Is Precision Surgery Applicable to Colorectal Liver Metastases? A Systematic Review and Meta-analysis of Studies that Investigate the Association of Surgical Technique with Outcomes in the Context of Distinct Tumor Biology

BACKGROUND

Although some data suggest that patients with mutRAS colorectal liver metastases (CRLM) may benefit from anatomic hepatectomy, this topic remains controversial. We performed a systematic review and meta-analysis to determine whether RAS mutation status was associated with prognosis relative to surgical technique [anatomic resection (AR) vs. nonanatomic resection (NAR)] among patients with CRLM.

PATIENTS AND METHODS

A systematic review and meta-analysis of studies were performed to investigate the association of AR versus NAR with overall and liver-specific disease-free survival (DFS and liver-specific DFS, respectively) in the context of RAS mutation status.

RESULTS

Overall, 2018 patients (831 mutRAS vs. 1187 wtRAS) were included from five eligible studies. AR was associated with a 40% improvement in liver-specific DFS [hazard ratio (HR) = 0.6, 95% confidence interval (CI) 0.44-0.81, p = 0.01] and a 28% improvement in overall DFS (HR = 0.72, 95% CI 0.54-0.95, p = 0.02) among patients with mutRAS tumors; in contrast, AR was not associated with any improvement in liver-specific DFS or overall DFS among wtRAS patients. These differences may have been mediated by the 40% decreased incidence in R1 resection among patients with mutRAS tumors who underwent AR versus NAR [relative risk (RR): 0.6, 95% CI 0.40-0.91, p = 0.02]. In contrast, the probability of an R1 resection was not decreased among wtRAS patients who underwent AR versus NAR (RR: 0.93, 95% CI 0.69-1.25, p = 0.62).

CONCLUSIONS

The data suggest that precision surgery may be relevant to CRLM. Specifically, rather than a parenchymal sparing dogma for all patients, AR may have a role in individuals with mutRAS tumors.

Laparoscopic Inguinal Hernia Repair in the Obese Patient Population: A Single-Center Five-Year Experience

Purpose The objective of the present study is to evaluate the distribution of the transabdominal preperitoneal (TAPP) and the totally extraperitoneal repair (TEP) procedures among the obese and non-obese patient populations, to show how obesity impacts daily practice by reviewing the experience of a single center, and finally, to assess the outcomes of the operations. Methods All patients who underwent elective, minimally invasive inguinal hernia repair in our hospital from January 2017 to January 2022 were included in the present study. The data that were analyzed were patient demographics, each individual patient's American Society of Anesthesiology (ASA) score, the minimally invasive technique (TAPP or TEP) utilized, the body mass index (BMI), and other comorbidities such as underlying diabetes, hypertension, and smoking status. Results A total of 109 patients were included in the present analysis, of which 81 (74.3%) underwent elective TEP repairs while 28 (25.7%) underwent elective TAPP repairs. Overall, 39 (35.7%) patients were included in the obesity subgroup with an average BMI of 35.4 ± 4.9, with a range from 30.1 to 52.7, and 70 (64.3%) were included in the non-obese subgroup, with an average BMI of 23.2 ± 3.3 and a range from 16.2 to 29.7. Conclusions The laparoscopic approach to the inguinal hernia repair in obese patients has similar outcomes as an open approach regarding the 30-day events, in the hands of experienced surgeons with the advantages of the laparoscopic approach vs. the open one.

Gastric conduit reconstruction after esophagectomy with right gastroepiploic artery absence: a case report

Gastric conduit reconstruction is the standard choice after esophagectomy. Conduit's vascular supply is of primary importance mainly based on right gastroepiploic vessels. A 57-year-old male with absent right gastroepiploic artery, due to a duodenal bleeding ulcer treated with gastroduodenal artery ligation 10 years ago, was treated for gastroesophageal cancer and required esophagectomy. Surgical merits of this troublesome scenario are highlighted. Previous surgical history is highly important for patients requiring complex surgery as esophagectomy. The use of the stomach as conduit after esophagectomy is always the primary option; however vascular supply of it should not be compromised. Variations are rare and careful planning may overcome obstacles as in this case.

Nivolumab-Induced Colitis in a Patient With Esophageal Adenocarcinoma: A Case Report

Nivolumab is an immune checkpoint inhibitor used in the treatment of several types of cancer. Among the adverse effects of this drug, immune-mediated colitis (IMC) has been described. However, in contrast to other checkpoint inhibitors, such as ipilimumab, drug-induced colitis due to nivolumab is not commonly reported. We report the case of a 59-year-old male who had undergone surgical resection for gastroesophageal junction adenocarcinoma, had been on nivolumab during the past five months, and presented with worsening diarrhea. Colonoscopy demonstrated local edema and mild colitis in a region of the colonic mucosa located 30 cm distal to the ileocecal valve. Biopsies revealed acute moderate colitis. The patient responded well to loperamide and dietary modifications. Although nivolumab rarely causes IMC, this occurrence requires proper management in order to avoid further complications.

Precision Surgery of Colorectal Liver Metastases in the Current Era: A Systematic Review

Liver resection for colorectal liver metastases (CRLM) is widely considered the treatment with the highest curative potential. However, not all patients derive the same oncological benefit, underlining the need for better patient stratification and treatment allocation. In this context, we performed a systematic review of the literature to determine the role of RAS status in selecting the optimal surgical strategy. Evidence comparing anatomical with non-anatomical resections depending on RAS mutational status was scarce and conflicting, with two studies reporting superiority in mutated RAS (mutRAS) patients and two studies reporting equivalent outcomes. The rate of incomplete microscopic resection (R1) was found to be increased among mutRAS patients, possibly due to higher micrometastatic spread lateral to the primary lesion. The impact of R1 resection margins was evaluated separately for mutRAS and wild-type patients in three studies, of which, two indicated an additive detriment to long-term survival in the former group. In the current era of precision surgery, RAS status can be utilized to predict the efficacy of liver resection in the treatment of CRLM, avoiding a potentially morbid operation in patients with adverse tumor profiles.

The Protective Effect of Bariatric Surgery on the Development of Colorectal Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Obesity is a known risk factor for developing colorectal cancer (CRC) and is associated with the formation of precancerous colonic adenomas. Bariatric surgery (BRS) is considered to reduce the cancer risk in morbidly obese patients. However, the currently available literature yields contradicting results regarding the impact of bariatric surgery on the incidence of CRC.

METHODS

A systematic literature search of the Medline, Embase, CENTRAL, CINAHL, Web of Science, and clinicaltrials.gov databases was undertaken following the PRISMA guidelines. A random effects model was selected.

