Anastomotic loop between common hepatic artery and gastroduodenal artery in coexistence with an aberrant right hepatic artery.

Anatomical variations of the hepatic arteries are not uncommon. The anomalous hepatic arterial supply is of paramount importance in hepatobiliary, pancreatic or liver transplantation and in laparoscopic surgery. We describe an unusual case of a 66-year-old Greek male cadaver, where a rare anastomosis (in the form of an enlarged arterial loop, 4.84 mm in diameter) between the common hepatic artery (6.42 mm) and the gastroduodenal artery (GDA) (4.82 mm) coexisted with an aberrant right hepatic artery (ARHA) (6.38 mm) originating from the superior mesenteric artery. The proper hepatic artery was absent. The ARHA followed a route posterior to the portal vein and the common hepatic duct, entering the liver and supplying the right hepatic segment. A hypoplastic right gastric artery emanated from the GDA. Our case report highlights the combined variations of hepatic arteries and possible anastomoses emphasizing that a thorough knowledge of the classic and variable hepatic arterial anatomy are mandatory for surgeons and radiologists performing hepatic surgery and arteriography to avoid potential iatrogenic injuries in hepatobiliary and pancreas area and further medico-legal implications.

Foramen magnum, occipital condyles and hypoglossal canals morphometry: anatomical study with clinical implications.

BACKGROUND: Current study examines morphometric alterations of the foramen magnum (FM), occipital condyles (OCs) and hypoglossal canals (HCs) and highlights all the morphometric parameters of the FM area that present side asymmetry, gender dimorphism and are affected by the ageing. MATERIALS AND METHODS: One hundred and forty-one (73 male and 68 female) Greek adult dry skulls were examined. RESULTS: Short and long OCs were detected in 27.7% and 26.2%. A combination of short OCs and long HCs was presented in 27.5%. A complete septum was found in 23.6% of the HCs and osseous spurs in 12.9%. Side asymmetry was detected regarding the HCs length (p = 0.046), the maximum extracranial (p = 0.001) and minimum intracranial (p = 0.001) diameters. Mean FM anteroposterior and transverse diameters, FM perimeter and FM surface area were significantly larger in male than in female skulls (p = 0.001 for each parameter). Similarly, the OCs length (right, p = 0.004 and left, p = 0.024) and width (right, p = 0.008 and left, p = 0.006) the left distance HC-OC posterior border (p = 0.048), the anterior (p = 0.011) and posterior (p = 0.001) intercondylar distances and the HCs right length (p = 0.046) were significantly greater in males. A significant decrease was observed with ageing in FM anteroposterior diameter (p = 0.038), FM surface area (p = 0.05), anterior intercondylar distance (p = 0.014) and HC-OC posterior border (p = 0.013). CONCLUSIONS: The study confirmed that only specific HC dimensions showed side asymmetry (HCs maximum extracranial and minimum intracranial diameters and HCs length), gender dimorphism (HCs right length and left distance HC-OC posterior border) and age influence (HC-OC posterior border and HC left extracranial minimum diameter) among young, adults and elderly individuals. FM and OCs dimensions presented gender dimorphism and the age influenced only FM anteroposterior diameter and surface area and the anterior intercondylar distance. The safe zone of OCs drilling in Greeks, calculated by the distance HC-OC posterior border represents the maximum HC depth and is among the lowest values reported in the literature. The significant decrease of this distance with ageing confirms the existence of a drilling safe zone for young, adults and elder individuals. Regarding OCs length, the same probability exists dealing with a short or a long OC during condylectomy. Before planning a transcondylar approach, the coexistence of short OCs and long HCs should be taken into account. These outcomes will be useful for a safe surgery in the craniocervical region in Greeks.

The effect of intraoperative lavage with short chain fatty acids (SCFAs) on rectal anastomosis of rats receiving corticosteroids.

