Ileal duplication mimicking intestinal intussusception:A congenital condition rarely reported in adult

Intestinal duplication is an uncommon congenital condition in young adults.A 25-year-old man complained of chronic,intermittent abdominal pain for 3 years following previous appendectomy for the treatment of suspected appendicitis.Abdominal discomfort and pain,suggestive of intestinal obstruction,recurred after operation.A tubular mass was palpable in the right lower quadrant.Computed tomography enterography scan identified suspicious intestinal intussusception,while Tc-99m pertechnetate scintigraphy revealed a cluster of strip-like abnormal radioactivity in the right lower quadrant.On exploratory laparotomy,a tubular-shaped ileal duplication cyst was found arising from the mesenteric margin of the native ileal segment located 15 cm proximal to the ileocecal valve.Ileectomy was performed along with the removal of the duplication disease,and the end-to-end anastomosis was done to restore the gastrointestinal tract continuity.Pathological examination showed ileal duplication with ectopic gastric mucosa.The patient experienced an eventless postoperative recovery and remained asymptomatic within 2 years of postoperative follow-up.

Application of laparoscopic surgery in gallbladder carcinoma

Gallbladder carcinoma(GC)is a rare type of cancer of the digestive system,with an incidence that varies by region.Surgery plays a primary role in the comprehensive treatment of GC and is the only known cure.Compared with traditional open surgery,laparoscopic surgery has the advantages of convenient operation and magnified field of view.Laparoscopic surgery has been successful in many fields,including gastrointestinal medicine and gynecology.The gallbladder was one of the first organs to be treated by laparoscopic surgery,and laparoscopic cholecystectomy has become the gold standard surgical treatment for benign gallbladder diseases.However,the safety and feasibility of laparoscopic surgery for patients with GC remain controversial.Over the past several decades,research has focused on laparoscopic surgery for GC.The disadvantages of laparoscopic surgery include a high incidence of gallbladder perforation,possible port site metastasis,and potential tumor seeding.The advantages of laparoscopic surgery include less intraoperative blood loss,shorter postoperative hospital stay,and fewer complications.Nevertheless,studies have provided contrasting conclusions over time.In general,recent research has tended to support laparoscopic surgery.However,the application of laparoscopic surgery in GC is still in the exploratory stage.Here,we provide an overview of previous studies,with the aim of introducing the application of laparoscopy in GC.

Choledochoduodenal fistula caused by migration of endoclip after laparoscopic cholecystectomy

The wide use of surgical endoclips in laparoscopic surgery has led to a variety of complications.Postcholecystectomy endoclips migrating into the common bile duct after laparoscopic cholecystectomy is rare.A migrated endoclip can cause obstruction,serve as a nidus for stone formation,and cause cholangitis.While the exact pathogenesis is still unknown,it is probably related to improper clip application,subclinical bile leak,inflammation,and subsequent necrosis,allowing the clips to erode directly into the common bile duct.We present a case of endoclip migrating into the common bile duct and duodenum,resulting in choledochoduodenal fistula after laparoscopic cholecystectomy and a successful reconstruction of the biliary tract by a hepaticojejunostomy with a Roux-en-Y procedure.This case shows that surgical endoclips can penetrate into the intact bile duct wall through serial maceration,and it is believed that careful application of clips may be the only way to prevent their migration after laparoscopic cholecystectomy.

Predictive factors for central lymph node metastases in papillary thyroid microcarcinoma

Papillary thyroid microcarcinoma(PTMC)measures 1 cm or less in its longest dimension.The incidence of PTMC is increasing worldwide.Surgery is the primary treatment;however,prophylactic central lymph node dissection is controversial,and discrepancies between different guidelines have been noted.Routine prophylactic central lymph node dissection may result in hypoparathyroidism and recurrent laryngeal nerve injury in some patients without lymph node metastasis,while simple thyroidectomy may leave metastatic lymph nodes in high-risk patients.To selectively perform prophylactic lymph node dissections in high-risk patients,it is important to identify predictive factors for lymph node metastases in patients with PTMC.Several studies have reported on this,but their conclusions are not entirely consistent.Several clinicopathologic characteristics have been identified as risk factors for central lymph node metastases,and the most commonly reported factors include age,gender,tumor size and location,multifocality,bilaterality,extrathyroidal extension,and abnormal lymph node found using ultrasound.Here,we provide an overview of previous studies along with a favorable opinion on or against these factors,with the aim of increasing the understanding of this topic among the medical community.In addition,current opinions about prophylactic central lymph node dissection are reviewed and discussed.

