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.

Benign Tumours and Pseudotumours Within the Porta Hepatis Masquerading as Perihilar Cholangiocarcinoma.

BACKGROUND: Hilar cholangiocarcinoma (HC), also referred to as Altemeier-Klatskins tumour, is a lethal primary extrahepatic carcinoma of biliary epithelial origin, arising within 2cm of the hilar confluence. Radical surgical excision provides the best chance for a cure; however, the management of patients with HC is challenging not only because of the need for a high level of skill in biliary and hepatic resections, but also because of the difficulty in reaching an accurate diagnosis preoperatively. In fact, the differential diagnosis of HC is a diagnostic dilemma which is currently persisting, as modern, sophisticated diagnostic modalities are not always able to provide a definitive preoperative diagnosis. This difficulty is compounded by the fact that alternative entities that mimic HC may be present in up to 25% of patients with hilar obstruction. This makes precise preoperative characterisation of a hilar stricture extremely important by preventing unnecessary, high-risk, major surgical procedures. Therefore, alternative benign entities masquerading as Altemeier-Klatskins tumour deserve an important place in the differential diagnosis of hilar obstruction. PURPOSE: Considering the important clinical implications that a precise diagnosis of the aetiological cause of a biliary obstruction at the liver hilum would have, this paper will focus on the differentiation between HC and benign hilar obstructions and will review benign tumours and pseudotumours masquerading as HC along with their specific diagnostic features.

The isoattenuating pancreatic adenocarcinoma: Review of the literature and critical analysis.

Dynamic CT has a reported sensitivity of as high as 97% in the detection of pancreatic cancer. Consequently, a substantial number of pancreatic tumors can still escape detection. The isoattenuating pancreatic adenocarcinoma is defined as a mass not directly visible on dynamic CT as its attenuation is indistinguishable from the attenuation of the pancreatic parenchyma. 88% and 100% of the isoattenuating adenocarcinomas <20 mm and >20 mm respectively are recognized only by the presence of secondary imaging findings highly suggestive of malignancy. Dynamic MRI can unmask 80% of the isoattenuating pancreatic adenocarcinomas. If MRI fails to unmask the mass, EUS-biopsy is not mandatory to be performed as biopsy proof is not required for solid pancreatic masses suspicious for malignancy before proceeding to surgery. The isoattenuating adenocarcinomas should not be regarded as early cancers as less than one-third of them are stage T1 tumors. After curative intent surgery, isoattenuating pancreatic adenocarcinoma patients have a significantly longer median survival than usual pancreatic adenocarcinoma patients associated with the higher rate of well differentiated tumors among isoattenuating tumors. The more favorable postsurgical survival of the isoattenuating pancreatic adenocarcinoma patients makes it even more imperative to correctly diagnose their cases at a resectable stage.

Alanine-glutamine dipeptide pretreatment protects rat renal function from small intestine ischemia-reperfusion injury.

AIM: Oxidative injury can cause renal function impairment and failure. Glutathione, a free radical scavenger, plays in the kidney a central role in oxidant-related events. The aim of this study was to investigate the potential beneficial effect of glutamine, a precursor of glutathione in the form of alanine-glutamine dipeptide (AGD) on small intestine ischemia/ reperfusion (I/R)-induced oxidant renal damage in rats. METHODS: Wistar rats were subjected to intestinal I/R for 30 min, induced by occlusion of the superior mesenteric artery, followed by 60 min reperfusion. AGD pretreatment was given 48 and 24 hours before I/R. At the end of the experimental procedure the left kidney was excised and a thin tissue slice was obtained for electron microscopy study. Kidney biopsies were obtained for malonyl dialdehyde, myeloperoxidase, and glutathione assays. RESULTS: Intestinal I/R caused significant oxidative injury in rat renal parenchyma consisted of severe alterations observed in subcellular renal structures associated with a significant increase in renal malonyl dialdehyde levels and a significant decrease in renal glutathione levels. Changes regarding subcellular renal structures were ameliorated in AGD pre-treated animals in which renal glutathione levels did not decreased significantly. CONCLUSION: Glutamine pretreatment in the form of AGD can prevent small bowel I/R-induced oxidant renal damage in rats.

Submucosal lipoma of the ascending colon as a source of massive lower gastro-intestinal bleeding: a case report.

