Pheochromocytoma crisis presenting with cardiogenic shock.

Pheochromocytoma is a catecholamine-secreting tumor of the adrenal glands whose typical presentation includes the triad of headache, palpitations, and diaphoresis. Pheochromocytoma crisis is an urgent medical condition whose diagnosis and management constitute a challenge for physicians. We present the case of a 55-year-old man who developed cardiogenic shock in the setting of a pheochromocytoma crisis. After stabilizing blood pressure with combined administration of α- and ß-blockers, the tumor was surgically removed. Our diagnostic and therapeutic challenges are discussed.

Giant malignant phyllodes tumor with distant metastases: a case report and review of the literature.

BACKGROUND: Phyllodes tumors (PTs) represent a rare type of breast tumor and are classified into benign, borderline, and malignant. Giant PTs, meaning those sized more than ten cm, are even rarer, most commonly malignant, and usually have a dismal prognosis due to the high metastatic potential. CASE REPORT: We report the case of a 55-year-old woman who underwent modified radical mastectomy and left axillary lymphadenectomy for a rapidly growing, giant, ulcerated mass of the left breast. Histopathologic examination revealed a malignant phyllodes tumor (MPT). Over one year after the initial surgery, the patient was found to have extensive thoracic and retroperitoneal metastases. CONCLUSION: Although giant PTs are uncommon, clinical suspicion should be high in rapidly growing breast mass patients. A comprehensive review of all metastatic giant MPT cases reported in the English literature emphasizes the lack of consensus regarding appropriate treatment. In the case of metastatic foci, pathologists need to be aware of the previous history to make a definitive diagnosis. Also, a comparative histopathologic study of the primary and metastatic tumors is sometimes necessary. HIPPOKRATIA 2022, 26 (1):41-45.

A retrospective analysis of 2000 cases with colorectal carcinoma.

PURPOSE: Colorectal cancer (CRC) is a major cause of death in the western world and a leading cause of cancer-related death. It is one of the most common human malignancies with >300,000 cases both in the United States and in the European Union each year. The present study was conducted to assess differences in various variables of CRC, such as location of the tumor, differentiation, Dukes classification, 5-year survival and possible changes in these patterns during the examined period. METHODS: We collected data on 2000 patients with colorectal cancer, diagnosed and treated from 1960 to 2008 in 1st Propedeutic Surgical Clinic of Aristotle's University, Thessaloniki. RESULTS: Of 2000 cases reviewed, cancer was almost equal presented to both sexes, for all groups. Rectum was the most common tumor location in all analyzed groups (40.1%). The most common tumor differentiation was the moderate one (68.5%). Concerning tumor staging, Dukes' B tumors were most common (42.5%), and the cancer-related 5-year survival was increased by the time from 42 to 71%. CONCLUSION: In the past 20 years, considerable improvements have been made in colorectal cancer therapy, and patients had received more sophisticated and multidisciplinary treatments, resulting in a better 5-year survival rate.

Gossypiboma presenting as mesosigmoid abscess [corrected].

INTRODUCTION: The term "gossypiboma" is used to describe any mass of non-absorbable surgical material. It is estimated that this complication appears every 1.000-10.000 procedures. It may lead to peritonitis, acute abdominal pain, intraperitoneal abscess, bowel obstruction, or perforation. REPORT OF A CASE: We present the case of an 80-year-old female patient admitted for chronic abdominal pain and fever. A CT scan and MRI were performed with a probable diagnosis of carcinoma or pelvic abscess. A surgical history of hysterectomy and repair of abdominal wall hernia with a mesh were mentioned. RESULTS: Exploratory laparotomy revealed the presence of an irregular, soft mass with characteristics of an abscess located into the mesosigmoid. Hartman's sigmoidectomy was performed, and the patient's postoperative course was uneventful. The histopathological examination confirmed the diagnosis of gossypiboma. CONCLUSIONS: Retained foreign intraperitoneal materials often represent diagnostic dilemmas, since symptomatology is no specific and the time elapsed from surgery is long. The policy of prevention's importance is highly appreciated.

Surgical management of colorectal injuries: colostomy or primary repair?

