A long-term evaluation of the modified mesh-plug hernioplasty in over 2,000 patients.

BACKGROUND: A modified technique for mesh-plug hernioplasty is a long-term, safe and efficacious treatment for primary unilateral inguinal herniorrhaphy. METHODS: Prospective analysis of 2,038 patients who underwent primary unilateral hernioplasty from 1997 to 2005 at a private university medical center. A modified technique using a mesh-plug was performed under local anesthesia with intravenous sedation. The modified technique consisted of placing the mesh plug into the preperitoneal space and suture fixation of the plug using the inner petals. The main outcome measures were Surgical morbidity, postoperative recovery, hernia recurrence, and chronic pain. RESULTS: There were 1,265 indirect and 773 direct hernias. Mean operative time was 28 min; mean recovery room time, 47 min. A total of 1,936 (95%) returned to normal activities within 3 days. Only 367 patients (18%) required prescription pain medication. Nine patients (0.4%) have been treated for chronic pain. No mesh infections or mesh migration have occurred. Three recurrences (0.15%) have been detected with a 99% follow-up over 2-10 years (mean 72 months). CONCLUSION: The modified mesh-plug hernioplasty is a safe and efficacious treatment option for the primary unilateral inguinal hernia patient.

A 15-year review of esophagectomy for carcinoma of the esophagus and cardia.

OBJECTIVE: To evaluate the effect of surgical approach and adjuvant therapy on patients with carcinoma of the esophagus and/or cardia. DESIGN: Retrospective analysis of 157 consecutive patients who underwent esophagectomy. SETTING: A private university medical center and its affiliated community hospital. PATIENTS: One hundred twenty men and 37 women (mean age, 61.7 years) with carcinoma of the esophagus and/or cardia that was surgically treated between 1978 and 1993. INTERVENTIONS: Three approaches were used for resection: Transhiatal esophagectomy (THE) (n = 67), transthoracic esophagectomy (TTE) (n = 71), and abdominal-only esophagectomy (AOE) (n = 19). Sixty-five patients received adjuvant radiotherapy and chemotherapy. MAIN OUTCOME MEASURES: Surgical mortality, morbidity, and survival and the effect of adjuvant therapy. RESULTS: The overall surgical mortality rate was 7.6%: 12.7% with the TTE, 4.5% with the THE, and 0% with the AOE approach. A significantly increased incidence of adult respiratory distress syndrome (P < .001) and empyema (P < .001) was seen with the TTE approach. The average intraoperative blood loss (P = .08) and the median intensive care unit stay (P = .26) and hospital stay (P = .40) were decreased with the THE and AOE approaches when compared with the TTE approach without significance. The overall median survival time was 17 months, with a 5-year survival rate of 21%. There was no significant difference in survival by pathologic stage between approaches. The addition of adjuvant therapy did not affect the overall median survival time or the 5-year survival rate. Node-positive patients did benefit from adjuvant radiotherapy and chemotherapy, with increased median survival times from 7 to 15 months and a 5-year survival rate from 0% to 15% (P = .01). CONCLUSIONS: The THE and AOE approaches have fewer early complications than does TTE. Both THE and TTE have equal long-term survival rates. Adjuvant therapy provides increased survival to node-positive patients with carcinoma of the esophagus and/or cardia.

Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases.

Complications of laparoscopic cholecystectomy were evaluated by a survey of surgical department chairpersons at 4,292 US hospitals. The 77,604 cases were reported by 1,750 respondents. Laparotomy was required for treatment of a complication in 1.2% of patients. The mean rate of bile duct injury (exclusive of cystic duct) was 0.6% and was significantly lower at institutions that had performed more than 100 cases. Bile duct injuries were recognized postoperatively in half of the cases and most frequently required anastomotic repair. Intraoperative cholangiography was practiced selectively by 52% of the respondents and routinely by 31%. Bowel and vascular injuries, which occurred in 0.14% and 0.25% of cases, respectively, were the most lethal complications. Postoperative bile leak was recognized in 0.3% of patients, most commonly originating from the cystic duct. Eighteen of 33 postoperative deaths resulted from operative injury. These data demonstrate that laparoscopic cholecystectomy is associated with low rates of morbidity and mortality but a significant rate of bile duct injury.

The management of hernia. Considerations in cost effectiveness.

