Laparoscopic Management of Mobile Cecum

Method:This study was a case–control series of 15 patients who underwent laparoscopic cecopexy. Age, gender, recurrent abdominal pain, and constipation based on Rome III criteria were assessed. Ileocecal–appendiceal unit displacement was graded as follows: I (cecum retroperitoneal or with little mobility); II (wide mobility, crossing the midline); and III (maximum mobility, reaching the left abdomen). Patients with Grades II and III underwent laparoscopic cecopexy. The clinical outcomes were evaluated according to modified Visick''s criteria, and postoperative complications were assessed according to the Clavien-Dindo classification.Results:The mean age was 31.86 ± 12.02 years, and 13 patients (86.7%) were women. Symptoms of constipation and abdominal pain were present in 14 (93.3%) and 11 (73.3%), respectively. Computed tomography was performed in 8 (53.3%) patients. The mean operative time was 41 ± 6.66 min. There were no postoperative infections. One (7.8%) patient was classified as Clavien Dindo IIIb and all patients were classified as Visick 1 or 2.Conclusion:Many patients with clinical and epidemiological features of functional colon disease in common in fact have an anatomic anomaly, for which the treatment of choice is laparoscopic cecopexy. New protocols should be developed to support this recommendation.     

Phlegmonous Appendicitis and Mobile Cecum Syndrome Simulating Ileal Duplication Cyst in a 9 Year Old Girl

Mobile cecum syndrome is a rare entity that produces recurrent lower abdominal pain mimicking appendicitis. Appendicitis developing in a mobile cecum at an abnormal location eludes the clinical diagnosis and confuses the clinicians unless a high index of suspicion is harbored. We present an unusual case of phlegmonous appendicitis in a mobile cecum masquerading as duplication cyst of ileum in a 9 years old girl.     

An Incidental Finding at Transplant Assessment: Case Report

A 43-year-old woman with chronic hypersensitivity pneumonitis was referred for lung transplant assessment. An echocardiogram as part of her work-up revealed a large left atrial myxoma, presenting a conundrum on how best to manage her combined pathology. Because of the level of pulmonary disease, early intervention to remove the myxoma was not thought be viable without postoperative support. Use of extracorporeal membrane oxygenation to bridge patients for lung transplant is feasible, yet risks increased perioperative mortality. We present the first reported case of simultaneous cardiac myxoma removal and lung transplant.     

Asymptomatic Synovial Chondromatosis of the Ankle: An Incidental Finding

Synovial chondromatosis is an uncommon, benign lesion of nodular cartilaginous neoplastic development of the synovium that can lead to loose bodies and arthritic degeneration if left untreated. Although very rare, malignant transformation to chondrosarcoma can occur. Primary and secondary forms of synovial chondromatosis also exist, and each has distinct clinical, radiographic, and histologic characteristics. In this article, we describe a case of extensive primary synovial chondromatosis of the ankle that was asymptomatic until just before presentation, and that was treated by means of open synovectomy with excision of the osteochondromatous lesions within the joint.     

Laparoscopic cecopexy for mobile cecum syndrome manifesting as cecal volvulus: Report of a case

A 44-year-old woman was admitted to our hospital for investigation and treatment of sudden abdominal pain and distention. Plain abdominal radiography and abdominal computed tomography (CT) findings were suggestive of sigmoid volvulus. She underwent an emergency colonoscopy, and the scope passed easily through the sigmoid colon and reached the ascending colon quickly. However, stenosis with concentricity of the fold was observed in the cecum, which was shifted upward and to the left. Based on these findings, we diagnosed cecal volvulus caused by mobile cecum syndrome. The patient’s symptoms resolved quickly after colonoscopic reduction and elective laparoscopic surgery was performed 18 days after admission. Perioperative examination revealed a mobile cecum caused by an elongated ascending colon. We sutured the cecum and ascending colon to the lateral peritoneum laparoscopically with interrupted sutures. The patient recovered well and was discharged on postoperative day 7. An unfixed intestine can be detected easily during laparoscopic surgery, which is minimally invasive and cosmetically, physically, and economically beneficial. Thus, we recommend laparoscopic cecopexy for mobile cecum syndrome.     

