胰腺结核诊治一例报告

病例:男,30岁。因间断性上腹部不适6个月入院。当时无咳嗽、发烧、黄疸、恶心、呕吐、腹泻和黑便等症状,入院前2个月出现不明原因低热,体温37．5～37．8℃,食欲减退伴体重下降5kg,无盗汗,既往无结核病史及结核病人接触史,无肿瘤家属史。查体:无阳性体征。超声检查:胰头颈部低回声约5．2cm×5．3cm大小,肝门部、腹主动脉周围可见多个回声不均匀减低区,互相融合;肝内外胆管、胰管未见扩张。     

Pancreatic tuberculosis: still a histopathological diagnosis

BACKGROUND: Pancreatic tuberculosis is usually unsuspected as it can present in various forms. Though an uncommon disease, once diagnosed it is potentially curable. PATIENTS AND METHODS: Retrospective review of the records of 9 patients with histologically proven tuberculosis of the pancreas. RESULTS: In none of the 9 patients was a preoperative diagnosis of tuberculosis possible. The diagnoses considered included: pancreatic cancer (n = 5); acute pseudocyst (n = 1); pancreatic abscess (n = 1); chronic pancreatitis with pancreatic head mass (n = 1), and carcinoma of the colon causing massive lower gastrointestinal bleeding (n = 1). All the patients underwent surgery. The diagnosis of tuberculosis was confirmed by histopathological examination of biopsy specimens obtained at the time of laparotomy. One patient died, the remaining patients received antitubercular therapy and are doing well at a median follow-up period of 26 months. CONCLUSION: In view of the nonspecific and variable clinical presentation and atypical radiological signs, a clinical diagnosis of pancreatic tuberculosis is usually not possible. Therefore there should be a high index of suspicion for this disease in young patients residing in endemic areas. Our experience highlights the importance of performing biopsy in apparently inoperable pancreatic mass lesions.     

Pancreatic tuberculosis

A 63-year-old Japanese man visited our institute with fever of unknown origin. Findings on preoperative imaging modalities were consistent with pancreatic carcinoma, but a positive tuberculin skin test indicated tuberculosis infection. Negative results for MycobacteriumDNA polymerase chain reaction from sputum and bone-marrow aspiration biopsy specimens ruled out pulmonary and miliary tuberculosis, respectively. Positron emission tomography (PET) with 2-[fluorine-18]-fluoro-2-deoxy- d-glucose (FDG) showed multiple labeled spots within the pancreas body and chest. Distal pancreatectomy was performed with a diagnosis of suspected pancreatic carcinoma, but the histological and microbiological diagnosis was Mycobacterium infection. A rare case of pancreatic tuberculosis evaluated by FDG PET is reported and discussed herein.     

Chronic dissecting aorta aneurysm: a medical or surgical disease?

The surgical results obtained in 40 cases of chronic dissecting aorta aneurysm are reported and compared with the results obtained in medically treated cases. Improved results with improved surgical techniques are described and the superiority of surgical treatment as opposed to medical treatment is stressed. Although mortality is decreasing, it is still very high and many surgical problems remain unsolved.     

Pancreatic carcinoma: surgical treatment

There is controversy in the literature over the surgical treatment of pancreatic carcinoma, especially whether gastro-enterostomy should be performed prophylactically when palliative biliary bypass is done. The authors report a retrospective study of 184 patients with pancreatic carcinoma treated at the H?tel-Dieu Hospital in Montreal between 1970 and 1982. Of these, 106 patients had cancer of the head of the pancreas. In this group, 15 had a Whipple procedure. Median survival was 512 days with no 5-year survivors. Forty-nine patients had biliary bypass alone and 3 needed gastroenterostomy later for duodenal obstruction. Eleven patients had both biliary--enteric bypass and gastroenterostomy. Biliary bypass using the common duct gives the same result as that using the gallbladder. Considering their reoperation rate of only 7.3%, the authors do not believe that prophylactic gastroenterostomy is indicated in these patients.     

Peritoneal tuberculosis in a 15-month-old male: surgical diagnosis of an insidious disease

BACKGROUND: Peritoneal involvement is a relatively rare complication of tuberculosis, accounting for approximately 3.3% of extrapulmonary disease in the United States. Clinical diagnosis relies on a preponderance of indirect evidence and is often delayed. We describe such a patient. METHODS: An otherwise healthy 15-month-old male presented with fever, abdominal distention, vague abdominal pains, and a few episodes of watery diarrhea. Standard laboratory and radiologic work-up was unrevealing, and after a prolonged hospitalization, caseating granulomas were identified at diagnostic laparotomy. RESULTS: Definitive treatment was further delayed pending culture results, and the patient's condition worsened until fulminant cardiovascular collapse led to his demise. CONCLUSIONS: Despite effective chemotherapeutic regimens, the overall mortality of tuberculous peritonitis may be as high as 51%. The diagnosis must be considered and empiric antituberculous treatment started early in the course of the disease, even if definitive diagnosis is still pending.     

Left main-stem coronary artery disease: surgical versus medical management

The survival of surgically and medically treated patients with left main-stem coronary artery stenosis has been analysed in detail. From 1978 to 1981, 85 patients with stenosis of the left main coronary artery greater than 50% were divided into two groups; 47 were treated surgically and 38 medically. Left ventricular function, previous myocardial infarction, associated right coronary artery occlusion and extent of the left main coronary artery disease were analysed using the chi 2 and independent Student's t-tests. These important variables were comparable in both groups. Severity of angina in the two groups both pre- and postmanagement were compared using the chi 2 test and Stuart-Maxwell test. These showed that the majority of surgically treated patients improved markedly as compared with the medically treated group. Survival was examined using the Kaplan-Meier product limit estimate. The difference between the survival curves was statistically significant (p less than 0.005, generalized Wilcoxon and Savage tests), with the surgical group having the more favourable outcome. One-year and 2-year survival for the surgically treated group was 97.8% and 91.3%, compared with 79.9% and 74.9% for the medically treated group.     

