Corticotroph microadenomas of the pituitary stalk. Diagnostic and therapeutic difficulties

Thirteen percent of the pituitary adenomas in our series have been corticotroph adenomas. Most have been microadenomas located in the adenohypophysis, more often laterally than posteromedially. In a few rare cases, the corticotroph cells of the pars tuberalis gave rise to an adenoma. Only 16 cases of pituitary stalk adenomas have been published to date. We report here three new cases among a series of 150 patients who underwent surgery for corticotroph adenomas (2% incidence as in the literature). There was no difference in the clinical or biological presentation of intrasellar and pituitary stalk adenomas. This location must be systematically searched on the MRI, but a negative exploration cannot excluded the diagnosis of pituitary stalk adenoma like in intrasellar ones. Two anatomical entities seems to be separated. Some stalk adenomas developed preferentially in the supradiaphragmatic space (one in our series) and are accessible for selective resection. Others develop within the pituitary stalk itself and sometimes in the pars distalis (two patients in our series) which requires section of the pituitary stalk with hypophysectomy if the lower limit is not clearly seen during surgery. The subfrontal or pterional access is the approach of choice for suprasellar tumors. These approaches remain controversial for pituitary stalk adenomas because of the poor visibility of the pituitary stalk and the floor of the third ventricle. The transnasosphenoidal approach with extension to the sphenoidal planum and opening of the optochiasmatic cisterna appears to be the best alternative for surgical removal of these adenomas.     

Percutaneous transhepatic pancreatic vein catheterization in localization of insulinoma

Localization of pancreatic insulinomas can present considerable operative difficulty. Blind pancreatic resections are likely to miss the tumor and are associated with the concomitant morbidity and mortality of repeated explorations and resections. While arteriography is often very helpful in locating the tumor preoperatively, there are some patients in whom a tumor blush cannot be seen. The use of percutaneous transhepatic pancreatic vein sampling for radioimmune insulin assay is reviewed, with particular emphasis on its usefulness in locating a small insulinoma. The technique is readily adaptable to other endocrine-secreting tumors of the pancreas.     

Retroperitoneal pyogenic infections with uncertain etiopathogenesis. Diagnostic and therapeutic difficulties

Retroperitoneal pyogenic collections can appear in most distinct pathological situations. Establishing the topography and pathogenic route are essential steps in developing the therapeutic attitude. Diagnosis of suppurative retroperitoneal process complicating a previously attested disease is less difficult. The challenges appears in that cases with atypical, clinical picture, which presents associated pathological states (diabetes mellitus, chronic alcoholism, behavioral disturbances), as well as in primary retroperitoneal infections (psoas abscess, infected retroperitoneal tumors) or in that situations in which the patient presents toxico-septic shock on admission. A retrospective study on the patients with retroperitoneal infections admitted in our Clinic between 1996 - 2006 was carried out. We selected the cases in which preoperative etiopathogenic diagnosis was uncertain (in some situations the exact etiopathogenic route remaining unknown even postoperatively). The aim of this study is to evaluate the factors contributing to this, and how therapeutic attitude was influenced.     

Aortic paraprosthetic infection. Diagnostic and therapeutic difficulties. Apropos of a case

Despite advances in vascular surgical techniques and antimicrobial therapy, aortic graft infection remains a difficult clinical problem to manage. We report a case of secondary paraprosthetic fistula. All complementary investigations were negative and the fistula was diagnosed by laparotomy. In situ replacement of the infected graft was decided despite signs of infection. The postoperative course was complicated by septic shock, successfully treated by organism-specific antibiotic therapy. In conclusion, complementary investigations should not delay laparotomy in patients with a aortic prosthesis presenting with unexplained infection. They must be considered to be suffering from a graft infection until proven otherwise. Conditions in situ replacement of the graft appears to be possible under these.     

