Daniel Paramythiotis

Middle Segmental Pancreatic Resection: An Option to Treat Benign Pancreatic Body Lesions

Objective:To clarify whether middle segmental pancreatic resection can be performed with comparable morbidity and mortality to classic pancreatic resections for lesions in the mid-portion of the pancreas. Summary Background Data:Pancreaticoduodenectomies or distal pancreatectomy, traditionally used to treat lesions of the pancreatic body, sacrifice a significant amount of normal pancreatic tissue. Middle segmental pancreatic resection has therefore been introduced to minimize loss of functioning pancreatic tissue. Patients and Methods:In a prospective 4-year single-center study, 40 consecutive patients with lesions of the neck or the body of the pancreas underwent a middle segmental pancreatic resection. A matched-pairs analysis comparing middle segmental pancreatic resection with pp-Whipple and distal pancreatectomy was included. Results:Seventeen patients had neoplastic lesions (4 solid malignancies, 9 cystic lesions, 4 neuroendocrine tumors) and 23 patients had focal chronic pancreatitis. Postoperative surgical morbidity was 27.5% and mortality 2.5%. The reoperation rate was 5.0%. Three patients (7.5%) developed pancreatic fistula. Median postoperative hospital stay was 11 days (range, 6–62 days). After a median follow-up of 29 months, 97.4% (38 patients) of the patients were satisfied with the operation. The mean quality of life status (EORTC QLQ-C30) was comparable to a normal control population. Matched-pairs analysis revealed no differences of perioperative parameters (except operation time), morbidity, and mortality. However, endocrine pancreatic function was better preserved (P < 0.05) in patients with middle segmental pancreatic resection. Conclusions:Middle segmental pancreatic resection is an appropriate procedure for selected patients with tumorous lesions in the mid-portion of the pancreas. It preserves pancreatic parenchyma and function and has a mortality and morbidity rate comparable to other pancreatic resection procedures.

Synchronous and metachronous colorectal carcinoma

BackgroundSynchronous 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.MethodsFrom 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.ResultsThe 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%.ConclusionsPatients 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.

Intra-abdominal pressure alterations after large pancreatic pseudocyst transcutaneous drainage

BackgroundAcute pancreatitis leads to abdominal hypertension and compartment syndrome. Weeks after the episodes pancreatic fluids sometimes organize to pseudocysts, fluid collections by or in the gland.Aims of the present study were to evaluate the intra-abdominal pressure (IAP) induced by large pancreatic pseudocysts and to examine the effect of their transcutaneous drainage on IAP.MethodsTwenty seven patients with a pancreatic pseudocyst were included. Nine patients with pseudocysts greater than 1l (group A) had CT drainage and eighteen (volume less than 1l) were the control group. The measurements of group A were taken 6 hours before and every morning after the drainage, while for group B, two measurements were performed, one at the day of the initial CT and one 7 days after. Abdominal compliance (Cabd) was calculated. Data were analyzed using students t-test.ResultsBaseline IAP for group A was 9.3 mmHg (S.D. 1.7 mmHg), while the first post-drainage day (PDD) IAP was 5.1 mmHg (S.D. 0.7 mmHg). The second PDD IAP was 5.6 mmHg (S.D. 0.8 mmHg), the third 6.4 mmH (S.D. 1.2 mmHg)g, the fourth 6.9 mmHg (S.D. 1.6 mmHg), the fifth 7.9 mmHg (S.D. 1.5 mmHg), the sixth 8.2 mmHg (S.D. 1.4 mmHg), and the seventh 8.2 mmHg (S.D. 1.5 mmHg). Group B had baseline IAP 8.0 mmHg (S.D. 1.2 mmHg) and final 8.2 mmHg (S.D. 1.4 mmHg). Cabd after drainage was 185.6 ml/mmHg (SD 47.5 ml/mmHg).IAP values were reduced between the baseline and all the post-drainage measurements in group A. IAPs seem to stabilize after the 5th post-drainage day. Baseline IAP was higher in group A than in group B, while the two values, at day 7, were equivalent.ConclusionThe drainage of large pancreatic pseudocyst reduces IAP. Moreover, the IAP seems to rise shortly after the drainage again, but in a way that it remains inferior to the initial value. More chronic changes to the IAP are related to abdominal cavitys properties and have to be further studied.

Inguinal Endometriosis: Three Cases and Literature Review

Three cases of endometriosis infiltrating the round ligament are presented. The initial diagnosis was irreducible hernia, since this rare nosologic entity often causes unusual preoperative symptoms and diagnostic problems. Diagnosis is frequently made by histologic examination. The rarity of inguinal endometriosis should not exclude it from a possible diagnosis in cases with a painful mass in the inguinal region in a fertile woman, especially if the groin mass is associated in size and tenderness with menstrual variability. Surgery is the treatment of choice and is curative; laparoscopy is suggested during the same operation to evaluate the intraperitoneal conditions.

Massive variceal bleeding secondary to splenic vein thrombosis successfully treated with splenic artery embolization: a case report

IntroductionSplenic vein thrombosis results in localized portal hypertension called sinistral portal hypertension, which may also lead to massive upper gastrointestinal bleeding. Symptomatic sinistral portal hypertension is usually best treated by splenectomy, but interventional radiological techniques are safe and effective alternatives in the management of a massive hemorrhage, particularly in cases that have a high surgical risk.Case presentationWe describe a 23-year-old Greek man with acute massive gastric variceal bleeding caused by splenic vein thrombosis due to a missing von Leiden factor, which was successfully managed with splenic arterial embolization.ConclusionsInterventional radiological techniques are attractive alternatives for patients with a high surgical risk or in cases when the immediate surgical excision of the spleen is technically difficult. Additionally, surgery is not always successful because of the presence of numerous portal collaterals and adhesion. Splenic artery embolization is now emerging as a safe and effective alternative to surgery in the management of massive hemorrhage from gastric varices due to splenic vein thrombosis, which often occurs in patients with hypercoagulability.

