Adjuvant chemoradiotherapy for resected pancreas cancer

The purpose of this article is to review pertinent literature assessing the evidence regarding adjuvant chemoradiotherapy for adenocarcinoma of the pancreas following curative resection. This review looks at randomized controlled studies with the emphasis on adjuvant chemoradiotherapy. In assessing the evidence from the studies reviewed in this article, the trials have been grouped according to the positive or negative results for or against adjuvant treatment. In addition, data from two large, single-institution studies affirming the role for adjuvant chemoradiotherapy has been included. Understanding the evidence from all of the randomized studies is important in shaping current practice recommendations for adjuvant therapy of surgically resected pancreas cancer. Adjuvant chemoradiotherapy following surgery is the current approach at many cancer treatment centers in the United States. In Europe, chemotherapy alone is the preferred adjuvant therapy. However, the type of adjuvant treatment recommended remains controversial due to conflicting study results. The debate will likely continue. Current practice should be based on the weight of evidence available at this time, which is in favor of adjuvant chemotherapy with chemoradiotherapy.

Sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery: A case report

We report a case of sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery. A 38-year old asymptomatic woman was referred to our hospital for evaluation of a submucosal tumor of the stomach. Endoscopic examination showed a solitary submucosal tumor without ulceration or central depression on the posterior wall of the antrum and biopsy specimens were not sufficient to determine the diagnosis. Endoscopic ultrasound revealed a tumor nearly 2 cm in diameter arising from the muscle layer and a computed tomography scan showed the tumor enhanced in the arterial phase. Laparoscopic wedge resection was performed for definitive diagnosis. Pathologically, the tumor was shown to be gastric carcinoid infiltrating the muscle layer which indicated the probability of lymph node metastasis. Serum gastrin levels were normal. As a radical treatment, laparoscopy-assisted distal gastrectomy with regional lymphadenectomy was performed 3 wk after the initial surgery. Finally, pathological examination revealed no lymph node metastasis.

Role of frozen section assessment for intraductal papillary and mucinous tumor of the pancreas

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas include a spectrum of dysplasia ranging from minimal mucinous hyperplasia to invasive carcinoma and are extensive tumors that often spread along the ductal tree. Several studies have demonstrated that preoperative imaging is not accurate enough to adapt the extent of pancreatectomy and have suggested routinely using frozen sectioning (FS) to evaluate the completeness of resection and also to check if ductal dilatation is active or passive, in order to avoid an excessive pancreatic resection. Separate main duct and branch duct analysis is needed due to the difference in the natural history of the disease. FS accuracy averages 95%. Eroded epithelium on the main duct, severe ductal inflammation mimicking dysplasia and reactive epithelial changes secondary to obstruction can lead to inappropriate FS results. FS results change the planned extent of resection in up to 30% of cases. The optimal cut-off leading to extend pancreatectomy is not consensual and our standard option is to extend pancreatectomy if FS reveals: (1) at least IPMN adenoma on the main duct; or (2) at least borderline IPMN on branch ducts; or (3) invasive carcinoma. However, the decision to extend resection must be taken after a multidisciplinary discussion since it does not exclusively depend on the FS result but also on age, general condition and expected prognosis after resection. The main limitation of using FS is the existence of discontinuous (“skip”) lesions which account for approximately 10% of IPMN in surgical series and can lead to reoperation in up to 8% of cases.

Natural history of intraductal papillary mucinous neoplasia: How much do we really know?

Information on the natural history of intraductal papillary mucinous neoplasia (IPMN) is currently inadequate due to a lack of carefully orchestrated long-term follow-up on a large cohort of patients with asymptomatic disease. Based on the available data, one can draw the conclusions that main duct IPMN is commonly associated with malignancy and an aggressive operative stance should be taken with resection being offered to most patients who are suitable operative candidates. In contrast, the majority of branch type IPMN with a diameter of less than 3 cm can be safely followed with routine surveillance imaging provided they lack the high-risk covariates of age, symptomatology, nodularity or wall thickness.

