Methods of safe laparoscopic cholecystectomy for left-sided (sinistroposition) gallbladder: A report of two cases and a review of safe techniques.

INTRODUCTION: Left-sided gallbladder is a rare anatomical variation. Usually it is discovered intra-operatively and is accompanied by anatomic variations that can prove quite challenging during laparoscopy. PRESENTATION OF CASE: From a total of almost 3000 laparoscopic cholecystectomies performed in our institution, two cases of left sided gallbladder were unexpectantly identified intraoperatively. There were no indications for the ectopy preoperatively. In both cases modifications of the standard laparoscopic technique were mandatory. They were performed safely with no post-operative complications. Modifications consisted of transposition of the subxiphoid entry port and alteration in the direction of traction of the rest of the graspers. A review of the literature for methods of safe laparoscopic cholecystectomy was conducted. DISCUSSION: The surgeon must be aware of the anatomic variances in the rare occasion of a left sided gallbladder, since preoperative diagnosis is very difficult. CONCLUSION: Knowledge of potential hazards and modifications of laparoscopic technique is mandatory in order to avoid complications.

Bilateral obturator pyomyositis with visceral involvement in an immunocompetent adult patient treated without surgery.

BACKGROUND: Primary pyomyositis is a rare bacterial infection that affects large muscle groups mainly in immunocompromised patients. Treatment options include antibiotic treatment with surgical or radiologic interventions. CASE: A 22-year-old immunocompetent athlete was diagnosed with bilateral obturator muscle pyomyositis involving pelvic floor muscles and the urinary bladder after muscle injury during training. Intravenous antibiotic treatment was administered, resulting in eradication of the infection. CONCLUSION: This is the first case of bilateral obturator pyomyositis with coexisting involvement of pelvic floor muscles (levator ani) and viscera (urinary bladder) treated exclusively and with success by the administration of appropriate antibiotic therapy. A non-operative approach may could be attempted for the avoidance of postoperative morbidity and complications, especially when early clinical suspicion and diagnostic work-up lead to early diagnosis.

Suggestion for a new grading scale for radiation induced pneumonitis based on radiological findings of computerized tomography: correlation with clinical and radiotherapeutic parameters in lung cancer patients.

BACKGROUND: The objective of this research is the computed axial tomography (CT) imaging grading of radiation induced pneumonitis (RP) and its correlation with clinical and radiotherapeutic parameters. MATERIALS AND METHODS: The chest CT films of 20 patients with non-small cell lung cancer who have undergone three- dimensional conformal radiation therapy were reviewed. The proposed CT grading of RP is supported on solely radiological diagnosis criteria and distinguishes five grades. The manifestation of RP was also correlated with any positive pre-existing chronic obstructive pulmonary disease (COPD) history, smoking history, the FEV1 value, and the dosimetric variable V20. RESULTS: The CT grading of RP was as follows: 3 patients (15%) presented with ground glass opacity (grade 1), 9 patients (45%) were classified as grade 2, 7 patients (35%) presented with focal consolidation, with or without elements of fibrosis (grade 3), and only one patient (5%) presented with opacity with accompanying atelectasis and loss of pulmonary volume (grade 4). Both univariate and multivariate analysis revealed as prognostic factors for the radiological grading of RP the reduction of FEV1 and the V20 (P=0.026 and P=0.003, respectively). There was also a significant (P<0.001) correlation of radiological grading of RP with FEV1 and V20 (spearman rho 0.92 and 0.93, respectively). CONCLUSIONS: The high correlation of the proposed radiological grading with the FEV1 and the V20 is giving a satisfactory clinical validity. Although the proposed grading scale seems relevant to clinical practice, further studies are needed for the confirmation of its validity and reliability.

Intrapancreatic accessory spleen issues: diagnostic and therapeutic challenges.

CONTEXT: Intrapancreatic accessory spleen is an exceptionally rare entity, commonly mistaken for a pancreatic neoplasm. Preoperative diagnosis based on radiologic imaging features is difficult. Aspiration cytology may be misleading due to poor sampling. CASE REPORT: We report a very rare case of an intrapancreatic accessory spleen which radiologically and cytologically mimicked a neuroendocrine pancreatic tumor. CONCLUSION: Modern imaging techniques will probably lead to an increasing number of intrapancreatic accessory spleens being discovered, posing significant diagnostic and therapeutic challenges.

Does clamping during liver surgery predispose to thrombosis of the hepatic veins? Analysis of 210 cases.

AIM: To test whether clamping during liver surgery predisposes to hepatic vein thrombosis. METHODS: We performed a retrospective analysis of 210 patients who underwent liver resection with simultaneous inflow and outflow occlusion. Intraoperatively, flow in the hepatic veins was assessed by Doppler ultrasonography during the reperfusion phase. Postoperatively, patency of the hepatic veins was assessed by contrast-enhanced CT angiography, when necessary after 3-6 mo follow up. RESULTS: Twelve patients (5.7%) developed intraoperative liver remnant swelling. However, intraoperative ultrasonography did not reveal evidence of hepatic vein thrombosis. In three of these patients a kinking of the common trunk of the middle and left hepatic veins hindering outflow was recognized and was managed successfully by suturing the liver remnant to the diaphragm. Twenty three patients (10.9%) who developed signs of mild outflow obstruction postoperatively, had no evidence of thrombi in the hepatic veins or flow disturbances on ultrasonography and contrast-enhanced CT angiography, while hospitalized. Long term assessment of the patency of the hepatic veins over a 3-6 mo follow-up period did not reveal thrombi formation or clinical manifestations of outflow obstruction. CONCLUSION: Extrahepatic dissection and clamping of the hepatic veins does not predispose to clinically important thrombosis.

Evaluation of the therapeutic response to In-111-DTPA octreotide-based targeted therapy in liver metastatic neuroendocrine tumors according to CT/MRI/US findings.

Thirteen (13) patients with liver neuroendocrine carcinomas metastases, positive for somatostatin receptors, confirmed by scintigraphy were infused with 4070-7030 MBq per session of In-111-octreotide after selective hepatic catheterization, exploiting the catastrophic activity of Indium Auger and Internal Conversion electron emission on cell DNA. Evaluation of the treatment was assessed by ultrasonography (US) as well as by computed tomography and/or magnetic resonance imaging scans. US appears to be the imaging procedure of choice because the examination is sensitive for evaluating lesions' edema and cystic components, provides precise measurement of tumor size, and is inexpensive. Degeneration US signs were classified in stage I (an echolucent rim in the periphery of the lesion), stage IIa (lesion with large cystic spaces), stage IIb (tiny cystic spaces) and stage III (absorption of the cystic component or stable cystic remnants).