Pancreatic Biopsy: Why? When? How?

For final diagnosis of pancreatic cancer histologic or cytologic confirmation is needed. Tissue or cell material can be achieved by percutaneous puncture as part of the preoperative workup. During operation core-needle, incisional, and wedge biopsies or fine-needle aspiration cytology (FNAC) can be chosen. Sensitivity and diagnostic accuracy are high for both histologic and cytologic examinations, and false-positive results are exceptional, giving a specificity of 100% in most published series. The complication rate is low, also for knife biopsies in recent reports, provided biopsy of seemingly normal tissue is avoided. Percutaneous puncture is currently restricted to patients found to have advanced disease and who are not candidates for laparotomy. Microscopic confirmation is required in all patients in whom chemotherapy, radiotherapy, or both are planned. However, for attempted radical surgery per se, biopsy is not mandatory if the clinical suspicion of cancer is high and the surgical team has documented low postoperative mortality and morbidity rates.     

CT colonography: Why? When? How?

Although optical colonoscopy is still the gold standard for diseases of the colon, radiologic examination of the colon is now being performed by CT scan. Evaluation of the colon is enhanced by distension, which "de-folds" the intestinal wall, thus facilitating its examination for abnormalities of the mucosa, the wall as a whole, and the diameter of the bowel lumen. Water or gas (CO(2)) may be used for the distension, depending on the suspected lesions. The water enema method of colonography combines filling the bowel lumen with water and intravenous injection of a contrast medium. It is indicated when there is a clinical suspicion of colon cancer, or for initial discovery of liver metastases, and for staging of colon tumors. This technique, which requires little or no colon cleansing preparation, can be performed with no special equipment and has a short learning curve. The gas enema method of colonography, or virtual colonoscopy, is performed by distending the colon with CO(2), without any intravenous injection of contrast medium. Its purpose is to detect polyps as part of a screening for precancerous growths. This technique, which does require bowel cleansing preparation, uses a dedicated console for reading and requires specific training.     

Split liver transplantation: where? When? How?

Donor scarcity is among the greatest concerns in the transplantation community. Dividing a liver graft theoretically offers a double benefit for candidates on the waiting list. Split liver transplantation entails a higher logistic and technical complexity that is extensively compensated, not only with an increase in the accessibility for child and adult candidates on the liver transplant waiting list, but also acceptable survival results.     

Kimmelstiel-Wilson结节形成:DN? MGRS?

正病例万某某,男,33岁,主因"浮肿反复2年,加重5个月",2018年1月12日收住入院。患者2016年7月因双下肢轻度浮肿,伴乏力、左眼视物模糊,就诊于某社区医院,查血压170/100 mm Hg、空腹血糖(FBG) 12. 9 mmol/L,诊断为"2型糖尿病"、"高血压",转诊于我院内分泌科住院治疗,入院后复查FBG19. 5 mmol/L;尿常规:PRO 150 mg/dl、GLU 1 000 mg/dl,24 h尿蛋白定量2. 85 g。入院诊断"2型糖尿病、糖尿病肾病?"、"高血压3级(极高危)",予降糖、降压、调脂、利尿等治疗,血糖、血压基本达标,水肿稍有减轻,尿蛋白未减少。出院后患者继续维持以上治疗,但未监测尿蛋白变化。2017年8月6日,     

Bile duct injury repair: when? what? who?

Laparoscopic cholecystectomy is associated with a two-to-four times higher risk of bile duct injury (BDI) than open cholecystectomy. BDI can lead to significant morbidity and even mortality. The first priority in BDI is to control peritoneal and biliary sepsis and to convert an acute BDI to a controlled external biliary fistula (EBF) — this can be achieved by endoscopic and/ or radiological intervention in most cases. This should be followed by assessment of the extent of injury — both biliary and vascular. Immediate management of BDI recognized during cholecystectomy depends on the type of injury, the condition of the patient, and the experience of the surgeon. For BDI recognized after cholecystectomy, early repair is not recommended, as the results are poor. The EBF may evolve into a benign biliary stricture (BBS), which should be electively repaired by a Roux-en-Y hepatico-jejunostomy. The use of an endoscopic stent as definitive management of BDI is not recommended. Long-term follow-up is essential after the repair of a BBS, as recurrence can occur several years after repair. Recurrent BBS is best treated with endoscopic balloon dilatation. Excellent early and long-term results can be obtained in specialized units at tertiary care referral centers.     

Pregnancy: A Contraindication?

According to David L. Sackett evidence-based medicine is the conscientious, explicit, and judicious use of current best evidence when making decisions about the care of individual patients. It means integrating individual clinical expertise with the best available external evidence from systematic research. On the basis of this idea in medicine the following communication summarizes and evaluates current statements and literature on laparoscopic surgery during pregnancy. The topic is an example for excellent individual clinical performance on one hand, as gynecologists have perform laparoscopic procedures during pregnancy for decades. On the other hand, pregnancy is considered to be a contraindication for laparoscopic surgery by clinicians, because no excellent external evidence from systematic research is available. To find an answer to the question of whether pregnancy is a contraindication for laparoscopic surgery we performed a literature search and gained information by conducting interviews with several experts in gynecology and endoscopic operations. We concluded that there are almost no “scientific” data about endoscopic surgery during pregnancy, but gynecologists representing the “real world” seem to have no fear of the procedure for their patients. Between the two extremes, performing laparoscopic operations during pregnancy might be advantageous for maximal patient-friendly surgery, but considering pregnancy as a contraindication for the laparoscopic approach might be the safer treatment. The reader may decide that the subject on endoscopic surgery in pregnancy is still open.     

Thalidomide: a comeback?

Thalidomide, a synthetic glutamic acid derivative first marketed in 1954 as a sedative, rapidly gained worldwide notoriety as a cause of phocomelia. To prevent further cases of this severe birth defect, thalidomide was removed from the market. Over the last few years, however, thalidomide has been found to exhibit properties of potential usefulness in a range of conditions. Trials are under way in rheumatic diseases, and safer analogs have been developed.     

Priapism: ecstasy related?

Priapism, an uncommon urological emergency, is commonly drug-induced. We present a previously unreported case of a young man with priapism probably related to Ecstasy.