Epithelial splenic cysts and life-threatening splenic rupture.

BACKGROUND/AIM: Primary splenic cysts are relatively uncommon and in the majority of cases are classified as epithelial cysts which are more frequent in young patients. Most of them are asymptomatic, and they are found incidentally during imaging techniques or laparotomy. We report two rare cases of patients with epithelial splenic cysts as an incidental finding during emergency laparotomy for splenic rupture. MATERIALS AND METHOD: The first patient was a 70-year-old man who presented with symptoms of acute abdomen after intensive cough during an episode of asthma. Emergency laparotomy findings were splenic rupture and intraperitoneal haemorrhage. A splenectomy was performed and the histological examination showed a ruptured spleen with an epithelial cyst. The second patient was a 19-year-old man who was transferred to the Emergency Department in hypovolemic shock due to intraperitoneal bleeding after a blunt abdominal injury. During laparotomy a splenic rupture was found, and an epithelial cyst. CONCLUSION: Epithelial splenic cysts are a rare entity and they can be an incidental finding during the surgical treatment of a spleen rupture and haemoperitoneum. These cysts may be a predisposing factor to splenic rupture in cases of increased intraabdominal pressure or blunt abdominal trauma.

Open or endovascular repair of aortoenteric fistulas? A multicentre comparative study.

OBJECTIVES: To compare aortoenteric fistula (AEF) outcome after endovascular (EV-AEFR) or open repair (O-AEFR). DESIGN: Multicentre retrospective comparative study. MATERIALS/METHODS: 25 patients with AEF (24 secondary, 23 males, median age 75 years) after aortic surgery (median four years). Preoperative sepsis was evident in 19 cases. Eight patients were managed with EV-AEFR and 17 with O-AEFR. RESULTS: The two groups were comparable in preoperative characteristics. In-hospital mortality after EV-AEFR was lower compared to O-AEFR (0% and 35%, respectively, p = 0.13). Similarly, morbidity after EV-AEFR was lower compared to O-AEFR (25% and 77%, respectively, p = 0.028). There was a trend for worse recurrence-free, sepsis-free, re-operation-free and AEF-related death-free rates after EV-AEFR, while the early survival advantage of EV-AEFR was lost after two years and the overall long-term survival rates (perioperative mortality included) of the two groups were similar. Preoperative sepsis had no effect on recurrence and sepsis-free rates (p = 0.94 and p = 0.92, respectively), but it was associated with worse two year overall survival (24% vs 50%, p = 0.32). On multivariate analysis, the number of symptoms (two vs one) at presentation was the single predictor of worse re-operation rates, AEF-related and overall survival. CONCLUSIONS: EV-AEFR was associated with no postoperative mortality in this study and can achieve satisfactory short and long-term results, comparable to O-AEFR. Further trials should focus on the role of EV-AEFR in patients at high risk for O-AEFR, due to shock or co-morbidities, or as a bridging procedure.

Primary inflammation of an epiploic appendix of the ascending colon. Is atypical presentation a reason for emergency laparotomy?

Right lower quadrant pain is a very common symptom in everyday clinical practice, and of variable etiology. In patients arriving in the emergency room with sudden-onset right lower quadrant pain, the commonest cause is acute appendicitis. Primary epiploic appendagitis, a rare entity, with a clinical presentation similar to other causes of acute abdomen, and one that subsides spontaneously, can constitute a problem in differential diagnosis, because it is a condition best treated conservatively. The exact diagnosis is a prerequisite for conservative treatment. We present the case of a 62 year old woman with primary epiploic appendagitis of the ascending colon that presented as acute abdomen, who underwent an exploratory laparotomy with the preoperative diagnosis of acute appendicitis.

Visfatin (nampt) and ghrelin as novel markers of carotid atherosclerosis in patients with type 2 diabetes.

