The integrity of colonic anastomoses following the intraperitoneal administration of oxaliplatin.

INTRODUCTION: The purpose of this experimental study was to determine the effect of oxaliplatin on the integrity of colonic anastomoses which were under oxaliplatin administration. MATERIALS AND METHODS: Thirty rats were randomized to two groups. After resection of a 1-cm segment of the transverse colon, an end-to-end sutured anastomosis was performed. Rats of the control group were injected with 3 ml of 0.9% sodium chloride solution and in the oxaliplatin group with 2.4 mg/kg of oxaliplatin intraperitoneally immediately after surgery and for seven postoperative days. All rats were sacrificed on the tenth postoperative day, and the anastomoses were examined macroscopically and graded histologically. Rats were measured for anastomotic bursting pressures and tissue hydroxyproline levels. RESULTS: The body weight changes were significantly greater in the oxaliplatin group (p = 0.005). Anastomotic dehiscence occurred only in the oxaliplatin group. The adhesion formation was significantly increased in the group of oxaliplatin compared to the control group (p = 0.001). The colonic bursting pressure was significantly lower in the oxaliplatin group compared to the control group (p < 0.001). The mean inflammatory cell infiltration was significantly lower in the oxaliplatin group (1.00 vs. 2.33, p < 0.001). The mean neoagiogenesis was significantly lower in the oxaliplatin group (0.80 vs. 2.20, p < 0.001). The mean collagen deposition was significantly lower in the oxaliplatin group and the mean fibroblast activity was significantly lower in the oxaliplatin group (1.27 vs. 2.53, p < 0.001). Hydroxyproline concentration was significantly lower in the oxaliplatin group (p < 0.001). CONCLUSION: Intra- and postoperative intraperitoneal administration of oxaliplatin definitely impairs healing of colonic anastomoses in rats.

Mirizzi syndrome with a fistula at the confluence of the hepatic ducts.

BACKGROUND: A rare case of Mirizzi syndrome with atypical presentation is reported. CASE REPORT: An 81-year-old woman with a known history of cholelithiasis presented with epigastric discomfort and indigestion. Imaging investigations revealed Mirizzi syndrome, while a cholecystobiliary fistula at the junction of the hepatic ducts was recognized intraoperatively and treated successfully with cholecystectomy and Roux-en-Y hepaticojejunostomy. During two years' follow-up the patient remains free of biliary symptoms. CONCLUSIONS: Diagnosis of Mirizzi syndrome requires a high degree of clinical suspicion, especially in cases without obstructive jaundice. A fistula at the level of the confluence of the hepatic ducts is a rare topographic variant of the syndrome that may need a totally different surgical approach.

Feasibility of therapeutic endoscopic retrograde cholangiopancreatography for bile duct stones in nonagenarians: a single unit audit.

BACKGROUND: Little information is available on short and long-term outcome of therapeutic endoscopic retrograde colangiopancreatography (ERCP) for choledocholithiasis in nonagenarians (>=90 years). The aim of this study was to evaluate retrospectively the feasibility of therapeutic ERCP in nonagenarians with choledocholithiasis, as compared with patients aged between 75 and 89 years. PATIENTS AND METHODS: During a 9-year period, therapeutic ERCP was performed for choledocholithiasis in 33 nonagenarian patients (group A) and 272 patients aged 75 to 89 years (group B). Clinical features, endoscopic findings, interventions, early and long-term results of therapeutic ERCP for a mean follow-up of 36 months were assessed and compared between the two groups. RESULTS: Group A patients had a higher incidence of acute cholangitis, concomitant diseases and gallbladder stones, as compared to group B patients. Furthermore, they required an emergency procedure, multiple sessions, stent insertion, and needle knife fistulotomy significantly more frequently (p<0.001). Group B patients underwent significantly more endoscopic manipulations and had a longer procedure time than group A patients. Complete bile duct stone clearance was achieved in 24.2% of group A patients and in 90.8% of group B patients (p<0.001). No ERCP related deaths occurred in group A patients. Cholecystectomy was not routinely performed in Group A patients having gallbladder stones. The rate of early and late complications was not significantly different between the two age groups. CONCLUSION: Therapeutic ERCP and biliary stenting have proved to be a feasible treatment option for the management of choledocholithiasis in nonagenarians.