Unsuspected Gallbladder Cancer During or After Laparoscopic Cholecystectomy

Objective To summarize the clinical features and outcomes of unsuspected gallbladder carcinoma （HGC） detected during or after laparoscopic cholecystectomy. Methods Medical records of 8005 patients, who underwent laparoscopic cholecystectomy in Peking Hnion Medical College Hospital between June 1993 and June 2011, were reviewed. Patients that pathologically diagnosed as HGC were retrospectively studied in terms of clinical features, preoperative and postoperative diagnosis, surviving period, and complications. Results In the 8005 patients who received laparoscopic cholecystectomy, 36 （0.45%） were diagnosed as LIGC during （25 patients） or after （11 patients） laparoscopic cholecystectomy. The gallbladder cancer was staged as T1 in 16 patients, T2 in 11 patients, and T3 in 9 patients. The 1-, 3-, and 5-year survival rates of all the patients were 88.9% （32/36）, 63.9% （23/36）, and 58.3% （21/36）. The 5-year survival rates in T1 stage, T2 stage, and T3 stage patients were 100%, 75.0%, and 0.0%, respectively. Conclusions The survival rate of HGC is associated with tumor stage, not with operation approaches. Laparoscopic cholecystectomy is appropriate for T 1 patients.

Current status and progress in laparoscopic surgery for gallbladder carcinoma

Gallbladder carcinoma(GBC)is the most common biliary tract malignancy associated with a concealed onset,high invasiveness and poor prognosis.Radical surgery remains the only curative treatment for GBC,and the optimal extent of surgery depends on the tumor stage.Radical resection can be achieved by simple cholecystectomy for Tis and T1a GBC.However,whether simple cholecystectomy or extended cholecystectomy,including regional lymph node dissection and hepatectomy,is the standard surgical extent for T1b GBC remains controversial.Extended cholecystectomy should be performed for T2 and some T3 GBC without distant metastasis.Secondary radical surgery is essential for incidental gallbladder cancer diagnosed after cholecystectomy.For locally advanced GBC,hepatopancreatoduodenectomy may achieve R0 resection and improve long-term survival outcomes,but the extremely high risk of the surgery limits its implementation.Laparoscopic surgery has been widely used in the treatment of gastrointestinal malignancies.GBC was once regarded as a contraindication of laparoscopic surgery.However,with improvements in surgical instruments and skills,studies have shown that laparoscopic surgery will not result in a poorer prognosis for selected patients with GBC compared with open surgery.Moreover,laparoscopic surgery is associated with enhanced recovery after surgery since it is minimally invasive.

Mirizzi Syndrome: Our Experience with 27 Cases in PUMC Hospital

Objective To retrospectively evaluate the diagnosis and treatment of Mirizzi syndrome （MS）. Methods Patients who received elective or emergency cholecystectomies in our center during 23 years were retrospectively evaluated. The data reviewed included demography, clinical presentations, diagnostic methods, surgical procedures, postoperative complications, and follow-up.

Extrathyroidal Implantation of Thyroid Hyperplastic/neoplastic Cells after Endoscopic Thyroid Surgery

Objective To report a case of the implantation of thyroid hyperplastic or neoplastic tissue after endoscopic thyroidectomy and discuss this complication in aspects of prevalence, pathogenesis, protection, and therapies. Methods A systematic search of literature from the PubMed database was conducted for identifying eligible studies on implantation of thyroid hyperplastic or neoplastic cells after endoscopic thyroid surgery. Results Overall, 5 reported cases on patients suffering from endoscopic thyroid surgery with implantation of thyroid hyperplastic or neoplastic cells were included in the systematic review. Conclusions Unskilled surgeons, rough intraoperative surgical treatment, scarification or rupture of tumor, contamination of instruments, chimney effect, aerosolization of tumor cells may be associated with the implantation after endoscopic thyroidectomy. To minimize the risk of such complication, we should be more meticulous and strict the endoscopic surgery indications.

