Management of peritoneal hydatid cysts: A fourty-year experience.

BACKGROUND: Hydatid disease is a global problem. We report our experience with such cases where the dominant cysts were located outside the liver and lungs. In particular, these cysts were found in the peritoneum which is an uncommon location. METHODS: Between 1967 and 2007 a total of 34 patients were operated for primary or secondary peritoneal cysts. Most of the patients were asymptomatic or had atypical symptoms. The diagnosis was based on the preoperative history, rupture of the cysts, serology, ultrasound (USS) and computer tomography (CT). Open surgery was the procedure of choice with conservative (18 cysts) and radical (25 cysts) methods. RESULTS: The outcome of surgery was good without postoperative mortality or severe morbidity and the recurrence rate was 23.5%. CONCLUSIONS: Conservative surgery can provide good results in symptomatic peritoneal cysts. Radical therapy is also ideal but only in properly selected cases. The management of this situation is difficult requiring sound operative experience preferably with a one-stage procedure after an appropriate preoperative preparation.

Laparoscopic low anterior resection for early rectal cancer.

INTRODUCTION: Early rectal cancer (ERC) is adenocarcinoma that has invaded into, but not extended beyond, the submucosa. Endoscopic or minimal access surgical procedures, such as laparoscopic resection, have emerged as a useful tool in the surgical treatment of such diseases. The aim of this study is to present and analyze the feasibility, the short- and long-term results of laparoscopic colorectal surgery (LCS) in patients with ERC. PATIENTS AND METHODS: Between 2002 and 4/2011, a total of 164 patients with colorectal cancer underwent laparoscopic surgery (LS). Of these, 7 patients (4.2%) had ERC and underwent laparoscopic anterior resection (LAR). The median follow-up was 41 months. RESULTS: The mean operative time was 2.5 h. None of the laparoscopic procedures was converted to open surgery. Liquids and solid food were started on median postoperative days 1 and 3, respectively. The median length of postoperative stay was 5 days. Postoperative complications occurred in 2 patients (28.5%), including wound infection in one patient (14.2%) and atelectasis in one patient (14.2%). None of the patients required an urgent re-operation. There was no mortality related to LS. CONCLUSIONS: LS for ERC can be used as a strategy sited between endoscopic mucosal resection and open anterior resection with beneficial long- and short-term results. It appears as a technically and oncologically safe procedure when performed by surgeons with sufficient experience in laparoscopic techniques.

Emergency and elective surgery for small bowel Crohn's disease.

Advancements in the medical treatment of Crohn's disease have reduced the need for surgery. The indications for surgery include the failure of medical management, especially the persistence or worsening of symptoms in spite of proper treatment and complications of the disease process. These complications include intestinal obstruction, intestinal perforation with fistula formation or abscess, free perforation, gastrointestinal bleeding, urologic complications, cancer, and perianal disease. In these cases, operative therapy should be directed to the specific indication for surgery, resecting only the segment of bowel involved in the complicating process while preserving as much bowel length as possible in order to prevent short-bowel syndrome. Laparoscopic surgery has been gaining acceptance as an alternative surgical approach for properly selected patients with Crohn's disease. In conclusion, identifying the need for surgery and determining the timing of operation are the cornerstones to successful surgical management of patients with Crohn's disease.

Cecal volvulus after twin gestation: laparoscopic approach.

INTRODUCTION: Intestinal obstruction in pregnancy is not common. Colonic volvulus occurs in 24% of such cases. Due to the rare incidence and lack of imaging during pregnancy, correct diagnosis is often delayed. CASE PRESENTATION: We present a case of a 33-year-old female with a twin pregnancy gestation, who presented with acute abdominal pain. Physical examination revealed a gravid uterus and tenderness in the lower abdominal quadrants. Due to intense uterine contractions, the patient was urgently submitted to cesarean delivery, giving birth to two healthy infants. Twelve hours after the cesarean section, right lower quadrant abdominal pain was persistently severe. Nausea, vomiting, diarrhea, and abdominal dilatation were also present. Abdominal X-ray and CT scan showed bowel obstruction, possibly secondary to cecal volvulus. The patient was subjected to explorative laparoscopy, cecal volvulus detorsion, and laparoscopic appendectomy. RESULTS: The postoperative course was uneventful, and the patient was discharged on the fourth postoperative day. CONCLUSIONS: Cecal volvulus in pregnancy is a rare, difficult to diagnose, clinical entity. It is associated with high morbidity and mortality, both of mother and fetus, because of delayed diagnosis. A high index of clinical suspicion is required in pregnant or puerperant women with signs and symptoms of bowel obstruction and persistent pain at the right low abdominal quadrant. As long as diagnosis is timely set, laparoscopy is a safe and successful means of surgical treatment.

The stapled hemorrhoidopexy syndrome: a new clinical entity?

