Total cysto-pericystectomy for huge echinococcal cyst located on hepatic segment IVb. Case report and review of the literature.

Hepatic hydatid disease is located mainly in the right liver. It is usually solitary and asymptomatic; however, a large cyst may cause compression symptoms. We report a case of a huge echinococcal cyst located in segment IVb of the liver in a 39-year-old female, 17 x 11 cm in dimensions, causing persistent epigastric pain and discomfort. The diagnosis was made by a computed tomography (CT) scan, which showed the cystic mass with the characteristic daughter cysts and reactive caps (pericystic wall) consisting of fibrous connective tissue and calcifications. The patient underwent radical resection by total cysto-pericystectomy and had an uneventful postoperative course. Follow-up showed no recurrence in CT and normal liver function test. Total cysto-pericystectomy, as an alternative to hepatectomy, is the preferable choice of radical resection operation, nowadays, in the management of liver hydatid disease even in huge cysts.

Improvement of home composting process of food waste using different minerals.

This article presents the experimental study of the process of composting in a prototype home-scale system with a special focus on process improvement by using different additives (i.e. woodchips, perlite, vermiculite and zeolite). The interventions with different bulking agents were realized through composting cycles using substrates with 10% additives in specific mixtures of kitchen waste materials. The pre-selected proportion of the mixtures examined was 3:1:1 in cellulosic:proteins:carbohydrates, in order to achieve an initial C/N ratio equal to 30. The control of the initial properties of the examined substrates aimed at the consequent improvement of the properties of the final product (compost). The results indicated that composting process was enhanced with the use of additives and especially the case of zeolite and perlite provided the best results, in terms of efficient temperature evolution (>55 °C for 4 consecutive days). Carbon to nitrogen ratios decreased by 40% from the initial values for the reactors were minerals were added, while for the bioreactor tested with woodchips the reduction was slight, showing slowest degradation rate. Moisture content of produced compost varied within the range of 55-64% d.m., while nutrient content (K, Na, Ca, Mg) was in accordance with the limit values reported in literature. Finally, the composts obtained, exhibited a satisfactory degree of maturity, fulfilling the criterion related to the absence of phytotoxic compounds.

Complicated liver echinococcosis: 30 years of experience from an endemic area.

BACKGROUND AND AIMS: Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management, and short-term outcome of patients with complicated liver echinococcosis. MATERIAL AND METHODS: A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with noncomplicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%), and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications, and hospital stay were assessed. RESULTS: Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated. CONCLUSIONS: Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently severe clinical manifestations, complexity of surgical management, and the increased postoperative complications characterize complicated liver echinococcal disease.

Postoperative adhesion prevention using a statin-containing cellulose film in an experimental model.

BACKGROUND: Intraperitoneal adhesions are a common problem in abdominal surgery. The aim of this study was to compare the effectiveness of Statofilm, a novel antiadhesive film based on cross-linked carboxymethylcellulose and atorvastatin, with that of sodium hyaluronate-carboxymethylcellulose (Seprafilm(®)) in the prevention of postoperative intraperitoneal adhesions in rats. METHODS: One hundred male Wistar rats underwent a laparotomy and adhesions were induced by caecal abrasion. The animals were allocated to five groups: a control group with no adhesion barrier, Seprafilm(®) group, placebo group with a film containing carboxymethylcellulose without atorvastatin, and low- and high-dose groups with films containing carboxymethylcellulose and atorvastatin 0·125 and 1 mg per kg bodyweight respectively. Adhesions were classified by two independent surgeons 2 weeks after surgery. Caecal biopsies were obtained for histological evaluation of fibrosis, inflammation and vascular proliferation. RESULTS: All antiadhesive film groups (Seprafilm(®), placebo, low-dose and high-dose) had statistically significant adhesion reduction compared with the control group (P < 0·001, P = 0·015, P < 0·001 and P < 0·001 respectively). The low-dose Statofilm was superior to Seprafilm(®) in terms of adhesion prevention (P = 0·001). Adhesions were present in three-quarters of rats in the Seprafilm(®) group, but only one-quarter in the low-dose Statofilm group. CONCLUSION: The data suggest that the newly developed adhesion barrier Statofilm has better results than Seprafilm(®) in preventing postoperative adhesions in rats. A low-dose atorvastatin-containing film, such as Statofilm, could be evaluated for future clinical application.

