An alternative management of a Littré hernia case: food for thought.

AIM: We present a novel approach to a Littré hernia case. CASE REPORT: A 62-year old male presented at our department with a painless mass in the inguinal area and was successfully treated for an inguinal Littré hernia. A Lichtenstein tension-free mesh repair was used without performing simultaneous diverticulectomy. DISCUSSION: Resection of an asymptomatic Meckel's diverticulum remains a controversial issue. In adult population, leaving an accidentally found silent Meckel's diverticula in situ could reduce the risk of postoperative complications without increasing late complications. Mesh-based techniques provide lower recurrence rates compared to non-mesh techniques. CONCLUSIONS: Management of asymptomatic Littré hernias presents a challenge for the operating surgeon. Treatment guidelines should be developed for the optimal management of these patients.

Minimally invasive esophagectomy for esophageal cancer: techniques and outcomes.

Despite recent improvements in diagnosis, surgical treatment and neo-adjuvant therapy, patients with esophageal cancer have poor prognosis with overall 5-year survival rates of 5-15%.Esophagectomy is the standard treatment for resectable esophageal cancer, but only one third of patients are considered candidates for cure. Minimally invasive techniques have been attempted to improve the postoperative outcomes in such a surgical procedure with high postoperative morbidity and mortality. The purpose of this review is to analyze the minimally invasive esophagectomy (MIE) techniques in the early-stage esophageal carcinoma. MIE is still crowed with heterogeneous studies with several different techniques. MIE comparing to open esophagectomy procedures have less morbidity with less overall in-hospital incidence of pulmonary infections and shorter duration of ICU admission. In addition,MIE techniques preserve the quality of life better than the open procedures, with faster postoperative recovery.

Expression of tissue IGF 1, TGFbeta and EGFR in the sequential steps of intestinal adaptation in a rat model of short bowel syndrome.

BACKGROUND: The long-term morphological changes and the expression of tissue growth factors IGF 1, TGFbeta and EGFR in the gut mucosa, during the process of intestinal adaptation were examined. METHODS: Four groups of rats were used: a. Sham rats (n = 10) underwent bowel transection and reanastomosis, b. SBS rats underwent an 80% small bowel resection: group A rats (n = 10) were sacrificed 15 days after surgery, group B (n = 10), 30 days after surgery, and group C (n = 10), 60 days after surgery. Morphological small bowel parameters (villus height, lumen diameter and others) of adaptation were examined sequentially. Tissue samples were studied immunohistochemically for the detection of IGF 1, TGFbeta, and EGFR. RESULTS: There was a significant increase in all morphological parameters at day 15, in the intestinal samples; a further increase followed at day 30 and day 60 (p < 0.0001). Accordingly, an increase in the expression of IGF 1, TGFbeta and EGFR was noted at day 15 (p < 0.05), and at day 30 (NS). CONCLUSION: Intestinal adaptation is an ongoing process lasting more than 2 months after massive small bowel resection. Peptide growth factors are expressed in the intestine continuously during this period, but the first two weeks are the most critical for the mucosal growth.

Management of cystic and solid pancreatic incidentalomas: a review analysis.

Incidentally discovered pancreatic lesions that are asymptomatic have become much more common in recent years. It is important to characterize these lesions and to determine which patients can be safely observed and which should undergo an operation, as a substantial proportion of them might be malignant or premalignant. This review focus on the diagnostic approach and management of the different types of cystic and solid incidental pancreatic lesions based on appropriate clinical input, imaging screening and histological criteria. The task of developing guidelines to deal with an incidentally found pancreatic lesion, however, is much more complex and controversial than with other organs incidentalomas. In most series, pancreatic incidentalomas (PIs) <2 cm and of cystic appearance are likely to be benign, whereas those >2 cm are usually premalignant or malignant. Serous cystadenomas can reach very large size and are usually benign lesions. The presence of a solid mass or a mural nodule in a cystic lesion along with main pancreatic duct dilatation, thick septations and biliary obstruction are considered features suspicious of malignancy. Mucinous cystic neoplasms and intraductal papillary mucinous neoplasms are malignant or lesions of malignant potential and need surgical exploration. Solid lesions are much more likely to be premalignant or malignant and most of patients will undergo resection. The decision to operate rather than follow a solid lesion is a matter of tumor size and of clinical judgment based on the age and patient comorbidities. The present study should serve as a general guide and not applied as strict principles. Key words: cystic pancreatic incidentalomas, diagnostic approach, management, solid pancreatic incidentalomas.

