Gallstone obstructive ileus 3 years post-cholecystectomy to a patient with an old ileoileal anastomosis.

The present case is one of gallstone obstructive ileus due to gallstones 3 yr after laparoscopic cholecystectomy. It is interesting because of the sex of the patient, the fact that ileus occurred 3 yr after cholecystectomy and that the localization of the obstruction was an old side-to-side ileoileal anastomosis due to a diverticulectomy following intussusception of Meckels' diverticulum at the age of 3.

Forty-four years' experience (1963-2006) in the management of primarily infected hydatid cyst of the liver.

BACKGROUND AND AIM: The aim of this study was to report our 44-year experience (1963-2006) in the management of primarily infected hydatid cyst of the liver. This is a retrospective review of demographic data, clinical presentation, diagnostic work-up, surgical management, and long-term outcome of patients treated at our center. MATERIAL AND METHODS: There were 77 patients with operated infected liver cysts. In the same period, a total of 460 cases with liver hydatidosis were treated surgically. Of those with suppurated cysts, 27 were men and 50 were women, with a mean age 54.5 years. RESULTS: Clinical manifestations of an abscess were identified in 75% of the patients. In the earlier cases of the study, the diagnosis was made from the clinical picture, laboratory studies, in combination with plain X-ray, hepatic scintigraphy, and in the later cases with US (ultrasonography), CT (computed tomography) or MRI (magnetic resonance imaging), and ERCP (endoscopic cholangiopangreatography). Abdominal and, rarely, thoracic and abdominal or thoracoabdominal incisions were used. Total cystopericystectomy in 8 patients and partial pericystectomy and proper drainage with one or two drainage tubes of the cystic cavity in the other 69 patients were carried out. Hospital stay was between 13 and 146 days with 5 re-operations. Two patients with grossly suppurated cysts and coexistent medical problems died. The disease recurred in five patients. CONCLUSIONS. We conclude that, under good perioperative antibiotic and metabolic coverage, the infected hydatid cysts have to be completely evacuated and properly drained. The application of "conservative" surgical procedures should be preferred. Further studies are needed to solve the clinical and therapeutic problems of this serious complication.

Groin swelling, the anatomic way out of abdominal haematomas: a case report and explicative literature review.

This case report concerns a previously healthy thirty-five-year-old female with complaints of inguinal hernia that ultimately proved to be a retroperitoneal haematoma. The patient suffered from a car accident 5 months before admission and was hospitalized. During her prior hospitalization, explorative laparotomy revealed a haematoma of the mesentery. The haematoma was treated conservatively, with fluid resuscitation and rest. During her second admission, MRI of the inguinal region revealed localized haematoma. During inguinal exploration, a fluid-filled bluish indirect hernia sac was identified and found to be contoured by free-flowing, non-clotting blood. The postoperative course was uneventful, and the patient was discharged six days following surgery.

Synergistic antitumor activity of oxaliplatin in combination with gemcitabine in pancreatic tumor-bearing mice.

Oxaliplatin (OX) and gemcitabine (GEM) are both drugs with proven clinical activity in various tumor types, have no overlapping toxic side effects and are different with respect to cellular metabolism. Therefore, we performed an in vivo study to determine the efficacy of the combination of these two drugs to optimize the scheduling of both substances using pancreatic ductal adenocarcinoma PAN-02, subcutaneously growing in C57Bl mice. A total of 164 mice were used for cytotoxicity and antitumor studies. The combination therapy resulted in better results than those observed when the drugs were administered individually. GEM (58 mg/kg) and OX (1.0 mg/kg) achieved a 52% reduction in tumor size on day 28 after transplantation and a T/C value of 168% when the intermittent treatment schedule on days 1, 4 and 7 after inoculation was used. This treatment schedule was superior to other therapeutic schedules, producing a synergistic antitumor effect much higher than the one expected by the simple addition of the effects by OX and GEM acting independently.

Randomized clinical trial of stapled hemorrhoidectomy vs open with Ligasure for prolapsed piles.

