Microwave ablation of a solitary colorectal liver metastasis complicated by stomach perforation and gastrocutaneous fistula - a case report.

BACKGROUND: Organ perforation secondary to thermal ablation is a rare but severe complication that can occur in certain patients, in whom tissue dissection and preservation cannot be adequately achieved. CASE DESCRIPTION: A 69-year-old man presented with a gastrocutaneous fistula 20 days after a microwave ablation of liver metastases from colorectal cancer. Besides skin rash, local tenderness, and gastric content discharge from a wound where the probe had been placed, no other signs or symptoms were present. The patient was treated surgically, and a wedge-shaped gastric resection was performed. His postoperative course was uneventful. After 8 months, the patient underwent the same procedure for local progression of the same lesion, using a pulsed MW antenna and a dedicated hydrodissection needle, without complications. CONCLUSIONS: A gastrocutaneous fistula is a rare complication of microwave ablation. However, adequate hydrodissection can minimize the risk for the development of these complications. Proper treatment of these complications does not preclude repeated usage of microwave ablation in the future.

A rare case of gastroesophageal adenocarcinoma in a 24-year-old male with achalasia complicated by postoperative aortoesophageal fistula due to stent placement and early local recurrence.

BACKGROUND: Esophageal cancer is the 8th most common and 6th most deadly malignancy worldwide. It is an aggressive type of cancer with poor prognosis, despite advances in therapeutic methods including those in thoracoabdominal surgery, chemotherapy and radiotherapy. It rarely manifests in young patients, but occurs frequently in older people. It has been related with achalasia regarding mainly the squamous cell carcinoma rather than the adenocarcinoma. Infiltrating esophageal tumors and radiotherapy can lead to the development of aortoesophageal fistula, a pathological communication between the aorta and the esophagus. CASE: We present the case of a 24-year-old male patient with a known history of achalasia for almost 15 years with a history of heavy smoking and drinking that presented with advanced lower esophageal adenocarcinoma. The patient was submitted, as per to his will, directly to Ivor Lewis esophagogastrectomy. One month later, dysphagia was manifested due to stenosis of the anastomosis, without any signs of local recurrence, and an esophageal metallic stent was placed. In the 3rd postoperative month, upper gastrointestinal bleeding presented due to an aortoesophageal fistula, caused by anastomotic dehiscence due to local recurrence and pressure from the stent, which was treated surgically. The patient, refusing chemotherapy at all stages, developed peritoneal carcinomatosis and died 6 months after surgery. CONCLUSION: Esophageal cancer is an aggressive type of cancer with a poor prognosis that is typically dia-gnosed in advanced stages. Despite the development of new therapeutic approaches, the high recurrence rate and the poor prognosis remain.

Laparoscopic repair of large inguinoscrotal hernias with combined use of plug and flat mesh.

BACKGROUND: This study's purpose was to examine the outcomes of the laparoscopic repair of large inguinoscrotal hernias with the combined use of a plug and flat mesh and to compare them to laparoscopic repair with the exclusive use of a flat mesh. CASE SERIES: Fifty male patients with large inguinoscrotal hernias underwent this procedure over two years. Twenty-five patients had a transabdominal preperitoneal (TAPP) hernia repair with the combined use of a plug and flat mesh, and 25 patients had TAPP repair using a flat mesh only. The novelty of this technique lies in the fact that after complete dissection of the hernia sack, a plug mesh is placed reversely, and its top edge is anchored onto the lower edge of the inguinal ligament with a standard fixation device. Next, a flat mesh is fixated, and the two meshes are sutured together with polypropylene sutures to form one combined mesh. One hernia recurrence was recorded during the follow-up period after the combined use of the plug and flat mesh. One patient developed a scrotal hematoma which was treated conservatively. CONCLUSIONS: The laparoscopic repair of large inguinoscrotal hernias with the combined use of a plug and flat mesh is a safe and effective technique with excellent short-term outcomes. It is a simple modification of the standard TAPP procedure. The recurrence rate of large inguinoscrotal hernias is also believed to be reduced. HIPPOKRATIA 2021, 25 (1):38-41.

