Pancreatic cancer: continuing diagnostic and therapeutic dilemma

Improved survival for patients with cancer of the pancreas awaits future therapeutic advances. A more immediate objective for these patients is to provide accurate diagnosis and effective palliation. Adherence to a diagnostic strategy should provide an accurate diagnosis with the least number of tests, minimizing cost to the patient in terms of both money and discomfort. Effective palliation using a variety of available techniques can and should be accomplished expeditiously in order to extend useful survival.     

Battered women: a diagnostic and therapeutic dilemma

A prospective study of women attending a surgical emergency department in an 8-month period showed that 117 (9%) had been battered. Offered in-patient treatment was accepted and completed by 58 women (the index group), while 59 declined or did not complete treatment (the drop-out group). Both groups were compared with age-matched controls. In the battered group there were more foreign-born women and more divorces than in the control group. The drop-out group differed from the index group either in being less severely injured and seeking only certification of injury for legal purposes, or in having more previous psychiatric morbidity. The consumption of somatic and psychiatric care during the preceding 10 years was significantly greater in the battered group than in the controls, probably due to the maltreatment and reluctance to report it spontaneously. Breaking of a battering pattern at an early stage requires awareness by surgeons, general practitioners and psychiatrists that recurrent injuries of unclear origin may be due to such violence.     

Renal oncocytoma: a diagnostic and therapeutic dilemma

From 1968 to 1983, 254 patients underwent an operation for presumed renal cell carcinoma. In this retrospective review the pathological diagnosis was renal oncocytoma in 11 patients (4 per cent). Renal oncocytomas were present bilaterally in 2 patients, including 1 with a coexisting renal cell carcinoma. In 2 other patients the oncocytomas were multicentric. The angiographic, computerized tomographic and sonographic findings in these patients typified renal cell carcinoma. Surgical treatment comprised radical or partial nephrectomy for unilateral and bilateral lesions, respectively. Because of the benign nature, multicentricity, possible bilaterality and absence of pathognomonic radiographic features, renal oncocytomas should be considered in the differential diagnosis of solid renal masses.     

Cervical manifestations of fibrosing mediastinitis: A diagnostic and therapeutic dilemma

Fibroinflammatory and fibrosclerosing lesions involving the head and neck outside the thyroid and orbit are exceedingly rare. We present two cases of fibroinflammatory and fibrosclerosing lesions originating in the mediastinum which extended superiorly to involve soft tissues of the neck. These cases indicate that a subset of fibroinflammatory and fibrosclerosing lesions found in the head and neck originate in the mediastinum.     

Cecal epiploic appendagitis: a diagnostic and therapeutic dilemma

Acute epiploic appendagitis (EA) is a rare and often misdiagnosed cause of acute abdominal pain. Though a benign and often self-limiting condition, EA's ability to mimic other disease processes makes it an important consideration in patients presenting with acute abdominal symptoms. Careful evaluation of abdominal CT scan findings is crucial in the accurate diagnosis of epiploic appendagitis, thus avoiding unnecessary surgical intervention. We report a case of a 29-year-old male presenting with a two day history of generalized abdominal pain. Physical exam revealed a diffusely tender abdomen with hypoactive bowel sounds. The patient had a leukocytosis of 18,000 and abdominal CT scan revealed right lower quadrant inflammatory changes suggestive of acute appendicitis. Laparoscopic exploration revealed an inflamed gangrenous structure adjacent to the ileocecal junction. Pathologic evaluation revealed tissue consistent with epiploic appendagitis. Retrospective review of the CT scan revealed a normal appearing appendiceal structure supero-lateral to the area of inflammation. The patient recovered uneventfully with resolving leukocytosis. We present a case of cecal epiploic appendagitis mimicking acute appendicitis and review the current literature on radiographic findings, diagnosis, and treatment of this often misdiagnosed condition. General surgeons should be aware of this self-limiting condition and consider this in the differential diagnosis.     

Leiomyoma of the rectum. A diagnostic and therapeutic dilemma

A case is reported of leiomyoma of rectum, a rare tumor since it is detected in 2 of 3000 rectal tumors. It occurs principally in patients between 40 and 50 years. The tumor is submucosal, is difficult to diagnose and biopsy is often valueless since it does not involve the tumor mass. The interest of the present case is that trans-rectal ultrasound imaging of the leiomyoma was performed. Differential histologic diagnosis between benign and malignant forms is a dilemma, these tumors being of slow growth with a marked tendency for recurrence and malignant degeneration. Treatment should always be surgical, with local resection if histology has excluded malignancy, followed by periodic surveillance. Radical surgery is indicated in malignant forms or for local recurrence of benign tumors.     

