IPMN: surgical treatment.

PURPOSE: Cystic pancreatic tumors are being detected more frequently, and particularly, intraductal papillary mucinous neoplasia (IPMN) has recently attracted increased attention. The detection rate of IPMN has increased over the last decade; however, management of this neoplasm remains controversial. METHODS: Based on a review of the relevant literature and the international guidelines, we discuss the diagnostic evaluation of IPMN, its treatment, and prognosis. RESULTS: While IPMN represents only a distinct minority of all pancreatic cancers, they appear to be a relatively frequent neoplastic form of pancreatic cystic neoplasm. It may not be possible to differentiate main duct disease from branch duct disease (MD-IPMN vs. BD-IPMN) prior to surgery. This distinction has not only an impact on treatment but also on prognosis, as MD-IPMN is more often malignant. IPMN has updated consensus guideline indications for conservative and surgical resection. CONCLUSIONS: Since patients with IPMN of the pancreas are at risk of developing recurrent IPMN and pancreatic ductal adenocarcinoma in the remnant pancreas and extrapancreatic malignancies, early recognition, treatment, and systemic surveillance are of great importance. No conclusions can be drawn from the available evidence with respect to the efficacy of surveillance and follow-up treatment programs. A better understanding of the natural course of IPMN and the biology of pancreatic cancer is mandatory to enable further diagnostic and treatment improvements.

[Surgical treatment of fistula-in-ano--a journey between Skylla and Charybdis]. / Die Therapie der Analfistel - Wahl zwischen Skylla und Charybdis.

This review discusses the pathogenesis, symptomatology, diagnostic work-up, and treatment options for fistula-in-ano, which is a common condition that affects ~ 20 in 100,000 per year with a predominance for young males. Fistula-in-ano normally presents as an acute anorectal abscess that subsequently becomes established as a chronic discharging fistula. The illness is characterized by chronic perianal discharge and intermittent pain. The aim of surgical treatment is permanent cure of the fistula whilst maintaining patient continence. This principle forms the basis of surgical decision-making and means that treatment options often have to be individualized for each patient. Low, simple fistulae may be treated by fistulotomy because of the low risk of incontinence. In contrast, high fistulae that contain a greater proportion of sphincter muscle demand more complex operations. Traditional reconstructive techniques (transanal advancement flap, primary sphincter reconstruction) aim to eradicate the fistula whilst leaving the sphincter muscle intact or readapted, whilst newer techniques (biosynthetic plugs) provide a scaffold to encourage normal tissue ingrowth with fistula occlusion. The newer procedures preserve the sphincter ideally. On the other hand success rates of these techniques are somewhat disappointing.

Diagnosis and treatment of rectovaginal endometriosis: an overview.

Rectovaginal endometriosis can be a cause of severe pain, dyspareunia and intestinal problems. A thorough examination is needed and should include diagnostic imaging, such as transvaginal or transrectal ultrasound or magnetic resonance imaging. Medical therapies, such as oral contraceptives, progestins and levonorgestrel-releasing intrauterine devices, all seem to reduce pain and should always be considered. Surgical treatment is challenging and implies a risk of severe complications. It is preferable to treat endometriotic lesions with superficial infiltration into the rectal wall by local laparoscopic excision, while segmental rectal resection is needed in the case of severe intestinal infiltration. This review describes available diagnostic tools, the possibilities for medical treatment and the alternative surgical approaches.

Quality issues in interpretation of optical coherence tomograms in macular diseases.

PURPOSE: To analyze the scan characteristics associated with poor-quality Stratus optical coherence tomograms submitted to a reading center for multicenter clinical trials. METHODS: Data from evaluation of 6,741 fast macular thickness map reports from trials involving age-related macular degeneration (AMD), diabetic macular edema, and retinal vein occlusion were analyzed. Optical coherence tomograms with an erroneous centerpoint thickness needing manual remeasurement (MR) were categorized as being of poor quality. The frequency of MR and the artifacts associated were analyzed by disease type, underlying retinal morphology, and severity of retinal thickening. RESULTS: MR was performed in 2,027 (30%) optical coherence tomograms. AMD had the highest frequency of MR (54.9%), followed by retinal vein occlusion (23.9%) and diabetic macular edema (16.3%). Boundary line errors were the most common artifact across all disease types (61.3% of scans requiring MR) and increased with increasing retinal thickness. Decentration artifact was seen in 15.4% of scans requiring MR. The median absolute difference between machine and manually measured centerpoint thickness assessed in a subset of 84 scans was 75.5 microm. CONCLUSION: Artifacts causing erroneous reported centerpoint thickness are common. Identifying clues that indicate suboptimal quality of optical coherence tomography (OCT) images are important to avoid erroneous interpretation of OCT data in clinical trials.

