Cholecystocolonic fistula with a giant colonic gallstone: the mainstay of treatment in an acute setting.

A cholecystoenteric fistula (CEF) is a rare complication of cholelithiasis with cholecystitis. Cholecystocolonic fistulas (CCFs) account for 8-26.5% of all CEFs. CCFs can cause colonic bleeding, obstruction or perforation, with such complications being mainly reported in the narrower sigmoid colon. Colonic biliary ileus, or obstruction due to the colonic gallstone impaction, is extremely rare in the proximal colon and its best management is yet to be elucidated. We present the case of a 73-year-old male patient with multiple comorbidities and previous abdominal surgeries who presented with hematochezia and intestinal obstructive symptoms. Imaging revealed a giant 5 × 7 cm2 gallstone in the proximal transverse colon. Laparotomy and stone extraction via colotomy were performed. Complicated proximal colonic gallstones are exceedingly rare with several operative and non-operative treatments already described. A time-saving surgery in a patient with serious comorbidities is reasonable when compared to a more extensive procedure including enterolithotomy, cholecystecomy and fistula closure.

Massive mesenteric panniculitis due to fibromuscular dysplasia of the inferior mesenteric artery: a case report.

BACKGROUND: Fibromuscular dysplasia (FMD) is a nonatheromatous, noninflammatory arterial disorder of unknown etiology resulting in vessel stenosis and/or aneurysm formation. The renal and cephalocervical (mainly carotid arteries) arterial beds are classically involved; involvement of visceral arteries is rare. Mesenteric panniculitis (MP) is an inflammatory process of mesenteric fat considered to be of unknown etiology. The majority of cases involve the small bowel mesentery; colorectal MP is rare. To our knowledge, no example of MP due to FMD has been described. CASE PRESENTATION: A 52 year old man presented with steadily worsening lower abdominal pain. Investigation revealed ischemic rectosigmoid mucosa associated with a large mesenteric mass of unknown nature. Angiography showed the disease was limited to the distribution of the inferior mesenteric artery. Subsequent symptoms of large bowel obstruction necessitated a left hemicolectomy. Pathologic examination showed bowel wall necrosis and massive panniculitis of the rectosigmoid due to FMD. Subsequent angiographic imaging of other vascular beds was negative. CONCLUSIONS: Several features of this case are noteworthy: FMD limited to the inferior mesenteric artery has not been previously reported, FMD has not previously been implicated as a cause of MP, and the massive extent of panniculitis. An accompanying literature review of cases of visceral FMD, traditionally believed to almost exclusively affect females, highlights a greater than anticipated number of males (33%), and a gender difference regarding concomitant involvement of cephalocervical and/or renal vascular beds (32% in males versus 80% in females). The latter observation may have implications regarding the value of radiologic screening of other vascular beds, particularly in asymptomatic males, in patients presenting with visceral artery FMD.

Pheochromocytoma presenting as inverted Takotsubo cardiomyopathy: a case report and review of the literature.

The classical entity of Takotsubo cardiomyopathy is well established in the literature, but mechanisms explaining it remain unelucidated. Recently, the uncommon inverted Takotsubo type (sparing apical ballooning) has been more frequently described. We report the case of a 26-year-old man admitted with gastrointestinal symptoms, whose clinical presentation for a stress-related cardiomyopathy, which usually presents with cardiopulmonary symptoms, was rather atypical. The cardiac assessment including echocardiography and cardiac magnetic resonance imaging (MRI) demonstrated a dilated cardiomyopathy, whereas coronary angiography showed the absence of atherosclerotic disease. The abdominal computed tomography (CT) scan revealed a left adrenal mass, and elevated urinary catecholamine levels were highly suggestive of a pheochromocytoma. Prompt medical and surgical treatments were instituted. During the left adrenalectomy the patient suffered from brief electromechanical dissociation requiring aggressive resuscitation. Postoperative course was unremarkable. Reverse Takotsubo heart failure is a recently recognized syndrome and a systematic review of the literature of 10 cases of pheochromocytoma-induced inverted Takotsubo is presented in the present article.

Medullary colon cancer presenting with total necrosis of all regional lymph node metastases: morphologic description of a presumed immune-mediated event.

Medullary carcinoma is a rare type of colon cancer with characteristic clinical and molecular features. Notably, despite its high-grade histology, the prognosis is generally better than for colonic adenocarcinoma of the usual type. We present herein a singular case of medullary colon cancer in which all of numerous lymph node metastases in the surgical resection specimen were completely necrotic in the face of a wholly viable primary tumor. Possible mechanisms are discussed with emphasis on immune-mediated factors.Virtual Slides: The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/13000_2014_204.

What is so odd about odds?

