Elective laparoscopic cholecystectomy for symptomatic uncomplicated gallstone disease: do the symptoms disappear?

Background

Symptomatic gallstone disease is considered an indication for cholecystectomy. A considerable proportion of patients may experience persistent symptoms after surgery. The purpose of the present study was to find out the rate of symptom persistence after elective laparoscopic cholecystectomy (LC) performed for symptomatic uncomplicated gallstone disease and, in particular, to clarify whether the recurrence rate differs according to the severity of preoperative symptoms.

Methods

During a 10-year period (1992–2001), 1,101 patients underwent elective LC at Turku City Hospital for Surgery. A questionnaire concerning the intensity of preoperative symptoms, persistence of symptoms postoperatively, and overall satisfaction with the outcome of the procedure was sent to patients. A total of 677 patients [mean age (range) 59 (21–94) years; 554 (83.1 %) females] with uncomplicated gallstone disease returned the completed form.

Results

Overall, 380 (57 %) patients reported attacks of intense upper abdominal pain, and 287 (43 %) reported episodic mild abdominal symptoms as the prevailing preoperative symptom. Two hundred and forty-eight (37 %) patients continued to have abdominal symptoms after the operation. Among those with predominantly mild abdominal symptoms preoperatively, 119 (41 %) reported the persistence of symptoms after the operation, while in the group with mainly severe upper abdominal pain attacks, 129 (33 %) patients had recurrences (p = 0.052).

Conclusions

According to our data, more than one-third of patients with symptomatic uncomplicated gallstone disease experienced persistent symptoms after elective LC. Patients with mild preoperative symptoms seemed to have more recurrences than those with severe symptoms, although the difference was not statistically significant.     

Adrenal pheochromocytoma with multiple neurofibromatosis on the trunk

We report a case of adrenal pheochromocytoma in a patient with neurofibromatosis type 1 (NF1). A 65-year-old female patient was admitted to our hospital for examination of a right adrenal mass. The adrenal tumor was incidentally discovered by abdominal computed tomography during examination for hypertension in another hospital. She had large multiple neurofibromatous lesions and café-au-lait spots on the trunk. We thought that it was difficult to make a skin incision on normal skin. Serum and urinary catecholamines were markedly increased. Magnetic resonance imaging revealed a solid round tumor 3 cm in diameter, located in the right adrenal gland. Laparoscopic right adrenalectomy was performed. Serum and urinary catecholamines returned to the normal range on post-operative day 10. Laparoscopic surgery may be a good option for NF1 patients with pheochromocytoma, especially those who had multiple neurofibromatosis on the trunk.     

Surgical excision of malignant pheochromocytoma in the left atrium.

We present a rare case of malignant pheochromocytoma in the left atrium and its surgical treatment. The patient was a 39-year-old male who presented a low-grade fever with perspiration. A large tumor was first detected in the left atrium by chest CT, and was confirmed by ultrasonic echo cardiogram and chest MRI. A left adrenal tumor was indicated also by abdominal echography. To prevent the risk of its embolization, surgical excision was performed on a subemergency basis. The patient developed near Shock State on the operative day, presumably due to catecholamine depletion. The preoperative urinary levels of norepinephrine and dopamine were abnormally high. Bilateral adrenal tumors also, confirmed postoperatively by abdominal MRI, were developing rapidly. The pathological examination revealed that the tumor was a pheochromocytoma.     

Risk factors for conversion of laparoscopic cholecystectomy to open surgery associated with the severity characteristics according to the Tokyo guidelines

Purpose

The aim of this retrospective study was to identify the risk factors associated with the severity characteristics in the Tokyo guidelines for conversion to open surgery in patients with acute cholecystitis (AC) who underwent laparoscopic cholecystectomy.

Methods

A total of 225 patients were enrolled in the study. The patients were classified into two groups: a conversion group and a no-conversion group. The preoperative characteristics and therapeutic strategy were analyzed as risk factors for conversion to open surgery. The postoperative outcomes were also analyzed.

Results

Conversion to open surgery occurred in 29 patients (12.9 %), including seven patients (6.7 %) with mild AC and 22 patients (18.5 %) with moderate AC. A univariate analysis showed that the risk factors for conversion to open surgery included a duration of symptoms longer than 72 h, an elevated C-reactive protein (CRP) value and the Tokyo guidelines 2013 (TG 13) severity classification. The multivariate analysis showed that the risk factors for conversion to open surgery included a duration of symptoms longer than 72 h and a CRP value >11.5 mg/dl.

