Spontaneous Splenic Rupture due to Metastatic Pancreatic Cancer.

Introduction. Nontraumatic splenic rupture is a rare event. On the other hand, splenic metastasis is also rare and usually found in the context of disseminated disease. Spontaneous splenic rupture caused by a metastatic deposit has been reported only as case reports. To the best of our knowledge, pancreatic cancer being the primary site has been reported in only a handful of cases. Case Presentation. A case of spontaneous splenic rupture in a 68-year-old male presenting with acute onset left shoulder pain, caused by metastatic pancreatic cancer to the spleen, is presented herein. During the investigation, the patient developed hypovolemic shock due to intra-abdominal hemorrhage, necessitating emergency splenectomy. The patient recovered well and was discharged from the hospital on the 8th postoperative day. Discussion. This study underlines the fact that the spleen is a rare site of metastasis, remaining mostly asymptomatic. However, it can nevertheless prove to be a life-threatening condition. The exact pathophysiological mechanism of splenic rupture due to metastasis still remains unknown, requiring further research. Emergency splenectomy remains the standard of care, and this clinical condition should be considered in the differential diagnosis of cases with acute abdomen and malignant neoplasm history.

Novel potential biomarkers for the diagnosis and monitoring of patients with ulcerative colitis.

Unambiguously, great progress has been achieved in the unraveling of more pathological pathways implicated in the development and progression of ulcerative colitis during the last decades. Novel effective drugs that have augmented the management armamentarium have been developed alongside this growing comprehension of the disease, rendering mucosal healing not only a feasible but the optimal goal of every therapy. Clinical evaluation, colonoscopy and biomarkers are the tools used by practitioners for the diagnosis and assessment of the status of the disease in order to achieve clinical remission and mucosal healing for their patients. Among these tools, colonoscopy is the gold method for the cause but is still an invasive, high-cost procedure with possible adverse events such as perforation. While clinical evaluation entails much subjectivity, biomarkers are objective, easily reproducible, non-invasive, cheap and potent surrogate tools of mucosal inflammation. Unfortunately, the well-established, currently in use serum biomarkers, such as C-reactive protein, erythrocyte sedimentation rate and others, do not display sufficiently acceptable sensitivity and specificity rates for the diagnosis of ulcerative colitis and, most importantly, do not represent precisely the mucosal inflammation status of the disease. Therefore, the discovery of new serum biomarkers has been the cause of several studies attempting to discover an "optimal" serum biomarker during the recent years. After thorough research, collection and examination of current data, this review focuses on and selectively presents promising, potential, novel serum biomarkers of ulcerative colitis as they are indicated by studies on the patient over the last years.

Surgical Management of Fistula-in-ano Among Patients With Crohn's Disease: Analysis of Outcomes After Fistulotomy or Seton Placement-Single-Center Experience.

BACKGROUND AND AIM: Fistula-in-ano is a common problem among patients with Crohn's disease and carries significant morbidity. We aimed to study the outcomes of surgical treatment of fistula-in-ano after fistulotomy or seton placement in patients with perianal fistulizing Crohn's disease. MATERIAL AND METHODS: A retrospective observational study of 59 patients diagnosed with Crohn's disease, who were treated surgically for fistula-in-ano between 2010 and 2014 in our department. The assessment of disease complexity included a detailed physical examination, magnetic resonance imaging of the rectum, and examination under anesthesia. Outcomes for analysis included wound healing rate and postoperative incontinence. RESULTS: High transsphincteric fistula was found in 44% of the patients, while mid or low transsphincteric fistulas were found in 51%. Three women (5%) had a rectovaginal fistula. All patients with high transsphincteric fistulas were treated with loose seton placement. Patients with mid- or low-level transsphincteric fistula were offered either fistulotomy or seton placement based on the clinical evaluation. The mean follow-up duration was 1.6 ± 1.1 years. In terms of recurrence, one patient treated with seton placement presented with recurrence 6 months after seton removal and one patient with fistulotomy failed to achieve wound healing. Minor incontinence was found in six patients treated with fistulotomy and in three patients treated with seton placement; however, this difference was not significant (chi-square = 1.723, df = 1, Monte-Carlo: p = 0.273). CONCLUSION: Fistulotomy could achieve good results in terms of wound healing and incontinence in strictly selected patients with Crohn's disease suffering from low-lying transsphincteric fistulae. For more high-lying or complicated fistulae, seton placement is more appropriate. For high transsphincteric fistulae, the only option is placement of loose seton.

