Bouveret's Syndrome as a Rare Complication of Cholecystolithiasis: Report of a Case

Bouveret's syndrome, which is gastric outlet obstruction caused by a gallstone in the duodenum or pylorus, is a very rare complication of gallstone disease. It occurs most commonly in women (65%), with a median age of 68.6 years. This disorder is usually treated by surgery, but it has also been successfully treated by endoscopy, with or without extracorporeal shock wave lithotripsy. The mortality rate has improved to 12% in recent years. Herein we report the case of a 76-year-old woman with Bouveret's syndrome, and review the literature on this unusual entity. Received: January 7, 2002 / Accepted: May 7, 2002 Reprint requests to: E. Shiloni     

Effects of Dietary Supplementation with Vitamin E,Riboflavin and Selenium on Central Nervous System Oxygen Toxicity

Abstract: We attempted to modify the resistance of rats to hyperbaric oxygen (HBO)-induced central nervous system (CNS) toxicity, by increasing the tissue antioxidant potential through dietary factors. Groups of rats were fed excesses of vitamin E (VIT E) alone or in combinations with riboflavin (RIB), selenium (Se) or both, for 30 days. A control group was maintained on an unsupplemented diet. On the 23rd day animals to be exposed were implanted with chronic electrodes for electrocorticographic (ECoG) recording. Later, each group was divided into two subgroups, of which one was exposed to 4.5 atmospheres absolute (ATA) of 100% oxygen (O₂) for 30 min., hereafter referred to as “exposed”, noting the time of appearance of first electrical discharge (FED) in their ECoG. The remaining subgroups were left unexposed. Forty-eight hours later, all animals were sacrificed and some of their tissues were analyzed for glutathione (GSH). The GSH level in the liver, brain, lungs and blood of all experimental subgroups were significantly higher than in the control unexposed counterparts. Combinations of RIB and/or Se with VIT E failed to show a greater increase in GSH over VIT E alone. This increase was, however, not accompanied by a meaningful delay in the appearance of FED. Forty-eight hours post-exposure, the brain GSH levels of all exposed subgroups were still lower than the respective pre-exposure levels. Yet, in the treated exposed subgroups the GSH levels observed 48hr after exposure were already higher than in the untreated unexposed controls. Thus, the dietary factors studied may enhance the reparative potential of oxidative tissue injury, but do not afford increased resistance of the brain to HBO, as judged by the respective FED times.     

Cytochrome P450 2D6 and outcomes of adjuvant tamoxifen therapy: results of a meta-analysis

Pharmacological evidence shows that cytochrome P450 2D6 (CYP2D6) function is important in the conversion of tamoxifen to its active metabolites. Many retrospective analyses have assessed the role of both CYP2D6 genotype and concurrent administration of drug inhibitors of CYP2D6 on outcome of tamoxifen therapy. These studies have frequently been of small size and their data highly variable. A published data meta-analysis of trials evaluating outcomes of tamoxifen therapy in early breast cancer was undertaken. Hazard ratios (HRs) were extracted for disease-free survival (DFS) and overall survival (OS). Pooled estimates were computed using inverse-variance and random-effect modeling. Data from 10 studies assessing CYP2D6 genotype were included in a meta-analysis. There was significant heterogeneity in the definition of comparison groups between studies. When compared to reduced CYP2D6 function, normal function was associated with a trend toward improved DFS (HR 2.07, 95% CI 0.96–4.49, P = 0.06) but not OS (HR 1.36, 95% CI 0.73–2.52, P = 0.34). Pooling of data from two studies evaluating CYP2D6 drug inhibitors showed that concomitant administration of these with tamoxifen was associated with a non-significant association with DFS (HR 1.37, 95% CI 0.69–2.73, P = 0.37). Analysis of the effect of CYP2D6 drug inhibitors on OS was not possible. The effect of CYP2D6 genotype on breast cancer seems to be relatively small and may not warrant testing of CYP2D6 genotype in all women with hormone receptor positive breast cancer. The effect of CYP2D6 genotype on outcome in low-risk patients may not be clinically relevant, while the upfront use of aromatase inhibitors is a reasonable alternative to tamoxifen in high-risk post-menopausal women, irrespective of CYP2D6 genotype. There are limited data supporting the association of potent inhibitors of CYP2D6 and detrimental outcome, but avoidance of such drugs seems reasonable.     

Magnesium sulfate suppresses electroencephalographic manifestations of CNS oxygen toxicity

We studied the effects of parenteral magnesium sulfate (MgSO4) administration on electroencephalographic seizures induced by hyperbaric oxygen (HBO) in awake rats. Sixteen rats chronically implanted with electrocorticographic electrodes were preinjected i.p. with either vehicle or 3 mmol/kg MgSO4 (the latter resulted in serum levels of 3.5-5.5 mmol/liter) and then exposed to 6 ATA O2 in a pressure chamber. The time to develop an electric ichtal seizure was measured and compared to that in the same animal receiving the alternate treatment 3 days later. Mean and median times after the magnesium treatment were almost double those of vehicle administration. A central anticonvulsive action of magnesium, which should be investigated over the entire HBO range, is indicated.     

Laparoscopic splenopexy of a wandering spleen.

A laparoscopic technique for splenopexy of a wandering spleen using an absorbable mesh in an adult woman is described for the first time. This patient was referred to surgery because of recurrent biliary colic secondary to cholecystolithiasis. The wandering spleen had been diagnosed at least 4 years earlier, but a conservative approach had been adopted for a symptomless patient. Laparoscopic cholecystectomy was performed concomitantly with splenopexy. Laparoscopic splenopexy seems a feasible and safe procedure, especially when performed by experienced laparoscopic surgeons.