Acute diverticulitis in patients under 50 years of age.

Acute diverticulitis typically occurs in patients over 80 years old. The last five years we observed an increased incidence of acute diverticulitis in patients under 50 years. The aim of this study is to evaluate the increased rate of patients under 50 years that are hospitalized due to acute diverticulitis. Also, we aim to confirm the common symptoms for this disease and the laboratory data, the changes in dietary history (Mediterranean diet) and lifestyle and to calculate the differences in the treatment and the severity in the course of the disease, between younger (<50) and older (>50) patients. PATIENTS AND METHODS: From 2003 to 2008, 118 patients were admitted to our Surgical Department for acute diverticulitis. 32 patients were under 50 years old. In the next five year period (2008-2013) the number of patients under 50 that were admitted due to acute diverticulitis doubled to 183 with 102 patients being over 50 years and 61 patients under 50. For all these patients, the medical and dietary history, laboratory and clinical examinations, radiographic and endoscopic findings were recorded. RESULTS: For patients aged over 50 years there is a predominance in male sex. Symptoms were the same in both groups and no difference in treatment was noted. Furthermore, readmission and recurrence rates were the same for both groups. The condition was equally aggressive in both groups. The only difference observed was increased obesity rate for patients under 50 and variation from the traditional Mediterranean diet to western diet habits. CONCLUSIONS: Although our study has limitations it seems that new cases of diverticular disease in patients have increased due to dietary changes, but treatment and severity have remained the same.

Necrotizing fasciitis associated with primary cutaneous B-cell lymphoma. A case report.

Necrotizing fasciitis is a rapidly progressive and life-threatening infection of the deeper skin layers and subcutaneous tissues that moves along the facial planes. OBJECTIVES: We present the rare case of a patient with necrotizing fasciitis associated with high malignancy b-cell lymphoma. Our purpose is to investigate the probable connection between the two pathologies and evaluate the importance of early surgical intervention. CASE REPORT: 51-year old Caucasian woman presented at the E.R. with history of a painful left thigh over a week and fever up to 38,4°C over the last three days. Necrosis of the soft tissues and fascial planes were observed clinically. After the initial treatment and due to the patient's multiple organ dysfunction (septic shock), she was transferred to the ICU were she was intubated resuscitated with IV fluids and given IV antibiotics. 24 hours after the admission it was decided that the patient should undergo surgery and an extensive debridement of the necrotic area was performed. The antibiogram of the blood culture revealed streptococcus pyogenes and she was administered penicillin while intubated and monitored in the ICU until the seventh postoperative day. On the eighth post-day she was transferred back to the surgical department, hemodynamically normal and stable. She was discharged one month later and she was referred to a plastic surgery center for the final reconstruction surgery. CONCLUSIONS: This case highlights that the high index of suspicion and the early aggressive surgical intervention seems to be very critical to improve survival of the patients with necrotizing fasciitis.

Primary small bowel melanoma. A case report and a review of the literature.

Primary malignant melanoma originating from the small intestine is extremely rare. Only a limited number of cases are described in the literature. Most commonly small intestine is affected by metastatic tumors from other primary lesions. We present a case of a 68-years old male diagnosed with primary malignant melanoma as an ulcerated and bleeding mass in the jejunum--located 40 cm away from the Treitz band. In our case the diagnosis was confirmed at laparotomy and enterectomy. Histology revealed a neoplastic infiltration involving the entire intestinal mucosa, with atypia of neoplastic cells and immunoreactivity to HMB45(+), Melan A(+) and S100(+), confirming the diagnosis of melanoma. There was not revealed a primary lesion in the skin, eye, anus, rectum or in other location by the post-operative investigation. An eleven-month close follow-up has not revealed any metastasis. Therefore a definitive diagnosis of primary malignant melanoma was set.

Computation of repetitions and regularities of biologically weighted sequences.

Biological weighted sequences are used extensively in molecular biology as profiles for protein families, in the representation of binding sites and often for the representation of sequences produced by a shotgun sequencing strategy. In this paper, we address three fundamental problems in the area of biologically weighted sequences: (i) computation of repetitions, (ii) pattern matching, and (iii) computation of regularities. Our algorithms can be used as basic building blocks for more sophisticated algorithms applied on weighted sequences.

Axillary lymphadenectomy for breast cancer - the influence of shoulder mobilisation on lymphatic drainage.

