Giant primary retroperitoneal seminoma: A case report.

INTRODUCTION: Primary extragonadal seminomas are rare tumors. There have been only a few cases of the primary retroperitoneal seminomas reported in the literature up to date. CASE REPORT: We reported a 56-year-old man with giant primary retroperitoneal seminoma presented with the enlargement of the left side of the abdomen and deep venous thrombosis of the left leg. Computed tomography of the abdomen showed a large tumor occupying the left part of the retroperitoneal space with 23 x 13 cm in diameter. Firm tumor mass having 25 x 15 cm in diameter was surgically removed from the left retroperitoneum. The tumor adhered the tunica adventitia of the aorta and it was carefully resected from the aortic wall. The diagnosis of seminoma was made during histopathological examination. The patient underwent chemotherapy. Two years after finished chemotherapy the patient accepted left orchiectomy with the aim of eliminating the possibility of the occult malignancy of the testicle. Histopathological analysis of the testicular tissue was normal and the diagnosis of primary retroperitoneal seminoma was confirmed. CONCLUSION. Despite its small incidence in general population, the diagnosis of retroperitoneal seminoma should be considered in male patients with nonspecific symptoms and with retroperitoneal tumor mass.

Relationship between of short-course preoperative radiotherapy and serum albumin level and postoperative complications in rectal cancer surgery.

BACKGROUND/AIM: The identification of risk factors could play a role in improving early postoperative outcome for rectal cancer surgery patients. The air of this s5udy was to determine the relationship between short-course preoperative radiotherapy (RT), serum albumin level and the development of postoperative complications in patients after anterior rectal resection due to rectal cancer without creation of diverting stoma. METHODS: This retrospective study included patients with histopathologically confirmed adenocarcinoma of the rectum with the clinical stage of T2-T4 operated on between 2007 and 2012. All the patients underwent open anterior rectal resection without diverting stoma creation. Preoperative serum albumin was measured in each patient. Tumor location was noted intraoperatively as the distance between the inferior tumor margin and anal verge. Tumor size was measured and noted by the pathologist who assessed specimens. Some of the patients received short-course preoperative RT, and some did not. The patients were divided into two groups (group 1 with short-course preoperative RT, group 2 without short-course preoperative RT). Postoperative complications included clinically apparent anastomotic leakage, wound infection, diffuse peritonitis and pneumonia. They were compared between the groups, in relation to preoperative serum albumin level, patient age, tumor size and location. RESULTS: The study included 107 patients (51 in the group 1 and 56 in the group 2). There were no significant difference in age (p = 0.95), gender (p = 0.12) and tumor distance from anal verge (p = 0.53). The size of rectal carcinoma was significantly higher in the group 1 than in the group 2 (51.37 +/- 12.04 mm vs. 45.57 +/- 9.81 mm, respectively; p = 0.007). The preoperative serum albumin level was significantly lower in the group 1 than in the group 2 (34.80 +/- 2.85 g/L vs. 37.55 +/- 2.74 g/L, respectively; p < 0.001). A significant correlation between the tumor size and the serum albumin level was found (p = 0.042). Overall, postoperative complications were observed in 13 (25.5%) patients in the group 1 and in 10 (17.8%) patients in the group 2 without significant difference between the groups (p = 0.18). A significantly lower level of serum albumin was found in patients with postoperative complications and in those who died. A significant difference in anastomotic leakage occurrence between groups was found (p = 0.039). Male gender and the lower level of serum albumin were significant predictors for anastomotic leakage occurrence (p = 0.05 and p = 0.002, respectively), but preoperative RT had no significant impact on it. CONCLUSIONS: A lower serum albumin level, but not short-course of preoperative RT, was significantly associated with postoperative complications development after rectal resection with' out diverting stoma.

Traumatic mesenteric pseudocyst.

INTRODUCTION: Mesenteric pseudocysts have rarely been described in literature. They belong to a group of mesenteric cysts that are very rare intra-abdominal pathology regardless of the origin. The diagnosis is often difficult to make, because of the diversity of clinical symptoms. The definitive histopathological diagnosis determines the origin and further course of treatment. CASE REPORT: We reported a patient with post-traumatic mesenteric pseudocyst. It was localised on the mesenteric side, in the direct contact with the small intestine. We surgically removed the pseudocyst along with a part of the small intestine with success. The patient's recovery was eventless, with no complications. CONCLUSION: Only by complete cyst removal, the definitive, accurate histopathological diagnosis and classification can be made.

A 60-year expirience in the treatment of pancreatic insulinoma in the Military Medical Academy, Belgrade, Serbia.

