Pancreatic Intraductal Papillary Mucinous Neoplasms: A Narrative Review.

Introduction: Intraductal papillary mucinous neoplasms (IPMNs) are the most frequent cystic pancreatic neoplasm. They derive from the main pancreatic duct or branch ducts. Aim: This narrative review aims to present and compare the current guidelines on the management of IPMNs. Materials and methods: We reviewed the most important scientific literature on the management of IPMNs. Discussion: The clinical presentation of IPMNs is usually nonspecific; common symptoms are abdominal pain, weight loss, and jaundice. There are no sex differences, and the incidence increases with age. It is considered a premalignant lesion associated with synchronous or metachronous carcinomas. Multifocal sites within the pancreas and the presence of solid components, like mural nodules, are predictive factors for developing malignancy. Magnetic resonance imaging (MRI) is the imaging technique of choice. However, computed tomography (CT) and endoscopic ultrasound (EUS) with fine-needle aspiration (FNA) can also contribute to the diagnosis. Resection is the optimal treatment for IPMNs that arise from the main duct, while several indications are suggested for the surgery on IPMNs of branch ducts. Conclusion: The decision on surgery is not always a simple task and should be based on high-risk features of the neoplasm. In any case, re-examination and follow-up are highly recommended.

Gastrointestinal Stromal Tumors: Our Ten-Year Experience of a Single-Center Tertiary Hospital.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are the most frequent mesenchymal neoplasms of the gastrointestinal tract. They have variable clinical presentation, prognosis, and molecular characteristics. Here, we present the results of our retrospective study including patients operated on for GIST during the last decade. METHODS: All the patients who underwent GIST resection during the decade 2008-2018 were included in the study. The diagnosis was based on the pathology report. All the data were collected and analyzed statistically using the Statistical Package for Social Science v25.0. Finally, after having applied the proper search terms, a comprehensive review of articles published in the Medline database was held. RESULTS: Thirty-two patients (sixteen women) were included in the study with a mean age of 69.6 years old (SD = 13.9). Twenty-one patients had a GIST in the stomach, eight in the small intestine, and three had an extra GIST. Of the 29 patients contacted, 21 were alive with a mean survival time of 74.3 months (SD = 49.6 months, min: 3.0 months, max: 161.0 months), whereas eight patients passed away. Finally, 13 patients were treated with tyrosine kinase inhibitors (TKIs) of whom only one died, while 9 patients passed away from those treated with surgery alone (p = 0.031). CONCLUSIONS: Our results were in concordance with the existing data in the literature. GISTs require patient-based therapeutical management depending on the histology of the tumors. Gastric tumors present a better prognosis than those localized in the intestine, while the use of TKIs has led to an improvement in patient survival rate.

Mucinous adenocarcinoma arising from a tailgut cyst: A case report.

BACKGROUND: Retrorectal hamartomas or tailgut cysts (TCs) are rare. In most cases, they are asymptomatic and benign; however, rarely, they undergo malignant transformation, mainly in the form of adenocarcinoma. CASE SUMMARY: A 55-year-old woman presented to our hospital with lower back pain. On magnetic resonance imaging, a large pelvic mass was found, which was located on the right of the ischiorectal fossa, extending to the minor pelvis. The patient underwent extensive surgical resection of the lesion through the right buttock. Histological examination confirmed the diagnosis of a retrorectal mucinous adenocarcinoma originating from a TC. Surgical resection of the tumour was complete, and the patient recovered without complications. The pilonidal sinus was then excised. One year later, semi-annual positron emission tomography-computed tomography and magnetic resonance imaging scans did not reveal any evidence of local recurrence or metastatic disease. CONCLUSION: Preoperative recognition, histological diagnosis, and treatment of TCs pose significant challenges. In addition, the possibility of developing invasive mucinous adenocarcinoma, although rare, should be considered.

Adenosquamous carcinoma of the pancreas: two case reports and review of the literature.

BACKGROUND: Among the total reported cases of pancreatic duct adenocarcinomas, around 1-2.9% are adenosquamous carcinomas of the pancreas. Due to limited data, preoperative diagnosis is a great challenge for physicians, and it is usually set post-operational, based on the pathologist report. We operated on two cases of adenosquamous carcinoma of the pancreas, which we present alongside the operation and treatment planning. CASE REPORT: A 69-year-old Caucasian female and a 63-year-old Caucasian male presented themselves with jaundice in our department. The abdomen computed tomography and magnetic resonance imaging scans revealed lesions of the pancreas. A pancreas-duodenumectomy was performed in both patients, and the post-operational histology analysis revealed adenosquamous carcinoma of the pancreas head. The patients were discharged in good condition and received further chemotherapy treatment after surgery. CONCLUSIONS: Two case reports of adenosquamous carcinoma of the pancreas are described here, which both underwent surgery resection. The limited available literature on this topic substantially limits the knowledge and guidance on treatment. A summarization of the available literature is attempted, alongside a description of possible fields of future research.

