N. Harlaftis

Prognostic significance of mucinous component in colorectal carcinoma

BackgroundMany factors influence survival in colorectal cancer patients, one of them is the mucinous component of the tumour. Mucinous adenocarcinoma is characterized by the extracellular mucin of more than 50% of the tumour volume.MethodsFrom 1970 to 1999, 1160 patients were admitted to our clinic for colorectal cancer. They were divided into four groups according to mucinous character of the tumour, in two time periods of 15 years.ResultsThere was an increase in the incidence of mucinous tumours from 20.8 to 30.5% in the second period. These tumours were more advanced (Dukes’ C) and especially right sided (34.5% vs. 17.9%). Five-year survival was increased during the second period but was of a lesser degree in the mucinous group (51.5% vs. 65.5%).ConclusionsColorectal mucinous carcinomas present at a more advanced stage, predominantly in men, with higher right colon location rate, and a worse overall 5-year survival rate than the non-mucinous colorectal cancers.

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.

Perforated diverticulum of the caecum. A difficult preoperative diagnosis. Report of 2 cases and review of the literature.

BackgroundPerforation of a solitary caecal diverticulum is a rare cause of acute abdomen and an uncommon differential diagnosis for acute appendicitis. Nine hundred cases have been described since Potiers’ first description of perforated caecal diverticulum in 1912.MethodsWe describe 2 cases of perforated diverticulum of the caecum. The first patient was a 50-year-old man diagnosed by subsequent histology, and the second a 77-year-old woman diagnosed intra-operatively. Radiography, ultrasound and CT scan of the abdomen pointed at the diagnosis in the second case. A right hemicolectomy was performed.ResultsThere were no complications, apart from a transient faecal fistula in the first patient managed conservatively. In both patients histology revealed a perforated caecal diverticulum.ConclusionsThe surgeon must be familiar with the diagnosis and management of this rare, inflammatory benign caecal entity.

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.

Manometric and clinical evaluation of patients after low anterior resection for rectal cancer

The aim of this study was to examine the anorectal physiological and clinical changes that occur after low anterior resection for rectal cancer. Since 1998, 30 patients underwent laboratory tests of anorectal function, preoperatively and 1 month and 6 months after low anterior resection. Postoperatively all patients presented with increased bowel frequency, 60% of the patients with mild soiling and 30% with urgency for defecation. Six months after surgery there was a significant improvement of these symptoms. The anal resting pressure was significantly decreased postoperatively, while maximum squeezing pressure remained unchanged. The rectoanal inhibitory reflex was absent in 80% of the patients and at 6 months after surgery it tended to recover. Rectal capacity and compliance were reduced in all patients. In the current study, the majority of patients demonstrated manometric anorectal changes and clinical anorectal function disorders during the first year after surgery. We observed that these disorders correlated with the low level of the anastomosis.

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.

A case of mucinous adenocarcinoma arising in long-standing multiple perianal and presacral fistulas

Chronic anal fistulas are not rare; however, the development of a carcinoma in long-standing, perianal fistulas is rare. We describe a case of an 85-year-old man with multiple, recurring, perianal fistulas, extending to the natal cleft. The patient underwent en bloc resection of the fistulas which were in direct continuity with the middle rectum. Histological examination revealed a mucinous colonic adenocarcinoma. Abdominal CT and colonoscopy revealed an extramural residual rectal mass. The patient refused a radical colorectal operation. Three years later, because of fistula recurrence, he underwent loop sigmoidostomy and radical en bloc excision of the perianal fistula and rectum, with immediate reconstruction by bilateral gluteal flaps. The patient was discharged on the 12th postoperative day, refusing adjuvant radiotherapy. We present this rare malignant entity, successfully treated by staged operations and without any adjuvant therapy.

Metastatic breast adenocarcinoma masquerading as colonic primary. Report of two cases.

BackgroundCommon sites of metastasis for the breast cancer are bones, lungs, the central nervous system and liver. The colon is the rarest site of metastasis for the breast carcinoma.Patients and resultsWe report our recent experience of two female patients, 55 and 57 years old respectively, who presented breast metastasis at the proximal transverse colon. They were operated for breast carcinoma followed by chemotherapy and radiotherapy, four and ten years before the metastasis was diagnosed. The symptoms were anaemia and bowel obstruction. Diagnosis was made by double contrast barium enema and colonoscopy. Postoperatively, both patients received systemic chemotherapy. At the follow-up, two and three years after, there is no evidence of recurrence or metastasis.ConclusionsPatients with history of breast cancer presenting with anaemia and/or bowel obstruction should be examined for possible metastasis to colon and should be treated surgically followed by systemic chemotherapy.

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.