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.

Small bowel incarceration associated with posthysterectomy enterocele

Enterocele represents a pelvic floor hernia with the sac most commonly protruding between the rectum and vagina. It may occur with or without prior hysterectomy and is very rarely complicated by small bowel obstruction. We report herein the case of a 70-year-old woman with a posthysterectomy enterocele presented with symptoms of small bowel obstruction and abdominal tenderness. The patient underwent exploratory laparotomy, which revealed small bowel incarceration. To our knowledge, this case represents the first published case of vaginal vault prolapse and enterocele associated with small bowel obstruction and incarceration. The pathogenesis, diagnosis, and treatment are discussed.

Effect of early propranolol administration on portal hypertensive gastropathy in cirrhotic rats

AIM

To investigate any protective effect of early propranolol administration in the development of portal hypertensive gastropathy in cirrhotic rats.

METHODS

For the development of liver cirrhosis and portal hypertensive gastropathy, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl(4)) administration. After two weeks of CCl(4) administration, the rats were randomly separated into two groups. In group A, propranolol was continuously administered intragastrically throughout the study, whereas in group B normal saline (placebo) was administered instead. Hemodynamic studies and vascular morphometric analysis of gastric sections were performed after complete induction of cirrhosis.

RESULTS

Vascular morphometric studies showed higher numbers of vessels in all mucosal layers in the control group. Statistical analysis revealed a significantly higher total vascular surface in the control group compared to the propranolol group, but with no statistically significant difference between the mean vascular surfaces between the groups. Our study clearly shows that the increased mucosal blood flow is manifested by a marked increase of vessel count.

CONCLUSION

Early propranolol's administration in portal hypertensive cirrhotic rats seems to prevent intense gastric vascular congestion that characterizes portal hypertensive gastropathy.

A case of Mirizzi's syndrome mimicking carcinoma: the role of CBD-stenting for easy surgical management

Mirizzi's syndrome accounts for an important risk for bile tree injury during surgery, since preoperative diagnosis is missed in half of the cases and is often difficult to differentiate from carcinoma. A 79-year-old male, with a known history of cholelithiasis, was admitted with a progressive obstructive jaundice over 20 days, without pain, fever, or other symptoms. Magnetic resonance cholangiopancreatography described possible microlithiasis of the distal bile duct, but on endoscopic retrograde cholangiopancreatography (ERCP), an irregular stenosis was detected under the junction of hepatic ducts, which was described as possibly neoplastic. A temporary stent was placed and the patient was referred for surgery. On first view the gallbladder appeared hard, embedded in adhesions, giving the impression of an unresectable tumor and the bile duct was not approachable. After a fundus-down incision of the gallbladder multiple stones were extracted. Frozen biopsies from the gallbladder wall were negative. The incision was extended towards the gallbladder neck and a large communication with the common bile duct (CBD) was revealed. A difficult partial cholecystectomy was performed, followed by cholecystojejunostomy with a Roux-en-Y jejunal loop. The patient had a totally uneventful postoperative course. Stent removal was succeeded endoscopically 1 month later. The importance of preoperative ERCP and CBD stenting is highlighted in this article. ERCP may have failed to distinguish Mirizzi's syndrome from carcinoma, however the stent placement saved the cardiologically compromised patient from further surgical manipulations. Therefore, in ambiguous cases, whatever the final diagnosis turns to be, either carcinoma or Mirizzi's syndrome, CBD stenting can be useful for the final management of the patient.

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.

Early propranolol administration does not prevent development of esophageal varices in cirrhotic rats

BACKGROUND AND AIMS

Variceal bleeding is the most serious complication of portal hypertension associated with high mortality. This study was conducted to investigate any protective effect of early propranolol administration in the development and degree of esophageal varices in cirrhotic rats with portal hypertension. This topic is controversial in the literature.

