Development of a duodenal gallstone ileus with gastric outlet obstruction (Bouveret syndrome) four months after successful treatment of symptomatic gallstone disease with cholecystitis and cholangitis: a case report

<p>Abstract</p> <p>Introduction</p> <p>Cases of gallstone ileus account for 1% to 4% of all instances of mechanical bowel obstruction. The majority of obstructing gallstones are located in the terminal ileum. Less than 10% of impacted gallstones are located in the duodenum. A gastric outlet obstruction secondary to a gallstone ileus is known as Bouveret syndrome. Gallstones usually enter the bowel through a biliary enteral fistula. Little is known about the formation of such fistulae in the course of gallstone disease.</p> <p>Case presentation</p> <p>We report the case of a 72-year-old Caucasian woman born in Germany with a gastric outlet obstruction due to a gallstone ileus (Bouveret syndrome), with a large gallstone impacted in the third part of the duodenum. Diagnostic investigations of our patient included plain abdominal films, gastroscopy and abdominal computed tomography, which showed a biliary enteric fistula between the gallbladder and the duodenal bulb. Our patient was successfully treated by laparotomy, duodenotomy, extraction of the stone, cholecystectomy, and resection of the fistula in a one-stage surgical approach. Histopathological examination showed chronic and acute cholecystitis, with perforated ulceration of the duodenal wall and acute purulent inflammation of the surrounding fatty tissue. Four months prior to developing a gallstone ileus our patient had been hospitalized for cholecystitis, a large gallstone in the gallbladder, cholangitis and a small obstructing gallstone in the common biliary duct. She had been treated with endoscopic retrograde cholangiopancreatography, endoscopic biliary sphincterotomy, balloon extraction of the common biliary duct gallstone, and intravenous antibiotics. At the time of her first presentation, abdominal ultrasound and endoscopic examination (including esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography) had not shown any evidence of a biliary enteral fistula. In the four months preceding the gallstone ileus our patient had been asymptomatic.</p> <p>Conclusion</p> <p>In patients known to have gallstone disease presenting with symptoms of ileus, the differential diagnosis of a gallstone ileus should be considered even in the absence of preceding symptoms related to the gallbladder disease. Gallstones large enough to cause intestinal obstruction usually enter the bowel by a biliary enteral fistula. During the formation of such a fistula, patients can be asymptomatic.</p

Hernienreparationen mit Netzprothesen klinische und experimentelle Untersuchungen

In einer prospektiv-randomisierten klinischen Studie zur Leistenhernienreparation wurde die konventionelle Shouldice Operation mit den spannungsfreien Verfahren durch Netzimplantation in endoskopischer (transabdominelle praeperitoneale Netzplastik, TAPP) und offener Technik (Plug und Patch Reparation; PP) verglichen. Bezogen auf das Hauptzielkriterium postoperative Schmerzen ergaben beide spannungsfreie Verfahren (TAPP, PP) signifikant guenstigere Ergebnisse als die Shouldice Operation. Bei vergleichbarer Komplikationsrate war die Dauer postoperativer Einschraenkungen bei den spannungsfreien Verfahren ebenfalls signifikant kuerzer als nach Shouldice Operation. Zur Verbesserung der fuer die spannungsfreie Reparation erforderlichen Netzimplantate wurde in einer Tierstudie versucht, die bislang durch Resorption ungenuegende mechanische Stabilitaet eines resorbierbaren Polyglycolsaeure-Netzes durch Zugabe von Fibrinkleber bzw. humanen thrombozytaeren Wachstumsfaktoren zu verbessern. Hierdurch gelang ein signifikanter Anstieg der mechanischen Stabilitaet, so daß in dem verwendeten Tiermodell keine Herniationen auftraten.In a prospective-randomized study conventional Shouldice operation was compared with tension-free procedures using mesh implantation in endoscopic (transabdominal preperitoneal mesh repair, TAPP) and open technique (Plug and patch repair; PP) for inguinal hernia repair. Regarding the mean end point postoperative pain both tension-free procedures (TAPP, PP) revealed significantly better results than Shouldice operation. Complications were comparable between the groups but duration of postoperative restrictions was significantly shorter after both tension-free procedures. To improve mesh quality for tension-free hernia repair an animal experiment was performed using a resorbable polyglycolic acid mesh. Despite good incorporation this mesh shows insufficient tensile strength due to absorption. Application of fibrin glue or platelet releasates significantly improve the mechanical stability of the repair protecting against herniation in this animal model

Hyperthermic intracavitary nanoaerosol therapy (HINAT) as an improved approach for pressurised intraperitoneal aerosol chemotherapy (PIPAC): Technical description, experimental validation and first proof of concept

Background: The delivery of aerosolised chemotherapeutic substances into pressurised capnoperitonea has been reported to be more effective than conventional liquid chemotherapy for the treatment of peritoneal carcinomatosis. However, recent reports reveal limitations of the currently available technology.Material and Methods: A novel approach for pressurised intraperitoneal aerosol chemotherapy (PIPAC), called hyperthermic intracavitary nanoaerosol therapy (HINAT), based on extracavitary generation of hyperthermic and unipolar charged aerosols, was developed. The aerosol size distribution, the spatial drug distribution and in-tissue depth penetration of HINAT were studied by laser diffraction spectrometry, differential electrical mobility analysis, time of flight spectrometry, scintigraphic peritoneography and fluorescence microscopy. All experiments were performed contemporaneous with conventional PIPAC for the purpose of comparison. Furthermore, a first proof of concept was simulated in anesthetised German Landrace pigs.Results: HINAT provides a nanometre-sized (63 nm) unipolar-charged hyperthermic (41 °C) drug aerosol for quasi uniform drug deposition over the whole peritoneum with significantly deeper drug penetration than that offered by conventional PIPAC