Carcinoid of the gallbladder. A report of a clinical case treated by video laparoscopic cholecystectomy

The authors report a clinical case of the gallbladder carcinoid tumour treated with laparoscopic cholecystectomy. After a short analysis of the classification, the malignant potentiality and the symptoms of gallbladder carcinoids, they conclude that it is possible to treat carcinoids with laparoscopic cholecystectomy, but only in some selected cases, that is to say in the absence of factors indicative of local invasion and that in the other cases it is preferable the classic surgical treatment of laparotomic resection.     

Porcelain gallbladder associated with primary biliary adenocarcinoma in a dog

A 9-year-old spayed female Poodle was admitted because of vomiting of 3 weeks' duration, lethargy, and anorexia. Palpation of the cranial portion of the abdomen elicited signs of pain. Principal laboratory abnormalities included mild segmented neutrophilia, lymphopenia, high serum alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase activities, and hyperbilirubinemia. Radiography revealed foamy appearing areas of mineral opacity in the region of the gallbladder. Ultrasonographically, a hyperechoic structure with acoustic shadowing was seen in the same region, and extrahepatic bile ducts were distended. Cholecystectomy was performed. The gallbladder wall felt thicker than normal and was bluish-white. Multiple choleliths were found in the gallbladder and extrahepatic bile ducts. Histologic examination revealed chronic proliferative lymphoplasmacytic cholecystitis with mineralization and a well-differentiated adenocarcinoma of the gallbladder neck. A diagnosis of porcelain gallbladder was made. The dog recovered without complications and was healthy 14 months after surgery. To our knowledge, porcelain gallbladder has not been reported in dogs. In human patients, it is defined as intramural mineralization of the gallbladder commonly associated with gallbladder neoplasia. Early recognition is important for appropriate surgical treatment.     

Primary biliary cirrhosis associated with mixed type autoimmune hemolytic anemia and sicca syndrome: a case report and review of literature

A case presenting with an unusual association of primary biliary cirrhosis and mixed type autoimmune hemolytic anemia plus sicca syndrome is described. The 49-yr-old female primary biliary cirrhosis patient had a confirmed sicca syndrome and presented with jaundice and life-threatening anemia. Laboratory tests revealed positive Coombs' test with coexisting cold and warm autoantibodies. She was successfully treated by blood transfusion with packed red cells lacking any red cell antigens corresponding to serum alloantibodies and pulse methylprednisolone therapy. The patient remained stable under maintenance treatment using oral steroids and ursodeoxycholic acid. This case is probably the first reported showing an association between primary biliary cirrhosis and mixed type autoimmune hemolytic anemia plus sicca syndrome and was probably induced by heterogenous and complicated autoimmune reactions.     

Megaesophagus and pneumonia associated with Mycobacterium chelonei. A case report and a literature review

The case of a 37-year-old woman who developed a subacute, bilateral, noncavitary pneumonia 5 years after a colon interposition esophagoplasty is presented. Mycobacterium chelonei, subspecies abscessus, was assigned a pathogenic role based on the findings of (1) a clinical and roentgenographic picture consistent with tuberculosis, (2) sputum smears showing acid-fast bacilli, (3) repeated sputum cultures yielding heavy growths of Mycobacterium chelonei, subspecies abscessus, and (4) a 12-mm by 12 mm-skin test response to homologous antigen (purified protein derivative-CL) with no response to an equivalent dose of purified protein derivative-S. The patient recovered fully without significant antituberculous chemotherapy. A survey of the literature revealed 11 similar case reports featuring a documented association between megaesophagus and pulmonary infection with rapidly growing mycobacteria.     

Specific respiratory manifestations associated with hemorrhagic rectocolitis. Analysis of a case and review of the literature

In a 59-year-old woman suffering from the syndrome of inappropriate antidiuretic hormone secretion, a small cell carcinoma of the uterine cervix was detected. The tumor was immunoreactive for antidiuretic hormone as well as for neuron specific enolase, chromogranin A, and Leu-7, but not vimentin. Electron microscopic examination of the tumor revealed neurosecretory granules. To our knowledge, this is only the second report of the syndrome of inappropriate antidiuretic hormone secretion with small cell carcinoma of the uterine cervix and the first one confirmed immunohistopathologically.     

Treatment of lithiasis of the common bile duct by endoscopic sphincterotomy and laparoscopic cholecystectomy

This paper describes the ongoing development of a region-wide system for monitoring the short-term outcomes of total knee replacement surgery. The system aims to collect data from a dozen hospitals, and relies on a close collaboration with locally based surgeons and medical audit staff. The intention is to provide routine comparative information based on a broad conception of outcome, that includes both clinical/technical measures and patient-derived assessments of general health status. These data may be reported in the context of relatively detailed case mix information. To date, both data capture and clinical support for the project have been good. Example reports are presented together with a discussion of current limitations and possible future developments.     

