Caput medusae sign; a unique finding during abdominal examination in patients with portal hypertension; case report

Grading operative findings at laparoscopic cholecystectomy following the new scoring system in Duhok governorate: Cross sectional study

Introduction

Numerous preoperative scoring systems predict difficult laparoscopic cholecystectomy. Recently, the intraoperative difficulties which are facing surgeons are studied. A new scoring system categorize patients according to many intraoperative findings with a final outcome whether converting to open cholecystectomy or continuing laparoscopically.

Patients and methods

This prospective study included 120 patients admitted for laparoscopic cholecystectomy for symptomatic gallstones from October 2019 to August 2020. Intraoperative difficulties were evaluated and patients were categorized according to intraoperative scoring for cholecystitis severity and compared depending to the rate of conversion to the open technique.

Results

Most patient were middle aged females having multiple gallstones, the mean operation time was 35 min and 7.8% of patients were converted to open cholecystectomy because of intraoperative difficulty.

There was a significant correlation between the conversion rate and each of distended and/or contracted gall bladder, inability to grasp the gall bladder with traumatic forceps, stone ≥1 cm impacted in Hartman's pouch, and bile or pus outside gallbladder (P values: 0.002, 0.000, 0.008 and 0.015) respectively, and no significant correlation with gallbladder adhesions, adhesions from previous upper abdominal surgery, BMI>30, and Time to identify cystic artery and duct >90 min (P values: 0.123, 1, 1, 0.078) respectively.

Conclusion

New intraoperative scoring systems are valuable in predicting difficulties and preventing increase operation time and possible injuries. The main points of difficulties are distended or contracted gallbladder, large stone impaction, difficult grasping the wall of the gall bladder and the presence of bile or pus outside the gall bladder.

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Laparoscopic cholecystectomy is a safe procedure with some difficulties.

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The definition of difficult LC is not well established until now.

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Recently intraoperative difficulties facing the surgeons are studied.

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Inflammation, adhesions, and obesity are some factors for difficulty.

Duodenal gangliocytic paraganglioma: A very rare cause for upper gastrointestinal bleeding: Case report with review of literature

INTRODUCTION

Gangliocytic paraganglioma is a rare tumors mainly arises from the second part of the duodenum. The tumor is generally benign, but some cases are associated with lymph node or distant metastasis. It must be differentiated from other tumors. The main treatment is good local surgical resection. Most patients have good prognosis after an appropriate resection.

CASE PRESENTATION

A 47-year-old male patient presented with recurrent attacks of epigastric pain and melena. The general examination revealed pallor with no jaundice. The abdomen was soft with no tenderness. There were no stigmata of chronic liver diseases. The hemoglobin level was 8 gm/dl with normal liver and renal functions. The patients received compatible blood. Endoscopy showed a large pedunculated polyp with ulceration in the second part of the duodenum just distal to ampulla of Vater. During surgery, the anterior wall of duodenum was opened, and a 4 cm pedunculated polyp was excised which was arising from the posterior wall of the duodenum just distal to the ampulla of Vater. The frozen section examination revealed a benign lesion. The final histopathology result was consistent with the diagnosis of gangliocytic paraganglioma. The patient had smooth post-operative recovery and no postoperative complications.

CONCLUSIONS

Gangliocytic paraganglioma is a rare tumor which mostly affects the second part of the duodenum. The tumor is considered benign but the possibility of the malignancy with lymphatic and distant metastases must be excluded before any surgery. The management plan must be addressed carefully and continuous follow up is recommended.