Association of an oversized adrenal cortical adenoma with expression of pheochromocytoma-like neurosecretory features.

Abnormal stimulation of adrenal function may be either direct, affecting similarly cortical and medullary secretion, or indirect affecting primarily the medulla. Indirect activation of clinically detectable adrenomedullary function may develop as a physical consequence of a non-functional adrenal tumor exerting pressure on the medulla by its size, location and direction of growth. Our case of an oversized and overweight adrenal tumor associated with expression of late-onset pheochromocytoma-like clinical symptoms may be explained by the physical indirect rather than the biological direct activation of adrenomedullary function like hyperplasia or cancer.

Reevaluating pancreatic duct ligation in Whipple procedure.

In an effort to avoid the morbidity and mortality related to pancreaticojejunal anastomosis after pancreaticoduodenectomy (PPD), we report on the treatment of the pancreatic stump by pancreatic duct ligation (PDL) following Whipple procedure. We studied a series of 9 consecutive unselected patients (8 with pancreatic cancer and 1 with chronic pancreatitis). Of those, pancreatic fistula occurred in 4 patients and persisted for 14 to 58 days (mean 35.4 days). Two patients died within 30 days after surgery from causes not related to PDL. None of our patients developed diabetes mellitus following PDL surgery, nor any of the other frequently mentioned postoperative complications such as acute pancreatitis or pancreatic insufficiency. In conclusion, PDL may occasionally lead to a controlled pancreaticocutaneous fistula with fading inactive contents over time not causing further metabolic complications but is a safe, simple and fast alternative to pancreaticojejunostomy.

Correlating functional staging to effective treatment of acute surgical illness.

BACKGROUND: Proinflammatory and anti-inflammatory events may eventually trigger host response, which acting via a broad spectrum of complex biological processes and molecular interactions may either enhance or resolve the symptoms of acute surgical illness (ASI). Staging the sequence of biological events that take place at the cellular level during the development of ASI may provide leads to effective stage-specific treatments. In line with the hypothesis that proper timing of therapeutic intervention may be crucial to the management of the disease, we have attempted in this review to correlate functional staging to effective treatment of ASI. DATA SOURCE: The present report proposes a conceptual synthesis on the biogenesis and treatment of ASI that is based on known molecular and cellular aspects of human inflammatory sequence and patient data from clinical trials. It also introduces proper timing of therapeutic intervention as a potentially important determinant for the successful outcome of the disease process. CONCLUSIONS: Progress in understanding the biogenesis of ASI did not result in successful therapeutic developments as yet. The challenge ahead should be a better understanding of the dynamics of the various processes and regulators in appropriate animal and clinical models of ASI, in order to properly intervene and direct effective therapies for the benefit of critically ill patients.

Minimal injury mastectomy in the surgical treatment of stage I and II breast cancer patients. A 20-year experience.

The main purpose of the present study is to enhance what we coined minimal injury mastectomy (MIM) as a reliable, efficient and acceptable procedure in the surgical treatment of breast cancer besides other therapeutic options currently used in the setting of adjuvant treatment (e.g. radiation therapy, chemotherapy or hormonal manipulations). We analysed retrospectively data of 142 patients with stage I and II breast cancer. Fifty-five of them had stage I, and the remaining 87 patients had stage II disease. Patients were submitted to minimal injury mastectomy, which is a broad segmental mastectomy, with limited or no axillary lymphadenectomy, thus minimizing locoregional trauma. Radiotherapy was given on a selective basis. Postoperative follow-up period ranged from one to 19.5 years (mean 103.5 months). Cosmetic results, shoulder function, texture of the breast and patient psychology were excellent in all the patients. In 55 stage I patients, six local recurrences occurred (12.72%), a mean 49.9 months after MIM, with ultimate local control of all patients and a remarkable survival after treatment of recurrences. In 87 stage II patients, six local (6.8%) and 16 systemic recurrences (18.7%) occurred, the latter after a mean period of 54.4 months postoperatively. It is concluded that with the minimal injury mastectomy, locoregional injury is minimized, preserving the regional immunological functions and by preventing lymphedema of the remaining breast, systemic resistance mechanisms are maintained and other adverse factors are avoided.

