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Laparoscopic sleeve gastrectomy (LSG) is gaining acceptance as a stand-alone bariatric procedure with proven efficacy on weight loss and obesity-related comorbidities. A specific and potentially severe complication of LSG is the staple line leak (SLL). Our aim was to report the SLL rate and its management in a prospective cohort of 378 LSGs.A total of 378 patients underwent LSG from July 2005 to July 2011. The gastric transection was performed by an initial 60 mm firing of 4.5 mm staples at the antrum and successive 60 mm firings of 3.5 mm staples at the gastric body and fundus toward the left diaphragmatic crus. A 36 Fr bougie was used to calibrate the gastric tube. The staple line was systematically reinforced with a partial-thickness running suture.The overall complications and SLL rate were 20/378 (5.29%) and 9/378 (2.38%), respectively. SLLs were managed by laparoscopic (n=2) or open (n=1) exploration, drainage and endoscopic self-expandable covered stent, computed tomography-guided percutaneous drainage (n=2), or a self-expandable covered stent alone (n=4). Medical support including total parenteral nutrition and adapted antibiotics was started in all patients. The combined treatment modalities were successful in all cases.SLL was the most common complication of LSG accounting for half of the overall complications. Percutaneous drainage and self-covered stents combined with antibiotics and parenteral nutrition are effective for SLL and should be proposed as first-line treatment in stable patients.

Laparoscopic surgery for choledocholithiasis is still evolving. Only a few reports of single-incision laparoscopic common bile duct exploration (LCBDE) have been published. One hundred and one consecutive patients underwent single-incision LCBDE (SILCBDE) by one surgeon with straight instruments during a 42-month period. Choledochotomies were performed on 61 patients (60.4%). The success rate of intrahepatic duct exploration was 68.0% (17/25) for patients undergoing transcystic choledochoscopic bile duct explorations following longitudinal cystic ductotomies. The ductal clearance rate was 100%. Eighteen procedures (17.8%) were converted, including one open surgery. Nineteen patients (18.8%) experienced 26 episodes of complications; the majority (19 episodes) were classified as Clavien–Dindo grade I. Excluding those patients with Mirizzi syndrome (McSherry type II), multivariate logistic regressions showed that patients who were older or had complicated cholecystitis had higher procedure conversion rates and that higher modified APACHE II scores, higher white blood cell counts, and longer operative times were independent risk factors for complications. Based on operative times, 20 successful SILCBDEs were needed to get through the learning phase. A higher transcystic approach rate (46.5 vs. 8.3%; P

PURPOSE To assess the impact of mesh size and fixation devices on short-term outcomes in a consecutive series of tension-free laparoscopic abdominal wall repairs. METHODS Data for 120 consecutive, unselected patients undergoing tension-free laparoscopic incisional (n=63) or umbilical (n=57) hernia repair were prospectively collected. A multivariate analysis was performed to evaluate variables influencing outcomes. RESULTS Persistent seromas were observed in 13 patients (10.83%) and 2 recurrences (1.98%) occurred. Mesh size >300 cm was associated with increased hospital stay [odds ratio (OR) 4.83; 95% confidence interval (CI), 1.5-15.53; P=0.008], increased postoperative day 1 (POD1) pain assessed with visual analog scale (OR 5.51; 95% CI, 1.76-17.2; P=0.003), and the presence of complications (OR 10.4; 95% CI, 1.85-58.96; P=0.007). Body mass index >30 resulted in increased hospital stay (OR 3.05; 95% CI, 1.23-7.57; P=0.01) and increased POD1 visual analog scale (OR 2.28; 95% CI, 1-5.18; P=0.04). CONCLUSIONS Mesh size and obesity were the main factors influencing postoperative outcomes.

The aim of this study was to assess the accuracy of a novel imaging modality, three-dimensional (3D) metabolic and radiologic gathered evaluation (MeRGE), for localizing parathyroid adenomas (PAs).Consecutive patients presenting with primary hyperparathyroidism who underwent both thin-slice cervical computed tomography (CT) and (99m)Tc-sestamibi (MIBI) scanning were included. 3D-CT reconstruction was obtained using VR-RENDER, which was used to perform 3D virtual neck exploration (3D-VNE). The MIBI scan was then fused with the 3D reconstruction to obtain 3D-MeRGE. Sensitivity, specificity, and accuracy were assessed. Parathyroid gland volume and preoperative parathormone (PTH) levels were analyzed as predictive factors of correct localization (i.e., correct quadrant).A total of 108 cervical quadrants (27 patients) were analyzed. Sensitivities were 79.31, 75.86, 65.51, and 58.61 % with 3D-MeRGE, 3D-VNE, MIBI, and CT, respectively. Specificity was highest with CT (94.93 %) followed by 3D-VNE (92.4 %). MIBI and 3D-MeRGE had the same specificity (88.6 %). 3D-MeRGE and 3D-VNE achieved higher accuracy than MIBI or CT alone. Mean PTH values were significantly higher in patients with lesions that were correctly identified (true positive, TP) than in those whose lesions were missed (false negative, FN) with 3D-VNE (219.60 ± 212.77 vs. 98.75 ± 12.76 pg/ml; p = 0.01) and 3D-MeRGE (217.69 ± 213.76 vs. 09.75 ± 20.48 pg/ml; p = 0.02). The mean parathyroid gland volume difference between TP and FN was statistically significant with all modalities except CT.3D-MeRGE and 3D-VNE showed high accuracy for localization of PAs. 3D-MeRGE performed better than MIBI or CT alone for detecting small adenomas and those with a low PTH level.

Introduction. A transanal, posterior, retrorectal approach has been demonstrated as a feasible natural orifice transluminal endoscopic surgery (NOTES) total mesorectal excision (TME) procedure. The aim was to assess the feasibility of a transrectal approach with a completely retroperitoneal mobilization of the left colon and mesenteric vessels in an acute porcine model. Materials and methods. Eight pigs were used. A purse-string suture was made 3 cm above the anal sphincter. Next, the retroperitoneal, perirectal space was entered with an endoscope through a single (or twin) anterior lateral, transrectal viscerotomy. A retroperitoneal tunnel was created using pneumodissection or endoscopically guided dissection to the inferior mesenteric artery (IMA). The IMA was skeletonized and lymph nodes retrieved using the IsisScope or other instruments. The IMA was divided with the Ligasure, clips, or ligature performed with the IsisScope. The rectum was dissected transanally in the “Holy” plane. After achieving mobilization using a completely retroperitoneal approach, the peritoneal attachments were then divided and the rectosigmoid specimen exteriorized through the anus. An explorative laparoscopy was then performed to evaluate the quality of the mobilization. Results. The procedure was successfully completed and the IMA correctly identified and ligated in all cases. In all but one case, no further mobilization was possible, even by a laparoscopic approach. Conclusions. Perirectal oncologic gateway to retroperitoneal endoscopic single-site surgery for left-sided colonic resections using both flexible and rigid surgical endoscopic platforms was feasible and reproducible in an acute porcine model. This technique might represent a step toward pure NOTES left-sided colorectal procedures.

