Myoplasty versus omentoplasty in the surgical treatment of hydatidosis of the liver dome.

BACKGROUND AND AIMS: Even though surgery is the mainstay in the management of hydatid disease of the liver, controversies still exist about the preferred operating technique. This study was conducted to evaluate myoplasty versus omentoplasty for the surgical treatment of hepatic dome hydatidosis. PATIENTS AND METHODS: Sixty-two patients with a hydatid cyst located over the right superior-posterior part of the liver or a cyst adherent to the right hemidiaphragm were classified into two groups according to the type of surgical approach. Group A comprised 50 patients who had undergone thoracoabdominal, right subcostal, or right paramedian incision. Group B comprised 12 patients who had undergone posterior-lateral thoracotomy. Twenty-four patients with a right thoracoabdominal incision underwent partial excision of the cyst with omentoplasty (18 patients), external drainage (four patients), and marsupialization (two patients). RESULTS: Twenty-six patients with a right subcostal or paramedian incision underwent partial resection of the cyst with omentoplasty (15 patients), external drainage (eight patients), and combination of procedures (three patients). Twelve patients that had undergone a right thoracotomy underwent partial excision of the cyst wall with myoplasty of the right hemidiaphragm. Surgical approaches such as thoracoabdominal, right subcostal, or paramedian incision were associated with higher morbidity rate than thoracotomy alone (P < 0.03). In addition, patients with myoplasty of the right hemidiaphragm were associated with a lower morbidity rate than those with omentoplasty (P < 0.02). Five patients had recurrent disease and were reoperated upon. Partial cystectomy and myoplasty of the right hemidiaphragm was performed with excellent results. CONCLUSIONS: These results suggest that a thoracic approach, with myoplasty of the right hemidiaphragm and high-vacuum drainage, might produce low complication and recurrence rates and the best clinical results. Consequently, it is a promising procedure that requires more application and evaluation.

Perforated carcinoma of the sigmoid colon in an incarcerated inguinal hernia: report of a case.

Perforation of the large bowel due to benign or malignant disease in an inguinal hernia is very rare, but should be considered as a potential cause of strangulated hernias. A 79-year-old man with a 2-day history of scrotal swelling and pain in the left side associated with fever and chills was brought to our Emergency Department, where he was classified as American Society of Anesthesiologists IVE. A large left incarcerated scrotal hernia was diagnosed and surgical exploration was performed using local infiltration anesthesia. A standard oblique inguinal incision was made, revealing perforation of the sigmoid colon due to cancer. A 40-cm segmental resection of the sigmoid colon was done, and a double-barrel colostomy was made through the inguinal incision. This surgical strategy involving construction of a double-barrel colostomy through the inguinal hernia incision could be an alternative method of managing such critically ill patients.

Prognostic significance and correlation with survival of bcl-2 and TGF-beta RII in colon cancer.

Bcl-2 and TGF-beta receptors type II (RII) in colon carcinomas were studied in a series of 113 patients, to determine their prognostic significance and to correlate their expression with other prognostic indicators. Bcl-2 expression in the tumor cells showed a reverse relation with tumor size (P = 0.018), histological grade (P = 0.04), and stage (P = 0.013). Univariate survival analysis using the log rank test showed that the survival of patients with bcl-2-positive tumors was significantly better than the survival of patients with bcl-2-negative tumors (P = 0.02). However, when entered into a multivariate analysis model, it was not found to be of independent prognostic significance. TGF-beta RII expression was correlated with stage (P = 0.03), while no statistically significant correlation was found between TGF-beta RII expression and histological grade or survival. In conclusion, these results provide additional evidence for the role of bcl-2 and TGF-beta RII in carcinogenesis of the colon, while they do not support the use of these factors as prognostic markers in patients with colon cancer.

Clinical implications of small bowel diverticula.

BACKGROUND: Small bowel diverticula are usually asymptomatic and rare. Their importance is based on the fact that they carry the risk of serious complications. OBJECTIVE: To study the implications and the therapeutic approach regarding small bowel diverticulosis. METHODS: The medical records of 54 patients with diverticular disease of the small bowel, including Meckel's and duodenum diverticula, were retrospectively reviewed. The mean age of the 32 male and 22 female patients was 53.2 years. RESULTS: Diverticula were found in the duodenum in 11 cases, in the jejunum and ileum in 21 cases, and with Meckel's diverticula in 22 cases. In 24% of the patients the diverticula were multiple. The most common clinical symptom was abdominal pain, in 44.4%. Most of the duodenum diverticula were asymptomatic; 47.6% of the patients with diverticular disease located in the jejunum and ileum presented with chronic symptoms. The overall diagnostic rate for symptomatic diverticula before surgery was 52.7%; in 33.3% diverticula were found incidentally during other diagnostic or therapeutic procedures. Forty-one patients were managed surgically. 15 patients were operated on urgently because of infection or rupture, 4 patients for bleeding, 5 patients for intestinal obstruction, and one patient for jaundice. CONCLUSIONS: The incidence of asymptomatic small bowel diverticula is difficult to ascertain. Patients with Meckel's and duodenal diverticula are usually asymptomatic, while the majority of jejunal and ileal diverticula patients present with chronic symptoms. The pre-operative diagnostic rate is higher for duodenal diverticula. Small bowel diverticula do not require surgical treatment unless refractory symptoms or complications occur.

Damage control surgery: an alternative approach for the management of critically injured patients.

Over the past 20 years, it has gradually become apparent that the results of prolonged and extensive surgical procedures performed on critically injured patients are often poor, even in experienced hands. The triad of hypothermia, coagulopathy, and metabolic acidosis effectively marks the limit of the patient's ability to cope with the physiological consequences of injury, and crossing this limit will frustrate even the most technically successful repair. These observations have led to the development of a new surgical strategy that sacrifices the completeness of immediate repair in order to adequately address the combined physiological impact of trauma and surgery. This approach is unfolded in three phases. During the initial operation, the surgeon carries out only the absolute minimum necessary to rapidly control exsanguination and prevent the spillage of intestinal contents and urine into the peritoneal cavity. Packing represents the traditional method for the management of major liver injuries. The second phase consists of secondary resuscitation in the intensive care unit, characterized by maximization of hemodynamics, correction of coagulopathy, rewarming, and complete ventilatory support. During the third phase, the intra-abdominal packing is removed and definitive repair of abdominal injuries is performed. The "damage control" concept has been shown to increase overall survival and is likely to modify the management of the critically injured patient.

Primary Tuberculosis of the Pancreas Mimicking a Pancreatic Tumor.

Tuberculosis of the pancreas is very rare, and isgenerally associated with miliary tuberculosis (1).The correct diagnosis is often missed if there is noevidence of tuberculosis in other organs (2). Therefore,it can present to the clinician as a difficult diagnosticdilemma. We present an extremely rare case of primary pancreatictuberculosis that was initially diagnosed aspancreatic tumor, in a non-immunocompromisedpatient who did not have miliary tuberculosis.