Unusual Configuration of a Giant Trans-Spatial Pancreatic Pseudocyst with Spontaneous Shrinkage: A Rare Case Report

Pancreatic pseudocysts are benign lesions that typically originate within the pancreatic parenchyma, or peripancreatic tissue. They commonly occur following recurrent episodes of pancreatitis or trauma. In this article, we present a case of a giant pancreatic pseudocyst with unusual trans-spatial extensions and spontaneous size decrement in a 40-year-old male patient with a history of alcohol abuse. He presented with chronic epigastric pain, and a physical examination showed only mild abdominal tenderness. Initial computed tomography showed a giant (18.4cm in its largest axis) pancreatic pseudocyst with left subdiaphragmatic and gastrohepatic extensions and concurrent splenic cysts. On follow-up ultrasound, the pseudocyst showed a significant spontaneous size decrement to less than half of its initial size. The giant size and trans-spatial characteristics of the pseudocyst, along with a relatively benign symptomatology and subsequent spontaneous shrinkage, constitute unique aspects of this case.

Analysis of Closed Claims Among All Medical Specialties: Importance of Communication and Other Non-Clinical Contributing Factors

Objective

Medical malpractice claims represent patient dissatisfaction of care delivered by their healthcare provider. Evaluation of contributing factors (CFs) associated with claims provides important information to optimize the patient-provider relationship.

Study Design

A total of 21,101 closed claims with 54,479 CFs (2.2 contributing factors per claim) from a large medical professional liability coverage provider were analyzed from 2010 to 2019.

Results

Four clinical CFs (technical performance, management of therapy, patient assessment, and patient factors) and four nonclinical CFs (communication between providers and patient, communication among providers, failure or delay in obtaining a consult, and insufficient documentation) were identified >1,500 times. Nonclinical CFs increased as a percentage from 50% in the first part of the study period to 54% in the second part of the study period (p < 0.01), and were more frequent in cases associated with indemnity when compared to clinical CFs (Nonclinical: 57% vs 43%; p < 0.001). Poor communication as a CF increased steadily during the study period (3-year average; 2010-2012: 777 CF/year vs 2017-2019: 1207 CF/year; p < 0.001). In claims associated with high severity injury, poor communication among providers was more significant than poor communication between the provider and patient (63% vs 29%; p < 0.001), mainly due to failure to convey the severity of the patient's condition. For non-surgical specialties except psychiatry, communication was the highest CF and the second or third CF for psychiatry or surgical specialties.

Discussion

Clinical and nonclinical CFs are equally important for malpractice claims. Communications issues are particularly important regardless of specialty. While focusing on clinical quality is important, implementing strategies that account for nonclinical issues, with a particular focus on communication, would have significant benefits particularly in an environment of increased consolidation of healthcare delivery systems.

Efficacy Analysis of Adjuvant Chemotherapy with Gemcitabine Plus Platinum or S-1 in Biliary Tract Carcinoma: A Multi-Center Retrospective Study

PURPOSE

Biliary tract cancers (BTCs) have a poor overall prognosis, as patients who underwent curative surgery frequently experience disease recurrence. At present, there is a paucity of well-documented adjuvant chemotherapy regimen. This study aimed to assess whether gemcitabine plus platinum or S-1 adjuvant chemotherapy have different impact on relapse-free survival (RFS).

PATIENTS AND METHODS

We selected patients undergoing radical biliary tract cancer surgery, pathologically confirmed adenocarcinoma and received gemcitabine plus platinum (cisplatin or oxaliplatin) or S-1 adjuvant chemotherapy from September 2013 to May 2020. The primary study endpoint was RFS. The secondary endpoint was safety.

RESULTS

Overall 136 patients were enrolled. The median follow-up was 32.3 months and the median RFS was 17.0 months (95% CI 8.9-25.1). The median RFS was 14.1 months (95% CI 6.7-21.5) in gemcitabine plus platinum group and 33.0 months (95% CI 9.3-56.7) in gemcitabine plus S-1 (GS) group, a non-significant difference both in univariate (P=0.092) and in multivariate analysis (P=0.058). Lymph node status (N- vs N+: HR=0.477, 95% CI 0.285-0.799; P=0.005) and chemotherapy cycles (<6 vs 6-8: HR=1.828, 95% CI 1.117-2.993; P=0.016) were independent impact factors for RFS. GS group had lower incidence of adverse reactions.

CONCLUSION

Compared with gemcitabine plus platinum, GS regimen has a tendency to obtain longer RFS (although there is no statistically significant difference) and less toxic. GS regimen has the potential to be investigated as a standard regimen for adjuvant chemotherapy.