Management of vesicoenteric fistulas arising from perforated Meckel's diverticulum: a report of a case and review of the literature.

Vesicoenteric fistulas are rare, with an incidence of 0.1%-0.2% in the general population, and Meckel's diverticulum is a rare cause, accounting for less than 5% of cases with challenging diagnosis due to atypical symptoms at the admission. This article presents a case of a vesicoenteric fistula formation between Meckel's diverticulum perforated by a foreign body and urinary bladder in a 38-years-old Caucasian male admitted to emergency department due to colicky abdominal pain located in the lower abdomen. An extensive review of the literature was conducted referring all the cases of vesicoenteric fistula incorporating Meckel's diverticulum to elucidate the clinical characteristics, explore the diagnostic yield, and to summarize the therapeutic approach.

Endovascular Retrieval of a Detached and Dislocated Venous Port Catheter in the Right Heart Chamber Using a Triple-Loop Snare Device.

The authors present a case of a successful percutaneous retrieval of a detached port-a-catheter device that had migrated to the right cardiac chambers in a patient with inoperable pancreatic cancer and hepatic metastases. The patient was admitted to the vascular clinic department on an urgent basis due to an accidental detachment of the catheter during removal at another hospital. The catheter had migrated from the initial placement site in the right subclavian vein to the superior vena cava and right heart chambers. Under local anesthesia, the right femoral vein was accessed using the Seldinger technique, and the migrated catheter was retrieved using a triple-snare-loop device for foreign body removal. Chest radiography after the retrieval procedure did not show any foreign bodies in the right heart chambers or superior vena cava. The patient was discharged home the following day.

Evisceration of a Small Bowel Segment Through a Drain Site: Lesson Learnt.

Evisceration is described as the removal of intra-abdominal organs outside the abdominal cavity after partial or complete dehiscence of an operative incision. Multiple organs have been reported in the literature as being eviscerated through a drain site. Zero point five per cent (0.5) to 1.2% of all cases include the small bowel. In most cases, evisceration occurs three to eight hours post-operation. This article reports a case of an eviscerated small bowel segment through a drain site, along with the drain six hours post-operative. To our knowledge, such a complication following open abdominal or laparoscopic surgery has not yet been reported. Due to the imminent risk of strangulation and subsequent necrosis of the eviscerated visceral organ, drain site evisceration requires immediate intervention.

Asymptomatic Spontaneous Migration of the Tip of Port-A-Cath System Into the Right Internal Jugular Vein: A Case Report of an Uncommon Complication.

Venous port catheters are devices that allow access to the central venous system and, in clinical practice, are used for patients who require long-term intravenous therapy. The ideal position of the catheter tip is the distal superior vena cava and can be confirmed by a postoperative chest X-ray. Complications during and after the implantation are not rare, but spontaneous migration of the catheter tip into the internal jugular vein is an uncommon complication. Catheter migration may be accompanied by neck, shoulder, and ear pain. Venous phlebitis and thrombosis, and neurological complications, can become potentially life-threatening. We report a case of a spontaneous catheter tip migration into the right internal jugular vein that was diagnosed in a random chest roentgenography. The patient was taken to the operative room, and the catheter was successfully removed.

Hand compartment syndrome due to extravasation of contrast medium. A technical error. A report of a case and review of the literature.

The extravasation of contrast agents is one of the most common and remarkable complications during a computed tomography (CT) scan. The clinical manifestations are commonly minimal, leading to mild symptoms. However, in rare cases of high-volume extravasation, the complications are extremely threatening. Compartment syndrome of the hand and the forearm leads to critical dysfunction and upper limb necrosis. This article reported an unusual case of hand compartment syndrome following extravasation of iodinated contrast agent from a peripheral venous catheter, during a CT angiography, and its surgical treatment. Moreover, a literature review regarding all published similar surgically treated cases was conducted.

Double appendixes: A rare case report.

Anomalies of the appendix are rare, and one of the rarest is the double appendixes. Most anomalies of the appendix are observed in adults and are discovered incidentally during surgery that does not primarily involve the appendix. It is usually missed, often with life-threatening consequences.