European Society of Coloproctology consensus on the surgical management of intestinal failure in adults.

Intestinal failure (IF) is a debilitating condition of inadequate nutrition due to an anatomical and/or physiological deficit of the intestine. Surgical management of patients with acute and chronic IF requires expertise to deal with technical challenges and make correct decisions. Dedicated IF units have expertise in patient selection, operative risk assessment and multidisciplinary support such as nutritional input and interventional radiology, which dramatically improve the morbidity and mortality of this complex condition and can beneficially affect the continuing dependence on parenteral nutritional support. Currently there is little guidance to bridge the gap between general surgeons and specialist IF surgeons. Fifteen European experts took part in a consensus process to develop guidance to support surgeons in the management of patients with IF. Based on a systematic literature review, statements were prepared for a modified Delphi process. The evidence for each statement was graded using Oxford Centre for Evidence-Based Medicine Levels of Evidence. The current paper contains the statements reflecting the position and practice of leading European experts in IF encompassing the general definition of IF surgery and organization of an IF unit, strategies to prevent IF, management of acute IF, management of wound, fistula and stoma, rehabilitation, intestinal and abdominal reconstruction, criteria for referral to a specialist unit and intestinal transplantation.

Management of retroperitoneal sarcomas: main prognostic factors for local recurrence and survival.

PURPOSE: Retroperitoneal sarcomas (RPs) are characterized by slow indolent growth and metastasize at a late point in their natural course. The purpose of this study was to review our experience in the management of RSs and identify prognostic factors for local control and survival. METHODS: Between January 1990 and December 2010, the hospital records of 75 patients with RSs were retrospectively studied. Sixty-four (85.3%) patients had undergone surgical resection in our hospital for primary RS, whereas 11 (14.7%) were referred to our department for recurrent disease. RESULTS: The patient median age was 57 years. Median tumor size was 18.5 cm. The most common histologic type was liposarcoma (44%) followed by leiomyosarcoma (17%), paraganglioma (10%), malignant fibrous histiocytoma (6.5%) and rare tumors such as 2 chondrosarcomas and 1 pecoma. Complete initial resection with negative macroscopic margins (R0) was achieved in 39 (60.9%) patients. En bloc resection of adjacent organs was required in 8 (12.5%) patients with primary RS and in 8 (72.9%) with recurrent disease. Mortality rate was 4%. For the group of patients initially treated in our hospital, 1-year recurrence rate was 34.3%. The 3- and 5-year overall survival rates were 56.2% and 53.1%, respectively. Satellite tumors were recognised in 13 (20.3%) patients treated for primary RS, from whom 11 (84%) recurred within one year. Seven patients received adjuvant chemotherapy. CONCLUSION: Radical surgical resection is the treatment of choice for patients with primary and locally recurrent RSs.

Results of salvage abdominoperineal resection after failed chemoradiation therapy for epidermoid anal canal carcinoma: Retrospective analysis at a single institution.

PURPOSE: The standard therapeutic approach to epidermoid anal canal cancer consists of combined radiation therapy and chemotherapy. Although disease control has been reported to have excellent results, as many as 40% of patients will develop locoregional disease progression. The treatment of choice for patients with persistent (PD) or recurrent disease (RD) is salvage abdominoperineal resection (APR). The purpose of this study was to review our experience with salvage surgery in this group of patients. METHODS: The medical records of all patients with epidermoid anal canal cancer treated from 1997 to 2010 in our department were retrospectively reviewed. Nine patients who presented with persistent or locally recurrent anal canal cancer were subjected to salvage APR. Before surgery, all of the patients had received chemoradiation therapy (CRT). RESULTS: There were 9 patients (7 women, 2 men) with a median age of 59 years (range 40-79). Six patients underwent radical salvage APR for persistent disease and 3 patients for recurrent disease. There were no deaths attributable to operation. The median follow-up time was 31.75 months (range 3-108) after salvage surgery. Two patients died of disease progression, with a median survival time of 24 months (range 12-36). At the time of last follow-up, 6 patients were alive without evidence of recurrent disease, and one patient was lost to follow-up. The median follow-up time for survivors was 34.3 months (range 3-108). CONCLUSION: Long-term survival can be achieved in the majority of patients who undergo radical salvage APR after failed CRT for epidermoid carcinoma of the anal canal.