Intraperitoneally administered irinotecan with 5-fluorouracil impair wound healing of colonic anastomoses in a rat model: an experimental study.

AIM: The aim of this experimental study is the assessment of the effects of the immediate post-operative intraperitoneal administration of 5-fluorouracil and irinotecan on the healing process of large bowel anastomoses in rats. MATERIALS AND METHODS: Sixty male Wistar rats were divided into 4 groups of 15 rats each. The rats underwent large bowel resection and anastomosis, followed by the intraperitoneal administration of normal saline (group 1), 5-fluorouracil (group 2), irinotecan (group 3) or the combination of 5-fluorouracil and irinotecan (group 4). All animals were killed on the eighth post-operative day. During post-mortem examination, the anastomoses were assessed macroscopically for a possible anastomotic leak and the extent of adhesion formation. Subsequently, the anastomotic bursting pressure was measured, and the anastomoses were assessed histologically. RESULTS: No anastomotic dehiscence was observed in the rats of group 1. In groups 2 and 3, we observed 3 anastomotic leaks in each group, and in group 4, we observed 5 leaks (P = 0.111). The mean bursting pressure of the anastomoses in group 1 was significantly higher compared to groups 2, 3 and 4 (P < 0.001). The least inflammatory cell infiltration score was observed in group 1 (P < 0.001). The lowest neoangiogenesis score was observed in group 2 and the highest in group 4. The collagen formation in group 1 was significantly higher compared to the other 3 groups (P < 0.001). Similar results were observed for the fibroblast activity, where group 1 revealed significantly higher fibroblast scores compared to groups 2, 3 and 4 (P < 0.001). Finally, groups 2, 3 and 4 showed significantly lower hydroxyproline levels compared to the control group (P < 0.001). CONCLUSION: The immediate, post-operative intraperitoneal administration of 5-fluorouracil or irinotecan had a negative effect on the healing process of the large bowel anastomoses in rats. The negative effects of the combination of 5-fluorouracil and irinotecan were statistically more significant compared to the single use of 5-fluorouracil or irinotecan.

Laparoscopic colectomy for colonic carcinoma.

AIM: The aim of this study is to present our experience with the laparoscopic treatment approach for colonic carcinoma. PATIENTS AND METHODS: Between 2005 and 2010, laparoscopic colectomy was performed in 13 patients; 9 patients underwent laparoscopic right hemicolectomy, 3 sigmoidectomy and 1 patient underwent laparoscopic caecectomy. RESULTS: With regards to the right hemicolectomies, the average operative time was 168 min and the average hospital stay 5.3 days. In patients who underwent laparoscopic sigmoidectomy, the average operative time was 176 min, while the average hospital stay was 10.2 days. Finally, the laparoscopic caecectomy was performed in 85 min. There was one conversion (7.7%) to an open procedure, as well as one case (7.7%) of anastomotic leakage, which was treated with re-laparotomy and a Hartmann's procedure. Up to today, all patients remain healthy with no signs of tumor recurrence. CONCLUSION: Laparoscopic colectomy for cancer, in the hands of an experienced laparoscopic surgeon, is a safe and efficient procedure.

Colonic lipomas: our experience in diagnosis and treatment.

AIM: The aim of this study is to present our experience in colonic lipomas. PATIENTS AND METHODS: We present 4 patients (1 male, 3 females) of mean age 65.5 years (range, 61-72 years) treated for single colonic lipomas. The diameters of the lesions were 4.5, 4, 3.5 and 2.5 cm, respectively. In 3 cases, colonic lipomas were located within the cecum, while in one patient within the descending colon, proximally to the splenic flexure. RESULTS: Lipomas of diameter greater than 3 cm caused nonspecific symptoms. Lipomas of higher diameter were removed laparoscopically with colotomy; in two cases, the patients underwent open hemicolectomy, because of the suspicion of malignancy, while the smallest lesion was resected endoscopically, using a bipolar snare. All patients recovered without complications and remain healthy with no signs of recurrence. CONCLUSION: In cases of ulcerated lipomas, greater than 3 cm of diameter, surgical resection is recommended.

