Pancreatic and extrapancreatic lesions in patients with intraductal papillary mucinous neoplasms of the pancreas: a single-centre experience.

PURPOSE: This study was performed to describe the possible presence of extrapancreatic neoplasms in patients with intraductal papillary mucinous neoplasm (IPMN) and to evaluate whether the extrapancreatic tumours were synchronous or metachronous to IPMNs. MATERIALS AND METHODS: One hundred and forty-two patients (56 men and 86 women; mean age 69.5 years, range 37-98) with IPMN diagnosed using the Sendai criteria were enrolled. Six patients (4.2%) had type I, 103 (72.5%) type II and 33 (23.2%) type III IPMN. All patients were studied using the following imaging techniques: ultrasonography (US), multidetector computed tomography (MDCT) and magnetic resonance cholangiopancreatography (MRCP). RESULTS: Pancreatic IPMN was localised in the head in 43 patients (30.3%), in the body in 13 (9.2%), in the tail in ten (7.0%), in the head-body in 17 (12.0%), in the body-tail in 15 (10.6%) diffuse throughout the gland in 44 (31.0%). The mean size of the cystic lesions was [(mean+/-standard deviation (SD)] 1.9+/-1.9 cm (range 0.5-8.0 cm). Twenty patients (14.1%) had associated pancreatic or extrapancreatic diseases. In evaluating the distribution of pancreatic or extrapancreatic diseases according to IPMN type, we found that this was not significantly different among types I, II and III (p=0.776). CONCLUSIONS: The majority of pancreatic and extrapancreatic cancers occur before the diagnosis of IPMNs is made and is not related to the type of IPMN.

Prognostic factors in periampullary and pancreatic tumor resection in elderly patients.

BACKGROUND: More than half of all patients with pancreatic adenocarcinoma are over 70 years of age. Life expectancy for the elderly population is increasing and currently major pancreatic resection provides the only meaningful chance of cure for periampullary and pancreatic tumors. Controversy over what constitutes the correct treatment of these tumors in elderly patients continues to this day. The aim of our study was to determine whether age alone or age plus some prognostic factors constitute contraindications to major pancreatic resections. METHODS: Between 2000 and 2005, data from 88 consecutive patients who had major pancreatic resection for periampullary or pancreatic tumors were entered into a prospective database. Fifty-three patients under 70 years of age (young patients), and 35 patients 70 years of age or older (elderly patients) were compared with respect to several characteristics and the postoperative course. RESULTS: Postoperative mortality and morbidity, length of hospital stay, and long-term survival were similar in the two groups. In the elderly group, the mortality rate was significantly higher in patients with chronic obstructive pulmonary disease (COPD), and the morbidity rate was significantly higher in patients with ASA 3 than in patients with ASA 1-2, in whom a pancreaticoduodenectomy or total pancreatectomy had been performed. CONCLUSIONS: Age alone is not a contraindication for major pancreatic resection. In elderly patients a careful evaluation of the co-morbidities and of the type of surgical procedure is mandatory in order to allow the proper selection of those patients best suited for surgery in specialized centers.

Mesenchymal tumors of the pancreas: CT findings.

This article reviews the CT imaging features of the most frequent mesenchymal tumors of the pancreas and stresses important distinctive patterns that may help distinguish specific entities. Various neoplasms (lymphangioma, lipoma, teratoma, pancreatoblastoma, schwannoma, neurofibroma, lymphoma, and sarcoma) are reviewed, with key differential points (structure, fatty and water densities, calcification, pattern of contrast enhancement, vascularization, and necrotic or regressive changes) emphasized. In addition, epithelial tumors are considered in the differential diagnosis.

[Role of spiral computerized tomography in the staging of pancreatic carcinoma]. / Ruolo della Tomografia Computerizzata spirale nella stadiazione del carcinoma pancreatico.

