A Rare Case of Thyroid Metastasis From Colorectal Cancer: Diagnostic and Therapeutic Challenges

The incidence of thyroid metastases among patients suffering from primary colorectal cancer is rare, and only a few cases have been described in the literature. As these metastases are usually asymptomatic, they most frequently present as incidentalomas on follow-up imaging. Hereby, we present and discuss an interesting case of metastatic sigmoid adenocarcinoma of the thyroid gland, diagnosed and treated at our institution.

Anatomy and Pathogenesis of Vascular Thoracic Outlet Syndrome

The current literature review article describes the anatomy and pathogenesis of the vascular nature of thoracic outlet syndrome (TOS), as well as gathers the latest and most important information concerning its diagnostic methods and treatment. This syndrome's subcategory includes the venous and the arterial. Data for this review was accumulated through the PubMed database in which only scientific studies published in the last decade (2012-2022) were searched. PubMed offered 347 results, of which 23 were judged suitable and used. Non-invasive methods both for the diagnosis and the treatment of vascular TOS are gaining ground. Medicine, at this point, finds itself on the verge of slowly putting aside the previous invasive gold-standard methods, to be used only in the most urgent situations. The vascular thoracic outlet condition is a rare form of TOS but is also the most trouble-causing one and the deadliest. Fortunately, it can be more efficiently managed because of the current medical innovations. However, further research is needed to establish their already confirmed effectiveness, so they can be even more widely trusted and used.

COVID-19 Vaccine Uptake among Healthcare Workers: A Systematic Review and Meta-Analysis

The vaccine-induced immunity of healthcare workers (HCWs) is crucial to controlling the COVID-19 pandemic. Therefore, we conducted a systematic review and meta-analysis to assess the COVID-19 vaccine uptake among HCWs worldwide and to identify predictors of vaccination. We searched Scopus, Web of Science, Medline, PubMed, ProQuest, CINAHL, and medRxiv up to 25 August 2022. We applied the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. We found 25 studies including 491,624 vaccinated HCWs, while the full sample included 555,561 HCWs. The overall proportion of vaccinated HCWs was 77.3%. Vaccine uptake for studies that were conducted in North America (85.6%) was higher than the proportion for studies that were conducted in Asia (79.5%), Europe (72.8%), and Africa (65.6%). The overall prevalence of COVID-19 vaccine uptake was 83.6% and 77.4% for physicians and nurses, respectively. Older age, white race, physicians' profession, seasonal influenza vaccine, direct COVID-19 patient care, and confidence in COVID-19 vaccine safety and effectiveness were positive predictors of vaccine uptake, while history of SARS-CoV-2 infection was a negative predictor. Deep understanding of the factors that influence HCWs' decisions to receive a COVID-19 vaccine is critical to implementing tailored communication strategies for HCWs who are at risk for not getting vaccinated.

Duplication of the Artery to the Cystic Duct: A Case Report of a Rare Anatomical Variation with Surgical Significance

Anatomical variations of the cystic artery are frequently documented, but variations of the artery to the cystic duct are extremely uncommon. We report a rare duplication of the artery to the cystic duct, revealed during laparoscopic cholecystectomy on an 18-year-old Caucasian female treated for gallstone disease. Both arterial branches were meticulously and carefully retracted and cauterized to avoid bleeding and subsequent postoperative complications. To our knowledge, this is the first reported case of an artery to the cystic duct duplication. The presence of congenital variations of the artery to the cystic duct encumbers surgical maneuvers and increases the potentiality of intraoperative injury and hemorrhage.

Attitudes toward COVID-19 Pandemic among Fully Vaccinated Individuals: Evidence from Greece Two Years after the Pandemic

Background

Considering the major effects of COVID-19 pandemic on health, social, economic, and political dimensions of all countries, positive attitudes toward COVID-19 pandemic are essential to control the pandemic. In our study, we investigated attitudes toward COVID-19 pandemic among fully COVID-19 vaccinated individuals two years after the pandemic and we identified predictors of attitudes.

Materials and Methods

We conducted an on-line cross-sectional study with 815 fully COVID-19 vaccinated individuals in Greece during May 2022. A self-administered and valid questionnaire was disseminated through social media platforms. We measured socio-demographic variables and COVID-19-related variables as potential predictors of attitudes toward COVID-19 pandemic. The outcome variable was attitudes toward COVID-19 pandemic (compliance with hygiene measures, trust in COVID-19 vaccination, fear of COVID-19, and information regarding the COVID-19 pandemic and vaccination).

Results

We found a very high level of compliance with hygiene measures, a high level of trust and information about the COVID-19 pandemic and vaccination, and a moderate level of fear of COVID-19. Also, we identified that females, participants with a higher educational level, those with a chronic disease, those with a better self-perceived physical health, and those without a previous COVID-19 diagnosis adhered more in hygiene measures. Trust in COVID-19 vaccination was higher among females, older participants, those with a higher educational level, those with a better self-perceived physical health, and those without a previous COVID-19 diagnosis. Moreover, females, older participants, those with a higher educational level, those with a chronic disease, those with a better self-perceived physical health, those that received a flu vaccine in previous season, and those without a previous COVID-19 diagnosis experienced more fear of COVID-19. Finally, level of information regarding COVID-19 pandemic and vaccination was higher for participants with a higher educational level, those without a chronic disease, those with a better self-perceived physical health, and those that received a flu vaccine in previous season.