BACKGROUND: Anastomotic failure is one of the most frequent complications in rectal surgery. The present study aims to elucidate the effect of intraoperative lavage with short chain fatty acids (SCFAs) on rectal anastomosis of rats receiving corticosteroids. METHODS: Fifty male Wistar rats were divided into five groups. Group A (control group, without lavage and medication), group B (lavage with saline solution and no medication), group C (lavage with SCFAs and no medication), group D (lavage with saline solution and injection of 30mg/kg methylprednisolone 7 days pre-operatively and 4 days post-operatively), group E (lavage with a SCFAs and methylprednisolone). On the 4(th) postoperative day the animals were sacrificed and bursting pressure of the anastomosis, CRP, IL-6 and TNF-a were measured. RESULTS: Kruskal-Wallis variance analysis showed statistically significant differences between the groups (p<0.001). The bursting pressure of the anastomosis was lower in groups B and D, while it was higher in group C. TNF-a values displayed differences between group D and groups A, C, E. CONCLUSIONS: Intraoperative lavage with SCFAs increases anastomotic strength by increasing the bursting pressure of anastomosis in rats receiving corticosteroid, while lavage with saline solution decreases it. Rectal irrigation with short-chain fatty acids may improve anastomotic healing, especially in patients receiving corticosteroids.

Surgical management of rectal prolapse.

PURPOSE: Rectal prolapse is uncommon; however, the true incidence is unknown because of underreporting, especially in the elderly population. Full-thickness rectal prolapse, mucosal prolapse and internal prolapse are three different clinical entities, which are often combined and constitute rectal prolapse. The aim of the study is to present our experience in the surgical management of rectal prolapse. METHODS: In a 6-year period (2004-2010), 27 patients were surgically treated for rectal prolapse. The majority of patients were women (25 women, two men) and their mean age was 72.36 years. The operations performed were two Delorme's procedures, five STARR (Stapled TransAnal Rectal Resection), 14 Wells procedures, two Wells combined with Thiersch, one Altemeier, one sigmoid resection combined with Wells and two Thiersch. RESULTS: An emergency sigmoidostomy was performed on a patient after Wells operation due to obstructive ileus. One death occurred on the 5th postoperative day due to pulmonary embolism. Two recurrences observed 8 months postoperatively, one in a patient after STARR operation and one in a patient after Thiersch technique. The great majority of patients are completely relieved of symptoms. CONCLUSIONS: The application of different modalities in the treatment of rectal prolapse is attributed to the fact that cause, degree of prolapse and symptoms, vary from one patient to another. Successful approach depends on many factors, including the status of a patient's anal sphincter muscle before surgery, whether the prolapse is internal or external and the overall condition of the patient.

Surgical management of colorectal injuries: colostomy or primary repair?

PURPOSE: Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not. METHODS: From 2008 to 2010, ten patients with colorectal injuries were surgically treated by primary repair or by a staged repair. RESULTS: The patients were five men and five women, with median age 40 years (20-55). Two men and two women had rectal injuries, while 6 patients had colon injuries. The mechanism of trauma in two patients was firearm injuries, in two patients was a stab injury, in four patients was a motor vehicle accident, in one woman was iatrogenic injury during vaginal delivery, and one case was the transanal foreign body insertion. Primary repair was possible in six patients, while diversion was necessary in four patients. CONCLUSIONS: Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries. Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia. The role of diversion in the management of unrepaired extraperitoneal rectal injuries and in cases with anal sphincter injuries is mandatory.

IL-17-producing T cells in lupus nephritis.

Significant evidence implicates interleukin-17 (IL-17) in the pathogenesis of systemic lupus erythematosus (SLE), particularly in the development of tissue damage. IL-17 production and IL-17-producing CD4+ and CD3 + CD4-CD8- cells are increased in patients with SLE. IL-17-producing cells are present in the inflamed kidney tissues from patients with lupus nephritis. In lupus-prone mice, IL-17 production appears to be involved in the expression of disease pathology and pharmacologic or genetic manipulation of its production results in suppression of the disease. It becomes obvious that the use of biologics including humanized anti-IL-17 antibodies or decoy IL-17 receptors deserve clinical consideration. Similarly, the development of drugs that suppress the production of IL-17 is in order.

