Treatment of peritoneal surface malignancies with hyperthermic intraperitoneal chemotherapy-current perspectives

Peritoneal carcinomatosis (ptc) represents advanced malignant disease and has generally been associated with a grim prognosis. Peritoneal surface malignancy is often the major source of morbidity and mortality; it is of major concern in cancer management. Although ptc is categorized as metastatic disease, it represents a special disease pattern considered to be a locoregional disease limited to the abdominal cavity. The combination of cytoreductive surgery (crs) and intraoperative hyperthermic intraperitoneal chemotherapy (hipec) has successfully been used as locoregional treatment for selected patients with ptc from gastric, colorectal, and ovarian cancer; with mesothelioma; and with pseudomyxoma peritonei. In the prophylactic setting, hipec can also be used to prevent ptc in high-risk patients, and the first results of the "second-look" approach are promising. Patient selection-in which the risks of perioperative morbidity and mortality, which are analogous to those for any other major gastrointestinal surgery, are assessed-is of utmost importance. Those risks have to be weighed against the anticipated survival benefit, which depends mainly on tumour biology, extent of disease, and probability of achieving complete crs. The present review discusses the principles of crs and hipec, the most significant recent clinical data, and current perspectives concerning the application of this treatment modality in various malignancies. Ongoing trials and future directions are noted. It appears that the combination of crs and hipec is an indispensable tool in the oncologist's armamentarium.

Adipose tissue fatty acids in breast cancer patients versus healthy control women from Crete

BACKGROUND

Few studies have implemented biomarkers of fatty acid intake in relation to breast cancer.

AIMS

To examine possible differences in adipose tissue fatty acid composition between breast cancer patients and healthy control women. The relationship between tumor promotion and adipose tissue fatty acid synthesis was also investigated.

METHODS

The study was conducted at the University of Crete. Subjects included 94 women with clinically diagnosed cancer of the breast and 131 healthy control women. Histological tumor grading and breast cancer staging were assessed. Fatty acids were determined by gas chromatography in gluteal adipose tissue.

RESULTS

Conditional logistic regression analysis controlling for potential confounders indicated that elevated adipose monounsaturated fatty acids and oleic acid are associated with reduced odds of breast cancer [OR (T2 vs. T1) 0.15; 95% CI 0.03-0.64, and OR (T2 vs. T1) 0.18; 95% CI 0.04-0.71, respectively]. Adipose myristic acid was associated with an increase in breast cancer risk [OR (T3 vs. T1) 5.66; 95% CI 1.3-23.9].

CONCLUSIONS

Adipose oleic acid is inversely related, whereas adipose myristic acid is positively related to breast cancer risk. These relations could be mediated by Her-2/neu and FAS oncogenes.

Intraperitoneal chemotherapy with taxanes for ovarian cancer with peritoneal dissemination

Paclitaxel and docetaxel are currently the two clinically available taxanes. The combination of a taxane and a platinum compound has become the systemic chemotherapy of choice for primary ovarian cancer. Despite the high activity of these drugs in systemic chemotherapy, the majority of patients with advanced ovarian cancer will develop recurrent disease and ultimately decease of this disease. Therefore, more effective systemic chemotherapy regimens or alternative treatment modalities are warranted. Intraperitoneal chemotherapy is such an alternative treatment option. Pharmacokinetic studies on intraperitoneal administration of paclitaxel and docetaxel demonstrated very high locoregional drug concentrations and exposure. Their activity and response seem to be dose-dependent and hence higher efficacy with limited systemic toxicity is to be expected. Intraperitoneal chemotherapy may be combined intraoperatively with hyperthermia, which enhances tissue penetration and cytotoxic activity of many drugs. The data concerning thermal enhancement of taxanes are inconsistent, but at the high locoregional concentrations provided by intraperitoneal drug administration such a thermal enhancement seems to exist. Clinical studies have clearly demonstrated the feasibility and efficacy of intraperitoneal instillation chemotherapy with taxanes in patients with ovarian cancer. Preliminary results of a phase III study demonstrated improved outcome with the addition of intraperitoneal instillation chemotherapy to systemic chemotherapy after optimal primary cytoreductive surgery. Intraoperative hyperthermic intraperitoneal chemotherapy with docetaxel has been performed in a single study, in which promising results were observed. Further clinical investigations with an adequate follow-up period are needed to confirm the promising initial results and to determine the exact efficacy of intraperitoneal chemotherapy with these drugs.

