A major dilemma facing liver transplant centres worldwide is the inadequate number of donor organs. In the United States alone, more than 17,000 patients are on the transplant waiting list, and the number of liver transplantations that are performed has been relatively constant at 5000/year for the past several years. Despite intensive efforts by the transplant community, the number of available cadaveric organs has remained static. This has occurred in the face of a steadily growing waiting list. Most reliable pharmacy offering efficient medications like birth control pills is ready to offer its services and all the help you need. Your health is precious, and so are you: as customer, person and patient, no matter which kind of treatment you are looking for.
In the United States, 8% to 10% of patients on the liver transplant waiting list die before an appropriate donor organ is available. Death is usually due to a complication of liver failure. Therefore, any decision to perform a transplant on certain patients earlier would further delay the procedure for other patients on the waiting list. It is likely that longer waiting times would result in additional complications and deaths among these patients.
Liver transplantation is a well-accepted treatment for patients with primary sclerosing cholangitis (PSC). It is clearly beneficial for patients who manifest end stage liver disease and hepatic synthetic dysfunction, and results in excellent short and long term survival rates. Most centres report one-year survival rates of 90% to 94% and five-year survival rates of 82% to 84%. One study showed that 70% of patients survived for at least ten years. Transplantation is also helpful for patients without liver failure who experience recurrent episodes of bacterial cholangitis and sepsis.
Unfortunately, PSC patients are at increased risk for the development of cholangiocarcinoma. This tumour can arise at any location in the biliary tree and is difficult to distinguish from the fibrotic biliary strictures that occur with the primary disease. Screening for the presence of cholangiocarcinoma with serologic and imaging studies yields many false positive and negative results. Thus, the tumour is often advanced at the time of diagnosis. Survival rates for patients with cholangiocarcinoma are poor, even with liver transplantation, and most centres regard it as an absolute contraindication for this procedure. Preliminary results from a small single centre study suggested that chemotherapy and radiation therapy may improve survival in selected patients. You will always be able to buy the required amount of medicine you need at this wonderful and fully licensed pharmacy that can take good care of you, no matter if you need birth control alesse at large amounts or just a bit of it to finish your treatment.
The poor prognosis of cholangiocarcinoma, which occurs in 10% to 20% of PSC patients, has led to attempts to improve the diagnostic and therapeutic modalities. Screening techniques, however, have done little to improve the outcome in these patients. One approach is to undertake liver transplantation early in the course of the disease to avert cholangiocarcinoma. Although this may seem to offer a simple solution to the problem, there are a number of reasons why this strategy is not feasible.
Gallbladder polyps are common in the adult population. The majority of PLG are cholesterol polyps; thus, most PLG have a low malignant potential. We suggest resection of polyps in patients with compatible symptoms, including biliary-type pain and dyspepsia. In addition, asymptomatic individuals older than 50 years of age or those whose polyps are solitary, greater than 10 mm in size, associated with gallstones, or growth on serial ultrasonography, should undergo resection (Table 2). The true malignant risk that is conferred by lesions being sessile or associated with wall thickening remains unclear. Further studies are necessary to define the impact of these possible risk factors before modification of the existing resection criteria should be considered. Furthermore, the role of novel diagnostic techniques, such as enhanced CT scanning, EUS and percutaneous fine needle aspiration, in assessing gallbladder polyps needs to be defined before their broad dissemination in the management of these lesions. Larger prospective studies of diagnosis and treatment must also be carried out in European and North American populations that have a lower risk of gallbladder cancer than most Asian countries because extrapolation of data from the latter may not be appropriate.