Conclusions

Understanding predictors of attitudes toward COVID-19 pandemic among fully vaccinated individuals is crucial for developing appropriate public health campaigns in the future. Vaccination should be accompanied by positive attitudes in order to decrease the frequency of negative outcomes of COVID-19, such as hospitalization, complications and mortality.

Surgical administration of multiple glomus tumors in uncommon anatomic regions in a 17-year-old female. A rare case report

Glomus tumor (GT) constitutes a rare, benign, soft-tissue tumor emerging from neuro-myo-arterial glomus bodies. Due to its rarity, and absence of typical symptoms, GT is usually misdiagnosed, with a potential risk of rupture and infection, or even malignant transformation. The present manuscript reports a rare case of a 17-year-old young woman with multiple GTs in her lower back, breach and left thigh that was surgically treated. The manuscript aims to highlight the importance of prompt diagnosis and surgical treatment of this peculiar tumor in young patients and raise surgeons’ awareness.

Intestinal necrosis and sigmoid colon obstruction due to bilateral strangulated femoral hernia in a male: a rare surgical and anatomic case report

Bilateral femoral hernia is a peculiar clinical condition, with female predominance, with only a few cases reported in the literature. There are only two cases of bilateral strangulated femoral hernias, and these occur solely in females. To our knowledge, in the present manuscript, a bilateral strangulated femoral hernia in a male patient is reported for the first time. A 68-year-old male proceeded to the emergency department of our institution with symptoms of bowel obstruction. Abdominal computed tomography, magnetic resonance imaging and subsequent emergency laparotomy revealed obstruction of the sigmoid colon and simultaneous necrosis of several loops of the small intestine due to bilateral strangulated femoral hernia. The operation was uneventful. Despite the scarcity of this clinical condition, surgeons' awareness is fundamental, in addition to deep knowledge of the pathology and the anatomy of femoral hernias, in order to diagnose and treat adequately strangulated and incarcerated femoral hernias.

Preoperative Imaging and Localization of a Mediastinal Parathyroid Adenoma. A Case Report

INTRODUCTION

Primary hyperparathyroidism (PHPT) is a common endocrine entity associated with increased parathyroid hormone (PTH) secretion. A single parathyroid adenoma is the cause of PHPT in the majority of cases. However, due to their embryological origin, discovery of ectopic parathyroid tissue is not extraordinary.

CASE PRESENTATION

This is a case of a rare mediastinal parathyroid adenoma in a 56-year-old woman with emphasis on the preoperative diagnosis and accurate localization.

CONCLUSION

Due to its small size and its various possible spots, ectopic parathyroid gland adenoma localization can be challenging. For this reason, careful preoperative mapping and surgical planning are essential before any exploration for parathyroid adenomas.

Liposarcoma of the pelvic fossa masquerading as hematoma: a rare case report and its surgical management

Liposarcomas constitute rare malignant tumors of the soft tissue, with wide anatomical distribution. The prompt diagnosis of a liposarcoma is extremely challenging since these tumors tend to remain asymptomatic, until they grow enough to displace adjacent anatomical structures. In the presented case, a 55-year-old Caucasian male proceeded to our institution complaining about irreducible swelling of the right iliac fossa and constant discomfort, over the course of a year. His medical history revealed injury of the right groin and pelvis a year ago. The diagnosis was ilioinguinal liposarcoma masquerading as hematoma, due to the previous injury. The patient underwent primary complete tumor resection, and the operation was uneventful. The essential diagnostic and surgical steps for the management of a liposarcoma, mimicking a hematoma are meticulously described.

Anomalous anatomic trajectory of the superior thyroid artery encountered during thyroidectomy. A rare case report

Superior thyroid artery (STA), which is one of the primary arteries supplying to the thyroid gland, constitutes a severe consideration of both surgeons and interventional radiologists. Knowledge of the origin, the trajectory, the branching patterns and the anatomic aberrations of STA are of paramount clinical significance, due to its proximity to the external branch of the superior laryngeal nerve and the potentiality of accidental hemorrhage. The present manuscript reports for the first time the anomalous trajectory of the left STA, coursing superficially, through the left sternothyroid muscle and underlines the clinical significance of such aberrations.

Intestinal Microbiota in Colorectal Cancer Surgery

Simple Summary

The microbial communities of the intestine exist in a delicate balance with the human. Colorectal cancer is one of the most common gastrointestinal malignancies, and the microbiota seems to be related to it. The intestinal microbiota of patients after colorectal surgery is changed due to surgical stress and other perioperative factors. The occurrence of complications after colorectal cancer (CRC) surgery may depend on these bacterial shifts, which could also be associated with prognosis and survival in postoperative CRC patients.

Abstract

The intestinal microbiota consists of numerous microbial species that collectively interact with the host, playing a crucial role in health and disease. Colorectal cancer is well-known to be related to dysbiotic alterations in intestinal microbiota. It is evident that the microbiota is significantly affected by colorectal surgery in combination with the various perioperative interventions, mainly mechanical bowel preparation and antibiotic prophylaxis. The altered postoperative composition of intestinal microbiota could lead to an enhanced virulence, proliferation of pathogens, and diminishment of beneficial microorganisms resulting in severe complications including anastomotic leakage and surgical site infections. Moreover, the intestinal microbiota could be utilized as a possible biomarker in predicting long-term outcomes after surgical CRC treatment. Understanding the underlying mechanisms of these interactions will further support the establishment of genomic mapping of intestinal microbiota in the management of patients undergoing CRC surgery.

