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  • The treatment of choice is controversial numerous

    2018-10-29

    The treatment of choice is controversial; numerous investigators have considered orchiectomy using an inguinal approach as the standard procedure of treatment in both adults and children. In recent years, however, a number of investigators advocate local excision or enucleation as the treatment of choice in both adults and children. Others believe that patients with no local or metastatic recurrence of the testicular epidermoid cyst should undergo local enucleation. Heidenreich et al conducted a literature review of 300 cases treated by the conservative approach (enucleation or wedge resection) and showed that none of the patients experienced local recurrence of peripheral metastasis. Ross et al believe the testis-sparing operation to be more appropriate in the pediatric population for the following reasons: (1) a greater percentage of pediatric testicular tumors are benign, as compared with adult testicular tumors; (2) teratoma is uniformly benign in the pediatric population; and (3) the risk of contralateral disease (e.g., torsion) is greater in children. Some investigators think that the benefits of testis-sparing operation, compared with orchiectomy, include an increase in chances of fertility later in life, even in patients with oligospermia or contralateral disease. However, the cytotoxic effect of an antispermatic reaction on an animal model that received testicular surgery (e.g., orchiectomy or biopsy) induced infertility. Although Steele et al discovered that antisperm g protein coupled receptors do not develop after biopsy, conflicting data exist for cryptorchidism, varicocele, and testicular biopsies as well. In a recent study, investigators reported that antisperm antibodies in semen are not associated with reproductive outcomes (fertilization and clinical pregnancy rate) after testicular biopsy or excision.
    Conclusions
    Introduction Although biliary stenting is a low-risk procedure compared with surgical treatment, it is complicated by pancreatitis (5.4%), cholangitis (<5%), hemorrhage (<2%), or gastrointestinal perforation (<1%). Iatrogenic hemobilia after this procedure is uncommon, though it tends to increase because of widespread use of invasive procedures. Stent-associated complications include migration, perforation, bleeding, and obstruction. While distal stent migration is relatively common and accounts for approximately 6% of all patients undergoing the procedure, stent-related bleeding is uncommon (1.25%). The most common site of a migrated biliary stent is the duodenum, whereas the small bowel or colon is rare. A migrated stent stuck into the ascending colon resulting in erosion accompanied by hemorrhagic shock has not been reported. We report, therefore, an intriguing case that underwent biliary stenting on account of common bile duct stone with obstructive jaundice, and then suffered from hemobilia after stenting. Recurrent gastrointestinal hemorrhage from distal stent migration caused the second episode of gastrointestinal hemorrhage that was treated as recurrent hemobilia. The case emphasizes that surgeons should have a high index of suspicion for stent-related complications and also emphasizes the need for meticulous evaluation of gastrointestinal bleeding and stent position in patients who have had biliary endoprosthesis placement.
    Case report A 60-year-old man suffered from an episode of right upper quadrant abdominal pain with a distended gallbladder containing gallstones. Percutaneous transhepatic gallbladder drainage (PTGBD) was performed under the initial diagnosis of acute cholecystitis. However, progressive jaundice developed, and he was transferred to our hospital/department from a local medical department. Pertinent data on serum chemistries were as follows: total bilirubin 28 mg/dL (normal range, 0.2–1.4), aspartate aminotransferase 41 U/L (normal range, 0–37), alanine aminotransferase 61 U/L (normal range, 0–40), and alkaline phosphatase 139 U/L (normal range, 28–94). Leukocytosis of 39,000/μL (normal range, 3900–10,600) with a left shift, a mildly decreased hemoglobulin (Hb) level of 12.2 g/dL (normal range, 13.5–17.5), and an elevated C-reactive protein of 168 mg/L (normal range, <5) were also noted. Intravenous ceftriaxone at a dose of 1 g every 12 hours was given under the impression of acute cholangitis with obstructive jaundice. Endoscopic retrograde cholangiopancreatography (ERCP) demonstrated a dilated common bile duct, purulent bile, and multiple ductal stones. An 8.5 French 12 cm plastic biliary stent was then placed without sphincterotomy up to left intrahepatic duct for temporary biliary decompression (Fig. 1).