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1/34. Renal fibrohistiocytic sarcoma. Three cases and a review of the literature.

    The purpose of this paper is to report three unpublished cases of so-called "renal malignant fibrous histiocytoma" which should be more appropriately called "renal fibrohistiocytic sarcoma", and to review and analyze the data concerning 41 cases collected from the literature and our three new cases, making a total of 44 cases. Our third case is very interesting; in addition to the fact that this condition is rare, this particular patient also had concomitant nonmalignant ascites and compression of the descending colon, both conditions being rarely associated with renal cancer. The average age of the patients was 58 years; in 66% of the cases the tumor involved the left kidney; 57% of the patients were males; the average tumor size was 12 cm; nephrectomy was performed in 93% of the cases; the average survival was 16 months. In none of the cases was a preoperative diagnosis correctly made. It is concluded that a triad of symptoms and signs (renal pain, weight loss, and large tumor size) as well as a triad of imaging characteristics (areas of low density on the CT scan, hypoechoic areas on ultrasound, and hypovascularity on angiography) may hold the promise of a preoperative diagnosis. It is suggested that the tumor arises from the system of Gerota's fascia-renal capsule.
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2/34. ascites and weight loss in a child: due to congenital division of the right atrium.

    Congenital division of an atrial chamber is a very rare congenital malformation that more commonly affects the left atrium but which may, in rare circumstances, involve the right atrium. Such a divided right atrium may present with symptoms consistent with increased portal venous pressure. Reported is a case with unusual clinical presentation. The patient underwent resection of the dividing shelf with good postoperative results.
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3/34. Adjustable silicone gastric banding: a series with three cases of band erosion.

    BACKGROUND: Among the various operations used for surgical treatment of morbid obesity, adjustable silicone gastric banding (ASGB) is the least invasive. Many good results have been described. During extended follow-up, however, serious complications may occur. We briefly describe our results with ASGB and will focus on three cases of band erosion. methods: From January 1996 to December 1998, 91 patients underwent laparoscopic adjustable gastric banding in our clinic. Follow-up until now is 100%. RESULTS: body mass index (BMI) in this series decreased from 44.7 at time of operation to 34.8 at 18 months of follow-up (42 patients). Complications, minor and major, occurred in 27.5%. Three patients are described in which the gastric band migrated and had to be removed operatively. CONCLUSIONS: Satisfactory weight loss can be established by ASGB. However, serious and potentially lethal complications can occur. In view of the former Angelchik esophageal antireflux prosthesis, abandoned because of its notorious migration, we must be aggressive in evaluating band migration. Thus, we plead for international registration of adjustable silicone gastric banding.
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4/34. Intragastric balloons for preoperative weight reduction.

    BACKGROUND: If medical treatment of obesity fails and if surgical gastroplasty is not indicated, insertion of an intragastric balloon may represent an intermediate modality. methods: Two patients are reported in whom a balloon was placed for weight reduction before elective surgery: 1) A 53-year-old woman with a BMI of 41.3 kg/m2 lost 18 kg in 6 months and then underwent surgical repair of a huge incisional hernia; 2) A 58-year-old woman with a BMI of 35.8 kg/m2 had total hip arthroplasty after losing 15.5 kg in 5 months. RESULTS: The uneventful postoperative recovery in both patients was thought to be positively influenced by their preoperative weight loss. CONCLUSION: In morbidly obese patients, intragastric balloon placement may contribute to preoperative weight reduction before elective surgery.
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ranking = 3.5
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5/34. fertility and body composition after laparoscopic bilateral adrenalectomy in a 30-year-old female with congenital adrenal hyperplasia.

    Congenital adrenal hyperplasia due to 21-hydroxylase deficiency is caused by an inborn defect in the 21-hydroxylase gene (CYP21), leading to virilization of female patients and causing ambiguous genitals in the majority of female infants. adult women may suffer from loss of libido, irregular or absent cycles, and reduced fertility, despite intensive medical treatment. These problems have stimulated the search for alternative treatment modalities. We present an adult female patient, who was difficult to treat medically and whose clinical situation markedly improved after laparoscopic bilateral adrenalectomy. The procedure was well tolerated and without side effects. Postoperatively the elevated serum progesterone and 17-hydroxyprogesterone levels, as well as the undetectable LH levels, normalized. The procedure resulted in marked clinical improvement. Within 12 months after surgery she lost 11 kg in weight. This weight loss consisted mainly of adipose tissue. Acne disappeared, and she had a regular 4-week menstrual cycle, with progesterone levels that are compatible with a luteal phase. The introduction of laparoscopic techniques may give an impulse to the application of surgical therapy at a larger scale in patients with 21-hydroxylase deficiency who are difficult to treat with adrenal suppression therapy.
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6/34. The spectrum and significance of primary hypophysitis.