Indications of anti-HY immunity in recurrent placental abruption.

PROBLEM: Placental abruption is a potential life-threatening condition for both the fetus and the mother, being significantly more common in pregnancies with male fetuses. The pathogenesis of placental abruption remains unknown. However, some recent reports point toward a maternal immune response against the fetus as a possible mechanism. No data exist concerning special characteristics of patients suffering recurrent placental abruptions. METHOD OF STUDY: Identification of all patients with recurrent placental abruption in a retrospective review of 881 consecutive Caucasian women seen in our tertiary centre for recurrent pregnancy losses between 1986 and 2005. The HLA, DRB1, DRB3, 4, 5 and DQB1 genotypes of patients were compared with relevant controls. RESULTS: Eight patients were identified with recurrent placental abruption. The patients had a total of 22 abruptions; 18 (82%) in which the fetus died. Seven patients (88%) had first-born boys, and 15 abruptions (68%) involved male fetuses. All patients with a first-born boy, except one, had HLA-class II alleles known to restrict CD4+ T-cell responses against male-specific minor histocompatibility (HY)-antigens (HLA-DRB1*15, HLA-DRB3*0301 and HLA-DQB1*05). Haplotypes with these HLA-alleles constituted 64% of the patients' haplotypes compared to 28% of those of the controls (p=0.009). Furthermore, 43% of the patients were homozygous for these haplotypes compared to 5% of controls (p=0.023). CONCLUSION: We have found that recurrent placental abruption is exclusively almost preceded by the birth of a boy and the majority of patients have HLA-class II known to restrict CD4 T-cell reactions against HY-antigens. This indicates that maternal immunological responses against HY-antigens play a role in recurrent placental abruption.

Does caffeine reduce postoperative bowel paralysis after elective laparoscopic colectomy? (CaCo trial): study protocol for a randomized controlled trial.

BACKGROUND: Postoperative bowel paralysis is common after abdominal operations, including colectomy. As a result, hospitalization may be prolonged, thereby leading to increased cost. A recent randomized controlled trial showed that the consumption of regular black coffee after colectomy is associated with a significantly faster resumption of intestinal motility. The mechanism by which coffee stimulates intestinal motility is unknown, but caffeine seems to be the most likely stimulating agent. Thus, the effect of caffeine on postoperative bowel activity after colon surgery will be analyzed in this trial, herein referred to as CaCo. METHODS/DESIGN: Patients scheduled for elective laparoscopic colectomy or upper rectum resection are eligible to participate in this double-blinded, placebo-controlled, randomized trial. Patients fulfilling all inclusion criteria will be allocated after the surgical procedure to one of three treatment arms: 100 mg caffeine, 200 mg caffeine, or placebo (corn starch). Patients will take the capsules containing the study medication three times daily with a meal. The primary endpoint of the study is the time to a solid bowel movement. The study treatment will be stopped after the patient produces a solid bowel movement or has taken ten capsules, whichever occurs first. To determine the colonic passage time, patients will take a capsule with radiopaque markers at breakfast for the first 3 days after surgery. On the fourth day, the location of the markers will be determined with an abdominal X-ray scan. Further secondary objectives are the postoperative morbidity and mortality, well-being, sleeping behavior, and length of hospital stay. The study size was calculated to be 180 patients with an interim analysis occurring after 60 patients. DISCUSSION: From a previous study investigating coffee, evidence exists that caffeine might have a positive influence on the postoperative bowel activity. This double-blinded, placebo-controlled, randomized trial tries to show that caffeine will shorten the postoperative bowel paralysis and, thus, will improve recovery and shorten the hospital stay after colon surgery. TRIAL REGISTRATION: Clinicaltrials.gov NCT02510911 Swiss National Clinical Trials Portal SNCTP000001131.

Mannan-binding lectin polymorphisms and serum levels in patients with endometriosis.

OBJECTIVE: To investigate a possible association between endometriosis and low levels of mannan-binding lectin (MBL). STUDY DESIGN: Case-control study of blood samples from 100 patients with endometriosis compared with results from a group of 350 blood donors. RESULT: The frequency of MBL levels <100ng/ml was 14.0% in patients and 14.9% in controls. Correspondingly, the frequencies of low producing MBL genotypes were 15.0% and 16.0%, respectively. CONCLUSION: No association was found between endometriosis and low levels of MBL.

[Limited effect of gonadotrophin-releasing hormone analogues for patients with endometriosis]. / Begrænset effekt af gonadotropinfrisættende hormon-analoger til patienter med endometriose--en gennemgang af et Cochranereview.

