Complicated liver echinococcosis: 30 years of experience from an endemic area

BACKGROUND AND AIMS

Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management, and short-term outcome of patients with complicated liver echinococcosis.

MATERIAL AND METHODS

A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with noncomplicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%), and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications, and hospital stay were assessed.

RESULTS

Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated.

CONCLUSIONS

Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently severe clinical manifestations, complexity of surgical management, and the increased postoperative complications characterize complicated liver echinococcal disease.

Clinical features of colonic diverticular disease

Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.

Retractile mesenteritis appearing as a sigmoid colon tumor

Retractile mesenteritis is a rare, fibrosing, inflammatory disease affecting the adipose tissue of the intestinal and colonic mesentery. So far, about 300 cases have been reported in the literature. We present a case of retractile mesenteritis.

Deeply infiltrating rectal endometriosis with lymph node involvement

BACKGROUND

Sigmoidorectal endometriosis accounts for 70% of the cases of intestinal endometriosis. Symptoms are non-specific, frequently resembling adenocarcinomas.

CASE

A 45-year-old woman complaining of recurrent rectal bleeding underwent colonoscopy in which a rectal polypoid mass was found. She underwent anterior rectosigmoidectomy and the histological examination of the resected bowel revealed rectal endometriosis with lymph node involvement.

CONCLUSION

Lymphatic infiltration of epicolic lymph nodes raises questions about the benign nature of this presumed innocent disease.

Unusual findings in inguinal hernia surgery: report of 6 rare cases

BACKGROUND AND AIM

To present our experience with unexpected findings during hernia surgery, either unusual hernial contents or pathologic entities, like neoplastic masses, masquerading as a hernia.

PATIENTS AND METHODS

We studied retrospectively 856 patients with inguinal hernia who were admitted to our surgical department over a 9-year period. In addition, our study included patients complaining of inguinal protrusion, even without a definitive diagnosis of inguinal hernia upon admission.

RESULTS

Five patients presented with unusual hernial contents. Three of them had a vermiform appendix in their sac. Acute appendicitis (Amyands hernia) was found in only one case. One patient had epiploic appendagitis related with a groin hernia. Moreover, an adult woman was diagnosed with ovarian and tubal inguinal hernia. Finally, we report a case of a massive extratesticular intrascrotal lipoma, initially misdiagnosed as a scrotal hernia.

CONCLUSION

a hernia surgeon may encounter unexpected intraoperative findings. It is important to be prepared to detect them and apply the appropriate treatment.

Pelvic malakoplakia simulating recurrence of rectal adenocarcinoma: report of a case

Malakoplakia represents a chronic inflammatory disease associated with a broad spectrum of bacterial infections. On histopathology, Michaelis-Gutmann bodies are considered as pathognomonic histopathological findings. Rarity of the disease and wide variety of clinical presentation makes its diagnosis very challenging. We report herein the case of a 66-year-old woman who, having undergone lower anterior resection for rectal adenocarcinoma 3 and a half years ago, presented with urinary frequency and dull abdominal pain. CT scan revealed a soft tissue tumour infiltrating the preperitoneal fat over the urinary bladder, which was considered as recurrence of the rectal carcinoma. On laparotomy, a tumour invading the bladder, small intestine and the anterior abdominal wall was resected and the patient recovered uneventfully. On histopathology, malakoplakia of urinary bladder was revealed. Overstaging of patients' malignancy due to malakoplakia is not uncommon, so its early identification can help avoid incorrect treatment.

Primary Ewing sarcoma of the stomach--a newly described entity

The Ewing sarcoma family of tumors (ESFT) includes classic Ewing sarcoma of the bone, extraosseous or soft tissue Ewing sarcoma, Askin tumors of the chest wall, and peripheral primitive neuroectodermal tumors of the bone and soft tissues. They share a common neural histogenesis, tumor genetics and biology. The genetic hallmark of the ESFT is the presence of t(11;22)(q24;q12), which creates the EWS/FLI1 fusion gene and results in the expression of a chimeric protein. Although Ewing tumors can occur at any age, the great majority are found in individuals less than 20 years of age. We herein report a case of gastric Ewing sarcoma in a 68-year-old male. This patient illustrates the second reported occurrence of primary Ewing sarcoma in the stomach and the first reported with the t(11;22)(q24;q12) gene translocation.

