Simplified Technique of Conventional Cholecystectomy in a Patient with Situs Inversus Totalis: A Case Report from Nepal

Introduction: Situs inversus is a rare autosomal recessive disorder occurring in 1:5,000 to 1:20,000 indiviuals. Cholecystectomy is a standard treatment for symptomatic gallbladder stone. We report a case of cholelithiasis in patient with inversus totalis who underwent cholecystectomy. Case presentation: A 48 years old obese female patient with dextrocardia and hypertention presented with a recurrent left upper abdominal pain for two years. Ultrasound abdomen showed gallbladder stone. Conventional cholecystectomy was done with a small left subcostal incision. The postoperative period was uneventful and the patient was discharged on 3rd post operative day. Conclusion: Cholecystectomy is the treatment of choice in patients with a left sided gallbladder stone, like in normal gallbladder and it is safe.

P-BN21 Diagnostic accuracy of transabdominal ultrasound for assessing gallbladder polyps

Background Gallbladder polyps are common findings on transabdominal ultrasound (TAUS) and their implications are not entirely clear. Current guidelines advise monitoring with serial TAUS and to offer laparoscopic cholecystectomy if criteria are met to minimise risk of malignant transformation. TAUS is easily accessible and useful at identifying gallbladder polyps, however, has limitations when differentiating between pseudopolyps and true gallbladder polyps with malignant potential. This study looks at a district general hospital’s outcomes for patients undergoing laparoscopic cholecystectomy for gallbladder polyps. Methods This retrospective study identified patients who had polyps identified on TAUS and subsequently undergone laparoscopic cholecystectomy from 2011 to 2021. We identified patients using hospital coding and subsequently assessed their pre-operative imaging and clinic letters to ensure gallbladder polyps were the reason for cholecystectomy. The size of polyp on TAUS was noted and pathology reports were assessed to determine if polyps had been correctly identified on TAUS and if these were true or pseudopolyps. Clinic letters were assessed to determine if patients were symptomatic pre-operatively. Results 66 patients were identified as having polyps pre-operatively. The size of polyp ranged from 2-19mm with a mean of 7.4mm. 39 (59%) patients were symptomatic pre-operatively. TAUS findings correlated with pathology findings of polyps in 45 (68%) patients. Of the 21 patients with no polyps on pathology: 11 had gallstones, 9 had chronic cholecystitis and 1 normal gallbladder. Of the polyps identified 44 were pseudopolyps and only 1 was a true adenoma – 39 cholesterol polyps, 3 inflammatory polyps and 2 adenomyomatosis. There was no evidence of dysplasia on the adenoma, it measured 5mm on TAUS and the patient was symptomatic. Conclusions This study highlights the limitations of TAUS in correctly identifying true polyps. The 41% of asymptomatic patients all had benign findings on pathology and likely had no benefit from surgery. Whilst TAUS is a useful method of identifying potential polyps these findings would suggest that other methods of identifying true polyps should be sought to minimise patients undergoing unnecessary surgery.

Laparoscopic Cholecystectomy for Large/Giant Gallstones: Case Report and Brief Review of Literature.

Background Gallstones disease (GSD) is the most common biliary pathology. GSD is one of the common surgical problems in which lead people admit to the hospital in Nepal. Its prevalence is found to be 4.87%. The size of a gallstone is important, as giant/large gallstones have a higher risk of complications and present technical difficulties during laparoscopic cholecystectomy (LC). Open cholecystectomy is preferred in most cases with giant gallstones. With the availability of experienced laparoscopic surgeons and modern laparoscopic equipment LC is also feasible in large/giant gallstones. In this case report, we report 2 cases of one large and one giant gallstone each which were successfully done laparoscopically.Case Presentation Case 1 A 51 years old female presented with 5 months history of intermittent right upper quadrant colicky pain related to fatty food with no significant past medical and surgical history.Ultrasound abdomen showed normal gallbladder with multiple gallstones, largest measuring approximately 4cms. She was planned for elective LC. The gallbladder was removed out after extension of the infra-umbilical incision. On the cut section, we found multiple gallstones with one large gallstone measuring 4*3.3*3 cm and weighted 23.2 gm. Her post-operative period was uneventful. Case 2 A 39 years old female, known case of hypertension under calcium channel blocker(CCB) and angiotensin receptor blocker(ARBs) presented with 5 months history of intermittent right upper quadrant colicky pain related to fatty foods with non-significant surgical history. Ultrasound abdomen showed a normal gallbladder with a single large gallstone (approximately 4.7 cm). Elective LC was performed and the gallbladder was removed out after extension of infraumbilical incision. On the cut section, we found a single giant gallstone measuring 5* 3*2.8 cm and weighted 24.7 gm. Her post-operative period was uneventful.Conclusion Large/giant gallstones are associated with a high risk of complications and cholecystectomy is warranted in symptomatic and asymptomatic patients. Even for large/giant gallstones, LC appears to be the treatment of choice over open cholecystectomy and should be performed by an experienced laparoscopic surgeon, taking into consideration the possibility of conversion to open in case of inability to expose the anatomy and any intraoperative technical difficulties.