RESULTS

Twelve retrospective cohort studies, incorporating a total of 6,279,722 patients, were eligible for inclusion in the final quantitative analysis. Eight studies originated from North America, while four reported on European patients. Patients in the Bariatric Surgery group exhibited a significantly reduced risk for developing colorectal cancer (RR 0.56, 95% CI 0.4-0.8, p < 0.001), while sleeve gastrectomy was found to be significantly associated with a smaller incidence of CRC (RR 0.55, 95% CI 0.36-0.83, p < 0.001), and gastric bypass and banding did not.

CONCLUSIONS

A significant protective effect of BRS against the development of CRC is implied. In the present analysis, the incidence rate of colorectal cancer was approximately halved amongst the obese individuals that were operated on.

Severity of Pancreatic Leak in Relation to Gut Restoration After Pancreaticoduodenectomy: The Role of the Roux-en-Y Configuration

Background

Pancreatic leak after pancreaticoduodenectomy and gut restoration via a single jejunal loop remains the crucial predictor of patients' outcome. Our reasoning that active pancreatic enzymes may be more disruptive to the pancreatojejunostomy prompted us to explore a Roux-en-Y configuration for the gut restoration, anticipating diversion of bile salts away from the pancreatic stump. Our study aims at comparing two techniques regarding the severity of postoperative pancreatic fistula (POPF) and patients' outcome.

Methods

The files of 415 pancreaticoduodenectomy patients were retrospectively reviewed. Based on gut restoration, the patients were divided into: cohort A (n = 105), with gut restoration via a single jejunal loop, cohort B (n = 140) via a Roux-en-Y technique assigning the draining of pancreatic stump to the short limb and gastrojejunostomy and bile (hepaticojejunostomy) flow to long limb, and cohort C (n = 170) granting the short limb to the gastric and pancreatic anastomosis, whereas hepaticojejunostomy was performed to the long limp. The POPF-related morbidity and mortality were analyzed.

Results

Overall POPF in cohort A versus cohorts B and C was 19% versus 12.1% and 9.4%, respectively (P = 0.01 A vs B + C). POPF-related morbidity in cohort A versus cohorts B and C was 10.5% versus 7.3% and 6.3%, respectively (P = 0.03 A vs B+C). POPF-related total hospital mortality in cohorts A versus B and C was 1.9% versus 0.8% and 0.59%, respectively (P = 0.02 A vs B+C).

Conclusion

Roux-en-Y configuration showed lower incidence and severity of POPF. Irrespective of technical skill, creating a gastrojejunostomy close to pancreatojejunostomy renders the pancreatic enzymes less active by leaping the bile salts away from the pancreatic duct and providing a lower pH.

Giant Ovarian Thecoma Associated with Meigs Syndrome: A Striking Case

Introduction: Meigs syndrome consists of the presence of a benign ovarian tumor, ascites and pleural effusion, and the latter two subdued after surgical excision of the ovarian tumor. Elevated Ca-125 in this context is confusing and is reported only in a handful of cases. A rare but striking case with the above features is presented herein. Case Presentation: A 46-year-old woman with a giant pelvic/abdominal mass originating from her right adnexa, ascites and pleural effusion, with elevated Ca-125 (938 IU/mL) was treated with the presumptive diagnosis of stage IV ovarian cancer. Imaging modalities showed a 22 cm solid adnexal mass and the patient underwent total abdominal hysterectomy and bilateral salpigooophorectomy, omentectomy and drainage of 4L of ascetic fluid. Surprisingly, final histopathology was negative for malignancy, characterizing the primary tumor as ovarian thecoma. Ascites and pleural effusion resolved by the seventh postoperative day, setting the diagnosis of Meigs syndrome. Discussion: Meigs syndrome accounts for 1% of all ovarian tumors, however it should be considered in the differential diagnosis when clinicians come across the classic triad of the syndrome, even when Ca-125 is elevated. These patients have normal life expectancy with meticulous management, while pathophysiology of this condition remains uncertain in various points.

The role of surgery after prolonged primary chemotherapy for advanced oesophageal adenocarcinoma

BACKGROUND

Most patients presenting with oesophageal cancer do so with advanced disease not suitable for surgery. However, there are examples of encouraging survival following surgery in highly selected patients who respond well to chemotherapy.

METHODS

This was a retrospective cohort study of patients who presented with advanced but nonvisceral metastatic oesophageal cancer. Consecutive patients on a prolonged primary chemotherapy pathway who underwent surgical resection following a favourable response to chemotherapy were included. Survival and recurrence rates were analysed using Cox regression, providing hazard ratios (HRs) with 95% confidence intervals (CIs).

RESULTS

A total of 57 patients included in the cohort operated between 2007 and 2015, the overall median survival was 44 months and the 5-year survival was 42%. Prechemotherapy cN0/cN1 (HR: 0.27, 95% CI: 0.12-0.62) conferred an independent survival advantage compared to cN2 and cN3 disease. Poor differentiation (HR: 2.46, 95% CI: 1.11-5.42), R1 resection (HR: 2.43, 95% CI: 1.14-5.19) and advanced nodal status (HR: 3.28, 95% CI: 1.44-7.47) predicted worse survival on univariable analysis. Poor differentiation (HR: 3.93, 95% CI: 1.62-9.56) was independently associated with poor survival when adjusted for other variables.

CONCLUSION

Patients who present with advanced inoperable oesophageal cancer who have a favourable response to chemotherapy represent a limited group of patients who may benefit from surgery.

Review of the Literature on Leiomyoma and Leiomyosarcoma of the Adrenal Gland: A Systematic Analysis of Case Reports

BACKGROUND/AIM

To date few cases of smooth muscle-derived tumors of the adrenal gland have been reported and their treatment remains a medical challenge. The aim of this manuscript was to systematically review the literature and present the tumor characteristics and their management in order to provide a standardized approach to their diagnosis and management.

MATERIALS AND METHODS

We searched five databases (PubMed, Scopus, Elsevier, ResearchGate, Google scholar) for relevant articles published until March 2020.

RESULTS

Twenty-two cases of adrenal leiomyoma, four cases of adrenal smooth muscle tumor and forty-five cases of adrenal leiomyosarcoma were included.

CONCLUSION

We present the demographic, clinical, radiological, pathological and oncological characteristics and prognosis of tumors of the adrenal gland arising from smooth muscle cells, as well as describe the common clinical investigations and therapeutic modalities that have been reported as part of their management.