Diagnosis and treatment of chronic pancreatitis

OBJECTIVE: To summarize our experience in treatment of chronic pancreatitis (CP). METHODS: Clinical data on 245 patients with CP treated at our hospital from May 1983 to October 2001 were reviewed. RESULTS: Of the 245 patients, 122 suffered from CP for a year (49.8%) and 191 for 5 years (78.0%). The rate of positive diagnosis of B-ultrasound, CT, ERCP, B_2-Ty-Para-aminobenzoic acid (PABA) for CP was 74.2%, 80.7%, 76.5% and 72.8%, respectively. 169 patients (69.0%) received surgical treatment. After the operation, 98.8% of the 169 patients experienced decreased pain with a complication rate of 1.2%. CONCLUSION: Early diagnosis and appropriate operative time and management are of vital importance in improving patients' quality of life and controlling the natural history of the disease.

A long adult intussusception secondary to transverse colon cancer

The occurrence of adult intussusception arising from colorectal cancer is quite rare. We present the case of a 76-year-old man with sudden abdominal pain and vomiting. Clinical symptoms included severe abdominal distension and tenderness. Computed tomography scan of the abdomen revealed left-sided colocolic intussusception with a lead point. The patient underwent a left hemicolectomy with right transverse colostomy. Pathologic evaluation revealed moderately differentiated adenocarcinoma invading the muscularis propria; the regional lymph nodes were negative for cancer cells. The postoperative course was uneventful.

Ileo-ileal intussusception caused by diffuse large B-cell lymphoma of the ileum

The occurrence of adult intussusception from small intestinal lymphoma is quite rare.We present an82-year-old man with a two-month history of intermittent abdominal pain,nausea and fatigue.Clinical symptoms included moderate abdominal tenderness in the right lower abdomen.Computed tomography scan of the abdomen revealed a mass in the terminal ileum with the sign of"bowel within bowel"which was suspicious of ileo-ileum intussusception.The patient underwent laparoscopic segmental ileal resection.Pathologic evaluation revealed a diffuse large B cell non-Hodgkin’s lymphoma of the ileum.The postoperative course was uneventful.

Active gastrointestinal diverticulum bleeding diagnosed by computed tomography angiography

A diverticulum is a bulging sack in any portion of the gastrointestinal tract. Small intestine diverticular disease is much less common than colonic diverticular disease. The most common symptoms include non-specific epigastric pain and a bloating sensation. Major complications include diverticulitis, gastrointestinal bleeding, acute perforation, intestinal obstruction, intestinal perforation, localized abscess, malabsorption, anemia,volvulus and bacterial overgrowth. We report one case of massive jejunal diverticula bleeding and one case of massive colonic diverticula bleeding, both diagnosed by acute abdominal computed tomography angiography and treated successfully by surgery.

Surgical procedure determination based on tumor-node-metastasis staging of gallbladder cancer

