PlasmaKinetic™ (bipolar) transurethral resection of prostate: a prospective trial to study pathological artefacts, surgical parameters and clinical outcomes

INTRODUCTION

The aims of the study were to compare the degree of cautery artefacts in prostatic chips between monopolar and PlasmaKinetic™ transurethral resection of prostate (TURP), and to determine if there is any difference in the intraoperative and post surgical parameters between them.

METHODS

After institutional review board approval, patients were prospectively enrolled to undergo PlasmaKinetic™ TURP. Their parameters were compared with those of the historical monopolar TURP controls. All histological specimens were reviewed by a single senior pathologist.

RESULTS

46 patients were recruited to undergo PlasmaKinetic™ TURP. The resection time was significantly longer for the bipolar group compared to the monopolar group (50.2 versus 36.7 min, p-value is 0.001). The speed of resection (resection weight/time) was lower for the bipolar group (0.45 versus 0.56 g/min, p-value is 0.017). More irrigant was used for the bipolar group (21.2 versus 15.6 litres, p-value is 0.001) intraoperatively. There was no statistically significant difference in terms of intraoperative drop in haemoglobin and serum sodium change between the two groups. There seems to be a lesser degree of cautery artefacts in the PlasmaKinetic™ group than the monopolar group (42.17 versus 45.07 microns); however, this was not statistically significant (p-value is 0.452).

CONCLUSION

Bipolar TURP seems to result in a lesser degree of cautery artefacts when compared to conventional monopolar TURP, albeit statistically insignificant, compared to monopolar TURP. TURP also resulted in a longer resection time and increased irrigant use, but no difference in blood loss and serum sodium levels.

Clinical application of fluorescence endoscopic imaging using hypericin for the diagnosis of human oral cavity lesions

Background:

Diagnosis of oral cancer is conventionally carried out using white light endoscopy and histopathology of biopsy samples. However, oral tumours are mostly superficial and the lesion and its margins can be difficult to visualise under white light. We present clinical data on fluorescence diagnostic imaging of oral lesions using hypericin, a plant-based photosensitiser.

Methods:

Fluorescence images of lesions and normal tissue were captured using an endoscope after hypericin administration. The images were analysed to extract their colour parameters, which, along with the red-to-blue intensity ratios, were analysed and used to discriminate between tissue types. The results were correlated with those from histopathology.

Results:

The red-to-blue intensity ratio increased from normal to hyperplastic to cancerous tissue and was a good parameter to discriminate between these tissue types, with sensitivity and specificity levels of 90% and above.

Conclusion:

Our results show that hypericin fluorescence imaging has the potential to be used for the clinical diagnosis of oral cancer. Further study to enhance the clinical potential of this technique includes the development of a real-time image processing and analysis system interfaced to the endoscope to enable same-day cancer diagnosis and demarcation of lesion margins in a clinical setting.

Solitary Intestinal Fibromatosis with Perinatal Bowel Obstruction

Three newborn male infants presented with bowel obstruction in the first day of life and at surgery were found to have solitary tumors involving the small or large intestine. Histologic examination in each case showed a transmural infiltrative spindle cell lesion having the morphologic features of fibromatosis. Ultrastructural studies in one case revealed the tumor to be composed of myofibroblasts. The patients are all alive and well without recurrences 26 months to 10 years after surgery. Only 3 previous cases of solitary congenital fibromatosis of the intestinal tract have been reported. Some of the other congenital spindle cell tumors cited in the literature under various names have morphologic and biologic similarities to our cases and may in fact be examples of congenital fibromatosis. The appropriate treatment of this unusual lesion is local excision, and the prognosis is excellent.

Acinic cell tumour: a metastasis in the lung diagnosed by electron microscopy of aspirated material

A case of acinic cell carcinoma, metastatic to lung is presented. Fine needle aspiration showed a low-grade adenocarcinoma. Electron microscopy of the aspirated material, however, allowed definite preoperative diagnosis of metastatic acinic cell carcinoma. The lesion was successfully resected and diagnosis confirmed on histology. Ten years previously an acinic cell carcinoma of similar histology had been excised from the left parotid region.

