Lipomatosis of the ileocecal valve treated with right hemicolectomy as the consequence of an incomplete diagnostic procedure

Lipomatosis is an excessive local or general accumulation of fat in the body. It is usually asymptomatic, but depending on localization and size it can cause the patient to experience various difficulties. It can occur within digestive system as a benign mass. We report a case of a 50 year old female presented with mild intestinal symptoms and anemia. She had a lipomatous change of ileocecal valve and due to positive fecal occult blood test, barium enema and incompletely performed colonoscopy was misdiagnosed as a malignant tumor and was treated accordingly.

Histopathology of residual rectal carcinoma following preoperative radiochemotherapy

Preoperative radiotherapy with (CRT) or without chemotherapy (RT) in the management of patients with locally advanced rectal carcinoma is increasingly accepted as therapeutic modality to reduce local recurrence and improve survival, decrease tumor size and/or stage, has less toxicity compared to postoperative therapy, improves sphincter preservation and the ability to perform a curative resection. In a brief review of literature we discussed the possible prognostic role of most important pathologic parameters and their clinical implications. At present, predictive value of tumor response to neoadjuvant therapy remains uncertain, whether evaluated as five-point histological tumor regression grade (TRG) or recently proposed three-point rectal cancer regression grade (RCRG). However, most reports emphasize reduced local reccurence rates and disease-free survival advantage in patients with complete tumour regression or tumour down-staging, occuring in up to 20% and 60% of cases, respectively. Patients with advanced post-treatment tumour stage (ypT3/4), positive lymph nodes (ypN1/2), vascular invasion, positive circumferential resection margin, clearance < 2mm, or absence of tumor regression are shown to have poor clinical outcome. Among CRT-induced morphological features, only "fibrotic-type" stromal response with minimal inflammatory infiltrates and absence of surface ulceration are correlated to recurrence-free survival. Preliminary unpublished results of a pilot study from our multidisciplinary prospective trial relate to correlation of histopathologic parameters and morphologic changes to rectal cancer regression grade (RCRG). Therefore, we studied 22 consecutive patients, mean age 56 (range 23-69) years, with transmural cT3/4 stage and were subgrouped as follows: RCRG-1 (7 patients, 31.8%), RCRG-2 (9 patients, 40.,9%) and RCRG-3 (6 patients, 27,2%). In addition, 14 patients (63%) showed tumour downstaging and only 1 patient (4.5%) nodal down-staging after ypTNM restaging. There was the predominance of fibrotic-type stroma (16 patients, 72.8%) versus fibro-inflammatory response (6 patients, 27.2%), frequent tumoral necrosis (13 patients, 59%) but infrequent surface ulceration (5 patients, 22.7%) and peritumoural eosinophylic infiltration as well as endocrine cell differentiation (4 patients, 18%). The second aim of our study was to investigate determinants of radiosensitivity, i.e. the relationship between proliferative activity indices (Ki-67 and PCNA) as well as the induction of apoptosis (p53) and the tumour regression (RCRG) after neoadjuvant CRT. The interaction between Ki-67 and PCNA immunoexpression levels and the benefit of CRT was significant for Ki-67 (p = 0.03), but not for PCNA (p = 0.08) and p53 levels (p = 0.4). In a conclusion, high percentage of Ki-67-positive tumor cells in the preoperative biopsy predicts an decreased treatment response after preoperative CRT of rectal cancer. However, long-term follow-up and large studies are necessary to establish the value of regression grade and the need for its prediction by reliable biological markers.

