First Case of Human Anisakiosis in Greece: Acute Invasive Infection Mimicking Peritoneal Malignancy.

Consumption of raw and mildly processed seafood, in the context of modern Western world eating trends, is recognized as a major driver for human fish-borne infections. However, these zoonoses and their unfamiliar risks remain neglected and underappreciated among European diagnosticians. In contemporary Europe anisakidosis is one of the most important fish-borne zoonoses. It is caused by ingesting the third-stage infective larvae of the nematode parasites that belong to the family Anisakidae. The case described herein, is an intestinal and ectopic form of anisakiosis (Anisakis spp.), causing symptoms of subacute abdomen and masquerading as an intraperitoneal malignancy. It is the first anisakidosis case reported in Greece, affecting a young patient who had been repeatedly exposed to the parasite by consuming homemade raw fish. Right hemicolectomy, omentectomy and excision of a descending colon nodule were uneventfully performed. The pathology report confirmed granulomatous tissue with eosinophilic infiltration and parasites that were morphologically and molecularly identified as Anisakis spp. Although challenging, acquiring an accurate diagnosis of anisakidosis can prevent unnecessary surgery, as the infection typically is self-resolving, and if treatment is deemed necessary, it can be limited to antiparasitic medication. However, in rare cases, extra-gastrointestinal migration of larvae can cause severe damage with practically unknown risks, posing a diagnostic and therapeutic dilemma. In such a clinical case scenario, surgical exploration can decisively contribute to a definitive diagnosis and early identification of intraabdominal complications necessitating surgical intervention.

Successful surgical management of massive hemoretroperitoneum caused by spontaneous rupture of retroperitoneal lymph node metastases in a patient with advanced mixed germ cell tumor: a COVID-19 pandemic-related surgical challenge.

BACKGROUND: Spontaneous rapture of a germ cell tumor (GCT) metastases causing massive hemoretroperitoneum in a patient without choriocarcinoma component who has not received previous systemic chemotherapy is an exceedingly rare event. In such a devastating case scenario, a high index of clinical suspicion for early diagnosis and appropriate management is crucial. CASE PRESENTATION: We report on a 25-year-old male patient with a 4-month history of orchiectomy for testicular GCT (tGCT), who presented in the emergency department with acute abdomen and hemodynamic instability. Urgent computed tomography scan depicted a retroperitoneal mass measuring approximately 13 × 11.4 × 15 cm and massive intraperitoneal hemorrhage. Hemoperitoneum caused by spontaneous rapture of the metastatic retroperitoneal mass was suspected. COVID-19 pandemic-related deviation from the oncologic surveillance standards combined with COVID-19-related patient's emotional distress and self-neglect had led to loss of opportunity for appropriate adjuvant chemotherapy, obviously leading to the development of this devastating complication. An emergency, surgical exploration was decided. The bleeding mass was adequately exposed following a Cattell-Braasch maneuver and active bleeding was controlled by a challenging resection of approximately 80% of the lymph node mass volume. Pathological evaluation of the specimen revealed teratoma with low volume of yolk sac tumor component and extensive necrosis, findings compatible with the patient's history. Postoperative recovery was uneventful, followed by early start of adjuvant chemotherapy. Two years after the operation the patient is doing well with no evidence of recurrent disease. CONCLUSIONS: Massive hemoperitoneum is a devastating event that exceedingly rarely can complicate the clinical course of patients with advanced tGCT. Emergency surgical intervention is usually necessary however, sound judgement and careful surgical techniques are required for a positive and uneventful outcome. During COVID-19 pandemic, first-line medical personnel push their limits further not only to ensure health care services standards but also, to manage unpredictable, life-threatening cancer-related complications, associated with COVID-19-related deviation from appropriate oncologic surveillance and care.

"Mesopancreas-first" radical resection of pancreatic head cancer following the Cattell-Braasch-Valdoni maneuver: Appreciating the legacy of pioneers in visceral surgery.

