It is probably better to use a staple size that kinase blocker imatinib (Gleevec) quality sumycin 500 mg antibiotic kill good bacteria. There may be a role for preoperative imatinib for pany’s stapler for 10 years cannot assume that she knows very large tumors that appear marginally resectable on exactly how to use the other company’s similar stapler discount sumycin uk 5 infection control procedures. Patients who experience disease familiar with the new instrument before using it in the progression or intolerable side effects on imatinib are operating room. This is why when stapling across an existing antrum and pylorus, resulting in gastric stasis. When feasible, staple lines in the stomach and duodenum mosis and Roux duodenojejunostomy. Instillation 28 Concepts in Surgery of the Stomach and Duodenum 277 of methylene blue and intraoperative endoscopy are other Pancreatitis useful methods to confirm staple-line integrity. Staple-line bleeding into the lumen can be problematic Pancreatitis following gastroduodenal operation is generally and rarely can be life threatening. Either of the papillae can be injured during aggres- rhage and bleeders controlled. More com- gastrojejunostomy, intraoperative endoscopy should monly, the more proximal minor papilla is occluded or be performed if excessive staple-line hemorrhage is transected. The problems are interrelated in that infection predisposes to the other two complications, and all Postoperative Complications three share risk factors. Wound infection is related to intra- operative contamination, which is more significant in the set- Pulmonary Problems ting of acid suppression, gastric cancer, and obstruction. Appropriate use of prophylactic antibiotics and good surgical Atelectasis is probably the most common complication technique are important preventative measures. Adequate analgesia, incentive spi- disease, abdominal distension, obesity, infection, malnutri- rometry, and early ambulation help minimize this prob- tion, and steroid therapy have all been shown to increase the lem. Pulmonary embolism is unusual with current prophylactic practices but should be considered Early Gastric Stasis in any postoperative patient with acute shortness of breath, chest pain, or unexplained fever and tachycardia. Occasionally in the hospitalized patient who is recovering from gastric surgery, the nasogastric tube “cannot be removed” because of persistent nausea and vomiting. Alternative methods of gastric intubation and alimentation Following a gastric or duodenal operation, any suture line are preferable to a major reoperation during the first 6 weeks may leak and create a potentially fatal situation. These prob- postoperatively when the inflammatory response in the sur- lems manifest by the fifth or sixth postoperative day and are gical field may be intense. Reoperation during this early associated with increasing abdominal pain, fever, distension, postoperative period is often difficult, hazardous, and usually and leukocytosis. In patients and drainage of the peritoneal cavity, decompression of the with a small gastric remnant where a Stamm gastrostomy leaking segment (e. If the initial Witzel technique), and another (distal) tube may be placed operation was laparoscopic, sometimes an adequate reopera- antegrade as a Witzel feeding jejunostomy. Reoperation should thus usually be delayed for patients with postvagotomy diarrhea respond to cholestyr- 3–6 months after the first operation unless a high-grade or amine, and in others codeine or loperamide is useful. Following ablation or resection of the pylorus, most patients have bile in the stomach on endoscopic examination along with some degree of gross or microscopic gastric inflamma- Dumping Syndrome tion (Malagelada et al. Attributing post- operative symptoms to bile reflux is therefore problematic, Clinically significant dumping occurs in 5–10 % of patients as most asymptomatic patients also have bile reflux. It is usually epigastric pain, and quantitative evidence of excess entero- due to ablation of the pylorus, but decreased gastric compli- gastric reflux. Curiously, symptoms often develop months or ance with accelerated emptying of liquids (e. Medical therapy for early dumping syndrome consists of Remedial operation eliminates the bile from the vomitus dietary management and if necessary somatostatin analog and may improve the epigastric pain, but it is quite unusual to (octreotide). Bile reflux gastritis after distal It is the rare patient with dumping symptoms who requires gastric resection may be treated by Roux-en-Y gastrojejunos- an operation. To eliminate bile reflux, the Roux results of remedial operation for dumping are variable and limb or Henley loop should