Local recurrence and five year survival after abdominoperineal resection of the rectum due to rectal carcinoma

In the period 01.01.1991-12.31.1996, 523 operations due to rectal carcinoma were performed on the First Surgical Clinic, the Third Department for Colorectal Surgery. Most common localization of tumor was in the distal third of the rectum 65.2%. In the middle third, there were 28.9% and in the upper, intraperitoneal third 5.9%. We performed 286 low anterior stapled resections, 93 anterior resections with hand-sewn anastomosis and 144 Abdominoperineal excisions of rectum (Miles procedure). Pathohistological examination revealed adenocarcinoma in all cases. In this study we analyzed local recurrence and five-year survival after long-term follow-up in the group where Miles procedure was carried out as a potentially curative procedure (except 4.9% cased with Dukes D stage). There were 74.3% males and 23.7% females median age 59.2 years. According to Dukes classification there were 4.9% in stage A, 47.2% in stage B, 43.1% stage C, and 4.9% stage D. There were 4(2.7%) postoperative deaths. Recurrence of the disease was registered in 44 (30.5%) patients. Local recurrence alone was found in 14 (9.7%) patients, while distant spread was registered in 30 (20.8%) patients. At present, the median follow-up is at 72.9 months. Analysis by the Kaplan-Meier's test shows cumulative survival of 61%, and disease free survival of 63.4% at 60 months of the follow-up. Dukes C is associated with a very poor prognosis; survival after 60 months of follow up shows cumulative Survival of 0.35 while Dukes B has far better prognosis (0.86). Analysis of disease free survival by Dukes stage shows that Dukes C has the worst prognosis (disease free survival 0.36 after 60 months), while stage B has much better prognosis (0.84). Local recurrence analysis by the Kaplan-Meier's test shows disease free survival of 84.9% at 60 months of follow-up. Analysis of local recurrence by Dukes stage shows 1.00% disease free survival for cases in stage A, 0.94 for Dukes B and 0.66 for Dukes C, while overall comparison between groups regarding local recurrence using the Wilcoxon (Gehan) statistic shows statistically significant difference (p-0.005). There is no statistical difference between Dukes A and Dukes B cases in distribution of local recurrence.

Double mucinous cystadenoma of the pancreas associated with thecoma of the ovary

Cystadenomas of the pancreas are rare single and isolated tumors, usually appearing in young and middle aged women. Thecomas are rare usually unilateral, benign, estradiol, much rarer androgens producing ovarian tumors. We present a 19 year old girl in whom we removed two mucinous cystadenomas of the tail of the pancreas, 7 and 2 cm in diameter as well as a thecoma of the right ovary. As far as we know this combination of tumors have not been reported before.

The role of overlapping sphincteroplasty in traumatic fecal incontinence

Fecal incontinence is one of the most distressing conditions. Even there is a great variety of etiologic factors, they can be systematized in two main categories; fecal incontinence with normal and fecal incontinence with abnormal function of pelvic floor muscles. The latter is more interesting for surgeons since this category includes the great majority of surgically caused and surgically correctable fecal incontinences. Disruption of the anal sphincter caused by obstetric injury, anorectal operations or external trauma is the commonest cause of fecal incontinence. In the period 1990-1999, 53 patients with fecal incontinence caused by sphincter injury were treated on the third department for colorectal surgery, First Surgical Clinic. There were 43 females and 10 males with a mean age of 36.1 years (range 18-64). Causes of fecal incontinence were: obstetric trauma 38 patients. (71%), fistulotomy 9 (17%), war injuries 3 (6%) and nonspecific 3 (6%). The severity of incontinence was graded by Browning--Parks's classification. There were no patients in group A and B, in group C were 11 patients and in D group 37 patients. Wexner score system was also utilized preoperatively and postoperatively to determine continence function more precisely. Clinical exam, anoscopy and special investigations, such as anal manometry, EMG and defecography were carried out in all cases. Period between injury and repair was between 6 months and 20 years. Severe pudendal neuropathy was present in 17 patients. Five patients had oostomies performed at the time of injury. In three cases was present traumatic cloaca and in one case rectovaginal fistula. Overlapping sphincter repair technique was carried out in all cases. Full bowel preparation and antibiotics were prescribed. Anterior sphincteroplasty was performed in 39 cases, lateral in 7, posterior in 3 and anterior sphincteroplasty + posterior plication of puborectalis (Parks operation) in 4 patients. Protective colostomy was not performed in any case. The outcome of the procedure was considered as excellent, good, fair and poor (excellent when full control of solid and liquid stool and flatus was achieved, good when there was continence to feces but not to flatus, fair when patients could control only solid feces and poor when only partial control of solid feces was obtained). The overall functional results were as follows: Excellent in 25 patients (47.2%), good in 12 (22.7%), fair in 11 (20.7%) and poor in 5 (9.4%). Wound infection occurred in 9 (16.9%) patients, leading to disruption of sutures in three patients with consequent poor results. Two of them were reoperated. The duration of follow-up was from 5 to 60 months. We conclude that an overlapping sphincteroplasty is a method of choice in treating fecal incontinence caused by trauma. The best results are achieved with anterior sphincteroplasty. Results of posterior sphincteroplasty were disappointing. If present, pudendal neuropathy directly influences the outcome of sphincteroplasty. Manometric studies correlate with the clinical outcome.

