Appendicular Neuroendocrine Neoplasm is Associated with Acute Appendicitis - Don't Miss the Boat.

Background: Appendicular neuroendocrine neoplasms (ANEN) are rare tumours diagnosed incidentally on histology after an appendicectomy carried out for acute appendicitis. Five years survival rate of node-negative an early ANEN is over 90%. However, the growing interest, among clinicians, to treat appendicitis by antibiotics only, could potentially miss these indolent tumours. The aim of our study was to look at the incidence and management of ANEN discovered in appendicectomy specimens carried out for acute appendicitis. Methods: A retrospective review was performed for all patients undergone appendicectomy, at Barnsley hospital from 2009 to 2015, as suspected acute appendicitis, with particular focus on incidence, investigations and outcome of ANEN. Results: During 2009-2015, 1562 appendicectomies were carried out for acute appendicitis, with 11 specimens showed neuroendocrine tumours (0.70%). Mean age of patients was 31.73 years, with 81.8% female. 8 patients had laparoscopic appendicectomy (72.7%), 2 had open appendicectomy (18.2%), while one had laparoscopic converted to open appendicectomy. Tumour size was less 10 mm in 6 patients (54.5%), between 10-20 mm in 4 (36.4%). Majority were located at the body/base of appendix (54.5%). All tumours were grade 1 well differentiated tumours. 9 patients had clear resection margins, while two patients needed further surgery as an open right hemicolectomy as a curative procedure. In our series, 3 patients (27.27%) had follow up scans 2 years after surgery and showed no tumour recurrence. Conclusion: Appendicectomy is the curative procedure for the majority of ANEN. As shown in our study, if acute appendicitis is managed with conservative treatment only, there is less than 1% risk of missing the diagnosis of ANEN. Also, two of our patients had locally advanced diseases. These could definitely have a poor prognosis without ap-pendectomy.

A Rare Pathology of Difficult Laparoscopic Cholecystectomy: Xanthogranulomatous Cholecystitis.

Xanthogranulomatous cholecystitis (XGC) is a rare inflammatory condition of the gallbladder (GB). Preoperatively, it is a diagnostic challenge. One thousand and seventy nine laparoscopic cholecystectomy (LC) patients from September 2012 to June 2015 were retrospectively reviewed. Fourteen patients were identified with XGC. An analysis was carried out on this group of patients looking at postoperative pathology results, preoperative radiology, operative findings and outcome. The overall frequency of XGC was 1.3%. A thick walled GB was found in 11 patients on preoperative imaging. Retrospectively suggestive feature thick gallbladder walls with low attenuation mural nodules. No suspicion of cancer was demonstrated in the final histology or preoperatively. Five cases (36%) perforated intraoperatively. Although all were surgically challenging, no conversions to open were performed. The perforation risk could be higher. A difficult cholecystectomy should alert a surgeon to consider XGC as a diagnosis. Contrary to the popular belief, XGC was found to be difficult to differentiate from infection rather than malignancy.

Duodenal biopsies for the diagnosis of coeliac disease: are we adhering to current guidance?

BACKGROUND: The British Society of Gastroenterology guidelines recommend taking at least four duodenal biopsy specimens at the time of upper gastrointestinal (UGI) endoscopy if coeliac disease (CD) is suspected and it has been shown to increase the diagnostic yield of CD. We assessed the compliance to these guidelines within our institution. We then applied measures to improve our compliance rate and assessed the resulting impact on our diagnostic rate of CD. METHODS: We performed a retrospective audit of electronic records for all patients, with no prior diagnosis of CD, who underwent UGI endoscopy with duodenal biopsies between August 2014 and May 2015. We implemented measures to raise awareness among endoscopy users at our institution and carried out a reaudit between February and May 2016. RESULTS: 924 patients were found to be eligible in the first part of the study and 278 in the second part. The proportion of patients who had ≥4 biopsy specimens submitted increased from 21.9% to 60.8% (p<0.001). The diagnostic rate of CD increased from 3.5% in the audit group to 7.6% in the reaudit group (p=0.004). A positive serology result and suspected CD as an indication for biopsy were found to be independent predictors of the likelihood of complying with guidelines. CONCLUSIONS: Our study suggests that taking <4 duodenal biopsy specimens to assess for the presence of CD may lead to the diagnosis of CD being missed. Simple measures can improve the local compliance rate to current guidelines.

Acalculous Phrygian cap cholecystitis.

We report a case of a 53-year-old Caucasian woman who presented with symptoms of cholecystitis; an ultrasound and CT scans showed a mass lesion associated with the gallbladder and no gallstones. Laparoscopic cholecystectomy and further histological analysis confirmed acalculous cholecystitis in a Phrygian cap gallbladder.

Support expectations of cancer patients.

