I. Galanis

The effect of indwelling endoprosthesis on stone size or fragmentation after long-term treatment with biliary stenting for large stones

Background: Endoscopic biliary stenting is often used for large or difficult common bile duct (CBD) stones, but the effect of indwelling endoprosthesis on size or fragmentation of stones after long-term treatment with biliary stenting has not been formally established. We compared the stone size or fragmentation of common bile duct stones after a long period of biliary stenting. Methods: Endoscopic biliary endoprosthesis was performed for 49 high-risk patients with CBD stones too large or difficult to be extracted by conventional endoscopic means. Bile duct drainage was established in all the patients without complications. Of the patients, 24 died with endoprosthesis in situ all from causes unrelated to biliar disease; 22 underwent a second and three patients a third attempt at stone extraction. The largest stone diameter was >12 mm in all patients. Results: In 11 of 25 patients (44%) the endoprosthesis allowed resolution of the problem of unextractable common bile duct stones. Four patients showed no existence of stent, and ERCP complete stone clearance from the CBD on programmized appointment after endoprosthesis insertion. Reduced size or fragmentation of stones was obtained in seven patients, and the stones could be removed endoscopically. The remaining 14 patients demonstrated no significant change in the size or fragmentation of their stones, and endoprostheses were replaced. Conclusions: These results suggest that endoscopic endoprosthesis for large or difficult CBD stones is an effective method to clear the duct in selected cases, as well as an important definitive treatment in high-risk patients.

Malignant Fibrous Histiocytoma of the Abdominal Cavity: Report of a Case

Malignant fibrous histiocytoma (MFH) is a soft-tissue sarcoma originating from fibroblast cells, characterized by a high rate of metastasis or recurrence. This tumor rarely develops in the gastrointestinal tract, with no more than 30 cases described in the literature. We report a case of MFH of the abdominal cavity in a 45-year-old woman who presented with epigastric pain, anorexia, and weight loss. A computed tomography (CT) scan of the abdomen revealed multiple solid tumors in the peritoneal cavity. We performed exploratory laparotomy and found at least 15 solid whitish tumors attached to the wall of the small intestine, as well as to the parietal peritoneum. There were three metastases in the liver. All of the tumors were excised, most of which were about 10 cm in diameter. Histopathological findings indicated a stromal tumor consisting of spindle cells, and immunohistochemical examination of the resected specimens established the definite diagnosis of a pleomorphic MFH. The patient had an uneventful postoperative course and was given adjuvant chemotherapy. She is currently well 2 years after her operation. We review the clinical picture of this tumor in the abdominal cavity, and discuss its diagnosis, pathogenesis, and treatment.

Endoclipping for gastric perforation after endoscopic polypectomy: an alternative treatment to avoid surgery.

A 47-year-old woman underwent endoscopic polypectomy of a villous adenoma in the lesser curvature of the gastric antrum. Shortly after the procedure, she complained of severe abdominal pain. An abdominal x-ray showed air under the diaphragm, suggestive of gastric perforation. On re-endoscopy, the cavity at the site of polypectomy was closed using endoscopically applied metallic clips. She was treated with intravenous hyperalimentation, omeprazole, and antibiotics for 10 days. Ingestion of food was started 10 days after admission, and she was discharged without any complaints. She is free of symptoms on follow-up after 8 months, and endoscopy showed complete healing of the perforation. The procedure is the third described for the stomach in the English literature and emphasizes the use of endoclipping in selected cases of small and well-defined perforations.

Dieulafoy-like lesion of the colon presenting with massive lower gastrointestinal bleeding

The Dieulafoy’s lesion is a rare cause of severe gastrointestinal hemorrhage. The lesion is usually located in the stomach, although it may occur anywhere in the gastrointestinal tract. It is characterized by severe bleeding from a minute submucosal arteriole that bleeds through a punctate erosion in an otherwise normal mucosa. We describe an elderly patient who presented with severe lower gastrointestinal bleeding caused by a colonic Dieulafoy-like lesion. This is the third report of colonic Dieulafoy’s lesion treated successfully with endoscopic hemoclipping. We review the pathophysiology, clinical presentation, diagnosis, and treatment of this rare disease.

Detection of Tract Formation for Prevention of Bile Peritonitis after T-Tube Removal. Case Report

Abstract Bile leakage after removal of T-tube is a relatively rare complication caused by inadequate tract formation around the tube. We report a case of bile peritonitis after removal of a latex T-tube. The patient underwent reoperation and a new T-tube was introduced. The T-tube was removed six weeks later. Immediately after removal of the tube, the cutaneous ostium of the tube was catheterized with a thin Nelaton catheter. The administration of gastrographin showed the presence of an intact tract. The removal of the t-tube was uneventful. We would propose this method for detecting the tract after removal of the T-tube in order to prevent severe bile leakage after inadequate tract formation.