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Based on the available evidence, we agree with the recommendations of Boulton and Adams, with one exception (Figure 3). We suggest that the indications for resection in asymptomatic patients with small polyps (less than 10 mm in diameter) be expanded to include those with other features that increase the risk of malignancy. In addition to older age (over 50 years) and the presence of gallstones, additional high risk features include the presence of solitary polyps or polyp growth. The safety of laparoscopic cholecystectomy, as well as the dismal prognosis of gallbladder carcinoma discovered late in its course (less than 5% five-year survival for stage III and IV tumours), favour this approach. The roles of novel imaging and diagnostic techniques such as EUS, enhanced CT scanning and fine needle aspiration need to be further defined before their incorporation into the standard management of these lesions.
The management of patients with PLG requires the resolution of three key questions:
• Which patients with PLG should undergo resection?
• If a resection is planned, what is the optimal surgical approach?
• How often should lesions be monitored if surgical resection is deemed unnecessary?
In a recent review of the literature, Boulton and Adams suggested that all patients with gallbladder polyps who are symptomatic, have lesions greater than 10 mm in diameter or have complicating factors that increase the risk of malignancy (age over 50 years or concurrent gallstones) should undergo resection. According to Boulton and Adams, all others should be followed-up cautiously every three to six months with repeat abdominal ultrasounds. Generally, this seems to the consensus of several recent studies. These suggestions are based on the finding that most benign polyps are less than 10 mm in diameter, whereas malignant polyps usually exceed this diameter. Others recommend cholecystectomy for all patients with gallbladder polyps, independent of size or symptoms, while some suggest resection of small lesions (less than 10 mm in diameter) if the lesions are single, sessile, rapidly growing or associated with wall thickening, or if the patient is symptomatic or over the age of 60 years. This is your great chance – buy asthma inhalers to take full advantage of best quality drugs.
Computed tomography (CT) scanning can also aid in the diagnosis of gallbladder polyps. Unenhanced CT scans, however, can miss up to 60% of lesions that were initially visualized by ultrasound. A combined approach of unenhanced and enhanced CT scanning in the diagnosis of PLG has been reported to provide an overall sensitivity of 88%, a specificity of 87%, a positive predictive value of 88%, a negative predictive value of 87% and an overall accuracy of 87%. You can start online shopping right now – cialis canadian pharmacy for more advantages.
The ultrasonographic diagnosis of PLG requires the identification of hyperechoic material protruding into the gallbladder lumen (Figures 1 and 2). These echoes are characterized by the absence of shift with positional change; they may or may not cast an acoustic shadow. The sensitivity of ultrasound in detecting PLG ranges from 32% to 90%. Gallstones notoriously decrease ultrasound sensitivity; in patients without gallstones, the sensitivity approaches 99%. The specificity of ultrasound has been reported to be 94%. Other lesions, including sludge, chronic cholecystitis, heterotopic tissue, gallbladder carcinomas and metastatic disease, can be misdiagnosed as benign PLG. The correlation between ultrasonographic and pathological findings in the assessment of PLG has not been clearly defined. Some studies have found a poor correlation between ultrasound findings and pathology. Kubota et al reported accuracies of 89%, 57% and 72% for preoperative sonographic diagnoses of cholesterol polyps, adenomas and carcinomas, respectively, compared with histological findings. In one study of 34 patients who underwent a cholecystectomy for PLG, only 11 had macroscopic and histopatholog-ically proven PLG (thus, a sensitivity of 32%). The size of cholesterol polyps may also be overestimated by ultrasonography. Learn how to save money – buy glucophage to enjoy your shopping and your treatment.