Preoperative computed tomography and selection of patients with colorectal peritoneal carcinomatosis for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

AIM

A survival benefit has been observed for colorectal cancer patients with peritoneal carcinomatosis treated by cytoreductive surgery with intraoperative hyperthermic intraperitoneal chemotherapy (HIPEC). However, this treatment modality is associated with a considerable morbidity and mortality and in a significant number of patients survival is not improved. We studied whether poor survivors could be identified on preoperative computed tomography (CT), in order to avoid unnecessary surgery.

PATIENTS AND METHODS

Films of abdominopelvic CT scans from 25 such patients treated by cytoreductive surgery and HIPEC were retrospectively analysed by two radiologists separately. A simplified peritoneal cancer index (SPCI) was used to determine the extent of peritoneal involvement. Correlation between the on preoperative CT based SPCI-scores as well as number of involved abdominopelvic areas (N) and survival was examined with the log-rank test. The relation between each affected region and survival was evaluated with Cox regression analysis.

RESULTS

The preoperative SPCI- and N-scores of one of the radiologists had no statistically significant prognostic value, while for the second radiologist SPCI > or = 7 and N > or = 4 were associated with particularly poor outcome. Additionally, the presence of ileocaecal region involvement and, depending on the radiologist, the occurrence of tumour deposits in the left subdiaphragmatic area on CT appeared to be unfavourable prognostic signs.

CONCLUSIONS

The prognostic value of preoperative conventional CT appeared to be radiologist dependent and may, therefore, be of limited value in selecting colorectal cancer patients with peritoneal carcinomatosis who will not benefit from extensive cytoreductive surgery followed by HIPEC.

Treatment of advanced malignant eccrine poroma with locoregional chemotherapy

Malignant eccrine poroma is a rare disease with approximately 200 cases reported in the literature. Regional cutaneous and systemic metastases are rarely observed and their management has been generally unsuccessful. We report on a case in which topical 5-fluorouracil application and intra-arterial chemotherapy with docetaxel resulted in a histologically confirmed complete response of multiple regional skin metastases for more than 2 years. Despite intravenous administration of docetaxel, slow progression of systemic disease was observed.

Pylorus-preserving pancreaticoduodenectomy with external pancreatic remnant drainage

BACKGROUND

Pancreaticoduodenectomy is the mainstay of surgical treatment for various benign and malignant diseases of the head of the pancreas and the periampullar region. The incidence of postoperative morbidity remains significantly high. Various modifications have been advocated for the restoration of the digestive continuity and drainage of bile and pancreatic ducts in order to diminish this high morbidity rate.

METHODS

A new modification with the combination of an end-to-end duodenojejunal anastomosis and creation of an external pancreatic fistula following pylorus-preserving pancreaticoduodenectomy is described. Our initial experience with this modification in seven patients is reported and its advantages are discussed.

RESULTS

There was no mortality, while morbidity was 29%, including postoperative pneumonia and psychosis in one patient, and intra-abdominal abscess in another patient. No significantly delayed gastric emptying was observed and no patient developed diabetes, anastomotic ulcer or reflux cholangitis postoperatively.

CONCLUSIONS

The reported technique seems to be a safe modification of restoration after pancreaticoduodenectomy, with maintenance of anatomical gastrointestinal continuity, avoidance of complications from anastomosis with the pancreatic remnant, as well as maintenance of endocrine pancreatic function. However, long-term follow-up and larger comparative studies are needed to evaluate the impact of this modification on morbidity and mortality, including long-term nutritional complications.

Experience with benign splenic disease

PURPOSE

In the ongoing effort to improve patient treatment, a deeper understanding of the symptomatology, physical signs and management options of rare splenic, non-traumatic, benign diseases is extremely important.