Effect of experimentally induced liver cirrhosis on wound healing of the post-extraction tooth socket in rats

BACKGROUND

Wound healing in liver cirrhosis is known to be impaired possibly due to liver insufficiency and subsequent malnutrition status; however, there is no study to examine healing effectiveness of the tooth socket following an extraction in such patients.

MATERIALS AND METHODS

Irreversible cirrhosis was induced in 30 Wistar rats by repetitive weekly doses of CCl(4) and continuous administration of phenobarbital in a 12-week course was monitored by body weight measurement and ascites development, and was proved histologically. One week later, cirrhotic and control rats were subjected to extractions of two maxillary grinders on each side, one side by simple method, the other by surgical method. Half of the animals of each subgroup were sacrificed on the 10th post-extraction day, whereas the other half on the 30th post-extraction day, and histological sections were examined from all tooth sockets for wound-healing activity.

RESULTS

A malnutrition status was detected in cirrhotic rats with significant difference in their body weight. Several histological parameters of socket healing were not statistically different between cirrhotic and control animals. However, a significant delay on epithelialization and cancellous bone formation was detected on the 10th post-extraction day for either simple or surgical extractions in cirrhotic animals.

CONCLUSIONS

Liver cirrhosis in rats provokes a significant delay on epithelialization and mature cancellous bone formation and consecutively on early socket wound healing after a tooth extraction.

Invasive adenoviral infections in T-cell-depleted allogeneic hematopoietic stem cell transplantation: high mortality in the era of cidofovir

BACKGROUND

Adenovirus (ADV) infection occurs in 5-21% of allogeneic hematopoietic stem cell transplants (HSCT). Symptomatic enteritis and hemorrhagic cystitis may be encountered but are seldom fatal. In contrast, mortality rates of up to 75% are reported for adenoviral pneumonia or hepatitis. Cidofovir is currently being increasingly used for treatment of adenoviral infections after HSCT. The efficacy of cidofovir in patients with invasive adenoviral infection is not established.

FINDINGS

We reviewed 687 adult and pediatric patients who received allogeneic HSCT at our institution from 1998 through June 2005. ADV was isolated from 64 (9.3%) patients. Eleven patients received cidofovir for invasive disease occurring at median 39 days (range 3-145) post HSCT. The median age was 40 (range 6-61) years. Seventy-three percent received a T-cell-depleted graft and 18% had grade 3-4 graft-versus-host disease (GVHD) of the gut. Three out of 3 (100%) patients with adenoviral pneumonia died. One patient with hepatitis, cholecysitis, and viremia cleared the infection after 3 months. Two out of 7 (28.6%) patients with hemorrhagic colitis or cystitis died of ADV (1 with extensive GVHD).

CONCLUSION

Mortality rates of ADV pneumonitis after allogeneic HSCT remain high in the era of cidofovir. Clinical trials are needed to evaluate management strategies for this life-threatening infection.

Carcinoid of the ampulla of Vater--report of two cases

Carcinoid of the ampulla of Vater is extremely rare, accounting for less than 0.3% of all gastro-intestinal carcinoids. To our knowledge, only 80 cases of ampullary carcinoid have been reported in the literature to date. Ampullary carcinoid is more commonly presented with jaundice or upper abdominal discomfort and diagnosis is more often made postoperatively due to submucosal spread of the tumour. As metastatic potential cannot be predicted by tumour size, Whipple pancreatoduodenectomy rather than local excision is considered to be the treatment of choice. We report here two cases of ampullary carcinoid treated in our department.