Surgical treatment of a giant mesenteric fibromatosis mimicking a gastrointestinal stromal tumor: a case report and current treatment aspects.

Intra-abdominal fibromatosis (IAF), usually located at the mesenteric level, is a locally invasive tumor of fibrous origin. Although lacking the ability to metastasize, it has the tendency to recur. The case described here is a case of mesenteric fibromatosis with involvement of the bowel wall, which had the appearance of a gastrointestinal stromal tumor (GIST), a tumor with malignant behavior. This report outlines the fact that certain non-typical cases of IAF with involvement of the bowel wall can be misdiagnosed as GIST. It is of outmost importance to make an early and correct diagnosis in such equivocal cases, so that the appropriate treatment can be closed.

Prosthetic repair of incisional hernia combined with elective bowel operation.

BACKGROUND AND AIMS: Incisional hernia repair with mesh is considered a clean operation and it is not recommended to be perfomed at the same time with a potentially contaminated operation. The aim of this study is to assess the short-term results of a group of patients who underwent a colon operation and simultaneous incisional hernia repair with an onlay polypropylene mesh technique. PATIENTS AND METHODS: From Novemberto June 2006, 19 patients underwent incisional hernia repair with polypropylene mesh, with simultaneous colonic operation. In 13 patients reestablishment of bowel continuity after a Hartmann procedure was done, whereas in four patients a loop colostomy was closed. Two patients underwent colectomy for cancer. RESULTS: Post-operatively one patient had a seroma and two others had wound infections which required mesh removal. The mean follow-up was 70.15 +/- 48.40 months (range 3 to 142 months). During this period five patients died, four from progression of malignancy and one from myocardial infarction. Three patients (15.78%) developed recurrence, two patients with previous Hartmann's operation for complicated diverticulitis and wound infection and the third patient due to inappropriate mesh fixation with buttonhole hernia development. CONCLUSION: Prosthetic repair of incisional hernias can be safely performed simultaneously with a colonic operation, with an acceptable rate of infectious complications and recurrence. It is unjustifiable to avoid the use of mesh in a potentially contaminated field when an appropriate technique is used.

The prophylactic effect of L-arginine in acute ischaemic colitis in a rat model of ischaemia/reperfusion injury.

BACKGROUND/AIMS: The decreased synthesis of nitric oxide (NO) during ischaemia/reperfusion (I/R) has been implicated as the major underlying mechanism for the pathogenesis of acute ischaemic colitis (A.I.C.). The aim of this study was to investigate the prophylactic effect of L-arginine, a NO donor, on tissue injury during intestinal I/R, and compare its efficacy with that of exogenous vasodilators (molsidomine) and inert nitrogen-containing molecules (casein). MATERIAL AND METHODS: One hundred forty four Wistar rats underwent occlusion of the superior mesentery artery for 30, 60 and 90 min for induction of intestinal ischaemia, followed by 90 min of reperfusion. The rats were randomly assigned to receive L-arginine, molsidomine, or casein hydrolysate. In all groups, apart of the histological study, we determined the levels of serum malondialdehyde (MDA), a reliable marker indicating the degree of the tissue damage after intestinal I/R. RESULTS: Serum MDA levels were significantly lower in the L-arginine group compared to the untreated animals or those that had received molsidomine or casein, after a period of ischaemia of 90 minutes (p < 0.0005), as well as after a period of ischaemia of 60 or 90 minutes followed by a 90 minutes reperfusion (p = 0.011, and p < 0.0005, respectively). In addition, lesser histopathological damage was noted after the use of L-arginine compared to that caused by the administration of molsidomine and casein. CONCLUSION: These findings support a prophylactic effect of L-arginine in experimentally induced intestinal ischaemia. In short, L-arginine attenuates the degree of tissue damage in intestinal ischaemia and promotes healing of intestinal mucosa.

Limberg flap reconstruction for the treatment of pilonidal sinus disease.