Incidental Finding of Chronic Lymphocytic Leukemia After Podiatric Surgery: Case Report

Chronic lymphocytic leukemia (CLL) is hematopoietic neoplasm that typically remains insidious and undetected until symptoms arise. We present a patient that underwent podiatric surgery for a symptomatic bunion at the Veteran Affairs Medical Center Northport with resultant incidental finding of CLL. This facility mandates that all excised bone and tissue be submitted for gross examination by a pathologist. This case highlights the potential benefit of pathological examination of bone specimens for potential early detection of pathologies.     

An Incidental Finding of a Talonavicular and Talocalcaneal Joint Coalition After a Tibial Pilon Fracture: A Case Report

It has been proposed that patients with talocalcaneal and talonavicular coalitions have decreased ankle joint range of motion. It has also been reported that rotational forces regularly absorbed by the talocalcaneal joint are transferred to the ankle joint in patients with coalitions, increasing the stress on the ankle joint after trauma. To the best of our knowledge, only 1 reported study has detailed the increased stress placed on the ankle joint secondary to a coalition. We present a case study of a 53-year-old female who experienced a traumatic fall and subsequent right ankle fracture. Advanced imaging studies revealed a comminuted tibial pilon fracture and talocalcaneal and talonavicular joint coalitions. She underwent open reduction and internal fixation for treatment of the fracture, and the coalitions were not treated because they were asymptomatic. She was kept non-weightbearing for 6 weeks postoperatively and was returned to a regular sneaker at 10 weeks postoperatively. The postoperative films revealed stable intact fixation and pain-free gait with no increased restriction in her ankle joint range of motion. The hardware was removed at 13 months postoperatively. She had not experienced increased pain or arthritic changes at 15 months postoperatively.     

Incidence of Finding Residual Disease for Incidental Gallbladder Carcinoma: Implications for Re-resection

Re-resection for gallbladder carcinoma incidentally discovered after cholecystectomy is routinely advocated. However, the incidence of finding additional disease at the time of re-resection remains poorly defined. Between 1984 and 2006, 115 patients underwent re-resection at six major hepatobiliary centers for gallbladder carcinoma incidentally discovered during cholecystectomy. Data on clinicopathologic factors, operative details, TNM tumor stage, and outcome were collected and analyzed. Data on the incidence and location of residual/additional carcinoma discovered at the time of re-resection were also recorded. On pathologic analysis, T stage was T1 7.8%, T2 67.0%, and T3 25.2%. The median time from cholecystectomy to re-resection was 52 days. At the time of re-resection, hepatic surgery most often consisted of formal segmentectomy (64.9%). Patients underwent lymphadenectomy (LND) (50.5%) or LND + common bile duct resection (43.3%). The median number of lymph nodes harvested was 3 and did not differ between LND alone (n = 3) vs LND + common duct resection (n = 3) (P = 0.35). Pathology from the re-resection specimen noted residual/additional disease in 46.4% of patients. Of those patients staged as T1, T2, or T3, 0, 10.4, and 36.4%, respectively, had residual disease within the liver (P = 0.01). T stage was also associated with the risk of metastasis to locoregional lymph nodes (lymph node metastasis: T1 12.5%; T2 31.3%, T3 45.5%; P = 0.04). Cystic duct margin status predicted residual disease in the common bile duct (negative cystic duct, 4.3% vs positive cystic duct, 42.1%) (P = 0.01). Aggressive re-resection for incidental gallbladder carcinoma is warranted as the majority of patients have residual disease. Although common duct resection does not yield a greater lymph node count, it should be performed at the time of re-resection for patients with positive cystic duct margins because over one-third will have residual disease in the common bile duct. Presented at the 48th Annual Meeting of the Society for Surgery of the Alimentary Tract at Digestive Week 2007, Plenary Session, Washington, DC, March 23, 2007.     

Urachal Adenocarcinoma: Incidental Finding at the Time of Surgery for Ruptured Appendicitis

Background:

The urachus is a vestigial structure between the dome of the bladder and the umbilicus. Tumors may develop from the remnants, most of which are well-differentiated, mucinous adenocarcinomas. Urachal adenocarcinoma is an exceedingly rare type of tumor.

Methods:

We present a case of a 51-year-old female presenting to our institution with complaints of abdominal pain for 36 hours. The patient was taken to the operating room for an acute appendicitis. Laparoscopy was performed, and gross purulence and appendiceal perforation were noted as well as a mass on the anterior abdominal wall. Based on the location of the mass, we converted to an open midline laparotomy to treat both the perforated appendicitis and to remove the mass.

