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At least 145 records · Page 8Linked to original sources
PubMed2006

Management of pancreatic endocrine tumors in multiple endocrine neoplasia type 1.

INTRODUCTION: Pancreatic endocrine tumors (PETs) occur in at least 50% of patients with multiple endocrine neoplasia type 1 (MEN1) and are the leading cause of disease-specific mortality. However, the timing and extent of surgery for MEN1-related PETs is controversial owing to the indolent tumor growth seen in most patients and the desire to avoid complications associated with insulin dependence. To help resolve this controversy, we retrospectively analyzed the clinical characteristics, surgical treatment, and clinical outcome of patients with MEN1-related PETs. METHODS: All patients had histologic or radiographic confirmation of a PET in the setting of MEN1. Disease progression was defined radiographically as the development of new pancreatic tumors or distant metastases. Progression-free survival (PFS) and overall survival (OS) were used as the endpoints of this analysis. RESULTS: We identified 98 patients with MEN1, 55 (56%) of whom had PETs, including 27 women and 28 men with a median age of 37 years (range 8-69 years) at the time of diagnosis. Functioning PETs were present in 35 (64%) of 55 patients, and nonfunctioning tumors were present in 20 (36%). Pancreatic surgery was performed in 38 (69%) of the 55 patients; and the first operation included enucleation (n = 4), total pancreatectomy (n = 3), Whipple procedure (n = 4), and distal pancreatectomy (n = 27). The median size of the resected tumors was 2.8 cm (range 0.6-11.0 cm). Recurrent disease developed in the residual pancreas in 7 (20%) of 35 at-risk patients a median of 7.8 years after the first operation, and distant metastases occurred in 5 (14 %) of 36 surgically treated patients without distant metastasis (2 patients had distant metastases when surgery on the primary tumor was performed) at a median of 2.7 years following surgery. At last follow-up, 16 (29%) of 55 patients with PETs had died, 12 (22%) were alive with disease, 26 (47%) were alive without evidence of disease, and 1 (2%) was lost to follow-up. The median OS was 19.5 years (range 13-26 years) and was significantly longer for patients who had functioning PETs versus those with nonfunctioning tumors (P = 0.0007), for patients who underwent surgical resection of their PETs versus those who did not (P = 0.0043), and for patients with localized versus metastatic PETs at the time of diagnosis (P < 0.0001). Multivariate analysis revealed that younger age, hormonal function, and PET resection were independently associated with longer OS. CONCLUSIONS: Our data suggest that early diagnosis and surgical excision of MEN1-related PETs improves survival. However, translating these data into a surveillance strategy for the early detection of PETs is complex owing to the potential morbidity of pancreatic resection and the risk of long-term insulin dependence.

Adolescent↗
PubMedDate not supplied

Iatrogenic intestinal injury concomitant to iatrogenic bile duct injury: the second component.

OBJECTIVE: Bile duct injuries have a frequency of 0.1% to 0.3% even in the most experienced centers. Complex biliary lesions usually require a bilioenteric anastomosis, achieving good long-term results in 80% to 90% of the cases. Besides injuries to the abdominal contents during laparoscopy (by trocars or electrocautery), intestinal complications associated with reconstruction attempts can be observed. We analyzed the concomitant intestinal complications in 251 patients with iatrogenic biliary injuries reconstructed over this 12-year period. METHODS: A retrospective review of patients with biliary tract reconstruction after iatrogenic injury in a tertiary academic health-care center was done. All patients with concomitant intestinal injury were included; type of operation and postoperative outcome were analyzed. RESULTS: Among 251 patients, 35 cases had a concomitant intestinal injury. The most common site of fistulization was the duodenum (18 cases, 50%); 9 cases were associated with long-term subhepatic drains (more than three weeks), and the other 9 cases were associated with a dehiscent hepatoduodenostomy. Faulty Roux-en-Y reconstruction was observed in 5 cases. In 5 cases, fistulization of the jejunum and ileum, secondary to drain placement, was documented, as well as 3 cases with colonic injuries. Two patients had a dehisced Roux-en-Y anastomosis. One had a bilioenteric omega type ileal anastomosis, and 1 had a hepatoileal anastomosis without omega reconstruction. Primary repair of the duodenum with resection of the affected intestinal or colonic segment was done at the same time of biliary repair without related morbidity. CONCLUSIONS: Concomitant gastrointestinal injures were found with an incidence of 15% in our series. The most common site of fistulization is the duodenum. In half of the patients, it was secondary to a dehiscent hepatoduodenostomy, whereas in the other, it was caused by long-term subhepatic drains. Besides faulty Roux-en-Y reconstruction, fistulization was related with long-term drains. Primary repair and resection of the affected segment of jejunum, ileum, and colon can be done during the same operative stage of biliary reconstruction, without significant correlated mortality.