Clinical mimicry of hepatocellular carcinoma: imaging-pathological correlation

This pictorial essay aims to show the clinical mimicry of hepatocellular carcinoma (HCC) and its diagnostic difficulty, and to create awareness among clinicians and radiologists of potential diagnostic pitfalls. A selected consecutive series of hepatectomies with proven HCC over a three-year period, identifying clinical presentation, blood results and imaging of patients with difficult preoperative diagnosis, was reviewed. The imaging of the focal liver lesions is presented pictorially with pathological correlation. Six patients out of 34 cases of resected HCC were diagnosed to have benign (three liver abscesses) and neoplastic (one Klatskin tumour, one colorectal liver metastasis, one gallbladder cancer) conditions. Compared to the rest in the series, all six patients had normal serum alpha fetoprotein levels. On computed tomography, the mosaic appearance of HCC mimicked locules of liver abscess while HCC with pseudocapsule (rim enhancement) was misdiagnosed as unilocular abscess or metastatic lesion. Arterial enhancement on contrast-enhanced triphasic computed tomography was useful in diagnosis of HCC. In summary, HCC can mimic benign and neoplastic clinical syndromes. The diagnosis of liver abscess can delay subsequent diagnosis of HCC and potentially complicate the treatment plan. Contrast-enhanced triphasic computed tomography or magnetic resonance imaging is useful to resolve difficult diagnosis, especially when the serum alpha fetoprotein level is not raised.

A case of metastatic squamous cell carcinoma of the hypopharynx manifesting as acute abdomen

INTRODUCTION

Squamous cell head and neck cancers are usually confined to local and regional sites but occasionally, patients may present with rare manifestations of distant metastases.

CLINICAL PICTURE

A 23-year-old female was treated with concurrent chemo-radiotherapy for stage IVA post-cricoid squamous cell carcinoma. A month later, she presented with acute abdomen and was found to have extensive peritoneal nodules at laparotomy. Intestinal obstruction soon followed.

TREATMENT

She was managed conservatively for the intestinal obstruction and given weekly paclitaxel.

OUTCOME

She continued to deteriorate and succumbed shortly after the diagnosis of carcinomatosis peritoneii.

CONCLUSION

This rare and aggressive presentation reminds us to be cognizant of relapsed head and neck cancers manifesting atypically, and the need for more aggressive search of distant disease in at least some subgroups of head and neck cancer.

Multicentricity in papillary thyroid carcinoma: analysis of predictive factors

OBJECTIVES

Multicentricity has been cited as a rationale for total thyroidectomy in patients with papillary thyroid carcinoma (PTC) confined to one lobe. The purpose of this study was to examine the incidence of multicentricity of PTC in a cohort of 165 patients with PTC confined to one lobe and to examine clinical and pathologic features that may help predict for the presence of contralateral disease.

DESIGN

Retrospective review.

SETTING

Tertiary care hospital.

METHOD

A retrospective review of 165 patients with PTC confined to one lobe treated at the Toronto General Hospital from 1992 to 1997 was performed.

MAIN OUTCOME MEASURE

The predictive factors affecting the presence of multicentricity of PTC were analyzed.

RESULTS

The incidence of PTC present in the contralateral lobe was 56.3%. We were unable to find any correlation of multicentricity with age, sex, tumour size, extrathyroidal spread, thyroiditis, or tall cell variant of PTC. There were trends toward higher incidence of contralateral disease in those patients with a prior history of irradiation and those with lymphatic metastases, but these trends did not reach statistical significance.

CONCLUSIONS

The incidence of contralateral disease in papillary thyroid cancer treated at the Toronto Hospital was 56.3%. There was a higher incidence of contralaterality in those patients with a previous history of irradiation and in those with lymphatogenous metastases, but this did not reach statistical significance.