METHODS

For the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl(4)) administration. This operation enhances the development of cephalad collaterals, responsible for the induction of esophageal varices. After 2 weeks of CCl(4) administration, the rats were randomly separated into 2 groups. In group I, propranolol was continuously administered intragastrically throughout the study, whereas in group II normal saline (placebo) was administered instead. Cirrhosis was detected clinically by ascites development. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis, measuring the following parameters: portal pressure, total number of submucosal veins, total submucosal vessel area, mean cross-sectional submucosal vessel area, relative submucosal area (percentage) occupied by vessels and area of the single most dilated submucosal vein.

RESULTS

The statistical analysis revealed no statistically important difference between the 2 groups for the morphometrically studied parameters. However, portal venous pressure was lower in group I.

CONCLUSION

Early propranolol administration did not protect rats from developing esophageal varices, despite the fact that a significant decrease in portal pressure was detected.

Does emergency surgery affect resectability of colorectal cancer?

OBJECTIVE

Emergency surgery for colorectal cancer is common in daily practice, and is mainly implied by bowel obstruction. It is related to increased morbidity and mortality. Its relation with the stage and respectability of the disease is uncertain. This study aims to further clarify these parameters.

PATIENTS AND METHODS

Over the past 24-year period 121 patients had an emergency operation (12%) from a total of 1009 patients with colorectal carcinoma. There were 59 men (48.8%) and 62 women (51.2%) with a mean age of 68 years (range 21-93); 61 patients (50.4%) were > or = 70-years-old. The data of all these patients were studied retrospectively in comparison with those who underwent elective surgery. Emergency cases were further divided into two age groups (> or = 70 and < 70 years) and compared. The tumour location was mainly in the left colon, whereas obstruction was the predominant reason for acute presentation.

RESULTS

On operation, absence of macroscopic spread was noted in 57.8% of emergency cases and 72% of elective cases (p < 0.05). The resectability rates were 75% and 90% respectively (p < 0.05), and were not significantly affected by the age factor. There were no differences in the grade of malignant cell differentiation or in the depth of microscopic invasion (p > 0.05) in either group. For emergency operations, the morbidity was 20% (24 patients) and the 30-day mortality rate was 5.8% (7 patients). Both parameters were higher in patients > or = 70-years-old.

CONCLUSION

Emergency surgery for colorectal carcinoma is related to lower resectability and to higher--but acceptable--postoperative morbidity and mortality rates, when compared with elective surgical management.

Effect of early bosentan administration on the development of esophageal varices in cirrhotic rats: experimental study in Wistar rats

BACKGROUND

This study was conducted to investigate the effect of chronic bosentan administration on the development of esophageal varices in carbon tetrachloride-induced cirrhosis in rats.

METHODS

For the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein, followed by phenobarbital and carbon tetrachloride administration. Two weeks after the beginning of carbon tetrachloride administration, rats were separated into two groups. In group I, comprising 30 rats, bosentan was continuously administered throughout the study, whereas in group II, also 30 rats, placebo instead of bosentan was continuously administered. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis. The total number of veins counted in the submucosa, the number of submucosal veins/mm(2) of submucosa, the total submucosal area occupied by vessels, the mean cross-sectional vessel area, the relative submucosal area (percentage) occupied by vessels, and the area of the single most-dilated submucosal vein were studied.

RESULTS

Bosentan induced a significant (P < 0.05) decrease in portal pressure, while morphometric analysis revealed a significant reduction (P < 0.05) of all parameters studied in bosentan-treated rats, except in the total and relative number of submucosal veins.

CONCLUSIONS

Bosentan administration seemed to significantly attenuate dilation of submucosal veins in the lower esophagus of cirrhotic rats. This effect was mainly attributed to a decrease in the portal pressure induced by chronic bosentan administration.

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.

Gangrenous cystitis

Gangrenous cystitis is an extremely rare condition. During the last 70 years, only 30 cases have been reported in the literature. We report a case of gangrenous cystitis in a 70-year-old woman presented with symptoms of acute abdomen. Main causative factor was overdistension of the bladder due to catheter obstruction. She underwent debridement and drainage of the cystic remnant. The pathogenesis, diagnosis, and management of gangrenous cystitis are discussed.