Current management of diverticular disease complications.

Diverticular disease is a common problem in the western population and sometimes leads to serious complications such as hemorrhage, bowel stenosis, obstruction, abscesses, fistulae, bowel perforation, and peritonitis. The severity of these complications can differ, and it is not always clear which procedure is indicated in each case and what measures should be followed before bringing the patient into the operating room. Certain operations have high rates of morbidity and mortality, especially in compromised patients. Along with advancements in imaging and minimally invasive techniques, the indications for surgery have currently being adapted to "damage limitation" or "down-staging" protocols, which seem to offer improved results. There are still some questions to be solved in the following years by prospective studies, such as the usefulness of laparoscopic lavage in purulent peritonitis or of Hartmann's procedure in fecal peritonitis. These indications, based on current literature, are systematically discussed in the present review.

Clinical features of colonic diverticular disease.

Colonic diverticular disease is extremely common in developed countries. Although the majority of patients with diverticulosis remain asymptomatic, about one-third of the patients manifest the disease with either hemorrhage or inflammation. Diverticulitis may be uncomplicated or complicated by abscess formation, perforation with peritonitis, fistula, intestinal obstruction, or stricture. Controversy exists regarding the aggressiveness of diverticulitis during recurrent attacks of the disease as well as in special groups of patients including immunocompromised patients, young patients, and patients with right-sided disease. Clinical characteristics of symptomatic uncomplicated disease can be similar to irritable bowel syndrome, while acute diverticulitis is sometimes difficult to distinguish from segmental colitis associated with diverticulosis. The considerable clinical overlap between those entities with diverticular disease demonstrates that there are still areas of uncertainty in their physiopathology.

Intraperitoneal administration of bevacizumab intraoperatively does not affect abdominal wound healing in rats.

BACKGROUND: Bevacizumab is a monoclonal antibody targeted at vascular endothelial growth factor (VEGF) to treat advanced colorectal cancer as well as other malignancies, but the ideal time point for its administration in patients scheduled for surgery is not well defined due to serious concerns regarding possible side effects on wound healing. Therefore, we conducted an experimental study in rats to clarify this issue. METHODS: Four groups of 10 Wistar rats each underwent a 4-cm midline laparotomy and closure of the wound in 2 layers. In the treatment groups (A and B), bevacizumab (Avastin(®)) received a single dose of 5 mg/kg i.p., and an equal amount of saline was given to the control groups (C and D). Groups A and C were sacrificed on the 7th postoperative day, and groups B and D on the 14th postoperative day. Wounds were inspected by two independent observers upon sacrifice and results were recorded; wound tissues were sent for histology to assess the degree of fibrosis and measurement of tissue hydroxyproline levels. Serum levels of endothelin-1, C-reactive protein, pro-oxidant/antioxidant balance and carbonylated proteins were also determined. For statistical analysis, the Mann-Whitney U test was used. RESULTS: Wound healing did not differ among groups both on the 7th and the 14th postoperative days, and there was also no significant difference regarding the degree of inflammation, fibroblast proliferation and collagen synthesis, as well as hydroxyproline and biochemical marker levels among the groups. CONCLUSIONS: Intraperitoneal bevacizumab administered intraoperatively does not significantly affect abdominal wound healing in rats.

Tension-free by mesh-plug technique for inguinal hernia repair in elderly patients.

