[Cholangiocellular carcinoma of the common hepatic duct causing obstructive jaundice in a patient with metastatic colonic carcinoma within liver].

INTRODUCTION: Colorectal carcinoma, one of the most frequent carcinomas, produces liver metastasis very frequently. Surprisingly, those secondaries rarely cause obstructive jaundice. If it appears, it is usually caused by compression or infiltration of the major bile ducts close to the hepatic hilus, less frequently with bile duct obstruction by gelatinous mucus produced by the timour, much rarer by the tumour growth within the, otherwise intact, common bile duct and very rarely by metastasis into the biliary tree. CASE OUTLINE: We present a 67-year-old man who had been submitted to left colectomy for sygmoid colon carcinoma four years earlier, now, admitted with an obstructive jaundice, along with a number of liver and lung secondaries. Obstructive jaundice was caused by the vegetative tumour of the proximal part of the common hepatic duct which was resected and anastomosed with a Roux-en-Y jejunal limb. The postoperative recovery was uneventful. The patient died 7 months later without jaundice due to liver and lung secondaries. Histological findings showed cholangiocellular carcinoma of the common hepatic duct, while the histological findings of the liver tumour specimen confirmed metastatic colonic carcinoma. CONCLUSION: In case of obstructive jaundice in patients with metastatic colonic carcinoma within liver, other aethiological factors of biliary obstruction can not be excluded and have to be taken into differential diagnosis.

[Giant cryptogenic pyogenic gas containing left liver abscess].

INTRODUCTION: Pyogenic gas containing liver abscesses are rare. Less than 50 cases seem to have been described so far. Most of them were localised within the right liver. The majority of those abscesses appear in diabetic patients. CASE OUTLINE: The autors present a 64-year old diabetic male patient in whom the investigation (US, CT, plain X-ray) performed for fever of unknown origin confirmed a giant liver gas containing abscess that destroyed almost the entire left liver. Escherichia coli sensitive to several antibiotics was isolated from the abscess. The patient was cured by surgical drainage, limited debridement, lavage, drainage and antibiotics. CONCLUSION: Pyogenic gas containing liver abscesses are easy to diagnose nowadays. The type of surgical drainage has to be adapted to a particular patient.

[Disseminated subcutaneous fat necrosis and elbow joint arthritis as a complication of pancreatitis].

BACKGROUND: Intraabdominal fat necrosis of the retroperitoneum, mesenthery and omentum is a frequent complication of acute pancreatitis. Very rarely, during the disease multiple aseptic subcutaneous fat necrosis, polyarthritis, polyserositis, vasculitis, subcutaneous nodi and eosinophylia, isolated or in combination, may appear. They are known as "pancreatic disease syndrome". CASE REPORT: We presented a female patient, 43-year-old, in whom in the course of acute interstitial biliary pancreatitis had occur red multiple localized aseptic necrosis of subcutaneous fat tissue of extremities appeared mostly around the talocrural and wrist joints requiring multiple incision, as well as aseptic elbow joints arthritis requiring puncture of one elbow joint. The symptoms were followed by a prolonged febrility that settled within several weeks. CONCLUSION: Localized disseminated fat necrosis around joints, arthritis of major joints, alone or with some of other symptoms of the "pancreatic disease syndrome" have to be considered as a probable sign of pancreatitis, even in the abscence of major abdominal symptoms.

[Fibromyxoid sarcoma of the pancreas].

