The challenging diagnosis and treatment of duodenal diverticulum perforation: a report of two cases.

BACKGROUND: The duodenum is a common site for diverticulum formation. Most of the duodenal diverticula are asymptomatic, incidental findings. Perforation is a rare but potentially lethal complication of duodenal diverticular disease. Surgery remains the mainstay of treatment for perforated duodenal diverticula. In recent years, a few cases were successfully managed either conservatively or with endoscopy. CASE PRESENTATION: We present two cases of female patients treated in our department for duodenal diverticulum perforation. The first case was treated surgically with a diverticulectomy. The second case was managed conservatively with bowel rest and intravenous antibiotics. Both patients had an uncomplicated postoperative course and were discharged home. CONCLUSIONS: Both surgical and conservative treatments are viable options for a perforated duodenal diverticulum in selected patients. Patients with a contained duodenal diverticular perforation can be managed conservatively at the outset. Possibly, the introduction of a classification system for duodenal diverticulum perforation may help clinicians in making essential therapeutic decisions.

A Pilot Study of the Association VDR Polymorphisms With Primary Hyperparathyroidism.

BACKGROUND/AIM: Primary hyperparathyroidism (PHPT) is the third most common endocrine disorder characterized by autonomous parathyroid hormone (PTH) production from one or more parathyroid glands and hypocalcemia. Vitamin D through its receptor is a principal regulator of parathyroid glands function. VDR gene polymorphisms, which affect the expression or structure of VDR protein, may be involved in the genetic pathogenesis of PHPT. The aim of this study was to investigate the role of FokI, ApaI, TaqI, and BsmI VDR gene polymorphisms as genetic predisposing factors for PHPT. PATIENTS AND METHODS: Fifty unrelated patients with sporadic PHPT and an equal number of corresponding ethnicity, sex and age range healthy volunteers were enrolled in the study. Genotyping was performed with polymerase chain reaction and restriction fragment length polymorphism assay. RESULTS: Statistically significant difference was observed in TaqI genotype distribution between PHPT patients and controls, while no association was detected for the other studied polymorphisms. CONCLUSION: TaqI TT and TC genotypes may be associated with PHPT risk in Greek population. Further independent studies are needed to replicate and validate the role of VDR TaqI polymorphism in PHPT predisposition.

Looking for the Ideal Probiotic Healing Regime.

Wound healing is a multi-factorial response to tissue injury, aiming to restore tissue continuity. Numerous recent experimental and clinical studies clearly indicate that probiotics are applied topically to promote the wound-healing process. However, the precise mechanism by which they contribute to healing is not yet clear. Each strain appears to exert a distinctive, even multi-factorial action on different phases of the healing process. Given that a multi-probiotic formula exerts better results than a single strain, the pharmaceutical industry has embarked on a race for the production of a formulation containing a combination of probiotics capable of playing a role in all the phases of the healing process. Hence, the object of this review is to describe what is known to date of the distinctive mechanisms of each of the most studied probiotic strains in order to further facilitate research toward the development of combinations of strains and doses, covering the whole spectrum of healing. Eleven probiotic species have been analyzed, the only criterion of inclusion being a minimum of two published research articles.

The 3-D configuration of excisional skin wound healing after topical probiotic application.

Nowadays, there is an increasing knowledge that probiotic bacteria, topically applied, affects skin pathology. The objective of this study is to evaluate the effect on wound healing of locally applied probiotics by calculating the 3-D configuration of a standardized excisional wound. Fifty-two male Wistar rats were randomly allocated into groups: control, PRO1 [L. plantarum] and PRO2 [L. rhamnosus, B. longum]. Six excisional full-thickness wounds were created on each dorsum by an 8-mm circular biopsy punch; probiotics or saline were applied on days 0, 2, 4, 8, 16, photos of the wounds taken and specimens excised for histology [4 rats/group/time-point]. Both probiotic-groups exhibited accelerated healing significantly faster than the control, throughout, PRO2 exhibiting finally the best results [day 16]. However, only on day 2, did PRO1 exhibit the best results [wounded area, borders distance and epitheliazation line]. The results clearly demonstrate that the topical application of probiotics significantly improves the healing process, each strain working differently and more effectively in different healing phases. Thus, a combined formula containing different probiotics to modulate various healing phases is desirable. To this end our research continous.

