Subvesical bile duct and the importance of the critical view of safety: Report of a case.

INTRODUCTION: This is a case report in which a subvesical duct was identified intra-operatively during laparoscopic cholecystectomy. PRESENTATION OF CASE: A 49-year-old man underwent elective laparoscopic cholecystectomy for symptomatic cholelithiasis. During the procedure, the cystic duct and cystic artery were dissected. After ligation and division of these structures, a subvesical bile duct draining directly into the gallbladder was noted. In the present case, the subvesical duct was ligated and divided. The patient had an uneventful recovery. DISCUSSION: Subvesical bile ducts, also known as ducts of Luschka, represent anatomic variations of the biliary tree in which one or more bile ducts traverse in close contact with the gallbladder fossa. Inadvertent and undetected injury of these ducts are a frequent cause of cholecystectomy-associated bile leaks. CONCLUSION: Application of the critical view of safety principle may assist in intra-operative detection of aberrant biliary anatomy, thus preventing iatrogenic injury.

Medical student recognition of benign anorectal conditions: the effect of attending the outpatient colorectal clinic.

BACKGROUND: Benign anorectal conditions are fairly common. Physicians of various specialties usually see patients with these conditions before being referred to colorectal specialists, frequently with an incorrect diagnosis.We sought to evaluate the effect of attending an outpatient colorectal clinic by medical students on the diagnostic accuracy of these conditions. METHODS: Over a 1-year period, medical students were randomized into a group that attended the clinic, and one that did not. Both groups were shown images of six common benign anorectal conditions. The overall diagnostic accuracy as well as the diagnostic accuracy for each one of these conditions was prospectively evaluated for both groups. RESULTS: Nineteen students attended clinic and 17 did not. Overall diagnostic accuracy was 80.6% for students attending clinic and 43.1% for non-attending students. (p < 0.05) In the attending group, diagnostic accuracy was significantly greater for prolapsed internal hemorrhoids (73.6% versus 35.2%, p < 0.05), thrombosed external hemorrhoid, (73.6% versus 17.6%, p < 0.05) fissure (100% versus 47%, p < 0.05), and anal tags (68.4% versus 11.7%, p < 0.05%). CONCLUSION: Exposure to these conditions during surgical clerkships in medical school may help future specialists provide better care for patients with benign anorectal disorders.

Intersphincteric resection for low rectal cancer: an overview.

The treatment of rectal cancer has evolved from being solely a surgical endeavor to a multidisciplinary practice. Despite the improvement in outcomes conferred by the addition of chemoradiation therapy to rectal cancer treatment, advances in surgical technique have significantly increased rates of sphincter preservation and the avoidance of a permanent stoma. In recent years, intersphincteric resection for low rectal cancer has been offered and performed in patients as an alternative to abdominoperineal resection. An overview of this procedure, including indications, oncological and functional results based on current literature, is presented herein.

Female fertility and colorectal cancer.

PURPOSE: It is estimated that the incidence of cancer in women aged 40 years or less is 8%. Females under the age of 40 are in their childbearing years. In the Western world, colorectal cancer (CRC) is the most common malignancy of the gastrointestinal tract. It is the third most commonly diagnosed cancer and the second leading cause of cancer-related death in the USA. The incidence of CRC in patients under 40 is 3-6%. Over the past decades, there has been a significant improvement in survival rates due to progress in cancer treatment, including CRC. This has been achieved with advances in adjuvant chemotherapeutic regimens. In the case of locally advanced rectal cancer, radiation therapy is also used. Treatment for CRC may have adverse effects on female fertility. The purpose of this paper is to discuss the effects of treatment of CRC on female fertility as well as the options for fertility preservation. MATERIALS AND METHODS: A review of relevant English language articles was performed on the basis of a MEDLINE search of the keywords: female, fertility, fecundity, colon, rectal cancer, fertility preservation, chemotherapy, and radiation. RESULTS: Surgical resection for colon cancer possibly has no effect on female fertility. Resection below the peritoneal reflection may adversely affect fertility, based on lower fertility and fecundity rates associated with pelvic surgery for ulcerative colitis and familial adenomatous polyposis. Standard 5-FU-based chemotherapy may not have significant effects. The advent of oxaliplatin in adjuvant chemotherapy may be more harmful. Adjuvant and neoadjuvant radiation therapy may cause premature ovarian failure using current dosing schedules. The effect of pregnancy and female hormones on the incidence, progression, and recurrence of CRC remains unclear. Established methods for fertility preservation include ovarian transposition and embryo cryopreservation. Oocyte cryopreservation has yielded inferior results. An investigational fertility preservation method is ovarian tissue cryopreservation, with promising results. Ovarian suppression and the use of apoptotic inhibitors are also investigational at present. CONCLUSION: Young female patients need to be informed about the effects of treatment on fertility and options for fertility preservation. A multidisciplinary approach for appropriate consultation of these patients is mandatory.

Infarction of the ileocecal fold of Treves: a case of right lower quadrant pain.