[Acute lung injury related to blood transfusion]

Transfusion-related acute lung injury (TRALI) is a second most serious complication of the blood transfusion. It is a group of symptoms and signs such as dyspnoea, hypotension, cyanosis, cough, elevated temperature, fever and lung oedema that usually develops within an hour or two after transfusion. The full stage clinical presentation is developed between 4th and 6th hours after transfusion. The syndrome is caused by leucoagglutinins or by other lymphocytotoxic antibodies specific for some antigens present on the donor's leukocytes. Alveoles of the lung are the main place of the pathological changes such as intra-alveolar oedema, haemorrhage, hyaline membrane formation, alveolar cell hypertrophy and scant interstitial inflammation. Chest X-ray showed bilateral pulmonary infiltrates but without vascular congestion and with normal cardiac silhouette comparing to the status before transfusion. The syndrome has to be distinquished from pulmonary oedema caused by acute cardial insufficiency, overhydration, trauma and sepsis.

Long-term results after low anterior stapled anastomosis

In the period 01.01.1991-12.31.1996, 286 low anterior stapled resections of the rectum due to rectal carcinoma were performed at the First Surgical Clinic, the Third Department for Colorectal Surgery, Belgrade. There were 57% males and 43% females, median age 59.6 years. The most common localization of tumor was in the distal third of the rectum 181 (63%). In the middle third, there were 89 (31%) and in the upper, intraperitoneal third 16 (6%). Histopathological examination revealed adenocarcinoma in all cases. All operative specimens were examined by one pathologist and classified according to the Gunderson-Sosin modification of Dukes classification. There were 14 (4.9%) in stage A, 167 (58.4%) in stage B (B1,B2,B3), 89 (31.1%) stage C (C1,C2,C3) and 16 (5.6%) stage D. According to Broders classification, there were 129 (45%) well differentiated, 142 (50%) moderately and 15 (5%) poorly differentiated tumors. Anastomotic dehiscence was found in 17 patients (5.95%), mostly conservatively treated, except in 6 cases where spreading peritonitis developed requiring operative treatment. There were 9 (3.1%) postoperative deaths, a half of them with specifically operation related mortality. Recurrence of the disease was registered in 47 (18%) patients, out of 260 who were regularly followed up (26 were lost). Local recurrence alone was found in 21 (8.0%) patients, while distant spread was registered in 22 (8.46%) patients. Local and distant spread was found in 4 (1.5%) cases. At present, the median follow-up is at 54 months. Analysis by the Kaplan-Meier's test shows cumulative survival of 66% at 71 months of the follow-up. Seventy four percent of patients with curative operations exhibit no signs of recurrence at 5 years.

[Surgical treatment of ulcerative colitis--"pouch" or ileorectal anastomosis]

Treatment of Ulcerative Colitis was always a challenge for a therapeutist. The therapy of the disease is usually conservative but when refractory or complications occur, surgical treatment is the only appropriate solution. Evolution of surgical techniques in treatment of Ulcerative colitis from bipolar colostomies, by-pass procedures, partial resections, colectomies, proctocolectomies to recent restorative procedures with the ileal-pouch and preservation of the continuity of digestive tract, shows the severity of the disease and explains the dilemmas which surgeons had in choosing the appropriate operation. Inauguration of ileal reservoir in late seventies, brought a new advancement in postoperative results measured by better function and quality of life. Even the ileal reservoir proved its superiority in surgical treatment of Ulcerative colitis, some dilemmas still persist. Should be rectum and continuity of digestive tract preserved by ileal-rectal anastomosis or by restorative coloproctocolectomy and ileal-pouch-anal anastomosis?

