Cystic tumors of the pancreas: high malignant potential.

BACKGROUND: Cystic tumors of the pancreas are rare, accounting for 10% of pancreatic cysts and 1% of all pancreatic tumors; surgery is dictated by their malignant potential. OBJECTIVES: To evaluate the malignancy rate of pancreatic cystic tumors and patient outcome, and to determine predictors for malignant potential. METHODS: We retrospectively reviewed the medical records of patients who underwent pancreatic resection for cystic tumors between January 1996 and December 2007. RESULTS: The charts showed that 116 patients were operated on for a pancreatic cystic tumor; most were women (63%). The chief complaint was abdominal pain (57%). Incidental detection occurred in 27%. Preoperative workup included ultrasound, tomography, endoscopic ultrasound and fine-needle aspiration biopsy. Indications for surgery were mucinous tumor, symptomatic or enlarging cyst under surveillance, high carcinoembryonic antigen levels within the cyst, and typical manifestations of intraductal papillary mucinous tumor (IPMT). All tumors but one were resectable. Whipple operation was performed in 40%, distal pancreatectomy in 55% and total pancreatectomy in 5%. Mucinous tumors were found in 40%, of which 37T were cystadenocarcinoma and/or borderline tumor. IPMT was found in 39%; 38% of them with cancer. Other pathologies included symptomatic serous cystadenomas, neuroendocrine cystic tumors and pseudopapillary tumors. The perioperative mortality rate was 2.6%. Five-year survival rates for patients with benign vs. invasive/borderline mucinous neoplasms was 90% vs. 59%, and for non-invasive vs. invasive IPMT 89% vs. 45% respectively. CONCLUSIONS: Cystic tumors of the pancreas should be carefully evaluated. Surgery should be considered when a mucinous component is suspected due to the high rate of malignancy. Complete resection carries a high cure rate even in the presence of cancer.

[Post-operative delirium of the elderly patient--an iceberg?].

Post-operative delirium is common, and has an incidence of 37-74% as reported in different publications. The growing rates of the elderly among surgical patients makes that condition more relevant than ever, since these populations are highly susceptible to develop this condition. Contrary to the common assumption, delirium is not a unique complication of the elderly alone. Trauma and young surgical patients may also present its manifestations after major and complicated surgery in the different intensive care units. Post-operative delirium was shown to precede long term complications such as dementia. Many of the patients that develop delirium will be sent to long and complicated rehabilitation units, after being reLeased from hospitalization, thus increasing the economic burden on the medical system. Furthermore, the once recognized "ICU Psychoses" are no longer exclusive to intensive care units alone, and nowadays, infiltrate to all surgical departments. Simple, bedside clinical tools were developed, for rapid diagnoses of post-operative delirium. Adequate and on time diagnosis of this condition is crucial in the surgical patient, as it may be the only sign that predicts other severe surgical complications. This review exposes aspects of post-operative delirium in the elderly patient. Diagnostic modalities, as well as current management recommendations are discussed.

Pancreatic cancer: surgery is a feasible therapeutic option for elderly patients.

BACKGROUND: Compromised physiological reserve, comorbidities, and the natural history of pancreatic cancer may deny pancreatic resection from elderly patients. We evaluated outcomes of elderly patients amenable to pancreatic surgery. METHODS: The medical records of all patients who underwent pancreatic resection at our institution (1995-2007) were retrospectively reviewed. Patient, tumor, and outcomes characteristics in elderly patients aged ≥ 70 years were compared to a younger cohort (<70 y). RESULTS: Of 460 patients who had surgery for pancreatic neoplasm, 166 (36%) aged ≥ 70 y. Compared to patients < 70 y (n = 294), elderly patients had more associated comorbidities; 72% vs. 43% (p = 0.01) and a higher rate of malignant pathologies; 73% vs. 59% (p = 0.002). Operative time and blood products consumption were comparable; however, elderly patients had more post-operative complications (41% vs. 29%; p = 0.01), longer hospital stay (26.2 vs. 19.7 days; p < 0.0001), and a higher incidence of peri-operative mortality (5.4% vs. 1.4%; p = 0.01). Multivariable analysis identified age ≥ 70 y as an independent predictor of shorter disease-specific survival (DSS) among patients who had surgery for pancreatic adenocarcinoma (n = 224). Median DSS for patients aged ≥ 70 y vs. < 70 y were 15 months (SE: 1.6) vs. 20 months (SE: 3.4), respectively (p = 0.05). One, two, and 5-Y DSS rates for the cohort of elderly patients were 58%, 36% and 23%, respectively. CONCLUSIONS: Properly selected elderly patients can undergo pancreatic resection with acceptable post-operative morbidity and mortality rates. Long term survival is achievable even in the presence of adenocarcinoma and therefore surgery should be seriously considered in these patients.

Pancreatic incidentalomas: high rate of potentially malignant tumors.

