Kee-Hwan Kim

PANCREATIC ABSCESS CAUSED BY GASTRIC PERFORATION

A 73-year-old man visited the emergency department with a 4-day history of diffuse upper abdominal pain and fever. On admission, he was haemodynamically stable but appeared septic, with a temperature of 38.5 C. A physical examination showed left upper quadrant and left flank tenderness. Through a computed tomography (CT) scan, an air-containing cystic mass (11 cm · 6 cm in size) and a non-enhancing linear-opaque structure were observed in the tail of the pancreas (Fig. 1). We suspected that the abscess had developed because of bowel perforation caused by foreign bodies (FB). An emergent laparotomy was undertaken and a large cystic mass was found in the tail of pancreas, which severely adhering to the posterior wall of the stomach and the splenic hilum. A 4-cm long fish bone was found in the abscess cavity, which had penetrated through the posterior gastric wall. The fish bone was extracted and the perforation site was closed using 3:0 Vicryl sutures (Ethicon Inc., Somerville, NJ, USA). Distal pancreatectomy and splenectomy were carried out. The patient was discharged, well, on the 16th postoperative day. Foreign body ingestion is a common clinical problem, but most ingested FB do not cause any harm and pass uneventfully through the gastrointestinal tract (GIT) within 1week. GIT perforation is rare, occurring in less than 1% of the patients.1 FB perforation of the GIT may also be followed by migration of the object into a solid organ. To our knowledge, only two cases of a pancreatic mass secondary to GIT perforation by an FB have been reported.2,3 CT in this case showed a linear radiopaque structure in a pancreatic cystic mass close to the stomach. Initially, this was considered to be a blood vessel, but it was found to be nonenhancing. It was then suspected that an FB had perforated the GIT and migrated into the pancreatic tail. The preoperative diagnosis of GIT perforation by a fish bone is difficult to make for several reasons. First, most patients provide no history of swallowing the FB. Second, lesions are punctuated and their subsequent sealing by the omentum limits the spillage of free air or bowel contents. Third, plain radiography is an unreliable tool for the diagnosis of an ingested fish bone, as degree of radiopacity depends on fish species.4 However, although CT has been shown to be more helpful at detecting ingested fish bones, a high index of suspicion is required for a correct diagnosis, as the lesion can be mistaken for a blood vessel or a linear calcified lesion.5 The preoperative diagnosis of intra-abdominal abscess secondary to FB perforation is important, as the management involves draining the abscess, removing the foreign body and repairs to the perforated site. If correct diagnosis of FB perforation is not made, percutaneous drainage of the abscess might be chosen. This could result in a recurrent or persistent abscess.

Single center experiences of needle-scopic grasper assisted single incision laparoscopic cholecystectomy for gallbladder benign disease: comparison with conventional 3-port laparoscopic cholecystectomy.

Purpose Single incision laparoscopic cholecystectomy (SILC) has some technical problems. Our group has performed needlescopic grasper assisted SILC (nSILC) to overcome these problems. In this study, we introduce our technique and evaluate the safety and feasibility of this technique compared with the conventional laparoscopic cholecystectomy (CLC). Methods The medical records of 485 patients who received nSILC and CLC were reviewed retrospectively. Surgical outcomes including operative time, hospital stay, postoperative pain and perioperative complication were compared between the 2 techniques. Results Although wound complications were developed more frequently in nSILC group, there was no significant difference between groups in other surgical outcomes. In subgroup analysis, surgical outcomes of nSILC were similar with those of CLC not only in easy group but also in difficult group. Conclusion It seems that nSILC is safe and feasible not only in selected patients but also in difficult cases such as acute cholecystitis.