Anal melanoma in the era of sentinel lymph node mapping: a diagnostic and therapeutic challenge.

Melanoma of the anal canal is a rare malignancy that often has an atypical presentation. Locoregional metastases, which are often present at the initial presentation, may occur in both groin and pelvic lymph nodes, but the utility of lymph node dissection remains unknown. We explored the possibility of applying the technique of sentinel lymph node (SLN) mapping to anal melanoma. SLN mapping was performed in 2 patients with anal melanoma. Radioactive tracer and blue dye were injected around the lesions. The SLN was identified pre-operatively by lymphoscintigraphy, and at surgery with a hand-held gamma detector and by visualization of the dye. The SLN was identified in both patients, only in the groin in one and only in the presacral region in the other. One patient had a wide local excision of the anal lesion with house flap anoplasty, while the other had abdominoperineal resection with total mesorectal excision. There were no SLN metastases in either patient. The technique of SLN mapping and biopsy is easily adapted to surgery for malignant melanoma of the anus. SLN mapping and biopsy could aid in planning surgical strategy, but definitive conclusions may only be reached after more experience has been acquired.

The role of endoscopic retrograde cholangiopancreatography in management of patients recovering from acute biliary pancreatitis in the laparoscopic era.

BACKGROUND: Traditionally an episode of acute biliary pancreatitis (ABP) is an indication for direct imaging of the biliary tree. The optimal approach may vary according to local expertise, and endoscopic retrograde cholangiopancreatography (ERCP) is the most common. The fact that the incidence of choledocholithiasis in patients recovering from ABP varies between 3 and 33% raises a question about the necessity of visualizing the biliary tree in all patients recovering from ABP. METHODS: In order to evaluate this policy, we reviewed 48 ERCPs performed on patients recovering from ABP who were scheduled for laparoscopic cholecystectomy (LC). We checked the correlations between ERCP findings and the severity of pancreatitis, biochemistry values (which were sampled during the acute phase), and ultrasonographic (US) findings. RESULTS: The ERCP demonstrated common bile duct (CBD) stones in 11 (22.9%) patients. US finding of a dilated CBD and maximal aspartate transaminase (AST) values higher than 90 units/l were significantly correlated with CBD stones (a relative risk [RR] of 2.95 with a 95% confidence interval [CI] for a dilated CBD and RR of 3.89 with a 95% CI of 1.18-12.80 for an AST value higher than 90 units/l). No other parameters were significantly correlated with CBD stones. CONCLUSION: We, therefore, recommend performing a preoperative ERCP only on patients who present with an ultrasonographic finding of CBD dilatation. The correlation to high AST is still to be proven.

How does infected bile affect the postoperative course of patients undergoing laparoscopic cholecystectomy?

OBJECTIVES: To assess the rate of infected bile in patients undergoing laparoscopic cholecystectomy (LC) and to study the influence on the postoperative infective complications in this group of patients. METHODS: Bile samples of 247 patients undergoing LC were collected and cultured for aerobic and anaerobic bacteria. All patients were given prophylactic antibiotics. RESULTS: The overall rate of infected bile was 12.8% (56 positive cultures); of these, 54 were aerobic and 2 anaerobic bacteria. Only 2 patients developed infection at the umbilical site, and in both, the bile was sterile. None of the patients with positive bile cultures developed any signs of infection during a mean follow-up period of 26 months. CONCLUSION: The overall rate of septic complications following LC is extremely low, and at least in our study no correlation was found between infected bile and septic complications.

Is male gender a risk factor for conversion of laparoscopic into open cholecystectomy?

BACKGROUND: Based on a clinical observation that the conversion rate of laparoscopic cholecystectomy (LC) to open cholecystectomy (OC) is higher in males, we decided to review our records and to verify whether a significant difference in conversion rates exists between sexes. METHODS: A retrospective study on conversion rates of elective laparoscopic cholecystectomy (LC) into open cholecystectomy (LC) in relation to gender was carried out in 329 patients: 267 females and 62 males. RESULTS: Our data revealed that the probability of conversion is fivefold greater in males than females, 21% vs 4.5%, respectively (p = 0.0001). We attribute this striking difference to significantly more adhesions p = 0.0002) and anatomical difficulties (p = 0.003) in males during LC, leading to conversion. CONCLUSIONS: We conclude that conversion of LC to OC is more prevalent among males and is probably attributable to a greater incidence of anatomical difficulties.

The impact of woman's age and sperm parameters on fertilization rates in IVF cycles.

OBJECTIVE: To examine the predictive value of different sperm parameters and the age of a couple on fertilization rate. MATERIAL AND METHODS: One-hundred six consecutive sperm samples were analysed before insemination of oocytes in IVF cycles. Sperm count and motility were examined with the Makler Counter Chamber. Morphology was evaluated by the eosin nigrosin and giemsa stains. Membrane integrity was evaluated by the hypoosmotic swelling test (HOST). RESULTS: Using a step-wise logistic regression test the following parameters were all significantly correlated with the fertilization rates: sperm concentration after a 3-h layering (chi 2 = 15.85, P < 0.001), sperm motility index (chi 2 = 6.12, P < 0.0134), woman's age (chi 2 = 6.25, P < 0.012), and the hypoosmotic test (chi 2 = 6.63, P < 0.01). A fertilization capacity formula was established by using these four parameters to predict the fertilization capacity of a couple. Significantly lower fertilization rates were detected in elderly women with the partner sperm concentration of 7 x 10(6)/ml after 3-h layering, < 30% swollen spermatozoa in the HOST and motility index score of < 50. CONCLUSIONS: By the aforementioned formula, sperm fertilization capacity can be predicted by using simple sperm parameters and women's age. Elderly women with partners who have suboptimal sperm parameters reflected by low fertilization capacity scores may benefit from micro-manipulation procedures.

Are elevated liver enzymes and bilirubin levels significant after laparoscopic cholecystectomy in the absence of bile duct injury?

OBJECTIVE: Increased aspartate aminotransferase (AST), alanine aminotransferase (ALT), and bilirubin levels were noted incidentally after a laparoscopic cholecystectomy. The percentage in which such elevation occurs and its clinical significance in the absence of bile duct injury were investigated. SUMMARY BACKGROUND DATA: Bile duct injury is the most feared complication of laparoscopic cholecystectomy. Some laboratory tests may be indicative of this complication, such as increases in liver enzyme (AST, ALT, and alkaline phosphatase [ALP]) and bilirubin. These parameters have not been investigated in patients who had laparoscopic cholecystectomy and in whom no damage to the bile duct was noted. METHODS: Sixty-seven patients with normal results of preoperative liver function test were entered into the study. Blood was collected 24 hours after laparoscopic cholecystectomy, and AST, ALT, ALP, and bilirubin levels were measured. RESULTS: A mean 1.8-fold increase in AST occurred in 73% of patients; 82% showed a 2.2-fold increase in ALT. A statistically nonsignificant increase was noted in 53% of patients (ALP remained within normal limits), and in 14% of patients bilirubin levels were increased (they were primarily of the unconjugated type). CONCLUSIONS: In many patients a significant increase in AST and ALT levels occurred after laparoscopic cholecystectomy, but they returned to normal values within 72 hours. The cause of this is unclear, and these elevations appear to have no clinical significance.