Quantitative Aspects of Diffusion-weighted Magnetic Resonance Imaging in Rectal Cancer Response to Neoadjuvant Therapy.

BACKGROUND: The aim of the study was to evaluate the added value of the apparent diffusion coefficient (ADC) of diffusion-weighted magnetic resonance imaging (DW-MRI) in patients with rectal cancer who received neoadjuvant chemoradiotherapy (CRT). The use of DW-MRI for response evaluation in rectal cancer still remains a widely investigated issue, as the accurate detection of pathologic complete response (pCR) is critical in making therapeutic decisions. PATIENTS AND METHODS: Thirty-three patients with locally advanced rectal cancer were evaluated retrospectively by MRI in addition to diffusion-weighted images (DWI) and its ADC pre- and post-neoadjuvant CRT. These patients subsequently underwent curative-intent surgery. Tumor staging by MRI and ADC value were compared with histopathological findings of the surgical specimen. RESULTS: MRI in addition to DWI had a sensitivity of 96.1%, specificity of 71.4%, positive predictive value of 92.5%, and negative predictive value of 83.3% in the detection of pCR. The pre-CRT ADC alone could not reliably predict the pCR group. Post-CRT ADC cutoff value of 1.49 x 10-3 mm2/s had the highest accuracy and allowed a 16.7% increase in negative predictive value and 3.9% increase in sensitivity. Patients with pCR to neoadjuvant treatment differed from the other groups in their absolute values of post-CRT ADC (p < 0.01). CONCLUSIONS: The use of post-CRT ADC increased the diagnostic performance of MRI in addition to DWI in predicting the final pathologic staging of rectal carcinoma.

Primary extensive perianal cutaneous tuberculosis: A challenging diagnosis. Case report and a review of the literature.

RATIONALE: Perianal tuberculosis is extremely rare without previous or active pulmonary infection. Ulcerative skin lesion is a rare presentation of extrapulmonary tuberculosis in the oral, perianal, or genital mucosa and the adjacent skin. CASE REPORT: A 71-year-old woman complained of pain during evacuation and fecal incontinence for two years. There was an ulcerated lesion in the perianal and intergluteal region and perianal fistulous tracts. A polymerase chain reaction test on blood and biopsies of perianal ulcers, perianal fistula, and the intergluteal area was positive for Mycobacterium tuberculosis. The pathological examination revealed a chronic epithelioid granulomatous inflammatory process with the presence of multinucleated giant cells. After the end of the tuberculosis drug regimen, there was marked improvement in the patient's clinical condition. CONCLUSION: Even in the absence of an identifiable primary focus, tuberculosis should be considered in the differential diagnosis of ulcerative and fistulous lesions of the perianal area.

ALTERNATIVE FISTULA RISK SCORE AND FIRST POSTOPERATIVE DAY DRAIN FLUID AMYLASE AS PREDICTORS OF PANCREATIC FISTULA AFTER PANCREATICODUODENECTOMY.

BACKGROUND: The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. AIMS: The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. METHODS: This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. RESULTS: The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. CONCLUSION: The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

Mixed-type intraductal papillary mucinous neoplasm: Tailored surgical planning - case report.

INTRODUCTION: With the greater availability of imaging exams, the diagnosis of intraductal papillary mucinous neoplasms (IPMNs) has increased recently. However, there are still questions about adequate management approaches for this disease, especially regarding the best therapeutic strategy. The objective is to describe the case of a patient with mixed-type (MT) IPMN successfully treated by a tailored surgical plan that adopted duodenopancreatectomy and imaging to monitor the remaining lesions of the tail and body of the pancreas. PRESENTATION OF CASE: A 65-year-old asymptomatic man underwent ultrasonography of the abdomen and was diagnosed with a cystic tumor, measuring 3.0 × 2.5 cm, located on the head of the pancreas. Magnetic resonance cholangiopancreatography (MRCP) showed dilation of the main pancreatic duct and multiple cystic lesions scattered throughout the entire parenchyma. The patient underwent duodenopancreatectomy; postoperatively, he did not have complications and was discharged on the 6th postoperative day. The histopathological panel confirmed the presence of MT-IPMN of the intestinal pattern. The patient is currently well four years after surgery and is undergoing semiannual MRCP examinations to follow up the remaining lesions. DISCUSSION: MT-IPMNs represent 28-41% of all IPMNs. Among all subtypes, MT-IPMNs are the most challenging in terms of choosing the ideal therapeutic strategy. These lesions are the most difficult to treat because they can be multifocal and compromise different locations of the pancreatic parenchyma. CONCLUSION: MRI findings, Ca19.9 serum level and negative family history of pancreatic neoplasia were indications for the surgical choice for the MT- IPMN presented in this case.