Transabdominal Preperitoneal inguinal hernia repair leading to orchiectomy: A case report.

Introduction: And importance: The most common postoperative complications after inguinal hernia repair are hernia recurrence, hematoma, seroma, wound infection, chronic pain, numbness and swelling. The aim of this case report is to present a rare complication of inguinal hernia repair, a large scrotal abscess that was caused by an inoculated scrotal hematoma 3 months after Transabdominal Preperitoneal bilateral inguinal hernia repair. Case presentation: An 84-year-old patient presented to the emergency department complaining about fever, pain and progressive swelling of the left hemiscrotum. He had undergone a Transabdominal Preperitoneal bilateral inguinal hernia repair 3 months earlier and a scrotal paracentesis 17 days earlier due to a scrotal hematoma. The pelvic CT scan was indicative of a large abscess in the left hemiscrotum compressing the ipsilateral testicle. Surgical exploration of the inguinal area was performed and considering the patient's advanced age the abscess was excised "en bloc" with the ischemic ipsilateral testicle. The patient had an uneventful recovery and was discharged home on the third postoperative day. Clinical discussion: Scrotal abscess, although rare, should be considered in the differential diagnosis of scrotal pain after inguinal hernioplasty. Scrotal drainage is sometimes used in order to relive the patient's discomfort caused by a swollen scrotum, but if not performed properly it can lead to serious infections. Postoperatively, a suction drain or elevation and compression of the scrotum may prevent scrotal complications. Conclusion: Scrotal abscess is a rare complication of inguinal hernioplasty. Scrotal care pathways establishment after inguinal hernia repair could help reduce and manage complications.

Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options.

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8-3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient's clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Abdominal wall endometriosis: a case report.

Abdominal wall endometriosis is the development of endometrial tissue in the anterior abdomen usually due to an operation in which the uterus is manipulated. We herein delineate the presentation, clinical investigation, and surgical treatment of an abdominal wall endometriosis case. A 42-year-old female presented with acute abdominal pain in the lower quadrants in the margins of an old cesarean scar. Two masses in the abdominal wall highly suspected of consisting of endometrial tissue were found during the investigation of the patient. These ones were removed in surgery and endometrial tissue secondary to previous cesarean section was confirmed after histological analysis. Consequently, although rare, if a painful mass in a surgical scar, such as a Pfannenstiel incision, is found in women of reproductive age with a history of obstetric surgery, the differential diagnosis shall include endometriosis. There is a portion of cases in which endometriosis recurs within five years following conservative surgery.

Cutaneous Lesions: An Unusual Clinical Presentation of Small Cell Lung Cancer.

BACKGROUND Small cell lung cancer (SCLC) is the most aggressive type of lung cancer, accounting for 13% of all new lung cancer cases worldwide. Common metastatic sites are the brain, liver, adrenal glands, bone, and bone marrow, while cutaneous metastasis is rare and is associated with a poor prognosis, and presentation of SCLC as the first sign of malignancy is even rarer. CASE REPORT An 87-year-old patient with a history of tobacco abuse and free from any medication administration presented to the Emergency Surgical Department with 2 nodules in the skin of the abdomen. Excisional biopsy of the skin lesions was performed and the pathology showed metastatic small cell cancer originated from the lungs. A chest X-ray and CT scan confirmed the diagnosis of lung cancer. Chemotherapy was initiated. Following a short hospitalization period, the patient's condition worsened. The patient died in the Intensive Care Unit before completion of full cycles of chemotherapy and palliative radiation therapy. CONCLUSIONS A diagnosis of metastatic disease should be considered in patients with new cutaneous lesions and a smoking history. Skin lesions of metastatic lung cancer are often described as painless nodules, mobile or fixed, hard or flexible, single or multiple. Treatment in limited-stage disease usually includes chemotherapy combined with radiation. In extensive-stage disease, chemotherapy is the primary option. Small cell lung carcinoma is more responsive to chemotherapy and radiation therapy than are other cell types of lung cancer. For prevention, especially in high-risk patients, annual chest screening, smoking-prevention programs, and control of occupational exposure to culprit substances are highly recommended.