The aim of this study is to evaluate the impact of an expert monitoring on the quality and results of laparoscopic reversal of Hartmann's procedure (LRHP) performed by trainee surgeons by comparing their results to the expert's outcomes. Forty-two LRHP were performed between 2000 and 2008 following a step-by-step, standardised, full laparoscopic procedure. Patients operated upon by a senior surgeon were compared to patients operated upon by trainee surgeons while being mentored by the senior surgeon. Operative time, conversion, complications and post-operative outcome were measured. Each group included 21 patients. All patients underwent LRHP successfully. Two procedures were converted. No significant difference was observed between the expert and the trainees: operative time, 132 min (SD ± 50) vs. 131 min (SD ± 47) and complications (2–14%), 4 vs. 2. Three complications required re-operation, and three other were treated medically, including one dilatation of an anastomosis. Post-operative outcomes were comparable (oral intake, 3 vs. 2 days; post-operative hospital stay, 6 vs. 7.5 days); no mortality occurred. Standardisation simplifies this difficult laparoscopic procedure and offers the same outcome whether it is performed by an expert or by mentored trainees. The complications were comparable to those occurring at experienced centres (anastomotic leak or stricture, ureteral injury, re-operation). The expert mentoring does not prevent all complications but can solve intra-operative technical problems, thus improving the trainee's confidence. Mentoring should be promoted as it can be performed locally or remotely using modern interactive technology.

Background Totally implantable access ports are often used for the administration of chemotherapy or prolonged intravenous infusions in patients with cancer. The technique has been well described. However, some complications would happen. The pinch-off-syndrome is one of these complications. We report another presentation of pinch-off-syndrome and how to prevent. Methods From January 2005 to December 2007, 73 patients of catheter fracture were collected. The duration of Port-A implantation ranged from January 2003 to October 2007. During this period, 3358 port-catheters were implanted. There were three brands of Port-A implanted included 46% BardPort™ (Bard, Salt Lake City, UT, USA), 42% A Port (Arrow international, Reading, PA, USA) and 12% PORT-A CATH (Deltec, St. Paul, MN, USA). Results The most common clinical presentation was difficulty in injection in 32 cases (43.8%). The incidence of brand C was far lower than brand A and B. The most common site of fracture was at the proximal part (anastomosis between injection port and catheter) in 68 cases (93.2%). The incidence of fracture of Port-A was 6 in 738 (0.81%) in cut-down method; 67 in 2620 (2.56%) in percutaneous subclavian method. Most of thecases (34%) were no more than six months. Conclusion The most frequent location of fracture Port-A was in proximal part – anastomosis between injection port and catheter. The cause of easily fracture may be associated with pinch-off-syndrome and design of Port-A. This kind of fracture could be prevented by cut-down method and fixed one stitch in proximal part.

To treat secondary hyperparathyroidism with subtotal parathyroidectomy or total parathyroidectomy with autotransplantation might cause the disease to recur because of growth of the parathyroid remnant or the autografts. The aim of the present study was to determinate an alternative surgical treatment for secondary hyperparathyroidism. Of 94 uremic patients, 44 (median age: 50.5 years; 33 women/11 men) were assigned to group A, patients who were not expected to receive kidney transplantation for various reasons and had total parathyroidectomy without autotransplantation; 50 (median age 46 years; 33 women/17 men) were assigned to group B, patients who had either total parathyroidectomy with autotransplantation or subtotal total parathyroidectomy with preservation of parathyroid tissue in situ. Parameters measured included demographics, perioperative and follow-up biochemistry tests, operative time, postoperative complications, length of hospital stay, patients’ compliance with the postoperative calcium and 1,25 dihydroxy-viatmin D supplementation regimen, symptom relief, and presence of recurrence. Mean operative times were 103 and 122 min (P = 0.007); postoperative complication rates were 18.2% and 12.0% (P = 0.563); mean hospital stays were 6 and 9 days (P = 0.259); adequate patient compliance with the postoperative calcium and 1,25 dihydroxy-viatmin D regimens were 84.1% and 78.0%, respectively (P = 0.6); symptom relief rates were 88.6% and 80.0% (P = 0.277). Recurrence rates over 60 months in group A and group B were 4.5% and 18.0%, resectively (P = 0.028 by Kaplan-Meier analysis). Because of the lower recurrent rate and shorter operative time, total parathyroidectomy without autotransplantation may be an option for treating patients with symptomatic secondary hyperparathyroidism who are not expected to receive kidney transplantation.

A review of the literature pertaining to percutaneous transhepatic cholangioscopic lithotomy (PTCSL) showed that more than 50% of reported patients had undergone earlier biliary surgery.A retrospective study investigated 74 patients undergoing initial PTCSL for hepatolithiasis who had undergone no prior biliary surgery or manipulation. The patients were followed for 1 to 23 years after PTCSL for effective evaluation of the procedure outcome.Complete clearance of hepatolithiasis was achieved for 61 (82%) patients. The incomplete clearance rate was higher for patients with intrahepatic duct stricture (11/37 [30%] vs 2/37 [5%]; p0.05), although it showed no relation to the actual lobar distribution of hepatolithiasis (left: 7/41 [17%] vs right: 2/11 [18%] vs bilateral: 4/22 [18%]; p0.05). The recurrence rate for hepatolithiasis also was higher for patients with intrahepatic duct stricture (18/26 [69%] vs 13/35 [37%]; p0.05), but the recurrence rate showed no relation to the lobar distribution of hepatolithiasis (left: 18/34 [53%] vs right: 4/9 [44%] vs bilateral: 9/18 [50%] p0.05) or the presence of gallbladder stones (5/12 [42%] vs 26/49 [53%]; p0.05). Patients showing the coexistence of retained or recurrent hepatolithiasis demonstrated a higher incidence of recurrent cholangitis (57% [13/23] vs 14% [7/51]; p0.01) or cholangiocarcinoma (17% [4/23]) vs 0% [0/51]; p0.01).The findings show that PTCSL is effective for treating primary hepatolithiasis, and that complete stone clearance is mandatory to diminish the sequelae of hepatolithiasis. Intrahepatic duct stricture was the main factor contributing to incomplete clearance and stone recurrence.