BACKGROUND: The aim of the study was to compare the results in 95 patients randomly allocated to undergo either stapled or open hemorrhoidectomy using Ligasure. METHODS: Ninety-five patients with grade III and IV hemorrhoids were randomly allocated to undergo either stapled (50 patients) or open using Ligasure (45 patients). Stapled hemorrhoidectomy was performed with the use of a circular stapling device. Open hemorrhoidectomy was accomplished according to the Milligan-Morgan technique by using Ligasure. Postoperative pain was assessed by means of a visual analog scale (VAS). Recovery evaluation included return to pain-free defecation and normal activities. A 6-month clinical follow-up and an 18 (12-24) month median telephone follow-up were obtained in all patients. RESULTS: Operation time for open hemorrhoidectomy using Ligasure was shorter [median 13 (range 9.2-16.1) min vs 15 (range 8-17) minutes, p < 0.05]. Median range of VAS score in the stapled group were significantly lower [VAS score after 8 h: 3 (2-6) vs 5 (3-8), p < 0.01; VAS score after first defecation: 5 (3-8) vs 7 (3-9), p < 0.001. The stapled hemorrhoidectomy was associated with an increased incidence of intraoperative bleeding in 18 cases (36%) vs four cases (8.8%) of the Ligasure group. There were three cases (6%) from the stapled group with recurrence of the hemorrhoids and none from the open technique. CONCLUSIONS: Hemorrhoidectomy with a circular stapler device is easy to perform, but one more line of clips must be added to the device to avoid intraoperative bleeding from the cut line. Hemorrhoidectomy performed using Ligasure is more painful postoperatively but is a more radical operation.

Effect of ranitidine on healing of normal and transfusion-suppressed experimental anastomoses.

BACKGROUND: Histamine has been shown to participate in immune response. Wound healing is a process of immune system. This experimental study was done to find the effect of histamine2 receptor antagonist ranitidine on the healing process of intestinal anastomosis in rats. METHODS: Eighty Wistar rats in four groups of 20 each underwent colon resection and anastomosis. They were given 2 ml saline or blood, twice daily 0.4 ml saline or 0.4 ml saline containing 0.7 mg ranitidine. The animals were killed 3 or 7 days postoperatively and the anastomotic strength assessed by bursting pressure. RESULTS: The ranitidine group developed fewer anastomotic abscesses (p<0.001). Anastomotic strength was significantly reduced either on day 3 or 7 in animals given blood transfusions (p<0.04, p<0.001), whereas in animals given ranitidine this effect was partially reversed. CONCLUSIONS: These data indicate that ranitidine has no influence in anastomotic bursting pressure, but has a lower incidence of septic complications.

Large bowel obstruction in women with pelvic malignancies. What is the primary?

BACKGROUND: Large bowel obstruction is occasionally the mode of presentation of advanced colorectal or pelvic malignancies, and a prognostic of poor survival. The choices of treatment range from palliative tube decompression to curative or palliative surgery. METHODS: Twelve out of 500 women with various malignancies and symptomatology of large bowel obstruction were studied. All patients required urgent exploratory laparotomies. RESULTS: The primary site was established intra-operatively to be the colon (2 cases), stomach (2 cases) and ovaries (2 cases). In the remaining 6 cases there was uncertainty about the origin of primary disease. Routine histology and immuno-histochemistry of the specimens revealed the origin of primary malignancy in all cases. CONCLUSIONS: Meticulous histological examination is essential for the establishment of correct diagnosis and selection of the best available treatment in women with pelvic malignancies, presenting with acute bowel obstruction.

Perforated diverticulum of the caecum. A difficult preoperative diagnosis. Report of 2 cases and review of the literature.

BACKGROUND: Perforation of a solitary caecal diverticulum is a rare cause of acute abdomen and an uncommon differential diagnosis for acute appendicitis. Nine hundred cases have been described since Potiers' first description of perforated caecal diverticulum in 1912. METHODS: We describe 2 cases of perforated diverticulum of the caecum. The first patient was a 50-year-old man diagnosed by subsequent histology, and the second a 77-year-old woman diagnosed intra-operatively. Radiography, ultrasound and CT scan of the abdomen pointed at the diagnosis in the second case. A right hemicolectomy was performed. RESULTS: There were no complications, apart from a transient faecal fistula in the first patient managed conservatively. In both patients histology revealed a perforated caecal diverticulum. CONCLUSIONS: The surgeon must be familiar with the diagnosis and management of this rare, inflammatory benign caecal entity.

