Trans-cystic biliary catheterization and decompression in liver and biliary surgery.

BACKGROUND/AIMS: Trans-cystic biliary catheterization (TCBC) and decompression may be employed to prevent biliary leakage after liver and biliary surgery. METHODOLOGY: We evaluated medical records of patients that required trans-cystic biliary catheterization between 2001-2009; we retrospectively review prospectively collected data, including patient demographics, operational procedures, cholangiographies and post-operative follow-ups. RESULTS: Mean age was 54 years (16-80 years) and 63% of patients were female. TCBC was employed only during the operation in 13 patients due to biliary leakage suspicion, but no leakage was detected and cystic canal is ligatured after catheter removal at the same operation. In remaining patients, catheters were placed in the cystic duct and blocked in 1-12 days. Biliary fistula developed in five patients and bile leakage was stopped spontaneously under trans-cystic biliary catheterization and decompression. Three patients were diagnosed to have retained common bile duct stones by cholangiographies and all removed with endoscopic retrograde cholangiopancreatography. Catheters were withdrawn at 19-21 days post-operation. We experienced no TCBC related complications. CONCLUSIONS: Despite risks and difficulty of TCBC, it helps to demonstrate bile leak sites via trans-cystic flushing and to repair them as well as taking cholangiography, recognizing intra-luminal pathology, and also decompressing biliary system.

The importance of invasion and resection of superior mesenteric and portal veins in adenocarcinoma of the pancreas.

BACKGROUND/AIMS: To achieve a negative surgical margin, resection of superior mesenteric/portal vein is necessary in pancreatic cancer. This study is designed to demonstrate the demographic and clinical differences of the patients requiring major vein resection and the incidence of histopathological vein invasion. METHODOLOGY: A retrospective analysis of patients that underwent pancreaticoduodenectomy for adenocarcinoma of the pancreas between January 2000 and September 2011 was performed. Macroscopic adhesion to vein was considered as an invasion and a resection was performed. RESULTS: Twenty three of 100 patients that underwent pancreaticoduodenectomy for adenocarcinoma of the pancreas had vein resection. Although the operation time (p=0.001), blood loss (p<0.001) and perioperative blood transfusion (p<0.001) were higher in the vein resection group, there were no differences in perioperative and hospital mortality, complication rate and hospitalization time. The tumor was larger (p=0.001) and lymphovascular invasion (p=0.030), perineural invasion (p=0.011), median metastatic lymph nodes (p=0.007), rate of R1 resection (p=0.007) were higher in vein resection group. Only 9 patients out of 23 patients had histopathological vein wall invasion. Overall survival was also not significantly different (p=0.14). CONCLUSIONS: Overall survival in vein resected group was also not significantly different than patients with standard pancreaticoduodenectomy and not all macroscopic vein adhesion means histopathological vein wall invasion.

Effect of bariatric surgery on macular and peripapillary choroidal structures in young patients with morbid obesity.

OBJECTIVE: To examine the effect of bariatric surgery on the macular and peripapillary choroid in the late postoperative period in young patients with morbid obesity and compare them with a healthy control group. METHODS: This prospective controlled study included 50 eyes of 25 young patients with morbid obesity and 50 eyes of 25 age and sex-matched healthy controls. Sleeve gastrectomy was performed on all patients with obesity. Preoperative and 6-month postoperative macular and peripapillary choroidal thickness, total choroidal area (TCA), luminal area (LA), and choroidal vascularity index (CVI) were performed. Results were compared with healthy controls by using enhanced depth imaging optical coherence tomography. RESULTS: Choroidal thickness and CVI values were smaller in patients with obesity in both macular and peripapillary areas compared with the healthy control group (both p < 0.001). There was a statistically significant increase in the macular and peripapillary choroidal thickness of patients with obesity when the preoperative and the postoperative 6-month values after bariatric surgery were compared (both p < 0.001). Also, it was found that bariatric surgery increased TCA and LA values in the macular and all sectors of peripapillary areas (all p < 0.001), and CVI values in the temporal and nasal peripapillary sectors (p = 0.007, p = 0.012, respectively). CONCLUSIONS: Bariatric surgery was found to increase the macular and peripapillary choroidal thickness and the nasal and temporal peripapillary CVI values in young patients with morbid obesity in the late period. To the best of our knowledge, the current study has shown for the first time that bariatric surgery affects peripapillary choroid and CVI values.