Urgent ERCP and early elective laparoscopic cholecystectomy in biliary pancreatitis

BACKGROUND: For many years the best algorithm of treatment for complicated gallstone disease has been intensively discussed. Gallstone pancreatitis with cholangitis still belongs to the most often identified causes of death of necrotizing pancreatitis. The reduction of complication and lethality rates was mainly achieved by urgent ERCP and sequential cholecystectomy. In a prospective study we have combined endoscopic therapy with laparoscopic cholecystectomy (LC) and are discussing the results. PATIENTS AND METHODS: Between May 1991 and December 1996 146 patients with biliary pancreatitis were subjected to ERCP after laboratory tests and ultrasound screening of the biliary system. If there were no contraindications and the gallbladder was still in situ, LC was attempted during the initial admission. RESULTS: Of the 70 patients with attempted LC 26 had common bile duct calculi, 23 had an impacted papillary stone and 10 had signs of a stone passage. 59 patients underwent LC successfully, a conversion to open surgery was necessary in 11 patients. The morbidity rate amounted to 7%, lethality to 0%. DISCUSSION: Since a more liberal indication for ERCP in the management of acute pancreatitis was introduced the number of biliary related cases of acute pancreatitis is increasing. In response to early endoscopic bile duct clearance the rates of morbidity and mortality can be significantly reduced. Early LC is the ideal complementary treatment option to absolutely prevent recurrencies.     

The value of laparoscopic cholecystectomy in the treatment of gallbladder pathologies]

We have prospectively studied all cholecystectomies performed in one year in our clinic in two groups: 190 cases performed laparoscopically and 98 open. We used standardized records and the EPI 5 program on an IBM compatible computer. There were no significant differences between groups regarding weight, sex and proportion of cases with acute cholecystitis. There were however major differences regarding age, type of habitat, ASA score and association with acute pancreatitis, obstructive jaundice and angiocholitis. Conversion of laparoscopic cholecystectomy to open procedure was imposed in 17 cases (not included in statistical analysis) due to technical difficulties (12 cases), haemorrhagic accidents (6 cases), injury of the common bile duct (1 case), stones lost in the abdominal cavity (3 cases), local peritonitis (5 cases). Laparoscopic cholecystectomy lasted a mean of 74 minutes. We encountered 3 specific complications: one CBD injury recognized intraoperatively and managed by Kehr's procedure (one CBD injury in the open cholecystectomy group), one small bowel perforation and one of biloma. Mortality averaged 0.5% in the LC group (one case of late postoperative stroke considered not related to the procedure) and 1% in the open cholecystectomy group. The hospital admission period was significantly reduced in the LC group (5 days vs. 12 days). LC appears as a safe procedure with a low complication rate. Conversion to open procedure is not a complication. Our study recommend LC as the method of choice in the treatment of gallbladder lithiasis.     

Cutaneous metastatic adenocarcinoma of gallbladder origin: report of a case and review of the literature

In the English literature, there have only been seven reports of metastasis from cancer of the gallbladder to the skin. This is the report of a 75-year-old woman who developed cutaneous metastasis from an adenocarcinoma of the gallbladder which was confirmed histologically. We report the uncommon metastatic potential of gallbladder carcinoma to the skin.     

Hepatocellular carcinoma in primary biliary cirrhosis: a case report and review of the Japanese literature

We present a 66 year-old woman in the cirrhotic stage of primary biliary cirrhosis (PBC), who developed hepatocellular carcinoma (HCC). All serological tests for hepatitis B virus (HBV) and hepatitis C virus (HCV) were negative. We surveyed 16 reported cases (13 females and 3 males) of PBC associated with HCC in Japan. The presence of HCV RNA was determined by the polymerase chain reaction in all of the patients, 3 of whom (19%) were HCV RNA-positive. Although patients with PBC rarely develop HCC, it is suggested that HCV infection may play a minor role in the development of HCC in Japanese patients with PBC.     

Onychomycosis associated with Onychocola canadensis: ten case reports and a review of the literature

BACKGROUND: Onychocola canadensis is a nondermatophyte mold associated with onychomycosis particularly in temperate climates (eg, Canada, New Zealand, and France). The slow growth rate of O canadensis and lack of resemblance to any other known nail-infecting fungus may have delayed its discovery. We are aware of 23 mycologically confirmed cases of O canadensis in the literature. OBJECTIVE: We describe 10 previously unreported Canadian patients, specimens from whom grew O canadensis. We also review the literature on infections associated with this organism. METHODS: Cases of O canadensis onychomycosis were diagnosed on the basis of (1) the finding of compatible filaments on direct microscopy of nail and (2) consistent culture from repeated specimens. All patients from whom O canadensis was isolated were followed up, but those in whom outgrowth was not consistent were not accepted as having "authentic" infections. RESULTS: In 10 patients O canadensis was found to be associated with distal lateral subungual onychomycosis (6 patients), white superficial onychomycosis (1 patient), and as an insignificant contaminant in the nails of 3 patients. Less commonly the organism may cause tinea manuum or tinea pedis interdigitalis. O canadensis appears to be more frequent in the elderly, especially females. It is not unusual for a patient with onychomycosis caused by O canadensis to be a gardener or farmer, suggesting that the infectious inoculum may originate from the soil. The optimal therapy for onychomycosis caused by this organism remains unclear. CONCLUSION: O canadensis may be the etiologic agent of distal and lateral subungual or white superficial onychomycosis; however, it may sometimes be present in an abnormal-appearing nail as an insignificant finding, not acting as a pathogen.     