The effects of iloprost on colonic anastomotic healing in rats.

PURPOSE: The purpose of this experimental study is to investigate the effects of iloprost on colonic anastomotic healing in rats, after intraperitoneal administration. METHODS: Forty male Albino-Wistar rats were randomized into two groups of twenty animals each. They all underwent colonic resection followed by an inverted anastomosis. The rats of Group A (control) received 3 ml of NaCl intraperitoneally, while those of Group B (iloprost) received iloprost (2 µg/kg body weight), immediately postoperatively and daily until killed. Each group was further divided into two equal subgroups, depending on the day of killing. The animals of subgroups 1 were killed on the fourth postoperative day, while those of subgroups 2 on the eighth. Macroscopical and histological assessments were performed. Besides, anastomotic bursting pressures and the tissue concentrations in hydroxyproline and collagenase I were also evaluated. RESULTS: No anastomotic dehiscence was noted. The mean bursting pressure was higher in the iloprost group compared with the control group, but a significant difference was revealed only on the fourth postoperative day. Furthermore, iloprost significantly increased the new vessel formation on the fourth, as well as on the eighth postoperative day. CONCLUSION: Iloprost enhances the early phase of colonic anastomotic healing in rats.

Long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids: a prospective study with median follow-up of 6 years.

BACKGROUND: The aim of our study was to assess our early and long-term results after stapled haemorrhoidopexy for fourth-degree haemorrhoids. METHODS: Our study covers the time period from 1998 to 2002 and consists of 56 consecutive patients (33 men) with fourthdegree haemorrhoids who underwent stapled haemorrhoidopexy. RESULTS: During the postoperative period, 6 patients (10.7%) experienced pain for 7-14 days, which was treated with oral analgesia. Ten patients (17.8%) experienced gas incontinence and two of them also reported soiling. The incontinence subsided within 3-8 weeks. Median follow-up was 72.1 months (range, 55-86 months). Recurrence of the haemorrhoidal disease occurred in 33 patients (58.9%). The overall reintervention rate was 42.8%, as 24 patients required excisional haemorrhoidectomy by the Milligan-Morgan technique at a later stage. CONCLUSIONS: Stapled haemorrhoidopexy seems to be a safe, low-pain but ineffective technique for the treatment of fourth-degree haemorrhoids, as it is accompanied by high recurrence and reintervention rates in the long term.

Low-molecular-weight heparin in pregnancy: peripartum bleeding complications.

OBJECTIVE: To compare bleeding complications in pregnant patients treated with low-molecular-weight heparin (LMWH) to untreated controls. STUDY DESIGN: A case-control study of patients from 2001 to 2005 who received prophylactic or therapeutic doses of LMWH during pregnancy was carried out. Indications for LMWH included current or prior thromboembolism, thrombophilia, or heart valve replacement. Controls were chosen in a 2:1 ratio to cases, matched for delivery route, and selected as the next two consecutive deliveries. The primary outcome was postpartum hemorrhage (PPH). Odds ratios (ORs) were calculated with 95% confidence intervals (CIs). RESULTS: Forty-nine women treated with LMWH delivered 55 infants. Current or prior thromboembolic disease was the anticoagulation indication in 15/55 (27.3%) and 26/55 (47%) of pregnancies, respectively. There were more obese gravidas (OR 3.91, CI 1.70 to 9.09) and labor induction was more common in the LMWH group, 25/55 (45%) vs 29/110 (26%), P=0.01. There was no difference in estimated blood loss (295.7+/-145.7 vs 308.6+/-111.9 cm(3), P=0.62 vaginal; 687.5+/-251.8 vs 765.0+/-313.2 cm(3), P=0.34 cesarean), PPH (6/55, 11% vs 9/110, 8.2% OR 1.37, CI 0.16 to 11.5) or transfusion (3/55, 5.4% vs 4/110, 3.6% OR 1.50, CI 0.3 to 7.48) between the cases and controls. There were two cases of postpartum pulmonary emboli, one with a maternal mortality. CONCLUSION: Bleeding complications, including PPH and transfusion, in patients treated with LMWH during pregnancy were not increased when compared to normal controls matched for delivery route.