BACKGROUND: elderly patients are steadily becoming a growing part of the population. The aim of this study is to evaluate the outcome of open inguinal hernia repair in patients aged over 65 years. METHODS: from January 1999 to December 2008, a total of 719 patients underwent open tension-free inguinal hernia repair with mesh-plug; 301 among them were ≥ 65 years old. RESULTS: elderly patients had a mean age of 72.4 years (women 3.3%), while the mean age of younger patients was 48.7 years (women 5.7%). According to the ASA score, patients aged ≥ 65 years were at significantly higher risk than the younger patients. Spinal anesthesia was used most frequently in both groups. No significant differences were found in postoperative pain, mortality and recurrence. Morbidity and hospital stay were significantly higher in patients aged ≥ 65 years. CONCLUSIONS: open hernia repair in the elderly is safe and well tolerated, but it is associated with higher morbidity and longer hospitalization.

Retractile mesenteritis appearing as a sigmoid colon tumor.

Retractile mesenteritis is a rare, fibrosing, inflammatory disease affecting the adipose tissue of the intestinal and colonic mesentery. So far, about 300 cases have been reported in the literature. We present a case of retractile mesenteritis.

Deeply infiltrating rectal endometriosis with lymph node involvement.

BACKGROUND: Sigmoidorectal endometriosis accounts for 70% of the cases of intestinal endometriosis. Symptoms are non-specific, frequently resembling adenocarcinomas. CASE: A 45-year-old woman complaining of recurrent rectal bleeding underwent colonoscopy in which a rectal polypoid mass was found. She underwent anterior rectosigmoidectomy and the histological examination of the resected bowel revealed rectal endometriosis with lymph node involvement. CONCLUSION: Lymphatic infiltration of epicolic lymph nodes raises questions about the benign nature of this presumed innocent disease.

Early propranolol administration does not prevent development of esophageal varices in cirrhotic rats.

BACKGROUND AND AIMS: Variceal bleeding is the most serious complication of portal hypertension associated with high mortality. This study was conducted to investigate any protective effect of early propranolol administration in the development and degree of esophageal varices in cirrhotic rats with portal hypertension. This topic is controversial in the literature. METHODS: For the development of liver cirrhosis and esophageal varices, 60 rats underwent ligation of the left adrenal vein and complete devascularization of the left renal vein, followed by phenobarbital and carbon tetrachloride (CCl(4)) administration. This operation enhances the development of cephalad collaterals, responsible for the induction of esophageal varices. After 2 weeks of CCl(4) administration, the rats were randomly separated into 2 groups. In group I, propranolol was continuously administered intragastrically throughout the study, whereas in group II normal saline (placebo) was administered instead. Cirrhosis was detected clinically by ascites development. Hemodynamic studies and morphometric analysis of the lower esophagus were performed after complete induction of cirrhosis, measuring the following parameters: portal pressure, total number of submucosal veins, total submucosal vessel area, mean cross-sectional submucosal vessel area, relative submucosal area (percentage) occupied by vessels and area of the single most dilated submucosal vein. RESULTS: The statistical analysis revealed no statistically important difference between the 2 groups for the morphometrically studied parameters. However, portal venous pressure was lower in group I. CONCLUSION: Early propranolol administration did not protect rats from developing esophageal varices, despite the fact that a significant decrease in portal pressure was detected.

Primary Ewing sarcoma of the stomach--a newly described entity.

The Ewing sarcoma family of tumors (ESFT) includes classic Ewing sarcoma of the bone, extraosseous or soft tissue Ewing sarcoma, Askin tumors of the chest wall, and peripheral primitive neuroectodermal tumors of the bone and soft tissues. They share a common neural histogenesis, tumor genetics and biology. The genetic hallmark of the ESFT is the presence of t(11;22)(q24;q12), which creates the EWS/FLI1 fusion gene and results in the expression of a chimeric protein. Although Ewing tumors can occur at any age, the great majority are found in individuals less than 20 years of age. We herein report a case of gastric Ewing sarcoma in a 68-year-old male. This patient illustrates the second reported occurrence of primary Ewing sarcoma in the stomach and the first reported with the t(11;22)(q24;q12) gene translocation.

