Clear-cell epithelioid leiomyoma of the round ligament.

A case of clear-cell epithelioid leiomyoma of the round ligament in a 69-year-old woman is described. The neoplasm presented as a firm left inguinal mass. A preoperative computed tomography (CT) scan demonstrated an enhancing lesion extending extra-abdominally from the region of the external inguinal ring. The surgical resection specimen was tan-white, well-circumscribed, and measured 5.8 cm in maximum dimension. Microscopic examination revealed a well-demarcated neoplasm comprised of polygonal cells with abundant clear cytoplasm arranged in clusters and single files with abundant intervening hyalinized stroma. There was minimal nuclear atypia and mitotic figures were rare. Periodic acid-Schiff with diastase demonstrated intracytoplasmic glycogen. Immunohistochemical stains for pan-actin, smooth muscle actin, desmin, bcl-2, and vimentin were positive in the tumor cells, whereas stains for CD34, carcinoembryonic antigen, cytokeratin, epithelial membrane antigen, S100 protein, and neurofilaments were negative. Electron microscopy demonstrated features of smooth muscle differentiation including longitudinally oriented fine filaments with focal condensations, pinocytotic activity, and subplasmalemmal densities. This case illustrates the ubiquitous distribution of epithelioid smooth muscle neoplasms and highlights the potential pitfalls for diagnosis when they occur in an unusual location.

Intraductal carcinoma (carcinoma in situ) of the pancreas with microinvasion.

We report a case of predominantly intraductal carcinoma of the pancreas with microscopic foci of invasive carcinoma in a patient with chronic pancreatitis. In this article, we discuss the pathologic and prognostic features of pancreatic carcinoma in situ. This entity is probably overlooked due to a number of reasons, including the fact that, in most cases, pancreatic ductal carcinomas are extensively infiltrative at the time of surgical removal; the atypical epithelial changes in the intraductal carcinoma had been overlooked in the presence or absence of an invasive component; epithelial changes may be missed due to insufficient sampling; and last, the differentiation with atypical epithelial hyperplasia is a subjective matter. Intraductal carcinoma of the pancreas is a distinct pathological entity with characteristic morphologic changes restricted to the ductal epithelium, bearing important prognostic implications.

Laparoscopic ventral hernia repair: a community hospital experience.

From October 1993 to April 1994, laparoscopic ventral hernia repair was performed on 10 patients, all of whom had a history of failed ventral hernia repair and at least two prior ventral hernia repair procedures. Patients presented with complaints of abdominal discomfort, painful mass at the hernia site, or vague abdominal discomfort. No operative deaths occurred. Two patients had minor complications: a seroma at the repair site, which resolved spontaneously, and a superficial wound infection at a trochar site, which responded to an oral cephalosporin. Six patients were discharged within 24 hours of surgery and one patient was operated on as an outpatient and discharged the same day. Follow-up of all patients ranged from 10 to 17 months. No evidence of hernia recurrence has been noted. Some recurrent ventral hernias are amenable to laparoscopic repair, and this technique may be preferable in some patients, especially those who have had an earlier failed open repair with mesh. We do not advocate use of our technique for the first repair of a ventral hernia. Long-term follow-up is still needed to determine recurrence rates compared with conventional open techniques.

The use of T-bars in laparoscopic ventral hernia repair.

During the past 2 years 15 laparoscopic ventral hernias have been performed at our Community Hospital. Marlex mesh has been the material used. We have noticed some difficulty with the grasping and initial anchoring of the mesh. Percutaneously placed prolene sutures allow the mesh to be drawn upward with some effort. By using laparoscopic T-bars for the initial anchoring of the mesh to the anterior abdominal wall then stapling, the operative time was greatly reduced. This modification in technique allows for quicker placement of the mesh during the repair.

Laparoscopic feeding jejunostomy: a new technique.

Laparoscopic feeding jejunostomy has been performed and reported by others. The need for jejunostomy in certain patient populations, namely, patients with advanced head and neck cancer, esophageal cancer, or stomach cancer, is well accepted. This has led to numerous open techniques and now laparoscopic techniques. We describe in this report a new way of performing a laparoscopic jejunostomy and include intraoperative photographs.

Laparoscopic ventral hernia repair.

Laparoscopic repair of ventral hernia can be done with advanced training. We present a case report with intraoperative photographs and description of the surgical technique.

Laparoscopic preperitoneal prosthetic inguinal herniorrhaphy.

Laparoscopic minimally invasive surgical procedures are gaining popularity and becoming more readily available. Presented here is an application of laparoscopy for the repair of groin hernias. Included are actual intraoperative photographs and descriptions of the technique with its rationale for the laparoscopic preperitoneal approach and the use of a prosthetic material.

Cholecystectomy in the elderly.

A 4-year retrospective review of 212 patients over 70 years of age who underwent elective and emergency cholecystectomies was undertaken. Elective procedures were performed in 119 patients (76 women, 43 men) whereas 93 patients (43 women, 50 men) underwent emergency surgery. Complications developed in 25 and 34 patients, respectively. In the elective group, the most common complication involved the cardiovascular system, whereas sepsis with multiple organ failure accounted for all of the deaths in the emergency group. Among the 212 patients studied, there was a 3 percent mortality rate in the elective group and a 10 percent mortality rate in the emergency group, with an overall mortality rate of 6 percent. The results indicated that since the risks of elective cholecystectomy are relatively low in the elderly and the risks of cholecystectomy performed as an emergency are considerably higher (10 percent), symptomatic elderly patients with gallstones should be considered good candidates for early elective cholecystectomy.

Cholecystectomy in the elderly.

A two-year retrospective review of 137 patients over 70 years of age undergoing cholecystectomy, from January 1, 1983 to January 1, 1985, was done at Mount Sinai Medical Center of Miami Beach. This study focused on the clinical presentations, surgical management, and overall morbidity and mortality of this operative procedure in the elderly. There were 81 women and 56 men in the study ranging in age from 70 to 96. Elective procedures were performed in (78/137) 57 per cent of the patients while (59/137) 43 per cent underwent emergency surgery. Elective procedures were performed in (55/81) 68 per cent of the women and (23/56) 41 per cent of the men. Emergency surgery was required in (26/81) 32 per cent of the women and (33/56) 60 per cent of the men. Complications developed in (16/78) 20 per cent of the elective cases and (19/59) 32 per cent of the emergency cases. In the elective group, the most common complication involved the cardiovascular system. Sepsis with multiple organ failure accounted for all the deaths in the emergency group. Among the 137 patients in this series, there was a (3/78) 3.8 per cent mortality in the elective group and a (7/59) 12 per cent mortality in the emergency group with an overall mortality of (10/137) 7.3 per cent. The purpose of this study was to highlight the necessity for aggressive surgical management of biliary tract disease in the elderly.(ABSTRACT TRUNCATED AT 250 WORDS)

The preoperative use of cimetidine as a means of preventing symptomatic hypocalcemia following a parathyroid operation.

Cimetidine has been shown to lower circulating PTH levels effectively by causing an intraglandular rearrangement of PTH peptides in human parathyroid tissue in instances of primary hyperparathyroidism. A state of "euparathyroidism" is established. It has been statistically found at a 98.7 per cent confidence level that preoperative treatment with cimetidine effectively prevents symptomatic hypocalcemia postoperatively after parathyroid operations. It is anticipated that cimetidine has provided a tool for the in depth exploration of parathyroid disease.