The effect of insulin-like growth factor I on healing of colonic anastomoses in cortisone-treated rats.

PURPOSE: This study was designed to investigate whether intraperitoneally injected insulin-like growth factor I is able to protect colonic healing from the adverse effects of hydrocortisone therapy. METHODS: Eighty female Wistar rats were randomized into four groups (20 rats each). After resection of a segment of transverse colon, an end-to-end anastomosis was performed. Hydrocortisone (5 mg/kg body weight) was injected intramuscularly in rats of cortisone (Group B) and insulin-like growth factor I + cortisone (Group D) groups once daily for seven days before and after the operation. Insulin-like growth factor I (2 mg/kg body weight) was intraperitoneally injected in rats of the insulin-like growth factor I (Group C) and the insulin-like growth factor I + Cortisone (Group D) groups immediately after operation and on the second, fourth, and sixth postoperative days. Rats were killed on the seventh postoperative day. Anastomoses were graded macroscopically and histologically, and bursting pressures and anastomotic hydroxyproline levels were recorded. Statistical analyses were performed by using Fisher's exact test for the comparison of proportions and ANOVA for the comparison of means among groups with subsequent post-hoc analysis using Bonferroni correction. RESULTS: Leakage rate was significantly higher in the cortisone (Group B) group. Bursting pressures were significantly lower in the cortisone group, whereas they were significantly higher in the insulin-like growth factor I and insulin-like growth factor I + cortisone groups (Group C and D). Histology revealed a significant decrease of inflammatory cell infiltration, neoangiogenesis, and fibroblast activity in the cortisone group compared with the control group, whereas these parameters were significantly higher in the insulin-like growth factor I and insulin-like growth factor I + cortisone groups. Hydroxyproline levels were significantly higher in the insulin-like growth factor I and insulin-like growth factor I + cortisone groups. CONCLUSIONS: Hydrocortisone inhibits the healing of colonic anastomoses. However, insulin-like growth factor I given intraperitoneally mediates the deleterious effects of cortisone and protects colonic healing in rats.

Sebaceous gland tumors and internal malignancy in the context of Muir-Torre syndrome. A case report and review of the literature.

BACKGROUND: The Muir-Torre syndrome is a rare autosomal dominant condition and is currently considered a subtype of the more common hereditary nonpolyposis colorectal cancer syndrome, in which multiple primary malignancies occur together with sebaceous gland tumors. CASE PRESENTATION: We describe a case of a 62-year-old woman with three primary colorectal tumors, genital tumor, and sebaceous adenomas and present her family history of three generations. Our case represents the first case reported from Greece in the international literature. CONCLUSION: Recognition of the syndrome in patients with sebaceous gland tumors should facilitate early detection of subsequent malignancies if the patient is entered into appropriate screening programs.

Stapled haemorrhoidopexy for haemorrhoids in combination with lateral internal sphincterotomy for fissure-in-ano.

The aim of this prospective study is to describe the combined technique and results of stapled haemorrhoidopexy and lateral internal sphincterotomy for patients suffering from prolapsing 3rd-degree haemorrhoids and chronic fissure-in-ano. During the period from 1999 to 2004, 26 patients underwent combined surgical treatment for anal fissure and prolapsing symptomatic haemorrhoids. Preoperative and postoperative clinical evaluation and the patient's degree of satisfaction were recorded. Early complications included faecal urgency (3 patients) and pain (2 patients). Complete continence was restored within 10 weeks in all patients except 1 who had persisting incontinence to flatus. All fissures healed completely within 4 weeks. No haemorrhoidal or fissure recurrence has been observed during follow-up. The combination of stapled haemorrhoidopexy and lateral internal sphincterotomy is a safe and effective procedure for the treatment of prolapsing 3rd-degree haemorrhoids and chronic anal fissures.