Abnormalities of the ARF-p53 pathway in oral squamous cell carcinoma

Oral squamous cell carcinoma (OSCC) is associated with heavy smoking and drinking, but the molecular pathway of tumorigenesis is not understood. Inactivation of the p53 tumor suppressor gene is likely to play an important role since p53 mutation is frequently found. The p14ARF tumor suppressor gene is functionally linked to p53, because it is activated by oncogenes and causes p53-dependent growth arrest and apoptosis. The relationship between p14ARF and p53 inactivation has not been described for OSCC. We studied 25 cases of OSCC to determine if there is an inverse correlation between p53 mutation and p14ARF inactivation by homozygous deletion or mutation. p53 mutation was found in 16 of 25 cases (64%), including nine missense and seven truncating mutations. While all cases with missense mutations showed abnormal accumulation of p53 protein, there were also five carcinomas which showed increased p53 staining in the absence of mutation. p14ARF deletion or mutation was found in eight cases (32%), six of which also demonstrated p53 mutation. Our findings indicate that OSCC often involves loss of both p14ARF and p53 function and suggest that inactivation of these two tumor suppressor genes are not functionally equivalent during tumorigenesis.

Amelioration of disease severity by intraarticular hylan therapy in bilateral canine osteoarthritis

Because of its high molecular weight, the glycosaminoglycan molecule hyaluronan is responsible for the viscoelastic properties of normal synovial fluid. In osteoarthritis, the concentration and molecular weight of hyaluronan in synovial fluid is diminished: this impairs the ability of synovial fluid to effectively lubricate joints, absorb loads, and exert anti-inflammatory effects. Using a bilateral anterior cruciate-ligament transection and partial neurectomy canine model of osteoarthritis, this study examined the effect of viscosupplementation with hylan G-F 20 as a treatment for osteoarthritis. Twelve dogs underwent bilateral arthroscopic anterior cruciate-ligament transections and partial neurectomy of the knee joints. Beginning 1 week after the operation, six dogs received three weekly 500-microl injections of hylan G-F 20 in one knee and a sham injection of saline solution in the contralateral knee (early-treatment group). The remaining six animals underwent the same treatment 2 months following the procedure (late-treatment group). All dogs were killed at 8 months, and both knees were evaluated for gross pathology, histology, and proteoglycan content. In addition, with use of 500-MHz [1H] magnetic resonance spectroscopy, the synovial fluid from both knees was assessed for changes in metabolic profile. Differences in outcome were analyzed with paired t tests. Gross pathological and histological examination revealed significantly less severe changes of osteoarthritis in knees treated with hylan G-F 20 2 months after surgery than in the contralateral untreated knees. Magnetic resonance spectroscopy of the specimens in this late-treatment group showed significantly decreased glucose concentrations and significantly elevated isoleucine levels in the synovial fluid from knees treated with hylan G-F 20 compared with the controls. Previous magnetic resonance spectroscopy had shown that glucose concentrations increase with the onset of osteoarthritis and eventually diminish in end-stage osteoarthritis. The three injections of hylan were given after osteoarthritis was established, and the severity of the disease was ameliorated in the treated knees 6 months after treatment. This occurred although hylan G-F 20 is almost certainly cleared from joints by lymphatics within 4 weeks of injection, suggesting that hylan therapy can retard the progression of osteoarthritis for periods of time extending beyond the intraarticular residence time of the injected molecules and that hylan injections given at relatively early stages of osteoarthritis may have a chondroprotective effect. No changes in outcome were noted in the animals that received hylan G-F 20 immediately following surgery.

A central giant cell granuloma influenced by pregnancy

A case of a 17-year-old patient with exacerbation of a central giant cell granuloma of the mandible during pregnancy is reported. The possible relationship of the giant cell lesion to a pre-existing fibrous dysplasia is considered although there was lack of histological evidence.

