Surgical pancreatic sphincteroplasty. Historic or history ? A review.

BACKGROUND: Minimal invasive techniques represent a constantly expanding field of medicine and numerous well-established operative procedures have gradually been replaced. Likewise, surgical pancreatic sphincteroplasty, which has been the cornerstone in the management of pancreatic flow disorders for decades, has been largely replaced by endoscopy. Endoscopic pancreatic sphincterotomy however, is still not widespread and carries a significant risk of complications. In this study we attempt to review the role of the surgical approach in the modern era. METHODS: Pubmed database was searched for reports concerning surgical pancreatic sphincteroplasty alone or in comparison with endoscopy, without other limitations. RESULTS: Initially, 44 studies were obtained. Finally, 22 full papers were selected, pertaining review articles, case series or clinical studies. Only four of them were recent (after 2002) series of surgical sphincteroplasty, pertaining 561 patients. No randomized-controlled trials or meta-analyses were revealed. CONCLUSIONS: Pancreatic sphincterotomy, either surgical or endoscopic offers good to excellent long-term results in several disorders, like Sphincter Oddi dysfunction, especially when underlying parenchymal disease is limited. Surgical sphincteroplasty is nowadays indicated in most cases of endoscopic failure and in cases that the papilla cannot be approached. Bariatric patients with gastric by-pass and sphincter Oddi dysfunction in particular, have reported to show excellent outcome after surgery. Regardless the method, patient selection is still a very important determinant of success.

Laparoscopic surgery for malignant adrenal tumors.

Advances in imaging have improved early detection of primary and metastatic adrenal tumors. The laparoscopic approach, the gold standard for benign adrenal diseases, is controversial for malignant adrenal tumors. A prospective randomized study of the role of laparoscopic surgery in adrenal cancer is not feasible because of the rarity of the disease. A review of the literature demonstrates the safety and efficacy of laparoscopic adrenalectomy for solitary adrenal tumors. In primary adrenal malignancies, the laparoscopic approach should be considered cautiously, only when it can achieve complete tumor resection with an intact adrenal capsule. Conversion to an open procedure should be an early decision, prior to tumor morcellation or fracture of the tumor capsule. Patients who have local invasion, tumors that are too large, or require organ resection require an open procedure.

Drug-induced esophagitis.

Drug-induced esophagitis is being recognized increasingly in the past few years. Since 1970 more than 650 cases have been reported worldwide caused by 30 or more medications. We have reviewed these cases with a view to classifying this disease based on underlying pathological mechanism. Drug-induced esophageal injury tends to occur at the anatomical site of narrowing, with the middle third behind the left atrium predominating (75.6%). The disease is broadly classified into two groups. The first group being transient and self-limiting as exemplified by the tetracycline group induced injury (65.8%). The second is the persistent esophagitis group, often with stricture, with two distinct entities: (i) patients on nonsteroidal anti-inflammatory agents whose injury is aggravated by gastroesophageal reflux (21.8%) (reflux aggravated); and (ii) patients with potasium chloride and quinidine sulphate induced injury (12.4%) (persistent drug injury). Severe esophageal injury has been reported in some women taking biphosphonates as treatment for postmenopausal osteoporosis. Endoscopic findings in such patients with esophageal injury generally suggested a chemical esophagitis, with erosions or ulcerations and exudative inflammation accompanied by thickening of the esophageal wall. Most cases of medication-induced esophageal injury heal without intervention within a few days. Thus, the most important aspect of therapy is to make the correct diagnosis and then to avoid reinjury with the drug. When possible, potentially caustic oral medications should be discontinued.