Delayed duodenal stump blow-out following total gastrectomy for cancer: Heightened awareness for the continued presence of the surgical past in the present is the key to a successful duodenal stump disruption management. A case report.

INTRODUCTION: Duodenal stump disruption remains one of the most dreadful postgastrectomy complications, posing an overwhelming therapeutic challenge. PRESENTATION OF CASE: The present report describes the extremely rare occurrence of a delayed duodenal stump disruption following total gastrectomy with Roux-en-Y esophagojejunostomy for cancer, because of mechanical obstruction of the distal jejunum resulting in increased backpressure on afferent limp and duodenal stump. Surgical management included repair of distal jejunum obstruction, mobilization and re-stapling of the duodenum at the level of its intact second part and retrograde decompressing tube duodenostomy through the proximal jejunum. DISCUSSION: Several strategies have been proposed for the successful management post-gastrectomy duodenal stump disruption however; its treatment planning is absolutely determined by the presence or not of generalized peritonitis and hemodynamic instability with hostile abdomen. In such scenario, urgent reoperation is mandatory and the damage control principle should govern the operative treatment. CONCLUSION: Considering that scientific data about duodenal stump disruption have virtually disappeared from the current medical literature, this report by contradicting the anachronism of this complication aims to serve as a useful reminder for gastrointestinal surgeons to be familiar with the surgical techniques that provide the ability to properly manage this dreadful postoperative complication.

Mid common bile duct inflammatory pseudotumor mimicking cholangiocarcinoma. A case report and literature review.

INTRODUCTION: Biliary inflammatory pseudotumors (IPTs) represent an exceptional benign cause of obstructive jaundice. These lesions are often mistaken for cholangiocarcinomas and are treated with major resections, because their final diagnosis can be achieved only after formal pathological examination of the resected specimen. Consequently, biliary IPTs are usually managed with unnecessary major resections. PRESENTATION OF CASE: A 71-year-old female patient underwent an extra-hepatic bile duct resection en-bloc with the gallbladder and regional lymph nodes for an obstructing intraluminal growing tumor of the mid common bile duct (CBD). Limited resection was decided intraoperatively because of negative for malignancy fast frozen sections analysis in addition to the benign macroscopic features of the lesion. Histologically the tumor proved an IPT, arising from the bile duct epithelium, composed of inflammatory cells and reactive mesenchymal tissues. DISCUSSION: The present case underlines the value of intraoperative reassessment of patients undergoing surgical resection for histopathologically undiagnosed biliary occupying lesions, in order to optimize their surgical management. CONCLUSION: The probability of benign lesions mimicking cholangiocarcinoma should always be considered to avoid unnecessary major surgical resections, especially in fragile and/or elderly patients.

The role of open necrosectomy in the current management of acute necrotizing pancreatitis: a review article.

The optimal management of necrotizing pancreatitis continues to evolve. Currently, conservative intensive care treatment represents the primary therapy of acute severe necrotizing pancreatitis, aiming at prevention of organ failure. Following this mode of treatment most patients with sterile necroses can be managed successfully. Surgery might be considered as an option in the late phase of the disease for patients with proven infected pancreatic necroses and organ failure. For these patients surgical debridement is still considered the treatment of choice. However, even for this subgroup of patients, the concept of operative strategy has been recently challenged. Nowadays, it is generally accepted that necrotizing pancreatitis with proven infected necroses as well as septic complications directly caused by pancreatic infection are strong indications for surgical management. However, the question of the most appropriate surgical technique for the treatment of pancreatic necroses remains unsettled. At the same time, recent advances in radiological imaging, new developments in interventional radiology, and other minimal access interventions have revolutionised the management of necrotizing pancreatitis. In light of these controversies, the present paper will focus on the current role of surgery in terms of open necrosectomy in the management of severe acute necrotizing pancreatitis.