PATIENTS AND METHODS

The records of eight consecutive patients with benign splenic conditions, other than injury and abscess, were reviewed retrospectively in order to analyse the clinical presentation, diagnostic methodology and therapeutic procedures applied in these rare conditions. Of the eight patients, three were diagnosed with splenic hydatid cyst, two with pseudocysts, one with splenic epidermoid cyst, one with wandering spleen and one with infraction of an ectopic spleen with situs inversus of other intra-abdominal organs.

RESULTS

Upper abdominal pain was the most common presenting symptom and a tender palpable mass in the left upper abdominal quadrant, the predominant clinical finding. Pre-operative CT scanning confirmed the diagnosis in six patients, but failed to reveal the splenic pathology in the remaining two cases. Seven patients underwent splenectomy while saving splenic parenchyma was feasible in only one patient (12,5%).

CONCLUSIONS

Splenic, non-traumatic, benign diseases have vague clinical presentation and may create diagnostic difficulties. Although spleen saving intervention can be applied in selected cases, splenectomy would be required in most patients.

Gastric carcinoid in a young woman with systemic lupus erythematosus and atrophic autoimmune gastritis

BACKGROUND

Gastric carcinoid is a rare tumour that is associated with chronic atrophic gastritis in the majority of cases. It usually occurs in the 6th or 7th decade of life and is rarely diagnosed in patients under 30 years of age.

METHODS

We describe a case of multiple gastric carcinoids in a 23-year-old woman with systemic lupus erythematosus and atrophic autoimmune gastritis--an association that has not been reported previously.

RESULTS

The combination of atrophic autoimmune gastritis and gastric carcinoid with other autoimmune disorders has rarely been reported in the English medical literature.

CONCLUSION

The fact that it mostly concerns (relatively) young patients may suggest a potential causative relation between those autoimmune disorders and the early development of atrophic gastritis with hypergastrinaemia, which subsequently leads to the occurrence of gastric carcinoid tumours at a young age.

Axillary lymphadenectomy for breast cancer - the influence of shoulder mobilisation on lymphatic drainage

AIM

The purpose of the present study was to study the influence of external axillary compression dressing with immobilisation of the ipsilateral shoulder after axillary lymph node dissection (ALND) on postoperative axillary drainage.

METHODS

One hundred consecutive women with breast cancer undergoing ALND were enrolled in this study. They were allowed free shoulder movement and were compared with a matched historical control group of 60 patients, in whom the ipsilateral arm was immobilised for four days. For all patients the amount of drainage was recorded each postoperative day until drain removal. Prognostic data on drainage amounts and duration were gathered from all patients. Complications were recorded.

RESULTS

Hospital stay was the only statistically significant difference between the two groups, it was prolonged for patients with immobilisation of the arm. The parameters found to influence the drain production with a statistically significant difference were body mass index and the removal of more than 10 lymph nodes. Postoperative complications were similar in both groups.

CONCLUSIONS

External compression dressing of the axillary cavity with immobilisation of the ipsilateral arm has no impact on the postoperative drainage volume and duration. It is associated with adverse effects, such as discomfort, prolonged hospital stay and shoulder stiffness.

Gastric Carcinoid in a Young Woman with Systemic Lupus Erythematosus and Atrophic Autoimmune Gastritis

BACKGROUND

Gastric carcinoid is a rare tumour that is associated with chronic atrophic gastritis in the majority of cases. It usually occurs in the 6th or 7th decade of life and is rarely diagnosed in patients under 30 years of age.

METHODS

We describe a case of multiple gastric carcinoids in a 23-year-old woman with systemic lupus erythematosus and atrophic autoimmune gastritis--an association that has not been reported previously.

RESULTS

The combination of atrophic autoimmune gastritis and gastric carcinoid with other autoimmune disorders has rarely been reported in the English medical literature.

CONCLUSION

The fact that it mostly concerns (relatively) young patients may suggest a potential causative relation between those autoimmune disorders and the early development of atrophic gastritis with hypergastrinaemia, which subsequently leads to the occurrence of gastric carcinoid tumours at a young age.

Bilateral angiosarcoma of the breast after conservative treatment of bilateral invasive carcinoma: genetic predisposition?

