Transanal polypectomy using single incision laparoscopic instruments

Transanal excision of rectal polyps with laparoscopic instrumentation and a single incision laparoscopic port is a novel technique that uses technology originally developed for abdominal procedures from the natural orifice of the rectum. Transanal endoscopic microsurgery (TEM) is a well established surgical approach for certain benign or early malignant lesions of the rectum, under specific indications. Our technique is a hybrid technique of transanal surgery, a reasonable method for polyp resection without the need of the sophisticated and expensive instrumentation of TEM which can be applied whenever endoscopic or conventional transanal surgical removal is not feasible.

Small intestine diverticula: Is there anything new?

AIM: To globally approach the clinical entity of small bowel diverticulosis and, at the same time, set out the treatment options.

METHODS: We analysed 77 cases of diverticula located in the duodenum, jejunum and ileum that were treated in our department, evaluating the symptoms, diagnostic approach and offered treatment.

RESULTS: Almost half of the diverticula (46.7%) were incidentally discovered and Meckel’s diverticula represented the majority (43%) that were actually the only true diverticula. A high complication rate (53%) which included inflammation with or without perforation (22%), bleeding (10%) or obstructive ileus (12%) due to small bowel diverticulosis was reported. The preoperative diagnosis was often impossible (44% of complicated cases).

CONCLUSION: Although small bowel diverticulosis has a low incidence, it should be in the clinician’s mind in order to avoid misdiagnosis.

Trichobezoar: A rare cause of bowel obstruction

A bezoar is an intraluminal mass formed by the accumulation of undigested material in the gastrointestinal tract. A trichobezoar is a bezoar made up of hair and is a rare cause of bowel obstruction of the proximal gastrointestinal tract. They are seen mostly in young women with trichotillomania and trichotillophagia and symptoms include epigastric pain, nausea, loss of appetite and bowel or gastric outlet obstruction. We herein describe a case of a trichobezoar that presented as a gastric outlet obstruction and was subsequently successfully removed via a laparotomy.

A case report of extrahepatic portal vein aneurysm with thrombosis

Extrahepatic portal vein aneurysm (PVA) is very rare with only 17 previously reported cases. Methods of treatment include resection, thrombectomy, and portal venous decompression. We report herein the first case of large PVA with thrombosis which has been managed without surgical treatment over a long period. A PVA was detected in a 78-year-old woman by abdominal ultrasonography. Computed tomography revealed an aneurysm of 6 cm in a diameter in the porta hepatis. Portal venography showed obstruction of the portal vein and developed collateral vessels around the aneurysm. Since the patient had no symptoms of portal hypertension, we decided to carefully manage her clinical course without surgical treatment. At present, this patient is healthy and has developed no complications over the 5 years since leaving our hospital. This case suggests that surgical treatment is not required for PVA without portal hypertension.

Bowel endometriosis: Recent insights and unsolved problems

Bowel endometriosis affects between 3.8% and 37% of women with endometriosis. The evaluation of symptoms and clinical examination are inadequate for an accurate diagnosis of intestinal endometriosis. Transvaginal ultrasonography is the first line investigation in patients with suspected bowel endometriosis and allows accurate determination of the presence of the disease. Radiological techniques (such as magnetic resonance imaging and multidetector computerized tomography enteroclysis) are useful for estimating the extent of bowel endometriosis. Hormonal therapies (progestins, gonadotropin releasing hormone analogues and aromatase inhibitors) significantly improve pain and intestinal symptoms in patients with bowel stenosis less than 60% and who do not wish to conceive. However, hormonal therapies may not prevent the progression of bowel endometriosis and, therefore, patients receiving long-term treatment should be periodically monitored. Surgical excision of bowel endometriosis should be offered to symptomatic patients with bowel stenosis greater than 60%. Intestinal endometriotic nodules may be excised by nodulectomy or segmental resection. Both surgical procedures improve pain, intestinal symptoms and fertility. Nodulectomy may be associated with a lower rate of complications.

