Search

Although lymphocyst (retroperitoneal lymphocele) is not an uncommon complication after retroperitoneal surgery, with a reported incidence ranging from 0.6% to 48%, the occurrence of chylous ascites is a rare phenomenon. Most reports are anecdotal, and hospital records list the incidence of diagnosis as 0.001% of admissions. Diagnosis of chylous ascites is usually not difficult, inasmuch as aspiration and chemical analysis of the fluid yield the answer. Visualization of retroperitoneal fluid collection by computerized tomography or ultrasonography, however, does always raise the possibility of recurrence of tumor in cases where the primary operation was for cancer. Treatment of smaller lesions can be expectant. Respiratory exercises causing an increase in negative intrathoracic pressure may aid in the movement of fluid through the lymphatics. For larger collections, elemental diets and total parenteral nutrition are also often enough, but surgery is sometimes required. Simple insertion of a peritoneovenous shunt, as in this patient, can be as effective as major operations such as identification and ligation of the offending lymphatic or marsupialization of the cyst.

Using techniques originally developed for roentgenologic placement of much smaller bore catheters, a large bore, thick wall Silastic catheter has been used to decompress and internally drain the right hepatic biliary system, while a more traditional approach was used on the left. By avoiding the trap of standard procedures and retaining the ability to innovate, a good surgeon will be able to work out a satisfactory solution for a difficult problem for the ultimate betterment of the patient and self.

The median survival, from diagnosis, of patients with cancer of the gallbladder is 6 months. Our purpose in reviewing our experience was to identify factors, either in patient characteristics or treatment, that influence this statistic. In 22 years 71 cases of gallbladder carcinoma were referred to Roswell Park Memorial Institute in Buffalo, New York. Most had a cholecystectomy that revealed an unsuspected neoplasm, before referral. Mean age was 62 years and 75% were female. Symptoms, signs, and laboratory and imaging studies were uniformly unhelpful in determining the diagnosis. Early diagnosis at a stage amenable to surgical excision remains the sole salvation. Patients who receive chemotherapy did better than those who did not, but this is probably a reflection of patient selection. Newer treatment modalities are urgently needed.

Carcinoid tumor arising in a Meckel's diverticulum is a rare lesion with only 52 cases described in the literature. Most of these tumors are found incidentally at autopsy or during an operation performed for an unrelated reason. The lesion can, however, in about one-third of cases, be the cause of symptoms necessitating surgical intervention; the diagnosis is nearly never apparent till the specimen has been removed. When the signs do not match the symptoms, consideration of uncommon conditions such as this may help in making a correct preoperative diagnosis. Resection of the intestinal segment containing the diverticulum along with its mesentery to the level of the superior mesenteric vessels usually results in cure; however, metastatic disease and even carcinoid syndrome may still occur. Second primary malignancies are often found in patients with carcinoid of Meckel's diverticulum.