Male Gender and Laparoscopic Cholecystectomy

Sir, 
 
I read with interest the paper on male gender and laparoscopic cholecystectomy by Al-Mulhim.[1] While the author needs to be commended for a thoroughly researched article, some points need to be clarified for the benefit of younger surgeons. 
 
1. In the methodology, the author remarks that the pneumoperitoneum was created by closed method using a Veress needle. In some cases, where the patients had upper abdominal incisions, Hasson's technique was used. However, the author makes no comment about the patients who had undergone lower abdominal surgery especially by a lower midline incision. It is well known that omental and gut adhesions do develop underneath the scar, and sometimes these adhesions can be found covering a wider area internally than the skin incision. Faced with such a situation, it is wiser to use an open technique for the creation of pneumoperitoneum. Even though the gut injuries do occur with same frequency with open technique, in such cases the catastrophic vascular injuries are reduced. 
 
Introduction of Veress needle at the Palmer's point in the left hypochondrium after aspirating the contents of stomach and ruling out splenic enlargement is another way to deal with such patients. Using optical trocars has not been proven to be immune to mishaps. 
 
2. It is difficult to concur with the author on the irrelevance of preoperative ultrasound as a means to predict a difficult laparoscopic cholecystectomy. A routine ultrasound (USG) examination performed just before the admission can be helpful to the operating surgeon and can be done at the same time the patient is undergoing other preoperative investigations. A thick-walled gallbladder of more than 4 mm is a certain indicator about the possible difficult LC. In addition to this, the scan might document slipped stones in the common bile duct if the operator is experienced. This step becomes all the more essential if the USG has been performed at some other centre at an earlier date. The policy of preoperative USG examination should be adhered to by the surgeon till he masters the art of endosurgery and can tackle difficult cases with relative ease. 
 
3. The idea of any publication is to present the work of the author to readers. In addition it stimulates other surgeons to look beyond their horizons. It is essential for the author to present a clear message to the readers whether the results can be reproduced by a surgeon at the start of his career. The author has to clearly demarcate the thin line in his article between calculated boldness and overzealous ventures. The reader on his part has to understand his limitations in surgical skills and stick to a step care approach especially during the early phase of the “learning curve.”


Male Gender and Laparoscopic Cholecystectomy
Sir, I read with interest the paper on male gender and laparoscopic cholecystectomy by Al-Mulhim. [1] While the author needs to be commended for a thoroughly researched article, some points need to be clarified for the benefit of younger surgeons. Introduction of Veress needle at the Palmer's point in the left hypochondrium after aspirating the contents of stomach and ruling out splenic enlargement is another way to deal with such patients. Using optical trocars has not been proven to be immune to mishaps.
2. It is difficult to concur with the author on the irrelevance of preoperative ultrasound as a means to predict a difficult laparoscopic cholecystectomy. A routine ultrasound (USG) examination performed just before the admission can be helpful to the operating surgeon and can be done at the same time the patient is undergoing other preoperative investigations. A thick-walled gallbladder of more than 4 mm is a certain indicator about the possible difficult LC. In addition to this, the scan might document slipped stones in the common bile duct if the operator is experienced. This step becomes all the more essential if the USG has been performed at some other centre at an earlier date. The policy of preoperative USG examination should be adhered to by the surgeon till he masters the art of endosurgery and can tackle difficult cases with relative ease.
3. The idea of any publication is to present the work of the author to readers. In addition it stimulates other surgeons to look beyond their horizons. It is essential for the author to present a clear message to the readers whether the results can be reproduced by a surgeon at the start of his career. The author has to clearly demarcate the thin line in his article between calculated boldness and overzealous ventures. The reader on his part has to understand his limitations in surgical skills and stick to a step care approach especially during the early phase of the "learning curve."