Hepatitis associated with terbinafine therapy: three case reports and a review of the literature

Single-rooted premolar teeth, stained with blood utilizing the technique devised by Freccia & Peters (1981), were subjected to traditional and non-peroxide bleaching agents. Colour changes were recorded over a period of 7 days using a Speedmaster R75-CP Reflection Densitometer. The most efficient removal of staining occurred after the application of 30% hydrogen peroxide, with sodium perborate being 75% as effective. All bleaching agents realized their optimum efficacy within the first 3 days. A combination of three enzymes (amylase, lipase and trypsin) with disodium edetate was not as effective as the routine bleaching agents; however, the combination did have a modifying effect on the blood stains. It is suggested that other non-peroxide agents should be investigated to determine their efficacy in removing staining from experimentally induced blood-stained teeth.     

Episodic pain associated with a tumor in the parietal operculum: a case report and literature review

We report a young woman suffering brief painful episodes in her right arm which sometimes spread to the whole right side of her body. The episodes were initially rare, but over 13 months they became increasingly frequent until occurring every 20 min. Neurological examination was normal. Magnetic resonance imaging revealed a lesion in the white matter of the parietal operculum. Lesions in the parietal operculum associated with persisting thalamic pain or loss of pain sensation have been reported, but rarely with episodic pain. Since episodic painful attacks have been described in association with various suprathalamic lesions, we conclude that paroxysmal pain attacks may be another consequence of the disturbance of the normal pattern of thalamocortical connections to the second sensory cortical area by a lesion, in our case, of the subcortical area of the parietal operculum.     

Wilms tumor associated with polycythemia: case report and review of the literature

A 13 year review of patients diagnosed to have Ludwig's angina admitted to the Christian Medical College and Hospital, Vellore, India, between March 1982 and April 1995 is presented. The patients were either admitted to the ENT or paediatric surgical units. There were 41 patients, 24% being children and 76% adults. The clinical profile and outcome of these two groups were compared. In the paediatric group, none had dental caries while in the adult group, 52% had associated dental caries. In children, 70% were controlled with conservative medical management unlike the adults of whom 81% needed incision and drainage. Tracheostomy was necessary in 10% of the children and in 52% of the adults. The mortality was 10% in both groups.     

Acquired Glanzmann's thrombasthenia associated with Hodgkin's lymphoma: a case report and review of the literature

BACKGROUND: Acquired Glanzmann's thrombasthenia is a rare hemorrhagic diathesis resulting from impaired adhesive function of the platelet receptor GPIIb/IIIa (alpha(IIb)beta3). Typically, this disorder develops during adulthood, with patients manifesting fluctuating clinical and laboratory findings. To date, the underlying defect of most if not all cases of acquired Glanzmann's thrombasthenia results from an autoantibody or plasma protein inhibitor directed toward a demonstrably normal GPIIb/IIIa glycoprotein. METHODS: In this report, a patient with a history of treated Hodgkin's lymphoma presented with a severe hemorrhagic diathesis characterized by mild thrombocytopenia, a prolonged bleeding time, and defective platelet aggregation. RESULTS: Examination of the patient's platelet GPIIb/IIIa by Western blot analysis revealed no abnormality. Mixing studies demonstrated a non-immunoglobulin G plasma inhibitory factor, whereas flow cytometry analysis revealed elevated platelet-associated immunoglobulin (Ig) M. After an emergency colectomy for severe hemorrhage, the patient's qualitative and quantitative platelet parameters significantly improved. Pathology of the resected colonic segment demonstrated atypical lymphoid hyperplastic lesions. CONCLUSIONS: To the authors' knowledge, this is the first reported case of acquired Glanzmann's thrombasthenia associated with a putative IgM autoantibody. Furthermore, this report verifies the association of acquired thrombasthenia with lymphoproliferative disease. Although rare, awareness of this hemorrhagic diathesis as a possible sequelae of active or treated lymphoid disorders should encourage clinical vigilance of these patients.     

Standard means in laparoscopic surgery. The peculiar case of cholecystectomy

Legal suits against visceral surgeons have increased since the advent of laparoscopic surgery. The duties of physicians have not however changed with the development of laparoscopic techniques. Since the decree promulgated in 1936, physicians have a legal commitment to provide the means required for patient care. This obligation has been recalled in different court judgements and in the new deontology code. In addition, jurisprudence tends more and more towards responsibility without risk. Laparoscopic cholecystectomy is not risk-free. Although morbidity and mortality have not risen with laparoscopic procedures, the types of complications encountered have changed. Reported accidents have become more frequent. The number of suits against surgeons has also increased. Surgeons must therefore be highly prudent and diligent. Precautions concerning personnel management, the choice of material and its upkeep. Special care must be given to the peroperative pneumoperitoneum and the use of monopolar electrocoagulation. A peroperative cholangiogram should be obtained. A careful operative report is very important. The surgeon must be able to justify his competence. Finally, the surgical community should publish more results concerning the rate of complications in order to establish reference material for experts.