be at least 45 cm long, and a unpredictable. A variety of surgical approaches have been Braun enteroenterostomy should be placed a similar distance described, none of which works consistently well. Excessively long jejunal limbs may be include simple takedown of the gastrojejunostomy if the associated with obstruction or malabsorption. Whether Roux-en-Y proximal a previous operation, the Roux or Braun operations may be duodenojejunostomy (i. The benefits of decreased acid secretion would benefit the rare patient with disabling dumping fol- following total gastric vagotomy may be outweighed by lowing pyloroplasty is unclear. The Roux operation may be associ- Diarrhea ated with an increased risk of emptying problems compared to the other two options, but controlled data are lacking. Truncal vagotomy is associated with clinically significant Primary bile reflux gastritis (i. It occurs soon after operation is rare and may be treated with duodenal switch operation, and is usually not associated with other symptoms, a fact that essentially an end-to-end Roux-en-Y to the proximal duo- helps distinguish it from dumping (see above). The Achilles’ heel of this operation is, not surpris- may be a daily occurrence or it may be more sporadic and ingly, marginal ulceration. Possible mechanisms include intestinal dys- with proximal gastric vagotomy and/or chronic acid motility and accelerated transit, bile acid malabsorption, suppressive medication. Gastric stasis following operation on the stomach may be due to gastric motor dysfunction or mechanical obstruction (Speicher et al. The gas- Metabolic Problems tric motility abnormality may have been preexistent and unrecognized by the operating surgeon. Weight loss is common in patients who have be secondary to deliberate or unintentional vagotomy or undergone vagotomy or gastric resection (or both) (Harju 1990). An obstruction The degree of weight loss tends to parallel the magnitude of the may be mechanical (e. It may be insignificant in the large person or devastat- ulcer, efferent limb kink from adhesions or constricting ing in the asthenic female patient. The surgeon should always mesocolon, or a proximal small bowel obstruction) or func- reconsider before performing a gastric resection for benign dis- tional (e. The causes of weight loss after gastric situation is referred to as the Roux syndrome (Schirmer surgery generally fall into one of two categories: altered dietary 1994; Vogel and Woodward 1989). If a stain for fecal fat is negative, it is Gastric stasis presents with vomiting (often of undigested likely that decreased caloric intake is the problem. Consultation with an experi- medical treatment is successful in most cases of motor dys- enced dietitian may prove invaluable. Iron absorption takes place primarily in the prox- dietary modification and promotility agents. Intermittent oral imal gastrointestinal tract and is facilitated by an acidic envi- antibiotic therapy may be helpful for treating bacterial over- ronment. Intrinsic factor, essential for the enteric absorption growth with its attendant symptoms of bloating, flatulence, of vitamin B12, is produced by the parietal cells of the stom- and diarrhea. Vitamin B12 bioavailability is also facilitated by an Gastroparesis following vagotomy and drainage may be acidic environment. Leafy vegetables, a rich source of folate, treated with subtotal (75 %) gastrectomy. Thus, patients mosis with Braun enteroenterostomy may be preferable to who have had a gastric operation are at risk for anemia and Roux-en-Y reconstruction since recurrent gastric stasis should be monitored and treated appropriately.

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One should not be lulled into a false sense of security nonoperatively with success rates exceeding 90 %; only by the patient’s stable physiologic profile buy sumycin online antibiotic koi food, however cheap 250 mg sumycin overnight delivery virus wot, as rapid 17–20 % undergo splenorrhaphy. The following criteria for nonoperative manage- of contrast from the lower pole of the spleen (same patient as ment have proven safe and effective in our hands: in Fig. Imaging may be used as a criterion for moving stable patients out of critical units sooner. Follow-up imaging may also phy in patients with stable postobservation courses seem be helpful for determining which patients may return to 95 Concepts in Splenic Surgery 865 splenectomy, and heterotopic splenic autotransplantation must be in the trauma surgeon’s armamentarium. Laparoscopy for Management of Splenic Trauma Laparoscopy is another tool available to the trauma surgeon dealing with the diagnosis and management of splenic trauma. Its role in elective splenic