Peripheral lymphadenopathy: approach and diagnostic tools

Peripheral lymph nodes, located deep in the subcutaneous tissue, clean antigens from the extracellular fluid. Generally, a normal sized lymph node is less than one cm in diameter. Peripheral lymphadenopathy [LAP] is frequently due to a local or systemic, benign, self-limited, infectious disease. However, it could be a manifestation of underlying malignancy. Seventy-five percent of all LAPs are localized, with more than 50% being seen in the head and neck area. LAP may be localized or generalized. Cervical lymph nodes are involved more often than the other lymphatic regions. Generally, it is due to infections, but most of the supraclavicular lymphadenopathies are associated with malignancy. Based on different geographical areas, the etiology is various. For example, in tropical areas, tuberculosis [TB] is a main benign cause of LAP in adults and children. Complete history taking and physical examination are mandatory for diagnosis; however, laboratory tests, imaging diagnostic methods, and tissue samplings are the next steps. Tissue diagnosis by fine needle aspiration biopsy or excisional biopsy is the gold standard evaluation for LAP. We concluded that in patients with peripheral LAP, the patient's age and environmental exposures along with a careful history taking and physical examination can help the physician to request step by step further work-up when required, including laboratory tests, imaging modalities, and tissue diagnosis, to reach an appropriate diagnosis

Diffuse large B cell lymphoma of the rectosigmoid junction: case report and literature review

Primary colorectal lymphoma [PCL] is a rare condition that accounts for a small percentage of all gastrointestinal [GI] malignancies. There are several reports in the literature regarding the most common features of PCL. However, primary lymphoma in the rectosigmoid junction has been rarely reported. Our case was a 67-year-old male who presented with non-specific symptoms of bowel obstruction which, upon further workup, was diagnosed as a rare case of PCL located in the rectosigmoid junction

Evaluation of supporting role of early enteral feeding via tube jejunostomy following resection of upper gastrointestinal tract

Today, early diagnosis of upper gastrointestinal [GI] tract malignancies and their surgical resection is becoming more feasible. One of the important side effects in upper GI tract malignancies is malnutrition which has direct relationship with postoperative complications. Nonetheless, there is no easy regimen of nutrition for these patients especially for the first week after operation. Accordingly we present a simple method for improving feeding such patients via tube jejunostomy. The aim of this study was to investigate the impact of early enteral feeding [EEF] on postoperative course after complete resection of upper gastrointestinal tract malignancy and reconstruction. Between September 2005 to September 2008, 60 consecutive patients [22 female, 38 male] with upper GI tract malignancies who had undergone complete resection and reconstruction enrolled in this study. The patients randomly divided equally in two groups of control and EEF. Control group was treated with traditional management of nil by mouth and intravenous fluids for the first five postoperative days and then with liquids and enteral regular diet when tolerated. In EEF group the patients were fed by tube jejunostomy from 1[st] postoperative day and assessed for nutritional status before surgery and 5 days after surgery. Both groups were monitored on the basis of weight gain, clinical and paraclinical parameters and postoperative complications. Sixty patients were randomly divided to two equal groups. Surgical procedures were similar in two groups and no significant difference in demographic and basic nutritional status were found. On 5[th] postoperative day serum albumin was 4.2 +/- 0.4 g/dl in EEF and 3.6 +/- 0.3 g/dl in control group [p= 0.041]. Also serum transferrin was 260.8 +/- 2.5 mg/dl and 208 +/- 1.8 mg/dl in EEF and control group respectively [p<0.001]. Moreover, hospital stay was shorter in EEF group [7.7 +/- 3.1 vs. 14 +/- 2.5 days, p=0.009].There were four [13.3%] anasatomotic leakages in control group and one [3.3%] in EEF group [p=0.353]. Also there was six [20%] wound infection in control group and three [10%] in EEF group [p=0.472]. The EEF by tube jejunostomy can be an effective method of feeding patients in postoperative days of resection of GI malignancies. Postoperative hospital stay would be shorter and the level of laboratory parameters especially serum transferrin is higher in EEF in comparison with control group. It also may reduce postoperative complications such as wound infection and enterocutaneous fistula