Herniated pancreatic body within a paraesophageal hernia

A hiatal hernia can be classified as one of four types according to the position of the gastroesophageal (GE) junction and the extent of herniated stomach. Type I, or sliding hernias, account for up to 95% of all hiatal hernias and occur when the GE junction migrates into the posterior mediastinum through the hiatus. Type II occurs when the fundus herniates through the hiatus alongside a normally positioned GE junction. Type III is a combination of types I and II hernias with a displaced GE junction as well as stomach protruding through the hiatus. Type IV paraesophageal hernias are the rarest of the hiatal hernias. Usually, colon or small bowel is herniated within the mediastinum along with the stomach. We present a case of a paraesophageal hernia with the mid-body of the pancreas as part of the hernia contents.

Liver transplantation in HCV/HIV positive patients

Since the introduction of highly active antiretroviral therapy (HAART) in 1996 for human immunodeficiency virus (HIV)-infected patients, the incidence of liver diseases secondary to co-infection with hepatitis C has increased. Although data on the outcome of liver transplantation in HIV-infected recipients is limited, the overall results to date seem to be comparable to that in non-HIV-infected recipients. Liver transplant centers are now accepting HIV-infected individuals as organ recipients. Post-transplantation HIV replication is controlled by HAART. Hepatitis C re-infection of the liver graft, however, remains an important problem because cirrhotic changes of the liver graft may be more rapid in HIV-infected recipients. Interactions between the HAART components and immunosuppressive drugs influence drug metabolism and therefore meticulous monitoring of drug blood level concentrations is required. The risk of opportunistic infection in HIV-positive transplant patients seems to be similar to that in HIV-negative transplant recipients.

Clinicopathological features and the outcome of surgical management for adenocarcinoma of the appendix

AIM: To present a comprehensive analysis of incidence, clinicopathological features, appropriateness of surgical procedures, and survival for adenocarcinoma of the appendix.

METHODS: A retrospective case analysis was conducted for the 10-year period 1998-2008. All patients diagnosed with adenocarcinoma of the appendix were analyzed for their demographics details, clinical features, tumor incidence and characteristics, tumor stage, surgical procedures performed, and their survival.

RESULTS: Nine thousand three hundred and twenty-three patients underwent appendectomies during the study period, and of these, 10 (0.1%: 8 men and 2 women with a mean age of 53.1 years, age range 21-83 years) were found to have primary adenocarcinoma of the appendix. Appendicular neoplasia was not suspected pre-operatively in any of the patients. Six (60%) patients underwent secondary right hemicolectomy. Four (40%) cases had appendectomy alone, and two of them died, whereas all those who underwent right hemicolectomy are alive and disease free. Five (50%) were reported to have grade 1 disease, three (30%) grade 2, and two (20%) grade 3 with mean survival of 34, 48, and 22 mo, respectively. Six (60%) patients presented with advanced disease (Duke’s C and D). At the end of follow up (mean period: 37.9 mo), eight patients are alive and disease free at the end of follow up. Overall mean survival was 36.3 mo (confidence interval; 16%-56%) with 41.3 and 16 mo for men and women, respectively. Mean survival for those with and without lymph node involvement was 33.6 and 40.2 mo, respectively. Right hemicolectomy gave better results than appendectomy alone, although the difference was not statistically significant due to the small number of cases.

CONCLUSION: Adenocarcinoma of the appendix is extremely rare neoplasm with varied presentations, and is usually advanced when diagnosed. Right hemicolectomy is the treatment of choice for such tumors.

Ileal lipoma - a rare cause of ileocolic intussusception in adults: Case report and literature review

The occurrence of intussusception in adults is rare, accounting for less than 5% of all cases of intussusceptions and almost 1%-5% of bowel obstruction. The condition is found in less than 1 in 1300 abdominal operations and 1 in 100 patients operated for intestinal obstruction. The child to adult ratio is more than 20:1. We report a rare case of ileocolic intussusception in an adult secondary to an ileal lipoma.