Acute pancreatitis as the initial manifestation of an adenocarcinoma of the major duodenal papilla in a patient with familial adenomatous polyposis syndrome: a case report and literature review.

We report a case of an ampullary carcinoma presenting as acute pancreatitis in a patient with familial adenomatous polyposis (FAP) syndrome and severe duodenal adenomatosis. A 48-year-old woman was hospitalised because of an episode of acute pancreatitis. She had a history of prophylactic total colectomy for FAP 2 years earlier. On admission, abdominal ultrasonography and computed tomography revealed dilatation of the main pancreatic and common bile duct. Spigelman's stage IV duodenal adenomatosis involving the major duodenal papilla was diagnosed on endoscopy and a classical Whipple procedure was proposed. Pathologic examination of the duodenopancreatectomy specimen revealed a tubular adenocarcinoma of the papilla that occluded the major pancreatic ducts. The patient had no evidence of disease and experienced no recurrent attacks of acute pancreatitis during a 36-month period of follow-up.

Double Duct to Mucosa Pancreaticojejunostomy for Bifid Pancreatic Duct following Pylorus Preserving Pancreaticoduodenectomy: A Case Report.

Bifid pancreatic duct represents a relatively rare anatomical variation of the pancreatic ductal system, in which the main pancreatic duct is bifurcated along its length. This paper describes the challenging surgical management of a 68-year-old male patient, with presumptive diagnosis of periampullary malignancy who underwent a successful double duct to mucosa pancreaticojejunostomy for bifid pancreatic duct. Following pylorus preserving pancreaticoduodenectomy, careful intraoperative inspection of the cut surface of the residual dorsal pancreas identified the main in addition to the secondary pancreatic duct orifice. Bifid duct anatomy was confirmed via intraoperative probing and direct visualization of the ductal orifices. A decision was made for the performance of an end-to-site double duct to mucosa pancreaticojejunostomy. Postoperative outcome was favorable without any complications. Although bifid pancreatic duct is relatively rare, pancreatic surgeons should be aware of this anatomical variation and be familiar with the surgical techniques for its successful management. Lack of knowledge and surgical expertise for dealing with this anatomical variant may lead to serious, life threatening postoperative complications following pancreatic resections.

Retroperitoneal extra-adrenal ganglioneuroma involving the infrahepatic inferior vena cava, celiac axis and superior mesenteric artery: A case report.

INTRODUCTION: Ganglioneuromas are rare benign neoplasms arising from the sympathetic neuroendocrine system. These tumors usually occur in the abdomen and tend to grow around major blood vessels making often their complete excision challenging and demanding. PRESENTATION OF CASE: The authors present the challenging surgical management of a sizable retroperitoneal extra-adrenal ganglioneuroma involving the infrahepatic inferior vena cava, portal triad, celiac axis and superior mesenteric artery in a 23-year-old female patient. The tumor was safely and completely excised in toto with preservation of all neighboring vital anatomical structures using a midi laparotomy access. DISCUSSION: Ganglioneuromas should be included in the differential diagnosis of any retroperitoneal mass. Their management involves total surgical excision however, in some instances; it can be challenging and demanding because of their tendency to engage neighboring vital anatomical structures. CONCLUSION: A surgical strategy including meticulous operative dissection guided by the quality principles of surgical oncology although challenging and demanding can result to a safe and complete tumor excision, which is directly correlated with an improved patients' postoperative outcome and excellent prognosis.

Intraoperative hyperthermia in conjunction with multi-schedule chemotherapy (pre-, intra- and post-operative), by-pass surgery, and post-operative radiotherapy for the management of unresectable pancreatic adenocarcinoma.