Pediatric malignant ovarian tumors: a 43-year review

Thirty-eight girls with malignant ovarian tumors were reviewed and studied during a 43-year period, 1945 to 1988 inclusive. The age range was 3 to 16 years. Eighteen girls were prepubertal and 16 were pubertal at diagnosis. Precocious puberty was noted in 4 children. The most common presenting symptoms and signs were pain, abdominal swelling, and pelvic mass. Emergency surgery for acute pain (? appendicitis) was needed in only 7 patients. Tumor size and cysts did not relate to histology or outcome. Tumors were classified histologically (germ cell, sex cord/stromal, epithelial tumors). Twenty-one (54%) of the patients survived 1 to 27 years (median, 8 years). Sixteen were left with ovarian tissue, 11 functioning. Diagnosis and treatment have been aided by better noninvasive radiological methods, tumor markers, newer and better chemotherapy, and pathological review and reclassification of these tumors as pediatric experience slowly increases. We can make at least four statements that differ from our past experience: (1) pure endodermal sinus tumor was previously confused histologically with embryonal carcinoma; (2) gonadoblastoma is associated with 45,X/46,Y, 45,X, or 46,Y karyotype and is known to be premalignant; (3) sex cord/stromal tumors are not necessarily malignant and metastatic behavior cannot be predicted from the histology; and (4) currently, epithelial tumors are classified as cystadenomas and are considered to be borderline malignancy. Current management should aim at both cure and preservation of fertility with conservative surgery whenever possible. The future must lie in chemotherapy.

The spectrum of lymphoma in Malaysia: a histopathological study utilizing immunophenotyping

A retrospective study was made to determine relative incidence of lymphoma subtypes in Malaysia. High grade non-Hodgkin's lymphoma was found to be common. Low grade non-Hodgkin's lymphoma and Hodgkin's disease were relatively rare in this Malaysian series. Non-Hodgkin's lymphoma of B-cell immunophenotype was four times as common as that of T-cell lineage. There was a high incidence of primary extranodal non-Hodgkin's lymphoma.

Magnetic resonance imaging of cystic, partially differentiated nephroblastoma

The magnetic resonance imaging (MRI) appearance of a cystic, partially differentiated nephroblastoma is described, together with pathologic correlation. The difficulty in reaching a correct preoperative diagnosis even with multimodal imaging techniques is emphasized. MRI is an adjunct to ultrasonography and may be superior to computerized tomography (CT) scan in the evaluation of a child with multiloculated cystic renal mass.

Rhabdomyosarcoma of the prostate in childhood: current challenges

Since 1978, six boys with prostatic rhabdomyosarcoma have been treated at our institution. Three had localized disease and were managed by initial biopsy, vincristine, actinomycin-D, and cyclophosphamide (VAC) chemotherapy, and bladder-sparing surgery with or without irradiation. Further combination chemotherapy ("pulse" VAC, Adriamycin, VP-16, cisplatin, and ifosfamide) was continued for 20 to 22 months following the induction course. Two boys had microscopic residual disease undetected by frozen section and unresponsive to radiotherapy. Subsequent total cystectomy 4 and 7 months later resulted in eradication of disease. In one patient, preservation of the bladder was achieved at the age of 3 months for 8 years. Artificial sphincter inserted to cure his urinary incontinence failed because of ischemia secondary to cuff compression and scar tissue. He is alive today with a modified Koch pouch urinary diversion. Of the 50% who had metastatic disease at presentation, two were dead within 12 months despite aggressive chemotherapy and irradiation. The third is currently on treatment. Although chemotherapy has markedly improved the prognosis, surgery is still necessary in most cases for cure. Bladder salvage is a desirable goal; however, residual microscopic disease, difficulty with frozen-section disease detection, and poor tissue vascularization for subsequent sphincter replacement remain significant obstacles.

Melanotic neuroectodermal tumor of infancy: report of two cases

Melanotic neuroectodermal tumor of childhood is a rare lesion, but its presentation appears to be quite characteristic and a clinical diagnosis may be made with some confidence. Although this is an extremely rapidly growing, aggressive tumor, local excision appears to be adequate for cure.

