Laparoscopic management of an obstructing granulocytic sarcoma of the jejunum causing intussusception in a nonleukemic patient: report of a case.

Granulocytic sarcoma is an extramedullary tumor of immature myeloid cells which is often a forerunner to the development of acute myelogenous leukemia. Granulocytic sarcoma of the gastrointestinal tract frequently involves the small intestine and often presents with abdominal pain and obstruction. Our patient presented with a proximal jejunal mass causing intussusception and obstruction. This type of manifestation has never before been reported. A laparoscopy-assisted resection of the affected portion of jejunum was performed for him. The initial pathological findings were high-grade non-Hodgkin's lymphoma; immunohistochemistry confirmed a diagnosis of granulocytic sarcoma. After a follow-up of 14 months, there was no evidence of leukemia. This condition is often mistaken for lymphoma and confirmation is necessary by immunohistochemistry. Chemotherapy is the treatment of choice and surgery is indicated only in the event of complications, such as bowel obstruction, bleeding, or perforation. The prognosis of granulocytic sarcoma is similar to that of myeloid leukemia.

Laparoscopic antrectomy for a proximal duodenal Brunner gland hamartoma.

BACKGROUND: Adenoma is the most common cause of duodenal polyps, while hamartomas are very rare. We present a patient with a preoperative histology proved diagnosis of isolated duodenal tubulovillous adenomatous polyp with high-grade dysplasia for whom we performed laparoscopic antrectomy. CASE REPORT: The patient was a 56-year-old male with vague upper abdominal pain. Investigations revealed a 3-cm x 3-cm mass arising from the duodenal mucosa with no evidence of extraserosal spread. Histopathology documented an adenomatous polyp with high-grade dysplasia, so a laparoscopic antrectomy was performed. RESULTS: The patient had an uneventful postoperative period, requiring only 2 doses of parenteral analgesics. He was discharged on the seventh postoperative day. The final histopathological findings were consistent with benign hamartoma. No recurrence has been reported after 14 months of follow-up with endoscopy. DISCUSSION: Many procedures have been described for polyps, such as endoscopic excision, duodenectomy, pancreatoduodenectomy, and laparoscopic polyp excision. In our patient, the decision to perform duodenectomy was based on the preoperative findings of a sessile tubulovillous adenomatous polyp with high-grade dysplasia. Histologically, the 2 entities can be identical, especially with the small tissue volume obtained from endoscopic biopsy. CONCLUSION: Given these observations, antrectomy was probably ideal, because endoscopic excision would have been inadequate and even dangerous while pancreatoduodenectomy would have been too radical.

Bronchoscopic lung cryobiopsy: An Indian association for bronchology position statement.

BACKGROUND: Bronchoscopic lung cryobiopsy (BLC) is a novel technique for obtaining lung tissue for the diagnosis of diffuse parenchymal lung diseases. The procedure is performed using several different variations of technique, resulting in an inconsistent diagnostic yield and a variable risk of complications. There is an unmet need for standardization of the technical aspects of BLC. METHODOLOGY: This is a position statement framed by a group comprising experts from the fields of pulmonary medicine, thoracic surgery, pathology, and radiology under the aegis of the Indian Association for Bronchology. Sixteen questions on various technical aspects of BLC were framed. A literature search was conducted using PubMed and EMBASE databases. The expert group discussed the available evidence relevant to each question through e-mail and a face-to-face meeting, and arrived at a consensus. RESULTS: The experts agreed that patients should be carefully selected for BLC after weighing the risks and benefits of the procedure. Where appropriate, consideration should be given to perform alternate procedures such as conventional transbronchial biopsy or subject the patient directly to a surgical lung biopsy. The procedure is best performed after placement of an artificial airway under sedation/general anesthesia. Fluoroscopic guidance and occlusion balloon should be utilized for positioning the cryoprobe to reduce the risk of pneumothorax and bleeding, respectively. At least four tissue specimens (with at least two of adequate size, i.e., ≥5 mm) should be obtained during the procedure from different lobes or different segments of a lobe. The histopathological findings of BLC should be interpreted by an experienced pulmonary pathologist. The final diagnosis should be made after a multidisciplinary discussion. Finally, there is a need for structured training for performing BLC. CONCLUSION: This position statement is an attempt to provide practical recommendations for the performance of BLC in DPLDs.

Laparoscopic and perineal excision of an infected "dumb-bell" shaped retrorectal epidermoid cyst.

INTRODUCTION: Extraperitoneal cysts in the pelvis adjacent to the rectum are rare entities. They are of vague etiology, and the pathologic types of the acquired variety are dermoid, epidermoid, and teratoma. As far as we know, laparoscopic excision of a retrorectal epidermoid cyst has never before been reported. CASE REPORT: The patient was an elderly lady with a large pelvic cyst and another large cyst in the perineum, which displaced the vagina and the anus. Laparoscopy was performed; the pelvic cyst was punctured and then dissected out. The perineal extension of the cyst was excised via a perineal approach. The patient had an uneventful recovery and was discharged on the 4th postoperative day. Histopathologically, the cyst was of the epidermoid type. Follow-up after 26 months revealed no recurrence. DISCUSSION: Our case presented a diagnostic dilemma. Laparoscopic excision was tedious, though we completed the procedure successfully. Precaution was taken to avoid spillage of the contents and also to avoid injury to vital structures nearby, such as the iliac vessels and ureter. It is feasible to laparoscopically excise retrorectal cysts with a careful and meticulous dissection. CONCLUSIONS: The major advantages are rapid recovery with minimal morbidity and excellent cosmesis.