Parathyroid adenoma in pregnancy: A case report and systematic review of the literature.

Objective: Primary hyperparathyroidism is a common disorder of the parathyroid glands. Parathyroid adenoma (PA) in pregnancy is a relatively rare disease, whose diagnosis and treatment is a challenging task. The aim of the present study is to present a new case of parathyroid adenoma during pregnancy and to give a detailed account of all reported cases of parathyroid adenoma during pregnancy in the literature. Study design: A bibliographic research was performed, and characteristics of parathyroid adenomas in pregnancy such as age, gestational week at diagnosis, ionized calcium levels, genetic testing result, symptomatology, radiological method of localization, treatment method, gestational week at operation, and maternal/fetal complications were recorded. Results: A 34-year-old woman at her 25 weeks' gestation was diagnosed with parathyroid adenoma and was referred to our Surgical Department due to contraindication for conservative treatment. A parathyroidectomy was performed, and the maternal and fetal postoperative period was uneventful. Two hundred eleven cases of parathyroid adenoma in pregnancy were recorded in the literature, and statistical analysis was performed. The median gestational week at diagnosis was 21 ± 9.61 weeks. The mean level of ionized calcium was 2.69 mmol/l [SD = 0.75 (2.55-2.84 95% CI)]. Most cases were familiar (72.4%), while surgery was the preferred treatment option (67.3%). The majority of cases were asymptomatic (21.7%), and the main radiological method applied for localization was ultrasound (63.4%). Conclusion: Parathyroid adenoma in pregnancy is a rare condition. The early diagnosis is of great importance as surgical treatment at the second trimester of pregnancy outweighs the maternal and fetal risks.

Translation of the Pasieka's Parathyroid Assessment of Symptoms Questionnaire (PAS-Q) for Use in the Greek Population.

Introduction: In Europe, primary hyperparathyroidism is mainly considered an asymptomatic disorder, although there is evidence that patients' health-related quality of life is impaired. This aspect is mostly evaluated using Pasieka's Questionnaire: a disease-specific diagnostic tool. The purpose of this study was to translate the Pasieka's Questionnaire into the Greek language and adapt it to the Greek population. Materials and Methods: Pasieka's Questionnaire consists of 13 questions. Two bilingual, native Greek experts were selected for step one, each of whom offered a blinded Greek version of the questionnaire. In the second step, these two versions were merged into one which was retranslated back into the English language (step three) by two bilingual translators (English native speakers). In the fourth step, a committee was formed to draft the pre-final version of the questionnaire which was then submitted to the co-authors for final approval. Finally, after the approval of the final version, 50 patients with primary hyperparathyroidism were recruited for the pilot study of the questionnaire. Results: All 13 questions of the Pasieka's Questionnaire were translated without any major discrepancy. A high level of internal consistency was achieved (Cronbach's alpha was 0.904) and agreement between test-retest was excellent for every question. Conclusion: The Greek version of Pasieka's Questionnaire was validated and can be applied to evaluate the health-related quality of life of patients with primary hyperparathyroidism in Greek-speaking populations.

Massive subgaleal hematoma in a 62-year-old man treated with apixaban as a consequence of mild head trauma.

