Idiopathic spontaneous haemoperitoneum due to a ruptured middle colic artery aneurysm.

INTRODUCTION: Idiopathic spontaneous intra-abdominal haemorrhage is a rare, but challenging condition, associated with high mortality if not managed appropriately. The preoperative diagnosis is difficult, despite the recent advances in imaging. We present the clinical manifestations of this condition, as well as the available diagnostic and therapeutic modalities. PRESENTATION OF CASE: We report a case of a spontaneously ruptured dissecting aneurysm of the middle colic artery, which was managed with an emergency laparotomy and aneurysmatectomy. Interestingly, no evidence of vasculitis, infection or collagen disease was discovered during the histopathology examination of the specimen. DISCUSSION: The treatment of idiopathic spontaneous intra-abdominal haemorrhage revolves around patient resuscitation and management of the source of bleeding. In case of a ruptured aneurysm of the middle colic artery, the surgical management includes emergency laparotomy, arterial ligation and resection of the aneurysm. Transarterial embolisation has been suggested as a safe and less invasive alternative approach. CONCLUSION: A ruptured middle colic artery aneurysm should be included in the differential diagnosis of any unexplained intra-abdominal haemorrhage. Aneurysmatectomy is the treatment of choice, with radiologic interventional techniques gaining ground in the management of this entity.

The effect of bevacizumab on colon anastomotic healing in rats.

PURPOSE: The aim of the study was to investigate the effect of angiogenesis inhibition by bevacizumab, a monoclonal anti-vascular endothelial growth factor (VEGF) antibody, on the healing process of colonic anastomoses in rats, assessing some specific involved factors. This new agent is used mainly in metastatic colorectal cancer. The angiogenesis plays an important role in both wound healing and metastatic invasion and spread of malignant cells. There has not been any evidence assessing the optimal time for its safe use in operated patients. MATERIALS AND METHODS: Forty Wistar rats were randomly allocated into four equal groups. A colonic anastomosis was performed in all rats. Half of them received intraoperatively a single dose of bevacizumab 5 mg/body weight and the rest received placebo. The animals were sacrificed on the 7th (Avastin 7th, placebo 7th) and 14th (Avastin 14th, placebo 14th) postoperative day. The anastomosis was resected and sent for histological study and for tissue biochemical assays (VEGF, endothelin-1 (ET-1), C-reactive protein (CRP), pro-oxidant-antioxidant balance (PAB), carbonylated proteins, hydroxyproline) using specific enzyme-linked immunosorbent assay kits. For statistical analysis, the Mann-Whitney U test was used (of statistical significance when P < 0.05). RESULTS: No complication or anastomotic dehiscence was observed. Histology did not reveal statistically significant differences between groups concerning degree of inflammation, fibroblasts, collagen, and fibrosis. Likewise, hydroxyproline levels did not differ. However, some statistically significant differences were found in VEGF, CRP and carbonyl proteins (Avastin 7th vs placebo 7th, placebo 14th vs placebo 7th), ET-1, and PAB (Avastin 14th vs Avastin 7th), which did not finally affect the collagen synthesis marker hydroxyproline, nor did the anastomotic strength. CONCLUSIONS: Bevacizumab, when administered intraoperatively, has no significant effect on colon anastomotic healing in rats despite a transient mild ischemia.

Preventing intraperitoneal adhesions with atorvastatin and sodium hyaluronate/carboxymethylcellulose: a comparative study in rats.