Enhanced recovery after surgery programs hasten recovery after colorectal resections

Colorectal resection was traditionally associated with significant morbidity and prolonged stay in hospital. Laparoscopic colorectal resection was first described in 1991 as a minimally invasive form of colorectal surgery. It was later on assessed by multiple randomized controlled trials and meta-analysis and was found to be associated with a faster recovery, lower complication rates and a shorter stay in hospital compared with open resection. To assess the effect of enhanced recovery after surgery (ERAS) program on postoperative length of stay after elective colorectal resections, a literature review was conducted, supplemented by the results of 111 ERAS colorectal resections at regional NWS Hospital using a protocol based on the Fast Track approach described by Kehlet in 1999. ERAS has been shown to improve postoperative recovery, reduce length of stay and enhance early return to normal function when compared with traditional colorectal surgical protocols. The role of laparoscopic surgery in colorectal resections within a fast-track (ERAS) program is controversial. The current evidence suggests that within such a program, there is no difference between laparoscopic and open colorectal surgery in terms of postoperative recovery rates or length of hospital stay.

Peritoneovenous shunt for intractable ascites due to hepatic lymphorrhea after hepatectomy

A peritoneovenous shunt has become one of the most efficient procedures for intractable ascites due to liver cirrhosis. A case of intractable ascites due to hepatic lymphorrhea after hepatectomy for hepatocellular carcinoma that was successfully treated by the placement of a peritoneovenous shunt is presented. A 72-year-old Japanese man underwent partial resection of the liver for hepatocellular carcinoma associated with hepatitis C viral infection. After hepatectomy, a considerable amount of ascites ranging from 800-4600 mL per day persisted despite conservative therapy, including numerous infusions of albumin and plasma protein fraction and administration of diuretics. Since the patient’s general condition deteriorated, based on the diagnosis of intractable hepatic lymphorrhea, a subcutaneous peritoneovenous shunt was inserted. The patient’s postoperative course was uneventful and the ascites decreased rapidly, with serum total protein and albumin levels and hepatic function improving accordingly. For intractable ascites due to hepatic lymphorrhea after hepatectomy, we recommend the placement of a peritoneovenous shunt as a procedure that can provide immediate effectiveness without increased surgical risk.

Small bowel obstruction presenting with a rectal haematoma

We report on a case of an 85-year old man with an unusual presentation of small bowel obstruction. A palpable mass on digital rectal examination was subsequently visualised endoscopically with the appearance of a haematoma. The presence of a rectal mass as a presenting sign for small bowel obstruction is highly unusual and unreported in the literature.

Surgical treatment for abdominal actinomycosis: A report of two cases

Since actinomycosis sometimes causes an abdominal tumor which mimics malignancy, treatment strategy varies from case to case. We herein report two cases which were treated with a combination of antibiotics and surgical intervention. Both patients presented with an intra-abdominal tumor lesion mimicking malignant disease after an appendectomy for acute appendicitis. Case 1 received surgical extirpation of the abdominal tumor in the liver and kidney twice since the clinical diagnosis of actinomycosis was not made. In contrast, case 2 was successfully treated by a combination of antibiotics and laparoscopic surgery following the experience of case 1. When a high probability diagnosis can be made, a laparoscopic approach is a useful and effective option to treat this condition.

Pyogenic liver abscess: Changing patterns in approach

AIM

To define optimum management of the pyogenic liver abscess and assess new trends in treatment.

METHODS

One hundred and sixty nine patients with pyogenic liver abscess managed at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir (India) from July 2001 to August 2006 were studied to evaluate and define the optimum treatment.

RESULTS

Mortality in the surgically treated group of patients was 9.4% (12/119), while those treated non-surgically had a fatality rate of 16.66% (7/42). Multiple liver abscesses treated surgically had a surprisingly low mortality of 30%. The biliary tract (64.97%) was the most common cause of liver abscess. Multiple abscesses, mixed organisms and abscess complications are all associated with a significantly increased mortality. However, the lethality of the primary disease process was the most important factor in determining survival.

