A rare case of primary retroperitoneal extraovarian granulosa cell tumor

Extraovarian granulosa cell tumors (GCTs) are rare neoplasms. They arise from the ectopic gonadal tissue along the embryonal route of genital ridge. We present a case of an extraovarian tumor in an elderly female who presented with lump in the abdomen occupying the pelvic region. She was operated and the mass was excised with intact capsule. Histopathology revealed the mass to be an adult granulosa cell tumor. Extraovarian granulosa cell tumors are very rare with only 13 such cases reported in literature to date. The present case is the largest primary retroperitoneal adult granulosa cell tumor reported till date.

Influence of timing on performance of laparoscopic cholecystectomy for acute biliary pancreatitis

AIM

Gallstone disease is the most common cause of acute pancreatitis. Cholecystectomy is mandatory to avoid recurrence of pancreatitis. Our objective was to evaluate the results of laparoscopic cholecystectomy (LC) in patients with gall-stone induced pancreatitis.

METHODS

All patients presenting to us within the time frame from February 2004 to June 2008 with acute biliary pancreatitis were included in the study. The severity of pancreatitis was assessed by Ranson's criteria. ERCP and endoscopic sphincterotomy was performed when the common bile duct (CBD) was dilated (>6 mm) with either calculi or sludge as seen on imaging. Patients with successful ERCP with predicted demanding laparoscopic cholecystectomy were discharged instead for an elective LC, 4-6 weeks later. Patients with mild pancreatitis (with Ranson's score of 3 or less) and predicted uncomplicated LC underwent surgery at the same admission. The difficulty of the procedure was determined by the presence of adhesions in the gallbladder area, dissection in Calot's triangle, tackling the dilated cystic duct, intra-operative bleeding, and the need for a drain.

RESULTS

A total of 26 patients (12 male and 14 female; age range 23-75 years) with acute biliary pancreatitis comprised the study group. Eleven patients with suspected choledocholithiasis underwent ERCP and clearance of the CBD was done in all of them. Nine patients (2 ERCP and 7 non-ERCP) underwent early LC in the same admission. Seventeen patients (9 ERCP and 8 non-ERCP) were predicted as difficult cases for LC and underwent delayed LC. No patient had recurrent pancreatitis in the interval period.

CONCLUSION

There was no significant difference in the operative difficulty between early and delayed LC when patients were selected for timing of LC based on pre-defined criteria.

Varied presentations of gastrointestinal stromal tumour

Gastrointestinal stromal tumours (GIST) are soft tissue tumours arising from the mesenchyma in the gastrointestinal tract. These are rare tumours. However, over the past few years with the better understanding of the pathogenesis of GIST and better imaging facilities, the diagnosis is made more frequently. The characteristic diagnostic feature of GIST is the expression of CD34 and receptor tyrosine kinase KIT, CD117 by these tumours. The use of tyrosine kinase inhibitor imatinib mesylate has led to improved outcome. The presentation of GIST however remains non-specific, and varies depending upon the size and the organ of origin. We present a series of four cases of GIST with varied presentation.

Carcinoid tumor of bile duct

We report a 38-year-old lady with carcinoid tumor of the extrahepatic biliary tract who presented with recurrent obstructive jaundice and previous surgery for suspected choledocholithiasis. MRCP revealed a large bile duct tumor extending from the confluence up to the superior aspect of the pancreas; this was completely excised, with bilio-enteric anastomosis. These tumors are characteristically slow growing and, therefore, are amenable to aggressive surgical excision, which offers the best chance of cure.

Ischemic stricture of Roux-en-Y intestinal loop and recurrent cholangitis

The commonest complication of hepaticojejunostomy for the management of biliary strictures is recurrent cholangitis. We report a 54-year-old man who underwent choledochojejunostomy after choledochal cyst excision, and later developed ischemic stricture of the Roux-en-Y loop intestinal loop and recurrent cholangitis. The stricturous intestinal loop was excised with re-anastomosis with new Roux-en-Y loop, with uneventful recovery.

