Thoracobiliary fistula. A rare complication of thoracoabdominal trauma.

Thoracobiliary fistulas (bronchobiliary and pleurobiliary) are rare complications of thoracoabdominal trauma. Owing to their rarity, there is little consensus on the optimal management . The diagnostic suspicion however must be considered and it's important the correct selection of diagnostic imaging techniques. Biliptysis is the pathognomonic physical finding of bronchobiliary fistulas. Demonstration of high bilirubin levels in the pleural effusion is diagnostic for a pleuro-biliary fistula. The optimal treatment of bronchobiliary fistulas is operative, in order to prevent their dramatic consequences. For pleurobiliary fistulas, a light aggressive conservative approach is an appealing option in the beginning. Newer endoscopic techniques increase the non-operative approach.

The treatment of the ears with advanced pathology using a composite graft of perichondrium and cartilage.

In ears with advanced pathology the functional and anatomical results of a surgical procedure depend on factors such as total perforation, tympanosclerosis. Atelectasis. Suppuration or possibility a previous operation. A Perichondrium-Cartilage Composite Graft (PCCG) was used to repair the tympanic membrane by a total of 350 cases over a five-year period in total, 157 type I tympanoplasty procedures (15% with previous surgery) and 193 type III procedures (52% with previous surgery) were carried out. The graft was obtained from the tragus and/or the conceal cartilage. Two slightly different surgical techniques were used. Closure of the perforation in the tympanic membrane was successful in 94% of the procedures. An < or = 30 dB in 79% of the type III procedures. In conclusion, the PCCG is a reliable graft in cases of advances middle ear damage

Intestinal perforation by a foreign body, without identifying a perforation site at laparotomy.

A case is reported of a young man, who was presented with abdominal pain and an inflammatory abdominal mass resulting from intestinal perforation by a wooden spike. Thorough surgical exploration of the abdominal cavity didn't reveal the perforation site. An inflammatory mass in small bowel mesentery was excised and the cavity drained. The patient had an uneventful recovery. In cases of intestinal perforation by wooden spikes the site of perforation may not be identified. Healing of the opening after the passage of the spike is the possible mechanism. The outcome of these patients even without finding the opening is favorable.

Spinal cystic meningioma presenting as a ring enhancing lesion on MRI.

Spinal meningiomas are much more common in women. The peak age incidence of presentation occurs in the sixth decade. Cystic meningiomas are rare and seem to have a predilection for children. We report a case of cystic spinal meningioma in a young man presenting as a ring enhancing lesion on Magnetic Resonance Imaging (MRI). This case is unusual because of the atypical features of the tumour, the relatively young age and sex of the patient.

Acute cholecystitis: when is the best time for laparoscopic cholecystectomy?

Laparoscopic cholecystectomy is no more an elective procedure. The question is when to perform laparoscopic cholecystectomy in the face of acute cholecystitis. The last decade (1995-2004) 297 patients had a laparoscopic cholecystectomy for acute cholecystitis. One hundred forty six of them were operated in the first 24-48h after the onset of symptoms (group I), 68 were operated in less than 4 weeks time after the attack of the acute cholecystitis (group II), while the rest 83 patients had a history of acute cholecystitis at least four weeks before their elective laparoscopic cholecystectomy (group III). Analysis of the operative time, complications and hospital stay showed that laparoscopic cholecystectomy in acute cholecystitis is the recommended surgical procedure. The success of the operation depends on the degree of the inflammatory changes in the gallbladder and the expertise of the operator both in emergency and laparoscopic surgery. Timing of the operation is crucial to executing a successful procedure. The operation is easier, faster and safer when performed in first 4-5 days of the onset of symptoms.

Cavernous sinus chondroma. Case report and review of the literature.

Chondromas of the base of the skull are most commonly found in the parasellar and sellar regions, and present varying degrees of involvment of the cavernous sinus.However, those confined mainly to the cavernous sinus are rare, and only a few cases have been reported. A 50 year old man experienced left hemifacial pain followed by left abducens nerve palsy. Computerized tomography and magnetic resonance image depicted a well circumscribed mass in the left cavernous sinus. A pterional craniotomy was performed to approach this lesion intradurally. The tumour was subtotally removed Histologically the mass was diagnosed as a mature chondroma. Postoperatively, the left hemifacial pain disappeared and the diplopia improved from the first postoperative day. Successfull removal of lesions in the cavernous sinus requires individualisation of the case as well as choosing the correct surgical approach for the certain patient.