Patients' satisfaction is a paramount in the delivery of health care provisions, particularly in patients with poor prognosis. Effective communication with such patients helps in achieving a better satisfaction score. A survey was conducted on upper gastrointestinal cancer patients to assess their perceived satisfaction regarding the healthcare received. A frank but supportive communication helps in meeting the expectations of these patients in their cancer journey.

Endoscopic management of migrated biliary stent causing sigmoid perforation.

Endoscopically deployed biliary stents are a well established method for dealing with biliary diseases. Perforation of the gut secondary to migrated biliary stent is reported in less than 1% cases. The authors present the first case of a colonic perforation from migrated biliary stent which was managed endoscopically. An 82-year-old female had a biliary stent for a postcholecystectomy bile leak and presented 6 months later with left iliac fossa pain. Barium enema showed a stent perforating the sigmoid colon. In view of the patient's frailty and absence of peritonitis, an endoscopic retrieval of stent was attempted. Flexible sigmoidoscopy showed a stent partially embedded within the sigmoid diverticulum which was successfully removed and the defect was closed endoscopically using three titanium clips. She had an uncomplicated recovery following the procedure and was discharged home on the second day following the procedure.

Laparoscopic enterolithotomy is a valid option to treat gallstone ileus.

Gallstone ileus is a well-recognized clinical entity. It usually affects elderly female patients, and very often diagnosis can be delayed resulting in high morbidity and mortality. An abdominal x-ray and computed tomographic (CT) scan of the abdomen may show classical radiological features of small bowel obstruction, pneumobilia, and an ectopic gallstone. Laparotomy and enterlithotomy with or without definite biliary surgery is an established treatment. Since 1992, many cases of laparoscopic-assisted enterolithotomy have been reported. Only a few cases of a totally laparoscopic approach have been documented. We present the case of a 75-year-old lady who presented with features of intestinal obstruction. A plain x-ray of the abdomen and a CT scan confirmed the classical features of gallstone ileus. A totally laparoscopic enterolithotomy was performed using 6 ports. A 6-cm gallstone was retrieved through a longitudinal enterotomy. The transverse closure of the enterotomy was performed with intracorporeal suturing, resulting in an uneventful postoperative recovery. We suggest that a CT scan helps in the early diagnosis of the cause of intestinal obstruction, and totally laparoscopic enterolithomy with intracorporeal enterotomy repair is a valid, safe option.

Laparoscopic excision of heterotopic pancreas of stomach.

Heterotopic pancreas (HP) in stomach is a rare pathological entity that poses clinical dilemma for diagnosis and management. It carries a risk of developing serious benign and malignant complications. This is a case of 37-year-old lady who presented with dyspeptic symptoms and was found to have a 1.5 cm umblicated lesion in the distal stomach on gastroscopy. Endoscopic biopsy showed normal gastric mucosa and CT scan of stomach did not show any specific abnormality. A laparoscopic wedge excision was performed. Histology showed features of heterotopic pancreas. Endoscopic and histological pictures are presented to increase the awareness of this rare entity. Laparoscopic wedge excision's of a localized HP is recommended as a safe procedure to achieve diagnosis and plan for further management.

Gallstone Ileus Associated with Synchronous Carcinoid Strictures of the Small Bowel.

INTRODUCTION: Gallstone ileus and synchronous two carcinoids of small bowel, both pathologies have no known pathological reasons to be associated with each other and are not known to be together in one patient. CASE REPORT: We present a case of a 72-year-old lady who presented with small bowel obstruction as an emergency. At laparotomy we found gall stones entrapped between two carcinoid strictures in ileum. Segmental small bowel resection was performed without disturbing the biliary pathology. CONCLUSION: Association of these two pathologies in a single patient causing small bowel obstruction has never been reported. Importance of a thorough laparotomy is emphasized.

Heterotopic pancreas of the gallbladder associated with chronic cholecystitis.

CONTEXT: The presentation of heterotopic pancreas with cholecystolithiasis is exceedingly rare. Very few cases have been reported in the literature. The clinical significance so far is unclear. CASE REPORT: We report a case of a 20-year-old female, suffering with biliary colic. On clinical examination abdomen was unremarkable. Ultrasonographic examination shows suspicion of a single stone in the gallbladder. Her liver functions were slightly abnormal. MRCP did not show any abnormality in the gallbladder and the common bile duct was of normal caliber. She underwent a successful laparoscopic cholecystectomy and her symptoms resolved. Pathological examination of the gallbladder revealed an area of heterotopic pancreas. CONCLUSION: The preoperative diagnosis of heterotopic pancreas in the gallbladder is difficult. The significance of incidental finding of heterotopic pancreas in unclear and requires a systematic review of the subject.

Surgical management of gall bladder carcinoma.

CaGB is a rare form of cancer and its association with gallstone disease should be recognised. Although overall prognosis is poor, early diagnosis of CaGB and radical surgery provides better outcome. Careful examination of the specimen should be performed to determine the short-term outcome and long-term prognosis.