Ileal pouch dysfunction.

The causes of pouch dysfunction are inflammatory, non-inflammatory and iatrogenic. The most common long-term complication is pouchitis. Diagnosis should be based on clinical symptoms, endoscopic appearance and histologic findings. Ciprofloxacin and metronidazole are the treatment of choice for pouchitis. Fistulae and perianal abscesses should be suspected to be an expression of misdiagnosed Crohn's disease. Strictures are confronted by endoscopic balloon dilatation. Patients who will be refractory to all forms of medical treatment should have surgical treatment such as faecal diversion or pouch revision.

Perianal fistulas.

The most common cause of anal fistula is anal gland sepsis, resulting in formation of anorectal abscess, particularly if the latter allowed bursting spontaneously or has been inadequately opened at operation. Surgical treatment of the fistula must intent to its healing or simply its drainage or its transformation to a simpler one. Superficial, low transsphincteric and intersphincteric fistulas are treated by the lay-open technique. The use of a loose seton allows time for any sepsis and induration to settle before a decision about further treatment is made. Also, the use of a tight seton in the management of complex fistula may avoid an early muscle division before any tissue scarring happened. The patient with a perianal fistula must have a steady trustful relationship with his surgeon and must be fully informed on the therapeutic plan and reassured for a favourable outcome.

Colonic cancer in a patient with intestinal malrotation: a case report.

We present a case of a 76-year-old patient with intestinal malrotation, with incomplete rotation of the small intestine and abnormal positioning of the duodenum and superior mesenteric vessels over the transverse colon. Furthermore, the patient suffered of a concomitant cancer of the ascending colon.

Desmoid tumor of mesentery in familial adenomatous polyposis: a case report.

Our case concerns a 52-year-old male with FAP, who was treated surgically by restorative colectomy and ileal pouch anal anastomosis. Three years later, he presented with acute epigastric pain and obstructive ileum. While a mass in the left lateral abdominal region was palpated. The patient underwent laparotomy, some adhesions were dissected and biopsies were taken from the mass. Pathological examination revealed a desmoid tumor of the mesentery.

Enhancement of colonic anastomotic strength in rats by short-chain fatty acids.

BACKGROUND: The present study is aiming at elucidating the effect of intraoperative lavage with short-chain fatty acids (SCFAs) on colonic anastomosis in rats. METHODS: Forty male Wistar rats were randomized into four groups (10 rats each). After resection of a segment of transverse colon, an end-to-end anastomosis was performed. In the 1st group, no intraoperative large bowel lavage was performed; in the 2nd, a lavage with normal saline solution; in the 3rd, the animals received a diet rich in SCFAs pre- and postoperatively, and a lavage with normal saline was performed; and in the 4th group, an intraoperative lavage with SCFAs was carried out. On the 4th postoperative day, the animals were sacrificed. Septic complications, adhesions and anastomoses were graded macroscopically and histologically, and bursting pressure of the anastomoses, CRP, IL-6 and TNF-a was measured. RESULTS: Fewer septic complications (abscesses and minimal ruptures) and adhesions were observed in the 4th group with the intraoperative lavage with SCFAs. The bursting pressure also, in the same group, was higher (73.3 mmHg), followed by the 1st group (67.1 mmHg). CONCLUSION: Intraoperative lavage with SCFAs increases the bursting pressure of colonic anastomoses, while lavage with saline solution decreases it, in comparison to the group without lavage.

Groin swelling, the anatomic way out of abdominal haematomas: a case report and explicative literature review.

This case report concerns a previously healthy thirty-five-year-old female with complaints of inguinal hernia that ultimately proved to be a retroperitoneal haematoma. The patient suffered from a car accident 5 months before admission and was hospitalized. During her prior hospitalization, explorative laparotomy revealed a haematoma of the mesentery. The haematoma was treated conservatively, with fluid resuscitation and rest. During her second admission, MRI of the inguinal region revealed localized haematoma. During inguinal exploration, a fluid-filled bluish indirect hernia sac was identified and found to be contoured by free-flowing, non-clotting blood. The postoperative course was uneventful, and the patient was discharged six days following surgery.