Pelvic malakoplakia simulating recurrence of rectal adenocarcinoma: report of a case.

Malakoplakia represents a chronic inflammatory disease associated with a broad spectrum of bacterial infections. On histopathology, Michaelis-Gutmann bodies are considered as pathognomonic histopathological findings. Rarity of the disease and wide variety of clinical presentation makes its diagnosis very challenging. We report herein the case of a 66-year-old woman who, having undergone lower anterior resection for rectal adenocarcinoma 3 and a half years ago, presented with urinary frequency and dull abdominal pain. CT scan revealed a soft tissue tumour infiltrating the preperitoneal fat over the urinary bladder, which was considered as recurrence of the rectal carcinoma. On laparotomy, a tumour invading the bladder, small intestine and the anterior abdominal wall was resected and the patient recovered uneventfully. On histopathology, malakoplakia of urinary bladder was revealed. Overstaging of patients' malignancy due to malakoplakia is not uncommon, so its early identification can help avoid incorrect treatment.

Does emergency surgery affect resectability of colorectal cancer?

OBJECTIVE: Emergency surgery for colorectal cancer is common in daily practice, and is mainly implied by bowel obstruction. It is related to increased morbidity and mortality. Its relation with the stage and respectability of the disease is uncertain. This study aims to further clarify these parameters. PATIENTS AND METHODS: Over the past 24-year period 121 patients had an emergency operation (12%) from a total of 1009 patients with colorectal carcinoma. There were 59 men (48.8%) and 62 women (51.2%) with a mean age of 68 years (range 21-93); 61 patients (50.4%) were > or = 70-years-old. The data of all these patients were studied retrospectively in comparison with those who underwent elective surgery. Emergency cases were further divided into two age groups (> or = 70 and < 70 years) and compared. The tumour location was mainly in the left colon, whereas obstruction was the predominant reason for acute presentation. RESULTS: On operation, absence of macroscopic spread was noted in 57.8% of emergency cases and 72% of elective cases (p < 0.05). The resectability rates were 75% and 90% respectively (p < 0.05), and were not significantly affected by the age factor. There were no differences in the grade of malignant cell differentiation or in the depth of microscopic invasion (p > 0.05) in either group. For emergency operations, the morbidity was 20% (24 patients) and the 30-day mortality rate was 5.8% (7 patients). Both parameters were higher in patients > or = 70-years-old. CONCLUSION: Emergency surgery for colorectal carcinoma is related to lower resectability and to higher--but acceptable--postoperative morbidity and mortality rates, when compared with elective surgical management.

Effect of experimentally induced liver cirrhosis on wound healing of the post-extraction tooth socket in rats.

BACKGROUND: Wound healing in liver cirrhosis is known to be impaired possibly due to liver insufficiency and subsequent malnutrition status; however, there is no study to examine healing effectiveness of the tooth socket following an extraction in such patients. MATERIALS AND METHODS: Irreversible cirrhosis was induced in 30 Wistar rats by repetitive weekly doses of CCl(4) and continuous administration of phenobarbital in a 12-week course was monitored by body weight measurement and ascites development, and was proved histologically. One week later, cirrhotic and control rats were subjected to extractions of two maxillary grinders on each side, one side by simple method, the other by surgical method. Half of the animals of each subgroup were sacrificed on the 10th post-extraction day, whereas the other half on the 30th post-extraction day, and histological sections were examined from all tooth sockets for wound-healing activity. RESULTS: A malnutrition status was detected in cirrhotic rats with significant difference in their body weight. Several histological parameters of socket healing were not statistically different between cirrhotic and control animals. However, a significant delay on epithelialization and cancellous bone formation was detected on the 10th post-extraction day for either simple or surgical extractions in cirrhotic animals. CONCLUSIONS: Liver cirrhosis in rats provokes a significant delay on epithelialization and mature cancellous bone formation and consecutively on early socket wound healing after a tooth extraction.