Prognostic significance of mucinous component in colorectal carcinoma.

BACKGROUND: Many factors influence survival in colorectal cancer patients, one of them is the mucinous component of the tumour. Mucinous adenocarcinoma is characterized by the extracellular mucin of more than 50% of the tumour volume. METHODS: From 1970 to 1999, 1160 patients were admitted to our clinic for colorectal cancer. They were divided into four groups according to mucinous character of the tumour, in two time periods of 15 years. RESULTS: There was an increase in the incidence of mucinous tumours from 20.8 to 30.5% in the second period. These tumours were more advanced (Dukes' C) and especially right sided (34.5% vs. 17.9%). Five-year survival was increased during the second period but was of a lesser degree in the mucinous group (51.5% vs. 65.5%). CONCLUSIONS: Colorectal mucinous carcinomas present at a more advanced stage, predominantly in men, with higher right colon location rate, and a worse overall 5-year survival rate than the non-mucinous colorectal cancers.

Spontaneous rupture of the rectosigmoid with small bowel evisceration through the anus.

Spontaneous rupture of the rectosigmoid with small bowel evisceration through the anus is a rare and acute condition of the gastrointestinal tract. After Brodie's first description, only 52 such cases have been reported in the literature. An 83-year-old woman experienced a sudden, spontaneous rectosigmoid rupture and protrusion of small bowel loops, through the ruptured colon and out of the anus. After an immediate management, an emergency operation was performed, and a small bowel resection and suturing of the ruptured rectosigmoid were carried out for restoration of bowel continuity. On the 41st postoperative day, a massive cerebro-vascular accident (CVA) was the cause of the patient's death. Discussion of the aetiology and treatment of this rare condition.

Metachronous breast carcinoma (second malignancy), following "cure" from colorectal carcinoma.

Metachronous or synchronous breast carcinoma following or co-existing with colorectal carcinoma are well recognised clinicopathological entities, and the risk of developing both possibly underlines the similarities in carcinogenesis pathways for these carcinomas. We present a 60-year-old housewife with a history of a treated primary colon carcinoma (Duke's C) 15 years previously. Six months ago, during the follow-up care a small sub-areolar lesion was determined in a mammogram. A lumpectomy was performed under local anaesthesia, which revealed an infiltrating ductal carcinoma (6 mm in greatest diameter). Immuno-histochemical assays for oestrogen and progesterone receptors and c-erb B2 ongoprotein were performed. Axillary lymphadenectomy showed 1/11 positive node. She received adjuvant radiotherapy and hormone manipulation. To date, seven months later she is disease free. The aim of this report is to emphasise the risk of metachronous second malignancy of breast or colorectal carcinoma following colorectal carcinomas. A second primary colonic malignancy following breast primary carcinoma is more frequent than inverse clinical form.

Metastatic breast adenocarcinoma masquerading as colonic primary. Report of two cases.

BACKGROUND: Common sites of metastasis for the breast cancer are bones, lungs, the central nervous system and liver. The colon is the rarest site of metastasis for the breast carcinoma. PATIENTS AND RESULTS: We report our recent experience of two female patients, 55 and 57 years old respectively, who presented breast metastasis at the proximal transverse colon. They were operated for breast carcinoma followed by chemotherapy and radiotherapy, four and ten years before the metastasis was diagnosed. The symptoms were anaemia and bowel obstruction. Diagnosis was made by double contrast barium enema and colonoscopy. Postoperatively, both patients received systemic chemotherapy. At the follow-up, two and three years after, there is no evidence of recurrence or metastasis. CONCLUSIONS: Patients with history of breast cancer presenting with anaemia and/or bowel obstruction should be examined for possible metastasis to colon and should be treated surgically followed by systemic chemotherapy.

A case of mucinous adenocarcinoma arising in long-standing multiple perianal and presacral fistulas.

