Laparoscopic management of insulinomas.

BACKGROUND: Conventional surgical management of insulinomas involves an open technique. The laparoscopic approach has advantages in terms of improved postoperative pain and recovery time. This retrospective study evaluated the laparoscopic management of pancreatic insulinomas. METHODS: Between December 2000 and March 2007, 23 patients were referred for consideration of laparoscopic insulinoma resection. Two patients were not deemed appropriate for the laparoscopic approach and were managed with open surgery. All surgery was performed by one experienced pancreatic surgeon. Laparoscopic intraoperative ultrasonography was not available for the first six procedures, but was used thereafter. RESULTS: Twenty-one patients (five men and 16 women, median age 46 (range 22-70) years) had a successful resection. All had single tumours, five in the head, nine in the body and seven in the tail of the pancreas. One conversion to open operation was performed in a patient with an insulinoma in the head of the pancreas who had dense adhesions resulting from pancreatitis. Three patients developed a postoperative pancreatic fistula. There has been no recurrence of symptoms in any patient. CONCLUSION: Laparoscopic management of insulinomas is feasible and safe. Laparoscopic intraoperative ultrasonography is a promising adjunct to the procedure, even after accurate preoperative localization.

Metastatic breast carcinoma initially presenting as acute cholecystitis: a case report and review of the literature.

INTRODUCTION: The gallbladder is an infrequent site of metastatic malignant disease. Although malignant melanoma, renal cell and cervical carcinoma have been documented, breast carcinoma has rarely been reported to metastasize in the gallbladder. CASE REPORT: We describe such a case that manifested as acute cholecystitis and was incidentally recognized after cholecystectomy, in an otherwise disease-free 46-year-old female who had undergone mastectomy for breast cancer two years before. The patient was subjected to adjuvant chemotherapy, but unfortunately died just a year after diagnosis because of generalized peritoneal seeding of the tumor. DISCUSSION: Metastatic gallbladder involvement is rare, especially in cases of primary breast carcinoma, usually leading to symptoms of abdominal pain, mimicking acute or chronic cholecystitis. Thus, abdominal pain in a patient with a previous history of breast carcinoma should raise suspicion of gallbladder metastasis.

Gallbladder-duodenal fistula presenting with liver abscess and upper gastrointestinal bleeding.

BACKGROUND: Bilio-enteric communications leading to liver abscess formation are encountered rarely and are therefore not easily suspected by the attending physician. CASE OUTLINE: A bilio-enteric communication involving the gallbladder and the duodenum presented as a septic event with upper gastrointestinal bleeding in a 71-year-old man who was wrongly thought to have undergone a previous cholecystectomy. A pyogenic bacterial liver abscess developed from the fistula in the absence of biliary obstruction. The patient was treated surgically with disconnection of the fistula and drainage of the abscess. DISCUSSION: The liver abscess presumably arose as a consequence of contamination of the bile via the cholecysto-duodenal fistula. The previous operation is likely to have been a simple cholecystostomy.

Serine proteinase activation in esophageal cancer.

BACKGROUND: Activation of the plasminogen/plasmin system seems to contribute to tumor aggressiveness and shorter post-operative survival. In the present study we examined the relation of uPA (urokinase plasminogen activator), uPAR (uPA receptor) and PAI-1 (plasminogen activator inhibitor type 1) to the biological growth behavior of esophageal cancer, as well as their influence on survival in esophageal cancer. MATERIALS AND METHODS: The expression and distribution of uPA, uPAR and PAI-1 were analyzed by Northern blot analysis and immunostaining in 41 resected esophageal cancers and in normal esophagi. RESULTS: Northern blot analysis revealed a 5.0-, 3.6- and 5.4-fold increase in uPA, uPAR, and PAI-1 mRNA levels in esophageal cancer, respectively, in comparison to normal controls (p<0.01). These mRNA moieties were concomitantly increased in 86% of the tumors. uPA activity was 2.3-fold increased in esophageal cancer compared with normal controls (p<0.01). Statistical analysis revealed no differences in uPA, uPAR and PAI-1 immunoreactivity between well-differentiated, moderately-differentiated and poorly-differentiated tumors. Furthermore, survival analysis showed no difference in patients whose tumors exhibited positive uPA and uPAR immunostaining (median 11 months, range 4-36 months) versus patients whose tumors exhibited negative uPA and uPAR immunostaining (median 11 months, range 3-51 months). CONCLUSION: Our data revealed that overexpression of uPA, uPAR and PAI-1 is often present in human esophageal carcinomas. However, up-regulation of these factors is not correlated with tumor differentiation or survival. These findings indicate that, unlike other tumors, uPA, uPAR and PAI-1 seem not to be prognostic markers for esophageal carcinomas.

Timing and extent of surgical intervention in patients from hereditary pancreatic cancer kindreds.

Our knowledge of the molecular and genetic etiology of hereditary pancreatic cancer has expanded considerably and is steadily increasing. However, there are only a few hard data available regarding the clinical and surgical management of these patients. Surgery is currently performed when we detect dysplastic changes in the pancreas or when cancer is suspected. Of the available diagnostic modalities, endoscopic ultrasonography has proven so far to be the most useful for detecting dysplastic changes in the pancreases of patients from hereditary pancreatic cancer kindreds. It seems reasonable, once dysplasia has been diagnosed in a high-risk patient, to proceed to total pancreatectomy. The multifocal nature of dysplastic lesions precludes any type of operation that would leave behind pancreatic tissue. Currently, prophylactic whole-organ resection in the absence of premalignant lesions cannot be recommended since we do not know the exact risk for the development of cancer.