Faculty Bibliography

More commonly found in newborns, annular pancreas is associated with abnormal development resulting in a ring of pancreatic tissue around the duodenum. This is a case of a variant of annular pancreas presenting in adulthood. The patient is a forty-year old female with persistent abdominal pain for three months. Previous evaluation was suggestive for a thick-walled paraduodenal mass thought to be a duplication cyst. Her surgical history was significant for exploratory laparotomy for perforated gastric ulcers as an infant. Initially, her pain would resolve after percutaneous aspiration of the cyst and a course of antibiotics. Symptoms recurred, with pain persisting despite analgesics and operative resection of the mass was planned. During laparoscopy, this cystic mass appeared to be contiguous with the stomach as well as a segment of pancreatic tissue that was inflamed. This segment appeared to arise from the ventral pancreatic gland and traverse anteriorly towards the proximal duodenum. Unlike the classic annular pancreas, it did not encircle the duodenum, but instead, ended in a thick-walled cyst that appeared contiguous with the stomach. Intraoperative endoscopy, however, showed no luminal communication between the cyst and the stomach. Preoperative imaging did not show any communication with the main pancreatic duct. The cyst and aberrant pancreatic segment were dissected free from the duodenum and normal pancreas, and transected from the normal pancreatic body with a vascular load stapler. The cyst was incised and turbid fluid was released. Pathology was consistent with a thick-walled cyst between gastric and pancreatic tissue, with an aberrant relationship between the stomach and pancreas. The ectopic annular pancreas and pseudocyst are likely congenital and perhaps, provide a better explanation for the patient's laparotomy during infancy than perforated gastric ulcers. This is a unique presentation of an aberrant annular pancreas with a pseudocyst in an adult

Background: Healthcare disparities associated with insurance and socioeconomic status have been well characterized for several malignancies, such as lung cancer. To assess whether there are healthcare disparities in thyroid cancer, this study evaluated the stage on initial presentation of patients with differentiated thyroid cancer (DTC) in a public versus university teaching hospital. Methods: A retrospective chart review was performed to identify patients with a new diagnosis of DTC from January 1, 2007, to January 1, 2010, in a large public and adjoining university teaching hospital at a single academic medical center. Medical records were reviewed for demographics, pathology, and American Joint Committee on Cancer tumor-node-metastasis stage at initial presentation. Results: There were 49 cases of well-DTC (96% papillary and 4% Hurthle) in the public hospital and 370 cases (95% papillary, 2% Hurthle, and 3% follicular) in the university teaching hospital. Median age (years) at presentation was 50 in the public versus 48 in the university teaching hospital (p=0.39). Ninety-six percent of public hospital patients were from ethnic minorities compared with 16% of university teaching hospital patients (p<0.0001). Only 1 (2%) public hospital patient had private insurance compared with 85% of university teaching hospital patients. Tumor status (p=0.002) and stage (p=0.03) were more advanced and extrathyroidal extension (p=0.02) was more prevalent among public hospital patients compared with university teaching hospital patients. In a multivariable analysis, public hospital, male gender, increasing age, advanced tumor status, and the presence of lymphovascular invasion were the best predictors of more advanced disease stage. Public hospital patients were 3.4 times more likely to present with advanced DTC than university teaching hospital patients of the same age, gender, tumor status, and lymphovascular invasion status (95% confidence interval 1.29-8.95). Conclusions: In a public hospital, where the patient population is defined primarily by insurance status, patients were more likely to present with advanced-stage DTC than patients presenting to an adjacent university teaching hospital. These results suggest a disparity in the stage on initial presentation of DTC, possibly resulting in a delayed diagnosis of cancer.