Mass of the neck: an extremely rare location of hydatid disease.

Hydatid disease (HD) is a parasitic zoonosis which was first described by Hippocrates in the ancient years. Liver and lungs are the most commonly affected organs, while neck involvement is extremely rare. We report a case of a 75-year old male, who presented with an isolated right-side cervical mass. After clinical examination and screening tests, HD was diagnosed. Pre-operative and post-operative treatment with albendazole was administered and en-block surgical excision of the mass was performed. Histopathological examination of the specimen confirmed the diagnosis of HD. At one-year follow-up, the patient remained asymptomatic without any signs of recurrence. Although HD of the neck is an extremely rare entity, physicians should always include it in the differential diagnosis of neck masses.

Transrectal ultrasonography of perianal fistulas: a single center experience from a surgeon's point of view.

AIM: Two-dimensional transrectal ultrasonography can nowadays be safely used for preoperatively evaluation of perianal fistulas. The aim of this study is to demonstrate its efficacy by comparing the results of this imaging technique with the surgical findings, as well as recurrence rates. PATIENTS AND METHODS: A 4-year retrospective study with a mean follow-up of 4.7 years was performed, including patients treated surgically for a perianal fistula at the surgical department of a tertiary secondary hospital. All these patients underwent preoperatively a transrectal ultrasound with H2O2 for surgery planning, while 12 of them had also a MRI-scan. RESULTS: The sample was consisted of 53 patients with a mean age of 32.4 years and a 0.3 female/male ratio. During the mean 4.7 years follow up 2 patients (3,8%) had a recurrence, while in none of these cases an anal-sphincter muscle trauma was noted. The operative findings were in all cases consisted with the transrectal ultrasonography Results. The MRI-scan failed to demonstrate the presence of a fistula in 3 out of the 12 patients (25%). CONCLUSIONS: Our data support that the use of ultrasound with H2O2 preoperatively, for a safe surgery planning, leads to an accurate surgical procedure and fewer recurrence rates.

Combined Littre and Richter's femoral hernia: an extremely rare intra-operative finding.

Littre hernia is defined as the herniation of a Meckel's diverticulum, while Richter's hernia is the herniation of a portion of the bowel wall. An extremely rare case of a combined Littre and Richter's femoral hernia is reported. An 82-year-old male presented at the emergency department with a painful golf ball-like mass at the right inguinofemoral region. With the diagnosis of incarcerated femoral hernia, he was urgently taken to the operating room. Intraoperatively, an incarcerated Littre, as well as a Richter's hernia were revealed. Enterectomy and side-to-side small bowel anastomosis were performed. The patient made an uneventful recovery. To the best of our knowledge, the present is the first report of a combined Littre and Richter's femoral hernia. Such findings should be reported to raise the awareness of surgeons for complicated cases. It is of utmost importance to have a high suspicion index for strangulated hernias, to minimize the time between admission and surgery.

Malakoplakia of the large intestine: an incidental extremely rare finding.

Malakoplakia is a rare inflammatory disease, most commonly found in the urinary tract. It appears be related to a functional deficiency of macrophages, resulting in an inability to destroy digested bacteria and it is associated with various conditions that cause immunodeficiency. A rare case of malakoplakia of the colon in a healthy 68-year old male is presented. The patient underwent emergency surgery with colon resection and an end stoma with closure of the distal bowel (Hartmann's procedure), due to incarcerated ventral hernia and sigmoid-colon rupture. He underwent reversal of the Hartmann's procedure four months after the initial operation. The histological examination from the anastomotic rings revealed Michaelis-Gutmann bodies that are pathognomonic of malakoplakia. He received per os ciprofloxacin, bethanecol and ascorbic acid for 12 months. Follow-up endoscopy did not exhibit any signs of the disease. A case of a healthy patient presenting with malakoplakia without any underlying disease that causes immunodeficiency is extremely rare. Treatment of malakoplakia involves the eradication of microorganisms. Cholinergic agonists, such as bethanechol and ascorbic acid, as well as antimicrobial treatment with trimpethoprim/sulphamethoxazol and rifampicin are most commonly being used. Long-term antimicrobial treatment has been reported (6 months to 3 years).

Gemcitabine as palliative treatment in patients with unresectable pancreatic cancer previously treated with placement of a covered metal stent. A randomized controlled trial.

PURPOSE: To evaluate the efficacy of gemcitabine as palliative treatment in patients with advanced pancreatic cancer (PC) previously treated with placement of a covered metal biliary stent, taking into account survival and quality of life (QoL). PATIENTS AND METHODS: Forty-nine patients with unresectable PC and obstructive jaundice, previously treated with the placement of a covered metal biliary endoprosthesis, were randomized to receive gemcitabine (group A: 9 males, 7 females) or to be followed without any anticancer intervention (group B: 18 males, 15 females). Gemcitabine was administered weekly as intravenous (i.v.) 30 min infusion of 1000 mg/m2 for 3 consecutive weeks followed by 1-week rest (28-day cycle). QoL was evaluated with the QLQ-C30 questionnaire. RESULTS: 229 gemcitabine doses were administered (median doses per patient 14.3, range 7-22). No statistically significant differences were observed regarding survival (group A: median 21 weeks, range 13-33; group B: median 22 weeks, range 13-29; p=0.809). According to the average QLQ-C30 score, group B patients showed statistically significant higher values (p=0.0001). Leukopenia, neutropenia, thrombocytopenia and anemia were the most common side effects in group A (81.25, 68.75, 62.50 and 31.25%, respectively). CONCLUSION: Gemcitabine didn't show to improve survival and QoL in patients with advanced PC previously treated with a covered metallic biliary endoprosthesis due to obstructive jaundice.