The aim of this study was to evaluate the potential role of intraoperative hyperthermia (IOHT) in the management of stage IV pancreatic adenocarcinoma. Twenty-seven patients (group A) received pre-operative chemotherapy (5-FU), by-pass surgery with intraoperative bolus infusion of 5-FU and post-operatively multi-agent chemotherapy plus sandostatin and external beam irradiation (45Gy, 25 fractions, 5 days a week). In a non-randomized way, 10 patients (group B) received an additional single session of IOHT (43-45 degrees C, 1h) performed directly on the tumour using a waveguide applicator (433MHz) with interstitial measurements of temperature measured. A brief instrument was developed for evaluating patients' quality of life. No progressive disease (PD) was noticed in group B vs 11% (3/27) of PD in group A. There was also a significant increase of overall survival (OS) in group B vs A patients (p = 0.029, log-rank test). Moreover, there was a significant improvement for group B vs A patients regarding Karnofsky performance status (p < 0.001, Mann-Whitney test), pain score (p < 0.001, Mann-Whitney test) and quality of life score (p = 0.031, Mann-Whitney test). A significant correlation was noticed between OS and thermal parameters such as average T(min) (p = 0.043), average T(max) (p = 0.027) and cumulative minutes T(90) >or= 44 degrees C (p < 0.001). Combined IOHT with chemotherapy (pre-, intra- and post-operative) and external beam post-operative radiotherapy seem to have a potential benefit in the management of unresectable adenocarcinoma of the pancreas, concerning local response, OS and quality of life. Further clinical studies to evaluate the benefit of IOHT suggested in this study are warranted.

Cytoreductive surgery combined with intraoperative chemo-hyperthermia and postoperative radiotherapy in the management of advanced pancreatic adenocarcinoma: feasibility aspects and efficacy.

BACKGROUND/PURPOSE: The aim of our study was to evaluate the feasibility and the efficacy of cytoreductive surgery (CS) with intraoperative chemo-hyperthermia in the management of advanced stage IVA (T4N0M0) pancreatic cancer. METHODS: From August 1995 through March 1996, seven patients with unresectable adenocarcinoma of the pancreas underwent CS, with preoperative chemotherapy (5-fluorouracil [FU] for 96 h), plus 45-Gy external beam postoperative irradiation with a 6-MeV linear accelerator (1.8 Gy per fraction, 5 days per week). A single session of intraoperative hyperthermia was performed with a waveguide-type applicator operating at 433 MHz, and temperature was measured by inserting a flexiguide needle catheter carrying a thermometry probe with three measuring points into the tumor. The tumor region was heated to 43 degrees C-45 degrees C for up to 60 min, while 5-FU 500 mg was injected simultaneously through the gastroduodenal artery into the splenic artery (intraoperative regional chemotherapy). RESULTS: Postoperative recovery was uneventful for all patients. After the combined treatment, there was a significant decrease in the values of both serum carcinoembryonic antigen (CEA; P = 0.017, Wilcoxon test) and carbohydrate antigen (CA)19-9 ( P = 0.016; Wilcoxon test), from 7.6 +/- 1.5 ng/ml CEA and 869.6 +/- 126.9 U/ml CA to 3.5 +/- 0.8 ng/ml CEA and 104.7 +/- 35.4 U/ml CA19-9. Moreover, there was a significant improvement ( P = 0.016; Wilcoxon test) in Eastern Cooperative Oncology Group performance status, pain score, and body mass index. The median overall survival was 18.5 (SE, 1.8) months. CONCLUSIONS: Our preliminary clinical results suggest the tolerability and the considerable potential advantage of using cytoreductive resection with preoperative chemotherapy, intraoperative chemo-hyperthermia, and external beam postoperative radiotherapy for the management of advanced adenocarcinoma of the pancreas.

Radiation therapy alone for growth hormone-producing pituitary adenomas.

