Metastatic breast neuroendocrine tumor from the rectum-a needle in hay stack

Neuroendocrine tumors metastazing to the breast are exceedingly rare and account for less than 2% of tumors in the breasts. They are usually initially diagnosed as primary breast carcinoma and the correct treatment is delayed. Accurate preoperative identification of the tumor will result in the avoidance a major surgery including axillary lymphnodal clearance. We here report a case of a metastatic neuroendocrine deposit in the breast following a Laparoscopic Anterior Resection(for neuroendocrine tumor of rectum) and Right Hepatectomy (for synchronous liver metastasis)

Laparoscopic-assisted transgastric ERCP in patients with gastric bypass: a single centre experience

Background: Laparoscopic assisted transgastric endoscopic retrograde cholangiopancreatography (LAERCP)  is used for treatment in patients after  gastric bypass , where transoral access to the biliary tree is not possible. We describe our technique and experience with this procedure for  12  of our patients of which 7 of them had undergone Roux en y gastric bypass (RYGB) and 5 of them had undergone mini gastric bypass (MGB). Methods: For all 12 patients intraoperative cholangiography revealed common bile duct (CBD) stones. A combined laparoscopic-endoscopic approach was attempted. A small gastrotomy with a purse-string suture was performed on the anterior wall on remanant stomach. A side viewing scope was introduced through a 15 mm trocar on the upper left quadrant and through the gastrotomy. The duodenum was occluded to prevent air passage and small bowel distension. Endoscopic sphincterotomy and stone extraction were carried out according to standard techniques. Occlusion cholangiogram confirmed CBD clearance. There was one procedure-related complication, and the patients were discharged on the third postoperative day. The patients are doing well at 1 year follow up. Results: Average time since bypass was 3 years, and length of stay was 3 days. Seven patients underwent simultaneous cholecystectomy. Two patients, had cholecystectomy more than 2 years previously. Our technique involves access to the bypassed stomach via a laparoscopically placed 15 mm port. We observed one major complication. No minor complications except , port site infection for one patient was observed in our series. Conclusion: Biliary obstruction can occur many years after gastric bypass with or without cholecystectomy. Our findings suggest that gastric bypass patients may be at a higher risk of symptomatic cholelithiasis with CBD stones . LAERCP is a reliable option for common bile duct clearance; our technique of LAERCP is technically simple and associated with low complication rate, making it appealing to surgeons  trained in  laparoscopy