Taenia saginata: a rare cause of bowel obstruction.

Taenia saginata infection is caused by the bovine tapeworm and can be the cause of emergency surgical conditions. We report one case of small bowel obstruction leading to necrosis and another case of large bowel obstruction and volvulus due to an impacted tapeworm. The diagnosis of these rare circumstances is usually made intraoperatively.

Removal of knotted intravascular devices. Case report and review of the literature.

OBJECTIVE: to review published reports on knotted intravascular devices/catheters. METHOD: report of two cases and systematic review of the literature. RESULTS: a total of 113 reported cases of knotted intravascular devices/catheters were located. Pulmonary artery catheters (Swan-Ganz) were responsible for more than two thirds of the total reported intravascular knots. In 62% (70/113) of the cases withdrawal of the knotted catheters was achieved successfully with different interventional radiological techniques, avoiding the need for surgical exploration. In 32% (36/113) of the patients surgical removal was favoured. Capture with one of the interventional techniques and pulling down the knot into an easily accessible vein to be removed through an open venotomy, was the most common surgical procedure. However, in five cases, an open cardiotomy was required. In seven cases the patient's condition was critical and precluded any surgical procedure, so the knotted catheter was left in situ. The mortality of this event was 8% (9/113). CONCLUSIONS: interventional radiological techniques have largely replaced open surgical removal. Knotted catheters may need to be surgically removed when (a) the knot is large in size with many loops, or (b) intracardiac fixing of the knot is encountered.

Barium peritonitis: a rare complication of upper gastrointestinal contrast investigation.

Contrast examination of the gastrointestinal tract is rarely complicated by perforation. The colon and rectum are most commonly affected, with many perforations limited to the retroperitoneum. Generalised peritonitis is therefore rare, but is life-threatening and difficult to treat. We present two analogous cases in which extravasation of barium sulphate complicated contrast meal investigation. These cases illustrate important aspects in the management of this unusual occurrence.

Long-term results of management of type I choledochal cysts in adults.

Choledochal cysts in adults is a rare condition. The present study describes our experience with this abnormality of the biliary tree. During a 16-year period (1978-1993) eight adults with type I choledochal cyst were treated surgically in our departments. They were 4 men and 4 women with a mean age of 38.9 years (range 20-84). Symptoms, clinical findings and abnormalities in laboratory investigations included pain in all patients, history of cholangitis (n = 3), cholangitis (n = 2), acute pancreatitis (n = 1), palpable mass (n = 2), abdominal tenderness (n = 4), leucocytocis (n = 2), and increased levels of serum total bilirubin (n = 4), SGOT (n = 2), and serum alkaline phosphatase (n = 4). Diagnosis was established by intravenous cholangiography in one case, by CT-scanning in one, by ultrasonography in 5 and by intraoperative cholangiography in one. All the patients were treated surgically. Three of them underwent a Roux-en-Y choledochocystojejunostomy and one a choledochocystoduodenostomy. The other 4 patients were treated with cyst excision and Roux-en-Y hepaticojejunostomy. There were no deaths among our patients. The mean follow-up period was 6.7 years (range 1-17). So far, five episodes of mild ascending cholangitis have occurred in the patient treated with choledochocystoduodenostomy. One patient in whom a Roux-en-Y choledochocystojejunostomy was performed had 2 episodes of right upper quadrant colic pain and one episode of cholangitis. Both these patients were treated conservatively. The other 6 patients had no episodes of pain cholangitis or jaundice. In conclusion, the primary treatment of choledochal cyst type I is the excision of the cyst with Roux-en-Y hepaticojejunostomy. The Roux-en-Y choledochocystojejunostomy is indicated in cases where, for various reasons, the cyst can not be safely removed.

Emergency operations in the elderly: management and outcome.

For the purpose of highlighting the problems that arise in emergency surgical procedures in elderly patients and of defining safe management, the records of 797 patients aged over 70, operated urgently during a 22-year period, were reviewed. The mortality was 18.4% in the emergency and 4.5% in the elective operations (p < 0.0001). There was no correlation between mortality rates in different age groups. The majority of the patients (67.3%) with coexisting cardio or pulmonary diseases expired. The mortality was significantly lower in the second 11-year period (1982-1992) (14%) than in the first one (1971-1981) (23.8%), (p < 0.0001). In conclusion, age is not a contraindication for an emergency operation and does not affect mortality which appears to be directly related to the severity and nature of the disease and to the coexisting cardio pulmonary diseases. We must advise the elderly to be operated on timely. In some severe surgical conditions it is wise to perform ad hoc the most conservative operation.