Laparoscopic right hemicolectomy for goblet-cell carcinoid of the appendix: report of a rare case and literature survey.

Tumors of the appendix are rare entities, and the majority of them are discovered accidentally during an investigation for other conditions. Laparoscopic surgery for appendiceal goblet-cell carcinoid (GCC) has only been reported once before. Our patient was incidentally discovered to have an appendiceal tumor and was referred to us for laparoscopy. The tumor involved the body of the appendix and was adherent to the cecum. A laparoscopic hemicolectomy was successfully performed for the patient. Postoperative recovery was uneventful. Histopathology confirmed an appendiceal goblet-cell carcinoid. Immunohistochemistry was negative for the neuroendocrine markers, CK20 and CK7. GCC is a rare tumor of the appendix. Hemicolectomy is indicated in specific situations, such as local involvement or tumor size >2 cm. In our patient, the tumor was adherent to the cecum and tumor size was 5 cm. Therefore, a laparoscopic right hemicolectomy was performed primarily. There are several reports in the literature supporting both the laparoscopic and open approaches. Laparoscopic surgery for appendiceal tumors is safe, feasible, and even may be beneficial.

Laparoscopic right hemicolectomy for mucocele due to a low-grade appendiceal mucinous neoplasm.

Tumors of the appendix are rare entities causing mucoceles. The majority of them are discovered incidentally during investigation for other conditions. Laparoscopic surgery for appendiceal tumors is still controversial, as inadvertent rupture of the lesion due to improper handling will cause pseudomyxoma peritonei. The patient was incidentally discovered to have an appendiceal tumor and referred to us for laparoscopy. Because the tumor involved the entire appendix, a laparoscopic right hemicolectomy was performed without directly handling the tumor. Postoperative recovery was uneventful. Pathological diagnosis was low-grade appendiceal mucinous neoplasm. The safety of laparoscopic appendectomy for the management of incidentally discovered appendiceal tumors has not yet been established. Several reports in the literature support both laparoscopic and open surgery. The main concerns to be addressed are the adequacy of resection and intraperitoneal rupture of the tumor. Our patient successfully underwent laparoscopic surgery without any complications. A formal right hemicolectomy was performed because the tumor involved the entire appendix. We now think laparoscopic surgery for appendiceal tumors is safe, feasible, and even may be beneficial.

A rare cause of intermittent dysphagia: giant fibrovascular polyp of the proximal esophagus.

Fibrovascular polyps account for only 0.5-1% of all benign esophageal tumors and causes intermittent dysphagia. The patient was a 63-year-old gentleman with gradually progressive intermittent dysphagia of 40 days duration. Investigations revealed a submucosal tumor of the proximal esophagus causing luminal compromise. Excision was performed through a cervical esophagotomy and specimen was subject to histopathological examination. Postoperative recovery was uneventful and he was completely relieved of his symptoms.

Laparoscopic excision of an infected "egg-shelled" retroperitoneal pseudocyst.

Primary retroperitoneal pseudocysts are rare entities. Though laparoscopic approach has been described in their treatment, open surgical excision is still the mainstay of treatment for these lesions. We present a case of infected retroperitoneal pseudocyst and its successful laparoscopic excision. The patient was an 80-year old female. Contrast enhanced CT scan of the abdomen and ultrasonography confirmed a large retroperitoneal cyst. Laparoscopic resection was accomplished after puncturing and decompressing the cyst. There were no complications or conversion. The operating time was 176 minutes. The patient was discharged 3 days after surgery. Histopathology revealed a pseudocyst. Retroperitoneal pseudocysts can be resected laparoscopically with careful and meticulous laparoscopic dissection, utilizing the advantages of laparoscopy.

Thoracoscopic management of benign tumors of the mid-esophagus: a retrospective study.

Benign esophageal tumors are rare conditions. Traditionally, thoracotomy was the preferred route to approach these lesions. Now, increasingly more surgeons are using minimally invasive techniques to treat these benign mid-esophageal lesions. We present our experiences from a specialised minimally invasive surgery unit. We have managed 12 patients with benign tumors of the mid-esophagus from 1995 to 2007 in our institute. The enucleation was achieved with the patient placed in the prone position and approached via a right thoracoscopy in all cases. Hospital stay was 3-5 days and there were minor postoperative complications in 2 patients. Mortality was nil. There were 10 patients with leiomyoma and 2 with GISTs, as proved by immunohistochemistry. Short and long-term follow up was satisfactory, with none of the patients having recurrences or other problems. Leiomyomas and GISTs, respectively, are the commonest benign tumors of the esophagus. Tumors more than 5 cm have to be enucleated, and thoracotomy has been the traditional approach to these lesions. Thoracoscopy has definite benefits regarding reduced morbidity. The combined modality of peroperative endoscopy is useful in locating the lesion as well as confirming its complete removal. Based on our experience, a right thorax approach and the prone patient position is the ideal for thoracoscopic procedures.