The "artery-first" approach pancreaticoduodenectomy, with maximal mesopancreas excision and central vascular ligation, represents the current principal determinants of radicality in pancreatic head cancer resection. However, these modifications at the resection stage of pancreaticoduodenectomy constitute extremely demanding and technically complicated procedures. Among the most critical contributing factors in the difficulty of artery-first approaches is the spiral configuration of the mesoduodenum and proximal mesojejunum around the superior mesenteric artery axis. This creates complicated tridimensional anatomy, making surgical dissection in the inferior peripancreatic anatomic area extremely challenging and demanding. The Cattell-Braasch-Valdoni maneuver (right-sided medial visceral mobilization and intestinal derotation maneuver) restores the embryological twist of the duodenojejunal junction, which demystifies the distorted peripancreatic vascular anatomy and facilitates a safe and radical "mesopancreas-first" pancreatic head cancer resection. The aim of this paper was to present the advantages, efficacy, and safety of the Cattell-Braasch-Valdoni maneuver in artery-first approach radical pancreaticoduodenectomy and provide a detailed description of its surgical technique.

Efficacy of three different dosages of esomeprazole in the long-term management of reflux disease: a prospective, randomized study, using the wireless Bravo pH system.

OBJECTIVES: Gastroesophageal reflux disease (GERD) is a chronic condition that usually requires long-term maintenance therapy with proton-pump inhibitors (PPIs). In clinical practice, patients receive PPIs at the lowest dose to control symptoms. However, it is not known whether this approach adequately controls acidic esophageal reflux. We sought to investigate the efficacy of three different dosages of esomeprazole in patients receiving maintenance therapy for GERD, using the Bravo pH system. METHODS: Patients with a previous history of erosive esophagitis A or B (LA classification) that was healed at the time of enrollment or endoscopy-negative reflux disease (ENRD), documented with an abnormal pH study, were randomized to receive maintenance therapy with esomeprazole 40 mg twice daily (group A), once daily (group B), or every other day (group C). Intraesophageal pH was monitored for two consecutive days using the Bravo wireless system, 30 days after randomization. The parameters subjected to analysis were percent of total time pH<4 and the De Meester score. RESULTS: The pH results from 73 patients (group A=24, group B=24, group C=25 patients) were subjected to final analysis. On the first day of the study, the mean (+/-s.d.) percent of total time pH <4 and the De Meester score were group A: 0.9(1.2) and 4.1(4.0); group B: 1.5(1.6) and 7.0(6.9); group C: 1.3(1.0) and 6.0(3.3), respectively (P=0.262 and 0.134, respectively). On the second day of the study, the corresponding values were group A: 0.7(1.0) and 3.9(5.9); group B: 1.5(1.8) and 6.4(6.6); group C: 7.0(4.4) and 29.4(19.4), respectively. The difference was statistically significant (P<0.0001 and <0.0001, respectively). Further analysis showed that patients not receiving PPI had a significantly higher mean percent of total time pH<4 and De Meester score as compared with patients on PPI once or twice daily (P<0.001 and <0.001 respectively). CONCLUSIONS: The administration of esomeprazole 40 mg every other day does not control acidic esophageal reflux on the day off PPI. Esomeprazole 40 mg once daily effectively controls reflux of acid in patients with history of mild esophagitis or ENRD, whereas doubling the dose does not seem to confer any further advantage.

Challenging surgical management of a giant inguinoscrotal hernia: report of a case.

This report describes the surgical management of a giant inguinoscrotal hernia, which extended below the patient's knees, causing considerable physical discomfort and impairment of his quality of life. Initial management involved improving the patient's general condition and performing progressive preoperative pneumoperitoneum over 18 days. Surgery involved debulking the contents of the massive hernia sac by performing right hemicolectomy and transverse colectomy, repositioning of the small bowel into the abdominal cavity, resection of the giant hernia sac, and plastic reconstruction of the penis and scrotal region. The abdominal wall was reinforced with composite mesh. Despite a complicated postoperative course, the patient recovered well and has progressively returned to normal activities. Although challenging and demanding, surgery represents the only mode of treatment that can offer the patient with a giant inguinoscrotal hernia a satisfactory level of function and quality of life.

Isolated aberrant right cysticohepatic duct injury during laparoscopic cholecystectomy: Evaluation and treatment challenges of a severe postoperative complication associated with an extremely rare anatomical variant.