Expression and functional characterization of INPP4B in gallbladder cancer patients and gallbladder cancer cells

Background Inositol polyphosphate 4-phosphatase type II (INPP4B) is a negative regulator of the PI3K-Akt signalling pathway and plays a contradictory role in different types of cancers. However, the its biological role played by INPP4B in human gallbladder cancer (GBC) has not been elucidated. In this study, we investigated the expression, clinical significance and biological function of INPP4B in GBC patients and cell lines. Methods The INPP4B protein expression levels in gallbladder cancer tissues and normal gallbladder tissues were detected by immunohistochemistry, and the clinical significance of INPP4B was analysed. Knockdown and overexpression of INPP4B in GBC-SD and SGC-996 cells followed by cell proliferation, clonogenic, apoptosis detection, scratch wound-healing and transwell assays were used to identify INPP4B function in vitro. Results INPP4B was up-regulated in human GBC tissues compared with normal gallbladder tissues and was related to histopathological differentiation (p = 0.026). Here, we observed that INPP4B was highly expressed in high-moderately differentiated tumours compared with low-undifferentiated tumours (p = 0.022). Additionally, we found that INPP4B expression was not associated with overall survival of GBC patients (p = 0.071) and was not an independent prognostic factor. Furthermore, when we stratified the relationship between INPP4B expression and the prognosis of GBC based on histopathological differentiation, we found that INPP4B played a contradictory role in GBC progression depending on the degree of differentiation. In addition, INPP4B knockdown inhibited the proliferation, colony formation, migration and invasion in GBC cells, while INPP4B overexpression had the opposite effects in vitro, which indicates its role as an oncoprotein. Conclusions These findings suggested that INPP4B may play a dual role in the prognosis of GBC depending on the degree of differentiation and that INPP4B might act as an oncogene in gallbladder cancer cells.

Liver Segmentectomy by Intrahepatic Lithiasis

Intrahepatic cholelithiasis, which is defined as stones proximal to the confluence of the hepatic ducts, is considered endemic in Southeast Asia. Its pathogenesis is not completely understood yet. A 19-year-old female was admitted to the hospital with a history of recurrent biliary pancreatitis. Abdominal ultrasound detected normal gallbladder while magnetic resonance cholangiopancreatography revealed lithiasis at the hepatic duct of liver segment V. After preoperative evaluation a typical segmentectomy was done. The postoperative period was uneventful and the patient was well at 6-month follow-up.

The First Case Report of Ectopic Hepatic Tissue in a Guinea Pig

Ectopic hepatic tissue is an extremely rare developmental abnormality in human beings. Although this lesion is likewise rare in veterinary medicine and there were sparse reports in several species such as dogs, cats, cows, and calves, we incidentally encountered ectopic hepatic tissue in a guinea pig. In the case of guinea pigs, we report for the first time the occurrence of ectopic hepatic tissue implanted in the gallbladder. The healthy guinea pig remained asymptomatic, and its macroscopic findings also showed no abnormalities. Hematological examinations exhibited moderate decreases in white cell counts, hemoglobin concentrations, and packed cell volume ratio. Serum biochemical examinations showed decreases in total protein and albumin and increases in glucose levels, alkaline phosphatase, lactate dehydrogenase, creatine kinase, and γ-glutamyl transpeptidase. There were slight changes in electrolytes (Cl, Ca, and Mg) and inorganic phosphorus, indicating minor deviations from physiologic ranges. An increase in TBIL concentrations was not found in this examination. Histopathological examination revealed the presence of normal hepatic structures (hepatocytes and hepatic cords) within the wall of the normal gallbladder. The vascular and bile duct structures and portal triads were not observed in the ectopic hepatic tissue. In conclusion, this microectopic hepatic tissue in a guinea pig was characterized by the embedded structures of hepatic tissues, without foreign body reaction.

