Retroperitoneal Area Research Articles

Flaxseed flour diet during lactation until 180 days results in an increase in body adiposity in adult male rats

This study evaluated the influence of flaxseed flour intake on body adiposity in Wistar male rats at 180 days. At birth, we randomly assigned male Wistar rats to control (C) and experimental (FF) groups treated with a control or flaxseed flour diet until 180 days. We evaluated food and energy intake, body mass and length during 21–180 day period. We also evaluated oral glucose tolerance test (OGTT), lean and fat mass by dual-energy X-ray absorptiometry, serum glucose, insulin, HOMA-IR and leptin, intra-abdominal fat mass and retroperitoneal adipocyte area. Groups showed similar food, energy intake, body length, insulin, total lean mass and adipocyte area. FF group showed the following (P < .05): lower concentrations of glucose in OGTT and serum glucose (−15%), leptin (−56%), higher body mass, total (+38%), trunk (+35%), intra-abdominal (+52%), mesenteric (+36%) and retroperitoneal (+42%) fat mass. At 180 days, flaxseed flour was associated with high body adiposity.

Spleen-Preserving Laparoscopic Distal Pancreatectomy for Insulinoma in a Child

Introduction: Insulinomas are rare insulin-secreting neoplasms. Ten percent occur in the setting of multiple endocrine neoplasia-type 1 (MEN-1). This video presents the technical details of a spleen-preserving laparoscopic distal pancreatectomy in a child. Nowadays, the adoption of this approach is limited. Our aim is to bring this procedure closer to routine clinical practice. Operative Technique: A 13-year-old girl with neuroglycopenic symptoms for 6 months was referred to our institution for evaluation and management. The work-up demonstrated hyperinsulinemic hypoglycemia, a 3 cm lesion of the tail of the pancreas, a prolactinoma, and adenomas of two parathyroid glands (MEN-1). A four-trocar laparoscopic distal pancreatectomy was performed with the surgeon between the legs. We started with the division of the gastrocolic ligament using a 5 mm tissue-sealing device to enter the lesser sac. The stomach was retracted cephalad, allowing for a better exposure of the pancreatic tail. The peritoneum on the lower pancreatic margin was incised to get access to the retroperitoneal area. Retropancreatic attachments were dissected. With dissection advanced, the pancreas could be lifted up. The insulinoma became visible on the posterior margin and was well delimited with intraoperative palpation. The next step was dissection of the splenic vein on the superior border, embodied by the tail of the pancreas. Approaching small pancreatic vessels originating in the splenic vein is better performed with a hook monopolar electrocautery. We continued freeing toward the body of the pancreas. The peritoneum around the proximal splenic artery was also incised with the hook. If bleeding from the splenic vein is encountered, compression and application of fibrin sealant could provide hemostasis. A bleeding short vessel could be isolated, ligaclipped, oversewn, or coagulated. If bleeding is impossible to control, it is still possible to spare the spleen according to Warshaw's method (the splenic vessels are ligated and spleen becomes dependent on the short gastric vessels). Once the splenic vessels were retracted and the dissection completed, the umbilical 5-mm port was converted to a 12-mm port. The EndoGIA™ linear stapler was introduced and transection of the pancreas was performed using two 30 mm cartridges. The end of the proximal pancreas was over sewn to prevent pancreatic leak. The specimen was extracted in a retrieval bag through the umbilical port. A drain was left in situ. Results: The postoperative course was uneventful. No postoperative diabetes was observed and no treatment for hypoglycemia was necessary. Early oral feeding on postoperative day 2 was well tolerated. The drain was removed and the patient was discharged home in a good condition at postoperative day 5. Histology analysis confirmed the full resection of the intrapancreatic insulinoma but also revealed a second tumor more distally on the pancreatic tail. The patient remains asymptomatic 20 months after surgery. Conclusions: Spleen-preserving laparoscopic distal pancreatectomy is a feasible, effective, and safe procedure. Distal pancreatectomy is preferred to tumorectomy to avoid incomplete resection in cases of multifocal disease. Laparoscopy gives an excellent view of small vessels and has all the advantages of the mini-invasive surgery. Spleen preservation avoids the overwhelming postsplenectomy infection. No competing financial interests exist. Runtime of video: 5 mins 9 secs

A median sacral artery anterior to the iliocaval junction: a case report-anatomical considerations and clinical relevance for spine surgery.

