Dropped gallstones causing abdominal wall abscess and pleural empyema: a case series.

INTRODUCTION: Dropped gallstones are gallstones lost in the abdominal cavity during cholecystectomy. They are a rare occurrence and often cause minimal long-term issues. However, it is recognised that dropped stones can cause intra- or extra-abdominal sepsis. We present three cases below which highlight this. CASES: All three cases describe patients presenting for laparoscopic cholecystectomy, Cases 1 and 2 post-gallstone pancreatitis and Case 3 for gallbladder stones. Cases 1 and 3 presented nine months and five years post-operatively, respectively, with flank abscess. Both received CT scans, with incision and drainage performed to remove gallstone. Case 2 presented six weeks post-operatively with cough and breathlessness. CT scan showed pleural effusion with communication to subphrenic collection. Pus and gallstone fragments were drained. CONCLUSION: The above cases highlight that despite the majority of patients remaining asymptomatic, dropped gallstones should be considered amongst the differential in patients presenting with intra- or extra-abdominal abscess post-cholecystectomy, with timely intervention key to management.

Endoscopic mucosal resection for gastroesophageal cancer in a U.K. population. Long-term follow-up of a consecutive series.

BACKGROUND: Endoscopic mucosal resection (EMR) of early gastric and esophageal tumors is effective and avoids the morbidity and mortality of surgery. We report the long-term results of a consecutive series of 93 endoscopic resections, during a 7-year period, in a U.K. population. METHODS: Eighty-eight patients with 93 lesions were included. EMR was performed for 64 and 29 malignant and benign lesions, respectively. Patients with malignant disease were subgrouped into "high risk" or "low risk" for recurrence. RESULTS: Of the 35 lesions in the low-risk group, local control was achieved in 31; 29 after 1 EMR session. Two had residual invasive carcinoma, one had treatment ceased due to pancreatic cancer, and one patient did not attend follow-up. Of the 29 lesions in the high-risk group, local control was achieved in 15; 13 after 1 EMR session. Median follow-up was 53 months. Cancer specific survival for the 45 invasive cancers (T1m and T1sm) was 93%; three patients died from their disease. CONCLUSIONS: This study has shown for the first time in a U.K. population that EMR is effective in controlling disease in patients with local high grade dysplasia (HGD) and early invasive carcinoma, with no mortality and low morbidity.

Comparison of pre-treatment clinical prognostic factors in patients with gastro-oesophageal cancer and proposal of a new staging system.

BACKGROUND: Clinical staging in patients with gastro-oesophageal cancer, is of crucial importance in determining the likely benefit of treatment. Despite recent advances in clinical staging, overall survival remains poor. The aim of the present study was to examine the relationship between pre-treatment clinical prognostic factors and cancer-specific survival. METHODS: Two hundred and seventeen patients, undergoing staging investigations including host factors (Edinburgh Clinical Risk Score (ECRS)) and the systemic inflammatory response (Glasgow Prognostic score (mGPS)), in the upper GI surgical unit at Glasgow Royal Infirmary, were studied. RESULTS: During the follow-up period, 188 (87%) patients died; 178 of these patients died from the disease. The minimum follow-up was 46 months, and the median follow-up of the survivors was 65 months. On multivariate survival analysis of the significant factors, only cTNM stage (HR 1.84, 95% CI 1.56-2.17, p < 0.001), mGPS (HR 1.67, 95% CI 1.35-2.07, p < 0.001) and treatment (HR 2.12, 95% CI 1.73-2.60, p < 0.001) were independently associated with survival. An elevated mGPS was associated with advanced cTNM stage, poor performance status, an elevated ECRS and more conservative treatment. CONCLUSIONS: Pre-treatment mGPS improves clinical staging in patients with gastro-oesophageal cancer. Therefore, it is likely to aid clinical decision making for these difficult to treat patients.

Modified classification for adenocarcinoma of the gastro-oesophageal junction.

BACKGROUND: Incidence of the gastro-oesophageal junction adenocarcinoma is increasing. Siewert's classification subdivides junctional adenocarcinomas anatomically. Cytokeratin (CK) 7 and 20 immunophenotypes differentiate Barrett's intestinal metaplasia (IM) from gastric IM. Comparing CK immunostaining with Siewert's classification may establish tumour origin and influence surgical choice. METHODS: In this experimental study, 57 patients with gastro-oesophageal junction adenocarcinoma were subdivided endoscopically into 15 type 1, 26 type 2 and 16 type 3 adenocarcinomas. Representative biopsies were immunostained for CK7 and CK20. RESULTS: Intestinal metaplasia was associated with type 1 adenocarcinoma in 12 of 15 patients, 80%; with type 2 in 13 of 26 patients, 50% and type 3 in 6 of 16 patients, 37.5%. All type 1 patients showed Barrett's CK7/CK20 phenotype within IM; type 2 a mixture: 69% (n=9) Barrett's CK7/CK20 and 31% (n=4) gastric CK7/CK20 whereas type 3 patients had a gastric CK7/CK20 pattern in 83% (n=5). Immunostaining within the adenocarcinoma was variable. CONCLUSION: Siewert's type 1 adenocarcinomas express Barrett's CK7/CK20 pattern, type 3 a gastric CK7/CK20 pattern and type 2 tumours a mixture of Barrett's and gastric CK7/CK20 patterns within associated IM. CK immunostaining may refine Siewert's classification into oesophageal type 1 or gastric type 2 adenocarcinoma with IM.

A novel approach to high definition, high-contrast video capture in abdominal surgery.

OBJECTIVE: The aim of this study was to define the best available option for video capture of surgical procedures for educational and archival purposes, with a view to identifying methods of capturing high-quality footage and identifying common pitfalls. SUMMARY BACKGROUND DATA: Several options exist for those who wish to record operative surgical techniques on video. While high-end equipment is an unnecessary expense for most surgical units, several techniques are readily available that do not require industrial-grade audiovisual recording facilities, but not all are suited to every surgical application. METHODS: We surveyed and evaluated the available technology for video capture in surgery. Our evaluation included analyses of video resolution, depth of field, contrast, exposure, image stability, and frame composition, as well as considerations of cost, accessibility, utility, feasibility, and economies of scale. RESULTS: Several video capture options were identified, and the strengths and shortcomings of each were catalogued. None of the commercially available options was deemed suitable for high-quality video capture of abdominal surgical procedures. A novel application of off-the-shelf technology was devised to address these issues. CONCLUSIONS: Excellent quality video capture of surgical procedures within deep body cavities is feasible using commonly available equipment and technology, with minimal technical difficulty.