We present our experience in the treatment of growth hormone (GH)-producing pituitary adenomas using irradiation alone. Between 1983 and 1991, 21 patients suffering from GH-secreting pituitary adenomas were treated with radiotherapy alone. Two bilateral opposing coaxial fields were used in 10 patients and in the remaining 11 a third frontovertex field was added. Treatment was given in 1.8-2 Gy daily fractions and total dose ranged between 45 and 54 Gy. Treatment was given using a cobalt unit. Four patients treated with somatostatin prior to and 14 patients treated after the end of radiotherapy experienced symptom relief for 6-28 weeks. The 5-year actuarial rate of disease control was 72%. Five out of six failed patients had macroadenomas. Hypopituitarism was observed in 5/21 (24%) patients. Whereas RT alone is effective in the treatment of microadenomas, this is not true for large infiltrative macroadenomas.

Megavoltage pituitary irradiation lowers but seldom leads to safe GH levels in acromegaly: a long-term follow-up study.

Radiotherapy (RT) has long been used in the treatment of acromegaly, but confusion regarding the definition of biochemical cure has hampered interpretation of previous reports on the outcome of this treatment. In the present study we present additional data using the currently accepted criteria of biochemical cure in a large group of patients followed up by our department. Forty-six acromegalic patients were treated with external beam megavoltage RT and followed up for a mean of 7.6 years (range 2-22 years). Only four patients had had previous surgical treatment by either transsphenoidal or transfrontal routes. Following RT, mean basal GH levels decreased from 30.9 ng/ml (5-96 ng/ml) to 11.5 ng/ml (1-36 ng/ml) at 10 years of follow up with a further fall to 6.1 ng/ml (1-29 ng/ml) in those patients followed up for more than 10 years. As a result, although mean GH levels of less than 5 ng/ml were achieved in 9/28 (30.1%) at 5 years, 6/19 (31.6%) at 10 years, and in 6/11 (54.5%) of those patients followed up for more than 10 years post-RT, only 0/28 (0%), 7/28 (25%), 4/19 (21%) and 1/11 (1%) achieved GH levels of <2.5 ng/ml at 2, 5. 10 and >10 years following RT. Thus, in the whole series only 10/48 (20.8%) patients showed a decrease of GH level to less than 2.5 ng/ml at their latest follow up. Hypopituitarism as a result of RT was only infrequently observed in this series; gonadal deficiency developed in 12 (26.6%) patients, thyrotrophin (TSH) deficiency in 3 (6.6%) and adrenocorticotrophin deficiency in 2 (4.4%). In conclusion, megavoltage RT is an effective treatment for the control of GH hypersecretion in acromegaly, with a continuing lowering effect for several years following RT but seldom leads to safe GH levels.

Pelvic floor reconstruction after major cancer surgery.

BACKGROUND: Many surgical techniques to keep the small intestine out of the pelvis after cancer surgery have been developed. METHODS: We used part of the ileum and its mesentery sutured around the linea terminalis in ten patients who underwent surgery for rectal or gynecologic carcinomas. RESULTS: All imaging studies of our patients on the tenth postoperative day confirmed the position of the bowel above the pelvis. Four of ten patients had radiation treatment postoperatively without any problems. CONCLUSION: Use of the ileum to reconstruct the pelvic floor seems to be a simple and efficacious technique to keep the pelvic area free. We believe this warrants further investigation in a larger number of patients.

Combined teletherapy and intracavitary brachytherapy boost for the treatment of nasopharyngeal carcinoma.

For the non-metastatic nasopharyngeal carcinoma, external beam radiation therapy (median dose 64 Gy) and a boost of intracavitary irradiation (ICRT) has been given. Caesium-137 pellets of 40 mCi were used at a dose rate of 3-3.5 Gy/h, 1 cm from the sources. The median dose was 8.5 Gy. Overall 5-year actuarial survival for the 48 studied patients was 60.4% and LRFS was 64%. The procedure was well tolerated by our patients.

Radiotherapy effects on vertebral bone marrow: easily recognizable changes in T2 relaxation times.