Approximately 700,000 herniorrhaphies are performed annually in the United States for primary, recurrent, and bilateral inguinal hernias. This article describes the components of cost regarding the approach and management of groin hernias. The trends toward outpatient procedures, regional anesthetic agents, and early return to work are analyzed. The common types of repair are compared with reference to recurrence and complication rates. The advances and results of laparoscopic hernia are reviewed. In summary, a cost-effective approach for the management of inguinal hernias is presented that could reduce the yearly cost of hernia repair by hundreds of millions of dollars.

Invasive therapy of metastatic colorectal cancer to the liver.

Resection, when possible, is still the best hope for cure of colorectal metastasis to the liver. Poor prognostic indicators for survival include heavy tumor burden, the presence of extrahepatic disease, synchronous metastasis, and the inability to perform resection with a 1-cm margin. Questionable poor prognostic indicators include multiple metastases (more than three), bilobar disease, and the need to transfuse patients during resection. Preoperatively, a patient must be evaluated for the extent of liver disease and the presence of extrahepatic disease with a CT of the abdomen and routine studies of the chest. Intraoperatively, a surgeon should be able to perform or obtain ultrasonography of the liver to detect occult metastases and delineate anatomy. The surgeon should be experienced in wedge, segmental, and lobar resection. Equipment for cryotherapy and arterial infusion devices should be available, and staff experienced in these modalities should be present. If all of these factors are present, the options for the invasive treatment of colorectal metastasis to the liver can be carried out in a manner that should provide the most benefit at a low morbidity to this population of patients.

A prospective study of the mesh-plug hernioplasty.

A prospective study of patients with symptomatic inguinal hernias was undertaken to determine the safety and efficacy of the mesh-plug hernioplasty. Between May 1, 1997 and March 1, 1999 a total of 309 mesh-plug hernioplasties were performed on 283 patients. There were 43 recurrent and 26 bilateral hernioplasties. There were 273 men and 10 women ranging in age from 15 to 94 years (mean 47 years). There were 199 indirect, 104 direct, and six femoral hernias. Mean operative time for primary hernioplasty was 26 minutes (range 20-34) and 35 minutes (range 31-40) for recurrent hernioplasty. All procedures were performed as outpatient surgery with mean recovery room time being 45 minutes (range 25-27) for primary hernioplasty. Two hundred sixty-six patients (94%) returned to normal activities within 3 days. All manual laborers (124 patients) returned to work without restriction on postoperative day 14. Only 43 patients (15%) required prescription pain medication. At one year postoperatively 283 patients (100% follow-up) have been examined and no recurrence has been detected. At 2 years postoperatively 135 patients (100% follow-up) have been examined and no recurrence has been detected. The mesh-plug hernioplasty uses a minimum of medical resources, is associated with a small amount of postoperative pain, and has an early return to normal activities and manual labor without a documented early recurrence in this study.

A prospective experience with selective cholangiography.

A prospective study of patients with symptomatic cholelithiasis was undertaken to determine the effectiveness of identifying clinically significant choledocholithiasis with selective cholangiography. Between 1991 and 1995, 262 patients presented to the senior author (K.W.M.) with acute or chronic cholecystitis. Sixteen patients had a preoperative endoscopic retrograde cholangiopancreatography (ERCP) for an elevated alkaline phosphatase or total bilirubin greater than twice the normal value or an ultrasound finding suspecting choledocholithiasis. Ten of the ERCP patients had choledocholithiasis, with eight patients having successful clearance by ERCP. Ninety other patients had intraoperative cholangiography for abnormal serum liver biochemistries, a history of jaundice or pancreatitis, or a dilated common bile duct (CBD) (>6 mm) on ultrasound. Fourteen of the intraoperative cholangiography patients and the two remaining ERCP patients had choledocholithiasis requiring CBD exploration for clearance of their stones. There were no false-positive cholangiograms, and there were no bile duct injuries in this series. With 100 per cent follow-up of at least 2 years, only one patient required ERCP clearance of a retained CBD stone 13 months after cholecystectomy. The positive predictive value and the negative predictive value for the selective cholangiography criteria are 23 per cent and 99 per cent, respectively. In conclusion, clinically significant choledocholithiasis can be found effectively with selective cholangiography. Also, utilizing selective cholangiography reduces the number of routine cholangiograms by 60 per cent.

Endoscopic ultrasound for diagnosis and staging of pancreatic tumors.

