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The authors describe a case of retroperitoneal liposarcoma developing between the leaflets of the transverse mesocolon. They briefly summarise the classification and the symptomatology of retroperitoneal tumours and discuss the way of presentation of their case comparing it with literature data.
The following methodology is suitable for increasing the radicality of and the safety of the vessels during a transperitoneal operation for nephroblastoma and simultaneously for sparing the necessity of postoperative radiation: 1. primary exposure of the renal vascular cross, the vena cava, and the aorta through incision of the plica duodeno jejunalis together with mobilization of the duodenum to the right, the mesocolon to the left; 2. primary ligature of the a. renalis in front of the v. renalis (no problems on either side); 3. systematic retroperitoneal en bloc lymphodissection from the a. mesenterica superior to the forking of the aorta, laterally to the diaphragm, probative at the adnexa; 4. subsequent lateral release of the left-sided tumorous kidney, medial release of the right-sided tumorous kidney after mobilization of the cecum.
The obstruction to the third part of duodenum due to appendicular abscess is reported here. The abscess had tracked behind the mesocolon and obstructed the duodenum. The case was treated by drainage of abscess and anterior gastrojejunostomy.
For a group of 368 cases of chronic pancreatitis (CP) operated on since 1975, the authors have performed 85 biliary intestinal anastomoses using the gallbladder, for treatment of biliary obstruction. (These were cases not needing resection of the head of the pancreas). This original biliary-intestinal by-pass comprises resection of the cystic duct then bridging the gallbladder between the common bile duct and the duodenum (in 2 cases the jejunum). This anastomosis of common bile duct to infundibulum was termino-terminal except in 15 where portal vein dilatation necessitated a latero-terminal anastomosis. The gallbladder-intestinal anastomoses were termino-lateral. One patient with multi-system disease died on the 20th post-op day from cardio-respiratory problems not directly related to the procedure. No fistulae, biliary or intestinal occurred. The average hospitalization was 13.6 days. The average follow-up period is now 46 months (2 patients only have been lost to follow-up). One patient (not abstaining from alcohol) has presented with recurrent febrile episodes and transient alkaline phosphatase elevations. Two patients only have been re-operated (9th and 72nd months) for cholangiocholitis necessitating a re-do of the anastomosis infundibulum to bile duct. These 2 patients are well at 20 and 45 months respectively. No biliary calculi have been observed, with 22% of patients now being more than 5 years post-op. The authors have progressively left aside the anastomosis to a jejunal loop in favour of the gallbladder interposition described. This appears a better procedure for treating biliary obstruction in chronic pancreatitis even when complicated by portal vein dilatation. This procedure enables drainage of bile into its natural site at the 2nd part of the duodenum, so reducing the risk of ulceration. It also saves extending the operating field below the mesocolon and importantly in the already poorly nourished patient, it does not remove from function a segment of jejunum.
Computed tomography-guided fine-needle biopsies of the pancreas were performed in 54 patients. In 46/54 biopsies, the material obtained permitted a histological diagnosis despite the small external needle diameter of only 0.95 mm. The only complication was due to laceration of an artery of the transverse mesocolon. The prevalence of malignant tumors was 67%. Adenocarcinoma was diagnosed in more than 80% of all biopsies; rare findings were malignant carcinoid or centroblastic lymphoma. Benign tumors included mucinous adenocystoma and serous microcystic adenoma. Within the group of patients where pathologic-anatomic evaluation was possible, the sensitivity of fine-needle biopsy for malignant tumors was 87% and the specificity 100%. A positive needle biopsy diagnosis for a malignant tumor reduces the number of exploratory laparotomies needed and is helpful in the planning of surgery.
A case of five-year survival of jejunal leiomyosarcoma with metastases to the liver and mesentery treated with four times surgery was reported here. Four metastatic lesions were detected in the sigmoid mesocolon once and in the liver three times and resected with hope of cure. The patient, a 37 years old male, tolerated surgical procedures including an extended right hepatic lobectomy and recovered each time. He is leading a satisfactory daily life 5 years and 3 months after the initial operation although multiple liver metastases were detected 10 months after the fourth operation. A positive surgical therapy is advocated in selected patients who have spreading leiomyosarcoma of the bowel.
