Is Laparoscopic Resection Adequate in Patients with Neuroendocrine Pancreatic Tumors?

Since the first reports with laparoscopic resection of islet cell tumors in 1996, the experience worldwide is still limited, with only short-term outcomes available. Some have suggested that a malignant tumor is a contraindication to laparoscopic resection. Aim The aim of this study was to evaluate the feasibility, safety, and long-term outcome of the laparoscopic approach in patients with functioning, nonfunctioning, or overt malignant pancreatic neuroendocrine tumor (PNT). To our knowledge this is the largest single-institution series on this subject to date. Patients and methods A total of 49 consecutive patients (43 women, 6 men; mean age 58 years, range 22–83 years) underwent laparoscopic pancreatic surgery (LPS) from April 1998 to June 2007. Preoperative localization was done by computed tomography, magnetic resonance imaging, endoscopic ultrasonography, and Octreoscan imaging. Other than 9 PNTs localized in the head of the pancreas, all tumors were located in the left pancreas. Malignancy was diagnosed based on the presence of lymph nodes or liver metastasis. There were 33 patients with functioning tumors: 4 with gastrinomas (mean size 1.2 cm), 1 with a glucagonoma (4 cm), 3 with vipomas (3.2 cm), 2 with carcinoids (5.2 cm), 20 with sporadic insulinomas (1.4 cm), 2 with insulinoma/multiple endocrine neoplasia type 1 (MEN-1) (4.4 cm), and 1 with a malignant insulinoma (13 cm). Sixteen patients had a nonfunctioning tumor (mean size 5 cm). The following techniques were performed: laparoscopic spleen-preserving distal pancreatectomy (Lap SPDP), laparoscopic distal pancreatectomy with splenectomy (Lap SxDP) and laparoscopic enucleation (Lap En)/laparoscopic excision (Lap E). Lymph node dissection was performed when malignancy was suspected (Strasberg′s technique). Evaluation criteria included operative and postoperative factors, pathologic data including R0 or R1 resection (the pancreatic transection margin and all transection margins on the specimen were inked). Long-term outcomes were analyzed by tumor recurrence and patient survival. Results Four cases (8.2%) were converted to open surgery. Overall, Lap SPDP, Lap SxDP, and Lap En/Lap E were performed in 15 (33.3%), 8 (17.8%), and 22 (48.9%) patients, respectively. The operative time and blood loss was significantly lower in the Lap En group compared with the other laparoscopic techniques. The group of patients with malignant tumors undergoing Lap SxDP had a longer operating time and greater blood loss compared with the other distal pancreatectomy (Lap DP) techniques. Overall, the postoperative complications were significantly higher in the Lap En group (42.8%) than in the Lap DP (Lap SPDP + Lap SxDP) group (22%). These complications were mainly pancreatic fistula: 8.7% after Lap DP and 38% after Lap En. The overall morbidity was significantly higher after Lap SPDP (26.7%) than after Lap SxDP (12.5%) owing to the occurrence of splenic complications in the Lap SPDP group without splenic vessel preservation two of seven (28.5%). The means and ranges of hospital stay after Lap SPDP, Lap SxDP, and Lap En/Lap E were 5.9 (5–14), 7.5 (5–12), and 5.5 (5–7) days, respectively (NS). Pathology examination of the specimen showed R0 resection in all patients with malignant PNT. The mean time to resumption of previous activities for patients undergoing Lap DP or Lap En was 3 weeks. There were no postoperative (30 days) or hospital deaths. Conclusions This series demonstrates that LPS is feasible and safe in benign-appearing and malignant neuroendocrine pancreatic tumors (NEPTs). The benefits of minimally invasive surgery were manifest in the short hospital stay and acceptable pancreas-related complications in high-risk patients. LPS can achieve negative tangential margins in a high percentage of patients with malignant tumors. Although surgical cure is rare in malignant NEPTs, significant long-term palliation can be achieved in a large proportion of patients with an aggressive surgical approach.     

