Contemporary report of surgical outcomes after single-stage total pancreatectomy: A 10-year experience

BACKGROUND

Surgeons rarely perform elective total pancreatectomy (TP). Our study seeks to report surgical outcomes in a contemporary series of single-stage (SS) TP patients.

METHODS

Between the years 2013 to 2023 we conducted a retrospective review of 60 consecutive patients who underwent SSTP. Demographics, pathology, treatment-related variables, and survival were recorded and analyzed.

RESULTS

SSTP consisted of 3% (60/1859) of elective pancreas resections conducted. Patient median age was 68 years. Ninety percent of these patients (n = 54) underwent SSTP for pancreatic ductal adenocarcinoma (PDAC). Conversion from a planned partial pancreatectomy to TP occurred intraoperatively in 31 (52%) patients. Fifty-nine patients (98%) underwent an R0 resection. Median length of hospital stay was 6 days. The majority of morbidities were minor, with 27% patients (n = 16) developing severe complications (Clavien-Dindo ≥3). Thirty and ninety-day mortality rates were 1.67% (one patient) and 5% (three patients), respectively. Median survival for the entire cohort was 24.4 months; 22.7 months for PDAC patients, with 1-, 3-, and 5-year survival of 68%, 43%, and 16%, respectively. No mortality occurred in non-PDAC patients (n = 6).

CONCLUSION

Elective single-stage total pancreatectomy can be a safe and appropriate treatment option. SSTP should be in the armamentarium of surgeons performing pancreatic resection.

Rare occurrence of pseudomyxoma peritonei (PMP) syndrome arising from a malignant transformed ovarian primary mature cystic teratoma treated by cytoreductive surgery and HIPEC: a case report

Background

Pseudomyxoma peritonei (PMP) syndrome is a disease process that typically occurs from ruptured appendiceal mucocele neoplasms. PMP syndrome arising from malignant transformation of an ovarian primary mature cystic teratoma (MCT) is a pathogenesis rarely encountered.

Case Presentation

Herein, we report a 28-year-old patient evaluated and treated for a right ovarian mass and large volume symptomatic abdominopelvic mucinous ascites. Molecular profiling and genetic analysis revealed mutations in ATM, GNAS, and KRAS proteins while IHC demonstrated gastrointestinal-specific staining for CK20, CDX2, CK7, and SATB2. Peritoneal cytology showed paucicellular mucin. Diffuse peritoneal adenomucinosis (DPAM) variant of PMP arising from a ruptured ovarian primary MCT after malignant transformation to a low-grade appendiceal-like mucinous neoplasm was ultimately confirmed. Treatment included staged therapeutic tumor debulking and right salpingo-oophorectomy followed by cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC).

Conclusions

Our report builds upon the existing literature supporting this aggressive treatment option reserved for advanced abdominal malignancies utilized in this patient with a rare clinical entity.

Genetic heterogeneity of heritable ectopic mineralization disorders in a large international cohort

PURPOSE

Heritable ectopic mineralization disorders comprise a group of conditions with a broad range of clinical manifestations in nonskeletal connective tissues. We report the genetic findings from a large international cohort of 478 patients afflicted with ectopic mineralization.

METHODS

Sequence variations were identified using a next-generation sequencing panel consisting of 29 genes reported in association with ectopic mineralization. The pathogenicity of select splicing and missense variants was analyzed in experimental systems in vitro and in vivo.

RESULTS

A total of 872 variants of unknown significance as well as likely pathogenic and pathogenic variants were disclosed in 25 genes. A total of 159 distinct variants were identified in 425 patients in ABCC6, the gene responsible for pseudoxanthoma elasticum, a heritable multisystem ectopic mineralization disorder. The interpretation of variant pathogenicity relying on bioinformatic predictions did not provide a consensus. Our in vitro and in vivo functional assessment of 14 ABCC6 variants highlighted this dilemma and provided unambiguous interpretations to their pathogenicity.

CONCLUSION

The results expand the ABCC6 variant repertoire, shed new light on the genetic heterogeneity of heritable ectopic mineralization disorders, and provide evidence that functional characterization in appropriate experimental systems is necessary to determine the pathogenicity of genetic variants.

