[Rare neuroendocrine carcinoma of the gall bladder. Coincidental occurrence of an endometrioid ovarian adenocarcinoma]

HISTORY AND CLINICAL FINDINGS

The histological investigation of a surgical specimen (after cholecystectomy) from a 73-year-old woman revealed a poorly differentiated carcinoma with glandular structures and a lymph node metastasis.

INVESTIGATIONS

Comparative immunochemistry, done to exclude metastatic growth of the previously demonstrated endometrioid ovarian carcinoma, was (1) negative for CK7 and CA125, positive for CK20, chromogranin A and synaptophysin (gall bladder and lymph node metastasis); (2) positive for CK7 and CA125, negative for CK20, chromogranin A and synaptophysin (ovary).

DIAGNOSIS

The tumor lesion within the gall bladder and lymph node was classified as a neuroendocrine carcinoma, not a metastasis of the ovarian carcinoma.

TREATMENT AND CLINICAL COURSE

The patient underwent another laparotomy with resection of the stump of the cystic duct and the liver parenchyma surrounding the former gall bladder, including dissection of the lymph nodes within the hepatoduodenal ligament. After 14 months another metastasis of the neuroendocrine carcinoma of the gall bladder was found. But for eight years there has been no recurrence of the endometrioid adenocarcinoma of the left ovary.

CONCLUSION

Because of the increasing incidence of malignant diseases and second neoplasms there is a growing need for such diagnostic tests as histological and immunohistochemical analysis. This is the first case, according to the available literature, of an endometrioid adenocarcinoma of the ovary concomitant with a neuroendocrine carcinoma of the gall bladder.

"Hemosuccus pancreaticus"--primarily ultrasound-guided successful intervention using transcutaneous fibrin glue application and histoacryl injection

There is a broad spectrum of causes for upper gastrointestinal (GI) bleeding that can be stopped by various approaches. On the basis of the report of an extraordinary case, the favorable minimally invasive approach of applying fibrin glue and histoacryl/lipiodol to the vascular basis of a bleeding pseudoaneurysm leading to "Hemosuccus pancreaticus" as a rare cause of recurrent bleeding in the upper GI tract and dangerous complications in the case of chronic pancreatitis is described. There were recurrent bleeding episodes within the upper GI tract in a 40-year-old female patient. Her medical history was significant for chronic pancreatitis and pseudocyst. Abdominal ultrasound plus duplex ultrasonography revealed a pseudoaneurysm within the tail of the pancreas as the cause of "Hemosuccus pancreaticus". Ultrasound guidance was used to repeatedly apply 2 ml of fibrin glue and 2 x 2 ml of the mixture of lipiodol and histoacryl to the basis of the pseudoaneurysm which led to complete and permanent cessation of the bleeding. Immediate and follow-up control duplex ultrasonographies (up to one year) demonstrated sufficient exclusion of the pseudoaneurysm but a preservation of the lienal artery with no disturbance of the blood perfusion in the splenic parenchyma. In conclusion, this is one of the first reports of the successful cessation of recurrent bleeding into a pseudocyst out of pseudoaneurysm ("Hemosuccus pancreaticus") by an ultrasound-guided transcutaneous fibrin glue and histoacryl/lipiodol application, which 1. is recommended as an alternative but feasible and safe therapeutic tool, 2. can provide sufficient and permanent cessation of bleeding but preserve the perfusion of the natural vessel as an initial step in the possible therapeutic algorithm, and 3. can avoid, in case of success, more invasive approaches such as angiography-guided embolization with coils or implantation of a prosthesis and even open surgical intervention, in particular, in high-risk patients.

[Tubercular fibrosing conjunctivitis associated with facial cutaneous tuberculosis]

BACKGROUND

Tuberculous conjunctivitis has been described only rarely during the course of lupus vulgaris. We report a case of hemifacial cutaneous tuberculosis, diagnosed as atypical lupus vulgaris, associated with homolateral fibrosing tuberculous conjunctivitis.

PATIENTS AND METHODS

An 83-year-old woman presented inflammatory conjunctivitis without bullous involvement in the left eye leading to corneal neovascularisation, symblepharons and ptosis. Erythematous and atrophic papules were seen on the left side of the face. Biopsy of the skin and conjunctiva revealed a tuberculoid granulomatous infiltrate. Bacterial culture and PCR were both positive for Mycobacterium tuberculosis.

