- Email: [email protected]
Incisional recurrence of gallbladder cancer after laparoscopic cholecystectomy
years without complication. The use of a guide wire through the endoprosthesis before removal did not allow evaluation for stent clogging. Usually, pancreatic stents are routinely replaced every 4 to 6 months; otherwise, stent occlusion will occur. Our observation indicates that pancreatic stent migration may be a minor complication and that endoscopic retrieval is possible. REFERENCES 1. McCarthy J, Geenen JE, Hogan WJ. Preliminary experience
2. 3.
Figure 3. Pancreatography after removal of the pancreatic stent.
snare, but in the other patient the attempt to remove the en do prosthesis was unsuccessful; this patient seemed to have no further problems, but the duration of the follow-up was not given.! In the second report the removal of the stents was not described, but the two stents were replaced subsequently by a larger-diameter endoprosthesis. 4 In our series of 13 patients with pancreas divisum treated by dorsal duct stenting, intra-pancreatic migration of the prosthesis occurred in one case.1° In our patient attempts to remove the pancreatic stent from the dorsal duct were unsuccessful except by the technique with the metal spiraltipped device, described by Soehendra et al,7 The endoprosthesis remained within the dorsal duct for 4
Incisional recurrence of gallbladder cancer after laparoscopic cholecystectomy Stephen M. WeiSS, MD Paul A. Wengert, Jr., MD Sandra E. Harkavy, MD
Laparoscopic cholecystectomy has become the standard procedure for most patients with symptomatic
From the Department of Surgery, Polyclinic Medical Center, Harrisburg, Pennsylvania. Reprint requests: Stephen M. Weiss, MD, Department of Surgery, Polyclinic Medical Center, 2601 N. Third St., Harrisburg, PA 17110. 0016-5107/94/4002-0244$3.00
244
5. 6. 7.
22:271-7.
8. Cotton PB. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut 1980;21:105-14. 9. Bernard JP, Sahel J, Giovannini M, Sarles H. Pancreas divisum is a probable cause of acute pancreatitis: a report of 137 cases. Pancreas 1990;5:248-54. 10. Bordes G, Sahel J. Endoscopic treatment by stenting of dorsal duct in 13 cases of pancreas divisum [Abstract]. Digestion 1992; 52:68.
gallstones, and the list of contra-indications continues to contract.! Gallbladder cancer is an infrequent indication for cholecystectomy, and patients with gallbladder cancer are most likely to survive if the malignancy is too small to be seen on ultrasonography or computed tomography and found unexpectedly at surgery. In a large series of cases of carcinoma of the gallbladder evaluated by laparoscopy, surgical removal was thought to be appropriate for only 1 of 98 cases. 2 Although laparoscopic cholecystectomy has been proposed for gallbladder cancer,3 technical concerns about its adequacy for this condition exist. The present report describes a case in which tumor implantation at the umbilical incision during laparoscopic cholecystectomy resulted in development of metastases at this site. CASE REPORT
+0
GASTROINTESTINAL ENDOSCOPY Copyright © 1994 by the American Society of Gastrointestinal Endoscopy
37/4/52750
4.
with endoscopic stent placement in benign pancreatic disease. Gastrointest Endosc 1988;34:16-8. Grimm H, Meyer WH, Nam VC, Soehendra N. New modalities for treating chronic pancreatitis. Endoscopy 1989;21:70-4. Huibregtse K, Schneider B, Vrij AA, Tytgat GNJ. Endoscopic pancreatic drainage in chronic pancreatitis. Gastrointest Endosc 1988;34:9-15. Lans JI, Geenen JE, JohansonJF, Hogan WJ. Endoscopic therapy in patients with pancreas divisum and acute pancreatitis: a prospective, randomized, controlled clinical trial. Gastrointest Endosc 1992;38:430-4. Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc 1992;38::341-6. Waxman I, Fockens P, Huibregtse K, Tytgat GNJ. Removal of a broken pancreatic stent using a new stent retrieval device. Gastrointest Endosc 1991;37:631-2. Soehendra N, Mayedo A, Eckmann B. A new technique for replacing an obstructed biliary endoprosthesis. Endoscopy 1990;
A 41-year-old woman was seen for evaluation of right upper quadrant and back pain of 5 months' duration. She had no recent history of weight loss. Ultrasound examination GASTROINTESTINAL ENDOSCOPY
Figure 1. Laparoscopic view of irregularly thickened, whitish, inflamed gallbladder.
