The etiology, prognosis, and optimal management of primary gastric carcinoids remain controversial. Records of 36 consecutive patients with gastric carcinoid (15 men) were reviewed retrospectively between 1975 and 1990. Follow-up was complete in 97% of cases. Mean age at diagnosis was 58.4 years (range 24-82 years). The clinical presentations included anemia (72%), pain (69%), and carcinoid syndrome (11%). Associated autoimmune and endocrine abnormalities were common and included atrophic gastritis (67%), pernicious anemia (58%), hypothyroidism (39%), diabetes (19%), Addison's disease (6%), and hyperparathyroidism (6%). Lesions were nonantral in 78%, involving only the corpus in 42%, the fundus in 28%, and only the antrum in 8%; 42% were multiple. Urinary 5-hydroxyindoleacetic acid (5-HIAA) and serum gastrin levels were elevated in 17% and 50% of those tested, respectively. Histologic examination revealed that 28% of lesions were > or = 2 cm, and 33% had liver metastases on presentation or developed them during follow-up. Eight patients (22%) died of tumor with a median survival of 39 months. The presence of metastases, atypical histology, serosal involvement, and size > 2 cm were adverse prognostic factors. In patients without hypergastrinemia (n = 6), 66% developed metastases, 60% had elevated 5-HIAA, and 50% died of carcinoid tumor. In sharp contrast, those patients with hypergastrinemia and "typical" gastric carcinoids (n = 15), metastases and death did not occur (p < 0.003 and p < 0.005, respectively, compared with eugastrinemic patients).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMedDate not supplied

Long-term consequences of intraoperative spillage of bile and gallstones during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is associated with a higher incidence of iatrogenic perforation of the gallbladder than open cholecystectomy. The long-term consequences of spilled bile and gallstones are unknown. Data were collected prospectively from 1059 consecutive patients undergoing laparoscopic cholecystectomy over a 3-year period. Details of the operative procedures and postoperative course of patients in whom gallbladder perforation occurred were reviewed. Long-term follow-up (range 24 to 59 months) was available for 92% of patients. Intraoperative perforation of the gallbladder occurred in 306 patients (29%); it was more common in men and was associated with increasing age, body weight, and the presence of omental adhesions (each P < 0.001). There was no increased risk in patients with acute cholecystitis (P = 0.13). Postoperatively pyrexia was more common in patients with spillage of gallbladder contents (18% vs. 9%; P < 0.001). Of the patients with long-term follow-up, intra- abdominal abscess developed in 1 (0.6%) of 177 with spillage of only bile, and in 3 (2.9%) of 103 patients with spillage of both bile and gallstones, whereas no intra- abdominal abscesses occurred in the 697 patients in whom the gallbladder was removed intact ( P < 0.001). Intraperitoneal spillage of gallbladder contents during laparoscopic cholecystectomy is associated with an increased risk of intra-abdominal abscess. Attempts should be made to irrigate the operative field to evacuate spilled bile and to retrieve all gallstones spilled during the operative procedure.

Bile↗

PubMedDate not supplied

Duodenal carcinoid tumors: how aggressive should we be?

Duodenal carcinoid tumors are uncommon. It is not known whether they behave more like carcinoid tumors in the appendix (indolent course) or those in the ileum (often virulent)-crucial information for determining the need for radical resection. A retrospective review at our tertiary referral center (from 1976 to 1999) identified 27 patients with primary duodenal carcinoid lesions, excluding functional islet cell tumors. Endoscopic biopsy provided the diagnosis in 78% of patients. Treatment was by endoscopic excision (n = 11), transduodenal excision (n = 8), pancreaticoduodenectomy (n = 3), segmental distal duodenectomy (n = 2), or palliative operation (n = 2). One patient did not undergo operation because of comorbidity. Eighteen of 19 patients with tumors smaller than 2 cm remained disease free after local (endoscopic or transduodenal) excision. The exception was a patient with a small periampullary carcinoid lesion. In contrast, all four patients with carcinoid tumors 2 cm or larger who were resected for cure developed a recurrence (2 to 9 years postoperatively). We conclude that duodenal carcinoid tumors smaller than 2 cm may be excised locally; to ensure complete resection we recommend open transduodenal excision for tumors between 1 and 2 cm. Endoscopic follow-up is indicated. It is unclear whether patients with larger tumors benefit from more aggressive locoregional resection. Ampullary/periampullary carcinoid tumors should be considered separately, as their behavior is unpredictable.