INTRODUCTION: Fibromyxoid sarcoma is a rare mesenchymal neoplasm, usually appearing in the soft tissue of the extremities, less frequently in the groin, trunk, neck, and upper extremities. Within the abdomen, the tumour is usually localised within the retroperitoneum. CASE OUTLINE: We present a 56-year-old woman in whom, during the routinely performed investigation for atacks of choking with lots of bronchial secretion, and arterial hypertension, an ultrasonographer found a tumour within the head of the pancreas 6 x 6 cm in diameter. At operation, a dark pink, lobulated soft tumour, surrounded by a tiny capsule, clearly different from the completely normal pancreatic tissue of the posterior side of the head of the pancreas, was easily and ideally excised. The postoperative recovery was stormy. She developed postoperative pancreatitis, temporary biliary and duodenal fistula, which all settled by conservative treatment. The histology of the 80 g weighing tumour showed a circumscribed fibromyxoid sarcoma of low malignancy. Immunohistochemistry showed diffuse vimentin and CD34 strong positivity, as well as focal anti-SMA and anti-EMA immunopositivity. Six months after surgery, she died with signs of cerebrovascular insult, asthmatic status, and recurrent suppurative abdominal fistula, probably related to the previous pancreatitis. Ultrasonography showed a possible liver secondary. The exact cause of death was not confirmed as the autopsy was refused by the family. CONCLUSION: Primary sarcomas of the pancreas are very rare, but should be considered in differential diagnosis of pancreatic neoplasms. To the best of our knowledge, there has been no previously described fibromyxoid sarcoma of the pancreas.

[Mucinous cystadenoma of pancreatic head with focal malignant alteration in a 52-year-old man].

Mucinous cystadenomas of the pancreas are rare tumors appearing usually within the body and the tail of the pancreas in a young and middle-aged women. They rarely communicate with the pancreatic duct and occasionally may become malignant. The authors present a patient with a number of rare features. In a 52-year-old male, we did a radical pylorus-preserving cephalic duodenopancreatectomy for a mucinous cystadenoma within the head of the pancreas, which perforated into the main pancreatic duct causing chronic obstructive pancreatitis having few foci of malignant alteration. The postoperative recovery was uneventful, but three months later the patient died due to exacerbation of the underlying serious heart disease.

[Stromal tumour of duodenal autonomous nerves (plexosarcoma)].

Gastrointestinal tumours arising from autonomous nerves of Meisner's or Auerbach's plexus (plexomas and plexosarcomas) are rare tumours in only 87 cases described in the literature up to 2001. We present a very rare case of gastrointestinal stromal tumour (plexosarcoma) of the third and fourth portion of the duodenum, 130 x 98 x 87 mm in diameter, arising from its back wall, with central necrosis of the well circumscribed tumour, which communicated with the duodenum through an ulceration of 15 x 7mm in diameter, spreading towards the great vessels of the retroperitoneum. It was gradually and carefully removed, together with 17 cm of the duodenum and few centimetres of the jejunum with end-to-end duodenojejunostomy below the Vater's papilla. During the removal of the tumour, the superior mesenteric artery, being within the tumour's capsule, was accidentally ligated but not transsected. In spite of the removal of the ligature, the artery became thrombosed due to damage of the intima by ligature so that it had to be resected and reanastomosed. After otherwise uneventful recovery, except for a mild pus discharge through the drain, not far from the arterial anastomosis, the patient suddenly started bleeding on the 13th day after surgery. At emergency reoperation, a rupture of the mesenteric artery above the thrombosed anastomosis was found. In spite of absence of the arterial pulsation within the mesentery, the bowel looked vital and the back flow from the artery was satisfactory. The arterial rereconstruction was not possible, so the artery was ligated. The postoperative recovery was surprisingly uneventful. The patient was discharged ten days after surgery and has stayed symptom-free so far.

Hepatocellular adenoma with malignant alteration.

Hepatocellular adenoma is a rare benign tumor of the liver which appears almost exclusively in women taking oral contraceptives. Malignant alteration of the tumor is very rare with about 12 reported cases. Case outline. We present a 70-year-old woman who had not taken either oral contraceptive or other hormones ever in her life and in whom an abdominal tumor was discovered during the regular check-up for arterial hypertension. With ultrasonography and CT scan a solitary well demarcated mass within the right liver of otherwise normal appearance was diagnosed. During an open surgery a solitary, unilobular, spherical, well demarcated tumor on the lower surface of the segments IVb, V and VI of the liver, 115 x 100 x 90 mm in diameter was excised. The histology revealed a hepatocellular adenoma with malignant alteration. The patient is the eldest presented case of malignant alteration of hepatocellular adenoma who had never taken oral contraceptives or other hormones.

[Somatostatinoma of the Vater's papilla in a patient with von Recklinghausen's disease].