demonstrated irregular thickening of the gallbladder wall and at least one calculus in the gallbladder lumen. Total bilimg/dt. At laparoscopy, an enlarged gallrubin level was 0.2 mg/dl. bladder was found with multiple adhesions between its inferior surface and the omentum. The gallbladder wall was noted to be markedly enlarged, irregularly thickened, and whitish (Fig. 1). The appearance was thought to be most consistent with a chemically inflamed gallbladder. Although a diagnosis of gallbladder cancer was also considered, laparoscopic examination of the abdominal cavity revealed no evidence of metastatic cancer. Laparoscopic cholecystectomy was performed, the gallbladder being removed from the peritoneal cavity through the umbilical puncture site. Microscopic examination of the gallbladder demonstrated moderately differentiated adenocarcinoma penetrating all layers of the gallbladder wall. Peri-neural and vascular noted. invasion was also noted. Post-operatively, the patient received intravenous fluorouracil and leucovorin. Two months after surgery jaundice developed. Computed tomography demonstrated a large metastatic lesion on the inferior surface of the liver extendhepatis. Percutaneous trans-hepatic biliary ing to the porta hepatis. catheterization was performed to drain the bile duct obstruction internally. She was treated with intra-luminal iridium 192, 30 cGy. Fourteen weeks after surgery, a 2-cm non-tender, firm, sub-cutaneous nodule was noted deep in the umbilical incision. This nodule increased to 4 X 3 cm, and fine-needle aspiration was performed. Malignant cells consistent with metastatic adenocarcinoma were identified.
DISCUSSION
The techniques of laparoscopic cholecystectomy potentially compromise some basic principles of cancer surgery. In the current case with trans-mural cancer, removal of the gallbladder required direct contact between the malignancy and the tissues of the abdominal wall, increasing the likelihood of seeding of cancer cells. At least one case of parietal metastases after laparoscopic cholecystectomy has been previously described. 4 In this earlier reported case, the gallbladder was found to be acutely inflamed and filled with pus. VOLUME VOL UME 40, 40, NO.2, PART 1, 1994
Several techniques potentially minimize the risk of tumor implantation at the incision site during laparoscopic procedures for malignancies. Transferring the specimen to a plastic bag before removal through the abdominal wall, or use of a protective sleeve of adequate dimensions, would likely reduce the chance of tumor cell spillage at the incision. Another reason not to perform laparoscopic cholecystectomy in patients with gallbladder cancer is spillage of gallbladder contents during laparoscopic surgery, a frequent occurrence. In patients who do not have gallbladder cancer, this spillage seems to have little negative effect when properly managed, but patients with malignancy, leakage of bile and shedding of cancer cells into the peritoneal cavity can greatly increase the risk of intra-peritoneal recurrence. Many authorities recommend more extensive operations for gallbladder cancer,5 cancer,5 including peri-choledochal lymphadenectomy, wedge resection of the liver bed, resection of the hilus, or hepatectomy with liver transplantation. It is difficult to prove convincingly the efficacy of any of these aggressive surgical procedures, none of which can be performed with the laparoscope. Although laparoscopy may have no therapeutic value in gallbladder cancer, it can be extremely useful in the diagnostic evaluation of suspected cases. The diagnosis of gallbladder cancer is often suggested by imaging studies, 7 and laparoscopy has been shown to be very sensitive and accurate in confirming the diagnosis of biliary malignancy.2 In another series of patients with primary carcinoma of the gallbladder evaluated by laparoscopy,6 it was found that the combination of ultrasonography and laparoscopy improves overall diagnostic accuracy to 100 %. In both series,2, 6 most patients with suspected gallbladder cancer were found to have metastatic lesions in the liver, omentum, or peritoneal surfaces. A cancerous gallbladder is characteristically described as small and white and associated with inflammation and adhesions. 