Colonic lipomas are relatively uncommon lesions. They have been documented as the source of massive low gastro-intestinal bleeding in only five previous reports in the English language literature. We report an extremely rare case of massive haemorrhage caused by an ascending colon submucosal lipoma and review the pathophysiology, diagnosis and management.

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.

Recurrent arterial thromboses in a woman with heparin induced thrombocytopenia, successfully managed with iloprost followed by clopidogrel. An alternative therapeutic option for heparin induced thrombocytopenia type II syndrome.

In its more severe form heparin induced thrombocytopenia (HIT) is a rare immune mediated complication of heparin administration that potentially has catastrophic results, and significant mortality. In view of the severity of this condition it is important for the clinician to maintain a high index of suspicion and get alerted to the HIT syndrome by the precocity of platelet count decrease in any patient group, and especially in those previously exposed to heparin. We report on a 72-year-old woman who developed HIT syndrome that was complicated by recurrent arterial thromboses after receiving postoperative antithrombotic prophylaxis with tinzaparin, a low molecular weight heparin. The patient was successfully treated with iloprost (Ilomedin, iloprost tromethamine, Schering) a stable prostacyclin analogue, at the acute phase of the syndrome, followed by long-term treatment with clopidogrel (Plavix, clopidogrel bisulfate, Sanofi) an inhibitor of adenosine diphosphate (ADP) receptor. Although direct thrombin inhibitors have been proven to be effective for the treatment of HIT thrombosis, they do not completely eliminate the morbidity and mortality of this disorder. Our case report suggests that antithrombotic treatment by targeting of the activated platelets with a potent platelet inhibitor during the acute phase of type II HIT syndrome followed by long-term administration of oral anticoagulation may be an additional, safe and effective therapeutic alternative that merits to be systematically studied.

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.

Incarcerated small bowel in a spigelian hernia.

We report on a case of a 68-year-old man who was transferred to our department to undergo surgical treatment of intestinal obstruction and a palpable right sided abdominal mass. The abdominal computed tomography scan revealed a small bowel obstruction with an incarcerated spigelian hernia. A mesh repair was performed by suturing the mesh to the internal oblique muscle and to the rectus sheath. The postoperative course was uneventful, and no recurrence has occurred during the 2-year follow-up. An urgent operation should be performed as soon as an accurate diagnosis of incarcerated spigelian hernia has been made. Computed tomography should be helpful in order to establish an accurate diagnosis of the incarcerated hernia.

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.

Management of bile duct injury during and after laparoscopic cholecystectomy.

BACKGROUND: Bile duct injury (BDI) is perhaps the most feared complication of laparoscopic cholecystectomy (LC). Proper management of iatrogenic BDI is mandatory to avoid immediate or later life-threatening sequelae. The results of surgery depend mainly on the type of injury, prompt detection of the injury, and timing of the surgery. METHODS: Twelve patients with BDI after LC were treated. Eight of them were referred to our institution for further treatment. The follow-up evaluation was focused on clinical outcome and biochemical analysis. RESULTS: Five of the patients had minor BDI with leakage. In all of them, the BDI was recognized postoperatively. Two of these patients were managed by endoscopic retrograde cholongio pancreatographic sphincterotomy and stent placement. The other three patients underwent open laparotomy and bile duct ligation. Seven of the patients had major BDI. In two patients, biliary injuries were identified at the time of LC, and the procedure was converted to laparotomy. At the time of conversion, primary suture repair with T-tube drainage of the injured bile duct was performed. Strictures developed in these patients after 2 and 6 months, respectively, and they were treated with a Roux-en-Y hepaticojejunostomy. In five additional patients, BDI was recognized postoperatively. One of these patients died because of delayed detection of biliary peritonitis. At this writing, during a median follow-up period of 52 months, neither clinical nor biochemical evidence of biliary disease has been found in the remaining patients. CONCLUSIONS: Laparoscopic BDI has a high morbidity and mortality rate. Late recognition of the BDI remains a problem.

The endoscopic management of persistent bile leakage after laparoscopic cholecystectomy.

