Parastomal Gallbladder Herniation as an Incidental Preoperative Computed Tomography Finding.

A 65-year-old woman with a long surgical history was referred to our hospital's Colorectal Unit for ileostomy management. The patient retained an ileostomy for almost a decade after a series of complicated operations she had undergone, which had several side effects such as electrolyte imbalances, high output, weight loss, and a parastomal hernia. Our hospital's colorectal surgeon proposed to replace the ileostomy with a permanent sigmoidostomy and asked for an imaging evaluation of the parastomal hernia content before the surgery. A computed tomography of the abdomen was performed using our Computed Tomography Department's 64-detector row CT scanner after oral administration of contrast media, without intravenous contrast media injection due to allergy. Concerning the parastomal ileostomal hernia, besides small bowel loops with intraluminal gastrografin, inside the parastomal hernial sac, there also was an almost rounded cystic lesion. Absence of the gallbladder at its typical position and no record of cholecystectomy raised suspicion for gallbladder projection inside the sac. Our suspicion was confirmed during the surgery. Nonexisting acute cholecystitis allowed easy reduction of the gallbladder along with the small bowel loops inside the peritoneal cavity, without proceeding to cholecystectomy at the same time. Finally, ileostomy was annulated and an end colostomy was established. Four days after the surgery, the patient was discharged from the hospital and was happy to live an almost normal life thereafter.

Professor William Macewen (1848-1924): The Scottish Pioneer of Surgery.

Professor William Macewen (1848-1924) is one of the most important figures in world's surgery during 18th and early 19th century. He managed to provide numerous innovative techniques and instruments in various fields of surgery such as general surgery, orthopedic surgery, neurosurgery, and thoracic surgery. His innovations had a great impact after his time and constituted the fundaments for further surgical developments. He also was a pioneer in clinical photography with the creation of a huge archive. During his surgical career, he received many honors.

Adrianus Spigelius' (1578 - 1625) Ocular Anatomy.

The aim was to study Adriaan van den Spiegel's ideas on ocular anatomy. He is better known by his Latinized name as Adrianus Spigelius (1578 - 1625). He was a Flemish physician and anatomist who lived and worked in Padua, where in 1605 he was elected to be Professor of Anatomy and Surgery. Chapter IX of book ten of Spigelius' work on human anatomy, entitled De humani corporis fabrica libri X tabulis aere icisis exornati (1627) was devoted to an anatomical description of the eye. Corresponding to contemporary ideas of the production of knowledge Spigelius endeavoured to enhance Andreas Vesalius' (1514-1564) anatomy, he did not repeat his predecessor's theories of ocular anatomy. He conceptualised that the eye has six muscles, five tunics and three humors, while he gave a brief description of ocular physiology combining anatomy and the functional role of the anatomic ocular parts. CONCLUSION: He managed to correct Vesalius' errors and to present ocular anatomy with original notes, which so far, have been ignored and are highlighted now.

Philip Henry Mules (1843-1905) and his innovations in ocular surgery.

INTRODUCTION: The aim of the present study is to present an historical overview of the innovations in ocular surgery introduced by the very important surgeon, but mainly unknown, Philip Henry Mules (1843-1905). METHODS: Philip Henry Mules introduced the Mules' evisceration operation and the Mules' ptosis operation. He also invented surgical instruments such as Mules' scoop, Mules' repository, and Mules' enucleation scissors. He was interested also in ocular infection. RESULTS: Many of the innovations in ocular surgery introduced by Philip Henry Mules are still in use. CONCLUSIONS: Philip Henry Mules (1843-1905) was a respectable English ophthalmologist, who despite his short life, only 62-years-old, his innovations in ocular surgery were considered a breakthrough in the late nineteenth century, because in almost every textbook of ophthalmology they were cited and deserved a great merit.

Carl Ferdinand von Arlt, Ritter von Bergschmidt (1812-1887): A Pioneer in Ophthalmology.

Carl Ferdinand von Arlt, Ritter von Bergschmidt (1812-1887) was a pioneer in ophthalmology. The purpose of our paper is to highlight his scientific work. He did not only introduce new surgical techniques and invent new instruments in ocular surgery, but also influenced the development of ophthalmology in the 19th century. He was an excellent and reputable professor of ophthalmology, and his students became very respected figures in ophthalmology.

Secondary extramedullary plasmacytoma of sigmoid colon in a patient with multiple myeloma: a case report.