Receptor-Binding Cancer Antigen Expression in Thyroid Neoplasms: A Retrospective Study

Background: Receptor-binding cancer antigen (RCAS1) is a membrane protein, regarded as a tumor-associated antigen. Cancer cells evade immune response with RCAS1 up-regulation, inducing apoptosis to tumor infiltrating lymphocytes. Thyroid cancer incidence is rising and its accurate diagnosis in early stage is targeted. The aim of this study is to access RCAS1 expression in benign and malignant thyroid pathology. Methods: This is a retrospective study of 110 patients, who had thyroidectomy in a single tertiary referral centre between January 2008 until December 2014. Immunohistochemistry study for RCAS1 expression was carried out and correlation with clinical and histopathological data is attempted. Results: RCAS1 immunostaining was found positive in 81 out of 110 cases. Notably it was deemed positive in all malignant thyroid tissue samples (p 0.001). In thyroid malignancy, tumor size, thyroid capsule invasion and positive lymph nodes status were positively correlated with moderate and strong expression of RCAS1. For papillary thyroid carcinoma, the vast majority (35/37 cases, 94.6%) were also classified as having moderate or strong RCAS1 expression. Conclusions: RCAS1 expression can aid in differential diagnosis between benign and malignant thyroid pathology, while its strong expression correlates with worse oncological features.

Comparison of the laparoscopic versus open surgery in patients aged over 75 years old with colorectal cancer. Short- and Mid-term outcomes

PURPOSE

The benefit of minimally invasive surgery in colorectal cancer patients has been established, however it is not clear whether these advantages apply to older patients as well. The aim of this study was to review short- and mid-term outcomes in elderly patients, over the age of 75 years, with colorectal cancer.

METHODS

This was a retrospective study of selected patients over the age of 75 who underwent laparoscopic and open surgery for colorectal cancer between February 2013 and January 2018 in a tertiary referral center. All patients were categorized in two groups: Group 1 included patients who had open procedure (OP) and Group 2 those who underwent laparoscopic procedure (LP). Demographic, clinical, short- and midterm postoperative data were collected and analyzed between the two study groups.

RESULTS

A total of 78 patients were included in our cohort; 39 (50%) were operated with LP. The LP was equally safe in comparison with the OP, considering the similar postoperative complications [9 patients (34.6%) in LP and 5 patients (18.5%) in OP (p=0.224)], including anastomotic leakage in 2 patients (7.7%) in LP and 1 patient (3.7%) in OP group (p=0.61). The median postoperative hospital stay favored the laparoscopic approach (6 days in LP group and 8 days in OP group; p=0.001). The number of harvested lymph nodes were without statistically significant differences [LP group retrieved 20.0 nodes in comparison with 20.5 nodes in OP group (p= 0.816)]. The overall survival analysis showed no difference between the two approaches in 12 and 24 postoperative months (p=0.098 and 0.387, respectively).

Clinical significance of pulmonary nodules in decision-making and management of patients diagnosed with esophageal cancer

In esophageal cancer, metastatic spread to the lungs is detected in 4-9.7% of cases. During staging investigations, 22% of patients have pulmonary nodules detected on cross-sectional imaging. The purpose of this study is to elucidate the clinical importance of these incidentally found pulmonary nodules, in patients with clinically localized esophageal cancer. A retrospective cohort study was conducted from January 2008 to December 2012 in a tertiary esophagogastric referral center. One-hundred and forty-nine patients were included in the study. All patients underwent dedicated staging followed by neoadjuvant chemotherapy and surgery as indicated. Thirty-three (22.1%) patients had pulmonary nodules found in their preoperative staging. Only three (9%) patients proved to develop metastatic pulmonary disease on follow-up. Interestingly, in all three patients, the nodules were negative on initial 18-fluorodeoxyglucose positron emission tomography. Incidentally found pulmonary nodules in newly diagnosed patients with esophageal cancer during staging investigations are rarely metastases. Such nodules, in isolation, should not preclude patients from radical treatment.

Primary adrenal leiomyosarcoma: A case report

Adrenal leiomyosarcomas are rare mesenchymal tumors of the suprarenal region that are usually diagnosed after they have reached a large size. We report the case of a 62-year-old male with an incidentally found left adrenal mass. Magnetic resonance imaging of the retroperitoneal space showed a heterogeneously enhanced mass, measuring 10x8.2 cm, with characteristics suspicious of malignancy. The patient underwent left radical adrenalectomy after the hormonal evaluation of the tumor due to the high probability of adrenocortical carcinoma. However, microscopic examination of the tumor showed a spindle cell sarcoma. Immunohistochemically the neoplastic cells were found positive for desmin and smooth muscle actin and the diagnosis of a well differentiated adrenal leiomyosarcoma was established. During follow-up the patient presented an aggressive course as he developed bone, liver and pulmonary metastases early postoperatively, which were treated with radiation therapy and chemotherapy. The patient has progressive metastatic disease while on chemotherapy 31 months after surgery.

Sudden 'cure' of type two diabetes due to pancreatic insulinoma: A case report

Insulinomas are rare tumors of the islet cells of the pancreas and are the most common cause of endogenous hyperinsulinism. Although they usually present with symptoms of hypoglycemia, sometimes they can have vague symptoms. We present the case of a 62-year-old diabetic female who was diagnosed with a large insulinoma after being investigated for the 'cure' of her diabetes. We also review the literature regarding insulinomas in patients with diabetic. A 62-year-old, obese woman with type 2 diabetes mellitus was initially investigated for an unexplained normalization of her blood glucose levels after the cessation of antidiabetic medication due to an episode of severe hypoglycemia. She remained without antidiabetics for three months maintaining normoglycemia, and thereafter, she started experiencing frequent but less severe hypoglycemic episodes. She did not change her diet habits or level of activity and did not lose any weight. The patient underwent further investigation with a supervised 72 h fasting test, which resulted in the biochemical diagnosis of endogenous hyperinsulinism. Imaging studies revealed the presence of a large insulinoma in the head of the pancreas. Finally, the patient underwent a pylorus preserving Whipple procedure, which reversed the aforementioned 'normalization' of glucose levels and the underlying diabetes mellitus reappeared. Insulinomas are rare tumors causing hypoglycemia. Even more rarely are found in diabetic patients, making the diagnosis more challenging and probably delayed, as the symptoms are masked by the presence of diabetes, thereby leading to a more advanced disease diagnosis.

