Itamar Avigad

Congenital Hemangiopericytoma/Infantile Myofibromatosis: Radical Surgery Versus a Conservative “Wait and See” Approach

Infantile/congenital hemangiopericytoma, although sharing many similar histological features with adult hemangiopericytoma, has a much better prognosis. Nevertheless, most cases described in the literature were pursued by radical surgery with or without adjuvant chemotherapy. We describe a neonate who presented with a huge mass in the right gluteus, 6 x 5 x 4 cm, and a small ventral abdominal mass. The masses were confirmed on biopsy according to light microscopy, immunohistochemistry, and electron microscopy as congenital hemangiopericytoma. They shrank spontaneously within 2 weeks and vanished within 2 months. We present a hypothesis that masses appearing in the neonatal period with this histology and with no life-endangering pressure on vital organs should routinely be dealt with conservatively.

Is it justified to avoid radical cystoprostatectomy in elderly patients with invasive transitional cell carcinoma of the bladder

Background. Although radical cystectomy is accepted by most urologists as the treatment of choice for invasive carcinoma of the bladder and age alone is not considered a contraindication for radical surgery, many consider radical major operations to be unsuitable for elderly patients.

The Frequency of Histopathological Abnormalities in Incidental Appendectomy in Urological Patients: The Implications for Incorporation of the Appendix in Urinary Tract Reconstruction

In 1980 Mitrofanoff described the use of the isolated appendix as an intermittent catheterization route to empty a continent urinary reservoir. The procedure was popularized and numerous variations on the same principle were reported. Presence of histopathological abnormalities in the appendix may limit its suitability for reconstructive purposes. We studied the frequency of incidental histopathological abnormalities in appendixes removed electively in 122 urological patients during a radical pelvic operation. The implications for incorporation of the appendix in urinary tract reconstruction are evaluated. A total of 38 patients (31.1%) had notable histological abnormalities of the appendix: 35 had fibrous obliteration of the lumen, 2 had carcinoid tumor and 1 had a mucocele of the appendix. The rate of abnormal appendixes was significantly higher in elderly patients (more than 70 years old). Incidental pathology of the appendix is a frequent finding that may affect the immediate results and the late outcome of urinary tract reconstruction using the appendix. When such strategy of urinary tract reconstruction is considered, potential histopathological abnormalities should be anticipated. The patients should be informed and aware of possible unexpected changes in the preplanned procedure, while the surgeon must be familiar with these alternative reconstructive methods.

Correct preoperative localization: Does it permit a change in operative strategy for primary hyperparathyroidism?

BACKGROUND A meticulous bilateral neck exploration by an experienced endocrine surgeon offers a high cure rate with low morbidity for patients with primary hyperparathyroidism. The advent of localizing studies raises the possibility of unilateral neck exploration. The cost-effectiveness of preoperative localizing studies and unilateral neck exploration in primary hyperparathyroidism are controversial issues. This study was designed to determine the risks of missing a contralateral pathologic parathyroid gland in patients with preoperative localization that was confirmed at neck exploration. METHODS Preoperative studies (ultrasonography, nuclear radioactive imaging scan, or both) were performed in 79 patients with primary hyperparathyroidism. In 58 patients a definite localization of an enlarged parathyroid gland was confirmed at operation. All patients underwent a meticulous bilateral neck exploration. RESULTS Unilateral neck exploration was feasible only in 73.4% of the patients, according to our localizing modalities, and an additional enlarged parathyroid gland on the contralateral side, not detected before operation, was revealed in five patients (8.6%). False-positive rates were 1.7% for ultrasonography and 13% for scan. CONCLUSIONS These results indicate an unacceptably high surgical failure rate for unilateral neck exploration guided by preoperative localizing studies compared with a bilateral neck exploration by an experienced endocrine surgeon, questioning the cost-effectiveness of preoperative localizing studies.

The feasibility of in vivo resection of the left lobe of the liver and its use for transplantation

The anatomical possibility of resecting the left lobe of the liver (segments II and III) in living subjects and using it for transplantation was evaluated. A group of 60 cadaveric livers were dissected at autopsy. The vascular and biliary elements of the left lobe were isolated and the lobe was resected and evaluated for possible grafting. The left lobe was 12–28% (mean 19.4%) of the liver mass. An extrahepatic segment of the left hepatic vein was isolated in 95% of specimens. Arterial blood supply to the left lobe consisted of a single artery (92%) or two arteries (8%). A single portal vein segment to the left lobe (type I) was: found in 35% livers. Portal vein branches originated from a common orifice (type II, 35%) or separately (type III, 30%) from the left portal vein, and in these instances, preparation of a portal segment necessitated partial section of the left portal vein wall. Biliary drainage was extrahepatic in 56 livers and consisted of a single duct (type I, 78%), or two ducts (type II, 15%). The resected left lobe was evaluated as satisfactory (single hepatic vein and artery, types I or II portal vein, type I bile duct) in 48% of cases, while a less-satisfactory lobe (type III portal vein or type II bile duct) was obtained in 33%. It was found anatomically difficult or impossible to resect the left lobe for possible transplantation in 11 (19%) liver specimens.