Functional Assessment of Missense Variants in the ABCC6 Gene Implicated in Pseudoxanthoma Elasticum, a Heritable Ectopic Mineralization Disorder

Pseudoxanthoma elasticum, a heritable multisystem ectopic mineralization disorder, is caused by inactivating mutations in the ABCC6 gene. The encoded protein, ABCC6, a transmembrane transporter, has a specialized efflux function in hepatocytes by contributing to plasma levels of inorganic pyrophosphate, a potent inhibitor of mineralization in soft connective tissues. Reduced plasma inorganic pyrophosphate levels underlie the ectopic mineralization in pseudoxanthoma elasticum. In this study, we characterized the pathogenicity of three human ABCC6 missense variants using an adenovirus-mediated liver-specific ABCC6 transgene expression system in an Abcc6^-/- mouse model of pseudoxanthoma elasticum. Variants p.L420V and p.R1064W were found benign because they had abundance and plasma membrane localization in hepatocytes similar to the wild-type human ABCC6 transgene, normalized plasma inorganic pyrophosphate levels, and prevented mineralization in the dermal sheath of vibrissae in muzzle skin, a phenotypic hallmark in the Abcc6^-/- mice. In contrast, p.S400F was shown to be pathogenic because it failed to normalize plasma inorganic pyrophosphate levels and had no effect on ectopic mineralization despite its normal expression and proper localization in hepatocytes. These results showed that adenovirus-mediated hepatic ABCC6 expression in Abcc6^-/- mice can provide a model system to effectively elucidate the multifaceted functional consequences of human ABCC6 missense variants identified in patients with pseudoxanthoma elasticum.

Lateral rectus muscle disinsertion and reattachment to the lateral orbital wall

BACKGROUND/AIMS

Surgical correction of ocular alignment in patients with third cranial nerve paralysis is challenging, as the unopposed lateral rectus muscle often pulls the eye back to exotropia following surgery. The authors present a simple surgical approach to overcome this difficulty. This approach is also applicable to removal of unwanted overactivity of the lateral rectus in Duane syndrome.

METHODS

A review was made of the records of four patients with third cranial nerve paralysis and one with Duane syndrome with exotropia in which the lateral rectus muscle was removed from its scleral insertion and reattached to the orbital wall. Additional surgery to bring the eye to the midline included medial rectus resection, medial transposition of the vertical recti, and passive suturing of the eye to the medial orbit wall.

RESULTS

All patients achieved satisfactory ocular alignment following surgery. Ocular ductions were limited. These results were stable for 1.5-4 years of follow up. No major complications occurred.

CONCLUSION

Lateral rectus muscle disinsertion and reattachment to the orbital wall to absorb its force and thus remove abduction torque was a simple and safe surgical procedure for restoring ocular alignment in four patients with third cranial nerve paralysis and in one patient with Duane syndrome with severe exotropia.

The clinicopathologic basis of Graves' ophthalmopathy: a review

PURPOSE

Graves' ophthalmopathy (GO) is a controversial disease, with disagreement within the medical community regarding its pathogenesis, diagnosis, and treatment.

METHODS

We reviewed recent literature on clinical and pathological aspects of GO from both the endocrinologist's and ophthalmologist's perspective.

RESULTS

Investigations into the pathogenesis of GO have included possible antigenic targets, orbital cell types, and development of animal models. Diagnosis has been improved recently with new tools and grading systems, but can be complicated by conditions that may simulate one or more of the findings of GO. The new findings of clinical studies also compel practitioners to reassess commonly used GO treatments such as orbital irradiation.

CONCLUSIONS

Improved understanding of the pathogenic mechanisms of GO should hopefully lead to new diagnostic and therapeutic approaches to this problematic condition.

Diplopia as a complication of laser in situ keratomileusis surgery

A case is presented of a patient with high myopia who developed vertical binocular diplopia after decentred laser in situ keratomileusis (LASIK) surgery with associated decompensation of pre-existing exophoria into an exotropia. A 40-year-old man underwent LASIK surgery for high myopia in his right eye. Preoperatively, he was approximately -26.00/-2.00 x 35 degrees with visual acuity of 6/12(-2) in that eye. He also had an asymptomatic exophoria. After LASIK surgery, he achieved a refraction of -3.25/-0.50 x 80 degrees with 6/21 best-corrected visual acuity. He also developed binocular diplopia. The ablation zone had been decentred upwards and there was also an exo- and hypo-deviation of his right eye. He was able to superimpose the two images in free space with vertical and horizontal prisms.A hard contact lens also resulted in superimposition of the two images. Vertical decentration of the ablation zone can induce a vertical prism effect after LASIK surgery and result in vertical diplopia. This together with abnormal optics also caused loss of best-corrected vision and decompensation of his pre-existing exophoria into an exotropia.