Diabetic nephropathy in children and adolescents

Type 1 diabetes mellitus (T1DM) commonly occurs in childhood or adolescence, although the rising prevalence of type 2 diabetes mellitus (T2DM) in these age groups is now being seen worldwide. Diabetic nephropathy (DN) develops in 15–20% of subjects with T1DM and in similar or higher percentage of T2DM patients, causing increased morbidity and premature mortality. Although overt DN or kidney failure caused by either type of diabetes are very uncommon during childhood or adolescence, diabetic kidney disease in susceptible patients almost certainly begins soon after disease onset and may accelerate during adolescence, leading to microalbuminuria or incipient DN. Therefore, all diabetics warrant ongoing assessment of kidney function and screening for the earliest manifestations of renal injury. Pediatric health care professionals ought to understand about risk factors, strategy for prevention, method for screening, and treatment of early DN. This review considers each form of diabetes separately, including natural history, risk factors for development, screening for early manifestations, and strategy recommended for prevention and treatment of DN in children and adolescents.     

Mesangial hypercellularity in children: presenting features and outcomes

Mesangial hypercellularity (MH), in the absence of sclerosis or immune deposition, was a common finding on renal biopsy in our center. We studied 66 children with predominant MH. Among all patients older than 2.7 years, blood pressure (BP) percentile and glomerular filtration rate (GFR) remained stable. Serum albumin (Alb) trended higher (3.0 ± 0.2 start vs. 3.4 ± 0.2 end g/dl, p = 0.06) and urine protein/creatinine lower (4.2 ± 0.9 start vs. 2.3 ± 0.9 end mg/mg, p = 0.18) at the end of the study period. The proportion with stage 1 CKD remained constant: 94% start vs. 92% end. At end, Alb was lower in patients referred for nephrotic syndrome (NS): 4.4 ± 0.3 hematuria vs. 4.2 ± 0.2 proteinuria vs. 2.8 ± 0.3 NS g/dl, p < 0.05 vs. both. Alb was lower (p = 0.03) and urine protein/creatinine trended higher in patients with diffuse foot-process fusion (FPF). Twenty-five percent of patients with focal FPF developed NS, all had relapses, and 63% were steroid sensitive (SS). All but one with diffuse FPF presented with NS; 86% had relapses (mean 1 year) and 63% were SS. GFR trended higher at the end in those with matrix thickening (mat) (119.6 ± 4.7 no mat vs. 129.1 ± 2.6 mat ml/min per 1.73 m², p = 0.1). Those without mat were less SS (59% no mat vs. 80% mat) and were more likely to require alkylating agents (Alk) for NS. Among those with positive immunofluorescence (IF), 82% had immunoglobulin M (IgM) alone; those with positive IF were more SS and needed Alk for NS. MH predicts a favorable prognosis. FPF predicts NS and multiple relapses.     

Early mechanical failure in total knee arthroplasty

Early mechanical dysfunction of a total knee arthroplasty (TKA) is a challenging problem in terms of causality and solutions. The current strategy in our department is to perform a complete TKA revision rather than the less invasive partial procedures when a clear mechanical cause of failure has been found. In this investigation, we assessed 21 patients who underwent complete TKA revision in 2003-2004 in our institution within the first two years following the index TKA. Various clinical presentations included pain, stiffness, instability, and femoro-patellar signs. These corresponded to implant size, position, and fixation issues. The IKS knee score/function significantly increased from 47/47 to 85/78 at follow-up (six months minimum). Compared to the data in the literature, this systematic full revision seems to be a reasonable approach. This attitude takes advantage of the modularity of the implants for allowing perioperative adjustments of position, fixation, and constraint. Based on the results of our study, we propose a list of six mechanical pitfalls to be evaluated in the case of early dysfunction: frontal misalignment, sagittal overstuffing or malpositioning, axial malrotation, poor bone fixation, inappropriate constraint or ligamentous balance, and inappropriate level of the joint space.     

