Choledochal Cyst in Adults: Etiopathogenesis, Presentation, Management, and Outcome-Case Series and Review.

Background. Choledochal cyst, a rare congenital cystic dilatation of biliary tree, is uncommon in adults. Their presentations differ from children and surgical management has evolved. Methods. A retrospective review of the records of all the patients above 15 years, who underwent therapeutic intervention in our hospital, was carried out. Results. Ten cases of choledochal cyst were found; 8 female, with mean age 31 years. These included 8 cases of Todani type I and one case each of type II and type III. The predominant symptoms were abdominal pain and jaundice. Abdominal mass and past history of cholangitis and pancreatitis were seen in 2 patients. Investigations included ultrasound in 8 patients, CT in 7, ERCP in 3, and MRCP in 5. Surgical intervention included complete excision of the cyst with hepaticojejunostomy and cholecystectomy (type I), excision of the diverticulum (type II), and ERCP sphincterotomy (type III). Malignancy was not seen in any patients. The long-term postoperative complications included cholangitis in two patients. Conclusion. Choledochal cyst is rare in adults. The typical triad of abdominal pain, jaundice, and mass is uncommon in adults. The surgical strategy aims for single stage complete excision of the cyst with hepaticojejunostomy.

Large duodenal gastrointestinal stromal tumor presenting with acute bleeding managed by a whipple resection. A review of surgical options and the prognostic indicators of outcome.

CONTEXT: Duodenal gastrointestinal stromal tumors (GISTs) are uncommon and constitute a relatively small subset of GISTs which presents a unique dilemma having various surgical options. A case of a large ulcerating duodenal GIST arising from the second and third parts of the duodenum and involving the pancreas which was managed by a Whipple resection is presented. The literature is also reviewed to present the current status on surgical options, outcome, prognostic indicators and the role of imatinib mesylate in its management. CASE REPORT: A 58-year-old patient presented with acute gastrointestinal bleeding which was diagnosed to be due to a duodenal GIST following CT scan and endoscopic biopsy. The mass which measured about 10x9 cm originated from the 2nd part and extended into the 3rd part of the duodenum. He underwent a Whipple resection, and histopathology confirmed a duodenal GIST having a greater than 10 mitotic count per fifty high power field and areas of necrosis. Postoperatively, he received imatinib mesylate 400 mg bid; however, 4 months later, he presented with multiple disseminated peritoneal metastases and succumbed to the disease 2 months later. CONCLUSION: GISTs of the duodenum which are small in size and do not involve the papilla of Vater are better resolved using a limited resection of the duodenum since the outcome in terms of operative risk or disease recurrence is not influenced in these cases. However, large tumors with more extensive involvement would require a pancreaticoduodenectomy to achieve adequate tumor clearance. Even though duodenal GISTs have a relatively better prognosis as compared to GISTs at other sites, their aggressiveness ranges from small indolent tumors to aggressive sarcomas. Following tumor resection, a recurrence rate of about 40% has been reported. A more favorable prognosis in duodenal GISTs is attributed to a lower prevalence of P53 loss, the duodenal location of the tumor, a smaller size of the lesion and a low mitotic count. Imatinib mesylate is reported to play a role in neoadjuvant therapy as well as in the management of metastatic and recurrent disease, although some of these tumors may fail to respond.

Portal vein thrombosis postlaparoscopic splenectomy presenting with infarction of gut: review of risk factors, investigations, postoperative surveillance, and management.

Portal vein thrombosis after laparoscopic splenectomy is a known complication even though it is underappreciated. Presenting symptoms are usually mild and nonspecific. Progression to intestinal infarction and portal hypertension are potentially life threatening complications. The short hospital stay associated with laparoscopic approach could delay early diagnosis, unless routine imaging studies is planned after discharge. We present a patient who after laparoscopic splenectomy for idiopathic thrombocytopenic purpura developed portal vein thrombosis leading to infarction of small intestine 9 days after the surgery. She made uneventful recovery after resection and anticoagulation. Literature is reviewed to assess the risk factors and discuss the present status regarding investigations, surveillance in postoperative period, management of established case, and role of prophylactic anticoagulation.

Pancreatic metastasis from colon carcinoma nine years after a hemicolectomy managed by distal pancreatectomy. A review of the literature regarding the role and outcome of pancreatic resection for colorectal metastasis.