The median sacral artery (MSA) is a relatively small vessel that always arises from the posterior, terminal part of the infrarenal aorta. In most cases, the MSA runs behind the iliocaval junction. Here, we describe a very rare case of an MSA running in front of this junction. During a human cadaveric dissection of the retroperitoneal area, we unexpectedly observed that the MSA passed in front of the left common iliac vein. The anatomy of the MSA has been extensively described and variations are quite rare. On the basis of this specific case, knowledge of the anatomic interactions between the MSA and other lumbar retroperitoneal vessels may help to avoid potential complications during surgery.

Lymph node dissection should not be dismissed in case of localized renal cell carcinoma in the presence of larger diseases

ObjectiveTo assess whether even in the group of localized renal cell carcinoma (RCC), some patients might harbor a disease with a predilection for lymph node invasion (LNI) and/or lymph node (LN) progression and might deserve lymph node dissection (LND) at the time of surgery. Materials and methodsBetween 1990 and 2014, 2,010 patients with clinically defined T1-T2N0M0 RCC were treated with nephrectomy and standardized LND at a single tertiary care referral center. The endpoint consists of the presence of LNI and/or nodal progression, defined as the onset of a new clinically detected lymphadenopathy (>10mm) in the retroperitoneal lymphatic area with associated systemic progression or histological confirmation or both. We tested the association between clinical characteristics and the endpoint of interest. Predictors consisted of age at surgery, clinical tumor size, preoperative hemoglobin, and platelets levels. Multivariable logistic regression model and smoothed Lowess method were used. ResultsLNI was recorded in 14 cases (2.2%). The median follow-up after surgery was 68 months. During the study period, 23 patients (1.1%) experienced LN progression; 91% of those patients experienced LN progression within 3 years after surgery. Combining the 2 endpoints, 36 patients (1.8%) had LNI and/or LN progression. Clinical tumor size was the only independent predictors of LNI and/or LN progression (OR = 1.25). A significant increase of the risk of LNI and/or LN progression was observed in RCC larger than 7cm (cT2a or higher). ConclusionsLNI and/or LN progression is a rare entity in patients with localized RCC. Nonetheless, patients with larger tumors might still benefit from LND because of a non-negligible risk of LNI and/or LN progression.

A novel technique: Carbon dioxide gas-assisted total peritonectomy, diaphragm and intestinal meso stripping in open surgery for advanced ovarian cancer (Çukurova technique)

ObjectiveMost of the ovarian cancers are diagnosed at advanced stages. As peritoneal carcinomatosis increases, especially when it extends to the diaphragm and intestinal mesos, probability of obtaining complete cytoreduction is reduced. Complete cytoreduction (residue zero: R0) is one of the main factors affecting survival [1–3]. Here we present a novel technique of stripping the peritoneal surfaces as a part of cytoreductive surgery in such cases. MethodsA 55year-old woman diagnosed with peritoneal carcinomatosis was considered appropriate for primary cytoreduction after assessment of her thorax-abdominopelvic tomography, which revealed resectable intra-abdominal disease. Upon laparotomy, omental cake adherent to pelvis-filling mass, disseminated implants on the diaphragm, meso of the descending colon and small intestine were observed. The mass invaded the rectosigmoid colon, uterus, adnexa and the bladder resulting in frozen pelvis. Palpable retroperitoneal pelvic and para-aortic lymph nodes were detected. On the other side, stomach, anti-mesenteric surfaces and mesentery root of the small bowel were tumor-free. Hence, upon these perioperative and preoperative imaging findings, complete cytoreduction was thought to be achievable. Therefore, primary cytoreduction was performed. Total omentectomy, hysterectomy with bilateral salpingo-oophorectomy, rectosigmoid low anterior resection and retroperitoneal lymphadenectomy were performed. With the assistance of an injector needle connected to the insufflator tube (as in laparoscopic surgery), carbon dioxide gas was blown into the right retroperitoneal area and subsequently peritoneum was rapidly stripped up to the right diaphragm. The same procedure was then applied to the diaphragm and meso of the bowels, respectively. Owing to this technique, total stripping of all involved peritoneal surfaces was clearly facilitated and R0 goal was reached. ResultsGas insufflation caused convenient detachment of the peritoneal surfaces along their anatomical line which led to concluding the stripping procedures easily, rapidly and safely without bleeding. Thus, according to our experience, about 10 to 15min per procedure are saved in such cases. Potential complications of CO2 gas used here are not superior to those in transperitoneal or retroperitoneal laparoscopic procedures. During the operation, patient was followed-up for potential complications such as subcutaneous emphysema and CO2 gas embolism.Thus, hourly blood gas was monitored. Another potential complication is injury of the vessels while inserting the needle which can be avoided by cautious inserting under the peritoneal surfaces superficially and using transillumination. In case such injuries happen, tamponing is a sufficient measure. In our serial, no perioperative complications belonging to this technique were encountered. However, long term outcomes such as precise time difference, difference in blood loss, complication rates, adhesions, morbidity associated with this technique and its impact on survival of the patients with advanced ovarian cancer have yet to be investigated. Therefore, a prospective study to validate this technique's long-term usefulness has been initiated in our clinic. ConclusionWe believe that this practical and effective technique will offer significant improvements in efforts to achieve complete cytoreduction.