Mesenchymal hamartoma in a 10-month-old infant: appearance by magnetic resonance imaging

A previously well 10-month-old infant boy presented with a large hepatic tumor. Its sonographic and computed tomographic appearances were similar to those reportedly found in mesenchymal hamartomas. Magnetic resonance (MR) imaging showed a multiseptated mass with fluid-filled compartments and some displacement of major intra-abdominal vessels. This appears to be the first report of MR imaging of a mesenchymal hamartoma.

Effect of esophageal ligation on the growth of fetal rabbits

Controversy continues regarding the nutritional value to the fetus of swallowed amniotic fluid. To clarify this issue further, esophageal ligations were performed to prevent deglutition in utero in 63 fetal rabbits during the final trimester of pregnancy. Compared with sham-operated littermate controls, the fetuses that were ligated for periods of 4, 5, or 6 days showed significant reductions in weight of 6.1, 18.9, and 9.2%, respectively. These results compare well with the magnitude of weight reduction seen clinically in patients with esophageal atresia. Significant but less consistent reductions were also noted in crown-rump length and biparietal diameter. No significant differences were seen in either body composition or gastrointestinal tract histology. These results indicate that swallowed amniotic fluid does play a role in fetal nutrition and may be particularly important in the later stages of gestation when placental function is limited.

Fibrous hamartoma of infancy

We report a case of recurrent fibrous hamartoma of infancy in the inguinal region. To our knowledge this is the first such case reported, and it illustrates the benign nature and recurrent potential of the tumor.

Congenital mesoblastic nephroma: a clinicoradiologic study of 17 cases representing the pathologic spectrum of the disease

Congenital mesoblastic nephroma (CMN) is a rare infantile renal tumor with a generally excellent prognosis. We describe 17 tumors that fit into the pathologic spectrum of CMN proposed by Beckwith, which ranges from benign renal tumors, through atypical "gray zone" lesions of more aggressive potential, to "crossover" tumors akin to clear cell sarcoma of kidney. Nine patients with histologically typical CMN were significantly younger and had smaller tumors than did eight patients with atypical CMN. Clinical features did not differ in the two groups of patients. A distinctive "ring sign" on renal sonography was commonly seen in patients with typical intrarenal CMN. All 17 patients were alive with no evidence of disease at a mean follow-up of 10 years. Nephrectomy was adequate therapy for younger infants and for those with typical CMN. Nephrectomy was probably also adequate therapy for infants 3 months of age or younger with atypical CMN, even if the tumor extended to the surgical resection margins and into the perinephric connective tissues. Adjuvant chemotherapy or radiation or both should be reserved for patients older than 3 months who have grossly unresected tumors and for those patients whose tumors have an unequivocally malignant histologic appearance or evidence of aggressive biologic behavior.

Neoplastic potential in patients with disorders of sexual differentiation

The occurrence of tumors was determined in 157 patients with disorders of sexual differentiation at a major pediatric hospital from 1960 to 1980. Gonadoblastoma developed in 2 of the 4 patients with mixed gonadal dysgenesis (MGD) who had not had bilateral gonadectomy; this indicates the need for early gonadectomy in such cases. Gonadal embryonal carcinoma developed in 1 child with Turner's syndrome (1 of 71). Four cases of nephroblastoma occurred, 1 in a child with MGD (1 of 18) and 3 in male pseudohermaphrodites (3 of 35). The nature of the defect linking male pseudohermaphroditism with Wilms tumor remains to be established.

A chronic arteriovenous shunt for the testing of biomaterials and devices in dogs

A technique is described for an extracorporeal arteriovenous shunt in dogs which allows the testing of biomaterials in the shunt for several months in the same animal. The details of the preparation of the tubes and of the surgical technique are given. In contrast to other techniques, encircling ligatures are not placed around the cannulated blood vessels.