AIM: The aim of this study was to evaluate the effectiveness of technetium-99m tetrofosmin (Tc-99m TF) single photon emission computed tomography (SPECT) of the neck and chest to detect metastatic lesions in papillary thyroid carcinoma (PTC) after near total thyroidectomy and radioiodine (I-131) treatment in patients who present with elevated serum human thyroglobulin (hTg) levels but negative I-131 whole body scan (WBS). MATERIALS AND METHODS: Twenty patients with PTC treated by near total thyroidectomy and I-131 treatments were included in this study. All 20 patients had negative I-131 WBS results and elevated hTg levels (hTg 2.0 μIU/ml) under thyroid-stimulating hormone (TSH) stimulation (TSH 30 μIU/ml). Nineteen of the 20 cases were confirmed to have metastases by operation/biopsy histopathological findings or clinical follow-up longer than 1 year by additional morphological imaging techniques. The remaining patient has been followed up closely and has been disease free for 10 months. Tc-99m TF SPECT was performed to detect metastatic lesions. RESULTS: Tc-99m TF SPECT demonstrated lesions in 11/19 patients; a sensitivity of 57.9%. Tc-99m TF SPECT failed to demonstrate lesions in eight patients including smaller lymph nodes and miliary lung metastases. CONCLUSIONS: We conclude that Tc-99m TF SPECT is a useful additional tool to detect metastatic lesions in PTC with elevated hTg but negative I-131 WBS. However, smaller lymph nodes and miliary lung metastases may be missed.

Our preliminary studies found technetium-99m tetrofosmin (Tc- TF) chest imaging was related to Pgp or MRP1 expression and successfully predict chemotherapy response and in SCLC in human. However, there was no published literature to study relationship of Tc-TF chest images and LRP expression in SCLC patients. Therefore, the aim of this study was to investigate the relationships among Tc- TF accumulation in untreated small cell lung cancer (SCLC), the expression of P-glycoprotein (Pgp), multidrug resistance related protein-1 (MRP1), and lung resistance-related protein (LRP), as well as the response to chemotherapy in patients with untreated SCLC. Thirty patients with SCLC were studied with chest images 15 to 30 minutes after intravenous injection of Tc-TF before chemotherapeutic induction. Tumor-to-background (T/B) ratios were obtained on the static and plantar Tc-TF chest images. The response to chemotherapy was evaluated upon completion of chemotherapy by clinical and radiological methods. These patients were separated into 15 patients with good response and 15 patients with poor response. No significant differences of prognostic factors (Karnofsky performance status, tumor size, or tumor stage) were found between the patients with good and poor responses. Immunohistochemical analyses were performed on multiple nonconsecutive sections of biopsy specimens to detect Pgp, MRP1, and LRP expression. The difference in T/B ratios on the Tc-TF chest images of the patients with good versus poor response was significant. The differences in T/B ratios of the patients with positive versus negative Pgp expression and with positive versus negative MRP1 expression were significant. The difference in T/B ratios of the patients with positive versus negative LRP expression was not significant. We concluded that Tc-TF chest images could accurately predict chemotherapy response of patients with SCLC. In addition, The Tc-TF tumor uptake was related to Pgp or MRP1 but not LPR expression in SCLC.

Papillary carcinomas are the most common thyroid malignancies. They invade the regional lymphatics and metastasize frequently to local lymph nodes in the neck. Distant metastasis, generally to the lungs, is also common.The aim of this study is to evaluate the effectiveness of F18-fluorodeoxyglucose (FDG) positron emission tomography (PET) to detect metastatic lesions in patients with papillary thyroid carcinomas (PTC) after nearly total thyroidectomy and I-131 treatments who present with elevated human serum thyroglobulin (hTg) levels but negative 1-131 whole body scan (WBS). Twenty patients with PTC who underwent nearly total thyroidectomy and radioiodine treatments were included in this study.All of the 20 patients had negative I-131 WBS results and elevated hTg levels (hTgor = 2.0 microIU/mL) under thyroid-stimulating hormone (TSH) stimulation (TSHor = 30 microIU/mL).FDG-PET was perform to detect metastatic lesions. F18-fluorodeoxyglucose-PET could detect hypermetabolic lesions in 17 patients but failed to demonstrate miliary pulmonary metastases in two patients. No definite lesion was found in FDG-PET, x-ray chest computed tomography (CT) and other imaging studies of the remaining one patient This study showed that FDG-PET is a useful tool in detecting metastatic lesions in PTC with elevated hTg but negative I-131 WBS. However, miliary lung metastases may be missed in FDG-PET. In this circumstance, chest CT should be included in the follow-up protocol.

To evaluate the clinical benefits and disadvantages of adding metoclopramide to tramadol for patient-controlled analgesia (PCA).Forty adult patients, undergoing elective arthroplasties, were recruited into this prospective, randomized, double-blind study. During general anesthesia all patients received 2.5 mg x kg(-1) of tramadol as a loading dose at the beginning of wound closure. In the postanesthesia care unit (PACU) patients were randomly allocated to receive PCA containing either 20 mg tramadol + 1 mg metoclopramide per millilitre (n = 20, Group T+M) or tramadol 20 mg per millilitre (n = 20, Group T). The PCA setup was 1 mL/bolus with a lockout interval of five minutes. A blinded investigator assessed the vital signs, visual analogue scale, and severity of postoperative nausea and/or vomiting in the PACU. The PCA demand and delivery, overall satisfaction rate and adverse effects were recorded in the PACU and on postoperative days one and two.Nausea/vomiting scores were more severe (1.7 +/- 1.0 vs 0.2 +/- 0.5, 2.3 +/- 1.2 vs 0.6 +/- 0.6, 1.9 +/- 0.9 vs 0.2 +/- 0.5, at 12 hr, 18 hr, 24 hr, respectively, P0.05) and more frequent (7/20 vs 1/20, 5/20 vs 0/20 for nausea and vomiting respectively, P0.05) on postoperative day one in Group T compared to Group T+M. However, the incidence of sedation was higher in Group T+M (7/20 vs 1/20, P0.05).The incidence and severity of nausea/vomiting decreased if metoclopramide was added to tramadol for PCA. An increased incidence of sedation was noticed with this drug combination.

Background Findings related to the influence of the −160C → A promoter polymorphism and haplotypes of the E-cadherin (CDH1) gene have not been consistent in previous studies regarding the risk for sporadic gastric cancer. Investigators in most previous studies detected those genotypes using restriction fragment length polymorphism analysis. Therefore, we conducted a case–control study to investigate the association of the CDH1 − 160C → A promoter polymorphism and haplotypes for cancer risk related to sporadic diffuse and intestinal gastric cancer by direct sequencing analysis. Methods We included 107 diffuse gastric cancer cases, 60 intestinal gastric cancer cases and 134 controls. The genotypic polymorphisms in the −160 promoter region, exons and intron–exon boundaries of CDH1 were detected by direct sequencing analysis. Genotype frequencies were compared. The CDH1 − 160C → A promoter polymorphism and four polymorphisms (48 + 6 T → C, 2076C → T, 2253C → T and 1937–13 T → C) were included in the haplotype analyses, which were estimated using the expectation–maximization algorithm. Results Compared to controls, the frequency of the −160A allele was significantly higher in diffuse gastric cancer cases (P = 0.005), but it was not significantly different in intestinal gastric cancer cases (P = 0.119). Two sets of three-marker haplotypes (−160C → A, 48 + 6 T → C, 2076C → T and −160C → A, 1937–13 T → C, 2253C → T) were associated with the risk of diffuse gastric cancer (P = 0.011 and P = 0.042, respectively). Conclusion Based on direct sequencing analysis, our findings suggest that the CDH1 − 160C → A promoter polymorphism and haplotypes play significant roles in cancer risk for sporadic diffuse gastric cancer, but not for intestinal gastric cancer, in a Taiwanese population.

