Development of bile duct bezoars following cholecystectomy caused by choledochoduodenal fistula formation: a case report

BACKGROUND: The formation of bile duct bezoars is a rare event. Its occurrence when there is no history of choledochoenteric anastomosis or duodenal diverticulum constitutes an extremely scarce finding. CASE PRESENTATION: We present a case of obstructive jaundice, caused by the concretion of enteric material (bezoars) in the common bile duct following choledochoduodenal fistula development. Six years after cholecystectomy, a 60-year-old female presented with abdominal pain and jaundice. Endoscopic retrograde cholangiopancreatography demonstrated multiple filling defects in her biliary tract. The size of the obstructing objects necessitated surgical retrieval of the stones. A histological assessment of the objects revealed fibrinoid materials with some cellular debris. Post-operative T-tube cholangiography (9 days after the operation) illustrated an open bile duct without any filling defects. Surprisingly, a relatively long choledochoduodenal fistula was detected. The fistula formation was assumed to have led to the development of the bile duct bezoar. CONCLUSION: Bezoar formation within the bile duct should be taken into consideration as a differential diagnosis, which can alter treatment modalities from surgery to less invasive methods such as more intra-ERCP efforts. Suspicions of the presence of bezoars are strengthened by the detection of a biliary enteric fistula through endoscopic retrograde cholangiopancreatography. Furthermore, patients at a higher risk of fistula formation should undergo a thorough ERCP in case there is a biliodigestive fistula having developed spontaneously

Giant liver hemangioma resected by trisectorectomy after efficient volume reduction by transcatheter arterial embolization: a case report

<p>Abstract</p> <p>Introduction</p> <p>Liver hemangiomas are the most common benign liver tumors, usually small in size and requiring no treatment. Giant hemangiomas complicated with consumptive coagulopathy (Kasabach-Merritt syndrome) or causing severe incapacitating symptoms, however, are generally considered an absolute indication for surgical resection. Here, we present the case of a giant hemangioma, which was, to the best of our knowledge, one of the largest ever reported.</p> <p>Case presentation</p> <p>A 38-year-old Asian man was referred to our hospital with complaints of severe abdominal distension and pancytopenia. Examinations at the first visit revealed a right liver hemangioma occupying the abdominal cavity, protruding into the right diaphragm up to the right thoracic cavity and extending down to the pelvic cavity, with a maximum diameter of 43 cm, complicated with "asymptomatic" Kasabach-Merritt syndrome. Based on the tumor size and the anatomic relationship between the tumor and hepatic vena cava, primary resection seemed difficult and dangerous, leading us to first perform transcatheter arterial embolization to reduce the tumor volume and to ensure the safety of future resection. The tumor volume was significantly decreased by two successive transcatheter arterial embolizations, and a conventional right trisectorectomy was then performed without difficulty to resect the tumor.</p> <p>Conclusions</p> <p>To date, there have been several reports of aggressive surgical treatments, including extra-corporeal hepatic resection and liver transplantation, for huge hemangiomas like the present case, but because of its benign nature, every effort should be made to avoid life-threatening surgical stress for patients. Our experience demonstrates that a pre-operative arterial embolization may effectively enable the resection of large hemangiomas.</p

Effects Of Low And High Intra-Abdominal Pressure On Immune Response In Laparoscopic Cholecystectomy

Objective: Immunosuppression is directly related to the degree of trauma. The aim of this study is to compare the effects of low and high intra-abdominal pressure on immune response in moderate surgical trauma. Methods: Twenty-two patients, scheduled for laparoscopic cholecystectomy, were randomly allocated to one of 2 groups according to intra-abdominal pressure: low and high intra-abdominal pressure. This study was conducted in the Hacettepe University Faculty of Medicine, Operation Room, Ankara, Turkey. Serum interleukin (IL)-2 and IL-6 levels were measured. Results: Serum IL-2 showed a significant decrease before the incision in high intra-abdominal pressure group. The increase in serum IL-6 at the end of surgery and postoperatively was lower in low intra-abdominal pressure group. Conclusion: These results, can be interpreted as the immune system, are less depressed when there is lower intra-abdominal pressure. This may have clinical implications in immunocompromised patients.Wo