Congenital hepatic fibrosis with saccular dilatation of intrahepatic bile ducts and infantile polycystic kidneys

A case report is presented of a child who died in the neonatal period and who had the sonographic findings of multiple, tubular, fluid-filled spaces in the liver characteristic of Caroli's disease. There was an echodense renal cortex and pyramids. Necropsy findings were consistent with Caroli's disease but the liver also showed evidence of congenital hepatic fibrosis and there was infantile type polycystic disease of the kidneys.

Soft tissue recurrence of chondromyxoid fibroma

A 12-year-old girl presented with an isolated soft tissue recurrence of chondromyxoid fibroma after two previous excisions of tumor from the proximal tibia. Chondromyxoid fibroma is a rare benign tumor of bone. We present this case report of isolated soft tissue recurrence to emphasize a rarely reported complication of surgical extirpation.

Malignant sacrococcygeal teratoma--endodermal sinus, yolk sac tumor--in infants and children: a 32-year review

Fifteen cases of malignant sacrococcygeal teratoma were treated at our hospital over the last 32 years. These included five cases of endodermal sinus (yolk sac) tumor that arose in otherwise benign or immature teratoma, and ten cases of pure endodermal sinus (yolk sac) tumor. Most were females, and only one was a neonate. The presence of symptoms almost always indicated local extension or distant metastases. According to Altman's classification, all but two of these malignant tumors were Types III and IV. The resectability was low, but with aggressive radiotherapy and chemotherapy, second look operations in five have been possible with increasing optimism for survival. Two of five patients with secondary resections are alive and tumor-free almost two years after therapy was discontinued. So far, only the newborn is a long-term (14 years) cure.

Ileocaecal atresia

Meconium ileus is one of the commonest causes of distal small bowel obstruction in neonates. Within the last six years at our hospital two newborns presented with identical signs and symptoms of meconium ileus. Abdominal x-rays showed distal small bowel obstruction with ground glass opacity in the right lower quadrant. Gastrografin enema in both cases demonstrated a microcolon, but there was no reflux of this contrast material into the terminal ileum. Laparotomy in both babies revealed atresia of the ileocaecal valve with dilatation of the terminal ileum loops which contained normal meconium. Ileocolic resection was carried out in both neonates. Sweat chlorides and eventual recovery were normal. Pathology in one of the specimens showed muscularis passing across the atretic area with a telescoped pattern of the muscularis propria suggesting intussusception in utero. Although the presentation of a newborn may be that of meconium ileus, the fact that the Gastrografin enema is unable to enter the terminal ileum in a retrograde fashion should be an indication for immediate laparotomy rather than persisting in this mode of treatment. It is obvious that occasionally the radiological diagnosis of meconium ileus is incorrect.

CT features of reactive periostitis in the humerus: a lesion resembling myositis ossificans

A 5-year-old boy with a painful lesion in the proximal humerus is reported. Plain radiographs suggested the presence of a malignant bone lesion, and CT showed features similar to stress fractures. Pathologically, the changes were that of reactive periostitis.

Thirty years of experience with pediatric primary malignant liver tumors

Since 1950, 48 infants and children from 10 weeks to 16 years of age presented with primary hepatic malignancy. Signs and symptoms ranged from asymptomatic to those of malignant disease. All patients had a palpable abdominal mass. Jaundice was seen in five patients, four of whom had preexisting cirrhosis. Three male children had evidence of precocious puberty. Whereas liver function tests were usually normal, alpha-fetoprotein levels, when elevated, proved useful diagnostically and as a tumor marker in follow-up. Hepatic angiography and computed tomography (CT) scans have provided the most valuable preoperative assessment of hepatic architecture. Sixteen infants and children underwent resection for cure. Eleven of these patients are alive and disease free 6 months to 23 years later. Six additional patients had incomplete resection with subsequent radiotherapy and/or chemotherapy; only one such patient is disease-free past 3 years. Twenty-six tumors could only be biopsied; most of these patients died within 12 months regardless of what treatment they received. The histology was hepatoblastoma in 39 patients, hepatocellular carcinoma in 4, fibrolamellar carcinoma in 4, and malignant mesenchymal tumor (mesenchymoma) in 1. The patients with hepatocellular carcinoma and mesenchymoma all died. Three of four patients with fibrolamellar carcinoma are alive and disease-free following resection up to 3 years; this histology seems favorable. The other survivors had hepatoblastoma. The role of adjunctive chemotherapy and/or radiotherapy has not yet been determined.