Gastric femoral hernia in a male cadaver with gastroptosis: case report and review of the literature.

The shape and the position of the stomach and its anatomic relations to the round viscera vary from individual to individual, but they also vary in the same subject depending on many factors. The downward displacement of the stomach is called gastroptosis. In the literature, there are only five case reports where the stomach constituted the content of a femoral hernia. The current study presents a case of a gastric femoral hernia in a cadaver along with a review of the relevant literature. During routine dissection of a 67-year-old male cadaver with a very large stomach and gastroptosis, a femoral hernia containing a part of the great curvature of the stomach was found. The length of the hernia sac was 5 cm, and its width was 3.5 cm. There was a disposition of the intestinal coils to the posterior wall and the lesser pelvis. The cadaver's former medical history and skin observation before dissection excluded any previous abdominal surgery. This is the second case of stomach herniation through the femoral ring in a male subject ever reported. The symptoms in this pathology vary from complete absence to symptoms due to high stenosis of the digestive tract, stomach strangulation and stomach wall necrosis.

Bilateral femoral hernia in a male cadaver with vascular variations: case report and review of the literature.

Femoral hernia, which is a less common occurrence than inguinal hernia, is not congenital in most cases and is uncommon in young males. It is considered to be more common in females than in males due to an enlarged femoral ring in the former. A case of bilateral femoral hernia in a 64-year-old male cadaver is described within the framework of an anatomical approach. On the right side, the protrusion of the viscus appeared as a small intestine coil, whereas on the left side the protruded viscus appeared as a pelvic colon's appendix appiplocae. On both sides, the protruded viscus was located in front of an aberrant obturator artery, which oriented from the external iliac artery and not from the internal iliac artery as should be the case. The puberal branch of the inferior epigastric artery was absent. The cadaver's medical history and his skin examination excluded an abdominal surgery. In the literature, case reports of bilateral femoral hernia appear only seldom, especially those of male patients who had not undergone inguinal hernia repair surgery. In femoral hernias more often than in other types of hernia, the protruded viscus is strangulated and undergoes a tissue necrosis. Morbidity and mortality for complicated femoral hernia is high. Knowledge of vascular variation such as presented by the cadaver under study is extremely useful to the surgeon because any iatrogenic injury of the aberrant obturator artery during a laparoscopic repair may result in dangerous hemorrhage.

Effect of blood transfusion on gene expression of transforming growth factor beta-1 and the alpha subunit of interleukin-2 receptor in a model of colonic wound healing.

Blood transfusions have been shown in the past to compromise wound healing in experimental models of colonic anastomosis. Transforming growth factor beta (TGFbeta) has been proposed to play a major role in the process of colonic wound healing, and its expression is believed to be modulated by interleukin-2 (IL2). According to an earlier report, the postoperative administration of the histamine receptor-2 antagonist ranitidine increases the blood levels of soluble IL2 receptor in humans undergoing abdominal surgery and could thus affect molecular determinants of colonic anastomosis. In this study we examined the effect of blood transfusions, with and without ranitidine administration, on the gene expression of TGFbeta(1) and the specificity-conveying alpha subunit of the receptor for IL2, in rat perianastomotic tissue. Analysis of gene expression by semiquantitative RT-PCR revealed a tendency for downregulation of both genes, albeit in a statistically nonsignificant manner. This effect was not prevented by the postoperative administration of ranitidine. On the other hand, there appears to be a significant correlation between expression of TGFbeta(1) and that of IL2 receptor alpha subunit, irrespective of treatment.

Randomized clinical trial of stapled hemorrhoidectomy vs open with Ligasure for prolapsed piles.

