First Case of Human Anisakiosis in Greece: Acute Invasive Infection Mimicking Peritoneal Malignancy

Consumption of raw and mildly processed seafood, in the context of modern Western world eating trends, is recognized as a major driver for human fish-borne infections. However, these zoonoses and their unfamiliar risks remain neglected and underappreciated among European diagnosticians. In contemporary Europe anisakidosis is one of the most important fish-borne zoonoses. It is caused by ingesting the third-stage infective larvae of the nematode parasites that belong to the family Anisakidae. The case described herein, is an intestinal and ectopic form of anisakiosis (Anisakis spp.), causing symptoms of subacute abdomen and masquerading as an intraperitoneal malignancy. It is the first anisakidosis case reported in Greece, affecting a young patient who had been repeatedly exposed to the parasite by consuming homemade raw fish. Right hemicolectomy, omentectomy and excision of a descending colon nodule were uneventfully performed. The pathology report confirmed granulomatous tissue with eosinophilic infiltration and parasites that were morphologically and molecularly identified as Anisakis spp. Although challenging, acquiring an accurate diagnosis of anisakidosis can prevent unnecessary surgery, as the infection typically is self-resolving, and if treatment is deemed necessary, it can be limited to antiparasitic medication. However, in rare cases, extra-gastrointestinal migration of larvae can cause severe damage with practically unknown risks, posing a diagnostic and therapeutic dilemma. In such a clinical case scenario, surgical exploration can decisively contribute to a definitive diagnosis and early identification of intraabdominal complications necessitating surgical intervention.

Successful surgical management of massive hemoretroperitoneum caused by spontaneous rupture of retroperitoneal lymph node metastases in a patient with advanced mixed germ cell tumor: a COVID-19 pandemic-related surgical challenge

BACKGROUND

Spontaneous rapture of a germ cell tumor (GCT) metastases causing massive hemoretroperitoneum in a patient without choriocarcinoma component who has not received previous systemic chemotherapy is an exceedingly rare event. In such a devastating case scenario, a high index of clinical suspicion for early diagnosis and appropriate management is crucial.

CASE PRESENTATION

We report on a 25-year-old male patient with a 4-month history of orchiectomy for testicular GCT (tGCT), who presented in the emergency department with acute abdomen and hemodynamic instability. Urgent computed tomography scan depicted a retroperitoneal mass measuring approximately 13 × 11.4 × 15 cm and massive intraperitoneal hemorrhage. Hemoperitoneum caused by spontaneous rapture of the metastatic retroperitoneal mass was suspected. COVID-19 pandemic-related deviation from the oncologic surveillance standards combined with COVID-19-related patient's emotional distress and self-neglect had led to loss of opportunity for appropriate adjuvant chemotherapy, obviously leading to the development of this devastating complication. An emergency, surgical exploration was decided. The bleeding mass was adequately exposed following a Cattell-Braasch maneuver and active bleeding was controlled by a challenging resection of approximately 80% of the lymph node mass volume. Pathological evaluation of the specimen revealed teratoma with low volume of yolk sac tumor component and extensive necrosis, findings compatible with the patient's history. Postoperative recovery was uneventful, followed by early start of adjuvant chemotherapy. Two years after the operation the patient is doing well with no evidence of recurrent disease.

CONCLUSIONS

Massive hemoperitoneum is a devastating event that exceedingly rarely can complicate the clinical course of patients with advanced tGCT. Emergency surgical intervention is usually necessary however, sound judgement and careful surgical techniques are required for a positive and uneventful outcome. During COVID-19 pandemic, first-line medical personnel push their limits further not only to ensure health care services standards but also, to manage unpredictable, life-threatening cancer-related complications, associated with COVID-19-related deviation from appropriate oncologic surveillance and care.

Bile Duct Injuries during Laparoscopic Cholecystectomy: Management and Outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux- en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux- en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.

Isolated aberrant right cysticohepatic duct injury during laparoscopic cholecystectomy: Evaluation and treatment challenges of a severe postoperative complication associated with an extremely rare anatomical variant

A typical bile duct branching patterns represent one of the major causes of bile duct injury (BDI) during laparoscopic cholecystectomy (LC). The most common classified variations of bile duct branching, involve the right posterior sectoral duct (RPSD) and its joining with the right anterior or left hepatic duct. Variant bile duct anatomy can rarely be extremely complex and unclassified. This report describes an extremely rare case of an isolated injury to an aberrant right hepatic duct formed by the joining of ducts from segments V, VII, and VIII draining into the cystic duct (cysticohepatic duct) during LC, associated with an inferior RPSD opening to left hepatic duct. Detailed evaluation of both endoscopic and magnetic cholangiograms established the diagnosis. Bile duct injury was subsequently managed surgically by a demanding Roux-en-Y hepaticojejunostomy. This extremely rare case aims to serve as a useful reminder of the consistent inconsistency of biliary anatomy, alerting surgeons to beware of variant bile duct branching patterns during open or LC that constitute a dreadful pitfall for severe and life-threatening bile duct injuries.

Benign Tumours and Pseudotumours Within the Porta Hepatis Masquerading as Perihilar Cholangiocarcinoma

BACKGROUND

Hilar cholangiocarcinoma (HC), also referred to as Altemeier-Klatskins tumour, is a lethal primary extrahepatic carcinoma of biliary epithelial origin, arising within 2cm of the hilar confluence. Radical surgical excision provides the best chance for a cure; however, the management of patients with HC is challenging not only because of the need for a high level of skill in biliary and hepatic resections, but also because of the difficulty in reaching an accurate diagnosis preoperatively. In fact, the differential diagnosis of HC is a diagnostic dilemma which is currently persisting, as modern, sophisticated diagnostic modalities are not always able to provide a definitive preoperative diagnosis. This difficulty is compounded by the fact that alternative entities that mimic HC may be present in up to 25% of patients with hilar obstruction. This makes precise preoperative characterisation of a hilar stricture extremely important by preventing unnecessary, high-risk, major surgical procedures. Therefore, alternative benign entities masquerading as Altemeier-Klatskins tumour deserve an important place in the differential diagnosis of hilar obstruction.

PURPOSE

Considering the important clinical implications that a precise diagnosis of the aetiological cause of a biliary obstruction at the liver hilum would have, this paper will focus on the differentiation between HC and benign hilar obstructions and will review benign tumours and pseudotumours masquerading as HC along with their specific diagnostic features.