DISCUSSION

This case illustrates the need to consider tuberculosis when faced with an atypical facial eruption and ocular involvement.

A nationwide survey on bariatric surgery in Germany--results 2005-2007

BACKGROUND

Most studies on bariatric surgery outcomes are performed as clinical trials or reflect the clinical experience in single centers. The status of bariatric surgery in Germany has been examined since January 1st, 2005 with the cooperation of clinics and hospitals at the Institute of Quality Assurance in Surgery at the Otto-von-Guericke University of Magdeburg (Germany).

METHODS

In this prospective multicenter observational study, the data obtained for all primary bariatric procedures, including all repeated operations, performed on consecutive patients with morbid obesity at participating hospitals from 2005 to 2007 were prospectively collected using an Internet online data registry. In particular, perioperative characteristics, such as the spectrum of diagnostic measurements, type of surgical procedures, and short- and long-term outcomes, were investigated.

RESULTS

During the study period, 629 surgical procedures were performed at 21 hospitals in 2005, 828 procedures at 32 hospitals in 2006, and 1,666 procedures at 35 hospitals in 2007. In 2005 and 2006, gastric banding was the most frequently performed operation, followed by the Roux-en-Y gastric bypass (RYGBP). In 2007, a RYGBP was carried out in 42.1% of all bariatric procedures. Among all patients, 74.4% were female. The mean body mass index (BMI) was 48.5 kg/m(2) in 2005, 48.4 kg/m(2) in 2006, and 48.0 kg/m(2) in 2007. Follow-up data after 12 months were available for 63.8% of the patients in 2005 and 2006; these data showed greater reduction of BMI after malabsorptive rather than restrictive bariatric procedures. The mortality was 0.1% (30 days) and 0.16% (overall).

CONCLUSION

As indicated by the worldwide trend, there is an ongoing change from restrictive bariatric procedures to malabsorptive procedures and sleeve gastrectomy. Although the BMIs of German patients undergoing bariatric surgery appear to be substantially higher than those of patients from most other countries, there were no differences in intraoperative and short-term complications or in overall outcomes during follow-up when compared with published studies.

[Closure of a common iliac artery stump aneurysm after implantation of a bifurcational prosthesis. Combination of coil embolization and occlusion emulsion injection for iatrogenic bleeding]

Interventional radiology has an increasing spectrum of indications, in particular, for vascular medical problems. By Seldinger's puncture via the right femoral artery, an aneurysm of the right common iliac artery stump was sufficiently excluded with coil embolization. As a complication, an iatrogenic bleeding at the aneurysmatic neck was effectively stopped after the first interventional step with injection of an occlusion emulsion according to the bleeding site. Image-guided interventional measures in radiology allow a minimal invasive approach in a former classical field of vascular surgery. Furthermore, procedure-related complications can be increasingly controlled.

The metagenomics RAST server - a public resource for the automatic phylogenetic and functional analysis of metagenomes

Background

Random community genomes (metagenomes) are now commonly used to study microbes in different environments. Over the past few years, the major challenge associated with metagenomics shifted from generating to analyzing sequences. High-throughput, low-cost next-generation sequencing has provided access to metagenomics to a wide range of researchers.

Results

A high-throughput pipeline has been constructed to provide high-performance computing to all researchers interested in using metagenomics. The pipeline produces automated functional assignments of sequences in the metagenome by comparing both protein and nucleotide databases. Phylogenetic and functional summaries of the metagenomes are generated, and tools for comparative metagenomics are incorporated into the standard views. User access is controlled to ensure data privacy, but the collaborative environment underpinning the service provides a framework for sharing datasets between multiple users. In the metagenomics RAST, all users retain full control of their data, and everything is available for download in a variety of formats.

Conclusion

The open-source metagenomics RAST service provides a new paradigm for the annotation and analysis of metagenomes. With built-in support for multiple data sources and a back end that houses abstract data types, the metagenomics RAST is stable, extensible, and freely available to all researchers. This service has removed one of the primary bottlenecks in metagenome sequence analysis – the availability of high-performance computing for annotating the data.

Experiences of two centers of bariatric surgery in the treatment of intragastrale band migration after gastric banding-the importance of the German multicenter observational study for quality assurance in obesity surgery 2005 and 2006

BACKGROUND

Adjustable silicone gastric banding (ASGB) is an effective treatment in morbid obesity. Band migration is a long-term complication. Causes, clinical symptoms, timing and incidence are investigated in single centres only. In Germany, since January 1st, 2005, practice in bariatric surgery has been investigated in German prospective multicenter trial for quality assurance in obesity surgery.