surgery is well established, and there is interest in applying the lessons learned to select trauma cases, thereby facilitating splenic salvage while obvi- ating the need for open laparotomy. The role of diagnostic laparoscopy in the assessment of patients with penetrating thoracoabdominal trauma is well Fig. Concerns about potentially missed intraperito- neal injuries or the ability to treat discovered injuries has limited the application of diagnostic and therapeutic laparo- scopic techniques in this setting. However, multiple case reports have described successful laparoscopic splenic repair and salvage utilizing techniques of intracorporeal suture placement, application of fibrin glue, and absorbable mesh splenorrhaphy, and this role may continue to expand. Inadequate dissection of accessory spleens and splenosis with laparoscopic splenectomy: a shortcom- ing of the laparoscopic approach in hematologic approach in hema- tologic diseases. Autologous splenic transplantation for splenic In summary, recognition of the pivotal role of the spleen in trauma. Splenectomy con- computed tomography-diagnosed splenic injuries: utilization of tinues to be associated with an increased need for transfusion angiography for triage and embolization for hemostasis. Non-operative management and both blunt injuries and select penetrating injuries has become immune function after splenic injury. Splenectomy may be indicated for Consult with an experienced hematologist concerning blood patients with hereditary anemias (spherocytosis, ellipto- coagulation factors in the patient and arrange for careful cytosis, nonspherocytic hemolytic anemia), primary cross matching of an adequate quantity of blood. Patients with autoimmune hemolytic anemia, sec- cus, and Hemophilus influenzae at least 2 weeks prior to ondary hypersplenism, thalassemia, myelofibrosis, surgery. Because the specific therapy for dis- artery is a rarely used option in highly selected patients. Postoperative hemorrhage Under unusual circumstances, a large number of other dis- Injuring the greater curvature of the stomach eases may be benefited by splenectomy, such as Gaucher’s Injuring the pancreas disease, sarcoidosis, Felty syndrome, Niemann-Pick’s Postoperative sepsis, especially in immunologically impaired disease, and Fanconi syndrome. Chassin Avoiding Intraoperative Hemorrhage Avoiding Trauma to the Stomach First, ensure that exposure is adequate for each step of the During the course of clamping and dividing the short gastric operation. Removing a large spleen requires a long inci- vessels, it is easy, especially when a large spleen is being sion. In either case, the injury major vessel to avoid lacerating the splenic vein or a may result in a gastric fistula, which is a serious, life-threaten- major branch. Consequently, take care to identify clearly logic disorders, we prefer to isolate the splenic artery as each of the vessels and to achieve hemostasis and division of the first step. This frequently allows a large spleen to the short gastric vessels without damaging the stomach. In this way the ligated stumps of the brosis, have collateral veins in the normally avascular sple- short gastric vessels and any possibly traumatized gastric nophrenic and splenorenal ligaments. Preventing Postoperative Hemorrhage At the conclusion of the splenectomy, it is important to Preventing Postoperative Sepsis achieve complete hemostasis in the bed of the spleen, espe- cially along the tail of the pancreas, the left adrenal gland, Prevent subphrenic abscess by achieving good hemostasis and the posterior abdominal wall. We believe that points can be controlled by electrocautery; others require the use of prophylactic antibiotics administered intrave- clamping. Bleeding from the tail of the pancreas almost nously at the induction of anesthesia and repeated at inter- always necessitates insertion of fine suture-ligatures on vals for the next 24 h is an important means to help prevent atraumatic needles because the blood vessels tend to retract this complication. If there is diffuse oozing due to ger that the stomach or colon may be entered during a diffi- thrombocytopenia or other coagulation deficiencies, cult dissection. Routine drainage of the splenic bed appears administer platelets, fresh frozen plasma, and other coagu- to increase the incidence of postoperative subphrenic lation factors as needed after removing the spleen. Selective use of closed-suction drainage in patients continue to observe the operative site until the bleeding with pancreatic injury may be appropriate. Do not simply insert a few drains and close the drain within 5 days appears to lower the risk of infection. Accessory Spleen Accessory spleens are