Bony Metastasis of Gastric Adenocarcinoma
Sir, A 50-year-old male presented with history of abdominal pain, anorexia, early satiety, significant weight loss, and features of gastric outlet obstruction for 3 months. There was a history of maelena and hemetemesis. There was a history of dull aching pain in the right thigh for the last 2 weeks. Examination revealed marked pallor and a huge intra abdominal lump in the epigastric region extending to right hypochondrium and umbilical region. There was a hard swelling of size 5 × 4 cm on the medial aspect of right mid thigh.
Upper gastrointestinal endoscopy revealed a large polypoidal mass in body of stomach extending to fundus at least 5 cm distal to gastroesophageal junction. Computed tomography abdomen showed a heterogenous density exophytic mass arising from medial wall of body of stomach. X-ray of right thigh showed an osteolytic lesion in the midshaft region of femur [ Figure 1]. Biopsies obtained during endoscopy and fine needle aspiration cytology of soft tissue swelling of the right thigh revealed moderately differentiated adenocarcinoma.
Patient was explored and feeding jejunostomy done as growth was unresectable. On 10 th postoperative day, patient developed fracture of the shaft of the femur for which internal fixation was done. Patient was given single The Saudi Journal of Gastroenterology fraction radiotherapy along with chemotherapy (5-FU and leucoverin) and discharged.
Gastric carcinoma is a frequent tumor, especially in some parts of the world like Japan. Metastasis to the bone from gastric tumors is rare and has been estimated to appear in 13.4% of the autopsy cases of gastric carcinoma in a Japenese study. [1] It mainly affects patients with poorly differentiated tumors and widespread disease along with metastasis to other sites. However, there have been reports of bony metastasis from early gastric cancer. Metastasis to the bone can occasionally be the first manifestation of gastric tumor, [2] but have only rarely been described as a sole manifestation of tumor recurrence. [3] Skeletal metastatic lesions arising from gastric cancer are uncommon and usually of osteolytic type. The thoracic and lumbar vertebrae are the most frequent sites [2] although there have been occasional reports of metastasis to the calcaneal bone, [3] pelvis, and even the skull base. Metastasis to femur is very rare. [2,3] Radioisotope bone imaging is generally accepted as being the initial procedure of choice in search for bone metastasis. Roentgenographic evaluation for bone metastasis has limited value because symptoms from bone metastasis frequently occur before any radiological abnormality becomes evident.
Prognosis of patients with osseous metastasis from gastric cancer seem to be dismal (median survival time 5 months) and 3.5 years has been the longest survival period reported in the literature. Radiotherapy has been advocated as the best therapeutic alternative for pain control with a response rate of 75%. [4] However, recent reports have employed chemotherapy with 5-FU with no adverse side effects. Nevertheless, prognosis remains poor and therapy is mainly aimed at relieving pain and discomfort.

Hairdye-Induced Hepatitis: An Unusal Cause of Acute Hepatitis
Sir, We present an unusual case of acute hepatitis caused by hair dye.
Hair dye contains various mutagenic and carcinogenic chemicals and is examined as a risk factor for various malignancies. Hair dye-induced hepatitis is a rare condition. There is only one case of hair dye-induced hepatitis reported in the literature. [1] A 33-year-old healthy young female presented with pruritus, skin lesions and jaundice 2 days after using a new hair dye rather than her usual one. Clinically, she was febrile, icteric, with hepatosplenomegaly but no ascites. Laboratory investigations showed hypereosinophilia of 20%, abnormal liver profile with total bilirubin of 13.5 mg/dL, conjugated 6.8 mg/dL, alanine transaminase 190 IU/L, aspartate transminase 152 IU/L, alkaline phosphatase of 227 IU/L and albumin being 3.7 g/dL. An ultrasound of the abdomen showed features of acute hepatitis and a normal biliary system. The prothrombin time was normal.
Work-up for acute hepatitis indicated negative IgM antibody for hepatites A, E, and anti-HBc antibody. Additionally, hepatitis B virus DNA was undetectable. Serology for cytomegalovirus, Herpes simplex virus, Epstein barr virus, leptospira and malaria were negative. Wilson's and autoimmune markers were also negative. Drug-induced hepatitis was considered in view of chronology of events. Because the patient had an allergic reaction, lymphocyte activation test was performed to study Letters to the Editor