A Cochrane review concluded that gonadotrophin-releasing hormone analogues (GnRHas) are more effective at relieving endometriosis-associated pain than no treatment/placebo, while there was not found any difference in pain relief between GnRHas and danazol or between GnRHas and intrauterine levonorgestrel. A high frequency of hypoestrogenic side effects was found for GnRHas, since none of the studies included add-back therapy. This review confirmed that GnRHas can be used for endometriosis therapy, but first choice of medical treatment should be oral contraceptives or intrauterine levonorgestrel.

[Internal herniation during pregnancy following gastric bypass surgery]. / Intern herniering under graviditet efter gastrisk bypass-operation.

In Denmark, the number of bariatric operations, including gastric bypass surgery, has increased dramatically in recent years. Internal herniation as a possible cause of acute abdominal pain, is a well-known complication after gastric bypass operation. We report two cases of internal herniation during pregnancy following gastric bypass operation. The diagnosis of internal herniation can be difficult as radiologic investigations may be inconclusive. Clinical suspicion alone should lead to surgical exploration due to the risks of morbidity and mortality if patients are not diagnosed properly.

[Transrectal removal of displaced intrauterine device]. / Transrektal fjernelse af displaceret kobberspiral.

In this case a patient presented with an intrauterine device (IUD) which was displaced into the sigmoid. The IUD was successfully removed through a proctoscope under laparoscopic guidance. Displacement of IUD into the sigmoid is a rare complication and should be treated proactively.

Association of interleukin--10 promoter polymorphism and endometriosis.

PROBLEM: inflammatory processes are believed to play an important role in the pathogenesis of endometriosis. Interleukin-10 (IL-10) is an important immunoregulatory cytokine. The biological actions are mainly inhibitory including inactivation of macrophages and inhibition of pro-inflammatory cytokines. Twin and family studies have shown that between 50 and 75% of the observed variability of IL-10 secretion was explained by genetic factors. Several single nucleotide polymorphisms (SNPs) in the promoter region of IL-10 have been described, but the most investigated are located at positions −1082, −819 and −592 of the transcriptional start site. METHOD OF STUDY: three SNPs in the promoter region of IL-10 (−1082)G>A, (−819)C>T and (−592)C>A were examined in 100 Danish patients with endometriosis and 358 healthy Danish blood donors, and haplotype associations were tested. RESULTS: we observed no strong single IL-10 marker effects and no single haplotype showed significant association. However, the ACC/ACC genotype showed a significant association because this genotype was significantly higher among patients with endometriosis than in healthy controls [OR = 3.55 (CI = 1.42­18.92); P = 0.006]. CONCLUSION: our results suggest that the IL-10 ACC/ACC genotype, which is known to be a 'low-producer' of IL-10, is associated with endometriosis.

Quantitative analysis of the Stratus optical coherence tomography fast macular thickness map reports.

The cross sectional optical coherence tomography images have an important role in evaluating retinal diseases. The reports generated by the Stratus fast macular thickness scan protocol are useful for both clinical and research purposes. The centerpoint thickness is an important outcome measure for many therapeutic trials related to macular disease. The data is susceptible to artifacts such as decentration and boundary line errors and could be potentially erroneous. An understanding of how the data is generated is essential before utilizing the data. This article describes the interpretation of the fast macular thickness map report, assessment of the quality of an optical coherence tomography image and identification of the artifacts that could influence the numeric data.

[Bilateral tubal pregnancy]. / Bilateral ekstrauterin graviditet.

Bilateral tubal pregnancies are extremely rare and they are usually found after assisted reproductive techniques have been applied. A rare case of bilateral tubal pregnancy after natural conception, occurring in a woman without any predisposing factors for ectopic pregnancy, is presented. The condition was diagnosed during laparoscopic surgery, and she was optimally treated with conservative tubal surgery. A short review of the literature is provided and discussed along with the clinical features, diagnostic difficulties and treatment options of bilateral tubal pregnancy.

Low serum level of mannan-binding lectin is a determinant for pregnancy outcome in women with recurrent spontaneous abortion.

OBJECTIVE: The purpose of this study was to investigate the genetic background for the previously reported finding of an increased frequency of low levels of mannan-binding lectin in couples with unexplained recurrent spontaneous abortion and to evaluate the impact of low mannan-binding lectin levels on future pregnancy outcome. STUDY DESIGNS: Mannan-binding lectin levels were measured in 217 women with unexplained recurrent spontaneous abortion and 111 of their husbands and were compared with corresponding measurements in 104 couples with uncomplicated reproductive histories and 210 blood donors. An investigation of the genetic polymorphism, which is largely responsible for serum mannan- binding lectin levels, was done by polymerase chain reaction methods with DNA from a subset of the patients and control subjects. Information was collected about the outcome of the patients' next pregnancies, together with perinatal data concerning the patients' first birth that occurred before or after being assigned to the study. RESULTS: Among women with recurrent spontaneous abortion, 18.9% of the women had mannan-binding lectin levels of