Comparison of Preoperative Evaluation with the Pathological Report in Intraductal Papillary Mucinous Neoplasms: A Single-Center Experience.

The key to the successful management of pancreatic cystic neoplasm (PCN), among which intraductal papillary mucinous neoplasm (IPMN) is the one with the highest risk of advanced neoplasia in resected patients, is a careful combination of clinical, radiological, and histopathological findings. This study aims to perform the comparison of a preoperative evaluation with pathological reports in IPMN and further, to evaluate and compare the diagnostic performance of European evidence-based guidelines on pancreatic cystic neoplasms (EEBGPCN) and Fukuoka Consensus guidelines (FCG). We analyzed 106 consecutive patients diagnosed with different types of PCN, among whom 68 had IPMN diagnosis, at the Clinical Center of Serbia. All the patients diagnosed with IPMNs were stratified concerning the presence of the absolute and relative indications according to EEBGPCN and high-risk stigmata and worrisome features according to FCG. Final histopathology revealed that IPMNs patients were further divided into malignant (50 patients) and benign (18 patients) groups, according to the pathological findings. The preoperative prediction of malignancy according to EEBGPCN criteria was higher than 70% with high sensitivity of at least one absolute or relative indication for resection. The diagnostic performance of FCG was shown as comparable to EEBGPCN. Nevertheless, the value of false-positive rate for surgical resection showed that in some cases, overtreating patients or treating them too early cannot be prevented. A multidisciplinary approach is essential to adequately select patients for the resection considering at the same time both the risks of surgery and malignancy.

Environmental cadmium exposure and pancreatic cancer: Evidence from case control, animal and in vitro studies.

Although profoundly studied, etiology of pancreatic cancer (PC) is still rather scarce. Some of established risk factors of PC are connected to an increased cadmium (Cd) body burden. Hence, the aim of this study was to investigate the role of this environmental pollutant in PC development by conducting human observational, experimental and in vitro studies. The case-control study included 31 patients with a histologically based diagnosis of exocrine PC subjected to radical surgical intervention as cases and 29 accidental fatalities or subjects who died of a nonmalignant illness as controls. Animal study included two treated groups of Wistar rats (15 and 30 mg Cd/kg b.w) and untreated control group, sacrificed 24 h after single oral exposure. In in vitro study pancreas hTERT-HPNE and AsPC-1 cells were exposed to different Cd concentrations corresponding to levels measured in human cancerous pancreatic tissue. Cd content in cancer tissue significantly differed from the content in healthy controls. Odds ratio levels for PC development were 2.79 (95% CI 0.91-8.50) and 3.44 (95% CI 1.19-9.95) in the third and fourth quartiles of Cd distribution, respectively. Animal study confirmed Cd deposition in pancreatic tissue. In vitro studies revealed that Cd produces disturbances in intrinsic pathway of apoptotic activity and the elevation in oxidative stress in pancreatic cells. This study presents three different lines of evidence pointing towards Cd as an agent responsible for the development of PC.

Primary Intestinal Hodgkin Lymphoma Mimicking Intraabdominal Abscess in a Renal Transplant Recipient: A Case Report.

INTRODUCTION: Post-transplant lymphoproliferative disease (PTLD) comprises a variety of lymphoid and plasma cell disorders arising in patients with a solid organ transplant. Monomorphic lymphomas represent the most significant part of this wide spectrum, with the overall risk rising with the aggressiveness of lymphoid proliferation in comparison to the general population. The development of Hodgkin lymphoma is very rare in transplant recipients, comprising less than 6% of all monomorphic PTLD, while cases of primary intestinal Hodgkin lymphoma in these circumstances are anecdotal. CASE REPORT: We describe an exceptional case of intestinal Hodgkin lymphoma mimicking an intra-abdominal abscess that developed in a transplant recipient 19 years after kidney transplantation. By presenting this case, we wish to emphasize the importance of suitable diagnostic pathways in transplant recipients experiencing prolonged fever episodes or masses of unknown origin, thus raising the awareness of possible PTLD development in such patients. CONCLUSION: The lack of information about transplant recipients with Hodgkin PTLD regarding the site of involvement and type of treatment suggests the necessity of conducting larger international studies aimed at providing further insight into this particular group of patients.