Conclusions

A duration of symptoms longer than 72 h, which is included in the criterion for moderate AC severity in the TG 13, was an independent risk factor for conversion to open surgery. In addition, adoption of a high CRP value as an additional criterion for moderate AC may increase the utility of the TG 13.     

A case of composite pheochromocytoma-ganglioneuroblastoma in the adrenal gland with primary hyperparathyroidism

We report a case of composite pheochromocytoma-ganglioneuroblastoma in the adrenal gland with primary hyperparathyrodisim. A 55-year-old woman consulted our hospital for an examination of a right adrenal tumor, incidentally found by screening abdominal ultrasound sonography. On the clinical diagnosis of pheochromocytoma in the right adrenal gland from the findings of enhanced abdominal computed tomography, endocrinal examinations and 123I-metaiodobenzyl-guanidine scintigram, right adrenalectomy was performed transperitoneally. Histopathological diagnosis was an adrenal composite pheochromocytoma-ganglioneuroblastoma. This combination of compound adrenal tumor is extremely rare, and to date this case may be the seventh reported in Japan. Moreover, since her serum calcium level and intact parathyroid hormone level were high, so we considered the existence of multiple endocrine neoplasia type 2A. 99mTc-methoxyisobutylisonitrile scintigram and ultrasound of the neck revealed hyperparathyroidism, but medullary thyroid carcinoma was not detected. One year later, she was readmitted for parathyroid tumor excision, and histopathological finding was parathyroid adenoma. We concluded that she had both adrenal composite pheochromocytoma and hyperparathyroidism incidentally.     

Source of plasma adrenomedullin in a patient with pheochromocytoma receiving hemodialysis

Abstract  A 45-year-old man on long-term hemodialysis (HD) was incidentally discovered to have a pheochromocytoma and underwent successful resection. This patient was normotensive, and had no symptoms suggesting pheochromocytoma. The plasma concentrations of total adrenomedullin (AM-T) and mature AM (AM-m) were higher than those in normal controls. To elucidate the source of AM, we measured plasma AM levels by immunoradiometric assay before and 3 weeks after surgery in addition to plasma adrenaline, noradrenaline and dopamine. AM expression was also assessed by immunoblot and immunohistochemical analyses on normal adrenal and tumor tissues. After surgery, elevated plasma adrenaline levels returned to the normal range; however, the levels of AM-T and AM-m remained almost the same as the preoperative values. Furthermore, although AM was expressed in both normal adrenal and tumor tissues, the AM expression level was less in tumor. In this case, it was suggested that elevation in plasma AM level might be a factor associated with normotensive blood pressure; however, adrenal pheochromocytoma was not a major source of circulating AM. To our knowledge, this is the first case of pheochromocytoma in patient with HD associated with AM in the literature.     

The Surgical Treatment for Spinal Intradural Extramedullary Tumors

Background

We wanted to investigate the results of surgical treatment and analyze the factors that have an influence on the neurologic symptoms and prognosis of spinal intradural extramedullary (IDEM) tumors.

Methods

The spinal IDEM tumor patients (11 cases) who had been treated by surgical excision and who were followed up more than 1 year were retrospectively analyzed. Pain was evaluated by the visual analogue scale (VAS) and the neurologic function was assessed by Nurick''s grade. The pathological diagnosis, the preoperative symptom duration, the tumor location on the sagittal and axial planes and the percentage of tumor occupying the intradural space were investigated. In addition, all these factors were analyzed in relation to the degree of the preoperative symptoms and the prognosis. On the last follow-up, the MRI was checked to evaluate whether or not the tumor had recurred.

Results

The most common diagnosis was schwannomas (73%), followed by meningiomas (18%). The percentage of tumor occupying the intradural space was 82.9 ± 9.4%. The VAS score was reduced in all cases from 8.0 ± 1.2 to 1.2 ± 0.8 (p = 0.003) and the Nurick''s grade was improved in all cases from 3.0 ± 1.3 to 1.0 ± 0.0 (p = 0.005). The preoperative symptoms were correlated with only the percentage of tumor occupying the intradural space (VAS; r² = 0.75, p = 0.010, Nurick''s grade; r² = 0.69, p = 0.019). One case of schwannoma recurred.

