Laparoscopic cholecystectomy in a patient with situs inversus using ultrasonically activated coagulating scissors. Report of a case and review of the literature

Situs inversus totalis is a rare defect with a genetic predisposition, which can present difficulties in the management of abdominal pathology, especially in laparoscopic surgery, due to the mirror-image anatomy. Herein, we report on a patient with situs inversus totalis and symptomatic cholelithiasis. The patient had a successful laparoscopic cholecystectomy, using ultrasonically activated coagulating scissors. Diagnostic pitfalls and technical details of the laparoscopic cholecystectomy are discussed and a review of the relevant literature is presented.

Phenytoin-induced lymphocytic chemotaxis, angiogenesis and accelerated healing of decubitus ulcer in a patient with stroke

We studied the effect of topically applied phenytoin on the healing of a decubitus ulcer in the sacral region of an immobile patient with stroke. Another similar, but smaller, ulcer was treated with conventional treatment only and served as a control. The ulcers were measured once a week and biopsies were taken from the margins before, 1 week and 2 weeks after commencing treatment with phenytoin. Clinically, phenytoin substantially accelerated the rate of healing. Microscopic examination of the biopsies showed increased lymphocytic infiltration of the phenytoin-treated lesion. Anti-CD31 immunohistochemistry revealed dense CD31+ lymphocytic infiltration and increased angiogenesis only in the phenytoin-treated lesion. Our findings suggest that phenytoin enhances wound healing by stimulating lymphocytic chemotaxis and up-regulation of angiogenesis.

Predictive Value of Risk Factors in Patients with Obstructive Jaundice

Clinical and laboratory parameters that may affect post-operative mortality and morbidity were studied in 215 patients operated on for obstructive jaundice. The cause of the bile duct obstruction was benign disease in 56.7% of patients and malignant disease in 43.3%. Overall postoperative mortality and morbidity rates were 21.9% and 33.5%, respectively. Eight risk factors were shown to be associated with increased mortality: age < 70 years; malignancy; leucocytosis < 15 000 cells/μl and fever < 38.5°C; haematocrit ≤ 30%; creatinine < 1.3 mg/dl; albumin ≤ 3 g/dl; bilirubin < 20 mg/dl; and serum alkaline phosphatase > 100 IU/l. The simultaneous presence of less than three risk factors was always associated with post-operative survival, but concomitant existence of seven or more risk factors indicated 100% mortality. Understanding the factors related to post-operative morbidity and mortality in patients with obstructive jaundice will better guide appropriate surgical or non-surgical management and lead to improved survival.

Mucocele of the appendix: a report of five cases

Mucocele of the appendix is an uncommon disorder, characterized by a cystic dilatation of the lumen. It is often diagnosed clinically from signs and symptoms of acute appendicitis or, if it is asymptomatic, as an incidental finding during ultrasonography, computed tomography, and radiographic examinations of the gastrointestinal tract, or laparotomy. The incidence of mucocele ranges from 0.2% to 0.3% of all appendectomy specimens. We report five cases of appendiceal mucocele (all women, aged 19-90 years), who were admitted from January 1993 to January 2003 to our hospital. These cases represent 0.29% of the 1720 appendectomies performed during this period. Three of the patients were symptomatic and had appendectomies. The final diagnosis for mucocele was given at laparotomy. No colon neoplasms were identified during surgery, and subsequent colonoscopic examinations were also negative. The other two patients were asymptomatic of appendiceal tumor. Colonoscopy revealed two colonic malignant tumors in one patient and an adenocarcinoma of the sigmoid colon in the other. Mucocele of the appendix was diagnosed pre-operatively by ultrasound and computed tomography. One of the two patients underwent a right hemicolectomy and sigmoidectomy; the other one underwent an appendectomy, cecostomy and sigmoidectomy. Four of the patients recovered and are doing well today; one patient died on the twenty-fifth postoperative day. The most common symptom of mucocele is abdominal pain, although many patients may be asymptomatic. Mucocele is often associated with concomitant colon cancer, thus patients with this tumor should be systematically checked for other colonic lesions.

