Successful endoscopic transpapillary drainage of an infected pancreatic pseudocyst

Multifocal motor neuropathy (MMN) is a disorder with a highly characteristic clinical picture and one which is defined by a specific electrodiagnostic abnormality, namely, multifocal conduction block which is confined to motor axons. Sensory axons which traverse segments of severe or even complete motor conduction block conduct normally. A proportion of patients with MMN also have elevated levels of antibodies to GM1 ganglioside. However, about one half of MMN patients lack elevated levels of these antibodies and many others have only modest elevations, to a degree often seen in other neurological and even non-neurological disorders. Furthermore, clinical and electrophysiological improvement of MMN in response to treatment with high dose intravenous immunoglobulin is achieved in the absence of any change in antiglycolipid levels. Injection of serum from patients with MMN and elevated GM1 antibody levels produces demyelination in recipient rat nerves, suggesting a pathogenetic role for these antibodies in demyelination. However, sera of patients with identical antibody titers in other motor system diseases produced no demyelination, suggesting that the demyelinating factor resides in some other serum fraction. At present, there is insufficient evidence to support the contention that these antibodies play a critical pathogenetic role in MMN. Until more evidence is available it is important to define MMN on the basis of a characteristic clinical picture and a unique electrodiagnostic abnormality rather than on a pattern of serum antibodies.     

Ultrasound-directed percutaneous endoscopic cyst-gastrostomy for the treatment of a pancreatic pseudocyst

The incidence of pseudocysts in patients with chronic pancreatitis ranges from 20-40%. Unlike pseudocysts associated with acute pancreatitis, these do not usually resolve spontaneously. Traditionally, these cysts were drained surgically. More recently, however, they have been successfully managed with endoscopic drainage. This report reviews the history and results of nonsurgical pseudocyst management and describes a case of drainage obtained using an alternative method of ultrasound-directed percutaneous endoscopic cyst-gastrostomy.     

Traumatic pancreatic duct rupture in a child diagnosed by endoscopic retrograde pancreatography

We report on a child who sustained blunt abdominal trauma with pancreatic duct rupture diagnosed by preoperative endoscopic retrograde pancreatography (ERP). Duct laceration remained undiagnosed by computerized tomography or ultrasonography. Preoperative ERP is the only known method for the accurate diagnosis of injury to main pancreatic duct. Even in children with pancreatic trauma we recommend ERP before any surgery is attempted to help in decisions on operative strategy.     

Percutaneous drainage of pancreatic pseudocyst into the stomach

BACKGROUND: We present our experience with percutaneous ultrasonographically guided internal cystogastric drainage of pancreatic pseudocysts using a double pigtail catheter. METHODS: In nine patients, the pancreatic pseudocysts following acute pancreatitis were drained percutaneously into the stomach with the double pigtail catheter under ultrasonographical (US) control. The needle insertion through both gastric walls and the final position of the proximal curve of the catheter were monitored with a gastroscope. The position of the distal curve of the catheter was checked by US. There were no procedure-related complications. The patients were followed up monthly by clinical and US examination. RESULTS: At first follow-up 1 month after the intervention, none of the patients had evidence of the pseudocyst. The patients were not aware of the catheter and functioned normally throughout the procedure and catheter removal. The catheter was removed endoscopically after 5-8 months. CONCLUSIONS: The method is minimally invasive and also feasible in high-risk surgical patients. It requires a team consisting of an interventional radiologist, an ultrasonographer, and an endoscopist. In properly selected patients, the results are excellent.     

An audit on hospital management of bronchial asthma

Medical audit is a new concept in developing countries like Pakistan. We carried out this retrospective study on bronchial asthma. The purpose was to see if care given to patient with asthma meets the accepted international standard or not. During this audit several deficiencies were found. Documentation in notes about signs indicating severity of asthma was very poor. Peak flow recording in the notes was also very deficient. There was no documentation in notes whether inhalers technique of the patients has been checked or not. This audit shows that care given to asthma patients is far from satisfactory and we clearly need to improve in order to reach the accepted international standards.     

