Pilonidal sinus: a comparative study of treatment methods.

INTRODUCTION: Pilonidal disease is a very common anorectal problem without a clinical consensus on its optimal management. OBJECTIVE: To compare the methods used by our clinic and determine the outcomes in relation to healing, hospitalization time and recurrence. MATERIALS AND METHODS: We have studied all the cases of patients with pilonidal sinus that were treated surgically in our clinic from January 1, 1997 to December 31, 1999. RESULTS: A total of 111 patients were treated of whom 92 (82,8%) were men and 19 (17,2%) were women. Ages ranged from 16 to 65 years with an average age of about 25,1 years. Of the 111 patients, 63 were treated with marsupializationand the remaining 48 were treated by excision (29 with open excision and 19 with the primary suture technique). One hundred and two (91,9%) patients were discharged from the hospital after the surgical procedure, while the remaining 9 patients were hospitalized for 24 hours. The healing time for marsupialization was 27,3 days, the primary suture technique was 11,7 days and the open excision method took 46,4 days. Recurrence was observed in 16 patients (14,4%). Recurrence appeared in 4 (6,35%) of the 63 patients subjected to marsupialization, 1 of the 29 patients subjected to open incision, and 11 (57,8%) of the 19 patients subjected to primary closure. CONCLUSION: In the absence of inflammation and/or recurrence, marsupialization is the surgical method of choice as it has a low percentage of recurrence and an acceptably short healing period.In apparently large, inflamed and recurrent situations, open excision is preferred.

Hernia mesh repair of the anterior abdominal wall and antibiotic chemoprophylaxis: multiple doses of antibiotics failed to prevent or reduce wound infection.

BACKGROUND: Mesh repair of the anterior abdominal wall hernias is a popular technique and commonly accepted among the majority of surgeons. The technique used most frequently today is the free tension technique. It is uncertain whether antibiotic prophylaxis is necessary to prevent post operative wound infection, especially when a foreign body like a polypropylene mesh is used. METHODS: We have studied retrospectively the patients who received surgical treatment in our department for anterior abdominal wall hernia during the period of January 1995 -December 2004. Patients were divided into 3 groups based on the doses of antibiotics administered. RESULTS: In 780 out of 1245 cases, a mesh of polypropylene was used. In our sample, we excluded 221 patients due to diseases that made the use of antibiotics necessary. We have studied the frequency of superficial and deep infections in correlation with the use of antibiotics (cephalosporin of second generation or a combination of ampicillin plus sulbactam). CONCLUSION: No difference was observed in the incidence of surgical trauma infection in relation to the duration and the doses of antibiotic cover. The wound infection rate in the current study does not support the use of multiple doses of antibiotics, as this rate does not differ from the rates of infection reported in the literature. Further studies are needed to clarify if antibiotic chemoprophylaxis with one dose or no chemoprophylaxis should be recommended.

Intraperitoneal administration of local anesthetics in laparoscopic surgery: pharmacological, anatomical, physiological and pathophysiological considerations.

Local anesthetics, because of their ability to cause a reversible blockade in transmission of impulses along the central and peripheral neural pathways are used to induce analgesia. In laparoscopic surgery procedures, the reduction of postoperative pain is one of the biggest benefits compared with open surgery. However, the pain is not completely absent after laparoscopic surgery. The intraperitoneal administration of local anesthetic intraoperatively in laparoscopic surgery can reduce the intensity of postoperative pain. This method has been in use since the early nineties and seems to be effective. The purpose of this review is to assess the pharmacology of local anesthetics, the anatomy and physiology of the peritoneum, the physiology of preemptive analgesia, and the pathophysiology of pain and review the data from the use of this method so as to make it more effective. For the safest and longest intraperitoneal administration of local anesthetics the following significant points must be taken into consideration: administration of local anesthetic should be done at the beginning, in short-term intervention and both at the beginning and end of surgery for longer-term intervention, administration of local anesthetic should be combined with a vasoconstrictor, usage of solutions of small volume and high concentration of local anesthetic, coverage of the greatest possible surface of the parietal peritoneum (by using a nebulizer), adherence to a waiting period of 10-15 minutes after administration of local anesthetic and usage of a safe and longer duration local anesthetic like levobupivacaine.

Primary gallbladder cancer discovered postoperatively after elective and emergency cholecystectomy.