Chronic anal fistulas are not rare; however, the development of a carcinoma in long-standing, perianal fistulas is rare. We describe a case of an 85-year-old man with multiple, recurring, perianal fistulas, extending to the natal cleft. The patient underwent en bloc resection of the fistulas which were in direct continuity with the middle rectum. Histological examination revealed a mucinous colonic adenocarcinoma. Abdominal CT and colonoscopy revealed an extramural residual rectal mass. The patient refused a radical colorectal operation. Three years later, because of fistula recurrence, he underwent loop sigmoidostomy and radical en bloc excision of the perianal fistula and rectum, with immediate reconstruction by bilateral gluteal flaps. The patient was discharged on the 12th postoperative day, refusing adjuvant radiotherapy. We present this rare malignant entity, successfully treated by staged operations and without any adjuvant therapy.

Clinical short-term results of radiofrequency ablation in patients with liver metastases from colorectal cancer.

BACKGROUND: The aim of this study was to examine the therapeutic efficacy of radiofrequency tumour ablation in patients with liver metastases from colorectal cancer who are not suitable for hepatic resection. PATIENTS AND METHODS: Between April 2002 and January 2004, 18 patients underwent open radiofrequency ablation (RFA) for colorectal liver metastases. Median lesion size was 5.6 cm (range 3.0-8.0 cm). Patient's follow-up included ultrasound and computed tomography imaging at 3, 6 and 18 months postoperatively. RESULTS: Mean total procedure time was 86 min. The average hospital stay was 5 days. There was no treatment-related mortality. Twelve patients (66.7%) experienced mild right hypochondrium discomfort for 3 days and 6 patients (33.4%) low-grade fever for 4 days. Four patients died within 12 months with extrahepatic disease. In 4 patients lesions increased in size or new lesions developed, 7 patients are alive, symptom-free, with stable disease and 4 patients are free of disease. CONCLUSIONS: RFA is a safe, well tolerated procedure for the treatment of unresectable colorectal liver metastases.

Manometric and clinical evaluation of patients after low anterior resection for rectal cancer.

The aim of this study was to examine the anorectal physiological and clinical changes that occur after low anterior resection for rectal cancer. Since 1998, 30 patients underwent laboratory tests of anorectal function, preoperatively and 1 month and 6 months after low anterior resection. Postoperatively all patients presented with increased bowel frequency, 60% of the patients with mild soiling and 30% with urgency for defecation. Six months after surgery there was a significant improvement of these symptoms. The anal resting pressure was significantly decreased postoperatively, while maximum squeezing pressure remained unchanged. The rectoanal inhibitory reflex was absent in 80% of the patients and at 6 months after surgery it tended to recover. Rectal capacity and compliance were reduced in all patients. In the current study, the majority of patients demonstrated manometric anorectal changes and clinical anorectal function disorders during the first year after surgery. We observed that these disorders correlated with the low level of the anastomosis.

Synchronous and metachronous colorectal carcinoma.

BACKGROUND: Synchronous and metachronous colorectal carcinoma have an incidence of 2-10%. The purpose of the study was to evaluate the clinical characteristics, the accuracy of diagnostic examinations and the survival of these patients. METHODS: From 1970 to 1999, 1160 patients with colorectal cancer were admitted to our Department. During follow-up examination 50 patients (4.3%) were found to present with multiple primary colon cancers. Fifty-two per cent were synchronous and 48% metachronous tumours. RESULTS: The overall 5-year survival of the patients was 45.87%. Mortality was 10% for multiple primaries, while in patients with single cancer was 4.1%. The overall 5-year survival of the patients with multiple primaries tumours was 46.67%. CONCLUSIONS: Patients with colorectal cancer must be fully studied endoscopically. There has been an improvement in survival in recent years due to better surgical techniques, the introduction of more sophisticated examination methods and the meticulous follow-up of patients at risk.

Surgical treatment of multiple cystic echinococcosis.