In clinical studies, the relative likelihood of an event occurring between 2 groups is often expressed as the risk ratio (RR) or the odds ratio (OR). The RR is an intuitive parameter that is relatively easy to interpret. Quantitative interpretation of an OR is much more difficult and is often incorrectly equated to that of an RR. The problem is that OR may differ substantially from RR, especially when the outcome of interest is common in the study population. This article explains and clarifies controversial issues surrounding the use and interpretation of the OR. Theoretical concepts relating to ORs are illustrated by examples from the surgical literature. By reviewing articles from 5 surgical journals over a 5-year period, we show that the OR is often presented and misinterpreted as equivalent to the RR. When the discrepancy is large, using OR uncritically as an estimate of RR will strongly bias inferences about treatment effect or cause of disease by amplifying the apparent strength of an association between an exposure and an outcome.

Giant splenic artery aneurysms: case report and review of the literature.

Although splenic artery aneurysms (SAAs) are the most common visceral aneurysms, giant SAAs >10 cm in diameter have rarely been reported. We present the case of a 67-year-old asymptomatic man who was diagnosed with a 15-cm SAA in the absence of a clear etiologic factor. The patient underwent open surgical repair. A medial visceral rotation was performed to gain good vascular control and subsequently the aneurysm was ligated from within. A systematic review was carried out, allowing us to analyze 12 cases of giant SAAs >10 cm published to date. The difference in terms of demographics, clinical presentation, and arterial location between the giant SAA group and usual SAAs may indicate a different underlying physiopathology that remains unclear at this time.

A study of the effect of temperature on the pharmacokinetic profile of raltitrexed administered by intraperitoneal route in the rat.

BACKGROUND: Because heat can improve the activity of selected drugs when administered heated in the peritoneal cavity in the treatment of peritoneal carcinomatosis from colorectal origin, there is a great interest to evaluate new cytotoxic agents in this context. The purpose of this study is to assess the effect of heat on the pharmacokinetic profile of Raltitrexed administered intraperitoneally in rats. MATERIAL/METHODS: Rats #1 to #40 have been submitted to different doses of intraperitoneal Raltitrexed (2, 4, and 8 mg/m2) at different perfusion temperatures (37, 40 and 43 degrees C). After 25 minutes of perfusion, peritoneal fluid, portal and systemic blood were harvested and prepared for dosage of Raltitrexed. Rats #41 to #50 have been submitted to 8 mg/m2 of intraperitoneal Raltitrexed (37 and 43 degrees C) during 25 minutes. Then, a segment of small bowel and a section of parietal peritoneum were harvested and prepared for intracellular dosage of Raltitrexed. RESULTS: The dose of Raltitrexed administered is a determinant of its concentration in peritoneal perfusate, in portal vein blood and in systemic blood (p < 0.0002). We noticed that perfusate temperature had no significant effect on the concentration of drug in the portal vein blood (p = 0.29) and in the systemic blood (p = 0.25). However, temperature increased significantly (p < 0.04) the intracellular absorption of Raltitrexed. CONCLUSIONS: Because the effect of Raltitrexed is proportional to its intracellular concentration, it seems clear that Raltitrexed is of greatest interest when administered heated in the peritoneum because it can reach greater intracellular concentrations without a significant increase in systemic concentration, which is responsible of toxicity.

Phase I study on sentinel lymph node mapping in colon cancer: a preliminary report.

BACKGROUND AND OBJECTIVES: Lymph node (LN) metastasis is one of the most significant prognostic factor in colorectal cancer. In fact, therapeutic decisions are based on LN status. However, multiple studies have reported on the limitations of the conventional pathological LN examination techniques, and therefore, the actual number of patients with LN positive colorectal cancer is probably underestimated. We assume that lymphatic tumor dissemination follows an orderly sequential route. We report here a simple and harmless coloration technique that was recently elaborated, and that allows us to identify the sentinel LN(s) (SLN) or first relay LNs in colorectal cancer patients. The main endpoint of this clinical trial is the feasibility of the technique. METHODS: Twenty patients treated by surgery for a colic cancer were admitted in this protocol. A subserosal peritumoral injection of lymphazurin 1% was performed 10 min before completing the colic resection. A pathologist immediately examined the specimens, harvested the colored SLN, and examined them by serial cuts (200 microm) with H&E staining, followed by immunohistochemical staining (AE1-AE3 cytokeratin markers), when serial sections were classified as cancer free. RESULTS: The preoperative identification of the SLN was impossible in at least 50 of the cases, however, SLNs were identified by the pathologist in 90% of cases. In two patients (10%) SLN was never identified. The average number of SLN was 3.9. Immunohistochemical analysis of the SLN has potentially changed the initial staging (from Dukes B to Dukes C) for 5 of the 20 patients (25%). On the other hand, there was one patient (5%) with hepatic metastasis from adenocarcinoma for whom SLN pathology was negative for metastasis (skip metastasis). CONCLUSIONS: SLN biopsy is readily feasible with identification of SLN in at least 90% of patients with colorectal cancers. Our results indicate that 45% of patients initially staged as Dukes B had tumor cells identified in their SLN when these were subjected to our protocol. This represented a 25% upgrading rate when our complete study population is considered. However, controversy persist about the clinical significance and metastatic potential of these often very small clusters of tumor cells.