. CONCLUSIONS: This preliminary experience suggests that laparoscopic distal pancreatectomy is a feasible and safe procedure with a morbidity rate comparable with that for the conventional open procedure. However, laparoscopic surgery for malignant pancreatic tumors remains controversial. Larger series with longer follow-up periods are necessary to determine the role of laparoscopic surgery in the treatment of pancreatic pathologies.

The impact of a resident's seniority on operative time and length of hospital stay for laparoscopic appendectomy: outcomes used to measure the resident's laparoscopic skills.

BACKGROUND: Laparoscopic appendectomy (LA) frequently is performed by residents during calls. This study aimed at evaluating residents' surgical skills using parameters of operating time, length of hospital stay (LOS), and conversion rate in correlation with the operating team's level of seniority. In addition, this study compared the operating time for LA with that for open appendectomy performed by the same teams, and identified deterministic factors that have an impact on such parameters. METHODS: All records of patients undergoing appendectomy performed by residents alone during a 32-month period were reviewed retrospectively. Eight residents were assigned to two levels of seniority: juniors 3 years (S). Operating time and LOS were compared between the three surgical teams, namely, J/J, J/S, and S/J as operating and assistant surgeons, respectively. Operating time, conversion rates, and LOS were compared for the same team combinations. RESULTS: Residents alone performed 341 (151 laparoscopic and 190 open) appendectomies during on-call hours. Four of the residents had been 3 years or less in residency (J), and four had been in residency more than 3 years (S). The overall mean operating time was 1.33 +/- 0.48 h for LA and 1.2 +/- 0.5 h for open appendectomy (p = 0.016). The operating time correlated with the level of training for both LA (J/J, 1.6 +/- 0.38 h; J/S, 1.41 +/- 0.37 h; S/J, 1. 25 +/- 0.4 h; p = 0.03, ANOVA) and open appendectomy (J/J, 1.53 +/- 0.89 h; J/S, 1.4 +/- 0.63 h; S/J, 0.86 +/- 0.45 h; p = 0.023, ANOVA). The mean LOS was 2.9 +/- 3.1 days for open appendectomy and 2.1 +/- 2.8 days for LA (p = 0.065), and was not different after operation by any of the teams (J/J, J/S, S/J) for either the open or the laparoscopic procedure. CONCLUSIONS: There is a distinct difference in the surgical skills of residents according to level of seniority, as primarily reflected by operating time. Laparoscopic appendectomy requires longer time to perform in a teaching setting, but the most deterministic factor that dictates operating time is the composition of the surgical team rather than the laparoscopic approach.

Immune inhibitory effects of renal cell carcinoma extract on lectin and alloantigen-induced peripheral blood and tumor infiltrating lymphocyte blastogenesis.

The presence of tumor infiltrating lymphocytes (TIL) has been attributed to the host cell mediated immune response against the evolving malignancy. However, due to specific evasive and escape mechanisms, the immune competent cells are rendered ineffective. One such mechanism may be the production of immune suppressor substance(s), inhibiting lymphocyte proliferation, and subsequently, their transformation into effector cells. To evaluate a possible impact of RCC extract on lectin and alloantigen-induced proliferation of TIL and peripheral blood lymphocytes (PBL) from renal cell carcinoma (RCC) patients and from healthy control human subjects. Tumor extract and TIL were derived from 13 patients with RCC undergoing radical nephrectomy. Tumor infiltrating lymphocytes and PBL from these patients were activated with Concanavalin A (Con-A), Phytohemoglutinine (PHA) or Pokeweed (PW) and the rate of blastogenesis was measured by (3)H Thymidine incorporation. The same procedure was used in assay with PBL from control healthy blood donors. There was a significant reduction (88.6%) in the proliferative response to ConA of TIL compared to PBL from the same patients (P = 0.007). A similar decrease was seen following stimulation by PHA (85.8%, P = 0.01) and PW mitogen (78.5%, P = 0.001). A 79.5% decrease in response level of TIL to alloantigens compared to PBL from RCC patients (P = 0.021), was observed. Lectin induced proliferative response of RCC patients was significantly lower in the presence of RCC extract (82.9%) compared to normal kidney extract (P = 0.008). Alloantigenic stimulation of healthy individual PBL was also decreased significantly in the presence of RCC extract (92.9%, P = 0.0001) compared to normal kidney extract. Similarly, lectin induced stimulation of healthy control PBL in the presence of RCC extract was significantly lower (83.2%, P = 0.003). Our data suggest that RCC extract contains an immune suppressive substance(s), capable of inhibiting lymphocyte proliferative response of tumor infiltrating lymphocytes as well as of PBL from patients and healthy individuals alike. This may be one of the mechanisms by which the tumor evades the transformation of lymphocytes into effector killer cells, and thus affects the biological inter-relationship between tumor and host. Identification of this substance and its gene may provide an effective anti-tumoral treatment modality.