Loss of abdominal domain: Is it the abdominal wall or contents?

Background Intra-abdominal hypertension and abdominal compartment syndrome are significant sources of morbidity and mortality in the post-surgical and trauma patient. Several anatomic variables may contribute to the inability to close the abdomen such as retraction of the abdominal wall and intra-abdominal volume changes. This study seeks to quantify these changes and determined which predominates. Methods Retrospective analysis of computed tomography scans of patients whose abdomens could not be closed secondary to intra-abdominal hypertension. Patients were included who had computed tomography scans available with both an open abdomen and after primary abdominal wall closure. Abdominal wall lengths along with total abdominal, intra-peritoneal, and retroperitoneal cross-sectional areas were measured at two anatomic levels. Results Seven patients’ computed tomography scans were evaluated. The closed abdominal wall lengths averaged 2.3 cm and 2.1 cm longer after closure at each point of measurement (p = 0.002 and p = 0.03). Total abdominal cross-sectional area decreased post-closure by 14% for both measurements (p = 0.009 and p = 0.04). Conclusion Measurable increases in intra-abdominal cross-sectional area and decreases in abdominal wall length both contribute to the inability to safely close the abdomen in patients with intra-abdominal hypertension. These findings support the use of multimodal techniques in the management of the open abdomen.

Eyelid metastasis as presenting feature of disseminated leiomyosarcoma – A rare case report

Soft tissue sarcomas with smooth muscle differentiation are termed leiomyosarcoma. Leiomyosarcoma is an aggressive tumor commonly originating from smooth muscle cells of uterus or retro peritoneal areas. Distant metastasis occurs by hematogenous route to liver and lung. Eyelid metastasis without involvement of other ocular structures is extremely rare. A case of eyelid metastasis which on extensive investigations was proved to be from upper gastrointestinal tract leiomyosarcoma is reported here.

A hidden ureteral metastasis that originated from prostate cancer: a case report and literature review

Metastasis from primary prostate cancer (PCa) to the ureter is extremely rare. This study reports a 61-year-old male presenting with right flank pain and fever. Computed tomography urography (CTU) and magnetic resonance hydrography (MRH) showed right hydroureteronephrosis obstructed by soft tissue in the right ureter, retroperitoneal and left iliac vascular area lymphadenectasis. In addition, transitional cell carcinoma (TCC) was highly suspected. Ureteroscopy was performed, but nothing was found. Radical nephroureterectomy (RNU) with bladder cuff removal was finally applied as a thorough treatment based on its malignant intra-operative frozen result. Pathological examination revealed right ureteral carcinoma in the form of metastatic PCa. The Gleason score was 9 (5+4), grade V. We determined that RNU with bladder cuff removal was the best treatment for him and hematogenous metastasis was the most possible metastatic pathway from the prostate to the right ureter.