OBJECTIVE: Visfatin (nampt) and ghrelin are the most recently identified adipocytokines, but their role in atherosclerosis is poorly clarified. In our study we investigated their association with advanced carotid atherosclerosis and carotid intima-media thickness (CIMT) in patients with type 2 diabetes mellitus (T2DM). METHODS: 122 patients (50 males) with T2DM, aged 55-70 were enrolled. Sixty-four age- and sex-matched healthy individuals served as controls (group A). CIMT was assayed in all participants by ultrasound. Among diabetic patients, 47 appeared with carotid plaques (group B), while 75 without plaques (group C). Anthropometric parameters, blood pressure, glycemic and lipid profile, high-sensitivity CRP (hsCRP), insulin resistance (HOMA-IR), fibrinogen, nampt and ghrelin were measured. RESULTS: Diabetic patients had a higher mean-CIMT, increased body-mass index, worse lipid profile, elevated blood pressure and higher levels of white blood cells count, nampt and hsCRP with respect to controls (p<0.01). Among diabetic patients, groups B and C were comparable in anthropometric, glycemic and lipid parameters. Serum nampt was significantly higher in group B rather than in groups A and C (p<0.05). On the other hand, ghrelin levels were considerably lower only in diabetic patients with carotid atherosclerosis compared with healthy individuals. In univariate analysis, mean-CIMT correlated with age (r=0.312; p=0.003), nampt (r=0.341; p<0.001) and ghrelin (r=-0.421; p=0.002) and the latter associations remained significant in multiple regression analysis. CONCLUSIONS: High nampt and low ghrelin serum levels are significantly associated with advanced carotid atherosclerosis in patients with T2DM. Moreover these adipocytokines are independently associated with CIMT, implicating their role as novel atherosclerotic biomarkers and providing another important link between adiposity and atherosclerosis.

Beneficial changes of serum calcification markers and contralateral carotid plaques echogenicity after combined carotid artery stenting plus intensive lipid-lowering therapy in patients with bilateral carotid stenosis.

OBJECTIVES/DESIGN: In symptomatic patients treated with ipsilateral carotid artery stenting (CAS) plus intensive lipid lowering, we assessed the changes of osteopontin (OPN), osteoprotegerin (OPG) and the Gray-Scale Median (GSM) score contralateral to symptomatic carotid stenosis. MATERIALS/METHODS: Forty-six symptomatic patients (group A) with significant carotid stenosis (North American Symptomatic Carotid Endarterectomy Trial (NASCET): >70%) underwent ipsilateral CAS. Those patients had simultaneously contralateral low-grade carotid stenosis (NASCET: 30-69%). Group B included 67 symptomatic patients with low-grade bilateral carotid stenosis (NASCET: 30-69%), but without indications for revascularisation. All patients were treated with atorvastatin (10-80mg) to target low-density lipoprotein (LDL)<100mgdl(-1). Blood samples and plaques' GSM score contralateral to brain infarct were assayed at baseline and after 6 months. RESULTS: At baseline, there were no significant differences between groups (p>0.05). Six-month atorvastatin treatment equivalently improved lipid profile in both groups (p<0.05). The parameters hsCRP, OPN and OPG were significantly down-regulated within both groups, but to a greater extent in group A (p<0.05). Besides this, contralateral GSM score was significantly improved from baseline in both groups (p<0.01), but that increment was more pronounced in group A (vs. group B; p=0.041). These changes were inversely correlated with changes in OPN (p=0.014), OPG (p=0.011) and LDL (p=0.041). CONCLUSION: Ipsilateral CAS plus intensive lipid-lowering therapy was associated with enhanced contralateral carotid plaque stability and attenuated inflammatory burden and calcification inhibitors to a greater extent than atorvastatin therapy alone in patients with bilateral carotid stenosis.

Intensive lipid-lowering therapy ameliorates novel calcification markers and GSM score in patients with carotid stenosis.

OBJECTIVES/DESIGN: Carotid plaque echogenicity quantified by the Gray-Scale Median (GSM) score has been associated with plaque vulnerability. The aim of this study was to assess whether intensive lipid-lowering treatment with atorvastatin in patients with carotid artery stenosis ameliorates novel vascular calcification inhibitors, such as osteopontin (OPN) and osteoprotegerin (OPG), and improves GSM score. METHODS: Ninety-seven patients with carotid stenosis (>40%), but without indication for intervention, were treated for 6 months with atorvastatin (10mg-80mg) to target LDL<100mg/dl. Fifty-two age-and sex-matched healthy individuals served as the control group. Blood samples and GSM were obtained at the beginning and after 6 months. RESULTS: Systolic blood pressure, hsCRP, fibrinogen, OPN and OPG levels differed significantly between patients with carotid stenosis and healthy controls at baseline (p<0.05). Atorvastatin treatment improved lipid profile and significantly reduced hsCRP (p=0.002), WBC count (p=0.041), OPN (p<0.001) and OPG levels (p<0.001). GSM score increased considerably after atorvastatin therapy (from 58.33+/-24.38 to 79.33+/-22.3; p<0.001) and that effect appeared related to OPN (p=0.001), OPG (p=0.013) and LDL (p=0.01) reduction. CONCLUSIONS: In patients with carotid stenosis, intensive lipid-lowering therapy with statins attenuates serum OPN and OPG levels and enhances carotid plaque echogenicity, outlining their beneficial effects on plaque stability.