Revisional surgery may be required in a high percentage of patients (up to 30 %) after laparoscopic adjustable gastric banding (LAGB). We report our institutional experience with revisional surgery.From January 1996 to November 2011, 90 patients underwent revisional surgery after failed LAGB. Both Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) were proposed. In the presence of gastroesophageal reflux disease, esophageal dysmotility, hiatal hernia, or diabetes, RYGB was preferentially proposed.In two cases, revisional surgery was aborted due to local severe adhesions. Eighty-eight patients (74 females; mean age 42.79 ± 10.03 years; mean BMI 44.73 ± 6.19 kg/m(2)) successfully underwent revisional SG (n = 48) or RYGB (n = 40). One-stage surgery was performed in 29 cases. Follow-up rate was 78.2 % (n = 61) and 40.9 % (n = 36) at 12 and 24 months respectively. One major complication after SG (staple-line leakage) was observed. Overall postoperative excess weight loss (%EWL) was 31.24, 40.92, 52.41, and 51.68 % at 3, 6, 12, and 24 months of follow-up respectively. There was a statistically significant higher %EWL at 1 year in patients50 years old (55.9 vs. 41.5 % in patients50 years old; p = 0.01), of female gender (55.22 vs. 40.73 % in male; p = 0.04), and in patients in which the AGB was in place for5 years (57.09 vs. 47.43 % if5 years p = 0.02).Revisional surgery is safe and effective. Patients50 years, of female gender, and with the AGB in place for5 years had better %EWL after revisional surgery.

This study aims to report glycolipid changes after sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) in the setting of a prospective randomized clinical trial.One hundred patients were randomly assigned to RYGB (n = 45) and SG (n = 55). Fasting glucose, insulin, glycated hemoglobin (HbA1c%), triglycerides, and serum cholesterol (total, HDL, and LDL) were evaluated at inclusion and after 1, 3, 6, and 12 months. The index for homeostasis model assessment of insulin resistance (HOMA-IR) and β cell function (HOMA-B) were assessed.Mean postoperative 1-, 3-, 6-, and 12-month excess weight loss was 25.39, 43.47, 63.75, and 80.38 % after RYGB and 25.25, 51.32, 64.67, and 82.97 % after SG, respectively. Mean fasting glucose and fasting serum insulin were similarly and statistically significantly reduced in both RYGB and SG. Mean HOMA-IR improved in both groups, particularly in case of high preoperative values, and mean HOMA-B improved at 1 year after RYGB. HbA1c% dropped from 5.66 % (SD = 0.61) to 5.57 % (SD = 0.32) after RYGB and from 5.64 % (SD = 0.43) to 5.44 % (SD = 0.43) after SG. Total cholesterol was significantly higher at 1 month (p = 0.04), 3 months (p = 0.03), and 1 year (p = 0.005) after SG as compared to RYGB. LDL cholesterol decreased significantly after RYGB at 1 month (p = 0.03), 3 months (p = 0.0001), and 1 year (p = 0.0004) as compared to SG. HDL cholesterol was increased at 1 year in the RYGB group but not in the SG group. Triglycerides decreased similarly in both groups.Short-term glycemic control was comparable after SG and RYGB. An improved lipid profile was noted after RYGB in patients with abnormal preoperative values.

With the advances in laparoscopic instruments and surgical techniques, the use of laparoscopic appendectomy (LA) has been increasing rapidly in recent years. In this retrospective analysis, we aimed to determine the competitive edge of LA versus open appendectomy (OA) in different settings of disease complexity, gender, and age difference.A retrospective analysis of the patients diagnosed with acute appendicitis at Changhua and Chang-Bing Show-Chwan Memorial Hospitals from January 1, 2004 to December 31, 2009 was conducted. Trend and indication of OA and LA were recorded, combined with a comparison of medical costs, complication rates, wound infection rates, and hospital stays in different settings of disease complexity, gender, and age group.A total of 1366 appendicitis patients were enrolled, and the rate of LA use increased rapidly, from 8.1% in 2004 to 90.3% in 2009. The increased use of LA was seen in both the uncomplicated and complicated appendicitis patients and in both gender and age groups (pediatric, adult, and elderly). Compared with OA, LA was associated with a lower complication rate (9.5% versus 5.8%; P = .013), a lower wound infection rate (8.6% versus 4.2%; P = .001), and a shorter hospital stay (4.60 ± 3.64 versus 4.06 ± 1.84 days; P = .001), but a higher mean cost (32,670 ± 28,568 versus 37,567 ± 12,064 New Taiwan dollars). In the subgroup analysis, the patients with complicated appendicitis, female patients, and pediatric and elderly patients benefited from a reduced hospital stay. LA is about 15% more expensive than OA.LA is as safe and effective as OA in many settings of appendicitis and may be selectively advantageous in patients with complicated appendicitis and in elderly subgroups.

Background Hemobilia is a rare but lethal biliary tract complication. There are several causes of hemobilia which might be classified as traumatic or nontraumatic. Hemobilia caused by pseudoaneurysm might result from hepatobiliary surgery or percutaneous interventional hepatobiliary procedures. However, to our knowledge, there are no previous reports pertaining to hemobilia caused by hepatic pseudoaneurysm after T-tube choledochostomy. Case presentation A 65-year-old male was admitted to our hospital because of acute calculous cholecystitis and cholangitis. He underwent cholecystectomy, choledocholithotomy via a right upper quadrant laparotomy and a temporary T-tube choledochostomy was created. However, on the 19th day after operation, he suffered from sudden onset of hematemesis and massive fresh blood drainage from the T-tube choledochostomy. Imaging studies confirmed the diagnosis of pseudoaneurysm associated hemobilia. The probable association of T-tube choledochostomy with pseudoaneurysm and hemobilia is also demonstrated. He underwent emergent selective microcoils emobolization to occlude the feeding artery of the pseudoaneurysm. Conclusions Pseudoaneurysm associated hemobilia may occur after T-tube choledochostomy. This case also highlights the importance that hemobilia should be highly suspected in a patient presenting with jaundice, right upper quadrant abdominal pain and upper gastrointestinal bleeding after liver or biliary surgery.