The problem of recurrent thyroglossal duct remnants

The removal of a thyroglossal duct or sinus is a common pediatric surgical operation. It has been taught that if the duct remnant is removed down to and including the middle third of the hyoid bone, the "correct" operation has been done. The three authors have an experience totaling over 60 years in pediatric surgery during which time they operated on 270 thyroglossal duct cysts and sinuses. In this group were 27 recurrences of which three belonged to the authors. Most recurrent thyroglossal duct remnants were found to have the middle third of the hyoid bone still in place, and with its removal the patients were cured. However, during this period of time, there were thyroglossal duct cysts and sinuses which recurred in spite of the "correct" surgical procedure having been done. These patients had all been operated on between three and five times thus creating a difficult and unusual problem. The solution to these recurrent thyroglossal duct cysts and sinuses were deeper excisions to remove residual tracts deep to the previously removed hyoid bone, and/or wider excisions to excise previously missed respiratory epithelial remnants which deviated laterally from the midline. The latter tissue was found to be a more centrally directed branchial cleft sinus.

Yolk sac tumor of the bladder

A 1-year-old white boy presented with hematuria and was found to have a large polypoid bladder mass. Light and electron microscopic, and immunohistochemical diagnosis was a yolk sac (endodermal sinus) tumor. This is the first case of a primary yolk sac tumor of the bladder to be described in the English literature.

Tracheoplasty--a new operation for complete congenital tracheal stenosis

This is a report of a case of complete congenital tracheal stenosis confirmed by tracheobronchogram. The stenosis also involved the origin of the right main bronchus. The membranous portion of the trachea was absent. It was repaired through a sternotomy and right thoracotomy aided by partial cardiopulmonary bypass. The posterior trachea was opened from larynx to carina and on into the right main bronchus, and each posterior tracheal edge was sewn to the anterior wall of the esophagus with a running Prolene suture. Three months after repair bronchoscopy showed that the new membranous trachea was epithelialized and the entire airway was of good caliber; the only problem was a diffuse tracheomalacia. He died in his seventh postoperative month after a major airway complication due to tracheotomy, which occurred after an elective bronchoscopy. It is obvious that this operation is technically feasible. It was hoped that his airway would become sufficiently stable to allow the tracheotomy tube to be removed at some time in the future.

Lipoblastoma in infants and children

Lipoblastoma and lipoblastomatosis are rare benign tumors of embryonal fat with a tendency to local invasion but not to metastasize. To date, there have been 60 cases described in the international literature. There has never been a report in a child older than 8 yr. The main clinical characteristics are the presentation, usually below 3 yr of age, the rapid growth of the mass and the peripheral location, mainly in the extremities. Although CT scan may show a fatty tumor, there is no single test to make the differential diagnosis (which includes benign lipoma, liposarcoma and myxoliposarcoma) and the treatment should be based on clinical findings. We have treated four patients with this condition. Two were intrathoracic, one was intraperitoneal, and one was a tumor of the upper arm. All presented as rapidly-growing tumors and were clinically assumed to be malignant. We recommend complete but conservative excision of the tumor; there are reported recurrences after inadequate excision. This is a benign tumor and radical cancer surgery should be avoided.

Thymic changes in histiocytosis

In order to arrive at a hypothesis of the pathogenesis of thymic changes in histiocytosis, the thymus glands from thirty-two children with histiocytosis were studied. In general, the changes were a severe loss of cortical and medullary structures rather than stress type changes in which only the cortical structure changes. The thymic changes were then classified into three main groups: severe dysplasia equivalent to that seen in congenital immune deficiency, severe nonspecific involution, and a third group designated as a dysmorphic type which resembled those with dysplasia, but, in addition, showed smaller lobules and interstitial histiocytic infiltration. The thymic changes correlated with the type of histiocytic disease. For the purposes of this study, the disease was categorized as Type I or Type II, as previously described. Dysplastic changes were only seen in those patients with Type I histiocytic disease, while involution occurred in patients with Type II histiocytic disease. Dysmorphic change was apparent in both, but it had a much higher incidence in Type II.