Standard and Variable Key Anatomical Structures for Safe Surgical Repair of Bochdalek Hernia: A Rare Case Series

Bochdalek hernia (BH) is a developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax causing mechanical compression of the thoracic viscera. This type of hernia is rare in adults, usually asymptomatic and may be diagnosed incidentally in a routine chest X-ray. The aim of the present retrospective study was to highlight the standard and important anatomical structures that are crucial to safe surgical repair of BH during laparotomy and thoracotomy by the placement of mesh graft, along with a short review of the existing evidence. Records from 2005 to 2017 were reviewed to identify the patients with adult BH who underwent mesh repair through thoracotomy or laparotomy and evaluate the possible complications and results. Six patients were operated for adult BH with the above-mentioned techniques. Four underwent laparotomy and two were treated through thoracotomy. Mild fever was reported only in one patient. There was significant improvement in the symptoms of all patients and no recurrence was reported in the subsequent follow-up period. Surgical treatment is strongly indicated for both symptomatic and asymptomatic patients. Surgeons' in-depth knowledge of the anatomy of the diaphragm will ensure better outcomes for the patients.

Erratum: The clavipectoral fascia as the unique anatomical criteria for distinguishing breast parenchymal lesions from axillary lymph node metastasis

[This corrects the article DOI: 10.1093/jscr/rjz135.].

Non-Recurrent Right Laryngeal Nerve: a Rare Anatomic Variation Encountered During a Total Thyroidectomy

The non-recurrent laryngeal nerve (nRLN) is a rare anatomic variation that every head and neck surgeon must be aware of, in order to avoid intraoperative injury which leads to postoperative morbidity. We are reporting a case of a nRLN in a 47 year old female patient with medullary thyroid carcinoma who was surgically treated with total thyroidectomy and lymph node dissection. Both two inferior laryngeal nerves were identified, fully exposed and preserved along their cervical courses. However, we found that the right inferior laryngeal nerve was non-recurrent and directly arised from the cervical vagal trunk, entered the larynx after a short transverse course and parallel to the inferior thyroid artery. The safety of thyroid operations is dependent on high index of suspicion, meticulous identification and dissection of laryngeal nerves either recurrent or non-recurrent. This leads to minimum risk of iatrogenic damage of the nerves. Complete knowledge of the anatomy of these neural structures, including all their anatomic variations is of paramount importance.

Detailed and applied anatomy for improved rectal cancer treatment

Rectal anatomy is one of the most challenging concepts of visceral anatomy, even though currently there are more than 23,000 papers indexed in PubMed regarding this topic. Nonetheless, even though there is a plethora of information meant to assist clinicians to achieve a better practice, there is no universal understanding of its complexity. This in turn increases the morbidity rates due to iatrogenic causes, as mistakes that could be avoided are repeated. For this reason, this review attempts to gather current knowledge regarding the detailed anatomy of the rectum and to organize and present it in a manner that focuses on its clinical implications, not only for the colorectal surgeon, but most importantly for all colorectal cancer-related specialties.

Non small cell lung cancer metastasized to the breast and treated with modified radical mastectomy: a case report

Breast metastasis from extra-mammary malignancy is extremely rare with an incidence from 0.4% to 1.3%. Several types of malignancies that most commonly metastasize to the breast include leukemia, lymphoma, and melanoma.

AIM

We report a case of a 57-year-old male with a history of non-small cell lung cancer (NSCLC) who manifested a left breast mass, two years and four months after the initial diagnosis and treatRomament of NSCLC.

METHOD

Physical examination revealed a poorly defined mass in the upper outer quadrant of the left breast, suspicious for breast cancer. After mammography results, the patient underwent Fine Needle Aspiration that was indicative of cancer. He underwent then modified radical mastectomy and axillary lymph node dissection. Histology and immunohistochemical analyses were conducted, that revealed a NSCLC that metastasized to the left breast.

RESULTS

Finally, the prognosis of the patient was poor, as NSCLC relapsed from IIB to stage IV.

CONCLUSIONS

An accurate differentiation of metastasis to the breast from primary breast cancer is of paramount importance because the therapeutic approach and prognosis of the two differ significantly.

The clavipectoral fascia as the unique anatomical criteria for distinguishing breast parenchymal lesions from axillary lymph node metastasis

Diagnosing primary breast tumors of the axillary tail of Spence may be extremely challenging, since several lesions may be located in the axillary fossa. In the presented case, a 54-year-old post-menopausal Caucasian female patient presented to our institution complaining about a lump in her left axilla. The preoperative imaging modalities could not clarify whether the tumor is part of the tail of Spence or metastasis of the axillary lymph nodes. The diagnosis of primary adenocarcinoma of the axillary tail of Spence was made during a quadrantectomy of the left breast after the clavipectoral fascia, which constitutes the sole anatomical boundary between breast and axilla, was identified.

An anatomic aberration and a surgical challenge: Mediastinal parathyroid adenoma anterior the pericardium. A case report

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Ectopic parathyroid adenomas located deeper in the mediastinum remain a surgical challenge.