AIMS

In view of the increasing application of breast-conserving therapy (BCT) for early breast cancer during the last decades, the number of BCT-associated angiosarcomas is likely to increase. Their aetiology is not completely clear. The aim of this study was to examine the potential role of genetic predisposition for development of this rare tumour.

METHODS

The authors report on a case of consecutive bilateral development of angiosarcoma of the breast 6 and 12 years after BCT for bilateral invasive breast carcinoma. The literature was reviewed and the potential role of genetic predisposition was examined.

RESULTS

Such a case of bilateral BCT-induced breast angiosarcoma has not been previously reported in the international literature. The change on development of such a tumour bilaterally is 0.25-2.6 per million women who underwent bilaterally BCT with radiotherapy for invasive carcinoma. The case history and the literature review suggest that gene mutations are likely to play a role in development of post-radiation angiosarcoma of the breast.

CONCLUSIONS

It is assumed that genetic predisposition may play a role in the development of angiosarcoma after BCT. When such a predisposition is known, one might decide to avoid BCT in favour of mastectomy.

Primary psoas abscess. Report of three cases

BACKGROUND

Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections. Early diagnosis and appropriate management are therefore challenging aspects for physicians.

PATIENTS AND METHODS

We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36-51 years were admitted with fever, abdominal pain and a palpable tender mass.

RESULTS

The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor.

CONCLUSIONS

A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.

Rationale and techniques of intra-operative hyperthermic intraperitoneal chemotherapy

BACKGROUND

In recent years surgical cytoreduction followed by intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) was introduced as treatment modality in patients with peritoneal surface malignancy. In the current review the rational for this approach, the prerequisites and the different techniques used are discussed.

METHODS

A literature search through PubMed was performed.

RESULTS

Pharmacokinetic studies have shown an important dose advantage for intraperitoneal versus intravenous application. Hyperthermia enhances the penetration of cytostatic drugs into tumour tissue and also shows synergism with various cytostatic drugs. The penetration depth of drugs into tissue is limited, therefore HIPEC can only be effective in patients with minimal residual disease after (aggressive) surgery. HIPEC can be conducted in various ways, without clear proven advantage of one method over the others. Local complications after this combined treatment approach are mainly surgery related. Intraperitoneal chemotherapy may cause systemic toxicity, dependent on the drug used. In randomised studies cytoreductive surgery followed by HIPEC has proven its value in the prevention of peritoneal dissemination in gastric cancer. Phase II data on HIPEC in peritoneal carcinomatosis of colorectal origin and pseudomyxoma peritonei are promising, but randomised studies are still not available.

CONCLUSION

Aggressive surgical cytoreduction and HIPEC in patients with peritoneal surface malignancy has a clear rational and seems to have clinical value.

Extensive cytoreductive surgery followed by intra-operative hyperthermic intraperitoneal chemotherapy with mitomycin-C in patients with peritoneal carcinomatosis of colorectal origin

Peritoneal seeding from colorectal cancer has a very poor prognosis and is relatively resistant to systemic chemotherapy. We performed a phase I/II trial to investigate the feasibility and effectiveness of extensive cytoreductive surgery in combination with intra-operative hyperthermic intraperitoneal chemotherapy (HIPEC) in these patients. 29 patients with peritoneal carcinomatosis of colorectal origin without evidence of distant metastases underwent cytoreductive surgery and intra-operative HIPEC with mitomycin-C (MMC), followed by systemic chemotherapy with 5-fluorouracil (5-FU)/leucovorin. Surgical complications occurred in 11 patients (38%). One patient died directly related to the treatment, resulting in a mortality rate of 3%. MMC toxicity existed mainly of leucocytopenia (in 15 patients; 52%). After a median follow-up of 38 months (range 26-52 months) we found a 2- and 3-year survival rate (Kaplan-Meier) of 45 and 23%, respectively. Extensive cytoreductive surgery and HIPEC is feasible in patients with peritoneal seeding of colorectal cancer. First results suggest that a higher median survival could be achieved compared with conventional palliative surgery and systemic chemotherapy, therefore a randomised phase III study is now being conducted.