INTRODUCTION: Few pancreatic carcinomas (5-22%) are resectable at the time of diagnosis because this lesion is seldom diagnosed in an early stage. Unresectability is mainly due to the presence of metastases to the liver, peritoneum and lymph nodes and to tumor spread especially to the portal mesenteric trunk where it can invade, compress, reduce, or occlude the vessels. We investigated the diagnostic yield of multiplanar and 3D spiral CT in the assessment of pancreatic carcinoma resectability. MATERIAL AND METHODS: Twenty-seven patients with histologically confirmed pancreatic head cancer were submitted to spiral CT and color Doppler US in the Surgical Clinic I of the Bologna University. The examination results were correlated with the intraoperative findings of careful inspection and palpation and of US studies of the pancreatic mass and adjacent structures. The tumors were classified in relation to some CT parameters: tumor size (T), infiltration of the stomach (S) and/or duodenum, lymph nodes (N) or distant (M) metastases, involvement of vascular structures (V), particularly of portal or superior mesenteric vein, or superior mesenteric artery. Five grades of vascular involvement were considered. The results of these techniques were correlated with intraoperative findings from careful inspection and palpation and with US studies of the pancreatic mass and adjacent structures. RESULTS: Spiral CT revealed vascular involvement in 19 of 27 cases (70.4%): involvement of portal and superior mesenteric vein was found in 14 (73.6%), superior mesenteric vein was involved in 2 (10.6%), the portal vein in one (2%) and, finally the portal, superior mesenteric vein and superior mesenteric artery in 2 cases (10.6%). The spiral CT results were confirmed intraoperatively in 26 of 27 cases (96.3%); spiral CT did not reveal hepatic metastasis only in one case. Spiral CT with multiplanar reconstructions had very high specificity and sensitivity (100%) in the assessment of vascular involvement, while color Doppler US had the same specificity but lower sensitivity (84.2%). Spiral CT was less sensitive (80%) in the detection of liver metastases. CONCLUSIONS: We believe that spiral CT is currently the best technique for pancreatic carcinoma staging, providing useful information for correct surgical planning.

[Deglutition in patients treated with reconstructive laryngectomy]. / Studio della deglutizione nei pazienti sottoposti a laringectomia ricostruttiva.

INTRODUCTION: We stress the importance of dynamic radiologic studies of swallowing in the patients submitted to reconstructive laryngectomy. MATERIAL AND METHODS: January, 1989, to December, 1996, we examined 36 patients submitted to reconstructive laryngectomy, namely cricohyoidoepiglottopexy in 34 cases, cricohyoidopexy in 1 case and Guerrier's cricohyoidoepiglottopexy in 1 case. Dynamic radiologic studies were performed with fluoroscopic videorecording (Sony U-Matic RM 580) from an X-ray unit. The study was performed with the patients standing or sitting, initially acquiring AP and LL fluoroscopic images of the oropharyngeal region at rest and during swallowing. The patients then swallowed 2 boluses of 5 ml liquid (60%) and semiliquid (250%) barium. When aspiration was suspected, we began with a 2-ml bolus. RESULTS: The patients were grouped by symptoms: group A patients had no symptoms, group B patients had dysphagia and group C patients presented aspiration. The functional changes were: reduced pharyngeal contraction, reduced epiglottis deflection, reduced hyoid bone elevation, aspiration, altered upper esophageal sphincter function. The organic alterations were: parapharyngeal diverticulum, pharyngeal stenosis, posterior pharyngeal wall introflexion. Three group A patients had severe posterior pharyngeal wall introflexion, 4 had marked retention and 2 of them presented postswallowing aspiration. Two group B patients had major retention, 1 cricopharyngeal incoordination, 3 posterior pharyngeal wall introflexion, 2 a pseudodiverticulum and 2 a luminal stenosis. Seven group C patients had intraswallowing and 3 postswallowing aspiration. CONCLUSION: The videofluorographic identification of organic and functional complications, sometimes unknown in asymptomatic patients, is useful for therapy and suggests the speech specialist the best compensatory mechanism to improve the patients' swallowing and consequently their quality of life. Moreover, videofluorography of swallowing is a very useful tool in the follow-up, to monitor treatment outcome after rehabilitation.

[The role of the radiological hemithorax examination in closed trauma of the chest]. / Ruolo dell'esame radiologico dell'emicostato nei traumi chiusi del torace.

January, 1992, to September, 1994, a hundred and seventy-eight blunt chest trauma patients were examined with plain chest films and detailed rib studies. The patients were subdivided into three groups according to: a) the presence/absence of rib fractures correlated with clinical data; b) the depiction of rib fractures and/or thoracic complications; c) treatment customization in the presence/absence of rib fractures. In our series of patients the clinical data and the presence of rib fractures were poorly correlated. The detection rates of minor and major complications were also investigated on plain chest films and detailed rib studies. Plain chest films most frequently depicted the complications requiring conservative or surgical management and gave the indication for further imaging investigations. The detailed rib studies of the involved hemithorax yielded no further information useful to therapy except in few cases: and should therefore be limited to the cases exhibiting complications on chest films, which may benefit from surgical fixation. The accurate study of rib fractures is paramount in the cases where legal action may be undertaken.

[Incidence of dilatation of residual cystic duct in liver transplantation. Our experience with 152 cases]. / Incidenza della dilatazione del dotto cistico residuo nel trapianto del fegato. Nostra esperienza su 152 casi.