common and, if overlooked, may in Avoiding Pancreatic Injury time impair the therapeutic effect of a splenectomy. The greatest risk of injuring the tail of the pancreas occurs The most common location of accessory spleen is in the when the splenic blood supply is being ligated and divided at hilus of the spleen and the gastrosplenic, splenocolic, and the hilus of the spleen. Also search the perirenal area, the tail tail of the pancreas and individually ligating vessels rather of the pancreas, the small bowel mesentery, and the presacral than masses of tissue. If each clamp contains only a blood region for accessory spleens, although these locations are vessel and not other tissue, the pancreas is not crushed by a less commonly the site of an accessory spleen than is the area large hemostat or inadvertently transected. In some cases the subcostal incision may be improved by a Kehr extension up the middle to the xiphocostal junction, as illus- trated in Fig. A long midline incision may be preferable in patients with marked splenomegaly, especially if the patient has a narrow costal arch. To provide adequate exposure, a midline incision must extend a considerable distance below the umbi- licus. Apply a Thompson retractor to elevate the left costal margin and to draw it in a cephalad and lateral direction. Ligating the Splenic Artery Incise the avascular portion of the gastrohepatic ligament along the middle of the lesser curvature portion of the stom- ach and elevate the stomach to expose the upper border of the pancreas. Palpate the splenic artery as it courses along the upper border of the pancreas toward the spleen. Temporarily occlude this artery with a vascular clamp or by double-encircling it with a Silastic loop or a narrow umbilical tape fixed in place with a small hemostat. In most cases approach the splenic artery by opening the gastrocolic omentum outside the gastroepiploic arcade, applying clamps, and dividing and ligating the gastroepi- ploic vessel (Fig. Identify the splenic artery by pal- pating along the superior border of the pancreatic body or tail. Open the peritoneum over the artery and encircle the artery with a 2-0 silk ligature (Fig. Sometimes identifying the splenic artery requires division of the lower short gastric vessels. If this step has not already been accomplished, identify, clamp, divide, and ligate these Fig. If the upper short gastric vessel is not long enough to be divided easily at this time, delay it until the spleen has been completely mobilized. Mobilizing the Spleen With the left hand, retract the spleen in a medial direction to expose the splenophrenic and splenorenal ligaments, which are generally avascular. Only in the presence of portal hypertension is it necessary to ligate a number of bleeding vessels in these ligaments. Insert the left index fin- ger behind the incised splenorenal ligament and continue the incision by both sharp and blunt dissection until the spleen has been freed from the capsule of Gerota and the diaphragm (Figs.

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A trial of therapy may be initiated at this point and will assist in the diagnosis purchase 250 mg sumycin virus or bacterial infection. Other tests that may be done include a gonococcal antibody titer and a coagulation profile discount sumycin online visa bacterial transformation. If there is a urethral discharge, a smear and culture of the material should be made. If there is fever, febrile agglutinins, serologic tests for Lyme disease, brucellin antibody titer, blood cultures, and a Monospot test may be done. The presence of joint swelling without pain, especially on motion, would suggest Charcot’s disease. Involvement of the small joints is characteristic of rheumatoid arthritis, gonococcal arthritis, and Reiter’s syndrome. Involvement of the larger joints is more characteristic of gout and osteoarthritis. Asymmetrical involvement is more typical of gout, rheumatic fever, hemophilia, neoplasm, septic arthritis, and trauma. Symmetrical involvement is more characteristic of rheumatoid arthritis and osteoarthritis. The presence of fever should make one think of rheumatic fever, gonococcal arthritis or other types of septic arthritis, Reiter’s syndrome, rheumatoid arthritis, and lupus erythematosus. The younger patients with joint swelling most likely have gonococcal arthritis, lupus erythematosus, rheumatoid arthritis, and hemophilia. A synovial fluid analysis and culture may be done, if there is sufficient joint fluid. A trial of therapy can be initiated and may be diagnostic particularly in gonococcal arthritis. At this point, it is wise to refer the patient to a rheumatologist for further evaluation. Transient knee pain may be because