Anterior chest wall tuberculous abscess: a case report

The granulomatous inflammation of tuberculosis usually involves the lungs and the hilar lymph nodes. Musculoskeletal tuberculosis (TB) occurs in 1–3% of patients with TB, while TB of the chest wall constitutes 1% to 5% of all cases of musculoskeletal TB. Furthermore, nowadays it is rarer to find extrapulmonary TB in immunocompetent rather that non-immunocompetent patients. The present case reports a fifty-six-year-old immunocompetent man with an anterior chest wall tuberculous abscess. The rarity of the present case relates both to the localization of the tuberculous abscess, and to the fact that the patient was immunocompetent. The diagnosis of musculoskeletal tuberculous infection remains a challenge for clinicians and requires a high index of suspicion. The combination of indolent onset of symptoms, positive tuberculin skin test, and compatible radiographic findings, strongly suggests the diagnosis. TB, however, must be confirmed by positive culture or histologic proof. Prompt diagnosis and treatment are important to prevent serious bone and joint destruction.

The influence of continuous seven-day elevated intra-abdominal pressure in the renal perfusion in cirrhotic rats

Since hepatorenal syndrome is a functional renal failure due to renal ischemia in cirrhotics with refractory ascites, we investigated whether increased intra-abdominal pressure (IAP) impairs the renal function and perfusion in cirrhotic portal hypertensive rats. Eight groups of 32 rats each were studied, including 4 control and 4 CCl(4) cirrhotic groups. These were subdivided into two groups each, with and without an increased IAP, and further subdivided into groups of rats with and without NO inhibition. IAP was increased to 20 mm Hg for 7 consecutive days by means of an intraperitoneally placed balloon filled with water. The animals were studied in normal conditions and after inhibition of NO synthesis. Changes in mean arterial pressure and renal microcirculation by means of femoral artery catheterization and laser-Doppler technique, respectively, were recorded. Venous samples for determination of plasma renin-aldosterone activity, biochemical parameters of liver and renal function, and plasma nitrite/nitrate levels as an index of NO synthesis were drawn. Cirrhotic rats showed decreased renal microcirculation (P = 0.05), while elevated IAP produced a further decrease (P = 0.01). Renin-aldosterone levels found increased (P = 0.001) in cirrhotics, and elevated IAP produced a further increase (P = 0.01] in both groups. Inhibition of NO synthesis resulted in a nonsignificant decrease in both renal microcirculation and renin-aldosterone levels in all experimental groups. Liver and renal function was found to be impaired in cirrhotics, but increased IAP had a nonsignificant further functional impairment in both organs. In conclusion, chronically elevated IAP in cirrhotic rats is associated with an increase in renin-aldosterone levels and significant impairment of renal perfusion.

Acute appendicitis secondary to Enterobius vermicularis infection in a middle-aged man: a case report.

IntroductionAcute appendicitis due to Enterobius vermicularis is very rare, affecting mostly children. Whether pinworms cause inflammation of the appendix or just appendiceal colic has been a matter of controversy.Case presentationA Caucasian 52-year-old man was referred to our Emergency Department with acute abdominal pain in his right lower quadrant. The physical and laboratory examination revealed right iliac fossa tenderness and leukocytosis with neutrophilia. An open appendectomy was performed. The pathological examination showed the lumen containing pinworms. Two oral doses of mebendazole were administered postoperatively. The follow-up to date was without incident and he was free of symptoms one year after the operation.ConclusionThe finding of E. vermicularis in appendectomy pathological specimens is infrequent. Parasitic infections rarely cause acute appendicitis, especially in adults.One should keep in mind that the clinical signs of intestinal parasite infection may mimic acute appendicitis, although rare. A careful evaluation of symptoms such as pruritus ani, or eosinophilia on laboratory examination, could prevent unnecessary appendectomies.

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.

Hematemesis, a very rare presentation of solid pseudo-papillary tumors of the pancreas: a case report

IntroductionSolid pseudo-papillary tumors of the pancreas are rare and typically present in young female patients. They are slowly growing masses that may attain large size, and are of low malignant potential. Surgical resection is usually curative.Case presentationA 71-year-old woman presented to the emergency department with an episode of hematemesis but was otherwise hemodynamically stable. Emergency gastroscopy revealed a bleeding mass projecting to the duodenum. Fluid, blood and electrolyte resuscitation followed. Computed tomography revealed a small mass in the head of the pancreas. A Whipple operation was performed. Pathology revealed a solid pseudo-papillary tumor. The postoperative course of the patient was uneventful and no recurrence was present a year after the operation.ConclusionIn our case, the most noteworthy observations concern the small size of the tumor, the age of the patient and the presenting symptom. However, pancreaticoduodenectomy in a 71-year-old woman is a major effort and should only be undertaken by centers and surgeons experienced in complex hepatobiliary surgery. Furthermore, the unique nature of this case reminds every clinician that each patient has to be considered separately and with extreme caution.