Perianal Solitary Fibrous Tumor in a Rare Anatomical Presentation: A Case Report and Literature Review.

BACKGROUND Solitary fibrous tumors (SFTs) account for <2% of all soft tissue tumors and are slow-growing neoplasms of mesenchymal origin, which have been reported in various locations. They are frequently observed at the pleura and a perianal location is extremely rare. They show no predisposition by sex, are mainly benign, and usually occur between the 5th and 7th decades of life. CASE REPORT We report the case of an 80-year-old man with no comorbidities except hypertension, who presented with an asymptomatic perineal mass. Magnetic resonance imaging showed a solid tumor measuring 3.5×2.5 cm identified in the perineal midline. It was very close to the anal sphincter, showing no extension to the rectum or anus. The tumor was completely excised with negative margins. The postoperative course was uneventful and he was discharged home, free of any symptoms. The pathological examination showed a benign completely excised SFT, and no further treatment was necessary. At the 6-month and 1-year follow-ups, there was no sign of recurrence. CONCLUSIONS A comprehensive review of all the reported cases of perianal SFTs shows that the majority of these tumors present with no symptoms and have a favorable prognosis. Diagnosis is possible only after a pathological examination. The criterion standard of treatment is complete excision with negative margins. Once excised, the tumors have low rates of recurrence and metastasis. Tumors very close to the anal sphincter and with malignant potential need to be operated on with extra care to obtain clear margins without disrupting the continence mechanism.

Case Report of Synchronous Prostate, Hepatocellular, and Rectal Carcinomas and Review of the Literature.

Synchronous occurrence of three histopathologically distinct malignant tumors is a rare event, and there are no definitive guidelines about the optimal treatment of these patients. We report a case of synchronous prostate, hepatocellular, and rectal carcinomas and discuss our therapeutic strategy that resulted in excellent clinical results.

Retroperitoneal Cecal Perforation Resulting from Obstructive Ascending Colon Adenocarcinoma.

Most colorectal cancer patients in the early stages of the disease do not display any alarming symptoms. A total percentage of 9-27% of colorectal cancer patients present with acute abdomen, bowel obstruction, perforation, or bleeding. Perforation as the first presentation of the disease is seen in no more than 2.6-10% of patients. Intestinal perforation may be found on either the site of the tumor or on a more proximal site, caused by distention of the bowel due to peripheral obstruction. This is a case of a 75-year-old female patient who presents in the emergency department with retroperitoneal cecal perforation due to an obstructing tumor of the ascending colon. She underwent an emergency right hemicolectomy and washout of the retroperitoneal space. The cecum is not an unusual site of distention and subsequent perforation in the case of colonic obstruction, especially in the presence of a competent ileocecal valve. While the mechanism of diastatic cecal perforation is well described, it is the first time in the literature that this does not occur on the anterior surface of the organ. In our case, cecal perforation presents as a retroperitoneal abscess without peritoneal spillage. Nonetheless, it still carries a grim prognosis and urgent surgical intervention is needed.

The challenging diagnosis and treatment of duodenal diverticulum perforation: a report of two cases.

BACKGROUND: The duodenum is a common site for diverticulum formation. Most of the duodenal diverticula are asymptomatic, incidental findings. Perforation is a rare but potentially lethal complication of duodenal diverticular disease. Surgery remains the mainstay of treatment for perforated duodenal diverticula. In recent years, a few cases were successfully managed either conservatively or with endoscopy. CASE PRESENTATION: We present two cases of female patients treated in our department for duodenal diverticulum perforation. The first case was treated surgically with a diverticulectomy. The second case was managed conservatively with bowel rest and intravenous antibiotics. Both patients had an uncomplicated postoperative course and were discharged home. CONCLUSIONS: Both surgical and conservative treatments are viable options for a perforated duodenal diverticulum in selected patients. Patients with a contained duodenal diverticular perforation can be managed conservatively at the outset. Possibly, the introduction of a classification system for duodenal diverticulum perforation may help clinicians in making essential therapeutic decisions.

Survivin expression in hepatocellular carcinoma. Correlation with clinicopathological characteristics and overall survival.