Endoscopic ultrasound (EUS) is proving to be a useful tool for evaluation of clinically suspected pancreatic masses unsatisfactorily evaluated by other means of imaging. We reviewed the records of 19 patients who had CT and EUS performed for clinically suspected pancreatic masses. Each patient had subsequent surgical exploration. Nineteen patients (11 females and 8 males) presenting with symptoms (11 with obstructive jaundice, 6 with abdominal pain and weight loss) or incidental CT findings suspicious for pancreatic carcinoma underwent EUS for further pancreatic evaluation. All of these patients had exploratory laparotomies, with 13 pancreaticoduodenectomies, 3 distal pancreatectomies and splenectomies, 1 bypass procedure, 1 open pancreatic and hepatic biopsy showing metastatic disease, and 1 open exploration with negative fine-needle aspiration biopsy. EUS correctly identified pancreatic neoplasms in 17 of 19 cases, with two false positives. The tumors included 15 adenocarcinomas, 1 microcystic adenoma, and 1 lymphoma. Node status was correctly predicted in 9 of 12 specimens. Nine of 12 tumors had accurate tumor staging by EUS. Absence of vascular invasion was accurately predicted in 13 of 14 cases. Two patients had metastatic disease discovered at laparotomy. All 19 patients had preoperative abdominal CT scans, with six of these negative for pancreatic masses. EUS is more sensitive than CT in detecting pancreatic masses and is more accurate than CT in locally staging pancreatic tumors. This higher sensitivity is important because those patients with earlier stage tumors are the most likely to benefit from resection.

Hepatic resection for metastatic colorectal cancer.

One-hundred thirty-one primary hepatic resection for colorectal secondary tumors were performed at Rush-Presbyterian-St. Luke's Medical Center between 1975 and 1993. Perioperative mortality occurred in five patients (3.8%). Twenty-three patients had minor morbidities (18%); major morbidity occurred only in the five patients who died. Curative resections were performed in 107 patients. Overall actuarial survival at 2, 3, and 5 years was 62, 42, and 25 per cent, respectively. Patients with extrahepatic disease (5-year survival, 0% vs 27%; P = 0.049) and positive resection margins (0% vs 30%; P < 0.001) had significantly poorer survival. Among the curative resections, patients who had metachronous hepatic resections did significantly better than those who underwent synchronous colon and hepatic resections (35% vs 13%; P = 0.002). This survival benefit persisted when comparison was restricted to patients with synchronous metastases. Age, sex, race, number of lesions, site of colon primary resection, blood transfusion, disease-free interval, and extent of resection had no effect on survival. All patients who are acceptable surgical risks with potentially resectable metastatic colorectal cancer confined to the liver should undergo exploration. Assessment of resectability should include intraoperative ultrasound in all patients to maximize the probability of tumor clearance.

Liver resection for colorectal cancer: liver metastases in the aged.

The purpose of this study was to determine the morbidity and mortality in elderly patients undergoing liver resections for metastatic colon cancer and compare them with those of a control group of younger patients. The charts of all patients undergoing liver resection for colon cancer were retrospectively reviewed. Patients less than 70 years of age (Group A) were compared with patients 70 years of age or older (Group B). Between 1971 and 1995, 167 liver resections were performed for metastatic colorectal cancer. Of these, 41 patients were in Group A and 126 patients were in Group B. The mean age of Group A was 74.5 years, and that of Group B was 57 years. American Society of Anesthesiologists (ASA) classification was similar for both groups (Groups A and B were 75.6% and 81.1% ASA class II, respectively). Anatomic resections were performed in 49 per cent and wedge resections in 51 per cent of patients in Group A, and 68 and 32 per cent in Group B, respectively. Estimated blood loss was slightly less for Group A (1575 vs 1973 cm3), as was operative time (4.0 vs 4.7 hours). In-hospital mortality rate was 7.3 per cent for Group A and 2.4 per cent for Group B. The major morbidity rates were 29 and 17.5 per cent, respectively. Intensive care unit care was necessary in 73 per cent (mean length of stay 3.9 days) for Group A and 62.6 per cent (mean length of stay 2.0 days) for Group B. The average length of hospitalization was 13.1 days for Group A and 16.6 days for Group B. The recurrence rates were similar for the two groups [56% (Group A) vs 66% (Group B)], but mean survival was longer for younger patients (22.9 vs 33.5 months). We conclude that liver resection for colorectal cancer liver metastases in properly selected patients older than 70 years of age can be performed with acceptable morbidity and mortality rates. The long-term survival for older patients is less than that for younger patients, but is still a significant length of time. Therefore, we conclude that age alone is not a contraindication to liver resection for colorectal cancer metastases in patients older than 70.