140 consecutive cases of minimally invasive, radio-guided parathyroidectomy: lessons learned and long-term results.

BACKGROUND: The advent of highly accurate parathyroid imaging and the ever-increasing trend towards minimally invasive procedures have changed considerably the surgical approach to the patient with primary hyperparathyroidism (PHPT) caused by a single parathyroid adenoma. This study analyzes the short- and longer-term results of 140 patients who underwent minimally invasive, radio-guided parathyroidectomy. METHODS: Demographic, clinical, and pre-operative imaging data, operative findings, and short- and long-term results of 140 consecutive patients operated within a 20 months period (8/1999-4/2002), were prospectively entered into a database. Immediate pre-operative sestamibi scintigraphy with skin marking of focal adenoma uptake were followed by intraoperative hand-held gamma probe for the removal of the parathyroid adenoma by unilateral minimal access surgery. Preoperative and surgical data were analyzed and correlated to outcomes, measured by success or failure to cure PHPT, associated morbidity and mortality, predictive value of localizing studies, and postoperative laboratory results in the immediate as well as long-term period. RESULTS: 140 patients, mean age: 55.1 +/- 14.1 years (range 19-88 years), female to male ratio 94:46 with PHPT proven by concomitantly elevated serum calcium and parathormone (PTH) levels, with a single adenoma identified by sestamibi single photon emission tomography (SPECT) scintigraphy and high-resolution sonography, underwent minimally invasive, radio-guided parathyroidectomy. Mean serum levels of preoperative calcium, phosphorus, and PTH were 11.6 +/- 0.8 mg/dL (range 9.1-14), 3.0 +/- 0.3 mg/dL, and 147.1 +/- 94.3 pg/mL (range 68-784), respectively. Overall, in 3 out of 140 patients (2.1%), focused, minimally invasive surgery failed to identify and remove the adenoma. Positive predictive value when both localizing modalities concurred was 99.2%. Positive predictive value of SPECT scan alone was 97.2%. Overall success rate was 97.8% (137/140). 24 hours postoperative mean serum calcium was 9.2 +/- 0.8 mg/dL and at 6 months mean serum calcium, phosphorus, and PTH were 9.4 +/- 1.06 mg/dL, 3.2 +/- 0.8 mg/dL, and 32.1 +/- 11.9 pg/mL, respectively (p = 0.0001). There was no mortality. In 2 patients (1.4%) there was transient vocal cord paresis and there were 8 instances of clinically significant hypocalcemia. In 3 cases (2.1%), a second adenoma manifested itself 9-14 months following surgery and was removed by minimal access procedure. CONCLUSIONS: Minimally invasive, radio-guided focused parathyroidectomy for a single adenoma is safe and effective in curing hyperparathyroidism with a 97% success rate. A second adenoma occurring in less than 3% may be successfully treated with a second minimal access operation. The combined positive predictive value of concurring sestamibi SPECT scintigraphy and sonography of 99.2% may increase success rate, and thus implementing this technique in patients with concurring sonography and scintigraphy may be advocated.

Increased expression of activation markers in renal cell carcinoma infiltrating lymphocytes.

PURPOSE: As manifested by the presence of immune competent cells, failure to control the progression of renal cell carcinoma by a local immune response attests to impaired local cell mediated immunity. To test this hypothesis we compared the expression of T-cell activation markers in renal cell carcinoma infiltrating lymphocytes with the expression of activation markers of peripheral blood lymphocytes in the same patients. MATERIALS AND METHODS: Tumor infiltrating lymphocytes were harvested from a patient with renal cell carcinoma undergoing radical nephrectomy. Peripheral blood was obtained before surgery. Tumor infiltrating and peripheral blood lymphocytes were incubated with monoclonal antibodies defining specific differentiation and activation markers on the cell surface, and analyzed by flow cytometry. Cell subsets are expressed as a fraction of the total number of mononuclear cells. RESULTS: The T-cell subset level was significantly higher in peripheral blood than in renal cell carcinoma tissue of the same patient. However, the level of activated T-cell subset expressing HLA-DR was significantly higher in renal cell carcinoma tissue than in peripheral blood. The levels of interleukin-2 receptor and transferrin receptors expressing T-cell subsets were also significantly higher in carcinoma tissue than in peripheral blood. Natural killer cells were found in significantly higher proportions in renal cell carcinoma than in peripheral blood. CONCLUSIONS: These results point to significant activation of T, B and natural killer tumor infiltrating lymphocytes. The inability of tumor infiltrating lymphocytes to mount an effective immune response to renal cell carcinoma may be secondary to the presence of suppressive factors in the tumor that prevent tumor infiltrating lymphocytes from transforming into effector cells. These factors may be particularly valuable for the further study of renal cell carcinoma-host interactivity.