Extra-uterine pregnancy is the most common emergency in gynaecology and obstetrics in the Hospital Centre of Libreville, and the diagnosis of blood in the peritoneal cavity is synonymous with extra-uterine pregnancy. All the same, when the authors reviewed 429 cases of haemoperitoneum 17 were shown not to be due to ectopic pregnancy. Ruptures of ovarian cysts and uterine perforation from illegal abortions are often found but more rarely, have been rupture in the blind horn of a bicornuate uterus, choriocarcinoma in the tube, tubal bilharzia and thrombopenia due to AIDS. It is essential to carry out histological examination for the differential diagnosis between an ovarian pregnancy and a ruptured cyst as well as choriocarcinoma or bilharzia. If it is not possible to find the site of the bleeding even after looking underneath the mesocolon, a search must be made for coagulation disorders due to a virus such as HIV.
Three cases of duplications of the alimentary tract are presented. Case 1 was a 5-month-old male baby. He was admitted due to copiously painless rectal bleeding. Tc-99m pertechnetate scanning revealed unusual tubular and spherical lesions. Laparotomy findings were that a tubular ileal duplication m assured 100cm or so in length and communicated with ileal lumen by its distal orifice. Moreover, there were 2 spherical duplications like ping-pong ball in morphology located in neighboring mesentery. Case 2 was a 2-day-old male newborn. He was admitted because of persistent bilious vomiting on his second day of life. Plain film x-ray revealed dilated stomach and scanty bowel gas. Laparotomy finding was that a cystic duplication measured 1.5cm in length which located in and obstructed the lumen of proximal jejunum. Also there was a distal orifice of duplication in communication with jejunal lumen. Case 3 was a 4-year-and-4-month-old boy who admitted after intermittently non-projectile vomiting for a period of 1 1/2 year. Sonography showed a calcification lesion at right upper quadrant of abdomen. Panendoscopy saw a refraction at second part of duodenum. The findings of laparotomy were that 2 tumor masses laid upon gastrocolic ligament. One was ossified soft tissue (gastrocolic ligament) with 1.5 x 1 x 0.8cm3 in size, and the other was cystic duplication of transverse colon in contact with beneath mesocolon. All duplications of 3 cases were lined with ectopic gastric and small intestinal mucosa, and ulcerative lesion was found in case 3 only. All lesions were resected and removed with good results.
Anastomotic devascularization has been incriminated in the development of post-operative complications (fistula, stenosis) of circular stapling. The effect of circular stapling on left colonic blood supply in dogs has been evaluated. Twelve transanal colonic transsections (ILS 29 or 33), were performed at the level of the inferior mesenteric artery in 12 dogs, then examined at different post-operative times, after injection by barium sulfate and radiography. In group I (D1, D3, D7) the entire mesocolon was injected, in group II (D7, D12, D15), only the supra-anastomotic part was injected. In group I, there was no alteration in blood flow at the anastomotic margins. The vascular pattern at the site of anastomosis was similar to that observed in the normal colon. In group II, good blood supply was confirmed and no capillary cross-bridging was found at this early healing time. This study limits the role of anastomotic devascularization by staplers in the development of secondary complications of circular stapling. If such a devascularization has to be accused, it is more likely the consequence of the surgical technique than of the stapler "per se".