Poorly differentiated carcinoma of the rectum with aberrant immunophenotype: a case report.

We report a case of a poorly differentiated epithelial tumour of the rectum with a highly pleomorphic morphology and an aberrant immunophenotype, including the expression of epithelial markers, the focal parameter of neuroendocrine differentiation, and the unexpected detection of CD-117 overexpression. A 69-year-old man was admitted to our clinic complaining of rectal bleeding and weight loss. Colonoscopy showed an ulcerative bleeding mass located about 8 cm from the anal verge. Abdominal and pelvis CT scans demonstrated a large low-density lesion with extracanalicular growth from the middle rectum, with local lymph-node spread, and without tumour infiltration of other pelvic organs, or evidence of distant intra-abdominal spread. The patient underwent a low anterior resection for rectal cancer together with wide resection of lymph nodes. In immunohistochemical analysis, pankeratin and Epithelial Membrane Antigen (EMA) immunolabeling proved the epithelial nature of the tumor cells. Chromogranin A and Leukocyte Common Antigen (LCA) were negative, whereas CD-56 expression was scanty and Neuron Specific Enolase (NSA) was heavily and diffusely expressed. Ki67 immunoexpression was particularly increased. Interestingly, the intense c-kit immunoreactivity (100%) was a common feature. The above phenotypic and immunohistochemical profile was consistent with an anaplastic carcinoma of the large intestine, with focal neuroendocrine differentiation and diffuse immunoreactivity to c-kit protein. Given the resistance of this tumor to conventional chemotherapy and radiation, the incidence of the c-kit alteration may represent a novel approach to a gene-directed treatment using a c-kit inhibitor (STI571) similar to that which has been proposed in GISTs.

[Restoration of the continuity of the colon with preservation of an existing colostomy]. / Erhaltung einer vorbestehenden Kolostomie bei Re-Operation des Dickdarms - Ein technischer Hinweis.

A new technique for the restoration of the continuity of the colon with preservation of an existing colostomy is described here. A 75-year-old male with a three-year history of abdominal-perineal resection and a well functioning end colostomy was admitted to our department for a second primary cancer of the descending colon. At operation the colon was divided close to the abdominal wall; the colostomy was left in situ while the descending colon and mesocolon were radically resected. The viability of the colostomy was being continuously inspected. An EEA stapler was then inserted through the colostomy and an anastomosis was created. Shortening the length of the operation and avoiding the possible complications that follow the creation of a new stoma are the major benefits of the technique. Still, the viability of the colostomy after its separation of the rest of the colon and mesocolon has to be ensured before proceeding.

Acute segmental intestinal ischemia: diagnosis with spiral computed tomography.

The purpose of this study was to examine the usefulness and the validity of spiral computerized tomography (CT) in assessing acute segmental intestinal ischemia. We present the spiral CT imaging findings in surgically proven cases of intestinal ischemia. 46 patients were admitted to our facility over a five-year period with suspicion of acute enteric ischemia. 34 were first examined with spiral CT and underwent surgery. In 24 of the 34 patients (sensitivity 70.6%), at least one imaging finding specific for segmental intestinal ischemia was recognised (true positive examinations). Spiral-CT examination demonstrated non-specific or normal findings in 7 out of 34 patients with proven intestinal ischemia (20.6% false negative studies). In conclusion, spiral CT can be used in the investigation of patients with suspected acute intestinal ischemia to confirm or suggest the diagnosis or exclude other potential diagnoses.

A novel spleen-preserving laparoscopic technique using radiofrequency ablation in a porcine model.

