A newly recognized entity: intraductal "oncocytic" papillary neoplasm of the pancreas

Intraductal papillary-mucinous tumors of the pancreas are increasingly recognized, and their characteristic endoscopic and radiological features are well reported in the literature in recent years. Oncocytic features in these tumors are uncommon and unrecognized. Intraductal oncocytic papillary neoplasm is a distinct pancreatic tumor and is a recently recognized entity. We report a case of a 69-yr-old patient who presented with symptoms mimicking pancreatitis, resulting in delay in the diagnosis of her pancreatic tumor. She underwent a successful Whipple's procedure and subsequently has remained well. The resected specimen showed an intraductal oncocytic papillary-mucinous neoplasm. The entity is new and the literature information is inadequate at present to judge the biological behavior of this tumor. We discuss this recently recognized entity.     

"Window" laryngoplasty: a new combined laser endoscopic and open technique for conservation surgery

Endoscopic laser resection of early laryngeal carcinoma is an increasingly used treatment modality; however, the limited exposure achieved and the alteration of vocal function are still major problems. A new surgical procedure, "window" laryngoplasty, has been devised and tested in an in vivo study in 6 canines with 50 days' survival. The right vocal cord was incised endoscopically with the carbon dioxide laser, and the en bloc specimen with adjacent thyroid cartilage was removed through a window approach made in the thyroid cartilage. A sternohyoid muscle flap based superiorly was inserted into the cartilaginous window to reconstruct a pseudocord with coverage of either mucosa or fascia. A diode laser soldering technique was used to secure the mucosal graft in place. Epithelial transplantation can be accomplished externally with precise endoscopic guidance for reliable placement of the pseudocord. The results show that the new technique, a combination of endoscopic and open approaches, may be a better treatment choice than standard vertical partial laryngectomy in selected patients. Advantages of this technique include adequate en bloc resection, including adjacent cartilage for pathologic evaluation, preservation of the integrity of most of the laryngeal framework, avoidance of tracheotomy, and better functional results.     

Usefulness of simple endoscopic aspiration cytology of pancreatic juice for diagnosis of early pancreatic neoplasm. A prospective study

For detection of early cancer of the pancreas, endoscopic aspiration cytology of pancreatic juice without endoscopic retrograde pancreatography was performed in 64 consecutive outpatients who had symptoms or findings that suggested pancreatic disease. Patients with positive or suspicious cytologic results or abnormal US findings were admitted and underwent detailed examinations. Positive and suspicious cytologic results were obtained in 2 and 10 patients, respectively. Of those with positive and suspicious cytologic results, two, and one patient, respectively, were ultimately found to have pancreatic neoplasms. Of these three resected specimens, one was in situ carcinoma and two presented marked atypia. All patients were alive with no evidence of recurrence. No further cases of pancreatic neoplasm were found. Complications from the procedure did not develop in any patient. This technique is useful in the diagnosis of early neoplasms of the pancreas, because it is simple and safe to perform for outpatients.     

Attentional demands and the organization of reaching movements in rock climbing

Epiphrenic oesophageal diverticula are of the pulsation type, the underlying cause is a motility disorder. Resection is indicated by severe symptoms like dysphagia, regurgitation or aspiration and should be performed after endoscopic dilatative treatment of the neuromotor disturbance. Thoracoscopic resection under endoluminal endoscopic surveillance is considered to be a reliable procedure with low morbidity for the patient.     

Is prophylactic treatment after myocardial infarction evidence-based?

In Barrett's esophagus, the squamous lining of the lower esophagus is replaced by columnar epithelium. Barrett's esophagus is associated with gastroesophageal reflux and an increased risk of the development of esophageal cancer. Endoscopy shows red columnar epithelium in the lower esophagus. Biopsy is needed to confirm intestinal metaplasia. Some cases progress from dysplasia to invasive adenocarcinoma. Medical or surgical antireflux treatment controls symptoms and esophagitis, but Barrett's esophagus remains. Patients are usually followed up by endoscopy for detection of dysplasia or early cancer. For patients with low-grade dysplasia, follow-up is adequate; however, for those with high-grade dysplasia, esophagectomy or experimental endoscopic mucosal ablation is advised.     

