Pulmonary embolism with cavity formation, spontaneous pneumothorax, and high-output air leak in a patient with non-small-cell lung cancer.
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Carcinoma, Non-Small-Cell Lung↗
Biomedical subjects
G H Sakorafas
Publications and source records attributed to G H Sakorafas.
Pancreatic cancer after surgery for chronic pancreatitis.
BACKGROUND: Chronic pancreatitis is known to be a risk factor for pancreatic cancer. AIMS: To identify patients who were diagnosed with pancreatic cancer after undergoing surgery for histologically documented chronic pancreatitis. PATIENTS/METHODS: Records of 484 consecutive patients who underwent surgery for chronic pancreatitis from 1976 to 1997 were reviewed. RESULTS: Pancreatic cancer was diagnosed after a mean of 3.4 years (range: 2 months-1 years) in 14 patients (2.9%). In four patients, pancreatic cancer became evident within 12 months of surgery for chronic pancreatitis, suggesting cancer was present at the original surgery. Cancer presented with recurrent or persistent pain, jaundice, and/or weight loss. Pancreatic resection was possible in eight patients, but in the others, the cancer was inoperable. There was one long-term survivor (alive 14 years postoperatively), but for theothers mean survival was 10 months (16 months after resection vs. 4 months for inoperable cancer). CONCLUSION: Pancreatic malignancy should be suspected in patients who have had surgery for chronic pancreatitis when symptoms (such as recurrent pain, jaundice, weight loss, or anorexia) recur. Attempts at curative pancreatic resection are indicated and can offer palliation and the potential for a cure.
Adult↗
Paget's disease of the breast: a clinical perspective.
Paget's disease of the breast is a rare disorder of the nipple-areola complex often associated with an underlying in situ or invasive carcinoma. Eczematoid changes of the nipple-areola complex and persistent soreness or itching should raise suspicion of this disease. The histogenesis of Paget's disease of the breast continues to be debated and is important when considering treatment options. The epidermotropic theory suggests that Paget's cells are ductal carcinoma cells that have migrated from an underlying carcinoma of the breast parenchyma to the epidermis of the nipple. The in situ transformation theory has been proposed to explain the development of this disorder in patients in whom an underlying mammary carcinoma is not found or when there is an underlying carcinoma anatomically remote from the nipple-areola complex. Paget's cells are believed to arise as malignant cells in the epidermis of the nipple independent from any other pathologic process within the breast parenchyma. The current standard treatment of biopsy-proven Paget's disease involves mastectomy, although some studies have proposed the use of breast conservation therapy for patients in whom an underlying breast cancer cannot be located. We propose a treatment algorithm for patients presenting with Paget's disease of the breast.
Algorithms↗
Open tension free repair of inguinal hernias; the Lichtenstein technique.
BACKGROUND: Recurrences have been a significant problem following hernia repair. Prosthetic materials have been increasingly used in hernia repair to prevent recurrences. Their use has been associated with several advantages, such as less postoperative pain, rapid recovery, low recurrence rates. METHODS: In this retrospective study, 540 tension-free inguinal hernia repairs were performed between August 1994 and December 1999 in 510 patients, using a polypropylene mesh (Lichtenstein technique). The main outcome measure was early and late morbidity and especially recurrence. RESULTS: Inguinal hernia was indirect in 55 % of cases (297 patients), direct in 30 % (162 patients) and of the pantaloon (mixed) type in 15 % (81 patients). Mean patient age was 53.7 years (range, 18 - 85). Follow-up was completed in 407 patients (80 %) by clinical examination or phone call. The median follow-up period was 3.8 years (range, 1 - 6 years). Seroma and hematoma formation requiring drainage was observed in 6 and 2 patients, respectively, while transient testicular swelling occurred in 5 patients. We have not observed acute infection or abscess formation related to the presence of the foreign body (mesh). In two patients, however, a delayed rejection of the mesh occurred 10 months and 4 years following surgery. There was one recurrence of the hernia (in one of these patients with late mesh rejection) (recurrence rate = 0.2 %). Postoperative neuralgia was observed in 5 patients (1 %). CONCLUSION: Lichtenstein tension-free mesh inguinal hernia repair is a simple, safe, comfortable, effective method, with extremely low early and late morbidity and remarkably low recurrence rate and therefore it is our preferred method for hernia repair since 1994.