Acute appendicitis is the most common acute abdomen in general surgery. Show-Chwan Memorial Hospital began an AITS/IRCAD laparoscopic training program in late May 2008. In this retrospective analysis, we surveyed the impact of the AITS training program on surgeons’ preference for open appendectomy (OA) versus laparoscopic appendectomy (LA). From January 1, 2004 to July 31, 2009, patients diagnosed with acute appendicitis in Changhua Show-Chwan Memorial Hospital and Chang-Bing Show-Chwan Memorial Hospital were retrospectively analyzed. Demographic data, laboratory examinations, surgical methods, hospital stay, and complication rate data were collected and analyzed. The LA rate and effect of surgeons’ preference before and after AITS were compared. In all, 1,267 patients (58.2% male and 41.8% female; mean age, 36.6 years) were diagnosed with acute appendicitis during this period. Among them, 78.9% of patients had uncomplicated and 21.1% complicated appendicitis; 784 patients (61.9%) underwent OA, and 465 (36.7%) received LA. In 2004, only 8.1% of patients underwent LA, but the number increased rapidly to 90.4% in 2009 (P

Corrosive tracheobronchitis and lung perforation after caustic aspiration are not very common. We present a case of life-threatening acute respiratory system corrosion after aspiration of caustic alkaline crystals during a suicide attempt. The patient survived the severe burns of the tracheobronchial tract and the liquefaction necrosis of the lung lobe by aggressive airway protection procedures and surgical resection of the destroyed lung. We report this rare, clinical condition and discuss the possible mechanism and its management.

Esophageal transection in the Modified Sugiura procedure is advocated by some authors, but considered unnecessary by others. We compared the effectiveness of the Modified Sugiura procedure to our simplified Sugiura procedure that omits esophageal transection for the emergency treatment of bleeding esophagogastric varices.From January 1999 to September 2004 we treated 51 patients with cirrhosis of the liver and bleeding esophagogastric varices. All patients had failed management with emergency endoscopy treatment or balloon tamponade with vasopressin infusion. The patients were randomly divided into two groups and underwent the Modified Sugiura procedure with or without esophageal transections.There were no significant differences in age, gender, cause of cirrhosis, or Child-Pugh classification between the two groups. The preoperative hemoglobin levels, preoperative and intraoperative transfusion volume, mortality, morbidity, and days of hospitalization showed no significant differences between the groups. The operative time was shorter with the simplified Sugiura procedure. The 1-3 year survival rates and the rebleeding rates did not differ significantly between the two groups.Both treatments are effective emergency procedures for bleeding esophagogastric varices. Our simplified Sugiura procedure is an effective treatment for bleeding esophagogastric varices and requires a shorter operating time than the Modified Sugiura procedure.

It has been over 20 years since percutaneous transhepatic cholangioscopic lithotomy (PTCSL) or left lateral segmentectomy with postoperative cholangioscopy (POC) was applied in treating isolated left-sided hepatolithiasis (ILH). However, their efficacy in treating ILH is not elucidated clearly in the literature.A retrospective study was conducted in 59 patients with ILH undergoing either PTCSL or left lateral segmentectomy with POC during the past 22 years. The mean period of followup was 10.8 years (1-22 years).Hepatolithiasis restricted in the left external hepatic duct (LEHD), whose stones can be cleared by left lateral segmentectomy without undergoing POC, was only found in 17% (10/59) of the patients with ILH. The overall complication rate of left lateral segmentectomy with POC was 22% (4/18), and of PTCSL was 17% (7/41). Either in patients with (82%, 9/11 vs. 71%, 12/17; p0.05) or without intrahepatic ducts (IHDs) stricture (100%, 7/7 vs. 92%, 22/24; p0.05) in the liver remnant, the rates of complete stone clearance were comparable between left lateral segmentectomy with POC and PTCSL. The stone recurrence rate and cumulative nonrecurrence rate in patients with IHDs stricture in the liver remnant were also comparable between left lateral segmentectomy with POC and PTCSL (p0.05). Nevertheless, hepatolithiasis did not recur in patients without IHD stricture in the liver remnant after left lateral segmentectomy with POC, whose stone recurrence rate was lower than those without (0%, 0/7 vs. 50%, 10/20; p = 0.026) or with (0%, 0/7 vs. 7/12, 58%; p = 0.017) IHDs stricture undergoing PTCSL. After undergoing left lateral segmentectomy with POC, the cumulative nonrecurrence rate was also higher in patients without IHDs stricture in the liver remnant than those with IHDs stricture in the liver remnant (p0.05).Left lateral segmentectomy with POC and PTCSL have comparable efficacy in treating ILH. However, no stone recurs when ILH are completely removed without IHD stricture left in the liver remnant after left lateral segmentectomy with POC. The presence of IHDs stricture in the liver remnant is the major factor contributing to ILH recurrence after successful left lateral segmentectomy with POC.

Rupture of hepatocellular carcinoma (HCC) is a life-threatening complication. Peritoneal metastasis of HCC after spontaneous rupture was seldom noted. We report a case of intraperitoneal metastasis of HCC after spontaneous rupture. A previously asymptomatic 72-year-old man was admitted due to dull abdominal pain with abdominal fullness. He had a history of HCC rupture 10 mo ago and transarterial embolization was performed at that time. Abdominal computer tomography (CT) scan showed a huge peritoneal mass over the right upper quadrant area. Surgical resection was arranged and subsequent microscopic examination confirmed a diagnosis of moderately-differentiated HCC.

The patency of patch-enlarged (capsule-shaped) brachial arteries for long-term hemodialysis access was evaluated retrospectively. Twelve brachial arteries were patched with polytetrafluoroethylene (PTFE) grafts (standard wall thickness), making 1 x 2 cm aneurysms proximal to the elbow joints in 10 patients (six men with six patches, four women with six patches; patient age: 53 to 76 years, mean age +/- SD: 65.4 +/- 8.5 years) between September 2001 and April 2002. Ten patches were needled for each hemodialysis session as blood-drawing ports. The port's 1-year primary patency rate was 90%, 2-year patency was 70%, and 3-year patency was 70%. Two patches were needled in each hemodialysis session for dialyzed blood infusion access; both clotted within 1 year, with intact vessel continuity. Patch enlargement (capsule-shaped) of the brachial artery with a PTFE graft can be used as a long-term blood-drawing access in selected patients. This novel access may help patients with central vein stenosis or occlusion (which some patients had) and may help patients who have comorbid conditions such as chronic congestive heart failure or liver cirrhosis with ascites.

