A rare case of extrahepatic biliary mucinous cystic neoplasm in a middle-aged woman: A case report

Biliary mucinous cystic neoplasms are very rare tumors of the biliary tract with malignant potential. Preoperative diagnosis is challenging, as clinical, biochemical and radiological features are not specific. Surgical resection with negative margins is the gold standard treatment for these uncommon lesions. A 55-year-old woman presented at the Third Department of Surgery (Attikon University Hospital, Athens, Greece) with a history of mild right upper quadrant (RUQ) abdominal pain and jaundice. A 2-cm lesion in the distal common bile was identified by imaging. Following discussion in our multidisciplinary board meeting the patient underwent a pylorus preserving pancreatoduodenectomy, and histopathological examination revealed an ovarian-stromal type intraductal mucinous cystic neoplasm of the extra hepatic biliary. Since biliary mucinous cystic neoplasms are characterized by malignant transformation and high rates of recurrence, surgical resection with negative margins is the treatment of choice for both non-invasive and invasive biliary mucinous cystic neoplasms.

The Modulating Effect of Ursodeoxycholic Acid on Liver Tissue Cyclooxygenase-2 Expression Following Extended Hepatectomy

Introduction: Hepatic regeneration is a complex process involving a multitude of well-timed molecular operations. Ursodeoxycholic acid (UDCA) is postulated to exert a protective effect against oxidative stress and enzymatic degradation of the extracellular matrix, in turn potentiating the regenerative response. The aim of the present animal study is to evaluate the impact of UDCA administration in liver tissue expression of cyclooxygenase-2 (COX-2) in a setting of acute liver failure achieved by 80% hepatectomy.

Materials and methods: Twenty-four adult male Sprague-Dawley rats were randomly assigned to an experimental (UDCA) and a control group. Animals in the UDCA received oral pretreatment with UDCA for 14 days via feeding tube, while animals in the control group received saline. All animals underwent resection of approximately 80% of the liver parenchyma. Tissue and blood sample collection were performed 48 hours postoperatively.

Results: The postoperative mitotic index and Ki-67 levels were found to be elevated in the UDCA group (43±11.4 and 13.7±24.7 versus 31±16.7 and 7.6±5.7), albeit without any statistical significance. Pretreatment with UDCA significantly decreased COX-2 expression levels (p=0.28) as well as serum tumor necrosis factor α (TNFα) levels (37.3±10.9 pg/mL versus 75.4±14.4 pg/mL, p=0.004). COX-2 expression score was observed to be weakly correlated to Ki-67 levels in both groups. Although COX-2 expression score was not correlated with serum TNFα levels in the control group, animals pretreated with UDCA exhibited moderate correlation (r=0.45).

Conclusion: Preoperative administration of UDCA exerts a suppressive effect on tissue expression of COX-2 following 80% hepatectomy and enforces a positive correlation between COX-2 and serum TNFα levels, suggesting that UDCA preconditions liver tissue to display an enhanced regenerative response to circulating cytokines, most notably TNFα. The weak association of COX-2 with Ki-67 expression levels suggests that COX-2 may be of secondary importance during the early phases of liver regeneration.

The Effects of Ursodeoxycholic Acid Pretreatment in an Experimental Setting of Extended Hepatectomy: A Feasibility Study

Introduction Liver regeneration is an exceptionally complex process, orchestrated by a multitude of growth factors and cytokines. Tumor necrosis factor-alpha (TNF-a) and interleukin-6 (Il-6) have a pivotal role in the initiation of the regenerative response. Ursodeoxycholic acid (UDCA) exhibits a liver protective effect that enhances liver growth after injury. The aim of the present study is to evaluate the effect of UDCA in the circulating levels of TNF-a and Il-6 in rats undergoing extended 80% hepatectomy. Materials and methods Twenty-two male Sprague Dawley rats were randomly assigned in an experimental (UDCA group) and a control group. Mice in the UDCA-group received oral pretreatment of UDCA for two weeks preoperatively at a dosage of 25 mg/kg/day. An 80% hepatic resection was performed in both groups by resecting the middle, inferior right, and left lateral liver lobes. The experiment ended 48 hours postoperatively. Results UDCA pretreatment significantly depressed circulating levels of both TNF-a and Il-6 after the conclusion of the experiment as compared to the control group (p=0.001 and p=0.01, respectively). Furthermore, TNF-a levels were significantly reduced before the institution of liver injury (p=0.02). Mice in the UDCA-group exhibited better liver growth as demonstrated by significantly increased Ki-67 and mitotic rate (p=0.04 and p=0.02, respectively). Finally, the liver regeneration rate (LRR) was significantly elevated in the experimental group (UDCA group, 54.5% vs control group, 35.8%; p=0.002) signifying enhanced liver growth kinetics. Conclusion UDCA reduces the expression of TNF-a and Il-6 during the priming phase of liver regeneration. An 80% hepatectomy model of acute liver failure exhibited enhanced liver regeneration in the experimental group, plausibly due to the immunomodulatory effects of UDCA.

Small bowel perforation with multiple intestinal metastases from lung carcinoma: A case report

The present report describes the case of an 81-year-old woman who underwent an emergency explorative laparotomy due to small bowel perforation. Diffuse feculent peritonitis due to perforation of the jejunum was identified. In addition, six distinct tumors of the jejunum in close proximity to the perforation site, as well as two more lesions caudally at the ileum, were identified. A separate stenotic tumor was identified at the sigmoid colon, causing moderate dilatation of the whole intestine. An enterectomy, including the perforation site and the proximal six tumors, was performed, followed by limited enterectomies for the distal two tumors and side-to-side anastomoses of the small intestine. All resected tumors were identified at histology as metastatic from lung carcinoma. Postoperatively, the patient remained in a severe septic condition and succumbed the following day. Metastatic lesions from lung carcinoma in the small bowel wall are a rare finding predisposing to bowel perforation. When an acute condition coexists with multiple intestinal metastases, the mortality rate is high despite prompt surgical intervention.