Factors affecting the lifespan of autologous and synthetic arteriovenous access routes for haemodialysis.

OBJECTIVE: To try and establish a consensus about the ideal secondary access for haemodialysis by assessing factors that affect the longevity of various access routes. DESIGN: Multicentre survey, by questionnaire. SETTING: General hospital, Athens. SUBJECTS: All 1516 patients in the Athens area receiving chronic haemodialysis. MAIN OUTCOME MEASURES: Longevity of present and any previous access routes (n = 2323). Data including type of access, age, sex and the existence of diabetes, hypertension, hyperlipidaemia, or other systematic diseases were recorded. RESULTS: Some 1220 (80%) of the patients were using autologous access, 1049 (69%) arteriovenous (AV) fistulas at wrist and 171 (11%) at elbow. Variables were analysed using Cox's proportional hazard model. Age and female sex were significantly associated with failure of autogenous access (p < 0.001) although not affecting synthetic grafts. Autogenous fistula at the elbow was the only secondary access that was less likely to fail than the initial (baseline) fistula at the wrist. Among the various grafts, straight arm grafts had the best prognosis and straight forearm grafts were the most likely to fail (p < 0.001). CONCLUSION: An AV fistula at the elbow should be considered the second best after the fistula at wrist, but is not always feasible. A synthetic graft is more likely to be needed in elderly patients and women, in whom an autogenous AV fistula is more likely to fail.

Complications of congenital posterolateral diaphragmatic hernia in the adult. Report of two cases and literature review.

The literature on incarceration in Bochdalek hernias in adults is rather limited. Our purpose is to present two cases of this lesion that were treated surgically in the past ten years. The first patient, a 32 year old female was admitted in shock with an 8h history of left chest pain and dyspnoea. Chest X-ray showed a pleural effusion in the left hemithorax. Chest tube drainage revealed gastric fluid. We operated on her immediately, through a left thoracotomy, and found rupture of the stomach into the left pleural cavity. Strangulation of the fundus of the stomach due to congenital diaphragmatic hernia, Bochdalek's type, was found to be the cause of the rupture. We performed resection of the gangrenous segment of the stomach with primary closure. The second patient a 48 year old man was admitted with symptoms of large bowel obstruction. Per os gastrographin study showed the splenic flexure herniated into the left hemithorax. At the operation, through a paramedian left incision, the herniated large bowel was reduced back into the abdomen. In both cases the defect of the left hemidiaphragm was sutured with interrupted silk sutures. Both patients had an uneventful postoperative course. The diagnosis of Bochdalek hernia in the adult is usually made in case of complications, and that demands an immediate surgical repair.

Use of Marlex mesh in the repair of recurrent incisional hernia.

Recurrent incisional hernia remains a major problem for the general surgeon. The rate of recurrence of hernia repaired by primary closure using nylon sutures or with knitted monofilament polypropylene (Marlex) mesh was studied. A total of 102 repairs were performed over a 19-year period. Marlex mesh was used in 49 cases and primary closure in 53. All except two patients were followed from 1 to 15 (mean 7.6) years or to death. The incidence of recurrence was 8 per cent when Marlex was used and 25 per cent after primary closure. In both groups the majority of the recurrences were in the first 16 months after repair. The use of Marlex mesh should be considered in the management of recurrent incisional hernia.

Iatrogenic arterial trauma associated with hip fracture surgery.

During a 5 year period, 1417 patients with various types of hip fractures were surgically treated. Three cases of iatrogenic arterial injuries occurred during the correction procedures, giving an incidence of 0.21%. In 2 patients the profunda femoral and in one the common femoral artery were involved. The mechanisms of injury were: a protruding screw, beyond the medial border of the femur in the first patient, arterial tear, due to bone speculae in the second and external pressure to the artery from an avulsed lesser trochanter in the third. The clinical findings were false aneurysms in two and distal ischaemia in the third patient. All patients were surgically treated. Early diagnosis of this type of injuries is the cornerstone for a good outcome.

Surgical management of primary retroperitoneal liposarcomas.

During a 21-year period (1970-1991), 7 patients with primary retroperitoneal liposarcomas were treated surgically in our department. All the tumours were excised completely, and in 2 patients an additional nephrectomy was performed. Postoperatively 4 patients had adjuvant radiotherapy. Two other patients received adjuvant chemotherapy. Both of them had to be reoperated, because of a local recurrence 12 and 9 months after their first operation. There was one death on the first postoperative day, and 4 patients died 1 1/2-2 years after the initial operation. Two patients are still alive 34 and 22 months after their first operation with recurrent disease. Adjuvant therapy proved to be ineffective on the survival of our patients. The prognosis of retroperitoneal liposarcomas continues to be poor and the primary treatment has to be aggressive with complete resection of the tumor.