Population-based epidemiology, risk factors and screening of intraductal papillary mucinous neoplasm patients

Intraductal papillary mucinous neoplasm (IPMN) was first recognized in the 1980s with increasing publications over the last decade as the incidence increased sharply, especially at tertiary-care referral centers. Population-based studies have estimated the age and sex-adjusted cumulative incidence of IPMN to be 2.04 per 100 000 person-years (95% confidence interval: 1.28-2.80). It is now understood that IPMN can be classified anywhere along the spectrum of the adenoma to carcinoma sequence and often harbors mutations in genes such as KRAS early in the disease process. Many patients are diagnosed incidentally after imaging of the abdomen for other diagnostic purposes. Patients that present with a history of symptoms such as pancreatitis and abdominal pain are at high risk of harboring a malignancy. Clinicopathologic features such as involvement of the main pancreatic duct, presence of mural nodules, and side branch disease > 3.0 cm in size may indicate that there is an underlying invasive component to the IPMN. In addition, the incidence of extra-pancreatic neoplasms is higher in patients with IPMN, with reported rates of 25% to 50%. There are no current screening recommendations to detect and diagnose IPMN but once the diagnosis is made, screening for extrapancreatic neoplasms such as colon polyps and colorectal cancer should be considered. Surgical resection is the recommend treatment for patients with high-risk features while close observation can be offered to patients without worrisome signs and symptoms of carcinoma.

Intraductal papillary-mucinous neoplasia of the pancreas: Histopathology and molecular biology

Intraductal papillary-mucinous neoplasm (IPMN) of the pancreas is a clinically and morphologically distinctive precursor lesion of pancreatic cancer, characterized by gradual progression through a sequence of neoplastic changes. Based on the nature of the constituting neoplastic epithelium, degree of dysplasia and location within the pancreatic duct system, IPMNs are divided in several types which differ in their biological properties and clinical outcome. Molecular analysis and recent animal studies suggest that IPMNs develop in the context of a field-defect and reveal their possible relationship with other neoplastic precursor lesions of pancreatic cancer.

Imaging considerations in intraductal papillary mucinous neoplasms of the pancreas

With the widespread use of cross-sectional imaging, particularly computed tomography (CT) and magnetic resonance imaging (MRI), and the continuous improvement in the image quality of these techniques, the diagnosis of incidental pancreatic cysts has increased dramatically in the last decades. While the vast majority of these cysts are not clinically relevant, a small percentage of them will evolve into an invasive malignant tumor making their management challenging. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms (IPMN) are the most common pancreatic cystic lesions with malignant potential. Imaging findings on CT and MRI correlate tightly with the presence of malignant degeneration in these neoplasms. IPMN can be classified based on their distribution as main duct, branch duct or mixed type lesions. MRI is superior to CT in demonstrating the communication of a branch duct IPMN with the main pancreatic duct (MPD). Most branch duct lesions are benign whereas tumors involving the MPD are frequently associated with malignancy. The presence of solid nodules, thick enhancing walls and/or septae, a wide (> 1 cm) connection of a side-branch lesion with the MPD and the size of the tumor > 3 cm are indicative of malignancy in a branch and mixed type IPMN. A main pancreatic duct > 6 mm, a mural nodule > 3 mm and an abnormal attenuating area in the adjacent pancreatic parenchyma on CT correlates with malignant disease in main duct and mixed type IPMN. An accurate characterization of these neoplasms by imaging is thus crucial for selecting the best management options. In this article, we review the imaging findings of IPMN including imaging predictors of malignancy and surgical resectability. We also discuss follow-up strategies for patients with surgically resected IPMN and patients with incidental pancreatic cysts.