Endoscopic Retrograde Cholangiopancreatography for Ampullary Carcinomas: Friend or Foe?

The role of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in ampullary carcinomas is under debate due to potential associated complications. We report the case of a 59-year-old male diagnosed with ampullary cancer, who had undergone ERCP that was followed by bleeding and perforation. We conclude that interventions before surgical resection, including ERCP, may compromise patient outcome.

Metastatic squamous cell carcinoma to the pancreas: Report of an extremely rare case

Secondary pancreatic lesions are very uncommon. Resection of these metastatic lesions with a curative intent has been reported in selected patients; however, the survival benefit from these procedures has yet to be clearly determined. A 78-year-old male patient presented to our department with obstructive jaundice. Three years prior to presentation the patient had undergone right pneumonectomy, due to stage IIA, low-grade squamous cell lung carcinoma. After resection, the patient received adjuvant chemotherapy, with no evidence of local or systemic recurrence over the following 3 years. Abdominal computer tomography on admission revealed a 3-cm lesion located at the head of the pancreas, causing biliary obstruction. Endoscopic ultrasound biopsy revealed malignant cells, suspicious for squamous cell carcinoma. Due to the limited extent of the metastatic disease and in view of the patient's good condition, surgical resection was proposed and the patient successfully underwent pancreaticoduodenectomy. Histological examination of the resected specimen confirmed a squamous cell carcinoma, with an immunochemical profile similar to that of the primary lung tumor. Therefore, pancreatic resection with curative intent may be feasible in selected patients with secondary metastatic tumors. However, further studies are required in order to determine the benefit of these major procedures in terms of survival outcomes.

Toll-Like Receptors -2, -3, -4 and -7 Expression Patterns in the Liver of a CLP-Induced Sepsis Mouse Model

Objective: To investigate the expression of toll-like receptors (TLRs) in the liver of septic mouse model. Materials and methods: For this study seventy-two C57BL/6J mice were utilized. Sepsis was induced by cecal ligation and puncture (CLP) in the mice of the three septic (S) groups (euthanized at 24 hours, 48 hours and 72 hours). Sham (laparotomy)- operated mice constituted the control (C) groups (euthanized at 24, 48 and 72 hours). Blood samples were drawn and liver tissues were extracted and examined histologically. The expression of TLRs 2, 3, 4 and 7 was assessed via immunohistochemistry (IHC) and qrt-PCR (quantitative- Polymerase Chain Reaction). Results: Liver function tests were elevated in all S-groups in contrast to their time-equivalent control groups (S24 versus C24, S48 versus C48 and S72 versus C72) (p < 0.05). Liver histology displayed progressive deterioration in the septic groups. IHC and qrt-PCR both showed an increased expression of all TLRs in the septic mice in comparison to their analogous control ones (p < 0.05). Analysis of livers and intestines of the septic animals proved that all TLRs were significantly expressed in higher levels in the intestinal tissues at 24h and 48h (p < 0.05) except for TLR 3 in S48 (p > 0.05); whereas at 72 hours only TLR 4 levels were significantly elevated in the intestine (p < 0.05). Conclusion: TLRs seem to be expressed in significant levels in the livers of septic rodents, indicating that they have a possible role in the pathophysiology of liver damage in septic conditions.

De Garengeot's Hernia: Report of a Rare Surgical Emergency and Review of the Literature

This is a report of a case who was admitted and operated on for a strangulated femoral hernia. The hernia sac contained a gangrenous appendix, which was excised and the hernia was repaired with sutures without complication. De Garengeot's hernia, although very rare, should be included in the differential diagnosis of cases with strangulated hernia and should receive the optimal treatment.

Expression of Toll-like receptors (TLRs) in the lungs of an experimental sepsis mouse model

Background

Sepsis is a condition characterized by high mortality rates and often accompanied by multiple-organ dysfunction. During sepsis, respiratory system may be affected and possibly result in acute respiratory distress syndrome (ARDS). Toll-like receptors (TLRs), as a first line defense against invading pathogens, seem to be highly expressed in septic states. Therefore, expression of TLRs in the lungs of a sepsis animal model could indicate the involvement of the respiratory system and appear as a severity index of the clinical course.

Materials and methods

A total of 72 C57BL/6J mice, aged 12–14 weeks, were studied. The animals were divided into 3 sepsis (S) groups (24h, 48h and 72h) and 3 control (C) groups (24h, 48h and 72h), each consisting of 12 mice. The S-groups were subjected to cecal ligation and puncture (CLP) while the C-groups had a sham operation performed. Blood samples were drawn from all groups. Total blood count analysis was performed along with the measurement of certain biochemical markers. Additionally, lung tissues were harvested and the expression of TLRs, namely TLR 2, TLR 3, TLR 4 and TLR 7 were evaluated by means of immunofluorescence (IF) and qRT-PCR (quantitative-Polymerase Chain Reaction). Statistical analysis was performed by using one-way ANOVA followed by student t-test. Results were considered statistically significant when p<0.05.

Results

WBCs and lymphocytes were decreased in all S-groups compared to the corresponding C-groups (p<0.05), while RBCs showed a gradual decline in S-groups with the lowest levels appearing in the S72 group. Only, monocytes were higher in S-groups, especially between S48-C48 (p<0.05) and S72-C72 (p<0.05). Creatinine, IL-10 and IL-6 levels were significantly increased in the S-groups compared to the corresponding C-groups (S24 vs C24, S48 vs C48 and S72 vs C72, p<0.05). IF showed that expression of TLRs 2, 3, 4 and 7 was increased in all S-groups compared to the time-adjusted C-groups (p<0.05). Similarly, qRT-PCR revealed that expression of all TLRs was higher in all S-groups compared to their respective C-groups in both lungs and intestine (p<0.05). Comparing lung and intestinal tissues from S-groups, TLRs 2 and 4 were found increased in the lung at 24, 48 and 72 hours (p<0.05), whereas TLR 3 was higher in the intestine at all time points examined (p<0.05). Finally, TLR 7 levels were significantly higher in the intestinal tissues at 24 hours (p<0.0001), while lungs predominated at 48 hours (p<0.0001).

