Stylianos Apostolidis

Duplication of the inferior vena cava: anatomy, embryology and classification proposal

A case of a duplicated inferior vena cava (IVC) along with other anatomical vessel variations in a 72-year-old male cadaver is presented. The anomalous vessels involved, besides the IVC, were the left testicular vein and artery, the left suprarenal artery and a superior accessory left renal artery. Based on the gross appearance of the preaortic anastomotic trunk between the left and right IVC as well as on the underlying embryological features, a classification is proposed: incomplete bilateral duplication of the IVC and complete bilateral duplication of the IVC. The latter can be further divided into three types: major, minor and asymmetric.

Colorectal cancer in patients over 70 years of age: determinants of outcome.

BackgroundThe aim of this study was to evaluate operative risk factors, the mortality, morbidity and survival in old patients with colorectal cancer.MethodsFrom 1160 patients with colorectal cancer, 398 patients aged 70 years or older, from 1970 to 2000, were followed-up. Dukes’ classification, differentiation, sex, anatomical site and survival were compared with patients <70 years old.ResultsLong-term results have been proved to be similar both in young and old patients. Relative survival rate for patients aged 70–95 (70.5%) were similar to those for patients less than 70 years old (71.6%) and also comparable between male (72.3%) and female (68%) patients.ConclusionsElderly patients have a lower capacity to react to postoperative complications, but the relative survival is similar to younger patients. Advanced age alone should not be used as a criterion to deny surgery for colorectal cancer.

Ciliated hepatic foregut cyst communicating with the gallbladder

Dear Editors: Ciliated hepatic foregut cyst (CHFC) has previously been considered to be a rare lesion. However, in the last 15 years, the advent of radiological procedures has resulted in the publication of a number of case reports as well as three case series [1, 3, 4], suggesting that this entity has been underreported because it is usually asymptomatic. CHFC has a strong predilection for segment IV of the liver (medial segment of left lobe) and is lined by respiratory-type epithelium, similar to that seen in bronchogenic and esophageal cysts. Therefore, CHFC is believed to be of maldevelopmental origin, arising from remnants of the embryonic foregut, which, in addition to the liver, also forms the tracheobronchial tree, esophagus and other organs. Review of the literature has disclosed seven cases of CHFC located in the gallbladder wall [1, 2]. No communication between the cyst and the gallbladder lumen was found in any of these cases. To our knowledge, this is the first report of a CHFC connected to the gallbladder through a patent duct. A 39-year-old woman presented with colicky pain in the right upper quadrant of the abdomen, which was accompanied by nausea. There was no fever or jaundice. Murphy’s sign was positive. The patient’s past medical history was remarkable for appendectomy at 18 years of age and lithiasis of the right kidney at 19 years. Laboratory findings on admission were unremarkable, including: white blood cell count 7320 per mm, hematocrit 44.9%, hemoglobin 14.9 g/dl, platelets 221 10 per mm, bilirubin 0.69 mg/dl, aspartate aminotransferase 19 U/l (nl: 0–37 U/l), alanine aminotransferase 16 U/l (nl: 0–41 U/l), alkaline phosphatase 58 U/l (nl: 40–129 U/l), gamma glutamyl transferase 23 U/l (nl: 8–61 U/l), albumin 3.99 g/dl and globulin 2.67 g/dl. Testing for hepatitis B surface antigen and hepatitis C antibody was negative. Serum levels of carcinoembryonic antigen, CA 19–9 antigen and CA 50 antigen were within normal ranges. Abdominal ultrasonography showed a cystic structure in the liver measuring 64 31 mm. The gallbladder and large bile ducts appeared normal. No other pathology was noted. Abdominal computed tomography scan suggested that the cystic structure was multilocular and was closely associated with the gallbladder (Fig. 1A). On magnetic resonance imaging, the cyst was localized in segment V of the liver, in close relation to the gallbladder, and measured 51 50 mm. On surgery, it was found that the gallbladder and the cyst communicated through a short duct measuring approximately 2 cm, which was located at the junction of the body and neck. An additional duct, connecting the cyst with the cystic duct, was visualized on intraoperative cholangiography. The cyst contained bile and bile sludge. The gallbladder, its connection to the cyst and portions of the cyst wall were resected. The common bile duct was explored and was found to be free of stones or bile sludge; a Kehr T-tube was placed. A portion of omentum was then placed in the residual cavity. No stones were identified within the gallbladder. On gross examination, the gallbladder measured 7.5 2.7 cm, had a wall thickness of 0.3 cm and was lined by velvet-like, green-tan mucosa with yellow specks. The connecting duct, measuring 0.1–0.2 cm in diameter, was identified. The portions of cyst wall that were received for examination were flat, gray-tan tissue fragments, measuring up to 3.1 cm in greatest dimension. Histological examination showed a multilocular cyst with a fibrous wall, which was lined by ciliated, pseudostratified, columnar epithelium (Fig. 1B). Occasional goblet cells were present. The fibrous tissue contained T. Koletsa · V. Tzioufa · P. Hytiroglou ()) Department of Pathology, Aristotle University Medical School, 540 06 Thessaloniki, Greece e-mail: phitir@med.auth.gr Tel.: +30-231-0999218 Fax: +30-231-0999229

