Intramural duodenal hematoma after submucosal injection of epinephrine for a bleeding ulcer: case report and review.

We present a case of intramural duodenal hematoma as a complication of endoscopic therapy for a bleeding duodenal ulcer in an adult patient with no evidence of other pathologies. A 18-year-old man was admitted in emergency room with gastrointestinal bleeding manifested by melena. Previous medical history revealed that he had endoscopic sclerotherapy for bleeding duodenal ulcer 5 months before. Endoscopy revealed a Forrest 2a ulcer in the duodenal bulb and sclerotherapy was performed by injecting 10 ml of 0.2% epinephrine and 20 ml of Na- Cl 0.9% solution. Upper occlusion's signs appeared 36 hours after the procedure. The hematoma, that was identified by endoscopy and confirmed by MRI and CT scan of the abdomen, caused transient duodenal obstruction. Combined conservative management with nasogastric tube and total parenteral nutrition resulted in reduction of obstructive symptoms within 4 weeks.

Actual status of preoperative diagnosis of thyroid cancer in Albania.

INTRODUCTION: Thyroid cancer is the most common endocrine malignancy and accounts for almost 1% of human cancer. It is well known that the majority of cases occur in women in the middle decades of life. Thyroid cancer is a relatively rare disease; on the other hand clinically apparent thyroid nodules are present in 4-7% of the adult population. Most thyroid nodules are not malignant, with reported malignancy rates from 3-12%. It is important for the surgeon to know beforehand the diagnosis of malignancy, in order to perform a more radical operation on the thyroid gland. PATIENTS AND METHODS: In our study we have analyzed the preoperative clinical data of 84 patients operated in the First Clinic of General Surgery, UHC "Mother Theresa" in Tirana; all with a positive histopathologic diagnosis of thyroid cancer. The data comprised age, sex, age distribution, blood group, time-lapse from the first endocrinologic visit, clinical examination, signs and symptoms, imaging, functional tests, preoperative FNA, admission diagnosis, associated diseases and preoperative treatment. RESULTS: From the study emerged that only 9,3% of these patients were diagnosed preoperatively as thyroid cancer. Another related problem is the low percentage of preoperative FNA - only 22%. Among the signs and symptoms related to thyroid cancer we found that 40 and 33% of these patient presented dyspnea and dysphagia, respectively. The physical examination revealed apparent nodular growth of the thyroid gland in 81% and nodular hard consistency in 79% of cases. The proper endocrinologist consultation lacked in 23% of cases. CONCLUSION: In our opinion, close collaboration between endocrinologists and surgeons in a multidisciplinary frame is the key to correct preoperative thyroid cancer diagnosis and optimal treatment.

Cecal volvulus during pregnancy. Case report.

INTRODUCTION: Acute intestinal obstruction in pregnancy is a rare, but life-threatening complication associated with high fetal and maternal mortality. CASE REPORT: A 20-year old gravida presented with a 24 hour history of several episodes of vomiting, complete constipation and severe crampy abdominal pain. The patient was admitted with the diagnosis of acute abdomen associated with septic shock. On examination echography showed distended intestinal loops and presence of free peritoneal fluid. Abdominal X-ray with shielding of the fetus revealed colonic air-fluid levels. The obstetrician consult diagnosed dead fetus in utero and was decided to operate immediately. On laparotomy was found complete cecal volvulus with gangrene of cecum, part of ascending colon and terminal ileum. A right hemicolectomy was performed with side to side ileotransverse anastomosis. Afterwards a lower segment cesarean section was made and a stillborn fetus was delivered. The patient made an uneventful recovery and was discharged on 9th postoperative day. CONCLUSION: Cecal volvulus during pregnancy is a rare, but serious surgical problem. Correct diagnosis may be difficult until exploratory laparotomy is performed. Undue delay in diagnosis and surgical treatment can increase the maternal and fetal mortality.

Surgical treatment of the adenocarcinoma of the cardia.