Changes as the result of ageing in extraocular muscles: a post-mortem study

BACKGROUND

Extraocular muscles differ from typical skeletal muscle in many respects such as smaller fibre size, high mitochondrial content, unusual contractile/innervation patterns and highly developed microvascular bed. Changes in typical skeletal muscle with ageing have been well documented yet the reports on ageing changes in extraocular muscles is limited. The aim of this study was to examine these changes.

METHODS

The right inferior and medial rectus muscles were removed at post-mortem from patients with no history of prior ocular or neuromuscular disease. These included 25 patients aged between 23 and 88 years (14 male, 11 female). The median age of the patients was 69 years and 72% of patients were aged older than 66 years. The median post-mortem interval was 28 h,

RESULTS

In young adults between 20 and 30 years of age, the muscle fibres were regular, of fairly uniform size with minimal endomysial connective tissue and no lipofuscin was detected in fibres. In adults between 40 and 50 years of age, a small amount of subsarcolemmal lipofuscin was detected. Between 50 and 60 years of age, a few fibres with reduced density of myofibrils were noted. All patients over 65 years had definite changes of ageing and those between 70 and 80 years of age showed similar features to those between 60 and 80 years of age. These changes included variation in fibre size, increased endomysial fibrous tissue and increased endomysial adipose tissue, and loss of myofibrils with some fibres devoid of fibrils and comprising 'bags' of mitochondria. There was increased lipofuscin in a number of fibres, increased 'degenerative' changes such as vacuolation of fibres, scattered 'eosinophilic intracytoplasmic bodies' and increased numbers of 'ringbinden'.

The Heimann-Bielscholwsky phenomenon: dissociated vertical nystagmus

BACKGROUND

The Heimann-Bielschowsky phenomenon (HBP) is a unilateral vertical nystagmus with coarse, slow pendular movements that typically occurs in an eye with profound visual loss. There are no sinister neurological implications.

METHODS

Symptoms and signs on presentation and the subsequent course are described in detail in 10 patients. Eye movements were recorded for one patient.

RESULTS

Three patients had corrected vision of 6/24 or better. Strabismus was seen in eight patients. Symptoms of diplopia and oscillopsia were infrequent.

CONCLUSIONS

We believe that the HBP may be a reasonably common condition, although very under diagnosed. This condition may be similar to Central Fusion Disruption. Patients with HBP appear to have lost the potential for fusion.

Facial muscle spasms: an Australian study

PURPOSE

A group of patients suffering from blepharospasm, hemifacial spasm and Meige's syndrome were surveyed to determine the delay from the onset of their condition until a correct diagnosis was reached, the attitudes of practitioners towards them and their condition, the effect of their condition on their lifestyle and the effects of different types of treatment on their conditions.

METHODS

Questionnaires were offered to all patients with blepharospasm, hemifacial spasm and Meige's syndrome presenting to three ophthalmologists licensed to treat patients with botulinum toxin injections over a 12 month period.

RESULTS

Patients consulted an average of 4.4 practitioners before a correct diagnosis was made and many waited a number of years before obtaining satisfactory treatment. Approximately two-thirds of all practitioners consulted were unaware of their condition. Ten per cent of patients reported a family history of similar conditions. Most patients received relief from their symptoms with treatment using injections of botulinum toxin. More than 55% of patients considered themselves to have psychological problems (usually relating to stress and trauma) that they associated with the onset of their condition.

CONCLUSIONS

Facial muscle dystonias are rare and patient experiences suggest that they are poorly appreciated in the medical community. From the time they first see a practitioner with symptoms of facial dystonia, patients typically wait 2 years and see four practitioners before a correct diagnosis is made. Stress may be a factor in the symptomatic onset of this condition. Many patients describe pain as part of the presenting symptomatology. Botulinum toxin seems to be effective in the management of facial spasm.

The snapped inferior rectus

PURPOSE

To evaluate the management and possible aetiology of the snapped inferior rectus muscle in strabismus surgery.

METHODS

Three patients are described whose inferior rectus muscle broke across its width some 8-10mm behind the insertion while being held on a squint hook without excessive force during strabismus surgery. The proximal part of the muscle was not found. The distal part of the snapped muscle was excised for pathological examination. Transposition of the inferior halves of the adjacent horizontal muscles to the insertion of the inferior rectus (a modified inverse-Knapp procedure) was performed in all cases.

RESULTS

After the transposition surgery, one patient was orthotropic in the primary position, one patient required a prism correction to produce a range of single vision and the third patient was orthotropic after a further operation. There was good depression in one case and the other two had a limitation of depression. In all cases, horizontal movements remained intact and there were no signs of anterior segment ischaemia.