Intraductal papillary mucinous neoplasm and the pancreatic incidentaloma

Asymptomatic pancreatic lesions (APL) are a commonly encountered problem in today’s pancreatic surgical practices. Current literature regarding etiologies and incidence of APLs, particularly intraductal papillary mucinous neoplasm (IPMN), is presented. APLs constitute a wide spectrum of pathology (solid/cystic, benign/premalignant/malignant) but, overall, IPMN is now the most common diagnosis. The Sendai Guidelines and their function as a basis for risk stratification in branch duct IPMN are presented. The importance of traditionally analyzed cyst characteristics including size, presence of mucin or nodules and cyst fluid aspirate as indicators of malignancy is emphasized, noting also the potential correlation of main duct dilatation, thickened septae and elevated cyst fluid CEA with increased risk of malignancy. Current complication rates after resection of APLs are reviewed and found to be generally equivalent to those for symptomatic resections. A potential multidisciplinary treatment strategy is offered considering the costs of surgery versus repeated imaging or follow up endoscopy for these lesions. The decision for intervention is ultimately based on the Sendai Guidelines in the context of the individual patient.

Intraductal papillary mucinous neoplasm: Coming of age

Intraductal papillary mucinous neoplasm (IPMN) is a disease in evolution. Since its first description almost 30 years ago, a better understanding of the disease has steadily accrued. Yet, there are numerous challenges still for clinicians who treat this fascinating disease. A group of leading content experts on IPMN was assembled and charged with presenting cutting-edge knowledge on various topics for which they have considerable experience. This manuscript provides an historical perspective of both clinical and biological quandaries that have been resolved to date. Furthermore, it poses new avenues for investigation while highlighting the contributions of the various authors to this collective review.

Diagnostic and therapeutic endoscopic approaches to intraductal papillary mucinous neoplasm

Pancreatic cystic lesions are increasingly identified on routine imaging. One specific lesion, known as intraductal papillary mucinous neoplasm (IPMN), is a mucinous, pancreatic lesion characterized by papillary cells projecting from the pancreatic ductal epithelium. The finding of mucin extruding from the ampulla is essentially pathognomonic for diagnosing these lesions. IPMNs are of particular interest due to their malignant potential. Lesions range from benign, adenomatous growths to high-grade dysplasia and invasive cancer. These mucinous lesions therefore require immediate attention to determine the probability of malignancy and whether observation or resection is the best management choice. Unresected lesions need long-term surveillance monitoring for malignant transformation. The accurate diagnosis of these lesions is particularly challenging due to the substantial similarities in morphology of pancreatic cystic lesions and limitations in current imaging technologies. Endoscopic evaluation of these lesions provides additional imaging, molecular, and histologic data to aid in the identification of IPMN and to determine treatment course. The aim of this article is to focus on the diagnostic and therapeutic endoscopic approaches to IPMN.

Differences between main-duct and branch-duct intraductal papillary mucinous neoplasms of the pancreas

In the last decade, intraductal papillary mucinous neoplasms (IPMNs) have become commonly diagnosed. From a morphological standpoint, they are classified in main-duct IPMNs (MD-IPMNs) and branch-duct IPMNs (BD-IPMNs), depending on the type of involvement of the pancreatic ductal system by the neoplasm. Despite the fact that our understanding of their natural history is still incomplete, recent data indicate that MD-IPMNs and BD-IPMNs show significant differences in terms of biological behaviour with MD-IPMNs at higher risk of malignant degeneration. In the present paper, clinical and epidemiological characteristics, rates of malignancy and the natural history of MD-IPMNs and BD-IPMNs are analyzed. The profile of IPMNs involving both the main pancreatic duct and its side branches (combined-IPMNs) are also discussed. Finally, general recommendations for management based on these differences are given.