Effect of Nutritionally Relevant Doses of Long-Chain N-3 Pufa on Lipid Status, Oxidative Stress and Inflammatory Markers in an Average Middle-Aged Serbian Population.

BACKGROUND: This study investigated the effects of a nutritionally relevant intake of eicosapentaenoic (EPA) and docosahexaenoic (DHA) fatty acids derived from oily fish or a fish oil supplement on selected cardiovascular risk factors in average middle-aged individuals. METHODS: Thirty-three participants were randomized to receive salmon (oily fish) providing 274 mg EPA + 671 mg DHA/day or a commercial fish oil supplement providing 396 mg EPA + 250 mg DHA/day in a cross-over trial over an 8-week period separated by a 6-month washout period. Blood samples were collected before and after each intervention and lipids, inflammatory and oxidative stress parameters were determined. RESULTS: Plasma levels of EPA, DHA and total n-3 fatty acids significantly increased after both interventions. A decreasing trend in triglycerides was more pronounced with salmon than with the fish oil supplement, but the changes noticed were not significant. Although there were no relevant changes in inflammatory marker concentrations at the end of both interventions, significant negative correlations were noticed between total plasma n-3 fatty acids and soluble intercellular adhesion molecule and C-reactive protein throughout the whole intervention period (p<0.05). Among the oxidative stress parameters, intervention with salmon showed a prooxidative effect through a superoxide anion increase (p=0.025). A relevant positive correlation was also found between its concentration and total plasma n-3 fatty acids (p<0.05). Other oxidative stress markers were not significantly influenced by the dietary interventions applied. CONCLUSIONS: Following two sets of recommendations for n-3 fatty acids intake aimed at the general public had only a moderate effect on the selected cardiovascular risk factors in average healthy middle-aged subjects over a short-term period.

Single-incision laparoscopic cholecystectomy--initial experience with different multichannel ports.

Single-incision laparoscopic cholecystectomy is a relatively new minimally invasive surgical technique in treatment of benign gallbladder diseases. It is considered a bridge technique between conventional laparoscopic cholecystectomy (LC) and NOTES. We are presenting our initial experiences in SILC (single-incision laparoscopic cholecystectomy). Seventeen patients underwent SILC (11 women and 6 men) with an average age of 43 years. Mean BMI score was 29,4 kg/m2. The mean operative time was 93,5 minutes. There were conversions to conventional LC in two cases (11,6%). Average pain score measured on visual-analogue scale (VAS) 8 h after the operation was 2,00. All patients expressed satisfaction with achieved cosmetic effect. We conclude that SILC is safe and feasible procedure, with excellent cosmetic effect, but further prospective studies are required before SILC can be generally accepted.

Multiple port-site metastasis of incidental gallbladder carcinoma after laparoscopic cholecystectomy.

Laparoscopic cholecystectomy is a surgical procedure of choice for benign gallbladder diseases. In about 1-2% of cases histopathological examination demonstrate incidental gallbladder cancer (GBCA). We report a case of a 61 year old woman who developed port site metastases after laparoscopic cholecystectomy for adenocarcinoma of the gallbladder. Metastases appeared on all four port sites. Review of literature regarding incidental GBCA an port site metastases was also performed. We conclude that the retrieval bag should be routinely used in laparoscopic cholecystectomy; the procedure should be performed with minimal trauma; in cases of incidental GB carcinoma, full thickness excision of the abdominal wall of the port sites demands additional studies; additional liver bed excision and local lymphadenectomy for T1b carcinoma are yet to be considered.

Gastric adenomyoma.