[Spontaneous massive retroperitoneal hemorrhage from an adrenal gland cyst]

Adrenal cyst are rare disease. Bleeding, particularly massive, from these cysts is even rarer. The cyst causing spontaneous massive retroperitoneal bleeding in a 17 year old girl is presented. Adrenalectomy was successfully carried out. The patient stayed symptom free so far.

Cystadenomas of the pancreas

Cystadenomas of the pancreas are rare tumors. They represent about 10% of the pancreatic cystic masses. Several hundred cases seem to have been reported so far. These tumors appear as serous and mucinous. Over 13 years period (1983-1996) we treated 22 patients for cystadenoma of the pancreas. All patients were women. There were 6 serous and 16 mucinous cystadenomas. The average age in the serous group was 31 years (ranging from 23 to 42 years) and 43 years (ranging 17-64) in mucinous group. Two patients had tumor in the head, 20 others in the tail and body of the pancreas. The diameter of these tumors varied from 3.5 to 17.0 cm (average 9.6 cm). The leading symptoms were epigastric or left subcostal pain in 19 patients, palpable mass in 10, weight loss in 5, vomiting in 5, and melena in one patient. Tumor was accidentally found in a women undergoing abdominal operation for enteric fistula after hysterectomy. Serum amylase was moderately elevated in two patients. Diagnosis of pancreatic cystadenoma was proposed preoperatively in 16 patients (72.7%). In other cases, diagnoses of pancreatic cysts in 5 patients or hydatid cyst in 1 patient were made. An ideal operative removal (excision) was done in 7 patients, both excision of the tumor and splenectomy in 2, while distal pancreatectomy and splenectomy were carried out in 13 others. There was no mortality. One female patient developed left subphrenic abscess and left pleural effusion which were successfully treated by drainage and thoracocenthesis. One patient developed transient pancreatic fistula. All patients have been under close follow-up from 6 months to 13 years and all stayed symptom free so far.

[Dynamic graciloplasty in the treatment of severe fecal incontinence--2 case reports]

Severe fecal incontinence is a serious problem not only for the patient whose quality of life is diminished, but also for the surgeon, who sometimes has difficulties how to manage all the aspects of this complicated condition. Conservative treatment is often ineffective, while operative sphincter repair is feasible only when anal sphincter is relatively functional and conserved. Dynamic graciloplasty is a method where functional anal neosphincter is constructed by transposing m. gracilis and wrapping it around the anal canal with subsequent implantation of electric neurostimulator and electrodes. Relatively good continence can be achieved with this technique, especially in-patients where all other therapeutic options failed. We present two patients, 25 and 21 years old, operated on our department, both suffered from severe fecal incontinence from the time they were born. They were interviewed, underwent a physical examination and evaluated by anal manometry, defecography and electromyography. Severe fecal incontinence was revealed (18 and 20, according to the Continence grading scale). In both cases, Gamma graciloplasty was performed. At first patient, implantation of the neurostimulator was performed 8 months after graciloplasty, while in second case, both graciloplasty and implantation of the electrodes with neurostimulator were performed at the same time. Postoperative recovery was uneventful in both cases. There was minor infection of the perineal wound in one patient. Electrostimulation training program was started on 9th postoperative day in both cases. Functional results were revealed by questionnaire and anal manometry. The quality of life was significantly improved in both cases, with good continence and psychological recovery. Anal manometry revealed increased anal contraction pressure comparing with preoperative basal and squeeze pressures. Dynamic graciloplasty is a relatively new; high specialized method in treatment of intractable, fecal incontinence. It is safe and reliable procedure in hands of an well-experienced surgeon, if well indicated and performed.