MATERIALS AND METHODS

All patients underwent ASGB in two centres of bariatric surgery in Germany were prospectively registered using a computer-based data form. Patients with band migration were retrospectively evaluated, in particular, causes and characteristics of its management. The results were correlated with data obtained from the German prospective multicentre trial.

RESULTS

In total, 493 patients were enrolled in the study from February 1995 to February 2007. The follow-up rate was 79.9% (mean follow-up time period, 78.7 months; range, 2-148 months). Fifteen patients (3.0%) developed migration. In 14 cases, migration occurred within the range of 30-86 months after implantation. In one case, migration occurred 10 months after repositioning of the band. In the German multicentre trial, 629 patients underwent surgery during 2005 and 827 patients in 2006. In both periods, 74.4% of the patients were female and 25.6% male. The most frequently performed operation was ASGB (46.8%) followed by Roux-en-Y gastric bypass (38.5%).

CONCLUSION

Band migration requires band removal. Different symptoms and complications influence the kind of band removal. Multicentre data were evident in the case of high long-term complication rate after ASGB. Data of the German multicentre trial show the trend from restrictive bariatric procedures to malabsorptive approach.

[Antegrade aortomesenteric revascularisation originating from the supracoeliac aortic segment--a promising surgical option in chronic ischaemia of the visceral arteries]

INTRODUCTION

Ischaemia of the visceral arteries is considered to be an extraordinary challenge in the interdisciplinary therapeutic management.

AIM AND METHOD

Using a case series of patients with chronic ischaemia of the visceral arteries, our diagnostic and therapeutic experience was analysed with regard to postoperative quality of life (increase of body weight, frequency in daily diarrhoea), perioperative morbidity and hospital mortality in dependence on the type of surgical reconstruction of the visceral arteries.

RESULTS

During a time period of 2 years, 3 patients (male/female=1:2; mean age, 61.7 years) underwent surgical interventions on the visceral arteries from a total of 1118 vascular interventions (main indication revealed by colonoscopy and pathohistology of mucosal biopsy: ischaemic colitis). In all cases, symptomatology was affected by abdominal angina. Duplex sonography, angiography, and multislice CT scan revealed the combination of an occlusion of the coeliac trunk and of the superior mesenteric artery by atherosclerosis in 2 cases. In the remaining case, there was an isolated occlusion at the origin of the superior mesenteric artery. For revascularisation, the aortomesenteric reconstruction was subdivided according to the: i) target vessel: -combination of revascularised common hepatic artery and superior mesenteric artery (n=1) with an autologous Y-vein bypass ("reversed technique"), -exclusive revascularisation of the superior mesenteric artery (n=2)-prosthetic bypass; ii) origin of the bypass: -from the supracoeliac aortic segment (antegrade) n=3 (primarily in patients 1 and 3; as a redo operation in patient 2); -from the infrarenal segment (retrograde) n=1 (initial surgical intervention in patient 2) using an autologous venous bypass. In all cases, a significant improvement of the quality of life was observed as indicated by an increase of body weight (n=3; +no further abdominal angina) and primary wound healing in all 3 cases (hospital mortality, 0).

CONCLUSION

Chronic ischaemia of the visceral arteries is characterised by an increasing incidence and a stealthy onset and requires an interdisciplinary approach to find the correct diagnosis using all available diagnostic procedures including sufficient periodic follow-up investigations. We favour the antegrade aortomesenteric revascularisation from the supracoeliac aortic segment as a promising surgical option in chronic ischaemia of visceral arteries.

[The spectrum of war-like injuries in children and teenagers during a post-war wave of violence in Iraq]

BACKGROUND

In developing countries, war-like injury involving civilians, including children, is still a relevant and massive health problem and the human and economic costs of the injuries are tremendous.

OBJECTIVE

The aim of this study is to report on the spectrum of war-like injuries and their management in children and teenagers in an Iraqi surgical centre during a post-war wave of violence.

PATIENTS AND METHODS

All consecutive war-like injuries in children and teenagers younger than 16 years were documented in a clinical observational study (study design: Case series), who were treated during the time period of employment of the reporting author at the Casualty Unit of the University Hospital in Al Kadhimiyia (UHK), Baghdad (Iraq), over a 2-year period. The cases were studied with regard to descriptive criteria such as demographic patient characteristics, cause, site(s), and combination of injuries as well as their surgical management; among other factors, the specialty-depending distribution and outcome characterised by mortality were evaluated. Representative photographs have been selected from the photographic documentation in most cases.