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Their incidence reaches up to 20% of the general population and they tend to constitute a severe cause of failed primary surgery for PHPT.

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Such aberrations seem to be more common than described in the literature and there are possible anatomic aberrations that have not been described yet.

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Preoperative detection of the mediastinal parathyroid adenoma and detailed exposure of the operative field are essential for a safe mid-sternal thoracotomy.

Introduction

Ectopic parathyroid glands occur in 6–16% of cases of PHPT and they constitute a potential cause of failed primary surgical therapy. In particular, aberrant adenomas located deeper in the mediastinum, as in the presented case, remain a severe challenge for the surgeons.

Presentation of case

A 54-year-old Caucasian female proceeded to our institution with signs and symptoms of PHPT. Imaging studies performed identified a large mass localized in the lower anterior mediastinum, on the left of the median line. A mid-sternal thoracotomy was performed and the aberrant adenoma was finally detected anterior to the pericardium and the left pericardiophrenic vessels and the left phrenic nerve. The operation was uneventful. A meticulous review of the literature was conducted as well.

Discussion

Single parathyroid adenomas are the key culprits of PHPT. Anatomic aberrations of the location of the parathyroid glands and their adenomas are more common than described in the literature and there are possible anatomic aberrations that have not been described yet. All these anatomic variations constitute major risk-factors of thoracic bleeding and of nerve injury.

Conclusion

Detailed preoperative detection in addition to meticulous exposure of the operative field are fundamental in order to perform a safe adenoma excision without harmful impacts to the patient.

Anatomical variation of the trajectory of the brachiocephalic artery encountered during parathyroid adenoma excision. A rare case report and a surgical challenge

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BCT may present anatomical variations concerning its origin and its trajectory.

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Preoperative observation of these anatomical variations has vital clinical and surgical importance, since they constitute risk-factors of severe bleeding.

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Fundamentals to avoid iatrogenic injury are: (1) exposure of the trajectory and the origin of BCT, since it is quite evident that probable novel anatomic variations could be unexpectedly detected during the operation (2) good haemostasis and (3) preoperative utilization of diagnostic ultrasound.

Introduction

The brachiocephalic trunk (BCT), also known as the “anonymous artery” constitutes the first branch of the aortic arch that bifurcates at the level of the right sternoclavicular joint into the RCCA and the RSA. Anatomical variations of the origin and the trajectory of BCT are of vital clinical significance since they constitute major risk-factors of hemorrhage when performing tracheotomy, surgeries at the anatomic area of the neck as in the presented case.

Presentation of case

A 64-year-old Caucasian female proceeded to our institution with signs and symptoms of PHPT. Imaging studies performed identified a large mass localized posterior to the right thyroid lobe. During the operation, surgeons incidentally detected anterior to the trachea aberrant trajectory of the BCT. The operation was uneventful. A meticulous review of the literature was conducted as well.

Discussion

Anatomical anomalies of the origin and the trajectory of BCT are vaguely described in the literature. However, these anatomic variations constitute major risk-factors of accidental bleeding and subsequent complications when performing surgeries of the thyroid and parathyroid glands, tracheotomy and invasive radiological interventions.

Conclusion

Deep knowledge of such variations of the trajectory of the BCT in addition to detailed exposure of the operative field constitute the cornerstone in order surgeons to perform a safe intervention.

Superior mesenteric artery syndrome: a rare case of upper gastrointestinal obstruction

Superior mesenteric artery (SMA) or Wilkie’s syndrome is a rare clinical entity of partial or complete duodenal obstruction. The pathogenic mechanism is an acute angulation of the SMA which leads to compression of the third part of the duodenum between the SMA and the aorta. This is commonly due to loss of fatty tissue as a result of a variety of debilitating conditions. Its treatment is initially conservative and in case of failure, surgical therapy is unavoidable. We present a case of a 68-year-old female patient who presented in our Department with symptoms of dehydration after persistent vomiting for months. After complete radiologic workup, SMA syndrome was diagnosed and was successfully treated operatively. SMA syndrome might be a diagnostic challenge and must be always included in the differential diagnosis of upper gastrointestinal obstruction. Consequently, this paper aims to increase the awareness of a rare entity of duodenal obstruction.

Breast cancer section analysis correlates with sentinel lymph node biopsies: Precision and topographic anatomy

BACKGROUND

The mainstream treatment of breast cancer is radical mastectomy accompanied with Axillary Lymph Node Dissection (ALND). Lately, more conservative methods accompanied by adjuvant radiotherapy have been gradually replacing radical modalities. The Sentinel Lymph Node Biopsy (SLNB) has been considered such a valuable alternative to surgery conservative approach.

OBJECTIVE

To assess the agreement between SLNB in breast cancer patients and pathology results following ALND and to provide correlation between the sentinel lymph nodes (SLN) anatomical topography and biopsy positivity according to SLNBs.

METHODS

Two hundred female breast cancer patients (31 to 83 years of age) underwent partial or simple mastectomy with or without subsequent ALND. All patients were randomized against selection criteria and underwent SLNB.

RESULTS

In a set of 200 patients, 96.3% presented identical results between SLNB and pathology. 36% of them were confirmed with positive SLN through both approaches. Regarding the SLN topographic anatomical position, 67.3% of samples were located in the front axillary position, 24.5% in the front thoracic position, whereas 6.1% was located in the central axillary position.