Postoperative hypofractionated-accelerated radiotherapy (HypoAR) for locally advanced rectal cancer.

BACKGROUND: despite the advances in preoperative hypofractionated-accelerated radiotherapy for patients with locally advanced rectal cancer, postoperative radiotherapy delivered with standard fractionation (46-50 Gy in 5 weeks) remains a standard adjuvant schedule. The role of hypofractionated-accelerated radiotherapy in a postoperative setting remains largely unexplored. METHODS: eighty-eight patients with rectal cancer infiltrating the rectal wall and/or having metastasis to the perirectal lymph nodes were treated with surgery followed by adjuvant chemotherapy and, subsequently, with hypofractionated-accelerated radiotherapy. Ten fractions of 3.4 Gy were delivered to the pelvis for 10 consecutive fractions, within 12 days. The follow-up of patients alive at the time of analysis ranges from 12-120 months (median 48). RESULTS: mild abdominal discomfort and diarrhoea were frequent, but medical medication was demanded in 14/88 (15.9%) of patients. The incidence of late toxicities was low; 4/88 (3.5%) patients complained for intermittent intestinal urgency. Locoregional recurrence occurred in 8/88 patients (9%). The 5-year locoregional relapse-free survival was achieved in 89.7% of patients, and this dropped to 84% in node-positive patients (P = 0.45). The 5-year disease-specific overall survival was 72.4%. Nodal involvement showed a trend to negatively affect prognosis (5-year overall survival 68.2 vs. 79.6%; P = 0.23). CONCLUSION: postoperative hypofractionated-accelerated radiotherapy has minimal early and late toxicity. The locoregional control and disease-specific survival rates are similar to the expected from conventional postoperative chemoradiotherapy. The 2.5-fold decrease of radiotherapy treatment time, reduction of waiting lists and the lower overall cost of radiotherapy are additional benefits associated with hypofractionated-accelerated radiotherapy.

Comparison of Two Tubularized Incised Plate Urethroplasty Techniques in Hypospadias Reconstructive Surgery.

BACKGROUND: Hypospadias repair is a challenging type of urogenital reconstructive surgery for which different techniques are currently used. The purpose of this study is to determine the outcomes of distal, mid-shaft and proximal hypospadias repair using two new variations of tubularized incised plate (TIP) urethroplasty (TIP-δ and TIP-ελ) and to compare their complication rates with other already known operative techniques made from the same surgical team. METHODS: This study included 269 boys with hypospadias. The preoperative meatal site was distal in 179 patients, mid-shaft in 44 and proximal in 46. The average age at the operation was 17 months. The technique applied in distal hypospadias was Mathieu in 77 patients, Snodgrass in 28 and (TIP)-δ in 74. The technique applied in mid-shaft hypospadias was a tubularized island flap (TIF) in 12 patients, onlay island flap (OIF) in 5 and TIP-ελ in 27. The operative technique for proximal hypospadias was TIF in 15 patients, OIF in 10 and TIP-ελ in 21. TIP-δ and TIP-ελ are two new variants of TIP operation that we have used in our clinic since 2010. Postoperative complications were recorded, and we compared the outcomes obtained by applying the techniques. RESULTS: The use of TIP-δ in the distal hypospadias and long TIP-ελ in the mid-shaft and proximal hypospadias resulted in significantly fewer complications than the other surgical methods across all cases of hypospadias (p<0.05). CONCLUSION: The type of tissue used for neourethral coverage seems to play an important role in the outcome of hypospadias surgery.

Development of a Novel Experimental In Vitro Model of Isothiocyanate-induced Apoptosis in Human Malignant Melanoma Cells.

