Triple cancer of gallbladder, common bile duct and papilla of Vater: Report of a case and review of literature

INTRODUCTION AND IMPORTANCE

Synchronous malignancies of gallbladder and biliary tree are together rare entity whose pathogenesis is yet unknown. We report the case of a triple synchronous cancer of 3 distinct location: gallbladder, common bile duct (CBD) and papilla of Vater.

CASE PRESENTATION

An 84-years-old woman, was admitted to our Hospital with clinics features of obstructive jaundice. Dilatation of the biliary tree and CBD without evidence of gallstones was seen at US. CT scan confirmed distal CBD obstruction. An endo-US showed a nodule of the head of pancreas infiltrating the lower CBD. Finally, hepatic-MRI displayed a gallbladder malignancy with invasion of CBD. Preoperative staging showed 3 diagnostic suspicions: carcinoma of CBD on CT, pancreatic carcinoma on endo-US and malignancy of gallbladder on MRI. A cephalic duodenopancreatectomy and radical gallbladder resection was performed. Final pathology revealed 3 distinct location of moderately differentiated adenocarcinomas: Gallbladder, CBD and Vater's papilla. Microscopic examination didn't detect any direct continuity between the 3 tumors. Metastases were identified in the pancreaticoduodenal, peri-hepatic and peri-gastric lymph nodes.

CLINICAL DISCUSSION

Literature displayed 22 cases of synchronous malignancies of gallbladder and CBD and 1 case of triple cancer with associated Vater's papilla carcinoma. In most of these cases, an association with an anomalous pancreatic-bile duct junction was reported. Although the real incidence remain unknown, it was reported to occur in 5-10% of CBD cancers.

CONCLUSION

Suspicion of such combination of cancer should be remembered, especially when preoperative investigations don't allow a precise localization of tumor in the biliary tree.

Increased incidence of complicated acute appendicitis after the first COVID-19 pandemic peak: Have patients a different attitude towards COVID-hospitals?

Objective

The 11 March 2020 the World Health Organisation considered the COVID-19 Infection a pandemic disease. Between March and May 2020, the region of southern Switzerland was affected by the first pandemic peak, which was managed by dividing hospitals in Covid and non Covid facilities and by reducing elective surgery. At the end of the pandemic peak hospitals returned to their original structure but there was concern as to possible avoidance of former COVID facilities by patients because of fear of contracting of COVID-19 infection. For acute situations such as acute appendicitis, this could imply a delay of treatment. The aim of this retrospective study is to analyse the increment in incidence of complicated appendicitis in the post-pandemic period at our institution.

Methods

Clinical data of patients who underwent appendectomies in the period before and after the COVID-19 pandemic were analysed and compared. Diagnosis was based histopathological examination and/or on intra-operative or CT findings. Complicated appendicitis was defined as the presence of perforated or gangrenous appendicitis on histopathology or the presence of an abscess on CT scan. The incidence of complicated appendicitis, the time between onset of symptoms and patient admission (TOSA), the initial inflammatory blood tests and the complication rate was compared between the two periods.

Results

79 patients were included in the study, 31 in the post-COVID-19 peak group (A), April - October 2020, and 48 in the pre-pandemic group (B), April - October 2019. Incidence of complicated appendicitis was significantly higher in group A (55% vs 14% p = 0.02). These findings correlate with a greater TOSA (mean time 35 hours vs 17 hours, p = 0.01) and higher inflammatory values in the initial blood test, (mean WBC count 14.8 G/l vs 12.9 G/l, p = 0.08 and mean CRP value 73 mg/l vs 43 mg/l, p = 0.01) in group A.

Conclusion

Our data show a clear increase of incidence of complicated acute appendicitis after the pandemic peak in our hospital. Indeed patients tended to wait longer to visit our emergency department after the pandemic peak. One explanation is a possible fear by the patients of contracting COVID-19 infection in a former COVID hospital. Management of surgical emergencies during and after a pandemic peak phase should take into account the fact that patients may wait longer to visit a doctor thus aggravating the degree of their disease.

An aberrant right hepatic artery arising from the gastroduodenal artery: a pitfall encountered during pancreaticoduodenectomy

PURPOSE

Among the variations of the right hepatic artery (RHA), the identification of an aberrant RHA arising from the gastroduodenal artery (GDA) is vital for avoiding damage to the RHA during surgery, since ligation of the GDA is necessary during pancreaticoduodenectomy (PD). However, this variation is not frequently reported. The purpose of this study was to focus on an aberrant RHA arising from the GDA, which was not noted in the classifications reported by Michels and Hiatt.

