Abstract Dynamic CT has a reported sensitivity of as high as 97% in the detection of pancreatic cancer. Consequently, a substantial number of pancreatic tumors can still escape detection. The ...isoattenuating pancreatic adenocarcinoma is defined as a mass not directly visible on dynamic CT as its attenuation is indistinguishable from the attenuation of the pancreatic parenchyma. 88% and 100% of the isoattenuating adenocarcinomas <20 mm and >20 mm respectively are recognized only by the presence of secondary imaging findings highly suggestive of malignancy. Dynamic MRI can unmask 80% of the isoattenuating pancreatic adenocarcinomas. If MRI fails to unmask the mass, EUS-biopsy is not mandatory to be performed as biopsy proof is not required for solid pancreatic masses suspicious for malignancy before proceeding to surgery. The isoattenuating adenocarcinomas should not be regarded as early cancers as less than one-third of them are stage T1 tumors. After curative intent surgery, isoattenuating pancreatic adenocarcinoma patients have a significantly longer median survival than usual pancreatic adenocarcinoma patients associated with the higher rate of well differentiated tumors among isoattenuating tumors. The more favorable postsurgical survival of the isoattenuating pancreatic adenocarcinoma patients makes it even more imperative to correctly diagnose their cases at a resectable stage.
Previous studies on the development of post-endoscopic retrograde cholangiopancreatography (post-ERCP) hyperamylasemia and pancreatitis have focused on different risk factors, either procedure- or ...patient-related, and also prognostic factors, such as amylase levels together with the occurrence of pancreatic-type pain, which might be implicated. The aim of this study is to identify possible predictive risk factors and also prognostic factors in order to better organize the treatment strategy.
During a 5-year period, 556 ERCP procedures were performed by the same operator. Of these, 43 procedures were excluded from the study. Data recorded from the procedures included both patient characteristics and procedure details. Patients were evaluated for pancreatic-type pain at 4 and 24 h after the procedure, and serum amylase levels were determined at 2 and 24 h after the procedure. Pancreatitis was diagnosed on the basis of both clinical and laboratory examination, while patients with hyperamylasemia were in a normal clinical condition but had high serum amylase levels.
Post-ERCP pancreatitis occurred after 17 procedures (3.3%) and hyperamylasemia after 85 procedures (16.5%). Patients who developed pancreatitis all had pancreatic-type pain together with amylase levels higher than 4-5 times the upper normal limit at 24 h after ERCP. There was a significant association between serum amylase levels and post-procedure pancreatic-type pain both at 4 h and 24 h after ERCP (P = 0.006). Age less than 50 years, history of relapsing pancreatitis, pancreatic duct opacification, and difficulty in obtaining bile duct cannulation all proved to be significant predictive risk factors for the development of either hyperamylasemia or pancreatitis. In contrast, additional procedures and sphincterotomy seemed to reduce the likelihood of both complications.
Serum amylase levels higher than 4 - 5 times the normal upper limit together with the existence of pancreatic-type pain, at 24 h after ERCP, strongly suggest the occurrence of pancreatitis. When any of the predictive risk factors coexist during a procedure it would be better either to abandon the procedure and try again later or, if the situation is urgent, to have earlier recourse to an alternative, such as precut or needle-knife papillotomy.
Esophageal cancer is the 8th most common and 6th most deadly malignancy worldwide. It is an aggressive type of cancer with poor prognosis, despite advances in therapeutic methods including those in ...thoracoabdominal surgery, chemotherapy and radiotherapy. It rarely manifests in young patients, but occurs frequently in older people. It has been related with achalasia regarding mainly the squamous cell carcinoma rather than the adenocarcinoma. Infiltrating esophageal tumors and radiotherapy can lead to the development of aortoesophageal fistula, a pathological communication between the aorta and the esophagus.
We present the case of a 24-year-old male patient with a known history of achalasia for almost 15 years with a history of heavy smoking and drinking that presented with advanced lower esophageal adenocarcinoma. The patient was submitted, as per to his will, directly to Ivor Lewis esophagogastrectomy. One month later, dysphagia was manifested due to stenosis of the anastomosis, without any signs of local recurrence, and an esophageal metallic stent was placed. In the 3rd postoperative month, upper gastrointestinal bleeding presented due to an aortoesophageal fistula, caused by anastomotic dehiscence due to local recurrence and pressure from the stent, which was treated surgically. The patient, refusing chemotherapy at all stages, developed peritoneal carcinomatosis and died 6 months after surgery.
Esophageal cancer is an aggressive type of cancer with a poor prognosis that is typically dia-gnosed in advanced stages. Despite the development of new therapeutic approaches, the high recurrence rate and the poor prognosis remain.
Bile duct injury (BDI) is perhaps the most feared complication of laparoscopic cholecystectomy (LC). Proper management of iatrogenic BDI is mandatory to avoid immediate or later life-threatening ...sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery.
Twelve patients with BDI after LC were treated. Eight of them were referred to our institution for further treatment. The follow-up evaluation was focused on clinical outcome and biochemical analysis.
Five of the patients had minor BDI with leakage. In all of them, the BDI was recognized postoperatively. Two of these patients were managed by endoscopic retrograde cholongio pancreatographic sphincterotomy and stent placement. The other three patients underwent open laparotomy and bile duct ligation. Seven of the patients had major BDI. In two patients, biliary injuries were identified at the time of LC, and the procedure was converted to laparotomy. At the time of conversion, primary suture repair with T-tube drainage of the injured bile duct was performed. Strictures developed in these patients after 2 and 6 months, respectively, and they were treated with a Roux-en-Y hepaticojejunostomy. In five additional patients, BDI was recognized postoperatively. One of these patients died because of delayed detection of biliary peritonitis. At this writing, during a median follow-up period of 52 months, neither clinical nor biochemical evidence of biliary disease has been found in the remaining patients.
Laparoscopic BDI has a high morbidity and mortality rate. Late recognition of the BDI remains a problem.
Bile leakage after laparoscopic biliary surgery is a surgical challenge in which endoscopy can play an important role.
A total of 26 patients underwent endoscopic retrograde cholangiopancreatography ...(ERCP) in our department. Patients with evidence of major ductal injury were treated surgically. In all other cases, endoscopic sphincterotomy was performed, any retained bile duct stones were removed, and a biliary endoprosthesis or a nasobiliary catheter was inserted on a selective basis.
ERCP was successful in 24 patients. Seven patients were treated surgically after cholangiography revealed major ductal injury. Two more patients were eventually operated on due to bile peritonitis. Of the other 15 patients, 11 had leakage from the cystic duct and four had leakage from the gallbladder bed. Bile duct stones were removed from eight patients, an endoprosthesis were inserted in five patients, and a nasobiliary catheter was inserted in two patients. Bile leakage was treated successfully in all 15 patients with no further complications.
ERCP is a means of safe diagnosing the cause of a bile leakage and offers a definitive treatment in most cases.
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