BACKGROUND: Isothiocyanates are constituents of cruciferous vegetables which have been associated with reduced cancer risk partially through their ability to induce apoptosis in malignant cells including melanoma. MATERIALS AND METHODS: We have utilized human malignant melanoma (A375), epidermoid carcinoma (A431) and immortalized keratinocyte (HaCaT) cells exposed to various isothiocyanates, under different experimental conditions. RESULTS: An experimental in vitro model utilizing low isothiocyanate concentrations (0.1-5 µM for 48 h with all treatments being refreshed after 24h) was shown to be (i) most efficient in exerting an anti-cancer effect when compared to higher concentrations (5-100 µM for 24 or 48 h added as a single bolus) and (ii) specific to A375 cells while A431 and HaCaT cells remained unaffected. Such effect involved the activation of several caspases including (iii) initiator caspases 8, 9, 4 (indicating the involvement of intrinsic, extrinsic and endoplasmic reticulum-based pathways) and (iv) effector caspases 3, 7 and 6. CONCLUSION: Utilization of low isothiocyanate concentrations (under the conditions described herein) exerts an anti-cancer effect specific to human malignant melanoma cells thus providing a therapeutic basis for their utilization in management of the disease.

Temporal and Spatial Expression of TGF-b1 in the Early Phase of Patellar Tendon Healing after Application of Platelet Rich Plasma.

BACKGROUND: The aim of this study is to find out the spatial and temporal expression of TGF-b1 during the tendon healing, after application of Platelet Rich Plasma (PRP). METHODS: A patellar tendon defect model in rabbits was used for this purpose. 48 skeletally mature New Zealand White rabbits, weighing 3.5 kg, were used for this study. Equal numbers of animals from both groups were sacrificed at 4 different time points (1st, 2nd, 3rd, and 4th week). A full thickness patellar tendon substance in the right limb of each animal was excised from its central portion during the operation. PRP with a gel form was applied and filled the tendon defect in PRP group. No PRP was applied in the tendon defect of controls. Histological sections with hematoxylin-eosin and immunohistochemical sections with an anti-TGF-b1 primary antibody were made for the evaluation of the results. RESULTS: A differentiation of the healing process was observed in the PRP group in comparison with the control group. TGF-b1 expression was detected in various cell populations (inflammatory cells, endothelial cells, macrophages, and tenocytes). Both cytoplasmic and nuclear expressions were present. The larger amounts of immunoexpression were localized in epitenon and in the repair site. PRP group showed stronger and more extensive staining at 1st and 2nd week (P<0.0001), whereas control group showed more extensive staining at the 3(rd) and 4(th) week (P<0.0001). CONCLUSIONS: Our study demonstrates that locally application of PRP result in an alteration of TGF-b1 expression during the healing of a patellar tendon defect.

Regenerated Nerve Defects with a Nerve Conduit Containing Dental Pulp Stem Cells in Pigs: An Immunohistochemical and Electrophysiological Evaluation.

BACKGROUND: Dental pulp stem cells (DPSCs) present an exciting new tool in the field of peripheral nerve regeneration due to their close embryonic origin. In this study, we examined their potential in pigs, using biodegradable collagen conduits filled with DPSCs. To our knowledge, this is the first time DPCSs are tested for peripheral nerve regeneration in such large animal model. MATERIALS AND METHODS: The second lateral incisor was extracted from every animal's lower jaw and stem cells were isolated and cultured. The collagen nerve conduits containing the DPSCs were subsequently transplanted into the transected fifth and sixth intercostal nerves, while the seventh intercostal nerve was used as a control and no stem cells were added on the respective collagen conduit. RESULTS: A histological examination was performed on the 3rd and 6th postoperative months and showed the gradual development of neural tissue and immunohistochemical expression of neuron-specific enolase. An electrophysiological study was performed on the 6th postoperative month and showed similar potentials between the stem cell infusion region (5 ± 0.04 units) and their proximal stumps (5 ± 0.05 units) and slightly smaller potentials in the respective distal stumps (4 ± 0.045 units). CONCLUSION: The nerves where DPSCs were injected exhibited morphological and functional recovery, in contrast to the control nerves where no recovery was detected; thus, there is a first evidence of the therapeutic potential of DPSCs in peripheral nerve regeneration.