Endoscopic full-thickness resection of colorectal lesions with the full-thickness resection device: clinical experience from two referral centers in Greece

Background:

Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD^®) is an invasive treatment for colorectal lesions not resectable by conventional endoscopic techniques. This study presents the first Greek experience of the FTRD^® procedure, assessing the efficacy and safety of EFTR.

Methods:

We conducted a retrospective analysis of 17 consecutive patients treated with the FTRD^® at 2 referral centers from October 2015 through December 2018. The indications included difficult adenomas (non-lifting and/or at difficult locations), early adenocarcinomas and subepithelial tumors. Primary endpoints were technical success and R0 resection.

Results:

Technical success and R0 resection were achieved in 82.3% procedures (14/17) and in 87.5% of those with difficult adenomas (8 patients). In the subgroup with carcinomas (n=3), the rate of technical success and R0 resection was 66.6%, while in the subgroup with subepithelial tumors (n=6) the rate was 83.3%. Technical success and R0 resection were significantly lower for lesions >20 mm vs. ≤20 mm (P=0.0429). In the 17 patients a total of 3 adverse events occurred (17.6%) and one of the patients underwent laparoscopic appendectomy because of EFTR around the appendix.

Conclusions:

Our study showed favorable results concerning EFTR feasibility, efficacy and safety, especially for lesions ≤20 mm, non-lifting adenomas, and subepithelial tumors. Technical success, R0 resection, and adverse events rates were comparable with previously published data. Larger randomized studies are needed to better define the clinical benefit and long-term outcomes of EFTR in selected patients.

Hospitalisations for heart failure predict mortality in pulmonary hypertension related to congenital heart disease

OBJECTIVE

Despite the progress in the management of patients with adult congenital heart disease (ACHD), a significant proportion of patients still develop pulmonary hypertension (PH). We aimed to highlight the rate of the complications in PH-ACHD and the predicting factors of cumulative mortality risk in this population.

METHODS

Data were obtained from the cohort of the national registry of ACHD in Greece from February 2012 until January 2018.

RESULTS

Overall, 65 patients receiving PH-specific therapy were included (mean age 46.1±14.4 years, 64.6% females). Heavily symptomatic (New York Heart Association (NYHA) class III/IV) were 53.8% of patients. The majority received monotherapy, while combination therapy was administered in 41.5% of patients. Cardiac arrhythmia was reported in 30.8%, endocarditis in 1.5%, stroke in 4.6%, pulmonary arterial thrombosis in 6.2%, haemoptysis in 3.1% and hospitalisation due to heart failure (HF) in 23.1%. Over a median follow-up of 3 years (range 1-6), 12 (18.5%) patients died. On univariate Cox regression analysis history of HF hospitalisation emerged as a strong predictor of mortality (HR 8.91, 95% CI 2.64 to 30.02, p<0.001), which remained significant after adjustment for age and for NYHA functional class.

CONCLUSIONS

Long-term complications are common among patients with PH-ACHD. Hospitalisations for HF predict mortality and should be considered in the risk stratification of this population.

Surgical treatment of atrial septum lipomatous hypertrophy associated with syncopal attacks

Lipomatous hypertrophy of atrial septum (LHAS) is a rare benign cardiac condition characterized by fatty tissue infiltration located in the atrial septum. We presented a rare case of LHAS resulting in recurrent syncopal attacks.

Delayed duodenal stump blow-out following total gastrectomy for cancer: Heightened awareness for the continued presence of the surgical past in the present is the key to a successful duodenal stump disruption management. A case report

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Duodenal stump disruption is not a surgical anachronism, because it still remains one of the most dreadful postgastrectomy complications.

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Postgastrectomy duodenal stump disruption poses an overwhelming therapeutic challenge.

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Historical surgical sense and familiarity with the various well established methods for the treatment of duodenal stump disruption can provide to the surgical team the ability to successfully manage this devastating complication.

INTRODUCTION

Duodenal stump disruption remains one of the most dreadful postgastrectomy complications, posing an overwhelming therapeutic challenge.

PRESENTATION OF CASE

The present report describes the extremely rare occurrence of a delayed duodenal stump disruption following total gastrectomy with Roux-en-Y esophagojejunostomy for cancer, because of mechanical obstruction of the distal jejunum resulting in increased backpressure on afferent limp and duodenal stump. Surgical management included repair of distal jejunum obstruction, mobilization and re-stapling of the duodenum at the level of its intact second part and retrograde decompressing tube duodenostomy through the proximal jejunum.

DISCUSSION

Several strategies have been proposed for the successful management post-gastrectomy duodenal stump disruption however; its treatment planning is absolutely determined by the presence or not of generalized peritonitis and hemodynamic instability with hostile abdomen. In such scenario, urgent reoperation is mandatory and the damage control principle should govern the operative treatment.

CONCLUSION

Considering that scientific data about duodenal stump disruption have virtually disappeared from the current medical literature, this report by contradicting the anachronism of this complication aims to serve as a useful reminder for gastrointestinal surgeons to be familiar with the surgical techniques that provide the ability to properly manage this dreadful postoperative complication.

The rare sprengel deformity: our experience with three cases

Sprengel shoulder is a rare congenital deformity of one or both scapulae that is usually detected at birth. It occurs due to failure of the scapula to descend during intrauterine development and its cause is still unknown. Although the deformity appears randomly most of the time, familial cases have been reported. Sprengel shoulder is often associated with Klippel–Feil syndrome and other congenital skeletal deformities. Anteroposterior X-ray imaging can accurately diagnose Sprengel deformity. However, computed tomography and magnetic resonance scans with three-dimensional reconstruction are nowadays used in everyday practice in order to diagnose concomitant abnormalities, study in detail the anatomy of the affected shoulder(s), and plan appropriate management. We present here our imaging experience from three pediatric cases with Sprengel shoulder and take the opportunity to discuss this rare entity, which is, nevertheless, the commonest congenital defect of the scapula.

Retroperitoneal extra-adrenal ganglioneuroma involving the infrahepatic inferior vena cava, celiac axis and superior mesenteric artery: A case report

INTRODUCTION

Ganglioneuromas are rare benign neoplasms arising from the sympathetic neuroendocrine system. These tumors usually occur in the abdomen and tend to grow around major blood vessels making often their complete excision challenging and demanding.