Conclusion

TLRs seem to be highly expressed in the lungs of septic mice, therefore suggesting a potential role in the pathogenesis of ARDS during sepsis. While more studies need to be conducted in order to completely understand the underlying mechanisms, TLRs may represent a promising target for establishing novel therapeutic strategies in the treatment of sepsis.

Laparoscopic splenectomy: Current concepts

Since early 1990’s, when it was inaugurally introduced, laparoscopic splenectomy has been performed with excellent results in terms of intraoperative and postoperative complications. Nowadays laparoscopic splenectomy is the approach of choice for both benign and malignant diseases of the spleen. However some contraindications still apply. The evolution of the technology has allowed though, cases which were considered to be absolute contraindications for performing a minimal invasive procedure to be treated with modified laparoscopic approaches. Moreover, the introduction of advanced laparoscopic tools for ligation resulted in less intraoperative complications. Today, laparoscopic splenectomy is considered safe, with better outcomes in comparison to open splenectomy, and the increased experience of surgeons allows operative times comparable to those of an open splenectomy. In this review we discuss the indications and the contraindications of laparoscopic splenectomy. Moreover we analyze the standard and modified surgical approaches, and we evaluate the short-term and long-term outcomes.

A giant squamous cell carcinoma of the skin of the thoracic wall: a case report and review of the literature

Background

We report a case of a 48-year-old white woman who presented with a huge cutaneous protruding tumor of the thoracic wall below her left breast.

Case presentation

The lesion was excised with clear margins from the adjacent skin, and subcutaneous tissue was left to heal with second intention. A histological examination of the surgical specimen revealed a well-differentiated infiltrative cutaneous squamous cell carcinoma. Our patient neglected to attend our Oncological Department to receive chemotherapy. Today, 12 months after surgery, she is alive and without evidence of disease recurrence.

Conclusions

Cutaneous squamous cell carcinoma can reach a huge size if left untreated. Surgery is the primary mode of treatment, followed by chemotherapy if applicable.

Fast-Track Pancreaticoduodenectomy in the Elderly

It remains uncertain whether enhanced recovery after surgery (ERAS) protocols can be safely implemented for elderly patients, especially after highly complex surgery such as pancreaticoduodenectomy (PD). The present study was designed to assess the feasibility and safety of an ERAS protocol in elderly patients undergoing PD. Starting January 2010 to February 2015, we prospectively collected data from 85 consecutive patients who underwent PD with a fast-track program. Data of patients older and younger than 70 years were compared. Endpoints were morbidity, mortality, readmissions, length of stay, and compliance with ERAS elements. Forty-five patients were less than 70 years old and 40 patients were 70 years of age or older. Both mortality (4.4% vs 5%; P = 1.000) and overall morbidity (33.3% vs 37.5%; P = 0.821) did not differ significantly between the groups. Rates of intervention and relaparotomy were similar in both groups. Length of stay (10 vs 11.8 days; P = 0.099) did not differ significantly between the groups, nor did the readmission rates (6.7% vs 5.0%; P = 0.272). There were no differences in compliance with ERAS elements between groups. An ERAS program seems feasible and can be safely implemented for elderly patients undergoing PD.

Fast-Track Pancreaticoduodenectomy in the Elderly

It remains uncertain whether enhanced recovery after surgery (ERAS) protocols can be safely implemented for elderly patients, especially after highly complex surgery such as pancreaticoduodenectomy (PD). The present study was designed to assess the feasibility and safety of an ERAS protocol in elderly patients undergoing PD. Starting January 2010 to February 2015, we prospectively collected data from 85 consecutive patients who underwent PD with a fast-track program. Data of patients older and younger than 70 years were compared. Endpoints were morbidity, mortality, readmissions, length of stay, and compliance with ERAS elements. Forty-five patients were less than 70 years old and 40 patients were 70 years of age or older. Both mortality (4.4% vs 5%; P = 1.000) and overall morbidity (33.3% vs 37.5%; P = 0.821) did not differ significantly between the groups. Rates of intervention and relaparotomy were similar in both groups. Length of stay (10 vs 11.8 days; P = 0.099) did not differ significantly between the groups, nor did the readmission rates (6.7% vs 5.0%; P = 0.272). There were no differences in compliance with ERAS elements between groups. An ERAS program seems feasible and can be safely implemented for elderly patients undergoing PD.

E-cadherin in gastric carcinomas: Relations with histological parameters and its prognostic value

PURPOSE

Gastric cancer (GC) is still one of the most common malignancies with the majority of the tumors being diagnosed at advanced stage. The need for identification of prognostic and early detection biomarkers is thus compulsory. E-cadherin is one of the emerging biomarkers that is currently evaluated in the literature in the frame of epithelial-mesenchymal transition (EMT). Our aim was to study the expression of E-cadherin in the various histological subtypes of GC and to evaluate its prognostic value.

METHODS

This historical cohort survey was performed on gastric tumors obtained from 66 (46 men and 20 women) patients with documented gastric adenocarcinoma who underwent total or partial gastrectomy and regional lymphadenectomy from 2003 till 2011. Features such as tumor size, depth of invasion, grade and histological subtype, lymphovascular space invasion and regional lymph nodes involvement were also evaluated. Immunohistochemistry (IHC) was used for assessing the expression of E-cadherin with a semi-quantitative model.

RESULTS

The correlation of E-cadherin tissue expression with patient overall survival (OS) or disease-free survival (DFS) was not statistically significant, as well as with gender, T stage, N stage, TNM stage, grade, positive lymph nodes ratio or lymphovascular invasion.