Single-trocar transumbilical laparoscopy-assisted management of complicated jejunal diverticula.

Small-intestinal nonmeckelian diverticula are very uncommon and are considered to be acquired pulsion diverticula. Most of these diverticula are asymptomatic and are simply incidental findings. Complicated-acquired diverticular disease of the jejunum and ileum is a diagnostic dilemma. Small-bowel diverticulum is diagnosed with the aid of radiography techniques, such as small-bowel contrast series or enteroclysis. Laparotomy remains the gold standard for a definite diagnosis of asymptomatic and complicated diverticula, but laparoscopy is also very useful in the diagnosis and treatment of this condition. A surgical approach is the best form of treatment for complicated jejunoileal diverticula. The current report is about a patient who presented with iron deficiency anemia caused by a complicated jejunal diverticulum and managed with single-trocar transumbilical laparoscopy.

Overall survival and clinicopathological characteristics of patients with breast cancer in relation to the expression pattern of HER-2, IL-6, TNF-α and TGF-ß1.

The present study was conducted to investigate the prognostic significance of co-expression patterna of HER-2, IL-6, TNF-a and TGF-ß1 in breast cancer, by correlating the number of markers with positive expression with clinicopathological characteristics indicative of tumor progression and overall survival. One hundred thirty consecutive patients with primary breast cancer were prospectively included and evaluated. Serum concentrations of the above markers were measured by ELISA. Median split was used to subdivide patients with marker positive or negative expression. The presence of ≥ 3 positive markers was independently associated with extended lymph node (>3) involvement (aOR, 11.94, p=0.001) and lymphovascular invasion (aOR, 12.04, p=0.018), increasing the prognostic significance of each marker considered separately. Additional prognostic information regarding survival was also provided; as the number of positive markers increased, a gradually reduction of survival time was observed. In addition, patients with 4 positive markers had significantly shorter survival (25 vs 39 months, p=0.006) and a more than 4 fold increased risk of death (aHR, 4.35, p=0.003) compared to patients with 3 positive markers. Our findings suggest that the coexpression pattern of these four markers could be used clinically as a useful marker for tumor extension and outcome of breast cancer.

Narrow amifostine dose windows define radioprotection outcome, following fractionated whole-body irradiation of mice.

BACKGROUND: Amifostine is an important broad spectrum cytoprotective agent approved for protection during fractionated radiotherapy. The daily dose of amifostine used, however, is arbitrarily chosen and low compared to the actual tolerable dose. MATERIALS AND METHODS: Cohorts of mice (n=6) were treated with one up to 4 consecutive fractions of 6 Gy of whole-body γ-irradiation ((60)Co), supported with increasing daily subcutaneous (s.c.) doses of amifostine (10 mg/g-300 mg/g). Survival and weight loss were monitored. Histopathological analysis was performed in mice receiving 3 × 6 Gy. RESULTS: By increasing the amifostine dose from 13 to 50 mg and to 160 mg/g, the 50% lethal dose of radiotherapy increased from 2 × 6 Gy to 3 × 6 Gy and to 4 × 6 Gy, respectively. To keep the median weight loss to less than 25% of the initial weight, the dose of amifostine demanded was 23 mg/g, 68 mg/g and 121 mg/g, for 2 × 6 Gy, 3 × 6 Gy and 4 × 6 Gy, respectively. Histopathological analysis revealed a net protection of the liver and intestine of the mice receiving amifostine. Extensive and multiple vacuolar degeneration of the cytoplasm with focal necrosis of hepatocytes and loss of the intestinal villi was the most striking finding in the dying mice treated without amifostine. CONCLUSION: Taking into account the strong association of daily amifostine dose with cytoprotective efficacy and that a slight reduction of the daily amifostine dose can substantially reduce the clinical protective effect during fractionated radiotherapy, it is suggested that randomized trials should be re-appraised adopting amifostine schedules close to the maximum tolerable dose.

Application of PRP gel alone or in combination with guided bone regeneration does not enhance bone healing process: An experimental study in rabbits.

