Milan Radojkovic

Primary colorectal lymphoma: An overview

Lymphomas represent common hematological malignancies with increasing incidence in recent years. The major site of extranodal non-Hodgkin lymphoma is the gastrointestinal tract. Involvement of the large intestine is rare in comparison to the stomach or small bowel. The disease appears later in life, predominantly in the male population. Complaints are nonspecific, requiring a high index of suspicion in order to establish the diagnosis. The treatment varies from chemotherapy alone to multimodal therapies combining surgery, chemotherapy and radiotherapy. The small number of patients with various histological subtypes and different stage at presentation results in unclear protocol for the treatment of primary colorectal lymphoma. The purpose of this paper is to review current data on primary lymphoma of the colon and rectum while analyzing reported case series and published material on the subject.

Correlation of inflammation parameters and biochemical markers of cholestasis with the intensity of lipid peroxidation in patients with choledocholithiasis

BACKGROUND/AIM During choledocholitiasis inflammatory oxidant stress involves the promotion of mitochondrial dysfunction through an intracellular oxidant stress in hepatocytes leading mainly to necrosis and less to apoptosis. The product of oxidative stress, malondialdehyde (MDA), is extremely cytotoxic and damages cell membranes and intracellular macromolecules. The toxicity of MDA is based on its ability to act as a mutagenic agent in a cell. Therefore, the aim of this prospective study was to establish correlation of the parameters of inflammation and biochemical markers of cholestasis with the intensity of oxidative stress in pathogenesis of liver function disorders. METHODS Seventy adult subjects of either sex included in the study were devided into two groups: I--40 patients with obstructive icterus caused by choledocholithiasis, and II--30 healthy individuals. All the participants were subjected to a clinical, laboratory and ultrasonic check-up at the Internal Department of the Military Hospital in Nis. The parameters of oxidative stress: MDA, a measure of lipid peroxidation, and inflammation parameters: C-reactive protein (CRP), fibrinogen, albumins, number of leukocytes (Leu), granulocytes (Gr), lymphocytes (Ly) and monocytes (Mo) and biochemical markers of cholestasis: activity of gamma-glutamyltransferase (gamma-GT) and alkaline phosphatase (AP) enzymes, the level of total, direct and indirect bilirubin were determined by standard biochemical methods. RESULTS Lower values of albumin (p < 0.001), and significantly higher values of fibrinogen (p < 0.05) and CRP (p < 0.001) were found in the blood of the patients with cholestasis due to choledocholithiasis in relation to the controls. Significantly higher values of Leu (p < 0.01) and Gr (p < 0.001) with decreasing number of Ly (p < 0.001) and Mo (p < 0.001) were found in blood of the patients with cholestasis due to choledocholithiasis in relation to the control. Similarly, higher values of gamma-GT, and AP (p < 0.001), as well as the level of total, direct and indirect bilirubin (p < 0.001) were found in blood of the patients with cholestasis due to choledocholithiasis in relation to the controls. The concentration of MDA (p < 0.001) was increased in the patients with choledocholithiasis in relation to the controls. There was a significant positive linear correlation of the number of leukocytes (r = 0.51, p < 0.05) and the concentration of total (r = 0.87, p < 0.01), direct (r = 0.85, p < 0.01) and indirect (r = 0.88, p < 0.01) bilirubin with the concentration of MDA in the group of patients with choledocholithiasis. CONCLUSION Neutrophils and the levels of total, direct and indirect bilirubin have a significant positive linear correlation with the level of lipid peroxidation in patients with choledocholithiasis. Neutrophilia and hiperbilirubinemia observed in this way represent important parameters in estimating the level of liver tissue damage in choledocholithiasis.

Case of rectal angioleiomyoma in a female patient.

Angioleiomyoma represents a benign stromal tumor, which usually occurs in the subcutaneous tissue of the extremities, although its occurrence in the gastrointestinal tract is very rare. A case of rectal angioleiomyoma in a 40 year-old female patient is described here. Six months earlier, the patient suffered from periodical prolapse of an oval tumor from the anus, along with difficulties in bowel movement. A transanal extirpation of the tumor was performed. This is the first reported case in the English literature of a patient presenting with prolapsed angioleiomyoma of the rectum. During the immediate postoperative period, as well as 6 mo later, the patient had an unremarkable postoperative recovery.

Double giant chronic bilomas with late presentation: 9 years after cholecystectomy.

