Cribiform variant of papillary thyroid cancer and familial adenomatous polyposis.

BACKGROUND: Familial adenomatous polyposis (FAP) is an autosomal dominant cancer predisposition syndrome characterised by the progressive development of multiple colorectal adenomatous polyps and an increased incidence of colorectal carcinoma. It is often accompanied by other benign or malignant extracolonic manifestations, including gastric and duodenal tumours, osteomas, desmoid tumours, retinal pigmentation, and thyroid and adrenocortical tumours METHODS AND RESULTS: We report the case of a 42-year-old white female with FAP who was referred to our Endocrine Surgery Unit for surgery because of a palpable mass in the left side of the neck. An ultrasound-guided fine needle aspiration biopsy showed a cribriform-morular variant (CMV) of papillary thyroid carcinoma (PTC). The incidence, clinical presentation, histology and treatment options for this rare histological subtype are discussed. CONCLUSIONS: The diagnosis of CMV of PTC is very strongly related to the FAP syndrome and must be suspected when a thyroid node appears in FAP patients. Likewise, any patient without known FAP who presents this histology in a surgically biopsied or resected thyroid node should undergo total colonoscopy for screening of colonic polyposis and genetic study of the APC gene sequence.

[Chonic diarrhea and malabsorption due to common variable immunodeficiency, gastrectomy and giardiasis infection: a difficult nutritional management]. / Diarrea crónica refractaria y malabsorción secundaria a hipogammaglobulinemia común variable, infestación crónica por giardia lamblia y gastrectomía total por adenocarcinoma gástrico: un manejo nutricional complejo.

Gastric cancer is a frequent cause of cancer-related mortality in the world. Surgery is the only potentially curative therapy, although the adverse effects of surgery are common and considerable. Common variable immunodeficiency is in many cases cause of gastrointestinal system problems such as chronic diarrhea caused by infestation with giardia lamblia, nodular lymphoid hiperplasia ad loss of villi leading frequently to malapsortion and malnutrition. Nutritional deficiencies due to malapsorption (postgastrectomy and secondary to loss of villi, giardiasis and common variable inmunodeficiency) are common. We present the case of a patient with gastric cancer who underwent a gastrectomy with common variable hipogammaglobulinemia and chronic infestation by giardia lamblia, with serious diarrhea resistant to treatment and malabsorption.

Conservative approach versus urgent appendectomy in surgical management of acute appendicitis with abscess or phlegmon.

BACKGROUND: Surgical management of acute appendicitis with appendiceal abscess or phlegmon remains controversial. We studied the results of initial conservative treatment (antibiotics and percutaneous drainage if necessary, with or without interval appendectomy) compared with immediate surgery. METHODS: We undertook an observational, retrospective cohort study of patients with a clinical and radiological diagnosis of acute appendicitis with an abscess or phlegmon, treated in our hospital between January 1997 and March 2009. Patients younger than 14, with severe sepsis or with diffuse peritonitis were excluded. A study group of 15 patients with acute appendicitis complicated with an abscess or phlegmon underwent conservative treatment. A control group was composed of the other patients, who all underwent urgent appendectomy, matched for age and later randomized 1:1. The infectious risk stratification was established with the National Nosocomial Infections Surveillance System (NNIS) index. Dependent variables were hospital stay and surgical site infection. Analysis was with SPSS, with p < 0.05 considered significant. RESULTS: Interval appendectomy was performed in 7 study group patients. Surgical site infection episodes were more frequent in the control group (6 vs. 0, p < 0.001). A greater percentage of high risk patients (NNIS ≥ 2) was identified in the control group (80 vs. 28.7%, p < 0.03), mostly related with contaminated or dirty procedures in this group (p < 0.001). No significant difference between groups was found in hospital stay. CONCLUSION: Initial conservative treatment should be considered the best therapeutic choice for acute appendicitis with abscess or phlegmon.

Is liver transplantation without abdominal drainage safe?