INTRODUCTION: The aim of this study was to assess the hypothesis that application of platelet-rich plasma (PRP) gel in mandibular defects in rabbits, alone or in combination with guided bone regeneration (GBR) techniques, could enhance the bone healing process. MATERIALS AND METHODS: Thirty New Zealand white rabbits were used. Three groups of 10 animals each were assigned, and the animals were sacrificed after 12 weeks. During the operation, a rotating trephine bur was used to create circular defects 10-mm in diameter in the region anterior to the jaw angles. In group human fascia lata (HFL), a human fascia lata membrane was used. In group PRP, PRP gel was used to fill the defect, and in group HFL+PRP, PRP was used to fill the defect which after that was covered with a human fascia lata membrane. RESULTS: In general, none of the control sides and the PRP treated sides had full development of bone or filling of the defect through bone bridging. Conversely, the sides on which the fascia lata membrane or the combination of membrane and PRP had been applied were characterized mostly by development of newly formed bone that bridged the gap. CONCLUSIONS: Our results suggest that the application of PRP gel alone or in combination with GBR does not enhance bone healing process.

Intrapleural administration of lipoplatin in an animal model.

BACKGROUND: Lipoplatin is a new liposomal cisplatin already tested in solid tumors with encouraging results. Little is known about the activity of lipoplatin administered intrapleurally (IP). AIM: The aim of this study was to assess in an animal model the pharmacokinetics, and potentially induced histopathological lesions of lung and kidney after IP vs. IV injection of lipoplatin. METHODS: 15 male Wistar rats were assigned to an IV group at dose 10mg/kg of lipoplatin (group 1) and to IP groups at 10 (group 2) or 20mg/kg (group 3) equal to 60 and 120 mg/m(2) in humans respectively. After lipoplatin administration, serial plasma samples were analyzed by atomic absorption spectrometry for the maximum plasma concentration (C(max)), the area under the plasma concentration-time curve (AUC), and the total body clearance (CL). Pleura, lungs and kidneys of the rats were histologically examined for possible lesions. RESULTS: The C(max) was significantly higher in groups 1 vs. 2 (p = 0.02) and vs. 3 (p = 0.01). The AUC of groups 3 vs. 1 was significantly higher (p = 0.028) but the AUC of groups 2 vs. 1 was significantly lower (p = 0.02). CL in IP rats did not differ considerably compared to the IV. Inflammatory changes were noted in the pleura of IP rats and mild kidneys lesions in IV group. CONCLUSION: Compared to the IV route, IP20 administration of lipoplatin yielded higher AUC, equal CL, but a significantly lower C(max). As C(max) is a determinant of lipoplatin toxicity, IP administration might offer a more effective therapeutic index while improving tolerability. We noted fibrotic changes in the pleura of IP rats, and mild kidneys changes in IV rats, as expected.

Lung autophagic response following exposure of mice to whole body irradiation, with and without amifostine.

PURPOSE: The effect of ionizing irradiation on the autophagic response of normal tissues is largely unexplored. Abnormal autophagic function may interfere the protein quality control leading to cell degeneration and dysfunction. This study investigates its effect on the autophagic machinery of normal mouse lung. METHODS AND MATERIALS: Mice were exposed to 6 Gy of whole body γ-radiation and sacrificed at various time points. The expression of MAP1LC3A/LC3A/Atg8, beclin-1, p62/sequestosome-1 and of the Bnip3 proteins was analyzed. RESULTS: Following irradiation, the LC3A-I and LC3A-II protein levels increased significantly at 72 h and 7 days. Strikingly, LC3A-II protein was increased (5.6-fold at 7 days; p<0.001) only in the cytosolic fraction, but remained unchanged in the membrane fraction. The p62 protein, was significantly increased in both supernatant and pellet fraction (p<0.001), suggesting an autophagosome turnover deregulation. These findings contrast the patterns of starvation-induced autophagy up-regulation. Beclin-1 levels remained unchanged. The Bnip3 protein was significantly increased at 8 h, but it sharply decreased at 72 h (p<0.05). Administration of amifostine (200 mg/kg), 30 min before irradiation, reversed all the LC3A and p62 findings on blots, suggesting restoration of the normal autophagic function. The LC3A and Beclin1 mRNA levels significantly declined following irradiation (p<0.01), whereas Bnip3 levels increased. CONCLUSIONS: It is suggested that irradiation induces dysfunction of the autophagic machinery in normal lung, characterized by decreased transcription of the LC3A/Beclin-1 mRNA and accumulation of the LC3A, and p62 proteins. Whether this is due to defective maturation or to aberrant degradation of the autophagosomes requires further investigation.