Extrapancreatic malignancies and intraductal papillary mucinous neoplasms of the pancreas

Over the last two decades multiple studies have demonstrated an increased incidence of additional malignancies in patients with intraductal papillary mucinous neoplasms (IPMNs). Additional malignancies have been identified in 10%-52% of patients with IPMNs. The majority of these additional cancers occur before or concurrent with the diagnosis of IPMN. The gastrointestinal tract is most commonly involved in secondary malignancies, with benign colon polyps and colon cancer commonly seen in western countries and gastric cancer commonly seen in Asian countries. Other extrapancreatic malignancies associated with IPMNs include benign and malignant esophageal neoplasms, gastrointestinal stromal tumors, carcinoid tumors, hepatobiliary cancers, breast cancers, prostate cancers, and lung cancers. There is no clear etiology for the development of secondary malignancies in patients with IPMN. Although population-based studies have shown different results from single institution studies regarding the exact incidence of additional primary cancers in IPMN patients, both have reached the same conclusion: there is a higher incidence of extrapancreatic malignancies in patients with IPMNs than in the general population. This finding has significant clinical implications for both the initial evaluation and the subsequent long-term follow-up of patients with IPMNs. If a patient has not had recent colonoscopy, this should be performed during the evaluation of a newly diagnosed IPMN. Upper endoscopy should be performed in patients from Asian countries or for those who present with symptoms suggestive of upper gastrointestinal disease. Routine screening studies (breast and prostate) should be carried out as currently recommended for patient’s age both before and after the diagnosis of IPMN.

Prognosis of invasive intraductal papillary mucinous neoplasms of the pancreas

Intraductal papillary mucinous neoplasms (IPMN) are mucin producing cystic neoplasms of the pancreas histologically classified as having non-invasive and invasive components. The five-year survival rates for non-invasive and associated invasive carcinoma are 90% and 40%, respectively in resected IPMN lesions. Invasive carcinoma within IPMN lesions can be further classified by histological subtype into colloid carcinoma and tubular carcinoma. Estimated five-year survival rates following resection of colloid carcinoma range from 57%-83% and estimated five-year survival following resection of tubular carcinoma range from 24%-55%. The difference in survival outcome between invasive colloid and tubular IPMN appears to be a function of disease biology, as patients with the tubular subtype tend to have larger tumors with a propensity for metastasis to regional lymph nodes. When matched to resected conventional pancreatic adenocarcinoma lesions by the Memorial Sloan Kettering Cancer Center pancreatic adenocarcinoma nomogram, the colloid carcinoma histological subtype has an improved estimated five-year survival outcome compared to conventional pancreatic adenocarcinoma, 87% and 23% (P = 0.0001), respectively. Resected lesions with the tubular carcinoma subtype overall have a similar five-year survival outcome compared to conventional pancreatic adenocarcinoma. However, when these groups were stratified by regional lymph node status patients with negative regional lymph nodes and the tubular subtype experienced significantly better survival than patients with a similar nodal status and ductal adenocarcinoma with estimated five-year survival rates of 73% and 27% (P = 0.01), respectively.

Extent of surgical resections for intraductal papillary mucinous neoplasms

Intraductal papillary mucinous neoplasms (IPMNs) can involve the main pancreatic duct (MD-IPMNs) or its secondary branches (BD-IPMNs) in a segmental of multifocal/diffuse fashion. Growing evidence indicates that BD-IPMNs are less likely to harbour cancer and in selected cases these lesions can be managed non operatively. For surgery, clarification is required on: (1) when to resect an IPMN; (2) which type of resection should be performed; and (3) how much pancreas should be resected. In recent years parenchyma-sparing resections as well as laparoscopic procedures have being performed more frequently by pancreatic surgeons in order to decrease the rate of postoperative pancreatic insufficiency and to minimize the surgical impact of these operations. However, oncological radicality is of paramount importance, and extended resections up to total pancreatectomy may be necessary in the setting of IPMNs. In this article the type and extension of surgical resections in patients with MD-IPMNs and BD-IPMNs are analyzed, evaluating perioperative and long-term outcomes. The role of standard and parenchyma-sparing resections is discussed as well as different strategies in the case of multifocal neoplasms.