BACKGROUND: Gastric adenomyoma is a rare, hamartomatous tumor localized most frequently in the gastric antrum. Review of the available literature shows only sporadic reports or smaller series. CASE REPORTS: We presented a 72-year-old woman admitted due to epigastric pain with dyspeptic difficulties. Biochemical parameters and tumor markers were within the referential limits. Diagnostic procedures (upper endoscopy, endoscopic ultrasonography and computerized tomography) revealed an intramural tumor prominence with intact mucosa on the posterior wall of gastric antrum, not accessible for biopsy. Surgical treatment was performed with total extirpation of the tumor. Histopathological examination verified adenomyoma with focal low grade epithelial dysplasia. Cytologic immunophenotype was consistent with smooth muscle stromal and epithelial tumor (CK7 and CK20 ++ immunophenotype). Stromal component revealed low proliferative index (Ki-67 protein immunoexpression level 3%), and p53 less than 0.1% in both epithelial and stromal components. Following the operation, the patient remained in good condition. CONCLUSION: Uncertain malignant potential of the gastric adenomyoma in the presented case indicates that timely diagnostics with adequate surgical treatment is crucial for an adequate treatment.

Is identification of malignant lesions of the liver and of hemangiomas possible by Doppler ultrasonography and radionuclide angiography?

The aim of this study was to try to diagnose malignant liver lesions and hemangiomas by means of vascularisation and perfusion studies. The study was performed in 32 patients with hepatocellular carcinoma (HCC), in 74 with metastatic liver carcinoma (MLC) and in 40 with hemangiomas (H). Color Doppler ultrasonography (DUS) was done with an ATL Ultramark 9 apparatus with convex probe 2.5 MHz using pulse and DUS. Hepatic radionuclide angiography (HRA) was performed with bolus injection of 740 MBq (99m)Tc-pertechnetate, (1 min, 1 f/s), using ROTA scintillation camera and MicroDelta computer. Hepatic perfusion index (HPI) indicated the percentage of the portal blood inflow to the liver. Our results showed that in HCC and MLC there was a decrease of portal inflow while arterial inflow was increased resulting in pulse arterial wave velocity increase and in continuous venous waves velocity in the tumors. There was significant linear correlation between the increase of the arterial inflow and the arterial pulse wave found in the center and in the margin of the tumors. In hemangiomas, hepatic perfusion index related to arterial inflow was within normal range. In conclusion, our results suggest that HCC and MLC have specific characteristics in vascular and/or perfusion studies while hemangiomas show normal liver parenchyma findings.

Spleen cystic echinococcosis: clinical manifestations and treatment.

AIM: The aim of our study was to demonstrate clinical manifestations and diagnostic methods of splenic echinococcosis and suggest surgical approach. METHODS: The study involved 20 patients of previously diagnosed spleen echinococcosis. A diagnosis was made for each patient, based on medical history, biochemical and serological tests, physical examination and abdominal ultrasonography. All the patients received a CT scan of the abdomen. These patients had undergone the following surgery procedures: total splenectomy 13 (60%), and spleen-preserving surgery 7 (35%) patients. Histological examination confirmed the spleen echinoccocosis in all the patients. RESULTS: Nonspecific left upper abdominal pain was present in 10 (50%) cases, while 5 (25%) patients presented with the right upper abdominal pain with dyspepsia and five patients (25%) were asymptomatic. Postoperative complications developed in 2/13 (15.4 %) patients who underwent total splenectomy, while there were no complications after spleen-preserving surgery. CONCLUSION: Spleen-preserving surgery should be undertaken if possible in patients with spleen echinococcosis, and total splenectomy is reserved for the patients with large cysts located centrally or near the hilus.

Liver actinomycosis mimicking liver tumour.

BACKGROUND: The liver actinomycosis is a rare disease associated with complex differentiation from the liver metastases or hepatocellular carcinoma. CASE REPORT: A 50-year-old immunocompetent female patient was admitted to the Surgical Department in an exhausted condition, with dyspnea, significant weight loss and intermittent fever in the recent two months. Diagnostic procedures that followed, including abdominal ultrasound and computed tomography led us to the diagnosis of metastatic liver disease of unknown etiology with pleural and pericardial effusion. Intraoperatively, the presence of liver pseudotumor without malignancy in the liver was confirmed. Histological examination confirmed the diagnosis of liver actinomycosis. Prolonged treatment with high dose penicillin was performed and all signs and symptoms resolved completely without further problems. The control abdominal ultrasond finding was normal. CONCLUSION: Liver actinomycosis has a nonspecific presentation, often mimicking liver tumor. A timely diagnosis as well as a combined surgical and antibiotic therapy is necessary in the treatment of patients with primary disease and prevention of complications.