Management of Boerhaave's syndrome: report of three cases.

From 2000 to 2005, three patients with Boerhaave's syndrome were successfully managed in our Department. Two of them received the appropriate treatment belatedly, with primary closure and bolstering tissue wrap. One of them required further intervention with a cervical esophagostomy and exclusion of the perforated esophagus. The third patient with an esophageal perforation related disorder, was managed with surgical exploration and drainage alone. Primary suturing of the esophagus should be performed only in patients with an early perforation. In cases of prolonged delay between rupture and diagnosis, esophageal resection with cervical esophagostomy and gastrostomy is advocated as the safest therapy.

Effect of IGF-I on healing of colonic anastomoses in rats under 5-FU treatment.

BACKGROUND: The aim of this experimental study was to investigate whether insulin-like growth factor I (IGF-I) can protect the colonic healing from the adverse effects of intraperitoneal administration of 5-fluorouracil (5-FU). MATERIALS AND METHODS: Eighty male Wistar rats were randomized into four groups of 20 rats each. Immediately after anastomoses were performed, rats in the control group were injected with 1 mL/100 gr of intraperitoneal saline solution, which was repeated daily until killed. Rats in the 5-FU and IGF-I +5-FU groups received 5-FU in a dose of 20 mg/kg body weight intraperitoneally, from the day of operation until killed. Rats in the IGF-I and IGF-I +5-FU groups received IGF-I in a dose of 2 mg/kg body weight intraperitoneally, immediately after the colonic anastomosis was performed and on 2nd, 4th, and 6th postoperative day. Rats were sacrificed on the 7th postoperative day. RESULTS: The dehiscence rate in the 5-FU group was 30% and it was significantly higher compared with the control and the IGF-I group (P = 0.020 for both comparisons). However, in the IGF-I +5-FU group, the dehiscence rate decreased to 10%. The administration of IGF-I resulted in a significant rise of bursting pressure in the IGF-I +5-FU group compared with the 5-FU group (P < 0.001). There was no statistical difference in bursting pressure between the IGF-I +5-FU and control groups (P = 1.000). The hydroxyproline levels were higher in the IGF-I and the IGF-I +5-FU groups as a result of the stimulating act of IGF-I. CONCLUSION: IGF-I, when given intraperitoneally, seems to mediate some of the adverse effects of 5-FU on the colonic healing in rats.

Management of nonfunctioning pancreatic endocrine tumors in the context of multiple endocrine neoplasia type 1 syndrome.

UNLABELLED: The aim of our study is to present our experience in the surgical treatment of nonfunctioning pancreatic endocrine tumors (NFPETs) in patients with multiple endocrine neoplasia type 1 (MEN-1). PATIENTS AND METHOD: Between 1996 and 2006 a total of 11 patients with clinically confirmed MEN 1 syndrome were monitored in an annual screening program that included evaluation of the pancreas. Our policy was to use Computed Tomography (CT), Magnetic Resonance Imaging (MRI) and Endoscopic Ultrasound (EUS) in combination with biochemical screening in an effort to early diagnose and categorize the pancreatic involvement in MEN-1. RESULTS: NFPETs were identified in 4 female patients (36.4%). Diagnosis of NFPET was established 4.2 years later than that of MEN 1. The median tumor diameter at diagnosis was 2.2 cm (range 1.8-2.6 cm). All patients were treated by distal pancreatectomy. Diagnosis of NFPET was established in histological sections by staining with neuroendocrine tumor markers. Adjuvant therapy with streptozocin in combination with 5-fluorouracil was applied in two patients. After surgery the patients were followed up annually with clinical evaluation, biochemical tests and imaging studies. CONCLUSIONS: Early detection of NFPETs in patients with MEN-1 syndrome can be accomplished by biochemical and radiological screening program. NFPETs should be removed when diagnosed, in order to achieve a timely and efficient prophylaxis against further tumor growth and malignant development.

Laparoscopic cholecystectomy without intraoperative cholangiography.

