Eleftheria Ignatiadou

Highly elevated serum levels of CA 19-9 in choledocholithiasis: a case report

We present a case of a 79-year-old woman admitted to our hospital with pain in the right upper abdominal quadrate radiated to the back, jaundice, fever and chills. The laboratory tests showed serum carbohydrate antigen 19-9 levels of 99.070 U/ml (normal values: 0-37 U/ml). The rest of the biochemistry showed alkaline phosphatase of 550 IU/l, direct bilirubin: 17.5 mg/dl, total bilirubin: 28.4 mg/dl. Abdominal sonography demonstrated dilated common bile duct. Two weeks postoperatively, the carbohydrate antigen 19-9 fell to 970 U/ml and returned within normal range (31 U/ml) two months later. Furthermore, the magnetic resonance cholangiopancreatography performed postoperatively demonstrated normal configuration of the biliary tree and the common bile duct.

Non-toxic megacolon due to transverse and sigmoid colon volvulus in a patient with ulcerative colitis

Intestinal volvulus in patients with inflammatory bowel disease is rare. A 83-year-old woman diagnosed with ulcerative colitis five years ago was referred to our hospital due to abdominal distension. The patient had been diagnosed with pancolitis and dolichocolon and was started on mesalazine 1.5 g/day treatment resulting in long-term remission. Physical examination showed abdominal distention with no rebound; however on auscultation abdominal sounds were absent. Patient had no signs of toxicity. Temperature was 38.2 °C, heart rate was 82 bpm and respirations were 16/min. Laboratory investigation showed elevated white blood cell count (20,000/mm(3)) with hemoglobin at 13.2 g/dl and C-reactive protein at 310 mg/dl. Radiology was suggestive of megacolon and volvulus. Patient underwent endoscopy, which revealed normal rectal mucosa; there were however present areas of bowel gangrene. Urgent laparotomy was performed which revealed double transverse and sigmoid colon volvulus. A left hemicolectomy and transversectomy were performed. A case of a patient with ulcerative colitis is being presented here, exhibiting a non-toxic megacolon, resulting from a double transverse and sigmoid volvulus probably stemming from congenital dolichocolon. This case is stressing the importance of prompt differential diagnosis in such cases of megacolon as any symptom misinterpretation may result in unfavorable outcomes.

Fournier's gangrene complicating ulcerative pancolitis

Fournier gangrene is a very rare and a rapidly progressing, polymicrobial necrotizing faciitis or myonecrosis of the perineal, perianal and genital regions, with a high mortality rate. Infection is associated with superficial traum, urological and colorectal diseases and operations. The most commonly found bacteria are Escherichia coli followed by Bacteroides and streptococcal species. Diabetes mellitus, alcoholism, and immunosuppression are perpetuating co-factors. Fourniers gangrene complicating inflammatory bowel disease has been reported in three patients so far, two with Crohns disease. A 78-year-old man diagnosed with ulcerative pancolitis was referred for fever, and painful perianal and scrotal swelling after perianal surgery for a horseshoe-type perianal abscess. Since bowel disease diagnosis, patient was on mesalazine and achieved long-term remission. Perianal abscess occurred suddenly one week before perianal surgery without any evidence of pre-existing fistula or other abnormalities. Physical examination showed extensive edema and crepitus of perineum and genitalia and patient had symptoms of significant toxicity. The diagnosis of Fourniers gangrene was made and patient underwent emergency surgery with extensive surgical debridement of the scrotal and perianal area and Hartman procedure with a diverting colostomy. In addition, patient started on therapy with mesalazine 3gr, methylprednisolone 16 mg, parenteral nutrition and broad spectrum of antibiotics. Two days after the first operation the patient needed a second operation for perianal debridement. On the fourth day, blood cultures showed E. coli. Patient had an uneventful recovery and was discharged after 34 days of hospitalization. On follow up, disease review is scheduled and colostomy closure is planned.