Extensive surgical cytoreduction and intraoperative hyperthermic intraperitoneal chemotherapy in patients with pseudomyxoma peritonei

BACKGROUND

Pseudomyxoma peritonei remains a fatal disease. However, extensive surgical cytoreduction combined with intraoperative heated intraperitoneal chemotherapy (HIPEC) has recently emerged as a new treatment modality, which might improve survival.

METHODS

Patients underwent treatment if the tumour appeared to be technically resectable on preoperative abdominal computed tomography and there were no distant metastases. After aggressive surgical cytoreduction, HIPEC with the administration of mitomycin C was performed for 90 min. Depending on histological grading, patients received adjuvant 5-fluorouracil and leucovorin therapy.

RESULTS

Forty-six patients were treated. Optimal surgical cytoreduction was obtained in 40 patients. Postoperative surgical complications occurred in 18 patients. Four patients died as a direct result of the treatment. Bone marrow suppression due to mitomycin C toxicity occurred in 22 patients. There was no other major toxicity related to the HIPEC procedure. After a median follow-up of 12 months, 40 patients are alive, eight of whom have proven recurrence. The actuarial survival rate (Kaplan-Meier) at 3 years was 81 per cent.

CONCLUSION

These results confirm that extensive surgery combined with HIPEC is feasible in patients with pseudomyxoma peritonei and that improved long-term survival might be achieved.

Treatment of malignancy arising in pilonidal disease

BACKGROUND

Malignant degeneration is a rare complication of pilonidal disease and is associated with a high recurrence rate and poor prognosis compared with regular nonmelanoma skin cancer. Treatment in our departments and in the international literature was evaluated.

METHODS

We analyzed the data from three patients with malignant degeneration who were treated in our departments and an additional 56 patients who were found after an extensive literature search.

RESULTS

A total of 47 males and 12 females, with a mean age of 52 years, were most frequently primarily treated with surgery. After a mean follow-up time of 28 months, 20% of all patients died with evidence of disease and an additional 10% died of unrelated causes. The overall recurrence rate was 39%, with a median time to recurrence of only 9 months. The local recurrence rate was lower when radiotherapy was added to surgical treatment alone (30% vs. 44%). Re-excision of local recurrence resulted in some long-term survivals.

CONCLUSIONS

Early diagnosis and treatment may lead to improvement of the relative poor prognosis. Surgical treatment should be tailored according to the locoregional extent. The high recurrence rate after surgical treatment can be reduced by the addition of radiotherapy. Although repeat surgery for recurrent disease may involve extensive resection and morbidity, this may result in prolonged survival.

Unusual origins of Pseudomyxoma peritonei

Pseudomyxoma peritonei is a rare neoplastic condition in that gelatinous intraperitoneal fluid collections and mucinous implants on the peritoneal surfaces and omentum are found. The pathological origin is usually an adenoma or well-differentiated adenocarcinoma of the appendix. A smaller number of cases arises from ovarian tumors. We report two unusual cases of pseudomyxoma peritonei. As a child, the first patient underwent several surgical procedures of the large bowel to relieve the consequences of Hirschsprung disease that were complicated by recurrent enteric fistulae. Colonic epithelial cells, with neoplastic changes due to chronic inflammation in the presence of enteric fistulae, were probably dislocated during these episodes, causing pseudomyxoma peritonei. In the second patient, pseudomyxoma was caused by intraperitoneal seeding of a mucinous urachal adenocarcinoma. We hypothesize that seeding of mucus producing epithelial cells into the abdominal cavity may result in this rare entity called pseudomyxoma peritonei, regardless of the source.

Malignant peritoneal mesothelioma treated by continuous hyperthermic peritoneal perfusion chemotherapy

Malignant mesothelioma of the peritoneum is a rare tumour for which the therapeutic approach has not yet been standardized. The efficacy of the current regimes is limited. Effective locoregional therapy is crucial, since this tumour is most often confined to the peritoneal cavity at the time of the initial diagnosis and remains there for much of its clinical course. If and when haematogenous metastases occur, they rarely contribute to the death of the patient, which is often caused by the overgrowth of the primary tumour and its local complications. A case of diffuse malignant peritoneal mesothelioma treated by cytoreductive surgery and continuous hyperthermic peritoneal perfusion with cisplatin is reported. The patient received systemic combination chemotherapy postoperatively. She is in good condition and free of disease 28 months after her treatment. Continuous hyperthermic peritoneal perfusion chemotherapy has recently been used in patients with secondary peritoneal carcinomatosis from digestive and gynecological malignancies with promising results. It is also possible that the same treatment alone or in combination with systemic chemotherapy may be effective in the treatment of primary peritoneal malignancies, as in the case of diffuse peritoneal mesothelioma.