PD04-04 THE EFFECT OF ANATOMICAL LOCATION OF RETROPERITONEAL LYMPH NODE METASTASES ON CANCER SPECIFIC SURVIVAL IN PATIENTS WITH CLEAR CELL RENAL CELL CARCINOMA

You have accessJournal of UrologyKidney Cancer: Advanced (including Drug Therapy) I1 Apr 2017PD04-04 THE EFFECT OF ANATOMICAL LOCATION OF RETROPERITONEAL LYMPH NODE METASTASES ON CANCER SPECIFIC SURVIVAL IN PATIENTS WITH CLEAR CELL RENAL CELL CARCINOMA Alessandro Nini, Alessandro Larcher, Carlo Terrone, Alessandro Volpe, Fabio Muttin, Francesco Ripa, Federica Regis, Roberta Lucianò, Alberto Briganti, Roberto Bertini, Francesco Montorsi, and Umberto Capitanio Alessandro NiniAlessandro Nini More articles by this author , Alessandro LarcherAlessandro Larcher More articles by this author , Carlo TerroneCarlo Terrone More articles by this author , Alessandro VolpeAlessandro Volpe More articles by this author , Fabio MuttinFabio Muttin More articles by this author , Francesco RipaFrancesco Ripa More articles by this author , Federica RegisFederica Regis More articles by this author , Roberta LucianòRoberta Lucianò More articles by this author , Alberto BrigantiAlberto Briganti More articles by this author , Roberto BertiniRoberto Bertini More articles by this author , Francesco MontorsiFrancesco Montorsi More articles by this author , and Umberto CapitanioUmberto Capitanio More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2017.02.223AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Positive nodal status and the number of positive nodes are well known independent predictors of survival in renal clear cell carcinoma (ccRCC) patients. However, no study has ever tested whether the location of nodal metastases does affect cancer specific survival (CSS) in ccRCC patients. METHODS Among 2,884 patients treated with nephrectomy at two European Tertiary Care Centers, 419 (14.4%) underwent open extended retroperitoneal lymph node dissection (LND) defined as the removal of hilar, side-specific (paraaortic or pre-retrocaval) and interaortocaval nodes. Cox regression analyses were used to assess the effect of the area involved (hilar vs. side-specific vs. interaortocaval) and the number of anatomical areas affected by nodal disease (1 vs. 2 vs. 3 areas) on CSS. Multivariable analyses were adjusted for age, pathologic T stage, metastases at diagnosis and Fuhrman grade. RESULTS ccRCC patients who were selected for nephrectomy and extended LND (n=419) showed pT1-pT2 in 37.4%, pT3 in 56.1% and pT4 in 6.4% of patients. Mean tumor size was 9 cm (median 8.3, range 1-23). Overall, 95 patients (22.9%) showed nodal disease at final pathology. Mean number of nodes removed was 15 (range 3-58). Hilar nodes vs. paraaortic/precaval vs. interaortocaval were found positive in 11% vs. 18% vs. 12% of the cases, respectively. In 46 (11%), 26 (6.2%) and 23 (5.5%) cases 1, 2 or all retroperitoneal nodal areas were affected, respectively. Among patients with 1 positive nodal site, 26% of patients were positive only in the interaortocaval area and 54.3% only in side-specific station. Among patients with 2 positive nodal areas, 3.8% had hilar and interaortocaval areas involved but not side-specific one, and 53.8% had side-specific and interaortocaval areas involved but not hilar one. Mean follow up period of 75.1 months. CSS at 1 and 2 years resulted 58% and 40% vs. 56% and 28% vs. 37% and 30% for patients with 1, 2 or 3 areas affected by nodal disease (p=0.5), respectively. At MVA, the number of nodal stations involved by disease did not affect CSS (all p>0.5). Conversely, the presence of nodal disease in the interaortocaval area resulted an independent predictor of CSS (Hazard Ratio 1.8, p=0.05). CONCLUSIONS When ccRCC patients harbour nodal disease, its spreading is not systematic and can occur at any nodal station without involving the others. However, the number of anatomical areas involved by nodal invasion does not affect CSS. Conversely, presence of interaortocaval positive lymph nodes is an independent predictor of CSS in RCC patients. © 2017FiguresReferencesRelatedDetails Volume 197Issue 4SApril 2017Page: e63-e64 Advertisement Copyright & Permissions© 2017MetricsAuthor Information Alessandro Nini More articles by this author Alessandro Larcher More articles by this author Carlo Terrone More articles by this author Alessandro Volpe More articles by this author Fabio Muttin More articles by this author Francesco Ripa More articles by this author Federica Regis More articles by this author Roberta Lucianò More articles by this author Alberto Briganti More articles by this author Roberto Bertini More articles by this author Francesco Montorsi More articles by this author Umberto Capitanio More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Distributive Shock in the Emergency Department: Sepsis, Anaphylaxis, or Capillary Leak Syndrome?