BACKGROUND: The aim of the study was to compare the results in 95 patients randomly allocated to undergo either stapled or open hemorrhoidectomy using Ligasure. METHODS: Ninety-five patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open using Ligasure (45 patients). Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique by using Ligasure. Postoperative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and an 18 (12-24) month median telephone follow-up were obtained in all patients. RESULTS: Operation time for open hemorrhoidectomy using Ligasure was shorter [median 13 (range 9.2-16.1) min vs 15 (range 8-17) minutes, p < 0.05]. Median range of VAS score in the stapled group were significantly lower [VAS score after 8 h: 3 (2-6) vs 5 (3-8), p < 0.01; VAS score after first defecation: 5 (3-8) vs 7 (3-9), p < 0.001. The stapled hemorrhoidectomy was associated with an increased incidence of intraoperative bleeding in 18 cases (36%) vs four cases (8.8%) of the Ligasure group. There were three cases (6%) from the stapled group with recurrence of the hemorrhoids and none from the open technique. CONCLUSIONS: Hemorrhoidectomy with a circular stapler device is easy to perform, but one more line of clips must be added to the device to avoid intraoperative bleeding from the cut line. Hemorrhoidectomy performed using Ligasure is more painful postoperatively but is a more radical operation.

Effect of ranitidine on healing of normal and transfusion-suppressed experimental anastomoses.

BACKGROUND: Histamine has been shown to participate in immune response. Wound healing is a process of immune system. This experimental study was done to find the effect of histamine2 receptor antagonist ranitidine on the healing process of intestinal anastomosis in rats. METHODS: Eighty Wistar rats in four groups of 20 each underwent colon resection and anastomosis. They were given 2 ml saline or blood, twice daily 0.4 ml saline or 0.4 ml saline containing 0.7 mg ranitidine. The animals were killed 3 or 7 days postoperatively and the anastomotic strength assessed by bursting pressure. RESULTS: The ranitidine group developed fewer anastomotic abscesses (p<0.001). Anastomotic strength was significantly reduced either on day 3 or 7 in animals given blood transfusions (p<0.04, p<0.001), whereas in animals given ranitidine this effect was partially reversed. CONCLUSIONS: These data indicate that ranitidine has no influence in anastomotic bursting pressure, but has a lower incidence of septic complications.

Colorectal cancer in patients over 70 years of age: determinants of outcome.

BACKGROUND: The aim of this study was to evaluate operative risk factors, the mortality, morbidity and survival in old patients with colorectal cancer. METHODS: From 1160 patients with colorectal cancer, 398 patients aged 70 years or older, from 1970 to 2000, were followed-up. Dukes' classification, differentiation, sex, anatomical site and survival were compared with patients <70 years old. RESULTS: Long-term results have been proved to be similar both in young and old patients. Relative survival rate for patients aged 70-95 (70.5%) were similar to those for patients less than 70 years old (71.6%) and also comparable between male (72.3%) and female (68%) patients. CONCLUSIONS: Elderly patients have a lower capacity to react to postoperative complications, but the relative survival is similar to younger patients. Advanced age alone should not be used as a criterion to deny surgery for colorectal cancer.

Metastatic breast adenocarcinoma masquerading as colonic primary. Report of two cases.

BACKGROUND: Common sites of metastasis for the breast cancer are bones, lungs, the central nervous system and liver. The colon is the rarest site of metastasis for the breast carcinoma. PATIENTS AND RESULTS: We report our recent experience of two female patients, 55 and 57 years old respectively, who presented breast metastasis at the proximal transverse colon. They were operated for breast carcinoma followed by chemotherapy and radiotherapy, four and ten years before the metastasis was diagnosed. The symptoms were anaemia and bowel obstruction. Diagnosis was made by double contrast barium enema and colonoscopy. Postoperatively, both patients received systemic chemotherapy. At the follow-up, two and three years after, there is no evidence of recurrence or metastasis. CONCLUSIONS: Patients with history of breast cancer presenting with anaemia and/or bowel obstruction should be examined for possible metastasis to colon and should be treated surgically followed by systemic chemotherapy.