Biliary, pancreatic, and hepatic imaging for the general surgeon.

Technologic advancements have allowed imaging modalities to become more useful in the diagnosis of hepatobiliary and pancreatic disorders. Computed tomography scanners now use multidetector row technology with contrast-delayed imaging for quicker and more accurate imaging. Magnetic resonance imaging with cholangiopancreatography can more clearly delineate liver lesions and the biliary and pancreatic ducts, and can diagnose pathologic conditions early in their course. Newer technologies, such as single-operator cholangioscopy and endoscopic ultrasonography, have sometimes shown superiority to traditional modalities. This article addresses the literature regarding available imaging techniques in the diagnosis and treatment of common surgical hepatobiliary and pancreatic diseases.

Surgical considerations for the familial cancer syndrome, neurofibromatosis 1: a comprehensive review.

Neurofibromatosis 1 is one of the more common inheritable disorders that surgeons may encounter. A plethora of systemic associations, both benign and malignant, can affect these patients, and an acute awareness of these associations is essential for proper surgical care. A complete review of this disorder from the surgical perspective follows, highlighting the importance of this awareness. A brief review on the management and follow-up of surgical malignancies associated with this disorder is included.

Endometrial adenocarcinoma metastatic to the right ventricle: a case report and review of the literature.

BACKGROUND: Endometrial adenocarcinoma of any histologic type rarely metastasizes to the heart. Only three such metastases to the myocardium and three to the pericardium have been reported antemortem in the literature. The rarity of this metastasis is likely explained by the relative avascularity of the endocardium and velocity of blood. METHODS AND RESULTS: A 62-year-old female was admitted for increasing shortness of breath over the previous month. Her past medical history was significant for a resected Stage IC endometrial adenocarcinoma endometrioid type 15 months prior. The tumor was found to be a poorly differentiated (Grade 3) endometrial adenocarcinoma invading over half the myometrium. The periaortic and pelvic lymph nodes as well as the cervix and pelvic organs were free of tumor. The patient was later treated with adjuvant external beam radiotherapy. An echocardiogram demonstrated a large right ventricular mass. Subsequent endocardial biopsy showed a poorly differentiated, Grade 3, endometrial adenocarcinoma of endometrioid histologic type. The tumor was deemed inoperable given its size and vast involvement of the myocardium so palliative care was provided and the patient expired 17 days later. CONCLUSION: Management of metastatic adenocarcinoma to the heart is not well established due to the rarity of this lesion. Previously reported cases vary in the therapeutic approach as well as the outcome. To this date the best outcome has been a survival of 6 years after treatment of the metastasis with radiotherapy and concurrent cisplatin and pegylated liposomal doxorubicin.

Multiple sequential intussusceptions causing bowel obstruction in a preterm neonate.

We present a case of multiple sequential intussusceptions in a preterm neonate that resulted in mechanical bowel obstruction. The differential diagnosis of abdominal obstruction in a neonate is extensive, requiring a thorough review of presentation and methodical workup to determine etiology (Teitelbaum DH. Obturation obstruction of the intestine. In: O'Neill JA, editor. Principles of pediatric surgery. St. Louis (MO): Mosby, 2003. p. 605-612). Rare causes must be considered in a patient with no obvious etiology on contrast studies and persistent symptoms. Intussusception, a common cause of obstruction and pain in older infants and children, can rarely occur in neonates and is unfortunately difficult to diagnose preoperatively (J Pediatr. 1955;47:87-94; Pediatr Surg Int. 1998;13:232-236; Ann Saudi Med. 2000; 20:310-312; Eur J Pediatr. 1999;158:830-832; J Paedatr Child Health. 2004;40:388-391; Radiology. 1977;125:463-466; J Perinat Med. 2004;32:190-194).

LaPlace's law revisited: cecal perforation as an unusual presentation of pancreatic carcinoma.

BACKGROUND: Pancreatic cancer is often locally and distally aggressive, but initial presentation as cecal perforation is uncommon. CASE PRESENTATION: We describe a patient presenting with pneumoperitoneum, found at initial exploration to have a cecal perforation believed to be secondary to a large cecal adenoma, after palpation of the remainder of the colon revealed hard stool but no distal obstruction. Postoperatively, however, the patient progressed to large bowel obstruction and upon reexploration, a mass could now be delineated, encompassing the splenic flexure, splenic hilum, and distal pancreas. Histological evaluation determined this was locally invasive pancreatic adenocarcinoma, and therefore the true etiology of the original cecal perforation. CONCLUSION: Any perforation localized to the cecum must be highly suspicious for a distal obstruction, as dictated by the law of LaPlace.