Adenocarcinomas of the esophagogastric junction should be classified into adenocarcinoma of the distal esophagus (Type I), true carcinoma of the cardia (Type II), and subcardial carcinoma (Type III) in a pathogenic and therapeutic point of view. During a 15-year period (1995 - 2009), 117 surgical laparotomies for adenocarcinoma of the cardia were performed in elective surgery in the First Clinic of General Surgery UHC "Mother Theresa" in Tirana. The classification was performed by summarizing the information obtained from oral contrast radiography, endoscopy, and intra-operative findings. There were 54 (46%) patients of Type I, 40 (34%) of Type II and 23 (20%) of Type III . Surgical procedures included "subtotal esophagectomy and proximal gastrectomy", "distal esophagectomy and proximal gastrectomy", "total gastrectomy and distal esophagectomy". All anastomoses performed in the above mentioned procedures were hand sewn. Thirty-seven patients (32%) resulted inoperable at the time of laparotomy and 80 (68%) patients were treated with curative intent, those resulting in an operability index of 68%. The overall morbidity and mortality rates of 29% and 4,3% respectively.

Rectal cancer surgery. A ten years experience.

Rectal cancer is one of the most common malignancies in the western world population. The management of rectal cancer has changed thoroughly in recent years owing to the rapid advances in surgical techniques, imaging and adjuvant therapy. The present study analyses extensively 152 patients operated for diagnosis of, rectal cancer in the First Clinic of General Surgery UHC "Mother Theresa" in Tirana, Albania, in a ten years period. In the medical and operative records were analysed demographic, diagnostic, clinic, operative, pathology and postoperative patient's data. M : F ratio was 1,5:1. The average age of all patients was 59,8 ± 12,2 (29 - 79) years. 48% of all patients were of the age group 61 - 70 years. The diagnosis interval was 6 ± 4,6 months. The mean distance of tumor from the anal verge was 8,3 ± 4,2 (3,7 - 16) cm. 30% of all patients resulted stage D, according to the Astler - Coller classification. Overall operability index was 97,5%. 30 % of patients were treated with palliative operative procedures. 67,5% of all patients were treated with curative intent. The most common curative operation was low anterior resection with mesorectal excision in 76 patients (51%). The mean postoperative hospital stay was 12 ± 9,7 (3 - 45) days. Overall postoperative morbidity and mortality were 30% and 2,6% respectively. The surgical treatment of rectal cancer has changed radically in recent years in Albania. Relatively new surgical techniques, like low anterior resection and use of adjuvant chemoradiotherapy have improved the outcome, quality of life and survival of our patients.

It's Fournier's gangrene still dangerous?

BACKGROUND: Fournier's gangrene is known to have an impact in the morbidity and despite antibiotics and aggressive debridement, the mortality rate remains high. OBJECTIVES: To assess the morbidity and mortality in the treatment of Fournier's gangrene in our experience. METHODS: The medical records of 14 patients with Fournier's gangrene who presented at the University Hospital Center "Mother Teresa" from January 1997 to December 2006 were reviewed retrospectively to analyze the outcome and identify the risk factor and prognostic indicators of mortality. RESULTS: Of the 14 patients, 5 died and 9 survived. Mean age was 54 years (range from 41-61): it was 53 years in the group of survivors and 62 years in deceased group. There was a significant difference in leukocyte count between patients who survived (range 4900-17000/mm) and those died (range 20.300-31000/mm3). Mean hospital stay was about 19 days (range 2-57 days). CONCLUSION: The interval from the onset of clinical symptoms to the initial surgical intervention seems to be the most important prognostic factor with a significant impact on outcome. Despite extensive therapeutic efforts, Fournier's gangrene remains a surgical emergency and early recognition with prompt radical debridement is the mainstays of management.

Toxic adenoma of the thyroid gland and Wolff-Parkinson-White syndrome.

We report the case of a 17-year-old girl with toxic adenoma scheduled for surgery right lobectomy and isthmectomy of thyroid gland. During the examination before surgery, patient was diagnosed for the first time as having with Wolff-Parkinson-White (WPW) syndrome. In the operating room, after the induction of anesthesia, the electrocardiogram showed wide QRS complex tachycardia with a rate of 180 beats/min, which was diagnosed as paroxysmal supraventricular tachycardia. The patient was treated immediately with antiarrhythmic drugs: adenosine iv three times (at doses of 6 mg, 12 mg, 12 mg bolus) and esmolol iv twice (at doses 28.5 mg). This approach resulted in disappearance of the delta wave and tachycardia for the whole surgery period. In this case report we discuss the role of induction of anesthesia and presence of toxic adenoma in a patient with WPW.