CONCLUSIONS

The correlation between the SLN topographic anatomical position and the pathology results, revealed that the majority of the SLN accumulates in the front axillary region. A larger patient population will statistically support this association.

Safe Popliteal Node Dissection and Utility of Key Anatomical Structures: A Rare Case Series

Metastasis in popliteal nodes is an extremely rare clinical condition that is scarcely reported in the literature, and popliteal node dissection is an infrequently performed surgical procedure. During the two decades of 2000-2020, 26 patients came to our institution for popliteal node dissection due to metastasis from the primary region to popliteal fossa lymph nodes. We report here that with lymphoscintigraphy, popliteal node dissection is an adequate therapeutic procedure in cases of metastasis to popliteal fossa from acral primary tumors. However, because the frequency of this surgical procedure is typically low, surgeons are often inadequately trained in the proper approach using key anatomical structures to guide them during popliteal node removal. We describe a stepwise surgical approach in the hopes of increasing the surgeon's knowledge, which is pivotal and fundamental for performing successful popliteal lymphadenectomy without hazardous impacts to the patient.

Body donation for research and teaching purposes: the contribution of blood donation units in the progress of anatomical science

BACKGROUND

Cadaver's dissection has a fundamental role in teaching and understanding the anatomy. Postmortem body donation (PMBD) is an important source of cadavers and provides an opportunity to carry out research or educational activities in medicine and surgery. The objective of the current study is to determine the perspectives and attitudes toward PMBD among blood donors (BLD) and elderly people. These data are fundamental to highlight the PMBD extent and individual factors that might influence PMBD.

MATERIALS AND METHODS

Six hundred and fifty questionnaires were distributed to 500 (327 male and 173 female, mean age 39.9 ± 9.6 years) blood donors (BLD) and 150 elderly people (62 males and 88 females, mean age 74 ± 9.4 years). A specially designed self-administered questionnaire covering demographic data, knowledge and attitude of the participants concerning body donation (BD) was used.

RESULTS

Concerning the perception of BD among BLD and elderly people, the most common reason for BD in both study groups was the contribution in research, while the commonest reason for hesitating about BD was the lack of information, following by personal reasons. The BLD were more likely to be interested in BD for contribution in research and personal reasons. Additionally, BLD were less likely than the elderly to hesitate about BD for religious and personal reasons and more likely to hesitate about BD for not being informed. BLD who were interested in BD for contribution in research were significantly older. Elderly people who hesitated about BD for personal reasons were significantly older. In the BLD group, those who responded that blood and body donation are the same were significantly younger, while in the elderly group - significantly older. The proportion of BLD who declared that blood and body donation is the same was significantly higher in more educated people.

CONCLUSIONS

A need for well-organised and informative BD programmes is evident. Orientating the public towards this practice is of high moral and medical value, since with this important promotion the altruistic act of BD will expand globally.

Complete unilateral ureteral duplication encountered during intersphincteric resection for low rectal cancer

Complete duplication of ureters is a very rare clinical entity that may either be asymptomatic or present with a variety of clinical findings. In the presented case a 51-year-old Caucasian female underwent an intersphincteric resection for low rectal cancer. Intraoperatively, during the standard bilateral recognition and mobilization of the ureters, complete unilateral duplication of the left ureter was incidentally detected, deriving from a single renal parenchyma. Such a congenital abnormality though constitutes a major risk-factor of accidental ureteral injury during operations including pelvis. Conclusively, meticulous exposure of both ureters combined with surgeons’ unceasing awareness constitute the cornerstone of a safe operation.

Anatomic variation of the relation between the inferior mesenteric artery and the bifurcation point of abdominal aorta during lower anterior resection: A rare case report

INTRODUCTION

Identification and ligation of the inferior mesenteric artery (IMA) is a crucial surgical step when performing lower anterior resection (LAR) for rectal cancer. Anatomic variations of the relation between the IMA and the bifurcation point of abdominal aorta (AA) encumber surgical maneuvers and are of great clinical importance.

PRESENTATION OF CASE

An unusual anatomic variation of the relation between IMA and the bifurcation point of AA was unexpectedly detected during LAR to a 69-year-old Caucasian female patient. The operation was uneventful. A meticulous review of the recent literature was conducted as well.

DISCUSSION

Variations of the mesenteric vascular supply are mainly identified incidentally, during the operation. In particular, variations of IMA are extremely uncommon in the literature. However, such kind of congenital variations, are not as rare as considered and their presence encumbers surgical maneuvers and increases the potentiality of intraoperative injury and hemorrhage.

CONCLUSION

Surgeons' deep knowledge and unceasing awareness concerning probable anatomic variations of the relation between the IMA and AA, combined with detailed exposure of the operative field and of the relationship between these adjacent arteries constitute the cornerstone of a safe operation.

