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.

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 (UGC) detected during or after laparoscopic cholecystectomy.Methods Medical records of 8005 patients,who underwent laparoscopic cholecystectomy in Peking Union Medical College Hospital between June 1993 and June 2011,were reviewed.Patients that pathologically diagnosed as UGC 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 UGC 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 UGC is associated with tumor stage,not with operation approaches.Laparoscopic cholecystectomy is appropriate for T1 patients.

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.Results There were 27 patients diagnosed with MS among 8697 cholecystectomies performed during that period.The preoperative diagnostic modalities included ultrasonography,computed tomography,magnetic resonance cholangiopancreatography,and endoscopic retrograde cholangiopancreatography.The incidence of MS Type I(12/27,44.4%)had the dominance in the four types,the incidence of MS Type II and III were 33.3%(9/27)and 22.2%(6/27),and there were no MS Type IV patients.Laparoscopic cholecystectomy was performed in 15(55.6%)patients,but only 3(11.1%)patients with MS Type I had a successful surgery,and the other 12 were converted to open cholecystectomy.The remaining 12 patients directly underwent open cholecystectomy.The surgical procedures except laparoscopic cholecystectomy included simply open cholecystectomy(including laparoscopic cholecystectomy converted to open cholecystectomy)(6/27,22.2%),open cholecystectomy,T-tube placement with choledochotomy(9/27,33.3%),open cholecystectomy,closure of the fistula with gallbladder cuff,T-tube placement(3/27,11.1%),and open cholecystectomy with excision of the external bile ducts,and Roux-en-Y hepatico-jejunostomy(6/27,22.2%).Of them,88.9%(24/27)patients recovered uneventfully and were discharged in good condition without any operation related mortality.Conclusions Endoscopic retrograde cholangiopancreatography is a good method with diagnostic and therapeutic purposes.Total or partial cholecystectomy is generally adequate for MS Type I.For MS Type II-IV,paritial cholecystectomy,choledochoplasty,or if impossible,Roux-en-Y hepatico-jejunostomy may be performed.Laparoscopic cholecystectomy may be successful in selected preoperatively diagnosed MS Type I patients,and open cholecystectomy is the standard therapeutic method.

Schwannoma originating from the recurrent laryngeal nerve in a thyroid cancer patient: A case report and review of the literature

BACKGROUND Schwannoma rarely originates from the recurrent laryngeal nerve, and there are few reports on schwannoma originating from the recurrent nerve in the mediastinum. Herein, we present an extremely rare case of schwannoma originating from the recurrent laryngeal nerve in the neck.CASE SUMMARY This is a case report of one patient diagnosed with thyroid cancer with schwannoma originating from the recurrent laryngeal nerve in the neck, which was incidentally found during a thyroidectomy, and a review of the literature.CONCLUSION Preoperative diagnostic examinations are of less use for detecting schwannoma originating from a recurrent laryngeal nerve in the neck in such small size, which may only incidentally be found during a thyroidectomy. Surgical excision with opening the capsule and shelling out the tumor is the treatment of choice. If the nerve is unable to be preserved, end-to-end recurrent laryngeal nerve anastomosis may be a simple and minimally invasive reconstruction procedure to improve phonation.

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.

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.

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.

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.