BACKGROUND: Somatostatinomas of the gastrointestinal tract secret hormon somatostatin which can cause "inhibitory syndrom" comprising diabetes mellitus, cholelithiasis and steatorrheic diarrhea. It is also secreted by the D cells of Langerhans's islands of the pancreas as well as endocrine cells of the stomack, small bowel, salivary glands and parafollicular cells of the thiroid gland. Somatostatinomas of the digestive tract appear within the pancreas and duodenum. Patients suffering from von Recklinghausens's disease are paticularly prone to the somatostatinomas of the duodenum. CASE REPORT: In this paper we presented a 51-year-old female patient with von Recklinghausen's disease in whom, during the investigation for obstructive jaundice, tumor of the Vater's papilla was found. The patient was submitted to Whipple's duodenopancreatectomy. Histology and immunohistochemistry discovered type B glandular carcinoid tumor with strong antisomatostatin and mild antigastrin immunoreactivity. The patient stayed symptom-free more than four years now. CONCLUSION: Patients with von Recklinghausen's disease should be examined for other tumors, particularly carcinoids of the duodenum and papilla, especially if the signs of cholestasis are present.

[Angiectatic pseudocyst of the pancreatic head].

BACKGROUND: Arteriovenous malformations of the pancreas are very rare, most frequently congenital ones, but tending to increase frequency, predominantly due to the introduction and use of new diagnostic modalities. They usually present with gastrointestinal bleeding and abdominal pain. CASE REPORT: The autors presented a 52-year-old woman in whom, during the investigation for the abdominal pain and gastrointestinal bleeding, an ultrasonography showed a hypoechogenic lesion within the head of the pancreas 3 cm in diameter. Endoscopic ultrasound showed an irregular hypoechogenic lesion. Computed tomography showed a low density area within the lesion (< 10HU). At endoscopic retrograde cholangiopancreatography, a cystic lesion within the head of the pancreas was filled with contrast from the normal pancreatic duct. Angiography showed an arteriovenous malformation within the head of the pancreas. The patient underwent pylorus preserving cephalic duodenopancreatectomy. The diagnosis of arteriovenous malformation, probably of congenital origin, was confirmed on histology. CONCLUSION: Arteriovenous malformations should be considered in patients with gastrointestinal bleeding of unknown etiology. In this case, the lesion was taken into account preoperatively, based on color Doppler ultrasonography and angiography. The best results of treatment can be achieved with resection, but it has to be performed before an eventual portal hypertension takes place.

[Hemangioma of the spleen].

Although the most frequent benign tumors of the spleen, hemangiomas are very rare, much rarer than hemangiomas of the liver. They manifest as localized (either single or multiple) or diffuse lesions, vary from solid to cystic, histologically from capillary to cavernous. Usually, they are small in size (1-3 cm), rarely larger and very rarely of large size. A 67-year old woman admitted to Institute of Hematology, CCS, for investigation of the left upper abdominal pain, loss of appetite, loss in weight and malaise. As the investigation showed a number of hypoechogenic lesions within the enlarged, diffusely non-homogenic spleen, splenectomy was indicated. The spleen weighing 2600 grams was removed, in which the number of lesions histologically corresponded to hemangioma of the spleen. Postoperative recovery was uneventful. The patient has remained symptom free more than two years after surgery.

[Infected giant liver cyst].

Congenital liver cysts are not as rare as it was thought in the past. Thanks to new imaging diagnostic techniques, these cysts have been discovered with increasing frequency. Uncomplicated congenital liver cysts are usually asymptomatic or followed by mild symptoms. Various complications of these cysts were reported. Infection of the congenital liver cyst is, however, very rare complication. A 65-year old man with huge infected congenital central liver cyst containing 3400 ml of pus from which Escherichia coli was cultivated was presented. The patient had a number of other histologically confirmed congenital cysts of the liver and the cyst of the left kidney. The patient was cured by pus evacuation, partial excision of the cyst wall and drainage of the cavity and subphrenic space. The uninfected cysts were operated using deroofing technique. A year after surgery the patient remained symptom free.