Intraoperative Irrigation With Bupivacaine for Analgesia After Orchiopexy and Herniorrhaphy in Children

Effective postoperative analgesia is important, especially in pediatric surgery. The efficacy of intraoperative surgical wound irrigation with bupivacaine for postoperative analgesia was investigated in 90 children undergoing elective inguinoscrotal surgery. We found that this method effectively reduced postoperative pain and narcotic drug requirement. Bupivacaine irrigation was simple and complication-free. We believe that the irrigation of surgical wounds with bupivacaine should be a routine procedure in elective inguinoscrotal surgery in children.

Segmental dilatation of the ileum: An uncommon cause of neonatal intestinal obstruction

Two cases of congenital segmental dilatation of the ileum are reported. In both cases additional abnormal segments of bowel were not diagnosed during the initial laparotomy, and further surgical exploration was required. Consideration of this entity in the differential diagnosis of neonatal intestinal obstruction may enable definition of the optimal site for bowel resection and anastomosis.

Ureteral substitution using the isolated interposed vermiform appendix in a patient with a single kidney and transitional cell carcinoma of the ureter

A patient with a single kidney presented with ureteral obstruction caused by a combination of primary transitional cell carcinoma of the ureter and extrinsic involvement of the ureter by a second primary malignant retroperitoneal lymphadenopathy. Due to the complexity of the case, we chose to perform a partial ureterectomy and used a method of ureteral substitution using the interposed vermiform appendix in combination with a psoas hitch. Application of the psoas hitch may allow the use of the appendix in most cases in which ureteral substitution becomes necessary. Antireflux mechanism is easily achieved with the appendix using the split cuff nipple technique. Finally, the use of the appendix allows complete retroperitonealization of the anastomoses to both ureter and bladder. We anticipate that the appendix will be used more commonly in the future as a ureteral substitute as more urologists become more comfortable with it through its use in various reconstructive procedures.

A bizarre bezoar: case report and review of the literature

Abstract A bizarre case of a foreign-body bezoar is presented. A 16-year-old girl swallowed large amounts of toilet paper as a means of dieting. She presented with a palpable abdominal mass, multiple bezoars in the bowel, and paper excretion in the feces before admitting intentional ingestion of toilet-paper balls. Administration of Gastrografin via a nasogastric tube and enemas resulted in gradual excretion of the paper balls.

Analysis of Peripheral Blood Lymphocyte Cell Surface Density of Functional and Activation Associated Markers in Young and Old Hemodialysis Patients

Aging has been associated with specific shifts in various peripheral blood immune competent cell subsets. As part of pre-transplant immune profile evaluation possible parallel age-related changes in mean T-cell surface density of several cluster differentiation and activation linked antigens were into 2 groups: group 1-114 patients 40 years old or younger and group 2-36 patients 55 years old or older. Peripheral blood CD3+, DR+, CD3+DR+, CD4+, CD4+DR+, CD8+, CD8+DR+, CD56+, CD8+CD56+, CD3+IL-2-R+ and CD3+TR+ (interleukin-2 and transferrin receptors bearing CD3+ cells respectively), all mononuclear cells expressing IL-2-R and TR, and CD4+CD45+ cell subsets were analyzed and enumerated by 2-color flow cytometry. Subset relative levels as well as absolute counts were recorded. Cell surface density computation was performed using a computerized mathematical model based on fluorescence intensity vector analysis and cell size score determination based on light scatter pattern from raw data obtained by flow cytometry studies. Younger age was significantly associated with higher absolute cell count of CD3+ (p < 0.001), DR+ (p < 0.05), CD4+ (p < 0.01), CD8+ (p < 0.005), CD3+IL-2-R+ (p < 0.05), CD3+TR+ (p < 0.03) and IL-2-R+ (p < 0.05). Older patients had a slightly higher mean absolute count of CD4+CD45+ subset (p not significant) and significantly higher mean count for CD8+CD56+ cell subset (p < 0.001). When cell subset levels were compared between the 2 groups as the relative fraction of cells expressing a given marker out of all mononuclear cells gated out by flow cytometry, younger age was significantly associated with higher levels of CD3+ (p < 0.005), CD8+ (p < 0.001), CD4+DR+ (p < 0.004), CD3-TR+ (p < 0.05) and CD8+IL-2-R+ (p < 0.05). In contrast, slightly higher subset levels of CD56+ (p not significant), and significantly elevated levels of CD8+CD56+ (p < 0.0019) and CD4+CD45+ (p < 0.004) were observed in the older patients. Cell surface density analysis showed that younger patients had higher mean density per cell of CD3 (p < 0.05), CD8 (p < 0.001), IL-2-R on CD3+ cells (p < 0.05) and TR on CD3+ cells (p < 0.05). Mean cell surface density of CD56 on all CD56+ cells as well as on CD8+ cells was higher in older individuals (p < 0.001 and p < 0.003, respectively).(ABSTRACT TRUNCATED AT 400 WORDS)