PURPOSE: Haemorrhoidal disease is a rather common disease of unknown cause. A new technique for treating prolapsing haemorrhoids known as the stapled hemorrhoidopexy (SH) or the "Longo procedure" is widely used. Serious adverse events were reported in 2000 and some discussion over the syndrome but nothing since. METHODS: Two hundred and five patients underwent SH by our surgical team at the Interbalkan European Medical Center. Modified SH was performed. RESULTS: Despite the low incidence of postoperative complications (11/205), 36.58% of patients developed syndrome comprised of urgency to defecate, sensation of anal foreign body and incomplete defecation and mild cramp like anal discomfort, immediately after surgery or in the following 48 h. There is not statistically significant relationship between the presence of the syndrome and the gender, the presence of muscle fibres in the resected "ring" the degree of haemorrhoidal disease, age and ring length. CONCLUSION: Observations led us to conclude that the stapled hemorrhoidopexy syndrome (SHS) is probably caused by the irritating presence of the titanium staples in the rectal mucosa and by the resection itself.

Breast cancer metastatic to the rectum: a case report.

INTRODUCTION: Patients with breast cancer may present with systemic recurrence in any organ, primarily the bones, lungs, lymph nodes, liver, pleura, and adrenal glands. We report a case of rectal tumor, metastatic from breast cancer, which represents an unusual location of metastasis. CASE PRESENTATION: A 74-year-old woman, operated for lobular breast cancer 5 years ago, but not compliant with the annual follow-up, presented with severe constipation and pseudodiarrhea. Digital examination and anoscopy revealed a mass at the lower rectum, 2 cm distant from the anal verge. CT and MRI scan of the abdomen confirmed this finding and did not reveal metastatic lesions elsewhere. The patient underwent abdominoperineal resection. RESULTS: The postoperative period was uneventful, and the patient was discharged on the 7th postoperative day. The histopathological findings revealed rectal cancer, metastatic from the known invasive lobular breast cancer. CONCLUSIONS: Rectal metastasis from breast cancer is very rare. The presented case emphasizes the need to keep in mind this possibility and at all times associate the emergency condition with the related history of breast cancer.

Forty-four years' experience (1963-2006) in the management of primarily infected hydatid cyst of the liver.

BACKGROUND AND AIM: The aim of this study was to report our 44-year experience (1963-2006) in the management of primarily infected hydatid cyst of the liver. This is a retrospective review of demographic data, clinical presentation, diagnostic work-up, surgical management, and long-term outcome of patients treated at our center. MATERIAL AND METHODS: There were 77 patients with operated infected liver cysts. In the same period, a total of 460 cases with liver hydatidosis were treated surgically. Of those with suppurated cysts, 27 were men and 50 were women, with a mean age 54.5 years. RESULTS: Clinical manifestations of an abscess were identified in 75% of the patients. In the earlier cases of the study, the diagnosis was made from the clinical picture, laboratory studies, in combination with plain X-ray, hepatic scintigraphy, and in the later cases with US (ultrasonography), CT (computed tomography) or MRI (magnetic resonance imaging), and ERCP (endoscopic cholangiopangreatography). Abdominal and, rarely, thoracic and abdominal or thoracoabdominal incisions were used. Total cystopericystectomy in 8 patients and partial pericystectomy and proper drainage with one or two drainage tubes of the cystic cavity in the other 69 patients were carried out. Hospital stay was between 13 and 146 days with 5 re-operations. Two patients with grossly suppurated cysts and coexistent medical problems died. The disease recurred in five patients. CONCLUSIONS. We conclude that, under good perioperative antibiotic and metabolic coverage, the infected hydatid cysts have to be completely evacuated and properly drained. The application of "conservative" surgical procedures should be preferred. Further studies are needed to solve the clinical and therapeutic problems of this serious complication.

Carotid artery disease in octogenarians: endarterectomy or stenting?

AIM: Carotid endarterectomy (CEA) is the gold standard for the treatment of carotid stenosis, but carotid angioplasty and stenting (CAS) has emerged as a potential less invasive therapeutic alternative to patients who would otherwise be considered as high risk for open surgery. The aim of this review was to pool the most current studies of the growing body of literature in which outcomes of CEA or CAS are compared in octogenarians and non-octogenarians to determine the current safety and efficacy of these therapeutic procedures, due to a lack of randomized controlled trials. METHODS: An electronic search of Medline, PubMed and Cochrane databases was supplemented by a review of bibliographies of relevant articles, as well as manual searches of relevant journals. Outcomes included 30-day stroke rate, death rate, combined stroke/death rate and myocardial infarction rate between octogenarians and non-octogenarians. RESULTS: Randomized clinical trials or studies comparing CEA and CAS in the same study population were not identified. CEA and CAS outcomes, in octogenarians compared to younger cohorts, were evaluated in 10 and 5 studies, respectively. Analysis of data indicates no significant difference in adverse events reported in the two groups in the majority of studies of CEA, as opposed to the findings of CAS studies. CONCLUSION: The current review supports the viewpoint that CEA remains the standard of care in octogenarians, towards which other procedures to prevent stroke should be compared. It also challenges the definition of the ''high-risk''/age blanket classification and suggests that until the longevity, safety and efficacy of CAS is established, wide applicability of CAS to such ''high-risk'' patients should be questioned and limited to ongoing controlled clinical trials.