Evaluation of In Vivo Adhesion Properties of New Generation Polyglactin, Oxidized Regenerated Cellulose and Chitosan-Based Meshes for Hernia Surgery.

Introduction Composite meshes coated with anti-adhesive barriers have been developed by taking advantage of the robustness of polypropylene meshes for use in hernia repair. We aimed to evaluate the effects of composite meshes containing polyglactin, polycaprolactone, oxidized regenerated cellulose and chitosan on the adhesion formation. Methods Forty-two Sprague Dawley male rats were divided into six groups of seven rats according to the content of the meshes used. A defect was created on the right abdominal wall of the rats and an oval composite mesh of 2 cm in diameter was placed over the defect and fixed. The rats were sacrificed under anesthesia on the 7th postoperative day. Macroscopic and histopathological examination was performed and the incorporation of the mesh with the abdominal wall and the presence of intraabdominal adhesions were evaluated. Results When the macroscopic findings of the rats were evaluated, there was a statistically significant difference between the rat groups in terms of the distribution of peritoneal adhesion scores (p<0.05). There was no statistically significant difference between the rat groups in terms of the distribution of inflammation, fibrosis and macrophage levels (p>0.05). Conclusion It was evaluated that the development of intraabdominal adhesion and the strength of adhesion decreased when biocompatible adhesion barriers with anti-adhesive properties such as oxidized regenerated cellulose and chitosan were used in the structure of composite meshes used in hernia repair. Hemostatic and antibacterial properties of these substances are promising to create the ideal mesh.

[Factors affecting mortality in acute mesenteric obstruction]. / Akut mezenterik tikanmada mortaliteyi etkileyen faktörler.

BACKGROUND: Acute mesenteric obstruction (AMO) is usually fatal. This study was designed to demonstrate the demographic characteristics and prognostic factors of affected patients. METHODS: The patients admitted to our emergency department and diagnosed as having AMO between January 2000 and December 2004 were investigated retrospectively. Their demographic characteristics, laboratory results, per-operative findings and mortality were investigated retrospectively. RESULTS: Thirty patients (18 males, 12 females; mean age: 67 [26-92]) were evaluated. 43.3% of patients survived. Surviving patients had statistically significantly lower alanine aminotransferase (ALT) but also higher pH and creatinine levels (p=0.0027, 0.0004, 0.02). Colonic involvement also increased mortality (p<0.001). Papaverine infusion, embolectomy and second-look operations had no effect on outcome. CONCLUSION: Preoperatively increased liver enzymes, acidosis, and colonic involvement indicated poor prognosis. Papaverine infusion, embolectomy and second-look operations showed no advantages with respect to survival.

The effects of systemic inflammatory response on prognosis of pancreatic ductal adenocarcinoma.

BACKGROUNDS/AIMS: The aim of this study was to investigate the prognostic significance of neutrophyil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), CRP and CA19-9 in patients were diagnosed with pancreatic ductal adenocarcinoma (PDAC) to better verify pre-operative risk stratification and management. METHODS: This retrospective study included data from 133 consecutive patients with PDAC, who were treated between 2013 and 2015. PDAC diagnosis was made by cytology or assumed by radiological assessment or surgical resection samples. All clinico-pathological data were retrieved from medical records at our institution. The laboratory data were obtained before any treatment modality. Dates of death were obtained from the central registry. RESULTS: There was a statistically significant relation between radiological staging and CA19-9 and survival (p=0.001, p=0.005) and there are significant differences in CA19-9 level between stage I and III, I and IV, II and III, and II and IV. Both CRP and CA19-9 levels were statistically significantly higher in patients with radiological lymph node metastasis than patients with N0 disease (p=0.037, p=0.026). NLR and CA19-9 levels were also higher in metastatic disease (p=0.032, p=0.007). According to Spearman's correlation analysis, we found in all patients that there was a negative correlation between the survival time and CRP and neutrophil count (p=0.019, p=0.011). CONCLUSIONS: Preoperative CRP, CA19-9 and NLR are simple, repeatable, inexpensive and well available marker, can give information on lymph node and solid organ metastasis and survival, give clues to prognosis and be useful in clinical staging of patients with PDAC.