    Hypophysitis can present clinically as a mass lesion of the sella turcica. Secondary hypophysitis occurs in cases where a definite etiologic agent or process inciting the inflammatory reaction can be identified. In contrast, primary hypophysitis refers to inflammation confined to the pituitary gland with no identifiable etiologic associations. We report three cases of primary hypophysitis to illustrate the spectrum of three clinicopathological entities that encompass this disease: lymphocytic hypophysitis, granulomatous hypophysitis, and xanthomatous hypophysitis. Our three patients underwent surgery, with variable response. However, conservative, supportive treatment with or without surgical decompression is generally favored over aggressive and extensive surgical resection that results in hypopituitarism. We conclude that the optimal management of patients with hyophysitis requires a high index of suspicion before extensive surgical resection. Histological confirmation of the diagnosis of hypophysitis can be obtained by performing a biopsy or by requesting an intraoperative frozen section consultation.
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7/34. Fludeoxyglucose positron emission tomography in the diagnosis of giant cell arteritis.

    We describe a case in which fludeoxyglucose F 18 positron emission tomography (PET) led directly to the diagnosis of giant cell arteritis in an elderly woman with a fever of unknown origin.The patient presented with a 3-month history of fatigue, fever, headache, visual disturbance, jaw claudication, and anemia. A computed tomographic scan showed an anterior mediastinal mass that was suspected of being malignant. A fludeoxyglucose F 18 PET scan performed for preoperative evaluation identified striking uptake of fludeoxyglucose F 18 in the walls of the entire aorta, left main coronary artery, and subclavian, carotid, and common iliac arteries bilaterally, suggestive of an arteritis, a diagnosis subsequently confirmed by the findings of an arterial biopsy. Her erythrocyte sedimentation rate was 129 mm/h. There was normalizaton of the PET scan 2 weeks following treatment with prednisolone. This case suggests that fludeoxyglucose F 18 PET contributes to the noninvasive diagnosis of giant cell arteritis, as well as to the evaluation of the extent of disease, response to therapy, and disease recurrence.
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8/34. Pancreatic heterotopia and other uncommon causes of non-malignant biliary obstruction.

    The vast majority of patients developing obstructive jaundice will have an underlying malignancy. When the etiology of the obstruction cannot be defined prior to operative intervention, identification of a non-malignant process will occur only subsequent to a major operation. The clinical course of a patient with complete distal common bile duct obstruction as the result of pancreatic heterotopia is discussed. This uncommon diagnosis prompted a review of the literature on this subject enabling this detailed discussion inclusive of the embryology, prevalence and clinical presentations of this entity. Our review further identified a varied group of other non-malignant causes of biliary obstruction that may be mistakenly interpreted to represent biliary or pancreatic malignancy.
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9/34. Genital tuberculosis can present as disseminated ovarian carcinoma with ascites and raised Ca-125: a case report.

    In women with an adnexal mass, ascites and elevated Ca-125 levels, ovarian carcinoma must be ruled out. However, several other conditions, including genital tuberculosis, may present similarly. A 41-year-old woman with weight loss, ascites and elevated levels of Ca-125 was evaluated for ovarian cancer. Computerized tomography revealed an adnexal mass, ascites and lymph nodes on the peritoneal surface. paracentesis of the ascitic fluid revealed a lymphocytic exudate but failed to show any malignant cells. At laparotomy, frozen sections of tissue biopsies were negative for malignancy; however, a total hysterectomy plus adnexectomy was performed. Postoperatively histologic examination revealed typical features of genital tuberculosis. Antituberculosis treatment was effectively given to the patient. serum levels of Ca-125 were undetectable 12 weeks after treatment. In conclusion, genital tuberculosis can be misdiagnosed and confused with ovarian cancer. Intraperitoneal tuberculosis should be considered in the differential diagnosis in cases in which ovarian cancer is suspected, even when malignancy-associated risk factors are present.
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keywords = operative
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10/34. Treatment of devastating postgastrectomy symptoms: the potential role of jejunal pouch reconstruction.

    After gastrectomy a few patients develop severe symptoms and malnutrition. There are probably several reasons for this, such as insufficient gastric reservoir function, malassimilation, diarrhea and dumping. The patient presented here developed severe malnutrition after partial gastrectomy and his weight gradually decreased from 95 to 40 kg during the first 6 postoperative years. His major complaint was postprandial vomiting and early satiety. During the course of his illness, he was repeatedly investigated with computerized tomography scans, repeated endoscopies with biopsies, barium examinations, etc. Finally the only positive finding was bacterial intestinal overgrowth, but antibiotic treatment did not improve his condition. After repeated periods of parenteral nutrition or enteral tube feeding, an S-shaped jejunal pouch was attached to the gastric remnant. Dual-energy X-ray absorptiometry was used to examine the body composition and bone density in the immediate postoperative period and 1 year after the operation. During the first postoperative year he gained 11 kg weight and reported an essentially normal food intake. Both laboratory and clinical parameters improved and a gain in lean body mass was recorded. patients with severe postgastrectomy symptoms, with no other plausible explanation than nonexistent or insufficient gastric reservoir function, may benefit from re-reconstruction with a jejunal pouch.
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ranking = 1.5
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