Results:

Pathology confirmed the diagnosis of perforated appendicitis and a mucinous-producing urachal adeno-carcinoma.

Discussion:

Data support both open and laparoscopic approaches for appendicitis. This case, although rare, highlights the importance of laparoscopy in a complete and thorough examination of the abdominal cavity. A standard right lower quadrant incision for an open technique would likely have resulted in omission of this lesion, and the patient would have presented at a more typical late stage of her cancer development with significantly more morbidity.     

Incidental Finding of Multiple Synchronous Neoplasms in Explanted Liver After Transplantation: A Case Report

Liver transplantation is the only potentially curative treatment for patients with end-stage liver disease. After the procedure, histopathologic analysis of the liver explant may reveal neoplasms that were not previously diagnosed in preoperative imaging examinations. This incidental finding of primary liver neoplasms in the explant is not an uncommon situation in liver transplant, and hepatocarcinomas and cholangiocarcinomas are the types of tumors most frequently encountered in this scenario. These are the most common primary neoplasms of the liver, and liver transplantation is often a curative treatment for these types of tumors when they are in their earlier stages. In contrast, liver plasmacytoma is a rare type of plasma cell neoplasm, consisting of a single mass of monoclonal plasma cells, which is treated primarily by radiotherapy and is seldom encountered in the setting of liver transplant. We report the case of a patient who underwent liver transplantation for the treatment of cryptogenic cirrhosis, with no preoperative diagnosis of liver tumors. Analysis of the liver explant revealed the presence of three synchronous neoplasms with different histologic origins: a 27-mm hepatocellular carcinoma, a 17-mm intrahepatic cholangiocarcinoma, and a 25-mm solitary hepatic plasmacytoma. The patient received no further adjuvant treatment and remained well and with no signs of disease recurrence over an observation period of 44 months. We found no previous report in the literature of the synchronous presence of these three types of liver neoplasms.     

Treatment of Symptomatic Mobile Aortic Thrombus

Background: Mobile thoracic or abdominal aortic thrombi are a potential source of embolism to visceral organs or lower limbs. Detection levels of this type of aortic pathology after any embolic event have increased considerably. Nevertheless, therapeutic management of an intraluminal mobile thrombus of the aorta remains controversial. The aim of this study is to describe the treatment modalities for symptomatic mural aortic thrombi based on three cases diagnosed at our institution and to review the literature.

Methods: During the last decade, several patients with peripheral embolisation were diagnosed with an intraluminal mobile aortic thrombus. Three patients who were treated differently were selected and reviewed. In addition a literature search was performed on PubMed and Medline from their inception to the present for all English language articles using the following keywords: blue toe syndrome, peripheral arterial embolisation, mobile thrombus and aorta. The advantages and drawbacks of medical management, open and endovascular treatment are described.

Results: Three particular patients with embolisation due to a floating aortic thrombus were reviewed. The first patient underwent a thoracotomy with replacement of the descending thoracic aorta. Another case was treated successfully by implanting an endovascular stent graft in the descending thoracic aorta. The last patient was treated medically because of the involvement of the visceral vessels. When reviewing the literature, no randomised controlled trials were found but several case reports have described both open and endovascular techniques. No long-term follow up of this rare pathology is available.

Conclusions: In the literature there is no consensus how to treat a symptomatic floating aortic thrombus. This report shows that therapeutic strategies are influenced by the localisation of the thrombus, the co-morbidities of the patient and the physician’ s preferences. Endovascular treatment in combination with high dose statins has become the preferred treatment method although long-term data are lacking.     

Mobile Technologies for the Surgical Pathologist

Recent advances in hardware and computing power contained within mobile devices have made it possible to use these devices to improve and enhance pathologist workflow. This article discusses the possible uses ranging from basic functions to intermediate functions to advanced functions. Barriers to implementation are also discussed.     

