Magnetic resonance cholangiopancreatography in the preoperative assessment of patients with biliary pancreatitis.

BACKGROUND: The ultimate treatment of acute biliary pancreatitis (ABP) is undoubtedly laparoscopic cholecystectomy, but controversy remains about the optimal imaging method in the preoperative assessment of these patients. In this study, we evaluated the usefulness of magnetic resonance cholangiopancreatography (MRCP) in detecting common bile duct (CBD) stones and associated pathologies in patients with ABP. At the same time, we tried to determine the natural transit time of gallstones from gallbladder to duodenum in ABP. METHODS: Between February 1999 and October 2006 a prospective observational study was conducted and 104 consecutive patients with ABP were recruited. MRCP findings were correlated with subsequent endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, intraoperative cholangiography or clinical follow-up. RESULTS: MRCP correctly predicted the presence of CBD stones in 19 out of 104 patients, and there were two false-positive and four false-negative results. The ability of MRCP to detect CBD stones was: positive predictive value 90.5%, negative predictive value 95.2%, sensitivity 82.6%, specificity 97.5% and overall accuracy 94.2%. MRCP performed within 48 h after admission showed CBD stones in 28.6% of the patients decreasing to 8.0% after 1 week. MRCP disclosed cholecystitis in 25 patients, anatomical variants of the cystic duct in 10 patients and a wide variety of other abnormalities of the upper abdominal cavity. CONCLUSION: MRCP is highly accurate in the preoperative detection of CBD stones and other biliopancreatic pathologies in patients with gallstone pancreatitis.

Endoscopic volume adjustment of intragastric balloons for intolerance.

BACKGROUND: A new type of saline-filled, spherical-shaped balloon, which moves freely within the stomach, has been increasingly used as a tool to assist weight reduction. Balloon intolerance is an infrequent complication, characterized by continuous nausea and vomiting or abdominal pain, uncontrollable by medical therapy. This has usually been followed by puncture, deflation and extraction of the balloon. METHODS AND RESULTS: We present 4 patients in whom intolerance was treated by endoscopic volume adjustment of the device. After partial defilling of the balloon, epigastric symptoms disappeared rapidly, while the patients respectively lost 5.2, 14.4, 5.9 and 15.8 kg of body weight at the end of the treatment. Practical recommendations are provided to ensure a successful endoscopic reintubation of the balloon's valve. CONCLUSION: Early intolerance to an intragastric balloon can be successfully treated by endoscopic volume adjustment of the device.

Intragastric balloons for preoperative weight reduction.

BACKGROUND: If medical treatment of obesity fails and if surgical gastroplasty is not indicated, insertion of an intragastric balloon may represent an intermediate modality. METHODS: Two patients are reported in whom a balloon was placed for weight reduction before elective surgery: 1) A 53-year-old woman with a BMI of 41.3 kg/m2 lost 18 kg in 6 months and then underwent surgical repair of a huge incisional hernia; 2) A 58-year-old woman with a BMI of 35.8 kg/m2 had total hip arthroplasty after losing 15.5 kg in 5 months. RESULTS: The uneventful postoperative recovery in both patients was thought to be positively influenced by their preoperative weight loss. CONCLUSION: In morbidly obese patients, intragastric balloon placement may contribute to preoperative weight reduction before elective surgery.

Adjuvant portal-vein infusion of fluorouracil and heparin in colorectal cancer: a randomised trial. European Organisation for Research and Treatment of Cancer Gastrointestinal Tract Cancer Cooperative Group, the Gruppo Interdisciplinare Valutazione Interventi in Oncologia, and the Japanese Foundation for Cancer Research.

BACKGROUND: There is conflicting evidence on the efficacy of regional adjuvant chemotherapy, via portal-vein infusion (PVI), after resection of colorectal cancer. We undertook a randomised controlled multicentre trial to investigate the efficacy of PVI (500 mg/m2 fluorouracil plus 5000 IU heparin daily for 7 days). METHODS: 1235 of about 1500 potentially eligible patients were randomly assigned surgery plus PVI or surgery alone (control). The patients were followed up for a median of 63 months, with yearly screening for recurrent disease. The primary endpoint was survival; analyses were by intention to treat. FINDINGS: 619 patients in the control group and 616 in the PVI group met eligibility criteria. 164 (26%) control-group patients and 173 (28%) PVI-group patients died. 5-year survival did not differ significantly between the groups (73 vs 72%; 95% Cl for difference -6 to 4). The control and PVI groups were also similar in terms of disease-free survival at 5 years (67 vs 65%) and the number of patients with liver metastases (79 vs 77%). INTERPRETATION: PVI of fluorouracil, at a dose of 500 mg/m2 for 7 days, cannot be recommended as the sole adjuvant treatment for high-risk colorectal cancer after complete surgical excision. However, these results cannot eliminate a small benefit when PVI is used at a higher dosage or in combination with mitomycin.