Metastatic breast adenocarcinoma masquerading as colonic primary. Report of two cases.

BackgroundCommon sites of metastasis for the breast cancer are bones, lungs, the central nervous system and liver. The colon is the rarest site of metastasis for the breast carcinoma.Patients and resultsWe report our recent experience of two female patients, 55 and 57 years old respectively, who presented breast metastasis at the proximal transverse colon. They were operated for breast carcinoma followed by chemotherapy and radiotherapy, four and ten years before the metastasis was diagnosed. The symptoms were anaemia and bowel obstruction. Diagnosis was made by double contrast barium enema and colonoscopy. Postoperatively, both patients received systemic chemotherapy. At the follow-up, two and three years after, there is no evidence of recurrence or metastasis.ConclusionsPatients with history of breast cancer presenting with anaemia and/or bowel obstruction should be examined for possible metastasis to colon and should be treated surgically followed by systemic chemotherapy.

Myofibroblasts and colonic anastomosis healing in Wistar rats

BackgroundThe myofibroblasts play a central role in wound healing throughout the body. The process of wound healing in the colon was evaluated with emphasis on the role of myofibroblasts.MethodsOne hundred male Wistar rats weighing 274 ± 9.1 g (mean age: 3.5 months) were used. A left colonic segment was transected and the colon was re-anastomosed. Animals were randomly divided into two groups. The first group experimental animals (n = 50) were sacrificed on postoperative day 3, while the second group rats (n = 50) were sacrificed on postoperative day 7. Healing of colonic anastomosis was studied in terms of anastomotic bursting pressure, as well as myofibroblastic reaction and expression of α-smooth muscle actin (α-SMA), adhesion formation, inflammatory reaction and neovascularization.ResultsThe mean anastomotic bursting pressure increased from 20.6 ± 3.5 mmHg on the 3rd postoperative day to 148.8 ± 9.6 Hg on the 7th postoperative day. Adhesion formation was increased on the 7th day, as compared to the 3rd day. In addition, the myofibroblastic reaction was more profound on the 7th postoperative day in comparison with the 3rd postoperative day. The staining intensity for α-SMA was progressive from the 3rd to the 7th postoperative day. On the 7th day the α-SMA staining in the myofibroblats reached the level of muscular layer cells.ConclusionsOur study emphasizes the pivotal role of myofibroblasts in the process of colonic anastomosis healing. The findings provide an explanation for the reduction in the incidence of wound dehiscence after the 7th postoperative day.

Colonic cancer in a patient with intestinal malrotation: a case report

We present a case of a 76-year-old patient with intestinal malrotation, with incomplete rotation of the small intestine and abnormal positioning of the duodenum and superior mesenteric vessels over the transverse colon. Furthermore, the patient suffered of a concomitant cancer of the ascending colon.