Inguinal tumor as the first manifestation of a pancreatic pseudocyst

We report a case of pancreatic pseudocyst in alcoholic pancreatitis, that presented as a mass in the inguinal region. The mechanism of this peculiar clinical presentation was the dissemination of the content of the pseudocyst along the psoas muscle. We review the involvement of psoas muscle in pancreatic pathology, giving emphasis to reports of inguinal or thigh masses as initial manifestations.     

Cystadenoma of the pancreas: report of a case diagnosed by endoscopic retrograde pancreatography

The first case of a cystadenoma of the pancreas occurring in an African patient is reported. cystadenoma of the pancreas is a rare tumour. It should be suspected when a patient presents with a pancreatic cyst but without a history of pancreatitis, alcoholism or abdominal trauma. Estimation of the serum amylase level, selective coeliac and superior mesenteric arteriograms, and endoscopic retrograde pancreatography (ERP) are helpful in making the preoperative diagnosis. The ERP appearances in cystadenoma of the pancreas are described.     

The role of endoscopic third ventriculostomy in the management of shunt malfunction

OBJECTIVE: To evaluate the effectiveness of third ventriculostomy as an alternative to shunt revision in the management of shunt malfunction and infection in obstructive hydrocephalus. METHODS: All of the clinical notes of 30 patients treated with third ventriculostomy for malfunctioning or infected shunts between January 1, 1974, and December 31, 1996, were retrospectively reviewed. Third ventriculostomy was performed under fluoroscopic control in the first seven patients and endoscopically in the remainder. A successful outcome was achieved if further shunt revision surgery was avoided. The median follow-up duration was 8.7 years RESULTS: Twenty-three patients (76.7%) experienced successful outcomes, resulting in shunt independence. Of the seven failures, three were technical failures at the time of surgery and the remaining four were manifest within a median of 10 days, resulting in shunt revision. There have been no delayed failures. CONCLUSION: Third ventriculostomy is a valuable alternative to shunt revision in patients affected by obstructive hydrocephalus presenting with shunt malfunction or infection. It should be considered in all suitable cases as the first-line treatment for obstructive hydrocephalus of all causes. Because all failures were manifest within a short time, it is likely that these successes will be durable.     

Infected transplant pancreatic pseudocyst managed by catheter drainage and pancreatico-ileostomy

This study investigated whether appetitive operant food reinforcement or free-feeding behavior in rats, food-restricted to 85% of body weight, was disrupted by exposures to 3 h of restraint stress or by 3 h of restraint plus water immersion stress (RWI). Rats were trained under a 3-cycle 10-min time-out-10-min time-in fixed-ratio 15 (FR15) schedule of food reinforcement. Free-feeding was measured in a 3-cycle 10-min food jar-out-10-min food jar-in test conducted in the operant chambers. Three hours of restraint stress did not significantly affect response rate or food reinforcement in the operant FR15 task or in the free-feeding condition. In contrast, 3 h of RWI completely abolished operant food reinforcement and suppressed response rate, whereas free-feeding was significantly reduced but not abolished in food-restricted, hungry rats. We conclude that acute restraint stress in food-restricted, hungry rats does not affect their appetite or motor ability to lever-press for food nor did it affect their ability to feed in a free-feeding situation. In contrast, RWI stress may have induced a motor impairment, or some other aspect of motivation independent of hunger, that disrupted their performance in the operant FR15 task.     