CONCLUSION

Transperitoneal surgical drainage and antibiotics are the mainstay of treatment. Percutaneous drainage is recommended for high risk patients only.

Small for size syndrome following living donor and split liver transplantation

The field of liver transplantation is limited by the availability of donor organs. The use of living donor and split cadaveric grafts is one potential method of expanding the donor pool. However, primary graft dysfunction can result from the use of partial livers despite the absence of other causes such as vascular obstruction or sepsis. This increasingly recognised phenomenon is termed “Small-for-size syndrome” (SFSS). Studies in animal models and humans have suggested portal hyperperfusion of the graft combined with poor venous outflow and reduced arterial flow might cause sinusoidal congestion and endothelial dysfunction. Graft related factors such as graft to recipient body weight ratio < 0.8, impaired venous outflow, steatosis > 30% and prolonged warm/cold ischemia time are positively predictive of SFSS. Donor related factors include deranged liver function tests and prolonged intensive care unit stay greater than five days. Child-Pugh grade C recipients are at relatively greater risk of developing SFSS. Surgical approaches to prevent SFSS fall into two categories: those targeting portal hyperperfusion by reducing inflow to the graft, including splenic artery modulation and portacaval shunts; and those aiming to relieve parenchymal congestion. This review aims to examine the controversial diagnosis of SFSS, including current strategies to predict and prevent its occurrence. We will also consider whether such interventions could jeopardize the graft by compromising regeneration.

An ongoing dispute in the management of severe pancreatic fistula: Pancreatospleenectomy or not?

The aim of this manuscript is to review controversies in managing severe pancreatic fistula after pancreatic surgery. Significant progress in surgical technique and perioperative care has reduced the mortality rate of pancreatic surgery. However, leakage of the pancreatic stump still accounts for the majority of surgical complications after pancreatic resection. Various strategies have been employed in order to manage pancreatic fistula. Nonetheless high grade pancreatic fistula evokes controversy in relation to the choice of treatment. A Medline search was performed, with regard to conservative treatment options versus completion pancreatectomy for the management of pancreatic fistula grade C. Pancreatic fistula rates remain unchanged with an incidence ranging from 5%-20% and this is considered as the most important cause of postoperative death. Many authors claim that completion pancreatectomy has probably lost its role in favour of interventional radiology procedures, while others believe that completion pancreatectomy continues to have a place in the management of patients with severe clinical deterioration after pancreatic fistula who do not respond to non-surgical interventions. There is no agreement on the best clinical management of severe pancreatic fistula after pancreatic surgery. Completion pancreatectomy is reserved for patients not improving with conventional measures.

Adjuvant chemoradiotherapy for resected pancreas cancer

The purpose of this article is to review pertinent literature assessing the evidence regarding adjuvant chemoradiotherapy for adenocarcinoma of the pancreas following curative resection. This review looks at randomized controlled studies with the emphasis on adjuvant chemoradiotherapy. In assessing the evidence from the studies reviewed in this article, the trials have been grouped according to the positive or negative results for or against adjuvant treatment. In addition, data from two large, single-institution studies affirming the role for adjuvant chemoradiotherapy has been included. Understanding the evidence from all of the randomized studies is important in shaping current practice recommendations for adjuvant therapy of surgically resected pancreas cancer. Adjuvant chemoradiotherapy following surgery is the current approach at many cancer treatment centers in the United States. In Europe, chemotherapy alone is the preferred adjuvant therapy. However, the type of adjuvant treatment recommended remains controversial due to conflicting study results. The debate will likely continue. Current practice should be based on the weight of evidence available at this time, which is in favor of adjuvant chemotherapy with chemoradiotherapy.

Sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery: A case report

We report a case of sporadic gastric carcinoid tumor successfully treated by two-stage laparoscopic surgery. A 38-year old asymptomatic woman was referred to our hospital for evaluation of a submucosal tumor of the stomach. Endoscopic examination showed a solitary submucosal tumor without ulceration or central depression on the posterior wall of the antrum and biopsy specimens were not sufficient to determine the diagnosis. Endoscopic ultrasound revealed a tumor nearly 2 cm in diameter arising from the muscle layer and a computed tomography scan showed the tumor enhanced in the arterial phase. Laparoscopic wedge resection was performed for definitive diagnosis. Pathologically, the tumor was shown to be gastric carcinoid infiltrating the muscle layer which indicated the probability of lymph node metastasis. Serum gastrin levels were normal. As a radical treatment, laparoscopy-assisted distal gastrectomy with regional lymphadenectomy was performed 3 wk after the initial surgery. Finally, pathological examination revealed no lymph node metastasis.

Role of frozen section assessment for intraductal papillary and mucinous tumor of the pancreas

Intraductal papillary mucinous neoplasms (IPMN) of the pancreas include a spectrum of dysplasia ranging from minimal mucinous hyperplasia to invasive carcinoma and are extensive tumors that often spread along the ductal tree. Several studies have demonstrated that preoperative imaging is not accurate enough to adapt the extent of pancreatectomy and have suggested routinely using frozen sectioning (FS) to evaluate the completeness of resection and also to check if ductal dilatation is active or passive, in order to avoid an excessive pancreatic resection. Separate main duct and branch duct analysis is needed due to the difference in the natural history of the disease. FS accuracy averages 95%. Eroded epithelium on the main duct, severe ductal inflammation mimicking dysplasia and reactive epithelial changes secondary to obstruction can lead to inappropriate FS results. FS results change the planned extent of resection in up to 30% of cases. The optimal cut-off leading to extend pancreatectomy is not consensual and our standard option is to extend pancreatectomy if FS reveals: (1) at least IPMN adenoma on the main duct; or (2) at least borderline IPMN on branch ducts; or (3) invasive carcinoma. However, the decision to extend resection must be taken after a multidisciplinary discussion since it does not exclusively depend on the FS result but also on age, general condition and expected prognosis after resection. The main limitation of using FS is the existence of discontinuous (“skip”) lesions which account for approximately 10% of IPMN in surgical series and can lead to reoperation in up to 8% of cases.

Natural history of intraductal papillary mucinous neoplasia: How much do we really know?

Information on the natural history of intraductal papillary mucinous neoplasia (IPMN) is currently inadequate due to a lack of carefully orchestrated long-term follow-up on a large cohort of patients with asymptomatic disease. Based on the available data, one can draw the conclusions that main duct IPMN is commonly associated with malignancy and an aggressive operative stance should be taken with resection being offered to most patients who are suitable operative candidates. In contrast, the majority of branch type IPMN with a diameter of less than 3 cm can be safely followed with routine surveillance imaging provided they lack the high-risk covariates of age, symptomatology, nodularity or wall thickness.

Population-based epidemiology, risk factors and screening of intraductal papillary mucinous neoplasm patients

Intraductal papillary mucinous neoplasm (IPMN) was first recognized in the 1980s with increasing publications over the last decade as the incidence increased sharply, especially at tertiary-care referral centers. Population-based studies have estimated the age and sex-adjusted cumulative incidence of IPMN to be 2.04 per 100 000 person-years (95% confidence interval: 1.28-2.80). It is now understood that IPMN can be classified anywhere along the spectrum of the adenoma to carcinoma sequence and often harbors mutations in genes such as KRAS early in the disease process. Many patients are diagnosed incidentally after imaging of the abdomen for other diagnostic purposes. Patients that present with a history of symptoms such as pancreatitis and abdominal pain are at high risk of harboring a malignancy. Clinicopathologic features such as involvement of the main pancreatic duct, presence of mural nodules, and side branch disease > 3.0 cm in size may indicate that there is an underlying invasive component to the IPMN. In addition, the incidence of extra-pancreatic neoplasms is higher in patients with IPMN, with reported rates of 25% to 50%. There are no current screening recommendations to detect and diagnose IPMN but once the diagnosis is made, screening for extrapancreatic neoplasms such as colon polyps and colorectal cancer should be considered. Surgical resection is the recommend treatment for patients with high-risk features while close observation can be offered to patients without worrisome signs and symptoms of carcinoma.