An open, minimally invasive approach to the lumbar spine.

A minimum 2-year follow-up retrospective review was undertaken to assess our experience with an anterior paramedian muscle-sparing approach to the lumbar spine for anterior spinal fusion (ASF). The records of 28 patients (November 1991 through January 1996) undergoing ASF via a left lower quadrant transverse skin incision (6-10 cm) with a paramedian anterior rectus fascial Z-plasty retroperitoneal approach were reviewed. Diagnosis, number, and level of lumbar interspaces fused, types of fusion, estimated blood loss, length of procedure, length of hospital stay, and complications were analyzed. All cases were completed as either a same-day anterior/posterior (24 of 28) or as a staged procedure at least 1 week after posterior fusion (4 of 28). The General Surgery service performed the muscle-sparing approach, whereas the Orthopedic Spine service performed the ASF. There were 14 men and 14 women, with a mean age of 35.5 years (range, 11-52 years). Diagnoses included spondylolisthesis in 20 cases (including four grade III or IV slips), segmental instability (degenerative or postsurgical) in 7, and 1 flatback deformity. A single level was fused in 20 cases (L4/5 in 4 and L5/S1 in 16), two levels were fused in 5 cases (L4/5 and L5/S1) and three levels were fused in 2 cases (L3/4, L4/5, and L5/S1). The mean length of stay was 7.4 days (range, 5-12 days). The mean estimated blood loss was 300 mL for the anterior procedure alone and 700 ml for both anterior/posterior procedures on the same day. The mean length of operating room time for the anterior approach and fusion was 117 minutes (range, 60-330 minutes). Posterior instrumentation was used in all cases. Anterior interbody struts used included 19 autogenous tricortical grafts, 4 fresh-frozen allografts (2 femoral rings and 2 iliac crests), 3 carbon fiber cages packed with autogenous bone, and a Harms titanium cage with autograft. There was one L5 corpectomy for which a large tricortical allograft strut was utilized. There were no vascular, visceral, or urinary tract injuries. In three cases a mild ileus developed, which resolved spontaneously. We conclude that the anterior paramedian muscle-sparing retroperitoneal approach is safe, uses a small skin incision, avoids cutting abdominal wall musculature, and allows for multiple-level anterior spinal fusions by a variety of interbody fusion techniques. This approach does not require transperitoneal violation or added endoscopic instrumentation, nor does it limit fusion level and technique of fusion, as is the case with the recently popularized laparoscopic approach to the lumbar spine.

Do angiogenesis and growth factor expression predict prognosis of esophageal cancer?

A retrospective study of surgically resectable esophageal cancers was undertaken to determine the relationship between angiogenesis score and growth factor expression with tumor size, histology, degree of differentiation, depth of invasion, nodal disease, and the presence of Barrett's esophagus. The office and hospital charts of 27 patients who had esophageal resection for carcinoma between 1990 and 1995 at Rush-Presbyterian-St. Luke's Medical Center were reviewed. Data collection included patient demographics, survival, tumor size, histology, differentiation, depth of invasion, nodal metastases, and the presence of Barrett's esophagus. The pathology specimens were immunostained for von Willebrand factor (factor VIII-related antigen). Immunostaining was also performed for vascular endothelial growth factor and transforming growth factor alpha. Twenty normal esophageal specimens served as controls. Angiogenesis score was determined by counting vessels under conventional light microscopy at x200 magnification, and growth factor expression was graded on a scale of 1 to 4. Cancers had higher angiogenesis and growth factor expression than controls (P = 0.01). Patient age, tumor size, histology, differentiation, depth of invasion, and Barrett's esophagus did not correlate with angiogenesis score or tumor growth factor expression. Lymph node status did correlate with both angiogenesis score and growth factor expression (P < or = 0.02). We conclude that high angiogenesis score and growth factor expression correlate with the presence of lymph node metastases. This may help select patients for preoperative radiation and chemotherapy or determine the extent of surgery performed for esophageal carcinoma.

Prognostic factors associated with resectable adenocarcinoma of the head of the pancreas.