THE EFFECTS OF VITAMIN-E ON IMMUNE REGULATION AFTER THERMAL-INJURY

In [Phys. Rev. E 88, 042126 (2013)] it is stated that Tsallis distributionsdo not emerge from thermalization with a "bath" of finite, energy-independent,heat capacity. We report evidence for the contrary

MANAGEMENT OF NIPPLE DISCHARGE

In a series of 9,312 women who consulted one of the authors with a complaint of disease of the breast between 1959 and 1991, nipple discharge was the presenting symptom in 448 (4.8 percent). Nipple discharge was spontaneous in 243 (2.6 percent) and provoked in 205 (2.2 percent) of the patients. The ages of the patients ranged from 13 to 75 years (mean of 42.5 years) in the spontaneous and 16 to 70 years (mean of 37.8 years) in the provoked discharge group. When a palpable mass was found, biopsy was undertaken, while in instances of nipple discharge only, subareolar exploration was performed. Of the 115 patients in the spontaneous and 25 patients in the provoked groups who underwent biopsy, the most frequent cause of nipple discharge was intraductal papilloma (47.8 percent). Nipple discharge was the result of carcinoma in 35 patients (14.4 percent) in the spontaneous and six patients (2.9 percent) in the provoked group, respectively. In patients with a palpable mass, the incidence of carcinoma was 61.5 percent compared with 6.1 percent in patients with nipple discharge only

Clinicopathologic And Radiopharmacokinetic Factors Affecting Gamma Probe-Guided Parathyroidectomy

Hypothesis: The kinetics of technetium Tc 99m sestamibi (MIBI) in primary hyperparathyroidism are variable and affected by the cellular size of the abnormal glands, the parathyroid hormone levels, and the functional expression of P-glycoprotein (Pgp). The success of gamma probe-guided parathyroidectomy is closely related to the parathyroid-to-thyroid activity ratio at the time of surgery. Preoperative determination of maximum uptake ratio may improve the surgical outcome. Design: Thirty-one patients with primary hyperparathyroidism attributed to a solitary parathyroid adenoma (27 patients) or multiglandular hyperplasia (4 patients) underwent dynamic MIBI imaging preoperatively. Maximum MIBI activity and activity elimination half-life in the abnormal parathyroid glands and thyroid glands were measured, and the maximum uptake ratio was calculated. After a second MIBI injection on the day of surgery, all patients underwent gamma probe-guided para thyroidectomy and cervical exploration. Timing of surgery after MIBI injection was individualized according to the optimal time to surgery (time to maximum uptake ratio), which was determined by preoperative scintigraphy. During surgery, the gamma probe was used to measure ex vivo counts of excised lesions and adjacent postexcision normal tissue (background). image characteristics, MIBI kinetics, and gamma probe findings were correlated with gland volume, oxyphil cell content, Pgp expression, and serum parathyroid hormone levels. Results: Probe localization of abnormal glands at maximum uptake ratio was successful in all patients. The volume of the parathyroid lesion ranged from 0.03 to 9.8 mL (median, 0.7 mL). Parathyroid maximum MIBI activity correlated with the volume of the gland (r=0.54, P=.002) and serum parathyroid hormone level (r=0.58, P=.001). No correlation between maximum MIBI activity and oxyphil cell content or Pgp expression could be demonstrated. Elimination half-life of MIBI from parathyroid inversely cor-related with Pgp (r=-0.36, P=.05). The ex vivo lesion background count ratio positively correlated with volume of the gland (r=0.66, P=.001) and parathyroid hormone level (r=0.48, P=.006). Ex vivo lesion counts and Pgp expression were negatively correlated (r=-0.37, P=.04). Conclusions: A strong relationship between volume of the parathyroid gland, serum parathyroid hormone levels, and MIBI uptake exists in primary hyperparathyroidism. Gamma probe-guided localization of abnormal gland(s) can be more successful if surgery is undertaken at maximum uptake ratio. High Pgp expression increases MIBI parathyroid clearance rate, decreases gamma probe counts, and may significantly alter the optimal time to surgery.WoSScopu