BACKGROUND/AIM: Insulinomas are rare benign tumors in the most cases and the most frequent endocrine tumors of the pancreas. A wide spectrum of clinical manifestations in patients with insulinoma is the reason for difficult recognition of the disease with a long period of time between the onset of symptoms and the diagnosis. Diagnostic procedures include Whipple's triad, 72-hour fast test and topographic assessment. The only currative therapy for patients with insulinoma is operative treatment. METHODS: This retrospective study included 42 patients with diagnosis of insulinoma treated in our institution in a 60-year period. In all the patients a demographic and clinical data, types of biochemical methods for diagnosis, and diagnostic procedures for insulinoma localization were analyzed. Tumor size and localization, surgical procedures, postoperative complications and outcome were assessed. RESULTS: A study included 42 patients, 29 women and 13 men. The median age at diagnosis was 43 years. Median time between the onset of symptoms and diagnosis was 3 years. The most common clinical symptoms and signs were disturbance of consciousness and abnormal behavior in 73%, confusion and convulsions in 61% of patients. The diagnosis of insulinoma was estimated by Whipple's triad and 72-hour fast test in 14 patients. Determination of insulinoma localization was assessed by angiography in 16 (36%) of the patients, by ultrasound (US) in 3 of 16 (18.8%) patients, by abdominal computed tomography (CT) in 8 of 18 (44.5%) patients, and magnetic resonance imaging (MRI) in 2 of 8 (25%) patients. Insulinoma was found in 13 of 13 (100%) patients by arterial stimulation with venous sampling (ASVS) and in 13 of 14 (93%) patients by endoscopic ultrasound (EUS). Of the 42 patients, 38 (90.5%) underwent operative procedure. Minimal resection was performed in 28 (73.6%) of the patients [tumor enucleation in 27 (71%) and central pancreatectomy in one (2.6%) of the patients], and the major resection was performed in 9 (23.6%) of the operated patients [distal splenopancreatectomy in 8 (21%) and pancreaticoduodenectomy in one (2.6%) patient]. The overall mortality rate in postoperative period was 2.6% (one patient). CONCLUSION: A combination of ASVS and EUS as diagnostic procedures ensures high accuracy for preoperative determination of insulinoma localization. Minimal resection such as enucleation shoud be performed whenever it is possible.

Long-term outcome of a modified balloon dilatation in the treatment of patients with achalasia.

BACKGROUND/AIM: Balloon dilatation is a standard approach to the initial achalasia treatment. Modified dilatation is also applied to rise efficacy and to lower complications. METHODS: A total of 57 patients were analysed within a median follow-up of 8.2 years. No premedication was used, dilatation was performed up to the pain treshold, while introduction and positioning of a dilatator was done in combination of endoscopic and radiological control. Dilatation effect was estimated by both Kim Symptom Scoring and objective parameters: body weight rise and radiological scintigraphic findings. RESULTS: Excellent and good results were obtained in 50 (88%) of the patients, while in 7 (12%) of the patients surgery was performed. There was no difference in dilatation efficacy regarding sex of the patients, but the results were better in the patients above 40 years. Duration of symptoms, body weight loss, esophageal lumen width do not indicate the definitive dilatation outcome. Esophageal scintigraphy and body weight increase were in a direct correlation with the effect of dilatation measured with the Kim Symptom Scoring. After the one to two repeated dilatations the efficacy increased from 74% to 88% justifying the repetition of dilatation. In 2 (3.57%) of the patients, that is in 2.65% of the totally dilated patients, perforation was recorded. There was no lethal outcome of dilatation, and the other complications were not clinically significant. CONCLUSION: Modified balloon dilatation can be recommended for initial method in achalasia treatment due to high efficacy, easy performance in daily hospital while complications are in standard range.

Sclerosing mesenteritis as a rare cause of upper ileus.

INTRODUCTION: Sclerosing mesenteritis is a rare pathological entity characterized by non-specific tumor-like expansion in mesentery. Accurate diagnosis of this disease is rarely made preoperatively. Surgery takes place in diagnosis, as well in treatment of the disease. We presented a case of sclerosing mesenteritis that affected the final portions of duodenum and initial part of jejunum with clinical picture of upper gastrointestinal obstruction. CASE REPORT: A 46-year-old man without previous medical history was presented with vomiting and loss of weight in the last 6 months. Due to suspicion of parapancreatic tumor by CT examination and clinical presentation of the disease, the patient underwent laparotomy. A mass infiltrated mesenteric root, initial part of superior mesenteric artery, the fourth duodenum portion and the ligament of Treitz, while the stomach and duodenum were dilatated. The intraoperative biopsy indicated a benign process. The mass was reduced with desobstruction of the duodenum. Definitively, histopathological finding showed fibromatosis in different phases of activity. Postoperative course passed without complications. The patient continued to receive an immunosuppressive drug therapy. After a 6-month treatment the patient showed no gastrointestinal problems. CONCLUSION: Sclerosing mesenteritis that affects the duodenum and the proximal part of the jejunum with subacute upper gastrointestinal obstruction is an extremely rare condition. In the presented case a surgical procedure was necessary for marking the diagnosis and treatment as well.