RESULTS

From March 2003 to March 2005, 272 injured children and teenagers aged 16 years or less were enrolled in the study. The injuries in the majority of the casualties were caused by explosions in civilian areas, mortar bombardment of civilian buildings and housing, and family assassinations. The injuries were more common in males with a male to female ratio of 3.1 : 1; 206 (75.7 %) of the casualities were males and 66 (24.3 %) were females. Of the 272 casualties studied, 52 (19.1 %) were 5 years old or less, 95 (34.9 %) were between 6 to 11 years, and 125 (45.9 %) were between 12 to 16 years old. There were 126 (46.3 %) minor casualties, who were managed in the outpatient emergency unit, while 146 (53.6 %) casualties had serious and major injuries, 120 (44.1 %) of whom were admitted to UHK and 6 were transferred to other hospitals. Twenty (7 %) casualties died (12 on arrival and 8 during resuscitation) and two casualties were discharged at their parents demand shortly after admission without receiving adequate medical care. Fragmentation weapons (blast injuries) caused 216 (79.4 %) casualties, 54 (19.8 %) casualties experienced gunshot wounds and 2 (0.7 %) substantial burns. Injuries to the lower limbs and trunk were the most common injuries in this series accounting for 126 (46.3 %) of all injuries.

CONCLUSION

There is a considerable risk not only for adolescents but even for children under conditions similar to those of civil war. However, the challenge is to provide an appropriate treatment in spite of the potential severity of injuries. This requires an adequate logistic management, surgical expertise as well as equipment and even the collaboration with surgical centres from supporting countries.

Surgery of inferior vena cava associated malignant tumor lesions

BACKGROUND

Tumor lesions of the inferior vena cava (IVC) can originate from the vein or can develop by malignant tumor infiltration from the surrounding tissue. In this context, particular attention should be paid to tumor lesions with pegs into or within the IVC. The aim of this series of a single surgical center was to analyze the perioperative management, the individual-specific and -adapted surgical technique, as well as the outcome including prognostic considerations in IVC-associated malignant tumor lesions.

PATIENTS AND METHODS

Over a 6-year time period, all consecutive patients with IVC-associated malignant tumor lesions and their patient- and finding-specific characteristics were registered, data and parameters of the diagnostic and therapeutic management were documented, and both the short- and long-term outcomes (complication rate, perioperative morbidity/mortality, tumor recurrence rate, survival) were assessed with periodic follow-up investigations.

RESULTS

Overall, 12 patients were enrolled in the study from 1/1/2001-31/12/2006:6 primary IVC-tumors (leiomyosarcomas, 50%) and 6 secondary IVC-tumors (2 retroperitoneal tumor lesions, 16.7%, 3 renal cell carcinomas 25% and 1 carcinoma of the adrenal gland, 8.3%). 4 of the secondary tumors had pegs into the IVC. The RO resection rate was 83%. The perioperative morbidity was 33%; whereas, the hospital mortality was 8.3% (n = 1). Surgical reconstruction of IVC was achieved in each case (100%). There was a mean postoperative observation period of 20 months (range, 1-58 months). Complete follow-up documentation was obtained for all of the patients (100%). Three patients experienced recurrent tumor growth (27.5% out of n = 11). While the overall mortality through the follow up observation period was 27.5%, the tumor-specific mortality was 16%.

CONCLUSIONS

The primary surgical aim is RO resection to provide a long-term outcome with no tumor recurrence including the reconstruction of the IVC based on a reasonable risk-to-benefit ratio. The favorable outcome of this case series demonstrates that IVC-associated tumor lesions can be approached if there is an appropriate expertise of the surgical team, a sufficient perioperative management and an adequate financial background with a reasonable survival rate. The variable prognosis of the various tumor lesions depends on tumor entity, stage, resection status and individual risk factors.

Correlation of endoscopic ultrasonography (EUS) for differential diagnostics between inflammatory and neoplastic lesions of the papilla of Vater and the peripapillary region with results of histologic investigation

PURPOSE

There is currently no imaging procedure that allows precise differentiation between inflammatory and malignant lesions of the papilla of Vater (papilla) in a satisfying manner. The aim was to study whether endoscopic ultrasonography (EUS) as an initial diagnostic step 1. may have the potential to distinguish between different tissue characteristics, such as tumor growth or inflammation of the papilla, because of its high resolution capacity and 2. is superior to the accuracy of histologic investigations of mucosal biopsies by means of a prospective collection and retrospective evaluation of the data.