Hem-o-Lok clip is safe in minimally invasive general surgery: a single center experience and review of data from food and drug administration

There are several methods for the ligation of structures during minimally invasive operations. The hem-o-lok clip is a nonabsorbable polymer clip with a lock engagement feature. There are few reports about its use in minimally invasive general surgical procedures. In this report, we describe our experience with the hem-o-lok clip during basic, minimally invasive, general surgery procedures and the adverse events during application of the hem-o-lok. We retrospectively reviewed all laparoscopic appendectomies [LAs], cholecystectomies [LCs], and splenectomies [LSs], performed by 6 general surgeons at a university-affiliated hospital over 4 years. Clip failure was defined as intraoperative or postoperative bleeding due to clip malfunction that necessitated placement of another clip, conversion to an open procedure, or postoperative re-exploration. Leakage from the cystic duct and appendiceal stump was also considered clip failure. A search of the US Food and Drug Administration Manufacturer and User Facility Device Experience [MAUDE] database using the appropriate keywords was performed on July 7, 2011. This online resource contains reports of adverse events involving medical devices. Over a 4-year period, 856 laparoscopic operations, comprising 770 LC, 55 LS, and 31 LA, were performed. We did not observe any incidence of clip failure. There were 22 reports of hem-o-lok clip failure in the MAUDA database. Eighty-two percent [n=18] of clip failures were reported during laparoscopic nephrectomy. There was no report of failure after LA. There were 2 reported clip failures after LC [with bile leakage] and 1 after LS [tearing of splenic vessels with intraoperative bleeding]. There was also a report of migration of the hem-o-lok clip into the common bile duct, which occurred 4 years after a complicated LC. Hem-o-lok clips that are properly applied during basic laparoscopic procedures are a secure option for the ligation of the structures. Surgeons must be educated regarding the proper application technique

Sleep-related eating disorder: a case report of a progressed night eating syndrome

Night eating syndrome is a common disorder in eating behaviors that occurs in close relation to the night time sleep cycle. Although eating disorders are common in society, night eating syndrome has been left neglected by health care professionals. In this report we present a case of eating disorder that exhibits some novel features of night eating syndrome. Our case was a progressed type of eating disorder which may increase awareness among physicians about sleep-related eating disorders.

Assessment and treatment of choledocholithiasis when endoscopic sphincterotomy is not successful

Background: Choledocholithiasis exists in approximately 15% of patients with gallstones and is present in 3%-10% of those undergoing cholecystectomy

Methods: In this study, we retrospectively analyzed the outcome patients with choledocholithiasis that were managed by open common bile duct [CBD] exploration according to our center's protocol. Endoscopic retrograde cholangiopancreatography [ERCP] was performed for CBD stone clearance. If ERCP and sphincterotomy were not successful, open surgical exploration of CBD was performed with T-tube inser-tion without routine intraoperative cholangiography [IOC]

Results: We studied 1462 patients with choledocholithiasis. ERCP was successful in in 1276 [87.2%] patients. A total of 186 [12.8%] underwent surgery. Of these, 82 [45.2%] had CBD exploration and T-tube insertion without IOC. Choledochoduodenostomy was performed in 82 [44.1%] patients and choledochojejunostomy was performed in 20 [10.8%]. Retained stones were found only in 4 cases which were treated by ERCP

Conclusion: ERCP is successful in most cases with choledocholithiasis. If ERCP fails, open exploration of CBD and T-tube insertion, or biliary-enteric anastomosis are acceptable ways for CBD drainage. The rate of retained stone is not more than expected, thus elective IOC is more acceptable than routine IOC. Routine IOC is time-consuming and particularly difficult in elderly patients and emergency conditions