Postoperative follow-up of patients with colorectal cancer: a combined evaluation of CT scan, colonoscopy and tumour markers.

BACKGROUND: The purpose of this study is to present the experience of our department regarding the importance of the systematic postoperative follow-up of patients with colorectal cancer, early diagnosis and treatment of the recurrence of the disease or a metachronous cancer. METHODS: In a study that took place between October 2001 and February 2004 amongst 67 patients that were operated upon for colorectal cancer, 41 were systematically being followed up through CT scan, colonoscopy and tumour markers. RESULTS: In the 14th and 18th months postoperatively for 2 of the patients the CT scan showed hepatic metastasis, while the colonoscopy was negative. Regarding the tumour markers, one (CEA) was elevated in one patient while three were elevated in the others. For 2 out of the 41 patients the colonoscopy showed recurrence of the disease within one and two years respectively. The CT scan proved to be free of metastasis and the tumour markers were falling within the normal range for one of the patients while for the other CEA was elevated. Both patients underwent additional colectomy. Postoperative increase of the tumour markers was observed in 9 patients. The above patients had normal markers in the immediate postoperative period. For 4 out of the 9 patients recurrence or spread of the disease was observed while the rest of them are still being followed up. CONCLUSIONS: In conclusion, we believe that the systematic postoperative follow-up of the patients with colorectal cancer through CT, colonoscopy and the use of tumour markers contributes decisively to the early diagnosis and treatment of any possible recurrence of the cancer or a metachronous cancer or misdiagnosed concomitant cancer.

Metachronous colorectal adenocarcinomas.

BACKGROUND: The purpose of our study is to emphasise the diagnostic and therapeutic problems of metachronous colorectal cancer. MATERIALS AND METHODS: Between 1990 and February 2004, amongst 185 patients that were treated for colorectal cancer, in four of them a metachronous carcinoma was diagnosed. RESULTS: 1st patient: male 41 years, underwent colectomy of the descending colon for adenocarcinoma. Four years later, a rectosigmoidal cancer was found infiltrating urinary bladder. 2nd patient: male 62 years, underwent right hemicolectomy. Eight years later two synchronous cancers were diagnosed, in the left colic flexure and in the sigmoid colon. 3rd patient: female 73 years, underwent low anterior resection for rectal cancer. Eight years later, caecal and ascending colon cancers were diagnosed with hepatic metastases. 4th patient: female 60 years underwent transversectomy. Six years later caecal cancer was diagnosed with pulmonary metastases. Amongst the four patients, only the fourth had an adequate postoperative follow up. CONCLUSIONS: Extended radical colectomies in young patients and in those where adenomatous polyps coexist will reduce the incidence of metachronous carcinoma. Effective and persistent postoperative surveillance in patients with colorectal cancer will greatly contribute in the detection and treatment of metachronous carcinomas.

Endovascular treatment of popliteal artery aneurysms.

OBJECTIVE: To present the results of the endovascular treatment of popliteal artery aneurysms. METHODS: From April 1999 to January 2002, 11 patients, aged 40-94 years, with 12 popliteal aneurysms were treated. Nine (75%) underwent an endoluminal repair, of whom three were done emergently due to an aneurysm rupture. Aneurysm diameter was 28-105 (mean 69) mm. A Hemobahn stent graft was inserted in six, Wallgraft in two and Passager in one case. RESULTS: During a mean follow-up of 14 (3-31) months, four (44%) thromboses occurred: two in the early postoperative period (30 days) and two during the late postoperative period. Two of the four occluded grafts were successfully reopened, and in the one a stenosis of the distal end of the stent graft was treated with balloon dilatation. Patency rates at 1 and 12 months were 64/47% (primary patency) and 88/75% (secondary patency), respectively. CONCLUSION: Initial experience with endovascular treatment of the popliteal aneurysm in high-risk patients yielded modest results. Larger number of patients and further follow-up time is necessary to evaluate the long-term results.