Polypropylene composite hernia mesh with anti-adhesion layer composed of polycaprolactone and oxidized regenerated cellulose.

Hernia surgeries are at the top of the general surgery operations. However, visceral adhesion, which is one of the worst complications of these operations, is still a major problem. One of the most preferred methods to prevent adhesion is the use of biomaterials. Polypropylene (PP) mesh is frequently preferred product in clinical applications owing to its mechanically robust structure against deformation within the body. However, PP meshes do not have anti-adhesive properties. Oxidized regenerated cellulose (ORC), on the other hand, is one of the most preferred products in preventing the adhesion in clinical use. ORC is not easily processable due to solubility limitations; and it must be used externally. In this study, for the first time, we designed a composite mesh structure with ORC and produced an antibacterial and anti-adhesive double-sided mesh by electro-spinning ORC micro-particles with poly(ε­caprolactone) (PCL) on PP mesh to form a composite structure. We conducted in vitro cell culture studies to determine bio-compatibility performances. We evaluated the anti-adhesion and comprehensive bio-compatibility studies through in vivo experiments. The results revealed that ORC presence and optimization of ORC degradation by coating with PCL play an important role in adhesion prevention and introduced a product prototype with efficient anti-adhesion properties.

A Polypropylene-Integrated Bilayer Composite Mesh with Bactericidal and Antiadhesive Efficiency for Hernia Operations.

Polypropylene (PP) mesh has been widely used in hernia fixation operations for more than one hundred years, and peritoneal adhesion is still one of the main complications after hernia fixation operations. For preventing peritoneal adhesion, many solutions have been offered, including gel systems, adhesion barrier membranes, and bilayer meshes. Among these, bilayer meshes come to the forefront as they serve for both hernia repair and adhesion prevention. In this study, we developed an easy and effective method to produce a multifunctional PP-integrated bilayer mesh composed of poly(lactic-co-glycolic acid) and chitosan with no need for neutralization. We made the composite mesh by electrospinning a layer onto the PP mesh. We evaluated the material characteristics, in vitro bactericidal activities, and interactions between the cells and materials. Then, we conducted in vivo efficiency studies. The results proved that the PP-integrated bilayer composite mesh is bactericidal against Escherichia coli and Staphylococcus aureus, is tissue-compatible, and supremely prevents adhesion.

Intrathoracic splenosis secondary to previous penetrating thoracoabdominal trauma diagnosed during delayed diaphragmatic hernia repair.

Although intraperitoneal splenosis is a very common disease, intrathoracic splenosis is very rare. It is generally an asymptomatic disease that occurs after thoracoabdominal trauma, and is diagnosed as an intrathoracic mass that leads to unnecessary investigations to be differentiated from other benign or malignant lesions of the chest. We present a patient with an intrathoracic mass which was preoperatively diagnosed as a diaphragmatic hernia on chest X-ray and magnetic resonance imaging. We have intraoperatively recognized that many pieces of splenic tissue have been herniated through a diaphragmatic defect, and formed intrathoracic splenosis. We repaired the diaphragmatic hernia defect after excision of fragments of the spleen.

Preoperative assessment of the axilla by surgeon performed ultrasound and cytology in patients with breast cancer.