PRESENTATION OF CASE

The authors present the challenging surgical management of a sizable retroperitoneal extra-adrenal ganglioneuroma involving the infrahepatic inferior vena cava, portal triad, celiac axis and superior mesenteric artery in a 23-year-old female patient. The tumor was safely and completely excised in toto with preservation of all neighboring vital anatomical structures using a midi laparotomy access.

DISCUSSION

Ganglioneuromas should be included in the differential diagnosis of any retroperitoneal mass. Their management involves total surgical excision however, in some instances; it can be challenging and demanding because of their tendency to engage neighboring vital anatomical structures.

CONCLUSION

A surgical strategy including meticulous operative dissection guided by the quality principles of surgical oncology although challenging and demanding can result to a safe and complete tumor excision, which is directly correlated with an improved patients' postoperative outcome and excellent prognosis.

Alanine-glutamine dipeptide pretreatment protects rat renal function from small intestine ischemia-reperfusion injury

AIM

Oxidative injury can cause renal function impairment and failure. Glutathione, a free radical scavenger, plays in the kidney a central role in oxidant-related events. The aim of this study was to investigate the potential beneficial effect of glutamine, a precursor of glutathione in the form of alanine-glutamine dipeptide (AGD) on small intestine ischemia/ reperfusion (I/R)-induced oxidant renal damage in rats.

METHODS

Wistar rats were subjected to intestinal I/R for 30 min, induced by occlusion of the superior mesenteric artery, followed by 60 min reperfusion. AGD pretreatment was given 48 and 24 hours before I/R. At the end of the experimental procedure the left kidney was excised and a thin tissue slice was obtained for electron microscopy study. Kidney biopsies were obtained for malonyl dialdehyde, myeloperoxidase, and glutathione assays.

RESULTS

Intestinal I/R caused significant oxidative injury in rat renal parenchyma consisted of severe alterations observed in subcellular renal structures associated with a significant increase in renal malonyl dialdehyde levels and a significant decrease in renal glutathione levels. Changes regarding subcellular renal structures were ameliorated in AGD pre-treated animals in which renal glutathione levels did not decreased significantly.

CONCLUSION

Glutamine pretreatment in the form of AGD can prevent small bowel I/R-induced oxidant renal damage in rats.

Splenic artery aneurysm in a cardiac transplant patient: a case report

We present the case of a 61-year-old woman who underwent repair of a symptomatic 4-cm splenic artery aneurysm. This patient had received heart transplantation for hypertrophic congestive cardiomyopathy 5 years before this event. She was under immunosuppression therapy with cyclosporine, prednisone and azathioprine. The aneurysm was ligated both proximally and distally without removal of the spleen. To our knowledge, this is the first reported case of an isolated splenic artery aneurysm in the heart transplant population. We discuss the potential role of immunosuppressive agents and hormonal factors in the development of this extremely rare occurrence.

Profunda femoris as an access site vessel for a hybrid approach to the treatment of a para-anastomotic common iliac artery aneurysm and intermittent claudication, occurring after previous abdominal aortic thbe graft repair and femoro-femoral bypass graft. A case report

A true para-anastomotic right common iliac artery aneurysm and intermittent claudication developed in a 76-year-old man 5 years after open abdominal aortic aneurysm repair with a Dacron tube graft. Following the initial operation the patient developed acute left iliac occlusive disease necessitating an immediate right-to-left femoro-femoral crossover bypass graft. The patient was a poor open surgical candidate because of multiple medical comorbidities. Therefore, a hybrid approach was used consisting of exposure and catheterization of the right profunda femoris artery, which was used as the access site vessel for the deployment of a covered stent graft extending from the ostium of the common iliac artery into the external iliac artery. Simultaneously, the right profunda femoris provided inflow for an open above-knee profunda femoro-popliteal bypass graft to perfuse the right lower extremity. Postoperative angiography demonstrated primary technical success, with exclusion of the aneurysm and no endoleak. The patient is doing well 34 months postoperatively, with a patent endograft and no sign of intermittent claudication. Profunda femoris proved to be an excellent alternative to the common femoral artery for the application of a hybrid technique in a high-risk patient with complicated anatomy.

Early endograft collapse following endovascular treatment of a traumatic thoracic aortic disruption: a case report

The authors present the case of a 39-year-old man who underwent endovascular repair of a thoracic aortic disruption. Implantation of a Gore TAG stent-graft achieved total exclusion of the traumatic lesion with no contrast extravasation. However, on the third postoperative day, the patient developed complete anuria necessitating continuous venovenous hemofiltration. On the IV postoperative day there were no palpable femoral pulses and the pressure gradient between the lower and upper limbs was -80 mmHg. Given the development of severe intestinal and peripheral hypoperfusion status a possible endograft collapse was suspected. Urgent computed tomography (CT) angiography demonstrated central subtotal collapse of the device and proper distal sealing. A second TAG stent-graft was deployed successfully within the collapsed device with no contrast extravasation and good apposition of the stent-graft to the aortic wall. At 6 months, there is no sign of graft collapse or endoleak. Endovascular reintervention succeeded re-expansion of the collapsed endoprosthesis and resolution of the initial symptoms.

Appendectomy for an adult with cyanotic congenital heart disease

Few patients with cyanotic congenital heart disease reach adulthood without a cardiac operation. The prognosis for ''unrepaired'' pulmonary atresia with ventricular septal defect is approximately 8% in the 1st decade of age. Consequently, the number of adults with this particular heart disease (unrepaired) who are expected to need a non-cardiac surgery is extremely low. General anesthesia may aggravate the preexisting right to left shunt and lead to persistent severe hypoxemia. The goal of anesthetic management should be to maintain intravascular volume. Systemic and pulmonary vascular resistance changes, such as might occur due to acidosis, hypothermia, hypercarbia or excessive airway pressures, should be avoided. Maintenance of preload, contractility and sinus rhythm is of major importance. The complex pathophysiology of such heart disease, in addition to the circumstances of emergency operation, exacerbate the total anesthetic risk. We present here a rare case of an acute appendectomy with successful outcome in an adult with pulmonary atresia and ventricular septal defect.

Feasibility of therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones in nonagenarians: a single unit audit

BACKGROUND

Little information is available on short and long-term outcome of therapeutic endoscopic retrograde colangiopancreatography (ERCP) for choledocholithiasis in nonagenarians (>=90 years). The aim of this study was to evaluate retrospectively the feasibility of therapeutic ERCP in nonagenarians with choledocholithiasis, as compared with patients aged between 75 and 89 years.

