Emergency treatment of complicated colorectal cancer in the elderly. Should the surgical procedure be influenced by the factor 'age'?

The complication rate in patients affected by colorectal cancer (CRC) is high and the prognosis especially in the elderly patients is poor. The aim of this retrospective study is to compare the complicated CRC outcome between elderly patients and a group of patients younger than 70 years old, treated at the same time period. Between 1997 and 2007, 24 patients older than 70 years old with CRC (Group A), in an emergency situation, were operated on by the same team of surgeons. During the same time period, 20 patients, aged less than 70 years (Group B), with similar clinical and surgical findings, were operated on. All patients had undergone emergency procedures for occlusion, perforation and haemorrhage. We compared both groups in terms of preoperative health status, morbidity and mortality rates. According to ASA classification, Group A was considered of greater intraoperative danger (P = 0.01). Despite the fact that there was no statistically significant difference between the two groups, patients aged > 70 years presented higher morbidity and mortality rates. This fact is probably due to their overall health status. The surgical approach of patients with complicated CRC should not be influenced by the patient's age.

Treatment of early rectal cancer.

The treatment of rectal cancer has undergone a tremendous surgical evolution over the past century. In the past three decades, transanal excision has emerged as a popular treatment option for T1 and selected T2 rectal adenocarcinomas, allowing less morbidity for early cancers. The surgical options offered to the patient are the Parks' per anal excision and the transanal endoscopic microsurgery (TEM).

Spontaneous abdominal wall endometriosis: a case report.

Endometriosis is the presence of endometrial glands and stroma outside the uterus. Spontaneous abdominal wall endometriosis (AWE) is any ectopic endometrium found superficial to the peritoneum without the presence of any previous scar. Rarely, endometriosis represents a disease of specific interest to the general surgeon, on account of its extrapelvic localisations. We describe a case with spontaneous AWE presenting as a painful mass with cyclic symptoms. A 28-year-old woman presented to the day-surgery division of our department, suffering from a painful mass in the left lower abdominal quadrant. A mobile mass of 5 x 4 cm was identified. The initial diagnosis was lipoma and excision was planned. During the operation two masses were spotted, very close to one another, and were excised within healthy limits. Pathology revealed endometrial glands surrounded by a disintegrating mantle of endometrial stroma and fibrous scar tissue in which there was a scattering of leucocytes. The woman had no scars. She was discharged from hospital after 2 hours. Two years after the excision she is free of disease and no recurrence has been observed. Spontaneous AWE is rare, accounting for 20% of all AWEs. The triad ; mass, pain and cyclic symptomatology helps in the diagnosis, but unfortunately it is not present in all cases. Spontaneous endometriomas are usually diagnosed by pathology and the treatment of choice is surgical excision.

Horner's Syndrome: An Uncommon Complication of Thyroidectomy and Selective Lateral Neck Dissection.

BACKGROUND: Horner's Syndrome is defined by myosis, enophthalmos, lack of sweating and eyelid ptosis, as well as vascular dilatation of one half of the face, caused by damage of the ipsilateral cervical sympathetic chain. It is known that Horner's syndrome is an unusual complication of thyroidectomy and selective lateral neck dissection. Its exact pathophysiology is not totally explained and its treatment remains conservative. CASE PRESENTATION: A 27-year-old man developed one-sided partial eyelid ptosis, enophthalmos and myosis two hours after a total thyroid gland excision and a selective lateral neck dissection for papillary carcinoma. A clinical diagnosis of Horner's syndrome was formed. He was treated conservatively and presented with an incomplete recovery at a 2-month follow up. CONCLUSIONS: The present case report underlines the adjacent anatomical correlation between the thyroid gland, the celluloadipose tissue and the cervical sympathetic trunk throughout thyroidectomy and selective lateral neck dissection. Every surgeon should be familiar with the potential complications in order to preoperatively counsel patients, as well as avoid them during the surgical procedure.

Laparoscopic Excision of an Adrenal Ganglioneuroma Presented as an Incindentaloma of the Retro Peritoneum.

Adrenal ganglioneuroma (GN) is a benign tumor of retro-peritoneum that is presented as an incidentaloma. GNs most commonly have been diagnosed by imaging examinations notably by CT scan. Differential diagnosis from other malignant adrenal tumors is often difficult. The only examination that confirms diagnosis is only the histopathological one. Surgical excision of a GN has been proposed as the best solution for both diagnostic and therapeutic purposes. This case report is about a 68-year old male patient presenting with a non-typical abdominal pain. The imaging investigation showed an incidentaloma over 4cm at its large axis. The patient underwent laparoscopic excision of the tumor. We present the steps followed during the diagnosis the appropriate treatment and the follow up examinations as a result of this rare finding.

Laparoscopic Cholecystectomy with Freehand Laparoscopic Camera Controller.

