Emerging role of laparoscopy in the diagnosis of lymphoma

PURPOSE: The results of laparoscopic procedures on patients with suspected or known lymphoma were analyzed to review the application and define the role of laparoscopy in lymphoma. PATIENTS AND METHODS: The hospital records of 94 patients who underwent 101 procedures between June 1993 and October 1996 were reviewed for demographic and clinicopathologic information. RESULTS: The procedure was diagnostic in 85 patients, either at primary presentation (48 patients), possible relapse (21 patients), in the course of treatment (eight patients), or of a liver lesion (eight patients). In the remaining 16 patients, it was used to stage possible intraabdominal disease. Twenty-seven patients had a previous unsuccessful diagnostic procedure. There were no operative deaths and eight postoperative complications (8%). The laparoscopy revealed non-Hodgkin's lymphoma (NHL) in 48 patients, Hodgkin's disease (HD) in 14 patients, other neoplastic conditions in six patients, and benign conditions in 33 patients. There was adequate information in all procedures in which lymphoma was diagnosed for treatment decisions. There was one false-negative and one nonresult for technical reasons. Ten patients commenced chemotherapy before discharge after a median delay of 3.5 days. In five of 24 patients (21%) with recurrent or persistent lymphoma, the precise diagnosis was significantly different from the original one. CONCLUSION: From our experience, laparoscopy can safely provide tissue samples of suspected lymphoma for full diagnostic analysis. It should be considered when percutaneous biopsy is not technically possible, when chromosomal or genetic analysis is needed for treatment decisions, or when the results of percutaneous biopsy are inadequate to make therapeutic decisions.     

Minireview: on the structure and gating mechanism of the mitochondrial channel, VDAC

The peripheral artery occlusive disease is a widely spread disease and its diagnosis, treatment options and consequences are frequently underestimated. Especially for the old patient, preservation of an extremity may mean mobility and quality of life. The increasing life expectancy and behaviour of prosperity including a lack of mobility are causing a rise in the frequence of atherosclerotic diseases. The prevalence of occlusive vascular diseases in patients between 55 to 64 years of age is currently 11% and is, therefore, a wide-spread disease. However, the socio-economic relevance of the occlusive vascular diseases is frequently underestimated. It causes both very high direct costs (treatment procedures, prostheses etc) as well as high indirect costs (permanent disability). Therefore, early diagnosis and treatment plays an important role in the avoidance of a progression of the disease. For an early diagnosis of the stage I of occlusive vascular diseases it makes sense to examine the vessels of patients at risk (i.e. diabetes mellitus, hypertension, hyperlipidemia, nicotine abuse, and overweight). Dopplerultra-sound and oscillometry are highly sensitive and specific diagnostic measures. The eradication of risk factor and the treatment of the secondary diseases plays the most important role in this disease stage without symptoms. A specific vessel training is indicated during stage II to encourage the development of collateral blood flow. Additionally, an interventional diagnostic and therapy should be considered in this stage with limitations in the daily activities. The administration of vasoactive drugs is controversly discussed. The acetylsalicylic acid (ASA) is remaining the most investigated substance for reducing the progress of the arteriosclerotic process. The administration of ticlopidine is justified in cases of ASA-allergies. The stages III and IV are characterized by pain at rest and necrosis. Firstly, the indication for a transcutaneous transluminal angioplasty, thrombolysis or bypass-surgery should be proofed. If procedures of revascularization are not possible, prostaglandines may improve the pain at rest and wound healing. Beside the stage of the occlusive vascular disease, the presence of risk factors, the physical status of the patient, and the location of the occlusion are of great importance for the decision about the treatment procedure.     

Malignant pleural mesothelioma

The incidence of malignant pleural mesothelioma (MPM) has risen for some decades and is expected to peak between 2010 and 2020. Up to now, no single treatment has been proven to be effective and death usually occurs within about 12-17 months after diagnosis. Perhaps because of this poor prognosis, early screening has incited little interest. However, certain forms may have a better prognosis when diagnosed early and treated by multimodal therapy or intrapleural immunotherapy. Diagnosis depends foremost on histological analysis of samples obtained by thoracoscopy. This procedure allows the best staging of the pleural cavity with an attempt to detect visceral pleural involvement, which is one of the most important prognostic factors. Although radiotherapy seems necessary and is efficient in preventing the malignant seeding after diagnostic procedures in patients, there has been no randomized phase III study showing the superiority of any treatment compared with another. However, for the early-stage disease (stage I) a logical therapeutic approach seems to be neoadjuvant intrapleural treatment using cytokines. For more advanced disease (stages II and III) resectability should be discussed with the thoracic surgeons and a multimodal treatment combining surgery, radiotherapy and chemotherapy should be proposed for a randomized controlled study. Palliative treatment is indicated for stage IV. In any case, each patient should be enrolled in a clinical trial.     