Intussusception of the small bowel due to Peutz-Jeghers syndrome: a case report

The Peutz-Jeghers syndrome is an autosomal dominant disorder characterized by hamartomatous polyposis of the gastrointestinal tract, melanin pigmentation of the skin and mucous membranes, and an increased risk for cancer. The incidence of surgical complications in these patients is relatively rare, and correlates with the size and location of the polyps. Herein we report the case of a 27-year-old woman presented with episodes of abdominal pain, abdominal distention and intermittent vomiting. Moreover, multiple pigmentation of the mouth was also noted. A preoperative diagnosis of a double jejunal intussusception and jejunal occlusion was based on the findings of small bowel enema and computed tomography. The diagnosis was confirmed at laparotomy.

Endotoxinemia in the portal and the systemic circulation in obstructive jaundice

Endotoxinemia in patients with obstructive jaundice is linked to acute renal failure and sepsis and remains a major cause of complications during postoperative treatment. The current study examines the mechanisms of endotoxinemia in the portal and the systemic circulation in obstructive jaundice. As an experimental model of the disease we used rabbits subjected to sham operation. Serum total bilirubin aminotransferases and endotoxin concentrations were determined at 2, 5, 8, and 13 days after operation. Endotoxin concentrations were estimated by the limulus lysate endotoxin test. A high frequency of portal or systemic endotoxinemia is observed in obstructive jaundice, but no difference between endotoxinemia levels in the portal and systemic circulation was observed.

Phytobezoars as a cause of small bowel obstruction associated with a carcinoid tumor of the ileocecal area: Report of a case

Background: Carcinoid tumors are slowly growing malignant neoplasms associated with an indolent clinical course. About 60% of such tumors are located within the gastrointestinal tract. Case Report: We describe an unusual case of small bowel obstruction associated with of a carcinoid tumor of the ileum. A 70-year-old woman was presented with abdominal pain, vomiting, and clinical signs of mechanical bowel obstruction. X-ray and CT-scan of the abdomen showed hydroaeric levels and the presence of intraluminal hyper-dense ?stones?, presumably of gallbladder origin. A diagnostic laparotomy revealed that a large part of the final ileus was edematous, with prominent evidence of intestinal loop adhesions. The edematous part of the ileum was resected. Incision of the intestinal wall revealed a 2-cm soft mass at 8 cm from the ileocecal valve, where the presence of ten fruit pits obstructed the intestinal cavity. Histopathological examination confirmed the diagnosis of a carcinoid tumor. Conclusion: An interesting case of small-bowel obstruction with a double cause is presented: an ileal carcinoid and fruit pit bezoars. The pathophysiology of the obstruction is discussed.

Serum levels of tumor necrosis factor-alpha and nutritional status in pancreatic cancer patients

BACKGROUND

Tumour necrosis factor-alpha (TNF-alpha) is a multifunctional cytokine associated with cancer-related cachexia. In this study we evaluated serum levels of TNF-alpha in pancreatic cancer patients and investigated their relationships to cachexia.

PATIENTS AND METHODS

Serum TNF-alpha levels were determined in 63 patients with pancreatic cancer using an enzyme immunoassay specific for human TNF-alpha.

RESULTS

Serum TNF-alpha levels were detected in 36.5% of patients. Patients with metastatic disease showed significantly higher positive serum TNF-alpha rate compared to those with non-metastatic disease. Patients with detectable serum TNF-alpha levels had significantly lower body weight and body mass index, lower haematocrit and haemoglobin values, and lower serum total protein and albumin levels compared to those with undetectable TNF-alpha levels. Serum TNF-alpha levels were inversely correlated with body weight, body mass index, haematocrit, haemoglobin, and serum protein and albumin levels.

CONCLUSIONS

TNF-alpha levels are detectable in the serum of pancreatic cancer patients, particularly in those with advanced disease, and these levels correlate with poor nutritional status.