A typical bile duct branching patterns represent one of the major causes of bile duct injury (BDI) during laparoscopic cholecystectomy (LC). The most common classified variations of bile duct branching, involve the right posterior sectoral duct (RPSD) and its joining with the right anterior or left hepatic duct. Variant bile duct anatomy can rarely be extremely complex and unclassified. This report describes an extremely rare case of an isolated injury to an aberrant right hepatic duct formed by the joining of ducts from segments V, VII, and VIII draining into the cystic duct (cysticohepatic duct) during LC, associated with an inferior RPSD opening to left hepatic duct. Detailed evaluation of both endoscopic and magnetic cholangiograms established the diagnosis. Bile duct injury was subsequently managed surgically by a demanding Roux-en-Y hepaticojejunostomy. This extremely rare case aims to serve as a useful reminder of the consistent inconsistency of biliary anatomy, alerting surgeons to beware of variant bile duct branching patterns during open or LC that constitute a dreadful pitfall for severe and life-threatening bile duct injuries.

Endoscopic full-thickness resection of colorectal lesions with the full-thickness resection device: clinical experience from two referral centers in Greece.

BACKGROUND: Endoscopic full-thickness resection (EFTR) using the full-thickness resection device (FTRD®) is an invasive treatment for colorectal lesions not resectable by conventional endoscopic techniques. This study presents the first Greek experience of the FTRD® procedure, assessing the efficacy and safety of EFTR. METHODS: We conducted a retrospective analysis of 17 consecutive patients treated with the FTRD® at 2 referral centers from October 2015 through December 2018. The indications included difficult adenomas (non-lifting and/or at difficult locations), early adenocarcinomas and subepithelial tumors. Primary endpoints were technical success and R0 resection. RESULTS: Technical success and R0 resection were achieved in 82.3% procedures (14/17) and in 87.5% of those with difficult adenomas (8 patients). In the subgroup with carcinomas (n=3), the rate of technical success and R0 resection was 66.6%, while in the subgroup with subepithelial tumors (n=6) the rate was 83.3%. Technical success and R0 resection were significantly lower for lesions >20 mm vs. ≤20 mm (P=0.0429). In the 17 patients a total of 3 adverse events occurred (17.6%) and one of the patients underwent laparoscopic appendectomy because of EFTR around the appendix. CONCLUSIONS: Our study showed favorable results concerning EFTR feasibility, efficacy and safety, especially for lesions ≤20 mm, non-lifting adenomas, and subepithelial tumors. Technical success, R0 resection, and adverse events rates were comparable with previously published data. Larger randomized studies are needed to better define the clinical benefit and long-term outcomes of EFTR in selected patients.

Hospitalisations for heart failure predict mortality in pulmonary hypertension related to congenital heart disease.

OBJECTIVE: Despite the progress in the management of patients with adult congenital heart disease (ACHD), a significant proportion of patients still develop pulmonary hypertension (PH). We aimed to highlight the rate of the complications in PH-ACHD and the predicting factors of cumulative mortality risk in this population. METHODS: Data were obtained from the cohort of the national registry of ACHD in Greece from February 2012 until January 2018. RESULTS: Overall, 65 patients receiving PH-specific therapy were included (mean age 46.1±14.4 years, 64.6% females). Heavily symptomatic (New York Heart Association (NYHA) class III/IV) were 53.8% of patients. The majority received monotherapy, while combination therapy was administered in 41.5% of patients. Cardiac arrhythmia was reported in 30.8%, endocarditis in 1.5%, stroke in 4.6%, pulmonary arterial thrombosis in 6.2%, haemoptysis in 3.1% and hospitalisation due to heart failure (HF) in 23.1%. Over a median follow-up of 3 years (range 1-6), 12 (18.5%) patients died. On univariate Cox regression analysis history of HF hospitalisation emerged as a strong predictor of mortality (HR 8.91, 95% CI 2.64 to 30.02, p<0.001), which remained significant after adjustment for age and for NYHA functional class. CONCLUSIONS: Long-term complications are common among patients with PH-ACHD. Hospitalisations for HF predict mortality and should be considered in the risk stratification of this population.

Surgical treatment of atrial septum lipomatous hypertrophy associated with syncopal attacks.

Lipomatous hypertrophy of atrial septum (LHAS) is a rare benign cardiac condition characterized by fatty tissue infiltration located in the atrial septum. We presented a rare case of LHAS resulting in recurrent syncopal attacks.