OBJECTIVES: The aim of this study was to compare the effectiveness of atorvastatin with the sodium hyaluronate/carboxymethylcellulose (HA/CMC, Seprafilm; Genzyme; Genzyme Biosurgery Corporation, Cambridge, MA) in preventing postoperative intraperitoneal adhesion formation in rats. METHODS: Sixty Wistar rats underwent a laparotomy, and adhesions A were induced by cecal abrasion. The animals were divided into 4 groups: group 1, control A; group 2, (A + atorvastatin); group 3, (A + HA/CMC), and group 4, (A + atorvastatin + HA/CMC). The atorvastatin (groups 2 and 4) and HA/CMC (groups 3 and 4) were administered intraperitoneally before the abdominal wall was closed. After 14 days, adhesions were classified by 2 independent surgeons. RESULTS: The adhesion scores (mean +/- standard deviation) for groups 1, 2, 3, and 4 were 2.93 +/- .59, 1.85 +/- 1.07, 1.80 +/- .86, and 1.93 +/- .70, respectively. The differences in adhesion scores among all 3 preventive groups (groups 2, 3, and 4) were statistically significant when compared with the control group (P = .005, P = .002, and P = .009, respectively). CONCLUSIONS: These data suggest that atorvastatin, administered intraperitoneally, is as effective as HA/CMC without an expectable additive effect in preventing postoperative adhesions in rats.

A case of Mirizzi's syndrome mimicking carcinoma: the role of CBD-stenting for easy surgical management.

Mirizzi's syndrome accounts for an important risk for bile tree injury during surgery, since preoperative diagnosis is missed in half of the cases and is often difficult to differentiate from carcinoma. A 79-year-old male, with a known history of cholelithiasis, was admitted with a progressive obstructive jaundice over 20 days, without pain, fever, or other symptoms. Magnetic resonance cholangiopancreatography described possible microlithiasis of the distal bile duct, but on endoscopic retrograde cholangiopancreatography (ERCP), an irregular stenosis was detected under the junction of hepatic ducts, which was described as possibly neoplastic. A temporary stent was placed and the patient was referred for surgery. On first view the gallbladder appeared hard, embedded in adhesions, giving the impression of an unresectable tumor and the bile duct was not approachable. After a fundus-down incision of the gallbladder multiple stones were extracted. Frozen biopsies from the gallbladder wall were negative. The incision was extended towards the gallbladder neck and a large communication with the common bile duct (CBD) was revealed. A difficult partial cholecystectomy was performed, followed by cholecystojejunostomy with a Roux-en-Y jejunal loop. The patient had a totally uneventful postoperative course. Stent removal was succeeded endoscopically 1 month later. The importance of preoperative ERCP and CBD stenting is highlighted in this article. ERCP may have failed to distinguish Mirizzi's syndrome from carcinoma, however the stent placement saved the cardiologically compromised patient from further surgical manipulations. Therefore, in ambiguous cases, whatever the final diagnosis turns to be, either carcinoma or Mirizzi's syndrome, CBD stenting can be useful for the final management of the patient.

Retroperitoneal, mediastinal, and subcutaneous emphysema, complicating colonoscopy and rectal polypectomy.

Complications of flexible endoscopy-though still rare-are increasing in frequency lately as more invasive procedures are routinely performed. Perforation, hemorrhage, coagulation disorders, thrombophlebitis, and splenic rupture have all been reported to complicate colonoscopy and colorectal polypectomies. In this paper, we report on a case of retroperitoneal, mediastinal, and neck surgical emphysema, complicating colonoscopy and rectal polypectomy, presented initially as a change in the voice and facial swelling.

The effect of capecitabine on the healing of colonic anastomoses in rats.

PURPOSE: Capecitabine is a fluoropyrimidine carbamate with antineoplasmatic activity, recommended for the treatment of colorectal cancer. This study was designed to assess the effectiveness of the perioperative administration of capecitabine on the healing process of colonic anastomosis. METHODS: Sixty Wistar rats were used, which were randomized in 2 groups of 30 each. The study group was subjected to colonic anastomosis and treated with therapeutic doses of capecitabine (359 mg/kg, or 2/3 of the mean toxic dose) by mouth one week before anastomosis and throughout the study. The control group received only placebo medication. Both groups were further divided into three subgroups, each of ten animals. In both study and control groups, ten animals were killed in each session on postoperative Days 3, 7, and 14. RESULTS: We found no negative impact on the healing of colonic anastomosis on capecitabine administration. The rate of anastomotic leakage and septic complications were not found to be significantly different between the study and control groups. The median bursting pressure was found to be significantly higher in the study subgroup killed on the third day (68 vs. 46 mmHg of the control group). CONCLUSIONS: Perioperative administration of capecitabine does not have a negative impact on colonic anastomosis in rats.