Genital actinomycosis. Diagnostic and therapeutic difficulties. Report of three cases]

Genital actinomycosis is a rare bacterial infection affecting women of child-bearing age, which is sometimes related to the use of an IUD or an intra-vaginal pessary. Nevertheless, this relationship is at best tenous and actinomycosis is not the only bacterial infection caused by IUD use. Genital actinomycosis often occurs as a pelvic tumour which is sometimes difficult to correctly diagnose and consequently treat accordingly. Rapid diagnosis is essential in order to avoid any irreparable tissue damage. Treatment of this condition consists of a combination of antibiotics and surgery to achieve complete recovery. Three cases are described.     

Role of laparoscopic ultrasonography in intraoperative localization of pancreatic insulinoma

Background: A combination of digital palpation and ultrasonography plays an important role in locating insulinomas intraoperatively. Laparoscopic resection of insulinomas has been described recently, but experience in locating insulinomas during laparoscopy is lacking. Methods: From January 1998 to January 1999, three patients with pancreatic insulinomas underwent laparoscopy and laparoscopic ultrasonography aimed at intraoperative localization and potential resection. The role of laparoscopy and laparoscopic ultrasonography in locating insulinomas is evaluated. Results: Preoperative localization studies were routinely performed, and two patients had an occult tumor before laparoscopy. None of the tumors was detected by laparoscopic examination, but laparoscopic ultrasonography identified solitary tumors located at the body and tail of the pancreas. Conversion to laparotomy was performed in one patient as a planned procedure. One patient underwent laparoscopic enucleation, whereas the other had a laparoscopic distal pancreatectomy. Conclusions: Laparoscopic ultrasonography seems to be sensitive in locating insulinomas at the body and tail of the pancreas. It optimizes and facilitates resection of insulinomas through a minimally invasive approach. Received: 8 March 1999/Accepted: 10 August 1999/Online publication: 7 September 2000     

Diagnostic difficulties in the differentiation of pancreatic pseudocyst and cystic pancreatic neoplasm

Cystic tumours of the pancreas are rare and may be difficult to differentiate from pseudocysts, especially when the lesion is discovered after abdominal trauma. The case of a 48‐year‐old woman who developed a cystic lesion of the pancreas 4 months after blunt abdominal trauma is reported. Whilst the lesion had diagnostic features consistent with pseudocyst, the final diagnosis of benign mucinous cystadenoma was established only after radical resection 27 months later. The possible role of trauma in its aetiology is discussed.      

Diagnostic and therapeutic difficulties of leucoplakia of the renal pelvis

2 cases of leucoplakia of the renal pelvis are reported. In the first one the diagnosis was established after nephrectomy and histological examination of the specimen. In the second one it was suspected on urine examination and was confirmed on histology. The current aspects about its cause and the difficulties concerning its diagnosis and treatment are discussed.     

Small intestinal hemorrhage due to rare etiology. Diagnostic difficulties and therapeutic approaches

Understanding of the pathogenesis, diagnosis, and treatment of lower GI bleeding has drastically changed during the last 50 years, but it continues to be a frequent cause of hospital admission and also a factor in hospital morbidity and mortality. Acute lower gastrointestinal hemorrhage (ALGIH) represents only 20% of the GI bleeding and the small intestine is the site of hemorrhage in about 1% of cases. Although in the last four decades, diagnostic methods for locating the precise bleeding point improved greatly, still the adequate localization of the lesion is very difficult to achieve through algorithmic approaches. We performed a clinical study and we retrospectively analyzed 5 patients (mean age = 59,8 years, 1 female) who had a surgical intervention for acute lower GI hemorrhage in the last decade, in order to emphasize diagnosis difficulties when the bleeding arises from small lesions in the small bowel that is not easily accessible for direct visualisation. Surgery was the treatment of choice in every case consisting in segmental resections of the involved small bowel, along with viscerolysis and exploratory gastro-jejunostoma. The mortality rate was 20% (1 postoperative death of cardiac etiology). There have been no specific postoperative complications in the other four patients and a good outcome was reported. The diagnosis is particularly difficult and when colonic and upper gastrointestinal evaluations fail to identify a source of bleeding, a small intestinal source should be considered. We can conclude that the most important factor in the management of ALGIH is determination of specific localization of the lesion.     