Laparoscopic adrenalectomy offers distinct benefits to patients and has now become the gold standard for the removal of adrenal lesions. Nonetheless, the procedure poses a challenge for surgeons in regards to the maneuverability of instruments, the two-dimensional operating field and the counterintuitive movements. This study reports our experience using the Zeus robotic surgical system in laparoscopic adrenalectomy compared with traditional laparoscopic adrenalectomy.From January 2003 to February 2005, a total of 12 patients were prospectively enrolled to receive robot-assisted laparoscopic adrenalectomy (RALA) or traditional laparoscopic adrenalectomy (TLA). The time necessary for robotic setup and operation was recorded, as well as complications, technical problems, postoperative hospital stay, morbidity, and mortality.Five RALA procedures and seven TLA were successfully completed. There was no significant difference between the groups in terms of age, body mass index, and tumor size. Resection times were longer in the RALA group (168.0 +/- 30.7 min vs. 131.4 +/- 29.0 min, p = 0.05). There were no perioperative complications. There was neither postoperative mortality nor morbidity at the time of discharge and during one year follow-up.RALA is as safe and technically feasible as TLA, It provides a real benefit for the surgeon with the three dimensional view, a comfortable sitting position, the elimination of the surgeon's tremor, and increased degrees of freedom of the operative instruments compared with TLA. However, patient outcomes and operative costs should be evaluated further.

Background and Aims: The aim of this study was to determine the prevalence and risk factors of gallstone disease (GSD) in an adult population of Taiwan through a population-based screening study. Methods: A cross-sectional community study in a rural village of Taiwan was conducted in 3333 Chinese adults (aged ≥18 years) undergoing ultrasonography. A questionnaire on personal history was completed to ascertain whether the removed gallbladder contained stones in all cholecystectomized subjects, the dietary habits (vegetarian/non-vegetarian diet), the history of GSD in the participant’s first-degree relatives, the history of gastrointestinal surgery (vagotomy, gastrectomy for peptic ulcer disease, or ileal resection), parity, and use of oral contraceptives. The demographic characteristics and biochemical parameters were recorded Results: The overall prevalence of GSD was 5.0% (4.6% in men, 5.4% in women) with no significant sex differences (men/women: odds ratio [OR] 0.71, 95% confidence interval [CI] 0.50–1.01, P = 0.058). Logistic regression analysis showed that increasing age (men: 40–64 years, OR 7.38, 95% CI 2.59–21.01, P

Robotic surgical systems have recently been used to perform laparoscopic procedures in several diseases. We report the initial 2 cases of robotic-assisted laparoscopic adrenalectomy from Taiwan. Both cases were performed transperitoneally using the ZEUS surgical system (Intuitive Surgical Inc., Mountain View, CA, USA). This system consists of 3 interactive robotic arms and a remote control unit, allowing the surgeon to control the 2 instrument arms and 1 camera arm via a surgical console. The key component of the ZEUS surgical system is the MicroWrist (Computer Motion Inc., CA, USA) technology, which allows the surgeon to roll, pitch and grip laparoscopic tools freely and provides the surgeon with a 3-dimensional view of the operative field. Postoperative courses were uneventful and the patients were discharged on the third and fourth postoperative days, respectively. No intraoperative or postoperative complications were encountered. These cases suggest that robotic-assisted laparoscopic adrenalectomy is technically feasible, and that the role of robotic surgery in urologic laparoscopy is likely to expand in Taiwan.

Although serum leptin concentrations are reported by several studies to increase in patients with liver cirrhosis, the mechanisms underpinning this increase remain unclear. Circulating tumor necrosis factor alpha (TNF-alpha) concentrations are also recognized to increase in liver cirrhosis. Furthermore, TNF-alpha administration to rodents results in increased expression and secretion of leptin from adipose tissue in a manner dependent on type 1 TNF-alpha receptor (TNF-RI). The present study was undertaken to examine adipose leptin expression and to explore potential relationships between leptin expression and TNF-alpha in subjects with liver cirrhosis. Liver cirrhosis was induced in male Sprague-Dawley rats by dimethylnitrosamine (DMN) administration or by common bile duct ligation (BDL). Ad libitum and pair-fed animals constituted controls. Serum leptin and TNF-alpha concentrations were determined by immunoassay. Gene expression was determined by the reverse transcription-polymerase chain reaction, and protein levels were measured by Western blotting. Serum leptin values after adjustment of body fat mass in DMN-treated rats were significantly higher than in pair-fed or ad libitum groups. Leptin mRNA and protein levels in epididymal fat in DMN rats increased by 1.8-fold and 2.3-fold, respectively, as compared with ad libitum controls, and by 4-fold and 6-fold, respectively, as compared with the pair-fed group. Epididymal TNF-alpha and membranous TNF-RI (mTNF-RI) concentrations were both 2.3 times higher in DMN rats than in ad libitum controls but did not differ between ad libitum and pair-fed groups. Adipose leptin protein levels correlated directly with TNF-alpha and mTNF-RI concentrations in combined DMN, ad libitum, and pair-fed rats (r=0.64 and r=0.49, respectively; P

In an attempt to obviate the necessity for hospitalisation, the ablative dose of 131I in the treatment of thyroid cancer is divided into two or three fractions at weekly intervals in some hospitals with no special bed for 131I treatment. Thyroid stunning has been observed in patients receiving a 131I dose between 74 and 370 MBq (2–10 mCi). However, the influence of 131I uptake after administration of a higher dose, such as 1,110–1,850 MBq of 131I, has never been reported. In this study, we evaluated the degree of reduction in 131I uptake after patients received 1,480 MBq of 131I and evaluated the clinical value of fractionated ablative doses of 131I. Thirty-five patients with functional thyroid cancer received a total of 4,440 MBq (120 mCi) of 131I which was divided into three fractions administered at weekly intervals. In all patients two 131I whole-body scans were performed. The first scan was performed directly prior to the second dose of 131I (7 days after the first administration of 131I), and the second scan was performed 7 days after the second administration of 131I and directly prior to the third administration. Regions of interest including the neck and lungs were drawn to calculate the uptake of 131I in the thyroid remnant and possible cervical lymph node and lung metastases. The mean uptake of 131I was 2.73% 7 days after the first administration, and decreased significantly to 0.26% 7 days after the second administration. The mean decrease was as high as 80.7%. The decrease in 131I uptake was significant in all patients except the two with lung metastases. In the two patients with lung metastases, no definite evidence of decreased uptake was noted; the uptake of 131I in the lung metastases even increased on the second 131I image in one of these patients. After administration of 1,480 MBq of 131I, the decreased uptake was significant in all neck lesions but not in lung metastases. The use of fractionated ablative doses of 131I is not to be recommended in patients without lung metastases. However, the influence of fractionated ablative doses of 131I in patients with lung metastases is worthy of further study.

The aim of this study was to evaluate the usefulness of 18-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) and technetium-99m methoxyisobutylisonitrile (Tc-99m MIBI) single photon emission computed tomography (SPECT) in detecting metastatic cervical lymph nodes (LN) in well-differentiated thyroid carcinoma (DTC) after total thyroidectomy and radioiodine-131 (I-131) treatments in patients with elevated serum human thyroglobulin (hTg) levels but negative I-131 whole body scan (WBS). Fifteen DTC patients underwent nearly total thyroidectomy and I-131 treatments with cervical LN metastases were included in this study. All subjects had negative I-131 WBS and elevated hTg levels (hTgor = 10 microIU/ml) under thyroid-stimulating hormone (TSH) stimulation (TSHor = 30 microIU/ml). FDG-PET could detect all of the 15 (100%) patients with metastatic cervical LN, but Tc-99m MIBI SPECT revealed lesions in only 9 out of 15 (60%) patients (p value0.05). This study demonstrated that FDG-PET is more sensitive than Tc-99m MIBI SPECT in detecting metastatic cervical LN in DTC with elevated serum hTg levels but negative I-131 WBS.

