Intraductal Papillary Mucinous Neoplasm of the Pancreas: Current Perspectives.

In this article, we aimed to review the literature on the clinics and management of intraductal papillary mucinous neoplasm (IPMN). Intraductal papillary mucinous neoplasm of the pancreas is a mucin-producing cystic mass originating from the pancreatic ductal system. Approximately 25% of the pancreatic neoplasms resected surgically and 50% of pancreatic cysts detected incidentally are IPMNs. They can be benign or malignant in character, while malignant transformation of benign forms can be encountered. It is important to determine IPMNs in the early stages, implementation of appropriate treatment approaches, and follow-up to provide better prognosis. We reviewed the studies published in the English medical literature through PubMed and summarized the clinical features and current approaches to the treatment and follow-up of the IPMN. Due to the recent advances and widespread implementation of radiological imaging techniques, the incidental detection rate of IPMNs has increased significantly. The effective treatment of the disease is possible via the detailed diagnosis of the disease, determination of the prognostic factors, and a multidisciplinary approach. Recent literature also emphasized the molecular profile determination approaches for assessment of prognosis of patients with IPMN. Current knowledge on IPMN, a clinically important epidemiologic problem, shows that the treatment should be personalized considering the prognostic features and life expectancy of the patient.

Nonfunctional Pancreatic Neuroendocrine Tumors: Advances in Diagnosis, Management, and Controversies.

In this article, we aimed to review the literature on the clinics and management of nonfunctional pancreatic neuroendocrine tumors (NPNET). Pancreatic neuroendocrine tumors (PNET) are rare tumors with a <1/100,000 incidence and constitute approximately 2 to 10% of all pancreatic tumors. Nonfunctional PNETs are difficult to detect at early stages since they have no symptoms. Except those detected accidentally during different diagnoses, the majority of PNETs are detected in the advanced stages, with symptoms related to tumor size or liver metastasis. We reviewed the studies published in the English medical literature through PubMed and summarized the clinical features and current approaches to the treatment and follow-up of the NPNET. The common imaging techniques used for the detection of tumor localization, size, locoregional, and metastatic involvement are contrasted computed tomography, magnetic resonance imaging, endoscopic ultrasonography, and somatostatin receptor scintigraphy. Surgical resection is the only curative treatment. However, in advanced locoregional disease and liver metastasis, interventive ablative therapies such as palliative reductive surgery, selective hepatic arterial embolization, radiofrequency ablation; and systemic therapies, such as peptide receptor radionuclide therapy, chemotherapy, somatostatin analogous therapy, interferon, VEGF inhibitor, and mTOR inhibitor may be used as symptom relieving or may improve progression-free survival and total survival. Current knowledge on NPNET shows that the treatment should be personalized considering the prognostic features and life expectancy of the patient.

Laparoscopic cholecystectomy in a single, non-teaching hospital: an analysis of 1557 patients.

BACKGROUND: Laparoscopic cholecystectomy may lead to serious complications, although it is the gold standard treatment for gallstones. In this article, the aim was to review our experience with laparoscopic cholecystectomies. SUBJECTS AND METHODS: All laparoscopic cholecystectomies were performed in a single, non-teaching hospital between January 2000 and October 2010 and were reviewed retrospectively to analyze the effect of preoperative risk factors on outcome and the associated major complications. RESULTS: This study included 1557 laparoscopic cholecystectomies, and the mean age of the patients was 54.1±12.3 years. The mean duration of the operation and the mean length of stay were 43.4 minutes and 1.2 days, respectively. Conversion to an open cholecystectomy was necessary in 39 patients, and thus the conversion rate was 2.5%. In total, 57 (3.7%) complications occurred in 51 patients. Serious common bile duct injury was seen in 4 (0.27%) cases. The other common complications included bile leakage in 10 (0.64%) and postoperative bleeding in 7 (0.45%) patients. The mortality rate was 0.13%. Risk factors for conversion to open surgery were male gender, age >55 years, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks. Factors that increased the morbidity rate were male gender, an American Society of Anesthesiologists score of III, emergency admission due to acute cholecystitis, and a history of previous acute cholecystitis attacks. CONCLUSIONS: Our results may serve as a baseline for comparison with future studies done at single, non-teaching hospitals where surgical teams perform laparoscopic cholecystectomies over a long period of time.

