Stavros Mathioulakis

Multiple giant diverticula of the jejunum causing intestinal obstruction: report of a case and review of the literature.

Multiple diverticulosis of jejunum represents an uncommon pathology of the small bowel. The disease is usually asymptomatic and must be taken into consideration in cases of unexplained malabsorption, anemia, chronic abdominal pain or discomfort. Related complications such as diverticulitis, perforation, bleeding or intestinal obstruction appear in 10-30% of the patients increasing morbidity and mortality rates. We herein report a case of a 55 year-old man presented at the emergency department with acute abdominal pain, vomiting and fever. Preoperative radiological examination followed by laparotomy revealed multiple giant jejunal diverticula causing intestinal obstruction. We also review the literature for this uncommon disease.

Multiarticular chronic tophaceous gout with severe and multiple ulcerations: a case report

IntroductionGout is a common inflammatory arthritis caused by articular precipitation of monosodium urate crystals. It usually affects the first metatarsophalangeal joint of the foot and less commonly other joints, such as wrists, elbows, knees and ankles.Case presentationWe report the case of a 75-year-old Caucasian man with tophaceous multiarticular gout, soft-tissue involvement and ulcerated tophi on the first metatarsophalangeal joint of the left foot, on the first interphalangeal joint of the right foot and on the left thumb.ConclusionUlcers due to tophaceous gout are currently uncommon considering the positive effect of pharmaceutical treatment in controlling hyperuricemia. Surgical treatment is seldom required for gout and is usually reserved for cases of recurrent attacks with deformities, severe pain, infection and joint destruction.

Primary retroperitoneal mucinous cystadenoma of borderline malignancy in a male patient. Case report and review of the literature

BackgroundPrimary retroperitoneal mucinous cystadenoma of borderline malignancy represents a rare tumor, with unclear histogenesis, concerning almost exclusively women. Only two cases concerning male patients have been reported.Case reportWe herein report a case of a 37 year old man undergone laparotomy for a sizable retroperitoneal tumor resulting after the histological examination to a primary retroperitoneal mucinous cystadenoma of borderline malignancy.ConclusionThis is the third case of primary retroperitoneal mucinous cystadenoma of borderline malignancy in a male patient reported in the literature. The preoperative diagnosis is impossible. Laparotomy constitutes the only diagnostic and curative approach.

Strangulated intestinal hernia through a drain site

INTRODUCTION Intra-abdominal drains have been widely used in order to prevent intra-abdominal fluid accumulation and detection of anastomotic leakage. PRESENTATION OF CASE We herein report a case of small bowel herniation followed by strangulation in an 82 year old woman who had undergone sigmoidectomy for colorectal cancer. DISCUSSION Although several complications related to drain usage such as drainsite infection, hemorrhage and intestinal perforation may occur, intestinal incarceration through drain site is rarely reported. CONCLUSION Drains must be used with caution and only if indicated. Careful insertion, regular post-operative or post-removal inspection is strongly recommended.

Malignant fibrous histiocytoma masquerading as gluteal abscess.