of rheumatic fever, sarcoidosis, palindromic rheumatism, or trauma. Unilateral knee pain would suggest gout, septic arthritis, bursitis, hemophilia, pseudogout, osteogenic sarcoma, and traumatic conditions, such as torn meniscus, hemarthrosis, sprain of collateral ligaments, and fracture. Iliotibial band syndrome, compartment syndrome, and patellofemoral syndrome are important to consider in athletes, especially gymnasts and ballet artists. If there are prominent systemic symptoms, one should consider lupus erythematosus, Reiter’s disease, rheumatoid arthritis, other collagen disease, scurvy, and rheumatic fever. Younger patients are more likely to have traumatic conditions, such as fracture, sprains, bruises, or a torn meniscus. Patients in their 20s are more likely to have rheumatoid arthritis, Reiter’s disease, and lupus erythematosus, whereas patients in the fourth or fifth decade and older would be more likely to have osteoarthritis, gout, and pseudogout. An x-ray may show a fracture, osteoarthritic changes, and punched-out lesion of gout or chondrocalcinosis (suggesting pseudogout). Synovial fluid analysis and culture may be done, if there is sufficient joint fluid. He/she may want to do an arthroscopic examination before proceeding with other tests for arthritic conditions. Unilateral knee swelling is most likely because of trauma, gout, pseudogout, hemophilia, septic arthritis, tuberculosis, osteogenic sarcoma, torn meniscus, or osteomyelitis. Bilateral swelling of the knee is more commonly seen in osteoarthritis, lupus erythematosus, Reiter’s disease, and rheumatoid arthritis. The presence of fever suggests septic arthritis, rheumatic fever, rheumatoid arthritis, osteomyelitis, lupus erythematosus, and Reiter’s disease. Systemic symptoms suggest lupus erythematosus, rheumatoid arthritis, and Reiter’s disease, as well as rheumatic fever. Knee swelling in younger patients is more likely to be because of rheumatic fever, septic arthritis, lupus erythematosus, Reiter’s disease, and rheumatoid arthritis. Older patients are more likely to be affected with gout, pseudogout, and osteoarthritis. Osteogenic sarcoma seems to occur between the ages of 5 and 25 years in most cases. If there is significant swelling, an arthrocentesis for synovial fluid should be done and the fluid analyzed and cultured. A therapeutic trial may be initiated at this point and can assist in the diagnosis. Additional diagnostic tests to order in cases of knee swelling may be found on page 310. A history of cough would suggest tuberculosis of the spine, emphysema, and metastatic carcinoma. If the patient is a woman in her 40s, menopausal osteoporosis should be suspected. Children are more likely to have kyphosis because of rickets, leukopolysaccharidosis, Hurler’s disease, Scheuermann’s disease, Pott’s disease, or Morquio’s disease. Adults are more likely to suffer from osteoarthritis, Paget’s disease, Parkinson’s disease, osteomalacia, osteoporosis, and ankylosing spondylitis. If positive, a lung scan separates pulmonary infarction from the other conditions in this group. Presence of poor peripheral pulses suggests arteriosclerosis, diabetes mellitus, Buerger’s disease, and femoral artery thrombosis. Neurologic disorders associated with leg ulceration include tabes dorsalis, diabetic neuropathy, hemiplegia, and many other disorders. A positive smear or culture of material from the ulcer may be found in osteomyelitis, tuberculosis, syphilis, anthrax, and other fungal diseases. Ultrasonography, catheter arteriography or venography may establish the level of arterial or venous obstruction. This would suggest a viral infection, infectious mononucleosis, or lymphatic leukemia. Obviously, in this situation one should consider a monocytic leukemia, but severe infections can also present this picture. If there is a massive splenic enlargement, the possibility of myeloid metaplasia or chronic myelogenous leukemia must be considered. Cultures should be taken of all body fluids and an unspun drop of urine looked at under the microscope. A sedimentation rate, chemistry panel, blood and bone marrow smear examination, serial blood cultures, blood smears for malarial parasites, and Monospot test, all have their place in the workup, but a hematology consult is wise before undertaking more expensive tests. If so, this suggests hypersplenism, aplastic anemia, aleukemic leukemia, myelophthisic anemia, megaloblastic anemia, or paroxysmal nocturnal hemoglobinuria. If not, one should look for a viral infection, agranulocytosis, or idiopathic leucopenia. An enlarged spleen should suggest hypersplenism of various causes, even though it may be associated with the other disorders listed above on occasion.