Differentiating intraductal papillary mucinous neoplasms from other pancreatic cystic lesions

Intraductal papillary mucinous neoplasms (IPMN) can be difficult to distinguish from other cystic lesions of the pancreas. To understand better and discuss the current knowledge on this topic, the literature and the institutional experience at a large pancreatic disease center have been reviewed. A combination of preoperative demographic, historical, radiographic, laboratory data, as well as postoperative pathologic analyses can often distinguish IPMN from other lesions in the differential diagnosis.

Laparoscopic surgery for rectal cancer: The state of the art

At present time, there is evidence from randomized controlled studies of the success of laparoscopic resection for the treatment of colon cancer with reported smaller incisions, lower morbidity rate and earlier recovery compared to open surgery. Technical limitations and a steep learning curve have limited the wide application of mini-invasive surgery for rectal cancer. The present article discusses the current status of laparoscopic resection for rectal cancer. A review of the more recent retrospective, prospective and randomized controlled trial (RCT) data on laparoscopic resection of rectal cancer including the role of trans-anal endoscopic microsurgery and robotics was performed. A particular emphasis was dedicated to mid and low rectal cancers. Few prospective and RCT trials specifically addressing laparoscopic rectal cancer resection are currently available in the literature. Improved short-term outcomes in term of lesser intraoperative blood loss, reduced analgesic requirements and a shorter hospital stay have been demonstrated. Concerns have recently been raised in the largest RCT trial of the oncological adequacy of laparoscopy in terms of increased rate of circumferential margin. This data however was not confirmed by other prospective comparative studies. Moreover, a similar local recurrence rate has been reported in RCT and comparative series. Similar findings of overall and disease free survival have been reported but the follow-up time period is too short in all these studies and the few RCT trials currently available do not draw any definitive conclusions. On the basis of available data in the literature, the mini-invasive approach to rectal cancer surgery has some short-term advantages and does not seem to confer any disadvantage in term of local recurrence. With respect to long-term survival, a definitive answer cannot be given at present time as the results of RCT trials focused on long-term survival currently ongoing are still to fully clarify this issue.

Successful embolization assisted by covered stents for a pseudoaneurysm following pancreatic surgery

Delayed intra-abdominal hemorrhage after pancreatic surgery is a potentially lethal complication. Transarterial coil embolization and/or the placing of an endovascular stent are minimally invasive and effective procedures. An artery that is extensively eroded and rendered friable due to operative skeletonization or postoperative inflammation sometimes contributes to delayed intra-abdominal hemorrhage or rebleeding after coil embolization. This report presents a case of successful management of postoperative hemorrhage in a-74-year-old Japanese male. He experienced bleeding from a pseudoaneurysm of the brittle hepatic artery following total pancreatectomy. Initially the pseudoaneurysm was successfully treated with covered coronary stent-grafts, but rebleeding occurred 1 mo later due to the brittleness of the artery. Rebleeding was definitively managed by the complete packing of the stent by coil embolization. He remains stable at 18 mo following the final embolization. A stent graft can be used for protecting a brittle artery to avoid injury by coil embolization.

Gastroduodenal artery aneurysm rupture in hospitalized patients: An overlooked diagnosis

Gastroduodenal artery (GDA) aneurysm rupture is a rare serious condition. The diagnosis requires a high level of suspicion with specific attention to warning signs. Early diagnosis can prevent fatal outcomes. In this report, we describe a case of GDA aneurysm rupture presenting as recurrent syncope and atypical back and abdominal discomfort. The rupture manifested as hemorrhagic shock. The diagnosis was made by computed tomography of the abdomen which showed acute peritoneal and retroperitoneal bleeding. Angiographic intervention failed to coil the GDA and surgery with arterial ligation was the definitive treatment.

