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.

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.

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.

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.

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.

Potential Effect of Preoperative Immunotherapy on Anesthesia of Patients with Anti-N-methyI-D-aspartate Receptor Encephalitis

Anti-N-methyl-D-aspartate receptor （anti-NMDA-R） encephalitis is a newly recognized neuro-autoimmune disease. Patients usually present with a series of neurological and psychiatric syndromes including memory impairment, seizures, dyskinesia, autonomic nervous system dysfunction, etc. Anti-NMDA-R encephalitis usually affects young women with teratoma being a common co-existing condition in nearly 47% of the diagnosed patients. Previous studies have shown that teratoma removal, being the current first-line therapy, may enhance the effectiveness of autoimmune therapy and decrease the incidence of relapse, However, poorly controlled encephalitis poses as a perioperative anesthetic risk. Therefore, timing of the surgery is of great concern and is a question yet to be answered. Due to low incidence of anti-NMDA-R encephalitis in general population, literature of the perioperative management in these group of patients is scarce. Only few case reports were found yet, none has discussed the issue of surgery timing. In this study, 6 patients with anti-NMDA-R encephalitis undergoing teratoma removal were reviewed, and timing of surgery and anesthetic management for these patients were discussed.