2, 6, 7 The appearance of such a gallbladder viewed in isolation can be difficult to distinguish from chronic cholecystitis without cancer. Biopsy of suspected metastases can typically be performed laparoscopically with a high degree of accuracy and few complications. Cholecystectomy is of little benefit in cases of gallbladder cancer in which metastases or trans-mural disease is present, and laparoscopy can thus be valuable in confirming the diagnosis so that unnecessary laparotomy can be avoided. In the infrequent cases in which no evidence of advanced gallbladder cancer can be found but a high index of suspicion for gallbladder cancer is nonetheless present, open cholecystectomy is indicated, perhaps with the addition of a more aggressive surgical procedure. 5 245
REFERENCES 1. Dagnini G, Marin G, Patella M, Zotti M. Laparoscopy in the diagnosis of primary carcinoma of the gallbladder. Gastrointest Endosc 1984;30:289-91. 2. de Aretxabala X, Roa I, Araya JC, et al. Operative findings in patients with early forms of gallbladder cancer. Br J Surg 1990; 77:291-3. 3. Gagner M, Rossi RL. Radical operations for carcinoma of the gallbladder: present status in North America. World J Surg 1991;15:344-7. 4. Furuta K, Yoshimoto H, Watanabe R, Hashimoto M, Iwashita
A. Laparoscopic cholecystectomy for a suspected case of gallbladder cancer. Am J Gastroenterol 1991;86:1851. 5. Kriplani AK, Jayant S, Kapur BM. Laparoscopy in primary carcinoma of the gallbladder. Gastrointest Endosc 1992;38: 326-9. 6. Pezet D, Fondinier E, Rotman N, et al. Parietal seeding of carcinoma of the gallbladder after laparoscopic cholecystectomy. Br J Surg 1992:79:230. 7. NIH Consensus Conference Statement on Gallstones and Laparoscopic Cholecystectomy. Am J Surg 1993;165:390-6.
Endoscopic management of ceftriaxone pseudolithiasis involving the common bile duct and gallbladder Edward Lebovics, Michael S. Halata, Jorge A. Rosario, Jose Lantin, Steven M. Schwarz, William S. Rosenthal,
MD MD MD MD MD MD
Ceftriaxone is a third generation ,B-Iactamase-resistant parenteral cephalosporin with a long half-life, allowing once or twice daily dosing. It is indicated for a variety of infections, including lower respiratory tract, urinary tract, intra-abdominal, pelvic, bone, joint, skin, and meningeal. 1 It is also the therapy of choice for Lyme disease with severe cardiac, neurologic, or rheumatologic involvement. 22 Twenty percent to 40 % of administered ceftriaxone is excreted in bile.1,3 The precipitation of a ceftriaxone-calcium salt can be ultrasonographically detected in 25 % to 43 % of treated patients 4, 5 as early as 4 days after the initiation of therapy, manifested as highly echo genic sludge or tiny calculi. 4 Postulated factors favoring the development of ceftriaxone precipitates include dose, renal insufficiency, hypercalcemia, and states associated with decreased bile flow and impaired gallbladder emptying (e.g., fasting).6-9 Management is generally limited to discontinuation of the drug because the precipitates invariably disappear after 2 to 63 days (mean, 15 days),4 a feature that has stimulated the term "pseudolithiasis." Yet, in a minority of patients symptoms may be sufficiently severe to require intervention. CholecystecFrom the Departments of Medicine and Pediatrics, New York Medical College, Valhalla, New York. Reprint requests: Edward Lebovics, MD, Chief, Section of Hepatobiliary Disease, Division of Gastroenterology, New York Medical College, Valhalla, NY 10595. 0016-5107/94/4002-0246$3.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright Copyright"D 1994 by the American Society for Gastrointestinal Endoscopy
37/4/50100
246
Figure 1. Endoscopic retrograde cholangiogram showing
a 0.5 cm common bile duct stone (open arrow) that was extracted after performance of a sphincterotomy. Note the multiple small calculi in the partially filled gallbladder (closed arrow).
to my has been performed in several cases.1°' 11 Notably, the gallbladders in these cases were free of acute or chronic inflammation on pathologic examination. Only one case of choledocholithiasis from ceftriaxone precipitates has been reported. This patient had biliary obstruction and pancreatitis and recovered with conservative management. 12 Several other cases of elevated liver biochemical tests suggesting choledocholithiasis but without documentation by imaging studies have appeared. 13, 14 We report a case of ceftriaxone pseudolithiasis GASTROINTESTINAL ENDOSCOPY
2. 3.