评价超声造影与CT平扫加增强对胰岛细胞瘤的术前定位效果

目的比较经腹超声造影与CT平扫加增强对胰岛细胞瘤的术前定位准确性。方法回顾性分析41例胰岛细胞瘤患者(男性16例,女性25例,年龄在18～75岁,平均42.9±12.45岁)术前的超声造影、CT平扫加增强的检查结果,比较两种种检查的准确性。结果通过血液生化明确诊断为胰岛细胞瘤的41例患者38例患者进行了平扫及增强CT检查,其中22例患者的肿瘤定位准确,准确率为57.8%;34例进行了超声造影检查,其中29例患者定位准确,准确性85.3%;31例患者进行了内镜超声检查,其中25例定位准确,准确性为80.6%。统计分析表明超声造影与CT平扫加增强定位准确性存在显著差异(P<0.05)。结论与CT比较,超声造影对胰岛细胞瘤术前定位的准确性更高,在术前定位方面具有优势。     

Complicated diverticular disease of the right colon. Diagnostic and therapeutic difficulties: our experience

Right colon diverticulitis is an uncommon disease in Western countries. Often the disease is congenital and the clinical manifestations presenting at onset simulate the signs and symptoms typical of other diseases, such as acute appendicitis, appendicular abscess or caecal carcinoma. Since the diagnosis is usually intraoperative, diverticulectomy is recommended only in particular cases, with no complications resulting from inflammatory reactions. In the other cases, right hemicolectomy or segmental resection are the elective surgical treatments, depending on the patient's clinical condition and on the local anatomical situation. The authors describe 8 cases of complicated right colon diverticulitis, one of which with haemorrhagic complications, observed over the period from January 1999 to March 2003. The rareness and diagnostic and therapeutic difficulties of this disease are emphasised.     

Value of the Contrast-enhanced Ultrasonography and contrast-enhanced CT in preoperative localization of pancreatic insulinoma

目的 比较经腹超声造影与CT平扫加增强对胰岛细胞瘤的术前定位准确性.方法 回顾性分析41例胰岛细胞瘤患者(男性16例,女性25例,年龄在18 ～75岁,平均4.2.9±12.45岁)术前的超声造影、CT平扫加增强的检查结果,比较两种种检查的准确性.结果 通过血液生化明确诊断为胰岛细胞瘤的41例患者38例患者进行了平扫及增强CT检查,其中22例患者的肿瘤定位准确,准确率为57.8％;34例进行了超声造影检查,其中29例患者定位准确,准确性85.3％;31例患者进行了内镜超声检查,其中25例定位准确,准确性为80.6％.统计分析表明超声造影与CT平扫加增强定位准确性存在显著差异(P＜0.05).结论 与CT比较,超声造影对胰岛细胞瘤术前定位的准确性更高,在术前定位方面具有优势.     

Diagnostic and therapeutic aspects of fine-wire localization biopsy for impalpable breast cancer.

During the first 2 years (July 1989 to July 1991) of the Avon Breast Screening Service, fine-wire localization biopsy was indicated in 213 impalpable breast lesions. A total of 144 lesions were benign and 69 malignant. Only four of 213 lesions (1.9 per cent) were not excised at the first localization. Factors influencing reoperation in the 69 patients with malignant impalpable lesions were examined. There was a significant association (P < 0.001) between parenchymal disturbances on mammography and invasive carcinoma, and between non-invasive carcinoma and microcalcification (P < 0.001). In 31 patients the localization biopsy was the only surgical procedure. Thirty-eight patients required further surgery: 12 underwent further local excision and 26 mastectomy. Reoperation was more frequent in patients with calcification than in those with parenchymal disturbance (P < 0.001). The most frequent indications for mastectomy were inadequate excision of widespread comedo ductal carcinoma in situ or invasive ductal carcinoma combined with extensive ductal carcinoma in situ. Fine-wire localization biopsy was a combined therapeutic and diagnostic procedure in 31 of 69 women with impalpable screen-detected lesions. The majority of patients required further surgery because radiological abnormalities underestimated the extent of disease.