PURPOSE: Several factors have been considered important for the decision between diversion and primary repair in the surgical management of colorectal injuries. The aim of this study is to clarify whether patients with colorectal injuries need diversion or not. METHODS: From 2008 to 2010, ten patients with colorectal injuries were surgically treated by primary repair or by a staged repair. RESULTS: The patients were five men and five women, with median age 40 years (20-55). Two men and two women had rectal injuries, while 6 patients had colon injuries. The mechanism of trauma in two patients was firearm injuries, in two patients was a stab injury, in four patients was a motor vehicle accident, in one woman was iatrogenic injury during vaginal delivery, and one case was the transanal foreign body insertion. Primary repair was possible in six patients, while diversion was necessary in four patients. CONCLUSIONS: Primary repair should be attempted in the initial surgical management of all penetrating colon and intraperitoneal rectal injuries. Diversion of colonic injuries should only be considered if the colon tissue itself is inappropriate for repair due to severe edema or ischemia. The role of diversion in the management of unrepaired extraperitoneal rectal injuries and in cases with anal sphincter injuries is mandatory.

Inflammation of solitary caecal diverticula:a rare aetiology of acute abdominal pain [corrected].

Caecal diverticula are rare, representing the 3.6% of colonic diverticula. They may have congenital origin and remain asymptomatic, presenting as an accidental finding. We present a case of a 42-year-old Caucasian woman, admitted with a 12-h history of sudden onset of sharp right iliac fossa pain, anorexia, and nausea. There was leukocytosis (23.49 × 10(3)/µl) and increased C-reactive protein (11.76 mg/dl). CT scan showed an inflamed appendix. At laparotomy, a diffuse caecal phlegmon with an inflammatory solitary caecal diverticula was found. A limited right hemicolectomy was performed. Histological examination confirmed the caecal diverticulitis without malignancy. Post-operative period was uneventful. Three months later, endoscopy showed no diverticula or other pathologies. Solitary caecal diverticulum is very rare, but surgeons must bear this in mind in case of pain in right iliac fossa.

Enhancement of colonic anastomotic strength in rats by short-chain fatty acids.

BACKGROUND: The present study is aiming at elucidating the effect of intraoperative lavage with short-chain fatty acids (SCFAs) on colonic anastomosis in rats. METHODS: Forty male Wistar rats were randomized into four groups (10 rats each). After resection of a segment of transverse colon, an end-to-end anastomosis was performed. In the 1st group, no intraoperative large bowel lavage was performed; in the 2nd, a lavage with normal saline solution; in the 3rd, the animals received a diet rich in SCFAs pre- and postoperatively, and a lavage with normal saline was performed; and in the 4th group, an intraoperative lavage with SCFAs was carried out. On the 4th postoperative day, the animals were sacrificed. Septic complications, adhesions and anastomoses were graded macroscopically and histologically, and bursting pressure of the anastomoses, CRP, IL-6 and TNF-a was measured. RESULTS: Fewer septic complications (abscesses and minimal ruptures) and adhesions were observed in the 4th group with the intraoperative lavage with SCFAs. The bursting pressure also, in the same group, was higher (73.3 mmHg), followed by the 1st group (67.1 mmHg). CONCLUSION: Intraoperative lavage with SCFAs increases the bursting pressure of colonic anastomoses, while lavage with saline solution decreases it, in comparison to the group without lavage.

Colonic cancer in a patient with intestinal malrotation: a case report.

We present a case of a 76-year-old patient with intestinal malrotation, with incomplete rotation of the small intestine and abnormal positioning of the duodenum and superior mesenteric vessels over the transverse colon. Furthermore, the patient suffered of a concomitant cancer of the ascending colon.

Gallstone obstructive ileus 3 years post-cholecystectomy to a patient with an old ileoileal anastomosis.

The present case is one of gallstone obstructive ileus due to gallstones 3 yr after laparoscopic cholecystectomy. It is interesting because of the sex of the patient, the fact that ileus occurred 3 yr after cholecystectomy and that the localization of the obstruction was an old side-to-side ileoileal anastomosis due to a diverticulectomy following intussusception of Meckels' diverticulum at the age of 3.