Case report: The "veiled right kidney sign"--an ultrasound finding in retroperitoneal perforation of the duodenum

We report a case of traumatic duodenal perforation where the diagnosis was first considered during abdominal ultrasound examination. A subsequent CT scan identified the site of perforation which was confirmed at laparotomy. This condition typically produces few clinical signs or symptoms initially but has a high mortality related to delayed diagnosis. The ultrasound findings that prompted early diagnosis are described.     

Evaluation of axis alignment system for correction of myopic astigmatism with the excimer laser

BACKGROUND: Anomalous pancreaticobiliary junction (APBJ) without congenital choledochal cyst (CCC) carries a high risk of gallbladder carcinoma development. The aim of this study was to obtain information allowing early diagnosis and appropriate management. METHODS: The clinical features, imaging findings and surgical outcome of 18 patients with APBJ without CCC were analysed retrospectively. RESULTS: Fourteen patients had symptoms, including those of acute pancreatitis (five patients). In 16 patients the gallbladder showed abnormalities, including carcinoma (eight) and mucosal hyperplasia (11). Ultrasonography detected gallbladder carcinoma with 100 per cent sensitivity and mucosal hyperplasia with 91 per cent sensitivity. A long common channel was demonstrated by endoscopic retrograde cholangiopancreatography (ERCP) in all patients, endoscopic ultrasonography in nine of ten, and magnetic resonance cholangiopancreatography (MRCP) in five of five. Five of eight patients with gallbladder carcinoma underwent extended cholecystectomy with bile duct excision. Three patients with cancer and eight with no cancer had cholecystectomy alone. None developed bile duct carcinoma or acute pancreatitis after operation. All patients without malignancy remained asymptomatic for a mean follow-up period of 4.7 years. CONCLUSION: Prophylactic cholecystectomy is recommended for patients with APBJ without CCC. For early diagnosis of APBJ, gallbladder abnormalities on ultrasonography or acute pancreatitis of unknown aetiology should prompt further investigation with ERCP or less invasive imaging modalities such as endoscopic ultrasonography and MRCP.     

Instrumentation and setup for endoscopic plastic surgery

The use of endoscopic techniques mandates the need for basic understanding of endoscopic instrumentation and operating room setup in order to avoid procedural delays and surgeon frustration. The electronic systems for endoscopic surgery-cameras, light sources, monitors, and so on-have been well developed for other specialties and are fully adaptable to endoscopic plastic surgical procedures. Hand instruments, however, are in the early phases of refinement for subcutaneous plastic surgical procedures and will undoubtedly improve over the next several years. Adaptation of existing instrumentation and development of new operating tools continue and promise to make endoscopic plastic surgical procedures of the future more ergonomic and efficient. Similarly, while operating room setup for endoscopic plastic surgical procedures varies depending on individual circumstances, application of a few basic principles will help in making this step quick and simple. The knowledge and experience of scrub technicians and nurses experienced in endoscopic techniques can be invaluable to the surgeon just beginning to use endoscopic techniques in plastic and reconstructive surgery.     

Endolaparoscopic "Rendez-vous" in the treatment of cholecysto-choledochal calculosis

Different methods, all of which equally efficacious and safe, can be selected to access the choledochus in patients with cholecysto and choledocholithiasis on the basis of clinical and anatomosurgical parameters. From 1990 we evaluated three groups of patients who underwent surgery at different times and with different methods: sequentially (endoscopic sphincterotomy and laparoscopic cholecystectomy), one step laparoscopy and combined laparo-endoscopy. The results obtained seem to show that the treatment with laparoscopy alone is the most advantageous in terms of cost-benefit, while the endoscopic access of the choledochus during laparoscopic cholecystectomy is the one to prefer in terms of efficacy and safety.     