Ureteroscopic holmium laser lithotripsy in patients with renal impairment

Objectives In this study, we try to evaluate the efficacy and safety of holmium lasers for treatment of ureteric stones in patients with renal impairment or obstructive anuria. Patients and methods Twenty-six patients were included in this study, of which 20 patients presented with elevated blood urea and serum creatinine (2.1–7.6 mg%), and six patients presented with calcular anuria (mean serum creatinine 22 mg%). None of the patients had a ureteric stent or nephrostomy tube before the ureteroscopy. All patients were treated with holmium laser. A stone basket or grasper was used to remove significant stone fragments at the end of the procedure in seven patients. In these seven patients, ureteric stents were placed at the end of the procedure. Results All patients were free of any stone fragments at 1 week and at 3 months postoperatively. In all patients, including the six with obstructive anuria, the renal impairment resolved or improved as evidenced by normalization or fall in blood urea and creatinine. Thus, in this small group of uremic patients, the success rate for treatment of ureteral stone was 100%. Conclusions A holmium laser is a safe and effective modality of ureteroscopic lithotripsy in patients with significant renal impairment or even obstructive anuria. The use of holmium laser with ureteroscopy may be considered in this group of patients as long as the general condition of the patient permits the safe administration of anesthesia.     

Endoscopic ultrasound-guided fine-needle aspiration and Trucut biopsy in thoracic lesions: When tissue is the issue

Background Endoscopic ultrasound-guided fine-needle aspiration (EUS FNA) has a high accuracy in the evaluation of mediastinal lesions. The use of a core biopsy needle for EUS guided biopsy (EUS TCB) may further improve the yield of EUS. The aims of this study are to evaluate the safety of EUS TCB in thoracic lesions and to compare the diagnostic accuracy of TCB with FNA and FNA + TCB. Methods A single-center retrospective study. All patients underwent EUS-FNA and TCB. A cytopathologist was not present during the procedure. EUS FNA, TCB and FNA + TCB diagnostic accuracy were compared. Results A total of 48 patients were included. The lesions sampled included 41 lymph nodes (six aorto-pulmonary window, 32 subcarinal, two right paratracheal, one paraesophageal ATS station 8), five lung masses, and two esophageal masses. Twenty-nine patients had malignant disease and 19 had benign disorders. The overall diagnostic accuracy of FNA, TCB and FNA + TCB was 79%, 79% and 98% respectively (p = 0.007). TCB changed the diagnosis in nine cases missed by FNA. EUS TCB was better than FNA for benign diseases (89% vs. 63%, p = 0.04). All eight patients with a prior failed biopsy had a correct diagnosis established by EUS. No patient required mediastinoscopy or thoracoscopy after EUS. Conclusion The combination of TCB and FNA is superior to FNA alone. EUS-guided TCB should be considered in patients with benign disorders of the mediastinum when other modalities fail to yield a diagnosis.     

Statistical analysis of fatal bleeding pelvic fracture patients with severe associated injuries

Background Bleeding pelvic fracture patients with severe associated injuries have a high mortality rate that is exacerbated by several factors. To gain deeper etiological insights into this injury, we investigated the specific risk factors associated with the high mortality rate. Methods A total of 102 bleeding pelvic fracture patients with severe associated injuries (abbreviated injury score ≥3) were treated at our level I trauma center between January 1994 and December 2004. Predictors of death within 24 h of arrival were determined by univariate and multivariate analyses using anatomic and physiologic parameters, including injured body part, shock symptoms, age, sex, injury severity score (ISS), and fracture type. Results Overall, 47 of the 102 patients died within 24 h of arrival. Hemorrhage shock was responsible for the majority of deaths (47%). Other causes included central nervous system injury (21%), multiple injuries (central nervous system injury plus shock, 18%) and multiple organ failures (7%). Univariate analyses revealed that patients presenting with head and neck injuries and shock symptoms on arrival were associated with an increased risk of death (P < 0.01 for both variables). Multivariate analyses revealed that these injuries and shock symptoms were independently associated with a higher risk of death (odds ratios of 2.704 and 4.632, respectively). The mechanism of injury, fracture type, age, sex, and ISS were not associated with an increased risk of death. Conclusions Statistically significant risk factors were brain injuries and shock symptoms on arrival. Brain injuries should be heavily weighted when evaluating the prognosis of bleeding pelvic fracture patients.     