The role of laparoscopy in the management of suspected pancreatic and periampullary malignancies

Laparoscopic evaluation of patients with suspected periampullary malignancies has been utilized more frequently in recent years. Its exact role with regard to staging and surgical bypass for palliation have yet to be clearly defined. To better define the role of laparoscopy in the evaluation and palliation of periampullary malignancy, a retrospective review of the Duke experience was carried out. Fifty-three patients with suspected pancreatic or periampullary malignancies were referred for surgical evaluation at Duke University Medical Center between 1993 and 1995. All patients underwent CT scanning and lesions were classified as resectable or unresectable based on previously established criteria. Patients either underwent laparoscopic evaluation (n = 30; 11 with laparoscopic palliation) or proceeded directly to celiotomy (n = 23). Charts were reviewed for postoperative course including complications, length of stay, and hospital costs. Although laparoscopy had a sensitivity of 93.3% for metastatic disease, CT scans accurately staged 86.8% of patients missing only one patient with peritoneal/hepatic disease. Based on these results, laparoscopy may not be beneficial for every patient with a suspected pancreatic malignancy. Retrospectively an attempt was made to determine which patients benefited from laparoscopy and which patients are best served by proceeding directly to open exploration. From these data we devised an algorithm that outlines an efficient and cost-effective approach for this patient population.     

Biliary complications of Fasciola hepatica: the role of endoscopic retrograde cholangiography in management

The parasite Fasciola hepatica resides in the biliary tree but rarely causes significant clinical sequelae. In this report, we review our experience with four patients in whom F. hepatica infection resulted in biliary complications, especially severe biliary colic and jaundice. The diagnosis was achieved with endoscopic retrograde cholangiography which demonstrated the worms in the extrahepatic bile ducts. Endoscopic sphincterotomy was performed uneventfully in all patients allowing balloon extraction of the parasites and resolution of their symptoms.     

An audit of flexor tendon injuries in zone II and its influence on management

This paper reports the results of a one-year audit of flexor tendon injuries in zone II managed in a controlled mobilization program. It discusses the rationale for the use of this program and compares results with those of other units. On the basis of these results, the authors suggest that rehabilitation programs for patients with this type of injury should be tailored to individual needs and that trends in management should be carefully evaluated before implementation.     

Successful closure and embolization of a fistula between the pancreatic duct and a pseudocyst using ethibloc

In this study the morphologic features and subpopulation of lymphocytes in the blood of women with uterine cervical cancer HPV 16 positive and HPV 16 negative was compared. The essential morphological differentiation in two groups of cancer was not found, but a statistically significant increase in CD 19 lymphocytes in the blood of women with cervical cancer HPV 16 positive was discovered. The authors suggest, that an increase in CD 19 might be connected with stronger expression of virus-oncogenic antigens on the neoplasma cells.     

Dissemination of pancreatic carcinoma following endoscopic sphincterotomy

Endoscopic sphincterotomy (ES) is sometimes advocated for the temporary decompression of an obstructed bile duct by a periampullary tumor. We report a 27-year-old woman with a small carcinoma of the pancreatic head who developed acute pancreatitis and a pseudocyst following ES. At operation, malignant spread was virtually confined to the walls of the resolving pseudocyst cavity. Despite radical resection, she died from recurrent carcinoma 7 months postoperatively.     

An audit of fatal acute pancreatitis

Acute pancreatitis has a mortality of about 10%: this figure has not changed over the last 20 years. A retrospective audit of fatal acute pancreatitis was performed in a teaching hospital with a catchment population of about 750,000 patients to examine patient characteristics. Using Hospital Activity Analysis code 577.0, all fatal cases of acute pancreatitis were studied in a six-year period 1987-93. Additionally, all post mortem diagnoses of acute pancreatitis were traced. The overall post mortem rate in Nottingham at the time of the study was about 35%. All available records, X-ray and biochemical data were studied and appropriate information recorded and analysed for 65 fatal cases. Only 15% were post mortem diagnoses, lower than in previous series; 72% had respiratory and 67% had renal complications. Only 34% had been admitted to the intensive care unit. A third of patients had had surgery; 67% of these was some form of external drainage. Of the 14 patients with proven gallstone pancreatitis only three had endoscopic retrograde cholangiopancreatography; 42% of patients had idiopathic disease. Not all the patients diagnosed ante mortem had the full biochemical predicted severity criteria analysed: pO2 and calcium analysis was performed in about 80%. Pre-mortem diagnoses of pancreatitis was achieved more frequently than in other comparable series.