Bowel intussusception in adults: a report of three interesting cases and current trends for diagnosis and surgical management.

BACKGROUND: Bowel intussusception in adults remains a rare and constant diagnostic challenge for surgeons. It has an incidence of around 2-3 new cases per million per year, and its primary cause is benign or malignant neoplasms of the small bowel and colon. This report aims to outline the importance of high clinical suspicion regarding intussusception in adults presenting with abdominal pain in the emergency department.  Case report: This is a retrospective review of three cases of adult ileocecal intussusception that were treated in a single surgical department in three years (2015-2018). All patients underwent right hemicolectomy in keeping with the principles of surgical oncology. Each patient had a different clinical presentation, while, in terms of the underlining pathology, the first had an adenocarcinoma of the ascending colon, the second an adenocarcinoma of the ileocecal valve, and the third one an inflammatory fibroid polyp of the ileocecal valve, also known as Vanek's tumor. CONCLUSION: Large bowel intussusception in adults is quite an interesting entity, not only for its rarity but for its non-specific and atypical clinical presentation as well. High suspicion from the clinician's part and availability of a computed tomography scan is the key to diagnosis. It is not unusual for imaging modalities to be unable to identify the cause of the intussusception. Thus, surgery is always the preferred method of treatment, as, more often than not, a neoplasm of the small or the large bowel is the underlining pathology.  HIPPOKRATIA 2019, 23(1): 37-41.

Groin swelling, the anatomic way out of abdominal haematomas: a case report and explicative literature review.

This case report concerns a previously healthy thirty-five-year-old female with complaints of inguinal hernia that ultimately proved to be a retroperitoneal haematoma. The patient suffered from a car accident 5 months before admission and was hospitalized. During her prior hospitalization, explorative laparotomy revealed a haematoma of the mesentery. The haematoma was treated conservatively, with fluid resuscitation and rest. During her second admission, MRI of the inguinal region revealed localized haematoma. During inguinal exploration, a fluid-filled bluish indirect hernia sac was identified and found to be contoured by free-flowing, non-clotting blood. The postoperative course was uneventful, and the patient was discharged six days following surgery.

Metastatic spread of cutaneous melanoma to the sigmoid colon: a rare but important consideration.

BACKGROUND: Cutaneous melanoma is known for its aggressive tendency for metastasis, most commonly to lymph nodes, lung, liver, and brain. CASE REPORT: We present the case of an 80-year-old male, with a history of cutaneous melanoma, found to have biopsy-proven metastatic melanoma deposits in the sigmoid colon. This rare case was initially thought to be a walled-off perforation secondary to diverticulitis. Although, computed tomography, showed features more strongly suggestive of malignancy. We propose early consideration of bowel metastasis in patients with a history of cutaneous melanoma presenting with lower gastrointestinal symptoms. CONCLUSION: Once malignancy is included in the differential for any inflammatory type bowel lesion, arranging endoscopy and biopsy is essential to confirm the diagnosis and guide management. Multidisciplinary team discussion is recommended to determine the most appropriate treatment strategy - radical versus palliative, which must always consider the patient's performance status alongside cancer staging. HIPPOKRATIA 2017, 21(4): 194-196.

Anal canal gastrointestinal stromal tumors - report of a rare case and review of the literature.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) are considered as rare gastrointestinal tumors, and their location in the anal track is exceptionally unusual. We describe the case of a 28-year-old man with anal GIST, and a review of the cases that have been reported so far in the literature. CASE REPORT: The patient was referred for treatment of a gradually enlarging perianal mass. Clinical examination and imaging including orthosigmoidoscopy, transanal ultrasound, and magnetic resonance imaging (MRI) revealed a mass sized 7.5 cm in greatest diameter, in relation with the sphincters, which was excised under general anesthesia. His postoperative course was uneventful and he was discharged on the fourth postoperative day. Pathologic examination revealed characteristics of anal GISTs and further treatment with tyrosine kinase inhibitors was planned. CONCLUSION: Anal GISTs usually present with rectal bleeding and pain, and only sixteen cases have been reported in the literature. MRI is the radiologic examination of choice, while optimal treatment is considered surgery in combination with adjuvant therapy. Long-term follow-up is necessary. Hippokratia 2016, 20(4): 313-316.