Study of molecular and granular layer of dentate gyrus of female rats neonatally treated with estrogen.

The proliferation of hippocampal dentate gyrus granule cells was investigated using (3)H-thymidine incorporation in control and estrogen-treated rats. Newborn 3-day old female Wistar rats were treated with a single dose of 1 mg of estradiol and 30 microCi (3)H-thymidine, and were sacrificed when 10 days old. The total number of neurons and the number of labeled granule cells in the granular layer and its subdivisions of both suprapyramidal and infrapyramidal limbs were analyzed using a stereological method. In both limbs, the total number of neurons as well as the total number of labeled granule cells in the granular layer were significantly increased in treated rats compared to corresponding controls. The thicknesses of the molecular and the granular layers and their subdivisions of both suprapyramidal and infrapyramidal limbs were analyzed using a stereological method. In treated female rats the molecular layer (ML) in both limbs was significantly decreased, and the granular layer (GL) was significantly increased in suprapyramidal limb. However, in the infrapyramidal limb an increased number of labeled cells in treated animals were significant in all particular zones of the granular layer. In the suprapyramidal limb's granular layer a significant increase in labeled cells was observed in subgranular zone (SGZ). Our results suggest a differential effect of estradiol on thicknesses of the ML and the GL, and dentate gyrus granule cells proliferation through the early rat life.

Color Doppler sonography and angioscintigraphy in hepatic Hodgkin's lymphoma.

AIM: To estimate the characteristics of Color Doppler findings and the results of hepatic radionuclide angiography (HRA) in secondary Hodgkin's hepatic lymphoma. METHODS: The research included patients with a diagnosis of Hodgkin's lymphoma with metastatic focal lesions in the liver and controls. Morphologic characteristics of focal liver lesions and hemodynamic parameters were examined by pulsed and Color Doppler in the portal, hepatic and splenic veins were examined. Hepatic perfusion index (HPI) estimated by HRA was calculated. RESULTS: In the majority of patients, hepatomegaly was observed. Lesions were mostly hypoechoic and mixed, solitary or multiple. Some of the patients presented with dilated splenic veins and hepatofugal blood flow. A pulse wave was registered in the centre and at the margins of lymphoma. The average velocity of the pulse wave was higher at the margins (P > 0.05). A continuous venous wave was found only at the margins of lymphoma. There was no linear correlation between lymphoma size and velocity of pulse and continuous wave (r = 390, P < 0.01). HPI was significantly lower in patients with lymphomas than in controls (P < 0.05), pointing out increased arterial perfusion in comparison to portal perfusion. CONCLUSION: Color Doppler ultrasonography is a sensitive method for the detection of neovascularization in Hodgkin's hepatic lymphoma and estimation of its intensity. Hepatic radionuclide angiography can additionally help in the assessment of vascularisation of liver lesions.

A study of pulmonary embolism after abdominal surgery in patients undergoing prophylaxis.

AIM: To determine risk factors for pulmonary embolism and estimate effects and benefits of prophylaxis. METHODS: We included 78 patients who died subsequently to a pulmonary embolism after major abdominal surgery from 1985 to 2003. A first, retrospective analysis involved 41 patients who underwent elective surgery between 1985 and 1990 without receiving any prophylaxis. In the prospectively evaluated subgroup, 37 patients undergoing major surgery between 1991 and 2003 were enrolled: all of them had received a prophylaxis consisting in low-molecular weight heparin, given subcutaneously at a dose of 2850 IU AXa/0.3 mL (body weight < 50 kg) or 5700 IU AXa/0.6 mL (body weight > or = 50 kg). RESULTS: A higher incidence of thromboembolism (43.9% and 46.34% in the two groups, respectively) was found in older patients (> 60 years). The incidence of pulmonary embolism after major abdominal surgery in patients who had received the prophylaxis was significantly lower compared to the subjects with the same condition who had not received any prophylaxis (P < 0.001, OR = 2.825; 95% CI, 1.811-4.408). Furthermore, the incidence of pulmonary embolism after colorectal cancer surgery was significantly higher compared to incidence of pulmonary embolism after other abdominal surgical procedures. Finally, the incidence of pulmonary embolism after colorectal cancer surgery among the patients who had received the prophylaxis (11/4316, 0.26%) was significantly lower compared to subjects undergoing a surgical procedure for the same indication but without prophylaxis (10/1562, 0.64%) (P < 0.05, OR = 2.522; 95% CI, 1.069-5.949). CONCLUSION: Prophylaxis with low molecular weight heparin is highly recommended during the preoperative period in patients with diagnosis of colorectal cancer due to high risk of pulmonary embolism after elective surgery.