It remains difficult to pre-operatively differentiate follicular carcinoma and adenoma even under intraoperative investigations including histopathologic diagnosis of frozen sections.We retrospectively compared dual phase thallium (Tl-201) thyroid scan and fine-needle aspiration (FNA) cytology to detect follicular carcinoma in 12 patients with cold thyroid nodules. Fine-needle aspiration cytology results were assessed and categorized by experienced pathologists into benign, suspicious, and malignant. Dual phase Tl-201 thyroid scan including an early (10-min) image and a delayed (3-hour) image were acquired after 2 mCi (74 MBq) of Tl-201 was injected intravenously. Dual phase Tl-201 thyroid scan findings were visually interpreted as positive and negative results.Based on FNA cytologic interpretation criteria, three nodules were diagnosed as benign, five nodules were diagnosed as suspicious, and four nodules were diagnosed as malignant. However, based on dual phase Tl-201 thyroid scan interpretation criteria, all of the 12 nodules could accurately diagnose as malignant.We conclude that dual phase Tl-201 thyroid scan was more accurate in diagnosing follicular carcinoma when comparing with FNA cytology.

The aim of this study was to evaluate the usefulness of 18-fluoro-2-deoxyglucose (FDG) positron emission tomography (PET) and technetium-99m tetrofosmin (Tc-99m TF) single photon emission computed tomography (SPECT) to detect metastatic neck lymph nodes (LN) in papillary thyroid carcinoma (PTC) after total thyroidectomy and radioiodine-131 (I-131) treatments in patients with elevated serum human thyroglobulin (hTg) levels but negative I-131 whole body scan (WBS). Thirteen PTC patients underwent nearly total thyroidectomy and I-131 treatments with proven neck LN metastases were included in this study. All subjects had negative I-131 WBS and elevated hTg levels (hTgor = 10 mu IU/ml) under thyroid-stimulating hormone (TSH) stimulation (TSHor = 30 mu IU/ml). FDG-PET and Tc-99m TF SPECT were used to detect metastatic neck LN in PTC. FDG-PET could detect all of the 13 (100%) patients with metastatic neck LN, but Tc-99m TF SPECT revealed lesions in only 8 out of 13 (61.5%) patients (p0.05). This study demonstrated that FDG-PET is more sensitive than Tc-99m TF SPECT to detecting metastatic neck LN in PTC with elevated serum hTg levels but negative I-131 WBS.

We previously established that a 5 mg x kg(-1) intraoperative dose can reduce the nausea/vomiting associated with tramadol patient-controlled analgesia (PCA). This study was conducted to identify the most appropriate initial dose to improve the quality of tramadol PCA.During general anesthesia, 60 patients undergoing knee arthroplasty were randomly allocated to receive 1.25 mg x kg(-1) (Group I), 2.5 mg x kg(-1) (Group II), 3.75 mg x kg(-1) (Group III), or 5 mg x kg(-1) (Group IV) tramadol. The emergence condition was recorded. The titration of additional tramadol 20 mg + metoclopramide 1 mg doses by PCA every five minutes was performed in the postanesthesia care unit (PACU) until the visual analogue scale (VAS) score wasor = 3. An investigator blinded to study group recorded the VAS and side effects every ten minutes.In the PACU, significantly more tramadol (8.4 +/- 3.1 vs 4.3 +/- 2.1, 2.5 +/- 1.8, and 0.4 +/- 0.3, P0.05), and a higher incidence (15/15 vs 5/15, 3/15, and 2/15, P0.05) of PCA use was observed in Group I compared to Groups II-IV. VAS was significantly higher in Group I than in Groups II-IV at zero and ten minutes (P0.05). Unexpected delayed emergence anesthesia (30 min) was observed in Group III (n = 1) and in Group IV (n = 2). Sedation was more important in Groups III and IV than in Groups I and II (P0.05).When considering efficacy and side-effect profile, 2.5 mg x kg(-1) of tramadol is the optimal intraoperative dose of this drug to provide effective postoperative analgesia with minimal sedation.

Background. The purpose of this study was to retrospectively evaluate technetium 99m tetrofosmin (Tc-TF) uptake in parathyroid adenomas and compare the results with their expression of multidrug resistance-mediated 170-kDa P-glycoprotein (Pgp). Methods. Twenty patients with larger parathyroid adenomas (> 1.5 g) and the other 40 patients with smaller parathyroid adenomas (0.5-1.5 g) underwent early and delayed (10-minute and 2-hour) Tc-TF parathyroid imaging before operation. In this retrospective study, immunohistochemical analyses were performed on multiple nonconsecutive sections of the 40 parathyroid adenomas and 40 normal control specimens (20 normal parathyroid glands and 20 normal thyroid specimens) to detect Pgp expression. Results. The Tc-TF parathyroid image accurately localized 17 larger and 16 smaller parathyroid adenomas, but not the remaining 3 larger and 4 smaller adenomas. The 17 larger and 16 smaller parathyroid adenomas with significant Tc-TF uptake on the delayed 2-hour parathyroid images revealed negative Pgp expression, but the 3 larger and 4 smaller adenomas without significant Tc-TF uptake, as well as 20 normal parathyroid glands and 20 normal thyroid specimens, revealed positive Pgp expression. Conclusions. Not only the size of parathyroid adenomas, but Pgp expression also limited the sensitivity of Tc-TF parathyroid image to localize parathyroid adenomas before the operation. (Surgery 2002;132:456-60.)