BackgroundDistributive shock is a hyperdynamic process resulting from excessive vasodilatation. Impaired blood flow causes inadequate tissue perfusion, which can lead to end-organ damage. Although the most common etiology is septic shock, anaphylactic and other etiologies should be considered. Case ReportWe report the case of a 30-year-old female who presented to the emergency department with nonspecific symptoms and hypotension after a viral upper respiratory infection. Her physical examination revealed mild edema and rebound tenderness in the right upper and bilateral lower quadrants. She also presented with hypotension concomitant with hypoperfusion symptoms, which were manifested by the loss of consciousness in the hour after her presentation. Neither etiologic agent nor drug use history was provided at the presentation; these may have caused anaphylaxis; however, she later reported that she took a propolis extract 1 day earlier. The hypotensive state was refractory to large amount of crystalloid infusion and a series of examinations were performed to determine the shock etiology. Computed tomography images showed pneumonic infiltrates in the lower zone of the right lung, an enlarged liver, a thickened gallbladder wall, and an extensive amount of free fluid in the perihepatic and retroperitoneal areas. All radiologic changes were thought to be due to a secondary condition that triggers them, none were considered as septic focus. Capillary leak syndrome was considered in differential diagnosis and 3 days after her presentation, her hypotension improved and she was discharged in a healthy state. Why Should an Emergency Physician Be Aware of This?Capillary leak syndrome is a variant of distributive shock. After assessing other etiologies for this condition, emergency physicians should focus on a triggering event that may have caused hypoalbuminemia and a fluid shift.

Clinical features, treatment and prognosis of neuroblastoma with bone metastasis in children

Objective To summarize the clinical features of neuroblastoma (NB) with bone metastasis, and preliminarily to analyze the relationship between clinical features, treatment effects and prognosis of NB with bone metastasis and further studying why children with NB would have bone metastasis happened.As such, this paper was seek for more effective therapy to improve patients′survival rates. Methods The retrospective research was carried out to analyze the medical records of 130 patients with bone metastasis of NB from March 2007 to July 2013 who were diagnosed and systematically treated in Beijing Children′s Hospital(BCH) Affiliated to Capital Medical University accor-ding to BCH-NB-2007 protocol.The data were reviewed for the medical history, clinical features and laboratory examination results before treatment.The research evaluated the treatment outcome and overall survival rate of the 88 cases treated and followed up all along at BCH.The deadline for follow-up was December 31, 2014. Results One hundred and thirty children of NB with bone metastasis were included in the research.There were 87 boys and 43 girls; the age was between 8-147 months, the median age was 41 months, 94(72.3%) children′s age was less than 5 years old.The main primary site was retroperitoneal and adrenal region(106 cases, 81.5%) and mediastinum(17 cases, 13.1%). The main clinical symptoms were fever(81 cases, 62.3%), bone pain(51 cases, 39.2%), abdominal pain(29 cases, 22.3%), and abdominal mass(14 cases, 10.8%). A total of 88 cases got systemic treatment and follow-up at BCH.Only 1 infant with NB, at 8 months old with a retroperitoneal mass, with bone marrow and bone metastasis, but no MYCN gene amplification, was given carboplatin plus etoposide and cyclophosvnamide, vincristine and doxorubicin according to European neuroblastoma risk grouping for alternating 8 times, he received tumor resection after 4 courses of chemotherapy and was followed up for 20 months, and the condition was now in stable.The remaining 87 patients as high risk(HR)-NB, were treated regularly by BCH-NB-2007 protocol, with the median follow-up time of 23 months, 52 cases(59.1%) turned out to have tumor progression or relapse.Forty cases died of tumor related diseases and 1 case died of measles infection.The expected overall survival rates were 49.5% in 3 years and 41.3% in 5 years. Conclusions NB with bone metastasis was very common in children over 18 months, and their common clinical symptoms are fever, bone pain and anemia.More than 80% of primary tumor was located in retroperitoneal and adrenal gland area, most of the patients with bone marrow metastasis.Since the overall prognosis is poor in these children, continuous clinical and further study is needed to investigate the causes of bone metastasis in children with NB, and to provide a basis for more effective treatment. Key words: Neuroblastoma; Bone metastasis; Clinical features; Prognosis

