Intraductal papillary mucinous tumors of the pancreas: helical CT with histopathologic correlation

PURPOSE: To evaluate the accuracy of preoperative computed tomography (CT) in predicting the location and type of ductal involvement and malignant transformation in intraductal papillary mucinous (IPM) pancreatic tumors and to determine the predictive factors for malignancy at CT. MATERIALS AND METHODS: The helical CT scans obtained in 36 operated on patients with a diagnosis of IPM pancreatic tumor were retrospectively assessed. CT-histopathologic correlation was then performed. RESULTS: The final diagnoses of IPM tumor were combined type (n = 26) and branch duct type (n = 10) lesions. Histologic analysis revealed adenocarcinoma (n = 9), hyperplasia (n = 8), low-grade dysplasia (n = 12), and high-grade dysplasia (n = 7). The lesions were located mainly in the head or uncinate process (n = 20) or were diffuse or multifocal (n = 12). In 12 patients (13 cases), CT-histopathologic correlation was poor, including that in the evaluation of ductal involvement (n = 7), evaluation of lesion location (n = 2), and diagnosis of malignant transformation (n = 4). The most specific predictive signs of malignancy were presence of diabetes and, at CT, a solid mass, main pancreatic duct dilatation greater than 10 mm, diffuse or multifocal involvement, and attenuating or calcified intraluminal content. CONCLUSION: The main causes of poor CT-histopathologic correlation were related to evaluation of main pancreatic duct involvement and diagnosis of malignant transformation. The association between diabetes and specific CT criteria was highly suggestive of malignancy.     

A urethral stent for the treatment of detrusor-striated sphincter dyssynergia

OBJECTIVE: To assess the technique, efficacy and complications of the Ultraflex urethral stent (Boston Scientific Corp., Boston, MA) for the treatment of detrusor-striated sphincter dyssynergia (DSD). PATIENTS AND METHODS: Forty consecutive patients with DSD who had a Ultraflex stent placed in the membranous urethra were evaluated prospectively. DSD was caused by spinal cord injury in 30, multiple sclerosis in six and other neurological diseases in four. All patients were either tetraplegic or paraplegic and unable to use intermittent self-catheterization. Previous bladder management consisted of an indwelling catheter in 15 patients, chronic suprapubic catheters in two, intermittent catheterization in nine, and trigger reflex micturition in 14. The Ultraflex stent was placed under local anaesthesia. The stents were 50 mm long in 36 patients, 45 mm in two and 40 mm in two. The mean (SD) follow-up was 16.9 (13. 8) months. RESULTS: The mean (SD) residual urine decreased from 245. 9 (117) mL before stenting to 65.2 (19.3) mL at 12 months afterward (n = 19). One stent was removed at 13 months for chronic prostatic and urinary tract infection leading to autonomic dysreflexia. There was no stent stenosis and 17 of 18 stents had > 75% epithelial coverage at one year. None of the stents migrated. Seven patients underwent secondary bladder neck incision through the stent. The stent length was increased in four patients using a second overlapping distal stent, twice during the first procedure and twice within 6 months because the sphincter was inadequately covered. CONCLUSIONS: The Ultraflex stent achieved the expected results for a prosthetic sphincterotomy and appears to be an appropriate but less invasive treatment for DSD.     

Stromal Decidual Change in the Pregnant Cervix: Colposcopic, Cytological and Histological Considerations

Summary: Forty-two pregnant patients with cytology smears suggesting cervical intra-epithelial neoplasia were examined in a special clinic by colposcopy, cytology and biopsy. This study was concerned with the recognition of decidual change in the cervical stroma in these patients, establishing its incidence and deterrnining whether its presence influenced interpretation of the colposcopic and cytological findings.
Intense decidual change was seen in die biopsy from 6 patients (14.3%); in 4 of these the change was colposcopically apparent, and in 1 decidual cells were present in the cytology smear. Colposcopically, decidual alteration can be distinguished from atypical transformation zone changes suggestive of cervical intra-epithelial neoplasia. Similarly, in cytology smears, die well preserved decidual cells of cervical origin are not difficult to distinguish from atypical squamous cells.     

Percutaneous extraction of retained biliary T-tubes: a new technique

Retained T-tubes are rare complications after biliary surgery. The authors present three cases of retained T-tubes in patients with transplanted liver that could not be removed by a standard manual traction. The authors describe a new simple percutaneous method that allows removal of these T-tubes without complication.     