PATIENTS AND METHODS

During a 9-year period, therapeutic ERCP was performed for choledocholithiasis in 33 nonagenarian patients (group A) and 272 patients aged 75 to 89 years (group B). Clinical features, endoscopic findings, interventions, early and long-term results of therapeutic ERCP for a mean follow-up of 36 months were assessed and compared between the two groups.

RESULTS

Group A patients had a higher incidence of acute cholangitis, concomitant diseases and gallbladder stones, as compared to group B patients. Furthermore, they required an emergency procedure, multiple sessions, stent insertion, and needle knife fistulotomy significantly more frequently (p<0.001). Group B patients underwent significantly more endoscopic manipulations and had a longer procedure time than group A patients. Complete bile duct stone clearance was achieved in 24.2% of group A patients and in 90.8% of group B patients (p<0.001). No ERCP related deaths occurred in group A patients. Cholecystectomy was not routinely performed in Group A patients having gallbladder stones. The rate of early and late complications was not significantly different between the two age groups.

CONCLUSION

Therapeutic ERCP and biliary stenting have proved to be a feasible treatment option for the management of choledocholithiasis in nonagenarians.

Submucosal lipoma of the ascending colon as a source of massive lower gastro-intestinal bleeding: a case report

Colonic lipomas are relatively uncommon lesions. They have been documented as the source of massive low gastro-intestinal bleeding in only five previous reports in the English language literature. We report an extremely rare case of massive haemorrhage caused by an ascending colon submucosal lipoma and review the pathophysiology, diagnosis and management.

Management of Boerhaave's syndrome: report of three cases

From 2000 to 2005, three patients with Boerhaave's syndrome were successfully managed in our Department. Two of them received the appropriate treatment belatedly, with primary closure and bolstering tissue wrap. One of them required further intervention with a cervical esophagostomy and exclusion of the perforated esophagus. The third patient with an esophageal perforation related disorder, was managed with surgical exploration and drainage alone. Primary suturing of the esophagus should be performed only in patients with an early perforation. In cases of prolonged delay between rupture and diagnosis, esophageal resection with cervical esophagostomy and gastrostomy is advocated as the safest therapy.

Reliability of selective surveillance colonoscopy in the early diagnosis of colonic ischemia after successful ruptured abdominal aortic aneurysm repair

PURPOSE

To evaluate the reliability of selective surveillance colonoscopy based on 6 specific perioperative risk factors in the early diagnosis of colonic ischemia (CI) after successful ruptured abdominal aortic aneurysm (rAAA) repair.

PATIENTS AND METHODS

From 1999 to 2005, 62 consecutive patients underwent rAAA repair. In 59 of them, routine aggressive surveillance colonoscopy was offered every 12 hours within the first 48 hours, and CI was graded consistently. Patients with stage I or stage II CI were treated conservatively and were followed up with repeat colonoscopy, whereas patients with stage III CI underwent immediate laparotomy and colectomy. In parallel, 6 specific perioperative risk factors (PRFs) were retrospectively analyzed.

RESULTS

Overall mortality was 33.9%. Nineteen patients (32.2%) developed CI and 12 (63.2%) of them survived. Thirteen (22%) had grade III CI and among these 6 survived. In patients with CI the mortality rate was 36.2%. Patients with less than 3 PRFs had no CI whereas all instances of CI could be diagnosed if colonoscopy was offered selectively in patients with more than 3 PRFs. The positive predictive value of CI increased with the number of PRFs. Patients with 5 or 6 PRFs were about 101 times more likely to develop CI compared with patients with 0 to 4 PRFs (P<.001).

CONCLUSION

Our study showed that CI is a frequent complication after successful rAAA repair and could reliably be early diagnosed if surveillance colonoscopy was offered selectively in patients with more than three PRFs.

Earlier eradication of intra-anal warts with argon plasma coagulator combined with imiquimod cream compared with argon plasma coagulator alone: a prospective, randomized trial

PURPOSE

Despite the increasing incidence of condylomata acuminate, optimal treatment of anal warts is still undecided. This prospective, randomized study was designed to compare the efficacy of combined argon plasma coagulation and imiquimod cream vs. argon plasma coagulation alone in the management of intra-anal warts.

METHODS

From October 2002 to March 2005, 49 patients with intra-anal warts were randomly assigned to argon plasma coagulation plus imiquimod cream (n = 24) vs. argon plasma coagulation alone (n = 25). Therapeutic sessions were repeated until the elimination of the warts. Efficacy of therapy was defined as the time needed for eradication. All patients were followed up for a mean period of 12 months for signs of recurrence.

RESULTS

Elimination of warts was achieved earlier in patients receiving combination therapy compared with those receiving monotherapy with argon plasma coagulation (62.5 +/- 5.4 days vs. 91.2 +/- 6.4 days; P = 0.0016). A subgroup analysis performed in HIV-positive patients showed similar results (combination therapy 95 +/- 22.6 days; monotherapy 124.3 +/- 20.7 days; P = 0.033); however, in HIV-positive patients warts were eradicated later compared with HIV-negative patients (110.8 +/- 25.7 days vs. 65 +/- 25.4 days; P < 0.0001). No major complications were observed in our study population. After the follow-up period, recurrence of warts was evident in 22.7 percent of patients in the combination group compared with 34.7 percent of patients in the monotherapy group (P = 0.51). Recurrence was significantly higher in HIV-positive patients compared with HIV-negative patients (P = 0.0039).

CONCLUSIONS

Combination therapy with argon plasma coagulator plus imiquimod cream results in earlier clearance of intra-anal warts in both immunocompetent and immunocompromised patients; however, it does not affect the rate of recurrence.

A single-center experience in the management of Altemeier-Klatskin tumors

AIM

of this study is to present our experience in the management of patients with Altemeier-Klatskin tumor, with particular focus on the risk factors that influence survival after tumor resection.

METHODS

Over a 15-year period, 37 patients with hilar cholangiocarcinoma were managed in our Department. The mean age of the patients was 62.5 years. Twenty-one patients were treated by palliative measures while sixteen patients had resection of the tumor and 11 of these had negative histological margins. An associated major hepatectomy was performed in six. In parallel, certain risk factors that could influence survival were analyzed.