Age-associated prognosis following curative resection for colorectal cancer.

BACKGROUND: The aim of this study is to determine the age-associated prognosis in patients who underwent curative resection for colorectal cancer. PATIENTS AND METHODS: Between 1993 and 1999, a total of 136 patients underwent curative surgical procedures for colorectal cancer. The study population was divided into three groups according to the age of the patients. Group A: patients younger than 45 years, group B: patients between 45 and 75 years and group C: patients older than 75 years. Tumour location, Dukes' staging, tumour differentiation and five-year survival were evaluated. RESULTS: There was no significant association between age and tumour staging or tumour differentiation (p=0.990, p=0.753 and p=0.308, respectively). The overall survival at 5 years was 85.7% for the young patients, 77.5% for the middle-aged patients and 62.5% for the elderly patients. CONCLUSIONS: This aged-grouped study indicates that prognosis is comparable between younger and middle-aged patients whereas in elderly patients it is worsening but not statistically significantly.

Five-year survival after curative resection for adenocarcinoma of the colon.

BACKGROUND: The purpose of this study was to evaluate the 5-year survival of patients with colon adenocarcinoma that underwent elective or emergency curative surgical treatment. PATIENTS AND METHODS: Between 1993 and 1998, 80 patients underwent a potentially curative colonic resection based on mobilisation along anatomic planes. Among the patients, 26 underwent right colectomy, 3 transverse colectomy, 13 left colectomy and 38 sigmoidectomy. All patients classified as TNM stage III underwent adjuvant chemotherapy. The Kaplan-Meier method was used to analyse survival. RESULTS: Overall 5-year survival was 69.5%. Patient's sex and age, mucinous characteristics of the tumour and tumour location did not significantly affect survival. Patients with higher Duke's classification and TNM stage had significantly worse 5-year survival (p=0.025 and p=0.007, respectively). Although patients with good tumour differentiation had the highest 5-year survival, this difference was not statistically significant (p=0.211). CONCLUSIONS: The treatment of colon adenocarcinoma with curative resection by the end of the 20th century is accompanied with acceptable rates of overall 5-year survival.

Repair of parastomal hernia with the use of polypropylene mesh extraperitoneally.

Parastomal hernia is the most frequent complication of colostomy. Many surgical techniques have been postulated and prosthetic surgery seems to represents the first-choice treatment. The aim of this study is to report the surgical treatment of 4 patients that developed parastomal hernia, 3-10 months after abdominoperineal excision of the rectum and permanent sigmoidostomy due to carcinoma of the rectum. The repair was made with the use of polypropylene mesh extraperitoneally. One case of limited skin necrosis occurred without any serious consequences. No recurrence has been recorded among the patients, up to this day (follow-up period: 36 months). In conclusion, the suturing of fascial defect and the use of polypropylene mesh extraperitoneally is effective in the treatment of parastomal hernia.

Survival after curative resection for rectal cancer by the end of the 20th century.

BACKGROUND: The aim of this study was to define the survival rates in patients with rectal carcinoma treated with curative resections. PATIENTS AND METHODS: Between 1993 and 1998, 54 patients with rectal cancer underwent curative resection by conventional technique. Tumour location, TNM staging and tumour differentiation were evaluated. Among the 54 patients, 14 underwent high anterior resection, 28 low anterior resection, 7 abdominoperineal resection and 5 underwent local excision. Survival rates were calculated using the Kaplan-Meier method and long-range analysis. RESULTS: Five-year survival was 70.4%. The survival rate statistically significantly decreased with increasing TNM tumour stage (p=0.009). Patients with poor differentiation of the tumour had the lowest 5-year survival (33%) compared to patients with moderate (72%) and good (78%) tumour differentiation. Sex and age did not affect survival. Location of the tumour in the distal end of the rectum and mucinous characteristics are poor prognostic factors affecting survival. CONCLUSIONS: Curative resection combined with chemoradiotherapy, whenever necessary, is accompanied with acceptable 5-year survival rates.