Objective assessment of the contribution of each diagnostic test and of the ordering sequence in jaundice caused by pancreatobiliary carcinoma

BACKGROUND

Computer-assisted diagnostic systems are not substantially more accurate than the clinician in the differential diagnosis of jaundice but may help in optimal selection and sequencing of tests. The present study aimed to assess with an electronic diagnostic tool the pattern of ordering tests and the diagnostic contribution and related financial cost of each test in jaundiced patients with pancreatobiliary carcinoma, in an effort to make the clinician's diagnostic behaviour more efficient and economical.

METHODS

Clinical and diagnostic test data were prospectively gathered from 356 jaundiced patients with pancreatobiliary carcinoma and entered in a Bayesian diagnostic programme. The test results were added to the existing diagnostic evidence, and the programme calculated the diagnostic contribution of each test.

RESULTS

A total of 1804 diagnostic tests were ordered. Quantitative assessment of the diagnostic contribution of each test showed that percutaneous transhepatic cholangiography and computed tomography were associated with the highest provision of information. The most cost-effective tests were ultrasonography and liver function tests.

CONCLUSIONS

It is possible to determine objectively the diagnostic contribution of each test in establishing the diagnosis of pancreatobiliary carcinoma. The observed physician behaviour in ordering the various diagnostic tests might be improved with regard to its efficacy and its cost-effectiveness profile.

Peritoneal expansion by artificially produced ascites during perfusion chemotherapy

HYPOTHESIS

In cases of peritoneal carcinomatosis, continuous hyperthermic peritoneal perfusion chemotherapy (CHPPC) accomplishes homogeneous distribution of the drug and heat to the entire peritoneal cavity and exposure of the visceral and parietal surfaces to the perfusate. A new closed technique for expansion that produces artificial ascites is safer for medical personnel because of less heat and drug loss and more efficacious in its hemodynamic effect on the patient.

DESIGN

Prospective study.

SETTING

University hospital.

PATIENTS

Twenty-one patients with peritoneal carcinomatosis.

INTERVENTIONS

We performed 23 continuous hyperthermic peritoneal perfusion chemotherapy (CHPPC) procedures with peritoneal cavity expansion to an intra-abdominal pressure up to 26 mm Hg, using artificially produced ascites with 4 to 9 L normal saline solution.

MAIN OUTCOME MEASURES

Intraoperative and postoperative complications and hemodynamic changes during CHPPC.

RESULTS

No intraoperative complications were recorded. The artificially produced ascites did not cause significant hemodynamic changes. During the immediate postoperative period, 1 patient died of intra-abdominal hemorrhage and leakage of a colorectal anastomosis, resulting in a mortality rate of 4% in our series. Minor complications were seen in 14 patients. The complications were not attributable to the expansion technique.

CONCLUSIONS

Our proposed modification of closed-circuit CHPPC appears to be well tolerated and safe in patients with a high tumor load, as well as for the theater personnel. It remains to be investigated whether the theoretical advantages of the proposed technique will also lead to better long-term results.

The clinical significance of acquired jejunoileal diverticula

OBJECTIVE

Because of the relative rarity of acquired jejunoileal diverticulosis, including its symptomatology and complications, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. The purpose of the present study was to draw attention to jejunoileal diverticula and their complications as a site of gastrointestinal symptoms.

METHODS

The records of 10 patients with symptomatic jejunoileal diverticula treated in our departments were reviewed.

RESULTS

The clinical presentation was varying and nonspecific. Jejunoileal diverticula were diagnosed peroperatively in four patients operated on successfully for their acute complications. In one case the diagnosis was considered after a radiotargeted erythrocyte bleeding scan and in five other cases enteroclysis for chronic abdominal complaints demonstrated jejunoileal diverticula. The death of one patient operated on for massive hemorrhage from jejunal diverticula was probably related to delayed diagnosis and treatment.