Limy bile syndrome: review of seven cases.

BACKGROUND: Milk of calcium bile or limy bile is a rare disorder in which the gall bladder is filled with a thick, paste-like, radiopaque material. METHODS: Seven patients with limy bile syndrome were treated in our department from 1980 to 2003. There were five women and two men, and their age ranged from 30 to 64 years. A retrospective analysis of clinical symptoms, diagnostic work-up, treatment approach and operative findings was performed. RESULTS: All patients presented with intermittent right upper abdominal quadrant pain. Three of the seven patients (42.85%) presented with complications like acute cholecystitis (two of seven patients) and obstructive jaundice (one of seven patients). Diagnosis was based on clinical findings, plain abdominal X-rays, ultrasonography and computed tomography scanning. Surgery was the treatment of choice and cholecystectomy alone or in combination with common bile duct exploration and drainage (if needed) was performed. CONCLUSION: The clinical aspect of the disease is similar to that of biliary lithiasis and the diagnosis is easily made by the characteristic spontaneous opacification of the gall bladder on plain abdominal X-rays. Complications such as acute cholecystitis, pancreatitis or obstructive jaundice can also be present. Although some cases of conservative pharmaceutical treatment as well as cases of spontaneous disappearance of limy bile have been reported, surgical treatment remains the treatment of choice.

Mixed exocrine-endocrine tumor of the pancreas.

CONTEXT: Neoplasms of the pancreas usually show ductal, acinar or endocrine differentiation. Tumors with mixed exocrine and endocrine components are unusual. We herein describe a case of a mixed ductal-endocrine tumor. CASE REPORT: A 65-year-old woman was referred to our department with a diagnosis of carcinoma of the tail of the pancreas. The patient had a short history of upper abdominal pain, nausea and melena. Upper gastrointestinal endoscopy revealed gastric fundus varices and CT scan demonstrated an inhomogeneous tumor located in the tail of the pancreas infiltrating the spleen and the splenic vein. The patient underwent distal pancreatectomy and splenectomy, and had an uneventful recovery. Pathological examination revealed a mixed ductal-endocrine tumor. The endocrine component was immunoreactive for glucagon, gastrin and somatostatin, and non-reactive for insulin. CONCLUSIONS: Because of the rarity and unpredictable biologic behavior of these tumors, the need for adjuvant therapy has not yet been well-defined. The patient has had a follow-up CT scan every six months, and one and a half years later remains disease free.

Effect of early octreotide administration on the development of esophageal varices in cirrhotic rats.

This study was conducted to investigate the effect of chronic octreotide administration on the development of esophageal varices in rats being at the early stages of carbon tetrachloride-induced cirrhosis. For the development of liver cirrhosis and esophageal varices 96 rats underwent ligation of left adrenal vein followed by phenobarbital and carbon tetrachloride administration. After 2 weeks of carbon tetrachloride administration, rats were randomly separated into three groups. Chronic octreotide administration started in group A, normal saline in group B, while 32 rats consisted control group. Haemodynamic studies and morphometric analysis of the lower esophagus were performed 2 weeks after complete induction of cirrhosis. Total submucosal vessel area, mean cross-sectional area of submucosal vessels, percentage of submucosa occupied by vessels, the area of the most dilated submucosal vessel as well as the number of submucosal vessels were studied. Octreotide administration induced a significant ( [Formula: see text] ) decrease of portal vein pressure. Morphometric analysis revealed a significant reduction ( [Formula: see text] ) in octreotide-treated rats of both "total submucosal vessel area" and area of "the most dilated submucosal vessel". Chronic octreotide administration partially prevented rats from the development of esophageal varices. Octreotide-treated rats were found to have a less pronounced dilatation of submucosal veins compared to placebo-treated group rats. We believe that this effect was mainly due to the decrease of portal vein pressure induced by chronic octreotide administration.