In case of chronic pulmonary embolism buy sumycin with amex antimicrobial zeolite, selected patients can be well managed successfully by embolectomy discount sumycin 500 mg mastercard antibiotic expiration. In many such cases there is marked reduction in pulmonary function associated with occlusion of more than half the pulmonary arterial bed producing pulmonary hypertension. When the valves of these perforators become incompentent, they become dilated and produce localized dilatations at their junctions with the superficial vein which can be detected both by inspection and palpation. Defects in the deep fascia through which these dilated perforators pass may also be palpated. When these perforators become incompetent, high ambulatory venous pressure developing within the deep veins of the calf during exercise is directly transmitted through these perforators to the superficial venous system. Ultimately there is a sustained rise in capillary pressure in the surrounding skin with the development of oedema, induration, fat necrosis and ulceration. Following thrombosis, major deep veins may become patent by recanalization, however the delicate valves will remain imprisoned laterally in organised thrombosis. The result is the patent and valveless deep venous system which transmits the gravitational pressure of the blood column unimpeded from the level of the heart to the ankles. This is the main predisposing feature in the pathophysiology of the chronic venous insufficiency, (ii) Occasionally the congenital or familial causes of varicosities may also cause deep vein abnormalities. It must occur with incompetent perforators through which the high deep venous pressure in the ambulatory state is transmitted to the superficial tissues. These perforators may have been involved in the initial thrombosis or may become incompetent by dilatation resulting from the back pressure of the valveless deep venous system. Fibrinogen escapes through large pores in the venules of the skin of chronic venous insufficient lower limb. This fibrin accumulation acts as a barrier to diffusion of oxygen and other nutrients. As a result of this the subcutaneous tissue becomes thick, hard and tender, known as liposclerosis. These changes alongwith stasis dermatitis which produces brawny oedema, cutaneous atrophy and pigmentation ultimately lead to tissue death and ulceration. There may be associated varicose veins, but this condition is mainly due to deep vein abnormalities and incompetent perforators. All these are usually seen on the medial aspect of the leg just above the ankle posterior and superior to the medial malleolus. The venous ulcers are characteristically shallow with surrounding rims of bluish discolouration and erythema. Indications for this operation are — (i) severe varicosities, (ii) moderate to severe symptoms of varicosities and (iii) presence of venous ulcers even with aggressive conservative management. It is particularly effective if performed before the patient has developed an ulcer. Longitudinal incision is made 1 cm behind and parallel to the posterior subcutaneous tibial border. The margins of deep fascia are now elevated and the perforators are ligated flush to the deep fascia and then divided. For iliofemoral occlusion the contralateral saphenous vein is passed suprapubically and anastomosed to the affected side. For femoropopliteal occlusion, the obstructed segment can be by-passed by anastomosis of saphenous vein to the popliteal- tibial trunk at the level of the knee. Gradually brawny oedema appears distally due to coagulation of lymph within the lymphatics. Acute lymphangitis is more frequently caused by Haemolytic Streptococci, though it can also occur due to Staphylococcal infections. When infection occurs in the distal limb with organisms mentioned above, such infection spreads through the lymphatics to the regional lymph nodes. This is often associated with enlarged and tender regional lymph nodes which indicate their involvement. Since beta-haemolytic streptococci are the common infecting organisms, penicillin is the antibiotic of choice, unless culture and sensitivity tests approve other antibiotic. Incision is almost always contraindicated unless there is definite signs of purulent accumulation e. The clinical importance of this condition lies in the fact that acquired lymphoedema may be precipitated due to this condition. These tumours are often seen in the area of the jugular buds in the neck, though these are also seen in the axilla, shoulder and groin. Localized cluster of dilated lymph sacs in the skin and subcutaneous tissue which cannot connect into the normal lymph system grows into lymphangioma or benign neoplasm of lymphatics. These are typically seen on the innerside of the thigh, on the shoulder or in the axilla. Lymphangiography reveals that the lesion is separate from the main lymphatic system. Treatment is excision, when lymphangiography confirms that the lesion is separate from the main lymphatic. These are often found in the face, mouth, lips (causing enormous enlargement of the lips or macrocheilia) and in the tongue (a common cause of macroglossia). Remaining 5% are found scattered in different parts of the body — in the mediastinum, groin, pelvis and even retroperitoneum. Peculiarly a few cervical cystic hygromata may have mediastinal extension extending as far as the diaphragm. In the depth the locules are quite big and towards the surface the locules become smaller and smaller in size. The swelling is mainly painless, though occasionally it may be painful when it becomes infected. Regional lymph nodes usually do not enlarge until and unless the lesion gets infected. In the neck the lesion is removed under general endotracheal anaesthesia using transverse incision. The cyst wall often lies close to the carotid artery, jugular vein, vagus nerve and brachial plexus. It must be remembered that the excision must be complete to avoid any chance of recurrence. This lesion is a developmental anomaly and is not a malignant tumour, so this condition is rarely associated with recurrence. But as for all cysts, if cyst wall is left behind fluid may reaccumulate to cause reappearance of the swelling. That is why macroscopically identifiable cystic wall should be dissected away to prevent recurrence. Kinmoth described sclerosing treatment for this lesion in adults with apparent satisfactory result.