Middle colic vein draining to splenic vein: a rare anatomic variation encountered during a right hemicolectomy

Right or subtotal colectomy either open or laparoscopic may be a challenging operation owing to technical difficulties. One of these, is to identify a safe and adequate dissection plane, ligating and dissecting lymph nodes around middle colic vessels. The purpose of this study was to depict a rare anatomic variation of middle colic vein (MCV) draining to splenic vein. We report the case of a 55-year-old male patient, who was subjected to a right hemicolectomy for an adenocarcinoma in the ascending colon. During dissecting the transverse mesocolon from the greater omentum, for complete mesocolic excision (CME), we encountered that the MCV drained in the splenic vein. With respect of this rare anatomic variability, CME was completed without hemorrhage. Our aim is to depict that deep knowledge of MCV anatomy and its variations is of paramount importance to achieve CME and to avoid dangerous or massive bleeding.

K-ras Mutations as the Earliest Driving Force in a Subset of Colorectal Carcinomas

K-ras oncogene is a key factor in colorectal cancer. Based on published and our data we propose that K-ras could be the oncogene responsible for the inactivation of the tumor-suppressor gene APC, currently considered as the initial step in colorectal tumorigenesis. K-ras fulfills the criteria of the oncogene-induced DNA damage model, as it can provoke well-established causes for inactivating tumor-suppressors, i.e. DNA double-strand breaks (causing allele deletion) and ROS production (responsible for point mutation). The model we propose is a variation of the currently existing model and hypothesizes that, in a subgroup of colorectal carcinomas, K-ras mutation may precede APC inactivation, representing the earliest driving force and, probably, an early biomarker of colorectal carcinogenesis. This observation is clinically useful, since it may modify the preventive colorectal cancer strategy, restricting numerically patients undergoing colonoscopies to those bearing K-ras mutation in their colorectum, either in benign polyps or the normal accompanying mucosa.

Laparoscopic abdominoperineal resection for the treatment of a mucinous adenocarcinoma associated with an anal fistula

Mucinous adenocarcinoma associated with an anal fistula is a rare oncologic entity which may pose diagnostic and therapeutic challenges for Surgeons and Medical Oncologists. Few reported cases without definite therapeutic guidelines exist. It represents 2-3% of all gastrointestinal malignancies and arises from chronic anal fistulas, ischiorectal or perianal abscesses. We report a case of perianal mucinous adenocarcinoma in a 65-year-old male initially surgically treated multiple times for a recurrent fistula in ano of 5 years duration. He presented with an ischiorectal and a perianal fistula. Incisional biopsy from fistulotomy revealed mucinous adenocarcinoma. Contrast enhanced computed tomography scan and magnetic resonance imaging showed a localized perianal growth of a tumor which was further evaluated with colonoscopy. With no evidence of metastasis, we performed a laparoscopic abdominoperineal resection (APR). Two years follow-up after APR and without adjuvant chemotherapy there is not any evidence of recurrence or distant metastasis.

Anomalous course of the sigmoid colon and the mesosigmoid encountered during colectomy. A case report of a redundant loop of sigmoid colon

Introduction Sigmoid colon constitutes a part of the large intestine that presents several congenital anatomic variations. In particular, the presence of a redundant loop of sigmoid colon is of tremendous importance for surgeons, obstetricians and radiologists, since it is closely related to multiple pathological conditions and functional implications of the neighboring anatomical structures.

PRESENTATION OF CASE

An unusual anatomic variation in position and length of the sigmoid colon and its mesocolon was unexpectedly detected during right hemicolectomy to a 67-year-old Caucasian male patient due to colon cancer. The operation was uneventful. A meticulous review of the literature was conducted as well.

DISCUSSION

A redundant loop of sigmoid colon may go unnoticed or it might lead to urinary, digestive and vascular complications. Its presence is associated with acute and chronic pathological conditions, sigmoid volvulus and serious confusions in radiological diagnosis and instrumentation.

CONCLUSION

Surgeons' thorough knowledge concerning this rare anatomic variation is fundamental and crucial in order to establish a correct diagnosis and assert the appropriate management when performing operations including pelvis and abdomen.

Abnormal distance of the extralaryngeal bifurcation point of the recurrent laryngeal nerve from the cricothyroid joint

The extralaryngeal bifurcation point of the recurrent laryngeal nerve (RLN) is typically located in a mean distance of 0–2 cm from the cricothyroid joint (CTJ). In the presented case though, the left RLN was unexpectedly identified bifurcating in a mean distance of 7 cm from the left CTJ in a young woman with multinodular goiter during total thyroidectomy. The RLN was carefully exposed throughout its course for the avoidance of iatrogenic injury of the nerval structure. The operation was uneventful. The present manuscript aims to highlight a scarce anatomic variation and its implications for thyroidectomy. Rare anatomic variations of the RLN such as the presented one encumber thyroid surgery and represent a severe risk factor of RLN injury. Meticulous operative technique combined with surgeons’ perpetual awareness concerning this peculiar anatomical aberration leads to an injury-free thyroid surgery.

Anomalous origin of the right colic artery from the right gastroepiploic artery during complete mesocolic excision: a rare case report

Complete mesocolic excision (CME) is a standardized surgical procedure for colonic cancer that requires ample knowledge of the anatomical patterns of the colic arteries. Variations of the colic vessels encumber both surgical and endovascular techniques. In the presented case below, the right colic artery was incidentally detected emerging from the right gastroepiploic artery, during CME. Surgeons should be always aware of this variation in order to perform safe abdominal surgeries and sufficient resection of the regional lymph nodes with a view to minimizing the probability of recurrence of disease when encountering colonic cancer.