[Aggressive intraabdominal fibromatosis].

BACKGROUND: Intraabdominal or mesenteric fibromatosis is a rare benign nonmetastatic neoplasm that appears as a sporadic lesion or in patients with familiar polyposis. Its evolution is unpredictable. About 10% of the cases shaw a very aggressive growth. CASE REPORT: We presented a 22-year-old woman in whom an aggressive intraabdominal fibromatosis had appeared during the first pregnancy as a well circumscribed ovoid tumor, involving the terminal ileum, the caecum, the ascending colon, the right kidney, the ureter, and the right common iliac artery. The tumor was excised with right colectomy, nephroureterectomy and resection of the involved artery using arterial reconstruction with graft interposition. Two years after the surgery the patient developed an inoperable tumor recurrency with a fatal outcome. CONCLUSION: In spite of a successful surgical excision during the original surgery intraabdominal or mesenteric fibromatosis might have an aggressive evolution leading to an inoperable tumor recurrency and a fatal outcome.

[Isolated hydatid cyst of the adrenal gland].

INTRODUCTION: Hydatid cyst of the adrenal gland is extremely rare even in generalized hydatid disease, with less than 20 cases reported in world literature including those found in autopsy. CASE OUTLINE: The authors present the second case of the adrenal gland hydatid cyst described in Serbian literature, in 52-year old woman. During the investigation for the epigastric pain by ultrasonography and computed tomography, calcified cyst of the sixth segment of the liver, 44x39 mm in diameter, was diagnosed. However, during an open surgery, it turned out to be the cyst of the right adrenal gland. The cyst as well as the entire adrenal gland was removed. The hydatid nature of the cyst was confirmed by histological examination. The post-operative recovery was uneventful. The patient has remained symptom-free over two years after the surgery. CONCLUSION: To the best of our knowledge, this is the second case reported in Serbian and 18th case published in world literature.

[Tubular adenoma of the gallbladder with squamous metaplasia].

Adenomas of the gallbladder are rare tumors. They may be papillar or tubular. Tubular adenoma appears in middle aged and older patients, although it may develop even in children. This is a case report of forty-year old woman in whom a polypoid lesion was discovered in the gallbladder during regular ultrasonographic control after the liver surgery for hemangioma. The gallbladder was removed during an open surgery. A polypoid tumour of 20x7x5mm in size on wide pedicle was found in the gallbladder. Histology showed tubular adenoma with mild epithelial dysplasia in some places and with antral and squamous metaplasia. The recovery was uneventful.

[Inflammatory pseudotumor of the spleen].

BACKGROUND: Inflammatory pseudotumors are benign tumor lesions of an unknown etiology that can appear almost at any organ, sometimes along with infectious agens, like Epstein-Barr virus. They are extremely rare in the spleen, with less than 80 cases described in the world literature. It is a single, very rarely multinodal lesion. Middle aged patients are mostly affected. Symptoms are either absent or uncharacteristic, so that the tumors are discovered by chance or during investigations of other diseases. CASE REPORT: We presented a 56-year-old woman in whom a nodal lesion of 2 cm in diameter had been discovered in the spleen during a routine check-up after a mild traffic accident. The lesion had grown up to 6 cm in diameter during a 5-year follow-up causing a mild pain over the upper left abdomen and left shoulder. Fine needle biopsy failed to show the exact nature of the lesion. Splenectomy was performed due to a suspected lymphoproliferative disorder. Histology and immunohistochemistry of the lesion of the upper pole of the spleen showed inflammatory pseudotumor. Epstein-Barr virus was not present. The patient developed postsplenectomy thrombocytosis (up to 850 x 10(9)/1) which settled down within 10 weeks. CONCLUSION: . Inflammatory pseudotumors of the spleen are extremely rare. The exact diagnosis can be established only by histology and/or immunohistochemistry of the spleen removed for a suspected lymphoproliferative disorder, most frequently lymphoma. The patient was cured with splenectomy.

[Lymphoepithelial cyst of the pancreas].