Selective beta blockade improves the outcome of cardiopulmonary resuscitation in a swine model of cardiac arrest.

BACKGROUND AND OBJECTIVES: Epinephrine has been the mainstay drug of choice for cardiac resuscitation for more than 30 years. Its vasopressor effects favoring initial resuscitation point to its beta-adrenergic action. However, its beta-adrenergic actions may have detrimental effects. The aim of the present experimental study was to evaluate the efficiency of coadministration of Esmolol, an ultra-short-acting beta-blocker, and of epinephrine in a swine model of cardiac arrest. MATERIALS AND METHODS: Fourteen pigs (19 +/- 2 Kg) were anesthetized and instrumented. Ventricular Fibrillation (VF) was produced electrically. After induction of VF, the animals were left untreated for 5 minutes. Animals were randomized into two groups, control and study group. Six animals were used in the control group, and 8 in the study group. The control group received 10 ml of normal saline via a peripheral vein, while the study group received 0.4 mg/kg Esmolol in 10 ml dilution. Epinephrine was administered to all animals after the first unsuccessful defibrillation set, and all animals received standardized Advanced Life Support. RESULTS: Seven animals (87.5%) restored cardiac rhythm compatible with a pulse in the Esmolol group, compared to 2 animals (33.3%) in the control group (p = 0.018). The average time until restoration of circulation was 16 +/- 3.2 minutes in our control group and 12.8 +/- 1.4 minutes in Esmolol group (p = 0.059). Coronary perfusion pressure (CPP) was significantly higher in the Esmolol group. CONCLUSIONS: Esmolol improves significantly the outcome of cardiopulmonary resuscitation and the average time of restoration of circulation, while in the proposed dosage does not alter the CPP at the beginning of CPR. However, it augments CPP from the sixth minute of CPR and afterwards.

Lower limb veins color and spectral Doppler ultrasonography examination. An examination protocol.

Lower extremity's venous pathology was traditionally investigated by intravenous venography. Nowadays Color Doppler flow imaging is widely accepted as a well established, noninvasive method for the evaluation of deep pelvic and lower extremity's venous system. The vast majority of authors conclude that the method can safely replace diagnostic venography in all patients with venous thrombosis, thrombophlebitis and valve or communicating veins insuffciency. Optimal performance of Color Doppler flow imaging as a diagnostic tool for the whole lower limb veins requires: Proper equipment specifications and settings. Knowledge of regional venous anatomy. Established examination protocols. Evaluation of morphological and functional findings. Documentation of the findings. All these steps are described as a sequence of guidelines, photographs and multiple ultrasonographic images. Our paper can be useful to all physicians or sonographers involved with color Doppler studies for the evaluation of lower limb venous diseases and abnormalities.

Lower gastrointestinal bleeding treated with transcatheter arterial embolization. Case report and review of the literature.

Acute lower gastrointestinal bleeding, is often a dramatic situation, associated with mortality rate up to 28%. Currently transcatheter alternatives have found their place in the therapeutic spectrum of this situation. An interesting question is when should this procedure be performed and which are the difficulties when performing it. We present the case of a 75-year old woman with acute massive lower gastrointestinal bleeding on the tenth post-operative day of a colic and partial ileal resection. Superselective angiography of the superior mesenteric artery was obtained that disclosed marked contrast extravasation of distal branches of the left colic artery as well as from a small branch feeding the distal enteric anastomoses. Clinical success was achieved after superselective embolization which was accomplished by using polyvinyl alcohol particles. The patient was discharged 5 days later and there were no procedure-related complications during 6-month follow-up period. So, especially in post-operative patients who are considered to be poor candidates for surgical treatment, arterial embolotherapy should be established not only as treatment option, but also as first line therapy for LGI bleeding.

Brain CT scan indexes in the normal pressure hydrocephalus: predictive value in the outcome of patients and correlation to the clinical symptoms.