Peyronie's disease: etiology, medical, and surgical therapy

Peyronie's disease remains an enigma. With the recent introduction of an animal model for Peyronie's disease, the entry of a number of double-blind placebo-controlled clinical trials, and the application of new molecular diagnostic methods, the investigation of this wound-healing disorder of the penile tunica albuginea should illuminate many of the unknowns. Investigators need to be open to innovations in other fields of medicine involving idiopathic fibrosing conditions in other organ systems, eg, Dupuytren's contracture, keloids, hypertrophic scarring, etc. Applications from these other disciplines will undoubtedly widen our scope about Peyronie's disease. While a minority of patients respond with observation alone, most authorities recommend at least a trial of medical therapy with a safe, inexpensive, and well-tolerated agent, as early-stage disease is reputedly more likely to respond better than patients with established, longstanding Peyronie's plaques. The reintroduction of intralesional therapies (verapamil and interferon alpha-2b) provides the clinician with an alternative minimally invasive intervention that has promising possibilities. In severe fibrotic or calcified plaques or with major structural abnormalities, the judicious use of surgery with or without grafting materials and a penile prosthesis can restore many men back to their previous level of high esteem and provide both partners an excellent quality of life.     

胰腺结核11例临床分析

目的 加强对胰腺结核的认识,提高正确诊断率,使其得到合理治疗。方法 回顾性分析我院在１９８４～１９９４年收治的胰腺结核１１例。结果 本组胰腺结核临床表现：发热 ６例、腹痛７例、腹部包块３例,黄疸２例、盗汁３例、体重下降５例等。根据临床表现确定诊断１例;经Ｂ型超声引导细针穿刺细胞学检查确定诊断１例;其余９全行开腹探查,由穿刺或术中病理学检查确定诊断。全部病例接受抗结核治疗。得到随访９例,随访２～１０     

Ethical dilemmas for pediatric surgical patients

Anesthesiologists are confronted with interesting and sometimes difficult ethical situations in pediatric surgery. They are forced to deal with everything from "do not resuscitate" issues, heroic last-chance surgical efforts, religious and cultural conflicts, disputes among colleagues, and situations that are, at worst, uncomfortable and, at best, miscarriages of duty. It is incumbent on anesthesiologists to learn how to logically and appropriately handle these issues. The pediatric surgical patient requires special consideration in bioethics. This article discusses the principle of autonomy and its ascension in importance in bioethics. The concepts of informed parental permission, assent, and dissent are presented. The authors provide a framework for ethical problem-solving, as well as a discussion of judicial decision-making. In addition, several examples of clinical-ethical situations and the processes used for resolutions are discussed. By using a well-reasoned ethical decision-making process, any situation, from the simple conflict to the most serious resuscitation and withdrawal of care issues, may be appropriately resolved.     

Gestational macromastia: a medical and surgical challenge

Gestational macromastia is a rare and complex disorder. Establishing an optimal medical and surgical management regimen has been challenging. Medical regimens have included tamoxifen, progesterone, bromocriptine, and testosterone. Surgical therapies have included reduction mammaplasty and mastectomy. This report will highlight the successful medical and surgical management in a woman with severe gestational macromastia.     

Neural arch tuberculosis: a morbid disease

Summary We have reviewed the clinical features, together with the radiographs and computerised tomography, in 9 patients with tuberculosis of the vertebral body and neural arch. All presented with paraparesis or paraplegia. The morbidity associated with this disease is so serious that it is essential to have an accurate means of evaluating the lesion as early as possible. Routine radiographs can only indicate the level of the disease and the loss of disc space, but cannot define the full extent of the lesion. Computed tomography shows details of the tuberculous involvement of the neural arch, as well as the vertebral body and spinal canal; the site and extent of the soft tissue lesions can also be seen. This is essential for evaluation of the neural arch involvement which will enable the clinician to select the appropriate treatment, and so prevent neurological complications.

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Résumé La pathologie associée à l'atteinte étendue de l'arc postérieur dans la tuberculose vertébrale de l'adulte rend nécessaire de disposer de moyens précis de détecter précocement cette lésion. Notre expérience et celle d'autres auteurs montre que cela est possible grâce à l'utilisation de la tomodensitométrie (TDM). Les radiographies ordinaires du rachis permettent de préciser le niveau des lésions et l'importance de la destruction discale, mais elles ne permettent pas d'estimer l'extension à la totalité de la vertèbre. Le traitement chirurgical, lorsqu'il est nécessaire, peut être différent en cas du tuberculose vertébrale postérieure de celui que réclament les lésions corporéales. La TDM est essentielle pour préciser cette atteinte en ce qui concerne les indications thérapeutiques.

     

Multidrug-resistant pulmonary tuberculosis: surgical challenges

Multidrug-resistant tuberculosis (MDR-TB) continues to be a significant public health problem worldwide. The treatment of MDR-TB consists mainly of chemotherapy. However, surgery has been reported to be an effective adjunctive therapy in selected cases. This article discusses the scope of the problem of MDR-TB and the most accepted modern standard therapy. The indications for surgical intervention as well as an analysis of the results of this therapy are also discussed.