Pancreatic intraductal papillary mucinous neoplasm masquerading as ampullary adenoma: a diagnostic puzzle

Intraductal papillary mucinous neoplasm (IPMN) is the most common pancreatic cystic lesion, remaining mostly asymptomatic. An atypical presentation of such a lesion, initially thought to be an ampullary adenoma, is presented herein. A 78-year-old white male with painless jaundice was treated in a tertiary hospital. Imaging and endoscopic investigations pointed towards an ampullary adenoma obstructing and causing dilatation of both bile and pancreatic ducts. Endoscopic papillectomy was carried out and histology revealed tubulovillous adenoma. Follow-up duodenoscopy 3 months later showed a recurrent lesion with mucous leaking from the pancreatic duct. Cytology revealed mucin-rich atypical cells, consistent with main-duct IPMN. Pancreatoduodenectomy was performed, finally revealing main-duct IPMN protruding through Vater’s ampulla. Cystic pancreatic lesions are increasingly found and IPMN is the most common of these. On the other hand, the management of ampullary adenomas has been revolutionized by endoscopic treatment and the advent of endoscopic papillectomy, with expanding indications. Meticulous clinical and imaging work up of these patients is essential to avoid suboptimal treatment. IPMN should be included in the differential diagnosis of ampullary adenomas, especially in the presence of a grossly dilated pancreatic duct.

Risk factors for postoperative complications after elective ileocolic resection for Crohn’s disease: a retrospective study

Background

The incidence of postoperative complications (POC) in patients with Crohn’s disease (CD) who undergo intestinal resection is high. The literature provides conflicting data about the risk factors for POC, especially regarding preoperative immunosuppressive medications. The purpose of this study was to evaluate the impact of anti-tumor necrosis factor (TNF) agents on the postoperative course and identify other predictors for POC after ileocolic resection (ICR).

Methods

This was a single-center retrospective study that included 153 CD patients who underwent elective ICR in a Greek tertiary center between January 2010 and December 2018. Risk factors for overall POC and intra-abdominal septic complications (IASC) were assessed with univariate and multivariate analyses.

Results

Overall POC and IASC occurred in 35 (22.9%) and 19 (12.4%) patients, respectively. In multivariate analysis, anti-TNF agents (n=61), as either monotherapy or combination treatment, were not associated with an increased risk for overall POC (21.3% vs. 23.9%, P=0.71) or IASC (13.1% vs. 12.0%, P=0.83). Similarly, no combined immunosuppressive regimen significantly correlated with POC. Patients with perianal disease, disease duration >10 years, or previous intestinal resections had significantly higher rates of both overall POC and IASC. In multivariate analysis, previous resection was the only independent risk factor for overall POC (odds ratio [OR] 3.90, 95% confidence interval [CI] 1.38-11.06; P=0.010) and IASC (OR 4.56, 95%CI 1.51-13.77; P=0.007).

Conclusions

Preoperative administration of anti-TNF agents or other immunosuppressive regimens was not a risk factor for total POC or IASC. A history of previous resection independently correlated with both overall POC and IASC.

Neoadjuvant chemoradiotherapy in rectal cancer and anorectal sphincter dysfunction: Review of the literature

PURPOSE

The purpose of this article was to review the current medical literature regarding deterioration of anorectal function in patients receiving neoadjuvant chemoradiotherapy before surgery for locally advanced rectal cancer.

METHODS

We reviewed the current literature including research studies, electronic database PUBMED-MEDLINE, published research results and metanalysis papers from high-volume institutes, collecting and comparing the different results. Pathophysiology as well as emerging solutions for treating anorectal sphincter dysfunction were researched in order to provide an insight of this complex issue.

RESULTS

All available data suggest that neoadjuvant radiation therapy impairs internal anal sphincter function mostly through nerve damaging mechanisms, as nerves are more susceptible to damage than muscular fibers.

CONCLUSION

Current radiotherapy recommendations are oriented in exclusion of anal canal from radiation field when oncologically safe or using new sphincter-sparing techniques for neoadjuvant radiotherapy aiming to improve the patient quality of life receiving radiation therapy prior to surgery. However, more well designed studies are required to assess the pathophysiology as well as treatment options for this complex matter, which strongly affects the quality of life of rectal cancer patients.

Staged esophagectomy: surgical legacy or a bailout option?

Staged esophagectomy was developed in the mid-twentieth century in an attempt to reduce high rates of postoperative morbidity and mortality. Nowadays, the operation has almost been abandoned due to its significant disadvantages, especially the need for multiple surgeries, inability of patients to feed between operations, and morbidity of esophageal stoma. However, staged esophagectomy is still occasionally useful for very high-risk patients and in particular cases, for example multiple cancers of the aerodigestive tract and emergent esophagectomy. Staged esophagectomy is based on the division of surgical stress into two operations, which gives the patient time to recover before final restoration. Gastric tube ischemic preparation may be a more important mechanism in staged esophagectomy. This approach may survive and expand with the application of ischemic gastric pre-conditioning through embolization or laparoscopic ligation of the gastric arteries, which is a less explored and promising technique.

The Prognostic Role of Pre-operative Positron Emission Tomography-Computed Tomography and Endoscopic Ultrasound Parameters in Oesophageal Adenocarcinoma

Background: To evaluate the prognostic role of Positron Emission Tomography/Computed Tomography (PET/CT) and Endoscopic Ultrasound (EUS) performed before neoadjuvant chemotherapy (NAC) and surgery for oesophageal adenocarcinoma (OAC) patients, focusing on lymph node (LN) assessment. Methods: OAC patients treated in a single tertiary center during January 2008 until December 2014 were retrospectively studied. All patients had PET/CT and EUS before NAC and oesophagectomy. PET-FDG-avid local LNs and maximum standardized uptake value (SUVmax) of the primary tumour, EUS positive LNs and EUS tumour length were recorded. Univariate, multivariate and survival analyses were performed. Results: Following exclusions 151consecutive patients met the inclusion criteria, (median age 62 years). PET/CT and EUS sensitivity for local LNs metastasis was 39.2% and 88.6%, with specificities of 83.33% and 19.15% respectively. No overall survival (OS) difference was found between patients with PET/CT FDG-avid LNs and those with negative LNs (p=0.347). SUVmax uptake was divided into high and low (median cut-off value: 10) with no significant difference in OS between groups (p=0.141). EUS tumour length was not prognostic (OS, p=0.455). Conclusions: Initial LN staging in OA is inaccurate. Although PET/CT and EUS assessments may be complimentary, none independently predicted survival.

Large Paraesophageal Hiatus Hernia: Is Surgery Mandatory?