METHODS

A total of 574 patients undergoing a PD between Jan 2001 and Dec 2015 at a tertiary care hospital in Switzerland (n = 366) and between Jan 2009 and May 2015 at a hospital in Japan (n = 208) were included in the analysis. Of these, preoperative CT angiography or/and MRI angiography findings were available for 532 patients. We retrospectively analyzed the hepatic artery variations, patient demographics, and surgical outcomes.

RESULTS

Among the 532 patients who received a PD, an RHA originating from the GDA was observed in 19 cases (3.5%). Eleven patients (2.1%) had both an aberrant RHA and an aberrant left hepatic artery (LHA) (Hiatt Type 4). Six patients (1.2%) had a replaced CHA arising from the SMA (Hiatt Type 5). We could, therefore, correctly identify the aberration in all cases.

CONCLUSIONS

We observed rarely reported but important aberrant RHA variations arising from the GDA. To prevent injury during PD in patients with this type of aberrant RHA, intensive preparations using CT and/or MRI imaging before surgery and intraoperative liver Doppler ultrasonography are considered to be essential.

Laparoscopic treatment of an infected urachalcyst and diverticulum in a young adult: Presentation of a case and review of the literature

INTRODUCTION

A urachal remnant is a rare anomaly in adults, with a heterogeneous presentation. We report a case of an infected urachal cyst associated with a urachal diverticulum.

PRESENTATION OF CASE

We report the case of a 16-year-old male who presented to our hospital with lower abdominal pain without any other signs of general infection. A physical examination revealed umbilical erythema with associated tenderness. All laboratory tests were normal. An ultrasound scan revealed an urachal cyst near the umbilicus and a second cyst near the bladder dome. We decided on a staged treatment with antibiotic administration followed by surgical excision of the urachus during laparoscopy. The patient was discharged on day 10 without complications. Pathology revealed chronic inflammatory tissue without signs of malignancy.

DISCUSSION

Urachus is a fibrous remnant of the allantois that progressively obliterates after birth, forming the median umbilical ligament. Incomplete regression of the urachal lumen results in several anomalies. These anomalies require treatment when discovered because of an increased risk of infection and neoplastic differentiation. A urachal cyst is the most common type of anomaly, and infection is the usual mode of presentation. Surgical intervention with complete excision of the urachus is the treatment of choice. A staged approach with antibiotic administration followed by surgery is recommended if signs of infection are present.

CONCLUSION

Urachal anomalies in adulthood are rare, with a nonspecific presentation. However, identifying a urachal anomaly is important because of the increased risk for infection and neoplastic differentiation. The laparoscopic approach is safe and patients recover rapidly.

A giant adrenal pseudocyst mimicking an adrenal cancer: case report and review of the literature

Adrenal pseudocysts are rare lesions that develop within the adrenal glands, generally from vessel ectasia or from degenerative adenomas or hematomas. They are usually non-functional and asymptomatic. The reported potential malignant transformation of an adrenal cyst is ca. 7% and indicates radical excision of these masses. We report the case of a 69-year-old man with hypertension, chronic obstructive pulmonary disease, and obesity in whom microscopic hematuria was detected during a routine examination performed by his family doctor. To investigate the cause of this microscopic hematuria, the patient underwent computed tomography of the abdomen, which showed a well-defined 12-cm lesion of the left adrenal gland with calcification and necrotic components that was compressing the left kidney, pancreas, and spleen. Suspecting adrenal carcinoma, after preoperative staging, a left subcostal laparotomy was performed, with resection of the left adrenal gland, a splenectomy, and resection of the pancreatic tail. The histology showed an adrenal pseudocyst with a fibrous capsule containing amorphous eosinophilic material with calcification and cholesterol crystals. The patient's postoperative course was uneventful, and he was discharged 12 days after surgery.

Perseverations and non-verbal confabulations on the Rey-Osterrieth Complex Figure Test in a fronto-temporal dementia single case study

We describe the case of a patient with late onset fronto-temporal dementia (FTD), who presented with typical personality changes, but also perseverative and confabulatory behaviors while performing the Rey-Osterrieth Complex Figure Test. We hypothesize that the progressive atrophy of orbitobasal, medial, and dorsolateral frontal cortices may give rise to both confabulations and perseverations in the non-verbal domain. In agreement with previous studies, reporting atypical profiles, this case report underlines the clinical heterogeneity of FTD. Authors declare that they have no conflicts of interest.