BACKGROUND: Bile leakage after laparoscopic biliary surgery is a surgical challenge in which endoscopy can play an important role. METHODS: A total of 26 patients underwent endoscopic retrograde cholangiopancreatography (ERCP) in our department. Patients with evidence of major ductal injury were treated surgically. In all other cases, endoscopic sphincterotomy was performed, any retained bile duct stones were removed, and a biliary endoprosthesis or a nasobiliary catheter was inserted on a selective basis. RESULTS: ERCP was successful in 24 patients. Seven patients were treated surgically after cholangiography revealed major ductal injury. Two more patients were eventually operated on due to bile peritonitis. Of the other 15 patients, 11 had leakage from the cystic duct and four had leakage from the gallbladder bed. Bile duct stones were removed from eight patients, an endoprosthesis were inserted in five patients, and a nasobiliary catheter was inserted in two patients. Bile leakage was treated successfully in all 15 patients with no further complications. CONCLUSION: ERCP is a means of safe diagnosing the cause of a bile leakage and offers a definitive treatment in most cases.

Post-ERCP pancreatitis and hyperamylasemia: patient-related and operative risk factors.

BACKGROUND AND STUDY AIMS: Previous studies on the development of post-endoscopic retrograde cholangiopancreatography (post-ERCP) hyperamylasemia and pancreatitis have focused on different risk factors, either procedure- or patient-related, and also prognostic factors, such as amylase levels together with the occurrence of pancreatic-type pain, which might be implicated. The aim of this study is to identify possible predictive risk factors and also prognostic factors in order to better organize the treatment strategy. PATIENTS AND METHODS: During a 5-year period, 556 ERCP procedures were performed by the same operator. Of these, 43 procedures were excluded from the study. Data recorded from the procedures included both patient characteristics and procedure details. Patients were evaluated for pancreatic-type pain at 4 and 24 h after the procedure, and serum amylase levels were determined at 2 and 24 h after the procedure. Pancreatitis was diagnosed on the basis of both clinical and laboratory examination, while patients with hyperamylasemia were in a normal clinical condition but had high serum amylase levels. RESULTS: Post-ERCP pancreatitis occurred after 17 procedures (3.3%) and hyperamylasemia after 85 procedures (16.5%). Patients who developed pancreatitis all had pancreatic-type pain together with amylase levels higher than 4-5 times the upper normal limit at 24 h after ERCP. There was a significant association between serum amylase levels and post-procedure pancreatic-type pain both at 4 h and 24 h after ERCP (P = 0.006). Age less than 50 years, history of relapsing pancreatitis, pancreatic duct opacification, and difficulty in obtaining bile duct cannulation all proved to be significant predictive risk factors for the development of either hyperamylasemia or pancreatitis. In contrast, additional procedures and sphincterotomy seemed to reduce the likelihood of both complications. CONCLUSIONS: Serum amylase levels higher than 4 - 5 times the normal upper limit together with the existence of pancreatic-type pain, at 24 h after ERCP, strongly suggest the occurrence of pancreatitis. When any of the predictive risk factors coexist during a procedure it would be better either to abandon the procedure and try again later or, if the situation is urgent, to have earlier recourse to an alternative, such as precut or needle-knife papillotomy.

Prosthetic graft placement using the deep forearm veins in hemodialysis patients: a preliminary report.

When the superficial arm veins are not suitable for the creation of a conventional endogenous arteriovenous (A-V) fistula or the placement of a prosthetic graft in the forearm, the use of the deep forearm veins as an outflow system to construct an A-V graft access seems to be a reasonable alternative. Using this approach, we placed 6 prosthetic grafts in 6 hemodialysis patients in whom conventional methods had failed. Adequate functioning of this 'deep vein'-type vascular access in these 6 patients has been maintained for 3, 6, 11, 15, 19 and 24 months, respectively, without complications or any need for further interventions. Only one graft failed after 6 months. Our preliminary results indicate that this technique can be used successfully when the superficial forearm veins have been exhausted, thus avoiding the use of upper-arm or axillary veins.

Effect of early postoperative enteral feeding on the healing of colonic anastomoses in rats. Comparison of three different enteral diets.