Helicobacter pylori risk associated with sibship size and family history of gastric diseases in Japanese adults

BACKGROUND: Data on whether long-acting somatostatin analogue octreotide causes or prevents pancreatic injury following endoscopic retrograde cholangiopancreatography (ERCP) are controversial. AIM: This multicentre, prospective trial studied the effect of octreotide on pancreatic injury in a large unselected group of patients after ERCP and endoscopic sphincterotomy. METHODS: The study was carried out in a prospective random manner on 2102 patients in 11 endoscopic centres. Patients in the study received 0.1 mg octreotide acetate and those in the control group received isotonic sodium chloride, subcutaneously before and 45 min after ERCP. Pancreatic injury was assessed by clinical symptoms such as pain, fever and abdominal tenderness. Serum amylase and blood sugar were determined prior to, and 6 and 24 h after the endoscopic procedure. RESULTS: Data from 599 patients in the study group and 600 in the control group were included in the final evaluation. When all the patients were considered, octreotide did not induce pancreatic injury as assessed by clinical symptoms, and diminished the increase of serum amylase levels following ERCP. However, when subgroups of patients were studied, the frequency of increased amylase levels decreased significantly in patients with chronic obstructive pancreatitis and in patients who underwent endoscopic sphincterotomy (P < 0.01). The peak serum glucose level was higher in the treated group when compared to the controls. CONCLUSION: The prophylactic use of long-acting somatostatin does not alter the frequency of post-ERCP pancreatic injury, but it may diminish the rate of increased serum amylase levels in patients with chronic obstructive pancreatitis and also in those with an endoscopic sphincterotomy.     

A prospective study of gastric and oesophageal carcinoma

A prospective study of carcinoma of the stomach and oesophagus has been carried out for 2 1/2 years. Seventy-three cases of carcinoma of the stomach, and 16 cases of carcinoma of the oesophagus have been documented. For carcinoma of the stomach, operability rate was 72-6% and resectability rate was 41-9%; overall survival was poor, 20-9% at 12 months. For those who underwent resection, survival at 12 months was 45-5%. No cases of early gastric cancer are among those studied. For carcinoma of the oesophagus, four patients had a resection, and only one has survived for more than 12 months. In the clinical sphere there is a need for early endoscopic as well as radiological investigation of dyspeptic symptoms. In the research field there is a need for studies of chemotherapy in combination with surgery in the initial treatment of gastric carcinoma.     

Nonoperative management of esophageal perforation secondary to balloon dilatation

Esophageal perforation is usually considered a surgical emergency. However, esophageal perforation after therapeutic endoscopic manipulation is a different entity. This type of perforation occurs in a controlled environment and the perforation is usually detected early. Three documented cases of perforation during endoscopic balloon dilatation are described. They were successfully treated nonoperatively.     

Nissen fundoplication for reflux esophagitis. Long-term clinical and endoscopic results in 109 of 127 consecutive patients

OBJECTIVE: This study evaluates the clinical and endoscopic long-term results of Nissen fundoplication in reflux esophagitis. SUMMARY BACKGROUND DATA: Nissen fundoplication has been reported to give good results in the treatment of gastroesophageal reflux with success rates up to 78-97%. Most of the previous studies on long-term results of fundoplication have, however, been based on interviews with only sporadic endoscopic examinations. METHODS: Of 127 patients consecutively treated with Nissen fundoplication for reflux esophagitis, 109 were available for follow-up after a median of 77 months. Upper gastrointestinal endoscopy was done in 105 cases, and all the patients with reflux symptoms or abnormal endoscopic observations were referred to esophageal 24-hour pH monitoring and manometry. RESULTS: No symptoms of gastroesophageal reflux were reported by 73 of the 109 patients, but dysphagia was present in 47. Endoscopy showed defective fundic wrap in 24 patients. Objective evidence of reflux was found in 24 patients (endoscopic esophagitis in 18 and pathologic 24-hour pH score without esophagitis in 6). Esophagitis was found in 14 of the 24 patients with defective wrap, but in only 4 of the 81 with infact wrap. CONCLUSIONS: Nissen fundoplication alleviated symptoms of gastroesophageal reflux and cured esophagitis in great majority of cases. The main determinant of outcome was the state of the fundic wrap.     