Purpose/Aim: Paraesophageal hiatus hernias are seldom found, however the incidence is increasing accounting for 5-10% of all hiatal hernias. The aim of this review is to emphasize controversies in clinical presentation, essential workup investigations and highlight non-surgical and surgical management options. Materials and Methods: A PubMed literature search using the keywords "large or giant paraesophageal hernia", "hiatus or hiatal hernia", "laparoscopic surgery", "antireflux surgery", "mesh", "gastric volvulus" and "diaphragmatic hernia" published between 1998 until 2017 was conducted. Results: Presenting symptoms are non-specific and can be erroneously attributed to various more common medical conditions. Significant complications as gastric volvulus and stomach necrosis, may occur and the obscured clinical presentation can be confusing for the clinician. Management options in the elective setting are controversial, and surgical repair cannot be easily justified for a minimally symptomatic condition, especially in an elderly and perhaps frail patient. However, in the era of laparoscopic surgery around the hiatus, reduced operative stress makes surgical repair appealing in the elective setting. Surgical matters as the adjunct of an antireflux procedure or not, the use of prosthetic mesh to reinforce the hiatus, gastropexy and the clinical importance of radiological or endoscopic recurrence are still under debate. Conclusions: The laparoscopic treatment of paraesophageal hiatus hernias is effective with low morbidity rates, offered in symptomatic patients and good operative risk asymptomatic individuals. More studies are needed to assess improvement suggestions, as the use of prosthetic mesh or gastropexy, regarding complications and recurrence risks.

Correlation Between Contrast-enhanced Ultrasound Characteristics (Qualitative and Quantitative) and Pathological Prognostic Factors in Breast Cancer

BACKGROUND/AIM

Little is known about the correlation between contrast-enhanced ultrasound (CEUS) characteristics and pathological prognostic factors in breast cancer. The aim of this study was to explore the correlation between CEUS characteristics and pathological prognostic factors.

PATIENTS AND METHODS

A retrospective study with 34 malignant breast lesions was conducted. CEUS characteristics included qualitative characteristics (e.g. lesion's enhancement degree and order, internal lesion homogeneity etc.) and quantitative characteristics (e.g. peak intensity, time to peak etc.). Also, pathological prognostic factors were included (e.g. tumor grade, estrogen receptor status etc.).

RESULTS

Blurred lesion margins were observed more often in tumors of high histological grade (p=0.01) and in estrogen receptor-negative tumors (p=0.049). Furthermore, perilesional enhancement was associated with positive Ki-67 expression (p=0.049), while heterogeneous internal sentinel lymph node enhancement was associated with malignant infiltration of the node (p=0.002).

CONCLUSION

CEUS has the potential to provide a prevision of pathological prognostic factors in malignant breast lesions, helping in the better early patient management.

Pelvic Exenteration Put into Therapeutical and Palliative Perspective: It Is Worth to Try

Pelvic exenteration (PE) is one of the most drastic operations in surgical oncology, associated with severe morbidity and mortality. The objective of our study was to review our experience of PE in terms of surgical characteristics, complications, and overall survival. All patients who had PE surgery between January 1999 and December 2015 were identified. Patients with verified distant metastatic disease were excluded. Patients with advanced pelvic tumors experiencing incapacitating postradiation severe damages were included. The following parameters were recorded: age, sex, indication for surgery, tumor histology, type of exenteration, urinary tract and colon reconstruction methods, operative time, blood transfusion, intensive care unit admissions, length of hospital stay and readmissions, and characteristics of perioperative morbidity and mortality. A total of 25 patients were submitted to PE by our surgical team. Most of the patients suffered from cervical cancer followed by bowel cancer. There was no perioperative mortality. Early postoperative complications ensued in 56% of the patients. Most complications involved the urinary system. Five years survival was estimated at 38%. Most patients (n = 9, 36%) died due to their primary disease, 5 (20%) died because of complications following operation, and 2 (8%) died because they denied oral feeding, which was associated with depression. Patients with a variety of malignancies can benefit from PE. Meticulous surgical technique, perioperative care, counseling, and nutritional support play an important role.

A comparison of the left thoracoabdominal and Ivor-Lewis esophagectomy

The purpose of this study was to assess the oncological outcomes of a large multicenter series of left thoracoabdominal esophagectomies, and compare these to the more widely utilized Ivor-Lewis esophagectomy. With ethics approval and an established study protocol, anonymized data from five centers were merged into a structured database. The study exposure was operative approach (ILE or LTE). The primary outcome measure was time to death. Secondary outcome measures included time to tumor recurrence, positive surgical resection margins, lymph node yield, postoperative death, and hospital length of stay. Cox proportional hazards models provided hazard ratios (HR) with 95% confidence intervals (CI) adjusting for age, pathological tumor stage, tumor grade, lymphovascular invasion, and neoadjuvant treatment. Among 1228 patients (598 ILE; 630 LTE), most (86%) had adenocarcinoma (AC) and were male (81%). Comparing ILE and LTE for AC patients, no difference was seen in terms of time to death (HR 0.904 95%CI 0.749-1.1090) or time to recurrence (HR 0.973 95%CI 0.768-1.232). The risk of a positive resection margin was also similar (OR 1.022 95%CI 0.731-1.429). Median lymph node yield did not differ between approaches (LTE 21; ILE 21; P = 0.426). In-hospital mortality was 2.4%, significantly lower in the LTE group (LTE 1.3%; ILE 3.6%; P = 0.004). Median hospital stay was 11 days in the LTE group and 14 days in the ILE group (P < 0.0001). In conclusion, this is the largest series of left thoracoabdominal esophagectomies to be submitted for publication and the only one to compare two different transthoracic esophagectomy strategies. It demonstrates oncological equivalence between operative approaches but possible short- term advantages to the left thoracoabdominal esophagectomy.

The Role of TAMIS (Transanal Minimally Invasive Surgery) in the Management of Advanced Rectal Cancer - One Shared Story of Three Exceptional Cases

Purpose of the study: The current gold standard for contemporary treatment of rectal cancer is total mesorectal excision (TME), achieving excellent local disease control and low recurrence rates. However, TME may be associated with postoperative mortality and quality of life deterioration. Therefore, the need to develop less radical treatment strategies has emerged. Transanal minimally invasive surgery (TAMIS) is currently indicated only for early rectal cancer. However, local excision following chemoradiation has yielded promising clinical outcomes in selected cases with more advanced disease. Materials and methods: We describe three cases of patients with advanced rectal cancer, who were managed with TAMIS, either due to patients' unwillingness to tolerate permanent colostomy or due to significant comorbidities. Results: Two of the three patients who also received adjuvant chemoradiation are still in remission for 18 and 15 months respectively. The third patient died early after hospital release due to unrelated causes. Conclusions: Local excision utilizing minimally invasive techniques, alongside with chemoradiotherapy and close follow up can be a viable alternative in carefully selected rectal cancer patients with advanced disease who deny permanent colostomy or are ineligible for major operations.

Minimal surgical management of penile paraffinoma after subcutaneous penile paraffin injection

Objectives

To describe our reconstructive technique, without flap or graft use, after penile self-augmentation with injected substances, such as paraffin, which are still performed with unfortunate consequences.

Patient and methods

Successful single-stage minimal surgical management of an already twice unsuccessfully managed ulcerative penile paraffinoma in a 38-year-old Greek man.