Adult↗
Postobstructive chronic pancreatitis: results with distal resection.
HYPOTHESIS: For most patients with chronic obstructive pancreatitis, distal pancreatectomy confers pain relief. DESIGN: Retrospective case series. Follow-up was complete in 80% of study subjects (mean follow-up, 6.7 years). SETTING: Tertiary care center. PATIENTS: Among 484 patients with chronic pancreatitis undergoing operation from 1976 to 1997, 40 with postobstructive chronic pancreatitis were identified. Criteria for selection included an isolated, dominant major pancreatic duct stricture or cutoff, changes of chronic pancreatitis in the distal pancreas, and ostensibly normal parenchyma without calcification in the proximal gland. The patients were reviewed with regard to operative procedure, postoperative course, and outcome. MAIN OUTCOME MEASURES: Outcome measures included degree of pain relief, morbidity and mortality of operation, survival, rates of endocrine and exocrine insufficiency, and ability to return to work and/or normal activities. RESULTS: All but 1 of the 40 patients had abdominal pain, and 20 (50%) had recurrent episodes of acute pancreatitis. Suspicion of malignancy was a concern in 16 patients (40%). Thirty-eight patients underwent distal pancreatectomy; 1 had a central resection and another a Roux-en-Y cystojejunostomy. There was no operative mortality, but significant morbidity occurred in 15%. Among 31 patients with preoperative pain in whom long-term follow-up was available, complete or significant pain relief was achieved in 25 (81%); 74% returned to normal social function, but about half had some element of pancreatic insufficiency. CONCLUSIONS: Distal pancreatectomy is a safe procedure and achieves pain relief and good quality of life in a large percentage of patients (80%) with presumed postobstructive chronic pancreatitis. However, some of these patients with chronic pancreatitis involving the entire gland have disease masquerading as postobstructive chronic pancreatitis secondary to an ostensibly isolated dominant pancreatic ductal stricture.
Abdominal Pain↗
Surgical management of chronic pancreatitis at the Mayo Clinic.
The authors' approach to the overall surgical management of chronic pancreatitis is to treat complications, that is, pain and, less commonly, obstruction and bleeding. The authors' practice is to exhaust nearly all forms of nonsurgical intervention before suggesting a surgical approach. Nonresponders are then evaluated for severity of pain, interference of quality of life, and presence of chemical dependency. Appropriate candidates undergo imaging examinations to determine the primary site of disease, presence of pancreatic ductal dilatation, and associated peripancreatic complications. The surgical treatment approach involves classic lines of proximal resection (pylorus-preserving pancreaticoduodenectomy) for small duct disease and lateral pancreaticojejunal drainage for a dilated pancreatic duct. The authors have not yet routinely adopted the duodenum-preserving head resections of Beger and Frey, or thoracoscopic transthoracic splanchnicectomy, but they remain open-minded and avidly await good confirmatory, independent trials of these promising surgical interventions.
Chronic Disease↗
Lateral pancreatojejunostomy in the surgical management of chronic pancreatitis. Current concepts and future perspectives.
Chronic pancreatitis is a medical disease, but surgery will be required for a selected subgroup of patients. Main indications for surgery in chronic pancreatitis are severe truly incapacitating pain refractory to medical therapy, local complications of pancreatitis or suspicion of malignancy. Surgical options include resective and drainage procedures. The choice of operation depends on the structural anatomy of the gland and the adjacent organs. Lateral pancreatojejunostomy is the preferred drainage procedure, because it is safe and effective in relieving the pain, while it preserves whatever pre-surgical pancreatic endocrine/exocrine function exists. It is indicated in large duct chronic pancreatitis (diameter of the main pancreatic duct >7 mm]; however, recently there is an increased interest in defining its role in small duct disease. The main advantage of the lateral pancreatojejunostomy over the resectional procedures is the preservation of the pancreatic parenchyma and endocrine and exocrine pancreatic function and the significantly lower early and late morbidity and mortality
Animals↗
Paget's disease of the breast.
