esko P

The accuracy of ultrasonography in classification of groin hernias according to the criteria of the unified classification system

BackgroundThe modern concept of type-related individualized groin hernia surgery imposes a demand for precise and accurate preoperative determination of the type of groin hernia. The aim of this prospective study was to evaluate the accuracy of ultrasonography in classification of groin hernias, according to the criteria of the unified classification system. Unified classification divides groin hernias into nine types (grades): type I (indirect, small), II (indirect, medium), III (indirect, large), IV (direct, small), V (direct, medium), VI (direct, large), VII (combined-pantaloon), VIII (femoral), and O (other).Patients and methodsOne hundred and twenty-five adult patients with clinically diagnosed or suspected groin hernias were examined. Ultrasonography of both groins was performed with a 5 to 10-MHz linear-array transducer. Preoperative ultrasonographic findings of type of groin hernia were compared with the intraoperative findings, which were considered the gold standard.ResultsTotal accuracy of ultrasonography in determination of type of groin hernia was 96% (119 of 124 correct predictions of type of groin hernia compared with surgical explorations). All hernias of types I, IV, V, VII, and VIII were correctly identified with ultrasonography (sensitivity and specificity 100%). In the remaining five cases of the 124 (4%), hernia was incorrectly classified with ultrasonography: type VI (direct, large) was misdiagnosed as type III (indirect, large) in three cases, type III as type VI in one case, and type III as type II (indirect, medium) in one case. The sensitivity and the specificity of ultrasonography in classifying type II were 100 and 99%, respectively, for type III, 85 and 97%, and for type VI, 90 and 99%.ConclusionUltrasonography of the groin regions could be used with great accuracy for precise classification of groin hernias in adults. Each type of groin hernia, according to the unified classification system that we used for classification, has a characteristic ultrasonographic presentation, which is demonstrated in this study.

Foregut caustic injuries: results of the world society of emergency surgery consensus conference

IntroductionLesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available.Purpose of the studyThe aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition.MethodsAn extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015).ResultsOne-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council.ConclusionsThe recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.

Primary inflammatory myofibroblastic tumor of the stomach in an adult woman: a case report and review of the literature

Inflammatory myofibroblastic tumor has been defined as a histologically distinctive lesion with uncertain behaviour. The term inflammatory myofibroblastic tumor more commonly referred to as “pseudostumor ”, denotes a pseudosarcomatous inflammatory lesion that contains spindle cells, myofibroblasts, plasma cells, lymphocytes and histiocytes. It exhibits a variable biological behavior that ranges from frequently benign lesions to more aggressive variants. Inflammatory myofibroblastic tumor mostly occurs in the soft tissue of children and young adults, and the lungs are the most commonly affected site, but it has been recognized that any anatomic localization can be involved. Inflammatory myofibroblastic tumors in adults are very rare, especially in the stomach. We present a case of a 43-year old woman with primary inflammatory myofibiroblastic tumor in the stomach and a review of the literature.

Invasive Lobular Breast Cancer Presenting an Unusual Metastatic Pattern in the Form of Peritoneal and Rectal Metastases: A Case Report

Gastrointestinal metastases from invasive lobular breast cancer are uncommon with the stomach and small intestines being the most common metastatic sites. Peritoneal and rectal metastases are very rare and only rarely occur as the first manifestation of disease. We herein report the case of a 47-year-old woman who presented with abdominal carcinomatosis as a first sign of invasive lobular breast carcinoma (ILC). Identifying the most important immunohistochemical markers for ILC: gross cystic disease fluid protein 15, estrogen and progesterone receptors enabled a correct diagnosis. After a six year disease-free period, relapse occurred with severe obstruction due to rectal metastasis from lobular breast carcinoma. Since there was no widespread metastatic disease, surgery with concomitant hormonal therapy was performed.

Minimally invasive surgery for benign esophageal disorders: first 200 cases

SummaryBackgroundTo evaluate the method of introduction, feasibility, and early results of a laparoscopic surgery for benign foregut disorders in a single high volume center.MethodsA retrospective clinical study included consecutively laparoscopically operated patients due to benign foregut disorders. The study was conducted at the Department of Esophagogastric Surgery, First Surgical University Hospital, School of Medicine, University of Belgrade from March 2010 until July 2014. Complete preoperative diagnostics data, details of surgical procedures, and follow-up results are included.ResultsOverall, 200 consecutive patients were enrolled in the study. GERD and achalasia were the most common indications for laparoscopic surgery, with 81 and 72 patients respectively. Due to giant hiatal hernia, 37 patients were operated on, while the rest were less common indications. There were no conversions to open procedures. In three patients, pneumothorax resulted from intraoperative pleural lesion. One mucosal perforation occurred in an achalasia patient. One reoperation was conducted due to excessive port site bleeding. Short term follow-up results are highly satisfactory, and are presented in detail for every patient group.ConclusionIntroduction of laparoscopy in a foregut surgery high volume center for the treatment of benign foregut disorders can be obtained with low incidence of complications, and satisfactory short term functional results.

From Ockham’s razor to Hickam’s dictum and back—Saint’s theory and the insights in herniosis

SummaryIntroductionThe goal of this review article is to present the relationship between the theory of herniosis and Saint’s triad through the two philosophical stand points frequently encountered in diagnostic medicine, Ockham’s razor and Hickam’s dictum. The Saint’s triad was recognized when association between hiatal hernia, colonic diverticular disease, and gallstones have been proven to appear more often than just by pure chance alone.MethodologyA systematic review of the literature was performed using MEDLINE (PubMed search), EMBASE, and the Cochrane databases, and it included papers published from 1948 until 2014.ResultsThe data obtained by search are presented to analyze the theory of herniosis. Connective tissue disorder is being recognized as a cornerstone beneath the Saint’s triad, and the facts backing up this stand point are now systematically displayed to readers. Special emphasis is given on review of current literature reports on origin of hiatal hernia and its influence on everyday surgical perceptive.ConclusionSaint’s triad, once the most cited example of Hickam’s dictum is now being put to trial with the theory of herniosis, proving a sharper edge to Ockham razor stand point. It is upon the reader, from the arguments given, to choose which principle will prevail, in further thinking about this particular problem.