The role of colonoscopy in the management of intestinal obstruction: a 20-year retrospective study

PurposeThe aim of the study was to assess the use colonoscopy over time in the assessment of large bowel obstruction in a tertiary university hospital.MethodsRetrospective analysis of surgical and colonoscopy records for the years 1990-2009 in a university hospital. All patients diagnosed with non-conservatively managed bowel obstruction were included.ResultsWe recorded 644 patients diagnosed with non-conservatively managed bowel obstruction. Four hundred forty-one (67.3%) were managed only by surgery, 157 (23.6%) were managed by colonoscopy, and 46 (6.9%) by combined colonoscopy and surgery. Patients over 77 years were more likely to receive colonoscopy as monotherapy or combined with surgery as compared to younger patients. Management by colonoscopy only and by combined colonoscopy and surgery increased over time.ConclusionsColonoscopy in the management of non-conservatively treated bowel obstruction increased over time. However, therapeutic colonoscopy still has a limited role in bowel obstruction either as monotherapy or combined with surgery.

Lumpectomy and partial breast irradiation--risks and benefits for early breast cancer.

Breast-conserving surgery followed by radiation therapy is the standard local treatment of early primary breast cancer. Radiation therapy limited to the part of the breast closest to the site of the excised tumor (accelerated partial breast irradiation, APBI) might be beneficial for these patients, but definitive results of ongoing trials should be awaited. Partial breast intraoperative radiation (IORT) has recently been developed to further improve the results of partial irradiation. Given that tumornegative margins are required for IORT, Schiller et al. considered how to identify and select patients for IORT by predicting those with tumorfree excision margins. The authors analyzed data from 708 patients who underwent 730 lumpectomies and found a 17% rate of positive margins at first resection. They could accurately (98%) predict negative margin status for the subset of patients older than 50 years with a preoperative core needle biopsy (CNB) showing invasive cancer less than 3 cm that can be localized under ultrasound. Are these patients truly ideal for consideration of IORT, as the authors suggest? What about the other subsets of patients including those aged <50 years, with a family history of breast cancer, extensive intraductal component, and multicentricity and multifocality? Local recurrence after lumpectomy or breast-conserving surgery still remains a substantial problem despite modern radiation therapy, with a local relapse rate of 10% or greater at 10 or 20 years after therapy. Young age, family history, BRCA1/2 mutation carriers and positive or close resection margins are considered risk factors for local recurrence after breast-conservation therapy (BCT). Partial breast irradiation either as APBI or IORT is probably an inappropriate treatment for patients at high risk of local recurrence. Treatments that achieved a reduction in local recurrence were also associated with a reduction in mortality after long-term follow up in a recent landmark meta-analysis of randomized trials. Thus, every effort should be made to achieve local control. This principle of local control appears to be important also for other solid cancers, such as, gastric cancer. Overall, prognosis of gastric cancer is poor with exception early-stage gastric tumors. Despite the validation of the efficacy of adjuvant systemic chemotherapy, local control with adequate D2 surgery or D1 surgery plus chemoradiotherapy may improve survival. There is currently a trend toward less extensive surgery and partial breast irradiation with the aim of reducing adverse effects and improving quality of life, but strong evidence is needed that these modern therapies are safe and do not increase local recurrence or reduce overall survival. Research on molecular and genetic biomarkers already provides promising findings towards personalized treatment. 26–28 More work is required for prospective validation before these markers can be used in the clinic for selecting breast cancer patients for minimal surgery and partial breast irradiation. Published online February 1, 2008. Address correspondence and reprint requests to: D. Ziogas, MD; E-mail: deziogas@hotmail.com

Successful Nonoperative Management of Spontaneous Splenic Hematoma and Hemoperitoneum due to CMV Infection.

Introduction. Spontaneous splenic hematoma or splenic rupture due to CMV infection in immunocompetent adults is rare and life-threatening. Case Report. Herein we report a rare case of spontaneous splenic hematoma and hemoperitoneum due to CMV infection in a 23-year-old Caucasian male in whom conservative management was successful. Conclusion. Spontaneous splenic hematoma and spontaneous splenic rupture are extremely rare conditions during primary CMV infection. Though rare, they must be always considered by the operating surgeon, because any misinterpretation may result in unfavorable outcomes.

Screening for or Prevention of Local Ipsilateral Recurrence and Contralateral Breast Cancer After Breast-Conserving Surgery?