The ileocecal fold of Treves is a peritoneal structure extending from the antimesenteric surface of the terminal ileum to the base of the appendix. No known pathologic conditions have been previously associated with it. We report a 30-year-old woman with acute onset of right lower quadrant pain. Her history was atypical for appendicitis. Endovaginal ultrasonography did not reveal gynecologic pathology. After a period of observation, the patient underwent diagnostic laparoscopy. This revealed inflammation and necrosis of the ileocecal fold of Treves and a normal-appearing appendix. The lesion was removed and appendectomy was performed. The patient's symptoms resolved immediately after surgery. Histopathologic examination of the lesion revealed fat necrosis, hemorrhagic necrosis, and lymphocytic infiltration. The appendix was normal. In conclusion, infarction of the ileocecal fold of Treves may be included in the differential diagnosis of right lower quadrant abdominal pain. Laparoscopy facilitates the diagnosis and treatment of unusual abdominal lesions.

The effect of L-arginine and aprotinin on intestinal ischemia-reperfusion injury.

BACKGROUND: Intestinal ischemia/reperfusion (I/R) results in local mucosal injury, systemic injuries, and organ dysfunction. These injuries are characterized by altered microvascular and epithelial permeability and villous damage. Activation of neutrophils, platelets, and endothelial factors are known to be involved in this process. Cytokines such as TNF-alpha, IL-1, IL-6, and oxygen-derived free radicals are believed to be important pathogenic mediators. Capillary no-reflow is also known to play a role in I/R. The aim of our study was to examine the role of L-arginine, a known nitric oxide (NO) donor, and aprotinin, a protease inhibitor with multiple effects, on intestinal I/R. METHODS: Pigs weighing 20-25 kg were used. Ischemia was established by clamping the superior mesenteric artery (SMA) at its origin and was sustained for 2 hours. Duration of reperfusion was 2 hours. The animals were divided into four groups: group A, the control group, which was submitted to I/R injury only; group B, in which L-arginine was administered at a rate of 5 mg/kg/min during ischemia and continuing throughout reperfusion; group C, in which aprotinin was administered with an initial bolus dose of 20,000 U/kg during ischemia followed by a continuous dose at 50 U/hour throughout reperfusion; and group D in which both substances were administered. In all groups TNF-alpha, IL-1, and IL-6 levels were measured using ELISA at baseline, 2 hours of ischemia, and 1 hour and 2 hours of reperfusion. SMA blood flow was measured with a Doppler probe at baseline, 10 min, 1 hour, and 2 hours of reperfusion. Histological changes of the intestinal mucosa were examined and graded on a five-point scale in all groups. RESULTS: In the control group, levels of TNF-alpha, IL-1, and IL-6 were significantly increased during reperfusion (p < 0.05) compared to baseline. Administration of L-arginine and aprotinin led to suppression of the release of TNF-alpha, IL-1, and IL-6 during reperfusion in a statistically significant manner (all p < 0.05). A synergistic or additive effect of L-arginine and aprotinin was not observed. SMA blood flow in the control group was decreased (p > 0.05) during reperfusion compared to baseline. In animals treated with L-arginine and aprotinin, SMA blood flow during reperfusion was significantly increased (p < 0.05) compared to the control group. Histologic examination of the intestinal mucosa was characterized by flattening of the villi and necrosis in the control group. In the treated animals, less severe histological changes were noted. CONCLUSIONS: Administration of L: -arginine and aprotinin may lead to amelioration of intestinal I/R injury. We did not note a synergistic or additive effect of these two substances. These findings warrant further studies in clinical settings for future treatment efforts.

Bile leaks from the duct of Luschka (subvesical duct): a review.

BACKGROUND: Gallstone disease remains the most common disease of the digestive system in Western societies and laparoscopic cholecystectomy one of the most common surgical procedures performed. Bile leaks remain a significant cause of morbidity for patients undergoing this procedure. These occur in 0.2-2% of cases. The bile ducts of Luschka, or subvesical ducts, are small ducts which originate from the right hepatic lobe, course along the gallbladder fossa, and usually drain in the extrahepatic bile ducts. Injuries to these ducts are the second most frequent cause of postcholecystectomy bile leaks. METHODS: A literature search using MEDLINE's Medical Subject Heading terms was used to identify recent articles. Cross-references from these articles were also used. RESULTS: Subvesical bile duct leaks can be detected by drip-infusion cholangiography using computed tomography preoperatively, direct visualization or cholangiography intraoperatively, and fistulography, endoscopic retrograde cholangiopancreatography (ERCP), and magnetic resonance cholangiopancreatography with intravenous contrast postoperatively. ERCP is the most common diagnostic method used. Most patients with subvesical duct leaks are symptomatic, and most leaks will be detected postoperatively during the first postoperative week. Drainage of extravasated bile is mandatory in all cases. Reduction of intrabiliary pressure with endoscopic sphincterotomy and stent placement will lead to preferential flow of bile through the papilla, thus permitting subvesical duct injuries to heal. This is the most common treatment modality used. In a minority of patients, relaparoscopy is performed. In such cases, the leaking subvesical duct is visualized directly, and ligation usually is sufficient treatment. Simple drainage is adequate treatment for a small number of asymptomatic patients with low-volume leaks. CONCLUSIONS: Subvesical duct leaks occur after cholecystectomy regardless of gallbladder pathology or urgency of operation. They have been encountered more frequently in the era of laparoscopic cholecystectomy. Intraoperative cholangiography does not detect all such leaks. Staying close to the gallbladder wall during its removal from the fossa is the only known prophylactic measure. ERCP and stent placement are the most common effective diagnostic and therapeutic methods used. Intraoperative and perioperative adjunctive measures, such as fibrin glue instillation and pharmacologic relaxation of the sphincter of Oddi, can potentially be used in lowering the incidence of subvesical bile leaks.