Primary extensive perianal cutaneous tuberculosis: A challenging diagnosis. Case report and a review of the literature

Abstract Rationale Perianal tuberculosis is extremely rare without previous or active pulmonary infection. Ulcerative skin lesion is a rare presentation of extrapulmonary tuberculosis in the oral, perianal, or genital mucosa and the adjacent skin. Case report A 71-year-old woman complained of pain during evacuation and fecal incontinence for two years. There was an ulcerated lesion in the perianal and intergluteal region and perianal fistulous tracts. A polymerase chain reaction test on blood and biopsies of perianal ulcers, perianal fistula, and the intergluteal area was positive for Mycobacterium tuberculosis. The pathological examination revealed a chronic epithelioid granulomatous inflammatory process with the presence of multinucleated giant cells. After the end of the tuberculosis drug regimen, there was marked improvement in the patient's clinical condition. Conclusion Even in the absence of an identifiable primary focus, tuberculosis should be considered in the differential diagnosis of ulcerative and fistulous lesions of the perianal area.

Alternative fistula risk score and first postoperative day drain fluid amylase as predictors of pancreatic fistula after pancreaticoduodenectomy / Escore alternativo de risco de fístula e níveis de amilase do fluido de drenagem no primeiro dia de pós-operatório como preditores de fístula pancreática após pancreaticoduodenectomia

ABSTRACT BACKGROUND: The high morbidity and mortality rates of pancreaticoduodenectomy are mainly associated with pancreaticojejunal anastomosis, the most fragile and susceptible to complications such as clinically relevant postoperative pancreatic fistula. AIMS: The alternative fistula risk score and the first postoperative day drain fluid amylase are predictors of the occurrence of clinically relevant postoperative pancreatic fistula. No consensus has been reached on which of the scores is a better predictor; moreover, their combined predictive power remains unclear. To the best of our knowledge, this association had not yet been studied. METHODS: This study assessed the predictive effect of alternative fistula risk score and/or drain fluid amylase on clinically relevant postoperative pancreatic fistula in a retrospective cohort of 58 patients following pancreaticoduodenectomy. The Shapiro-Wilk and Mann-Whitney tests were applied for assessing the distribution of the samples and for comparing the medians, respectively. The receiver operating characteristics curve and the confusion matrix were used to analyze the predictive models. RESULTS: The alternative fistula risk score values were not statistically different between patients in the clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 59.5, p=0.12). The drain fluid amylase values were statistically different between clinically relevant postoperative pancreatic fistula and non- clinically relevant postoperative pancreatic fistula groups (Mann-Whitney U test 27, p=0.004). The alternative fistula risk score and drain fluid amylase were independently less predictive for clinically relevant postoperative pancreatic fistula, compared to combined alternative fistula risk score + drain fluid amylase. CONCLUSION: The combined model involving alternative fistula risk score >20% + drain fluid amylase=5,000 U/L was the most effective predictor of clinically relevant postoperative pancreatic fistula occurrence following pancreaticoduodenectomy.