Figure 3. Pancreatography after removal of the pancreatic stent.
snare, but in the other patient the attempt to remove the en do prosthesis was unsuccessful; this patient seemed to have no further problems, but the duration of the follow-up was not given.! In the second report the removal of the stents was not described, but the two stents were replaced subsequently by a larger-diameter endoprosthesis. 4 In our series of 13 patients with pancreas divisum treated by dorsal duct stenting, intra-pancreatic migration of the prosthesis occurred in one case.1° In our patient attempts to remove the pancreatic stent from the dorsal duct were unsuccessful except by the technique with the metal spiraltipped device, described by Soehendra et al,7 The endoprosthesis remained within the dorsal duct for 4
Incisional recurrence of gallbladder cancer after laparoscopic cholecystectomy Stephen M. WeiSS, MD Paul A. Wengert, Jr., MD Sandra E. Harkavy, MD
Laparoscopic cholecystectomy has become the standard procedure for most patients with symptomatic
From the Department of Surgery, Polyclinic Medical Center, Harrisburg, Pennsylvania. Reprint requests: Stephen M. Weiss, MD, Department of Surgery, Polyclinic Medical Center, 2601 N. Third St., Harrisburg, PA 17110. 0016-5107/94/4002-0244$3.00
244
5. 6. 7.
22:271-7.
8. Cotton PB. Congenital anomaly of pancreas divisum as cause of obstructive pain and pancreatitis. Gut 1980;21:105-14. 9. Bernard JP, Sahel J, Giovannini M, Sarles H. Pancreas divisum is a probable cause of acute pancreatitis: a report of 137 cases. Pancreas 1990;5:248-54. 10. Bordes G, Sahel J. Endoscopic treatment by stenting of dorsal duct in 13 cases of pancreas divisum [Abstract]. Digestion 1992; 52:68.
gallstones, and the list of contra-indications continues to contract.! Gallbladder cancer is an infrequent indication for cholecystectomy, and patients with gallbladder cancer are most likely to survive if the malignancy is too small to be seen on ultrasonography or computed tomography and found unexpectedly at surgery. In a large series of cases of carcinoma of the gallbladder evaluated by laparoscopy, surgical removal was thought to be appropriate for only 1 of 98 cases. 2 Although laparoscopic cholecystectomy has been proposed for gallbladder cancer,3 technical concerns about its adequacy for this condition exist. The present report describes a case in which tumor implantation at the umbilical incision during laparoscopic cholecystectomy resulted in development of metastases at this site. CASE REPORT
+0
GASTROINTESTINAL ENDOSCOPY Copyright © 1994 by the American Society of Gastrointestinal Endoscopy
37/4/52750
4.
with endoscopic stent placement in benign pancreatic disease. Gastrointest Endosc 1988;34:16-8. Grimm H, Meyer WH, Nam VC, Soehendra N. New modalities for treating chronic pancreatitis. Endoscopy 1989;21:70-4. Huibregtse K, Schneider B, Vrij AA, Tytgat GNJ. Endoscopic pancreatic drainage in chronic pancreatitis. Gastrointest Endosc 1988;34:9-15. Lans JI, Geenen JE, JohansonJF, Hogan WJ. Endoscopic therapy in patients with pancreas divisum and acute pancreatitis: a prospective, randomized, controlled clinical trial. Gastrointest Endosc 1992;38:430-4. Johanson JF, Schmalz MJ, Geenen JE. Incidence and risk factors for biliary and pancreatic stent migration. Gastrointest Endosc 1992;38::341-6. Waxman I, Fockens P, Huibregtse K, Tytgat GNJ. Removal of a broken pancreatic stent using a new stent retrieval device. Gastrointest Endosc 1991;37:631-2. Soehendra N, Mayedo A, Eckmann B. A new technique for replacing an obstructed biliary endoprosthesis. Endoscopy 1990;
A 41-year-old woman was seen for evaluation of right upper quadrant and back pain of 5 months' duration. She had no recent history of weight loss. Ultrasound examination GASTROINTESTINAL ENDOSCOPY
Figure 1. Laparoscopic view of irregularly thickened, whitish, inflamed gallbladder.