Primary malignant deciduoid peritoneal mesothelioma: a report of the cytohistological and immunohistochemical appearances.

Malignant deciduoid mesothelioma (MDM) is a rare variant of epithelioid mesothelioma. This type of tumor might be associated with the asbestos exposure and carries a poor prognosis in general. MDM was first described by Nascimento et al. in 1994 in a peritoneal lesion of a young woman. And its diagnosis is frequently mistaken with florid mesothelial hyperplasia and peritoneal deciduosis. There are 44 MDM cases reported in the literature up today. A 59-year-old woman patient referred to our clinic was identified with an abdominal mass. Computed tomography of whole abdomen of the patient showed a mass with the widest transverse dimension of 65 × 60 mm at abdominal bifurcation in the mesenteric region. The patient was diagnosed with MDM after the cytopathological examination of the fine needle aspiration biopsy performed from the mass. Consequently, she received a total mass excision and right hemicolectomy under general anesthesia. The cytomorphological appearance of the ascitic fluid is detailed for the first time by Gillespie et al. and is described only in two manuscripts. In the present study, we aimed to report a case of a 59-year-old woman since she was diagnosed with MDM and because her cytological findings were further supported by histomorphological and immunohistochemical evaluations of the operation material obtained from the patient.

Lymph node surgery in papillary thyroid carcinoma.

Papillary thyroid carcinoma is the most common type of thyroid cancer, and cervical lymph node metastasis of the disease is high. Lymph node surgery of the papillary thyroid carcinoma is controversial because of the good prognosis of the disease. Although controversy continues on prophylactic lymph node dissection, therapeutic lymph node dissection is recommended in all guidelines for patients who have known lymph node metastases.

The effect of hepatectomy on coagulation: an evaluation by thromboelastography.

OBJECTIVES: Liver has a major role in coagulation. The hemostatic derangements measured by the mostly used coagulation parameters as prothrombin time, activated partial thromboplastin time, and thrombocyte count do not always correlate with the bleeding associated with liver diseases and these factors do not measure the thrombotic risks. So, thromboelastography is used in new clinical and laboratory research. The aim of this study is to study the effect of different levels of hepatectomy on coagulation. METHODS: Laparatomy, 40% hepatectomy, and 70% hepatectomy was performed in three different groups of rats. Prothrombin time, international normalized ratio, activated partial thromboplastin time, thrombocyte count, fibrinogen levels, and thromboelastography parameters were obtained at the 0, 6, and 24th hour of the study. RESULTS: Fibrinogen level at the 24th hour was greater than the early hours in both of the hepatectomy groups. Prothrombin time and international normalized ratio values were significantly higher in hepatectomy groups than in the sham group. There were no statistically significant difference in the clotting time, clot formation time, alpha-angle, and maximum clot firmness values in any of the thromboelastography channels, in any of the study times, in between the sham, 40% hepatectomy, and 70% hepatectomy groups. CONCLUSION: There is no difference between 40 and 70% hepatectomy when the coagulopathy is evaluated. The coagulation derangements as reflected by the increase in fibrinogen and prolongation of prothrombin time and activated partial thromboplastin time after hepatectomy were not supported by thromboelastography parameters in this study.

Renal cell carcinoma metastasis to focal nodular hyperplasia focus on liver in a patient with Von Hippel-Lindau disease.

Von Hippel-Lindau disease is an autosomal dominant disorder occurring in 1 of 36,000 births and associated with various tumors and cysts in the central nervous system and other visceral organs. At present, metastasis from renal cell carcinoma (RCC) and neurologic complications are the most common causes of death from Von Hippel-Lindau disease. We report a case of Von Hippel-Lindau disease diagnosed during a screening and was found to have metastasis of RCC to a focal nodular hyperplasia lesion on the liver. In the literature, misdiagnosis of benign liver lesions as metastases of RCC has been reported, but there has not been a case reported to have a metastasis of RCC within a benign liver lesion. To our knowledge, this is the first case of RCC metastasis to a benign lesion of the liver.