CONTEXT: Pancreatic metastasis from colorectal malignancy is rare and accounts for less than 2% of all pancreatic metastases. A case of colonic metastasis to the pancreas is reported and the literature is reviewed to assess the role and outcome of pancreatic resection for metastatic tumors from colorectal malignancy. CASE REPORT: A 58-year-old female underwent an emergency left hemicolectomy for an obstructing descending colon growth. The lesion was reported to be adenocarcinoma, Dukes C, with involvement of the serosa and 3 lymph nodes. A postoperative staging CT scan showed no other metastases and she received 6 cycles of FOLFOX chemotherapy (folinic acid, 5-flurouracil and oxaliplatin). Nine years after the colectomy during a routine follow-up, there was a sudden rise in her CEA levels. A CT scan revealed a 6.8x4.8 cm mixed consistency lesion in the tail of the pancreas which, on fine needle aspiration cytology, was confirmed to be adenocarcinoma. She underwent a distal pancreatectomy, and histopathology of the resected specimen confirmed a metastatic tumor from colon cancer. She then received 5 cycles of adjuvant chemotherapy. She was symptom free for nine months and subsequently succumbed to recurrent disease. CONCLUSION: Pancreatic metastasis from colorectal malignancy is rare. These patients could be asymptomatic in 17% of cases. The time-interval between the diagnosis of colorectal cancer and the detection of pancreatic metastasis varies widely but is approximately 24 months. The median survival time for post-pancreatic resection is 16 months. Pancreatic resection appears to offer good palliation until recurrence of the disease occurs and the possibility of long term cure is rare.

Laparoscopic Splenectomy Using LigaSure.

BACKGROUND: Laparoscopic splenectomy (LS) has become the standard approach for most splenectomy cases. Bleeding is the main complication and cause for conversion. We present our experience with the LigaSure and discuss its advantage as a vessel sealing system in achieving safe vascular control. METHOD: Over a 3-year period, we performed 12 consecutive LS using LigaSure at a single center. A literature review of all the patients who had undergone laparoscopic splenectomy with of the LigaSure to achieve vascular control at the hilum was carried out, assessing its advantages and outcome. RESULTS: Twelve LS were performed. Eleven of these patients had ITP, and one patient had sickle cell disease. The mean blood loss was 70mL (range, 50 to 460), and operating time was 126 minutes (range, 110 to 240). Two postoperative complications occurred: portal vein thrombosis in one case and subphrenic collection in the other. The literature review revealed 8 studies with 231 cases in which the LigaSure was used to perform laparoscopic splenectomy. A significant reduction in operating time (average 102 minutes) and intraabdominal blood loss (66mL) was observed with the LigaSure compared with endostaplers. CONCLUSION: The use of LigaSure and the semilateral position results in a gain of time and safety in addition to low intraoperative bleeding, need for transfusion, minimal complications and a low conversion rate.

Splenic flexure volvulus presenting with gangrene.

Volvulus of the splenic flexure is very rare cause of colonic obstruction constituting 2% of cases of colonic segmental volvulus. Primary splenic flexure volvulus (SFV) is due to congenital absence or laxity of the phrenocolic, gastro colic, and splenocolic ligaments while secondary volvulus is due to other causes including some prior surgery releasing these ligaments. A preoperative diagnosis can be established based on the characteristic radiological findings on plain x-ray abdomen and CT scan. We present a case of SFV in a young man who presented with acute abdominal pain, and distension, and illustrate the usefulness of CT scan, and plain x-ray of the abdomen in making a preoperative diagnosis. Laparotomy revealed a gangrenous SFV, which was resected and primary anastomosis was carried out. Literature is reviewed with regards to predisposing factors, presentation, investigation, and management among the more than 32 cases reported so far.

Papillary Carcinoma of the Thyroid Presenting Primarily as Cervical Lymphadenopathy: An approach to management.

Papillary carcinoma of thyroid usually presents as a palpable thyroid mass. This could be associated with pain, hoarseness, stridor or dysphagia. Rarely, it presents solely as cervical lympadenopthy in the presence of an otherwise grossly normal thyroid gland. This could pose management problems. We report here a middle-aged lady who presented with cervical lymphadenopathy which on fine needle aspiration cytology was confirmed as metastatic papillary thyroid carcinoma. The thyroid gland was, however, normal on clinical examination and radiological investigations. Neck exploration confirmed a grossly normal thyroid gland; however, the cervical lymph node was found to invade the internal jugular vein. She underwent a total thyroidectomy and unilateral functional block dissection with resection of the involved segment of the internal jugular vein. Histopathology confirmed metastasis in the lymph node and a 2mm sized microcarcinoma in the resected thyroid gland. A radioactive iodine scan in the postoperative period revealed no other metastasis. The patient was prescribed lifelong thyroxine. She is on regular follow-up and 4 years following surgery continues to do well.

Isolated agenesis of the gallbladder.

We report a rare case of agenesis of the gallbladder, which was misdiagnosed as cholecystitis. This is the first reported case from the Middle East. Despite advances in biliary imaging, the diagnosis is usually made at surgery. Like most patients, our patient became asymptomatic after the surgery. Extensive dissection to exclude the presence of gallbladder in an ectopic site is discouraged.