Reliability of selective surveillance colonoscopy in the early diagnosis of colonic ischemia after successful ruptured abdominal aortic aneurysm repair.

PURPOSE: To evaluate the reliability of selective surveillance colonoscopy based on 6 specific perioperative risk factors in the early diagnosis of colonic ischemia (CI) after successful ruptured abdominal aortic aneurysm (rAAA) repair. PATIENTS AND METHODS: From 1999 to 2005, 62 consecutive patients underwent rAAA repair. In 59 of them, routine aggressive surveillance colonoscopy was offered every 12 hours within the first 48 hours, and CI was graded consistently. Patients with stage I or stage II CI were treated conservatively and were followed up with repeat colonoscopy, whereas patients with stage III CI underwent immediate laparotomy and colectomy. In parallel, 6 specific perioperative risk factors (PRFs) were retrospectively analyzed. RESULTS: Overall mortality was 33.9%. Nineteen patients (32.2%) developed CI and 12 (63.2%) of them survived. Thirteen (22%) had grade III CI and among these 6 survived. In patients with CI the mortality rate was 36.2%. Patients with less than 3 PRFs had no CI whereas all instances of CI could be diagnosed if colonoscopy was offered selectively in patients with more than 3 PRFs. The positive predictive value of CI increased with the number of PRFs. Patients with 5 or 6 PRFs were about 101 times more likely to develop CI compared with patients with 0 to 4 PRFs (P<.001). CONCLUSION: Our study showed that CI is a frequent complication after successful rAAA repair and could reliably be early diagnosed if surveillance colonoscopy was offered selectively in patients with more than three PRFs.

Bloodless laparoscopic liver resection using radiofrequency thermal energy in the porcine model.

The aim of this study was to assess the feasibility and safety of laparoscopic hepatectomy using radiofrequency (RF) thermal energy in a porcine model. Fifteen female domestic pigs weighing 29.3 kg (range 25 to 35 kg) were used. Five transversal abdominal incisions (3 of 1 cm and 2 of 0.5 cm) were made for the introduction of the video camera and the other laparoscopic instruments. With the porta hepatis not clamped, the liver was inspected and the preferred lobe each time was divided using RF (cool-tip electrode 3 cm) with minimum bleeding. Serum liver enzymes and blood counts were drawn pre and postoperatively. All animals were killed after 1 week. The mean time of the procedures was 119 minutes (range 100 to 155 min). There were no intraoperative complications. Mean blood loss was 27 mL (range 5 to 60 mL), and the mass of the resected specimen was 132.5 g (range 65 to 305 g). There were no postoperative complications or deaths. Bloodless laparoscopic hepatectomy was technically feasible and safe in the porcine model using cool-tip electrode and 500-kHz RF Generator.

Bile duct injuries during laparoscopic cholecystectomy: management and outcome.

The aim of this study is to analyze our experience with the management of bile duct injuries (BDIs) following laparoscopic cholecystectomy (LC). From 1996 to 2004, 21 patients with BDI after LC were treated in our department. The BDIs were graded according to the classification of Strasberg. Ten patients had minor BDI. Minor injuries were classified as A in six and D in four patients. In three patients, endoscopic retrograde cholangiopancreatography sphincterotomy and stent placement was adequate treatment. Six patients required laparotomy and bile duct ligation or suturing, and one patient underwent laparoscopy with additional ligation of a duct of Luschka. Eleven patients had major BDIs. These injuries were classified as E1 in two, E2 in three, E3 in four, and E4 in two patients. Among the patients with a major BDI, Roux-en-Y hepaticojejunostomy was performed. After a median follow-up of 69.45 months, no evidence of biliary disease has been detected among our patients. BDIs should be managed in a specialist unit where surgeons skilled to perform such repairs should undertake definitive treatment. Roux-en-Y hepaticojejunostomy is the procedure of choice in the management of major BDIs as it is accompanied by satisfactory results.

The rare sprengel deformity: our experience with three cases.