Pitfalls and complications with laparoscopic intraperitoneal expanded polytetrafluoroethylene patch repair of postoperative ventral hernia.

BACKGROUND: This study reviewed our experience with laparoscopic ventral postoperative (incisional) hernia repair. METHODS: Clinical data from the first 100 cases were analyzed retrospectively. RESULTS: Between 1997 and 2000, 64 women and 36 men (mean age, 58.4 +/- 13.6 years; range, 27-87 years) underwent laparoscopic hernioplasty. Hernias (mean diameter, 6.2 +/- 3.7 cm) were in a midline (74%), subcostal (10%), or other incision location, and were recurrent in 25%, of the patients. The mean operative time was 119 +/- 77 min. Extensive adhesiolysis was necessary in 37 cases. There was no mortality. The recorded complications included inadvertent enterotomies (n = 6), seromas (n = 11), prolonged ileus (n = 4), and prolonged fever (n = 3). Seven cases were converted; to repair accidental enterotomies (n = 4) due to difficult adhesiolysis (n = 2), or to control bleeding (n = 1). Six patients underwent reoperation because of enetric leak (n = 3) or bowel obstruction (n = 3). There were two documented recurrences (2%). The mean follow-up period was 19 months (range, 12-54 months). CONCLUSIONS: Laparoscopic intraperitoneal approach to postoperative ventral (incisional) hernia repair may be associated with significant complications and morbidity, which can be prevented in part by meticulous technique and liberal conversions. The justification of this procedure is the low recurrence rate, according to preliminary results.

Down regulation of CD45 expression on CD4 T cells during acute renal allograft rejection: evidence of a decline in T suppressor/inducer activity.

Acute rejection is associated with the activation of helper and cytotoxic cells. A shifting balance between the suppressor/inducer CD45+ CD4+ and T helper/inducer (CD4+CD45-) cells may be responsible for the transition from quiescence to overt rejection. We examined the kinetics of CD45 expression on CD4+ T cells in renal allograft recipients from pretransplant values to acute rejection and after reversal of rejection, searching for a shift in balance between helper/inducer and suppressor/inducer cell subsets. Using two color flow cytometry, the peripheral blood levels of CD4+, CD4+CD45- [T helper/inducer (Thi)], CD4+CD45+ [T suppressor/inducer (Tsi)], CD3+, and CD8+ T cells subsets and their interrelationships, were determined in 49 patients prior to transplantation, and in 10 of them, during acute rejection and after its reversal. Results were analyzed and compared to data obtained from 10 healthy blood donors. Acute rejection was associated with a significant decline in CD45+ CD4+ expression compared to quiescent phase (22% +/- 3.7% vs. 26.5% +/- 3.2%, p = 0.05) and controls (29.5% +/- 6.2%, p = 0.01). No difference was observed compared to pretransplant levels (19.9% +/- 3.2%, p = ns). CD45-/CD45+ (Thi/Tsi) ratio was lowest during quiescence (0.75) compared to rejection (0.97, p = 0.05), in controls (0.98, p = 0.05) and pretransplant values (1.4, p = 0.01). Acute rejection was characterized by higher Thi/CD8+ and lower Tsi/CD8+ ratio (103 and 88 respectively, p = 0.045), compared to clinical quiescence (104 and 116 respectively, p = 0.039). These data suggest that acute rejection is associated with down regulation of CD4+CD45+ suppressor/inducer subset. This shift may account for the transition from quiescence to overt rejection, concurring with reports on CD4+CD45 regulatory function.

Fibroadenoma of the breast: analysis of associated pathological entities--a different risk marker in different age groups for concurrent breast cancer.