Common bile duct stones in acute biliary pancreatitis: an endoscopic study.

The knowledge of the natural history of common bile duct stones in biliary pancreatitis may be helpful in the debate concerning the timing of endoscopic sphincterotomy in relation to surgery. The endoscopic cholangiographies of 211 patients with biliary pancreatitis were analyzed. The presence of bile duct stones was recorded, as well as the time interval between admission and endoscopic retrograde cholangiopancreatography (ERCP). The predicted severity of pancreatitis was determined by the modified Glasgow criteria. The overall incidence of bile duct stones was 28.9%. This incidence was 43.8% during the first 2 days and decreased to < 20% after 1 week. There was no correlation between the severity of disease and the presence of bile duct stones. The performance of an ERCP 1 week after the admission for biliary pancreatitis will avoid a substantial number of unnecessary endoscopic sphincterotomies. Prediction of the severity of disease does not alter the yield of bile duct stones.

Transvaginal removal of gallbladders with large stones after laparoscopic cholecystectomy.

Very large gallstones sometimes render laparoscopic cholecystectomy time consuming and difficult. In addition, several advantages of laparoscopy, namely decreased postoperative pain and minimal abdominal scarring, could be compromised by the need to enlarge the umbilical incision. Besides the solution of the mechanical or electrohydraulic fragmentation of such large gallstones, as described by several authors, we propose a posterior colpotomy as a simple technique for removing very large gallbladders in women.

The brown bowel syndrome and gastrointestinal adenocarcinoma. Two complications of vitamin E deficiency in celiac sprue and chronic pancreatitis?

The brown bowel syndrome is a rare disorder caused by vitamin E deficiency occurring in malabsorption syndromes. In patients with celiac sprue and chronic pancreatitis, the death rate from malignancy is high. We believe that vitamin E deficiency is responsible for the development of the brown bowel syndrome and may be partially responsible for the high incidence of malignancy in patients with celiac sprue and chronic pancreatitis. We report such a patient, and review the literature.

Vitamin status in patients with acute pancreatitis.

The serum levels of 6 vitamins were prospectively evaluated in 20 patients with acute biliary pancreatitis and in 20 patients with acute alcoholic pancreatitis. Twenty healthy subjects acted as controls. There were no statistically significant differences in the levels of vitamin B12 and D among the groups. Patients with alcoholic pancreatitis had significantly lower levels of vitamins A, E (p < 0.01) and C (p < 0.001) than those of the control group. Plasma levels of vitamin K were decreased or undetectable in 6 patients with biliary and 3 with alcoholic pancreatitis. The pathophysiological and clinical implications of this abnormal vitamin status in patients with acute pancreatitis are unknown. Nevertheless, multi-vitamin supplementation seems justified, especially in patients affected by alcoholic pancreatitis. Vitamin K should be administered in both types of pancreatitis when blood coagulation tests are disturbed.

Granular cell tumour of the appendix in a patient irradiated for a rectal carcinoma.

We report on a 47-year-old man with a granular cell tumour of the appendix, discovered incidentally during surgery for a rectal adenocarcinoma that had been irradiated preoperatively. A detailed immunocytochemical analysis revealed positivity for S-100 and neuron-specific enolase (NSE). Electron microscopically, the cytoplasm of the tumour cells contained numerous pleomorphic lysosomes. In the appendix tissue adjacent to the tumour a neuroma and the histological features of radiation injury were present. Our findings suggest that this granular cell tumour may have originated from a pre-existing appendix neuroma which underwent granular degeneration, possibly as a result of radiation.

Surgical treatment of a retroperitoneal neurofibroma in von Recklinghausen's disease.