Incidental Finding of Gastrointestinal Stromal Tumors (GISTs) during Laparoscopic Gastric Bypass

Background: Gastrointestinal stromal tumors (GISTs) are rare tumors, accounting for <1% of all neoplasms of the alimentary tract. GISTs have not been previously reported in association with gastric bypass surgery. Methods: This study is a retrospective review of 517 consecutive morbidly obese patients who underwent laparoscopic Roux-en-Y gastric bypass (LRYGBP) between January 2002 and August 2005. Incidental intraoperative findings of gastric GIST were recorded. Results: 4 patients (0.8%) were noted to have GISTs intra-operatively upon inspection of the stomach prior to partition. All GISTs were identified along the anterior aspect of the upper third of the stomach and were removed by laparoscopic wedge excision with at least a 1 cm margin. The 4 tumors were <1 cm in size and all had immunohistochemical analysis positive for CD117 (c-kit). None of the tumors had determinants of malignant behavior (high mitotic rate, necrosis or pleomorphism). Conclusion: We have found a 0.8% incidence of gastric GISTs in our morbidly obese patients undergoing LRYGBP. All of these small, benign tumors were found incidentally in asymptomatic patients. This case series underscores the need to fully assess the stomach prior to gastric pouch formation. Without the ability to grossly determine the benign or malignant behavior of GISTs, all these tumors found incidentally should be resected with adequate margins.     

An Unusual Aberrant Muscle in Congenital Clubfoot: An Intraoperative Finding

Congenital clubfoot is a common congenital deformity, characterized by equinus of the hindfoot and adduction of the midfoot and forefoot, with varus through the subtalar joint complex. A cavus deformity will also be present. The etiology of this congenital deformity remains elusive. Muscle anomalies are not commonly found in patients with idiopathic clubfoot, and, when present, their significance is not clear. The presence of a flexor digitorum accessorius longus muscle and an accessory soleus muscle found at surgical correction of clubfoot deformity has been previously reported. Our case was a female child, aged 2 years, 3 months, who developed bilateral relapsed congenital clubfoot. She was found to have an unusual aberrant muscle in both legs. This was discovered accidentally during surgical correction of her deformity through posteromedial soft tissue release. This muscle might have contributed to the hindfoot varus and equinus in the clubfoot deformity, because the latter were completely corrected after release of the muscle from its insertion. Awareness of such a new anatomic variant, with the other anatomic variants found in clubfoot deformity, will not only improve our understanding of normal lower limb development, but could also lead to improved genetic counseling and diagnostic and treatment methods of such a common congenital deformity.     

Incidental Parathyroidectomy during Thyroid Surgery: An Underappreciated Complication of Thyroidectomy

The aim of this study was to investigate the incidence, risk factors, and clinical relevance of incidental parathyroidectomy during thyroid surgery. Prospective analysis of data in patients following thyroidectomy, specifically regarding the presence of parathyroid parenchyma in the thyroidectomy specimens, the underlying thyroid pathology, and the presence of postoperative hypocalcemia (biochemical/clinical). The clinical records of 158 patients who underwent thyroid surgery during a 2-year period were reviewed. Pathology reports were carefully reviewed for the nature of the underlying thyroid disease, the presence, number, and size of incidentally resected parathyroid gland(s), their location, and possible parathyroid pathology. Serum calcium levels were measured preoperatively, on the day of surgery, and on postoperative days 1, 2, and 7 or even later as needed. Two groups of patients were studied: a group with incidental parathyroidectomy following thyroidectomy (group A) and a group without incidental parathyroidectomy after thyroidectomy (group B). Total/near-total thyroidectomy was the procedure of choice and was performed in 154 patients; total lobectomy and contralateral subtotal lobectomy was performed in the other 4 patients. Elective central neck lymph node dissection was performed in four patients with neck lymphadenopathy. Inadvertently removed parathyroid tissue was found in 28 cases (17.7 %); in 6 of these patients (21%) the parathyroid tissue was intrathyroidal. The percentage of women in group A was significantly higher than in group B (93% vs. 58.5%, P = 0.0002). There was no statistically significant difference between the two groups (A and B) regarding the preoperative (presumed) diagnosis, the histologic diagnosis of thyroid disease (benign versus malignant), the type/extent of surgery, or the presence of thyroiditis. Biochemical and clinical hypocalcemia was observed in 6 (21%) and 2 (7%) patients in group A, respectively, and in 30 (23%) and 8 (6%) patients of group B, respectively. There was no statistically significant difference regarding the occurrence of postoperative hypocalcemia (clinical/biochemical) between the two groups (P = 0.33). Incidental parathyroidectomy is not uncommon following thyroidectomy and in a significant percentage of cases it may be due to the intrathyroidal location of the parathyroid glands. Incidental parathyroidectomy was not found to be associated with postoperative hypocalcemia (biochemical/clinical). Incidental parathyroidectomy may be considered as a potentially preventable but clinically minor complication of thyroid surgery.