M. Christodoulakis

The clinical significance of acquired jejunoileal diverticula

Objective:Because of the relative rarity of acquired jejunoileal diverticulosis, including its symptomatology and complications, diagnosis is often difficult and delayed, resulting in unnecessary morbidity and mortality. The purpose of the present study was to draw attention to jejunoileal diverticula and their complications as a site of gastrointestinal symptoms.Methods:The records of 10 patients with symptomatic jejunoileal diverticula treated in our departments were reviewed.Results:The clinical presentation was varying and nonspecific. Jejunoileal diverticula were diagnosed peroperatively in four patients operated on successfully for their acute complications. In one case the diagnosis was considered after a radiotargeted erythrocyte bleeding scan and in five other cases enteroclysis for chronic abdominal complaints demonstrated jejunoileal diverticula. The death of one patient operated on for massive hemorrhage from jejunal diverticula was probably related to delayed diagnosis and treatment.Conclusion:Jejunoileal diverticula should not always be dismissed as asymptomatic findings, as they may be the cause of vague, chronic symptomatology and acute complications, including intestinal obstruction, hemorrhage, and perforation. Awareness of the fact that jejunoileal diverticula may cause chronic nonspecific abdominal symptoms and serious acute complications may lead to earlier diagnosis and timely treatment with lower morbidity and mortality.

Obesity-Associated Disorders Before and After Weight Reduction by Vertical Banded Gastroplasty in Morbidly vs Super Obese Individuals

Background: The amount of excess weight which must be lost in order to cure or to improve disorders associated with obesity remains unknown. This study was designed to compare super obese and morbidly obese patients in terms of weight reduction following VBG and to investigate the effects of postoperative weight changes to preexisting co-morbidities. Methods: 125 patients underwent VBG. Group A consisted of 80 morbidly obese patients (64%) and group B consisted of 45 super obese patients (36%). Preoperative examination was planned to identify and determine the severity of any disorders associated with obesity, that the patients may have had. Following VBG, all patients were followed-up at regular time periods, for at least 2 and up to 4 years. The progress of preexisting co-morbidities was evaluated and carefully recorded. Results: Among the 80 patients of Group A, there were 240 total co-morbidities (3 per patient), and in group B there were 196 co-morbidities (4.35 per patient) preoperatively. Dyspnea during fatigue and arthritis were found at statistically higher incidence in the super obese category. At the end of the second postoperative year, greater weight loss in terms of number kilograms was seen in patients in group B, but these patients did not reach a BMI lower than 35, while patients in group A had mean BMI below 30. In group A, 66% of the co-morbidities completely resolved, 19% significantly diminished and 15% remain unchanged. In group B, the respective percentages were 53% , 27.5% and 19.5%. However, after weight reduction by VBG a significant number of co-morbidities remain in the super obese patients (92 or 2.044 per/patient), and this is believed to be due to the greater remaining excess weight. Conclusion: Reduction of body weight by VBG is associated with resolution or improvement of a significant number of the obesity-associated disorders. However, super obese patients remain obese after surgery, and this results in two-fold higher remaining morbidity.

Treatment of malignancy arising in pilonidal disease

AbstractBackground: Malignant degeneration is a rare complication of pilonidal disease and is associated with a high recurrence rate and poor prognosis compared with regular nonmelanoma skin cancer. Treatment in our departments and in the international literature was evaluated. Methods: We analyzed the data from three patients with malignant degeneration who were treated in our departments and an additional 56 patients who were found after an extensive literature search. Results: A total of 47 males and 12 females, with a mean age of 52 years, were most frequently primarily treated with surgery. After a mean follow-up time of 28 months, 20% of all patients died with evidence of disease and an additional 10% died of unrelated causes. The overall recurrence rate was 39%, with a median time to recurrence of only 9 months. The local recurrence rate was lower when radiotherapy was added to surgical treatment alone (30% vs. 44%). Re-excision of local recurrence resulted in some long-term survivals. Conclusions: Early diagnosis and treatment may lead to improvement of the relative poor prognosis. Surgical treatment should be tailored according to the locoregional extent. The high recurrence rate after surgical treatment can be reduced by the addition of radiotherapy. Although repeat surgery for recurrent disease may involve extensive resection and morbidity, this may result in prolonged survival.

Primary intrahepatic biliary cystadenomatous tumors

Biliary cystadenoma and cystadenocarcinoma are rare tumors. The clinical features of, and optimal surgical management for these lesions have not been defined clearly. In this report, we describe three cases of cystadenomatous tumors of the biliary tract: two of a cystadenoma and one of a cystadenocarcinoma. The differential diagnosis of the cystic tumors of the liver in countries with a high prevalence of liver hydatid disease is very important.

Staple-line Disruption Following Vertical Banded Gastroplasty

Background: The purpose of this study was to determine the frequency with which staple-line disruption occurs following vertical banded gastroplasty (VBG) in morbidly obese patients, to investigate the effect of this complication on weight loss, and to identify any clinical symptoms that might be associated with staple-line disruption. Methods: From April of 1992 to June of 1994, 60 patients with morbid obesity underwent VBG. Double-contrast radiographic examination of the upper gastrointestinal tract was performed on all patients at 6, 12, 24, and 36 months postoperation to assess the integrity of the staple line. At these same times, the weight of each patient was measured, so that the patients found to have staple-line disruption could be compared to those without disruption in terms of weight loss. Results: Over the duration of the study, staple-line disruption was found in 12 patients (20%). All of these patients demonstrated satisfactory weight loss. Between the group of patients with staple-line disruption versus the group without disruption, weight loss did not differ significantly at any time up to 3 years postoperation. In addition, in the patients with staple-line disruption, no clear symptomatology that might be associated with this complication was discovered. Conclusions: Our results lead to the conclusion that small disruptions in the staple line lack clinical importance and do not significantly affect weight loss for at least the first 3 postoperative years. Furthermore, staple-line disruption does not seem to be associated with any specific clinical symptoms. Follow-up of all patients via barium meal is the correct approach for discovering the exact incidence of this complication.