The effect of localized radiotherapy on vertebral bone marrow was demonstrated in two patients using quantitative MRI studies with pixel-by-pixel measurement of T2 relaxation times with generation of T2 images. Conventional T1-weighted spin-echo images were obtained as well. Irradiated vertebral bone marrow was found to have longer T2 relaxation times than the neighboring nonirradiated bone marrow. These changes corresponded to the increased signal intensity on T1-weighted images and to the field of radiotherapy and were noted 2.5 to 32 mo after radiotherapy. Radiologists should be aware of the increased T2 relaxation times in irradiated bone marrow to correctly assess spinal disorders in irradiated patients. The reported T2 changes may reflect the abundance of adipose cells that proliferate in bone marrow after radiotherapy, or may indicate an additional histological change, such as bone marrow necrosis or edema. Conclusive histological proof remains to be obtained.

MRI of abdominal hydatid disease.

Seventy hydatid cysts in 30 patients were studied with magnetic resonance imaging (MRI) and computed tomography (CT); all cases were confirmed surgically. MRI detected all cysts when confined to solid organs, whereas small-sized cysts (< or = 2 cm) may be missed when located in the peritoneal cavity. Hydatid cysts of less than 3 cm (noncomplicated) present no specific findings of hydatid disease. MRI findings suggesting hydatid disease demonstrate a relatively thick hydatid cyst wall, daughter cysts, and germinal membrane detachment. T2-weighted images proved to be superior to T1- or PD-weighted images in demonstrating hydatid cyst wall thickness, germinal membrane detachment, and daughter cysts. In all spin-echo sequences, the maternal cystic content presented much higher signal intensities than that of daughter cysts. This difference in signal intensity is more obvious in T2-weighted images, except in complicated, infected cases. CT proved to be superior to MRI in demonstrating wall calcifications.

A feasibility study of partially accelerated radiotherapy for invasive bladder cancer.

Thirty-nine patients with histologically confirmed invasive bladder carcinoma (T2-3, N0, M0) were treated with a partially accelerated radiotherapy scheme. After 40 Gy/4 weeks of conventional fractionation we have accelerated the treatment in the last week giving two daily fractions of 2 Gy each, 4-6 h apart in the bladder only. Although the follow-up of some of the patients is not very long our results indicate that this relatively short radiotherapeutic scheme is feasible, convenient and probably safe for patients living in remote areas.

Clinical expressions of the expansion of the bone marrow in the chronic anemias: the role of radiotherapy.

PURPOSE: In the chronic anemias and particularly in the hemoglobinopathies and in the myeloproliferative disorders there is compensatory hypertrophy and expansion of the bone marrow. This results in severe rarefaction of the bone and in extramedullary hemopoiesis. METHODS AND MATERIALS: Morbid clinical expressions of the osseous changes are spontaneous fractures and osteoarthropathy, while extramedullary hemopoiesis presenting in the form of tumor-like masses may cause pressure symptoms on adjacent organs, particularly on the spinal cord. RESULTS AND CONCLUSION: Extramedullary hemopoiesis masses can be easily diagnosed since they present typical radiological appearance. Radiotherapy has been used for the treatment of these conditions.

Oral magnetic particles as a contrast agent for MR imaging of the abdomen. A phase III clinical trial.

Twenty patients were investigated with MR imaging of the abdomen before and after the administration of oral magnetic particles in the form of a per os solution for opacification of the gastrointestinal lumen. The parameters which were evaluated were a) distribution of the contrast medium in the gastrointestinal tract, b) delineation with the contrast medium of the region of interest c) image quality of general contract effect of the contrast medium d) diagnostic accuracy compared with CT and plain MRI of the same region. At a concentration of 0.5 mg/oral magnetic particles produced a constant negative signal from the gastro- intestinal tract in all spin echo sequences (T1 weighted, T2 weighted, proton density). Its diagnostic accuracy was similar to CT but better than plain MR examination of the same region in 70% of the cases. The diagnostic accuracy was inferior in the lower abdomen because of underdistension of the bowel. Perhaps the solution to the problem would be the combined per os and per rectum administration of the contrast medium.