Pancreatic cystic neoplasms: predictors of malignant behavior and management

Pancreatic cystic neoplasms are being increasingly identified with the widespread use of advanced imaging techniques. In the absence of a good radiologic or pathologic test to preoperatively determine the dianosis, clinical characteristics might be helpful. The objectives of this analysis were to define the incidence and predictors of malignancy in pancreatic cysts. Patients with true pancreatic cysts who were treated at our institution were included. Patients with documented pseudocysts were excluded. Demographic data, clinical manifestations, radiological, surgical, and pathological records of those patients were reviewed. Eighty-one patients had true pancreatic cyst. The mean age was 47 +/- 15.5 years. There were 28.4% serous cystadenoma, 21% mucinous cystadenoma, 6.2% intraductal papillary tumors, 8.6% solid pseudopapillary tumors, 1.2% neuroendocrinal tumor, 3.7% ductal adenocarcinoma, and 30.9% mucinous cystadenocarcinoma. Malignancy was significantly associated with men [P = 0.04], older age [0.0001], cysts larger than 3 cm in diameter [P = 0.001], presence of solid component [P = 0.0001], and cyst wall thickening [P = 0.0001]. The majority of patients with malignancy were symptomatic [26/28, 92.9%]. The symptoms that correlated with malignancy included abdominal pain [P = 0.04] and weight loss [P = 0.0001]. Surgical procedures were based on the location and extension of the lesion. The most common pancreatic cysts were serous and mucinous cysts. These tumors were more common in females. Old age, male gender, large tumor, presence of solid component, wall thickness, and presence of symptoms may predict malignancy in the cyst

Pelvic floor dyssynergia: Efficacy of biofeedback training

Paradoxical contraction of the pelvic floor during attempts to defaecate is described as pelvic floor dyssynergia [anismus]. It is a behavioural disorder [no associated morphological or neurological abnormalities]; consequently, biofeedback training has been recommended as a behavioural therapy for such a disorder. The aim of the present study was to evaluate long-term satisfaction of patients diagnosed with pelvic floor dyssynergia after biofeedback. Sixty patients [35 females and 25 males] with a mean age of 30 +/- 12 years and a 4 year duration of constipation were included. Forty-five patients had normal colonic transit and 15 patients had slow colonic transit. History, physical examination and barium enema were done to exclude constipation secondary to organic causes. Colonic and pelvic floor functions [colon-transit time, anorectal manometry, EMG and defaecography] were performed before and after biofeedback treatments. Patients were treated on a weekly basis with an average of [6 +/- 2] sessions. At the end of sessions, 55 out of 60 patients [91.6%] reported a subjectively overall improvement. Symptoms of dyschezia were reported less frequently after biofeedback. Age and gender were not predictive factors of outcome. No symptoms at initial assessment were predictive for patient's satisfaction but the only factor of predictive value was the diagnosis of anismus and the motivated patient who wanted to continue the sessions. Biofeedback remains a morbidity free, low-cost and effective outpatient therapy for well-motivated patients complaining of functional constipation and diagnosed as pelvic floor dyssynergia

Surgical management of gastric gastrointestinal stromal tumor: a single center experience