Paget's disease of the breast is a rare disorder of the nipple-areola complex that is often associated with an underlying in situ or invasive carcinoma. A change in sensation of the nipple-areola, such as itching and burning, is a common presenting symptom. Objectively, eczematoid changes of the nipple-areola complex are common. The later stages of Paget's disease of the breast are characterized by ulceration and destruction of the nipple-areola complex. Eczematoid changes of the nipple-areola complex and persisting soreness or itching, without obvious reason, is a suspicious symptom for Paget's disease of the breast and calls for thorough evaluation, including mammography. Exfoliative cytology with demonstration of Paget's cells may be useful, but a negative finding does not exclude Paget's disease of the breast. Surgical biopsy is the diagnostic standard and therefore the diagnosis should always be confirmed by open (surgical) biopsy. The histogenesis of Paget's disease of the breast continues to be debated. The epidermotropic theory holds that Paget's cells are ductal carcinoma cells that have migrated from the underlying breast parenchyma to the nipple epidermis. According to the in situ transformation theory, the Paget's cells arise as malignant cells in the nipple epidermis independent from any other pathologic process within the breast parenchyma. This theory has been proposed to explain those cases in which there is no underlying mammary carcinoma or when there is a carcinoma remote from the nipple-areola complex. Each of these theories is plausible; however, treatment approaches differ markedly depending on the theory of histogenesis. Mastectomy has been considered the standard of care in the management of patients with Paget's disease of the breast. Nowadays, however, some patients with Paget's disease of the breast are candidates for breast-conserving therapy. Patients must be selected carefully on an individual basis. Until there is a better understanding of the relationship of Paget's disease of the breast to the underlying cancer the surgeon should understand the natural history and behaviour of this lesion and be aware of both the risks of under- and over-treating patients with Paget's disease of the breast.
Breast Neoplasms↗
Nipple discharge: current diagnostic and therapeutic approaches.
Nipple discharge is a complex diagnostic challenge for the clinician. A variety of diseases (such as intraductal papillomas, mammary duct ectasia, breast cancer, pituitary adenomas, breast abscesses/infections, etc.) can manifest as nipple discharge. The importance of nipple discharge for both the patient and the physician is the possible association of this condition with an underlying carcinoma. With heightened public awareness of breast cancer, an increasing number of women are asking their health care providers about nipple discharge. A detailed clinical evaluation is invaluable to determine the pathophysiology, assess the risk of malignancy, and plan treatment of the patient with nipple discharge. A combination of diagnostic tests, including mammography, breast ultrasonography, and possibly galactography can help the clinician to establish the diagnosis and plan proper management. Depending on the underlying breast pathology, a central or single lactiferous duct excision is the procedure of choice. Breast carcinoma associated with nipple discharge should be treated by either a modified radical mastectomy of breast-conservation therapy (i.e. duct-lobular segmentectomy with adequate, free margins [ideally>1cm], levels I and II axillary lymph node dissection, followed by breast irradiation).
Breast Diseases↗
Breast cancer surgery--historical evolution, current status and future perspectives.
The diagnosis and management of breast cancer have changed dramatically over the past two decades in response not only to new technologies but also to cultural and social aspects of the discase. Mastectomy (either radical or modified radical) was the historical mainstay of the treatment of breast cancer for decades. Although mastectomy continues to be appropriate for some patients, breast conservation has become the preferred method of treatment for many patients. Meeting the dual goal of optimum cosmesis and minimal rates of in-breast recurrences after breast-conservation therapy requires the selection and integration of appropriate diagnostic methods (including breast imaging techniques and breast biopsy techniques) its well as therapeutic methods (breast irradiation techniques, and systemic cytotoxic and hormonal therapy). To achieve optimal breast-conservation treatment, a multidisciplinary approach is neccessary. Mastectomy followed by breast reconstruction is a valuable alternative for patients who require or choose mastectomy. After tumor downstaging with induction chemotherapy, a large percentage of patients with large or locally advanced tumors will be able to undergo breast-conservation therapy Partial (levels I and II) axillary lymph node dissection remains the standard of care in the surgical management of patients with invasive breast cancer. Recently there has been intense interest in selective axillary lymph node dissection, focused mainly on the identification of patients who are likely to benefit from axillary lymph node dissection, using sentinel lymph node biopsy.
Biopsy, Needle↗
Pancreaticobiliary fistula: an unusual complication of necrotising pancreatitis.
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Biliary Fistula↗
Problems of reconstruction during pancreatoduodenectomy.