Lymphoepithelial cysts of the pancreas are very rare with less than 35 cases described in the literature. A 49-year old male with a cystic tumor in the tail of the pancreas of 8 cm in diameter discovered during the investigation for mild pain in the upper abdomen was presented. The tumor was easily removed during the open surgery. It contained yellowish dense pus-like fluid whose culture remained sterile. Histology showed the lymphoepithelial cyst of the pancreas. Postoperative recovery was uneventful and preoperative pain disappeared. Eight and a half years later, he died due to complications after orthopedic surgery of the spine.

[Solitary fibrous tumor of the visceral pleura of the right lung base].

Solitary fibrous tumors are relatively frequent. They may occur throughout the body. About 20% of tumors develop in the thorax, out of which vast majority is localized on its wall. Within thorax, they usually originate from pleura, most frequently the visceral one. Authors present a 67- year old male in whom the tumor was diagnosed during the investigation for dyspnea. During operation, solitary, well circumscribed, firm, ruber-like tumour, 11 x 10 x 9 cm in diameter, covered with serosa, arising from the visceral pleura of the base of the right lung was easily excised. The classical histological and immunohistochemical examinations confirmed the diagnosis of benign fibrous tumor. Postoperative recovery was uneventful. Preoperative symptoms disappeared.

[Desmoid tumor within lesser sac].

Desmoid tumors or fibromatoses comprise a number of benign fibrous proliferative lesions that have local infiltrative growth and tendency to recur after incomplete excision. They never metastasize. The authors present a 31-year-old woman who, due to epigastric pain and palpable mass detected on presentation, underwent the excision of firm tumorous mass, 210 x 140 x 115 mm in diameter, from the lesser sac. Compressing the splenic vein, the tumor caused left-sided portal hypertension which subsided after the mass was removed. The recovery was uneventful. The histological examination verified typical desmoid tumor. Twelve years after surgery, the patient remained symptom-free with no signs of recurrence.

[Isolated metastasis of the granulosa cell tumor of the ovary in the small intestine mesentery 19 years after salpingo-oophorectomy].

INTRODUCTION: Granulosa cell tumour is uncommon malignant tumor which belongs to the sexual cord-stromal tumors of the ovary. It arises from the specialized stromal cells of the ovary. These tumors are unilateral in 95%. Over 90% of patients survive more than 10 years after surgery, but the recurrence may appear even 25 years after surgery. CASE REPORT: The authors present a 54-year-old woman who was admitted for abdominal pain and ultrasonography revealed tumor in the abdomen. During the surgery, a spheric, well circumscribed tumor of the mesentery, close to the forth portion of duodenum, was excised. Histological and immunohistochemical examinations verified that it was the metastasis of the granulosa cell tumor of the ovary that had been removed 19 years ago when salpingo-oophorectomy had been performed. Postoperative recovery was uneventful. Twenty six months later, the tumor 4 cm in diameter recurred, and was localized to the left of duodenum, close to the inferior mesenteric artery, which was perfectly ideally, together with fat tissue and surrounding lymph nodes. She has remained symptom free so far. CONCLUSION: To the best of our knowledge, this is the first case of the isolated metastasis of the granulosa cell tumor in the mesentery, that appeared 19 years after original surgery.

[Slip of the T tube within the common bile duct--a little known complication of the T tube drainage].

Complications related to the T tube drainage of the common bile duct are not uncommon. Some, like dislocations of the T tube out of the common bile duct, could be very serious, particularly if developed during the first few days after surgery, when the abdominal drain in the subhepatic space had been already removed.Then, an emergency reoperation might be necessary. The slip of the T tube upwards or downwards inside the common bile duct is not so rare. Fortunately, it is less dangerous and can usually be resolved without reoperation. It takes place several days after surgery, followed by the right subcostal pain, occasionally with temperature, rise of the bilirubin and with decrease or complete cessation of the bile drainage through the T tube. The diagnosis can be made only on the basis of T tube cholangiography. The re-establishment of the proper T tube position must be done under X-ray visualization. Seven cases of the T tube slip within the common bile duct, its clinical presentation, diagnosis and method of repositioning were presented. Possible mechanism of complication was described. As far as we know, the complications have not been described by other authors.