UNLABELLED: This observational, analytical cohort consisted of 35 consecutive liver transplant (OLT) patients with no intra-abdominal drain and a control cohort of 35 subjects operated immediately before the former who had placement of an intra-abdominal drain. We sought to assess the impact of abdominal drainage on the diagnosis and prevention of early postoperative complications: hemoperitoneum, reinterventions, biliary leaks, or percutaneous drainage. We assessed variables related to the recipient (age, indication, pretransplant ascites, body mass index, Model for End-Stage Liver Disease score and rejection), the donor (age, steatosis, ischemia time) and intra- and postoperative factors (surgery time, blood product use, and coagulopathy). The end point was defined as the need for a reintervention, paracentesis, appearance, and drainage of collections as well as lengths of hospital and intensive care unit (ICU) stays. The postoperative ICU and in-hospital stays were similar between groups (3.7 vs 3.9 days and 12 vs 14 days, respectively). Two patients in the group with drainage were reoperated due to hemoperitoneum, whereas we did not reoperate any patients in the group without drainage. No patient from either group developed a biliary fistula or required drainage of an intra-abdominal collections. The need for paracentesis was greater among the group without drainage (23% vs 5.7%; P < .04) and among those with a prior history of severe ascites. Patients with drainage displayed a greater incidence of perihepatic hematomas by ultrasound (53% vs 21%; P < .08) and required more postoperative blood products, especially platelets (P > .04) and plasma (P < .01). CONCLUSION: OLT without intra-abdominal drainage is safe, not increasing morbidity. It seems likely that drainage may be responsible for intra-abdominal hematomas and greater consumption of blood products.

An alternative method of reconstruction of hepatic venous outflow in domino liver transplantation.

The double piggyback technique has been proposed for domino liver transplantation. To make this possible, it is necessary to reconstruct the venous outflow of the domino liver graft on the back table. We describe an alternative method of reconstruction of hepatic venous outflow, in which a neocaval segment is obtained using both common iliac veins from the cadaveric donor.

Impact of donor age on the results of liver transplantation in hepatitis C virus-positive recipients.

OBJECTIVE: Hepatitis C virus (HCV)-cirrhosis is the most frequent indication for orthotopic liver transplantation (OLT) among adults in most European and American transplant centers. The aim of this study was to analyze the impact of donor age on graft survival among HCV-positive cirrhotic transplant patients. MATERIALS AND METHODS: We performed an observational, retrospective study between March 1997 and December 2004, analyzing 340 liver transplantations. The patients were divided into 4 groups, considering whether the HCV infection was the indication for OLT and whether the age of the donor was older or younger than 48 years: group 1 (HCV, <48 years); group 2 (HCV, >48 years); group 3 (non-HCV, <48 years); and group 4 (non-HCV, >48 years). RESULTS: A univariate analysis showed that posttransplantation graft survival was clearly influenced by recipient HCV serologic status (P = .018). However, no graft survival differences were found when the analysis variable was age (>48 or <48 years). When both variables were studied, a positive HCV serology did not modify graft survival when the donor age was <48 years (P = .32), but had a statistically significant negative impact when the age was >48 years (P = .02). CONCLUSIONS: The use of older donors for HCV recipients resulted in worse graft and patient survivals in our study. This difference in survival was not present in non-HCV recipients or when grafts for HCV recipients were procured from younger donors. Donor age <30 years was a protective factor for graft survival among HCV recipients.

Influence of immunosuppression and effect of hepatitis C virus on new onset of diabetes mellitus in liver transplant recipients.