BACKGROUND: Gallbladder cancer is a rare neoplasm associated with high mortality and poor prognosis. It is usually correlated with cholelithiasis and presents more commonly in elderly and female patients. Diagnosis is seldom made preoperatively because of the indolent progression of the tumor. METHODS: The hospitalization and surgical records of our surgical department were examined from January 1992 to December 2001, searching for patients who had undergone cholecystectomy. Additionally, the histopathological diagnoses of the same period were studied searching for patients with the diagnosis of gallbladder cancer established post-operatively and not intraoperatively by frozen section. RESULTS: In the period of 1992- 2001, a total of 1,536 cholecystectomies took place and 14 cases of gallbladder cancer were diagnosed postoperatively. The ratio of men to women is 3/ 11 with a mean age of 69.4 years. The clinical symptoms were nonspecific and mortality was 57%. CONCLUSION: In most cases gallbladder cancer is diagnosed after cholecystectomy and even in these cases it can be in an advanced stage and the prognosis of this rare neoplasm is poor.

Neuroendocrine tumor of the cystic duct.

Neuroendocrine tumours of the extrahepatic bile ducts are extremely rare with less than 70 cases having been reported in the literature. Neuroendocrine tumours are neoplasms of variable malignant potential that arise from the embryonic neural crest cells. They most commonly occur in young females and usually present with painless jaundice. Preoperative diagnosis is seldom made and neuroendocrine tumours are usually incidentally found during abdominal surgical intervention for other indication. Due to their indolent biological behaviour aggressive surgical treatment is recommended. We present a case of an incidentally discovered neuroendocrine tumour of the cystic duct in a 41 year old woman following laparoscopic cholecystectomy for symptomatic gallbladder microlithiasis. The present case is the 8th case of cystic duct NET and the 63rd of extrahepatic bile duct NET. While a rare location for a NET, it is important to report cases of biliary tract neuroendocrine tumours in order for their pathogenesis and physical history to be clarified.

Thoraco-abdominal injuries: the general surgeon's perspective.

BACKGROUND: Thoraco-abdominal traumatic injuries affect the inferior part of the thoracic cavity and the superior part of the abdominal cavity. This study summarizes five years of our surgical department's experience in the diagnosis and management of thoracoabdominal trauma patients. METHODS: We examined records from our surgical and emergency room departments from January 1996 to December 2000, and selected patients with thoraco-abdominal injuries. RESULTS: Fifty-five patients were treated who suffered coexisting trauma of the thoracic and abdominal cavity. Males represented the majority of patients and mean age was 38.2 years. Traffic accidents were the major cause (55%) followed by criminal acts of violence (32%) and falls (13%). The most common thoracic injuries were rib fractures (40%) and simple lung contusions (35%) and the abdominal organs most commonly injured were the spleen (35%), liver (25%) and kidney (20%). Surgical interventions were performed in 68% of patients, whereas the remaining patients were treated conservatively. CONCLUSIONS: Thoraco-abdominal injuries are characterized by high heterogeneity and can provide significant decision-making challenges. The accurate diagnosis of all coexisting injuries is critically important, as the diagnosis will determine surgical or non-operative management of these injuries.

Duodenal gastrointestinal stromal tumor presenting with acute upper gastrointestinal bleeding treated with segmental resection.

Gastrointestinal stromal tumours (GISTs) are considered to derive from the interstitial cells of Cajal or their precursors and are defined by their expression of c-kit protein (CD117) that is positive in 95% percent of cases. These are rare mesenchymatous tumours, while they represent the most common mesenchymal tumours of the alimentary tract. The majority of GISTs develop in the stomach and small intestine and more rarely in the rectum, colon, esophagus and mesentery; only 3-5% of all GISTs are located in the duodenum. The presenting symptoms include early satiation, dysphagia, bloating, abdominal pain and gastrointestinal bleeding, either acute or chronic. Surgery remains the mainstay of treatment for localized, non-metastatic, resectable GISTs. We present a case of duodenal gastrointestinal stromal tumour of the third portion of the duodenum that presented with acute upper gastrointestinal bleeding treated with segmental duodenal resection.

Lymphoepithelioma-like gastric carcinoma presenting as giant ulcer of the lesser curvature: case report.

Lymphoepithelioma-like gastric carcinoma (LELGC) has special clinicopathologic features that differentiate it from the common gastric adenocarcinoma. LELGC is a rare neoplasm of the stomach with an incidence of 1-4% of all gastric cancers and is characterized by desmoplastic stroma uniformaly infiltrated by abundant lymphocytes and plasma cells. LELGC is closely associated with the Epstein-Barr virus (EBV), with 80-100% of LELGC being EBV-positive. LELGC has a male predominance, occurs in elderly people and is usually located in the upper and middle portion of the stomach. We report a rare case of lymphoepithelioma-like gastric carcinoma located in the lesser curvature at the border of the gastric body to the pyloric antrum.

Incidentally discovered white subcupsular liver nodules during laparoscopic surgery: biliary hamartoma and peribiliary gland hamartoma.