CONCLUSIONS

73.0% of the evaluated tumors showed abnormal E-cadherin expression in IHC, but the correlation of E-cadherin tissue expression with patient OS or DFS was not statistically significant. Literature stands equivocal about the association between E-cadherin gene mutation, and histopathology and tumor invasiveness. Our results further strengthen the need of larger studies to fully elucidate the predictive role of E-cadherin in the natural history of GC.

Early Diagnosis and Surgical Treatment for Necrotizing Fasciitis: A Multicenter Study

Background

Necrotizing fasciitis (NF) is a group of relatively rare infections, usually caused by two or more pathogens. It affects the skin and subcutaneous tissues of lower and upper limbs, perineal area (Fournier’s gangrene), and the abdominal wall. Early diagnosis and aggressive surgical management are of high significance for the management of this potentially lethal disease.

Methods

We conducted a retrospective study in patients who presented, during the last decade, at four University Surgical Departments in the area of Athens, Greece, with an admission diagnosis of NF. Demographic, clinical, and laboratory data were gathered, and the preoperative and surgical treatment, as well as the postoperative treatment was analyzed for these patients.

Results

A total of 62 patients were included in the study. The mean age of patients was 63.7 (47 male patients). Advanced age (over 65 years) (P < 0.01) and female sex (P = 0.04) correlated significantly with mortality. Perineum was the mostly infected site (46.8%), followed by the lower limbs (35.5%), the upper limbs, and the axillary region (8.1%). Diabetes mellitus was the most common coexisting disease (40.3%), followed by hypertension (25.8%) and obesity (17.7%). The most common symptom was local pain and tenderness (90.3%). Septic shock occurred in eight patients (12.9%) and strongly correlated with mortality (P < 0.01). Laboratory data were used to calculate the LRINEC score of every patient retrospectively; 26 patients (41.9%) had LRINEC score under 6, 20 patients (32.3%) had LRINEC score 6–8, and 16 patients (25.8%) had LRINEC score >9. Surgical debridement was performed in all patients (mean number of repeated debridement 4.8), and in 16 cases (25.8%) the infected limb was amputated. The mean length of hospital stay was 19.7 days, and the overall mortality rate of our series was 17.7%.

Conclusion

Diagnosis of NF requires high suspect among clinicians, as its clinical image is non-specific. Laboratory tests can depict the severity of the disease; therefore, they must be carefully evaluated. Urgent surgical debridement is the mainstay of treatment in all patients; the need of repetitive surgical debridement is undisputed.

Carcinoid syndrome from a carcinoid tumor of the pancreas without liver metastases: A case report and literature review

A carcinoid tumor of the pancreas (CTP) is a rare pancreatic neoplasm, and usually presents with carcinoid syndrome (CS). CS consists of the classic symptom triad of cutaneous flushing, diarrhea and valvular disease, and occurs in the majority of patients with liver metastases. In the present study, the patient presented with symptoms of CS. A diagnosis of CTP with CS was suspected due to high levels of urine 5-hydroxyindolacetic acid, and this was confirmed by a fine-needle aspiration biopsy. Computed tomography showed extended lymphadenopathy, but no liver metastases. The patient was managed conservatively with octreotide long acting repeatable. To the best of our knowledge, this is the second literature case of CS associated with CTP without liver metastases.

Duodenal gangliocytic paraganglioma, successfully treated by local surgical excision-a case report

•

Duodenal gangliocytic paraganglioma is a rare tumor usually with benign behavior.

•

Resection of the tumor, either endoscopically or surgically is the treatment of choice.

•

Complete removal of the mass offers cure and long-term survival.

Introduction

Duodenal gangliocytic paragangliomas are rare neoplasms often arising in proximity to the major duodenal papilla of Vater. These neoplasms are considered to have a benign behavior with lymph node metastases being a rare phenomenon and distant metastatic disease even more so. Resection of the tumor is the only definitive therapy.

Presentation of case

A 67 year old male presented to a referring hospital with symptoms of fatigue and malaise. Evaluation with CT imaging revealed a 3.1 cm intraluminal mass situated grossly at the junction of the third with the fourth portion of the duodenum. The tumor was found to be situated near the ampulla of Vater and was excised through a longitudinal duodenotomy followed by myotomy of the sphincter of Oddi.

Discussion

Complete resection of duodenal gangliocytic paragangliomas by surgical or endoscopic means is the only potential cure. Endoscopic removal is the first option and is both safe and adequate. Ηowever, localized excision may be utilized instead in those cases in which endoscopic removal is not possible or cannot achieve negative margins. Recurrent disease after complete resection is unlikely.

Conclusion

Cases of duodenal gangliocytic paragangliomas are best managed with endoscopic resection. However, local surgical excision remains as a second-choice procedure. Adjuvant chemotherapy and radiotherapy are unnecessary after complete excision.

From Clinical Standards to Translating Next-Generation Sequencing Research into Patient Care Improvement for Hepatobiliary and Pancreatic Cancers

Hepatobiliary and pancreatic (HBP) cancers are associated with high cancer-related death rates. Surgery aiming for complete tumor resection (R0) remains the cornerstone of the treatment for HBP cancers. The current progress in the adjuvant treatment is quite slow, with gemcitabine chemotherapy available only for pancreatic ductal adenocarcinoma (PDA). In the advanced and metastatic setting, only two targeted drugs have been approved by the Food & Drug Administration (FDA), which are sorafenib for hepatocellular carcinoma and erlotinib for PDA. It is a pity that multiple Phase III randomized control trials testing the efficacy of targeted agents have negative results. Failure in the development of effective drugs probably reflects the poor understanding of genome-wide alterations and molecular mechanisms orchestrating therapeutic resistance and recurrence. In the post-ENCODE (Encyclopedia of DNA Elements) era, cancer is referred to as a highly heterogeneous and systemic disease of the genome. The unprecedented potential of next-generation sequencing (NGS) technologies to accurately identify genetic and genomic variations has attracted major research and clinical interest. The applications of NGS include targeted NGS with potential clinical implications, while whole-exome and whole-genome sequencing focus on the discovery of both novel cancer driver genes and therapeutic targets. These advances dictate new designs for clinical trials to validate biomarkers and drugs. This review discusses the findings of available NGS studies on HBP cancers and the limitations of genome sequencing analysis to translate genome-based biomarkers and drugs into patient care in the clinic.