AIM: To investigate the impact of surgical procedures on prognosis of gallbladder cancer patients classified with the latest tumor-node-metastasis(TNM) staging system.METHODS: A retrospective study was performed by reviewing 152 patients with primary gallbladder carcinoma treated at Peking Union Medical College Hospital from January 2003 to June 2013. Postsurgical follow-up was performed by telephone and outpatient visits. Clinical records were reviewed and patients were grouped based on the new edition of TNM staging system(AJCC, seventh edition, 2010). Prognoses were analyzed and compared based on surgical operations including simple cholecystectomy, radical cholecystectomy(or extended radical cholecystectomy), and palliative surgery. Simple cholecystectomy is, by definition, resection of the gallbladder fossa. Radical cholecystectomy involves a wedge resection of the gallbladder fossa with 2 cm nonneoplastic liver tissue; resection of a suprapancreatic segment of the extrahepatic bile duct and extended portal lymph node dissection may also be considered based on the patient's circumstance. Palliative surgery refers to cholecystectomy with biliary drainage. Data analysis was performed with SPSS 19.0 software. KaplanMeier survival analysis and Logrank test were used for survival rate comparison. P < 0.05 was consideredstatistically significant.RESULTS: Patients were grouped based on the new 7th edition of TNM staging system, including 8 cases of stage 0, 10 cases of stage Ⅰ, 25 cases of stage Ⅱ, 21 cases of stage ⅢA, 21 cases of stage ⅢB, 24 cases of stage ⅣA, 43 cases of stage ⅣB. Simple cholecystectomy was performed on 28 cases, radical cholecystectomy or expanded gallbladder radical resection on 57 cases, and palliative resection on 28 cases. Thirty-nine cases were not operated. Patients with stages 0 and Ⅰ disease demonstrated no statistical significant difference in survival time between those receiving radical cholecystectomy and simple cholecystectomy(P = 0.826). The prognosis of stage Ⅱ patients with radical cholecystectomy was better than that of simple cholecystectomy. For stage Ⅲ patients, radical cholecystectomy was significantly superior to other surgical options(P < 0.05). For stage ⅣA patients, radical cholecystectomy was not better than palliative resection and non-surgical treatment. For stage ⅣB, patients who underwent palliative resection significantly outlived those with non-surgical treatment(P < 0.01)CONCLUSION: For stages 0 and Ⅰ patients, simple cholecystectomy is the optimal surgical procedure, while radical cholecystectomy should be actively operated for stages Ⅱ and Ⅲ patients.

Risk factors for preoperative carcinogenesis of bile duct cysts in adults

BACKGROUND Bile duct cyst(BDC)is a rare congenital bile duct malformation.The incidence of bile duct malignancy in BDC patients is markedly higher than that in the general population.However,few studies have been conducted on the risk factors for preoperative carcinogenesis in BDC patients.AIM To analyze the risk factors associated with preoperative carcinogenesis in BDC patients.METHODS The medical records of BDC patients treated at our hospital between January 2012 and December 2018 were retrospectively reviewed.We constructed a database and compared the characteristics of BDC patients with dysplasia and carcinoma against those with benign cysts.The risk factors for preoperative carcinogenesis were identified using univariate and multivariate analyses.RESULTS The cohort comprised 109 BDC patients.Ten patients had preoperative dysplasia or adenocarcinoma.Univariate and multivariate analyses showed that gallbladder wall thickness>0.3 cm[odds ratio(OR),6.551;95%confidence interval(CI),1.351 to 31.763;P=0.020]and Todani type IV(OR,7.675;95%CI,1.584 to 37.192;P=0.011)were independent factors associated with preoperative carcinogenesis.CONCLUSION BDC is a premalignant condition.Our findings show that gallbladder wall thickness>0.3 cm and Todani type IV are independent risk factors for preoperative carcinogenesis of BDC.They are therefore useful for deciding on the appropriate treatment strategy,especially in asymptomatic patients.

Surgical treatment of chronic pancreatitis

Objective: To summarize the experience in the surgi- cal treatment of chronic pancreatitis. Methods: 189 patients with pancreatitis admitted from May 1983 to August 1999 to our hospital were reviewed. Results: 136 (72 %) patients received surgical treat- ment including pancreatoduodenectomy (15 pa- tients), distal pancreatectomy (12), internal drain- age of pancreatic pseudocyst (28), side-to-side pan- creaticojejunostomy (16), relief of biliary stenosis (58), and pancreatic biopsy (7). Pain was relieved in 97.8 % of the patients, and the complication rate was 1.5%. Conclusions: It is crucial to select various surgical strategies at a proper time for chronic pancreatitis patients. Patients with chronic pancreatitis compli- cated by dilation or obstruction of the pancreatic duct or with biliary pancreatitis should be operated on in early stages, whereas those with other types of chronic pancreatitis should receive the therapy focu- sing on the alleviation of their symptoms, not on ear- ly surgical intervention. The timing and modality of surgery are important in improving the life quality of the patients and changing their natural history of the disease.