Pancreaticojejunostomy after pancreaticoduodenectomy: results of a new technique.

BACKGROUND/AIMS: Pancreaticoduodenectomy is the standard treatment for periampullary tumors. One of the major causes of morbidity after pancreaticoduodenectomy is the failure of the healing at the pancreaticoenteric anastomosis. The aim of this study is to summarize the results of a new technique which is designed to decrease the panreticoje-junostomy anastomotic leakage. METHODOLOGY: The demographic characteristics, operation indications, types of the pancreaticoduodenectomy, duration of the postoperative hospitalization, morbidity and mortality of the consecutive patients whose pancreaticojejunostomy anastomosis after pancreaticoduodenectomy was performed by modified invagination method at Hacettepe University Medical School Department of General Surgery between February 2005 and December 2007 were evaluated prospectively. RESULTS: Thirtyone patients were included in the study. The operation indications were pancreas cancer for 17 patients, ampulla Vateri cancer for 8 patients, duodenum cancer for 3 patients, cancer of the distal choleduct for 2 patients and gall bladder cancer for 1 patient. Twenty complications had occurred in a total of 15 patients. There were no pancreaticojejunostomy anastomotic leakage and mortality in any of the patients. CONCLUSIONS: An ideal pancreaticojejunostomy anastomosis after pancreaticoduodenectomy should be safe, simple and secure. This modified invagination method seems to be promising when these parameters are taken in to account.

Hepatic focal nodular hyperplasia developing in a Fanconi anemia patient: a case report and literature review.

Fanconi anemia, an autosomal recessive and X-linked disorder, is known to be associated with a variety of neoplasms. Liver tumors are one of the most frequently observed neoplasms but the association between the two disorders remains obscure. We present a case of a 27-year old female Fanconi anemia patient diagnosed with a mass on the right lobe of the liver measuring 90x75x60 mm. Histopathological examination of the mass after right hepatic lobectomy revealed focal nodular hyperplasia. This appears to be the first reported case of a hepatic focal nodular hyperplasia of such proportion associated with Fanconi anemia. Previously reported cases of liver tumors in association with Fanconi anemia in the English Literature were either hepatocellular carcinomas or hepatic adenomas.

Synchronous and metachronous occurrence of gastric adenocarcinoma and gastric lymphoma: A review of the literature.

The occurrence of both primary gastric lymphoma and gastric adenocarcinoma in the same patient is a rare entity. The possible causative factors of synchronous or metachronous occurrence of both malignancies and varieties in the treatment modalities are reviewed according to published cases in English language medical literature.

Giant liver hemangioma: therapy by enucleation or liver resection.

Hemangioma is the most common primary tumor of the liver. The widespread use of ultrasonography (USG) and computed tomography (CT) has made the diagnosis more common. Although the vast majority of hemangiomas are diagnosed incidentally and are asymptomatic, treatment is still controversial. Surgery is the treatment of choice, especially in giant, symptomatic hemangiomas and uncertainty of diagnosis. Twenty-two patients (median age: 46 years) underwent resection (n = 12) or enucleation (n = 10) for liver hemangioma from 1989 to 2002. The primary indication for surgery was abdominal pain. Ten patients who were treated by enucleation were compared with twelve patients who were treated by liver resection. Mean tumor size was 90 mm with a range of 40-270 mm. There were no statistically significant differences in tumor size, preoperative liver function tests, hemoglobin levels, and platelet counts between the two groups. Operative time was longer in the resection group, and statistically significant the difference was (p = 0.048). Blood transfusion requirement and blood loss during intraoperative period were higher in the resection group (p = 0.025, p = 0.01, respectively). There were three postoperative complications, 1 in the enucleation group (pleural effusion), 2 in the resection group (liver abscess and wound infection). There was no surgery-related mortality in either group. Although most hemangiomas can be removed by enucleation or liver resection with low morbidity and mortality, if the location and number of hemangiomas are appropriate, enucleation is the choice of the therapy. Hospital stay, blood transfusion requirement, and blood loss can be kept minimal by the selection of enucleation.