BACKGROUND: Extramedullary plasmacytoma is an uncommon tumor that most often involves the nasopharynx or upper respiratory tract. Extramedullary plasmacytoma is a type of plasma cell neoplasm that can present as a primary tumor or secondary to another plasma cell neoplasm, such as multiple myeloma. Secondary extramedullary plasmacytoma is usually noted in the advanced stages of the disease. Involvement of the gastrointestinal tract occurs in approximately 10% of cases. CASE PRESENTATION: A 71-year-old Caucasian woman with known diverticular disease of the colon and multiple myeloma diagnosed 3 years previously, with monoclonal bands of immunoglobulin A, lambda light chains, and multiple osteolytic lesions, presented to our hospital with abdominal pain, abdominal discomfort, and pneumoperitoneum. She underwent left colectomy for diverticulitis with perforation, and an extramedullary secondary colonic plasmacytoma was found in histopathological examination of the sigmoid colon. CONCLUSIONS: Plasmacytoma is known to occur in extraosseous sites. The stomach and small intestine are the most commonly involved sites in the gastrointestinal tract. Secondary extramedullary plasmacytoma of the colon is rare. Colonic plasmacytoma may have varying clinical presentations, such as inflammatory bowel disease and multiple colonic strictures. Although these cases are rare, treating physicians as well as radiologists, pathologists, and surgeons should be aware of this entity.

Eugène Louis Doyen (1859-1916): The Reformer of French Surgery.

Eugène Louis Doyen (1859-1916) is considered as the reformer of French surgery at the end of 19th and early 20th century. Although he had a short life, dying at the age of 57, he left his mark in the history of French medicine and especially surgery, not only because he introduced many new medical instruments but also for his innovative idea to introduce cinematography in surgical education, which is crucial until today in the education of every surgeon in the world.

Neuroendocrine breast carcinoma metastatic to the liver: Report of a case and review of the literature.

INTRODUCTION: Primary neuroendocrine breast carcinoma (NEBC) is a rare entity of breast cancer. PRESENTATION OF CASE: We herein report a case of right hepatectomy for a NEBC liver metastasis. DISCUSSION: Little is known about its evolution, bilologic behavior and optimal treatment. Its malignant potential has been addressed in few reports, with cases of metachronous metastases in diverse sites, even years following treatment of the breast primarily. CONCLUSION: Treating this kind of cancer implies both breast and hepatic surgery. Primary neuroendocrine breast carcinoma (NEBC) is a rare entity of breast cancer. Little is known about its evolution, biologic behavior and optimal treatment. Its malignant potential has been addressed in few reports, with cases of metachronous metastases in diverse sites, even years following treatment of the breast primarily. We herein report a case of right hepatectomy for a NEBC liver metastasis.

Giant fibrovascular polyp of the esophagus - imaging techniques can localize, preoperatively, the origin of the stalk and designate the way of surgical approach: a case report.

Fibrovascular polyps of the esophagus are rare benign lesions that arise from the cervical esophagus and can reach very big size before they become symptomatic. Surgical excision is the treatment of choice, since endoscopic removal is not always feasible.We present this case in order to emphasize the significance of localizing, preoperatively, the exact origin of the pedicle in planning the way of surgical approach. We consider the accurate pre-operative assessment of the origin of the pedicle essential for the proper surgical treatment of such a polyp. In respect to this, imaging provides important information concerning the exact location of the pedicle, the vascularity of the polyp and even tissue elements of the mass.

Esophagectomy without thoracotomy: 25 years of experience over 750 patients.

OBJECTIVE: This study aimed to review and evaluate our experience in 750 patients, who underwent transhiatal esophagectomy (THE) and analyze our data. Special attention was paid to some strategies, which we developed in the course of time, regarding the postoperative management of these patients and formulation of improved guidelines. PATIENTS AND METHODS: This is a retrospective analysis of all THE operations performed between January 1981 until May 2007 in 750 patients: 60 patients (8%) had benign lesions, while 690 (92%) had malignant ones (5.2% of malignancies were located in the upper esophagus, 7.4% in the middle esophagus, 19% in the lower esophagus, and 68.4% at the cardioesophageal junction). THE and esophageal reconstruction were performed at the same operation in all patients. The stomach was our esophageal substitute of first choice with the colon and jejunum being acceptable alternatives in patients with prior gastric surgery and those necessitating synchronous gastrectomy for cancer invasion. A gastric tube was used as an esophageal substitute in 624 patients (83.2%), the whole stomach in 70 (9.4%), the colon in 43 (5.73%), and a jejunal loop in 13 (1.73%). RESULTS: The overall in-hospital mortality rate was 2.93% (22 patients). There was no intraoperative death. Major complications included atelectasis or pneumonia (4.8%), pleural effusion (22.7%), myocardial infarction (0.5%), recurrent laryngeal nerve paralysis (1.33%), and three tracheal lacerations (0.4%). The anastomotic leak rate decreased gradually over time from 29.4% to 11.1% in the last 6 years. The average intraoperative blood loss was 315 ml and 82% of the patients did not receive any blood transfusion. Late functional results were good or excellent in 93%. The average length of hospital stay was 11 days and intensive care unit stay was 2.3 days. The actuarial 5-year survival rate after THE for carcinoma was 21%. CONCLUSION: THE is a safe and effective method of esophageal resection with low morbidity and mortality rates and good functional results when performed by experienced surgeons. We believe that our strategies concerning the way of dissecting the cervical esophagus, avoidance of performing pyloromyotomy, the delayed removal of the cervical drain and the delayed advance to oral feeding have reduced, noticeably, morbidity and mortality in our series.