BACKGROUND: The aim of this retrospective study was to evaluate the outcome of laparoscopic cholecystectomies (LCs) performed in our Academic Surgical Unit, and the impact of our policy not to perform intraoperative cholangiograms (IOCs) on the incidence of bile duct injuries (BDIs). MATERIALS AND METHODS: Data was collected for the time period from 1992 (when the laparoscopic procedure was first introduced in our Unit) until 2005. During this time, 1851 patients underwent an LC. Patients with a history of jaundice, ultasonographic bile duct dilatation, bile duct stones, or deranged liver function tests were referred initially for an endoscopic retrograde cholangiopancreatography procedure. An IOC was not performed on any patient. RESULTS: The conversion rate was 23.9% among the patients with acute cholecystitis and 1.6% among the patients with a noninflamed gallbladder. This difference was statistically significant. The morbidity reached 1.1%, as minor or major complications were present in 22 of 1851 patients. Complications consisted of BDI in 7 patients (0.37%). Six patients presented with minor BDI. Two of the BDIs occurred among the group of patients with acute cholecystitis, whereas the remaining 5 occurred in the group of patients with a noninflamed gallbladder. This distribution was not statistically significant. CONCLUSIONS: The low BDI rate in our series allowed us to recommend an LC procedure without an IOC. Performing a cholangiogram either routinely or selectively is not wrong. However, adherence to a meticulous hemostatic technique, thorough knowledge of the anatomy, and a low threshold for conversion may also enable satisfactory results to be achieved.

Pseudoaneurysm of the popliteal artery complicated by peroneal mononeuropathy in a 4-year-old child: report of a case.

Pseudoaneurysms of the popliteal artery (PPA) rarely occur in children. In fact, we found only 10 cases reported in the medical literature. We report the case of a 4-year-old boy who presented with a painful palpable mass in the right popliteal fossa. He also had mild, painless right foot-drop and difficulty toe-walking on the same side. The diagnosis of a PPA was based on the findings of triplex ultrasound and computed tomographic-angiography. We attributed the cause of the lesion to blunt trauma, which he had suffered 2 years earlier. Thorough preoperative evaluation excluded the possibility of a self-immune process or a bone tumor in the region. Neurological examination demonstrated a mild, isolated, peripheral mononeuropathy of the right peroneal nerve. Thus, we performed surgical repair using an autologous reversed great saphenous vein graft. The patient had an uneventful postoperative course and his peripheral neuropathy and foot-drop resolved completely within 1 month after surgery. Now, after 3 years of follow-up, the patient has a patent graft and a fully functioning limb. PPAs are rare, especially in children, and trauma is the predominating underlying cause. PPAs should be treated immediately after diagnosis because their complications are associated with high rates of functional impairment and even limb loss.

Adrenocortical oncocytoma -- a rare tumor of undefined malignant potential: report of a case.

Adrenocortical oncocytomas are exceptionally rare. To our knowledge, only 23 cases have been reported in the world literature, most of which were benign and nonfunctioning. We report a case of adrenocortical oncocytoma diagnosed by pathological examination of an extirpated right adrenal mass in a young woman. We discuss this case and review the literature on this unusual entity.

A single center experience in minimally invasive treatment of postcholecystectomy bile leak, complicated with biloma formation.

BACKGROUND: Bilomas are localized collections of bile occurring usually post-operatively from an injured cystic or bile duct. Our study aims to evaluate the efficacy of minimal access endoscopic and percutaneous modalities in treating symptomatic bile leak and biloma formation. PATIENTS AND METHODS: Sixteen patients with biloma after open or laparoscopic cholecystectomy underwent assessment of the site and extent of the bile leak via endoscopic retrograde cholangiography (ERC). Endoscopic sphincterotomy was performed in all patients who were managed non-operatively, any retained duct stones were removed, and an endoprosthesis was inserted in a selected basis. Percutaneous drainage of the bile collection, under ultrasound or computed tomography guidance, followed ERC. RESULTS: ERC supplemented by computed tomography or ultrasound guided percutaneous biloma drainage was successful in 15 patients. One patient having major ductal injury was treated surgically. Thirteen patients had leakage from the cystic duct, one from the right hepatic duct, and one from an aberrant right hepatic duct. Bile duct stones were removed from seven patients an endoprosthesis was inserted in six and a nasobilary catheter in one. Bilomas resolved and bile leakage was treated successfully in all 15 patients with no further complications. CONCLUSION: ERC accurately diagnoses the cause of postcholecystectomy bile leakage and biloma formation. Furthermore, endoscopic sphincterotomy and selective stent insertion in coordination with percutaneous drainage procedures represents in the majority of cases the corner stone of a definitive treatment.