Enterocutaneous fistula in cancer patients: etiology, management, outcome, and impact on further treatment

Enterocutaneous fistulae that develop in patients with cancer represent a difficult management situation, which is often complicated by prior treatment including surgery, radiation therapy, and chemotherapy. A fistula may in turn delay potentially beneficial treatment of the underlying malignancy. To provide a better understanding of this problem, we reviewed the National Institutes of Health experience with enterocutaneous fistulae in adult patients with cancer. The medical records of patients with cancer who developed a fistula from the gastrointestinal tract during the period 1980 through 1994 were reviewed. Etiology, management, outcome, and impact on further treatment were assessed. Twenty-five patients with gastrointestinal fistulae were identified. The most common primary tumor site was the colon/rectum in males and the ovary in women. The majority of patients had metastatic disease at diagnosis and a history of prior therapy and presented with anorexia and weight loss. The fistula was usually single, most commonly developed from the jejunum/ileum (13 patients) or colon/rectum (6 patients), and occurred postoperatively after procedures on the small bowel (10 patients) or colon (8 patients). Malnutrition and sepsis developed in 60 per cent of patients. Thirty-day mortality was 16 per cent and correlated with prior radiation therapy, location and output from the fistula, and hypoalbuminemia. An enterocutaneous fistula negatively impacted on the provision of further therapy for the majority of patients (63%). Enterocutaneous fistula in the patient with cancer occurs most frequently in the setting of extensive prior therapy and is associated with prolonged morbidity. Identification of high-risk patients and early management of fistulas once they develop may prevent delays in subsequent cancer therapy and decrease morbidity.     

Diagnosis of pulmonary infections in mechanically ventilated patients

The optimal management strategy for ventilator-dependent patients who develop symptoms suggestive of lung infection remains controversial. Proponents of the empirical approach prefer to treat most patients with fever and pulmonary infiltrates with one or more new antibiotics, even if it may be difficult (1) to determine whether pneumonia has developed in such patients, (2) in case of infection, to precisely identify the responsible microorganisms and thereby select the optimal antimicrobial treatment, and (3) to avoid resorting to broad-spectrum drug coverage in patients without true infection. Our personal bias is that using bronchoscopic techniques to obtain protected specimen brush and bronchoalveolar lavage specimens from the affected area in the lung permits to devise a therapeutic strategy superior to the one based only on clinical evaluation. These bronchoscopic techniques, when they are performed before new antibiotics are administered, enable physicians to identify most patients who need immediate treatment and select optimal therapy, in a manner that is safe and well tolerated by patients. Furthermore, they frequently permit the clinician to withhold antimicrobial treatment in patients without infection, minimizing the risk of the emergence of resistant microorganisms in the intensive care unit. In patients with clinical evidence of severe sepsis, the initiation of antibiotic therapy should not, however, be delayed while awaiting bronchoscopy, and patients should be given immediate treatment with antibiotics. In that case, "simplified" non-bronchoscopic diagnostic procedures might allow obtaining reliable distal pulmonary secretions for quantitative cultures on a 24-hour basis just before the initiation of a new antimicrobial therapy.     

Epileptic seizures in patients with multiple sclerosis. Is the prognosis of epilepsy underestimated?

Spinal arteriovenous malformations are uncommon disorders associated with considerable difficulty in diagnosis and treatment. They are divided into dural arteriovenous fistulas and intradural medullary spinal cord angiomas. In this retrospective series of six patients the clinical outcome of embolization is presented. The patient material consisted of three dural fistulas and three cord angiomas, one of which bled causing sudden paresis, pain and incontinence. In the remaining five patients the symptoms were progressive consisting of paraesthaesias, paraparesis, pain and incontinence. The clinical status of four patients was not changed after the treatment, one deterioriated and one improved. There were no bleedings after the therapy. In one patient spinal angiography for follow-up was performed and recanalization was seen in the dural fistula after particle embolization. Also, in one cord angioma embolized with particles reflow appeared in the immediately repeated angiography. For permanent angioma occlusion tissue adhesive is preferred as embolic material. Surgical therapy as an alternative or adjuvant to embolization is discussed with a review of the literature. Early timing of the therapeutic intervention is stressed to avoid the development of irreversible ischaemic medullopathy and to prevent haemorrhage. The therapeutic procedures at the early stage of the disease may be curable or, at least, halt the progression of the symptoms. Cross-sectional imaging studies and myelographies may reveal the lesion. For the definitive diagnosis of spinal angioma with its vascular feeders and for the evaluation of its occlusion grade after the therapy selective spinal angiography is needed.     