[Mental disorders in patients with acute necrotic pancreatitis].

INTRODUCTION: The prognosis of patients with acute pancreatitis is still uncertain regardless of modern therapeutic procedures. It is even more emphasized if the acute pancreatitis is followed by psychic disorders. OBJECTIVE: The aim of the study was to provide an overview of the incidence of certain psychosomatic disorders in patients with acute pancreatitis and evaluate priority therapeutic procedures. METHOD: In this study, we analysed 16 patients with psychosomatic disorders followed by the episode of acute pancreatitis among 202 patients that were hospitalized in the period from 1993 until 2000. The diagnosis was based on anamnesis, clinical and laboratory findings and diagnostic procedures such as X-ray, US, CT and MRI. RESULTS: Among 16 patients with psychosomatic disorders followed by acute pancreatitis, 13 (81.25%) patients were operated on and 3 (18.75%) patients were medically treated. 6 patients experienced hallucinations, 5 memory deficiency, 16 disorientation and 14 confabulation. CONCLUSION: Psychosomatic disorders in patients with acute pancreatitis require complex medical treatment. Due to the already mentioned complications, the management of these conditions is very difficult and with uncertain results.

Depression and anxiety levels in therapy-naive patients with inflammatory bowel disease and cancer of the colon.

AIM: To assess whether depression and anxiety are more expressed in patients with the first episode of inflammatory bowel disease (IBD) than in individuals with newly discovered cancer of the colon (CCa). METHODS: A total of 32 patients with IBD including 13 males and 19 females, aged 27 to 74, and 30 patients with CCa including 20 males and 10 females, aged 39-78, underwent a structured interview, which comprised Hamilton's Depression Rating Inventory, Hamilton's Anxiety Rating Inventory and Paykel's Stressful Events Rating Scale. RESULTS: Patients of the IBD group expressed both depression and anxiety. Depressive mood, sense of guilt, psychomotor retardation and somatic anxiety were also more pronounced in IBD patients. The discriminant function analysis revealed the total depressive score was of high importance for the classification of a newly diagnosed patient into one of the groups. CONCLUSION: Newly diagnosed patients with IBD have higher levels of depression and anxiety. Moreover, a psychiatrist in the treatment team is advisable from the beginning.

Spontaneous gastrojejunal fistula is a complication of gastric ulcer.

Spontaneous gastrojejunal fistula formation is an extremely rare complication of gastric ulcer disease. We report a 77-year old woman who presented with diffuse abdominal pain, weight loss, malaise, nausea, and occasional dark stools. Laboratory tests showed extreme hyposideremic anemia with inflammatory syndrome. In addition, biochemical parameters of malnourishment were presented. Upper endoscopy revealed the patent esophagus along the full length without any pathological changes. Large and deep ulceration with perforation in the small intestine was detected in the posterior gastric wall. The small intestine loop was reached by endoscope through spontaneously developed gastrojejunal fistula. Polytopic biopsies of described ulcerative change were carried out. Histopathologically reepithelialized ulcerous zone was seen in the gastric mucosa. Also, gastrojejunal fistula was visualized after wide opening of hepatogastric and gastrocolic ligament. Jejunal loop 25 cm from ligament of Treitz was attached to mesocolon and posterior gastric wall because of ulcer penetration. Postoperative course was uneventful. Per oral intake started on the 4(th) postoperative day, and the patient was discharged on the 8(th) postoperative day. In summary, this case indicates that persistent symptoms of peptic ulcer disease associated with nutritional disturbances may be caused by gastrojejunal fistula.