Blockade of Kupffer cells by gadolinium chloride reduces lipid peroxidation and protects liver from ischemia/reperfusion injury.

BACKGROUND/AIMS: The implication of lipid peroxidation in the inhibitory effect of GdCl3 (gadolinium chloride) on Kupffer cells activation has not been extensively investigated. The aim of this study was to examine the effect of GdCl3 inhibition of Kupffer cells activation on lipid peroxidation after severe total hepatic ischemia/reperfusion. METHODOLOGY: Male Wistar rats (n = 40) were randomly divided into a sham-operation group, a control ischemia/reperfusion group, and two ischemia/reperfusion groups pretreated with GdCl3 (10 mg and 20 mg/kg bw intravenously, 48 and 24 h prior to operation). Following 60 min of total hepatic ischemia and 120 min of reperfusion, the rats were sacrificed, and liver samples were taken for determination of malondialdehyde and light microscopy examination. Blood samples were also taken for assay of aspartate and alanine transaminase. Additional animals (n = 60) were followed up for a 7-day survival rate determination. RESULTS: Ischemia/reperfusion decreased the survival rate to 13.3%, increased (p < 0.001) the levels of aspartate and alanine transaminase in serum to 2387 +/- 75 and 2157 +/- 87 IU/L, respectively, and increased (p < 0.001) malondialdehyde levels in liver to 1.609 +/- 0.096 nmoles/g compared with 1.164 +/- 0.060 in the sham operation group. Pretreatment with GdCl3 increased the survival rate to 60%, and decreased (p < 0.001) the levels of aspartate transaminase in serum to 1549 +/- 66 and 1496 +/- 55 IU/L, the levels of alanine transaminase in serum to 1302 +/- 48 and 1305 +/- 63 IU/L, and the levels of malondialdehyde in liver to 1.132 +/- 0.034 and 1.149 +/- 0.57 nmoles/g for the lower and the higher doses of GdCl3, respectively. Histological examination showed protection of liver parenchyma in the animals treated with GdCl3. CONCLUSIONS: Experimental data suggest that GdCl3 inhibition of Kupffer cells activation protects liver from ischemia/reperfusion injury by a mechanism that reduces lipid peroxidation.

Fine needle aspiration biopsy cytology in the diagnosis of thyroid cancer: comparative study of 213 operated patients.

Between 1982 and 1984, fine needle aspiration biopsy cytology (ABC) was performed in 1100 patients (aged 14-80, 993 women), with nodular goitre, who had either a solitary cold nodule or dominant hypofunctioning nodule(s) within a multinodular or diffusely enlarged gland. Surgery was performed in 213 patients based on clinical and cytological criteria, and the histology of the surgical specimens was correlated with the cytological findings. ABC specimens were sufficient for cytological diagnosis in 190 patients and were classified as malignant (positive), suspicious or benign. In 37 patients who had a final histological diagnosis of malignancy, cytology was positive or suspicious in 33 and benign in 4. In the remaining 153 patients with benign histology there were 7 positive or suspicious aspirates, and 146 benign. The 37 malignancies included papillary carcinomas in 26 patients (24 positive or suspicious and 2 benign on cytology), Hürthle-cell tumours in 6 (6 positive), follicular carcinoma in 1 (negative), anaplastic carcinoma in 1 (suspicious), medullary carcinoma in 2 (1 positive, 1 negative), and lymphoma in 1 (positive). Our results indicate that the overall sensitivity rate of the ABC method for cancer was 89.2 per cent, the diagnostic specificity 95.4 per cent, the false-positive rate 17.5 per cent and the false negative rate 2.6 per cent. The overall accuracy of the method was 94.2 per cent. It is concluded that papillary and Hürthle-cell carcinomas can be diagnosed accurately with ABC but we recommend that the method be used in conjunction with clinical information and other conventional diagnostic procedures.