Entamoeba histolytica: computer-assisted modeling of phosphofructokinase for the prediction of broad-spectrum antiparasitic agents

Approximately 34 cases of intracranial tuberculomas with paradoxical response to antituberculous chemotherapy have been documented worldwide. In most of the previously reported cases of this entity an associated tuberculous meningitis has been reported. The majority of these patients were children or young adults, who had inoperably located intracranial tuberculomas in high risk regions developing a few weeks or months after the start of appropriate chemotherapy. 53% of them recovered completely, 37% improved with mild neurological deficits and 10% died. It is interesting that these intracranial tuberculomas developed or enlarged at a stage when systemic tuberculosis was being treated successfully. We report our recent experience with these potentially curable tumours of the central nervous system. The literature is reviewed and diagnostic and therapeutic considerations are discussed. The possible immunological mechanisms of this phenomenon are analysed. In conclusion, patients, who are suspected to be suffering from CNS-tuberculosis should receive a prolonged (12-30 months) course of effective antituberculous therapy. Evidence of new intracranial tuberculomas or the expansion of older existing lesions require no change in the antituberculous drug programme. In such cases systemic dexamethasone as adjuvant therapy for 4 to 8 weeks is worthwhile and effective. Surgical intervention may be necessary in situations with acute complications of CNS tuberculosis such as shunting procedures for the treatment of hydrocephalus. When the diagnosis is not firm and there is no response to therapy within 8 weeks, a stereotactic biopsy of a suspected tuberculoma should be performed. If the largest lesion is not located in high risk deep regions of the brain, it should be total removed surgically. With this combined management, a satisfactory outcome can be obtained in the majority of cases.     

Advancement sleeve flaps for treatment of severe perianal Crohn's disease

BACKGROUND: Traditionally proctectomy has been the treatment for severe, complex fistula in ano from Crohn's disease. However, based on the success of rectal advancement flaps in Crohn's disease, circumferential transanal sleeve advancement flaps (TSAFs) were proposed for this subgroup of patients with severe fistula. METHODS: From 1991 to 1995, 13 patients (12 women) with severe perianal Crohn's disease and multiple fistula tracts underwent a TSAF procedure. Data were collected retrospectively using a standard data sheet. RESULTS: There were no postoperative deaths or major morbidity. One year after surgery, the fistula had healed in eight of 13 patients (with three requiring additional surgery before healing). Of patients in whom the procedure failed, three underwent proctectomy for progression of disease and the other two had recurrence of a rectovaginal fistula 6 and 8 months after surgery. Of six variables evaluated (previous procedure, steroid use, steroid dosage, associated Crohn's disease, associated procedures and diverting stoma), only associated procedures were significantly related to a successful outcome (P=0.008). CONCLUSION: Some patients with severe perianal Crohn's fistula and a relatively normal rectum can be offered TSAFs. Even with successful outcome in eight of 13 patients, this may still be a viable option if the only alternative would be total proctocolectomy and a permanent stoma.     

Retrograde pancreatography. Technical tips and spectrum of pathology

ERP is an important technique in the diagnosis of diseases involving the pancreatic ducts, in determining therapeutic strategy, and in assessing the results of surgical bypass procedures. ERP facilitates the diagnosis of the majority of pancreatic tumors at a stage when they normally present to the clinician. It assists the diagnosis of small tumors in the ampullary region at an early stage when other tests are negative. In cases of obscure recurrent pancreatitis, ERP may identify a mechanical cause (e.g., stone, stricture). ERP is useful in the diagnosis of CCP only in the precalcified stage. If histologic confirmation already has been obtained at surgery, ERCP is not required. Compared with noninvasive techniques, ERP provides additional information: It enables a concomitant examination of the gastroduodenal tract and opacification of the bile ducts; additional procedures may be performed, such as intraductal cytologic brushings, biochemical and cytologic analysis of pancreatic juice, endoscopic manometry, and pancreatoscopy. The diagnostic yield is increased if these procedures are performed during ERCP. Because ERP outlines the ductal anatomy, it is of great value in assessing therapeutic strategy. In cases of acute recurrent pancreatitis or chronic pancreatitis, ERP provides an important baseline for performing procedures such as ductal drainage and therefore reduces the inappropriate use of exploratory laparotomy. In cases of necrotic pancreatitis or pancreatic trauma, ERP enables accurate localization of a pancreatic fistula and facilitates any subsequent surgical procedure. Finally, ERP is the method of choice when assessing the patency of pancreatic-digestive anastomosis.     

