Suture granuloma of the abdominal wall with intra-abdominal extension 12 years after open appendectomy

Most complications after appendectomy occur within ten days; however, we report the unusual case of a suture granuloma 12 years after open appendectomy. The afebrile 75-year-old woman presented with a slightly painful palpable mass in the right lower abdomen. There was no nausea or vomiting and bowel movements were normal. She lost 10 kg during the 3 mo before presentation. The patient had undergone an appendectomy 12 years previously. Physical examination revealed a tender mass, 10 cm in diameter, under the appendectomy scar. The preoperative laboratory findings, tumor markers and plain abdominal radiographs were normal. Multi-slice computed tomography scanning showed an inhomo-genous abdominal mass with minimal vascularization in the right lower abdomen 8.6cm×8cm×9 cm in size which communicated with the abdominal wall. The abdominal wall was thickened, weak and bulging. The abdominal wall mass did not communicate with the cecum or the ascending colon. Complete excision of the abdominal wall mass was performed via median laparotomy. Histopathological examination revealed a granuloma with a central abscess. This case report demonstrates that a preoperative diagnosis of abdominal wall mass after open appendectomy warrants the use of a wide spectrum of diagnostic modalities and consequently different treatment options.

Capsule endoscopy in celiac disease

Video capsule endoscopy is an attractive and patient- friendly tool that provides high quality images of the small bowel. Obscure gastrointestinal bleeding is the primary and most evaluated indication to capsule endoscopy;however,indications are expanding and a small number of preliminary reports have been presented concerning the role of video capsule endoscopy in the diagnosis of celiac disease. The purpose of this review is to update the current knowledge and to hypothesize on future perspectives of the use of video capsule endoscopy in patients with celiac disease.

Diagnostic laparoscopy and laparoscopic ultrasonography withlocal anesthesia in hepatocellular carcinoma

Diagnosis of hepatocellular carcinoma (HCC), a common digestive malignancy, remains a challenge. The aim of this study was to evaluate the feasibility of performing laparoscopy and laparoscopic ultrasound with local anesthesia as a diagnostic procedure in HCC. Laparoscopy and laparoscopic ultrasound with local anesthesia was performed in the gastrointestinal endoscopy unit in three patients diagnosed of HCC. Endoscopy staged diffuse liver disease. Laparoscopic ultrasonography identified all liver tumors not visible during endoscopy and guided needle biopsy in one case. No complications happened. In conclusion, laparoscopy and laparoscopic ultrasound,performed as a minimally invasive diagnostic procedure can be a safe and very promising tool in planning therapy of HCC.

Multifocal intraportal invasion of breast carcinoma diagnosed by laparoscopy-assisted liver biopsy

Hepar lobatum carcinomatosum (HLC) is defined as an acquired hepatic deformity consisting of an irregularly lobulated hepatic contour caused by intravascular infiltration of metastatic carcinoma. To date, only nine cases of HLC have been reported in the literature. We report a case of a 68-year-old woman showing hepatic metastasis of breast carcinoma in radiologically unidentified form. Initially, she received left partial mastectomy for breast cancer but solid hepatic metastases were identified in S2 and S6, 9 mo after surgery. Then, they responded to chemotherapy and radiologically disappeared. After radiological disappearance of the liver tumors, the patient's blood chemistry showed abnormal liver function. A CT scan demonstrated heterogeneous enhancement effect in the liver in the late phase,suggesting uneven hepatic blood supply. Hepatic deformity was not obvious. Laparoscopy revealed a slightly deformed liver surface with multiple indentations and shallow linear depressions. Furthermore, a wide scar was observed on the surface of S2 possibly at the site where the metastatic tumor existed before chemotherapy. Liver biopsy from the wide scar lesion showed intraportal tumor thrombi with desmoplastic change. Because of its similarity to the histology of the original breast cancer, we concluded that the hepatic functional abnormalities and slightly deformed liver surface were derived from the circulatory disturbance caused by microscopic tumor thrombi. Besides, since the wide scar was located at the site of the pre-existing tumor,it is probable that chemotherapy was an important cause of fibrous scarring as a result of tumor regression. These morphologic findings are compatible with those of HLC.Laparoscopy-assisted liver biopsy was useful to make definite diagnosis, even though the hepatic deformity was radiologically undetectable.