Academic Medical Centers↗
PubMed2001

[Surgical treatment of gastroesophageal reflux disease in adults].

Pathological gastroesophageal reflux is common. The aim of this review was to compare the results of different surgical techniques. Papers were selected on Medline from 1990 to April 2001. A critical analysis was performed, concerning definitions of included patients, surgical techniques, and criteria of evaluation. For comparison, the results of 23 randomized studies were mainly selected. Their heterogeneity has not allowed a meta-analysis. A few techniques had poorer results than others: simple closure of His angle, Hill operation, Belsey Mark IV technique, and Angelchik prosthesis. In most studies, results of partial fundoplication on reflux were as good as those of total Nissen fundoplication and fewer patients had postoperative dysphagia. In a double blind trial, immediate advantages of laparoscopic approach were less important than those observed in non comparative studies. Another trial was interrupted after inclusion of 103 patients because of the higher rate of side-effects in the laparoscopic group. These results may help the surgeon in the choice of a technique. Patients have to be informed of potential adverse effects of the different techniques chosen by their surgeon.

Adult↗
PubMed2005

Endoscopic stenting versus surgical bypass in advanced malignant distal bile duct obstruction: cost-effectiveness analysis.

OBJECTIVE: Palliative treatment of obstructive jaundice from advanced tumour of the distal bile duct is controversial. The aim of this study was to compare the clinical outcomes and costs between endoscopic stent insertion and surgery. METHODS: The clinical data for 116 patients treated with either endoscopic plastic stenting (65 patients) or surgical bypass (51 patients) were reviewed and analysed. RESULTS: No significant difference was found between the two groups in terms of the length of hospital stay, survival time, cost, effectiveness, and early complications. However, late complications were significantly more common in the stenting group (p = 0.007). Jaundice recurred in 15 stented patients at a median time of 3 months due to stent blockage, and one surgical patient had recurrent jaundice from anastomosis stricture. Late gastric outlet obstruction occurred in one of 36 surgical patients who did not undergo prophylactic gastroenterostomy and one of 65 stented patients developed this complication. CONCLUSION: Both techniques are equally effective in biliary drainage, but stenting has a higher rate of recurrent jaundice. We recommend surgery for patients with low surgical risks and endoscopic stent in those with a short life expectancy or those unfit for surgery.

Adult↗
PubMed2002

Chronic pancreatitis: Asia-Pacific consensus report.

Current knowledge about chronic pancreatitis (CP) is limited and there is a particular dearth of information about the entity known as tropical pancreatitis. A consensus working party was convened by the Trustees of the Journal of Gastroenterology and Hepatology Foundation to conduct a systematic investigation into available evidence about the epidemiology, etiopathogenesis, diagnosis and management of CP. A literature search and formal survey of international experts in the field were used to assemble reliable evidence about these issues. The present review summarizes the results of the working party's findings and presents a series of practice guidelines to improve diagnosis, investigation and treatment of patients with CP, particularly those in the Asia-Pacific region. Areas for further research have also been identified.

Asia↗
PubMed2005

Obstructive fibrostenotic Crohn's disease.

Crohn's disease is often complicated by gastrointestinal strictures. Postoperative recurrence at the anastomotic site is common and repeated surgical interventions may be necessary. Medical treatment may relieve active inflammation (see chapter on active luminal disease) but fibrous strictures will not respond to this. Mechanical treatment methods consist of endoscopic balloon dilation, stricturoplasty or surgical resection. Fibrostenotic Crohn's disease does not respond to medical therapy and requires endoscopic or surgical treatment.

Catheterization↗
PubMedDate not supplied

Gastrointestinal endoscopy in high-risk patients.