The primary aortoenteric fistula in The Netherlands--the unpublished cases

OBJECTIVE: Primary aortoenteric fistula is a rare disorder of which only four patients have been reported in the Dutch literature so far. The objective of our study was to obtain more realistic figures on the incidence of this condition, with data on the clinical presentation, diagnostic procedures, treatment and results in a group of patients not previously reported as "case histories". METHODS: A questionnaire was sent to all surgical clinics in The Netherlands. Out of 180 questionnaires, 102 have been returned reporting 27 patients to which data of eight others treated in our own institution were added. RESULTS: In all but one of these 29 patients the fistula was caused by an atherosclerotic aneurysm, the one exception being caused by an ingested cocktail pin. Gastrointestinal haemorrhage was the predominant symptom, being present in 28 of the patients, while the complete triad of haemorrhage, pain and a pulsating mass was found in only eight patients. Twenty-seven patients were treated with an in situ graft of which 14 are doing well at long term follow-up. CONCLUSIONS: Primary aortoenteric fistula is far more common than one would expect from the number of patients reported in literature. A high index of suspicion based on a complete physical examination remains the key to a correct diagnosis. Direct closure of the intestine and in situ grafting of the aorta is the treatment of first choice.     

Genital fistulas caused by diverticular disease of the sigmoid colon

OBJECTIVE: Our purpose was to bring to the attention of gynecologists a subject not mentioned in a single textbook of gynecology, namely, genital fistulas resulting from diverticular disease of the sigmoid colon. STUDY DESIGN: We report our experience with 13 genital fistulas caused by sigmoid diverticulitis. RESULTS: Ten fistulas involved the vagina, one the vagina and bladder, one the tube, and one the uterus. Average age of the patients was 68.6 years (range 54 to 89 years). Presenting symptom in 12 patients was a malodorous vaginal discharge. All with vaginal lesions had previously undergone total hysterectomy. A barium enema failed to demonstrate a fistula in 8 of 11 patients. Colonoscopy failed in 8 of 8 patients. All fistulas were demonstrated by retrograde dye studies. Ten patients operated on were cured. Three patients refused surgery; of these, 1 had intestinal obstruction, 1 may have had spontaneous closure of the fistula, and 1 is being observed. Surgery involved staged procedures in 2 patients, fistulectomy in 4, and bowel resection and anastomosis in 4. CONCLUSIONS: Sigmoidovaginal fistulas are the most prevalent variety of cologenital fistula caused by sigmoid diverticulitis. The diagnosis should be considered in a patient > 50 years old who complains of a foul vaginal discharge and has a history of total hysterectomy. Its presence is best demonstrated by vaginogram. Surgical therapy is advised, the extent of which will rest on the surgeon's judgment of the severity of the inflammatory process found at exploration.     

Gallbladder puncture and drainage as therapy of acute cholecystitis

PATIENTS AND METHODS: An ultrasound-guided, percutaneous puncture (n = 30) and cholecystostomy (n = 10) was performed on 40 high-risk patients aged between 38 and 99 (mean age 78 years old) suffering from acute lithogenic cholecystitis or acalculous stress cholecystitis on account of general inoperability. Two catheter dislocations and in 3 cases a slight bile leakage were observed as complications. RESULTS: The puncture and drainage led to a dramatic alleviation of pain for all patients, the involution of a paralytic subileus and improvement of the general condition. Eighteen patients underwent a laparoscopic or open interval cholecystectomy in a stabilised condition. There was no recurrence of inflammation in 22 patients over a follow-up period of up to 5 years, so that one can assume a cicatrised healing of the acute choleycstitis. CONCLUSIONS: Ultrasound-guided, percutaneous puncture and cholecystostomy are effective, low-risk, and only slightly invasive procedures which can be employed for risk patients with acute cholecystitis as a life-saving, and in some cases definitive treatment. On account of pathogenic considerations, they should be included in the diagnostic and therapeutic concept at an early stage, particularly for acute, acalculous stress cholecystitis.     

