Multiple synchronous anorectal malignant melanoma coexisting with adenocarcinoma of the sigmoid colon

Primary anorectal malignant melanoma is an exceptionally rare neoplasm associated with poor prognosis. Anorectal malignant melanoma has been very rarely described with coexisting primary tumors of the colorectum. A 56-year-old female patient was admitted with a history of rectal bleeding. She had experienced increasing constipation and a sense of obstruction in the rectum for 6 months. Flexible rectosigmoidoscopy showed a large, pedinculated polypoid lesion extending from the anal canal to the rectum. She underwent a transanal local excision and was diagnosed with a melanoma of the anorectum with positive margins. Therefore, a formal abdominoperineal resection was performed. In addition to multiple synchronous anorectal malignant melanoma, we incidentally found another primary tumor in the proximal surgical margin of the resected specimen. Histopathologically, the lesion was an intramucosal adenocarcinoma of the sigmoid colon. Postoperatively, the patient received adjuvant chemotherapy of six cycles duration. At present, the patient has completed 18 months of follow-up.

Management of hepatic artery aneurysms

BACKGROUND

Hepatic artery aneurysm (HAA) is a rare clinical entity that can lead to potentially life threatening complications. We reported our personal experience of 4 cases, in which we used different procedures.

METHODS

The first case had a pseudo-aneurysm involving the right hepatic artery. The second case had a pseudo-aneurysm, which was localized distal to the accidentally ligated right hepatic artery from the previous cholecystectomy operation. The third case had multiple aneurysms with accompanying dissecting abdominal aortic aneurysm. The fourth case had a pseudo-aneurysm originating from the proper hepatic artery. A covered stent was successfully placed in the case 1. In the second case, the right hepatic artery was ligated distal to the aneurysm. In the third case, vascular structures were not appropriate for vascular reconstruction, and a covered stent placement and embolization were unsuccessful. In the fourth case, ligation of the proper hepatic artery and cholecystectomy was performed.

RESULTS

The third case with multiple aneurysms died from multi-organ failure due to sepsis. The remaining cases (case 1, 2, and 4) are disease free and alive.

CONCLUSION

HAAs are more commonly observed clinical entities, and their treatment should be handled for each patient separately. Computerized tomography-Angiography and intraoperative Doppler ultrasound are useful radio-diagnostics for determination of aneurysm and planning the operative procedure (Fig. 5, Ref. 15).

Predictive factors for conversion to open surgery in patients undergoing elective laparoscopic cholecystectomy

BACKGROUND

Laparoscopic cholecystectomy (LC) has become the standard surgical procedure for symptomatic gallbladder disease. The aim of this study was to identify factors that may be predictive of cases that would require a conversion to laparotomy.

METHODS

In the period of 2002-2007, 2015 patients who underwent elective LC were included in the study. Patients were divided into two groups. Group 1 (n = 1914) consisted of patients whose operation was successfully completed with LC. Group 2 (n = 101) consisted of patients who had a conversion. A prospective analysis of parameters, including patient demographics, laboratory values, radiologic data, and intraoperative findings, was performed. Multivariate stepwise logistic regression was used to determine those variables predicting conversion.

RESULTS

One-hundred and one (5.0%) patients required a conversion. Significant predictors of conversion to open cholecystectomy in univariate analysis were increasing age, male gender, previous upper abdominal or upper plus lower abdominal incisions, an elevated white blood cell count, high aspartate transaminase, alkaline phosphatase and total bilirubin levels, preoperative ultrasound findings of a thickened gallbladder wall and dilated common bile duct, preoperative endoscopic retrograde cholangiopancreatography (ERCP), high-grade adhesion, and scleroatrophic appearance of the gallbladder intraoperatively. Multivariate analysis revealed that a history of previous abdominal surgery, preoperative ERCP, high-grade adhesion, and scleroatrophic appearance of the gallbladder predicted conversion.

CONCLUSIONS

Patient selection is very important for efficient, safe training in LC. Based on the presented data, pathways could be suggested that enable the surgeon to precisely decide, during LC, when to convert to open surgery.

Surgical treatment for gastric cancer in Turkish patients over age 70: early postoperative results and risk factors for mortality

PURPOSE

The aim of this study was to evaluate the effects of advanced age on early postoperative results and to investigate risk factors for mortality in Turkish gastric cancer patients.