Isolated bladder rupture in an elderly patient after blunt trauma. Case report and review

A 74-year-old man presented to the hospital after having a mechanical fall at home on his left side of the body. On arrival he was stable, and investigation revealed fractured left humerus, and he was admitted for observation and pain management. Two days later he started to have severe lower abdominal pain and acute kidney injury. Urinary catheter inserted and about 2 liters of bloody urine emptied, and Abdominopelvic CT scan requested which showed massive fluid in the retroperitoneal area, subsequent CT Cystogram confirmed perforation of the bladder on the left lateral wall. The patient was hemodynamically stable and kept in a high intensive care unit for close observation, and he improved dramatically, and follow-up scan showed healing of perforated bladder. Bladder rupture is not a standard presentation after blunt trauma but should be kept in mind when dealing with elderly patients with pre-existing urinary retention or other medical comorbidities.

Unicentric Retroperitoneal Castleman Disease Presenting with Pleural Effusion

Castleman disease (Angiofollicular Lymph Node Hyperplasia AFH) is a rare lymphoproliferative disorder that is especially uncommon in the retroperitoneal area. We report a case of 32 year old male who was complaining of shortness of breath and was found to have right sided pleural effusion. Further investigations revealed right sided retroperitoneal mass which was completely excised laparoscopically. Pathologic diagnosis came out as Castleman disease. The patient recovered well after surgery and his shortness of breath and pleural effusion did not recur for the subsequent 6 months of follow up.

EFFECTS OF FLOUR OR FLAXSEED OIL UPON INTRA-ABDOMINAL ADIPOSITY IN MALE RATS SUBJECTED TO EARLY WEANING

The present study was designed to evaluate intra-abdominal adiposity in rats subjected to early weaning and subsequently treated with diet containing flour or flaxseed oil until young life. Pups were weaned for separation from mothers at 14 days (early weaning, EW), and 21 days (control, C). After 21 days, control (C60) was fed with control diet. EW was divided into control (EWC60); flaxseed flour (EWFF60); flaxseed oil (EWFO60) diets until 60 days. At 21-60 day, intra-abdominal fat mass were evaluated. At 60 days, retroperitoneal adipocyte area was determined. At 21 days, EW group displayed lower (P&lt;0.05) intra-abdominal fat mass. At 60 days, EWC60 group displayed lower (P&lt;0.05) intra-abdominal fat mass. Adipocytes area were lower (P&lt;0.05) in experimental groups. EWC60 displayed lower (P &lt; 0.05) adipocytes area (vs. EWFF60 and EWFO60). Flour and flaxseed oil diets contribute to recovery of intra-abdominal adiposity after precocious interruption of lactation.

Reversal of GI Bleeding with Idarucizumab in a Patient on Dabigatran and Incidental Finding of a Retroperitoneal Hematoma

Introduction: The increase in use of anticoagulation has led to the development of many new drugs that target improved compliance. Because these drugs increase the risk of bleeding, the availability of reversal agents has become an important aspect when considering their prescription. We present a case of a 78 year old male on Dabigatran who presented with gastrointestinal (GI) bleeding from a marginal ulcer and was successfully treated with Idarucizumab. Case: Our patient is a 78 year old male with a history of atrial fibrillation (on Dabigatran), recent panreatectomy with Roux-en-Y reconstruction for intraductal papillary mucinous neoplasm who presented to the hospital with an episode of bloody bowel movement, dizziness and weakness. He had a pulse of 107 bmp and blood pressure of 91/44 mmHg. His physical exam was pertinent for lethargy and blood per rectum. Pertinent laboratory findings included creatinine of 1.2 mg/DL, hemoglobin of 11.1 g/dL and PTT of 86.6. Upon arrival to the emergency department, he was resuscitated with 1 L normal Saline and his BP improved to 118/55 mmHg. Since he was having a hemodynamically significant GI bleed, he was given Idarucizumab to reverse the anticoagulant effect. Subsequent lab findings revealed a PTT of 48 and hemoglobin of of 8.3 g/dL. Patient had an EGD which revealed patent enteroenterostomy characterized by congestion, erythema, friable mucosa, inflammation and ulceration, and evidence of extrinsic compression on the posterior stomach wall. CT scan of the abdomen showed a 19.7 cm x 9.1 cm x 8.0 cm heterogeneous collection of fluid in the retroperitoneal area. He subsequently went for a laparotomy and had evacuation and suturing of the bleeding splenic artery. Discussion: Dabigatran remains one of the safest new oral anticoagulant agents as it has a reversal agent recently FDA approved for life threatening bleeds. In our patient, the GI bleed was a direct consequence of his recent pancreatectomy with Roux-en-Y reconstruction as evident from the marginal ulceration and inflammation seen on EGD. His GI bleed subsequently resolved with eventual normalization of PTT signifying reversal of the affect of Dabigatran. What makes this case more interesting is the incidental discovery of a large retroperitoneal hematoma based on the extrinsic compression of the stomach found on EGD. This serves as a great reminder to always consider a retroperitoneal bleed in an anticoagulated patient with a recent GI surgery.