RESULTS

The resectability rate was 43.2%. The 30-day mortality rate was 7.4% and postoperative morbidity was 37.5%. The sites of the resected tumors were Bismuth-Corlette type I lesions in 3 patients, type II in 6, type IIIa in 2, and type IIIb in 5. The median survival of patients undergoing resection was significantly higher than of patients not undergoing resection (p<0.001). Furthermore, patients with R0 resection and histological clear margins experienced significantly superior survival than patients with R1 resection and positive margins (p=0.001, and p<0.001 respectively). Resections resulting in cancer-positive margins did not portend a survival benefit.

CONCLUSION

Negative surgical margins, tumor differentiation and infiltrating macroscopic appearance, were statistically significant prognostic factors. Our findings emphasize that complete resection of the tumor with negative histological margins offers the best possibility of long-term survival, and that the addition of hepatectomy to biliary resection results in a greater number of patients with margin negative resections.

Management of nonfunctioning pancreatic endocrine tumors in the context of multiple endocrine neoplasia type 1 syndrome

The aim of our study is to present our experience in the surgical treatment of nonfunctioning pancreatic endocrine tumors (NFPETs) in patients with multiple endocrine neoplasia type 1 (MEN-1).

PATIENTS AND METHOD

Between 1996 and 2006 a total of 11 patients with clinically confirmed MEN 1 syndrome were monitored in an annual screening program that included evaluation of the pancreas. Our policy was to use Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and Endoscopic Ultrasound (EUS) in combination with biochemical screening in an effort to early diagnose and categorize the pancreatic involvement in MEN-1.

RESULTS

NFPETs were identified in 4 female patients (36.4%). Diagnosis of NFPET was established 4.2 years later than that of MEN 1. The median tumor diameter at diagnosis was 2.2 cm (range 1.8-2.6 cm). All patients were treated by distal pancreatectomy. Diagnosis of NFPET was established in histological sections by staining with neuroendocrine tumor markers. Adjuvant therapy with streptozocin in combination with 5-fluorouracil was applied in two patients. After surgery the patients were followed up annually with clinical evaluation, biochemical tests and imaging studies.

CONCLUSIONS

Early detection of NFPETs in patients with MEN-1 syndrome can be accomplished by biochemical and radiological screening program. NFPETs should be removed when diagnosed, in order to achieve a timely and efficient prophylaxis against further tumor growth and malignant development.

Pseudoaneurysm of the popliteal artery complicated by peroneal mononeuropathy in a 4-year-old child: report of a case

Pseudoaneurysms of the popliteal artery (PPA) rarely occur in children. In fact, we found only 10 cases reported in the medical literature. We report the case of a 4-year-old boy who presented with a painful palpable mass in the right popliteal fossa. He also had mild, painless right foot-drop and difficulty toe-walking on the same side. The diagnosis of a PPA was based on the findings of triplex ultrasound and computed tomographic-angiography. We attributed the cause of the lesion to blunt trauma, which he had suffered 2 years earlier. Thorough preoperative evaluation excluded the possibility of a self-immune process or a bone tumor in the region. Neurological examination demonstrated a mild, isolated, peripheral mononeuropathy of the right peroneal nerve. Thus, we performed surgical repair using an autologous reversed great saphenous vein graft. The patient had an uneventful postoperative course and his peripheral neuropathy and foot-drop resolved completely within 1 month after surgery. Now, after 3 years of follow-up, the patient has a patent graft and a fully functioning limb. PPAs are rare, especially in children, and trauma is the predominating underlying cause. PPAs should be treated immediately after diagnosis because their complications are associated with high rates of functional impairment and even limb loss.

Influence of the stable prostacyclin analog iloprost on the healing of colonic anastomosis in rats

AIM

The aim of this study was to investigate whether iloprost injected intraperitoneally immediately after colon resection can improve anastomotic healing on the fifth and eighth postoperative days.

METHODS

Forty Wistar rats were randomised into 2 equal groups. After the resection of a 1 cm segment of transverse colon, an end to end sutured anastomosis was generated. From the day of the operation, group 1 (control) received intraperitoneal 3 cc saline solution once daily until sacrifice, while group 2 (iloprost) received iloprost in a dose of 2 mg/kg body weight intraperitoneally once daily until sacrifice. Each group was further randomly divided into 2 equal subgroups and animals were sacrificed on the fifth (subgroup A), and eighth (subgroup B) postoperative days. After sacrifice, anastomoses were examined macroscopically and were measured for bursting pressures and tissue hydroxyproline levels while anastomotic healing process was evaluated histopathologically.

RESULTS

None of the rats exhibited any clinical evidence of leakage and there were no instances of peri-anastomotic abscess or peritonitis. Bursting pressure on the fifth postoperative day was significantly higher in the iloprost group than in the control group (P<0.001), while on the eighth postoperative day, bursting pressure was higher in the iloprost group but not significantly different (P=0.165). On both the fifth and eighth postoperative days rats in the iloprost group developed significantly more marked neo-angiogenesis and, in parallel with this, there was a trend showing a higher inflammatory cell infiltration.

CONCLUSION

The intraperitoneal administration of iloprost promoted neo-angiogenesis and enhanced colonic healing on the fifth postoperative day.

Adrenocortical Oncocytoma — A Rare Tumor of Undefined Malignant Potential: Report of a Case

Adrenocortical oncocytomas are exceptionally rare. To our knowledge, only 23 cases have been reported in the world literature, most of which were benign and nonfunctioning. We report a case of adrenocortical oncocytoma diagnosed by pathological examination of an extirpated right adrenal mass in a young woman. We discuss this case and review the literature on this unusual entity.

Effect of iloprost on impaired anastomotic healing caused by 5-fluorouracil plus leucovorin

PURPOSE

This experimental study was designed to investigate whether iloprost can reverse impaired colonic healing caused by immediate postoperative intraperitoneal administration of 5-fluorouracil plus leucovorin.

METHODS

Eighty Wistar rats were randomized into four groups. After resection of a 1-cm segment of transverse colon, an end-to-end sutured anastomosis was generated. Rats received saline solution (Group 1), 5-fluorouracil plus leucovorin (Group 2), iloprost (Group 3), and 5-fluorouracil plus leucovorin plus iloprost (Group 4) intraperitoneally from the day of operation and once daily until killing. Each group was further randomized into two subgroups. Subjects were killed on the fifth (Subgroup a) and eighth (Subgroup b) postoperative days. After killing, anastomoses were examined macroscopically and graded histologically. Rats were measured for anastomotic bursting pressures and tissue hydroxyproline levels.