BACKGROUND: Multiple hydatid disease is a complex surgical problem, and its treatment can follow either conservative principles (drainage or obliteration of the cavity) or radical principles (cystoperi-cystectomy or liver or lung resection). METHODS: A total of 220 patients with multiple cystic echinococcosis (428 cysts) were managed between 1967 and 1998 with conservative operations (group A) or radical operation (group B). There were 90 men and 130 women, with a mean age of 52 years (range 18-77 years). There were two cysts in 124 patients, three cysts in 40 patients, four in 15 and more than four in 41 patients. These multiple cysts were located at one anatomical site (n=140) or at more than one site (n=80). Multiple (2-3) hepatic cysts occurred in 142 patients, multiple (2-3) lung cysts in 15 and multiple peritoneal cysts in 13 patients. Hepatic cysts co-existed with lung cysts in another 32 patients, with peritoneal cysts in 14 patients and once each with splenic, splenic plus lung cysts and renal cysts, one retroperitoneal cyst coincided with small peritoneal cysts. RESULTS: The operative procedure employed was dependent on the type and site of the parasite and the condition of the host. Three of 208 patients operated conservatively (group A) died postoperatively as opposed to receiving radical treatment. Morbidity rates were 8.8% and 12.5% in group A and B and mean hospital stay was 15.8 and 15.1 days, respectively. In group A there was an 8.6% recurrence rate, and recurrent disease was finally managed in each group the overall result could be considered satisfactory. DISCUSSION: We conclude that conservative surgery can provide good results in multiple cystic echinococcosis. Radical surgery, with its time-consuming major procedures, is ideal but only in properly selected cases.

Results of a prospective, randomized, double blind comparison of the efficacy and the safety of sequential ciprofloxacin (intravenous/oral)+metronidazole (intravenous/oral) with ceftriaxone (intravenous)+metronidazole (intravenous/oral) for the treatment of intra-abdominal infections.

The efficacy and the safety of sequential intravenous/oral (i.v./p.o.) ciprofloxacin (CIPX) plus i.v./p.o. metronidazole (MTR) was compared with i.v. ceftriaxone (CTRX) plus i.v./p.o. MTR in the treatment of complicated intra-abdominal infections. One hundred and forty two patients received study medications. Of these, 135 could be studied. Sixty-nine patients were randomized in the CIPX arm of the study and 66 in the CTRX arm. In the CIPX group 58 patients were switched to oral treatment and 11 patients remained in the intravenous arm. In the CTRX group 57 patients switched to oral MTR continuing i.v. CTRX and 9 patients remained in the i.v. branch. Success rates at the end of treatment in patients who switched to oral were 100% in both the CIPX group and the CTRX group. For validated patients continuing on oral, the success rates at the end of treatment were 63.6 and 33.3% in the CIPX and CTRX groups respectively. Overall success rates at the end of treatment and follow-up in all patients were 94.2% in the CIPX group and 89.4% in the CTRX group. Overall success rates at the end of treatment in patients with proven bacterial infection were 92.9% in the CIPX group and 88.3% in the CTRX group. Duration of hospitalization (days) for studied patients was 22.7+/-8.2 in the CIPX and 19.6+/-14.5 in the CTRX group. There was no statistical difference between the CIPX and CTRX groups in both the intent to treat and in the modified intent to treat populations. Conversion to oral therapy with CIPX/MTR was as effective as continued intravenous therapy with CTRX and oral MTR in those patients able to tolerate oral feeding.

Late empyema after lobectomy for echinococcal disease of the lung.

The case of a 57-year-old man who had previously undergone left lobectomy for echinococcal disease of the lung is described. Sixteen years later he presented with empyema and bronchopleural fistula, which were treated using a pedicled intercostal muscle bundle, an omental pedicle and partial thoracoplasty. The patient recovered and is well 6 years later.

The significance of dysplasia in colorectal adenomatous polyps associated with carcinoma.

The relation of colorectal carcinoma and adenomatous polyps was studied retrospectively in 72 patients. Severe dysplasia was found in 47.8% and malignant transformation in 18.2% of the patients with adenomatous polyps and coincidental colorectal carcinoma. The incidence decreased to 21.4% and 7.1%, respectively, in patients with adenomatous polyps only. This difference between the two groups constitutes indirect evidence of malignant potential of adenomatous polyps associated with colorectal carcinoma. Moreover, when severe dysplasia of an adenomatous polyp is found, the patient should be carefully examined for synchronous colorectal carcinoma.