Temporal and spatial expression of TGF-beta1 in an Achilles tendon section model after application of platelet-rich plasma.

BACKGROUND: To investigate the effect of platelet-rich plasma (PRP) on TGF-beta1 expression during tendon healing. METHODS: We used 48 skeletally mature New Zealand White rabbits. 24 rabbits received the PRP, and 24 rabbits served as an untreated control group. Equal numbers of animals were sacrificed at 1st, 2nd, 3rd, and 4th week. The surgical procedure involved a transverse incision to transect the Achilles tendon. A volume of 1ml of PRP was then injected into the tendon mass in the PRP group. Histological and immunohistochemical evaluations with an anti-TGF-beta primary antibody were performed. RESULTS: The pattern of expression of TGF-beta1 in the PRP group was characterized by a significant upregulation during the first 2 weeks and subsequently significant downregulation in the 3rd and 4th week in comparison with the controls. CONCLUSIONS: Our results suggest that PRP may affect the tendon healing process by altering the expression of TGF-beta1.

Immunohistochemical study of angiogenesis after local administration of platelet-rich plasma in a patellar tendon defect.

A full thickness defect was made in the central portion of the patellar tendon of 48 New Zealand white rabbits. Platelet-rich plasma (PRP) gel was then applied and filled the tendon defect. The same procedure was performed in the control group, without the application of PRP. Animals were sacrificed after one, two, three, and four weeks. Histological and immunohistochemical analyses using a monoclonal antibody against CD31 were performed. The histological examination showed a superior healing process in the PRP group compared with the control group. Especially in the third week, the tissue formed in the PRP group was more mature and dense with less elastic fibres remaining. Neovascularisation was significantly higher in the PRP group during the first two weeks and significantly lower in the third and fourth weeks (p < 0.0001). Histological examination and study of angiogenesis showed that the application of PRP enhances and accelerates the tendon healing process.

The influence of platelet-rich plasma on angiogenesis during the early phase of tendon healing.

BACKGROUND: The poor vascularity of tendons is a major factor in their limited healing capacity. The aim of this study was to assess the effect of Platelet Rich Plasma (PRP) on angiogenesis during tendon healing. MATERIALS AND METHODS: Forty-eight skeletally mature New Zealand White rabbits were used. The Achilles tendon was transected transversely and 0.5 ml of PRP was injected into the tendon mass on each side of the incision on both limbs. The injection in the control group consisted of saline. Six animals from each group (12 tendons each) were sacrificed after 1, 2, 3, and 4 weeks following treatment. Three sections from each Achilles were stained with hematoxylinosin for microscopic examination. Further three sections were immunostained with a monoclonal antibody against CD31 (Daco Co), followed by image analysis to count new vessel numbers and statistical analysis was performed. RESULTS: There was significantly more angiogenesis in the PRP group compared to the control group during the first two weeks of the healing process, i.e., inflammatory and proliferative phase (p < 0.0001). The orientation of collagen fibers in the PRP group was better organized. The number of the newly formed vessels in the PRP group were significantly reduced at 4 weeks compared to the controls (p < 0.0001) suggesting the healing process was shortened. CONCLUSION: PRP seems to enhance neovascularization which may accelerate the healing process and promote scar tissue of better histological quality. CLINICAL RELEVANCE: Although these results need replication and further biomechanical research, PRP may promote tendon healing acceleration.