Role of staging laparoscopy in peri-pancreatic and hepatobiliary malignancy

Even after extensive preoperative assessment, staging laparoscopy may allow avoidance of non-therapeutic laparotomy in patients with radiographically occult metastatic or locally unresectable disease. Staging laparoscopy is associated with decreased postoperative pain, a shorter hospital stay and a higher likelihood of receiving systemic therapy compared to laparotomy but its yield has decreased with improvements in imaging techniques. Current uses of staging laparoscopy include the following: (1) In the staging of pancreatic adenocarcinoma, laparoscopic staging allows for the identification of sub-radiographic metastatic disease in locally advanced cancer in approximately 30% of patients and, in radiographically resectable cancer, may identify metastatic disease in 10%-15% of cases; (2) In colorectal liver metastases, selective use of laparoscopic staging in patients with a clinical risk score of over 2 identifies unresectable disease in approximately 20% of patients; (3) In hepatocellular carcinoma, laparoscopic staging could be selectively used in high-risk patients such as those with clinically apparent liver cirrhosis and in patients with major vascular invasion or bilobar tumors; and (4) In biliary tract malignancy, staging laparoscopy may be used in all patients with potentially resectable primary gallbladder cancer and in selected patients with T2/T3 hilar cholangiocarcinoma. Because of the decreasing yield of SL secondary to improvements in imaging techniques, staging laparoscopy should be used selectively for patients with pancreatic and hepatobiliary malignancy to avoid unnecessary non-therapeutic laparotomy and to improve resource utilization. Each individual surgeon should apply his or her threshold as to whether staging laparoscopy is indicated according to the quality of preoperative imaging studies and the availability of resources at their own institution.

Pancreatic metastases: An increasing clinical entity

Pancreatic metastases, although uncommon, have been observed with increasing frequency recently, especially by high-volume pancreatic surgery centers. They are often asymptomatic and detected incidentally or during follow-up investigations even several years after the removal of the primary tumor. Renal cell cancer represents the most common primary tumor by far, followed by colorectal cancer, melanoma, sarcoma and lung cancer. Pancreatic metastasectomy is indicated for an isolated and resectable metastasis in a patient fit to tolerate pancreatectomy. Both standard and atypical pancreatic resection can be performed: a resection strategy providing adequate resection margins and maximal tissue preservation of the pancreas should be pursued. The effectiveness of resection for pancreatic metastases is mainly dependent on the tumor biology of the primary cancer; renal cell cancer is associated with the best outcome with a 5-year survival rate greater than 70%.

Endobronchial metastasis from adenocarcinoma of gastric cardia 7 years after potentially curable resection

Endobronchial metastasis (EBM) is a rare form of metastasis from extrapulmonary malignant tumors, although there are few reports of EBM from gastric cancer specifically. We report the case of a 51-year-old woman who had undergone gastrectomy for advanced gastric cancer seven years previously but was diagnosed with a solitary lung tumor by follow-up computed tomography. On diagnosis of primary lung cancer, she underwent pulmonary lobectomy, but immunohistochemical examination confirmed the resected tumor to be an EBM from the gastric cancer. Six months later, she was diagnosed with peritoneal metastases and underwent chemotherapy with gastric cancer regimen. She is still alive at 33 mo after the lobectomy. Generally, the prognosis for EBM is poor although multidisciplinary treatment can lead to long-term survival. Precise diagnosis on the basis of detailed pathological and immunohistochemical evaluation can contribute to deciding the most effective treatment and improving prognosis.

A standardized technique for safe pancreaticojejunostomy: Pair-Watch suturing technique

AIM: To prevent pancreatic leakage after pancreaticojejunostomy, we designed a new standardized technique that we term the “Pair-Watch suturing technique”.

