Rothmund-Thomson syndrome is a genetic disorder with characteristic findings in childhood as well as a predisposition to osteosarcoma, skin cancer, and hematological malignancy. We present the first reported case of duodenal malignancy in a patient with Rothmund-Thompson syndrome. An enlarged Virchow's node was noted and an advanced duodenal adenocarcinoma was diagnosed shortly thereafter. The features of Rothmund-Thomson syndrome are discussed, as well as current management and screening guidelines for duodenal adenocarcinoma.

Background: Smoking cessation programs started as late as 4 weeks before surgery reduce perioperative morbidity and death, yet outpatient clinic interventions are rarely provided. Our aim was to evaluate the feasibility of implementing a tobacco treatment protocol designed for an outpatient surgical setting. Methods: We completed a pre–post feasibility study of the implementation of a systematic, evidence-based tobacco treatment protocol in an outpatient colorectal surgery clinic. Outcomes included smoking prevalence, pre- and postimplementation smoker identification and intervention rates, recruitment, retention, smoking cessation and provider satisfaction. Results: Preimplementation, 15.5% of 116 surveyed patients were smokers. Fewer than 10% of urveyed patients reported being asked about smoking, and none were offered any cessation intervention. Over a 16-month postimplementation period, 1198 patients were seen on 2103 visits. Of these, 950 (79.3%) patients were asked smoking status on first visit and 1030 (86.0%) were asked on at least 1 visit. Of 169 identified smokers, 99 (58.6%) were referred to follow-up support using an opt-out approach. At 1-, 3- and 6-month follow-up, intention-to-quit rates among 78 enrolled patients were 24.4%, 22.9% and 19.2%, respectively. Postimplementation staff surveys reported that the protocol was easy to use, that staff would use it again and that it had positive patient responses. Conclusion: Implementation of our smoking cessation protocol in an outpatient surgical clinic was found to be feasible and used minimal clinic resources. This protocol could lead to increases in identification and documentation of smoking status, delivery of smoking cessation interventions and rates of smoking reduction and cessation.

Objective: Gallbladder agenesis (GBA) is a rare congenital disorder with an estimated incidence of about 0.06%. Despite the absence of a gallbladder, these patients may present with symptoms mimicking biliary colic or cholecystitis. Ultrasound findings and liver function tests are often misleading. Some of these patients undergo laparoscopy without successful identification of gallbladder and paradoxically report symptom relief. Case: We present a case of GBA in a 54 year-old female, who presented with right-sided abdominal pain. The clinical history and examination were consistent with biliary colic. Initial investigations, including liver function tests, upper endoscopy and ultrasound did not demonstrate upper gastrointestinal pathology and did not clearly identify a gallbladder. Subsequent HIDA scan and CT of the abdomen did not visualize a gallbladder. An MRCP confirmed gallbladder agenesis. The patient was managed conservatively and was symptom free on discharge and follow-up. Discussion: We wish to highlight four learning points: 1. Patients with gallbladder agenesis often present with biliary symptoms. 2. Ultrasound and CT of the liver may not always identify this anomaly. 3. MRCP is the gold standard for making a diagnosis of gall- bladder agenesis. 4. Surgeons must have a high index of suspicion of GBA when the gallbladder is poorly visualized or not identified on ultrasound.