Dear Editor, We have the intention to report of a 68-year-old man with very late presentation of two well-encapsulated giant bilomas. They occurred 9 years after open cholecystectomy, performed for an acute calculous cholecystitis. Early and late postoperative course was absolutely uneventful. Nine years later, few days before actual admission, he felt unclear symptoms of abdominal pressure and discomfort. Clinical examination and ultrasonography (US) showed large cystic masses in the right and left part of the abdomen. Computed tomography (CT) density values were 16 Hounsfield units (HU). At first, we suspected on the extrapancreatic pseudocysts. However, the pancreas was normal on the CT. At magnetic resonance imaging (MR), lesions were heterogeneously intense (T1) and homogenously hyperintense on the T2-weighted images (Figs. 1 and 2). Magnetic resonance cholangiopancreatography (MRCP) showed a normal biliary tree, with no strictures or stones and without any communication. Analysis of percutaneous needle aspirate showed clear bile with no cellular structures and bilirubin concentration of 680 mcm/L. The bilomas measured in total 5.2 L of the stagnant bile. The smaller one (16.3×10.7 cm) was located in the right part of the abdomen, into the subhepatic space and right paracolic gutter. The bigger one (22.7×11.2 cm) occupied left subphrenic space with propagation into the left paracolic gutter. Because of the failure of percutaneous drainage (incomplete drainage of the left biloma despite of the two repositioning of the drainage catheter), the patient was operated on, with simple surgical drainage. Surgical exploration and intraoperative cholangiography showed a normal biliary tree. The patient remains symptom-free with normal clinical and laboratory data more than 12 months after surgery. A biloma is a well-demarcated, encapsulated or not, bile collection outside the biliary tree caused by iatrogenic, traumatic, and spontaneous injury of the biliary tree [1–6]. It usually arises a few days or weeks after the injury [2, 3, 7]. Slow leakage of uninfected bile may be asymptomatic for a long time. The main curiosity in our case report is the fact that the patient was asymptomatic for 9 years after the cholecystectomy. We believe that biloma occurred from lowproducing bile leakage as a complication of cholecystectomy. Our opinion is based on the fact that stagnant bile was firmly captured inside a 5-mm-thick fibrous capsule biloma. Also, the bilomas might be a result of typical spontaneous rupture of the biliary tree during the long period of the 9 years after operation [2, 6]. The size and location of bilomas depend on the cause of the biliary rupture, the site and the rate of the bile leakage, and the reabsorption capacity of the peritoneum [3, 10]. The maximal reported diameter of the biloma was 40 cm containing 5,700 mL of bile [3]. Most extrahepatic bilomas are located on the right. However, bilomas may be found in the left upper quadrant or bilaterally [2, 10]. Retroperitoneal localization of the biloma is very rare [7], with the possibility of the abdominal wall bile staining [8] or biliscrotum formation [9]. The diagnosis is established on the clinical history, biloma location, US, CT, and MRCP findings. The USguided percutaneous needle aspiration with a chemical analysis definitely confirms the diagnosis of biloma. Although the asymptomatic patients may be treated conservatively, the appropriate treatment for most of the Langenbecks Arch Surg (2008) 393:617–618 DOI 10.1007/s00423-007-0270-6

Presentation of pericardial hydatid cyst as acute cardiac tamponade

We report a case of a 47-year-old man with isolated pericardial hydatid cyst (without myocardial involvement) that presented as acute pericardial tamponade. After initial investigation and transthoracic echocardiography, emergent pericardial drainage was performed for downgrading the urgency of a definitive treatment for a hydatid cyst. A computed tomography examination after the pericardial drainage showed a pericardial cyst without heart muscle involvement, making the treatment possible through anterior thoracotomy and without performing cardiopulmonary bypass. Complete surgical removal of the cyst was performed. The postoperative course was uneventful. The patient received postoperative albendazole treatment. He remained asymptomatic and no recurrence was observed during a 1-year follow-up period.

Giant primary retroperitoneal myxoid leiomyoma: A case report

INTRODUCTION Leiomyomas are benign smooth muscle tumors that usually arise from the uterus. CASE REPORT We present a patient with a 6-month history of vague abdominal discomfort, occasional nausea, vomiting and urinary incontinence. On examination, there was an extremely large firm unpainfull palpable abdominal mass. Laboratory investigation revealed mild leukocytosis and blood creatinine elevation. Abdominopelvic ultrasonography and computed tomography revealed a massive well bordered, encapsulated intraabdominal tumor, extending from the pelvis to epigastrium and almost completely fulfilling the pelvic and abdominal cavity. At laparotomy, tumor arising from the retroperitoneum was excised in toto. Histopathological examination disclosed that the tumor was composed mainly of smooth muscle cells and very rare fibrous connective tissue elements with myxomatous alteration and with no mitotic activity. The negative results of numerous additional parameters analyzed (pancytokeratin, epithelial membrane antigen, S100 protein, CD68, CD34, desmin, aktin) ruled out different origin of a tumor. One year after resection the patient had no complaints and no radiological evidence of tumor recurrence. CONCLUSION Considering current limitations in radiological diagnosis, in toto resection of these tumors is necessary to rule out malignancy.