Portal vein embolization with N-butyl cyanoacrylate before partial hepatectomy in patients with hepatocellular carcinoma and underlying cirrhosis or advanced fibrosis

PURPOSE: To describe the safety, complications, and liver regeneration associated with the left liver after embolization of the right portal vein (PV) in patients with hepatocellular carcinoma (HCC) developed in the setting of advanced liver fibrosis and cirrhosis. MATERIALS AND METHODS: Forty patients (31 men, nine women; mean age, 62 years) with HCC underwent PV embolization over a 4-year period. Embolization was performed from a left PV percutaneous access with use of n-butyl cyanoacrylate (NBCA) mixed with iodized oil. Computed tomography (CT) volumetry was performed before and 1 month after PV embolization to measure the left lobe volume as well as the functional liver ratio defined by the ratio between the left lobe and the total liver volume minus tumoral volume. PV pressure and liver enzyme levels were compared before and 1 month after the procedure and complications were registered. Factors potentially affecting regeneration (age, sex, diabetes, chemoembolization, functional liver ratio before PV embolization, and Knodell histologic score) were evaluated by one-way and stepwise regression analysis. RESULTS: PV embolization could be achieved successfully in all cases. Two patients had partial PV thrombosis on the 1-month follow-up CT and two patients developed transient ascites after PV embolization. The left lobe volume increase was 41% +/- 32% after PV embolization and the functional liver ratio increased from 28% +/- 10% to 36% +/- 10% (P < .0001). Hypertrophy of the left lobe was greater in patients with a low functional liver ratio before PV embolization and those with an F3 fibrosis score. Other factors had no influence on left lobe regeneration. CONCLUSION: PV embolization with use of NBCA is feasible in patients with advanced fibrosis and cirrhosis. Hypertrophy of the left lobe of the liver after PV embolization has a statistically significant correlation with lower functional liver ratio and lower degrees of fibrosis.     

Effect of site of starch digestion on portal nutrient net fluxes in steers

Processing of maize grain is known to modulate the site of starch digestion, thus the nature and amount of nutrients delivered for absorption. We assessed the effect of site of starch digestion on nutrient net fluxes across portal-drained viscera (PDV). Three steers, fitted with permanent digestive cannulas and blood catheters, successively received two diets containing 35 % starch as dent maize grain. Diets differed according to maize presentation: dry and cracked (by-pass, BP) v. wet and ground (control, C). Ruminal physicochemical parameters were not significantly affected. Between C and BP, the decrease in ruminal starch digestion was compensated by an increase in starch digestion in the small intestine. The amount of glucose and soluble alpha-glucoside reaching the ileum was not affected. The amount of glucose disappearing in the small intestine increased from 238 to 531 g/d between C and BP, but portal net flux of glucose remained unchanged (-97 g/d). The portal O2 consumption and net energy release were not significantly affected, averaging 16 % and 57 % of metabolizable energy intake, respectively. The whole-body glucose appearance rate, measured by jugular infusion of [6,6-2H2]glucose, averaged 916 g/d. The present study shows that the increase in the amount of glucose disappearing in the small intestine of conventionally fed cattle at a moderate intake level induces no change in portal net flux of glucose, reflecting an increase in glucose utilization by PDV. That could contribute to the low response of whole-body glucose appearance rate observed at this moderate level of intestinal glucose supply.     

The 'precautionary principle' as a guide for future drug development

During the last decade, the 'precautionary principle' health has gained importance. It is an approach to manage uncertain risks and to prevent any damage to the environment or human. A key element is to take action, even if some cause and effect relationships are not fully established scientifically. Although there are also critics of this principle, it is meanwhile, also increasingly implemented in medicine. An important subject is medicinal products of human or animal origin. Manifold official precaution-guided regulations have been stated to improve their safety, particularly to avoid any infection by viruses and pathogens causing transmissible spongiform encephalopathies. In addition to numerous regulations and decisions, it is generally recommended to substitute animal and human-derived products with adequate alternatives wherever possible. This is a great challenge for research and drug development. One option is recombinant proteins, which however, are not generally free of any risk of contamination. Therefore, the best strategy might be the development of synthetic, specifically acting drugs. The most widely used medicinal product of animal origin at present is heparin. Although there has been no indication of any viral contamination, many other reasons suggest its substitution by alternative antithrombotics. These actually promoted the research on new anticoagulants. With the approval of fondaparinux, the first synthetic, selective factor Xa, a first alternative to the porcine-derived heparin has become available. In addition, other synthetic antithrombotics are currently in clinical development. In principle, it is thus possible that the prophylaxis and therapy of thromboembolic diseases will become completely independent of animal-derived drugs, which would be in line with the precautionary principle.