Management of 100 consecutive cases of pancreatic serous cystadenoma: wait for symptoms and see at imaging or vice versa?

Abstract Pancreatic serous cystadenomas have a low malignancy rate. When nonsymptomatic, in selected patients, they can be managed without surgery; however, a high degree of diagnostic reliability is crucial. We admitted 100 consecutive cases (87 women with a median age of 51.86 years). Of these, 44 were symptomatic and 56 were diagnosed incidentally. Ultrasound correctly diagnosed 53% of the cases, incorrectly 31%, and was nondiagnostic in 16%. Computed tomography scan had similar rates (54%, 34% and 12%, respectively), while magnetic resonance imaging improved diagnostic accuracy to 74% and reduced incorrect diagnoses to 26%. In 21 cases, exploratory needle aspiration of the cyst was carried out; only 8 samples (38%) resulted in a diagnosis; in 12 patients (57%) insufficient material was acquired to allow for diagnosis, one case demonstrated epithelial dysplasia. In 1 patient an exploratory puncture resulted in a very serious bleeding. Sixty-eight patients were treated surgically, the 44 symptomatic cases and another 24 patients with ill-defined oligocystic lesions that could not be differentiated as serous or mucinous in the preoperative period. Two patients underwent resection because of frank tumor growth. In the two time periods analyzed (the first 7 years and the subsequent 6.5 years) the relationship between cases observed/operated on did not significantly change. Twenty-one (30.8%) distal pancreatectomies, 14 (20.5%) intermediate resections, 10 (14.7%) pancreaticoduodenectomies 4 (5.8%) enucleations, and 1 (1.4%) duodenum-preserving pancreatic head resection were carried out. Nine patients (13.2%), underwent exploratory laparotomy with a diagnostic biopsy. Another 9 underwent decompressive interventions with cystojejunostomies. The morbidity was 27.9%, with a reoperation rate of 7.3% and zero mortality. In general the patient’s pain resolved in the postoperative period. Median follow-up was 43 months (range, 4–191 months). One patient died from other causes, and all others are currently alive. In the group of 32 patients who did not undergo operation, the median follow-up is 69 months (range, 8–164 months). Until more sophisticated technologies can be developed, the current diagnostic work-up will not result in increased preoperative diagnosis of serous-cystic tumors of the pancreas. This is mainly relevant to the oligocystic forms, which account for about one fourth of all serous tumors observed. Electronic Publication     

Liver Retransplantation for Hepatic Abscess Due to Hepatic Artery Thrombosis: A Case Report

Introduction

Hepatic artery thrombosis (HAT) is a well-recognized complication of liver transplantation (LT). HAT is an important risk factor for infectious, in particular hepatic abscess, which can cause graft loss and increasing morbidity and mortality.

Nipple-sparing mastectomy for breast cancer and risk reduction: oncologic or technical problem?

BACKGROUND: We evaluated the risks and benefits of nipple-sparing mastectomy in a multiinstitutional experience in the settings of risk-reducing surgery and breast cancer treatment. STUDY DESIGN: We analyzed data on 123 patients who had undergone nipple-sparing mastectomy with breast reconstruction for prophylaxis (n=55), treatment of breast cancer (n=41), or both (n=27) at four large centers. RESULTS: Median patient age was 45 years (range 22 to 70 years). There were 192 procedures (69 bilateral, 54 unilateral). Forty-four patients had invasive cancer; 20 had ductal carcinoma in situ (DCIS); 4 had phyllodes tumor. In all of these patients, the nipple tissue was cancer free on pathologic review. Median followup was 24.6 months (range 2.0 to 570.4 months). Local recurrence developed in two patients: one had DCIS in the upper-outer quadrant, with 71.8 months of followup; the other's cancer was invasive, in the upper-outer quadrant, with 6 months of followup. Distant metastasis developed in a third patient, who died 50 months after the procedure. Breast cancer developed in two patients after prophylactic mastectomy: one in the upper-outer quadrant at 61.8 months; one in the axillary tail at 24.4 months. No patients had recurrences in the nipple-areolar complex. Necrosis of the nipple was reported in 22 of 192 patients (11%) and it was judged minimal (less than one-third total skin of nipple) in 13 of 22 patients (59%). Overall cosmesis was judged by the patient and surgeon as good to excellent in the majority of patients. Level of satisfaction with cosmetic results was similar between prophylactic and treatment patients. CONCLUSIONS: The risk of local relapse was very low in our series of nipple-sparing mastectomies performed for DCIS or invasive cancer. Nipple-sparing mastectomy in the risk-reducing and breast cancer-treatment settings may be feasible in selected patients and should be the subject of additional prospective clinical trials.     