The ligament of Parks as a key anatomical structure for safer hemorrhoidectomy: Anatomic study and a simple surgical note

Hemorrhoids are a common anal disorder which affects both men and women of all ages. One out of ten patients with hemorrhoidal disease, requires surgical treatment. Unfortunately though, hemorrhoidectomy is closely related to complications that can be present early or late postoperatively. In the present manuscript, the safe surgical technique which emphasizes to the identification of the key anatomical structure of the ligament of Parks (Trietz's muscle) is adequately described. A total of 200 patients with grades III and IV hemorrhoids, underwent Milligan-Morgan or Ferguson's hemorrhoidectomy. The mucosal ligament of Parks was identified to all patients and was used as a key anatomical structure through the excision of the hemorrhoids. Its identification guides surgeons during the operation and reduces the major problem of postoperative complications. Finally, since the mucosal ligament of Parks represents a constantly identifiable landmark, it allows simple and reliable identification of the internal sphincter muscle and minimizes the probability of postoperative complications.

Anatomic variation of the relation between the facial nerve and the retromandibular vein during superficial parotidectomy: A rare case report

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The facial nerve (FN) and the retromandibular vein (RMV) are anatomical structures in close proximity. Anatomic variations of their relationship complicate parotid surgery and increase the potentiality of nerve injury or bleeding.

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The true prevalence of such kind of variations seems to be underestimated, since the literature is restricted.

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Novel variations of the relationship of the FN with the RMV are probable. Therefore, surgeons’ knowledge and perpetual awareness are fundamental and essential in order to perform safe parotid surgery.

Introduction

Identification and preservation of the facial nerve (FN) is a major challenge when performing parotidectomy. Anatomic variations of the relation between the FN and the retromandibular vein (RMV) pose a high risk of nerve injury and bleeding during the operation.

Presentation of case

An unusual anatomic variation of the relation between the FN and the RMV was unexpectedly detected during superficial parotidectomy. The operation was uneventful. A meticulous review of the recent literature was conducted as well.

Discussion

Variations of the relation between the FN and the RMV are mainly identified during the operation, since when performing parotidectomy, surgeons typically detect all the FN branches by locating the RMV. Such kind of variations, are not as rare as considered and their presence complicates parotid surgery and increases the potentiality of nerve injury and hemorrhage.

Conclusion

Surgeons’ deep knowledge and perpetual awareness concerning the probable anatomic variations of the relation between the FN and the RMV combined with detailed exposure of the operative field and of the relationship between these adjacent anatomical structures lead to safe parotid surgery.

Leiomyomatosis peritonealis disseminata: A case report and meticulous review of the literature

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Differential diagnosis of LPD from leiomyosarcoma or benign metastasizing leiomyoma remains difficult.

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Ample history of the patient, clinical evaluation, preoperative guided FNA and histopathologic analysis of the FNA tissue and of the tumor resection are essential for differential diagnosis.

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Prompt diagnosis of LPD is crucial because, although benign in nature, LPD may degenerate into malignancy.

Introduction

Leiomyomatosis peritonealis disseminata (LPD) is a peculiar benign clinical disorder characterized by proliferation of peritoneal and subperitoneal nodules. LPD is a difficultly diagnosed benign disease that rarely degenerates into malignancy.

Presentation of case

A 40-year-old Caucasian female with vaginal bleeding proceeded to our institution for elective excision of abdominal and pelvic masses which were firstly considered as leiomyosarcomas. The histologic diagnosis of the mass lesions revealed smooth muscle benign cells. This is the first case of LPD reported in Greece. A meticulous review of the literature was conducted as well.

Discussion

The differential diagnosis of LPD is difficult due to its clinical resemblance with peritoneal carcinomatosis or metastatic lesions and with benign metastasizing leiomyoma (BML) as well. Etiological factors, pathophysiology and clinical manifestations which lead to a safe diagnosis of LPD are adequately described.

Conclusion

Surgeons’ thorough knowledge concerning this rare clinical condition is fundamental and crucial in order to establish a correct diagnosis and assert the appropriate treatment and the minimization of the probability of malignant transformation of LPD.

Trepanation Practices in Asclepieia: Systematizing a Neurosurgical Innovation

BACKGROUND

As ancient Greeks started looking for deities that could fulfill the pragmatic needs of common people, local heroes started being mythologized and worshipped through cults.

METHODS

The most widespread such example was Asclepius, possibly a skilled war surgeon who followed military expeditions to Colchis and Troy. Our study investigates the possibility of the early neurosurgery to have been started inside Asclepieia by Asclepius and his followers.

RESULTS

Asclepius was worshipped at religious temples called Asclepieia where certain specific medical and surgical techniques were followed. The most advanced technique was skull trepanation, which was most likely done as an acute operation to release intracranial pressure. The contemporary Hippocratic corpus provided extensive descriptions of the technique, and archaeologic evidence has shown that many patients survived the operation.

CONCLUSIONS

Decompressive craniectomy techniques have been practiced for millennia but it is possible that they were first systematized as a neurosurgical innovation through the Ancient Greek religious cult followed in Asclepieia.

Surgical anatomy of double pyramidal lobe on total thyroidectomy: a rare case report

Double pyramidal lobe is a scarce anatomical variation of the thyroid gland. Its presence impinges on the completeness of total and subtotal thyroidectomy and the postoperative treatment. Surgeons should be always aware of this variation in order to perform sufficient resection of the thyroid gland and minimize the possibility of recurrence of benign and malignant thyroidopathies.

