Cholelithiasis in gallbladder cancer: coincidence, cofactor, or cause!

BACKGROUND: While gallstones are associated with cancers of the gallbladder, the actual nature of their relationship needs to be clarified. This would aid the recommendations on the need for prophylactic cholecystectomy. METHODS: A systematic search of the scientific literature was carried out using the Medline, the Embase, and the Cochrane Central Register of Controlled Trials for the years 1891-2009 to obtain access to all publications involving gallstones in gallbladder cancer. RESULTS: While some epidemiological evidence supports a causal relationship for gallstones in gallbladder cancer, other studies have demonstrated a relatively low incidence of gallbladder cancer in countries reporting a high incidence of gallstones as a whole. In those studies where gallstones appear to have a causative role for cancer, the risk increases with increasing size, volume and weight, and number of the stones. The impact of duration of the stone or its composition is not clear. Experimental evidence from studies examining the impact of artificially introducing gallstones in the gallbladder has failed to lead to carcinogenesis. CONCLUSIONS: The evidence at the current time indicates that gallstones are a cofactor in the causation of gallbladder cancer. Absolute proof of their role as a cause for gallbladder cancer is lacking. The recommendation for prophylactic cholecystectomy in countries reporting a high incidence of gallbladder cancer and associated gallstones needs to be tailored to the epidemiological profile of the place.

Laparoscopic biopsy in patients with abdominal lymphadenopathy.

BACKGROUND: Abdominal lymphadenopathy (AL) - a common clinical scenario faced by clinicians - often poses a diagnostic challenge. In the absence of palpable peripheral nodes, tissue has to be obtained from the abdominal nodes by image-guided biopsy or surgery. In this context a laparoscopic biopsy avoids the morbidity of a laparotomy. AIM: This retrospective analysis of prospectively collected data represents our experience with laparoscopic biopsy of abdominal lymph nodes. MATERIALS AND METHODS: Between October 2000 and November 2005, 28 patients with AL underwent laparoscopic biopsy. Pre-operative radiological imaging studies had identified a nodal mass in 20, a solitary node in 1, a cold abscess in 1 and a mesenteric cystic lesion in 1 patient. In five patients with chronic right lower abdominal pain and normal ultra-sonographic findings mesenteric nodes were identified and biopsied during diagnostic laparoscopy. RESULTS: The sites of biopsied lymph nodes included para-aortic (10), mesenteric (8), external iliac (3), left gastric (2), obturator (1), aorto-caval (1) and porta hepatis (1). One patient with enlarged peripancreatic nodes mass and another with a mesenteric cystic mass had cold abscesses drained in addition to biopsy. There were no perioperative complications and the median postoperative stay was 2 days (range 1-4 days). Histopathology revealed tuberculosis in 23 patients, reactive adenitis in 2, lymphoma in 1 metastatic carcinoma in 1, and a retroperitoneal sarcoma in 1. CONCLUSIONS: In patients with AL, laparoscopy provides a safe and effective means of obtaining biopsy. It is of particular value in patients in whom (a) the nodes are small or present in locations unsuitable for image-guided biopsy, (b) adequate tissue cannot be obtained by image-guided biopsy or (c) previously undiagnosed lymphadenopathy is encountered during diagnostic laparoscopy.

Vacuum-assisted abdominal wall lift for minimal-access surgery: a porcine model study.

Carbon dioxide pneumoperitoneum, although used universally in laparoscopy, has several well-documented complications and disadvantages. The authors describe a simple method of creating vacuum between a rigid shell and the abdominal wall in a porcine model to create adequate operative space for minimal-access surgery, which does not requires carbon dioxide, does not raise intraabdominal pressure, and is safe, cost effective, and feasible. The proposed device and method could be useful wherever basic laparoscopic equipment and a vacuum pump are available, including many parts of the developing world. The study was carried out with three groups using individual porcine models for each study. Group 1 was studied for feasibility of abdominal wall lift, adequacy of intraabdominal space, optimal vacuum levels, and safety and efficacy of the procedure. Group 2 was subjected to laparoscopic cholecystectomy and salpingectomy. Group 3 was studied for 2 days and 8 days after the animals were subjected to prolonged, high-level vacuum and monitored every 24 h to establish long-term effects. In all three groups the safety and efficacy of the proposed method were established, as well as the absence of physiological or histological alterations.

Breakage of fascial closure device during laparoscopic surgery.

Breakage of instruments during laparoscopic surgery is rare. However, when it does occur, locating and retrieving the broken part of the instrument can be cumbersome. Moreover, inability to do so may carry serious medicolegal implications. We report a patient in whom the tip of a fascial closure device broke during laparoscopic surgery. This was located by intraoperative fluoroscopy and retrieved from the extraperitoneal plane via a small incision. The paper discusses the probable factors responsible for breakage of the fascial closure device in our patient and reviews the previously reported cases of the rare complication of breakage of instruments during laparoscopic surgery.