Gastrointestinal stromal tumors [GISTs] are the most common mesenchymal tumors of the gastrointestinal tract. Surgery remains the mainstay of curative treatment. Our objective is to evaluate the outcome of surgical treatment of primary gastric GIST. Between January 1997 and April 2008, thirty seven consecutive patients underwent resection for GISTs [35 patients with primary gastric GISTs and two patients with intestinal GISTs who were excluded from the study]. These patients underwent upper endoscopy +/- biopsy, barium meal and abdominal CT scan. Patients' demographics and clinical presentations were analyzed. Perioperative parameters measured included operative times, estimated blood loss, intraoperative finding, surgical techniques, morbidity length of hospitalization. Recurrence and survival were also analyzed. Of the 35 patients with gastric GISTs included in the study, 63% were female. The median age was 59 +/- 14 years [range, 23 to 75 years]. The primary presenting symptoms were bleeding and dyspepsia; 43% of these tumors were located mainly in the body of the stomach. Tumor size was <10 cm in 80% of the patients. The average tumor size was 6.3 +/- 3.2 cm [range from 3 to 13 cm]. regarding the surgical management, 20 patients [57%] underwent gastric wedge resection, eight patients [23%] underwent partial gastrectomy and the remaining seven patients [20%] underwent total gastrectomy. Radical resections were found in 32 patients [91.5%] while palliative resections were found in three patients [8.5%]. The resected lymph nodes were negative in 32 patients [91.5%]. Recurrence was noted in three patients, with a median time to recurrence of 14.3 months [range, 7 to 28 months]. The three-and five-years survival in patients who underwent wedge resection was 92% and 81%, respectively, where it was 95% and 87%, respectively, in patients who underwent gastrectomy [either partial or total]. There were no major intraoperative complications or mortalities. Complete surgical resection either through wedge resection or gastrectomy with negative margins remains the gold standard treatment of patients with primary respectable gastric GISTs

Endoscopic management of postoperative bile duct injuries: a single center experience

Biliary endoscopic procedures may be less invasive than surgery for management of postoperative bile duct injuries [POBDI]. This retrospective work presents the experience of a single referral center during a period of 14 years in endoscopic management of POBDI. Between 1994 [March] and 2008 [May], ERCP had been performed on 277 patients suspected to have POBDI. Patients shown to have complete transaction of bile duct were prepared for definitive surgery. For patients with simple biliary leak, sphincterotomy was performed with stenting. Pneumatic dilatation and stenting were done on patients with biliary stricture and preserved ductal continuity. ERCP was repeated every 3 months till the site of narrowing disappeared. The mean age was 45.3 years, 162 [58.5%] were females. The most common previous surgery was cholecystectomy [open, [N=119] 44%, and laparoscopic, [N=77] 28%]. ERCP failed in 17 patients [6.1%]. For successfully cannulated cases [N=260, 93.9%], the type of bile duct injury diagnosed at ERCP was completely ligated CBD [N=31/260, 11.9%]. Bile leakage was detected in [N=167/260, 64.2%] all patients with endoscopic sphincterotomy and stent insertion, the leak stopped in all of them. Biliary stricture was diagnosed in 33/260 patients [12.7%] and 17 of them had repeated balloon dilatation with stenting while the remaining had surgical correction. The success rate of endoscopic therapy for biliary strictures was 82%. Cholangiogram was normal in 29 patients [11.2%]. Endoscopic therapy is safe and effective in the management of postoperative bile duct leak. For postoperative bile ductal strictures, ERCP is a less favorable option

Outcome of pouch surgery for ulcerative colitis: Single center experience

The purpose of the present study is to present the experience of our center in surgical management of ulcerative colitis [UC], stressing on evaluating the outcome of pouch surgery. Fifty eight patients underwent surgery for UC between 1996 and 2007 at Mansoura Gastroenterology Center. A retrospective analysis has been done of all patients with UC undergoing surgery which includes details of the patient's history, indication of surgery, type of operation, postoperative morbidity, and functional outcome. The main indication for operation was failed medical treatment [n=42, 72.4%]. Pouch surgery was performed in 25/58 patients [43.1%]. The majority of patients, 23/25 [92%] had J-shaped pouch. Twenty patients [80%] had a defunctioning ileostomy. There was one postoperative death after pouch surgery. Early complications after pouch surgery included pelvic sepsis [n=4], small bowel obstruction [n=2], pouch hemorrhage [n=1], wound sepsis [n=3]. The most common long-term complication after pouch surgery [n=14] was anastomotic stricture [n=9, 42.6%]. Five patients [35.7%] presented with pouchitis. Median daytime stool frequency was 5.1. Three patients [21.4%] presented with fecal incontinence. Pouch surgery is a major one that attains many complications. However, the long term results and patient's satisfaction are reasonable