[Colorectal anastomosis dehiscence following radical surgical operation for rectal carcinoma].

UNLABELLED: BACKGROUND/AIM. Colorectal cancer (CRC) is one of the biggest health problems of modern humanity, especially in highly developed countries. In Serbia about 3,200 patients suffer from CRC, out of whom about 1,100 patients suffer from rectal cancer (RC), while about 2,100 patients suffer from other colon segments cancer. The aim of the study was to show the incidence genesis of one of the possible early postoperative complications regarding dehiscence of the colorectal anastomosis (CRA) with a group of patients suffering from RC and operated by using sphincter-saving procedures, in the period from 1993 to 2007, and then to compare the incidence genesis of these complications with those in the published series of the reporting colorectal institutions. METHODS: The research included 242 patients radically operated on for RC in a 15-year period using some of sphincter-saving procedures following by a careful analysis of the symptoms of subclinical dehyscencias not solved with the reintervention as well as of the clinically evidented dehyscencias mostly solved by reoperation. RESULTS: With 22 (9.1%) patients in the first 10 postoperative days there were early postoperative symptoms of CRA dehiscence. In 6 (2.47%) of the patients there were subclinical signs of raised body temperature, less quantity of feces content, and after the conservative treatment they ended in spontaneous process of rehabilitation. In 16 (6.61%) patients there was clinically evidented anastomosis dehiscence followed by abundant drainage of feces content, signs of local peritonitis, pelvic sepsis, so we had to undertake surgical intervention. CONCLUSION. Comparing the results of a few tenths of published studies with our results we proved that performing and operative technique of colorectal anastomosis in the patients suffered and radically surgically treated for RC, is quite adequate with the operative technique in reporting world institutions that are engaged in surgical treatment of RC.

Splenic artery pseudoaneurysm as a complication of pancreatic pseudocyst.

INTRODUCTION: Pancreatic pseudocyst presented as pseudoaneurysm of the splenic artery is a potential serious complication in patients with chronic pancreatitis. CASE REPORT: A 42-year-old male patient with a long-standing evolution of chronic pancreatitis and 8-year long evolution of pancreas pseudocyst was referred to the Military Medical Academy, Belgrade due to worsening of the general condition. At admission, the patient was cachectic, febrile, and had the increased values of amylases in urine and sedimentation (SE). After clinical and diagnostic examination: laboratory assessment, esophagogastroduodenoscopy (EGDS), ultrasonography (US), endoscopic ultrasonography (EUS), multislice computed scanner (MSCT) angiography, pseudoaneurysm was found caused by the conversion of pseudocyst on the basis of chronic pancreatitis. The patient was operated on after founding pancreatic pseudocyst, which caused erosion of the splenic artery and their mutual communication. Postoperative course was duly preceded without complications with one year follow-up. CONCLUSION: Angiography is the most reliable and the safest method for diagnosing hemorrhagic pseudocysts when they clinically present as pseudoaneurysms. A potentially dangerous complication in the presented case was treated surgically with excellent postoperative results.

Decompressive laparotomy with temporary abdominal closure versus percutaneous puncture with placement of abdominal catheter in patients with abdominal compartment syndrome during acute pancreatitis: background and design of multicenter, randomised, controlled study.

BACKGROUND: Development of abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) has a strong impact on the course of disease. Number of patients with this complication increases during the years due more aggressive fluid resuscitation, much bigger proportion of patients who is treated conservatively or by minimal invasive approach, and efforts to delay open surgery. There have not been standard recommendations for a surgical or some other interventional treatment of patients who develop ACS during the SAP. The aim of DECOMPRESS study was to compare decompresive laparotomy with temporary abdominal closure and percutaneus puncture with placement of abdominal catheter in these patients. METHODS: One hundred patients with ACS will be randomly allocated to two groups: I) decompresive laparotomy with temporary abdominal closure or II) percutaneus puncture with placement of abdominal catheter. Patients will be recruited from five hospitals in Belgrade during two years period. The primary endpoint is the mortality rate within hospitalization. Secondary endpoints are time interval between intervention and resolving of organ failure and multi organ dysfunction syndrome, incidence of infectious complications and duration of hospital and ICU stay. A total sample size of 100 patients was calculated to demonstrate that decompresive laparotomy with temporary abdominal closure can reduce mortality rate from 60% to 40% with 80% power at 5% alfa. CONCLUSION: DECOMPRESS study is designed to reveal a reduction in mortality and major morbidity by using decompresive laparotomy with temporary abdominal closure in comparison with percutaneus puncture with placement of abdominal catheter in patients with ACS during SAP. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NTC00793715.