Conclusions

The degree of neurologic symptoms was correlated with the percentage of tumor occupying the intradural space. All the tumors were able to be excised through the posterior approach. The postoperative neurologic recovery was excellent in all the cases regardless of any condition. Therefore, aggressive surgical excision is recommended even for cases with a long duration of symptoms or a severe neurologic deficit.     

A compound tumor in the adrenal medulla--pheochromocytoma combined with ganglioneuroma: a case report

We report a case of a compound adrenal medullary tumor. A 63-year-old woman was referred to our hospital for examination of a right adrenal tumor, incidentally found by abdominal computed tomography (CT). CT and magnetic resonance imaging (MRI) revealed a round heterogeneous tumor, 5 cm in diameter, on the upper pole of the right kidney. A view of the total body scan demonstrated the uptake into the tumor after the injection of 123I-metaiodobenzyl-guanidine. Serum and urinary adrenaline levels were slightly elevated, and urinary excretion of vanillylmandelic acid was markedly elevated. Her blood pressure was normal. From these findings, the tumor was suspected to be a pheochromocytoma of the right adrenal gland and was resected reteroperitoneally. Pathological diagnosis was a compound adrenal medullary tumor, which was composed of pheochromocytoma and ganglioneuroma. This combination of the adrenal medullary tumor is extremely rare, and to date this case may be the sixth case in the Japanese medical literature.     

Epidermoid cyst originating from an intrapancreatic accessory spleen

We report a rare case of an epidermoid cyst originating from an intrapancreatic accessory spleen, in a 40-year-old Japanese man with no clinical symptoms. A cystic tumor in the pancreatic tail was detected incidentally by abdominal ultrasonography. The patient was referred to the KKR Tachikawa Hospital for further examination of the tumor. Preoperative imaging findings suggested that the tumor was an epidermoid cyst originating from an intrapancreatic accessory spleen. On both pre-and post-contrast computed tomography and magnetic resonance images, the solid compartment of the tumor had the same X-ray attenuation and intensity as the spleen. Upon surgical excision, the mass consisted of solid and cystic components that were macroscopically evident on the preoperative images. Microscopic analysis revealed that the solid component was an accessory spleen in the pancreatic tail, whereas the cystic component was lined with stratified epithelium representative of an epidermoid cyst. This is the thirteenth report (in English) of an epidermoid cyst originating from an intrapancreatic accessory spleen, and the first case to be diagnosed prior to surgery.     

Proposal of the Surgical Options for Primary Tumor Control During Sentinel Node Navigation Surgery Based on the Discrepancy Between Preoperative and Postoperative Early Gastric Cancer Diagnoses

Background

There is no consensus on the optimal method of primary tumor control, determined by preoperative clinical factors, during sentinel node (SN) navigation surgery for early gastric cancer (EGC). In this study, we investigated the accuracy of clinical diagnosis based on preoperative examination in patients with EGC and proposed surgical options for primary tumor control during SN navigation surgery.

Methods

We analyzed 815 patients with clinical stage IA gastric cancer who underwent gastrectomy at the National Cancer Center in Korea between March 2001 and February 2011. The clinical stage was determined by endoscopy, endoscopic ultrasonography, and abdominal computed tomography.

Results

The preoperative assessment of tumor depth and tumor size was accurate in 57.5 and 70.8 % of patients, respectively. Tumor depth and size were underestimated in 8 and 25.3 % of patients. The overall accuracy of histologic diagnosis by endoscopic biopsy was 87.2 %. Of those tumors diagnosed preoperatively as differentiated, 20.5 % revealed mixed histology of undifferentiated type.

Conclusions

The recommendation for SN biopsy may be limited to tumors sized 3 cm or smaller to avoid positive lateral margins and to minimize the risk of skip metastases. Endoscopic resection may safely be applied to small mucosal cancers, but other surgical options should be employed for undifferentiated large mucosal lesions, given their tendency for diffuse invasion. Full-thickness resection is preferable for submucosal cancers, to secure clear vertical margins.     

Pheochromocytoma in a long-term hemodialysis patient.