RESUMO RACIONAL: A alta morbimortalidade da pancreaticoduodenectomia está associada, principalmente, à anastomose pancreatojejunal, a mais frágil e suscetível a complicações como a fístula pancreática pós-operatória clinicamente relevante (clinically relevant postoperative pancreatic fistula - CR-POPF). OBJETIVOS: O escore alternativo de risco de fístula (alternative fistula risk score) e os níveis de amilase do fluido de drenagem no primeiro dia pós-operatório (first postoperative day drain fluid) são preditores da ocorrência de fístula pancreática pós-operatória clinicamente relevante. Nenhum consenso foi alcançado sobre qual das pontuações é um melhor preditor; além disso, seu poder preditivo combinado permanece obscuro. Até onde sabemos, essa associação ainda não havia sido estudada. MÉTODOS: Este estudo avaliou o efeito preditivo do escore alternativo de risco de fístula e/ou do fluido de drenagem no primeiro dia pós-operatório em uma coorte retrospectiva de 58 pacientes após pancreaticoduodenectomia. Os testes de Shapiro-Wilk e Mann-Whitney foram aplicados para avaliar a distribuição das amostras e para comparar as medianas, respectivamente. A curva de características operacionais do receptor e a matriz de confusão foram utilizadas para analisar os modelos preditivos. RESULTADOS: Os valores do escore alternativo de risco de fístula não foram estatisticamente diferentes entre os pacientes dos grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 59,5, p=0,12). Os valores de fluido de drenagem no primeiro dia pós-operatório foram estatisticamente diferentes entre os grupos fístula pancreática pós-operatória clinicamente relevante e não- fístula pancreática pós-operatória clinicamente relevante (teste U de Mann-Whitney 27, p=0,004). O escore alternativo de risco de fístula e fluido de drenagem no primeiro dia pós-operatório foram independentemente menos preditivos para fístula pancreática pós-operatória clinicamente relevante, em comparação com escore alternativo de risco de fístula + fluido de drenagem no primeiro dia pós-operatório combinados. CONCLUSÕES: O modelo combinado envolvendo escore alternativo de risco de fístula>20% + fluido de drenagem no primeiro dia pós-operatório=5.000 U/L foi o preditor mais eficaz da ocorrência de fístula pancreática pós-operatória clinicamente relevante após pancreaticoduodenectomia.

Relato raro de atresia jejunoileal em dois irmãos nascidos com três anos de diferença / Rare jejunoileal atresia in two singleton brothers born three years apart

A atresia do intestino delgado é malformação congênita, conhecida como causa comum de obstrução intestinal no período neonatal. A atresia duodenal familiar é extremamente rara e tem sido atribuída a aberrações cromossômicas e a consaguinidade, sugerindo herança autossômica recessiva. As anomalias intestinais distais, como a atresia jejunoileal,são malformações congênitas raras do intestino delgado e têm sido relacionadas a oclusões vasculares tanto no início quanto no final da gestação além de causas genéticas. A atresia jejunoileal familiar em gêmeos é de ocorrência extremamente rara e é relacionada a algumas drogas e tinturas que são instiladas durante a gestação para diagnósticopor amniocentese e tem sido descrita como causa da atresia jejunoileal em irmãos gêmeos. Autores de dois diferentes estudos descrevem que esta atresia é significantemente mais frequente em gêmeos que em irmãos nascidos separadamente. No presente artigo descrevemos dois casos extremamente raros em dois irmãos nascidos com três anosde diferença, ambos com atresia jejunoileal sem outras malformações associadas ou anomalias cromossômicas, que foram acompanhados pela equipe em 2004 e 2007, respectivamente. Apesar das investigações, não foram encontradas nenhuma razão para essa ocorrência. Contudo, os autores estão seguindo os dois meninos desde então e não detectaramalterações no desenvolvimento de nenhum deles que pudessem sugerir qualquer malformação associada.

Small intestinal atresia is a common congenital malformation and it is a well-known cause of intestinal obstruction in neonates. Familial occurrence of duodenal atresia is extremely rare and has been attributed to chromosomal aberrations and parental consanguinity suggesting autosomal recessive inheritance. Distal intestinal anomalies, such as jejunoileal atresia, are a rare congenital malformation of the small bowel and have been related to vascular occlusion in the earlier or later stages in pregnancy and genetic causes. Familial jejunoileal atresia in twins is an extremely rareoccurrence that is attributed to the use of some chemicals and other dyes instillated during diagnostic amniocentesis and has been described as a cause of jejunoileal atresia in twin-brothers. Authors of two different research institutes stated that jejunoileal atresia is significantly more frequent in twins than in singletons. In the present article we describean extremely rare occurrence in two singleton infants, who were born three years apart, with similar jejunoileal atresia with no other associated malformations or chromosomal anomalies, who were treated in 2004 and 2007, respectively. Despite investigation, we did not find any reason for this particular occurrence; however they will be closely followed inorder to detect any development alterations that could indicate an associated malformation.