BACKGROUND: Fibroadenoma, one of the most common benign breast lesions, has a characteristic age-specific incidence and is associated with other pathological entities in 50% of cases. The clinical or imaging diagnosis of fibroadenoma may be erroneous, and in some cases is found to be invasive cancer. The clustering of such entities, their correlation with age, and the risk of synchronous breast malignancy are uncertain. OBJECTIVE: To explore the possibility of any significant clustering of fibroadenoma-associated benign breast diseases and to assess the possible risk of concomitant breast cancer. METHODS: We analyzed the pathological results of 147 women undergoing excisional biopsies for fibroadenoma diagnosed pre-operatively either by clinical examination and imaging (n = 17) or by radiology alone (n = 30). The inter-relationships among all entities associated with fibroadenoma were studied by hierarchical cluster analysis. The correlation of the various pathologies with the risk of invasive breast cancer in relation to the patient's age was also evaluated. RESULTS: Fibroadenoma-associated pathologies were found in 48% of the cases: sclerosing adenosis (23%), duct ectasia (17.7%), apocrine metaplasia (15.6%), florid fibrocystic disease (12.9%), duct papillomatosis (11.6%), infiltrating duct carcinoma (5.4%), duct carcinoma in situ (3.4%), and 1 case of lobular carcinoma in situ (0.6%). An orderly internal hierarchy and three significant clusters emerged: a) epithelial apocrine metaplasia, duct ectasia and sclerosing adenosis (similarity coefficients 16.0, 11.0 and 8.0 respectively); b) papillomatosis, florid fibrocystic disease and calcifications (similarity coefficients of 6.0, 4.0 and 2.0 respectively); and c) infiltrating duct carcinoma and duct carcinoma in situ (similarity coefficients of 1.8 and 1.6 respectively). Seven of the eight patients with breast cancer were older than 40 years. CONCLUSIONS: In about half of the cases fibroadenoma was associated with other pathological entities clustered in an orderly hierarchy. The rarity of synchronous breast cancer in the younger age group and its more common association with fibroadenoma in the older age groups dictate a different approach to each. The finding of fibroadenoma in women older than 40 indicates the need for surgical excision.

Bedside laparoscopy in the ICU: report of four cases.

BACKGROUND: Patients in the intensive care unit (ICU) may suffer from life-threatening abdominal pathologies, which may necessitate a surgical intervention. Diagnosis may be difficult, as deep sedation and analgesia often mask symptoms, and physical examination is unreliable. Imaging studies are not accurate enough, and exploratory laparotomy carries significant morbidity and mortality rates in this patient population. The unstable patient is difficult to mobilize to the imaging department or to the operating room. Bedside laparoscopy may overcome these difficulties. PATIENTS AND METHODS: We describe our initial experience with the use of bedside laparoscopy in critical patients with suspected abdominal pathology. The procedure was performed in four patients over a 4-month period and completed in all four. RESULTS: The findings were: turbid fluid consistent with viscus perforation in a patient with unexplained sepsis after cardiac surgery, sterile hemorrhagic fluid in a patient with malignancy and thrombotic thrombocytopenia purpura, a retroperitoneal mass from which biopsies were taken in a patient with sudden respiratory failure, and abdominal abscess in a patient after bowel resection for mesenteric embolism. None of these patients had a laparotomy after the laparoscopy. Patients 1 and 4 died a few hours after the procedure from sepsis, and patients 2 and 3 died several days later. CONCLUSION: Bedside laparoscopy in the ICU is feasible, informative, and accurate. It has a role in diagnosing abdominal pathologies and planning further treatment. It may avert a nontherapeutic laparotomy. Unfortunately, the prognosis in these patients is poor. Earlier use of this diagnostic modality may improve patient outcome.

Closure of laparoscopic trocar site wounds with cyanoacrylate tissue glue: a simple technical solution.

Cyanoacrylate-based tissue glue has been widely used for many years around the world, and was recently approved for use in the United States, mainly for skin cuts and lacerations. Other applications were described, in different surgical situations. Although ideal for small, clean incisions, its use in laparoscopic surgery is currently limited. Over a year period, 100 patients with more 250 trocar site wounds had their wounds glued using histoacryl. Infection rate was extremely low (one case), and partial dehiscence of the wound happened in two patients, where wound edge approximation was not optimal. Cosmetic results were excellent and patient satisfaction was high, as no sutures had to be removed. Glue application is easy and quick, with no risk of needle sticks, and it is a viable option for laparoscopic wound closure.

[Laparoscopic adrenalectomy for pheochromocytoma].

Laparoscopic adrenalectomy has recently been shown to be a safe and effective strategy of treating a variety of benign adrenal tumors. The ability to reduce hypertensive crisis during surgery for pheochromocytoma by adequate preoperative alpha- and beta-blockade and early intraoperative venous ligation have reached a level sufficient to permit a safe laparoscopic approach. During the period January 1995 to December 1999, laparoscopic adrenalectomy was attempted in twelve patients with unilateral pheochromocytoma and in 2 patients with multiple endocrine neoplasia type II. All procedures were completed laparoscopically. The mean operative time was 90 minutes (45-120). Blood transfusion was not required and there were no postoperative complications. The median hospital stay was 3 days.