The aim of this study is to find out the correlation of the ventricular size of the brain, as it is estimated using brain computed tomography (CT) scan indexes in patients with normal pressure hydrocephalus (NPH), to: a) the clinical symptoms, and b) the results of cerebrospinal fluid (CSF) shunting procedures. We looked for any predictive value in the estimation of brain CT scan indexes, in patients as above, in whom a shunt is going to be placed. It is well known that it is very difficult to decide who is going to improve after shunting. We studied 40 cases of patients with the diagnosis "NPH" in whom the ventricular shunts were placed. Every symptom (motor disturbance, deficit of memory, incontinence) was separately evaluated preoperatively. The outcome of shunting was also evaluated and the patients were graded. The following CT scan indexes were estimated from the preoperative CT scans of the brain in every case: the ventricle-brain ratio (VBR), the bi-caudate and bi-frontal ratios, the third ventricle-Sylvian fissure (3V-SF) ratio, and the four largest cortical gyri. The method we have used for statistics is "one way analysis of variance", correlating the CT scan indexes to the symptoms of the patients preoperatively, and the outcome of them postoperatively. The main conclusion is that the size of the lateral ventricles of the brain preoperatively is not correlated to the outcome after CSF shunting surgery, but it is correlated to the symptoms of NPH preoperatively.

Gastrointestinal stromal tumor of the gastric serosa protruding to the greater omentum. Report of a giant tumor with a rare histological pattern.

We report an unusual case of a 76 year old woman admitted to our hospital for investigation of anemia and palpable epigastric mass. Intraoperatively a huge (19 cm), well defined tumor was found adhering to the stomach wall, protruding into the greater omentum and compressing the transverse colon. A tumorectomy was performed and the greater omentum was removed due to its close relation. Pathology revealed a high risk Gastrointestinal Stromal tumor of the gastric serosa. Histologically the tumor was of mixed type (spindle and epithelioid cells) with hem-angio-peri-cytomatoid pattern peripherally, variably myxoid stroma, central necrosis and cytologic pleomorphism. On immunohistochemical examination there was a consistent positivity for c-kit (CD-117) and CD-34, but without myogenic or neural differentiation. We consider this case unusual because of its huge size, its gastric serosal location and its extremely rare histological pattern.

Effects of nimodipine administration on small bowel mucosa under conditions of laparotomy and consequent 48-hour starvation in a rat model.

BACKGROUND/AIMS: The combination of starvation and surgical trauma induces disturbances to the intestinal mucosal structure and function, as well as changes in mucosal barrier function in the rat small bowel. The aim of the present study was to evaluate the effects of nimodipine administration, on intestinal mucosal structural changes and enterocyte apoptosis, following laparotomy and subsequent postsurgical starvation (PSS) in the rat. METHODS: Thirty Wistar rats were divided into two experimental groups: A: Control group (n=15), where the animal models underwent laparotomy and consequent 48-hours PSS and B: Nimodipine group (n=15), where the rats underwent laparotomy, followed by intraperitoneal nimodipine administration and consequent 48-hour (h) PSS. Small bowel mucosal structural changes and enterocyte epithelial apoptosis were determined 48 h following laparotomy. RESULTS: Nimodipine rats (group B) demonstrated a significant decrease in small bowel villous height in jejunum (p=0.016) and ileum (p=0.002). Similarly, crypt depth decreased in jejunum (p<0.001) and ileum (p<0.001). Nimodipine group exhibited significantly higher apoptotic index in ileum compared to control rats (p=0.006). CONCLUSION: Nimodipine did not protect the intestinal mucosa from damage caused by surgery and consequent PSS and had obvious damaging effects on intestinal mucosa with derangements to its structure and subsequent mucosal atrophy.

Ultrasound-guided interventional procedures. How we do it.

Ultrasound-guided fine needle aspiration biopsy (FNAB) is currently used as an alternative combined modality, which enables accurate detection and evaluation of solid and cystic abnormal lesions. It's easily performed, with low cost and most effective as it decreases the number of unnecessary operational procedures; that take place to rule-out malignancy. The aim of this paper is to suggest the schedule of an effective protocol, easily approached by residents and physicians with minimal, or no experience on ultrasound interventional procedures. Our tutorial is based on more than 350 fine needle aspiration biopsies that were carried-out in our Institution during the last two years. It includes images and graphics of patients preparation, needle selection, sampling and aspiration technique. On-site cytologic preparation and brief references on possible complications and common piifalls are also described.

Large bowel familiary cancer in patients without familiary polyposis.