CONCLUSIONS

The unique relations of the inferior rectus to the surrounding tissues may be a factor in causing the breaking of this muscle. Two of the patients were elderly and this may be a factor also. Transposition surgery is the appropriate management when the proximal part of the snapped muscle cannot be located and has satisfactory but imperfect results.

Diplopia following subcutaneous injections of botulinum A toxin for facial spasms

PURPOSE

To study the incidence, cause, recovery time, and prevention of diplopia following subcutaneous injection of botulinum A toxin for the treatment of facial spasms.

METHODS

Patients who experienced diplopia after botulinum A toxin injections had their deviations examined in detail. When the muscle that caused diplopia was identifiable, the injection closest to that muscle was omitted in the next treatment in an attempt to prevent diplopia.

RESULTS

Of 250 patients receiving about 1500 sets of injections, 25 (1.7%) incidents of diplopia occurred in 10 patients. Excluding two patients who declined further treatment after having diplopia on their first botulinum A toxin treatment, seven of the remaining eight patients had multiple incidents of diplopia. The most common pattern of diplopia was "uncertain diagnosis." The most common identifiable cause of diplopia was paresis of the inferior oblique muscle. Omission of the injection into the central portion of the lower eyelids in the next treatment prevented recurrence of diplopia in only one of the four patients. No significant correlation between botulinum A toxin doses injected and times to recovery was noted.

CONCLUSIONS

Diplopia following botulinum A toxin treatment is uncommon. Seven patients (3% of patients studied) had 22 episodes of diplopia (88% of episodes). When diplopia occurs, it tends to recur on reinjection, sometimes with a prolonged recovery time. This response may not be dose dependent. The extraocular muscles of some patients may be more susceptible to chemodenervation than others, or botulinum A toxin may diffuse to extraocular muscles more easily in some patients than in others.

Facial tics

This short paper presents an approach to management of facial tics, which are rare in adults. Facial tics are usually progressive. If bilateral, the condition is usually 'benign essential blepharospasm'. If unilateral they are usually due to hemifacial spasm.

MRI in the heavy eye phenomenon

The heavy eye phenomenon presents as progressive esotropia and hypotropia in high myopia. It appears to be due to compression of the lateral rectus muscle against the lateral orbital wall by the enlarged myopic globe. We present the first published magnetic resonance imaging (MRI) scans of this condition and a summary of the literature.

Ophthalmic manifestations of head injury

Head injuries are frequently associated with ophthalmic problems. The commonest problems seen in this series of 161 patients with head injury were problems with poor accommodation (16% of patients; 58% of these persisted), convergence (14% of patients; 35% of these persisted), pseudomyopia (19%; 55% persisted) and optic atrophy (26% of the patients; 78% of these were mild and easily missed on routine testing, and 22% were severe). Motility disorders were common, especially cranial nerve palsies. Other less frequent motility disturbances included apparent inferior oblique palsy, comitant esotropia, and exotropia which was often of the convergence insufficiency type.

Headaches and the ophthalmologist

Many patients are referred to an ophthalmologist because of headaches. If the headaches are provoked by visual activity, the ophthalmologist can often treat the patient. An approach to assessing the larger number of headache patients without visual problems is presented.

Arterial macroaneurysm of the optic disc

A 64-year-old man presented with an arterial macroaneurysm on the optic disc, an unusual location for retinal arterial macroaneurysm. The macroaneurysm resolved spontaneously without sequelae.

Appendiceal filling by double-contrast barium enema

The barium enema is a safe and useful diagnostic modality in the evaluation of patients with suspected acute appendicitis. Complete appendiceal filling with barium virtually excludes this diagnosis. Frequently positive diagnostic information is obtained. Only 1 study in the literature documents the frequency of normal appendiceal filling by barium enema. The authors utilized the single-contrast technique. We recorded the frequency of normal appendiceal filling with the double-contrast technique and then compared our data with the previously published study to determine if there is a significant clinical disadvantage to the double-contrast technique when acute appendicitis is a diagnostic consideration.

Abnormal fibrinolysis in retinal vein occlusion

Some cases of central and branch retinal vein occlusion are associated with and may be caused by abnormal fibrinolytic mechanisms. The abnormality we described is that of plasminogen activator enzyme deficiency, which is a treatable condition. That seven cases were seen by one practitioner in a two year period may indicate that this particular condition is under-recognised.