A right adrenal tumor was found incidentally by renal echography in a 25-year-old man, who had been on hemodialysis for 4 years. Inquiry and clinical examination suggested pheochromocytoma, which was confirmed by plasma catecholamine measurements. Subsequent adrenalectomy was uneventful. Although hypertension, headache, and diaphoresis are common symptoms in a dialyzed patient, pheochromocytoma has to be eliminated in the presence of this clinical triad.     

Laparoscopic resection of pheochromocytoma

Summary The following case report presents the diagnostic procedures, laparoscopic therapy, and postoperative course of a 48-year-old patient with pheochromocytoma. During the previous 15 years, he had occasionally presented with hypertension, intermittent attacks of severe perspiration, and tachycardia; no diagnostic measures were performed at the time. During an ultrasound examination of the abdomen performed due to gastrointestinal complaints, a 5-cm adrenal tumor was discovered incidentally. Further diagnostic procedures then indicated the presence of a pheochromocytoma which was resected laparoscopically. The anesthesia was tolerated well, although isolated systolic blood pressure peaks to 200 mmHg were observed. The laparoscopic tumor resection presented no problems, although identifying the tumor proved to be difficult and resulted in an extended operation time of 4 h and 20 min. The postoperative course was unremarkable. This case report presents our laparoscopic technique and confirms that techniques proven in the open resection of a pheochromocytoma can also be utilized in the laparoscopic approach.     

A case of adrenal pheochromocytoma with contralateral adrenocortical adenoma

A case of a pheochromocytoma in the right adrenal gland and adrenocortical adenoma in the left adrenal gland of a 58-year-old male is reported. The patient was incidentally found to have a right adrenal tumor by ultrasonographic study. A computerized tomographic (CT) study and magnetic resonance image (MRI) study revealed bilateral adrenal tumors. The sizes of the right tumor and left tumor were 2.5 x 3.5 cm and 1.2 x 1.0 cm, respectively. The intensity of each tumor was different on T2-weighted MRI. 131I-MIBG scintigram showed the uptake of right adrenal gland. The existence of pheochromocytoma was confirmed by the elevated levels of catecholamines. We performed venous sampling to be certain whether the patient had unilateral or bilateral pheochromocytoma. As a result, bilateral adrenal pheochromocytoma was diagnosed. Therefore, we performed bilateral adrenalectomy. However, histopathological examination revealed right pheochromocytoma and left non-functioning adrenocortical adenoma.     

Preoperative anxiety: detection and contributing factors

The purpose of this study was to determine whether there is a correlation between anxiety the night before surgery and that existing immediately preoperatively, whether anaesthetists can detect preoperative anxiety and to establish the presence of any factors that might assist in the determination of preoperative anxiety. Anxiety was measured objectively using the Spielberger State-Trait Anxiety Inventory (STAI), and the Multiple Affect Adjective Check List (MAACL). Anxiety was found to be higher infemales and those not having had a previous anaesthetic, and to remain constant from the afternoon before surgery to the immediate preoperative period. Anaesthetists were found to be poor assessors of anxiety unless they specifically questioned their patients about this.     

Multi-institutional Assessment of Sphincter Preservation for Rectal Cancer

Background

Sphincter-preserving surgery (SPS) has been proposed as a quality measure for rectal cancer surgery. However, previous studies on SPS rates lack critical clinical characteristics, rendering it unclear if variation in SPS rates is due to unmeasured case-mix differences or surgeons’ selection criteria. In this context, we investigate the variation in SPS rates at various practice settings.

Methods

Ten hospitals in the Michigan Surgical Quality Collaborative collected rectal cancer-specific data, including tumor location and reasons for non-SPS, of patients who underwent rectal cancer surgery from 2007 to 2012. Hospitals were divided into terciles of SPS rates (frequent, average, and infrequent). Patients were categorized as ‘definitely SPS eligible’ a priori if they did not have any of the following: sphincter involvement, tumor <6 cm from the anal verge, fecal incontinence, stoma preference, or metastatic disease. Fixed-effects logistic regression was used to evaluate for factors associated with SPS.

Results

In total, 329 patients underwent rectal cancer surgery at 10 hospitals (5/10 higher volume, and 6/10 major teaching). Overall, 72 % had SPS (range by hospital 47–91 %). Patient and tumor characteristics were similar between hospital terciles. On multivariable analysis, only hospital ID, younger age, and tumor location were associated with SPS, but not sex, race, body mass index, American Joint Committee on Cancer (AJCC) stage, preoperative radiation, or American Society of Anesthesiologists (ASA) class. Analysis of the 181 (55 %) ‘definitely-eligible’ patients revealed an SPS rate of 90 % (65–100 %).