CONCLUSIONS

Jejunoileal diverticula should not always be dismissed as asymptomatic findings, as they may be the cause of vague, chronic symptomatology and acute complications, including intestinal obstruction, hemorrhage, and perforation. Awareness of the fact that jejunoileal diverticula may cause chronic nonspecific abdominal symptoms and serious acute complications may lead to earlier diagnosis and timely treatment with lower morbidity and mortality.

The clinical significance of acquired jejunoileal diverticula

OBJECTIVE

Because of the relative rarity of acquired jejunoileal diverticulosis, including its symptomatology and complications, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. The purpose of the present study was to draw attention to jejunoileal diverticula and their complications as a site of gastrointestinal symptoms.

METHODS

The records of 10 patients with symptomatic jejunoileal diverticula treated in our departments were reviewed.

RESULTS

The clinical presentation was varying and nonspecific. Jejunoileal diverticula were diagnosed peroperatively in four patients operated on successfully for their acute complications. In one case the diagnosis was considered after a radiotargeted erythrocyte bleeding scan and in five other cases enteroclysis for chronic abdominal complaints demonstrated jejunoileal diverticula. The death of one patient operated on for massive hemorrhage from jejunal diverticula was probably related to delayed diagnosis and treatment.

CONCLUSIONS

Jejunoileal diverticula should not always be dismissed as asymptomatic findings, as they may be the cause of vague, chronic symptomatology and acute complications, including intestinal obstruction, hemorrhage, and perforation. Awareness of the fact that jejunoileal diverticula may cause chronic nonspecific abdominal symptoms and serious acute complications may lead to earlier diagnosis and timely treatment with lower morbidity and mortality.

Cysts of the adrenal gland: diagnosis and management

OBJECTIVE

Cysts of the adrenal gland are rare, but with the wider application of sonography and computed tomography more adrenal cysts are detected incidentally. To gain more insight into this entity, five such cases are reported and their diagnostic approach and management are discussed.

PATIENTS AND METHODS

The records of five patients with six cysts of the adrenal glands seen at our department from 1987 till 1995 are reviewed. There were four males and one female and their age ranged from 24 to 72 years, with a mean age of 43 years. One patient had a primary hydatid cyst of the right adrenal gland, which was preoperatively thought to arise from the liver or the right kidney. A second patient had a very large pseudocyst of the left adrenal gland, which is the largest ever reported in the literature. The other four cysts in three patients were found incidentally during sonography or computed tomography.

RESULTS

The hydatid cyst with a rim of normal adrenal tissue was excised. The large pseudocyst was removed together with the adrenal gland. In the cases of the incidentally found cysts, observation of the patient with regular follow-up was decided upon. All patients are in good condition and without symptoms 2 to 10 years after the initial diagnosis.

CONCLUSIONS

Adrenal cysts are rare and their diagnosis may pose problems. Symptomatic adrenal cysts should be operated, but small, asymptomatic, non-functional cysts with benign characteristics may be treated conservatively with regular follow-up by sonography or computed tomography and hormonal evaluation.

Intramural haematoma of the duodenum: a rare cause of duodenal obstruction

Intramural haematoma is a rare cause of duodenal obstruction. Its most common cause is abdominal trauma. Diagnostic difficulty arises if the patient or the child's parents fail to mention the episode of trauma, regarding it as an unrelated or insignificant event, as in the presented case. Computed tomography is the imaging modality of choice. Intramural duodenal haematoma is best treated conservatively, since operative treatment is associated with a high complication rate and longer hospitalization.

Splenic abscess: a diagnostic and therapeutic challenge

The records of five patients treated in our department for splenic abscess are analysed and the literature is reviewed. Computed tomography revealed the correct diagnosis in all patients, while clinical presentation was often nonspecific. Spleen-preserving management was possible in two patients (40%). Outcome was uneventful for four patients. One patient with a splenic abscess caused by Mycobacterium tuberculosis and acquired immunodeficiency syndrome, died 4 months after splenectomy from sepsis. We discuss the clinical presentation of splenic abscess, its diagnostic approach, and treatment. Additionally, we studied whether spleen-preserving management is feasible or not.

