This retrospective review was performed with an intent to clarify several misconceptions associated with superior vena cava syndrome (SVCS). During a 16-yr period, we diagnosed and treated 63 patients with SVCS, including seven (11%) children younger than 10 yr of age. Thirty patients (47.6%) had bronchogenic carcinoma, and 13 (20.6%) had lymphoma. In 43 cases SVCS was the presenting symptom of a mediastinal condition. Forty-one patients underwent diagnostic procedures with no major complications, and diagnosis was obtained in 36. Only six patients had surgical treatment, and 45 had radiation therapy, chemotherapy, or both. There was no mortality associated directly with venous congestion. Symptomatic relief occurred in 80% of treated patients. We conclude that: (1) SVCS per se should not be feared (symptomatic relief is the rule), (2) accurate diagnosis can be achieved with minimal morbidity, and (3) the versatile underlying etiology dictates the outcome that can be improved with appropriate therapy.

The fistula recurrence rate following two-stage seton fistulotomy in non-CD patients was high. In CD patients the use of permanent loose seton is effective in controlling local sepsis in about half of patients and has low rates of subsequent incontinence.

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The appearance of the costal pleura at high-resolution computed tomography (CT) was evaluated with a cadaver and 25 normal subjects. This was contrasted with the high-resolution CT appearance of the costal pleura in 15 patients with mild pleural thickening, 13 of whom had been exposed to asbestos. On high-resolution CT scans in the normal subjects, a 1-2-mm-thick line of soft-tissue attenuation at the point of contact between lung and chest wall represents the visceral and parietal pleura, pleural contents, endothoracic fascia, and innermost intercostal muscle. In a paravertebral location, the innermost intercostal muscle is lacking, and a thin line seen on high-resolution CT scans reflects pleura and endothoracic fascia. Transverse thoracic and subcostal muscles and extrapleural fat pads can be seen as tissue internal to a rib and may be confused with pleural thickening. In 13 of the 15 patients with mild pleural thickening, the 1-3-mm-thick pleura was separable from the underlying normal intercostal muscle by a layer of extrapleural fat. High-resolution CT was more sensitive than CT with 1-cm collimation in depicting this degree of pleural abnormality.

Hypothesis: Laparoscopic ultrasound examination combined with biopsy of the cystic wall and aspiration of cystic fluid improves differential diagnosis of pancreatic cystic lesions contributing to surgical decision making. Study Design: A prospective evaluation of the impact of laparoscopic ultrasound on surgical decision making in patients with pancreatic cysts. Setting: A general community hospital; the department of surgery serves as referral for pancreatic surgery. Patients: During a 36-month period, 15 patients with pancreatic cystic lesions were prospectively evaluated by laparoscopy and laparoscopic ultrasound with ultrasoundguided biopsy of the cystic wall and aspiration of cystic fluid for cytologic study, viscosity, and determination of levels of amylase and tumor markers (carcinoembryonic antigen, cancer antigen 19.9). Results: Laparoscopic ultrasound contributed new, additional data in 8 patients (53%) when compared with compiled imaging data obtained by conventional ultrasound, computed tomography, magnetic resonance imaging, and endoscopic ultrasound. A solid cystic component was detected in 6 patients and additional small (Ͻ1 cm) cysts in 3 patients. Amylase and tumor marker levels, biopsy of the cystic wall, and cytologic examination had significant impact on surgical decision making in 6 patients. Nine patients underwent resection of the cystic lesion. Three patients diagnosed as having benign cysts had laparoscopy with laparoscopic ultrasound only. Three patients with suspicious lesions refused surgery. Laparoscopic ultrasound predicted correctly the nature of the cyst in 7 of 9 surgically treated patients (sensitivity, 78%). Two patients with serous cystadenoma had high levels of tumor markers (false-positive). Conclusion: Although a rather invasive procedure that requires general anesthesia and hospitalization, laparoscopy with laparoscopic ultrasonography was found to significantly contribute to the differential diagnosis of pancreatic cystic lesions.