The discriminative value of patient characteristics and dyspeptic symptoms for upper gastrointestinal endoscopic findings: a study on the clinical presentation of 1,147 patients

The discriminative value of patient characteristics and dyspeptic symptoms for upper gastrointestinal endoscopic findings was prospectively assessed in 1,147 patients attending for their first diagnostic endoscopy and who answered paper (n = 431) or computerized (n = 716) questionnaires. The questionnaires provided detailed information concerning present dyspeptic symptoms, with special attention to provoking and/or relieving factors, and smoking and/or drinking habits. In logistic regression models each of a number of 'specific endoscopic diagnoses' was contrasted with normal endoscopy (n = 390), and 'relevant endoscopic disease' (oesophagitis, peptic ulcers, cancers; n = 269) was contrasted with 'irrelevant' and normal endoscopic findings (n = 878). From the regression model a receiver operating characteristic (ROC) curve could be constructed, and the area under the ROC curve (AUC) was calculated to summarize the discriminative power of the regression model. The best discrimination from patients with a normal endoscopy was achieved for patients with gastric (AUC = 0.86) or duodenal (AUC = 0.85) ulcers, followed by patients with hiatus hernia (AUC = 0.78 or oesophagitis (AUC = 0.77). The discriminative performance of the regression models was somewhat less for duodenitis/bulbitis (AUC = 0.75) and endoscopic gastritis (AUC = 0.73). In an open-access endoscopy unit setting, the value of preinvestigation history-taking for the prediction of clinically relevant endoscopic disease was very limited (AUC = 0.63).     

Lipomas of the large intestine

The incidence of lipomas of the colon is difficult to evaluate due to lack of symptoms. They are often discovered by chance during endoscopic or radiological examination and sometimes display only obstructive symptoms. A barium enema may be useful for the preoperative diagnosis of lipoma of the colon. The difficulty of obtaining a clear preoperative diagnosis influences the type of surgical treatment undertaken. Thus, a resection is often preferred to the simple removal of the lipoma by colotomy or endoscopy.     

Factors predictive of early complications of endoscopic treatment of bile duct calculi

BACKGROUND/AIMS: Factors associated with an increased early complication rate of the endoscopic sphincterotomy procedure have been identified. Precut or needle knife papillotomy has been shown to improve the success rate of endoscopic retrograde cholangiography and endoscopic sphincterotomy, but has often been reported to be hazardous. In order to identify patients with bile duct stones at risk for a complicated course in connection with endoscopic clearance of the calculi, factors predictive of early complications were sought. METHODOLOGY: 417 consecutive patients with bile duct calculi at endoscopic retrograde cholangiography were considered for endoscopic treatment in our department from 1981 to 1992. Endoscopic sphincterotomy was performed in 246 patients with intact gallbladders and in 147 with prior cholecystectomy, 55 of whom had retained calculi. RESULTS: There was a 9.4% overall and 7.1% major early complication rate of the EST procedure and a 30-day mortality of 0.5% (2 patients, non-procedure related). In 22% (6/27) of the patients with major complications, surgery was required or preferred to additional endoscopic measures. Complete stone removal failed in 35/393 patients (8.9%). The immediate and early complication rate of standard sphincterotomy was not found to be increased in patients with prior or present biliopancreatic complications, failed bile duct clearance at first attempt, or juxtapapillary diverticula. It was the same after standard sphincterotomy as after precut papillotomy followed by immediate or delayed sphincterotomy. No increased morbidity was found after failed therapy as compared to failed diagnostic precut papillotomy. There was neither a greater need for, nor an increased complication rate following, precut papillotomy in patients with, as compared to those without, juxtapapillary diverticula. Endoscopic experience did not influence the complication rate. There were no significant differences regarding outcome or risk factors associated morbidity between patients with and without intact gallbladder. CONCLUSIONS: These findings confirm that endoscopic treatment is safe and that precut papillotomy can be performed without increased morbidity. Furthermore, none of the commonly identified factors associated with increased morbidity were found to be risk factors in this study.     