Current treatment of colorectal liver metastases.

BACKGROUND: The aim of our study is to present our experience in the treatment of liver metastases in patients with colorectal cancer. PATIENTS AND METHODS: Between 1997 and 2003 a total of 12 patients with liver metastases from a primary colorectal cancer were treated in our department. They were 8 males and 4 females with a median age of 64 years (range 56-70 years). RESULTS: Ten patients underwent liver resection. The surgical procedures were 4 major hepatectomies (3 right hepatectomies, 1 left lobectomy) and 9 wedge liver resections. In total, 16 metastatic lesions were resected. Already at the time of the primary tumour, 5 patients presented with a synchronous liver metastasis. In 3 of them, liver metastasis was resected together with the primary tumour, and in the rest, resection was performed 1 month after the initial operation. In 5 patients liver metastases were metachronous and were diagnosed 3-14 months after the initial operation. The median survival of the patients was 39 months. Two patients (one with 2 metastatic lesions) underwent radiofrequency ablation (RFA) of the metachronous metastatic lesions and remain well 3-6 months postoperatively. CONCLUSIONS: Hepatectomy is the treatment of choice for hepatic metastasis of colorectal cancer, whenever feasible. Recent promising treatments such as RFA can further improve the outcome of these patients.

Anaemia as a symptom of right colon cancer.

BACKGROUND: The aim of our study is to determine the proportion of iron deficiency anaemia in patients with right colon cancer at diagnosis and to remind of the need of investigation of the large bowel in patients presenting with anaemia. PATIENTS AND METHODS: From 1988 to 2003, 86 patients with right colon cancer underwent operative management. RESULTS: Seventy-five patients (87.2%) with right colon cancer had anaemia at diagnosis. The mean Ht value was 33.00% (ranging from 16 to 47%). CONCLUSIONS: Iron deficiency anaemia is a common symptom of right colon cancer. During the evaluation of patients with iron deficiency anaemia, examination of the right colon is needed.

Anastomotic leakage following anterior resection for rectal cancer.

BACKGROUND: The aim of this study is to present the incidence of anastomotic leakage after anterior resection for rectal cancer and to demonstrate the therapeutic approach for the treatment of this complication. PATIENTS AND METHODS: During the last ten years, 93 patients underwent anterior resection of the rectum for rectal cancer. Low anterior resection with total mesorectal excision (TME) was performed in 72, and high anterior resection in 21 patients. The definition of the anastomotic leakage was based on clinical features, peripheral blood investigations and abdominal CT scan. RESULTS: Clinically apparent anastomotic leakage developed in 9 patients (9.7%). Four patients were managed conservatively and five operatively. Postoperative mortality among the patients with anastomotic leakage was not recorded. CONCLUSIONS: The incidence of anastomotic leakage after anterior resection of the rectum for rectal cancer is relatively low. It remains however the most serious complication following rectal resection for cancer.

Is TNM classification related to early postoperative morbidity and mortality after colorectal cancer resections?

BACKGROUND: To examine the role of TNM staging system as a predictive factor for postoperative morbidity and mortality, after colorectal cancer resections. PATIENTS AND METHODS: During the last ten years, 368 patients with colorectal cancer were referred to our institution. All patients, who underwent primary treatment elsewhere or defunctioning colostomy only, or who did not undergo surgical therapy were excluded from the analysis. The early postoperative outcomes registration of the remaining 351 patients (197 men, median age 66.2 years) was retrospectively linked to TNM stage. RESULTS: TNM stage had a poor prognostic value for the early postoperative morbidity rate. In addition, according to the statistical analysis, the proportion of early postoperative mortality proved to be higher in patients with TNM stage III or IV colorectal cancer. CONCLUSIONS: TNM classification could be considered as a reliable predictor of early postoperative mortality, but has no role in the prediction of early postoperative morbidity after colorectal resections.