Four members of a family, thirteen subjects of which developed cancer for three consecutive generations were surgically treated in our Unit for colon cancer. It is well known to day that adenocarcinoma of the colon, as well as of other organs, has been proved to occur in certain families by a dominant trait, in the absence of any precancerous lesions. Due to this and because none of our patients has had any of the above mentioned lesions and because their tumors developed in the colon de novo, we have to accept that there is a hereditary predisposition in the development of familial cancer generally, which holds for our patients too. Because of a very high incidence of cancer, close follow-up of these families is recommended, that must start early and completed by chromosome and immunobiologic studies for all first, second and third degree relatives.

Rectus sheath haematoma. report of two cases.

Rectus sheath haematoma is a well-documented clinical entity. The accumulation of blood within the rectus sheath produces a painful swelling that can mimic an intraperitoneal mass, with features of an acute abdomen. Accurate diagnosis is essential, in order to avoid an unnecessary laparotomy. Two cases of this entity are reported. The correct diagnosis was established by appropriate assessment of the clinical, laboratory and imaging findings.

Spontaneous pneumothorax. When and how to treat.

INTRODUCTION: Spontaneous pneumothorax, whether primary or secondary, may occur in patients with or without a history of pneumonic disease. AIM OF THE STUDY: From 1992 to 2002, we treated 275 patients, 230 male and 45 female, in the department of Thoracic Surgery of the General Hospital of Nikaia-Piraeus. In this study the Authors report the data concerning the frequency correlated with age, sex, causes, symptoms, as well as the ways of treatment, in order to compare them and their results with those recorded in Greek and international literature. CONCLUSIONS: It is made obvious by our material that only approximately 10% of patients suffering from spontaneous pneumothorax need surgery (thoracotomy), while the remaining patients can be managed with closed thoracic drainage or conservative treatment and monitoring.

Intracranial hemorrhage in a HIV patient. Case report and review of the literature.

The authors report on a case of a hemophilic male patient, aged 43, HIV positive, HCV positive, who had an episode of intracerebral hemorrhage after a car accident. Intracranial hemorrhage is the most feared complication of hemophilia, especially among HIV positive, who now are considered to be a group at high risk for bleeding. In this report, it is reviewed available data on clinical and imaging features of ICH and the association between ICH and HIV.

Therapy of the empyema thoracis. Why not thoracostoma?

Empyema toracis can be defined as a purulent pleural effusion. From 1998 to 2003 we treated 106 patients (87 men and 19 women), aged between 23 and 82 years, affected by localized empyema toracis. All of them received initially a chest tube and 73 of them (60 men and 13 women), in combination with selected antibiotics, had an uneventful recovery. Twenty three patients (17 men and 5 women) underwent thoracotomy and pleural decortication, and 7 patients (6 men and 1 woman) underwent open drainage, that means a thoracostoma. All these 7 patients were affected by chronic empyema: 3 of them with residual post-pneumectomy empyema (1 for lung cancer and 2 for tubercular lung disease); 3 had destroyed lung and 1 was suffering for multiorgan deficiency (respiratory, cardiac and chronic renal insufficiency). The thoracostoma procedure was under general tube anaesthesia with tracheal intubation. The mean surgical time was 26 minutes. The mean postoperative hospital stay was 10 days. In this period of time no death has been recorded or any kind of complication. Before the dismission all of them were teached with their familiars how to take care of the remaining thoracostoma. After the dismission all the patients were followed as outpatients for a variable period, for 14 and 36 months. During this period there were neither complications nor recidives, and all the patients have accepted the "thoracostoma" as a new way of life. Therefore thoracostoma appears as an acceptable, useful and no dangerous solution for the treatment of the chronic thoracic empyema.

The management of acute gastric volvulus.

Acute gastric volvulus occurs when the stomach or a part of it rotates more than 180 degrees which leads to obstruction (closed loop syndrome), that finally concludes to incarceration and ischemia of the organ. It can be observed as a result of diaphragmatic hernia, a gap of the diaphragm, pancreatic or gastric cancers, traumatic injuries and fixation anomalies. Parï first described acute gastric volvulus in 1579, in a patient with diaphragmatic injury after trauma. The first reports of successful surgical repair and anatomo-pathologic findings were published in 1866 and 1897.

Misleading interpretation of distended post-op bowel images in Helical CT scan.

Differential diagnosis of distended post-op colon can be misleading when based solely to imaging findings. A case report of an artefact giving the impression of faecal leak or foreign body (gossypiboma) in Spiral Computerized Tomography after colonic surgery is presented. The patient was managed conservatively due to the lack of clinical evidence of abdominal emergency, A second CT scan twenty days later revealed no findings besides minor colonic diverticulas.