BACKGROUND: Preoperative evaluation of the axilla, an important prognostic determinant for patients with invasive breast cancer, is achieved by non- or minimally invasive methods to avoid the potential hazards of operative intervention. The aim of this study was to determine statistical power of axillary ultrasound (US) and US-guided fine needle aspiration cytology (FNAC) for evaluating axillary status. METHODS: Axillary lymph nodes were imaged for malignant involvement by high resolution US in 93 breast cancer patients with clinically negative axilla. Cytological samples were obtained by US-guided FNAC from image-suspicious lymph nodes. Cytology-positive patients directly underwent axillary lymph node dissection (ALND). Patients with US and/or cytology-negative axilla underwent sentinel lymph node biopsy (SLNB). Using statistical analysis, US findings and US combined with FNAC were compared with SLNB and final pathology to measure performance. RESULTS: US was suspicious for metastasis in 38 patients (41%), of whom 16 (42%) were cytology-positive. Axilla was positive in 36/93 patients (38.7%). Sixteen patients with positive FNAC directly underwent ALND. SLNB and/or final pathology was positive in 13/55 patients (23.7%) with negative US (false negative of US) and in 7/22 patients (31.8%) with positive US but negative cytology (false negative of FNAC). SLNB and/or final pathology was negative in 15/38 patients (39.5%) with positive US (false positive of US). Sensitivity, specificity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of US alone were 63.8%, 73.6%, 69.8%, 60.5% and 76.3%, respectively, and 69.6%,100%, 81.6%, 100% and 68.1%, respectively, for US combined with FNAC. CONCLUSION: Statistical measures of the US alone did not achieve a satisfactory value for excluding operative biopsy. US-negative and US-positive but cytology-negative cases still require SLNB for accurate evaluation of axillary status. On the other hand, US-guided positive cytology can obviate SLNB proceeding directly to ALND and avoiding frozen section of sentinel node(s).

The Factors Effecting Lymphovascular Invasion in Adenocarcinoma of the Colon and Rectum.

Adenocarcinomas of the colon and rectum are the most common gastrointestinal malignancy, and lymph node metastases are established as a prognostic factor. Lymphovascular invasion has been recognized as an indication of lymph node metastases. This prompted us to investigate the features of primary tumor that may serve as a risk factor for lymphovascular invasion in colorectal carcinoma. Clinical and pathologic tissue data of colorectal carcinoma treated in our hospital were retrieved from the computer files at Haydarpasa Numune Education and Research Hospital, from June 1998 to December 2010, retrospectively. We excluded all patients who have two-thirds distal rectal carcinoma to rule out neoadjuvant treatment bias. Tissues from the specimens were stained with standard hematoxylin and eosin. Clinical data including age and sex of patient, location and diameter of tumor, perineural invasion, peritumoral lymphocytic infiltration, tumor grade, lymphovascular invasion, Pathologic T level (pT), and lymph node metastasis were recorded. Lymphovascular invasion was present only in 43 patients out of 108. Only pT and lymph node metastases were found to be statistically significant related to lymphovascular invasion (p = 0.04 and p < 0.001). Perineural invasion, pT, and peritumoral lymphocytic infiltration are the factors with p < 0.2 in the univariate analysis that were investigated with multivariate analysis, but no factor was found as an independent prognostic factor for lymphovascular invasion. Lymphovascular invasion is significantly related to lymph node metastases. Only pT is found as a factor that increases the lymphovascular invasion.

Hematological, Biochemical, and Immunological Laboratory and Histomorphological Effects of Sleeve Gastrectomy on Female Rats.

Restriction of food intake leads to immunologic and histomorphological changes in rats demonstrated by Moriyama. This study is planned to show how sleeve gastrectomy restricts food intake and its effects on biochemical liver function, immunologic and hematologic laboratory parameters, and histomorphological changes in rats. We used sleeve gastrectomy model on seven young adult female rats and compared study group with sham and control groups. Food consumption of rats was measured. All rats were sacrificed on the 50th day, and blood and tissue samples were collected. There was a significant low food intake in sleeve gastrectomy group (p = 0.013). No differences were observed on hematologic, biochemical, and immunologic laboratory parameters between groups. Toxicity parameters in liver samples such as cytoplasmic atrophy, single-cell hepatocellular necrosis, and necrotic eosinophilic cells were significantly high in sleeve gastrectomy group (p = 0.005). Histomorphological examination of the spleen and kidneys revealed significant changes in sleeve gastrectomy and sham groups compared with controls (p = 0.004 and p = 0.018, respectively). Although sleeve gastrectomy does not lead to alteration in hematologic, biochemical, and immunologic laboratory parameters, it causes decreased food consumption, which results in toxicological histomorphological changes in rat liver as well as some changes in kidney and spleen samples.