Pilonidal disease is a common chronic disorder of the sacrococcygeal area affecting young people. Recent reports have advocated different surgical approaches, such as open or closed technique, but recurrence complicates all forms of treatment. We conducted this case review to evaluate the validity of Limberg flap reconstruction method in the treatment of chronic recurrent pilonidal disease. In the period between September 2003 and December 2004, 32 male patients with complicated/recurrent pilonidal disease were operated on using the Limberg flap reconstruction method. The patients' mean age was 26.4 + 1.6 years (range 19-47 years). All patients fared well, had a satisfactory wound healing, had minimal pain and were mobilized immediately after surgery. They stayed at hospital for 6 to 32 hours. No patient had serious wound infection or flap ischemia. They all returned to normal activity within 4 to 12 days. Follow-up ranged between 14 and 28 months. No patient had recurrence during the above period. Limberg flap reconstruction has several advantages compared to the classical surgical methods for the treatment of pilonidal disease. The patients have a short hospital stay, are mobilized soon after surgery and have a minimal morbidity and recurrence rate.

Colonic duplication in adults: report of two cases presenting with rectal bleeding.

Gastrointestinal duplication is an uncommon congenital abnormality in two-thirds of cases manifesting before the age of 2 years. Ileal duplication is common while colonic duplication, either cystic or tubular, is a rather unusual clinical entity that remains asymptomatic and undiagnosed in most cases. Mostly occurring in pediatric patients, colonic duplication is encountered in adults only in a few cases. This study reports two cases of colonic duplication in adults. Both cases presented with rectal bleeding on admission. The study was focused on clinical, imaging, histological, and therapeutical aspects of the presenting cases. Gastrografin enema established the diagnosis in both cases. The cystic structure and the adjacent part of the colon were excised en-block. The study implies that colonic duplication, though uncommon, should be included in the differential diagnosis of rectal bleeding.

Non-parasitic splenic cysts: a report of three cases.

Primary splenic cyst is a relatively rare disease, and the majority of cases are classified as epithelial cysts. Three cases with nonparasitic splenic cysts are presented: two epithelial and one pseudocyst. All cases had an atypical symptomatology, consisted mainly of fullness in the left upper abdomen and a palpable mass. Preoperative diagnosis was established with ultrasonography and computerized tomography. Two cases with large cysts located in the splenic hilum were treated with open complete splenectomy. The most recent case, a pseudocyst, was managed laparoscopically with partial cystectomy. All cases did not have any problems or recurrence during follow-up. Laparoscopic partial cystectomy is an acceptable procedure for the treatment of splenic cysts, because it cures the disease preserving the splenic tissue. Complete splenectomy is reserved for cases in which cyst excision cannot be done otherwise.

Factors affecting metabolic and electrolyte changes after reperfusion in liver transplantation.

BACKGROUND: The metabolic and electrolyte changes were evaluated after various durations of cold and warm ischemia times to correlate ASA status with hemodynamic changes that may affect the severity of the reperfusion syndrome. PATIENTS AND METHODS: Sixty-one patients who underwent liver transplantation (OLT) were monitored by arterial pH, PaO2, PaCO2, HCO2, BE, K+, Ca2+, Na+, GL, and serial Ht at three specific times: after the skin incision (baseline), 10 minutes before reperfusion (T2), and 10 minutes after reperfusion (T3). Changes in metabolic parameters were correlated with ASA status, hemodynamic changes, time of OLT, as well as cold and warm ischemia times. RESULTS: The pH in ASA IV patients was significantly lower at T1 and T3, and PCO2 higher in ASA V at T1. A significant correlation was observed between pH, PaCO2, HCO3-, BE, Na+, Ca2+, and glucose with the phase of the procedure. The pH and HCO3- decreased significantly from T1 and T2, increasing during T3. Ca2+ fell from T1 to T2 increasing in T3. Mean glucose and sodium levels increase from T1 to T3. Mean BE dropped from T1 to T2 and increased at T3 without a significant correlation between the metabolic parameters in any phase of the study and the cold or warm ischemia times. Patients with a high ASA status showed an increased risk for cardiovascular collapse after reperfusion. CONCLUSIONS: Patients with advanced ASA status are more prone to metabolic and acid-base disturbances during reperfusion, without any relation to the cold or warm ischemia times. High ASA status shows an increased risk for cardiovascular collapse after reperfusion.