Hematemesis, a very rare presentation of solid pseudo-papillary tumors of the pancreas: a case report

IntroductionSolid pseudo-papillary tumors of the pancreas are rare and typically present in young female patients. They are slowly growing masses that may attain large size, and are of low malignant potential. Surgical resection is usually curative.Case presentationA 71-year-old woman presented to the emergency department with an episode of hematemesis but was otherwise hemodynamically stable. Emergency gastroscopy revealed a bleeding mass projecting to the duodenum. Fluid, blood and electrolyte resuscitation followed. Computed tomography revealed a small mass in the head of the pancreas. A Whipple operation was performed. Pathology revealed a solid pseudo-papillary tumor. The postoperative course of the patient was uneventful and no recurrence was present a year after the operation.ConclusionIn our case, the most noteworthy observations concern the small size of the tumor, the age of the patient and the presenting symptom. However, pancreaticoduodenectomy in a 71-year-old woman is a major effort and should only be undertaken by centers and surgeons experienced in complex hepatobiliary surgery. Furthermore, the unique nature of this case reminds every clinician that each patient has to be considered separately and with extreme caution.

Surgical treatment of haemorrhoids with the use of the circular stapler and open haemorrhoidectomy. A comparative study

Abstract The surgical treatment of haemorrhoids with the use of a circular stapler is a novel method. A comparative retrospective study of two groups of patients treated surgically for third- and fourth-degree haemorrhoids was conducted. Fifty patients (group A) underwent a surgical intervention with the circular stapler in the rectal mucosa 4 cm above the dentate line. In another group of 50 patients (group B), the standard open haemorrhoidectomy (Milligan-Morgan) was carried out. The new method (group A) compared with the standard haemorrhoidectomy (group B) was found to be less time consuming (mean time, 10±2 minutes vs. 35±5 minutes, p<0.001). The majority of patients (28) in group A experienced mild pain (VAS, 3–5) while pain for the majority of patients in group B was 5–7 on the VAS scale (p<0.01). The duration of postoperative hospitalisation was 1±1 days for the patients of group A and 5±2 days for the patients of group B (p<0.05). The early postoperative bleeding rate was 6% in group A and 12% in group B (p<0.01). None of the patients of group A developed incontinence and 6 (12%) patients in group B developed mild liquid incontinence during the first postoperative month. During the period of follow-up (12 months to 3 years, median length 18 months in outpatient visits), no patient in either group developed recurrence of haemorrhoids or rectal prolapse. In conclusion, the surgical treatment of haemorrhoids with the circular stapler seems to be an efficient alternative to the standard open haemorrhoidectomy when this is indicated.

Chronic constipation due to presacral teratoma in a 36-year-old woman: a case report

IntroductionTeratomas of the sacrococcygeal area are usually diagnosed in infancy and are rarely seen in adults.Case presentationWe report the case of a 36-year-old Greek woman experiencing chronic constipation due to a benign presacral teratoma. Imaging examinations showed a pelvic mass without evidence of malignancy. An ovoid tumour with a maximum dimension of 6 cm was surgically removed. A histologic examination revealed a mature cystic teratoma. Two years after surgery, the patient is well, with no evidence of recurrence and no constipation.ConclusionSacrococcygeal teratomas are rare in adults. A high index of suspicion is important in making an early diagnosis. Rectal examination and radiologic evaluation are also valuable.

Groin swelling, the anatomic way out of abdominal haematomas: a case report and explicative literature review.

Abstract This case report concerns a previously healthy thirty-five-year-old female with complaints of inguinal hernia that ultimately proved to be a retroperitoneal haematoma. The patient suffered from a car accident 5 months before admission and was hospitalized. During her prior hospitalization, explorative laparotomy revealed a haematoma of the mesentery. The haematoma was treated conservatively, with fluid resuscitation and rest. During her second admission, MRI of the inguinal region revealed localized haematoma. During inguinal exploration, a fluid-filled bluish indirect hernia sac was identified and found to be contoured by free-flowing, non-clotting blood. The postoperative course was uneventful, and the patient was discharged six days following surgery.