Alessandra D’Avanzo, Sareh Parangi, Eugene Morita, Nancy D. Perrier, Hurng± Sheng Wu, Allan E. Siperstein, Quan± Yang, Duh Patrick A. Treseler and Orlo H. Clark From the Endocrine Surgical Fellow, UCSF and aFederico IIo University of Naples, Naples, Italy, Department of Surgery, Beth Israel Medical Center, Boston, Mass, Department of Nuclear Medicine UCSF/Mt. Zion Medical Center, Department of Surgery, Wake Forest University School of Medicine, Taichung Veterans General Hospital± Division of General Surgery, Taichung 407, Taiwan, Department of General Surgery, The Cleveland Clinic Foundation, Department of Veteran Affairs, San Francisco, CA, Department of Pathology, UCSF/Mt. Zion Medical Center, Department of Surgery, UCSF/Mt. Zion Medical Center, San Francisco, CA, USA

Objective To investigate whether the increased homocysteine levels occur in the first 6 months postoperatively, when nutritional intake is the most inadequate and weight reduction is the most drastic. Patients and Methods Fasting glucose, insulin, lipoprotein, homocysteine, folic acid and vitamin B12 levels and oral glucose tolerance test (OGTT) were determined in 12 morbidly obese subjects (3 men and 9 women with a mean age of 31±3 years, mean±SEM) before, 6 and 12 months after banded gastroplasty. Results Gastroplasty resulted in significant weight loss, from 12±16 to 92±6 and 88±7 kgs, 6 and 12 months postoperatively (all p

Although patients with differentiated thyroid cancer (DTC) of follicular cell origin usually have an excellent prognosis, some patients die from progressive tumor. Numerous postoperative criteria have been used to predict prognosis in patients with DTC. The purpose of this investigation was to determine whether the TNM and metastases, age, completeness of resection, invasion, size (MACIS) classifications predicted survival time and why patients died from DTC. The extent of initial treatment and causes of death were also evaluated in these patients who died from thyroid cancer.Between 1965 and 1995, 102 of 1,224 patients with DTC treated at the University of California at San Francisco (UCSF) and UCSF/Mount Zion Medical Centers died from DTC. Risk factors including age at diagnosis, gender, histologic characteristics, TNM and MACIS classifications, the intervals among initial treatment, recurrence, and death, and the initial and subsequent treatments were documented in these 102 patients.Among the 102 patients who died of DTC 50% were men and 50% were women. The mean age of patients with DTC at diagnosis was 58 years at recurrence, 62 and 65 years at death. Thirty percent of these patients initially had unilateral thyroid operations and 70% had a bilateral operation. Tumors at presentation ranged from 0.6 to 13.0 cm (mean 4.4 cm); 46% of patients presented with late-stage tumors (TNM stage III, IV; MACIS score8). At presentation 46% of the patients had locally recurrent disease or regional metastases and 18% had distant metastases. Patients with persistent disease had a significantly shorter survival time than those with recurrent disease (p0.001). Both TNM and MACIS classifications were good predictors of survival time. Reoperations were performed in 51% of papillary, 26% of follicular, and 67% of Hürthle cell thyroid cancer patients. Fifty percent of patients with papillary thyroid cancer, 50% of patients with Hürthle cell thyroid cancer, and 11% of patients with follicular cell thyroid cancer died of locally advanced disease.As expected, patients with local or regional recurrence and those with TNM stage I or MACIS score6 survived longer than patients with distant metastasis and TNM stage III or IV, MACIS score6, but some patients thought to be at low risk (TNM stage I; MACIS6) also died from thyroid cancer.

AIM: To study the role of CDH1/E-cadherin (E-cad) gene alteration profiles including mutation, loss of heterozygosity (LOH), promoter polymorphism and hypermethylation in mechanisms of CDH1 inactivation in gastric carcinoma (GC). METHODS: Specimens were collected surgically from 70 patients with GC. Allelotyping PCR and detection of LOH, denaturing high pressure liquid chromatography and DNA sequencing, restriction fragment length polymorphism analysis, methylation specific PCR, and immunohistochemical staining were used. RESULTS: Promoter polymorphism was not a major mechanism of E-cad inactivation. Only one truncating mutation was found in a diffuse type tumor (3%). Both LOH and promoter hypermethylation were major mechanisms of E-cad inactivation, but interestingly, there was a negative association between the fraction of allelic loss (LOH) in tumors and hypermethylation of CDH1. Therefore LOH and hypermethylation were two different tumorigenic pathways involved in GC. CONCLUSION: Given the findings that somatic mutation was extremely low and the relationship between LOH and hypermethylation was inverse, any two combinations of these three factors cannot fulfill the classical two-hit hypothesis of CDH1 inactivation. Thus, other mechanisms operating at the transcriptional level or at the post-translational level might be required to induce E-cadherin inactivation.

AIM: To retrospectively establish the diagnostic criteria of gallstone ileus on CT, and to prospectively apply these criteria to determine the diagnostic accuracy of CT to confirm or exclude gallstone ileus in patients who presented with acute small bowel obstruction (SBO). Another purpose was to ascertain whether the size of ectopic gallstones would affect treatment strategy. METHODS: Fourteen CT scans in cases of proved gallstone ileus were evaluated retrospectively by two radiologists for the presence or absence of previously reported CT findings to establish the diagnostic criteria. These criteria were applied in a prospective contrast enhanced CT study of 165 patients with acute SBO, which included those 14 cases of gallstone ileus. The hard copy images of 165 CT studies were reviewed by a different group of two radiologists but without previous knowledge of the patient’s final diagnosis. All CT data were further analyzed to determine the diagnostic accuracy of gallstone ileus when using CT in prospective evaluation of acute SBO. The size of ectopic gallstone on CT was correlated with the clinical course. RESULTS: The diagnostic criteria of gallstone ileus on CT were established retrospectively, which included: (1) SBO; (2) ectopic gallstone; either rim-calcified or total-calcified; (3) abnormal gall bladder with complete air collection, presence of air-fluid level, or fluid accumulation with irregular wall. Prospectively, CT confirmed the diagnosis in 13 cases of gallstone ileus with these three criteria. Only one false negative case could be identified. The remaining 151 patients are true negative cases and no false positive case could be disclosed. The overall sensitivity, specificity and accuracy of CT in diagnosing gallstone ileus were 93%, 100%; and 99%, respectively. Surgical exploration was performed in 13 patients of gallstone ileus with ectopic stones sized larger than 3 cm. One patient recovered uneventfully following conservative treatment with an ectopic stone sized 2 cm in the long axis. CONCLUSION: Contrast enhanced CT imaging offered crucial evidence not only for the diagnosis of gallstone ileus but also for decision making in management strategy.

Background Mucoceles resulting from cystadenomas of the appendix are uncommon. Although rare, rupture of the mucoceles can occur with or without causing any abdominal complaint. There are several reports associating colonic malignancy with cystadenomas of the appendix. Herein, we report an unusual and interesting case of right inguinal hernia associated with left colon cancer. Case presentation A case of ruptured mucocele resulting from cystadenoma of the appendix was presented as right inguinal hernia in a 70-year-old male. The patient underwent colonoscopy, x-ray, ultrasound and computed tomography. Localized pseudomyxoma peritonei associated with adenocarcinoma of the descending colon was diagnosed. The patient underwent segmental resection of the colon, appendectomy, debridement of pseudomyxoma and closure of the internal ring of right inguinal canal. He is free of symptoms in one year follow-up. Conclusion Synchronous colon cancer may occur in patients with appendiceal mucoceles. In such patients, the colon should be investigated and colonoscopy can be performed meticulously in cases of ruptured mucoceles and localized pseudomyxoma peritonei. Surgical intervention is the current choice of management.