AIM: The purpose of the present study was to study the influence of external axillary compression dressing with immobilisation of the ipsilateral shoulder after axillary lymph node dissection (ALND) on postoperative axillary drainage. METHODS: One hundred consecutive women with breast cancer undergoing ALND were enrolled in this study. They were allowed free shoulder movement and were compared with a matched historical control group of 60 patients, in whom the ipsilateral arm was immobilised for four days. For all patients the amount of drainage was recorded each postoperative day until drain removal. Prognostic data on drainage amounts and duration were gathered from all patients. Complications were recorded. RESULTS: Hospital stay was the only statistically significant difference between the two groups, it was prolonged for patients with immobilisation of the arm. The parameters found to influence the drain production with a statistically significant difference were body mass index and the removal of more than 10 lymph nodes. Postoperative complications were similar in both groups. CONCLUSIONS: External compression dressing of the axillary cavity with immobilisation of the ipsilateral arm has no impact on the postoperative drainage volume and duration. It is associated with adverse effects, such as discomfort, prolonged hospital stay and shoulder stiffness.

Salvage chemotherapy with high-dose leucovorin (LV) and 48-hour continuous infusion (CI) of 5-fluorouracil (5-FU) in combination with conventional doses of cyclophosphamide (CPM) in patients with metastatic breast cancer (MBC) pretreated with anthracycline and taxanes.

The purpose of this study was to evaluate the activity and tolerance of high-dose leucovorin (LV) and infusional 5-fluorouracil (5-FU) in combination with conventional doses of cyclophosphamide (CPM) as salvage chemotherapy in patients with metastatic breast cancer (MBC) pretreated with anthracyclines and taxanes. 41 patients (median age 59 years) with MBC refractory or resistant to anthracyclines and taxanes were enrolled. The patients' performance status (WHO) was 0 in 10 patients (24%), 1 in 22 (54%), and 2 in 9 (22%). 30 (73%) patients had received 2 or more prior chemotherapy regimens. Cyclophosphamide (600 mg m(-2)) was given i.v. bolus on day 1 and LV (500 mg m(-2) d(-1)) as a 2-h infusion followed by 5-FU (1.5 g m(-2) d(-1)) over a 22 h c.i. for 2 consecutive days. Cyclophosphamide was administered every 28 days while 5-FU/LV every 14 days. In an intention-to-treat analysis, complete response (CR) was achieved in 2 (4.9%) patients and partial response (PR) in 9 (22%) (overall response rate 26.9%; 95% CI: 13.27-40.39%). Stable disease (SD) and progressive disease (PD) were observed in 9 (22%) and 21 (51%) patients, respectively. The overall response rate was 6% and 40% in patients with primary and secondary resistance to anthracyclines/taxanes, respectively (P = 0.047). The median duration of response and the median time to disease progression was 8 and 9.5 months, respectively. The median overall survival was 13 months and the probability for 1-year survival 51%. Grade 3/4 neutropenia occurred in 9 (22%) patients and 4 (9%) patients developed grade 3/4 thrombocytopenia. Non-haematological toxicity was mild. There were no cases of febrile neutropenia, toxic deaths or treatment-related hospital admissions due to toxicity. The combination of high-dose 5-FU/LV with conventional doses of cyclophosphamide is a well tolerated and effective salvage regimen in patients with MBC heavily pretreated with both anthracyclines and taxanes.

Obesity-associated disorders before and after weight reduction by vertical banded gastroplasty in morbidly vs super obese individuals.

BACKGROUND: The amount of excess weight which must be lost in order to cure or to improve disorders associated with obesity remains unknown. This study was designed to compare super obese and morbidly obese patients in terms of weight reduction following VBG and to investigate the effects of postoperative weight changes to preexisting co-morbidities. METHODS: 125 patients underwent VBG. Group A consisted of 80 morbidly obese patients (64%) and group B consisted of 45 super obese patients (36%). Preoperative examination was planned to identify and determine the severity of any disorders associated with obesity, that the patients may have had. Following VBG, all patients were followed-up at regular time periods, for at least 2 and up to 4 years. The progress of preexisting co-morbidities was evaluated and carefully recorded. RESULTS: Among the 80 patients of Group A, there were 240 total co-morbidities (3 per patient), and in group B there were 196 co-morbidities (4.35 per patient) preoperatively. Dyspnea during fatigue and arthritis were found at statistically higher incidence in the super obese category. At the end of the second postoperative year, greater weight loss in terms of number kilograms was seen in patients in group B, but these patients did not reach a BMI lower than 35, while patients in group A had mean BMI below 30. In group A, 66% of the co-morbidities completely resolved, 19% significantly diminished and 15% remain unchanged. In group B, the respective percentages were 53%, 27.5% and 19.5%. However, after weight reduction by VBG a significant number of co-morbidities remain in the super obese patients (92 or 2.044 per/patient), and this is believed to be due to the greater remaining excess weight. CONCLUSION: Reduction of body weight by VBG is associated with resolution or improvement of a significant number of the obesity-associated disorders. However, super obese patients remain obese after surgery, and this results in two-fold higher remaining morbidity.

