Selective ductectomy for the diagnosis and treatment of intraductal papillary lesions presenting with single duct discharge.

Solitary ductal papilloma of the breast, although considered a benign disorder has a potential association with carcinomas. We studied and analyzed the role of selective ductectomy (SD) for the diagnosis and treatment of intraductal lesions presenting with single duct discharge and ductography suggestive of intraductal (papillary) lesions. During a ten-year-period, files of patients presenting with single (or rarely dual) duct discharge were retrospectively reviewed. The examinations included mammography, ductography and ultrasonography and cytology of the fluid discharged from the duct in all patients. Patients treated with SD were considered further and their histological diagnosis and treatment were analyzed. The series included 100 patients. In 6 cases malignancy was found in the specimen consisting of four in situ and two invasive ductal carcinomas. These 6 patients had a second operation and this was followed by adjuvant treatment. Nine further patients had atypical ductal hyperplasia in or around papillomas and one patient had lobular neoplasia around her papilloma. In the present series, the incidence of carcinoma associated with the clinical suspicion of papillary lesions was 6%, and further 10% had low grade neoplastic proliferations resulting in the diagnosis of atypical papillomas or atypical ductal hyperplasia or lobular neoplasia around the papilloma, indicating that single duct discharge may be a symptom a malignancy, and that ductal papillomas have malignant potential. For such a low risk and grade of malignancy simple follow-up could be one option, but in some cases SD could be applied to relieve the patients from symptoms and establish a diagnosis.

A new concept for esophageal resection--prevascularization: an experimental study.

We aim to elaborate upon a basically new animal model for esophageal resection. A total of 17 operations on 10 dogs were performed in order to develop a model in which resection of the cervical part of the esophagus involves two steps. The first step comprises omental flap transplantation from the abdomen to the cervical region by a microsurgical method, this omental flap improving the blood supply to the organ (prevascularization). The second step is segmental resection of the esophagus 14 days later. Of the five transplanted grafts, four still survived one week after the operation; for technical reasons, one flap had thrombotized. In the two long-term survival cases with esophageal resection after prevascularizastion, there were no major complications: the resections were successful, and the omental flap 'grew into' the tissue structure of the esophagus, assisting the healing of the anastomosis. Segmental resection of the cervical part of the esophagus was performed successfully via a new type of operation on dogs.

[Intraabdominal sclerosing panniculitis--myofibroblast proliferation that can mimic malignancy]. / Intraabdominalis sclerotisáló panniculitis--malignitást utánozni képes myofibroblast-proliferáció.

Intraabdominal sclerosing panniculitis is a fibroinflammatory lesion of the intraabdominal fat tissue of unknown origin. The authors report 4 secondary cases, that were associated with other kind of intestinal pathology. The cases had different clinical manifestation (mesenterial sclerosis leading to bowel obstruction, lesion simulating transmural spread or peritoneal metastasis of colorectal carcinoma, and chance finding associated with ulcerative colitis). They review the literature and summarize the features of the reactive process characterized by a spindle cell proliferation, fibrosis (sclerosis), chronic inflammatory infiltrate and fat necrosis. The immunohistochemical staining pattern of spindle cells favors a myofibroblastic origin. These cells, like cells of many other, but not all myofibroblastic lesions are CD-34 negative. The significance of recognizing the lesion as such is highlighted by the fact that the correct diagnosis has been seldom made without excision of the involved bowel segment. Theoretically surgical excision should be reserved for cases with bowel obstruction, or underlying pathology requiring this intervention. They believe that with awareness of the lesion secondary cases are not as rare as previously thought, although primary cases (those not associated with other intestinal pathology or specific etiologic agents) are only rarely encountered in everyday practice. They share the view that both primary and secondary cases are reactions to noxious agents, but this agent is unknown in primary cases.

[Results of lengthening 20 humeri]. / Výsledky dvaceti prolongací pazní kosti.