Digital image processing in physiological studies

INTRODUCTION: New possibilities for transcatheter treatment of the cardiovascular system are guaranteed with the improvement of materials and the availability of new devices. Nevertheless, a rationalization of the potential activity in this sector seems to be necessary, and it could arise through the presence of Catheterization Laboratories "open" to diagnostic procedures and therapy that are not confined to the coronary system. This clinical study reports the experiences and results of our work in this field. MATERIALS AND METHODS: During the period from May 1995 to May 1997, our laboratory performed 205 diagnostic procedures that did not involve the coronary system. Based on this diagnostic work, there emerged 91 cases with an indication for transcatheter intervention, which was subsequently performed at our laboratory. There were 68 peripheral angioplasty procedures on the iliofemoral axis, 2 angioplasties of the subclavian artery, 8 of the renal artery, 2 procedures involving the treatment of A-V fistulas, one case of femoral pseudoaneurysm treatment and 10 cases of transcutaneous pericardiotomy performed with a balloon catheter. All the procedures were performed by our laboratory staff using materials that are normally at our disposal. RESULTS: Successful results were obtained in 65 out of the 68 peripheral angioplasty procedures and in all of the 8 renal and 2 subclavian angioplasties. The positioning of the endoprosthesis for the closure of the A/V fistula was effective in one of the two cases. The transcatheter treatment of the femoral pseudoaneurysm was successful. In all cases where a pericardiotomy was performed with a balloon catheter, there was no reoccurrence of cardiac tamponade during the follow-up period. No complications were noted as a result of any of the procedures. CONCLUSIONS: Our experience documents how it is possible to increase the diagnostic and therapeutic options in a Catheterization Laboratory. However, willingness on the part of the staff to update their skills continually and collaborate with other specialists is necessary in order to maintain optimal operative standards.     

Bowel endometriosis. Eight cases of colorectal resection

Colo-rectal endometriosis requiring colon resection are reported in 8 patients to illustrated the diagnostic and therapeutic problems encountered in the management of this uncommon localisation. Pericatamenial or catamenial bowel symptoms associated with pelvic genital involvement were encountered in all cases. Clinical examination, barium enema and colonoscopy are essential to guide surgical management looking for multiple localisations. However their diagnostic value is low as endometriosis rarely involves the mucosa. Endosonography appears to be very promising in evaluating the depth of infiltration of the bowel. The treatment of bowel endometriosis is controversial and varies greatly according to the patient's complaints and clinical data. The indications and limits of all treatment modalities including abstention, medical, and surgical treatment are discussed. From the cases reported we conclude that symptomatic bowel endometriosis should be fully excised whenever possible, and the surgical procedure should be adapted to the depth of infiltration. A full thickness excision or bowel resection is mandatory in patients with deep muscularis involvement. These procedures, which are often difficult due to extensive fibrosis and adhesions, may be achieved by laparoscopy in selected patients.     

Vesicocolonic fistulas in diverticulitis

Diverticulitis is a disease affecting patients in the fifth to sixth decades. The charts of 12 patients with cesicocolonic fistulas secondary to diverticulitis were reviewed. Their presentation was primarily urological with pneumaturia present in 10 of 12 patients and fecaluria present in 5 of 12. The process of fistulization occurs in stages. If the incipient stage can be identified early fistulization can be prevented and the morbidity and mortality rates will be reduced significantly. In older patients with bladder irritation (with or without positive urine cultures) a high degree of suspicion for diverticular disease will ensure an accurate diagnosis earlier. Patients with penumaturia or fecaluria present less of a diagnostic challenge. Cystoscopy is a reliable procedure and we recommend its use in discovering a vesicocolonic fistula. Surgical therapy should be individualized for each patient and good results were obtained with primary resection as well as staged repair.     

Bronchopericardial fistula after placement of an automatic implantable cardioverter defibrillator: radiographic and CT findings

OBJECTIVE: We describe our experience with bronchopericardial fistula as a complication of infection in patients who have undergone placement of automatic implantable cardioverter defibrillator systems. CONCLUSION: Bronchopericardial fistula should be suspected in patients who present with hemoptysis and who have undergone placement of an automatic implantable cardioverter defibrillator using pericardial or epicardial defibrillator patches. Air between a defibrillator patch and the heart on chest radiographs or CT is diagnostic.     