Dermatofibrosarcoma protuberans: a case report and review of the literature.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) represents less than 0.1% of all tumors, but it is considered the most common skin sarcoma. Wide local excision (=5 cm) has been largely replaced by Mohs micrographic surgery; however, recurrence is not rare. Description of the case: A 35-year-old man presented with a large tumor on the upper side of his back and underwent local excision with the possible preoperative diagnosis of lipoma. Upon histological examination, the diagnosis of DFSP was made, and the patient underwent wide local excision with skin flap reconstruction and was referred for adjuvant radiotherapy.On twenty months follow-up, no recurrence has been observed. CONCLUSION: DFSP is the most common cutaneous sarcoma. It originates in the dermis and tends to infiltrate underlying structures, including muscles, tendons, fascia and bone. In our case, the tumor was confined to the skin and subcutaneous tissue, however, our patient underwent adjuvant radiotherapy to avoid a possible relapse that would infiltrate deeper structures. Long-term follow-up is strongly recommended. Hippokratia 2016, 20(1): 80-83.

24-hr measurement of gastric mucosal perfusion in conscious humans.

BACKGROUND/AIMS: Gastric mucosal blood flow estimation in humans is obtained through an endoscope and the time of measurement lasts only a few minutes. Thinking that long-term monitoring of mucosal perfusion would be a significant contribution to the study of gastric physiology, we registered gastric mucosal blood flow continuously for 24 hours, using single fiber laser-Doppler technology. METHODOLOGY: The study was undertaken in 16 healthy subjects (8 of them had their gastric acidity inhibited with a proton pump inhibitor) and in 8 patients with an endoscopically proven, active duodenal ulcer. A 140 cm-long single fiber laser-Doppler microprobe was positioned through a gastrointestinal tube in the middle of the gastric corpus and the mucosal microcirculation was monitored from 14.00 h until 13.59 h the following day. Data were stored and processed to evaluate the probable circadian rhythms, using maximum entropy spectrum analysis. RESULTS: We found that the daily variations of gastric mucosal perfusion follow a circadian rhythm. The respective patterns with maximum and minimum values were: healthy controls, maximum at 02.00, 10.00, 18.00 h and minimum at 5.30, 14.00 and 22.00 h. Healthy controls treated by a proton pump inhibitor, maximum at 02.00, 07.00, 18.00 h and minimum at 04.00, 12.00 and 22.00 h. Ulcer patients, maximum 07.00 and 21.00 h and minimum at 17.00 and 24.00 h. CONCLUSIONS: It is concluded that long-term measurement of gastric mucosal blood flow in conscious humans is feasible and that this factor of gastric physiology follows a concrete circadian rhythm, which is not particularly influenced by acid inhibition, but is completely distorted in ulcer patients.

Deterioration of visceral perfusion caused by intra-abdominal hypertension in pigs ventilated with positive end-expiratory pressure.

Experimental studies and clinical experience suggest that the combination of positive end-expiratory pressure (PEEP) ventilation and intra-abdominal hypertension might alter splanchnic hemodynamics to a significantly greater degree than the effect of either of them alone. Therefore, we assessed the intestinal and hepatic hemodynamics in two steps of PEEP ventilation, adding tense pneumoperitoneum in a pig model. The hepatic artery, portal vein, and superior mesenteric artery blood flow, as well as the hepatic and intestinal mucosal microcirculation, and the hepatic pO2 and intestinal mucosal pH, were assessed before, then with 5 cmH2O and 10 cmH2O PEEP alone, and in combination with a 12-mmHg pneumoperitoneum, in ten domestic pigs. Statistical analysis of the hepatic and intestinal measurements revealed a significant decrease (P = 0.001) in all parameters in relation to the baseline, during the 5-cmH2O and 10-mmH2O PEEP ventilation period. The addition of 12 mmHg intra-abdominal pressure led to an extreme deterioration in all parameters (P = 0.001), in relation to both the baseline and the 10-cmH2O PEEP measurement. These findings demonstrate that PEEP and intra-abdominal hypertension act cumulatively on the abdominal viscera, producing conditions of extremely low hypoperfusion and ischemia.