Subgaleal hematoma, accumulation of blood in the loose areolar tissue of the subgaleal space of the skull, is considered the most catastrophic complication of instrumental delivery. It is a rare finding in older ages, usually associated with coagulation disorders, severe head trauma leading to skull base fractures and accidental or abusive hair pulling. Complications include periorbital necrotising fasciitis, permanent blindness, infections and, in extreme rare cases, airway obstruction. Most cases of subgaleal hematoma resolve spontaneously, without the need of aspiration or drainage.We present here the case of a 62-year-old male on anticoagulant therapy with apixaban for chronic atrial fibrillation, who came to the emergency department after a car accident suffering from mild head trauma. The patient was complaining of a diffuse headache and physical examination showed a large ecchymosis and edema on the frontal area of the head. His neurological examination was unremarkable. Full-body computed tomography (CT) revealed a fracture of the third right rib. Twelve hours after admission, due to an excessive decrease of hematocrit, a second CT was performed. Although the images didn't show intracranial hemorrhage or skull base fractures, a large and diffuse hematoma of the subaponeurotic space was observed and the diagnosis of subgaleal hematoma was confirmed.Massive subgaleal hematoma after mild head trauma is rather infrequent. Early diagnosis improves outcomes and can avert serious complications. Therapeutic strategy should be based on the severity of each case. In our case, conservative treatment appeared to be a valid alternative to surgery, as hematoma resolved spontaneously within 10 days. It is noteworthy that the use of anticoagulation is the only evident factor that could have been the precipitating factor for the development of the hematoma in our patient.

Perianal Solitary Fibrous Tumor in a Rare Anatomical Presentation: A Case Report and Literature Review.

BACKGROUND Solitary fibrous tumors (SFTs) account for <2% of all soft tissue tumors and are slow-growing neoplasms of mesenchymal origin, which have been reported in various locations. They are frequently observed at the pleura and a perianal location is extremely rare. They show no predisposition by sex, are mainly benign, and usually occur between the 5th and 7th decades of life. CASE REPORT We report the case of an 80-year-old man with no comorbidities except hypertension, who presented with an asymptomatic perineal mass. Magnetic resonance imaging showed a solid tumor measuring 3.5×2.5 cm identified in the perineal midline. It was very close to the anal sphincter, showing no extension to the rectum or anus. The tumor was completely excised with negative margins. The postoperative course was uneventful and he was discharged home, free of any symptoms. The pathological examination showed a benign completely excised SFT, and no further treatment was necessary. At the 6-month and 1-year follow-ups, there was no sign of recurrence. CONCLUSIONS A comprehensive review of all the reported cases of perianal SFTs shows that the majority of these tumors present with no symptoms and have a favorable prognosis. Diagnosis is possible only after a pathological examination. The criterion standard of treatment is complete excision with negative margins. Once excised, the tumors have low rates of recurrence and metastasis. Tumors very close to the anal sphincter and with malignant potential need to be operated on with extra care to obtain clear margins without disrupting the continence mechanism.

Retroperitoneal Cecal Perforation Resulting from Obstructive Ascending Colon Adenocarcinoma.

Most colorectal cancer patients in the early stages of the disease do not display any alarming symptoms. A total percentage of 9-27% of colorectal cancer patients present with acute abdomen, bowel obstruction, perforation, or bleeding. Perforation as the first presentation of the disease is seen in no more than 2.6-10% of patients. Intestinal perforation may be found on either the site of the tumor or on a more proximal site, caused by distention of the bowel due to peripheral obstruction. This is a case of a 75-year-old female patient who presents in the emergency department with retroperitoneal cecal perforation due to an obstructing tumor of the ascending colon. She underwent an emergency right hemicolectomy and washout of the retroperitoneal space. The cecum is not an unusual site of distention and subsequent perforation in the case of colonic obstruction, especially in the presence of a competent ileocecal valve. While the mechanism of diastatic cecal perforation is well described, it is the first time in the literature that this does not occur on the anterior surface of the organ. In our case, cecal perforation presents as a retroperitoneal abscess without peritoneal spillage. Nonetheless, it still carries a grim prognosis and urgent surgical intervention is needed.

Case Report of Synchronous Prostate, Hepatocellular, and Rectal Carcinomas and Review of the Literature.

Synchronous occurrence of three histopathologically distinct malignant tumors is a rare event, and there are no definitive guidelines about the optimal treatment of these patients. We report a case of synchronous prostate, hepatocellular, and rectal carcinomas and discuss our therapeutic strategy that resulted in excellent clinical results.

Ducts of Luschka as a rare cause of postoperative biloma. MRCP findings.