Idiopathic Double Perforation of the Gastrointestinal Tract

A 73-year old woman was operated on with diffuse peritonitis and multiple abscesses throughout the mesentery which were drained. After the operation the patient could not recover. After an indicative computerized tomography the patient was re-explored. Perforation of the ileum and gastric perforation at the pylorus were found. There was no history of underline disease. The double perforation of the GI tract was surgically managed but the patient's course was fatal.

Advents in the Diagnosis and Management of Ischemic Colitis

BACKGROUND

Ischemic colitis (IC) is a common type of ischemic insult, resulting from decreased arterial blood flow to the colon. This disease can be caused from either atherosclerotic occlusive vascular disease or non-occlusive disease. The aim of this study is to present the diagnostic methodology and management of this severe disease based on current literature.

METHODS

A literature search has been done including articles referring to modern diagnosis and management of IC.

RESULTS

IC is usually a transient disease, but it can also cause gangrene of the colon, requiring emergency surgical exploration. Diagnosis is troublesome and is based on imaging examinations, mainly computerized tomography, which in association with colonoscopy can delineate the distribution pattern and severity of disease.

CONCLUSION

The majority of patients with mild disease have usually complete clinical recovery within a short period. The severe forms of the disease carry high morbidity and mortality rates and prompt surgical intervention is the only way to improve the associated severe prognosis.

Adhesions and Healing of Intestinal Anastomoses

Background. Postoperative adhesions are the result of aberrant peritoneal healing. As they are the leading cause of postoperative bowel obstruction, anti-adherence barriers are advocated for their prevention. This study looks into the effect of these biomaterials on the healing of intestinal anastomoses. Materials and Methods. Thirty-three New Zealand White rabbits underwent laparotomy, transection of the terminal ileum, and creation of an end-to-end anastomosis. Animals were randomized into 3 groups: the Control group (n = 11); the Icodextrin group, receiving icodextrin 4% intraperitonealy (n = 11); and the HA/CMC group, having the anastomosis wrapped with a hyaluronic acid/carboxymethylcellulose film (n = 11). All animals were sacrificed on the seventh postoperative day. Macroscopic adhesions were graded and anastomotic strength was tested by the burst pressure. Histological healing was assessed in a semiquantitative way for the presence of ulceration, reepithelization, granulation tissue, inflammation, eosinophilic infiltration, serosal inflammation, and microscopic adhesions. Univariate and multivariate analysis was used. Results are given as medians with interquartile range. Results. The median adhesion scores were the following: Control 1 (0-3), Icodextrin 0 (0-1), HA/CMC 0 (0-0), P = .017. The burst pressure did not differ between the groups; however, all except one bowel segments tested burst away from the anastomosis. The macroscopic and histological anastomotic healing was comparable in all 3 groups. A poor histological anastomotic healing score was associated with a higher adhesion grade (odds ratio = 1.92; 95% confidence interval = 1.06-3.47; P = .032). Conclusion. Adhesion formation was inhibited by the materials tested without direct detrimental effects on anastomotic healing. Poor anastomotic healing provokes adhesions even in the presence of anti-adhesion barriers.

Improvement of gastric emptying by enhanced recovery after pancreaticoduodenectomy

BACKGROUND

Enhanced recovery after surgery (ERAS) has improved postoperative outcomes particularly in colorectal surgery. This study aimed to assess compliance with an ERAS protocol and evaluate its effect on postoperative outcomes in patients undergoing pancreaticoduodenectomy.

METHODS

Fifty patients who had received conventional perioperative management from 2005 to 2009 (conventional group) were compared with 75 patients who had received perioperative care with an ERAS protocol (fast-track group) from 2010 to 2014. Mortality, complications, readmissions and length of hospital stay were evaluated and compared in the groups.

RESULTS

Compliance with each element of the ERAS protocol ranged from 74.7% to 100%. Uneventful patients had a significant higher adherence to the ERAS protocol (87.5% vs 40.7%; P<0.001). There were no significant differences in demographics and perioperative characteristics between the two groups. Patients in the fast-track group had a shorter time to remove the nasogastric tube, start liquid diet and solid food, pass flatus and stools, and remove drains. No difference was found in mortality, relaparotomy, readmission rates and overall morbidity. However, delayed gastric emptying and length of hospital stay were significantly reduced in the fast-track group. The independent effect of the ERAS protocol in reducing delayed gastric emptying and length of hospital stay was confirmed by multivariate analysis.

CONCLUSION

ERAS pathway was feasible and safe in improving gastric emptying, yielding an earlier postoperative recovery, and reducing the length of hospital stay.

Cytopathologic diagnosis of fine needle aspiration biopsies of thyroid nodules

Fine-needle aspiration (FNA) cytology is an important diagnostic tool in patients with thyroid lesions. Several systems have been proposed for the cyropathologic diagnosis of the thyroid nodules. However cases with indeterminate cytological findings still remain a matter of debate. In this review we analyze all literature regarding Thyroid Cytopathology Reporting systems trying to identify the most suitable methodology to use in clinical practice for the preoperative diagnosis of thyroid nodules. A review of the English literature was conducted, and data were analyzed and summarized and integrated from the authors’ perspective. The main purpose of thyroid FNA is to identify patients with higher risk for malignancy, and to prevent unnecessary surgeries for benign conditions. The Bethesda System for Reporting Thyroid Cytopathology is the most widely used system for the diagnosis of thyroid FNA specimens. This system also contains guidelines for the diagnosis and treatment of indeterminate or suspicious for malignancy cases. In conclusion, patients who require repeated FNAs for indeterminate diagnoses will be resolved by repeat FNA in a percentage of 72%-80%.

