Metallic fragments on mammography after intraoperative deployment of radiopaque clips.

OBJECTIVE: Our objective was to report the occurrence and determine the frequency of metallic fragments in the breast after placement of surgical clips that are used to delineate the margins of the biopsy cavity. CONCLUSION: Metallic fragments are commonly present in patients who have surgical clips placed during breast biopsy for both benign and malignant disease. Awareness of this phenomenon may prevent the misidentification of these fragments as microcalcifications and thus avert unnecessary concern or biopsy.

What alternatives has minimally invasive surgery provided the surgeon?

When a new technology bursts on the horizon and reenergizes a field that has seemed to be flagging, as minimally invasive surgery has done for the field of general surgery, many enthusiasts rapidly embrace the discipline. Questions should arise, however, as to what novelty has really been introduced, where it should fit in our treatment of patients, and, when the dust settles, what alternatives truly have been provided to the advantage of our patients. This article provides information and data about some of these procedures, while trying to address these issues and answer some questions that new technology raises.

Treatment of Mycobacterium chelonae infection with controlled localized heating.

An immunocompetent man acquired a localized cutaneous infection caused by the atypical mycobacterium Mycobacterium chelonae. This was successfully treated with controlled localized heating with a hand-held radiofrequency heat generator. Possible mechanisms of effects of heat on this organism are discussed.

Gallstone lithotripsy vs cholecystectomy. A preliminary cost-benefit analysis.

From July 1988 to January 1989, we compared the course of 48 patients undergoing elective cholecystectomy with that of 18 undergoing extracorporeal shock wave lithotripsy for symptomatic cholelithiasis with respect to treatment, hospitalization, recovery, and cost. For elective cholecystectomy, average length of surgery was 76 minutes (range, 31 to 186 minutes); average length of stay was 4 days; total cost was $6240; morbidity was 10%; and return to work averaged 5 weeks. Average extracorporeal shock wave lithotripsy treatment length was 136 minutes (80 to 158 minutes); average length of stay was 2 days; total cost was $5921; and hematuria and petechiae were seen in 33% and 28%, respectively. Re-treatment cost was $4880. All of these patients were active in 24 hours; return to work averaged 3 days. As results of the Food and Drug Administration study are still pending, recurrence and re-treatment rates are unknown. We conclude that extracorporeal shock wave lithotripsy is less costly, initially, with further reductions probable when performed on an outpatient basis. Though re-treatment may be required, return to normal activity is dramatically shortened.

Extracorporeal shock-wave lithotripsy of gallstones: Boston experience with the Dornier MPL 9000 lithotripter.

After the success of shock-wave therapy for fragmentation of renal stones, machines for shock-wave therapy of gallbladder stones were quick to follow. In Munich, gallstones were successfully treated in 174 of 175 patients who were also taking ursodiol to help solubilize the calculous rubble left after treatment. In Boston, of the initial 87 patients accepted, 58 were treated for a single stone (mean diameter 15.7 mm), 16 were treated for 2 stones, and 13 for 3 stones. Although reporting of exact results is not possible before the Food and Drug Administration issues a clearance, it is fair to say that both patients and physicians are generally pleased with the results.

Management of biliary obstruction. A comparison of percutaneous, endoscopic, and operative techniques.

Surgery for obstructive jaundice is being challenged by endoscopic and percutaneous techniques. To compare their safety and efficacy, the courses of 157 patients treated for biliary obstruction were examined. Outcome was judged by mortality, complications, and need for further intervention. Forty-eight patients underwent endoscopic papillotomy (43 [90%] had stone disease) with two deaths and 11 cases of (23% incidence) of cholangitis. Pancreatitis developed in 9 (19%). Twenty-seven patients (56%) required further endoscopic, percutaneous, or surgical intervention. Sixty-five patients underwent transhepatic drainage (58 [89%] had malignant neoplasms) with a 28% (n = 18) mortality rate. Cholangitis developed in 26 (40%), and 50 (77%) required further transhepatic or surgical intervention. Forty-four patients underwent surgery (22 [50%] had stone disease and 12 [27%] had malignant neoplasms) with a 4.5% (n = 2) mortality rate. Cholangitis developed in 3 (7%), pancreatitis developed in 2 (4.5%), and bleeding developed in 1 (2%). Eight (18%) required further intervention. While endoscopic papillotomy provides efficacious treatment for stone disease, surgery provides a more expeditious, less morbid relief for malignant obstruction.

Fish odor syndrome: trimethylaminuria with milk as chief dietary factor.

A 10-year-old boy had a two-year history of a rotten fish odor, noted particularly in the summer after exercise. The odor was partially controlled by frequent bathing. Dietary history was unremarkable except for large daily milk intake. Milk elimination resulted in a prompt disappearance of the odor. Studies of the patient's urine after choline loading established the diagnosis of trimethylaminuria. Restriction of dietary milk as well as foods containing choline and trimethylamine oxide eliminated the offensive odor.