This experimental study compares the effects of early postoperative administration of three enteral diets of different compositions on the healing of colonic anastomoses. Sixty Wistar rats were subjected to colonic anastomoses. Following surgery, the rats were randomly allocated to four groups of 15 each. The rats in control group A received an electrolyte and glucose solution, the rats in group B received a complete balanced nutrition, in group C a complete balanced nutrition supplemented with fiber and in group D an isocaloric specialized elemental nutrition enriched with glutamine. The rats were sacrificed on day 7 following operation. Rupture of the anastomosis was higher in rats of the control group compared to the other three groups. Adhesion formation was more extensive in group A in comparison to the other three groups. The anastomotic bursting pressures were statistically significantly higher in groups C and D compared to the other two groups (p < 0.05). There was no statistically significant difference between group C and D (p > 0.05) while a statistically significant difference was noted between group B and group A (p < 0.05). Histological examination showed more profound inflammatory reaction in group A compared to the other three groups. There was also a statistically significant difference between group B and groups C and D while inflammatory reaction was of no statistically significant difference between group C and group D. Healing of the anastomoses was statistically significantly impaired in group A compared to the other three groups. There was no statistically significant difference between group C and group D while a statistically significant difference was found between group B and groups C and D. In conclusion, early postoperative enteral feeding improves healing of experimental colonic anastomoses in rats. This effect was more evident when fiber-supplemented diets or diets enriched with glutamine were administered.

Management of large rectal wall defects with open pedicle grafts of small intestine. An experimental study.

The aim of this study was to evaluate the possible repair of large rectal wall defects using an open pedicle ileal graft as a mucosal patch. This experiment was carried out in 14 adult mongrel dogs. By excision of a portion of the antimesenteric wall comprising 50-70% of the circumference and measuring 5-6 cm in length, a suitable full thickness defect was created in the lower part of the rectum. A segment of the distal ileum was then isolated on a mesenteric pedicle and opened from its antimesenteric border. This was sutured over the defect in two layers. The animals were observed for a period of 15 days to 12 months. All the animals survived the operation apart from 1 dog that died of fecal peritonitis. Function of the rectum generally remained normal. Barium X-ray did not show any obstruction, shrinkage of the patch, lumen dilatation or extravasation. At the time of autopsy pedicles of ileal grafts appeared intact and pulsating. On gross examination there was no evidence of focal hemorrhage, ulceration or any cicatricial thickening of the grafts. Healing was good and the ileal mucosa retained its villi and general characteristics without any major inflammatory reactions. There was an increase in the number of goblet cells which returned to normal in 6 months.

Intracerebroventricular infusion of neurotensin suppresses gastric acid secretion in dogs.

Synthetic neurotensin (NT) was infused intracerebroventricularly in 14 mongrel dogs to study the effects of the peptide on gastric secretion and on gastrin and NT levels. The infusion was performed with a specific apparatus, and gastric fluid was collected with a Pavlov pouch. NT was given in two series of experiments: as a bolus intracerebroventricular injection of 269.8 pmol/kg and as a continuous intracerebroventricular infusion at a rate of 539.6 pmol/kg/h for 30 min. The bolus injection caused a very significant decrease of gastric fluid volume, a significant decrease of HCl output and a significant increase of its pH, while serum immunoreactive gastrin increased significantly. The continuous infusion of NT caused similar changes in gastric secretion. The plasma NT levels did not change. In conclusion, the intracerebroventricular administration of NT increases the serum gastrin levels, decreases the volume and HCl content of gastric fluid, and increases its pH.

Changes in gastric secretion after intracerebroventricular infusion of bombesin in dogs.

Synthetic bombesin (BBS) was infused intracerebroventricularly in 14 mongrel dogs, to study the effects of the peptide on gastric secretion and on gastrin and neurotensin levels. The infusion was performed with a specific apparatus, and gastric fluid was collected with a Pavlov pouch. BBS was given in two series of experiments: as a bolus intracerebroventricular injection of 308.6 pmol/kg and as a continuous intracerebroventricular infusion at a rate of 617.3 pmol/kg/h for 30 min. The bolus injection caused a very significant decrease of gastric fluid volume, a significant decrease of HCl output, and a significant increase of its pH, while serum immunoreactive gastrin increased significantly. The continuous infusion of BBS caused similar changes in gastric secretion. The plasma neurotensin levels did not change. In conclusion, the intracerebroventricular administration of BBS increases the serum gastrin levels, decreases the volume and HCl content of gastric fluid, and increases its pH.