Laparoscopic cholecystectomy can be complicated by a post- operative biloma. Bile leak from the duct of Luschka is reported to be the second most frequent cause, reported in 0.15%-2% of the patients. This case report aims to underline the significance of this anatomic variation and how the management of the aforementioned complication can be facilitated by MRI- MRCP. A 78 year old male patient underwent an elective laparoscopic cholecystectomy and was found to have a post-operative biloma. An MRCP was carried out to visualize the bile tree and bile leak was identified to be originated from a duct of Luschka. The patient was referred for an ERCP, sphingterotomy and placement of biliary stent to release the pressure in the bile ducts. In the next few days the bile leak was controlled and eventually ceased. The patient was discharged free of symptoms and no sign of bile leak was to be found on his follow up imaging. In comparison with other imaging modalities picturing the bile tree, MRCP fits the ideal profile to be used as a first line choice for clinicians, as it offers detailed anatomical images with high contrast between bile and adjacent tissues, without using any contrast agent or radiation.

External Oblique Muscle Schwannoma: A Rare Anatomical Presentation.

INTRODUCTION: Schwannomas or neurilemmomas are rare, benign, and usually solitary lesions that arise from the nerve sheath. In the majority of cases, these tumors involve the extremities, head, neck, and trunk. CASE PRESENTATION: In the present study, a 52-year-old man presented to our surgical department for the evaluation of a symptomatic lump in his left lateral abdominal wall. CT and MRI confirmed the presence of a cystic mass located between the external and internal oblique muscles. Histopathology and immunohistochemistry confirmed it to be benign schwannoma. DISCUSSION: Schwannomas have rarely been reported in the abdominal wall. To the best of our knowledge, this is the first case of schwannoma located in the left upper abdominal wall and the fifth case of abdominal wall schwannoma reported according to the reviewed medical literature. CONCLUSION: Benign schwannoma should be included in the differential diagnosis of cystic and symptomatic lesions of the abdominal wall. The treatment of choice is surgical excision, and recurrence is extremely rare.

Metachronous Ovarian Metastases in a Patient with Primary Colorectal Cancer. A Case Report and Review of the Literature.

BACKGROUND Metachronous ovarian metastasis from primary colorectal cancer (CRC) is a rare condition that is diagnosed after the treatment of CRC. In most cases, ovarian metastases present without specific symptoms or signs and are usually diagnosed during follow-up imaging. A rare case is presented of metachronous ovarian metastasis from primary CRC, diagnosed on follow-up by computed tomography (CT) and magnetic resonance imaging (MRI), and includes a review of the literature. CASE REPORT A 66-year-old woman recently underwent a left hemicolectomy for a stage T3, N0, M0 primary adenocarcinoma of the sigmoid colon, which was completely excised. Three years later, follow-up CT and MRI imaging showed a right ovarian cyst. She underwent exploratory laparotomy and bilateral salpingo-oophorectomy, which identified tumor in the right ovary. Histopathology and immunohistochemistry confirmed metachronous ovarian metastasis from CRC. The patient was referred for further treatment. CONCLUSIONS Newly-diagnosed ovarian metastasis from primary colorectal cancer (CRC) is challenging to diagnose and manage, and may initially be incorrectly diagnosed as malignancy of primary ovarian origin. This case demonstrated that it is important to confirm the diagnosis with imaging, histology, and the appropriate use of tumor markers. Because ovarian metastases do not respond favorably to chemotherapy, the treatment of choice is surgery. However, for women who are treated for CRC, the use of prophylactic oophorectomy remains controversial.

Cecal diverticulitis is a challenging diagnosis: a report of 3 cases.

BACKGROUND: Cecal diverticulitis is an uncommon cause of acute abdominal pain and presents clinically similar to acute appendicitis. There are many perspectives concerning the management of this condition, ranging from different types of surgical resections to conservative treatment with antibiotics. CASE REPORT: We present 3 cases of cecal diverticulitis. One of the patients was treated conservatively with intravenous antibiotics and the other 2 were treated with surgical resection. CONCLUSIONS: Conservative treatment with intravenous antibiotics can be used in uncomplicated cecal diverticulitis. Complicated cecal diverticulitis is managed surgically and the type of resection depends mainly on the extent of inflammation.

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.