BACKGROUND: Partial splenectomy is considered to be the optimal management for a variety of diseases. At the same time, laparoscopic procedures are increasingly used because they present certain advantages against their open counterparts. In this study, the safety and efficacy of radiofrequency ablation (RFA) were evaluated in laparoscopic partial splenectomy performed in a pig model. METHODS: Eight domestic pigs were used. Four abdominal trocars were inserted under general anesthesia and the spleen was stabilized with laparoscopic clamps. A RFA needle electrode was inserted transcutaneously, and coagulative necrosis of a zone of the splenic parenchyma between the body and the lower pole was performed. Bloodless sharp division and removal of the lower pole followed. After 0, 7, 30, or 120 days, the animals were killed and examined. RESULTS: Blood loss and operation time were minimal. Mortality and morbidity were zero. No abnormal findings were encountered during the postmortem abdominal exploration. CONCLUSION: This study demonstrates the feasibility, safety, and efficacy of laparoscopic RFA-assisted partial splenectomy. The RFA-assisted laparoscopic partial splenectomy adds a novel technique to the surgeon's armamentarium for the preservation of a part of the spleen.

Laparoscopic liver resection using radio frequency ablation in a porcine model.

BACKGROUND: The aim of this study was to assess the feasibility, efficacy, and safety of laparoscopic left lateral lobe resection, using radiofrequency ablation (RFA) with internally cooled tip electrodes, in a porcine model. METHODS: Eight domestic pigs underwent left lateral hepatic lobectomy. RFA was the sole hemostatic method applied throughout the entire operation. After 0, 7, 30, or 120 days the animals were killed in order to study the macroscopic and microscopic findings on the liver edge. RESULTS: An average of 90 min was enough for the entire operation. No signs of blood loss or infection were observed up to 4 months postoperatively. There was no mortality either during or after surgery. The pathology of the liver revealed the three zone lesions. CONCLUSION: Our study demonstrates that laparoscopic left lateral lobectomy using RFA is technically feasible hi the porcine model and is proved to be highly effective and safe hemostatic method.

Pretransplantation prevalence of human herpes virus 8 antibodies in kidney donors and recipients in Athens, Greece.

AIM: The aim of this study was to estimate the prevalence of anti-human herpes virus 8 (HHV8) antibodies in a cohort of renal donors and recipients in Athens, Greece. HHV8, the etiological agent of posttransplantation Kaposi's sarcoma, causes significant morbidity and mortality. METHODS: Serum samples from 97 subjects (49 donors and 48 recipients) were tested with an enzyme-linked immunosorbent assay (ELISA) prior to renal transplantation. RESULTS: Only 2 subjects (both transplant recipients) were found to be anti-HHV8-positive. Both subjects were of Albanian origin. CONCLUSION: Infection with HHV8 appears to be limited in the Greek population. However, in light of significant long-term morbidity with which HHV8 is related in immunocompromized patients, studies on the general population are needed to estimate the prevalence of HHV8 infection in the country and devise clear guidelines for pretransplantation screening and posttransplantation follow-up.

Human herpesvirus type 8 genotypes in iatrogenic, classic and AIDS-associated Kaposi's sarcoma from Greece.

BACKGROUND: Kaposi's sarcoma-associated herpesvirus (KSHV)/human herpesvirus 8 (HHV-8) is consistently found in almost all observed Kaposi's sarcomas (KS), whether AIDS-associated, iatrogenic or classic. To our knowledge no data are available on the genetic polymorphism of HHV-8 from Greece. We report the study of 15 renal transplant recipients with KS, 5 with AIDS-associated KS, 11 with classic KS and 60 healthy individuals from Greece. MATERIALS AND METHODS: Polymerase chain reaction (PCR) was carried out on DNA extracted from peripheral-blood mononuclear cells (PBMC) or KS cutaneous biopsies, using specific primers for the HHV-8, KS330 fragment from ORF-26 (233 bp) and the highly variable region (VR1) from ORF-K1 (363 bp). RESULTS: HHV-8 DNA was detected in 30 out of 31 (97%) KS cases, regardless of their clinico-pathological subtype and in 10 out of 60 (16.7%) healthy individuals. Sequencing of the ORF26 fragment demonstrated that the 40 HHV-8 strains were of the A and C sub-types. Furthermore, sequencing of the ORF-K1 showed that these HHV-8 strains of Greek origin were of the A1, A4, C1 or C3 sub-type. CONCLUSION: Our findings imply a possible link of the C3 subtype of HHV-8 in renal transplant-related KS cases (iatrogenic KS) in Greece, a link of the A4 subtype in AIDS-associated KS cases and a potential involvement of the A1 subtype in Greek classic KS incidences, as HHV-8 strains among healthy individual tested belong to the C1, C3 or A1 subtypes.