PATIENTS AND METHODS

Between 1995 and 2002, a significant pathologic finding in the papilla and the peripapillary region was revealed using EUS in 311 patients (overall, 4,832 EUS investigations); the comparison of this suspicion with the results of histologic investigation was only possible in 183 subjects. In 133/183 patients, a biopsy for histologic investigation was not able to be obtained prior to the use of EUS. Diagnosis was set up using EUS, which tried to differentiate between benign or malignant lesions of the papilla. Histologic investigation of the 133 tumor lesions of the papilla became possible by taking deep transpapillary biopsies following papillotomy, papillectomy or by obtaining specimens from surgical resections.

RESULTS

Using EUS, differentiation between inflammatory and neoplastic lesions of the papilla or the peripapillary region was correct in 109 of 133 cases (82%), while suspected EUS-based diagnosis "papillitis stenosans" (inflammatory lesions of the papilla of Vater) in 4 subjects (3%) was corrected to adenoma and carcinoma, respectively (n=2 each) by histologic investigation. In 20 of 133 patients with suspected neoplastic lesions, inflammatory lesion of the papilla of Vater was detected resulting in an overall sensitivity of 92.3% and specificity of 75.3%.

CONCLUSIONS

EUS makes it possible to detect small intraampullary tumors and segmental thickening of the wall of the prepapillary biliary duct, which cannot be revealed by conventional imaging. In patients with biliary symptoms, EUS can reliably visualize and characterize a malignant lesion as a first diagnostic tool (detection rate, 82%) and may be considered the basis for subsequent diagnostic steps for verifying diagnosis correctly, e. g., using histologic investigation.

[Acute blepharoptosis caused by fibrous dysplasia]

We report a case of fibrous dysplasia revealed by acute ptosis in a 38-year-old patient. Ophthalmologic examination disclosed a moderate right ptosis. The rest of the results were strictly normal except for a known facial asymmetry. Visual acuity was 20/20 in both eyes, there was no extrinsic or intrinsic oculomotor disorder, and funduscopy was normal. Given this acute presentation, emergency cerebral imagery was carried out, providing a diagnosis of fibrous dysplasia with orbital and cavernous repercussions, with no sign of cerebral disorder or obvious vascular lesion. Progression was marked by a regression of the ptosis. Fibrous dysplasia is a rare pathology but presents varied clinical presentations. The authors present the broad characteristics of this pathology and the management of an acquired ptosis. They discuss the possible mechanisms involved in the drop of the right upper eyelid of this patient and the therapeutic solutions.

Differential influence of the ventral subiculum on dopaminergic responses observed in core and dorsomedial shell subregions of the nucleus accumbens in latent inhibition

It has previously been reported that dopamine (DA) responses observed in the core and dorsomedial shell parts of the nucleus accumbens (Nacc) in latent inhibition (LI) are dependent on the left entorhinal cortex (ENT). The present study was designed to investigate the influence of the left ventral subiculum (SUB) closely linked to the ENT on the DA responses obtained in the Nacc during LI, using an aversive conditioned olfactory paradigm and in vivo voltammetry in freely moving rats. In the first (pre-exposure) session, functional blockade of the left SUB was achieved by local microinjection of tetrodotoxin (TTX). In the second session, rats were aversively conditioned to banana odor, the conditional stimulus (CS). In the retention (test) session the results were as follows: (1) pre-exposed (PE) conditioned animals microinjected with TTX, displayed aversion toward the CS; (2) in the core part of the Nacc, for PE-TTX-conditioned rats as for non-pre-exposed (NPE) conditioned animals, DA levels remained close to the baseline whereas DA variations in both groups were significantly different from the DA increases observed in PE-conditioned rats microinjected with the solvent (phosphate-buffered saline (PBS)); (3) in the shell part of the Nacc, for PE-TTX-conditioned rats, DA variations were close to or above the baseline. They were situated between the rapid DA increases observed in NPE-conditioned animals and the transient DA decreases obtained in PE-PBS-conditioned animals. These findings suggest that, in parallel to the left ENT, the left SUB controls DA LI-related responses in the Nacc. The present data may also offer new insight into the pathophysiology of schizophrenia.