The temporary stent technique: an easier method of micro-venous anastomosis

The microvascular repair of small veins is technically difficult. A new method using a temporary "stent" has been studied experimentally in microvenous anastomoses of the femoral veins in twenty-four rats. The technique is described in detail. The results were evaluated by gross observation and by histological section. Improved patency rates were demonstrated and the advantages of the technique are discussed. The technique could be very useful in the anastomoses of small, fragile veins, particularly by the less experienced microsurgeon.

Intestinal stricture after necrotizing enterocolitis

Between 1974 and 1979 inclusive, 20 of 175 neonates with previous necrotizing enterocolitis (NEC) developed obstruction from intestinal stricture 1-20 mo after the diagnosis of NEC. Seven were found in the small bowel, 19 in the colon. Treatment included proximal decompressive enterostomy with subsequent resection in 6 and primary resection in 11. Two died during attempts to restore GI continuity and one died from cardiac disease before any GI surgery. Morbidity occurred in six. Various stages of wound healing from acute inflammation to dense fibrosis were found in pathologic specimens. Fibrosis was most marked in the submucosa and most consistently found in specimens resected 3 mo after the acute episode of NEC. Intestinal stricture develops in 6%-33% of the infants with previous NEC. Eighty percent of these strictures are colonic, 30% are left sided, and 15% are multiple. Multiple lesions are exclusively colonic. Histology varies with age of lesion. The predominant feature of stricture is submucosal fibrosis. Strictures less than 3 mo old still have acute inflammatory disease, older strictures are mature and fibrotic. The best diagnostic tools are a high index of suspicion and a barium enema. An intestinal stricture should be suspected in any infant with a past history of NEC and: (1) symptoms of obstruction or failure to thrive; (2) previous exteriorization or proximal diversion of acute or chronic NEC lesions; or (3) peritoneal drainage under local anesthesia for NEC perforation. Treatment should be tailored to the infant's condition and the time elapsed since the acute NEC episode. Resection of the stricture must be complete otherwise recurrence or leak is unlikely. Intestinal diversion with a 3-6-mo delay before reconstruction appears safer in the child with little margin for error. Earlier restoration of blood flow and cessation of intestinal function during the acute episode of NEC might reduce the incidence of stricture.

Impression cytology in conjunctivitis

A technique is described for studying the cellular response in various conjunctival disorders. A round plastic disc (Thermanox) is pressed against the patient's conjunctive, and the material adhering to the disc is stained with a modified Wright's stain (Diff-Quik) for light microscopy. This method compares favourably with the classic conjunctival scraping method. The advantages of the impression technique are that no local anesthetic is needed for abtaining conjunctival samples, it is painless and can readily be used in children, repeated samples can be taken within a short time, the staining procedure can be completed within 15 seconds, and the discs can be processed for electron microscopic studies of the cellular samples.

Obstructive circular-muscle defect in the small bowel in a one-year-old child

Investigation to determine the cause of vomiting in a 14-mo-old child revealed partial obstruction at a narrowed segment of mid small bowel, with local deficiency of circular muscle and ballooning proximally. The pathogenesis of this apparently unique lesion is uncertain.

Benign sacrococcygeal teratomas in infants and children: a 25 year review

A review of 33 infants treated over 25 years for benign sacrococcygeal teratoma shows that this is predominantly a newborn tumour presenting mostly as an external mass and carrying an excellent prognosis provided surgical treatment is prompt and complete excision accomplished. Resectability was 100% in this series as is usually the case. This tumour must however, be differentiated from other masses presenting in the sacrococcygeal area by a careful histologic study since these other lesions generally require a different therapeutic approach.