Conclusions

SPS rates vary by hospital, even after accounting for clinical characteristics using detailed chart review. These data suggest missed opportunities for SPS, and refute the general hypothesis that hospital variation in previous studies is due to unmeasured case-mix differences.     

The impact of abdominal aortic calcification and visceral fat obesity on lower urinary tract symptoms in patients with benign prostatic hyperplasia

Objectives

To investigate the impact of abdominal aortic calcification and visceral fat area (VFA) on lower urinary tract symptoms (LUTS) and clinical parameters in patients with benign prostatic hyperplasia (BPH).

Methods

We retrospectively studied 250 patients with LUTS associated with BPH. Each participant was examined with routine examination including measurement of various data; (1) voided volume (VV), maximum urinary flow rate on free uroflowmetry, (2) postvoid residual urine volume and prostate volume using transabdominal ultrasound, (3) International Prostate Symptom Score (IPSS) and Overactive Bladder Symptom Score (OABSS), and (4) aortic calcification index (ACI) and VFA were measured by abdominal CT.

Results

Mean age of the patients was 72.4 ± 9.6 years. ACI significantly correlated with VV (P = 0.0392) and tended to correlate with maximum urinary flow rate, while ACI did not correlate with subjective symptoms. VFA significantly correlated with nocturia score of IPSS (P = 0.0177) and frequency score of OABSS (P = 0.0166) and tended to correlate with urgency score of IPSS and maximum urinary flow rate.

Conclusions

Aortic calcification index (ACI) correlated with only objective parameters, while VFA correlated with only storage symptoms. This study suggested that abdominal aortic calcification and VFA have certain influence on LUTS and clinical parameters in patients with BPH.     

Primary ovarian leiomyoma: A case report

INTRODUCTION

Primary ovarian leiomyoma is a rare benign tumour of the ovary seen in women between 20 and 65 years old. It is usually diagnosed incidentally during pelvic examination or pathologic examination after surgery.

PRESENTATION OF CASE

We describe a case of unilateral, ovarian leiomyoma. Transvaginal ultrasonography and magnetic resonance imaging (MRI) revealed a right adnexial mass. Unilateral salpingo-oophorectomy was performed, and histological examination revealed a leiomyoma arising primarily in the ovary. The diagnosis was confirmed immunohistochemically.

DISCUSSION

The tumour may be asymptomatic or may manifest with lower abdominal pain like in our case. The definitive diagnosis of these lesions is difficult prior to surgical removal. Because there is no pathognomonic symptoms or characteristic imaging findings. The correct diagnosis of an ovarian leiomyoma requires identification of the smooth muscle nature of the tumour.

CONCLUSION

This rare tumour of the ovary should be considered in the differential diagnosis of solid ovarian masses. An immunohistochemical analysis is recommended for definitive diagnosis.     

Surgical treatment of a tuberculous thoracoabdominal aneurysm

We report a case of tuberculous thoracoabdominal aneurysm successfully treated by surgery. Computerized tomography was diagnostic for location and etiology. The therapeutic plan included antituberculosis drug therapy started before surgery, direct PTFE prosthetic replacement and omentoplasty. A survey of other reports dealing with tuberculous abdominal or thoracic aorta involvement shows that their frequency, as that of tuberculosis in general, is diminishing.     

Small Nonfunctioning Islet Cell Tumor in the Body of the Pancreas: Report of a Case

Islet cell tumors of the pancreas are uncommon, and nonfunctioning tumors are even rarer than functioning ones. We report the case of a 67-year-old woman with a small nonfunctioning islet cell tumor, 6 × 5mm in diameter, which was detected incidentally by ultrasonography, and subsequently confirmed by double-helical computed tomography. Diagnosis was established by histopathological examination after 80% distal pancreatectomy with splenectomy, and by various laboratory tests. Histologically, the islet cell tumor showed highly cellular spindle or epithelioid cells, which were positive for Grimelius stain. Immunohistochemical examination revealed that the tumor cells were positive for chromogranin A, but negative for somatostatin, insulin, glucagon, and gastrin. Its small size, location, and benignity make this a very rare type of nonfunctioning islet cell tumor.