Intraductal papillary-mucinous neoplasia of the pancreas: Histopathology and molecular biology

Intraductal papillary-mucinous neoplasm (IPMN) of the pancreas is a clinically and morphologically distinctive precursor lesion of pancreatic cancer, characterized by gradual progression through a sequence of neoplastic changes. Based on the nature of the constituting neoplastic epithelium, degree of dysplasia and location within the pancreatic duct system, IPMNs are divided in several types which differ in their biological properties and clinical outcome. Molecular analysis and recent animal studies suggest that IPMNs develop in the context of a field-defect and reveal their possible relationship with other neoplastic precursor lesions of pancreatic cancer.

Imaging considerations in intraductal papillary mucinous neoplasms of the pancreas

With the widespread use of cross-sectional imaging, particularly computed tomography (CT) and magnetic resonance imaging (MRI), and the continuous improvement in the image quality of these techniques, the diagnosis of incidental pancreatic cysts has increased dramatically in the last decades. While the vast majority of these cysts are not clinically relevant, a small percentage of them will evolve into an invasive malignant tumor making their management challenging. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms (IPMN) are the most common pancreatic cystic lesions with malignant potential. Imaging findings on CT and MRI correlate tightly with the presence of malignant degeneration in these neoplasms. IPMN can be classified based on their distribution as main duct, branch duct or mixed type lesions. MRI is superior to CT in demonstrating the communication of a branch duct IPMN with the main pancreatic duct (MPD). Most branch duct lesions are benign whereas tumors involving the MPD are frequently associated with malignancy. The presence of solid nodules, thick enhancing walls and/or septae, a wide (> 1 cm) connection of a side-branch lesion with the MPD and the size of the tumor > 3 cm are indicative of malignancy in a branch and mixed type IPMN. A main pancreatic duct > 6 mm, a mural nodule > 3 mm and an abnormal attenuating area in the adjacent pancreatic parenchyma on CT correlates with malignant disease in main duct and mixed type IPMN. An accurate characterization of these neoplasms by imaging is thus crucial for selecting the best management options. In this article, we review the imaging findings of IPMN including imaging predictors of malignancy and surgical resectability. We also discuss follow-up strategies for patients with surgically resected IPMN and patients with incidental pancreatic cysts.

Intraductal papillary mucinous neoplasm and the pancreatic incidentaloma

Asymptomatic pancreatic lesions (APL) are a commonly encountered problem in today’s pancreatic surgical practices. Current literature regarding etiologies and incidence of APLs, particularly intraductal papillary mucinous neoplasm (IPMN), is presented. APLs constitute a wide spectrum of pathology (solid/cystic, benign/premalignant/malignant) but, overall, IPMN is now the most common diagnosis. The Sendai Guidelines and their function as a basis for risk stratification in branch duct IPMN are presented. The importance of traditionally analyzed cyst characteristics including size, presence of mucin or nodules and cyst fluid aspirate as indicators of malignancy is emphasized, noting also the potential correlation of main duct dilatation, thickened septae and elevated cyst fluid CEA with increased risk of malignancy. Current complication rates after resection of APLs are reviewed and found to be generally equivalent to those for symptomatic resections. A potential multidisciplinary treatment strategy is offered considering the costs of surgery versus repeated imaging or follow up endoscopy for these lesions. The decision for intervention is ultimately based on the Sendai Guidelines in the context of the individual patient.

Intraductal papillary mucinous neoplasm: Coming of age

Intraductal papillary mucinous neoplasm (IPMN) is a disease in evolution. Since its first description almost 30 years ago, a better understanding of the disease has steadily accrued. Yet, there are numerous challenges still for clinicians who treat this fascinating disease. A group of leading content experts on IPMN was assembled and charged with presenting cutting-edge knowledge on various topics for which they have considerable experience. This manuscript provides an historical perspective of both clinical and biological quandaries that have been resolved to date. Furthermore, it poses new avenues for investigation while highlighting the contributions of the various authors to this collective review.