N. Symeonidis

Complicated liver echinococcosis: 30 years of experience from an endemic area.

Background and Aims: Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management, and short-term outcome of patients with complicated liver echinococcosis. Material and Methods: A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with noncomplicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%), and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications, and hospital stay were assessed. Results: Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated. Conclusions: Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently severe clinical manifestations, complexity of surgical management, and the increased postoperative complications characterize complicated liver echinococcal disease.

Primary Ewing Sarcoma of the Stomach – A Newly Described Entity

The Ewing sarcoma family of tumors (ESFT) includes classic Ewing sarcoma of the bone, extraosseous or soft tissue Ewing sarcoma, Askin tumors of the chest wall, and peripheral primitive neuroectodermal tumors of the bone and soft tissues. They share a common neural histogenesis, tumor genetics and biology. The genetic hallmark of the ESFT is the presence of t(11;22)(q24;q12), which creates the EWS/FLI1 fusion gene and results in the expression of a chimeric protein. Although Ewing tumors can occur at any age, the great majority are found in individuals less than 20 years of age. We herein report a case of gastric Ewing sarcoma in a 68-year-old male. This patient illustrates the second reported occurrence of primary Ewing sarcoma in the stomach and the first reported with the t(11;22)(q24;q12) gene translocation.

Effect of Experimentally Induced Liver Cirrhosis on Wound Healing of the Post-Extraction Tooth Socket in Rats

Background: Wound healing in liver cirrhosis is known to be impaired possibly due to liver insufficiency and subsequent malnutrition status; however, there is no study to examine healing effectiveness of the tooth socket following an extraction in such patients. Materials and Methods: Irreversible cirrhosiswas induced in 30 Wistar rats by repetitive weekly doses of CCl4 and continuous administration of phenobarbital in a 12-week course was monitored by body weight measurement and ascites development, and was proved histologically. One week later, cirrhotic and control rats were subjected to extractions of two maxillary grinders on each side, one side by simple method, the other by surgical method. Half of the animals of each subgroup were sacrificed on the 10th post-extraction day, whereas the other half on the 30th post-extraction day, and histological sections were examined from all tooth sockets for wound-healing activity. Results: A malnutrition status was detected in cirrhotic rats with significant difference in their body weight. Several histological parameters of socket healing were not statistically different between cirrhotic and control animals. However, a significant delay on epithelialization and cancellous bone formation was detected on the 10th post-extraction day for either simple or surgical extractions in cirrhotic animals. Conclusions: Liver cirrhosis in rats provokes a significant delay on epithelialization and mature cancellous bone formation and consecutively on early socket wound healing after a tooth extraction.

Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients.

Background: Elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years. Methods: From January 1999 to December 2008, a total of 719 patients underwent open tension-free inguinal hernia repair with mesh-plug; 301 among them were ≥ 65 years old. Results: Elderly patients had a mean age of 72.4 years (women 3.3%), while the mean age of younger patients was 48.7 years (women 5.7%). According to the ASA score, patients aged ≥ 65 years were at significantly higher risk than the younger patients. Spinal anesthesia was used most frequently in both groups. No significant differences were found in postoperative pain, mortality and recurrence. Morbidity and hospital stay were significantly higher in patients aged ≥ 65 years. Conclusions: Open hernia repair in the elderly is safe and well tolerated, but it is associated with higher morbidity and longer hospitalization.

Current management of diverticular disease complications.

Diverticular disease is a common problem in the western population and sometimes leads to serious complications such as hemorrhage, bowel stenosis, obstruction, abscesses, fistulae, bowel perforation, and peritonitis. The severity of these complications can differ, and it is not always clear which procedure is indicated in each case and what measures should be followed before bringing the patient into the operating room. Certain operations have high rates of morbidity and mortality, especially in compromised patients. Along with advancements in imaging and minimally invasive techniques, the indications for surgery have currently being adapted to “damage limitation” or “down-staging” protocols, which seem to offer improved results. There are still some questions to be solved in the following years by prospective studies, such as the usefulness of laparoscopic lavage in purulent peritonitis or of Hartmann’s procedure in fecal peritonitis. These indications, based on current literature, are systematically discussed in the present review.

Intraperitoneal administration of bevacizumab intraoperatively does not affect abdominal wound healing in rats.

Background: Bevacizumab is a monoclonal antibody targeted at vascular endothelial growth factor (VEGF) to treat advanced colorectal cancer as well as other malignancies, but the ideal time point for its administration in patients scheduled for surgery is not well defined due to serious concerns regarding possible side effects on wound healing. Therefore, we conducted an experimental study in rats to clarify this issue. Methods: Four groups of 10 Wistar rats each underwent a 4-cm midline laparotomy and closure of the wound in 2 layers. In the treatment groups (A and B), bevacizumab (Avastin®) received a single dose of 5 mg/kg i.p., and an equal amount of saline was given to the control groups (C and D). Groups A and C were sacrificed on the 7th postoperative day, and groups B and D on the 14th postoperative day. Wounds were inspected by two independent observers upon sacrifice and results were recorded; wound tissues were sent for histology to assess the degree of fibrosis and measurement of tissue hydroxyproline levels. Serum levels of endothelin-1, C-reactive protein, pro-oxidant/antioxidant balance and carbonylated proteins were also determined. For statistical analysis, the Mann-Whitney U test was used. Results: Wound healing did not differ among groups both on the 7th and the 14th postoperative days, and there was also no significant difference regarding the degree of inflammation, fibroblast proliferation and collagen synthesis, as well as hydroxyproline and biochemical marker levels among the groups. Conclusions: Intraperitoneal bevacizumab administered intraoperatively does not significantly affect abdominal wound healing in rats.

Deeply infiltrating rectal endometriosis with lymph node involvement.

Abstract Background: Sigmoidorectal endometriosis accounts for 70% of the cases of intestinal endometriosis. Symptoms are non-specific, frequently resembling adenocarcinomas. Case: A 45-year-old woman complaining of recurrent rectal bleeding underwent colonoscopy in which a rectal polypoid mass was found. She underwent anterior rectosigmoidectomy and the histological examination of the resected bowel revealed rectal endometriosis with lymph node involvement. Conclusion: Lymphatic infiltration of epicolic lymph nodes raises questions about the benign nature of this presumed innocent disease.

Clinical features of colonic diverticular disease

Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.

Pelvic malakoplakia simulating recurrence of rectal adenocarcinoma: report of a case

Malakoplakia represents a chronic inflammatory disease associated with a broad spectrum of bacterial infections. On histopathology, Michaelis-Gutmann bodies are considered as pathognomonic histopathological findings. Rarity of the disease and wide variety of clinical presentation makes its diagnosis very challenging. We report herein the case of a 66-year-old woman who, having undergone lower anterior resection for rectal adenocarcinoma 3 and a half years ago, presented with urinary frequency and dull abdominal pain. CT scan revealed a soft tissue tumour infiltrating the preperitoneal fat over the urinary bladder, which was considered as recurrence of the rectal carcinoma. On laparotomy, a tumour invading the bladder, small intestine and the anterior abdominal wall was resected and the patient recovered uneventfully. On histopathology, malakoplakia of urinary bladder was revealed. Overstaging of patients’ malignancy due to malakoplakia is not uncommon, so its early identification can help avoid incorrect treatment.

Retractile mesenteritis appearing as a sigmoid colon tumor.

Retractile mesenteritis is a rare, fibrosing, inflammatory disease affecting the adipose tissue of the intestinal and colonic mesentery. So far, about 300 cases have been reported in the literature. We present a case of retractile mesenteritis.