Rate and Risk Factors of the Advanced Adenomas Among Diminutive Colorectal Polyps.

Only 49 % of diminutive colorectal polyps are neoplastic, but a tiny percentage contains advanced histology. We aimed to determine the rate of advanced diminutive polyps and to evaluate the influence of age, gender, number, and localization. Patients undergoing a videocolonoscopy in October 2010 and April 2012 were collected prospectively. Subjects with polyps ≤5 mm in diameter were recruited into the study. The presence of a villous component of >25 % and a high degree of dysplasia were categorized as polyps with advanced histology. Two hundred eight diminutive polyps were identified in 102 patients. Twenty (9.6 %) diminutive polyps in 13 (12.74 %) patients showed advanced histology. The probability of having an advanced diminutive polyp was higher in patients who have more than one polyp or have polyps localized all along the colon or only to the distal part (p < 0.001 and p = 0.002). Having more than one polyp increases the likelihood of having advanced diminutive polyp according to a multivariate analysis (p = 0.003). Polyps accompanying any dysplastic diminutive polyp, being one of multiple polyps, and distributed all along the colon or localized to only the distal part have an increased probability of being an advanced diminutive polyp (p < 0.001, p = 0.047, p < 0.001, and p = 0.008). Multivariate logistic regression demonstrated that only any accompanying dysplastic diminutive polyp increases the probability of a polyp being advanced diminutive (p = 0.034). Diminutive polyps could have advanced histology. Multiple polyps located in the whole colorectum or to the distal part or accompanying any advanced polyps may harbor an advanced histology and should be removed.

Prostaglandins E1 and E2 analogues ameliorate mucosal injury secondary to distal colonic obstruction.

After colonic obstruction, increased intraluminal pressure may impair blood circulation and cause mucosal injury that sometimes progresses to perforation. This experimental study aims to evaluated effects of prostaglandin E (PGE) analogues in order to prevent mucosal injury secondary to distal colonic obstruction. This study was carried out on 40 male Wistar rats equally divided into four groups: group 1, control; group 2, colonic obstruction by ligation of the sigmoid colon; group 3, obstruction and administration of PGE1; group 4, obstruction and administration of PGE 2. Mucosal structural changes were assessed and scored by histopathological examination at 24 h postoperatively. The thickness of the mucosal layer of the cecal wall was measured as 179.3 and 122 microm (p <.001) in the control and obstruction alone group, respectively. Mucosal thickness was preserved by PGE1 (170 microm) and PGE2 (157.3 microm) administration. The mean damage score was 0.73 in the control and 3.3 (p <.001) in the obstruction alone group. This score was significantly lower in obstruction groups treated with both PGE1 and PGE2, 1.13 and 1.26 respectively (p <.001). Both PGE1 and PGE2 (PGE1 better than PGE2) ameliorate mucosal injury during distal colonic obstruction. We concluded that the administration of PGE analogues in case of mechanical obstruction of the left colon was beneficial for preserving the structure of the mucosal layer.

Prophylactic and therapeutic effects of oral budesonide for acute radiation-induced enteritis and colitis in rats.

