Laparoscopic cholecystectomy in a patient with total situs inversus - case report.

For many years, laparoscopic cholecystectomy remains the method of choice for both the treatment of symptomatic cholelithiasis, and chronic and acute cholecystitis (1). The experience of the surgeon grows with each laparoscopic procedure, which enables to operate in case of difficult anatomical conditions and associated anatomical variants. The aim of the study was to present a case of a 47-year old male patient with total situs inversus and several months history of recurrent left epigastric pain, radiating to the left scapula, being accompanied by nausea and vomiting. The study presented the operative technique of laparoscopic cholecystectomy and postoperative period data. In conclusion, laparoscopic cholecystectomy in a patient with total situs inversus is possible and safe, providing relevant precautions. The main issues certainly include a good and feasible plan of the operation, discussion concerning the possible intraoperative and postoperative complications, a good plan considering the localization of the trocars, as well as an experienced surgical team. One should also not forget that early conversion to classical cholecystectomy is not considered as failure, but might prevent accidental damage of the biliary ducts and long-term complications.

The role of dietary nutrition in stomach cancer.

Stomach cancer mortality still represents a significant proportion of all cancer deaths. The majority of patients with advanced cancer experience cancer anorexia-cachexia syndrome with weight loss, reduced appetite, fatigue, and weakness. Neoplastic cachexia is a very common clinical manifestation of upper gastrointestinal (GI) tract cancer and is generally assumed to be secondary to the mechanical effects of the tumor on the upper digestive tract. The main reasons are obstruction to swallowing, early satiety, nausea and vomiting. Another reason for weight loss is the co-existence of systemic inflammation. Nutritional treatment in the group of patients with gastric cancer is still used too rarely and the knowledge about it is still very limited. Nutritional support should be given for patients both in the pre- and postoperative period. Nutrition should also be used in palliative treatment in patients with unresectable stomach cancer. The main principles of nutritional support and its influence are presented in this publication.

[Bile duct infections as a late complication after endoscopic sphincterotomy]. / Zakazenia dróg zólciowych jako pózne powiklanie sfinkterotomii endoskopowej.

UNLABELLED: Nowadays endoscopic sphincterotomy (SE) is considered to be a "gold standard" in the treatment of residual choledocholithiasis and biliary pancreatitis. Nevertheless patients after invasive procedures concerning bile ducts with destruction of Oddi's sphincter often have increased succeptibility to chronic infections of bile ducts. AIM: Assessment of the influence of SE on bacterial colonization, development of main bile duct chronic inflammation and recurrent choledocholithiasis. MATERIAL AND METHODS: We included to the study 50 patients with main bile duct lithiasis, who underwent endoscopic cholangiopancreatography (ERCP). Among them there were 32 women in age from 45 to 87 (mean 69.7 +/- 12.3) and 18 men in age from 39 to 84 (mean 59.8 +/- 11.56). The studied group was divided into 3 subgroups: In I (control) group were included 10 patients diagnosed with ERCP techniques because of jaundice of unknown origin. Those patients did't have ERCP or operative revision of bile ducts before, but all of them underwent cholecystectomy in the past. Each II and III group consisted of 20 patients, who underwent SE before 12-24 and 25-36 months earlier respectively. Sterile uodenoscope was inserted to the region of major duodenal papilla, and then a sterile brush was used to collect material to cytological smear (brushing) from main bile duct. In all groups 2 ml of bile were taken by a catheter to a syringe. On the basis of radiograms from ERCP findings, the width of main bile duct was assessed. In all patients blood cell count, aspartate and alanine aminotransferases, gammaglutamyltranspeptidase, alkaline phosphatase, amylase, bilirubin, C-reactive protein and procalcitonine levels were measured. RESULTS: In our study all 40 patients with previously performed endoscopic sphincterotomy (SE) had bacterial colonization in bile ducts, mostly with Gramm negative pathogens. The most virulent pathogens vere cultured from bile duct swabs from patients after two or more revisions of common bile duct, and after a longer time from sphincterotomy. Those patients had multibacterial bile duct infections (Escherichia coli + Pseudomonas aeruginosa; P. aeruginosa + Enterococcus faecalis; E. faecalis + Enterobacter cloacae + Candida albicans; P. aeruginosa + E. cloacae). E. coil and E. faecalis were most frequently cultured (20 and 16 cases respectively). It was observed that with length of time from endoscopic sphincterotomy, the width of main bile duct and also amount of cultured pathogens and their virulency grow. Elevated transaminases activity and serum procalcitonine levels were observed in studied groups. 9 patients after previous sphincterotomy had recurrent lithiasis. CONCLUSIONS: Sphincterotomy contributes to colonization of main bile duct with pathogenic bacteria. With length of time from endoscopic sphincterotomy, and amount of performed endoscopic sphincterotomies the amount of cultured pathogens, their virulency and drug resistance grow. Chronic infection of bile ducts after endoscopic sphincterotomy causes higher risk of recurrent lithiasis.