Results

The patient was discharged with no postoperative complications, with a five-item version of the International Index of Erectile Function score of 23/25 (i.e. normal erectile function) and flaccid penile length of 5 cm.

Conclusions

Penile paraffinoma is a serious complication that can be successfully managed with a single-stage minimal surgical procedure, with normal aesthetic and functional results.

Incarcerated giant uterine leiomyoma within an incisional hernia: a case report

Uterine leiomyomas presenting as incarcerated or strangulated hernias in surgical emergencies are extremely rare and should be considered in the differential diagnosis in patients with known uterine fibroids and an irreducible ventral abdominal wall hernia. Detailed history and multidisciplinary approach optimize the diagnosis and decision making toward surgical treatment.

Risk factors for postoperative recurrence of Crohn's disease with emphasis on surgical predictors

Intestinal resection for Crohn’s disease is not curative and postoperative recurrence rates remain high. Early detection of indices associated with recurrence and risk stratification are fundamental for the postoperative management of patients. Early endoscopy at 6-12 months is the “gold standard” procedure, whereas other modalities such as fecal calprotectin and imaging techniques can contribute to the diagnosis of recurrence. The purpose of this review is to summarize current data regarding risk factors correlated with postoperative relapse. Smoking is a well-established, modifiable risk factor. There are sufficient data that correlate penetrating disease, perianal involvement, extensive resections, prior surgery, histological features (plexitis and granulomas), and improper management after resection with high rates for recurrence. The literature provides conflicting data for other possible predictors, such as age, sex, family history of inflammatory bowel disease, location of disease, strictureplasties, blood transfusions, and postoperative complications, necessitating further evidence. On the other hand, surgical factors such as anastomotic configuration, open or laparoscopic approach, and microscopic disease at specimen margins when macroscopic disease is resected, seem not to be related with an increased risk of recurrence. Further recognition of histological features as well as gene-related factors are promising fields for research.

Technical Intraoperative Maneuvers for the Management of Inferior Vena Cava Thrombus in Renal Cell Carcinoma

Introduction

Renal vein or inferior vena cava (IVC) invasion by neoplastic thrombus in patients with renal cell carcinoma (RCC) is not an obstacle for radical oncological treatment. The aim of this study is to present our technical maneuvers for complete removal of the intracaval thrombus without compromising hemodymanic stability of the patient.

Materials and methods

Between 2000 and 2014, 15 RCC patients with IVC involvement of levels I–III were treated with curative intent and were prospectively studied. The operative technique varied according to thrombus extent. For type I, extraction of the thrombus is facilitated by a 2–3 cm longitudinal incision on the IVC that begins at the level of the renal vein and extends cranially, encompassing a vessel wall rim of the orifice of the resected renal vein. For type II cases, the IVC is clamped above the neoplastic thrombus, and for type III, the IVC clamping is combined with hepatic blood flow control with “Pringle maneuver.” For type IV, the IVC is clamped above the diaphragm, or if the thrombus extends into the right atrium cardiothoracic input is appropriate.

Results

The main operative steps include preparation and control of the renal vessels and the IVC. Occasionally, for type III tumor thrombi, the patient becomes hemodynamically unstable when IVC is clamped suprahepatically. In such a case, a novel operative maneuver of milking the thrombus below the orifice of the hepatic veins, and subsequently the IVC clamp also beneath the hepatic veins, allowing release of the “Pringle maneuver” is performed. This operative step restores hepatic blood flow and hemodynamic stability and is based on the floating nature of the thrombus into the IVC. Mean operative time was 120 min (range from 90 to 180 min), and average liver and renal warm ischemia time was 20 min (range from 15 to 35 min). Postoperative overall hospital stay ranged from 7 to 13 days.

Conclusion

The technical solutions employed in the current study allow successful removal of neoplastic thrombi from the IVC in most cases, associated with minimal perioperative complication rate even for patients who due to multiple comorbidities would be considered otherwise inoperable.

Parotid Gland Lipoma: An Unusual Entity

The occurrence of lipomas in the parotid gland is extremely rare, and impossible to differentiate clinically. A case of this bizarre entity is reported herein, which was treated successfully with superficial parotidectomy. A 57-year-old man with a well-circumscribed, rubbery mass, probably arising from the right parotid gland was investigated in our hospital initially with ultrasound scan, and finally with MRI-scan. Both imaging modalities implied a benign lipomatous tumor and the patient underwent an uneventful superficial parotidectomy. Although adipose tissue is a natural component of parotid glands, lipomas arising in the gland are very unusual. The entity'™s incidence is about 1% (0.6-4.4%) of parotid gland mass lesions and history of previous trauma in the area is the most common pathophysiological mechanism described. Tomographic imaging modalities are very accurate in preoperative diagnosis and cosmetic appearance is the usual indication for surgical intervention. Any particular symptoms jeopardize clinically the diagnosis of parotid lipoma. As always, surgical excision should respect the facial nerve and branches.

Contrast-Enhanced Color Doppler Ultrasonography for Preoperative Evaluation of Sentinel Lymph Node in Breast Cancer Patients

BACKGROUND

Sentinel lymph node (SLN) biopsy is the standard of care for breast cancer patients with non-palpable axillary lymph nodes. We evaluated the usefulness of contrast-enhanced ultrasonography in preoperative detection of malignant SLNs.

METHODS

50 patients with breast cancer (median age: 60 years) underwent a color power Doppler ultrasonography with intravenous contrast (Sonovue®) preoperatively, and findings suggestive of metastatic disease to the SLN were documented. The final histopathological report and the radiological preoperative record were compared. Finally, the sensitivity, specificity and diagnostic accuracy of this evolving diagnostic modality were calculated.

RESULTS

Contrast-enhanced ultrasound scan identified a negative SLN in the axilla of 27 patients and final histopathology was negative for 30 cases in total, so negative predictive value was calculated as 90% and positive predictive value was 75%. Overall sensitivity was 83.33% and specificity was 84.38%. Moreover, the ability of contrast-enhanced ultrasound to differentiate between SLN status was only statistically significantly correlated with the actual final histopathological report (p < 0.001), while successful ultrasound prediction was not correlated with any factor.

CONCLUSIONS

SLN status can be evaluated preoperatively using contrast-enhanced color Doppler ultrasonography with high accuracy.

Collision tumor of the appendix: mucinous cystadenoma and carcinoid. A case report

INTRODUCTION

Mucinous cystadenoma is the most common of benign neoplasms of the appendix and carcinoid is the most common type of primary malignant lesions of the appendix.We report a rare case of a 57-year-old female with combined mucinous cystadenoma and carcinoid tumor of the appendix.Dual carcinoid and epithelial neoplasia is a rare occurrence in the appendix.