Sprengel shoulder is a rare congenital deformity of one or both scapulae that is usually detected at birth. It occurs due to failure of the scapula to descend during intrauterine development and its cause is still unknown. Although the deformity appears randomly most of the time, familial cases have been reported. Sprengel shoulder is often associated with Klippel-Feil syndrome and other congenital skeletal deformities. Anteroposterior X-ray imaging can accurately diagnose Sprengel deformity. However, computed tomography and magnetic resonance scans with three-dimensional reconstruction are nowadays used in everyday practice in order to diagnose concomitant abnormalities, study in detail the anatomy of the affected shoulder(s), and plan appropriate management. We present here our imaging experience from three pediatric cases with Sprengel shoulder and take the opportunity to discuss this rare entity, which is, nevertheless, the commonest congenital defect of the scapula.

Factors significantly contributing to a failed conventional endoscopic stone clearance in patients with "difficult" choledecholithiasis: a single-center experience.

The objective of this study is to retrospectively evaluate factors significantly contributing to a failed stone extraction (SE) in patients with difficult to extract bile duct stones (BDS). Patients and Methods. During a 10-year period 1390 patients with BDS underwent successfully endoscopic sphincterotomy. Endoscopic SE was graded as easy; relatively easy; difficult; and failed. Difficult SE was encountered in 221 patients while failed SE was encountered in 205. A retrospective analysis of the criteria governing the difficulty of endoscopic SE following the index endoscopic intervention was performed to evaluate their significance in determining failure of complete SE among patients with difficult to extract bile duct stones. Results. Age ≥ 85 years, periampullary diverticula, multiple CBD stones (>4), and diameter of CBD stones (≥15 mm) were all significant contributing factors to a failed SE in univariate statistical tests. In the definitive multivariate analysis age, multiple stones and diameter of stones were found to be the significant, independent contributors. Conclusion. Failed conventional endoscopic stone clearance in patients with difficult to extract BDS is more likely to occur in overage patients, in patients with multiple CBD stones >4, and in patients with CBD stone(s) diameter ≥15 mm.

Right porto-ovarian H-shunt for the surgical treatment of symptomatic portal biliopathy: a case report and literature review.

Portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis, is commonly followed by the development of an abnormal periportal and pericholedochal variceal network, which form a portal cavernoma. This may exert extrinsic pressure on the adjacent biliary ducts and gallblader, causing morphologic abnormalities, termed portal biliopathy, which is usually leading to asymptomatic cholestasis, while less frequently it can be associated with obstructive jaundice, gallstone formation, and cholangitis. Endoscopic stone extraction can effectively treat portal biliopathy when cholangitis is associated with common bile duct stones. Portosystemic shunts are indicated in cases of disease recurrence as they can achieve regression of portal cavernoma and usually relieve symptomatic portal biliopathy. This case describes an alternative partial portosystemic shunt that utilizes the right ovarian vein as an autologous conduit for the surgical treatment of symptomatic portal biliopathy.

Feasibility of therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones in nonagenarians: a single unit audit.

BACKGROUND: Little information is available on short and long-term outcome of therapeutic endoscopic retrograde colangiopancreatography (ERCP) for choledocholithiasis in nonagenarians (>=90 years). The aim of this study was to evaluate retrospectively the feasibility of therapeutic ERCP in nonagenarians with choledocholithiasis, as compared with patients aged between 75 and 89 years. PATIENTS AND METHODS: During a 9-year period, therapeutic ERCP was performed for choledocholithiasis in 33 nonagenarian patients (group A) and 272 patients aged 75 to 89 years (group B). Clinical features, endoscopic findings, interventions, early and long-term results of therapeutic ERCP for a mean follow-up of 36 months were assessed and compared between the two groups. RESULTS: Group A patients had a higher incidence of acute cholangitis, concomitant diseases and gallbladder stones, as compared to group B patients. Furthermore, they required an emergency procedure, multiple sessions, stent insertion, and needle knife fistulotomy significantly more frequently (p<0.001). Group B patients underwent significantly more endoscopic manipulations and had a longer procedure time than group A patients. Complete bile duct stone clearance was achieved in 24.2% of group A patients and in 90.8% of group B patients (p<0.001). No ERCP related deaths occurred in group A patients. Cholecystectomy was not routinely performed in Group A patients having gallbladder stones. The rate of early and late complications was not significantly different between the two age groups. CONCLUSION: Therapeutic ERCP and biliary stenting have proved to be a feasible treatment option for the management of choledocholithiasis in nonagenarians.