From our own experience and a subsequent review of the literature, we recommend right hemicolectomy as the treatment of choice for all malignant appendiceal neoplasms, except for small CCT less than 2 cm in diameter at the tip of the appendix, with a low proliferative index, without angiolymphatic or mesoappendiceal extension. Further adjuvant therapy should be considered after oncological assessment.
Murine lymphoid cell lines and rat thymocytes treated in vitro with glucocorticoid hormones provide a convenient system for studying the nuclear changes in apoptosis. Morphologically the nucleolus disintegrates and chromatin undergoes an unusual generalized condensation. This is associated with excision of most of the nuclear DNA to short but well-organized chains of nucleosomes, apparently by an endogenous non-lysosomal nuclease. The process is dependent upon macromolecular synthesis and probably is mediated, at least remotely, by the classical steroid-receptor-gene activation pathway. A similar process of chromatin condensation and excision can be produced by the calcium-magnesium ionophore A23187. In other circumstances of 'programmed cell death', analogous chromatin condensation, excision and requirements for macromolecular synthesis have been documented.
The timing and technique of perioperative biliary imaging in relation to laparoscopic surgery remains controversial. This study assessed the predictive value of magnetic resonance cholangiopancreatography (MRCP) in the diagnosis of biliary pathology. Clinical, laboratory and investigational data were evaluated from 374 patients undergoing MRCP at two hospital sites over a 5-year period. MRCP findings were compared with endoscopic retrograde cholangiopancreatography (ERCP) or operative findings and appropriate clinical endpoints. Complete data were available for 351 of the 374 patients (94%), of whom 232 (66%) were female. Median age was 64 years. The predominant presentation was abdominal pain (n = 190). Features of pancreatitis were present in 59, cholangitis in 26 and jaundice in 109 patients. Ultrasound was the initial investigation in 312 (89%) (176-gallstone positive). Common duct dilatation was evident in 114 patients and ductal calculi in 31. ERCP was successful in 212/283 (75%) patients. Significant ERCP induced pancreatitis occurred in 12 (5.6%). Comparison between MRCP and ERCP was not possible in 85 due to failure of either technique. Nine patients underwent other investigations including intraoperative cholangiogram (IOC), percutaneous transhepatic cholangiogram (PTC) and were included. Of the 221 patients with full comparative data available the MRCP showed a sensitivity of 97.98% and specificity of 84.4%. MRCP is highly sensitive and specific for choledocholithiasis and avoids the need for invasive imaging in most patients with suspected choledocholithiasis.
The results of the present study illustrate that there is no place for complacency in the surgical management of patients with severe acute pancreatitis. A clinical governance approach would promote pre-defined protocols between admitting hospitals and tertiary referral centres. Future research should target new interventions in patients with high admission APACHE-II scores in whom prognosis is particularly poor and explore the role of infection of necrotic tissue.
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