Contribution of insulin-like growth factor I to the healing of colonic anastomoses in rats.

The aim of this experimental study was to investigate the contribution of insulin-like growth factor I (IGF)-I in the colonic healing process when injected intraperitoneally after colon resection. Forty male Wistar rats were used. Rats in the control group were injected with 3 mL of a solution of 0.9% NaCl intraperitoneally after the operation and on postoperative day 2, 4, and 6. Rats in the IGF-I group received recombinant human IGF-I in a dose of 2 mg/kg body weight intraperitoneally, immediately after the colonic anastomosis was performed and on postoperative day 2, 4, and 6. All rats were killed on postoperative day 7. The hydroxyproline tissue content was significantly higher in the IGF-1 group than in the control group. The bursting pressures were also significantly higher in IGF-1 group than in the control group. The weight change between the groups differed significantly; in the control group the average weight decreased about 5% postoperatively, while in the IGF-1 group the average weight increased about 6%. The average inflammatory cell infiltration score was significantly higher in the control group. Neoagiogenesis did not differ significantly between the two groups. The fibroblast activity differed significantly between the two groups, as the control group had significantly less fibroblasts compared to the IGF-1 group. In conclusion, IGF-I when given intraperitoneally stimulates the healing of colonic anastomoses in the rats. Further studies are required in order to determine whether this effect is dose related.

Bloodless laparoscopic liver resection using radiofrequency thermal energy in the porcine model.

The aim of this study was to assess the feasibility and safety of laparoscopic hepatectomy using radiofrequency (RF) thermal energy in a porcine model. Fifteen female domestic pigs weighing 29.3 kg (range 25 to 35 kg) were used. Five transversal abdominal incisions (3 of 1 cm and 2 of 0.5 cm) were made for the introduction of the video camera and the other laparoscopic instruments. With the porta hepatis not clamped, the liver was inspected and the preferred lobe each time was divided using RF (cool-tip electrode 3 cm) with minimum bleeding. Serum liver enzymes and blood counts were drawn pre and postoperatively. All animals were killed after 1 week. The mean time of the procedures was 119 minutes (range 100 to 155 min). There were no intraoperative complications. Mean blood loss was 27 mL (range 5 to 60 mL), and the mass of the resected specimen was 132.5 g (range 65 to 305 g). There were no postoperative complications or deaths. Bloodless laparoscopic hepatectomy was technically feasible and safe in the porcine model using cool-tip electrode and 500-kHz RF Generator.

A single-center experience in the management of Altemeier-Klatskin tumors.

AIM: of this study is to present our experience in the management of patients with Altemeier-Klatskin tumor, with particular focus on the risk factors that influence survival after tumor resection. METHODS: Over a 15-year period, 37 patients with hilar cholangiocarcinoma were managed in our Department. The mean age of the patients was 62.5 years. Twenty-one patients were treated by palliative measures while sixteen patients had resection of the tumor and 11 of these had negative histological margins. An associated major hepatectomy was performed in six. In parallel, certain risk factors that could influence survival were analyzed. RESULTS: The resectability rate was 43.2%. The 30-day mortality rate was 7.4% and postoperative morbidity was 37.5%. The sites of the resected tumors were Bismuth-Corlette type I lesions in 3 patients, type II in 6, type IIIa in 2, and type IIIb in 5. The median survival of patients undergoing resection was significantly higher than of patients not undergoing resection (p<0.001). Furthermore, patients with R0 resection and histological clear margins experienced significantly superior survival than patients with R1 resection and positive margins (p=0.001, and p<0.001 respectively). Resections resulting in cancer-positive margins did not portend a survival benefit. CONCLUSION: Negative surgical margins, tumor differentiation and infiltrating macroscopic appearance, were statistically significant prognostic factors. Our findings emphasize that complete resection of the tumor with negative histological margins offers the best possibility of long-term survival, and that the addition of hepatectomy to biliary resection results in a greater number of patients with margin negative resections.

Endoscopic management strategies in relation to the severity of acute cholangitis.