INTRODUCTION: New-onset posttransplantation diabetes mellitus (PTDM), with an incidence of 10% to 30%, increased graft and patient morbidity and mortality. Such causal factors as age, obesity, therapy, immunosuppression, and hepatitis C virus (HCV) contribute to this disease. OBJECTIVE: We sought to determine the incidence of PTDM and impaired fasting glucose (IFG) concentration in transplant recipients to define the causal variables. MATERIAL AND METHODS: The study included 127 patients. Patients with pretransplantation diabetes and those with less than 6 months of follow-up were excluded. A descriptive observational study to assess the association between PTDM and IFG and the immunosuppression therapy used was performed by monitoring the potential confounding variables of age, obesity, and HCV. RESULTS: During mean follow-up of 73.7 months (range, 7-120 mo), 93 patients received cyclosporine A (CyA) and 34 received tacrolimus (Tac) therapy. Thirty patients (23.6%) developed PTDM or IFG including 15 (16%; PTDM, six IFG, nine) in the CyA group and 15 (PTDM, seven; IFG, eight) in the Tacrolimus group (P = .001; odds ratio [OR], 4.1). They were homogeneous with respect to confounding variables except for HCV (P = .01). Of the 55 patients with HCV infection, 12 developed PTDM or IFG, including three in the CyA group and nine in the tacrolimus group (P = .03; OR, 7.7), whereas in the 72 patients without HCV infection, the CyA or tacrolimus association with PTDM or IFG was significant (P = .05), Mantel-Haenszel test; OR, 4.9). The interaction between HCV and immunosuppression therapy was primarily produced in the IFG group (HCV-positive; P = .008; OR, 8). CONCLUSION: We observed an association between the use of tacrolimus and the development of PTDM or IFG. There is greater risk in HCV-positive patients, in particular in relation to IFG. The choice of immunosuppressive treatment might be decided on the basis of the patient's pretransplantation status.

Transfusion requirements during liver transplantation: impact of a temporary portacaval shunt.

UNLABELLED: We evaluated the consumption of blood products during liver transplantation in cirrhotic patients association with the placement of a temporary portacaval shunt (TPCS). PATIENTS AND METHODS: We retrospectively divided 349 cirrhotic patients transplanted in our unit between March 1997 and October 2005 into two groups: transplants without a TPCS (group I, 189 cases) and those with a TPCS (group II, 160 cases). In all cases, we preserved the inferior vena cava (piggyback). The dependent variables were consumption of blood-derived products (banked red cells, recovered red cells, fresh frozen plasma, platelets), surgery time, kidney function, intensive care unit stay, and hospital stay. RESULTS: Consumption of blood products was significantly lower among patients who received a TPCS. In group II, no platelet transfusion was required in 54% of the patients, and no banked red cells in 12% compared with 18% and 3%, respectively, among group I patients (P < .005). The mean overall transplant procedure time was 74 minutes shorter in group II (361 minutes) compared with group I (435 minutes) (P < .001). The overall hospital stay was shorter among patients transplanted after TPCS. CONCLUSION: Liver transplantation with a TPCS was accompanied by a reduction in the intraoperative use of blood-derived products, especially platelet transfusion. Among other advantages, this reduction resulted in a shorter posttransplant hospital stay.

[Pancreatic cystic metastasis from pulmonary carcinoma. Report of a case]. / Metastasi cistica pancreatica da carcinoma polmonare. Presentazione di un caso.

We report the case of a patients with a metachronous cystic pancreatic metastasis from an undifferentiated large cell lung carcinoma two years after the primary tumor had been surgically removed. Clinically, he presented with epigastric pain, fever, weakness and anorexia. The patient was operated and a palliative cystogastrostomy was performed after an intraoperative biopsy had been informed as positive for carcinoma. Six months later the patient died. Pancreatic metastases from lung carcinoma are found in approximately 7-9% of patients deceased of this neoplasm. Clinical and radiological findings simulate primary pancreatic tumors, being epigastric pain, jaundice and upper digestive bleeding the most frequent symptoms. They represent stages of advanced systemic disseminated tumoral disease, and because of this reason total or partial surgical curative resections will only be performed in a few cases of patients with isolated metastasis, criteria of resectability and without evidence of extended disease to other organs or systems. In the most of the cases, the treatment will only be palliative, even medical or surgical.