METHODS

From 2002 to 2007, 549 patients who underwent gastrectomy for gastric cancer were divided into two groups as patients younger than 70 years and patients aged 70 years or older.

RESULTS

There were 387 patients in the younger group and 162 in the older group. Morbidity rates were similar (25.1% vs. 29.0%). Mortality was higher among the elderly patients (2.6% vs. 9.9%). Advanced age, albumin levels lower than 3 mg/dl, higher American Society of Anesthesiologists score, palliative resections and resection of two or more additional organs were independent risk factors for mortality.

CONCLUSION

Age alone should not preclude gastric resection in elderly patients. However, for patients with multiple risk factors, more limited surgery should be considered.

Effects of CO(2) pneumoperitoneum on anastomotic healing in rats receiving preoperative 5-fluorouracil neoadjuvant chemotherapy

BACKGROUND

When used separately, antineoplastic agents and carbon dioxide (CO(2)) pneumoperitoneum have been reported to impair anastomotic healing in experimental animals. However, the effects of their combined use have not been previously investigated. The aim of this study was to investigate the possibility that neoadjuvant chemotherapy with 5-fluorouracil followed by CO(2) pneumoperitoneum would affect the healing of anastomoses in the colon.

METHODS

Sprague-Dawley rats (n = 48) were given 5-fluorouracil (20 mg/kg/day) for 5 days, and were then assigned to one of the three groups. Prior to surgery, the control group received no pneumoperitoneum. The other two groups received pneumoperitoneum at 6 and 12 mmHg, respectively, for 2 hr. The large intestine was transected and anastomosis was performed via median laparotomy. On postoperative days 3 and 7, relaparotomy was performed in half of the rats in each group. From the colon, a segment including the anastomosis was excised. Tissue hydroxyproline levels were measured. For histological evaluation, the Verhofstad scale was modified and used.

RESULTS

No significant differences in hydroxyproline levels were seen across the groups on postoperative days 3 or 7. However, by postoperative day 7, polymorphonuclear leukocytes and necrosis in the 6-mmHg group had decreased markedly, and granulation had improved.

CONCLUSION

Overall, these findings suggest that preoperative 5-fluorouracil therapy followed by pneumoperitoneum at 6 or 12 mmHg does not impair anastomotic healing.

Surgical outcomes and survival after multiorgan resection for locally advanced gastric cancer

BACKGROUND

Multiple organ resection for locally advanced (assumed T4) gastric cancer is associated with high morbidity and mortality. Our aim was to evaluate the efficacy of these surgeries with regard to surgical morbidity, mortality, and survival.

METHODS

Fifty-six patients underwent potentially radical gastrectomy combined with invaded organ resection. Early and late results of multiorgan resection and clinicopathologic factors influencing these results were evaluated.

RESULTS

Forty patients (71.4%) received 1 additional organ resection and 16 patients (28.6%) received 2 or more additional organ resections. Postoperative morbidity and mortality was 37.5% and 12.5%, respectively. Resection of 2 or more additional organs increased postoperative morbidity and advanced age increased mortality. The 1- and 3-year survival rates were 53.3% and 28.1%, respectively. Advanced age, lymph node metastasis, and resection of more than 1 additional organ were significant prognostic factors for survival.

CONCLUSIONS

For patients with locally advanced gastric carcinoma, multiple organ resection is worthwhile with careful patient selection.

Diffuse colorectal angiodysplasia misdiagnosed preoperatively as ulcerative colitis in a child: report of a case

Angiodysplasia is primarily a disease of the elderly, and it is rarely encountered in the pediatric population. We report a case of diffuse colorectal angiodysplasia, diagnosed postoperatively in a 13-year-old boy who underwent hand-assisted laparoscopic total proctocolectomy and ileal pouch anal anastomosis (IPAA) for assumed corticosteroid-resistant ulcerative colitis. The findings of preoperative repeated colonoscopies and biopsies had been consistent with active colitis. Distinguishing ulcerative colitis from angiodysplasia is not usually difficult in patients with rectal bleeding. To our knowledge, this is the fi rst case report of such a challenging diagnostic problem.