In the June issue of the Journal, Gorechlad et al. reported the occurrence of local failures following breastconserving surgery (BCS). They concluded that following free-resection margins and adjuvant radiation therapy, the overall rates of recurrence of a new ipsilateral breast cancer (IBC) or contralateral breast cancer (CBC) 5 years after treatment were very low. Furthermore, physical exam and mammography allowed for early detection of IBC and CBC and, thus, the authors noted that annual screening magnetic resonance imaging (MRI) is unlikely to improve overall survival. Although these findings are consistent with those from other recent retrospective studies, we would highlight potential higher risks of IBC and CBC and decreased overall survival for specific subsets of patients. Local control is important for long-term survival; this notion is supported by objective evidence. Indeed, accumulating evidence suggests that IBC and CBC may be the first isolated events to be observed during the long-term follow-up period. Instead of screening after BCS to detect these local failures at an early stage, prevention of these events may be a more effective approach in improving clinical outcomes for these women. The study by Gorechlad et al. may have been subject to bias and limited by several factors. First, it is well known that the median follow-up of 5.4 years is short; many local failures occur after 5 years and, thus, at least 10 years or 15 years follow-up is required for the assessment of local events. Second, the small sample size did not allow for subgroup analysis, to observe whether and which subsets of patients were at higher risk of local failures. Third, by including only those patients with free-resection margins in this retrospective analysis, selection bias cannot be excluded. How can we prevent local failures? It is clear that BCS is the preferred procedure for carefully selected patients with localized disease. A more aggressive surgery including contralateral prophylactic mastectomy (CPM) is likely to benefit only high-risk patients. Currently, a trend toward extensive surgery in unselected women occurs in some countries. For example, the current landscape in the extent of surgery is best delineated by the data of the Surveillance, Epidemiology and End Results (SEER) database for breast cancer patients treated in the USA. The rate of CPM has dramatically increased by 150% between 1998 and 2003. This finding suggests a surgical overtreatment rather than a targeted selection of high-risk women who may benefit from bilateral mastectomy (BM). Is risk stratification into high, moderate and low risk for IBC and/or CBC feasible today? There are several challenges and limitations in the identification of high-risk patients. Even following current guidelines, recommendation for appropriate surgery, radiation, and systemic adjuvant therapies including empirical chemotherapy and the new standard targeted agents trastuzumab and aromatase inhibitors (AIs) for selected patients, the long-term local failure rate is substantial for certain subgroups. Accumulating evidence suggests that among all patients treated for localized breast cancer, the subgroup of women with inherited mutations in BRCA1 or BRCA2 (BRCA) cancer susceptibility genes face the highest risk of IBC and CBC. Genetic testing identifies BRCA mutation carriers and has been integrated into the diagnostic work-up of patients with family history. Effective surgical interventions are increasingly used in clinical practice for primary prevention in both healthy women with BRCA mutations and patients with unilateral breast cancer. The risk of CBC among BRCA mutation carriers in a recent study by Metcalfe et al. was 3% annually or 29.5% at 10 years after unilateral breast surgery. In this study, CPM was very effective at reducing this risk by up to 97%. However, it should be noted that level-I evidence from randomized trials on the efficacy of CPM relative to BCS is still lacking. Another subgroup at increased risk of IBC and/or CBC is one with patients who have basal-like breast cancer. This subtype, defined on the basis of global gene expression profiling data using microarrays, approximates the triple-negative cancer. The term ‘‘triple negative’’ concerns patients with human epidermal growth factor receptor 2 (HER2), estrogen receptor (ER) and/or progesterone receptor (PR) negative status (HER2/HER/PR-negative). In the most recent study by Ngyyen et al., the IBC rate after a median follow-up of 70 months was 7.1% for the basal-like subtype. It is likely that long-term survivors with a triple-negative (HER2/ER/PR) tumor or a basallike subtype face a high risk of IBC and CBC given that trastuzumab and tamoxifen or AIs, which reduce both distant and local recurrences, are ineffective in these patients. Objective evidence has shown that all types of recurrence, including local, locoregional and distant, are important for long-term survival. Therefore, any effort should be made preoperatively to identify patients at high risk, because they might benefit from a personalized surgical strategy aimed at reducing local failure. This treatment strategy may have important clinical implications not Annals of Surgical Oncology 15(12):3617–3619 Published by Springer Science+Business Media, LLC 2008 The Society of Surgical Oncology, Inc.