A dose-finding study of the weekly administration of paclitaxel in patients with advanced solid tumors.

The purpose of this study was to determine the dose-limiting toxicities and the maximum-tolerated dose (MTD) of weekly administration of paclitaxel in patients with advanced solid tumors. Twenty-six patients with advanced solid tumors were treated with escalated doses of paclitaxel (starting dose 70 mg/m(2)/wk with increments of 10 mg/m(2)/wk) for 4 consecutive weeks every 6 weeks. No intrapatient escalation or growth factor support was allowed. The DLT was exceeded at the dose of 120 mg/m(2)/wk, and the dose-limiting events were grade IV neutropenia and treatment delay because of incomplete hematologic recovery. There was no cumulative myelosuppression. Grade IV neutropenia occurred in four (6%) cycles, and there was one episode of febrile neutropenia. Grade II/III fatigue occurred in 19 (73%) patients, resulting in discontinuation of treatment in 2 of them; grade II neurosensory toxicity and grade II alopecia occurred in 8 (31%) patients each. The MTD, which is also the recommended dose for further phase II studies, was 110 mg/m(2)/wk. Among the 21 patients with bidimensionally measurable disease, 2 (10%) partial responses were observed, both in patients with heavily pretreated advanced breast cancer. The weekly administration of paclitaxel for 4 consecutive weeks in cycles of 6 weeks is a feasible, safe, and active outpatient regimen that merits further evaluation in combination with other anticancer agents.

Treatment of malignancy arising in pilonidal disease.

BACKGROUND: Malignant degeneration is a rare complication of pilonidal disease and is associated with a high recurrence rate and poor prognosis compared with regular nonmelanoma skin cancer. Treatment in our departments and in the international literature was evaluated. METHODS: We analyzed the data from three patients with malignant degeneration who were treated in our departments and an additional 56 patients who were found after an extensive literature search. RESULTS: A total of 47 males and 12 females, with a mean age of 52 years, were most frequently primarily treated with surgery. After a mean follow-up time of 28 months, 20% of all patients died with evidence of disease and an additional 10% died of unrelated causes. The overall recurrence rate was 39%, with a median time to recurrence of only 9 months. The local recurrence rate was lower when radiotherapy was added to surgical treatment alone (30% vs. 44%). Re-excision of local recurrence resulted in some long-term survivals. CONCLUSIONS: Early diagnosis and treatment may lead to improvement of the relative poor prognosis. Surgical treatment should be tailored according to the locoregional extent. The high recurrence rate after surgical treatment can be reduced by the addition of radiotherapy. Although repeat surgery for recurrent disease may involve extensive resection and morbidity, this may result in prolonged survival.

Malignant peritoneal mesothelioma treated by continuous hyperthermic peritoneal perfusion chemotherapy.

Malignant mesothelioma of the peritoneum is a rare tumour for which the therapeutic approach has not yet been standardized. The efficacy of the current regimes is limited. Effective locoregional therapy is crucial, since this tumour is most often confined to the peritoneal cavity at the time of the initial diagnosis and remains there for much of its clinical course. If and when haematogenous metastases occur, they rarely contribute to the death of the patient, which is often caused by the overgrowth of the primary tumour and its local complications. A case of diffuse malignant peritoneal mesothelioma treated by cytoreductive surgery and continuous hyperthermic peritoneal perfusion with cisplatin is reported. The patient received systemic combination chemotherapy postoperatively. She is in good condition and free of disease 28 months after her treatment. Continuous hyperthermic peritoneal perfusion chemotherapy has recently been used in patients with secondary peritoneal carcinomatosis from digestive and gynecological malignancies with promising results. It is also possible that the same treatment alone or in combination with systemic chemotherapy may be effective in the treatment of primary peritoneal malignancies, as in the case of diffuse peritoneal mesothelioma.

Continuous spinal anesthesia/analgesia for perioperative management of morbidly obese patients undergoing laparotomy for gastroplastic surgery.