Giant condyloma acuminatum-malignant transformation

Giant condyloma acuminata are associated with malignant transformation in up to 50% of cases, high recurrence rate, and poor prognosis. Treatment strategies have included wide local excision, abdominopelvic resection, and addition of radiotherapy and adjuvant and/or neoadjuvant systemic chemotherapy.

Left-sided gallbladder (Sinistroposition) encountered during laparoscopic cholecystectomy: A rare case report and review of the literature

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LSG is a peculiar anatomical variation that is difficult to be identified preoperatively.

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LSG is associated with anatomical anomalies that may lead to intra-operative injuries.

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Safe laparoscopic cholecystectomy is feasible by placing the patient to left-side up position for better exposure of the operative field.

Introduction

True Left-sided gallbladder (LSG) is a rare anatomical variation with a prevalence of 0.3%. Mainly discovered during the operation, its surgical approach in the laparoscopic setting may be challenging even for an experienced surgeon.

Presentation of case

LSG was unexpectedly discovered in a young man during laparoscopic cholecystectomy. There were no pre-operative indications of this sinistroposition. The laparoscopic cholecystectomy was performed with minor surgical modifications and it was uneventful. A meticulous review of recent literature about LSGs was conducted as well.

Discussion

LSG is a scarce anatomical aberration that is difficultly identified pre-operatively. Surgeons should be aware of this aberration and of its accompanying anatomical variations in order to perform a safe laparoscopic cholecystectomy.

Conclusion

Surgeons, by placing the patient to left-side up position, are able to expose the Calot’s triangle and possible accompanying anatomical anomalies and thus perform a safe laparoscopic cholecystectomy without difficult surgical modifications.

Aberrant subvesical bile ducts identified during laparoscopic cholecystectomy: A rare case report and review of the literature

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Aberrant subvesical bile ducts are a rare anatomical variation defined as a network of bile ducts located in the peri-hepatic tissue of the gallbladder fossa.

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Their injury is almost inevitable and it leads to bile leakage, which is a life-threatening complication of laparoscopic cholecystectomy.

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Meticulous operative technique and detailed exposure of the operative field is the cornerstone of a safe laparoscopic cholecystectomy, when surgeons encounter this rare anatomical variation.

Introduction

Aberrant subvesical bile ducts are a scarce anatomical variation, consisted by a network of bile ducts located in the peri-hepatic capsule of the gallbladder fossa. These rare ducts are usually discovered intraoperatively and their presence poses the risk of bile injury and clinically significant bile leak.

Presentation of case

Aberrant subvesical bile ducts were unexpectedly identified in a young woman during laparoscopic cholecystectomy. These three ducts were clipped carefully for avoidance of bile duct injury and subsequent bile leak. The operation was uneventful. A meticulous review of the recent literature was conducted as well.

Discussion

This unusual anatomical variation of the biliary tract is mainly discovered during the operation. Thus, surgical injury of these ducts is nearly inevitable and it provokes the severe complication of bile leak. Bile injury represents the most crucial and life-threatening postoperative complication of cholecystectomies. Surgeons in the right upper quadrant of the abdomen should be constantly aware of this rare anatomical variation.

Conclusion

Aberrant subvesical bile ducts are associated with a high risk of surgical bile duct injury. Nevertheless, meticulous operative technique combined with surgeons’ perpetual awareness concerning this peculiar anatomical aberration leads to a safe laparoscopic cholecystectomy.

Langer's axillary arch

Langer's axillary arch is usually asymptomatic and difficult to detect preoperatively. When present, it is important for surgeons operating in the axillary region, to identify correctly the relevant anatomy. Simple surgical division is curative and necessary in order to achieve exposure of the axillary contents, lymphatic dissection, and neurovascular preservation.

Endovascular treatment of cerebral aneurysms in relation to their parent artery wall: a single center study

We report our two-year experience in the endovascular treatment of brain aneurysms in relation to their parent artery wall. We prospectively recorded patients with intracranial aneurysms (107 ruptured - 38 unruptured) treated with coiling during a two-year period: 145 patients, 94 females and 51 males - mean age 56 years. The aneurysms were divided into side-wall (A) and bifurcation (B) groups. A total occlusion rate was noted in post-embolization angiograms in 101 aneurysms (70%) with a morbidity of 4%. No angiographic recurrence arose in the six-month follow-up. The two groups had a similar total occlusion rate (68.31% and 71.8% respectively), while the complication rate was 3% in group A and 4.7% in group B. Significant differences between the two groups were noted in the number of assisted coiling cases: 28 out of 60 cases (46.7%) in group A - 14 out of 85 cases (16.5%) in group B. Further statistical analysis showed strong dependencies for the type of endovascular procedure between the ruptured and unruptured aneurysms in both groups (p 0.000<0.05), but no dependencies between the aneurysm occlusion rate and the ruptured or non-ruptured aneurysms, or between the occlusion rate and the type of endovascular procedure (p 0.552>0.05 and 0.071>0.05 respectively). In conclusion, the anatomic relation of the aneurysm sac with the wall of the parent artery is important, as significant differences in endovascular practice, devices and techniques were noted between side-wall and bifurcation aneurysms.