Adult↗

PubMedDate not supplied

Renal artery stenosis and a functioning hilar paraganglioma: a rare cause of renovascular hypertension--a case report.

Surgically correctable causes of hypertension are uncommon. Simultaneous occurrence of 2 such causes in the same individual is extremely rare. The authors describe a 25-year-old woman with congenital erythrocytosis, renal artery stenosis, and a paraganglioma. The possible mechanisms of renal artery stenosis in the presence of a catecholamine-secreting tumor are discussed.

Adult↗

PubMedDate not supplied

Metabolic disturbances after head injury: abnormalities of sodium and water balance with special reference to the effects of alcohol intoxication.

Eighty-eight patients with craniocerebral trauma were studied prospectively to assess the effects of the injury on sodium and water balance. Abnormalities of serum sodium and osmolality occurred in 11 of the 76 patients who were on the study more than 24 hours, and the incidence of these abnormalities was directly related to the severity of the craniocerebral injury. Hyponatremic hypo-osmolar states were as frequent as were hypernatremia and serum hyperosmolality. The major cause of the hyponatremia was inappropriate antidiuretic hormone secretion; hypernatremia was due to dehydration and occurred predominantly in comatose patients with increased insensible fluid losses associated with pyrexia. We recommend that the initial fluid intake after craniocerebral trauma be kept between 1500 and 1800 ml/24 hours and that further fluid management be dictated by repeated serum electrolyte determinations. The electrolyte balance should be monitored continuously after a significant head injury for up to 2 weeks, because hyponatremic states sometimes develop more than 1 week after injury. The serum alcohol was measured on admission, and the level of serum alcohol correlated well with the serum osmolality on admission; thus, the degree of elevation of serum osmolality was a very good guide to the serum alcohol level. However, there was no statistically significant correlation between alcohol intoxication or chronic alcoholism and the late development of serum sodium and osmolality disturbances.

Adolescent↗

PubMedDate not supplied

Correlations of plasma concentrations of B-cell polypeptides with pathologic features of insulinomas.

OBJECTIVE: To assess the correlations between plasma concentrations of b-cell polypeptides (insulin, C peptide) and size, multiplicity, and malignancy of insulinomas. METHODS: We retrospectively reviewed the medical records of 55 consecutively treated patients at our institution with surgically confirmed insulinoma. The 29 female and 26 male patients ranged from 13 to 77 years of age (median, 46). Plasma insulin, C peptide, proinsulin, and glucose concentrations were analyzed statistically in patients with benign and those with malignant insulinomas. RESULTS: Significant correlations were observed between plasma insulin and tumor size (r = 0.45; P = 0.001) and tumor volume (r = 0.41; P = 0.007) and between plasma C peptide and tumor size (r = 0.38; P = 0.004) and tumor volume (r = 0.33; P = 0.025). No differences between benign and malignant tumors were noted for plasma insulin, C peptide, glucose, nor tumor size or volume. No correlations were found between plasma insulin, C peptide, or glucose and number of tumors. CONCLUSION: The plasma levels of insulin and C peptide provide qualitative indications about the size of insulinomas.

Journal Article↗

PubMedDate not supplied

Mediastinal parathyroid carcinoma.

OBJECTIVE: To describe a patient with a mediastinal parathyroid carcinoma and hypercalcemia as well as to compare the features of parathyroid carcinoma with those of hypercalcemia due to other causes of primary hyperparathyroidism. METHODS: We present a case report and discuss the diagnosis and management of this rare tumor. RESULTS: In a 44-year-old man, severe hypercalcemia and normal findings on neck exploration led to referral and ultimate detection of an anterior mediastinal mass. Surgical resection and pathologic examination of the mass revealed a cystic parathyroid carcinoma. Subsequently, normalization of serum calcium and parathyroid hormone levels ensued. CONCLUSION: Parathyroid carcinoma as an alternative to the diagnosis of primary hyperparathyroidism should be considered in patients with dramatically increased serum calcium and parathyroid hormone levels at the time of initial examination. The mainstay of therapy for parathyroid carcinoma is complete surgical resection. Accurate preoperative localization of parathyroid carcinoma is helpful, especially in instances of reoperation or hypercalcemic crisis.

Journal Article↗