Current Trends in Laparoscopic Ventral Hernia Repair

Background and Objectives:

The purpose of this study was to analyze the surgical technique, postoperative complications, and possible recurrence after laparoscopic ventral hernia repair (LVHR) in comparison with open ventral hernia repair (OVHR), based on the international literature.

Database:

A Medline search of the current English literature was performed using the terms laparoscopic ventral hernia repair and incisional hernia repair.

Conclusions:

LVHR is a safe alternative to the open method, with the main advantages being minimal postoperative pain, shorter recovery, and decreased wound and mesh infections. Incidental enterotomy can be avoided by using a meticulous technique and sharp dissection to avoid thermal injury.

Adrenal incidentaloma or epinephroma and review of the literature. Differential diagnosis of adrenal incidentaloma

OBJECTIVE

A thorough review of the literature concerning Adrenal Incidentalomas (AI) was conducted.

RESULTS

We started with the definition and the history of the term Adrenal Incidentaloma. We introduce a new term, the term Epinephroma. We described the epidemiological characteristics of Adrenal Incidentalomas. We cited and commented the characteristics and pitfalls of various radiological modalities. We went on citing the various arguments in literature about the size of the tumour, the natural history, the biochemical characteristics and the treatment of Adrenal Incidentalomas.

CONCLUSION

advances in modern medical technologies has offered us an armamentarioum of new diagnostic modalities which has improved a lot our differential diagnostic abilities concerning an incidental adrenal tumour. However, despite the advances, still a lot of challenges exist.

Rupture After Endovascular Abdominal Aortic Aneurysm Repair

A total of 22 patients with ruptured abdominal aortic aneurysms (rAAAs) after previous endovascular aortic repair (EVAR; rAAAevar) were presented to 7 referral hospitals in Greece, between January 2006 and April 2012. Type Ia endoleak and endograft migration were identified in 72.7% and 50%, respectively. Compliance to follow-up protocol prior to rupture was 31.8%. In-hospital mortality was 36.4% (9.1% for those treated with secondary EVAR and 63.6% for those treated with open surgical repair, P = .02). An increase in the proportion of patients with rAAAevar among the total number of patients with rAAAs from 1.3% in 2007 to 18.2% in 2012 ( P for trend = .04) was recorded, corresponding to an annual increase of 2.8% (b = 2.84, P = .04). Rupture after EVAR seemed to be a clinical entity encountered with increasing frequency over the past years. Type I endoleak and endograft migration were most frequently observed, whereas compliance to follow-up was low.

Current concepts in the management of necrotizing fasciitis

Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most cases are polymicrobial, classed as type I. The clinical status of the patient varies from erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical condition is the most important clue for diagnosis. However, in equivocal cases, the diagnosis and severity of the infection can be secured with laboratory-based scoring systems, such as the laboratory risk indicator for necrotizing fasciitis score or Fournier's gangrene severity index score, especially in regard to Fournier's gangrene. Computed tomography or ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery at the infected sites. Management of the infection begins with broad-spectrum antibiotics, but early and aggressive drainage and meticulous debridement constitute the mainstay of treatment. Postoperative management of the surgical wound is also important for the patient's survival, along with proper nutrition. The vacuum-assisted closure system has proved to be helpful in wound management, with its combined benefits of continuous cleansing of the wound and the formation of granulation tissue.

Epidermoid cyst of an intrapancreatic accessory spleen: a case report and literature review

Background

An epidermoid cyst in an intrapancreatic accessory spleen is a rare lesion. Despite advances in radiologic techniques, in most cases it has been diagnosed preoperatively as a possible pancreatic neoplasm.

Case presentation

Herein, we present a 63-year-old Caucasian woman, diagnosed preoperatively with enhanced-contrast abdominal computed tomography, as having a potential cystic tumor in the tail of the pancreas. The patient underwent a distal pancreatectomy and splenectomy, and the histological examination revealed the presence of an epidermoid cyst of an accessory intrapancreatic spleen.

Conclusions

Familiarity with the imaging features, the clinical presentation and the location of the cyst are important to consider if this rare entity is to be included in the differential diagnosis of cystic neoplasms of the pancreas.

Kallikrein-related peptidases in cancers of gastrointestinal tract: an inside view of their role and clinical significance

Human tissue kallikrein (KLK1) and is related peptidases (KLK2-KLK15) are a family of 15 homologous serine proteases, participating in numerous processes of normal physiology. Considering the irreversible impact of proteases on substrates, the tissue-dependent regulation of KLKs activity becomes crucial for their beneficial role in normal homeostasis. Moreover, KLKs expression is strongly regulated at the transcriptional and post-transcriptional level by steroid hormones and miRNAs, respectively. Deregulation of KLKs expression, secretion and/or activation has been observed in most human malignancies and there is a trend to identify their role in the multi-complex process of cancer development. The identification of extracellular matrix (ECM) proteins, cell-surface receptors, cell-surface adhesion molecules and growth factors among substrates, clearly support the driving role of KLK abnormal expression and function during tumorigenesis and cancer progression. KLKs have also clinical utility in cancer diagnosis and monitoring like KLK 3 (PSA) in prostate cancer. In this review, we tried to summarize the existing literature about the role of KLKs in gastrointestinal cancers as well as to emphasize their clinical significance for patients' prognosis.