Donor and recipient pretransplant conditioning with nonlethal radiation and antilymphocyte serum improves the graft survival in a rat small bowel transplant model.

BACKGROUND: Lymphoid tissue within the intestinal graft require immunomodulatory strategies to prevent graft versus host disease (GVHD) after transplant. Herein, we evaluate the potential advantage of donor-specific bone marrow infusions in donor and or recipient preconditioned with total body irradiation and or antilymphocyte serum (ALS) on the incidence of GVHD and rejection after small bowel transplantation. METHODS: Heterotopic SBTx was performed from DA to Lewis rats and distributed in nine groups: control group G0 (n=4) and G1 (n=6) without irradiation; recipients in G2 (n=4) were given 400 rd although in groups 3 (n=5), G4 (n=6), G6 (n=5), G7 (n=5), and G8 (n=6) with 250 rd. Donors in G5 (n=4) and G6 were given 250 rd of total body irradiation 2 hours before intestinal retrieval. Donors and recipients in G7 and donors in G8 additionally received ALS (day -5). G1, 2, 3, 5, 6, 7, and 8 were infused with UDBM and G4 with the same amount of TCDBM. Animals received tacrolimus for 15 days and accessed for rejection, GVHD and for chimerism analysis. RESULTS: High mortality due to GVHD was observed in G2, 3, and 4, and correlated with high levels of donor T cells in recipients blood. G0 and G1 showed early acute rejection with progression toward chronic rejection, in contrast to the preconditioned groups. High and low doses of total body irradiation resulted in allogeneic and in a mixed chimerism, respectively. Decrease in donor chimeric cells after 11 weeks in preconditioned groups was correlated with severe allograft rejection. CONCLUSION: Donor preconditioning with 250 rd and or ALS combined with recipient preconditioning and donor-specific bone marrow infusions prevented GVHD and resulted in a transient mixed chimerism with inhibition of allograft rejection after small bowel transplantation.

Expression of PDGF-A, TGFb and VCAM-1 during the developmental stages of experimental atherosclerosis.

PURPOSE: A considerable number of growth factors, cytokines, and adhesion molecules are implicated in the development of atherosclerotic lesions. These molecules interact in a complex network influencing the evolution of several processes, such as lipid metabolism, cellular proliferation and tissue repair. The aim of this study was to evaluate the expression of the growth factors PDGF-A, and TGFb, and the adhesion molecule VCAM-1 in the sequential steps of experimental atherogenesis. METHODS: Forty-two New Zealand white male rabbits were divided into 4 groups. The group A rabbits (n = 8) received normal diet and served as control animals. The remaining groups were fed with a diet enriched with 1% cholesterol and 6% corn oil. The rabbits of group B (n = 9) were sacrificed 1 month after the beginning of the study, of group C (n = 15) after 2 months and of group D (n = 10) after 3 months. In tissue sections of the aortic arch the antibodies of the prementioned factors were detected immunohistochemically. RESULTS: In group A only TGFb and PDGF-A were detectable. In lesions of the first month PDGF-A expression was high but declined towards the third month. VCAM-1 expression was getting more intense up to the second month and subsided thereafter. TGFb expression intensified towards the third month. Changes in the expression of these factors were statistically significant. CONCLUSION: PDGF-A, responsible for the uncontrollable growth of smooth muscle cells, and VCAM-1, regulating monocyte recruitment in the intima, acts mainly during the early stages of atherogenesis. TGFb, one of the main factors controlling the formation of connective tissue matrix, has a gradually increasing expression towards the third month contributing probably to the fibrous plaque formation.

Extraperitoneal laparoscopic hernia repair with local anesthesia.

BACKGROUND: This review aimed to compare laparoscopic preperitoneal herniorrhaphy (LPPH) using a laryngeal mask airway and local anesthesia with conventional open herniorrhaphy using similar anesthetic conditions. METHODS: A retrospective review of 238 hernia operations was conducted from October 1996 through September 1998. Laparoscopic preperitoneal hernia repairs with the patient under laryngeal mask airway anesthesia were performed initially using 10 ml of 0.5% bupivacaine (LPPH+10 group). This was compared with hernia repair using 30 ml of 0.5% bupivacaine (LPPH+30 group). Both LPPH groups were compared with a plug and patch "Gilbert" hernia repair group. Postoperative pain was compared in the recovery room and outpatient suite. RESULTS: The LPPH+30 group required significantly less postoperative pain medication than the LPPH+10 group. The LPPH+30 group required slightly more pain medication in the recovery room than the open hernia repair group, but in the postanesthesia care unit (PACU) unit, the LPPH+30 group used less pain medication. A similar number of LPPH+30 patients, and open hernia repair patients required no pain medication. CONCLUSIONS: The use of a long-acting local anesthetic, (30 ml of 0.5% bupivacaine via laryngeal mask airway) for laparoscopic preperitoneal hernia repair compared favorably with conventional open hernia repair using similar anesthetic techniques.