Antecolic gastrointestinal reconstruction with pylorus dilatation. Does it improve delayed gastric emptying after pylorus-preserving pancreaticoduodenectomy?

OBJECTIVE: The aim of our study focuses upon prevention of delayed gastric emptying (DGE) after pancreaticoduodenectomy using a alternative reconstruction procedure. METHOD: Forty consecutive patients underwent a typical pylorus-preserving pancreaticoduodenectomy (PPPD) with antecolic reconstruction in a two-year period (January 2002 until January 2004), while a similar group of 40 consecutive patients underwent PPPD with application of pyloric dilatation between January 2004 and January 2006. Early and late complications were compared between the two groups. RESULTS: DGE occurred significantly more often in the group of patients treated by the classical PPPD technique (nine patients -22%) compared with those operated on with the addition of pyloric dilatation technique (two patients -5%) (p<0.05). The incidence of other complications did not differ significantly between the two groups. CONCLUSIONS: The application of dilatation may decrease the incidence of DGE after PPPD and facilitates earlier hospital discharge.

Persistent early organ failure: defining the high-risk group of patients with severe acute pancreatitis?

OBJECTIVES: The aim of our study was to evaluate the clinical significance of prolonged organ failure during the first week of severe acute pancreatitis and the potential correlation with final outcome. METHODS: Of 234 patients with acute pancreatitis admitted to our department between January 2002 and December 2006, 64 patients with predicted severe acute pancreatitis were studied according to the presence and also the duration of organ failure early in the course of the disease. RESULTS: Transient (<48 h duration) or persistent (>48 h duration) early organ failure (EOF) was present in 33 of 64 patients (51.5%). All 9 deaths (9/55 patients; 16.5% mortality) were recorded among patients who developed pancreatic necrosis, and the combination ofEOF and necrosis was present in most (8/9) patients with fatal outcome (P = 0.009). Persistent EOF was significantly associated with development of infected necrosis (P = 0.037) and worse outcome (P=0.028) as well. Multivariate analysis with backward elimination identified the duration of EOF as an independent factor affecting outcome. CONCLUSIONS: Persistent organ failure early in the course of acute pancreatitis is a major determinant of outcome. In combination with pancreatic necrosis, survival rate is strongly compromised.

Computed tomography versus Acute Physiology and Chronic Health Evaluation II score in predicting severity of acute pancreatitis: a prospective, comparative study with statistical evaluation.

OBJECTIVE: The aim of the study was to compare Acute Physiology and Chronic Health Evaluation II score and C-reactive protein as a clinical index and computed tomography-based severity index (CTSI) in predicting the course of acute pancreatitis. METHODS: One hundred forty-eight patients with acute pancreatitis were enrolled in the study during a 2-year period. All data concerning etiology, Atlanta classification, CT findings, Acute Physiology and Chronic Health Evaluation score, C-reactive protein levels, stay in the intensive care unit, length of hospital stay, treatment, complications, and deaths were analyzed with Mann-Whitney U, Wilcoxon, Pearson, and Spearman statistical tests. The CT was performed on a spiral unit after intravenous administration of contrast material. Images were graded according to the Balthazar-CTSI scoring system. RESULTS: A very good correlation was noticed between Balthazar-CTSI scores and local complications, whereas no statistically significant correlation was found between CT scores and stay in the intensive care unit. Among survivors and nonsurvivors, there were no statistically significant differences as far as CT scores were concerned. CONCLUSIONS: Although the extent of necrosis as defined on contrast-enhanced CT examinations is considered as a risk factor for a negative prognosis, our findings suggest that the initially documented disease severity according only to imaging parameters is not highly important for the final patient outcome.

Focal lymphoplasmacytic sclerosing pancreatitis: radiological-pathological correlation.

OBJECTIVE: To correlate cross-sectional imaging findings with histological results in patients with histopathologically proven lymphoplasmacytic sclerosing pancreatitis (LSP) after surgery. METHODS: Four cases of resectable pancreatic lesions that were proven to represent LSP are presented in our study. All patients were thought to harbor malignancy. A detailed research in patients' records was retrospectively done concerning clinical presentation and imaging studies. RESULTS: Characteristic imaging findings consistent with fibrotic changes were evident in only one case on magnetic resonance imaging. A discrete mass was evident on imaging in 2 patients that correlated well with pathology results. In the other patients, the extent of inflammatory changes on microscopic examination correlated well with the degree of pancreatic head enlargement on imaging studies. CONCLUSIONS: Lymphoplasmacytic sclerosing pancreatitis is a particular form of benign inflammatory pancreatic disease that is extremely difficult to diagnose preoperatively. Familiarization with the variable imaging findings is essential and may result in the reduction of the number of patients with LSP who undergo surgical resection.