Utility-balanced and utility-imbalanced rules: Reply to Widiger.

Utilities may be considered either during diagnosis, as suggested by the present author (see record 1982-30494-001), or after diagnosis, as proposed by T. A. Widiger (see record 1984-06863-001) in his critique of the author's paper. However, there are limiting conditions on each of these procedures. Utilities should be considered during diagnosis when labeling costs are significant, when fixed diagnostic–treatment linkages cannot be avoided, and when researchers wish to give differential weight to Types I and II diagnostic errors. It may be advisable to assign patients several diagnoses, depending on the purpose of the diagnoses. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Unusual presentation of hemoptysis in a 78-year-old with previous Nissen fundoplication

A 78-year-old individual, who had a previous transthoracic Nissen fundoplication 20 years earlier, presented to our institution with hemoptysis. Initial workup included chest roentgenogram, upper gastrointestinal series, and upper endoscopy, all of which were nondiagnostic. A repeat upper endoscopy diagnosed a gastrobronchial fistula by revealing a large gastric ulcer that penetrated into the lung parenchyma. The patient underwent surgery for takedown of the fistula. One of the most common symptoms associated with gastrobronchial fistula is hemoptysis, although insidious cough, recurrent pneumonia, or gastrointestinal bleeding are also observed. The most useful diagnostic study is an upper gastrointestinal series, which must be read with a high index of suspicion. Gastrobronchial fistula is most commonly a long-term complication from hiatal hernia repair. The most frequently used procedure for repair of this disorder is the Nissen fundoplication. This can be done from either an abdominal or transthoracic approach. When the procedure is done such that the gastric wrap is left above the diaphragm, serious complications can occur. These include gastric ulceration, gastric herniation with gastric outlet obstruction, slippage or perforation of the wrap, and gastrobronchial fistula. Because of these serious complications, the Nissen fundoplication with the wrap left above the diaphragm should only be used in certain situations, such as obesity and shortened esophagus.     

Pancreatic injuries resulting from penetrating trauma: a multi-institution review

Pancreatic injury from penetrating trauma continues to be a source of significant morbidity and mortality, with questions remaining regarding optimal treatment of injuries. Our goal was to evaluate current trends in the operative management of these injuries. Our patient population comprised all patients admitted to one of three Level I trauma centers over an 8-year period that had sustained penetrating pancreatic trauma. The study was a retrospective chart review. Sixty-two patients were identified. All had associated abdominal injuries, with the liver and stomach being the most commonly injured organs. There were 14 deaths (mortality 22.6%), 10 within the first 48 hours due to associated vascular injury. In the 52 patients surviving beyond 48 hours, there were 19 patients with injuries to the main pancreatic duct and 33 with parenchymal injuries only. Pancreatic resection was carried out for all patients with ductal injury except for one, who later required distal pancreatectomy for pseudocyst and pancreatic fistula. Significant pancreatic fistulae developed in five patients, three in patients treated by drainage and two in patients treated by resection. The incidence of fistula formation was significantly higher for drainage versus resection in the patients with ductal injuries. The incidences of other complications were not affected by type of pancreatic injury, associated injuries, or method of management. We conclude that the majority of deaths in patients with penetrating pancreatic trauma are due to associated organ or vascular injuries. Appropriate management of the pancreatic injury can reduce the long-term complications. These results support treating patients with suspected ductal injuries by appropriate resection. Drainage should probably be sufficient for most nonductal pancreatic injuries.     

Cholecystoduodenal fistula with subsequent gallstone ileus: case report of an unusual course

Gallstone ileus is a rare complication of cholecystolithiasis with a high mortality because of the advanced age of the patients and the often delayed diagnosis. Signs of a cholecystoduodenal fistula are often absent in conventional ultrasonic and radiological methods. Treatment options are: 1. Enterolithotomy, 2. One stage procedure or 3. Two stage procedure consisting of enterolithotomy and the surgery of the biliary tract. In the case of our patient we performed a conventional cholecystectomy and the closure of the cholecystoduodenal fistula, which was found accidentally. When the gallstone ileus appeared 6 days later the enterolithotomy was performed. Thus in case of accidentally found cholecystoduodenal fistula an exploration of the abdominal cavity and the small intestine to find the gallstone should be performed on principle. Gallstones with a diameter of more than 2-3 cm should be removed by enterolithotomy to prevent the gallstone ileus.