Tamoxifen-induced endometrial polyp. A case report and review of the literature.

A case of an endometrial polyp which developed in a 74-year-old woman treated with tamoxifen for 15 years after breast cancer surgery was the stimulus for this brief and concise review of the endometrial changes caused by anti-estrogen treatment in post-menopausal women with breast cancer. Tamoxifen therapy has been associated with the development of endometrial polyps, hyperplasia and adenocarcinoma possibly mediated through its agonistic estrogenic properties. Hysteroscopy follow-up should be performed in this group of patients and hysteroscopy should be done before the beginning of therapy and repeated once a year during the treatment.

Anorectal abscesses: need for accurate anatomical localization of the disease.

Anorectal abscesses constitute a common problem of the perianal area. Considerable morbidity is expected if an immediate and anatomically correct drainage procedure is not performed in a timely manner. Acute infection of an anal gland leads to the formation of the anorectal abscess, while the chronic stage of the infection appears as a fistula in ano. It is imperative to perform operations with accurate anatomical knowledge; this is particularly true in the case of fistula-in-ano and anorectal abscesses, for which inappropriate surgery can lead to disastrous results. Here we report our experience with anorectal abscesses in various locations in 14 patients. Four of the 14 had a transrectal drainage. The internal (transrectal) or external drainage of the anorectal abscesses depends mainly on the mechanism of their formation and the anatomical relationship of the abscess to the levator ani. Apart from a death occurring 1 month after drainage due to a cause not related to suppurative disease (subdural hematoma), all patients had an uneventful recovery and were discharged from hospital after a mean stay of 1.2 days. A brief and practical description of the macroscopic anatomy of the area will assist in understanding better the selection of the appropriate route of drainage of anorectal abscesses.

Experience with the intra-abdominal approach for complicated hernias of the inguinal region.

In this report we describe our experience using the transabdominal approach for the reduction and repair of incarcerated or strangulated hernias of the inguinal or femoral region. This technique allows for the division of the constricting ring under direct vision as atraumatically as possible and permits a simplified Cooper's ligament type of repair with great accuracy, safety and ease. Thus, all risks associated with the conventional techniques are minimized and the chances for success of reconstruction are markedly enhanced. Short and long term results have been excellent in 22 patients with complicated inguinal or femoral hernias, five of them recurrent and five with strangulated bowel, with a mean follow up of 80 months.

Washing with or without chloramphenicol in the treatment of peritonitis: a prospective, clinical trial.

One hundred one suitable patients with peritonitis of diverse origin were randomized into two groups. In each patient in group 1 (50 patients), the abdomen was washed after the appropriate surgical procedure with normal saline solution, and 2 gm chloramphenicol was introduced before abdominal closure; in each patient in group 2 (51 patients), the abdomen was washed as in group 1, but chloramphenicol was not instilled. All patients were given 1 gm chloramphenicol intramuscularly either preoperatively or intraoperatively and 3 gm daily for 3 days. Chloramphenicol was selected on the basis of its activity against aerobic and anaerobic bacteria and its demonstrated stimulating effect on peritoneal macrophages in vitro. All explorations were done through the midline, and the skin and subcutaneous tissues were closed secondarily 3 to 4 days after operation. No drains were used. The two groups were roughly comparable, but results were significantly better for all parameters studied in patients receiving chloramphenicol locally. Blood dyscrasias were not observed. It is suggested that the combination of washing and local antibiotics is superior to washing alone; in addition to its parenteral administration, chloramphenicol is of considerable value if instilled in the area of peritonitis after washing; and besides its bacteriostatic action, chloramphenicol may have a local stimulating effect on peritoneal defenses and may therefore be the drug of choice for local use in generalized peritonitis.