Cysts of the adrenal gland: diagnosis and management.

ObjectiveCysts of the adrenal gland are rare, but with the wider application of sonography and computed tomography more adrenal cysts are detected incidentally. To gain more insight into this entity, five such cases are reported and their diagnostic approach and management are discussed.Patients and methodsThe records of five patients with six cysts of the adrenal glands seen at our department from 1987 till 1995 are reviewed. There were four males and one female and their age ranged from 24 to 72 years, with a mean age of 43 years. One patient had a primary hydatid cyst of the right adrenal gland, which was preoperatively thought to arise from the liver or the right kidney. A second patient had a very large pseudocyst of the left adrenal gland, which is the largest ever reported in the literature. The other four cysts in three patients were found incidentally during sonography or computed tomography.ResultsThe hydatid cyst with a rim of normal adrenal tissue was excised. The large pseudocyst was removed together with the adrenal gland. In the cases of the incidentally found cysts, observation of the patient with regular follow-up was decided upon. All patients are in good condition and without symptoms 2 to 10 years after the initial diagnosis.ConclusionsAdrenal cysts are rare and their diagnosis may pose problems. Symptomatic adrenal cysts should be operated, but small, asymptomatic, non-functional cysts with benign characteristics may be treated conservatively with regular follow-up by sonography or computed tomography and hormonal evaluation.

Malignant peritoneal mesothelioma treated by continuous hyperthermic peritoneal perfusion chemotherapy

Malignant mesothelioma of the peritoneum is a rare tumour for which the therapeutic approach has not yet been standardized. The efficacy of the current regimes is limited. Effective locoregional therapy is crucial, since this tumour is most often confined to the peritoneal cavity at the time of the initial diagnosis and remains there for much of its clinical course. If and when haematogenous metastases occur, they rarely contribute to the death of the patient, which is often caused by the overgrowth of the primary tumour and its local complications. A case of diffuse malignant peritoneal mesothelioma treated by cytoreductive surgery and continuous hyperthermic peritoneal perfusion with cisplatin is reported. The patient received systemic combination chemotherapy postoperatively. She is in good condition and free of disease 28 months after her treatment. Continuous hyperthermic peritoneal perfusion chemotherapy has recently been used in patients with secondary peritoneal carcinomatosis from digestive and gynecological malignancies with promising results. It is also possible that the same treatment alone or in combination with systemic chemotherapy may be effective in the treatment of primary peritoneal malignancies, as in the case of diffuse peritoneal mesothelioma.

Emphysematous cystitis after orchiectomy

A 59-year-old man developed emphysematous cystitis 3 weeks after undergoing left orchiectomy because of suppurative epididymitis. The case is presented because of its unusual cause and to emphasize the high degree of suspicion required for the diagnosis.

Evidence-Based Management of Acute Malignant Colorectal Obstruction: Diverting Colostomy as a Bridge to Elective Surgery is a Valid Alternative

Colorectal cancer presents relatively often as acute bowel obstruction, which requires immediate intervention. Operative morbidity and mortality are increased by deterioration of the patient and the commonly poor condition of the proximal bowel. The optimal curative approach for obstructing colorectal carcinoma continues to be a topic of discussion and is the subject of this literature review. The pros and cons of the various strategies based on data provided by clinical studies are discussed. Primary decompression of the bowel with a colostomy or stent and delayed colectomy has the advantage of providing time for improvement of the patient’s general condition, recovery of the initially dilated large bowel, accurate disease staging, planning of preoperative treatment and resection by an experienced surgeon. In the absence of significantly dilated bowel the definitive surgical procedure may be performed laparoscopically. Since placement of a self-expanding metallic stent as a bridge to elective surgery is associated with a high complication rate, and probably with impaired oncological outcome, it should be considered only as an alternative to emergency surgery in those patients who have an increased surgical risk, or as a palliative procedure. Local availability and expertise, and high costs are further issues that need to be considered. The creation of diverting colostomy as a bridge to elective surgery is a safe and valid alternative. Although a second operation is required, the overall morbidity and mortality are no higher than for primary resection, while the rate of permanent colostomy is significantly lower, and there is evidence that the two-stage approach is associated with a better oncological outcome.

Jejunoileal Diverticulosis and Its Complications

Acquired diverticula of the jejunum and ileum are uncommon and asymptomatic in the majority of patients. They should not always be dismissed as an incidental finding, because they may be the cause of vague, chronic symptomatology. Acute complications, including intestinal obstruction, hemorrhage and perforation, are rare, but may necessitate immediate surgical intervention. Due to the relative rarity of these lesions and their complications, diagnosis is often difficult and delayed. The high mortality of the acute complications is related to delayed diagnosis and the advanced age of the patients. Four cases with complications of jejunoileal diverticulosis and three cases of asymptomatic jejunoileal diverticula are presented and the literature is reviewed.