demonstrated irregular thickening of the gallbladder wall and at least one calculus in the gallbladder lumen. Total bilimg/dt. At laparoscopy, an enlarged gallrubin level was 0.2 mg/dl. bladder was found with multiple adhesions between its inferior surface and the omentum. The gallbladder wall was noted to be markedly enlarged, irregularly thickened, and whitish (Fig. 1). The appearance was thought to be most consistent with a chemically inflamed gallbladder. Although a diagnosis of gallbladder cancer was also considered, laparoscopic examination of the abdominal cavity revealed no evidence of metastatic cancer. Laparoscopic cholecystectomy was performed, the gallbladder being removed from the peritoneal cavity through the umbilical puncture site. Microscopic examination of the gallbladder demonstrated moderately differentiated adenocarcinoma penetrating all layers of the gallbladder wall. Peri-neural and vascular noted. invasion was also noted. Post-operatively, the patient received intravenous fluorouracil and leucovorin. Two months after surgery jaundice developed. Computed tomography demonstrated a large metastatic lesion on the inferior surface of the liver extendhepatis. Percutaneous trans-hepatic biliary ing to the porta hepatis. catheterization was performed to drain the bile duct obstruction internally. She was treated with intra-luminal iridium 192, 30 cGy. Fourteen weeks after surgery, a 2-cm non-tender, firm, sub-cutaneous nodule was noted deep in the umbilical incision. This nodule increased to 4 X 3 cm, and fine-needle aspiration was performed. Malignant cells consistent with metastatic adenocarcinoma were identified.
DISCUSSION
The techniques of laparoscopic cholecystectomy potentially compromise some basic principles of cancer surgery. In the current case with trans-mural cancer, removal of the gallbladder required direct contact between the malignancy and the tissues of the abdominal wall, increasing the likelihood of seeding of cancer cells. At least one case of parietal metastases after laparoscopic cholecystectomy has been previously described. 4 In this earlier reported case, the gallbladder was found to be acutely inflamed and filled with pus. VOLUME VOL UME 40, 40, NO.2, PART 1, 1994
Several techniques potentially minimize the risk of tumor implantation at the incision site during laparoscopic procedures for malignancies. Transferring the specimen to a plastic bag before removal through the abdominal wall, or use of a protective sleeve of adequate dimensions, would likely reduce the chance of tumor cell spillage at the incision. Another reason not to perform laparoscopic cholecystectomy in patients with gallbladder cancer is spillage of gallbladder contents during laparoscopic surgery, a frequent occurrence. In patients who do not have gallbladder cancer, this spillage seems to have little negative effect when properly managed, but patients with malignancy, leakage of bile and shedding of cancer cells into the peritoneal cavity can greatly increase the risk of intra-peritoneal recurrence. Many authorities recommend more extensive operations for gallbladder cancer,5 cancer,5 including peri-choledochal lymphadenectomy, wedge resection of the liver bed, resection of the hilus, or hepatectomy with liver transplantation. It is difficult to prove convincingly the efficacy of any of these aggressive surgical procedures, none of which can be performed with the laparoscope. Although laparoscopy may have no therapeutic value in gallbladder cancer, it can be extremely useful in the diagnostic evaluation of suspected cases. The diagnosis of gallbladder cancer is often suggested by imaging studies, 7 and laparoscopy has been shown to be very sensitive and accurate in confirming the diagnosis of biliary malignancy.2 In another series of patients with primary carcinoma of the gallbladder evaluated by laparoscopy,6 it was found that the combination of ultrasonography and laparoscopy improves overall diagnostic accuracy to 100 %. In both series,2, 6 most patients with suspected gallbladder cancer were found to have metastatic lesions in the liver, omentum, or peritoneal surfaces. A cancerous gallbladder is characteristically described as small and white and associated with inflammation and adhesions. 