Chronic Intractable Nausea as the Singular Presentation of Metastatic Duodenal Neuroendocrine Tumor

Introduction: Nausea is a non-specific symptom, often dismissed by patients and doctors alike, but may be the first sign of some solemn disease process. Case presentation: A 33 year-old Caucasian woman was referred for evaluation of chronic intractable nausea of 10-month duration, associated with intermittent right upper quadrant pain. Review of systems was negative for other symptoms. The physical exam as well as lab-work including hepatic panel and amylase/lipase was unremarkable. CT abdomen revealed cholelithiasis and a multilobulated mass in the right paramedian aspect, adjacent to duodenum, closely associated with the pancreas. It was unclear if it was arising from the pancreas, duodenum, adrenal or retroperitoneal area. Endoscopic Ultrasound (EUS) revealed an 8x8cm heterogenous appearing mass arising from the duodenal wall distinct from pancreas and kidney. Fine needle aspiration (FNA) showed well-differentiated grade-1 neuroendocrine tumor (NET) positive for pan-CK, synaptophysin and chromogranin; CDX2 staining was positive confirming the gastrointestinal origin. Laparotomy confirmed the origin of mass from the second portion of duodenum and the patient successfully underwent pancreaticoduodenectomy. Histopathology of the tumor including liver metastases was consistent with well-differentiated grade-2 NET. Discussion: Neuroendocrine cells are a specialized group of cells, which are widely distributed throughout the mucosa of GI tract and secrete hormones in response to neural or chemical stimuli leading to varied clinical presentation and symptoms. The commonest presentation is abdominal pain, but may vary from nonspecific dyspepsia to GI bleeding. In our case, patient had intractable nausea, likely due to intermittent low-grade outlet obstruction from tumor growing in the duodenal wall. Conventional imaging including CT and MRI can detect NETs but may fail to reliably demonstrate the primary organ. In such scenarios, EUS can accurately detect the tissue of origin. EUS in addition to obtaining histology serves well in the loco-regional staging. Histologically, they stained positive for Chromogranin A, synaptophysin and neuron-specific enolase.Figure 1Conclusion: This case teaches one to investigate thoughtfully such purportedly trivial complaints, to unravel unexpected findings, like NETs. EUS is an irreplaceable asset in investigation of submucosal masses and can help differentiate the tissue of origin even when cross-sectional imaging fails.Figure 2Figure 3

Maternal Flaxseed Oil During Lactation Enhances Bone Development in Male Rat Pups.

Flaxseed oil is an alpha linolenic acid source important in the growth and body development stage; furthermore, this acid acts on adipose tissue and bone health. The aim of this study was to evaluate body composition, fatty acid composition, hormone profile, retroperitoneal adipocyte area and femur structure of pups at weaning, whose mothers were fed a diet containing flaxseed oil during lactation. After birth, pups were randomly assigned: control (C, n=12) and flaxseed oil (FO, n=12), rats whose mothers were treated with diet containing soybean or flaxseed oil. At 21days, the pups were weaned and body mass, length, body composition, biochemical parameter, leptin, osteoprotegerin, osteocalcin, fatty acids composition, intra-abdominal fat mass and femur structure were analyzed. FO showed (p<0.05): higher body mass (+12%) and length (+9%); body fat mass (g, +45%); bone mineral density (+8%), bone mineral content (+55%) and bone area (+35%), osteocalcin (+173%) and osteoprotegerin (+183%). Arachidonic acid was lower (p<0.0001), alpha-linolenic and eicosapentaenoic were higher (p<0.0001). Intra-abdominal fat mass was higher (+25%), however, the retroperitoneal adipocytes area was lower (-44%). Femur mass (+10%), distance between epiphyses (+4%) and bone mineral density (+13%) were higher. The study demonstrates that adequate flaxseed oil content during a lactation diet plays an important role in the development of pups.