Diagnostic laparoscopy.

Diagnostic laparoscopy began in a surgical unit in a developing country in 1972. The developers of this technique aimed to hasten diagnosis, reduce patient distress, and improve bed utilization in an overcrowded teaching hospital wherein simple investigations such as x-rays took weeks to materialize. Over a period of 18 years reaching to 1990, 3,200 diagnostic laparoscopies were performed on adults under local anesthesia with no mortality, a complication rate of 0.09%, an 84% diagnosis rate, and 74% undergoing histologic biopsies targeting a wide spectrum of pathology. The equipment cost spread out over the 3,200 patients works out to 30 rupees (0.60 dollar) per patient. With the availability of noninvasive diagnostic aids such as ultrasound, computed tomography, and magnetic resonance imaging used US, CT, MRI under the control of target biopsy, the role of diagnostic laparoscopy has altered. Since 1990, clinicians have had the sophistication of the video camera and the pneumoperitoneum insufflator. Diagnostic laparoscopy is used for the evaluation of liver and peritoneal pathology, abdominal tuberculosis, malignancy, acute abdomen, and abdominal trauma. It often is a prelude to laparoscopic treatment of the underlying pathology, specifically in cases of acute appendicitis.

Laparoscopic appendicectomy.

The clinical diagnosis of appendicular pathology has an unacceptably high false-positive rate, particularly in premenopausal women. Diagnostic laparoscopy is a significant aid towards accurate diagnosis. Laparoscopic appendicectomy can be safely and economically performed as a logical sequel to diagnostic laparoscopy. We describe our method of safe and cost-effective laparoscopic appendicectomy.

Laparoscopic surgery in the developing world. An overview of the Indian scene.

We present experience of laparoscopic surgery commencing in 1972 with diagnostic laparoscopy in a Surgical Unit in Bombay. By 1990 we had completed 2800 diagnostic laparoscopies with no mortality, 0.08% complication rate, 85% positive diagnosis and an instrument cost of about Rs. 35 (US $ 1.2) per patient. We have over the past 5 years performed 890 laparoscopic cholecystectomies (LC) with no mortality, no blood transfusion, and one CBD injury. With reusable equipment, monopolar diathermy and selective cholangiography, LC is cost-efficient in a developing country. Over this period over 60 laparoscopic appendectomies were performed, with the use of catgut ligatures and self-made endo-loops. laparoscopic appendectomy is cost-effective under our conditions. We have done 46 hernia repairs, and by contrast find it far more expensive and with inferior results to standard hernia repair. Advanced laparoscopy for ulcer and reflux disease, bowel resection, retroperitoneal and thoracic laparoscopy are being given a trial in several centres in the developing world.

Laparoscopic cholecystectomy in India.

The first 100 cases of laparoscopic cholecystectomy carried out in a "developing country" are studied. There were 77 females and 23 males. The mean age was 48 years (24-82 years). There was no mortality and 2% morbidity. The mean operative time was two hours and 15 minutes in the first 50 cases, one hour and 50 minutes in the subsequent 50. Twelve cases were converted to open surgery, nine within the first 50 cases, three in the subsequent 50. In developing countries the challenge of financial constraints as also a different spectrum of abdominal pathology calls for greater efforts of innovation and improvization. However, the rewards of laparoscopic cholecystectomy as compared to open cholecystectomy are significant in developing countries in terms of shorter hospitalisation (3.6 vs. 13 days), early return to work (12 vs. 36 days), better hospital bed utilization, and reduced expense.

Mixed tumour of salivary gland type of the male breast.

Benign breast tumours with a mixed cartilaginous and epithelial component are distinctly rare as evident from the literature. A case of Mixed Tumour of the breast presenting pre-operatively as a hard mass in a 65 year old male is reported. Histologically, it was composed of a mixture of benign cartilage, myoepithelial cells, tubules and a myxoid stroma in fat. A brief review of cartilage bearing lesions and mixed tumour in the mammary region is discussed.

Primary Budd-Chiari syndrome: its significance for the choice of surgical management of a patent right inferior hepatic vein.

Budd-Chiari syndrome is still a major problem and the overall prognosis for the patients is dismal and disappointing. The case history of a patient with not only outflow obstruction of the hepatic vein but also complete obstruction of the retrohepatic inferior vena cava is presented. She had a patent right inferior hepatic vein which partially decompressed the liver via a rich network of venous collaterals. Management included an inferior vena cava to inferior vena cava shunt using a Goretex graft. The patient fared well and the postoperative course was satisfactory. The case history of this patient illustrates the importance of precise pre-operative investigations for the choice of the type of surgical management. Each patient has to be considered individually on the basis of his or her mechanical peculiarities.