2, 6, 7 The appearance of such a gallbladder viewed in isolation can be difficult to distinguish from chronic cholecystitis without cancer. Biopsy of suspected metastases can typically be performed laparoscopically with a high degree of accuracy and few complications. Cholecystectomy is of little benefit in cases of gallbladder cancer in which metastases or trans-mural disease is present, and laparoscopy can thus be valuable in confirming the diagnosis so that unnecessary laparotomy can be avoided. In the infrequent cases in which no evidence of advanced gallbladder cancer can be found but a high index of suspicion for gallbladder cancer is nonetheless present, open cholecystectomy is indicated, perhaps with the addition of a more aggressive surgical procedure. 5 245
REFERENCES 1. Dagnini G, Marin G, Patella M, Zotti M. Laparoscopy in the diagnosis of primary carcinoma of the gallbladder. Gastrointest Endosc 1984;30:289-91. 2. de Aretxabala X, Roa I, Araya JC, et al. Operative findings in patients with early forms of gallbladder cancer. Br J Surg 1990; 77:291-3. 3. Gagner M, Rossi RL. Radical operations for carcinoma of the gallbladder: present status in North America. World J Surg 1991;15:344-7. 4. Furuta K, Yoshimoto H, Watanabe R, Hashimoto M, Iwashita
A. Laparoscopic cholecystectomy for a suspected case of gallbladder cancer. Am J Gastroenterol 1991;86:1851. 5. Kriplani AK, Jayant S, Kapur BM. Laparoscopy in primary carcinoma of the gallbladder. Gastrointest Endosc 1992;38: 326-9. 6. Pezet D, Fondinier E, Rotman N, et al. Parietal seeding of carcinoma of the gallbladder after laparoscopic cholecystectomy. Br J Surg 1992:79:230. 7. NIH Consensus Conference Statement on Gallstones and Laparoscopic Cholecystectomy. Am J Surg 1993;165:390-6.
Endoscopic management of ceftriaxone pseudolithiasis involving the common bile duct and gallbladder Edward Lebovics, Michael S. Halata, Jorge A. Rosario, Jose Lantin, Steven M. Schwarz, William S. Rosenthal,
MD MD MD MD MD MD
Ceftriaxone is a third generation ,B-Iactamase-resistant parenteral cephalosporin with a long half-life, allowing once or twice daily dosing. It is indicated for a variety of infections, including lower respiratory tract, urinary tract, intra-abdominal, pelvic, bone, joint, skin, and meningeal. 1 It is also the therapy of choice for Lyme disease with severe cardiac, neurologic, or rheumatologic involvement. 22 Twenty percent to 40 % of administered ceftriaxone is excreted in bile.1,3 The precipitation of a ceftriaxone-calcium salt can be ultrasonographically detected in 25 % to 43 % of treated patients 4, 5 as early as 4 days after the initiation of therapy, manifested as highly echo genic sludge or tiny calculi. 4 Postulated factors favoring the development of ceftriaxone precipitates include dose, renal insufficiency, hypercalcemia, and states associated with decreased bile flow and impaired gallbladder emptying (e.g., fasting).6-9 Management is generally limited to discontinuation of the drug because the precipitates invariably disappear after 2 to 63 days (mean, 15 days),4 a feature that has stimulated the term "pseudolithiasis." Yet, in a minority of patients symptoms may be sufficiently severe to require intervention. CholecystecFrom the Departments of Medicine and Pediatrics, New York Medical College, Valhalla, New York. Reprint requests: Edward Lebovics, MD, Chief, Section of Hepatobiliary Disease, Division of Gastroenterology, New York Medical College, Valhalla, NY 10595. 0016-5107/94/4002-0246$3.00 + 0 GASTROINTESTINAL ENDOSCOPY Copyright Copyright"D 1994 by the American Society for Gastrointestinal Endoscopy
37/4/50100
246
Figure 1. Endoscopic retrograde cholangiogram showing
a 0.5 cm common bile duct stone (open arrow) that was extracted after performance of a sphincterotomy. Note the multiple small calculi in the partially filled gallbladder (closed arrow).
to my has been performed in several cases.1°' 11 Notably, the gallbladders in these cases were free of acute or chronic inflammation on pathologic examination. Only one case of choledocholithiasis from ceftriaxone precipitates has been reported. This patient had biliary obstruction and pancreatitis and recovered with conservative management. 12 Several other cases of elevated liver biochemical tests suggesting choledocholithiasis but without documentation by imaging studies have appeared. 13, 14 We report a case of ceftriaxone pseudolithiasis GASTROINTESTINAL ENDOSCOPY