In our series of patients, we studied the incidence of residual cystic duct mucocele, which is still considered a rare complication in orthotopic liver transplantation (OLT). 152 OLTs were performed in 138 patients in the II Surgery Dept. of Bologna University, May 1986 to June 1994; a termino-terminal choledocho-choledochal anastomosis was performed in 145 of them. A choledocho-jejunal anastomosis was performed in other 7 patients. In 3 patients we observed an anechoic ovoidal structure localized just before the portal vein, near the main bile duct (MBD). Then, we monitored the evolution of this finding by ultrasonography (US), Doppler US, CT and CT-cholangiography. Integrated imaging, clinical and surgical data, led to the diagnosis of non-obstructive mucocele of residual cystic duct in OLT. To date, this complication has not led, on our series, to the necessity of new surgical procedures for cholestasis by MBD compression, which is in disagreement with literature data. In our series, the incidence of residual cystic duct mucocele is 2%, which is a higher value than those reported in the literature, suggesting that this condition be investigated carefully as a non-rare complication in OLT.

[Imaging technics in the indications for laparoscopic cholecystectomy. Echotomography and cholangiography compared]. / Tecniche di imaging nell'indicazione alla colecistectomia laparoscopica. Ecotomografia e colangiografia a confronto.

March 1991 through October 1992, in the Clinica Chirurgica II of the Bologna University, 59 patients were submitted to laparoscopic cholecystectomy; the age range was 25 to 76 years and the mean 50 years. In no patient stones bigger than 35 mm were observed and 31% of the subjects were treated with litholysis before surgery. Fifty-eight patients were affected with single or multiple cholelithiasis, 1 had adenomyomatosis and 4 patients had associated choledocholithiasis treated with preoperative ERCP. Both US and cholangiography were performed to detect absolute contraindications--e.g., acute cholecystitis, cholangitis, peritonitis and cirrhosis--or relative contraindications--e.g., choledocholithiasis, > 5 mm stones and short cystic duct. US proved to be more sensitive than cholangiography to assess the number of stones and gallbladder wall thickness and to diagnose acute cholecystitis or scleroatrophic gallbladder, but it appeared to be less reliable in case of choledocholithiasis, where cholangiography was the technique of choice, and in possible anatomical variations--e.g., short cystic duct--which must be detected before laparoscopic cholecystectomy. Cholangiography appeared to be rather inadequate to study cholelithiasis when associated with functional gallbladder exclusion (as it happened in 17% of our patients). Intraoperative cholangiography was performed on 2 patients only, because their obesity hindered the preoperative study. In conclusion, the need is stressed of combining US and cholangiography for the accurate preoperative evaluation of gallbladder stones patients.

[Psoriasis arthropathica. A review of the literature, general considerations and the authors' personal experience]. / L'artropatia psoriasica. Revisione della letteratura, considerazioni generali ed esperienza personale.

A retrospective study has been carried out on 897 psoriatic patients in order to verify the incidence and radiological patterns of psoriatic arthropathy (PA). Site of involved joints, appearance and degree of involvement were correlated with extent of skin disease and blood test results. Sixty-five patients (7%) showed "clinical" arthritis whereas only 20 cases (2.2%) were radiologically positive; among them, 35% were classified as "severe" forms. Peripheral arthritis was observed in all cases, involving the hand in 85% of patients. The distal interphalangeal joints were the most affected location in the feet (78%) and the proximal interphalangeal joints in the hands (94%). The extant small peripheral joints were involved in decreasing rates proceeding proximally. Bilateral and asymmetric involvement was observed in most of the patients; hypertrophic interphalangeal joints erosion was the typical pattern in 100% of cases, evolving in rheumatoid-like ankylosis in 23% of them. Spondylitis and/or sacroiliitis were associated in 50% of patients. No correlation between degree of arthritis and skin disease was found in our series, with the exception of proximal and axial joints arthritis, in which extensive skin disease and severe small joints involvement were associated in 80% of cases. Clear differential features were demonstrated between peripheral PA and rheumatoid arthritis, and between spinal involvement in PA and ankylosing spondylitis. Poor correlation of distal arthritis to psoriatic nail involvement was also demonstrated.

Leukemic infiltration of the eye: results of therapy in a retrospective multicentric study.

A multicentric retrospective study on leukemic ophthalmopathy (LO) is reported, including 38 patients (21 males, 17 females) with acute leukemia (AL) observed from 1976 to 1985. LO developed in four patients at the time of diagnosis of AL; ten were in first complete remission (eight off therapy), 12 in second remission, and 12 in combined relapse. The children were treated according to different schedules of systemic and intrathecal chemotherapy with or without radiotherapy (RT) of the affected eye. Ocular remission occurred in 32 of 38 patients, but with subsequent ocular relapse in six of the 32. Complete remission after LO treatment lasting for more than 24, 30, 40, and 78 months was observed in four of the ten children with isolated LO in first AL marrow remission. The authors concluded that systemic and intrathecal chemotherapy probably is associated with RT (at least 30 Gy to the affected eye). Aggressive treatment is justified because children with isolated ocular relapse can still be cured.