CASE REPORT

A 57-year-old Caucasian woman presented after incidentally palpating a mass on her right iliac fossa. Imaging modalities revealed a cystic tumor in the right iliac fossa with a diameter of about 8 cm, originating either from the right ovary or the appendix. She underwent laparoscopic surgical exploration, which revealed appendiceal mucocele and appendicectomy was finally performed as well as excision of a right ovarian cyst. Pathological examination showed acollision tumor consisting of mucinous cystadenoma and carcinoid tumor of the appendix. Because of the size and extension of the carcinoid tumor, which the pathology report revealed, she underwent re-exploration and laparoscopic right colectomy.

DISCUSSION

Mucinous cystadenoma is rare, but it is the commonest of benign appendiceal tumours accounting for 0.6% of appendectomy specimens. It can present as appendicitis,mucocele or if the tumour ruptures, as pseudomyxomaperitonei. On the other hand, carcinoid is the most common type of primary malignant lesion of the appendix and 0.3-0.9%of appendectomy specimens, with small predominance in female patients. Rare cases of mucinous cystadenomas of the appendix coexisting with carcinoid tumors were reported before, but in our case it was a collision tumor with no transitional zone between them. Also, the clinical presentation of our patient and the differential diagnosis of ovarian lesions from appendiceal tumors is worth being mentioned.

Synchronous cytomegalovirus and Clostridium difficile infection of the pouch: a trigger for chronic pouchitis?

Pouchitis occurs in up to one half of patients after restorative proctocolectomy with ileal pouch-anal anastomosis (IPAA). Cytomegalovirus (CMV) and Clostridium difficile are among the commonest secondary identifiable etiologies. A 17-year-old male with ulcerative colitis underwent IPAA due to refractory disease. Nine months later he experienced bloody diarrhea and fever. Laboratory testing and endoscopy confirmed pouch inflammation. Testing for C. difficile toxins A and B was positive. Histology revealed affluent inclusion bodies and immunohistochemistry detected reactivity against CMV protein. Treatment with metronidazole and vancomycin offered partial improvement, whereas the addition of gancyclovir led to a successful recovery. One month after completion of treatment symptoms recurred. Repeat testing precluded an identifiable infectious cause and the diagnosis of idiopathic chronic pouchitis was established. The patient is currently on maintenance treatment with the probiotic compound VSL#3.

Clinicopathological features and management of hepatic vascular tumors. A 20-year experience in a Greek University Hospital

PURPOSE

The aim of this study was to review the clinical features, diagnostic modalities, treatment options and pathological characteristics of various types of hepatic vascular tumors treated in our Institution over the last 20 years.

METHODS

From 1991 to 2011, 761 cases of various hepatic lesions, benign and malignant, were surgically treated in our hospital. Among these, 56 (7.35%) hepatectomy specimens referred to vascular tumors. The records of these patients were retrieved and demographics , tumor characteristics, treatment, and actuarial survival were analyzed. The various therapeutic procedures, postoperative complications, follow-up data and the pre-and postoperative diagnostic difficulties were registered and analyzed.

RESULTS

Pathological examination showed: hepatic hemangiomas in 35 (62.5%) patients (80% females), hepatic angiosarcomas in 7 patients (12.5%; males 71.4%), hepatic epithelioid hemangioendotheliomas in 9 (16%; females 50%) and hepatic angiomyolipomas in 5 patients (9%; females 60%).

CONCLUSIONS

Vascular tumors of the liver comprise a heterogeneous group of neoplasms, benign, malignant and of intermediate degree of malignant behavior. These lesions can create great diagnostic difficulties, pre- and postoperative considerations, but the correct pathological diagnosis and classification of vascular hepatic tumors are most of the times mandatory in order to choose the proper therapeutic actions.

Multifocal retroperitoneal sarcoma

Introduction. Retroperitoneal sarcomas comprise a small proportion of all soft tissue sarcomas, and multiple factors influence their clinical behavior. Histopathological type and grade as well as complete surgical resection especially on the first operative attempt are well recognized as the main prognostic factors. Multifocality is another prognostic factor, which compromises therapy and finally makes prognosis worse due to multiple adverse implications. Case Presentation. A rare case of a 65-year-old male patient suffering from a multifocal retroperitoneal liposarcoma successfully treated in our hospital is presented herein. Discussion. Also, general considerations for these tumors are discussed, and especially multifocality is underlined as an ominous sign of retroperitoneal sarcomas behavior. Despite multifocality, once again complete surgical excision remains the mainstay of treatment of these patients, as long as further systemic and local therapies do not provide durable results.

Rare non-epithelial primary breast neoplasms: a ten-year experience at a Greek University Hospital

PURPOSE

Non-epithelial breast neoplasms cover a large spectrum of histopathological entities. The demographics and clinical features are similar to epithelial breast lesions but the diagnosis, prognosis and management options are often very different.

METHODS

During 2001-2010, 1362 patients were examined at the Pathology Department of the Aretaieion General Hospital for various breast lesions. All specimens were processed routinely and slides stained with hematoxylin-eosin were re-examined. The patient clinical records were examined for demographics, clinical presentation and therapeutic approach.

RESULTS

In 23/1362 cases (1.68%) pathological examination showed non-epithelial lesions: in 12/1362 cases (0.8%) haemangiomas (11 women, one man), in 4 /1362 cases (0.3%) myofibroblastomas (MFB), in 2/1362 cases (0.1%) primary breast non-Hodgkin's lymphoma (NHL), in 3 /1362 cases (0.2%) granular cell tumor (GCT), and in 2/1362 cases (0.1%) angiosarcomas (one developed after radiotherapy for breast cancer).

CONCLUSIONS

Non-epithelial primary breast tumors are rare (1.68%) and present significant difficulty in accurate preoperative diagnosis and in certain cases in pathological diagnosis as well, which is necessary for the selection of the appropriate treatment. Avoidance of inappropriate therapies requires a multidisciplinary management approach.

Clinicopathological Characteristics of Four Cases of Adrenal Myelolipomas: A Rare Surgical Entity

Myelolipomas are unusual benign tumors or tumor-like lesions, composed of hematopoietic cells and mature adipose tissue. They usually are asymptomatic and behave as non-functioning, unilateral, small adrenal tumors often found incidentally on imaging studies. We report the clinicopathological characteristics of four cases of adrenal myelolipomas treated in our hospital, worth to mention because of their rarity and their significant size. Myelolipomas were first described by Gierke in 1905, and the term myelolipoma was coined by Oberling in 1929. The adrenal gland is the most common site, but myelolipomas are also rarely present in extra-adrenal sites, including the pelvis, mediastinum, retroperitoneum, and paravertebral region, as an isolated soft tissue mass. These tumors account for 2.6% of the primary adrenal masses with equal sex distribution and in our reviewed material of a decade they constitute about 5% in a series of surgically treated adrenals for various neoplastic processes of the adrenals. Although usually small in size, in our series a remarkable large size of the tumors examined was observed, ranging from 7 - 15 cm. Adrenal myelolipoma is often an “incidentaloma”, since its diagnosis is frequently based on autoptic findings or made during surgical interventions and imaging procedures performed for other purposes, as happened in our cases.