Detection of oncogenes in chronic pancreatitis.

BACKGROUND: The pathogenesis of chronic pancreatitis (CP) remains poorly understood. Recently, molecular biology has identified the genetic background for many patients with hereditary CP. In addition, a number of studies have focused on the detection of proto-oncogenes and tumour suppressor gene mutations in the pathogenesis of CP. So far, the use of these mutations (with the exception of mutations causing hereditary CP), as diagnostic and prognostic markers is still controversial. DISCUSSION: It is well known that the risk of pancreatic cancer in patients with CP, especially the hereditary form, is high. At present, there is insufficient evidence to show a clear relationship between the development of pancreatic cancer and certain mutations. New biotechnological methods, such as DNA array expression analysis, expand our knowledge of the molecular pathogenesis of this disease and may help to develop specific diagnostic, prognostic and therapeutic tools. However, until long-term studies examine the safety and efficacy of certain genetic markers, long-term follow-up of patients with CP who harbour mutations is needed.

Effect of ranitidine on healing of normal and transfusion-suppressed experimental anastomoses.

BACKGROUND: Histamine has been shown to participate in immune response. Wound healing is a process of immune system. This experimental study was done to find the effect of histamine2 receptor antagonist ranitidine on the healing process of intestinal anastomosis in rats. METHODS: Eighty Wistar rats in four groups of 20 each underwent colon resection and anastomosis. They were given 2 ml saline or blood, twice daily 0.4 ml saline or 0.4 ml saline containing 0.7 mg ranitidine. The animals were killed 3 or 7 days postoperatively and the anastomotic strength assessed by bursting pressure. RESULTS: The ranitidine group developed fewer anastomotic abscesses (p<0.001). Anastomotic strength was significantly reduced either on day 3 or 7 in animals given blood transfusions (p<0.04, p<0.001), whereas in animals given ranitidine this effect was partially reversed. CONCLUSIONS: These data indicate that ranitidine has no influence in anastomotic bursting pressure, but has a lower incidence of septic complications.

Prognostic significance of mucinous component in colorectal carcinoma.

BACKGROUND: Many factors influence survival in colorectal cancer patients, one of them is the mucinous component of the tumour. Mucinous adenocarcinoma is characterized by the extracellular mucin of more than 50% of the tumour volume. METHODS: From 1970 to 1999, 1160 patients were admitted to our clinic for colorectal cancer. They were divided into four groups according to mucinous character of the tumour, in two time periods of 15 years. RESULTS: There was an increase in the incidence of mucinous tumours from 20.8 to 30.5% in the second period. These tumours were more advanced (Dukes' C) and especially right sided (34.5% vs. 17.9%). Five-year survival was increased during the second period but was of a lesser degree in the mucinous group (51.5% vs. 65.5%). CONCLUSIONS: Colorectal mucinous carcinomas present at a more advanced stage, predominantly in men, with higher right colon location rate, and a worse overall 5-year survival rate than the non-mucinous colorectal cancers.

Synchronous and metachronous colorectal carcinoma.

BACKGROUND: Synchronous and metachronous colorectal carcinoma have an incidence of 2-10%. The purpose of the study was to evaluate the clinical characteristics, the accuracy of diagnostic examinations and the survival of these patients. METHODS: From 1970 to 1999, 1160 patients with colorectal cancer were admitted to our Department. During follow-up examination 50 patients (4.3%) were found to present with multiple primary colon cancers. Fifty-two per cent were synchronous and 48% metachronous tumours. RESULTS: The overall 5-year survival of the patients was 45.87%. Mortality was 10% for multiple primaries, while in patients with single cancer was 4.1%. The overall 5-year survival of the patients with multiple primaries tumours was 46.67%. CONCLUSIONS: Patients with colorectal cancer must be fully studied endoscopically. There has been an improvement in survival in recent years due to better surgical techniques, the introduction of more sophisticated examination methods and the meticulous follow-up of patients at risk.