No satisfactory means has been found to control the symptoms of diarrhea and weight loss caused by radiation-induced enteritis and colitis. As a glucocorticoid, budesonide has multiple effects, and this study aimed to test whether it could be effective in treating these symptoms. Twenty-eight male Wistar albino rats were randomly allocated into 4 groups. Group I received 0.1 mg/kg/day budesonide at 8-h intervals for 5 days and did not undergo radiation. Group II received 0.1 mg/kg/day budesonide at 8-h intervals for 1 day before radiation treatment and 4 days after irradiation. Group III received 0.1 mg/kg/day budesonide at 8-h intervals for 4 days after irradiation. Group IV received only radiation treatment. On the fifth day after radiation treatment, the rats underwent laparotomy. The rats were weighed before irradiation and before laparotomy. Because of diarrhea, all rats lost weight except group I, which showed weight gain. Weight loss was statistically significant only in group IV. Group I rats exhibited a normal jejunum, ileum, and colon. The other groups showed varying degrees of damage. We conclude that, particularly when given before irradiation, budesonide decreased the side effects of radiation-induced enteritis and colitis both clinically and morphologically. Future pathophysiological and clinical studies will be needed to support this result.

An unusual presentation of perforated appendicitis in epigastric region.

INTRODUCTION: Atypical presentations of appendix have been reported including backache, left lower quadrant pain and groin pain from a strangulated femoral hernia containing the appendix. We report a case presenting an epigastric pain that was diagnosed after computed tomography as a perforated appendicitis on intestinal malrotation. PRESENTATION OF CASE: A 27-year-old man was admitted with a three-day history of epigastric pain. Physical examination revealed tenderness and defense on palpation of epigastric region. There was a left subcostal incision with the history of diaphragmatic hernia repair when the patient was 3 days old. He had an intestinal malrotation with the cecum fixed at the epigastric region and the inflamed appendix extending beside the left lobe of liver. DISCUSSION: While appendicitis is the most common abdominal disease requiring surgical intervention seen in the emergency room setting, intestinal malrotation is relatively uncommon. When patients with asymptomatic undiagnosed gastrointestinal malrotation clinically present with abdominal pain, accurate diagnosis and definitive therapy may be delayed, possibly increasing the risk of morbidity and mortality. CONCLUSION: Atypical presentations of acute appendicitis should be kept in mind in patients with abdominal pain in emergency room especially in patients with previous childhood operation for diaphragmatic hernia.

Asymptomatic partial splenic infarction in laparoscopic floppy Nissen fundoplication and brief literature review.

Short gastric vessels are divided during the laparoscopic Nissen fundoplication resulting in splenic infarct in some cases. We report a case of laparoscopic floppy Nissen fundoplication with splenic infarct that was recognized during the procedure and provide a brief literature review. The patient underwent a laparoscopic floppy Nissen fundoplication. We observed a partial infarction of the spleen. She reported no pain. A follow-up computed tomography scan showed an infarct, and a 3-month abdominal ultrasound showed complete resolution. Peripheral splenic arterial branches have very little collateral circulation. When these vessels are occluded or injured, an area of infarction will occur immediately. Management strategies included a trial of conservative management and splenectomy for persistent symptoms or complications resulting from splenic infarct. In conclusion, we believe that the real incidence is probably much higher because many cases of SI may have gone undiagnosed during or following an operation, because some patients are asymptomatic. We propose to check spleen carefully for the possibility of splenic infarct.

A modified Rendezvous ERCP technique in duodenal diverticulum.

AIM: To postoperative endoscopic retrograde cholangiopancreatography (ERCP) failure, we describe a modified Rendezvous technique for an ERCP in patients operated on for common bile duct stone (CBDS) having a T-tube with retained CBDSs. METHODS: Five cases operated on for CBDSs and having retained stones with a T-tube were referred from other hospitals located in or around Istanbul city to the ERCP unit at the Haydarpasa Numune Education and Research Hospital. Under sedation anesthesia, a sterile guide-wire was inserted via the T-tube into the common bile duct (CBD) then to the papilla. A guide-wire was held by a loop snare and removed through the mouth. The guide-wire was inserted into the sphincterotome via the duodenoscope from the tip to the handle. The duodenoscope was inserted down to the duodenum with a sphincterotome and a guide-wire in the working channel. With the guidance of a guide-wire, the ERCP and sphincterotomy were successfully performed, the guide-wire was removed from the T-tube, the stones were removed and the CBD was reexamined for retained stones by contrast. RESULTS: An ERCP can be used either preoperatively or postoperatively. Although the success rate in an isolated ERCP treatment ranges from up to 87%-97%, 5%-10% of the patients require two or more ERCP treatments. If a secondary ERCP fails, the clinicians must be ready for a laparoscopic or open exploration. A duodenal diverticulum is one of the most common failures in an ERCP, especially in patients with an intradiverticular papilla. For this small group of patients, an antegrade cannulation via a T-tube can improve the success rate up to nearly 100%. CONCLUSION: The modified Rendezvous technique is a very easy method and increases the success of postoperative ERCP, especially in patients with large duodenal diverticula and with intradiverticular papilla.