Two cases of primary splenic hydatid cyst in Greece

Cystic disease of the spleen is an uncommon entity in general population. Most cases result from parasitic infection by Echinococcus granulosus, a form called splenic hydatid disease (SHD), with a reported frequency of 0.5-6.0% within abdominal hydatidosis. On the contrary, an isolated splenic involvement of hydatid disease is very uncommon even in endemic regions. Two cases of primary SHD managed with open and laparoscopic radical surgery in our department are reported herein. Primary SHD is a rare entity with non-specific symptoms underlying clinical suspicion by the physician for prompt diagnosis. Surgical treatment is the mainstay therapy, while laparoscopic approach when feasible is safe, offering the advantages of laparoscopic surgery.

Peritoneal mesotheliomas mimicking adnexal tumors. Clinicopathological characteristics of four cases and a short literature review

Three cases of peritoneal benign cystic mesotheliomas in women 32-34 years of age and one case of peritoneal malignant mesothelioma in a 47-year-old woman are reported. All cases presented with abdominal discomfort and/or pain and the physical and radiological diagnostic methods showed adnexal tumors. The cystic mesotheliomas developed in the cul-de-sac and the right pelvic sidewall, presented as multiple small cysts or large multilocular cystic mass. The malignant mesothelioma showed extensive infiltration of the omentum the intestinal loops and the surface of the uterus and adnexa, with bilateral hydrosalpinx and ascites. All cases presented histological and immunohistochemical characteristics consistent with tumors of mesothelial origin. No history of asbestos exposure was reported. The correct diagnostic and therapeutic approaches to these neoplasms are discussed.

Ovarian vein thrombosis mimicking acute abdomen: a case report and literature review

Background

Ovarian vein thrombosis (OVT) is a rare, but serious condition that affects mostly postpartum women. A high index of suspicion is required in order to diagnose this unusual cause of abdominal pain.

Case presentation

A 19-year-old woman at three days postpartum was admitted to our hospital because of severe right lower quandrant abdominal pain and fever 38.5'C. Physical examination revealed an acutely ill patient and right lower quadrant tenderness with positive rebound and Giordano signs. The patient underwent appendectomy which proved to be negative for acute appendicitis. Postoperatively fever and pain persisted and abdominal CT-scan with intravenous contrast agent demonstrated a thrombosed right ovarian vein. The patient was initiated on low-molecular weight heparin (LMWH) and antibiotic treatment and a month later a new abdominal CT-scan showed a patent right ovarian vein.

Discussion

Pathophysiologically, OVT is explained by Virchow's triad, because pregnancy is associated with a hypercoagulable state, venous stasis due to compression of the inferior vena cava by the uterus and endothelial trauma during delivery or from local inflammation. Common symptoms and signs of OVT include lower abdomen or flank pain, fever and leukocytosis usually within the first ten days after delivery. The reported incidence of OVT ranges 0,05-0,18% of pregnancies and in most cases the right ovarian vein is the one affected. Anticoagulation and antibiotics is the mainstay of treatment of OVT. Complications of OVT include sepsis, extension of the thrombus to the inferior vena cava and renal veins, and pulmonary embolism. The incidence of pulmonary embolism is reported to be 13.2% and represents the main source of mortality due to OVT.

Conclusions

OVT is a rare condition, usually in the postpartum period. A high index of suspicion is required for the prompt diagnosis and management especially in cases that mimic acute abdomen.

Arteriovenous malformation: An unusual cause of rectus sheath hematoma, following laparoscopic cholecystectomy

Rectus sheath hematoma (RSH) is an accumulation of blood in the rectus abdominis muscle sheath, secondary to several conditions which may cause the epigastric vessel rupture or muscular tear, but mostly affecting patients undergoing anticoagulation therapy.We present a rare case of a 67-year-old woman who underwent laparoscopic cholecystectomy and developed RSH on the 12th postoperative day. The patient was under anticoagulation therapy with acenocoumarole due to mitral valve replacement. The bleeding source was an arteriovenous malformation (AVM) rupture as indicated by the angiogram images and it was embolized succefully. The patient was discharged seven days later.

Parathyroid autotransplantation in extensive head and neck resections: case series report

Permanent or temporary hypoparathyroidism may be a debilitating result of radical cervical surgery, as noted most commonly following thyroid or parathyroid surgery. However, it can also be the outcome of any surgical procedure involving bilateral extensive manipulation of the anterior neck triangle, especially in order to ensure oncologically adequate surgical margins.

We report our experience of three patients that underwent parathyroid immediate autotransplanation following extensive surgical manipulations of the neck region for oncological reasons. PTH levels were restored to normal by the fourth postoperative week, allowing us to wean the patients off calcium and vitamin D₃ supplementation, which was attributed to full autograft function. Parathyroid autotransplantation, immediate or delayed, is a simple and safe technique which should be considered by the surgeon whenever there is a high risk for postoperative hypoparathyroidism following radical operations of the neck for oncological reasons.

Synchronous gastric adenocarcinoma and gastrointestinal stromal tumor (GIST) of the stomach: a case report

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract (1%), and stomach is the most common location involved. However, the co-existence of gastric adenocarcinoma and GIST is very rare. A case of an 80-year-old male with a simultaneous presentation of a gastric adenocarcinoma and GIST is presented. Various hypotheses have been proposed in order to explain this rare simultaneous development, but even though it's cause has not been proven yet.

Concurrent insulinoma and pancreatic adenocarcinoma: report of a rare case and review of the literature

Pancreatic adenocarcinoma is the 5th leading cause of cancer-related death in Western countries and insulinomas are rare endocrine neoplasms of the pancreas. The concurrent appearance of pancreatic adenocarcinoma and insulinoma is very rare and to the best of our knowledge has never been reported again. Herein, we present such an occurrence in a 74-year-old man. Resection of a mass in the uncinate process of the pancreas revealed pancreatic adenocarcinoma with severe desmoplastic reaction. Two years later, due to symptomatology persistence the patient was re-examined and a new 2cm mass in the uncinate process was found leading to surgery, which demonstrated a 2cm endocrine islet-cell tumor. Establishing a diagnosis in patients with insulinoma is difficult and the imaging studies still have low sensitivity and specificity except for intra-operative ultrasonography, which is the most accurate method detecting 90% of these lesions.