Acute intestinal obstruction caused by endometriosis mimicking sigmoid carcinoma

Endometriosis is a relatively frequent disease in fertile women. The intestine is involved in 12-37% of cases. Intestinal endometriosis is usually asymptomatic and complete obstruction of the bowel lumen occurs in less than 1% of cases. We report a case of endometriosis of the sigmoid, which caused complete intestinal obstruction and mimicked carcinoma of the sigmoid colon. This case demonstrates the difficulty of establishing an accurate pre- and peroperative diagnosis and the propensity of intestinal endometriosis to mimic colon cancer.

Staple-line disruption following vertical banded gastroplasty

BACKGROUND

The purpose of this study was to determine the frequency with which staple-line disruption occurs following vertical banded gastroplasty (VBG) in morbidly obese patients, to investigate the effect of this complication on weight loss, and to identify any clinical symptoms that might be associated with staple-line disruption.

METHODS

From April of 1992 to June of 1994, 60 patients with morbid obesity underwent VBG. Double-contrast radiographic examination of the upper gastrointestinal tract was performed on all patients at 6, 12, 24, and 36 months postoperation to assess the integrity of the staple line. At these same times, the weight of each patient was measured, so that the patients found to have staple-line disruption could be compared to those without disruption in terms of weight loss.

RESULTS

Over the duration of the study, staple-line disruption was found in 12 patients (20%). All of these patients demonstrated satisfactory weight loss. Between the group of patients with staple-line disruption versus the group without disruption, weight loss did not differ significantly at any time up to 3 years postoperation. In addition, in the patients with staple-line disruption, no clear symptomatology that might be associated with this complication was discovered.

CONCLUSIONS

Our results lead to the conclusion that small disruptions in the staple line lack clinical importance and do not significantly affect weight loss for at least the first 3 postoperative years. Furthermore, staple-line disruption does not seem to be associated with any specific clinical symptoms. Follow-up of all patients via barium meal is the correct approach for discovering the exact incidence of this complication.

Primary hydatid cyst of the adrenal gland

An extremely rare case of primary hydatid cyst of the adrenal gland is reported. Adrenal hydatid cysts are usually a manifestation of generalized echinococcosis. Only nine primary cases have so far been reported in the literature. The presentation is insidious. Correct preoperative diagnosis is difficult. Clinical and investigative findings are non-specific and ambiguous. Surgery is the treatment of choice.

Malignant melanoma of the penis

A case of malignant melanoma of the penis is herein reported. Malignant melanoma of the penis is rare and accounts for a small percentage of malignant melanomas and of malignant penile lesions. The diagnosis is often delayed by the patient's reluctance to consult a physician and by the intrinsic difficulty in clinical diagnosis of such a rare neoplasm. The surgical treatment is not standardized and is shortly discussed. In general, prognosis is poor and most patients die within a few years due to distant metastasis.

Primary intrahepatic biliary cystadenomatous tumors

BACKGROUND

Biliary cystadenoma and cystadenocarcinoma are rare tumors. The clinical features of, and optimal surgical management for these lesions have not been defined clearly. In this report, we describe three cases of cystadenomatous tumors of the biliary tract: two of a cystadenoma and one of a cystadenocarcinoma. The differential diagnosis of the cystic tumors of the liver in countries with a high prevalence of liver hydatid disease is very important.

METHODS

The authors report their institution's experience from 1988 to 1995 in treating two cystadenomas and one cystadenocarcinoma and review previously reported cases in the literature.

RESULTS

Clinical presentation is usually mild and atypical. During operation, the mass was resected en bloc with a margin of normal liver tissue in the cases of cystadenomas and, in the case of cystadenocarcinoma, a left hepatectomy with drainage of the common bile duct was performed. The two patients with adenomas remain well at 1 and 7 years after operation and our patient with adenocarcinoma is free of disease 8 years later.

CONCLUSIONS

The treatment of choice is radical excision of the mass, either with a wide margin of normal liver or by means of a typical lobectomy, depending on the size and location of the lesion. When the lesion can be removed completely, the prognosis is excellent.