Erectile dysfunction may predict coronary artery disease: relationship between coronary artery calcium scoring and erectile dysfunction severity

Objectives The aim of this prospective study is to evaluate patients with erectile dysfunction (ED) in terms of coronary artery calcium (CAC) levels assessed by multidetector computed tomography (MDCT) and to find out if ED severity may predict coronary heart disease risk. Patients and method Sixty men with a mean age of 55.7 (41–77) years with ED and 23 men with a mean age of 53.2 (39–76) years without ED, who admitted to our clinic between January 2005 and December 2005, were included in the study. All patients answered the standard International Index of Erectile Function (IIEF) forms, and were classified into four groups as mild, moderate, severe ED and no ED. CAC levels were assessed by MDCT protocol. CAC levels and IIEF scores were analyzed within each group. Results Pearson correlation test demonstrated significant negative correlation between IIEF score and CAC score (r = −497; P < 0.0001). CAC scores increased significantly with regard to IIEF scores decrease: IIEF 1–10 (n = 18), mean CAC: 557.7; IIEF 11–16 (n = 13), mean CAC: 541.3; IIEF 17–25 (n = 29), mean CAC: 84.6; and IIEF ≥ 26 [n = 23 (Control group)], mean CAC: 10.1. The difference between the mean CAC scores of these four groups was statistically significant (P < 0.0001). When we took the cut-off value for IIEF score 26 we observed significantly higher CAC scores at the group of IIEF < 26 (mean 325.5 vs 10.1; P < 0.0001). Conclusion We observed positive correlation with ED severity and CAC levels. Therefore, we think that detection and quantification of preclinical coronary artery disease by CAC scoring with a non-invasive method might have a great potential for early cardiac preventive measures.     

Solitary Lymph Node Metastasis in Gastric Cancer

The feasibility and diagnostic reliability of sentinel node (SN) biopsy for gastric cancer are still controversial. We studied the clinicopathological features and localization of solitary lymph node metastasis (SLM) in gastric cancer to provide useful information for use of the SN concept in gastric cancer. From 2000 to 2004, 3,267 patients with gastric cancer underwent D2 radical gastrectomy. The clinicopathological features of 195 patients with histologically proven SLM and the distribution of metastasized nodes were assessed. The incidence of SLM was 6.0% in all cases. Compared with the node-negative patients, significant differences were observed in age, tumor size, depth of invasion, and surgical type. The cumulative 5-year survival rate of patients with SLM was 80.5%, which was significantly lower than 90.2% for node-negative patients (P < 0.001). Of patients with SLM, 82.6% had it in the perigastric node area (N1), and the other 17.4% patients had skip metastasis in the N2-N3 nodes. Perigastric nodes were the most common first sites of drainage from the tumor, making them the main targets of the operative SN mapping procedure. Due to the higher than expected incidence of skip metastasis in gastric cancer, D2 lymphadenectomy should be performed until the reliability of SN navigation surgery is validated in multicenter prospective clinical trials.     

Influence of Imaging on the Negative Appendectomy Rate in Pregnancy

Appendectomy is the most common non-gynecologic surgery performed during pregnancy. Little data exist on the accuracy of imaging studies in the diagnosis of appendicitis in pregnancy. The objective of this study was to evaluate the probability of ultrasound and computed tomography (CT) scan in diagnosing appendicitis in pregnancy, as reflected in the negative appendectomy rate. We retrospectively reviewed the charts of 86 pregnant women who underwent an appendectomy between January 1, 1997 and January 1, 2006. Patients were divided into three groups: clinical evaluation, ultrasound, and ultrasound followed by a CT scan. The clinical evaluation group had 13 patients, with a negative appendectomy rate of 54% (7/13). Fifty-five patients underwent an ultrasound alone, with a negative appendectomy rate 36% (20/55). In the ultrasound/CT group (n = 13), the negative appendectomy rate was 8% (1/13). There was a significant reduction in the negative appendectomy rate in the ultrasound/CT scan group compared to clinical evaluation group (54 vs 8%, p < 0.05). This reduction was not achieved in the ultrasound group when compared to the clinical evaluation group or the ultrasound/CT group (p = 0.05). A significant reduction was achieved when the ultrasound/CT group was compared to the patients in the ultrasound only group who had a normal or inconclusive ultrasound (p < 0.05). Our data documents a very high negative appendectomy rate in the pregnant patient. We recommend an ultrasound followed by a CT scan in patients with a normal or inconclusive ultrasound.