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Disagreement remains on the best mode of therapy for spontaneous pneumothorax (SP). Treatment options vary from observation alone to thoracotomy depending on the stage of the disease and the preference of the physician. Between 1983 and 1988, 122 patients with SP were treated at the Elisabeth Hospital Tilburg according to a fixed protocol. Of these patients 86 (68%) were primarily treated with observation alone or with intercostal tubes. Seven of these patients (8%) had to be treated surgically after failure of the primary treatment. After thoracoscopical selection and in case of recurrent disease 39 patients underwent surgery: apical pleurectomy and bullectomy, in most cases by the transaxillary approach. In this group morbidity was minimal and there were no recurrences. We conclude that for most patients with spontaneous pneumothorax non-surgical therapy is the therapy of first choice.

Cryptorchidism is known to increase the incidence of testicular malignant tumours. In this report a patient is described with the Mullerian duct syndrome in connection with a cryptorchistic malignant testicular tumour.

The case history is presented of a 56-year-old man, who had a second primary carcinoma in the contralateral breast after 13 years. Both times, he underwent a modified radical mastectomy. The axillary lymph nodes were free from tumour. The incidence in men is about 1 per cent being bilateral in 14 out of 1,000 of these cases. The therapy for men is the same as for women. Because of the smaller breast volume, tumours in men are earlier discovered and show infiltration. If metastases cannot be detected, the first choice of treatment is surgical. Radiotherapy is indicated in case surgical intervention has not been radical.

Mediastinoscopy and CT are used to evaluate the mediastinum in patients with non small cell lung cancer to determine operability. Generally, the sensitivity and negative predictive value of CT are high, in a personal study in 150 patients 86% and 92%, respectively. When CT does not reveal enlarged lymph nodes, we recommend thoracotomy without mediastinoscopy. However, micrometastases in non-enlarged lymph nodes will be missed. All positive CT scans necessitate mediastinoscopy, because enlarged lymph nodes frequently are not invaded with tumour (in our study in 33%). CT used in this way will increase the percentage of positive results of mediastinoscopy. In patients with a peripheral tumour lymphogenic spread to the mediastinum is not uncommon (in our study in 22%) and mediastinal evaluation should not be omitted. In these patients mediastinoscopy is also of diagnostic value.

Adequate nutritional support is essential in patients with head and neck cancer, especially if extended oropharyngeal surgery is indicated. Enteral nutrition is an effective and safe alternative to parenteral nutrition, but the use of nasogastric tubes has several disadvantages in these patients. We describe our experience with percutaneous endoscopic gastrostomy as a standard procedure prior to surgical resection in patients with head and neck cancer.

During a 12 year period 42 patients underwent a pancreatoduodenectomy, on 35 occasions because of malignancy. Four patients (11%), all with pancreatic cancer, died in the postoperative period. Two of the seven patients with pancreatitis died (28%). No patient with pancreatic cancer survived one year. Seven of the 11 patients with distal common bile duct cancer survived one year and five out of seven patients with carcinoma of the ampulla of Vater survived one year. Local tumor recurrence occurred in at least 18 of 27 patients (67%), upper abdominal pain being the most important symptom. At long follow-up three patients had tumor recurrence in the laparotomy scar. In our experience resection offers the only chance of cure for patients with a tumor of the ampulla of Vater or the distal common bile duct. At present, however, resection is not the treatment of choice in patients with pancreatic cancer.

Paired and matched CT scans, one before and one after IV injection of contrast material, from 30 spinal CT studies were presented in a blind fashion to six observers with varying degrees of radiologic experience. The observers were asked to indicate which section of each pair gave the best delineation of intraspinal soft tissues. Seventy-five percent of the verdicts indicated the postcontrast image was superior in this respect, but the six observers were unanimous on this in only 50% of the cases. At a follow-up viewing of the same cases several weeks later, some 20% of the verdicts were changed. Experience in interpreting spinal CT scans did not prove to influence rating performance or improve intraobserver consistency. In summary, contrast material, in the dosage and injection mode used by us, appeared to be the most important factor in improving scan interpretation.

The results of surgical common bile duct exploration in 1007 patients were evaluated in a retrospective study. Overall mortality was 2%. Under the age of 70 years mortality was 0.9%. Mortality increased significantly in patients older than 80 years (9.5%), including the patients with acute cholangitis. The most frequently encountered complications were wound infection in 7%, severe pulmonary insufficiency in 4%, and cardiovascular problems in 3%. The results of the present series show that in the current state of pre-, intra- and postoperative care surgical common bile-duct exploration has a low morbidity and mortality rate in patients under 80 years of age.

Cryptorchidism increases the incidence of malignant testicular tumours. The case is described of a normally functioning male patient with a tumour in an undescended testis, in whom a special type of intersexuality was found: the persistent müllerian duct syndrome, one of the types of male pseudohermaphroditism, in which no disturbances of virilisation occur and which is often associated with cryptorchidism and other developmental anomalies.

The reliability of mediastinoscopy as described by Carlens was evaluated in 170 patients with lung cancer. When the primary tumour was located in the left upper lobe, the result of the mediastinoscopy was false-negative in 12 (31%) out of 39 patients. Other invasive procedures, such as left parasternal mediastinoscopy, might be more accurate in these patients.

Controversy exists regarding the routine use of breathing exercises in the prevention of pulmonary complications after upper abdominal surgery. We prospectively randomized 153 patients who had noncompromised pulmonary status; the control group (84 patients) engaged in no breathing exercises, and the respiratory therapy group (69 patients) engaged in preoperative and postoperative breathing exercises supervised by the physical therapist. Postoperative pulmonary complications were classified using criteria derived from chest roentgenograms, arterial blood gas samples, and temperature registration. The incidences of postoperative complications in the treatment group and in the control groups were 19% and 60%, respectively. In the present study, preoperative lung function tests had no additional or predictive value. We advise preoperative and postoperative breathing exercises as a prophylactic treatment in all patients scheduled for upper abdominal surgery.

Contrast-enhanced CT can be useful in differentiating between recurrent disk herniation and scar formation after disk surgery. Thirty such CT studies were assessed retrospectively to determine the utility of CT attenuation measurements in identifying intraspinal pathology. Measured values of intraspinal tissues, but also of "reference" materials such as CSF, blood, and muscle tissue, showed large individual variations; and enhancement patterns for recurrent herniation and scar formation were not specific. The chief value of contrast administration may lie in the clearer definition that is gained of various structures within the postoperative spine.