BACKGROUND: The authors determined prospectively the safety of continuous spinal anesthesia combined with general anesthesia and the efficacy of postoperative pain relief with continuous spinal analgesia for morbidly obese patients undergoing vertical banded gastroplasty. METHODS: 27 patients (13 men, 14 women) with a mean body mass index (BMI) of 50.4 +/- 7.8 and several co-morbidities were studied. All patients were anesthetized with the same anesthetic regimen, which included midazolam, fentanyl, propofol, muscle relaxants, nitrous oxide, isoflurane and intrathecal bupivacaine. Postoperative pain relief was provided for 5 days and all patients received the same regimen, which included intrathecal bupivacaine, fentanyl and intravenous tenoxicam. The intrathecal analgesic regimen was administered continuously through a pump which had the facility of providing bolus doses when requested in predetermined lockout intervals. Intra-operative monitoring included hemodynamic and respiratory parameters. Additional postoperative monitoring included respiratory rate, degree of sedation, sensory level of anesthesia, motor response and intensity of pain. RESULTS: Intraoperative anesthetic technique was safe and provided satisfactory results in the immediate postoperative period. Furthermore, the postoperative analgesia regimen provided effective analgesia in all patients. The mean doses of fentanyl and bupivacaine infused intrathecally for the first 24 postoperative hours were 14.1 +/- 2.0 microg.h(1) and 0.7 +/- 0.1 mg.h(1) respectively, while the requirements of analgesia decreased progressively with time. The technique provided effective analgesia with low pain scores, which was reflected by ease in mobilizing and performing physical exercises with the physiotherapist. Only minor complications related to anesthesia and analgesia were encountered. CONCLUSION: To our knowledge, this technique of anesthesia and postoperative analgesia has not been described before in morbidly obese patients. This regimen merits further controlled trials to establish its place in the perioperative management of morbidly obese patients.

Disorders associated with clinically severe obesity: significant improvement after surgical weight reduction.

BACKGROUND: Surgical treatment for patients with clinically severe obesity mainly aims to reduce morbidity. METHODS: Sixty-two patients were examined for disorders associated with morbid obesity before and after surgical weight reduction by vertical banded gastroplasty. All patients were followed-up for 12 to 48 months. RESULTS: At the end of the first postoperative year, 84% of the patients had lost at least 50% of their excess weight. Of the 218 weight-related pathologic conditions existing before the operation, 131 (60%) were completely cured, 50 (23%) showed significant improvement, and only 37 (17%) remained unchanged. The same percentages were obtained for patients followed tip for 24, 36, and 48 postoperative months. CONCLUSIONS: Surgical treatment of clinically severe obesity has a significant effect on the health of the patients by eliminating the associated disorders.

The clinical significance of acquired jejunoileal diverticula.

OBJECTIVE: Because of the relative rarity of acquired jejunoileal diverticulosis, including its symptomatology and complications, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. The purpose of the present study was to draw attention to jejunoileal diverticula and their complications as a site of gastrointestinal symptoms. METHODS: The records of 10 patients with symptomatic jejunoileal diverticula treated in our departments were reviewed. RESULTS: The clinical presentation was varying and nonspecific. Jejunoileal diverticula were diagnosed peroperatively in four patients operated on successfully for their acute complications. In one case the diagnosis was considered after a radiotargeted erythrocyte bleeding scan and in five other cases enteroclysis for chronic abdominal complaints demonstrated jejunoileal diverticula. The death of one patient operated on for massive hemorrhage from jejunal diverticula was probably related to delayed diagnosis and treatment. CONCLUSIONS: Jejunoileal diverticula should not always be dismissed as asymptomatic findings, as they may be the cause of vague, chronic symptomatology and acute complications, including intestinal obstruction, hemorrhage, and perforation. Awareness of the fact that jejunoileal diverticula may cause chronic nonspecific abdominal symptoms and serious acute complications may lead to earlier diagnosis and timely treatment with lower morbidity and mortality.

Cysts of the adrenal gland: diagnosis and management.

OBJECTIVE: Cysts of the adrenal gland are rare, but with the wider application of sonography and computed tomography more adrenal cysts are detected incidentally. To gain more insight into this entity, five such cases are reported and their diagnostic approach and management are discussed. PATIENTS AND METHODS: The records of five patients with six cysts of the adrenal glands seen at our department from 1987 till 1995 are reviewed. There were four males and one female and their age ranged from 24 to 72 years, with a mean age of 43 years. One patient had a primary hydatid cyst of the right adrenal gland, which was preoperatively thought to arise from the liver or the right kidney. A second patient had a very large pseudocyst of the left adrenal gland, which is the largest ever reported in the literature. The other four cysts in three patients were found incidentally during sonography or computed tomography. RESULTS: The hydatid cyst with a rim of normal adrenal tissue was excised. The large pseudocyst was removed together with the adrenal gland. In the cases of the incidentally found cysts, observation of the patient with regular follow-up was decided upon. All patients are in good condition and without symptoms 2 to 10 years after the initial diagnosis. CONCLUSIONS: Adrenal cysts are rare and their diagnosis may pose problems. Symptomatic adrenal cysts should be operated, but small, asymptomatic, non-functional cysts with benign characteristics may be treated conservatively with regular follow-up by sonography or computed tomography and hormonal evaluation.

