Migrated Laparoscopic Surgical Clips Causing Acute Cholangitis 32 Years After Laparoscopic Cholecystectomy.

Surgical clip migration post-laparoscopic cholecystectomy is a rare but important complication to consider in patients presenting with biliary obstruction. Titanium surgical clips are widely used in laparoscopic surgery to ligate vessels and ducts and are particularly important in laparoscopic cholecystectomy to ligate the cystic duct. More common complications associated with clips involve dislodgement, however, there are reported cases of migration into visceral structures causing an obstruction. We describe a case that demonstrated an acute migration of surgical clips into the common bile duct (CBD) within a three-week period, which occurred 32 years after laparoscopic cholecystectomy, likely attributed to erosion. On the patient's first presentation, she had acute pancreatitis with a CT demonstrating clips in the correct position. Three weeks later, the patient presented a second time with acute cholangitis and the repeat CT demonstrated the clips in the CBD. We hypothesize that the erosion of the bile duct is due to the pressure effects from either intra-abdominal organ movements or subtle clip movements, and eventually, persistent erosion leading to intra-ductal migration of the clips with the passage of the clips along the path of least resistance into the CBD, resulting in biliary obstruction. Management included standard treatment for biliary obstruction with intravenous broad-spectrum antibiotics and endoscopic retrograde cholangiopancreatography with excellent outcomes.

Combined chemotherapy and endoscopic ultrasound-guided intratumoral 32P implantation for locally advanced pancreatic adenocarcinoma: a pilot study.

BACKGROUND: This study evaluated clinical outcomes of combined chemotherapy and endoscopic ultrasound (EUS)-guided intratumoral radioactive phosphorus-32 (32P) implantation in locally advanced pancreatic adenocarcinoma (LAPC). METHODS: Consecutive patients with newly diagnosed LAPC were recruited over 20 months. Baseline computed tomography and 18F-2-fluoro-2-deoxy-D-glucose (18FDG) positron emission tomography-computed tomography were performed and repeated after 12 weeks to assess treatment response. Following two cycles of conventional chemotherapy, patients underwent EUS-guided 32P implantation followed by six chemotherapy cycles. RESULTS: 12 patients with LAPC (median age 69 years [interquartile range 61.5-73.3]; 8 male) completed treatment. Technical success was 100 % with no procedural complications. At 12 weeks, median reduction in tumor volume was 8.2 cm3 (95 % confidence interval 4.95-10.85; P = 0.003), with minimal or no 18FDG uptake in nine patients (75 %). Tumor downstaging was achieved in six patients (50 %), leading to successful resection in five (42 %), including four R0 resections (80 %). CONCLUSIONS: EUS-guided 32P implantation was feasible, well tolerated, and resulted in a 42 % surgical resection rate. Further evaluation in a larger randomized multicenter trial is warranted.

Oestrogen hormone receptors in focal nodular hyperplasia.

BACKGROUND: The role of hormones in focal nodular hyperplasia (FNH) has been investigated with conflicting results. OBJECTIVE: The aim of this study was to evaluate oestrogen and progesterone receptor immunohistochemical expression in FNH and surrounding normal liver (control material). METHODS: Biopsy materials from FNH and control tissue were investigated using an immunostainer. Receptor expression was graded as the proportion score (percentage of nuclear staining) and oestrogen receptor intensity score. RESULTS: Study material included tissue from 11 resected FNH lesions and two core biopsies in 13 patients (two male). Twelve samples showed oestrogen receptor expression. The percentage of nuclear oestrogen receptor staining was <33% in eight FNH biopsies, 34-66% in two FNH biopsies, and >67% in both core biopsies. The better staining in core biopsies relates to limitations of the staining technique imposed by the fibrous nature of larger resected FNH. Control samples from surrounding tissue were available for nine of the resected specimens and all showed oestrogen receptor expression. Progesterone receptor expression was negligible in FNH and control samples. CONCLUSIONS: By contrast with previous studies, the majority of FNH and surrounding liver in this cohort demonstrated oestrogen receptor nuclear staining. The implications of this for continued oral contraceptive use in women of reproductive age with FNH remain uncertain given the lack of consistent reported growth response to oestrogen stimulation or withdrawal.

Co-morbidities in trauma patients: common and significant.

INTRODUCTION: Trauma is a heterogeneous 'disease' that affects all age groups with varying degrees of severity. While injury severity, time to definitive care, and the quality of care in trauma patients have been quantified, it has been much more difficult to quantify pre-existing health status or 'host factors' in trauma patients and relate them to trauma outcome. Numerous studies have attempted this task, but none have succeeded in producing a simple system to quantify co-morbidities. As a prelude to developing a simple Abbreviated injury scale (AIS)-like score, the incidence of major and minor co-morbidities (and outcomes) in a cohort of admitted trauma patients > or =40 years of age were evaluated. METHODS: A prospective review of the Auckland Trauma Registry of trauma patients age > or =40 years that were admitted to Auckland Hospital between 1 January 2003 and 3 March 2003 was performed. Among the data collected were the patient's co-morbidities. The co-morbidities were divided into major and minor co-morbidities: major co-morbidities were defined by criteria found in the APACHE 2 PIC system, whereas minor co-morbidities were all the other co-morbidities not included in the APACHE 2 PIC system. RESULTS: A total of 105 patients were included. There were 57 males and 48 females in this study. Overall, 71% of the population had pre-existing co-morbid conditions, with 23% having a major co-morbid condition. Major trauma [injury severity score (ISS) of 15] was seen to decrease as age increases. The mortality rate in this group of patients was 4.7%. DISCUSSION: Co-morbidities were surprisingly common in trauma patients. Trauma outcome in patients with co-morbidities is difficult to predict and is not well addressed by any of the existing injury scales. The possibility of developing single 'AIS-like' co-morbidity score merits ongoing evaluation. The prevalence of co-morbidities in trauma patients > or =40 years of age suggests that the influence of co-morbidity on outcome should be considered in a much greater cohort than is currently the case.

Transfer function index: is it a reliable method for vein graft surveillance?

INTRODUCTION: Duplex ultrasound scanning is currently the best available non-invasive method for vein graft surveillance. However, it is expensive and its results are highly operator dependent. The aim of the present study is to compare, another non-invasive method of graft surveillance, the transfer function index (TFI), with duplex ultrasound scanning in identifying significant stenoses in infrainguinal saphenous vein bypass grafts. METHODS: Initially a retrospective pilot study was carried out between 1 January and 30 June 2002. Patients were identified from the vascular surgical operation database. The ultrasound report and TFI result of each patient were reviewed. Then a prospective comparative study was carried out between 1 July and 31 December 2002. Duplex ultrasound and TFI studies were undertaken at the 3 month interval. Comparisons were made between the accuracy and predictive value of ultrasound versus TFI in assessing significant graft stenosis. RESULTS: In the present retrospective study TFI measurement was significantly lower in the at-risk grafts than in the normal grafts (P = 0.001). In the prospective group TFI was again found to be significantly lower in the at-risk group (mean TFI 0.86) than in the normal group (mean TFI 1.064, P = 0.001). The sensitivity and specificity of the TFI were 92% and 97%, respectively. The accuracy of TFI was calculated to be 98%. CONCLUSION: TFI is an accurate non-invasive method of vascular graft surveillance. TFI can be carried out in the vascular clinic and is quick and inexpensive. Normally TFI could replace duplex ultrasound surveillance, with ultrasound being reserved for those with an abnormal TFI.