INTRODUCTION: Free hand laparoscopic camera controller (FHLCC) is a new innovative robotic device that has been recently implemented and adopted in laparoscopic surgery, providing the surgeon more comfort in carrying out his surgical skills without the difficulties related to the mutual understanding of the movements of the camera. CASE PRESENTATION: We report the first case of laparoscopic cholecystectomy performed in our hospital with the aid of the free hand laparoscopic camera controller. CONCLUSION: Free hand laparoscopic camera controller provides the surgeon comfort in carrying out his surgical skills without the difficulties related to the mutual understanding of the movements of the camera. It combines the benefits of minimally invasive and robotic assisted surgery, increases efficiencies and improves patient recovery times.

Minimally Invasive Video-Assisted Total Thyroidectomy (mi V.A.T.T.) - Case Series of 48 Patients.

PURPOSE: The first report of miVATT was published in 1998 by Miccoli, leading to a revolution in the field of thyroid surgery. This prospective study aims to evaluate the technique with regard to our department's experience over a four-year period. MATERIAL-METHODS: Between September 2009 and October 2013, 48 adult patients (37 females, 11 males) with a mean age of 41.3 (± 11.6) years underwent scheduled miVATT for benign thyroid lesions. Selection criteria included thyroid volume <15 ml and nodules not exceeding 3.5 cm of diameter. Thyroiditis, previous neck surgery and previous irradiation, mediastinal goiter and involvement in another clinical study constituted the exclusion criteria. The procedure we performed was miVATT as described by Miccoli with the only additions being the use of the Harmonic Scalpel and the fixation of the endoscope on a holding device. Also, no drains were applied. RESULTS: No conversions to open surgery were needed. Operation time for total thyroidectomy was 71.23 min (± 23.81) with a mean hospitalization of 1.14 days (± 0.4). Five patients (10.4%) exhibited transient hypocalcemia, whereas there were no recurrent laryngeal nerve palsies. Post-operative pain was mild and the final aesthetic result was considered excellent by the patients. CONCLUSION: miVATT is a safe and feasible alternative to the conventional thyroidectomy when performed in carefully selected patients by experienced surgeons.

Surgical management of gastrointestinal stromal tumors: a single centre's experience.

BACKGROUND: Gastrointestinal stromal tumors (GISTs) represent 85% of all mesenchymal neoplasms that affect the gastrointestinal track. Aim of this study is to report a case series of 18 GISTs treated surgically in a single centre and to discuss the diagnostic and therapeutic issues regarding these tumors. CASE SERIES: A retrospective search of the unit's medical records from 2002 to 2014 was carried out, to collect all cases diagnosed and treated for GISTs. Demographics and clinical features was obtained for all relevant cases. RESULTS: Eighteen cases (18) of GIST were identified. Eleven tumors were located in the stomach, 3 tumors in the duodenum and 4 tumors in the jejunum. The mean age at diagnosis was 62.5 (range 42-81) years, while the male to female ratio was 1.57/1 (11 males/7 females). Patients presented with a variety of symptoms and all underwent surgery. The 5-year-survival rate of these patients was 50%. CONCLUSION: Due to non-specific presentation of GISTs, initial diagnosis of these tumors may be delayed. High clinical suspicion and knowledge of their characteristics are essentials in order to achieve an early diagnosis and lead patients to surgery as soon as possible. Hippokratia 2015, 19 (1): 73-75.

Laparoscopic cholecystectomy after bariatric surgery.

BACKGROUND: This prospective study determines the value of laparoscopic cholecystectomy (LC) in patients with cholelithiasis after bariatric surgery. METHODS: Eighty-four consecutive patients who underwent bariatric surgery without concomitant cholecystectomy were studied. Patients were divided in two groups; group A including 50 patients (59.5%) without gallbladder disease, and group B included 34 patients (40.5%) with symptomatic cholelithiasis within 2 years postoperatively. Characteristics of both groups were compared and analyzed by the use of chi-square tests. RESULTS: In all 34 patients in group B LC was attempted, and the procedure was successful in 28 (82.4%). LC was converted to open procedure in 6 patients (17.6%). Two patients with choledocholithiasic obstructive jaundice underwent endoscopic retrograde cholangiopancreatography and endoscopic sphincterotomy prior to laparoscopic management. The mean operative time was 75 +/- 12 min, and the mean hospitalization was 2.8 +/- 1.1 days. CONCLUSION: Morbidly obese patients undergoing bariatric surgery are at high risk for developing symptomatic cholelithiasis postoperatively, which usually takes the form of acute cholecystitis. LC is feasible, effective, and seems to be the procedure of choice despite the technical difficulties.

The use of three different mesh materials in the treatment of abdominal wall defects.

Various prosthetic materials have been proposed for the repair of abdominal wall defects. These materials offer tension-free repair and significantly lower recurrence rate. Their respective properties are related to such complications as seroma, infection, fistula formation, intestinal adhesions and removal. We compared the final outcome in treating abdominal wall defects in 56 patients with three different prosthetic materials: conventional polypropylene in a preperitoneal location, expanded polytetrafluoroethylene mesh, and hydrophilic membrane coated polyester mesh in an intraperitoneal location. The hydrophilic coated polyester group exhibited the lowest complication rate and the polypropylene group the highest.