Safety of simultaneous colon and liver resection for colorectal liver metastases

BACKGROUND/AIM Surgical strategy for the treatment of resectable synchronous hepatic metastases of colorectal cancer (CRC) remains controversial. The aim of this study was to assess safety of simultaneous colon and liver rese cions and the direct effects of this type of treatment upon morbidity and mortality of the patients with synchronus hepatic metastases of CRC. METHODS Intraoperative and postoperative data of 31 patients with simultaneous liver and colorectal resection were compared with the data of 51 patients who had undergone colon and hepatic resection in the staging setting. Analized were demographic data, number of metastases, type of the liver resection, operation time, intraoperative blood loss, percentage of postoperative complications, morbidity and mortality and lenght of hospitalisation. RESULTS In the group of the patients operated simultaneously 5 hepatectomies, 3 sectionectomies, 2 trisegmentectomies, 3 bisegmentectomy, 6 segmentectomies, and 12 metastasectomies were combined with colon resection. In this group operation time (280 vs. 330 minutes) and in traoperative blood loss (450 vs. 820 ml) were lower than those in the two staged operation group. Postoperative complication rate was lower in the simultaneous group (19.35%o) than in the two-staged operation group (19.60%), without statistical significance. There was no hospital mortality in both groups. The patients having simultaneous resection required fewer days in the hospital (median 10.2 days) than the patients undergone operation in the two stage (18.34 days). CONCLUSION By avoiding a second laparotomy, overall operation time, blood loss, hospital stay and complication rate are reduced with no change in hospital mortality, so simultaneous colon and hepatic resection performed by the competent surgeons are safe and efficient for the treatment of synchronous colorectal liver metastases.

Large retroperitoneal schwannoma: a rare cause of chronic back pain

Schwannomas are tumours that arise from Schwann cells of the peripheral nerve sheath and rarely occur in the retroperitoneum. We report a 45-year-old woman who presented with a 2-year history of continuous progressive right-sided lower back and dull flank pain radiating into her posterolateral thigh. Abdominal magnetic resonance imaging showed a homogenous soft-tissue tumour with thick capsular lining, which lay in the right retroperitoneum. The tumour was removed at surgery. A histological examination confirmed the diagnosis of benign encapsulated cellular schwannoma. Complete tumour excision should be regarded as the treatment of choice for benign retroperitoneal schwannomas. Successful treatment of these tumours requires thorough preoperative planning and a multidisciplinary approach.

Histopathologic differentiation as a prognostic factor in patients with carcinoma of the hepatopancreatic ampulla of Vater

Objective Periampullary carcinomas are a group of neoplasms with variable histopathology that originate from the anatomical junction of different epithelial types including the bile duct, pancreatic duct, and duodenal mucosa. This study was performed to determine whether the histopathologic type of these tumors should be considered an independent prognostic factor. Methods We analyzed the specimen histopathology of 37 patients who underwent radical cephalic pancreatoduodenectomy for carcinoma of the ampulla of Vater during a 5-year period. We excluded patients with other tumors with an indication for Whipple’s procedure and those in whom R0 resection was not achieved. Results The carcinomas of the hepatopancreatic ampulla were intestinal in 23 (62%) patients, pancreatobiliary in 13 (35%), and mixed type in 1 (3%). The analysis demonstrated significantly more advanced local tumor spread, a more aggressive lymph node metastasizing pattern, and more frequent lymphatic and perineural invasion in patients with pancreatobiliary than intestinal and mixed type tumors. Conclusion Pancreatobiliary type of ampullary carcinoma is associated with a poorer prognosis than intestinal and mixed types because of its more aggressive behavior. Histopathology should be regarded as an independent predictor of survival and may have therapeutic and prognostic implications for patients.

Localised Langerhans cell histiocytosis of the hypothalamic-pituitary region: case report and literature review

IntroductionLangerhans cell histiocytosis (LCH) localised in the hypothalamic-pituitary region (HPR) is very rare, especially in adults. Diabetes insipidus (DI) is considered to be a hallmark of HPR LCH, while anterior pituitary abnormalities are usually seen as consequences of surgery, radiotherapy or chemotherapy.Case descriptionWe present a patient with localised HPR LCH with dominant anterior pituitary dysfunction and tumour mass effects but without DI. Seven years after surgery and local radiotherapy, she is stable. Control MRI shows no residual tumour growth and thorough physical examination is still without any signs of disease spread.ConclusionsAnterior pituitary deficiency can appear without DI and not only as a consequence of LCH treatment. All patients with LCH should be screened for this endocrine abnormality so that appropriate substitution therapy may be provided.