RESULTS

The leakage rate of the anastomoses was significantly higher in the 5-fluorouracil plus leucovorin group compared with the other groups (P = 0.049). Bursting pressure was significantly lower in 2a subgroup (5-fluorouracil plus leucovorin, postoperative Day 5) than in 4a (5-fluorouracil plus leucovorin plus iloprost, postoperative Day 5; P < 0.001). Adhesion formation was significantly higher in all b subgroups compared with the Control b subgroup. Neoangiogenesis was significantly higher in iloprost and iloprost plus 5-fluorouracil plus leucovorin subgroups compared with the 5-fluorouracil plus leucovorin subgroups. Hydroxyproline levels, collagen deposition, fibroblasts, and white cell count were significantly higher in the iloprost plus 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8) compared with the 5-fluorouracil plus leucovorin b subgroup (postoperative Day 8).

CONCLUSIONS

The immediate postoperative, intraperitoneal administration of iloprost counteracts and reverses the negative effects of 5-fluorouracil plus leucovorin chemotherapy and protects colonic healing in rats.

A single center experience in minimally invasive treatment of postcholecystectomy bile leak, complicated with biloma formation

BACKGROUND

Bilomas are localized collections of bile occurring usually post-operatively from an injured cystic or bile duct. Our study aims to evaluate the efficacy of minimal access endoscopic and percutaneous modalities in treating symptomatic bile leak and biloma formation.

PATIENTS AND METHODS

Sixteen patients with biloma after open or laparoscopic cholecystectomy underwent assessment of the site and extent of the bile leak via endoscopic retrograde cholangiography (ERC). Endoscopic sphincterotomy was performed in all patients who were managed non-operatively, any retained duct stones were removed, and an endoprosthesis was inserted in a selected basis. Percutaneous drainage of the bile collection, under ultrasound or computed tomography guidance, followed ERC.

RESULTS

ERC supplemented by computed tomography or ultrasound guided percutaneous biloma drainage was successful in 15 patients. One patient having major ductal injury was treated surgically. Thirteen patients had leakage from the cystic duct, one from the right hepatic duct, and one from an aberrant right hepatic duct. Bile duct stones were removed from seven patients an endoprosthesis was inserted in six and a nasobilary catheter in one. Bilomas resolved and bile leakage was treated successfully in all 15 patients with no further complications.

CONCLUSION

ERC accurately diagnoses the cause of postcholecystectomy bile leakage and biloma formation. Furthermore, endoscopic sphincterotomy and selective stent insertion in coordination with percutaneous drainage procedures represents in the majority of cases the corner stone of a definitive treatment.

Bloodless laparoscopic liver resection using radiofrequency thermal energy in the porcine model

The aim of this study was to assess the feasibility and safety of laparoscopic hepatectomy using radiofrequency (RF) thermal energy in a porcine model. Fifteen female domestic pigs weighing 29.3 kg (range 25 to 35 kg) were used. Five transversal abdominal incisions (3 of 1 cm and 2 of 0.5 cm) were made for the introduction of the video camera and the other laparoscopic instruments. With the porta hepatis not clamped, the liver was inspected and the preferred lobe each time was divided using RF (cool-tip electrode 3 cm) with minimum bleeding. Serum liver enzymes and blood counts were drawn pre and postoperatively. All animals were killed after 1 week. The mean time of the procedures was 119 minutes (range 100 to 155 min). There were no intraoperative complications. Mean blood loss was 27 mL (range 5 to 60 mL), and the mass of the resected specimen was 132.5 g (range 65 to 305 g). There were no postoperative complications or deaths. Bloodless laparoscopic hepatectomy was technically feasible and safe in the porcine model using cool-tip electrode and 500-kHz RF Generator.

Uncontrollable Intra-Abdominal Bleeding Necessitating Low Anterior Resection of the Rectum After Stapled Hemorrhoidopexy: Report of a Case

Stapled hemorrhoidopexy (SH) has become a widely accepted surgical procedure for hemorrhoids; however, one of the most serious complications of this technique is severe bleeding. We report a case of extensive hemoperitoneum after SH for third-degree hemorrhoids. On postoperative day (POD) 1, the patient complained of severe abdominal pain and clinical signs of peritonitis soon became evident. Computed tomography (CT) showed blood in the abdomen. We performed an emergency exploratory laparotomy, which revealed extensive hemoperitoneum, and a devitalized, edematous rectum with a tense hematoma, approximately 1 cm above the staple line and extending up to the level of the peritoneal reflection. We also found a small seromuscular laceration in the anterior aspect of the rectum just above the peritoneal reflection. This small laceration was bleeding actively. Thus, we performed a low anterior resection and the patient was discharged from hospital 10 days later. We report this case to raise awareness of the possibility of life-threatening intra-abdominal complications without evidence of typical rectal bleeding.

Recurrent arterial thromboses in a woman with heparin induced thrombocytopenia, successfully managed with iloprost followed by clopidogrel. An alternative therapeutic option for heparin induced thrombocytopenia type II syndrome

In its more severe form heparin induced thrombocytopenia (HIT) is a rare immune mediated complication of heparin administration that potentially has catastrophic results, and significant mortality. In view of the severity of this condition it is important for the clinician to maintain a high index of suspicion and get alerted to the HIT syndrome by the precocity of platelet count decrease in any patient group, and especially in those previously exposed to heparin. We report on a 72-year-old woman who developed HIT syndrome that was complicated by recurrent arterial thromboses after receiving postoperative antithrombotic prophylaxis with tinzaparin, a low molecular weight heparin. The patient was successfully treated with iloprost (Ilomedin, iloprost tromethamine, Schering) a stable prostacyclin analogue, at the acute phase of the syndrome, followed by long-term treatment with clopidogrel (Plavix, clopidogrel bisulfate, Sanofi) an inhibitor of adenosine diphosphate (ADP) receptor. Although direct thrombin inhibitors have been proven to be effective for the treatment of HIT thrombosis, they do not completely eliminate the morbidity and mortality of this disorder. Our case report suggests that antithrombotic treatment by targeting of the activated platelets with a potent platelet inhibitor during the acute phase of type II HIT syndrome followed by long-term administration of oral anticoagulation may be an additional, safe and effective therapeutic alternative that merits to be systematically studied.