To the Editor: Soft tissue sarcomas are rare tumors. They involve various types of connective tissue and account for approximately 1% of adult malignancies. Malignant fibrous histiocytoma (MFH) is a form of malignant sarcoma with a tendency to metastasize to distant areas of the body, especially the lungs. The treatment and outcome of this condition depend on the stage, type, and metastatic behavior of the tumor. We describe an interesting case of MFH that presented as a gluteal abscess. An 85-year-old female was referred to our department because of fever (39.4uC), erythema, and swelling of the left buttock. A clinical examination revealed a warm and painful abscess, 2 3 2 cm in diameter. Routine laboratory tests showed leukocytosis (17,000 mL), and anemia (hemoglobin 10.1 mg/dL). A chest radiograph, an abdominal sonogram, and urine and blood cultures were within normal ranges. The abscess was drained under local anesthesia, and surgical débridement was performed. Bacteriologic examination from the pus revealed the presence of Staphylococcus aureus, and according to the antibiogram, the patient was treated with doxycycline 100 mg twice daily for 10 days postoperatively. Forty-five days after the drainage, the patient was referred to the emergency department because of the rapid development of a sizable, friable, hemorrhagic mass arising from the site of the gluteal abscess that had been treated (Figure 1). Laboratory investigation revealed anemia (hemoglobin 8 mg/dL) and abnormal coagulation parameters (international normalized ratio 5). Axial contrastenhanced computed tomographic images demonstrated an increasingly hyperdense lesion. The center of the lesion was hypodense and probably necrotic, with irregular borders. The lesion was extending from the subcutaneous tissue, invading the adjacent gluteus maximus, gluteus medius, and piriformis muscles. Cytoreduction under epidural anesthesia was performed, and the resected specimen measured 17 3 15.5 3 4.5 cm in diameter. Histologic examination showed a variable morphologic pattern with storiform and pleomorphic areas. Storiform areas consisted of atypical spindle cells with medium or large irregular vesicular nuclei and prominent nucleoli. Pleomorphic areas contained plumper fibroblastic cells, with large vesicular clear nuclei and eosinophilic cytoplasm. Extensive necrosis was also present. Immunohistochemical stains revealed immunoreactivity for vimentin (Figure 2) and no reaction for pankeratin, desmin, HMB-45, smooth muscle actin, and S100. The histologic picture was compatible with MFH. Unfortunately, the patient died 15 days after the excision of the tumor because of pulmonary edema owing to chronic atrial fibrillation. Although the reason for the fatal outcome was unrelated to MFH, we believe that the delayed diagnosis of the tumor played a significant role in the patient’s poor condition. The incidence of MFH is estimated as 17% of soft tissue sarcomas, and the storiform-pleomorphic histologic variant represents 70% of MFH cases. Soft tissue sarcomas are usually asymptomatic, described as indolent, unmoveable masses. Rarely, they may mimic a hematoma or an abscess, and these uncommon presentations further delay diagnosis and treatment, as in our case. The development of an abscess has been commonly attributed to trauma, injection, or infection of underlying seborrheic cysts. Drainage of abscesses, often followed by débridement, is commonly performed under local anesthesia. Surgical excision of the lesion is the treatment of choice. Additional radiotherapy and/or chemotherapy should be individualized.

Traumatic mesenteric cyst after blunt abdominal trauma.

Mesenteric cysts are rare abdominal tumors of unclear histologic origin, usually asymptomatic. Post-traumatic mesenteric cyst usually results as a consequence of a mesenteric lymphangitic rupture or a hematoma followed by absorption and cystic degeneration. The preoperative histological and radiological diagnosis is difficult. We present the case of a 45-year-old male patient with sizable, palpable abdominal tumor, the gradual swelling of which the patient himself combined with the blunt abdominal trauma he acquired from an opponents knee in a football game 5 months ago.

Recurrent Urinary Tract Infections due to Asymptomatic Colonic Diverticulitis

Colovesical fistula is a common complication of diverticulitis. Pneumaturia, fecaluria, urinary tract infections, abdominal pain, and dysuria are commonly reported. The authors report a case of colovesical fistula due to asymptomatic diverticulitis, and they emphasize the importance of deeply investigate recurrent urinary tract infection without any bowel symptoms. They also briefly review the literature.

Rectus Abdominis Muscle Malignant Fibrous Histiocytoma Causing a Large Abdominal Wall Defect: Reconstruction with Biological Mesh

Malignant fibrous histiocytoma (MFH) is a common soft tissue sarcoma usually involving limbs and retroperitoneum. MFH of the rectus abdominis muscle is extremely rare. Surgery in similar cases leads to large abdominal wall defects needing reconstruction. Biological and synthetic laminar absorbable prostheses are available for the repair of hernia defects in the abdominal wall. They share the important feature of being gradually degraded in the host, resulting the formation of a neotissue. We herein report the case of an 84-year-old man with MFH of the rectus abdominis muscle which was resected and the large abdominal wall defect was successfully repaired with a biological mesh.

Choloperitoneum causes extensive coloring of the abdominal wall skin.

Laparoscopic cholecystectomy, because it is the less invasive surgical procedure, has been established as the procedure of choice for the treatment of patients with symptomatic gallbladder stones. However, bile leakage after laparoscopic cholecystectomy should not be overlooked. It is generally due to a minor biliary complication, although it can sometimes herald a major duct injury. Bile leakage rates of 1.2% to 4.0% in laparoscopic cholecystectomies have been reported, which are higher than the incidence with open cholecystectomies.