PURPOSE OF THE STUDY: The aim of the retrospective study was to evaluate the results of 20 performed lengthenings of the humerus in children and adolescents. MATERIAL: Assessment involved totally 20 lengthening procedures having been done in 18 patients, twice as a repeated procedure, in the period 1983-1999. The indication was shortening of humerus approaching at least the amount of 50 millimeters. Proportion of boys and girls was 7/13. The shortening arouse on the base of pyogenic infection in 12, post-traumatically in 3, congenitally in 2 and in one case it was caused by a bone cyst expansion. Mean value of shortening was 83 millimeters. Mean value of age was 12 years, ranging from 7 till 16 years. METHODS: Lengthening procedure was performed by the use of different types of external fixation. In most cases Wagner unilateral fixator was used (13 cases). The choice of external fixator was based more on its availability determined by economical reasons. Contrary to Wagner and Orthofix, Ilizarov fixator did not need the common replacement of different sizes of apparatus during lengthening. Osteotomy was routinely performed at the point between the distal and middle thirds of the length of humerus, approach was always associated with visualisation of the radial nerve. RESULTS: Serial x-rays were consecutively studied to specify the mean value of lengthening--71 millimeters, the mean value of distraction phase--91 days, the mean value of total period of fixation--197 days and the mean value of period determined at its end by the full re-canalisation of the lengthening zone--355 days. Mean value of bone lengthening index was calculated on 13.2 days/1 centimeter, mean value of bone healing index on 28.6 days/1 centimeter, and a modified bone healing index based on full recanalisation of the lengthening zone with a mean value of 44.5 days/1 centimeter. In no one case an additional bone grafting or plate osteosynthesis was necessary. Complications involved 3 cases of transient radial nerve palsy, which spontaneously resolved. DISCUSSION: As other reports of humerus lengthening respecting "callotasis method", this study showed almost uneventful distraction and healing This cohort involves a big sample of lengthenings resembling in its size the cohort of Cattaneo et al., the world's biggest group. CONCLUSIONS: It was proved, that the humerus lengthening is a safe method solving successfully the cosmetic problem of length deficiency. It seems, that presumably the keeping up the principle of "callotasis" brings about uneventful treatment programme.

[Clinicopathologic assessment of breast cancer with axillary recurrence]. / Axillarisan recidíváló emlórákok klinikopatológiai elemzése.

Surgical treatment of the axilla in breast cancer patients is a controversial issue, as not only staging must be ensured, but also regional disease control. Twenty seven histologically verified axillary recurrences encountered over a period of 20 years were analysed according to primary tumours and their axillary metastases. The median age of the 27 investigated patients was 57 years. Axillary recurrences occurred in 7 node negative patients (26%), 10 (37%) and 6 (22%) patients with 1-3 and more than 3 positive nodes, respectively. The number of histologically assessed lymph nodes was less than 6 in more than one third of the patients. No axillary status was available in 4 cases. Extracapsular axillary tumour spread seemed high (63%) in the recurrent group. Axillary recurrences may sometimes occur even after adequate surgical and radiotherapeutical interventions, and axillary nodal status established on the basis of low lymph node numbers and extracapsular tumour spread may predispose to this. Such features must be considered when planning adjuvant treatment options.

Nodal staging of colorectal carcinomas from quantitative and qualitative aspects. Can lymphatic mapping help staging?

