Savas Rafailidis

Limy bile syndrome: review of seven cases

Background:  Milk of calcium bile or limy bile is a rare disorder in which the gall bladder is filled with a thick, paste‐like, radiopaque material.

Retroperitoneal, mediastinal, and subcutaneous emphysema, complicating colonoscopy and rectal polypectomy.

Complications of flexible endoscopy-though still rare-are increasing in frequency lately as more invasive procedures are routinely performed. Perforation, hemorrhage, coagulation disorders, thrombophlebitis, and splenic rupture have all been reported to complicate colonoscopy and colorectal polypectomies. In this paper, we report on a case of retroperitoneal, mediastinal, and neck surgical emphysema, complicating colonoscopy and rectal polypectomy, presented initially as a change in the voice and facial swelling.

Somatostatin-producing pancreatic endocrine carcinoma presented as relapsing cholangitis -- a case report.

Somatostatin-producing endocrine tumors are rare neoplasms usually arising in the pancreas and duodenum and they account for less than 1% of all gastrointestinal endocrine tumors. Besides somatostatinoma syndrome, which is characterized by diabetes mellitus, steatorrhea and cholelithiasis, patients with somatostatin-producing endocrine tumors commonly complain of nonspecific symptoms such as vague abdominal pain, weight loss or changes in bowel habits. Tumor behavior cannot be predicted by histological features alone, and malignancy is determined by the presence of metastases. We report here a case of malignant pancreatic endocrine tumor producing somatostatin presented as relapsing cholangitis who was treated with Whipple pancreatoduodenectomy.

Effect of early bosentan administration on the development of esophageal varices in cirrhotic rats: experimental study in Wistar rats

BackgroundThis study was conducted to investigate the effect of chronic bosentan administration on the development of esophageal varices in carbon tetrachloride-induced cirrhosis in rats.MethodsFor the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein, followed by phenobarbital and carbon tetrachloride administration. Two weeks after the beginning of carbon tetrachloride administration, rats were separated into two groups. In group I, comprising 30 rats, bosentan was continuously administered throughout the study, whereas in group II, also 30 rats, placebo instead of bosentan was continuously administered. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis. The total number of veins counted in the submucosa, the number of submucosal veins/mm2 of submucosa, the total submucosal area occupied by vessels, the mean cross-sectional vessel area, the relative submucosal area (percentage) occupied by vessels, and the area of the single most-dilated submucosal vein were studied.ResultsBosentan induced a significant (P < 0.05) decrease in portal pressure, while morphometric analysis revealed a significant reduction (P < 0.05) of all parameters studied in bosentan-treated rats, except in the total and relative number of submucosal veins.ConclusionsBosentan administration seemed to significantly attenuate dilation of submucosal veins in the lower esophagus of cirrhotic rats. This effect was mainly attributed to a decrease in the portal pressure induced by chronic bosentan administration.

A case of Mirizzi's syndrome mimicking carcinoma: the role of CBD-stenting for easy surgical management.

Mirizzis syndrome accounts for an important risk for bile tree injury during surgery, since preoperative diagnosis is missed in half of the cases and is often difficult to differentiate from carcinoma. A 79-year-old male, with a known history of cholelithiasis, was admitted with a progressive obstructive jaundice over 20 days, without pain, fever, or other symptoms. Magnetic resonance cholangiopancreatography described possible microlithiasis of the distal bile duct, but on endoscopic retrograde cholangiopancreatography (ERCP), an irregular stenosis was detected under the junction of hepatic ducts, which was described as possibly neoplastic. A temporary stent was placed and the patient was referred for surgery. On first view the gallbladder appeared hard, embedded in adhesions, giving the impression of an unresectable tumor and the bile duct was not approachable. After a fundus-down incision of the gallbladder multiple stones were extracted. Frozen biopsies from the gallbladder wall were negative. The incision was extended towards the gallbladder neck and a large communication with the common bile duct (CBD) was revealed. A difficult partial cholecystectomy was performed, followed by cholecystojejunostomy with a Roux-en-Y jejunal loop. The patient had a totally uneventful postoperative course. Stent removal was succeeded endoscopically 1 month later. The importance of preoperative ERCP and CBD stenting is highlighted in this article. ERCP may have failed to distinguish Mirizzis syndrome from carcinoma, however the stent placement saved the cardiologically compromised patient from further surgical manipulations. Therefore, in ambiguous cases, whatever the final diagnosis turns to be, either carcinoma or Mirizzis syndrome, CBD stenting can be useful for the final management of the patient.

Small bowel incarceration associated with posthysterectomy enterocele.

Enterocele represents a pelvic floor hernia with the sac most commonly protruding between the rectum and vagina. It may occur with or without prior hysterectomy and is very rarely complicated by small bowel obstruction. We report herein the case of a 70-year-old woman with a posthysterectomy enterocele presented with symptoms of small bowel obstruction and abdominal tenderness. The patient underwent exploratory laparotomy, which revealed small bowel incarceration. To our knowledge, this case represents the first published case of vaginal vault prolapse and enterocele associated with small bowel obstruction and incarceration. The pathogenesis, diagnosis, and treatment are discussed.