BACKGROUND: Pancreatic incidentaloma (PI) is an increasingly common diagnosis that has received little attention. We characterized these tumors and compared them with symptomatic pancreatic tumors (nonincidentaloma [NI]). STUDY DESIGN: A retrospective database of 475 consecutive pancreatectomies that were performed from January 1995 to June 2007 at our institution was analyzed. Data for PI and NI patient cohorts were compared. RESULTS: Sixty-four PIs (13.5%) and 411 NIs (86.5%) were identified; 21% of pancreatic body and tail tumors versus 9% of tumors located in the pancreatic head were incidentally diagnosed (p = 0.001). Twenty-two PIs (34%) versus 278 NIs (67%) were malignant (p < 0.0001), 38 PIs (60%) were premalignant, and the remaining 4 (6%) had little or no risk for malignant progression. Intrapapillary mucinous cystic tumor was the most common diagnosis in the PI group (23.4%, n = 15). Of these, 13.3% (n = 2) were invasive versus 40.6% (n = 15) in the NI group (p = 0.02). Likewise, pathologic features for ductal adenocarcinomas were more favorable in PI versus NI tumors. Overall, PI patients had prolonged median disease-specific survival: 145 versus 46 months (p = 0.001). Median disease-specific survival for PI versus NI patients treated for adenocarcinoma were 22 versus 19 months, respectively (p = 0.4); 5-year disease-specific survival for PI versus NI patients treated for intrapapillary mucinous cystic tumor/mucinous cystadenoma were 94% versus 68%, respectively (p = 0.07). CONCLUSIONS: Operation for PI is common, and a substantial proportion of these lesions might be malignant or premalignant. Resection of these early tumors in asymptomatic individuals is associated with improved survival, as compared with patients with symptomatic disease.

Usage of blood products in multiple-casualty incidents: the experience of a level I trauma center in Israel.

OBJECTIVE: To predict how much blood will be needed based on the number of injured patients arriving after a multiple-casualty incident. DESIGN: A retrospective study evaluating data collected in 18 consecutive terrorist attacks in the city of Tel Aviv between January 1997 and February 2005. SETTING: A large, urban trauma center. PATIENTS: A total of 986 patients in 18 events. MAIN OUTCOME MEASURES: Number of packed red blood cell (PRBC) units transfused per patient. RESULTS: A total of 332 U of PRBCs were transfused. Half of the PRBC units were administered as massive transfusions to 4.7% of the patients. The number of PRBC units transfused per patient index (PPI) was related to incident size (mean [SD], 0.70 [1.60] to 1.50 [1.60]). The most frequent major blood group transfused was type O (50%). Half of the units of PRBCs were supplied during the first 2 hours. CONCLUSIONS: One unit of blood per evacuated victim is sufficient in a small multiple-casualty incident and 2 U is sufficient in a large multiple-casualty incident. Half of the PRBC units should be blood group O.

Immunomodulatory effects of ciprofloxacin in TNBS-induced colitis in mice.

BACKGROUND: Crohn's exacerbation and pouchitis are commonly treated with ciprofloxacin and metronidazole. Few studies have shown an advantage of this regimen compared with other antibiotics. Most attributed the effect to its better antibacterial coverage. Others have shown an apparent anti-inflammatory effect of quinolones in several in vitro and in vivo models of inflammation other than inflammatory bowel diseases (IBD). Our objective was to test the hypothesis that ciprofloxacin may act as an anti-inflammatory agent rather than just an antibacterial drug using a model of chemical colitis. METHODS: TNBS colitis was induced in BALB/c mice. The anti-inflammatory effect of ciprofloxacin compared with ceftazidime and dexamethasone was assessed. RESULTS: Mice treated with ciprofloxacin (7.5 mg/kg or 15 mg/kg) had significant reductions in clinical signs, body weight loss, splenic and colonic weight increase compared with saline-treated and ceftazidime-treated mice. Histologic analysis showed mild inflammation in ciprofloxacin-treated mice with a mean score of 3.8 +/- 0.5 points compared with moderate colitis scored 7.8 +/- 1.3 and 9.5 +/- 0.5 points in saline and ceftazidime-treated mice, respectively. Analysis of cytokine levels in colon homogenates showed a significant decrease of IL-1beta, IL-8, and TNFalpha levels in ciprofloxacin-treated animals. Immunohistochemistry for NFkappaB showed strong positivity in saline and ceftazidime-treated mice in contrast to weak focal stain in ciprofloxacin- and dexamethasone-treated mice. CONCLUSIONS: These findings imply that ciprofloxacin has an anti-inflammatory effect, rather than just an antibacterial one, making its use favorable in IBD patients.

Non-hip fracture-associated trauma in the elderly population.

BACKGROUND: The rate of trauma in the elderly is growing. OBJECTIVES: To evaluate the characteristics of non-hip fracture-associated trauma in elderly patients at a level I trauma center. METHODS: The study database of this retrospective cohort study was the trauma registry of a level I trauma center. Trauma patients admitted from January 2001 to December 2003 were stratified into different age groups. Patients with the diagnosis of hip fracture were excluded. RESULTS: The study group comprised 7629 patients. The non-hip fracture elderly group consisted of 1067 patients, 63.3% women and 36.7% men. The predominant mechanism of injury was falls (70.5%) and most of the injuries were blunt (94.1%). Injury Severity Score was found to increase significantly with age. The average mortality rate among the elderly was 6.1%. Age, ISS, Glasgow Coma Score on admission, and systolic blood pressure on admission were found to be independent predictors of mortality. CONCLUSIONS: Falls remain the predominant cause of injury in the elderly. Since risk factors for mortality can be identified, an effective community prevention program can help combat the future expected increase in morbidity and mortality associated with trauma in the elderly.