Sebaceous gland tumors and internal malignancy in the context of Muir-Torre syndrome. A case report and review of the literature

BACKGROUND

The Muir-Torre syndrome is a rare autosomal dominant condition and is currently considered a subtype of the more common hereditary nonpolyposis colorectal cancer syndrome, in which multiple primary malignancies occur together with sebaceous gland tumors.

CASE PRESENTATION

We describe a case of a 62-year-old woman with three primary colorectal tumors, genital tumor, and sebaceous adenomas and present her family history of three generations. Our case represents the first case reported from Greece in the international literature.

CONCLUSION

Recognition of the syndrome in patients with sebaceous gland tumors should facilitate early detection of subsequent malignancies if the patient is entered into appropriate screening programs.

Bile duct injuries during laparoscopic cholecystectomy: management and outcome

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux-en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux-en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.

Thoracic splenosis twenty-nine years after traumatic splenectomy mimicking intrathoracic neoplasm

Thoracic splenosis refers to a condition of ectopic splenic tissue in the thoracic cavity. It is usually a consequence of splenic tissue seeding in the pleural cavity after thoracoabdominal trauma. A rare case of thoracic splenosis, in a 62-year-old man who had had a traumatic splenectomy due to thoracoabdominal trauma 29 years earlier, is reported. The patient, a heavy smoker, was admitted for evaluation of a left-side thoracic lesion discovered on a plain chest film. Bronchoscopy, CT scan and needle biopsy proved inconclusive for the diagnosis. Exploratory thoracotomy was necessary to establish the diagnosis. During the operation, a thoracic splenosis was confirmed. To date, only 28 cases of thoracic splenosis have been reported in the literature. The purpose of this report is to present a new case of splenosis of the thoracic cavity simulating intrathoracic neoplasm.

Transfusion-related acute lung injury: a life-threatening transfusion reaction

BACKGROUND

We present the case of a 57-year-old woman who developed transfusion-related acute lung injury (TRALI) following a transfusion of packed red blood cells (pRBCs).

CASE REPORT

A 56-year-old woman had undergone a low anterior resection in 2002 because of a Duke's stage D adenocarcinoma of the rectum. In June 2003 she was referred to our department, presenting symptoms and signs of ileus. Abdominal radiograph revealed multiple air-fluid levels, while a computed tomography scan showed disease dissemination. Colonoscopic control verified recurrent disease in the anastomotic area. At surgery, a palliative loop ostomy was generated. In the 4(th) postoperative day it was decided that one unit of pRBCs be transfused. pRBC administration complicated with a severe reaction, developing within 35 minutes of the transfusion episode. The diagnosis of TRALI syndrome was based on clinical signs and symptoms. Hemodynamic stabilization and resuscitation required low doses of epinephrine, diuretics, and a high concentration of inspired oxygen in combination with bronchodilators. Ventilatory assistance was not required. Clinical improvement occurred 12 hours later. Full recovery of the syndrome was observed in 6 days, while chest X-ray returned to normal findings within 4 days.

CONCLUSIONS

TRALI syndrome is an immune-mediated transfusion reaction which can cause severe complications or even death. Early diagnosis and treatment improves survival and usually results in full recovery. TRALI remains a clinical diagnosis in an appropriate setting, supported by serologic studies if these are available.

Abdominal wall metastasis following treatment of rectal cancer

We present a 60-year-old man with a metastatic subcutaneous lump in the left lower quadrant of the abdomen, from rectal cancer, which was treated three years earlier with low anterior resection of the rectum. Excision of the abdominal wall metastasis was accomplished with negative histological margins, but six months later a new abdominal wall mass was detected. The patient underwent surgery again, in which the abdominal wall metastasis was resected en bloc with adherent portion of small bowel, along with inguinal lymph node dissection. The patient's condition deteriorated 10 months after the initial diagnosis, presenting again with abdominal wall cancer and dying from disseminated peritoneal disease.

Anastomotic leakage following anterior resection for rectal cancer

BACKGROUND

The aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication.

PATIENTS AND METHODS

During the last ten years, 93 patients underwent anterior resection of the rectum for rectal cancer. Low anterior resection with total mesorectal excision (TME) was performed in 72, and high anterior resection in 21 patients. The definition of the anastomotic leakage was based on clinical features, peripheral blood investigations and abdominal CT scan.

RESULTS

Clinically apparent anastomotic leakage developed in 9 patients (9.7%). Four patients were managed conservatively and five operatively. Postoperative mortality among the patients with anastomotic leakage was not recorded.

CONCLUSIONS

The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low. It remains however the most serious complication following rectal resection for cancer.

Long-term outcome of pneumatic dilation in the treatment of achalasia

OBJECTIVE

Achalasia is a well-defined esophageal motor disorder for which pneumatic dilation is an established therapeutic method. Even though it has been used for several years, there are limited data on the long-term outcomes of patients treated with this procedure. Hence, we aimed to evaluate the long-term efficacy of pneumatic dilation to control the symptoms of achalasia.

METHODS

The medical records of all patients treated in our unit for achalasia with pneumatic dilation were reviewed. We identified the long-term result of the initial procedure, the date of the first dilation, and the time interval between dilation and retreatment.

RESULTS

Of 260 patients who were treated with pneumatic dilation, 153 (67 men, 86 women) were followed up for more than 5 yr. The mean follow-up period was 11.09 +/- 3.91 yr, and the success rate of the dilation was 75.8%. Among these patients, 35 (19 men, 16 women) had follow-up periods of more than 15 yr. The mean follow-up time of those patients was 16.56 +/- 1.09 yr, and the success rate was 51.4%. Kaplan-Meier survival analysis showed that, overall, 50% of patients develop recurring symptoms after 10.92 yr.

CONCLUSIONS

Although 51.4% of patients continued to be in clinical remission more than 15 yr after the initial pneumatic dilation, the long-term success rate of pneumatic dilation seems to drop progressively with time.

Survival after curative resection for rectal cancer by the end of the 20th century

BACKGROUND

The aim of this study was to define the survival rates in patients with rectal carcinoma treated with curative resections.