Giant villous adenoma and McKittrick–Wheelock syndrome in an incarcerated rectal prolapse

the spleen was noted. The nodule was difficult to remove, hence splenectomy was performed. Pathological examination revealed normal spleen with a nodule surrounded by adipose tissue measuring 35 mm in maximum dimension [Fig. 1]. Microscopy revealed a foreign body reaction to an eosinophilic hyaline material consistent with the use of a haemostatic substance. The patient made an uneventful postoperative period with no recurrence on follow-up.

Spermatic cord metastasis presenting as strangulated inguinal hernia – first manifestation of a multifocal colon adenocarcinoma: a case report

Spermatic cord is a rare metastatic site of colorectal cancer. We herein report a case of spermatic cord metastasis of a previous undiagnosed multifocal colon adenocarcinoma, which was clinically presented as a strangulated groin hernia.

Intrahepatic lithiasis as a late complication of hepaticojejunostomy

The development of intrahepatic lithiasis proximal to a bilodigestive anastomosis is rare. We report a case of intrahepatic lithiasis of the right hepatic duct, which developed almost 6 years after a hepaticojejunostomy performed for an iatrogenic lesion of the common hepatic duct. The patient experienced repeated episodes of acute cholangitis and was treated with intracorporeal lithotripsy and dilation of the stenosis.

A rare case of a giant renal angiomyolipoma

SummaryBackground: Angiomyolipomas (AMLs) account for about 5 % of all renal tumours. Their benign nature frequently allows them to gain excessive size before diagnosis. AMLs larger than 4 cm in diameter are more likely to become symptomatic due to intratumoral or perinephric haemorrhages.Methods: We report a case of a giant angiomyolipoma of the kidney in a 32-year-old woman.Results: The patient presented to our hospital with a 2-month history of an intermittent, vague pain and a palpable mass of the right abdomen. CT and MRI revealed an excessive mass of soft tissues originating in the right kidney. The tumour extended from the caudate lobe of the liver to the right ovary, originating in the central renal parenchyma. A fat tissue component of the internal structure was apparent. Consequent MR angiography showed that the mass received blood supply from the right renal artery, as well as from the right iliac artery. The patient was treated with radical nephrectomy. The tumour weighed approximately 1.5 kg; its size was 31×16.5×8.5 cm.Conclusions: AMLs can be treated conservatively, as long as they do not exceed 4 cm in diameter. Giant AMLs are usually symptomatic and the treatment of choice is total nephrectomy. To our knowledge, our case is one of the largest AMLs ever reported in the literature.ZusammenfassungGrundlagen: Angiomyolipome (AML) stellen 5 % aller Nierentumoren dar. Ihre gutartige Natur erlaubt ihnen häufig enorme Größe zu erreichen, bevor sie diagnostiziert werden. AML größer als 4 cm im Durchmesser können mit steigender Frequenz als intratumorale oder perirenale Blutung symptomatisch werden.Methodik: Wir beschreiben den Fall einer 32-jährigen Patientin mit einem gigantischen Angiomyolipom der rechten Niere.Ergebnisse: Die Patientin präsentierte sich in unserer Klinik mit intermittierenden Bauchschmerzen seit 2 Monaten und eine tastbare Masse im rechten Unterbauch. CT and MRI zeigten einen Weichteiltumor, der von der Leber bis zum rechten Ovar hinreichte und der von der rechten Niere zu wachsen schien. Die Masse schien auch fettige Elemente zu besitzen. Die MR-Angiographie zeigte, daß der Tumor sowohl von der rechten Nierenarterie als auch von der rechten iliakalen Arterie versorgt wurde. Die Patientin wurde einer radikalen Nephrektomie unterzogen. Der Tumor wog etwa 1,5 kg und war 31×16,5×8,5 cm groß.Schlußfolgerungen: AML können konservativ behandelt werden solange sie kleiner als 4 cm im Durchmesser sind. Gigantische AML sind symptomatisch, und das Verfahren der Wahl ist die totale Nephrektomie. Unser Fall ist einer der größten AML, die bislang in der Literatur beschrieben wurden.

Retroperitoneal Abscess Formation as a Result of Spilled Gallstones during Laparoscopic Cholecystectomy: An Unusual Case Report

One of the complications of laparoscopic cholecystectomy for gallstone disease that seems to exceed that of the traditional open method is the gallbladder perforation and gallstone spillage. Its incidence can occur in up to 40% of patients, and in most cases its course is uneventful. However in few cases an abdominal abscess can develop, which may lead to significant morbidity. Rarely an abscess formation due to spilled and lost gallstones may occur in the retroperitoneal space. We herein report the case of a female patient who presented with clinical symptoms of sepsis six months following laparoscopic cholecystectomy. Imaging investigations revealed the presence of a retroperitoneal abscess due to retained gallstones. Due to patients decision to refuse abscesss surgical drainage, she underwent CT-guided drainage. The 24-month followup of the patient has been uneventful, and the patient remains in good general condition.