The rare occurrence of a retroperitoneal neurofibroma in a patient with von Recklinghausen's disease is presented. Malignant degeneration of a benign neurofibroma is a common threat in neurofibromatosis and cannot be definitely excluded by actual means. Therefore complete surgical removal of the retroperitoneal mass, even in asymptomatic patients, is advocated.

Gallstone pancreatitis in adolescents.

Two female adolescents, 16 and 18 years of age respectively, had to be operated for gallstone pancreatitis. They represented 2.2% of all patients with this disorder, admitted from 1978 to 1987 in our department. In one patient cholelithiasis was associated with obesity, in the other there was a positive family history of gallstones. Congenital anomalies of the biliary tract, hemolytic disorders, early pregnancy and other predisposing factors were absent. Although unfrequent, gallstone pancreatitis is a serious cause of acute abdominal distress in adolescents which can lead to severe morbidity. Adequate biliary tract surgery is curative.

Upper gastrointestinal bleeding due to benign tumours of the stomach.

Benign tumours of the stomach are usually asymptomatic and are discovered incidentally during radiology, endoscopy or pathological examination. In some cases, however, these tumours produce overt clinical symptoms. The authors report eight patients with significant upper gastrointestinal bleeding due to benign gastric tumours, who required surgical resection of their lesion. Histologically, the growths proved to be leiomyoma in five cases, polyps in two and lipoma in one. Surgical treatment consisted in local excision in three patients and subtotal gastrectomy in five patients. Bleeding was stopped in all cases and there was no operative mortality.

Retroperitoneal leiomyosarcoma.

The clinical history, radiological investigations, pathologic findings and treatment of four patients affected by retroperitoneal leiomyosarcoma were compared with data of the literature. These tumors have a great tendency to develop local recurrences after excision, but metastases to lymph nodes and distant organs usually occur lately. CT examination of the retroperitoneal space is a sensitive tool in the diagnosis and follow-up. Complete excision of the tumor followed by radiotherapy improves significantly the prognosis. Chemotherapy is advisable only when disseminated metastases appear. No correlation was found between the histologic appearance and the clinical behaviour.

Peritoneovenous shunt for pancreatic ascites.

A chronically ill patient with pancreatic ascites was successfully treated with a temporary LeVeen peritoneovenous shunt. This observation supports the use of a peritoneovenous shunt in the treatment of pancreatic ascites which is refractory to medical therapy and not amenable to major pancreatic surgery.

Agarose electrophoresis and inhibitor tests for isoamylase determination can give complementary clinical information.

We report the presence of an extremely high proportion of "aged" amylase in the serum and cyst fluid of a patient with a pancreatic pseudocyst. A salivary amylase inhibitor test helped us to differentiate these "aged" pancreatic amylases from salivary fractions having a similar electrophoretic mobility.

Endometriosis of the appendix.

Endometriosis has been encountered in different sites of the gastrointestinal tract. Involvement of the vermiform appendix, however, is rather unusual. Two cases of appendiceal endometriosis are reported in the present study: one patient had symptoms simulating acute appendicitis; in another patient it was an incidental finding during pelvic surgery. There are no clinical signs and findings pathognomonic of endometriosis of the appendix, but the condition may present as appendicitis. At surgery, the diagnosis can only be suspected when it is associated with obvious genital endometriosis. Correct diagnosis is established by microscopic examination of the lesion. Symptomatic endometriosis of the appendix will be cured by appendectomy.

Nonparallelism of digestive enzymes in rat pancreatic hypersecretion.

During a 4 days' cannulation of the pancreatic duct in conscious rats, pancreatic hypersecretion developed. The enzymic composition of the juice altered with time. Amylase secretion reached a plateau after 24 h, whereas the lipase secretion continued to increase for 48 h. The mean trypsinogen and chymotrypsinogen output was three times greater on the 4th day than during the first 24 h. The intrapancreatic content of the enzymes diminished with a different disappearance rate for each enzyme. After 96 h the pancreas contained only 15% of the initial amounts of amylase; lipase also decreased to 15%, chymotrypsinogen to 32% and trypsinogen to 42% of the basal value. Comparison of the rates of synthesis of enzymes on the 1st and the 4th days of study showed an increase of 89% for amylase, 291% for trypsinogen, 300% for chymotrypsinogen and 759% for lipase. It is concluded that the nonparallel content and secretion of digestive enzymes during the course of several days pancreatic hypersecretion is due to different synthesis rates for each enzyme.