Head injury and intoxication: a diagnostic and therapeutic dilemma

One hundred patients admitted to a surgical clinic with a diagnosis of concussion of the brain were studied regarding the abuse of alcohol and narcotic drugs. 58% of the patients were assessed as intoxicated on admission. Psychiatric evaluation revealed a history of alcohol dependence in 43 of the patients and experience of narcotic drugs in 25. Forty-six of the patients reported recurrent defects of memory and nine suffered from epilepsy. Amnesia therefore seems to be a factor of limited diagnostic value in concussion of the brain. Because of diagnostic difficulties, in patients with alcohol intoxication a more liberal attitude towards cranial X-ray and CT-scanning will be justified. Blood ethanol determination, measurement of blood gamma glutamyl transpeptidase and the mean blood corpuscular volume are clinically important to elucidate the etiology in patients with head injury. Active rehabilitative measures should be initiated in collaboration between the surgeon, psychiatrist and social worker to prevent post-concussional syndromes.     

嗜铬细胞瘤患者围手术期处理的改进

目的：探讨提高嗜铬细胞瘤患者围手术期安全性的措施。方法：对15例嗜铬细胞瘤患者、术前采用选择性α1受体阻滞剂多沙唑嗪控释片(可多华)控制高血压；11例患者采用3D DCEMRA进行肿瘤定位；术中均采用联合高容量血液稀释(AHH)和术中患者自体血回输纠正血容量。结果：除1例持续性高血压患者需联合钙离子拮抗剂和ACEI药物降压外．其余患者血压控制均为满意；根据3D DCEMRA定位选择手术径路者均顺利完成手术；AHH联合术中自体血回输使14例患者避免了异体输血。结论：本文围手术期处理改进．可多华可明显减少药物的不良反应；采用3D DCEMRA进行肿瘤定位，可增加手术安全性；AHH联合术中自体血回输可减少医疗成本和异体输血，以及由此而引起的并发症。     

Oncocytoma of the kidney: a diagnostic and therapeutic dilemma

Renal oncocytic tumours are uncommon and controversial in both their diagnosis and therapy. The need for correct cytological diagnosis is emphasised and total nephrectomy proposed as the elective surgical treatment owing to the real possibility of malignancy and multicentric diffusion. Conservative management should be reserved for bilateral tumours or where the tumour occurs in a solitary kidney.     

Primary duodenal tumors: a diagnostic and therapeutic dilemma.

The case records of ten patients with benign, three with endocrine, and 19 with malignant duodenal tumors were reviewed. Patients with benign tumors had episodes of bleeding that were recurrent in a number of cases. The endocrine tumors were all gastrinomas; patients had ulcer diathesis associated with the Zollinger-Ellison syndrome. All malignant tumors were symptomatic, with chronic gastrointestinal blood loss or duodenal obstruction. All benign tumors were demonstrated preoperatively, but only ten of 19 malignant tumors were confirmed preoperatively. The data suggest that duodenal tumors masquerade as more common diseases and as a result, their diagnosis and treatment are delayed inordinately. Awareness of this problem is encouraged, and a more aggressive diagnostic effort in selected patients, including fiberoptic endoscopy, is suggested.     

Inflammatory pseudotumor in childhood. A diagnostic and therapeutic dilemma.

We describe a case of inflammatory pseudotumor of the lower abdomen in a young child. The urinary bladder and abdominal wall were involved, and the pseudotumor simulated a malignant sarcomatous tumor. Surgical excision was undertaken, and the outcome was favorable. This rare tumor simulates a true neoplasm both clinically and morphologically and presents a diagnostic and therapeutic dilemma. Our case and a review of the literature indicate that an effort should be made to perform a radical excision. This is considered the treatment of choice except if it requires a mutilating procedure.     