Use of TachoSil® to Prevent Symptomatic Lymphocele after an Aggressive Tumor Debulking with Lymphadenectomy for Advanced Stage Ovarian Cancer. A Pilot Study

Objective: To describe the incidence of symptomatic lymphocele (SLC) after an aggressive tumor debulking surgery and lymphadenectomy in patients with ovarian cancer and peritoneal carcinomatosis with or without TachoSil®. Material and Methods: A pilot retrospective comparative observational study was performed between patients with advanced ovarian cancer International Federation of Gynecology and Obstetrics stages III-IV who underwent complete debulking surgery and radical retroperitoneal lymphadenectomy. In 18 patients, 4 TachoSil® patches were placed in the retroperitoneal area, since January 2014-October 2014. This group was compared with other 18 consecutive patients matched by age, International Federation of Gynecology and Obstetrics stage, surgical complexity, American Society of Anesthesiologists score, comorbidity, and BMI without the use of TachoSil®. Results: Baseline characteristics were similar between groups. There were no statistically significant differences in terms of surgical complexity, surgical time, estimated blood loss, node removed, length of hospital stay, and complications between groups. SLC was diagnosed in 7 patients (38.8%) without TachoSil®, and in 2 patients (11.1%) with TachoSil® (p = 0.121). The use of TachoSil® was associated with a statistically significant lower re-admission rate (p = 0.041) and with a significantly shorter time to adjuvant chemotherapy (p = 0.02). Conclusions: Using TachoSil® in women with advanced stage ovarian cancer who underwent radical debulking with retroperitoneal lymph node dissection is associated with a non-statistically significant reduction in the incidence of SLC. A larger-scale randomized controlled study should be conducted to confirm our preliminary results.

Extrapancreatic solid pseudopapillary tumors: A clinicopathological analysis of two cases.

Solid pseudopapillary tumors (SPTs) are unusual neoplasms that mostly occur in the pancreas, and predominantly affect young women. As a low-grade malignant neoplasm of the exocrine pancreas, they occasionally metastasize, usually to the liver or peritoneum. It has been reported that <1% of SPTs are primary extrapancreatic SPTs. In the present study, we present two rare, but conspicuous extrapancreatic SPTs. Both occurred in young women, and showed good prognoses following surgery. One was a recurrent SPT of the pancreas that metastasized to the ovary, and the other was a distinct primary neoplasm that arose in the retroperitoneal area. The pathological features of the two tumors, including solid and pseudopapillary growth patterns with pale or eosinophilic cytoplasm, were characteristic of SPTs of the pancreas. However, in the case of the metastatic ovarian tumor, focal necrosis and an increased nuclear-to-cytoplasmic ratio were observed. The presence of positive nuclear-cytoplasmic β-catenin, the loss of membranous E-cadherin expression, and a perinuclear punctate CD99 staining pattern on immunohistochemistical analysis, were essential features for diagnosis. The aim of the present study was to compare the morphological and immunohistochemical features of these tumors with those typical of pancreatic SPTs, and to raise awareness that SPTs are able to metastasize to unusual sites, and may also arise as primary tumors outside the pancreas, which may lead to diagnostic dilemmas.

A real health problem of our days: Colorectal Cancer

Abstract Acute pancreatitis represents the acute inflammatory process of the pancreas which can remain localized in the gland or could extend in the tissues around the pancreas or retroperitoneal tissues and also at the organs from the pancreatic lodge. The diagnosis is usually based on the increase in pancreas volume and on the changes in structure objected on the ultrasound examination. It is characterised by a “release” of enzymes out of the pancreatic ducts associated with oedema and necrosis in the parenchyma and in the retroperitoneal area.