In a 68-year-old male hospitalized for a traffic accident physical examination revealed a left tibial fracture and an asymptomatic left pleural effusion. The evolution was characterized essentially by the appearance of oedema of the legs, ascites, and aggravation of the left pleural effusion with concomitant right effusion. Immediate therapy consisted of digitalis and diuretics. Several days later the patient suddenly complained of epigastric pain irradiating to his arms, followed by vomiting. ECG showed transitory elevation of ST segment in V3 to V5. Blood levels of CK and CK-MB were normal. An electrocardiogram showed extensive antero-septal-apical akinesis and a very small cardiac effusion. Pleural and abdominal tap revealed the presence of a milky liquid containing 40 g/l proteins, 8.6 mmol/l triglycerides and 2.5 mmol/l cholesterol, with no atypical or tumorous cells. CAT scan revealed the presence of a retroperitoneal mass extending from the diaphragm to the iliac crests and apparently enclosing the aorta and the vena cava and causing bilateral hydronephrosis. The development of chylous ascites and/or chylothorax indicates the presence of an extrinsic or intrinsic obstruction of lymphatic drainage or the existence of a laceration or rupture of the thoracic canal. Chylous ascites is not a frequent finding, since only 28 cases have been diagnosed in 20 years at the Massachusetts General Hospital and 71 in 30 years at the Mayo Clinic. In these 2 series a tumoral etiology was found in more than 85% of the cases. The most frequently encountered tumor was lymphoma followed by cancer of the pancreas, stomach, or other tumors. CLINICAL DIAGNOSIS: Retroperitoneal tumor, most probably lymphoma; inferior vena cava compression syndrome; subacute antero-septal infarction. In spite of the poor general condition of the patient exploratory laparotomy was performed, and several specimens were taken from the lymphatic nodes located at the angle of Treitz, in the mesentery and the mesocolon and along the celiac axis. HISTOPATHOLOGICAL DIAGNOSIS: Non-Hodgkin B-cell malignant lymphoma, low-grade, lymphoplasmacytoid (immunocytoma) according to the Kiel classification, or small lymphocytic, plasmacytoid according to the International Working Formulation (abdominal lymph nodes, liver, epiploon, peritoneum, rectus abdominis muscle). EVOLUTION: Chemotherapy was instored consisting of a combination of prednisone, vincristine, and cyclophosphamide. The patient's condition was complicated by peritonitis. Laparotomy revealed phlegmonous cholecystitis and a perforated colon. The post-operative course was characterized by septic shock, cardiac and respiratory insufficiency which resulted in the death of the patient. Autopsy confirmed the presence of a low-grade lymphoma stage IV (retroperitoneum, mesentery, cervical, axillary and abdominal lymph nodes, liver, spleen, pancreas, colon, rectum, kidneys, adrenal glands, bronchi, epicardium). No evidence of an infarctus or oth
Intra-abdominal liposarcomas are very rare tumors. We present our personal experience with one case of mesenteric liposarcoma which had perforated into the peritoneal cavity, occurring in a seven-month pregnant female patient. Seven years later, the patient is doing well. The authors have carried out a review of the literature. In addition to liposarcomas of the mesentery and the mesocolon, they observed some cases of liposarcoma localized in the omentum and the stomach; other abdominal localizations occurred sporadically. Radical surgical excision was the choice treatment. Both the propensity for locoregional spread and the histological diversity set the conditions for prognosis; the latter seemed minimally influenced by either radio- or chemotherapy.
An immunohistochemical study of a rare initial manifestation of non-Hodgkin's lymphoma (NHL) in the ovaries is presented. There have been very few reports to date on immunohistochemical studies of lymphoma involving the ovaries. A 53-year-old woman suffering from lower abdominal pain and abnormal genital bleeding was diagnosed as having a tumor in her left ovary by ultrasonic echograms and CT scanning. The patient underwent a simple total hysterectomy and bilateral salpingo-oophorectomies. The tumor, measuring 14 x 10 x 10 cm, was located in the left ovary and extended to the major omentum, mesocolon and left ureter. The histology of the tumor was that of NHL showing diffuse proliferation of small cleaved cells. Immunohistochemical studies of the ovarian tumor showed that the tumor cells were of a B-cell lymphoma nature with LCA+, MB-1+, lambda+, keratin-, IgG-, IgM-, IgA-, kappa-, and MT-1-. Although the main lesion involved the ovary, the case could not be identified definitely as primary lymphoma of the ovary.
A rare case of cholangiocarcinoma and dysgerminoma synchronously associated with Turner's syndrome was reported. A 53-year-old woman was admitted to our hospital on July 12, 1984 due to intrahepatic and left inguinal tumors. Physical examination revealed the typical characteristics of Turner's syndrome. The karyotype from myelocyte and fibrocyte culture was interpreted as 45, X. The resected intrahepatic tumor was cholangiocarcinoma that had invaded to the transverse mesocolon and the duodenum, while the inguinal lesion was dysgerminoma derived from a dysgenetic gonad. As far as we have been able to ascertain through our investigations of the literature on malignant disease in Turner's syndrome, the association of cholangiocarcinoma with Turner's syndrome has not been reported previously.