Few studies have prospectively investigated the natural history of unresected gallbladder polyps. Eelkema et al reported no cases of gallbladder cancer in 113 patients fol-lowed-up for 15 years after the diagnosis of PLG on cholecystography. This study was limited, however, by the poor sensitivity of cholecystography in detecting PLG and, more importantly, by the loss to follow-up of half of the patients who were originally investigated. Moriguchi et al reported a similarly benign progression of gallbladder polyps. In that study, 109 patients with PLG were followed-up with serial ultrasounds every six to 12 months for at least five years. Gallbladder cancer was found in only one patient, but its location was different from that of the preexisting polyp. The size of most (84.5%) of the lesions did not change during the observation period. Only 16.7% of the largest lesions (those larger than 10 mm in diameter on the original ultrasound) enlarged. Shinkai and colleagues also reported no significant changes in the number or overall average size of cholesterol polyps in 60 patients followed-up sonographically for a mean of 22 months. During the follow-up period, nine patients underwent cholecystectomies; seven had histologically confirmed cholesterol polyps, one an adenoma and one a solitary dys-plastic lesion 2 mm in diameter. No patient developed adenocarcinoma of the gallbladder. A prospective German study, employing ultrasonographic examination of the gallbladder over a three-year period in 14,841 consecutive patients, revealed polypoid changes in 224 patients (1.5%). Of these, 95% were thought to be cholesterol polyps and the remainder were classified as benign lesions of uncertain etiology. During a short observation time of nine months, only 6.5% of the patients with cholesterol polyps had at least a 5 mm increase in the diameter of their polyps. A total of 21 patients suspected of having cholesterol polyps were operated on during this time. The diagnosis was confirmed in 17 patients; two had chronic cholecystitis and the remainder had other benign nonpoly-poid lesions. Of the 12 patients with benign polypoid lesions of uncertain etiology at the original ultrasonogram, six had cholecystectomies during the follow-up period. Surgical specimens revealed adenomas in two patients, gallbladder carcinoma in one, metastatic melanoma in one, ade-nomyomatosis in one and tissue heterotopy in one.
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A major concern in the management of the patient with PLG is the potential for malignant transformation, although the relationship between gallbladder polyps and cancer is controversial. Aldridge and Bismuth and others have argued that there is a polyp-cancer sequence, similar to that in the pathogenesis of colorectal carcinoma. Adenomatous polyps appear to have the highest risk of malignant transformation. In a study of 300 randomly selected gallbladders at cholecystectomy, 5% were found to harbour sessile adenomas. Furthermore, 19% of these cases exhibited small foci of moderate cellular atypia, and in 31% of these cases, carcinoembryonic antigen was positive. Kozuka et al reviewed the histology of 1605 resected gallbladders and found 11 benign adenomas, seven adenomas showing malignant change and 79 invasive carcinomas. Supporting evidence for an adenoma-adenocarci-noma sequence from this study included the correlation between the size of the lesion and malignant change, similar to that described in colorectal carcinoma, as well as the discovery of adenomatous components in all of the in situ carcinomas and 19% of the invasive carcinomas. There have also been several case reports of gallbladder polyps developing into gallbladder cancer, and adenomatous polyps containing carcinoma in situ. Further, patients with gastrointestinal polyp syndromes have been reported to develop gallbladder polyps and adenocarcinoma. Although gallbladder adenomas appear to carry the highest malignant potential, other seemingly innocent lesions have been reported to undergo malignant transformation. For example, adenomyomatosis of the gallbladder, which is extension of the mucosa into and through a thickened muscular wall, has historically been considered to be an innocuous lesion. Recently, however, several cases of gallbladder cancer have been described in areas of adenomyomatosis. Similarly, carcinoma in situ has been reported to occur in patients with cholesterol polyps. You can be sure your pharmacy offers *cheap viagra online delivering fast internationally.
Several other reports support the importance of polyp size in differentiating benign from malignant lesions. Koga et al reported a retrospective study of 411 patients who had undergone cholecystectomy; 32 patients had benign polyps and eight patients had malignancies. In that study, 94% of the benign PLG were less than 10 mm in diameter, whereas 88% of the cancers exceeded this diameter. Similarly, in 72 patients who had undergone resective surgery for PLG, Kubota and colleagues reported that 61% of benign lesions were less than 10 mm in diameter compared with only 12% of cancers. The size of carcinomatous PLG also appears to correlate with the extent of tumour invasion.
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