Metastatic melanoma within a transplanted kidney: a case report.

A 57-year-old woman recipient of a cadaveric renal allograft displayed metastatic melanoma within the transplant. The patient, who received imunnosuppressive therapy with cyclosporine, azathioprine, and prednisone, displayed normal renal function for 10 months posttransplantation. She was admitted due to multiple, large, rapidly growing skin nodules over the lower abdomen and to dyspnea. After a diagnostic evaluation, the renal graft was removed, revealing metastatic melanoma within the transplanted kidney and 2 focal points of melanoma within the skin lesions. The patient returned to hemodialysis, received chemotherapy and interferon A, but failed to respond and died 11 days after the nephrectomy.

Polyomavirus BK infection in Greek renal transplant recipients.

BK polyoma virus associated nephropathy is increasingly recognized as an important cause of allograft dysfunction among renal transplant recipients. Herein we present the cases of two renal transplant recipients who developed progressive functional deterioration suspicious for BK polyoma virus involvement. One patient had been treated with mycophenolate mofetil (MMF), cyclosporine (CsA), and prednisolone (P), and the second patient with tacrolimus (Tac), MMF, and (P). Using quantitative real-time polymerase chain reactions for BK virus DNA, we monitored the content of BK virus in the blood to evaluate disease progression. The high BK virus load initially detected in the blood samples from these patients decreased in the patient who received MMF, CsA, and P after the reduction of immunosuppression, but not in the patient who was treated with Tac, MMF and P. In contrast to previous reports, our patients had not received treatment with anti-lymphocyte globulin (ALG) or monoclonal anti-CD3 antibody (OKT3) after transplantation. It is concluded that even in the absence of vigorous antirejection treatment, immunosuppressive therapy based on Tac and MMF may carry the risk of BK virus-associated nephropathy. Because BK virus specific antiviral therapy is not available, its course may be monitored by measuring the viral load in blood.

Video-assisted transcervical thymectomy.

BACKGROUND: The optimal surgical approach for complete removal of the thymus gland has long been debated. In this report, the excision of the entire gland through a transcervical incision using video-assisted techniques is described. METHODS: Ten patients, including one with thymoma and myasthenia gravis, underwent surgery via the transcervical approach. After standard dissection up to the level of the innominate vein and ligation of the thymic vessels, a laparoscope was inserted into the mediastinum. In the patient with thymoma, the operation was completed by a small incision in the third intercostal space. RESULTS: No perioperative mortality or long-term morbitity was observed. The mean hospital stay was 69.6 h. After a mean follow-up period of 63.8 months, eight patients displayed complete remission, whereas one continued to receive minimal medication. The patient with thymoma showed considerable improvement, but remained on same medical regimen No complications were seen throughout the study. CONCLUSION: Video-assisted thymectomy improves effectiveness of the transcervical approach for thymectomy with a minimum of trauma and excellent results.

The significance of perioperative anemia in patients with resectable gastrointestinal tract tumors.

Cancer-related anemia occurs in more than 50% of patients with malignancies and constitutes a common finding in patients with gastrointestinal tract tumors. In the present article we present the possible pathogenetic mechanisms as well as the appropriate clinical and laboratory investigations for the anemia, which is associated with gastrointestinal tract malignancies. Moreover, we conducted a MEDLINE database search between 1992- 2003, focusing on the currently available methods for perioperative correction and treatment of anemia. The currently available evidence suggests that perioperative allogenic blood transfusion is associated with increased rates of postoperative infections and constitutes an independent adverse prognostic factor in gastrointestinal malignancies; autologous blood transfusions are of no clinical benefit compared to allogenic transfusions, as autologous blood is not immunologically neutral; and the shortterm results of erythropoietin (EPO) use remain controversial, while its long-term results remain unknown. Correction of anemia in every patient with resectable gastrointestinal malignancy is mandatory, because it improves surgical stress response, wound healing process and quality of life. Although EPO administration constitutes the treatment of choice for patients receiving chemotherapy and/ or radiotherapy, the best perioperative method for anemia correction remains unknown and further prospective randomized studies are required. From the surgical point of view, any effort for "bloodless surgery" should be attempted.