Spontaneous splenorenal shunt in a patient with liver cirrhosis and hypertrophic caudal lobe.

Spontaneous splenorenal shunt is a rare condition, sometimes causing complications in cirrhotic patients. We report a 30-year old man with liver cirrhosis, hypertrophic caudal lobe and spontaneous splenorenal shunt. Real-time and color Doppler ultrasonography evidenced enlarged caudal lobe (130 x 95 mm) with direct veins draining into dilated inferior cava vein (diameter 25 mm, flow 52 cm/sec). In the left renal hilus a large vein with a flow typical for portal vein system was found, velocity 25-37 cm/sec. Indirect splenoportography noticed splenomegaly, dilated lienal and portal vein with hepatopetal blood flow, perisplenic varices, and large spontaneous splenorenal shunt. Whole inferior caval vein was dilated, while hepatic veins were intact. Hemodynamic consequences of this large shunt were dilation of inferior cava vein with hyperkinetic systemic flow, and secondary hypertrophy of liver caudal lobe.

[Surgical treatment of pain in chronic pancreatitis].

INTRODUCTION: The principal indication for surgical intervention in chronic pancreatitis is intractable pain. Depending upon the presence of dilated pancreatic ductal system, pancreatic duct drainage procedures and different kinds of pancreatic resections are applied. OBJECTIVE: The objective of the study was to show the most appropriate procedure to gain the most possible benefits in dependence of type of pathohistological process in chronic pancreatitis. METHOD: Our study included 58 patients with intractable pain caused by chronic pancreatitis of alcoholic genesis. The first group consisted of 30 patients with dilated pancreatic ductal system more than 10 mm. The second group involved 28 patients without dilated pancreatic ductal system. Pain relief, weight gain and glucose tolerance were monitored. RESULTS: All patients of Group I (30) underwent latero-lateral pancreaticojejunal--Puestow operation. 80% of patients had no pain after 6 month, 13.6% had rare pain and 2 patients, i.e. 6.4%, who continued to consume alcohol, had strong pain. Group II consisting of 28 patients was without dilated pancreatic ductal system. This group was subjected to various types of pancreatic resections. Whipple procedure (W) was done in 6 patients, pylorus preserving Whipple (PPW) in 7 cases, and duodenum preserving cephalic pancreatectomy (DPCP) was performed in 15 patients. Generally, 89.2% of patients had no pain 6 month after the operation. An average weight gain was 1.9 kg in W group, 2.8 kg in PPW group and 4.1 kg in DPCP group. Insulin-dependent diabetes was recorded in 66.6% in W group, 57.1% in PPW group and 0% in DPCP group. CONCLUSION: According to our opinion, DPCP may be considered the procedure of choice for surgical treatment of pain in chronic pancreatitis in patients without dilatation of pancreas ductal system because of no serious postoperative metabolic consequences.

Bulk agent Plantago ovata after Milligan-Morgan hemorrhoidectomy with Ligasure.

The aim of this study was to determine usefulness of the bulk agent Plantago ovata in reducing postoperative pain and tenesmus after open hemorrhoidectomy (Milligan-Morgan with Ligasure). Ninety-eight patients were randomized into two groups of 49 patients each. In both groups Milligan-Morgan open hemorrhoidectomy with Ligasure was performed. The first group received postoperatively two sachets daily of 3.26 g of the bulk agent, Plantago ovata, for 20 days. The control group was treated postoperatively with glycerin oil. There was no statistically significant difference in age, gender distribution and hemorrhoid grading, between the two groups. The pain score after first defecation (p < 0.001) and after 10 days (p < 0.01) and the global pain score (p < 0.001) was statistically significantly lower in the group treated with Plantago ovata, while there was no statistically significant difference in the pain level after 20 days (p > 0.05). The hospital stay was statistically significantly shorter in the group receiving Plantago ovata (2.6 +/- 0.6 vs 3.9 +/- 0.7 days, p < 0.001). The incidence of tenesmus was higher in the control group (40.8% vs 10.2%, p < 0.01). Treating patients with Plantago ovata after open hemorrhoidectomy, reduces pain, tenesmus rate and shortens postoperative hospital stay.