Retrospective data analysis was performed to determine the minimum number of lymph nodes required for the staging of colorectal carcinomas, and a prospective feasibility study was carried out to identify sentinel nodes in order to clarify whether these may predict the nodal status. From among 240 colorectal carcinoma specimens investigated between 1996 and 1998, 224 tumors were analyzed for their nodal status. Lymphatic mapping with vital patent blue dye injection into the peritumoral sub-serosal layer was performed in 25 patients. Blue nodes were identified by the pathologist in the unfixed specimen immediately after the resection of the bowel and were assessed separately. Of the 123 node-positive carcinomas, 40 had more than 3 nodes involved. The nodal positivity increased substantially when more than 6 nodes were assessed. The cumulative percentage analysis demonstrated that ideally 16 and 13 nodes should be obtained for the identification of any nodal involvement or the involvement of more than 3 nodes, respectively. Lymphatic mapping was successful in 24 patients (96%). Blue nodes were predictive of the nodal status in 19 cases (79%), and were the only sites of metastasis in 2 patients (15% of the node-positive cases). Lymphatic mapping with the vital blue dye technique does not seem to facilitate the staging of colorectal cancers, at least in our patient population with relatively large and deeply infiltrating tumors, and unless the technique is improved or other selective features of lymph nodes are found, all lymph nodes should be assessed. A minimum of 6 nodes, and an optimum of 16 nodes or more, are suggested from these series.

[Meckel diverticulum as a possible source of complications]. / A Meckel-diverticulum mint lehetséges szövödményforrás.

The authors performed a retrospective analysis of 108 operations performed because of Meckel's diverticulum from Jan. 1, 1980 until Dec. 31, 1997. 87 incidental operations were performed (80.55%) and 21 operations were performed (19.54%) because of complications of Meckel's diverticulum. Of the 87 incidental cases, 44 were males and 43 were females. The diverticulum was resected in 70 cases, was inverted in 16 patients and was left untouched in 1 patient. There were postoperative complications in 10 cases (11.5%), however, only one complication was related to the diverticulum operation. There was one death due to pneumonia in the incidental group (1.14%). Of the 21 cases having complications there were 5 females and 16 males. The following complications were observed: 4 cases of ileus, 7 cases of perforation (a foreign body was found in two cases) and 10 cases of inflammation. The Meckel's diverticulum was resected in 19 cases and the small intestine was resected in 2 cases. Postoperative complications occurred in 3 cases (14.3%), however these were not related to the diverticulum operations. There were 2 deaths due to pneumonia and pulmonary embolism (9.5%). Histological examination revealed 7 cases of heterotopic gastric mucosa in both the incidental group and the group with complications. There was one case of heterotopic pancreatic tissue in the group with complications. The incidence of heterotopy in the incidental group was 8%, whereas in the group with complications the incidence was 33.3%. Histological examination also revealed reflux gastritis-like diverticulitis in 5 of the patients with heterotopic gastric mucosa. Meckel's diverticulum was diagnosed in 2 patients preoperatively by upper gastrointestinal series.

[Angiodysplasia as source of hemorrhage]. / Az angiodysplasia mint vérzésforrás.

UNLABELLED: Gastrointestinal bleeding of unknown origin presents a difficult diagnostic problem. The authors show 2 angiodys plasiastic cases. In the first case the clinical history contains multiple examinations and transfusions because of anaemia. The diagnosis was achieved by selective angiography. In the antrum of the stomach justified angiodysplasia was accompanied by aortic valve disease. Billroth I. operation was performed. In the other case anoscopy, colonoscopy and gastroscopy was necessary because of massive rectal bleeding but in the lack of bleeding source they performed right hemicolectomy due to hypothetical cecum angiodysplasia. The supposed diagnosis was proven by histology. CONCLUSION: in the case of unknown bleeding sources especially in older patients angiodysplasia should be considered more often and selective angiography should be indicated.

[Management of complications from endoscopic sphincterotomy]. / Az endoscopos sphincterotomia szövödményeinek kezeléséröl.

Endoscopic sphincterotomy can replace operation. It was to be chosen in case of recurrence common bile duct calculi. The authors describe 11 complicated cases (2.01%) (9 women, 2 men) which demanded surgical management out of the 546 endoscopic sphincterotomy performed during 10 years (1982-1991). Operations were performed on 6 patients and 3 of them died (0.55%). Operation was necessary because of perforation and bleeding (2 perforations, 2 bleedings, 2 bleedings and perforations at the same time).