[Prolonged survival of a female patient with total pelvic exenteration].

BACKGROUND: To present a female patient who lived 5 years after total pelvic exenteration (TPE). CASE REPORT: The female patient underwent TPE due to retrovesicovaginal fistula as a consequence of locoregional irradiation after the operation for the malignoma of the vaginal part of the uterus. In the formation of Bricker conduit, the ureter antireflux was achieved by the application of the "tobacco sack muff" made of the intestines around the ureter. By the use of this technique, the occurrence of pyelonephritis, as the leading cause of death in such patients, was prevented. CONCLUSION: TPE is a hope for significantly prolonged survival of patients with advanced pelvic malignomas, or with a postirradiatiation fistula.

[Solid-pseudopapillary tumors of the pancreas].

BACKGROUND: Solid-pseudopapillary tumors of the pancreas (SPT) is a very rare lesion. We presented the clinical and pathological characteristics of this tumor and reviewed the literature. CASE REPORT: We analysed the treatment of the two female patients, aged 21 and 37 years, with this tumor. The first female patient had the tumor withont involvement of the surrounding organs. The second female patient had the tumor with a high grade of malignancy which invaded blood vessels. We performed in both patients splenohemipancreatectomy, and then we reported the pathological characteristics of the tumors. We didn't find recidive in the observed postoperative follow-up of 4, and 6 years, respectively. CONCLUSION: SPT is a rare tumor of the pancreas that is diagnosed primarily in young women. The prognosis after surgical treatment was excellent. The histopathological analysis is the main procedure in establishing diagnosis, regardless the most recent diagnostic procedures.

[Preoperative evaluation of the feasibility of laparoscopic cholecystectomy].

AIM: To determine the possibility of preoperative evaluation of the feasibility of laparoscopic cholecystectomy based on the standard preoperative examinations and findings. METHODS: During 1997, 100 consecutively operated patients with the diagnosis of chronic calculous cholecystitis were followed up. Sex and age, and the results of blood count, sedimentation rate, ultrasonography (US), and intravenous cholangiography (IVC) were monitored. Based on adhesions, fibrosis in Calot's triangle and pericholecystitis, surgical interventions were classified as minor and major. RESULTS: Minor operations were performed in 57, and major in 43 patients. Earlier surgical interventions had been carried out in 8 (18.6%) patients from the major surgery group, while 9 (15.79%) patients had undergone minor surgery. Out of 57 patients with minor surgery, IVC verified the contrast medium filling of the gallbladder in 55 (96.49%) of the patients. Tense gallbladder or wall stratification was not revealed by ultrasonography in any of the patients from this group. Out of 43 patients with major surgery, the gallbladder was not filled with the contrast medium during IVC in 34 (79.07%) patients, while the stratified and tense gallbladder was found by US in 2 (4.65%) patients. The mean sedimentation rate was 14.3 in the patients with minor surgery, and 23.5 in major surgery group. Mean WBC in the patients with minor surgery was 7.4 x 10(9). The patients with major surgery had slightly increased mean value of the white cell count. It was 8.3 x 10(9). CONCLUSION: Statistically significant difference (p < or = 0.05) was found between the variables of the IVC, sedimentation rate, the white blood count, and the earlier operations. No significant difference was found between other analyzed variables.

[Menetrier's disease associated with ulcerative colitis]. / Ménétrier-ova bolest udruzena sa ulceroznim kolitisom.

In this paper a 21 year old patient was presented with Ménétrier's disease, associated with ulcerative colitis. The first symptoms of ulcerative colitis occurred at the age of eleven, since when the patient has been conservatively treated several times because of the exacerbations of the disease. During control examinations presence of polyploid changes in stomach was discovered by upper endoscopy. Gastrectomy was suggested because the patient had excessive anemic syndrome which required weekly substitutional therapy with deplasmatic eritrocytes, as well as hypoproteinemia, while multiple polyploid changes suspect for malignancy were gastroscopically identified. Patient accepted surgical treatment, and was transferred to the Clinic of Surgery. Total gastrectomy was performed, and patohistological finding confirmed Ménétrier's disease. After two weeks, the patient was released from the hospital in good general condition, with regular clinical and laboratory findings.