Total thyroidectomy without the use of drainage - case series of 66 patients.

AIM: The aim of this series is to study the need of drainage use after total thyreoidectomy. MATERIAL AND METHODS: Retrospective study of a series of patients who underwent total thyroidectomy from 2005 up to 2013. The presence or not of hematomas, seromas and hemorrhage were recorded. RESULTS: Out of the 66 patients included in this series, only one case of post-operative hematoma was recorded. Neither a hemorrhage nor a seroma were identified despite the volume, the underlying pathology and the co-morbidity of the patients involved. CONCLUSION: In our experience a thyroidectomy with adequate hemostasis does not require the use of drains.

Intrajejunal migration of adjustable gastric band: a case report.

Introduction. Laparoscopic gastric banding is a first line bariatric procedure that is performed worldwide and can achieve substantial weight loss. Despite its many advantages, as the least invasive bariatric procedure, it has several complications like gastric prolapse, stoma obstruction and migration of the gatstric band. Rarely are these complications life threatening, but re-operation is usually the only treatment. Case presentation. We report a rare case of intrajejunal migration of an adjustable gastric band that was placed laparoscopically four years ago. Conclusion. Gastric band migration is a rather common complication of laparoscopic gastric banding, but intrajejunal migration is very rare and requires high clinical suspicion, close follow-up and thorough pre-operative investigation so as to avoid intraoperative surprises and retrieve the displaced gastric band safely.

Gigantic hepatic amebic abscess presenting as acute abdomen: a case report.

INTRODUCTION: Amebiasis is a parasitic disease caused by Entamoeba histolytica. It most commonly results in asymptomatic colonization of the gastrointestinal tract, but some patients develop intestinal invasive or extra-intestinal diseases. Liver abscess is the most common extra-intestinal manifestation. The large number of clinical presentations of amebic liver abscess makes the diagnosis very challenging in non-endemic countries. Late diagnosis of the amebic abscess may lead to perforation and amebic peritonitis, resulting in high mortality rates. CASE PRESENTATION: This report describes a 37-year-old white man, suffering from hepatitis B, with a gigantic amebic liver abscess presenting as an acute abdomen due to its rupture. Rapid deterioration of the patient's condition and acute abdomen led to an emergency operation. A large volume of free fluid together with debris was found at the moment of entry into the peritoneal cavity because of a rupture of the hepatic abscess at the position of the segment VIII. Surgical drainage of the hepatic abscess was performed; two wide drains were placed in the remaining hepatic cavities and one on the right hemithorax. The patient was hospitalized in the ICU for 14 days and for another 14 days in our department. The diagnosis of amebic abscess was made by the pathologists who identified E. histolytica in the debris. CONCLUSION: Acute abdomen due to a ruptured amebic liver abscess is extremely rare in western countries where the parasite is not endemic. Prompt diagnosis and treatment are fundamental to preserving the patient's life since the mortality rates remain extremely high when untreated, even nowadays.

Synchronous and metachronous adenocarcinomas of the large intestine.

BACKGROUND AND AIM: The synchronous and consecutive (metachronous) development of two or more primary adenocarcinomas accounts for 3 to 5% of cases of colorectal cancer. Aim of this study is to review our experience in the management of patients with synchronous and metachronous lesions, and reach conclusions regarding their optimal diagnosis, treatment and follow-up. PATIENTS AND METHODS: Between 1987 and 2004, 12 patients (seven men and five women, mean age 67.5 years, range 47-83 years) with synchronous (three patients) and metachronous (nine patients) lesions were treated, comprising 4.3% of all patients submitted to surgery for colorectal cancer. The diagnosis lag for metachronous lesions ranged from 1.5 to 14 years. All three patients with synchronous cancers had two lesions. RESULTS: Staging colonoscopy and abdominal CT was conducted in 10 patients while the remaining two underwent only abdominal CT due to their critical condition at presentation. Surgery had curative intent in 10 patients and palliative in two. The mean postoperative hospital stay was 21 days (10-49 days). The postoperative mortality was zero. Patients survival after curative procedures was 80% for the first year, 60% for the third and 50% for the fifth year. After palliative surgery, survival was 50% for the first year, and zero for the third. CONCLUSIONS: Patients with colorectal cancer must be followed up regularly after surgery. Follow up aims at early diagnosis and treatment of metachronous lesions that can appear many years after diagnosis of the primary lesion. Preoperative colonoscopy is an invaluable diagnostic (biopsy) and staging (exclusion of synchronous lesions, localization of the primary) modality, dictating the surgical approach. Additionally, it contributes to cancer prevention allowing the discovery and removal of small polyps before their transformation.