The effects of alpha - tocopherol and verapamil on mucosal functions after gut ischemia / reperfusion.

BACKGROUND/AIMS: We have previously shown that in the canine small bowel autotransplantation model, adding alpha - tocopherol to Euro Collins solution for perfusion enhanced the integrity of the small bowel mucosa for up to 12 hours in the posttransplantation period. The purpose of this study was to investigate the effects of verapamil and a tocopherol on reperfusion injury in the canine small bowel autotransplantation model. METHODS: The study consisted of four groups of six animals each. In Group 1 (control group) grafts were perfused with Euro Collins solution while those of Group 2 were perfused with Euro Collins and alpha- tocopherol. Group 3 grafts were perfused with Euro Collins + verapamil and Group 4 with Euro Collins, alpha- tocopherol and verapamil. Autotransplantation model was used to avoid immunological injury. Graft function and mucosal integrity were assessed by the analysis of enzymatic activities (mucosal glutaminase, maltase and lactase) and histopathological examination. Malonyldialdehyde (per gram tissue) was used as an indicator of lipid peroxidation. RESULTS: Glutaminase activity of Group 4 was found to be higher than that of the other groups at all time points (p<0.05). In the verapamil group (Group 3), the amount of lipid peroxidation showed the greatest decrease in comparison to other groups at the 12 hour time point (p<0.05). Maltase activity in Group 3 was significantly different at all time points (p<0.05). Lactase activity showed no significant difference between groups at each time point. The microscopic appearance of tissue injury shown by histopathological examination of tissue samples obtained at different time points was related to decrease in mucosal enzymatic activities. CONCLUSIONS: alpha- tocopherol is a promising agent for the prevention of tissue injury caused by free oxygen radicals during organ transplantation. Verapamil, as an antioxidant, also has preventive effects in organ preservation. Using verapamil together with alpha- tocopherol in the same preservation solution did not increase the preventive effect of alpha- tocopherol.

The abdominal cocoon: a case report.

The abdominal cocoon is a rare disease that is characterized by a total or partial encasement of the small bowel by a thick and fibrotic membrane. Thirty-five cases were reported since it was first described. It occurs primarily in females. Preoperative diagnosis is a matter of challenge and usually made at laparotomy. We report a patient with partial intestinal obstruction and abdominal cocoon which was diagnosed peri-operatively. We review the literature and discuss the etiology of this disease.

Effects of alpha tocopherol and verapamil on liver and small bowel following mesenteric ischemia-reperfusion.

BACKGROUND/AIMS: We have previously shown that alpha tocopherol is a potent antioxidant which prevents reperfusion injury in a kidney and small bowel autotransplant model. In this study, the effect of systemic alpha tocopherol and verapamil on small bowel and hepatic functions following mesenteric ischemi-reperfusion was evaluated. METHODS: Fourty male Wistar Albino rats (weight, 250-300 g) all subjected to an ischemia-reperfusion experiment were divided into four groups of 10 as follows: Group 1: (SHAM), Group 2, given prophylactic and systemic alpha tocopherol, Group 3: given verapamil and Group 4: given (both verapamil and alpha tocopherol). RESULTS: Glutaminase activities 120 minutes after reperfusion were found to be significant in liver tissues (p=0.004). The highest to the lowest glutaminase activities in liver tissue at 120 minutes after reperfusion were in Group 1, Group 3, Group 2 and Group 4 respectively. Significant differences in MDA levels were found in the small bowel at 30 minutes and 120 minutes time points (p<0.05). There were statistically significant higher glutaminase levels at 30 minutes and 120 minutes of reperfusion in the small bowel, especially in Group 4 (p=0.005). CONCLUSION: Both small bowel and liver injuries reperfusion, can be decreased by prophylactic use of alpha tocopherol and verapamil. Glutaminase activity in liver tissue can also be affected by small bowel ischemia-reperfusion.