BACKGROUND AND STUDY AIMS: Acute cholangitis (AC) and especially suppurative cholangitis due to biliary lithiasis is an emergency situation that requires urgent biliary decompression. The aim of the study is to present our policy for the treatment of AC due to choledocholithiasis, endoscopically. METHODS: In a 4-year period, 71 patients presenting AC, due to lithiasis, underwent endoscopic retrograde cholangio-pancreatography and endoscopic sphincterotomy (ES). All patients had fever, jaundice, abdominal pain, and in case of suppurative cholangitis hemodynamic instability. Most of them seemed to be high-risk candidates for surgery. RESULTS: Forty-nine patients had AC and 22 patients had acute obstructive suppurative cholangitis (AOSC). ES (conventional or needle-knife biliary fistulotomy) was successful in 69 out of 71 (97%) patients. Two patients were eventually operated and were excluded from statistical analysis. Fifty of the 69 patients (72%) had a complete bile duct clearance in 1 session. Conventional ES, complete bile duct clearance, and other endoscopic maneuvers (balloon, basket, lithotripsy) were significantly more frequent in the AC group (P<0.001). Needle-knife biliary fistulotomy, and stent insertion were significantly more frequent in the AOSC group (P<0.001). Endoscopical treatment had low morbidity and total hospital stay time. CONCLUSIONS: ES is the procedure of choice for the treatment of AC offering definite treatment with low morbidity and short hospitalization. Urgent biliary decompression with minimal endoscopic maneuvers is crucial for the outcome of patients having AOSC.

Value of carcinoembryonic antigen assay in predicting hepatic metastases, local recurrence, and survival after curative resection of colorectal cancer.

PURPOSE: We measured carcinoembryonic antigen (CEA) levels in peripheral and portal venous blood, and bile from patients with colorectal cancer, to determine its role in predicting hepatic metastases, local recurrence, and survival. METHODS: The subjects were 73 patients who underwent curative surgery for colorectal cancer. RESULTS: The median serum, bile, and portal CEA levels were significantly lower in 5-year survivors than in patients in whom hepatic metastases or recurrent disease subsequently developed. The CEA level in portal blood and bile was a good indicator of hepatic metastases, with sensitivity of 92% and 100%, respectively. However, the accuracy of any CEA measurement for predicting hepatic metastases, local recurrence, or 5-year survival did not exceed 70%. CONCLUSIONS: None of these CEA measurements is accurate enough to be the basis of a management decision. Thus, we suggest that CEA measurement be used to assist in the prediction of a high risk of the development of hepatic secondaries and that these patients are followed up closely after curative resection.

Prognostic significance of CEA levels and detection of CEA mRNA in draining venous blood in patients with colorectal cancer.

BACKGROUND AND OBJECTIVES: The aims of this study were to determine carcinoembryonic antigen (CEA) levels and incidence of tumor cells using the RT-PCR technique in draining venous blood of patients with colorectal cancer, correlate the results with various histopathologic factors and determine their significance as prognostic factors. METHODS: From 1995 to 2000, 108 patients with adenocarcinoma of the colon or rectum, underwent curative surgery and enrolled in this prospective study. RESULTS: The 5-year survival group had significantly lower portal CEA levels compared to the hepatic metastasis outcome group. CEA mRNA was positive in the draining venous blood from 12 (11.1%) out of 108 patients included in the study. The rate of positive tumor cell detection in portal blood was significantly higher in the hepatic metastasis outcome group than in the 5-year survival and recurrence group. The proportion of patients with portal CEA > or =5 ng/ml was greater in patients with higher stage than in patients with lower stage. CONCLUSIONS: Positive CEA mRNA in draining venous blood predicted hepatic metastases and local recurrence with accuracy over 80% but with low sensitivity of 30% and 9%, respectively. Moreover, CEA level was a sensitive indicator in hepatic metastases as sensitivity was 95% and a specific indicator in predicting 5-year survival with specificity 84%.

Local excision as a treatment for tumors of ampulla of Vater.