The role of remote ischemic preconditioning in the treatment of atherosclerotic diseases

BACKGROUND

Remote ischemic preconditioning (RIPC) is the application of a transient and brief ischemic stimulus to a distant site from the organ or tissue that is afterward exposed to injury ischemia, and has been found to reduce ischemia-reperfusion injury (IRI) in various animal models. RIPC appears to offer two distinct phases of endothelial IRI protection, which are presumably mediated through neuronal and humoral pathways.

METHODS

We conducted a comprehensive literature review on the available published data about the potential effect of RIPC in patients undergoing IRI in one or more vital organs.

RESULTS

Our search highlighted 24 randomized clinical trials about the effect of RIPC on variable clinical settings (abdominal aortic aneurysm repair, open heart surgery, percutaneous coronary intervention, living donor renal transplantation, coronary angiography, elective decompression surgery, carotid endarterectomy, recent stroke, or transient ischemic attack combined with intracranial carotid artery stenosis). Most of the trials focused on postoperative cardiac or renal function after RIPC with conflicting results. Preconditioning protocols, age limits, comorbidities, and concomitant drug use varied significantly across trials, and therefore no firm conclusions can be drawn using the available data. However, no severe local adverse events were observed in any patient undergoing limb or arm preconditioning.

CONCLUSIONS

RIPC is a safe and well-tolerated procedure that may constitute a potentially promising innovative treatment in atherosclerotic diseases. Large, multicenter, randomized clinical trials are required to determine an optimal protocol for the RIPC procedure, and to evaluate further the potential benefits of RIPC in human ischemic injury.

Expression of tissue IGF 1, TGFbeta and EGFR in the sequential steps of intestinal adaptation in a rat model of short bowel syndrome

BACKGROUND

The long-term morphological changes and the expression of tissue growth factors IGF 1, TGFbeta and EGFR in the gut mucosa, during the process of intestinal adaptation were examined.

METHODS

Four groups of rats were used: a. Sham rats (n = 10) underwent bowel transection and reanastomosis, b. SBS rats underwent an 80% small bowel resection: group A rats (n = 10) were sacrificed 15 days after surgery, group B (n = 10), 30 days after surgery, and group C (n = 10), 60 days after surgery. Morphological small bowel parameters (villus height, lumen diameter and others) of adaptation were examined sequentially. Tissue samples were studied immunohistochemically for the detection of IGF 1, TGFbeta, and EGFR.

RESULTS

There was a significant increase in all morphological parameters at day 15, in the intestinal samples; a further increase followed at day 30 and day 60 (p < 0.0001). Accordingly, an increase in the expression of IGF 1, TGFbeta and EGFR was noted at day 15 (p < 0.05), and at day 30 (NS).

CONCLUSION

Intestinal adaptation is an ongoing process lasting more than 2 months after massive small bowel resection. Peptide growth factors are expressed in the intestine continuously during this period, but the first two weeks are the most critical for the mucosal growth.

A pleomorphic rhabdomyosarcoma mimicking an inguinal hernia: a case report and review of the literature

A 59-year-old male presented with a painful right inguinal swelling and deep vein thrombosis at the ipsilateral leg. An inguinal hernia was initially diagnosed, but during surgery a large mass was found anteriorly to the peritoneal sheaths. Histology revealed a high-grade pleomorphic rhabdomyosarcoma. The mass advanced rapidly, occupying the whole right iliac fossa and metastasizing to the lung. Despite first- and second-line chemotherapy, the patient deteriorated rapidly and died. Rhabdomyosarcomas should be managed in specialized centres as they have prognostic factors and histologic features still controversial and poorly clarified.

Simultaneous occurrence of colonic adenocarcinoma and MALT lymphoma: A series of three cases

Simultaneous development of adenocarcinoma and primary B cell lymphoma of mucosa-associated lymphoid tissue (MALT) lymphoma of the colon is rare; only one case has so far been reported out of 13 cases with the coexistence of colonic adenocarcinoma with involvement of the colon by lymphoma. We hereby present three more cases, two females (aged 75 and 71 years) and a male (aged 72 years). All three underwent colectomy based on a preoperative biopsy revealing colonic carcinoma. Histological examination of the resection specimens disclosed a colonic adenocarcinoma in two cases, whereas a tubulovillous adenoma with superficial foci of intraepithelial adenocarcinoma was seen in the third case. Moreover, in all three cases, a coexisting MALT lymphoma was diagnosed in the colon (1 case), in both colon and adjacent lymph nodes (1 case) or in colonic lymph nodes and omentum (1 case). In the last case, a post-operative bone marrow biopsy revealed extensive infiltration of the bone marrow, due to which the patient received postoperative chemotherapy. Diagnostic and treatment issues are briefly discussed.

Postoperative hypoproteinemia in cancer patients following extensive abdominal surgery despite parenteral nutritional support

Determination of the predictors of hypoproteinemia among cancer patients following extensive surgery may enhance their nutritional management and clinical outcome. This study evaluated the predictive factors of postoperative hypoproteinemia among cancer patients following extensive abdominal surgery. An age- and gender-matched case-control study (n = 115) was conducted among cancer patients undergoing extensive (cases; n = 81) and moderate (controls; n = 34) abdominal surgery. Case patients received total parenteral nutrition (TPN), including 3 units of fresh frozen plasma and 200 mL 5% human albumin solution, for 8 postoperative days (POD). Case patients had lower mean total serum protein (TSP) levels throughout POD 8 (F value = 13.81; P = 0.001). Despite TPN, cases had greatest mean (±SD) TSP percent change on POD 1 (-24.6% ± 13.0, vs. -12.6% ± 9.2; P < 0.0001) and did not regain preoperative levels (POD 8: -14.3% ± 12.5 vs. 6.9% ± 13.4; P = 0.006). The likelihood of hypoproteinemia in this group was greatest on POD 3 (OR = 30.57; 95% CI 5.44-171.83). Multivariate regression analyses indicated that the determinants of postoperative hypoproteinemia were age [Adjusted OR (AOR) = 1.04; 95% CI 1.00-1.08), preoperative TSP (AOR = 0.46; 95% CI 0.23-0.92), and extensive surgery (AOR = 2.65; 95% CI 1.01-6.95). Tailored nutritional support, regarding extent of surgery, preoperative TSP, and patient age are needed to deter the occurrence of postoperative hypoproteinemia and consequent adverse surgical outcome among cancer patients.