Pancreatite aguda necro-hemorrágica em pâncreas ectópico localizado no mesentério do colo ascendente: Um caso muito raro / Acute necrotic and hemorrhagic pancreatitis in ectopic pancreas located in the ascendent colon mesentery: A very rare case

O pâncreas ectópico é uma malformação congênita definida como o tecido pancreático sem continuidade com o pâncreas tópico normal, nem conexão com sua vascularização, apresentando ductos e vascularização independentes. As heterotopias pancreáticas descritas ocorrem mais frequentemente no interior do trato digestório proximal, principalmente no estômago, duodeno, próximo à papila de Vater, e jejuno. Descrevemos o caso de uma adolecente de 16 anos, com quadro abdominal doloroso progressivo há três dias que negava náusea,vômito e febre. Ao examefísico, abdome plano, flácido, doloroso à palpação profunda na região do flanco e do hipocôndrio direitos, com grande massa tumoral palpável nesta região, dolorosa e de pouca mobilidade. A ultrassonografia mostrou imagem de tumoração de aspecto misto, com 8 por 10 cm. A tomografia computadorizada helicoidal mostrou massa tumoral arredondada de aproximadamente 10 por 12 cm de diâmetro, encapsulada e adjacente à borda direita da veia cava inferior sem obstrução intestinal. No ato operatório foi identificado tumor arredondado, de aproximadamente 12 cmde diâmetro, anterior ao arco duodenal, medial ao lobo direito do fígado e vesícula biliar e no mesentério do colo ascendente. Embora raro e os exames radiológicos não definam o tipo de tumor existente, principalmente os localizados no mesentério, o pâncreas ectópico deve sempre ser incluído na elaboração do diagnóstico diferencial dasmassas tumorais abdominais, principalmente aquelas extraluminais.

Ectopic pancreas is a congenital malformation defined as pancreatic tissue that has no continuity with the normal topic pancreas or connection with its vascularization, but presents independent ducts and vascularization. Pancreas heterotopias occur most frequently in the interior of the proximal digestive tract, particularly in the stomach, duodenum, next to the ampulla of Vater and jejune. We describe the case of a 16 year-old girl presenting a three-day progressive painful abdominal condition with no nausea, vomit or fever. Physical exam showed a flat flaccid abdomen, painful when deeply palpated at the right flank and right hypochondrium area where a large palpable low mobility tumoral mass was located. Ultrasonography showed an image of a tumor with mixed aspect measuring 8 by10 cm. Helicoidal computerized tomography revealed a round-shaped tumoral mass of approximately 10 by 12 cm in diameter, encapsulated and adjacent to the right edge of the inferior cava vein, but not causing intestinal obstruction. At surgery, a round tumorwas identified with a diameter of approximately 12 cm, located at the anterior duodenal arch, medially to the liver right lobe and gall bladder and in the ascendant colon mesentery. Despite its rarity, and given that radiological exams do not define the type of an existing tumor especially those located in the mesentery, ectopic pancreas should always beconsidered in the elaboration of abdominal tumoral masses, particularly extra-luminal tumors.

Perfil das mulheres acometidas por prenhez ectópica tubária / Women profile with tubal ectopic pregnancy

A prenhez ectópica é definida como a implantação do óvulo fertilizado em qualquer lugar diferente de sua localização endometrial. É uma séria emergência ginecológica, pois é uma entidade hemorrágica grave. A sua prevalência se elevou significativamente nas últimas décadas e é considerada a primeira causa de morte materna no primeiro trimestre da gestação e a segunda causa de mortalidade materna geral. O principal local da prenhez ectópica é na tuba uterina. Diversos fatores de risco têm sido associados: doença inflamatória pélvica, fumo, idade, paridade, etnia, cirurgias prévias e uso de dispositivo intra-uterino. Foi traçado o perfil das mulheres acometidas por prenhez ectópica, através de um estudo do tipo caso-controle, durante o período de 2000 a 2004, na cidade de Sorocaba (SP), obtendo-se 78 casos de prenhez ectópica e 147 casos de prenhez intra-uterina. A análise estatística revelou como fatores de risco estatisticamente significantes o fumo, a idade e a paridade, todos com p<0,05. Assim sendo, mulheres com mais de 4 gestações, tabagistas e de idade mais avançada, estavam mais propensas a desenvolverem prenhez ectópica. Desta forma, é importante que mulheres em período fértil recebam orientação sobre esses fatores de risco, para que, assim, se possa reduzir a incidência desta patologia.