PURPOSE: Survivin expression is a potential prognostic indicator in various carcinomas. The prognostic value of Survivin for survival in hepatocellular carcinoma, (HCC) however, remains controversial. The aim of the study is to examine the expression of the inhibitor of apoptosis Survivin in HCC and investigate the correlation with the clinic-pathologic characteristics and overall survival (OS) following surgical resection. METHODS: Specimens from patients with resected HCC were examined by Immunohistochemical staining for Survivin and BCL-2expression. Clinical and histopathological data were retrieved from medical and pathology records, while OS was determined by reviewing records from the department of Oncology and personal communication with survivors. Bivariate analysis was performed using the Chi-square and Mann-Whitney U tests, while survival was estimated by Kaplan Meier method and compared with log-rank test. RESULTS: Sixty patients were included in the study. Survivin was expressed in 26 patients (43.3%). Survivin expression was significantly correlated to OS (p=0.014). A statistically significant negative correlation between Survivin and BCL-2 was also noted (p<0.001). CONCLUSIONS: Survivin expression reflects aggressive histological and clinical behavior of HCC and correlates with poorer OS. Further studies are required to confirm if Survivin can be used as a predictive biomarker to evaluate prognosis and target treatments for HCC.

Metachronous Ovarian Metastases in a Patient with Primary Colorectal Cancer. A Case Report and Review of the Literature.

BACKGROUND Metachronous ovarian metastasis from primary colorectal cancer (CRC) is a rare condition that is diagnosed after the treatment of CRC. In most cases, ovarian metastases present without specific symptoms or signs and are usually diagnosed during follow-up imaging. A rare case is presented of metachronous ovarian metastasis from primary CRC, diagnosed on follow-up by computed tomography (CT) and magnetic resonance imaging (MRI), and includes a review of the literature. CASE REPORT A 66-year-old woman recently underwent a left hemicolectomy for a stage T3, N0, M0 primary adenocarcinoma of the sigmoid colon, which was completely excised. Three years later, follow-up CT and MRI imaging showed a right ovarian cyst. She underwent exploratory laparotomy and bilateral salpingo-oophorectomy, which identified tumor in the right ovary. Histopathology and immunohistochemistry confirmed metachronous ovarian metastasis from CRC. The patient was referred for further treatment. CONCLUSIONS Newly-diagnosed ovarian metastasis from primary colorectal cancer (CRC) is challenging to diagnose and manage, and may initially be incorrectly diagnosed as malignancy of primary ovarian origin. This case demonstrated that it is important to confirm the diagnosis with imaging, histology, and the appropriate use of tumor markers. Because ovarian metastases do not respond favorably to chemotherapy, the treatment of choice is surgery. However, for women who are treated for CRC, the use of prophylactic oophorectomy remains controversial.

Ducts of Luschka as a rare cause of postoperative biloma. MRCP findings.

Laparoscopic cholecystectomy can be complicated by a post- operative biloma. Bile leak from the duct of Luschka is reported to be the second most frequent cause, reported in 0.15%-2% of the patients. This case report aims to underline the significance of this anatomic variation and how the management of the aforementioned complication can be facilitated by MRI- MRCP. A 78 year old male patient underwent an elective laparoscopic cholecystectomy and was found to have a post-operative biloma. An MRCP was carried out to visualize the bile tree and bile leak was identified to be originated from a duct of Luschka. The patient was referred for an ERCP, sphingterotomy and placement of biliary stent to release the pressure in the bile ducts. In the next few days the bile leak was controlled and eventually ceased. The patient was discharged free of symptoms and no sign of bile leak was to be found on his follow up imaging. In comparison with other imaging modalities picturing the bile tree, MRCP fits the ideal profile to be used as a first line choice for clinicians, as it offers detailed anatomical images with high contrast between bile and adjacent tissues, without using any contrast agent or radiation.

Translation of the modified NUTRIC score and adaptation to the Greek ICU setting.