A retrospective study of patients with surgically resectable adenocarcinoma of the pancreatic head was undertaken to determine which prognostic factors are independently associated with improved survival. Thirty-four men and 41 women (mean age, 61.9 years) had resection for adenocarcinoma of the pancreatic head between 1980 and 1997 at Rush-Presbyterian-St. Luke's Medical Center. Surgical resections included 15 total pancreatectomies, 43 pyloric-preserving procedures, and 17 standard Whipple procedures. Thirty-six patients received adjuvant radiation and/or chemotherapy. Overall median survival was 13 months, with a 5-year survival of 17 per cent. Thirty-day surgical mortality was 1.3 per cent. Significant factors that negatively influenced survival using univariate Kaplan-Meier analysis were: positive resection margin (P = 0.01), intraoperative blood transfusion (P = 0.01), and lymph node metastases (P = 0.01). Presenting signs and symptoms, patient demographics, operative procedure, tumor size, histologic differentiation, and adjuvant therapy did not have a significant impact on survival. Using multivariate Cox regression analysis, the only significant independent factors improving survival were the absence of intraoperative blood transfusion (P = 0.02) and a negative resection margin (P = 0.04). Performing pancreaticoduodenectomy for adenocarcinoma of the head of the pancreas with negative microscopic margins of resection and without intraoperative transfusion significantly improves survival.

A model for tracking student experiences on surgical clerkships.

UNLABELLED: This study was conducted to identify the range and nature of surgical clerkship experiences in three different hospital settings-university, community, and public. METHODS: An instrument was developed to track the location and type of learning experience, patient demographics, surgical content, and clinical experience of students on their surgical clerkship. Twenty-three students used the instrument to record the events of their surgical clerkship. Data were analyzed to describe the frequency of tasks performed, the nature and location of learning experience, exposure to surgical topics, and patient demographics. RESULTS: Students were involved in an average of 245 common surgical tasks over their 8-week clerkship. Of their exposure to common tasks, students had the opportunity to observe 25% and perform 70% of those tasks. Sixty-six percent of task work occurred on the patient floor and 23% occurred in the operating room. Students were exposed to a broad range of surgical topics, 71% of which were general surgery topics. Only 25% of these experiences were auditory, whereas 39% involved exposure to a patient, and 36% included participation in an operation. Patient load and characteristics tended to vary across hospital settings, and on average, students worked with 164 patients during their clerkship. The smallest patient load (m = 113) occurred in the university hospital and the largest patient load (m = 251) occurred in the public hospital. CONCLUSION: Although surgical services and hospital settings may offer students different clerkship experiences, the common clinical and didactic components of a surgical clerkship can balance a student's exposure to surgical topics and practice of clinical skills. Tracking surgical clerkship experiences is valuable in identifying the range and nature of medical students' didactic, clinical, and operative experiences.

Repair of tracheal defect with Goretex graft during resection of carcinoma of the esophagus.

Repair options for tracheal defects secondary to tumor or trauma have been unsatisfactory for emergent cases. We report a case in which the tracheobronchial tree was entered during resection of carcinoma of the esophagus and emergently repaired with a Goretex graft. The patient did well for 22 months after esophagectomy, at which time the graft was found to be infected and was removed. The patient continues to remain free of tumor 4 years after initial resection.

A prospective comparison of transabdominal preperitoneal laparoscopic hernia repair versus traditional open hernia repair in a university setting.

In this study, laparoscopic transabdominal preperitoneal inguinal hernia repair and traditional open inguinal hernia repair were compared in relation to operative time, hospital stay, pain medication use, recovery time, complications, and costs. Elective hernia repairs, 126 in 106 patients, were prospectively followed from January 1991 through September 1993. Seventy-five procedures were performed by laparoscopy and 51 by traditional open approach. Time off work, pain medication use, surgical complications, and hospital stay were all significantly less (p < 0.001) with the laparoscopic approach. Patients in the laparoscopic group returned to work on average 5.5 weeks earlier than patients who underwent traditional herniorrhaphy. The difference in operative times was not statistically significant; however, the difference in the cost of the operations was. In conclusion, laparoscopic inguinal hernia repair offers significantly decreased postoperative pain, shorter hospital stays, faster return to work, fewer complications, and comparable operative times, but at an increased expense for the cost of laparoscopic instrumentation and technology.

The current role of U tubes for benign and malignant biliary obstruction.