Malignant jaundice: Results of diagnostic and therapeutic endoscopy

Direct cholangiography plays an important role in the diagnosis of malignant obstructive jaundice. Endoscopic retrograde cholangiopancreatography is gradually gaining ground over percutaneous transhepatic cholangiography. Endoscopy can determine the exact location and extent of the obstruction. Typical changes of the ducts are often helpful in interpreting the causes of obstructive jaundice. Representation of the bile and pancreatic duct systems is successful in 95% of cases in the hands of an expert. Acute pancreatitis is a complication occurring in about 1% of cases. Immediate drainage can usually prevent septic complications. Endoscopic drainage is a palliative measure for inoperable patients. Compared to biliodigestive anastomoses, catheters are subject to clogging in the lessrisky, nonsurgical method. Blockage causes late cholangitis which can only be recognized and remedied by regular aftercare of the patient. Endoscopic placement of the prosthesis has an 85% rate of success. The rate of complications related to the procedure is 2%. The mortality rate is 1%.

---

Resumen La colangiografía directa mantiene un lugar importante en el diagnóstico de las ictericias obstructivas por neoplasia maligna. La colangiopancreatografía endoscópica retrógrada ha venido ganando ventaja sobre la colangiografía percutánea transhepática. La endoscopia puede determinar con exactitud la ubicación exacta y extensión de la lesión obstructiva, y ciertos cambios típicos a nivel de los canales con frecuencia proveen información clave en la interpretación de las causas. La opacificación radiológica de los sistemas canaliculares biliar y pancreático es exitosa en 95% de los casos en manos de un experto; la pancreatitis aguda ocurre como complicación en alrededor del 1% de los casos. La factibilidad de drenaje inmediato usualmente resulta en prevención de complicaciones sépticas. El tratamiento por drenaje endoscópico es una medida paliativa en pacientes inoperables. En contraste con las anastomosis biliodigestivas, los catéteres de drenaje utilizados en este método no operatorio y menos riesgoso, son susceptibles de obstrucción, y la obstrucción causa colangitis tardía que sólo puede ser reconocida y tratada mediante manejo de seguimiento regular del paciente. La implantation endoscópica de las prótesis tiene una tasa de éxito de 85%; la tasa de complicaciones del procedimiento es de 2% y la mortalidad de 1%.

---

Résumé La cholangiographie directe joue un rôle important dans le diagnostic de maladie maligne ictérique. La cholangiopancréatographie rétrograde endoscopique remplace peu à peu l'échographie. La cholangiographie peut déterminer avec précision la localisation et l'étendue de l'obstruction. Des images typiques sont parfois des indications de l'étiologie. L'arborisation des voies biliaires et pancréatiques est visualisée dans 95% des cas dans des mains expertes. La pancréatite aiguë complique l'évolution dans environ 1% des cas. Un drainage immédiat prévient en général les complications septiques. Le drainage par voie endoscopique est une solution palliative chez le patient inopérable. Comparées aux anastomoses biliodigestives, les prothèses se bouchent parfois; la méthode chirurgicale comporte moins de risques. L'obstruction de la prothèse provoque une angiocholite qui est prévenue et reconnue grâce à la surveillance régulière après la pose. La pose de prothèse par voie endoscopique réussit dans 85% des cas. Le taux de complications est de 2%. Le taux de mortalité est de 1%.

     

Recurrent "spontaneous" pneumoperitoneum: a diagnostic and therapeutic dilemma

The finding of intraperitoneal free gas usually indicates a perforated abdominal viscus, and requires emergency surgery. In a minority of cases, no perforation can be found, a situation that can be classified as "spontaneous" pneumoperitoneum. A conservative approach may be considered if clinical signs are minimal, particularly when peritoneal signs, fever and leucocytosis are absent. The various causes of spontaneous pneumoperitoneum are discussed.     

A diagnostic and therapeutic dilemma: an unusual complication of a coronary artery bypass surgery

We report a diagnostic and therapeutic challenge involving an unusual coronary artery bypass complication. This is the first report of extensive systemic-pulmonary shunts involving the left internal mammary artery, lateral thoracic and intercostal arteries following coronary artery bypass surgery. Although internal mammary to pulmonary arterial fistula are uncommon complications of coronary artery bypass surgery, clinicians should keep this in mind in managing patients with unexplained exertional dypsnea, especially with prior history of intrathoracic inflammation, mediastinitis, and disruption of the pleura. We also discuss various therapeutic approaches including surgical and percutaneous interventions.