Splenic abscess: a diagnostic and therapeutic challenge.

The records of five patients treated in our department for splenic abscess are analysed and the literature is reviewed. Computed tomography revealed the correct diagnosis in all patients, while clinical presentation was often nonspecific. Spleen-preserving management was possible in two patients (40%). Outcome was uneventful for four patients. One patient with a splenic abscess caused by Mycobacterium tuberculosis and acquired immunodeficiency syndrome, died 4 months after splenectomy from sepsis. We discuss the clinical presentation of splenic abscess, its diagnostic approach, and treatment. Additionally, we studied whether spleen-preserving management is feasible or not.

Acute intestinal obstruction caused by endometriosis mimicking sigmoid carcinoma.

Endometriosis is a relatively frequent disease in fertile women. The intestine is involved in 12-37% of cases. Intestinal endometriosis is usually asymptomatic and complete obstruction of the bowel lumen occurs in less than 1% of cases. We report a case of endometriosis of the sigmoid, which caused complete intestinal obstruction and mimicked carcinoma of the sigmoid colon. This case demonstrates the difficulty of establishing an accurate pre- and peroperative diagnosis and the propensity of intestinal endometriosis to mimic colon cancer.

Does draining the neck affect morbidity following thyroid surgery?

A prospective randomized study questioning the benefit of neck drainage in thyroid surgery is presented. Two hundred consecutive patients, candidates for elective thyroid surgery, were randomized into Group A (no drain) and Group B (drain). Reoperation for bleeding was necessary for two patients of Group A and for one patient in Group B. Minor hematomas occurred in seven patients from Group A and five patients from Group B; wound infection occurred in two and four patients in Groups A and B, respectively; and lymphatic discharge occurred in two patients from Group B. These differences were not statistically different. The present study failed to demonstrate any protective value from the use of drains. However, the hospital stay was shorter and pain scores were smaller in the non-drain Group A.

Staple-line disruption following vertical banded gastroplasty.

BACKGROUND: The purpose of this study was to determine the frequency with which staple-line disruption occurs following vertical banded gastroplasty (VBG) in morbidly obese patients, to investigate the effect of this complication on weight loss, and to identify any clinical symptoms that might be associated with staple-line disruption. METHODS: From April of 1992 to June of 1994, 60 patients with morbid obesity underwent VBG. Double-contrast radiographic examination of the upper gastrointestinal tract was performed on all patients at 6, 12, 24, and 36 months postoperation to assess the integrity of the staple line. At these same times, the weight of each patient was measured, so that the patients found to have staple-line disruption could be compared to those without disruption in terms of weight loss. RESULTS: Over the duration of the study, staple-line disruption was found in 12 patients (20%). All of these patients demonstrated satisfactory weight loss. Between the group of patients with staple-line disruption versus the group without disruption, weight loss did not differ significantly at any time up to 3 years postoperation. In addition, in the patients with staple-line disruption, no clear symptomatology that might be associated with this complication was discovered. CONCLUSIONS: Our results lead to the conclusion that small disruptions in the staple line lack clinical importance and do not significantly affect weight loss for at least the first 3 postoperative years. Furthermore, staple-line disruption does not seem to be associated with any specific clinical symptoms. Follow-up of all patients via barium meal is the correct approach for discovering the exact incidence of this complication.

Primary angiosarcoma of the breast.

We report a case of a 44-year-old woman with primary angiosarcoma of the left breast. An excisional biopsy was performed initially and the mass was interpreted as angiosarcoma. The pre-operative staging provided no evidence of metastasis. The patient then underwent a left mastectomy with the placement of an expandable prosthesis. For 3 months the prosthesis was progressively expanded to the desired size and it was then replaced with a permanent one. Primary angiosarcoma of the breast is a rare and often misdiagnosed disease. Treatment options are numerous and conflicting. The diagnostic approach and treatment options from the literature are presented and discussed.