P. Tsiaousis

Effect of Time on Risk of Perforation in Acute Appendicitis

Abstract Introduction: The aim of this study was to quantify the role of time between symptom onset and surgery on the changing risk of perforation, and to evaluate the possible factors leading to delay to the operation. Patients and methods: The files of 169 patients who underwent appendectomy in our clinic over a two-year period (May 2004-June 2006) were reviewed. The relative risk of perforation was calculated according to the “time-table” method. Time was divided into intervals, initially of 12 hours and, later on, of 24 hours. Results: 18 patients were found to have perforated appendicitis. The time from symptom-onset to first examination (“symptom onset to presentation” time, “SOP” time) was longer for patients with perforation than for those without (p = 0.047). On the other hand, the time from initial examination in the emergency department to the operating room (“ER to OR” time) was shorter for patients with perforation than for those without (p = 0.027). Overall time from symptom onset to operating room, showed no statistical difference between patients with rupture and those without. The risk of perforation was negligible within the first twelve hours of untreated symptoms, but then increased to 8% within the first twenty-four hours. It then decreased to approximately 1.3% to 2% during 36 to 48 hours, and subsequently rose again to approximately 6% (7.6% to 5.8%) for each ensuing 24-hour period. In multivariate analysis, neither the “SOP” nor the “ER to OR” time remained significant contributors to the probability of an individual to suffer from appendiceal perforation. Conclusion: When time matters and the risk of adverse outcomes can be reduced, we should change our current approach to care. Surgeons should be mindful of delaying surgery beyond 24 hours of symptom onset in patients with assumed appendicitis.

Carcinoma developing in ectopic pancreatic tissue in the stomach: a case report

The development of pancreatic tissue outside the confines of the main gland, without anatomic or vascular connections between them, is a congenital abnormality referred to as heterotopic pancreas. A heterotopic pancreas in the gastrointestinal tract is usually discovered incidentally and the risk of its malignant transformation is extremely low. In this study, we describe the first case of endoepithelial carcinoma arising in a gastric heterotopic pancreas of a 56-year old woman in Greece. She presented with epigastric pain, periodic nausea and vomiting. Esophagogastroduodenoscopy revealed an ulcerated lesion in the gastric antrum, biopsies of which showed intense epithelial dysplasia with incipient malignant degeneration. The pathology report of the distal gastrectomy specimen demonstrated a 2 cm in diameter ulcerative mass in the gastric antrum. Microscopically, an endoepithelial (in situ) carcinoma of the gastric antrum was determined, which in places turned into an microinvasive endomucosal adenocarcinoma. It also incidentally demonstrated heterotopic pancreatic ducts, detected within the mucosa to the muscularis propria of the same region of the stomach, in which an endoepithelial (in situ) carcinoma was evolving. The follow-up course was uneventful 6 months postoperatively.

Repair of a giant inguinoscrotal hernia

Giant inguinoscrotal herniae are infrequent in developed countries nowadays, nonetheless they may still typically present after years of neglect. The morbidity associated with them can be significant. Surgical management, although challenging even for the experienced surgeon, enables the patient to return to a reasonable level of function and quality of life. We present a case of a giant right inguinoscrotal hernia, which was treated with a multi-stage extensive operation, following adequate pre-operative respiratory preparation. The operation included reduction of the hernial contents in the abdominal cavity following omentectomy, right hemicolectomy and splenectomy, hernioplasty and reconstruction of the abdominal wall with the preperitoneal use of a Composix mesh and finally reductive reconstruction of the scrotum. The technique described represents a successful combination of various techniques described for the management of these patients.

The role of prosthetic repair in the treatment of an incarcerated recurrent inguinal hernia with acute appendicitis (inflamed Amyand's hernia).

Dear Sir, We read with considerable interest the paper by Kueper et al. [1], which was referred to the extreme case report of an incarcerated recurrent inguinal hernia with covered and perforated appendicitis which was managed with appendectomy and Bassini operation. The authors concluded that, in a septic environment, the implantation of a prosthetic material should be avoided due to the danger of infection. We report the second case of an incarcerated recurrent Amyand’s hernia with acute appendicitis, but the Wrst to be successfully treated with appendectomy and polypropylene plug placement at the same time. A 63-year-old man was admitted to our surgical emergency department with a 12-h history of right lower quadrant pain. Past medical history was unremarkable, with the exception of a right inguinal hernia, repaired with the Shouldice technique 7 years ago. Physical examination showed mild pressure pain in the right lower quadrant of the abdomen without peritoneal irritation. Moreover, there was a palpable, painful, non-reducible mass in the groin and localized tenderness over the inguinal region. Laboratory tests revealed mild leucocytosis (12,400/mm) and an elevated C-reactive protein level (CRP; 4.5 mg/dl). Abdominal X-ray showed air–Xuid levels suggesting small bowel obstruction. Abdominal computed tomography (CT) scan demonstrated distended small bowel loops being in contact with the right internal inguinal ring. However, the inguinal canal seemed to be intact. Based on his clinical condition and the CT Wndings, the patient was taken to the operating room. Through a median lower laparotomy, the terminal ileum was revealed to be tumescent and distended, and the cecum closely adherent to the anterior abdominal wall. Further exploration demonstrated an incarcerated inXamed appendix inside the sac of a recurrent indirect inguinal hernia. Appendectomy was performed and the hernia was repaired with the placement of a polypropylene plug in the internal inguinal ring. The patient received broadband antibiotics (cefoxitin sodium + metronidazole) preoperatively and for the next 5 days. He was discharged on the 6th postoperative day, after an uncomplicated recovery. Currently, 6 months after the operation, the patient’s condition is excellent. The proper management of an Amyand’s hernia remains a challenging issue. Most authors agree that normal appendix within the hernia sac does not require appendectomy and that every eVort should be made to preserve the organ for an uneventful postoperative course [2]. However, in cases of inXamed appendix, appendectomy is obligatory and, in these cases, the decision for a mesh hernia repair may seem very hazardous [1, 3]. On the other hand, the recommended primary suture using Shouldice or Bassini techniques could be technically very challenging in an inXamed and edematous area, thus, increasing the risk of recurrence. Torino et al. [4] believe that the use of a synthetic mesh could be feasible and safe if the inguinal area is previously irrigated with antibiotics, a drain is placed under the aponeurosis, and the patient is treated postoperatively with intravenous antibiotics. Based on our experience [5, 6], we believe that a septic environment (presence of strangulated or incarcerated inguinal or femoral hernia, inXamed Amyand’s hernia) is not an absolute contraindication for G. Chatzimavroudis (&) · B. Papaziogas · I. Koutelidakis · P. Tsiaousis · T. Kalogirou · S. Atmatzidis · K. Atmatzidis 2nd Department of Surgery, Medical School, Aristotle University of Thessaloniki, “G. Gennimatas” Hospital, Ethnikis Aminis 41, 54635 Thessaloniki, Greece e-mail: gchatzimav@yahoo.gr