BACKGROUND: Although local excision (ampullectomy) was first described by Halsted in 1899, its adequacy as an alternative surgical treatment for the ampullary tumors is still a matter of debate. The aim of this study was to evaluate the results of ampullectomy as a curative treatment for benign and malignant tumors arising from the ampulla, in a 14-year single-institution experience. METHODS: From 1990 to 2004, a total of 20 patients of adenocarcinoma (12) or adenoma (8) of the ampulla of Vater underwent local excision. Clinical data were collected and morbidity, mortality, as well as long-term survival were evaluated. The usefulness of several pre or intraoperative diagnostic methods was also recorded. Median follow-up was 85 (range 6-180) months. RESULTS: The combination of endoscopic preoperative biopsies and intraoperative frozen section examination adequately diagnosed ampullary tumors in all cases. The postoperative morbidity and mortality were 0%, whereas the 3 and 5-year survival rates for the patients with adenocarcinoma was 75 % and 33.3 % respectively. All the patients with adenoma are still alive without any sign of recurrence. CONCLUSION: In our series, local excision was a safe option, associated with satisfactory long-term survival rates in patients with benign lesions and in those with small(<2 cm), pT1, well differentiated ampullary tumours without nodal involvement.

Our local experience with the surgical treatment of ampullary cancer.

BACKGROUND: The aim of this study is to report the outcome after surgical treatment of 32 patients with ampullary cancers from 1990 to 1999. METHODS: Twenty-one of them underwent pancreaticoduodenectomy and 9 local excision of the ampullary lesion. The remaining 2 patients underwent palliative surgery. RESULTS: When the final histological diagnosis was compared with the preoperative histological finding on biopsy, accurate diagnosis was preoperatively established in 24 patients. The hospital morbidity was 18.8% as 9 complications occurred in 6 patients. Following local excision of the ampullary cancer, the survival rate at 3 and 5 years was 77.7% and 33.3% respectively. Among the patients that underwent Whipple's procedure, the 3-year survival rate was 76.2% and the 5-year survival rate 62%. CONCLUSION: In this series, local resection was a safe option in patients with significant co-morbidity or small ampullary tumors less than 2 cm in size, and was associated with satisfactory long-term survival rates.

Adrenal metastasis as first presentation of hepatocellular carcinoma.

BACKGROUND: Metastases from hepatocellular carcinoma (HCC) can be found in the lung and adrenal gland. We report case of a patient who presented with adrenal metastasis as the first clinical manifestation of HCC. CASE PRESENTATION: A patient was referred for surgical treatment for a tumor in retro-peritoneal space. The computerized tomography (CT) scan revealed a mass originating from the left adrenal gland. The patient underwent left adrenalectomy and the exploration of abdominal cavity did not reveal any other palpable lesions. Histologically, the resected lesion was a poorly differentiated metastatic tumor from HCC. Seven months later patient was readmitted complaining of cachexia, icterus, and significant weight loss. CT scan revealed hyperdense lesions of the liver. CONCLUSION: HCC may have atypical presentations like in present case. Fine needle aspiration/tru-cut biopsy might be useful in the investigation of an accidentally discovered adrenal mass regardless of the size and can lead to the detection of a primary tumor.

Transfusion-related acute lung injury: a life-threatening transfusion reaction.

BACKGROUND: We present the case of a 57-year-old woman who developed transfusion-related acute lung injury (TRALI) following a transfusion of packed red blood cells (pRBCs). CASE REPORT: A 56-year-old woman had undergone a low anterior resection in 2002 because of a Duke's stage D adenocarcinoma of the rectum. In June 2003 she was referred to our department, presenting symptoms and signs of ileus. Abdominal radiograph revealed multiple air-fluid levels, while a computed tomography scan showed disease dissemination. Colonoscopic control verified recurrent disease in the anastomotic area. At surgery, a palliative loop ostomy was generated. In the 4(th) postoperative day it was decided that one unit of pRBCs be transfused. pRBC administration complicated with a severe reaction, developing within 35 minutes of the transfusion episode. The diagnosis of TRALI syndrome was based on clinical signs and symptoms. Hemodynamic stabilization and resuscitation required low doses of epinephrine, diuretics, and a high concentration of inspired oxygen in combination with bronchodilators. Ventilatory assistance was not required. Clinical improvement occurred 12 hours later. Full recovery of the syndrome was observed in 6 days, while chest X-ray returned to normal findings within 4 days. CONCLUSIONS: TRALI syndrome is an immune-mediated transfusion reaction which can cause severe complications or even death. Early diagnosis and treatment improves survival and usually results in full recovery. TRALI remains a clinical diagnosis in an appropriate setting, supported by serologic studies if these are available.