Two techniques for end-to-end anastomosis of the small colon were evaluated in each of 6 horses. A simple interrupted suture pattern that excluded the mucosa and was oversewn with an inverting suture was compared with a triangulated double-row pattern of stainless steel staples. Anastomotic sites were evaluated at 2 weeks, 2 months, and 6 months for extent of abdominal adhesions, lumen diameter at anastomotic sites, bursting pressures, and healing response. Clinical postoperative complications were not associated with either technique. At postmortem examination, there was extensive adhesion formation from the mesocolon to the stapled anastomotic site. The suture technique resulted in greater luminal diameters (P less than or equal to 0.05), with good apposition of the tissue layers. Staples were missing as early as 2 weeks after surgery, and their loss was associated with separation of the muscularis at later evaluation periods. Regardless of technique, all but one anastomotic segment burst away from the anastomotic site along the mesenteric taenial band. For the 12 anastomoses performed in normal horses, the suturing technique was better than the stapling technique because of significantly larger lumen diameters, better anastomotic healing, and minimal intra-abdominal adhesion formation.
Activated c-raf(-1) gene was found in three transformants obtained by transfecting DNAs from rat hepatocellular carcinoma, metastasis of human colon cancer in mesocolon and normal mucosa from a different colon cancer patient. Rat and human activated c-raf(-1) genes were cloned into cosmid vectors; restriction enzyme mapping revealed both activated c-raf(-1) genes to have rearrangement in the center of the normal form of the gene, and the upstream sequences were replaced by unrelated sequences. Using genomic DNA fragments located immediately downstream of the recombination points, the activations of all these c-raf(-1) were shown to have occurred during the transfection process. The recombination points in both the rat and human clones isolated were located in the intron between exons 7 and 8, and nucleotide sequencing around these recombination points showed there to be an inverted repeat which could be involved in inducing in vitro recombination. Nucleotide sequencing of rat and human c-raf(-1) cDNAs revealed the upstream sequences, recombined to the 3' half of c-raf(-1), to be expressed as fusion mRNAs; the production of fused proteins was predicted from a long open reading frame, which is in-frame with the kinase domain encoded from the 3' half of the c-raf(-1) gene. There is a cysteine clustering region in an N-terminal region of the c-raf(-1) product deduced from the nucleotide sequence, and this cysteine clustering region was found to be highly homologous to that present in an N-terminal region of protein kinase C, although, in the latter cysteine clusters are present in duplicate. From analogy with the activation mechanism of protein kinase C, the N-terminal region of serine/threonine kinase coded by the c-raf(-1) gene is suggested to be a regulatory part of the enzyme activity, and it proposed that the replacement or truncation of this regulatory part could be the mechanism whereby c-raf(-1) is activated.
After briefly analyzing the concept and genesis of dysplasia starting with the normal large bowel cell and then illustrating the polyp-carcinoma sequence, the authors report on their experience with 283 endoscopic polypectomies in a total of 1.875 patients undergoing endoscopy of the rectum, sigmoid and large bowel since 1980. Forty-nine polyps presented severe dysplasia, and 38 had already degenerated to carcinoma; nine of the carcinomas had invaded the stalk and the patients were subjected to resection of the colon and mesocolon, lymph-node metastases being observed in 1 case.
The CT analysis of peritoneal ligaments and mesos is possible thanks to the fluid contrast introduced by ascites, but also by identification of their contents: fat and opacified vascular elements. Ascites renders easy the display of the falciform ligament. Other displayed ligaments are the smaller omentum, the gastrosplenic ligament, the splenopancreatic ligament, the phrenolienal and phrenocolonic ligaments, the mesocolon, the mesosigmoid, the mesentery and the broad ligaments. The radioanatomic patterns of those peritoneal elements are depicted.
We reported herein an unusual presentation of malignant peritoneal mesothelioma which appeared as a solid pelvic tumor in a 73-year-old man. The solid tumor was confined in the pelvic cavity, except for one tiny disseminated nodule on the mesocolon. The pelvic tumor was resected with whole pelvic organs en bloc. Histologically, the tumor consisted of tubular and sarcomatous structures, suggesting the biphasic malignant mesothelioma. One of the transplanted tumors in athymic mice was cystic and its histology had striking similarities to cystic mesothelioma. Transplantation of human neoplasms to athymic mice may be able to reproduce histological diversity of the tumor, even if it is not fully expressed in the original tumor.