Pancreatoduodenectomy may be a difficult operation, not only during the resectional part of the procedure, but also during reconstruction. Usually, these problems are due to local conditions of the organs/tissues, such as small diameter of the common bile duct or pancreatic duct, friable soft pancreas, vascular anomalies, etc. Reconstruction may also be problematic because of the hemodynamic instability of the patient during surgery (subsequent to massive hemorrhage), and in those unusual cases, delayed reconstruction may be a life-saving, wise choice.
Anastomosis, Surgical↗
Large right congenital diaphragmatic (Bochdalek) hernia: an incidental finding in an aged patient with acute intestinal obstruction.
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Aged↗
Molecular biology of pancreatic cancer: potential clinical implications.
The development of cancer involves the accumulation of genetic changes. Over the past decade there has a been spectacular advance in the knowledge of the genetic basis of cancer, mainly as a result of the rapid progression of molecular technology. Pancreatic cancer is one of the most lethal cancers. Conventional therapeutic approaches have not had much impact on the course of this aggressive neoplasm. Knowledge of the molecular biology of pancreatic cancer has grown rapidly. Genetic alterations in pancreatic cancer include oncogene mutations (most commonly K-ras mutations), and tumour suppressor gene alterations (mainly p53, p16, DCC, etc.). These advances have potential implications for the management of this deadly disease. Identification of a hereditary genetic predisposition to pancreatic cancer has led to the formation of pancreatic cancer registries around the world, with voluntary screening of patients and siblings for the hereditary genetic defect. Asymptomatic population screening remains unrealistic, but the recognition of subpopulations at increased risk from pancreatic cancer, along with novel and sensitive detection techniques, means that targeted population screening is a step closer. Intensive research is performed in specialist laboratories to improve the diagnostic approach in patients with pancreatic cancer. The use of such molecular diagnostic methods is likely to expand. Molecular biology may also have a great impact on the treatment of pancreatic cancer, and many therapeutic approaches are being evaluated in clinical trials, including gene replacement therapy, genetic prodrug activation therapy, antisense immunology and peptide technology. The 'molecular age' has the promise of delivering still better results. This review summarises recent data relating to the molecular biology of pancreatic cancer, with emphasis on features that may be of clinical significance for diagnosis and/or therapy.
Genes, Tumor Suppressor↗
A simple, effective and safe method for central venous catheter replacement.
With the possible exception of pulmonary artery catheters, central venous catheters (CVCs) have the highest rates of infection of all intravascular catheters, accounting for up to 90% of all vascular catheter-related bloodstream infections. The frequency of CVC-related infections is between 10-30%.
Catheterization, Central Venous↗
Pancreatoduodenectomy for chronic pancreatitis: long-term results in 105 patients.
HYPOTHESIS: For patients with head-dominant, small-duct chronic pancreatitis who require operative intervention, pancreatoduodenectomy can be performed safely and affords satisfactory pain relief in most. DESIGN: Retrospective case series. Follow-up was complete in 86% of study subjects (average, 6.6 years). SETTING: Tertiary care center. PATIENTS: Among 484 consecutive cases of chronic pancreatitis treated surgically from January 1976 through April 1997, 105 (22%) in which pancreatoduodenectomy was performed were reviewed with regard to criteria for selection, operative procedure, postoperative course. and long-term outcome. MAIN OUTCOME MEASURES: The main outcome measure was degree of pain relief. Additionally, late mortality, cause of death, the presence of endocrine and exocrine insufficiency, and quality of life were recorded. RESULTS: There were 72 men (69%) and 33 women (31%) with a mean age of 51 years (range, 24-77 years). The cause of chronic pancreatitis was alcohol related in 58 patients (55%) and idiopathic in 41 (39%). Clinical manifestations included abdominal pain in 86 patients (82%), obstructive jaundice in 27 (26%), and vomiting in 11 (11%). Suspicion of malignant neoplasm was a concern in 67 patients (64%). Operative morbidity was 32%, and mortality, 3%. Mean hospital stay was 16 days (range, 12-82 days). Survival was significantly lower than that of age-matched controls. Among 66 patients with preoperative pain, pain relief was achieved in 59 (89%); it was complete in 44 patients (67%) and partial in 15 (23%). Operation resulted in a significant increase in patients with normal functional status (73 patients [81%] vs 51 [49%]; P<.001). Forty patients (48%) had diabetes. Steatorrhea was observed in 39 patients (43%), while weight maintenance or gain occurred in 59 (66%). CONCLUSIONS: Pancreatoduodenectomy achieves pain relief and good quality of life in a large percentage of selected patients with small-duct, head-dominant disease and is especially useful when a malignant neoplasm must be excluded. Morbidity and mortality are acceptable in experienced hands. Onset of diabetes and steatorrhea, while reflecting the natural course of the disease, is likely accelerated by pancreatoduodenectomy.