In America more than 100,000 high-risk patients/year have conditions normally evaluated by gastrointestinal endoscopy. This review analyzes the safety and efficacy of gastrointestinal endoscopy in high-risk patients. Endoscopy during pregnancy raises the unique issue of fetal safety. The safety of esophagogastroduodenoscopy (EGD) during pregnancy has been examined in a case-controlled study of 83 patients, a mailed survey of 73 patients, and case reports. The safety of sigmoidoscopy during pregnancy has been examined in a case-controlled study of 45 patients, a mailed survey of 26 patients, and case reports. These studies suggest that EGD and sigmoidoscopy are not contraindicated during pregnancy. For example, EGD should be performed for significant upper gastrointestinal bleeding. The safety of colonoscopy during pregnancy is inadequately analyzed. In a study of 34 EGDs performed within 3 weeks of myocardial infarction, no endoscopic complications occurred in 26 clinically stable patients with uncomplicated myocardial infarction. However, 3 major endoscopic complications occurred in 8 clinically unstable patients. In a study of 9 sigmoidoscopies within 3 weeks of myocardial infarction, no sigmoidoscopic complications occurred in 7 clinically stable patients. Several studies have shown that EGD, sigmoidoscopy, or colonoscopy is safe in patients with advanced HIV infection. AIDS patients should generally be endoscoped with the same aggressiveness as other patients. However, endoscopy may be unwise in any terminal patient. No complication occurred in 60 patients undergoing EGD within 3 weeks of esophageal, gastric, or duodenal surgery. One minor complication occurred in 36 patients undergoing sigmoidoscopy within 3 weeks of colonic surgery. These results suggest that EGD or sigmoidoscopy is not contraindicated within 3 weeks of gastrointestinal surgery. No complications occurred in 53 chronic obstructive pulmonary disease patients undergoing EGD. EGD appears to be safe in chronic obstructive pulmonary disease patients without severe hypoxemia or acute bronchospasm. Emergency EGD can be performed in patients with severe hypoxemia after endotracheal intubation.

Contraindications↗
PubMed2006

EUS-guided mucosectomy for gastrointestinal cancer.

INTRODUCTION: the only way of improving prognosis and survival in gastrointestinal cancer is early diagnosis, with intramucosal localization as confirmed by endoscopic ultrasonography (EUS) or 20-MHz miniprobes (MPs) (T1) being most appropriate. Endoscopic mucosal resection (EMR) has proven effective in the treatment of this sort of lesions. PATIENTS AND METHOD: in a group (18 cases) with 15 cases of superficial gastrointestinal cancer and 3 cases of severe gastric dysplasia, 9 cases (3 esophageal, 4 gastric, 2 rectal) underwent a classic EMR following EUS or a 7.5- and 20-MHz miniprobe exploration. RESULTS: ultrasonographic studies showed a T1 in all but one esophageal case (Tis), and in both gastric dysplasias, with no changed layer structure being demonstrated in the latter (T0). No complications arose with classic EMR, and all 9 patients are alive and free from local or metastatic recurrence, except for one esophageal case, which recurred distally to the esophageal lesion (metachronous). CONCLUSIONS: echoendoscopically-assisted EMR is a safe, effective technique in the endoscopic management of superficial gastrointestinal (esophageal, gastric, colorectal) cancer. Recurrence most likely depends upon cancer multiplicity.

Aged↗
PubMedDate not supplied

Prospective study of the functional results of transanal endoscopic microsurgery.

BACKGROUND/AIMS: Most clinical research addresses the technological advances and oncological outcomes of transanal endoscopic microsurgery. Our aim was to examine the functional results. METHODOLOGY: From August 1999 to November 2000, 22 Taiwanese patients (14 men, 8 women; median age, 68 years) undergoing transanal endoscopic microsurgery were prospectively examined. Functional questionnaires and anorectal manometry were assessed before surgery and at 2 weeks, 6 weeks, 3 months, and 1 year. RESULTS: The median distance from the anal verge to the tumor was 10 cm. The median tumor diameter was 2.0 cm. The median duration of surgery was 120 minutes. No surgical mortality or morbidity and no local recurrence occurred during a median follow-up of 23 months. The mean stool frequency and consistency were significantly better at 3 months after surgery than before surgery. The maximal resting pressure significantly decreased after surgery. The maximal contraction pressure and maximal tolerated volume were significantly lower at 2 and 6 weeks than before surgery; these values recovered at 1 year. CONCLUSIONS: Transanal endoscopic microsurgery is safe for the cure of benign tumors and the palliative excision of malignant tumors in middle and upper rectum. Anorectal function was preserved and improved, though some anorectal manometric parameters changed over time.

Adenocarcinoma↗
PubMed2003

Diagnosis and treatment of mucobilia: report of 8 cases.

OBJECTIVE: To better understand mucobilia as well as its diagnosis and treatment. METHODS: The etiological factors, diagnosis, and treatment of 8 patients with mucobilia were discussed. RESULTS: Mucobilia characterized by copious mucin secretion in the extrahepatic bile duct resulted in obstructive jaundice and cholangitis. Four patients receiving curative resection of primary lesions were free from jaundice and cholangitis while the other 4 who had had palliative biliary drainage showed persistent symptoms. CONCLUSIONS: Mucobilia is attributable to biliary mucous metaplasia, and benign or malignant biliary tumors. Cholangioscopy and biopsy can offer precise information about the location and extension of the primary lesion. The best choice of treatment is curative resection of the primary lesion.

Adult↗