BACKGROUND & AIMS: Patients in the intensive care unit are experiencing an increased malnutrition risk. The NUTrition Risk in the Critically ill score (NUTRIC) is a validated tool for the identification of patients that will benefit the most, from nutritional intervention. The aim of the study was twofold, including: 1) to translate and adapt the NUTRIC score in the Greek language for more efficient and comprehensive use among clinicians, and 2) to assess its prognostic performance in a pilot sample. METHODS: The translation process followed standardized steps: 1) initial translation, 2) synthesis of different translations, 3) back -translation to the English language, 4) revision and cultural adaptation of the instrument by an expert committee. A pilot application study was conducted on 80 critically ill patients from three ICUs in Greek hospitals. The NUTRIC score was calculated using the final translated version. RESULTS: The translated score was considered easy to use, fast and comprehensive. No specific corrections were suggested by the expert committee. According to the translated version of the score 56% of the screened patients were classified as of high nutritional risk (score between 5 and 9). Compared to the low - NUTRIC patients, high - NUTRIC patients were older (56.4 ± 16.4 vs. 68.7 ± 12.7 yrs, p < 0.001), had increased APACHE (13.8 ± 6.5 vs. 23.8 ± 6.5, p < 0.001) and SOFA scores (4.7 ± 3.1 vs. 10.4 ± 3.1, p < 0.001) and demonstrated more comorbidities. Elevated 28 -day mortality was observed among high -NUTRIC patients compared to the low - NUTRIC ones (6 vs. 18 patients, p < 0.05). CONCLUSIONS: The Greek version of the NUTRIC score is ready for use among health care professionals employed in intensive care units in Greek speaking countries, aiming to discriminate critically ill patients benefiting from enhanced nutritional support.

Gastric schwannoma: report of two cases and review of the literature.

INTRODUCTION: Gastrointestinal schwannomas are benign, slow-growing and usually asymptomatic tumors. In some cases bleeding, epigastric pain and palpable mass may be occurring. Preoperative diagnosis is challenging due to the difficulty of differentiation from other submucosal tumors. Diagnosis is most often provided through the histology report. CASE PRESENTATION: In this study we report two cases of gastric tumors with the suspicion of a GIST preoperatively but histologically confirmed to be gastric schwannomas. Two patients of our study gave to us their written consent for publication. Research work has been reported with the PROCESS criteria. DISCUSSION: Surgical resection should be considered the mainstay of treatment in patients with gastric schwannomas. Possible complications such as bleeding or pyloric stenosis can be presented. The size and location of the tumor, as well as its relation to the surrounding organs, are essential factors in determining the type of resection. CONCLUSION: Gastric schwannomas are usually presented us submucosal mass. Preoperative diagnosis is challenging due to the difficulty of differentiation from other submucosal tumors. Endoscopic Esophagogastroduodenoscopy with biopsy and endoscopic ultrasound is essential to determine the nature of these lesions. Resection of the lesion in healthy borders is the treatment of choice. Patho-logical examination usually revealed positive S-100 protein and negative CD34, CD117, Actin and desmin strains.

Ideal treatment strategy for chylous mesenteric cyst: a case report.

BACKGROUND: A mesenteric chylous cyst is defined as a cyst occurring in the mesentery of the gastrointestinal tract anywhere from the duodenum to the rectum and is diagnosed most often during the fifth decade of life. CASE PRESENTATION: In our case report, we describe a case of 38-year-old Greek woman who presented at our Emergency Department complaining of abdominal pain without any other symptoms. Her medical and family histories were clear and she had never had any abdominal interventions. During an imaging examination with ultrasound of her abdomen, an anechoic lesion in her upper left abdomen was revealed. In a further investigation with computed tomography, a well-defined hypodense cystic 7.08 × 6.05 cm mass with mild enhancement was noted. The mass was excised by open laparotomy within healthy borders and the specimen was sent for pathological examination. The histopathological findings were found to be most consistent with a simple lymphatic (chylous) cyst of the mesentery. A review of the literature considering this rare entity was also performed to evaluate our treatment strategy and the result was analyzed. CONCLUSIONS: Chylous cysts represent a diagnostic challenge and they should be considered when a physician encounters an intraabdominal mass. Physical examination and imaging do not always provide a diagnosis and surgical management should be advised due to the potential complications that may develop.

Corrigendum to "Surgical Management of a Giant Adrenal Pseudocyst: A Case Report and Review of the Literature in the Last Decade".

[This corrects the article DOI: 10.1155/2018/8473231.].

Surgical Management of a Giant Adrenal Pseudocyst: A Case Report and Review of the Literature in the Last Decade.

Adrenal pseudocysts are rare entities and occurred in the 5th and the 6th decades of life. They are discovered accidentally, while appearing with nonspecific clinical and imaging findings. We report a case of a 28-year-old woman presented in our Emergency Department complaining about upper abdomen pain. Computed tomography revealed a hypodense cystic lesion containing hyperdense material. The size of a mass was 11. 7 × 9.3 × 6.6 cm in diameter close to the pancreas, but the origin was from the left adrenal gland. The mass was excised with surgical laparotomy. Giant adrenal pseudocysts are rare entities. Final diagnosis usually confirmed with the pathology examination. Management of such adrenal lesions depends on the unique characteristics, the surgeon's experience, and local resources.