Synchronous well differentiated neuroendocrine tumour and gastrointestinal stromal tumour of the stomach: a case report

BACKGROUND

Well differentiated neuroendocrine tumours (carcinoids), arising from cells of the diffuse neuroendocrine system, represent the most commonly encountered gastric endocrine tumours. Gastrointestinal stromal tumours (GISTs), which stem from interstitial Cajal cells located within the wall of the gastrointestinal tract and have a characteristic immunoreactivity for CD117 (c-kit protein), account for the majority of gastrointestinal mesenchymal neoplasms. Simultaneous occurrence of a GIST with a well differentiated neuroendocrine tumour in the stomach is very rare.

METHODS

Clinical history, endoscopy and histopathological findings were utilized for our diagnostic considerations.

RESULTS

We report the coexistence of a high risk GIST with a well differentiated neuroendocrine tumour of benign clinical behavior, both located in the stomach, in a 62-year-old man previously operated for a gastric well differentiated neuroendocrine tumour with uncertain malignant behaviour.

CONCLUSIONS

Even single well differentiated, sporadic, NETs of small size may coexist with GISTs. An appropriate initial therapeutic approach combined with a scrupulous follow-up seems to play a significant role in terms of preventing a metastatic disease.

Gastrointestinal stromal tumors (GISTs): an updated experience

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are relatively common mesenchymal tumors of the digestive tract characterized by c-KIT mutations. This is a comprehensive review of the current data of the literature on the various aspects of the diagnosis and treatment of these tumors.

METHODS

The stomach is the most commonly involved site for these tumors in the digestive tract. Computed tomography and endoscopy can usually establish the diagnosis. The study of certain specific immunohistochemical markers may contribute to better characterization of these tumors.

RESULTS

Surgical resection of GISTs has been the most effective therapy. In addition, targeted therapy with tyrosine kinase inhibitors may reduce the development of recurrence or decrease the disease progression in patients with metastatic disease.

CONCLUSIONS

The introduction of tyrosine kinase inhibitors has resulted in significant improvement in the overall prognosis of these patients. Furthermore, preoperative imatinib can decrease tumor volume and is associated with complete surgical resection in locally advanced primary GISTs.

Prosthetic repair of incisional hernia combined with elective bowel operation

BACKGROUND AND AIMS

Incisional hernia repair with mesh is considered a clean operation and it is not recommended to be perfomed at the same time with a potentially contaminated operation. The aim of this study is to assess the short-term results of a group of patients who underwent a colon operation and simultaneous incisional hernia repair with an onlay polypropylene mesh technique.

PATIENTS AND METHODS

From Novemberto June 2006, 19 patients underwent incisional hernia repair with polypropylene mesh, with simultaneous colonic operation. In 13 patients reestablishment of bowel continuity after a Hartmann procedure was done, whereas in four patients a loop colostomy was closed. Two patients underwent colectomy for cancer.

RESULTS

Post-operatively one patient had a seroma and two others had wound infections which required mesh removal. The mean follow-up was 70.15 +/- 48.40 months (range 3 to 142 months). During this period five patients died, four from progression of malignancy and one from myocardial infarction. Three patients (15.78%) developed recurrence, two patients with previous Hartmann's operation for complicated diverticulitis and wound infection and the third patient due to inappropriate mesh fixation with buttonhole hernia development.

CONCLUSION

Prosthetic repair of incisional hernias can be safely performed simultaneously with a colonic operation, with an acceptable rate of infectious complications and recurrence. It is unjustifiable to avoid the use of mesh in a potentially contaminated field when an appropriate technique is used.

Laparoscopic ventral hernia repair: pros and cons compared with open hernia repair

BACKGROUND

The purpose of this study was to analyse the surgical techniques, perioperative complications, and recurrence rate of laparoscopic ventral hernia repair (LVHR), in comparison with the open ventral hernia repair (OVHR), based on the international literature.

METHODS

A Medline search of the English literature was performed using the term "laparoscopic ventral hernia repair." Further articles were found by cross-referencing the references of each main article.

RESULTS

Current literature on the topic suggests that LVHR is a safe alternative to the open method with the main advantages being minimal postoperative pain, a shorter convalescence period, and better cosmetic results. Main complications after the laparoscopic approach, such as incidental enterotomy, protracted pain, postoperative seroma, or mesh infection occur at an acceptable rate. Furthermore, most articles favor LVHR versus OVHR in terms of recurrence rate.

CONCLUSIONS

Although further randomized studies are needed to draw safe conclusions in terms of complications and recurrence, LVHR is fast becoming the standard approach in the repair of abdominal wall hernias.

Sequential recurrences of ovarian granulosa cell tumour 10 and 11 years after initial diagnosis as haemoperitoneum and subhepatic mass: a case report and review of the literature

Adult granulosa cell tumours (GCTs) are rare ovarian neoplasms characterised by an indolent course and a propensity for late recurrence. Due to frequent endocrine manifestations most GCTs are diagnosed at an early stage. However, clinical behaviour can not be safely predicted on the basis of conventional clinicopathologic parameters. Surgery remains the cornerstone of therapeutic management. We report on a rare case of a Stage IA GCT twice recurring ten and 11 years after initial surgical treatment. The first recurrence presented as an acute abdomen due to haemoperitoneum after tumour rupture. The second recurrence presented as a subhepatic mass. This case emphasises the need for extended, lifelong follow-up even for patients with early stage, apparently completely removed GCTs. Prognostic parameters and therapeutic options especially for patients with recurrent disease are discussed.