Vassilis N Papadopoulos

Intra-abdominal pressure alterations after large pancreatic pseudocyst transcutaneous drainage

BackgroundAcute pancreatitis leads to abdominal hypertension and compartment syndrome. Weeks after the episodes pancreatic fluids sometimes organize to pseudocysts, fluid collections by or in the gland.Aims of the present study were to evaluate the intra-abdominal pressure (IAP) induced by large pancreatic pseudocysts and to examine the effect of their transcutaneous drainage on IAP.MethodsTwenty seven patients with a pancreatic pseudocyst were included. Nine patients with pseudocysts greater than 1l (group A) had CT drainage and eighteen (volume less than 1l) were the control group. The measurements of group A were taken 6 hours before and every morning after the drainage, while for group B, two measurements were performed, one at the day of the initial CT and one 7 days after. Abdominal compliance (Cabd) was calculated. Data were analyzed using students t-test.ResultsBaseline IAP for group A was 9.3 mmHg (S.D. 1.7 mmHg), while the first post-drainage day (PDD) IAP was 5.1 mmHg (S.D. 0.7 mmHg). The second PDD IAP was 5.6 mmHg (S.D. 0.8 mmHg), the third 6.4 mmH (S.D. 1.2 mmHg)g, the fourth 6.9 mmHg (S.D. 1.6 mmHg), the fifth 7.9 mmHg (S.D. 1.5 mmHg), the sixth 8.2 mmHg (S.D. 1.4 mmHg), and the seventh 8.2 mmHg (S.D. 1.5 mmHg). Group B had baseline IAP 8.0 mmHg (S.D. 1.2 mmHg) and final 8.2 mmHg (S.D. 1.4 mmHg). Cabd after drainage was 185.6 ml/mmHg (SD 47.5 ml/mmHg).IAP values were reduced between the baseline and all the post-drainage measurements in group A. IAPs seem to stabilize after the 5th post-drainage day. Baseline IAP was higher in group A than in group B, while the two values, at day 7, were equivalent.ConclusionThe drainage of large pancreatic pseudocyst reduces IAP. Moreover, the IAP seems to rise shortly after the drainage again, but in a way that it remains inferior to the initial value. More chronic changes to the IAP are related to abdominal cavitys properties and have to be further studied.

Inguinal Endometriosis: Three Cases and Literature Review

Three cases of endometriosis infiltrating the round ligament are presented. The initial diagnosis was irreducible hernia, since this rare nosologic entity often causes unusual preoperative symptoms and diagnostic problems. Diagnosis is frequently made by histologic examination. The rarity of inguinal endometriosis should not exclude it from a possible diagnosis in cases with a painful mass in the inguinal region in a fertile woman, especially if the groin mass is associated in size and tenderness with menstrual variability. Surgery is the treatment of choice and is curative; laparoscopy is suggested during the same operation to evaluate the intraperitoneal conditions.

Anterior chest wall tuberculous abscess: a case report

The granulomatous inflammation of tuberculosis usually involves the lungs and the hilar lymph nodes. Musculoskeletal tuberculosis (TB) occurs in 1–3% of patients with TB, while TB of the chest wall constitutes 1% to 5% of all cases of musculoskeletal TB. Furthermore, nowadays it is rarer to find extrapulmonary TB in immunocompetent rather that non-immunocompetent patients. The present case reports a fifty-six-year-old immunocompetent man with an anterior chest wall tuberculous abscess. The rarity of the present case relates both to the localization of the tuberculous abscess, and to the fact that the patient was immunocompetent. The diagnosis of musculoskeletal tuberculous infection remains a challenge for clinicians and requires a high index of suspicion. The combination of indolent onset of symptoms, positive tuberculin skin test, and compatible radiographic findings, strongly suggests the diagnosis. TB, however, must be confirmed by positive culture or histologic proof. Prompt diagnosis and treatment are important to prevent serious bone and joint destruction.

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.

Emphysematous cholecystitis: a case report

A 65-year-old Greek man with a history of diabetes mellitus and hypertension was admitted because of right upper quadrant pain, nausea and palpable right quadrant mass. On admission the patient was febrile (38.8°C) with a total bilirubin level of 1.99 mg/dl (direct 0.59 mg/dl); SGOT 1.26 mg/dl; Na 135 mmol/l and K 2.9 mmol/l. The white blood count was 15200/μl with 92.2% neutrophiles. Axial sections of single slice CT imaging (section thickness 10 mm), revealed emphysematous cholecystitis with thickening of gallbladder wall and wall enhancement after iv contrast enhancement, as well as, dilatation of the gallbladder with multiple gallstones precipitate and intraluminal air. The patient underwent subtotal cholecystectomy and a cholecystostomy was placed. The culture of the bile showed positivity to toxin A of Clostridium Difficile and to Escherichia Coli. The postoperative course of the patient was uneventful.