Adolescent with abdominal pain poorly responsive to analgesia

Case presentationA 14-year-old boy, with autism spectrum disorder, presented with a 1-day history of colicky abdominal pain, non-bilious vomiting, anorexia and loose normal-coloured stool. Two days previously, he had a poorly reheated takeaway chicken.On examination, body mass index (BMI) was >99th centile. He had inconsistent epigastric, periumbilical and umbilical tenderness, and guarding, with normal bowel sounds. Observations were within normal limits, but his pain was poorly responsive to paracetamol, ibuprofen, hyoscine butylbromide, codeine and morphine.Investigations are in table 1. On day 3, his temperature increased to 38.5° and a CT scan was performed, which showed concerning features (figure 1).Table 1Serology and further investigations throughout admissionDay 1Day 2Day 3Day 4Serology White cell count (3.8–10.6×109/L)7.514.615.713.6 Neutrophils (1.8–8.0×109/L)5.312.312.85.3 C reactive protein (<5 mg/L)12010398 Bilirubin (0–21 μmol/L)812Further investigations Urine dipstickNegative UltrasoundSmall volume of free fluid, normal gallbladder, pancreas and appendix not visualisedFigure 1CT scan of the abdomen (A) and pelvis (B).QuestionsWhat is the diagnosis?Appendicitis.Pancreatitis.Cholecystitis.Gastroenteritis.Which serology would have been most helpful at presentation?Renal function.Coagulation.Amylase and lipase.Gamma glutamyltransferase.What are the acute treatment principles?What is the the most common cause?Idiopathic.Gallstones.Medications.Genetic.Answers can be found on page 2.

Expression and Functional Identification of INPP4B in Gallbladder Cancer Patients and Gallbladder Cancer Cells

Purpose: Inositol polyphosphate 4-phosphatase type II (INPP4B) is a negative regulator of PI3K-Akt signaling pathway and plays a contradictory role in different types of cancers. However, its biological role in human gallbladder cancer (GBC) remain unclear. Here we aimed to investigate the expression, clinical significance and biological function of INPP4B in GBC clinical dates and GBC cell lines. Methods: The INPP4B protein expression levels in gallbladder cancer tissues and normal gallbladder tissues were detected by immunohistochemistry, and the clinical significance of INPP4B was analyzed. Knockdown and overexpression of INPP4B on GBC-SD and SGC-996 cells were used to identify INPP4B function in vitro, using cell proliferation assay, clonogenic assay, apoptosis detection, cratch wound-healing assay and transwell assay.Results: INPP4B was up-regulated in human GBC tissues compared with normal gallbladder tissues, and was related to histopathological differentiation. Here, we observed that INPP4B was highly expressed in high-moderate differentiated compared to low-undifferentiated. Additionally, we found that INPP4B expression was not associated with overall survival in GBC patients and was not an independent prognostic factor. Furthermore, when we stratified the relationship between INPP4B expression and prognosis of GBC from histopathological differentiation, we found that INPP4B played a contradictory role in GBC progression at different degrees of differentiation. In addition, INPP4B knockdown inhibited tumorigenicity in vitro, and INPP4B overexpression induced tumorigenicity in vitro, which may play a role as an oncoprotein.Conclusions: These findings implicated that INPP4B may play a dual role in the prognosis of GBC with different degrees of differentiation, and might act as an oncogene in gallbladder cancer cells.

Left renal vein entrapment syndrome: nutcracker syndrome!

Nutcracker syndrome (NCS) is a rare vascular compression disorder that involves compression of the left renal vein most commonly between the aorta and the superior mesenteric artery (SMA), although variations exist. It is associated with the formation of the left renal vein from the aortic collar during the 6th–8th week of gestation and abnormal angulation of the SMA from the aorta. Collateralisation of venous circulation including mainly the left gonadal vein and the communicating lumbar vein are the most significant effects. It has a female predilection occurring in the third to fourth decade and it tends to be diagnosed earlier in men. Affected individuals may present with a myriad of symptoms such as haematuria, left flank pain and proteinuria. As patients often present with these non-specific symptoms to primary care, knowledge of NCS is essential. The diagnosis can be rendered with Doppler ultrasonography, retrograde venography, CT angiography, intravascular ultrasound and magnetic resonance angiography. The authors describe the case of a 39-year-old woman with a low body mass index (BMI) presenting with generalised abdominal and flank pain as well as chronic microcytic anaemia. Physical examination findings were suggestive of biliary or renal colic. Laboratory investigations confirmed her anaemia (haemoglobin 88 g/L, mean corpuscular volume (MCV) 72 fL), but were otherwise unremarkable. Urinalysis showed proteinuria and haematuria. However, ultrasonography was unremarkable with a normal gallbladder and no evidence of calculi. Her CT scan showed marked compression of the left renal vein between the aorta and the SMA (nutcracker phenomenon), with upstream left renal, left gonadal and left lumbar vein dilatation. She was managed conservatively. This paper provides an overview of the aetiology, embryology, clinical manifestations, imaging modalities and management of NCS.