OBJECTIVE: The recent experience with U tubes at Rush-Presbyterian-St. Lukes Medical Center was reviewed in order to assess their current role in hepatobiliary surgery. SUMMARY BACKGROUND DATA: Transhepatic intubation by a variety of methods has been used routinely for biliary decompression and inhibition of anastomotic stricture since the 1960s. U tubes were popularized in the early 1970s. However, little has been written about their use and efficacy in recent years. Because of the apparent benefits associated with the use of U tubes versus other stenting techniques, the authors performed this study. METHODS: The hospital and office charts of all patients who had U tubes placed between 1980 and 1992 were reviewed retrospectively. Between 1980 and 1992, U tubes were placed intraoperatively in 54 patients for biliary decompression and/or stenting. Twelve patients were operated on for benign causes of obstruction. Forty-two patients with malignant tumors underwent surgery for U tube placement in conjunction with or without tumor resection and anastomotic bypass. RESULTS: There was a 0% operative mortality rate in the benign group. In six patients, the U tube played a major role in the long-term management of their disease processes. None of these patients has had restricture since removal of the tube. In the malignant group, the 30-day operative mortality rate was 12%. After 3 months, marked clinical improvement and complete biliary decompression were achieved, with mean bilirubin levels dropping from 14.0 mg/dL to 1.3 mg/dL. No patients in the malignant group required reoperation for recurrent biliary obstruction after U tube placement. CONCLUSIONS: The use of U tubes is advocated for biliary decompression and/or anastomotic stenting in patients with benign stricture or resectable malignancy and in patients with nonresectable, malignant biliary obstruction for adequate palliation of intractable jaundice.

Superior mesenteric and portal vein thrombosis following laparoscopic-assisted right hemicolectomy. Report of a case.

PURPOSE: This article describes a case of superior mesenteric and portal vein thrombosis following laparoscopic-assisted right hemicolectomy. METHODS: A retrospective case review was performed. RESULTS: Data continue to grow regarding safety and technical feasibility of laparoscopic-assisted colectomy. As this minimally invasive alternative to open colonic resection becomes more popular, it is inevitable that information on benefits and complications associated with it will continue to expand. We report a case of superior mesenteric and portal vein thrombosis following laparoscopic-assisted colon resection. To our knowledge, this represents a complication of laparoscopic colon resection not previously reported in literature. CONCLUSION: Careful patient selection for this procedure is important. Additionally, the incision for extracorporeal resection and anastomosis in laparoscopic-assisted colectomy must be planned appropriately and carefully monitored intraoperatively to avoid potential complication of vascular trauma leading to mesenteric vein thrombosis.

Fractionated irradiation of the regenerated rat liver.

Fractionated radiation therapy after liver resection for metastatic cancer has traditionally been a palliative procedure. Here, we consider that radiation may be an appropriate adjuvant therapy for cure after liver resection for metastases. This pilot study in rats establishes a model for evaluating the effects of fractionated irradiation posthepatectomy. Sixty Sprague-Dawley rats were randomized to four groups. The groups underwent laparotomy, laparotomy and radiation, hepatectomy, and hepatectomy and radiation. We found that the rats treated with radiation had statistically significant (P < 0.0001) clinical radiation change by liver function tests at 6 months. This damage was resolved to normal at 1 year regardless of hepatectomy. In fact, we demonstrate the possibility of a protective effect from radiation damage in the regenerated liver. We also demonstrate statistically significant histologic change at 8 months (P < 0.01) in the radiation-treated rats which does not resolve at 1 year.

Mucin Hypersecreting Intraductal Papillary Neoplasm of the pancreas.

Mucin Hypersecreting Intraductal Papillary Neoplasm is a rare neoplasm that arises from ductal epithelial cells. This entity is distinct from the more commonly known Mucinous Cystadenoma or Mucinous Cystadenocarcinoma. Despite this distinction, it has been erroneously categorized with these more common cystic neoplasms. Characteristic clinical presentation, radiographic, and endoscopic findings help distinguish this neoplasm from the cystadenomas and cystadenocarcinomas. Histopathologic identification is not crucial to the preoperative diagnosis. This neoplasm is considered to represent a premalignant condition and, therefore, surgical resection is warranted. Prognosis, following resection, is felt to be curative for the majority of patients. We present two cases of Mucin Hypersecreting Intraductal Papillary Neoplasm and discuss their diagnosis and surgical therapy.