Amanita preissii "mushroom" poisoning

"Mushroom" poisoning has rarely been reported in Australia. We present six cases of Amanita preissii poisoning successfully treated with atropine sulphate. The symptoms and signs were typical of muscarinic poisoning, which suggests that this alkaloid is the principal toxic component. A short time interval between the ingestion of poisonous fungi and the onset of symptoms, in our cases within one hour, indicates a good prognosis. The dangers of mistaking poisonous for edible varieties of fungi are emphasized, particularly in relation to immigrants not conversant with Australian fungi. Public education and control of marketing are advised.     

Patient with right-sided epigastric pain and "negative" ultrasound

In most cases pain in the right upper abdominal quadrant is of biliary origin. Diseases of the biliary system are often visualized by ultrasonography; however, a negative test does not rule out a biliary cause. Moreover, a number of several non-biliary diseases have to be considered. Patient history, physical examination and laboratory findings determine the further diagnostic approach and include radiologic (i.e. CT/scintigraphy) and/or endoscopic (upper GI endoscopy, ERCP) examinations. In difficult diagnostic situations specialized diagnostic tools may be indicated (e.g. manometry in suspected dysfunction sphincter of the Oddi.     

Prognostic factors for relapse of reflux oesophagitis and symptoms during 12 months of therapy with lansoprazole

BACKGROUND: Symptom relief and endoscopic healing are both important treatment goals in patients with reflux oesophagitis. Knowledge of predictive factors for treatment success could facilitate choice of treatment in individual patients. AIM: To assess the value of clinical data and data from baseline ancillary investigations in predicting the outcome of maintenance therapy with a proton pump inhibitor. METHODS: After healing and symptom relief had been obtained on open therapy with lansoprazole 30 mg daily, 103 patients with reflux oesophagitis grade 1 or 2 were randomized to maintenance therapy with lansoprazole 15 or 30 mg daily, and time until recurrence of symptoms and/or endoscopic changes was recorded. The predictive value of the following variables was assessed by Cox regression analysis: dose of lansoprazole, symptom severity, grade of reflux oesophagitis. Helicobacter pylori infection status, lower oesophageal sphincter resting tone, percentage of 24 h with an oesophageal pH of <4.0, and median 24 h intragastric pH before start of treatment. RESULTS: Dose of lansoprazole (P = 0.01) and symptom severity (P < 0.05) both significantly predicted time to relapse. Grade of reflux oesophagitis had only a borderline predictive value (P = 0.09), while H. pylori infection status and data from manometry and intraoesophageal 24-hour pH-metry did not predict relapse. CONCLUSIONS: Symptom severity before starting therapy is a significant predictive factor for treatment success during potent antisecretory therapy with lansoprazole, more so than endoscopic grade of reflux oesophagitis. In a group of patients with uncomplicated reflux oesophagitis being considered for maintenance therapy with lansoprazole, ancillary investigations with endoscopy, manometry and 24-hour pH-metry gave very limited prognostic information. H. pylori infected patients relapsed as early as patients who were not infected.     

Method of evaluation "MMexico" in emergency medicine

An 11-year-old boy suffered an inadvertent dural puncture during placement of an epidural catheter for postoperative analgesia. He developed symptoms of mild headache only, but severe and protracted orthostatic nausea and dizziness, which eventually resolved completely following epidural blood patch. His symptoms were atypical and could have been misinterpreted in the context of dural puncture for diagnosis, or for administration of intrathecal chemotherapy. The reported incidence of headache following dural puncture in children is low. It may be that the manifestations are different from those of adults and that the true incidence of symptoms related to leakage of cerebrospinal fluid is higher in children than currently recognised.