PATIENTS AND METHODS

Between 1993 and 1998, 54 patients with rectal cancer underwent curative resection by conventional technique. Tumour location, TNM staging and tumour differentiation were evaluated. Among the 54 patients, 14 underwent high anterior resection, 28 low anterior resection, 7 abdominoperineal resection and 5 underwent local excision. Survival rates were calculated using the Kaplan-Meier method and long-range analysis.

RESULTS

Five-year survival was 70.4%. The survival rate statistically significantly decreased with increasing TNM tumour stage (p=0.009). Patients with poor differentiation of the tumour had the lowest 5-year survival (33%) compared to patients with moderate (72%) and good (78%) tumour differentiation. Sex and age did not affect survival. Location of the tumour in the distal end of the rectum and mucinous characteristics are poor prognostic factors affecting survival.

CONCLUSIONS

Curative resection combined with chemoradiotherapy, whenever necessary, is accompanied with acceptable 5-year survival rates.

Repair of parastomal hernia with the use of polypropylene mesh extraperitoneally

Parastomal hernia is the most frequent complication of colostomy. Many surgical techniques have been postulated and prosthetic surgery seems to represents the first-choice treatment. The aim of this study is to report the surgical treatment of 4 patients that developed parastomal hernia, 3-10 months after abdominoperineal excision of the rectum and permanent sigmoidostomy due to carcinoma of the rectum. The repair was made with the use of polypropylene mesh extraperitoneally. One case of limited skin necrosis occurred without any serious consequences. No recurrence has been recorded among the patients, up to this day (follow-up period: 36 months). In conclusion, the suturing of fascial defect and the use of polypropylene mesh extraperitoneally is effective in the treatment of parastomal hernia.

Current treatment of colorectal liver metastases

BACKGROUND

The aim of our study is to present our experience in the treatment of liver metastases in patients with colorectal cancer.

PATIENTS AND METHODS

Between 1997 and 2003 a total of 12 patients with liver metastases from a primary colorectal cancer were treated in our department. They were 8 males and 4 females with a median age of 64 years (range 56-70 years).

RESULTS

Ten patients underwent liver resection. The surgical procedures were 4 major hepatectomies (3 right hepatectomies, 1 left lobectomy) and 9 wedge liver resections. In total, 16 metastatic lesions were resected. Already at the time of the primary tumour, 5 patients presented with a synchronous liver metastasis. In 3 of them, liver metastasis was resected together with the primary tumour, and in the rest, resection was performed 1 month after the initial operation. In 5 patients liver metastases were metachronous and were diagnosed 3-14 months after the initial operation. The median survival of the patients was 39 months. Two patients (one with 2 metastatic lesions) underwent radiofrequency ablation (RFA) of the metachronous metastatic lesions and remain well 3-6 months postoperatively.

CONCLUSIONS

Hepatectomy is the treatment of choice for hepatic metastasis of colorectal cancer, whenever feasible. Recent promising treatments such as RFA can further improve the outcome of these patients.

Synchronous polyps in patients with colorectal cancer

BACKGROUND

The aim of this study is to underscore the incidence of synchronous polyps in patients with colorectal cancer and to emphasise the importance of their perioperative detection and management.

PATIENTS AND METHODS

Three hundred and seven patients underwent a potentially curative resection for colorectal cancer during the last ten years. A total of 129 synchronous polyps were detected in 72 of the patients (23.5%). Complete preoperative colonoscopy was performed in 62 of the patients. Forty-three polyps (33.4%) in 37 patients were removed preoperatively, while 69 polyps (53.4%) in 25 patients were included in the surgical specimen. In 10 patients the colon was evaluated postoperatively and 17 polyps (13.1%) were removed via endoscopy.

RESULTS

A total of 81 polyps were detected in different surgical segments than the index cancer. Furthermore, 15 polyps were detected in the right colon of 55 patients with left colon cancer.

CONCLUSIONS

Synchronous polyps in patients with colorectal cancer are a frequent event. Thus, all patients should undergo a perioperative colonoscopy and endoscopic polypectomy, if feasible. The planned surgical procedure may alter as a consequence of the colonoscopic findings in some of the patients.

Age-associated prognosis following curative resection for colorectal cancer

BACKGROUND

The aim of this study is to determine the age-associated prognosis in patients who underwent curative resection for colorectal cancer.

PATIENTS AND METHODS

Between 1993 and 1999, a total of 136 patients underwent curative surgical procedures for colorectal cancer. The study population was divided into three groups according to the age of the patients. Group A: patients younger than 45 years, group B: patients between 45 and 75 years and group C: patients older than 75 years. Tumour location, Dukes' staging, tumour differentiation and five-year survival were evaluated.

RESULTS

There was no significant association between age and tumour staging or tumour differentiation (p=0.990, p=0.753 and p=0.308, respectively). The overall survival at 5 years was 85.7% for the young patients, 77.5% for the middle-aged patients and 62.5% for the elderly patients.

CONCLUSIONS

This aged-grouped study indicates that prognosis is comparable between younger and middle-aged patients whereas in elderly patients it is worsening but not statistically significantly.

Endoscopic management of retained bile stones with an indwelling T-tube

BACKGROUND

Endoscopic sphincterotomy (ES) is widely used for the treatment of residual bile duct stones in patients who had common bile duct (CBD) exploration and T-tube insertion.

METHODS

In a 4-year period 45 patients were referred for endoscopic removal of residual bile duct stones. All patients had been operated 7-15 days earlier for choledocholithiasis and had a T-tube in the common bile duct (CBD).

RESULTS

Four patients were excluded. Three patients had a periampullary carcinoma and the fourth patient had no residual stone seen at cholangiography. All patients had a successful ES, conventional in 34, precut-knife in 3, and with the rendezvous technique in 4 patients. In 24 patients, all having stones distal to the T-tube, complete clearance of the CBD was achieved during one session and the T-tube was removed after 48 h. In the remaining 17 patients (15 having stones proximal to the T-tube), the T-tube had to be removed first and following stone extraction, a plastic stent was inserted in the CBD. Complete bile duct clearance and stent removal was achieved in a second session 3-4 weeks later. There were no serious complications or biliary related symptoms after the procedures and after a mean follow-up period of 18 months.

CONCLUSION

The endoscopic technique is safe and efficient for the treatment of residual stones after CBD exploration with a T-tube insertion, offering immediate cure compared to the percutaneous techniques. It is also an ideal method for the diagnosis of periampullary carcinomas.