Metachronous breast carcinoma (second malignancy), following "cure" from colorectal carcinoma.

Metachronous or synchronous breast carcinoma following or co-existing with colorectal carcinoma are well recognised clinicopathological entities, and the risk of developing both possibly underlines the similarities in carcinogenesis pathways for these carcinomas. We present a 60-year-old housewife with a history of a treated primary colon carcinoma (Duke’s C) 15 years previously. Six months ago, during the follow-up care a small sub-areolar lesion was determined in a mammogram. A lumpectomy was performed under local anaesthesia, which revealed an infiltrating ductal carcinoma (6 mm in greatest diameter). Immuno-histochemical assays for oestrogen and progesterone receptors and c-erb B2 ongoprotein were performed. Axillary lymphadenectomy showed 1/11 positive node. She received adjuvant radiotherapy and hormone manipulation. To date, seven months later she is disease free. The aim of this report is to emphasise the risk of metachronous second malignancy of breast or colorectal carcinoma following colorectal carcinomas. A second primary colonic malignancy following breast primary carcinoma is more frequent than inverse clinical form.

Acute contact appendicitis due to a migrated pericardial drain: a case report.

IntroductionThe literature is replete with articles of foreign-body appendicitis and periappendicitis, but to our knowledge there are only two reports of extraintestinal foreign bodies causing contact appendicitis.Case presentationA 47-year old woman presented to the emergency department with a 24-hour history of right iliac fossa pain, nausea and vomiting, high fever and palpable right iliac fossa mass. The patient had an anamnestic of systemic lupus erythematosus, that caused acute pericarditis with effusion, that was treated with pericardiotomy and a pericardial drain. The laboratory tests showed leukocytosis The plain abdomen film showed no radiologic signs corresponding to acute abdomen, while the computed tomography revealed a radio-opaque formation in the right iliac fossa, corresponding to the palpable mass. Exploratory laparotomy revealed a pericardial drain. The microbiologic analysis of the abscess revealed Salmonella. The postoperative course of the patient was uneventful.ConclusionAcute appendicitis due to a foreign body, without an anamnestic of either surgery or injury may cause a severe diagnostic dilemma. The computed tomography images may lead to logic riddles that have to be solved by an explorative laparotomy. Foreign bodies rarely cause acute abdomen, nevertheless the probability has to be considered when an interventional technique has been applied even if the location of the intervention is far from the abdominal cavity.

Acute pneumomediastinum secondary to hydrogen peroxide therapy of upper right limb wound

ZusammenfassungGRUNDLAGEN: Das Pneumodiastinum oder auch Mediastinalemphysem ist eine krankhafte Luftansammlung im Mittelfellraum. Auch wenn das Mediastinalemphysem, das aus nichtmallignen Krankenheiten entsteht, hauptsächlich konservativ behandelt wird, in Fällen wo es durch Verletzungen in luftaustauschenden Organen (z. B. Luftröhre, Bronchien) und der Speiseröhre kann dies passieren, muss es unbedingt operativ behandelt werden. Das von einer sehr hohen Mortalitäts- und/oder Morbidität gefolgt. METHODIK: Fallbericht. ERGEBNISSE: Es handelt sich um einen männlichen Patienten mit klinischem und röntgenologischem Befund eines akuten Mediastinalempysems des vorderen Thoraxwand gefolgt, ohne welche Anreichen einer Entzündung. Der Patient wies ein Trauma am rechten Ellbogen auf, das mit 10% igen Wasserstoffperoxydlösungen behandelt wurde. Es wurde eine konservative Behandlung mit gutem Ausgang durchgeführt. SCHLUSSFOLGERUNGEN: Durch dem ob. Fall kommen wir zu der Schlussfolgerung dass, das Mediastinalemphysem, das aus einer Vielfalt von Entstehung Ursachen [gefährliche Säuren, andere Gründe] zustande kommt, von einer grossen differentialdiagnostischen Problematisierung charakterisiert wird. Eine Notfalloperation muss also solange vermieden werden, bis zumindest die Entstehungursache gefunden und somit eine sichere Diagnose gestellt werden kann.SummaryBACKGROUND: Pneumomediastinum, or mediastinal emphysema is defined by the presence of air or gas in the mediastinum. Although mediastinal emphysema due to benign causes is cured mainly conservatively, however, in cases of pneumomediastinum due to oesophageal or tracheobronchial rupture, surgical treatment is necessary and involves high morbidity and mortality. METHOD: Case report. RESULTS: A male patient with clinical and radiological signs of acute pneumomediastinum and subcutaneous emphysema of anterior thoracic wall, without signs of infection, is presented. A wound in the right elbow, which was treated by irrigation of 10% hydrogen peroxide solution, was reported. Conservative treatment was decided with good final outcome. CONCLUSIONS: It is concluded that although pneumomediastinum carries potentially life-threatening differential diagnoses, urgent surgical treatment should be avoided when accurate diagnosis is not previously set.