METHODS: Before anastomosis, we imagine the faces of a pair of watches on the jejunal hole and pancreatic duct. The first stitch was put between 9 o’clock of the pancreatic side and 3 o’clock of the jejunal side, and a total of 7 stitches were put on the posterior wall, followed by the 5 stitches on the anterior wall. Using this technique, twelve stitches can be sutured on the first layer anastomosis regardless of the caliber of the pancreatic duct. In all cases the amylase activity of the drain were measured. A postoperative pancreatic fistula was diagnosed using postoperative pancreatic fistula grading.

RESULTS: From March 2007 to July 2008, 29 consecutive cases underwent pancreaticojejunostomy using this technique. Pathologic examination results showed pancreatic carcinoma (n = 14), intraductal papillary-mucinous neoplasm (n = 10), intraductal papillary-mucinous carcinoma (n = 1), carcinoma of ampulla of Vater (n=1), carcinoma of extrahepatic bile duct (n = 1), metastasis of renal cell carcinoma (n = 1), and duodenal carcinoma (n = 1). Pancreaticojejunal anastomoses using this technique were all watertight during the surgical procedure. The mean diameter of main pancreatic duct was 3.4 mm (range 2-7 mm). Three patients were recognized as having an amylase level greater than 3 times the serum amylase level, but all of them were diagnosed as grade A postoperative pancreatic fistula grading and required no treatment. None of the cases developed complications such as hemorrhage, abdominal abscess, and pulmonary infection. There was no postoperative mortality.

CONCLUSION: Our technique is less complicated than other methods and very secure, providing reliable anastomosis for any size of pancreatic duct.

Peritoneal seeding from appendiceal carcinoma: A case report and review of the literature

Non-carcinoid appendiceal malignancies are rare entities, representing less than 0.5% of all gastrointestinal malignancies. Because of their rarity and particular biological behavior, a substantial number of patients affected by these neoplasms do not receive appropriate surgical resection. In this report, we describe a rare case of primary signet-ring cell carcinoma of the appendix with peritoneal seeding which occurred in a 40-year old man admitted at the Emergency Surgery Department with the clinical suspicion of acute appendicitis. After a surgical debulking and right hemicolectomy, the patient had systemic chemotherapy according to FOLFOX protocol. After completion of the latter, the patient underwent cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy. This report offers a brief review of the literature and suggests an algorithm for the management of non-carcinoid appendiceal tumors with peritoneal dissemination.

Abdominal wall actinomycosis simulating a malignant neoplasm: Case report and review of the literature

Abdominal wall actinomycosis is a rare disease frequently associated with the presence of an intra uterine device. We report on a case of a 47-year-old woman who had used an intrauterine device for many years and had removed it about a month prior to the identification of an abdominal wall abscess caused by Actinomyces israelii. The abscess mimicked a malignancy and the patient underwent a demolitive surgical treatment. The diagnosis was obtained only after histopathological examination. Postoperatively, the patient developed an infection of the wound which was treated with daily medication. The combination of long-term high dose antibiotic therapy with surgery led to successful treatment.

Innovations in chronic anal fissure treatment: A systematic review

A chronic anal fissure is a common perianal condition. This review aims to evaluate both existing and new therapies in the treatment of chronic fissures. Pharmacological therapies such as glyceryl trinitrate (GTN), Diltiazem ointment and Botulinum toxin provide a relatively non-invasive option, but with higher recurrence rates. Lateral sphincterotomy remains the gold standard for treatment. Anal dilatation has no role in treatment. New therapies include perineal support devices, Gonyautoxin injection, fissurectomy, fissurotomy, sphincterolysis, and flap procedures. Further research is required comparing these new therapies with existing established therapies. This paper recommends initial pharmacological therapy with GTN or Diltiazem ointment with Botulinum toxin as a possible second line pharmacological therapy. Perineal support may offer a new dimension in improving healing rates. Lateral sphincterotomy should be offered if pharmacological therapy fails. New therapies are not suitable as first line treatments, though they can be considered if conventional treatment fails.