Distribution and hydrolytic enzyme characteristics of Candida albicans strains isolated from diabetic patients and their non-diabetic consorts

Introduction:  The aim of this study was to investigate the oral colonization profile of Candida albicans strains isolated from diabetic patients and their non-diabetic consorts. In addition hydrolytic enzyme activity of these isolates was analysed.
Methods:  The genetic diversity of C. albicans oral isolates from 52 couples was established using isoenzyme marker and cluster analysis. Hydrolytic enzyme characteristics, namely secreted aspartyl proteinases (SAPs) and phospholipases (PLs) were also analysed.
Results:  Simultaneous colonization by C. albicans was observed in the consorts of 12 couples (23.1%). Patterns of monoclonal and polyclonal oral colonization by C. albicans strains were identified and the coexistence of identical or highly related strains was observed in both members of eight couples. The genetic diversity observed in the total yeast population revealed four large, genetically distinct groups (A to D) and the coexistence of strains in couples or consorts conjugally unrelated. SAP and PL activity was observed in the majority of C. albicans isolates without any association to particular strain, strain clusters (highly related isolates), or clinical characteristics of the consorts (diabetic, non-diabetic, and gender).
Conclusion:  Possible sources of transmission and oral propagation of groups (clusters) of strains of C. albicans can occur between diabetic and non-diabetic consorts. A conjugal genotypic identity exists in most C. albicans -positive couples, that is, both consorts share identical or highly related strains; however, this identity is not couple-specific as seen by the coexistence of clusters in couples and unrelated consorts.     

挤压综合征救治原则的争议探讨

挤压伤/挤压综合征是突发性自然或人为灾害中（地震、车祸、矿难或战争）最常见的损伤,可继发严重的全身反应,致死致残率极高,救治困难。本文总结近年来国内外地震造成的挤压伤/挤压综合征的发病率、机制、治疗措施及存在问题,以期改进治疗方法与措施,提高生存率及保肢率。     

Retroperitoneal and peritoneal drainage and lavage in the treatment of severe necrotizing pancreatitis

In severe necrotizing pancreatitis, the retroperitoneum is the main site both of autodigestion and of the production of toxins. With the aim of removing necrotic tissues and active enzymes from the retroperitoneum, we developed a surgical approach based on a wide exposure of the pancreas and on the insertion of multiple drainages with postoperative irrigations with hypertonic solutions and antiproteases. We treated 191 patients, and our results correlated with the timing of the operation. The operative mortality rate ranges from 8.1 in patients undergoing our procedure within 48 hours from the onset of the disease to 28.4 per cent when the operation was delayed for more than 96 hours. Our technique is detailed and the indications as to the timing of surgical treatment in instances of pancreatitis are discussed.     

Anterior sacral meningocoele presenting as a peri-anal abscess

Anterior sacral meningoceole is a rare occurrence and presentation as a perianal abscess has not been previously reported. The case is presented and the condition discussed. The potential risks of failing to establish the diagnosis, prior to surgery, are outlined.     

Impact of endoscopic surveillance of Barrett's esophagus on survival of patients with esophageal adenocarcinoma

In an attempt to reduce mortality from oesophageal adenocarcinoma, it has been recommended to enroll patients with Barrett's oesophagus in endoscopic surveillance programs in order to detect malignant degeneration at an early and possibly curable stage. The aim of this study was to assess the impact of endoscopic biopsy surveillance on the outcome of Barrett's adenocarcinoma. From November 1992 to December 2000, 328 patients with histologically proven oesophageal adenocarcinoma were referred to our department. One hundred of these patients had Barrett's adenocarcinoma. In 12 (12%) patients, cancer was discovered during endoscopic surveillance for Barrett's metaplasia. The prevalence of gastro-oesophatgeal reflux disease in the Barrett's group was 38.8% versus 8.1% (P < 0.01) of non-Barrett's patients. In the surveyed group, there were 9 (75%) early stage tumours (Tis-1N0), versus 10 (11.4%, P < 0.01) in the non-surveyed patients. Three out of five surveyed patients operated on for high grade dysplasia proved to have invasive carcinoma in the oesophagectomy specimen. All surveyed patients were alive after a median follow-up period of 50 months; the median survival in the non-surveyed group was 24 +/- 3 months (P < 0.01). Endoscopic surveillance of Barrett's oesophagus allows early detection of malignant degeneration and better long-term survival than in non-surveyed patients.