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.

Coeliac disease in an adult presenting as intussusception without a lead point.

A case of adult intussusception is presented in which previously undiagnosed coeliac disease was the cause. The diagnosis was made following microscopic examination of a resected segment of small intestine containing multiple intussusception sites. Adult intussusception is rare and in most cases associated with a 'lead point' lesion, often a tumour. As illustrated here, intussusception without a lead point in the adult patient may be the presenting sign of coeliac disease. Recognition of such may allow correct diagnosis and thus prevent unnecessary surgery.

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.