Appendiceal Mucocele. A retrospective Analysis of 19 Cases

BackgroundAppendiceal mucocele is an infrequent well-recognized entity that can present in a variety of clinical syndromes or can be asymptomatic and discovered incidentally.Patients and MethodsNineteen patients with a diagnosis of primary appendiceal mucocele treated in our institution between January 1, 1987 and December 31, 2006 were included in this retrospective analysis.ResultsThe histological examination of the specimens revealed simple and hyperplastic appendiceal mucocele in nine cases (47%), mucinous appendiceal cystadenoma in eight cases (42%), and mucinous appendiceal cystadenocarcinoma in two cases (11%). Thirteen patients (68%) underwent appendectomy, five patients (26%) right colectomy, and two patients (6%) underwent right colectomy for invasive appendiceal cystadenocarcinoma and at the same time right nephrectomy and sigmoidectomy, respectively, for concomitant malignancy.ConclusionMucocele of the appendix may be related to a benign or malignant appendiceal process, leading to individualized diagnosis and treatment.

Adrenal Pseudocyst Presenting as Acute Abdomen during Pregnancy

Abstract Pseudocysts of the adrenal gland are rare lesions, which are usually discovered as incidental findings. Since they are in the majority of cases non-functioning, they become symptomatic only when they are complicated with rupture, haemorrhage or infection. We present a case of a 28-year-old woman in the 26th gestational week, who developed an acute abdomen due to a haemorrhagic pseudocyst of the left adrenal. The patient was submitted to left adrenalectomy. The described case is the third reported case of cystic adrenal lesion discovered during pregnancy and only the first reported case of acute presentation of an adrenal pseudocyst during pregnancy.

Spleen Rupture Due to Primary Angiosarcoma: A Case Report

A case of a 79-year-old female with rupture of the spleen due to primary angiosarcoma is presented. Symptoms were non-specific. Diagnosis was based on histology postoperatively. Primary angiosarcoma of the spleen is a very rare and aggressive neoplasm with a high metastatic rate and almost uniformly fatal. Due to small number of reported cases, there are no guidelines concerning adjuvant or palliative treatment or any beneficial protocols of chemotherapy or radiotherapy up to date. Splenectomy prior to rupture seems to have a positive impact on long-term survival.

Effect of moxifloxacin on survival, lipid peroxidation and inflammation in immunosuppressed rats with soft tissue infection caused by Stenotrophomonas maltophilia

In order to investigate the effect of moxifloxacin on survival, lipid peroxidation and inflammation in immunosuppressed rats with soft tissue infection caused by Stenotrophomonas maltophilia, 144 white male Wistar rats were randomized into six groups: Groups A and B received saline or moxifloxacin once per day, respectively; Groups C and D received saline or moxifloxacin twice per day, respectively, and Groups E and F received saline or moxifloxacin three times per day, respectively. Blood samples were taken at 6 and 30 hr after administration of S. maltophilia. Malonodialdehyde (MDA), WBC counts, bacterial tissue overgrowth, serum concentrations of moxifloxacin and survival were assessed. Survival analysis proved that treatment with moxifloxacin every 8 hr was accompanied by longer survival than occurred in any other group. Tissue cultures 30 hr after bacterial challenge showed considerably less bacterial overgrowth in the spleens and lungs of moxifloxacin‐treated than in saline‐treated animals, but not in their livers. At 6 hr there were no statistically significant differences between groups. However, at 30 hr, MDA concentrations were significantly greater (P = 0.044) and WBC counts significantly lower (P = 0.026) in group D than in group C. No statistically significant variations were observed between the other groups. Moxifloxacin possibly stimulates lipid peroxidation and enhances phagocytosis, as indicated by MDA production and survival prolongation, without being toxic, as indicated by WBC count. Therefore, under the appropriate conditions, moxifloxacin has a place in treatment of infections in immunosuppressed patients and of infections caused by S. maltophilia.