Brain abscess following esophageal dilatation

The authors report a case of brain abscess following esophageal dilatation for corrosive stricture in a 23-year-old woman. High fever and neurological findings post dilatation led us to suspect this rare complication, which was confirmed by cranial computed tomography. Prompt treatment with antibiotics and surgical drainage led to a favorable clinical outcome. This serious complication should be kept in mind when long-term treatment of corrosive stricture by repeated esophageal dilatation is planned. Prior cases of brain abscess following esophageal dilatation are reviewed.

Clinico-pathological follow-up after total colectomy and straight ileo-anal anastomosis done for ulcerative colitis

BACKGROUND

Restorative proctocolectomy is used as surgical treatment for ulcerative colitis. We have earlier documented adaptative changes in the terminal ileum after total colectomy, and straight ileo-anal anastomosis.

AIM

To correlate the morphologic and functional changes in the ileal mucosa after total colectomy and hand-sewn straight ileo-anal anastomosis for ulcerative colitis.

METHODS

Thirty consecutive patients (age range 15-50 years, 24 men) who had undergone total colectomy, rectal mucosectomy and hand-sewn straight ileo-anal anastomosis for ulcerative colitis were included in the study. These patients were followed up at 3-monthly intervals following surgery for two years and later once every year for a median duration of 9.5 (range 1-17) years. The clinical parameters studied were weight gain, frequency of stools, nature of stools, nocturnal stool frequency and need for antidiarrheal drugs. At each follow-up visit they were subjected to per rectal ileoscopy with ileal biopsy and barium enema. Ileal biopsy was analyzed histologically and histochemically.

RESULTS

The clinical features improved over time, with average weight gain of 5 (range 1-7) Kg at one year. Frequency of stools decreased from 8-10 per day to 2-3 per day. The stools became semisolid and there was no need for antidiarrheal drug by the end of one year. All the patients showed adaptative changes in the ileum. The ileal mucosa was completely transformed into colonic type by the end of one year, colonoscopically (spacious lumen characteristic of colon), radiologically (disappearance of ileal characteristics with rectosigmoid-like appearance), histologically (blunting of villi with increase in goblet cells), and histochemically (sialomucin pattern to sulfomucin pattern).

CONCLUSIONS

The ileum undergoes adaptative changes with corresponding improvement of clinical parameters over time, after proctocolectomy and ileoanal anastomosis for ulcerative colitis.

Self-bougienage: long-term relief of corrosive esophageal strictures

BACKGROUND

Corrosive esophageal strictures require dilatation at frequent intervals.

OBJECTIVE

To determine the efficacy of self-dilatation in treatment of corrosive esophageal strictures.

METHODS

Retrospective analysis of data from 51 patients with corrosive esophageal strictures seen in a surgical unit. Eighteen patients underwent per-oral antegrade dilatation of stricture using gum elastic bougies (Group I); 15 patients underwent retrograde dilatation with endless string using an India rubber dilator devised at the authors' institution, followed by per-oral antegrade dilatation (Group II); 15 patients underwent retrograde dilatation followed by antegrade dilatation with endless string through esophagostomy (Group III). In three patients with stricture of the entire esophagus, endless string could not be passed; they were subjected to esophagocoloplasty. All patients were taught self-dilatation with gum elastic bougies as the final step, and were put on a progressive, domiciliary, self-dilatation program. Quarterly follow up was done for one year, to ascertain whether self-bougienage was being performed properly.

RESULTS

All patients responded well to treatment, with significant relief of dysphagia and improvement in health and barium study findings. Six patients developed mediastinitis (3, 2 and 1 in Groups I, II and III, respectively) during initial dilatation; all improved with conservative management. Only one patient who failed to carry out self-bougienage had to be readmitted and retrained in the procedure, after which he remained asymptomatic.

CONCLUSIONS

Patients with corrosive esophageal strictures can be treated with a long-term self-bougienage program, which avoids the need for frequent hospital admissions for esophageal dilatation.