Adult↗
Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper gastrointestinal bleeding.
BACKGROUND: Hemosuccus pancreaticus, a rare form of upper gastrointestinal bleeding, may complicate chronic pancreatitis and pose a significant diagnostic and therapeutic dilemma. AIM: To present our experience with this potentially life-threatening complication of chronic pancreatitis. METHODS: We reviewed our experience with management (both operative as well as angiographic embolization) of patients with hemosuccus pancreaticus complicating histologically documented chronic pancreatitis between 1976 and 1997. Diagnosis of hemosuccus pancreaticus was based on clinical presentation, preoperative endoscopic and radiographic imaging, operative findings, and pathologic evaluation. RESULTS: During the period, we managed eight patients with hemosuccus pancreaticus (1.5% of all patients with chronic pancreatitis treated surgically). Gastrointestinal bleeding presented as hematemesis in three and hematochezia in three, but all had recent melena and were anemic; three of these patients were hemodynamically unstable. Abdominal pain was present in six. When performed, angiography (n=6) was diagnostic of a pseudoaneurysm; computed tomography (n=7) showed a pseudoaneurysm in two and a pseudocyst in five. Endoscopy (n=8) revealed blood issuing from the ampullary papilla in two patients. Operative management (n=6) involved distal pancreatectomy, pancreatoduodenectomy, or total pancreatectomy in two patients each. Angiographic embolization was successful in one patient, but the other died from uncontrollable hemorrhage. CONCLUSIONS: Hemosuccus pancreaticus is rare, but should be considered in patients with chronic pancreatitis and gastrointestinal bleeding. In the absence of pancreatitis-related indications for surgery, angiographic embolization can be definitive treatment. If there are pancreatitis-related indications for operation, angiographic embolization may allow an elective operative procedure based on structural changes of the pancreas. If embolization fails, pancreatic resection is usually required, often on an emergent basis.
Adult↗
The significance of sinistral portal hypertension complicating chronic pancreatitis.
BACKGROUND: Sinistral portal hypertension, a localized (left-sided) form of portal hypertension may complicate chronic pancreatitis as a result of splenic vein thrombosis/obstruction. AIM: To determine appropriate surgical strategy for patients with splenic vein thrombosis/obstruction secondary to chronic pancreatitis. METHODS: We reviewed our experience with operative management of 484 consecutive patients with histologically documented chronic pancreatitis treated between 1976 and 1997. The diagnosis of sinistral portal hypertension was based on clinical presentation, preoperative endoscopic and radiographic imaging, and operative findings. "Symptomatic," herein defined, denotes those patients with sinistral hypertension and either gastrointestinal bleeding or hypersplenism. "Asymptomatic" patients were those with sinistral hypertension alone. RESULTS: Sinistral portal hypertension was present in 34 of the 484 patients (7%). Gastric or gastroesophageal varices were confirmed in 12 patients (35%), of whom 6 had variceal bleeding and 4 had hypersplenism (25%). All symptomatic patients were treated by splenectomy alone or in conjunction with distal pancreatectomy. Splenectomy at the time of pancreatectomy for primary pancreatic symptoms was also performed in 15 patients with (asymptomatic) sinistral portal hypertension. None of the 23 patients who had splenectomy rebled in mean follow-up of 4.8 years. In contrast, 1 of the 11 patients with asymptomatic sinistral portal hypertension who underwent pancreatic surgery without splenectomy died of later variceal bleeding 3 years after lateral pancreatojejunostomy. CONCLUSIONS: Symptomatic sinistral portal hypertension is best treated by splenectomy. Concomitant splenectomy should be strongly considered in patients undergoing operative treatment of symptomatic chronic pancreatitis if sinistral portal hypertension and gastroesophageal varices are also present.
Adult↗