Pancreatic neuroendocrine microadenomatosis presenting as a functional VIPoma.

Pancreatic microadenomas are benign tumors of neuroendocrine origin less than 5 mm in size. Whereas most microadenomas are non-functional; a few rare functional pancreatic microadenomas have been described in the setting of multiple endocrine neoplasia type one (MEN-1). In this report, we describe a unique case of multiple functional microadenomas of the pancreatic head in a patient who presented with persistent secretory diarrhea, refractory hypokalemia, metabolic acidosis and elevated plasma vasoactive intestinal peptide (VIP) levels. Following extensive serologic, radiographic and endoscopic work up, our patient underwent open pancreaticoduodenectomy with subsequent resolution of diarrheal symptoms and electrolyte abnormalities on postoperative follow up.

Patient Outcomes After Stent Failure for the Treatment of Acute Esophageal Perforation.

BACKGROUND: Esophageal stent placement for acute esophageal perforation has become part of the treatment algorithm for many thoracic surgery programs. Despite high success rates, there are patients for which stent placement is not successful. This investigation summarizes the outcomes of a relatively large group of such patients. METHODS: Patients who underwent esophageal stent placement for an acute perforation but required conversion to another form of therapy were identified from a prospectively collected institutional database. Excluded were patients whose perforation was associated with a malignancy. Patient demographics, operative and nonoperative invasive procedures, morbidities, mortality, and 6-month follow-up after discharge were reviewed. RESULTS: Between 2008 and 2015, 26 patients who failed to seal their esophageal leak after stent placement were identified. Eighteen (69%) of these patients required an operative repair with primary closure of the perforation. Four (15%) primary repairs had a persistent leak controlled with subsequent stent placement. Four (15%) patients required an esophagectomy with cervical esophagostomy. Three patients (11%), because of comorbid conditions, were referred for hospice care. One patient (3%) refused operative repair and developed a chronic fistula that resolved with subsequent stent placement. CONCLUSIONS: Esophageal stent placement continues to be a safe and effective treatment for acute esophageal perforation. Patients whose perforation does not seal with initial stent placement can be treated with primary surgical repair or esophagectomy without increasing their morbidity or mortality or compromising their prognosis.

Endoscopic management of esophageal leaks.

Traditionally, gold standard treatment for an acute esophageal perforation has been operative repair. Over the past two decades, there has been a paradigm shift towards the use of esophageal stents. Recent advances in biomaterial allowed a new generation of stents to be manufactured that combined (I) a non-permeable covering; (II) radial force sufficient to occlude a transmural esophageal injury and (III) improved ease of removability. The amalgamation of these developments set the stage for utilizing esophageal stents as part of the management algorithm of an acute esophageal perforation. This provides a safe and less invasive treatment route in lieu of direct primary repair and its well-documented significant failure rate. Esophageal stent placement for failed operative repair or esophageal leaks also had the potential to minimize the need for esophageal resection and diversion. When included in a multimodality hybrid treatment protocol, esophageal stents can optimize healing success rates and minimize the risks of adverse complications. This review summarizes the modern history of esophageal stent use in the treatment of esophageal perforation as well as the evidenced based recommendations for the use of esophageal stent placement in the treatment of acute esophageal perforation.

Clostridium difficile colitis: A clinical review.

BACKGROUND: Clostridium difficile colitis is an important cause of morbidity and mortality in the surgical patient. In recent years, Clostridium difficile infections have shown marked increases in frequency, severity, and resistance to standard treatment. With urgent operative interventions and novel endoscopic approaches, pseudomembranous colitis is being seen more commonly in surgical practices. DATA SOURCES: In this paper, we will review a number of papers from the literature. We will discuss the epidemiology, evaluation and treatment of Clostridium difficile infection. Fulminant colitis may require emergency operation. For the surgical endoscopist, fecal microbiota transplantation restores the gastrointestinal flora, and has been shown to be effective in more than 80% of patients. CONCLUSION: Clostridium difficile infection is a major cause of healthcare-related diarrhea leading to increased morbidity and mortality in surgical patients. Increases in failure rates and resistance to current treatments are clinical and economic challenges in the healthcare situation.

Maternal serum adiponectin and infant birthweight: the role of adiponectin isoform distribution.

OBJECTIVE: Adiponectin is an insulin-sensitizing protein that circulates in oligomeric complexes, including trimers, hexamers and high-molecular-weight (HMW) multimers. In pregnant women, conflicting associations have been reported between maternal serum levels of total adiponectin (i.e. reflecting all isoforms) and infant birthweight. As the HMW complex has recently been proposed as the primary mediator of metabolic bioactivity, we hypothesized that differences in isoform distribution may underlie these conflicting reports. Therefore, we evaluated the relationship between maternal adiponectin isoforms and infant birthweight. DESIGN/PATIENTS/MEASUREMENTS: HMW and total adiponectin, as well as the ratio of HMW to total adiponectin (ratio known as S(A)), were measured in healthy pregnant Caucasian women (n = 58) undergoing an oral glucose tolerance test (OGTT), following an abnormal glucose challenge test. RESULTS: On univariate analysis adjusted for neonate gender and length of gestation, birthweight was positively correlated with weight gain in pregnancy (r = 0.29, P = 0.031) and inversely associated with the IS(OGTT) index of insulin sensitivity (r = -0.27, P = 0.041), total adiponectin (r = -0.31, P = 0.021), HMW adiponectin (r = -0.34, P = 0.0093) and S(A) (r = -0.34, P = 0.011). On multiple linear regression analyses, however, total adiponectin was not related to birthweight. By contrast, HMW adiponectin was related at borderline significance (t = -1.87, P = 0.068), while S(A) emerged as an independent negative determinant of infant birthweight (t = -2.46, P = 0.0175). Adjusted mean neonatal birthweight was significantly higher in the infants of women comprising the lowest tertile of S(A) compared to women in the highest tertile of S(A) (3684 vs. 3424 g, P = 0.0375). CONCLUSIONS: The proportion of maternal serum adiponectin in HMW form (S(A)) is independently and inversely associated with infant birthweight. Thus, adiponectin isoform distribution, rather than total adiponectin concentration, may be a correlate of foetal size.