Major complications during laparoscopic cholecystectomy

Laparoscopic cholecystectomy may lead to serious complications, some of which can be disastrous if they are not recognized and managed immediately. Over the past 12-year period, 1225 laparoscopic cholecystectomies were performed. Totally, major complications occurred in 19 cases (1.5%). The conversion rate was 7.4%. Complications included common bile duct injury in 2 cases (0.16%), vessel injury by trocar or Veress needle in 4 cases (0.32%) including 1 case of aorta injury (0.08%), bleeding from the gallbladder bed or the cystic artery in 10 cases (0.8%), bile leak in 1 case (0.08%), duodenum injury in 1 case (0.08%), and transient liver ischemia in 1 thalassanemic patient (0.08%). The complication was recognized during the operation in 11 cases. Reoperation was necessary in five cases (0.4%), and conservative management was applied in three cases. Although infrequent, major complications may occur during laparoscopic cholecystectomy. Immediate recognition and management is critical and may lead to a safe outcome.

Anterior thoracic wall traumatic lymphocele: a case report

Traumatic lymphoceles are usually the result of surgical injuries or blunt trauma. Although usually described in the pelvis after radical pelvic node dissection or kidney transplantation, traumatic lymphoceles are rare. Diagnosis is based on CT scan and confirmed by fine needle aspiration with biochemical analysis. Treatment modalities are not standardized and different techniques have been described. We report herein a case of anterior thoracic wall lymphocele due to blunt trauma treated in our department.

Changes in coagulation and fibrinolysis during laparoscopic cholecystectomy

BACKGROUND

The influence of laparoscopic cholecystectomy on coagulation and fibrinolysis is debatable. There have been a few but controversial studies and the need for routine antithrombotic prophylaxis is unclear.

MATERIALS AND METHODS

In this prospective study we investigated changes in coagulation and fibrinolysis parameters in laparoscopic cholecystectomy. Blood samples taken before, during, and after surgery from 38 consecutive patients were analyzed. Measured parameters included the international normalized ratio, prothrombin time, partial thromboplastin time, antithrombin III activity, platelet count, mean platelet volume, fibrinogen, and D-dimers.

RESULTS

Statistically significant changes included increased perioperative international normalized ratio and D-dimers, and postoperative antithrombin III, fibrinogen, and D-dimers, as well as decreased perioperative antithrombin III and fibrinogen and postoperative international normalized ratio, platelet count, and mean platelet volume. Values of partial thromboplastin time had no statistically significant changes.

CONCLUSION

Reduced coagulation activity and increased fibrinolytic activity occur during and after laparoscopic cholecystectomy.

Safety of bowel resection for colorectal surgical emergency in the elderly

OBJECTIVE

Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study.

PATIENTS AND METHODS

In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma.

RESULTS

The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction.

CONCLUSION

Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.

Interdigital pilonidal sinus in a hairdresser

Pilonidal sinus of the interdigital web space of the hand is a rare occupational disease which occurs in hairdressers and professionals working with animals. This paper reports such a sinus in the hand of a male hairdresser and reviews the treatment of this condition.

Somatostatin-producing pancreatic endocrine carcinoma presented as relapsing cholangitis -- a case report

Somatostatin-producing endocrine tumors are rare neoplasms usually arising in the pancreas and duodenum and they account for less than 1% of all gastrointestinal endocrine tumors. Besides somatostatinoma syndrome, which is characterized by diabetes mellitus, steatorrhea and cholelithiasis, patients with somatostatin-producing endocrine tumors commonly complain of nonspecific symptoms such as vague abdominal pain, weight loss or changes in bowel habits. Tumor behavior cannot be predicted by histological features alone, and malignancy is determined by the presence of metastases. We report here a case of malignant pancreatic endocrine tumor producing somatostatin presented as relapsing cholangitis who was treated with Whipple pancreatoduodenectomy.

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.

Primary anaplastic large cell lymphoma of the spleen presenting as a splenic abscess

Large cell anaplastic lymphoma (ALCL) is characterized mainly by the presence of large, atypical lymphoid cells with anaplastic nuclear morphology and positivity to Ki-1 antigen. We describe, to our knowledge, the fourth reported case of primary ALCL of the spleen. The patient, a 62 year old woman, presented symptoms resembling a splenic abscess.