Treatment of ampullary neuroendocrine tumor by endoscopic snare papillectomy.

PATIENT: Female, 45 FINAL DIAGNOSIS: Neuroendocrine tumor Symptoms: Abdominal pain Medication: - Clinical Procedure: - Specialty: Gastroenterology and Hepatology. OBJECTIVE: Unusual setting of medical care. BACKGROUND: Neuroendocrine tumor of the ampulla of Vater is extremely rare and is generally a low-grade endocrine cell tumor. The merits of radical vs. local resection remain uncertain. CASE REPORT: A 45-year-old female patient presented with abdominal pain lasting for 2 months. Papilla that was tumor-like macroscopically was seen in the second part of the duodenum in endoscopic retrograde cholangiopancreatography. Biopsy was histologically confirmed as a low-grade neuroendocrine tumor. No lymphadenopathy or visceral metastasis was found on an abdominal CT scan, In-111 octreotide scan, and EUS. The ampulla was removed by endoscopic snare papillectomy. All margins of resection were negative for tumor. CONCLUSIONS: Endoscopic snare papillectomy may be the first step in the management of neuroendocrine tumors of the ampulla of Vater in high-risk surgical candidates and selected patients such as those with a well differentiated, low-grade, small tumor without regional/ distant metastasis. However, it can also be used in younger patients who wish to avoid surgical resection.

Medical and surgical treatment of idiopathic granulomatous lobular mastitis: a benign inflammatory disease mimicking invasive carcinoma.

PURPOSE: Idiopathic granulomatous lobular mastitis (IGLM) is a rare chronic inflammatory disease of the breast with obscure etiology that mimics invasive carcinoma both clinically and radiologically. The treatment of IGLM remains controversial. The aim of proper management is to use a combination of medical and surgical treatment of this benign condition to achieve a good cosmetic result and low recurrence rate. METHODS: A retrospective analysis of 19 patients with IGLM is performed based on the findings of clinical, radiological, and pathological examinations. The results of two treatments are presented: medical treatment with oral corticosteroids, and consecutive surgical excision after a follow-up period of 20 months (range, 6-75 months). RESULTS: The majority of patients treated in this paper were young (mean, 34 years) parous women with a history of hormonal medication use. The main clinical finding is large, irregular, and painful mass. Hypoechoic lobulated, irregular tubular or oval shaped masses had been imaged by ultrasound. Mammographic findings were an ill-defined mass, enlarged axillary lymph nodes, asymmetric density, and architectural distortion. Diagnoses of IGLM had been established by cytological or histological examination. Symptoms subside and inflammatory changes regressed with medical treatment. The remaining lesions were excised by consecutive breast conserving surgery. The disease recurred in one patient during the follow-up period. CONCLUSION: IGLM is an inflammatory breast disease found in young women who present with a large painful irregular mass, which mimics carcinoma, as a physical change. Breast imaging modalities are not helpful to differentiate IGLM from invasive cancer. The correct diagnosis is established by cytological or histological examination. Medical treatment with corticosteroids provides significant regression of the inflammatory disease, allowing more conservative surgery. Consecutive surgical excision of the remaining lesions with good cosmetic results provides definitive treatment and reduces the risk of recurrence.