Apoptosis and rejection in rat intestinal transplantation: correlation with FK506 doses and donor specific bone marrow infusions.

BACKGROUND: Our purpose was to investigate the occurrence and the evolution of apoptosis of enterocytes during acute and chronic rejection in an experimental model of allogeneic heterotopic small bowel transplantation (SBTx). METHODS: Forty-five rats were divided in 10 experimental groups according to the dose of FK506 administration and donor bone marrow infusions (DBMI). Groups 1 and 2 did not received BMI. Groups 3 and 4 received 150x106 cells at day 0, groups 5 and 6 received 75x106 cells at days 0-4, groups 7 and 8 received 75x106 cells at days 4 and 10, and groups 9 and 10 received 30x106 cells at days 4, 10, 15, 20, and 25. Animals of groups 1, 3, 5, 7, and 9 were immunosuppressed with 0.5 mg/kg FK 506, although the remaining groups with 1 mg/kg FK 506, from day 0 to 4 after transplant. Fragment end labeling of DNA was used to detect apoptosis. RESULTS: The number of apoptotic cells detected was highest at day 15 (184+/-154) and then progressively decreased thereafter (day 30=159+/-197; day 45=80+/-167; day 60=0). The number of apoptotic enterocytes was found increased during mild (151+/-108) and moderate (281+/-161) allograft rejection, although a low apoptotic rate was observed in cases without rejection (59+/-13) and during severe (53+/-131) and chronic rejection (46+/-136). Furthermore the number of labeled cells was found inversely correlated with fibrosis (P<0.0001). There was no correlation between apoptosis and the presence or absence of DBMI; however, at day 15 rats receiving 1 mg/day of FK 506 had a significantly lower number of apoptotic cells detected (127+/-103 vs. 233+/-174; P<0.02). CONCLUSIONS: In this study the number of apoptotic cells correlated positively with mild and moderate rejection episodes. In case of severe and chronic rejection a low apoptotic rate was found due probably to extensive necrosis and fibrosis of the mucosa. These data suggest an important role of apoptosis in acute and chronic intestinal rejection in a rat model of intestinal transplantation. Determination of apoptosis in allografts might represent an early sign of small bowel rejection and a useful marker in defining the degree of rejection and its outcome/prognosis.

Intestinal transplantation for the treatment of desmoid tumors associated with familial adenomatous polyposis.

BACKGROUND: Desmoid tumors associated with familial adenomatous polyposis (FAP) are locally invasive. Often occurring in the mesentery of the intestine, they sometimes recur after resection. Complications can include intestinal failure and dependence on parenteral nutrition. We describe 9 patients who underwent intestinal transplantation for the treatment of desmoid tumors associated with FAP. METHODS: Records of patients undergoing intestinal transplantation for desmoid tumors at 2 transplant centers were reviewed for patient age, sex, type of graft, procedure date, tumor site, desmoid complications, medications, extracolonic manifestations, status at follow-up, and length of survival. RESULTS: Nine patients with FAP and intestinal failure caused by desmoid tumors were treated with isolated intestinal (n = 6), multivisceral (n = 2), or combined liver-intestinal transplantation (n = 1). Desmoid tumors recurred in the abdominal walls of 2 patients. Two patients died: one as a result of sepsis, the other because of a rupture of a mycotic aneurysm of the aortic anastomosis. One graft lost to severe rejection was replaced with a second intestinal graft. Eleven to 53 months after transplantation, 7 patients were alive, well, independent of parenteral treatment, and leading apparently normal lifestyles. CONCLUSIONS: Transplantation of the intestine alone or as part of a multivisceral transplantation may help rescue otherwise untreatable patients with complicated desmoid tumors.