During routine laparoscopic surgery, the surgeon may encounter the presence of small white subcapsular liver nodules, either solitary or multiple. The lesions may mimic liver metastasis and in many cases are not demonstrated in the preoperative ultrasound or computed tomography. The aim of this article is to familiarize the laparoscopic surgeon with the incidental discovery of these nodules which represent the two types of intrahepatic benign bile duct proliferations and include biliary hamartomas, which are usually multiple benign malformations of the intrahepatic bile ducts, and peribiliary gland hamartoma, which is usually solitary and consists of a benign epithelial tumor of the liver derived from bile duct cells.

Colonic lipomas: our experience in diagnosis and treatment.

AIM: The aim of this study is to present our experience in colonic lipomas. PATIENTS AND METHODS: We present 4 patients (1 male, 3 females) of mean age 65.5 years (range, 61-72 years) treated for single colonic lipomas. The diameters of the lesions were 4.5, 4, 3.5 and 2.5 cm, respectively. In 3 cases, colonic lipomas were located within the cecum, while in one patient within the descending colon, proximally to the splenic flexure. RESULTS: Lipomas of diameter greater than 3 cm caused nonspecific symptoms. Lipomas of higher diameter were removed laparoscopically with colotomy; in two cases, the patients underwent open hemicolectomy, because of the suspicion of malignancy, while the smallest lesion was resected endoscopically, using a bipolar snare. All patients recovered without complications and remain healthy with no signs of recurrence. CONCLUSION: In cases of ulcerated lipomas, greater than 3 cm of diameter, surgical resection is recommended.

Mesothelial mesenteric cyst in patient with ascending colon cancer. Case report.

Mesenteric cysts are rare cystic malformations of the mesentery. They are usually located at the iliac mesentery. Clinically most mesenteric cysts are asymptomatic, but sometimes they present with non-specific abdominal symptoms. Diagnosis can be aided using US, CT and MRI but careful interpretation of the images and high index of suspicion of this rare condition is essential for the correct diagnosis, which cannot always be preoperatively established. The therapeutic method of choice is complete surgical excision of the cyst which minimizes the possibility of recurrence. Histopathologically they are classified in six group. We present a case of a mesothelial mesenteric cyst in patient with colon cancer. The cyst was misdiagnosed as urinary bladder diverticulum in the preoperative CT scan.

Long term follow up of eosinophilic granuloma of the rib.

UNLABELLED: BACKROUNDS: Eosinophilic granuloma is one of the rarest causes of bone tumors, especially in adults. Eosinophilic granuloma is the commonest form of Langerhans cell histiocytosis and represents the unifocal osseous form of the disease which usually affects the skull and long bones. Eosinophilic granuloma, is a benign disease in which diagnosis and differential diagnosis presents more difficulties than treatment. OBSERVATION: We present a case of eosinophilic granuloma of the rib with long term follow-up of 14 years which was treated with a combination of surgery and chemotherapy. CONCLUSION: Prognosis of adult eosinophilic granuloma is excellent and the recurrence rate is limited. All available treatment options, including surgery, chemotherapy, corticosteroids, radiation, and even palliative treatment have very good results and in many cases the disease seems to heal spontaneously. However the disease, due to its rarity and unknown pathogenesis still remains an enigma for the clinical doctor.

Progress in rectal cancer staging and treatment.

Colorectal cancer poses a worldwide major health issue. Rectal cancer has somewhat distanced itself from colonic cancer as a different oncologic entity, due to differences in diagnosis and treatment. Several developments over the last years have improved screening, diagnostics, pre-operative therapy, surgical techniques and postoperative patient care. The multidisciplinary approach to rectal cancer, mainly through the co-operation of surgeons, oncologists and radiologists, seems to be one of the most important steps in the management of that disease.

Large bowel obstruction due to endometriosis.

We report on three cases of premenopausal female patients with large bowel endometriosis causing intermittent obstruction.

Sister Mary Joseph's nodule as the sole presenting sign of gastric signet ring cell adenocarcinoma.

The Sister Mary Joseph's nodule is a periumbilical metastatic tumor originating from advanced metastatic intra-abdominal and intrapelvic malignancies. It is an inconspicuous and uncommon clinical sign, which not only shows the presence of visceral malignancy but also reveals the poor prognosis of these malignancies. The majority of cases originate from gastrointestinal or ovarian cancer. We present a case of an 80-year-old woman with an umbilical nodule, which was the sole presenting symptom of advanced signet ring cell carcinoma of the stomach with generalized peritoneal carcinomatosis. There are very few cases of gastric signet ring cell adenocarcinoma presenting as a SMJN, a fact rather striking as signet ring cell gastric carcinoma has an increased frequency of peritoneal dissemination and carcinomatosis of the peritoneum.