Major complications during laparoscopic cholecystectomy.

Laparoscopic cholecystectomy may lead to serious complications, some of which can be disastrous if they are not recognized and managed immediately. Over the past 12-year period, 1225 laparoscopic cholecystectomies were performed. Totally, major complications occurred in 19 cases (1.5%). The conversion rate was 7.4%. Complications included common bile duct injury in 2 cases (0.16%), vessel injury by trocar or Veress needle in 4 cases (0.32%) including 1 case of aorta injury (0.08%), bleeding from the gallbladder bed or the cystic artery in 10 cases (0.8%), bile leak in 1 case (0.08%), duodenum injury in 1 case (0.08%), and transient liver ischemia in 1 thalassanemic patient (0.08%). The complication was recognized during the operation in 11 cases. Reoperation was necessary in five cases (0.4%), and conservative management was applied in three cases. Although infrequent, major complications may occur during laparoscopic cholecystectomy. Immediate recognition and management is critical and may lead to a safe outcome.

Safety of bowel resection for colorectal surgical emergency in the elderly.

OBJECTIVE: Colorectal emergency requiring radical surgery is becoming increasingly frequent in the elderly and problems remain as regards the best management policy. Our long-time experience is presented in this study. PATIENTS AND METHODS: In the last 23 years, 105 elderly patients, aged > or = 65 years, with colorectal disease underwent an emergency operation in our Surgical Department. Forty-five patients (mean age 72 years) had benign disease and 60 patients (mean age 76.5 years) colorectal carcinoma. RESULTS: The carcinoma was located in the left colon (68%), right colon (18%) and rectum (14%). Mostly, patients with malignant cancer presented with obstructive ileus, and patients with benign tumours with perforation and peritonitis, with a predominance of diverticulitis. A resection operation either with primary anastomosis or Hartmann's procedure was performed in 75% of cases; in the rest, only palliation was resorted to. Forty-three percent of the patients with colorectal cancer emergency were > or = 80 years of age. The mean morbidity was 25% and mortality 17%, which make up to 33% and 26.6% for benign disease, and 20% and 10% for malignant cancer, respectively. The mortality rate was higher in patients with perforation than those with obstruction. CONCLUSION: Advanced age is not a contraindication to radical surgery in case of colorectal emergency in the elderly. In the majority, a resection operation is feasible. In high-risk patients, colostomy is a life-saving alternative.

Interdigital pilonidal sinus in a hairdresser.

Pilonidal sinus of the interdigital web space of the hand is a rare occupational disease which occurs in hairdressers and professionals working with animals. This paper reports such a sinus in the hand of a male hairdresser and reviews the treatment of this condition.

Targeting activated lymphocytes with an entirely human immunotoxin analogue: human pancreatic RNase1-human IL-2 fusion.

A hybrid human protein was produced in E. coli by fusing the genes encoding human pancreatic RNase1 (hpRNase1) and human IL-2 (hIL-2). The recombinant hpRNase1-hIL-2 inhibited protein synthesis in HTLV-1-infected, malignant T cells, which hyperproduce high affinity IL-2 receptors, with an IC(50)of 2x10(-8) M, whereas no inhibition was detectable in control cells with lower affinity receptors. HpRNase1 alone had an IC(50)of almost 10(-3) M. A molar excess of hIL-2 blocked the protein synthesis inhibition dose-dependently. In a human mixed lymphocyte culture, hpRNase1-hIL-2 inhibited the proliferation of responder cells with potency comparable to that of cyclosporine, while non-effective doses of FK506 importantly improved its potency. Despite its short half-life in animals, hpRNase1-hIL-2 rapidly enters cells in a few minutes and arrests the protein translation in less than 10 h. Thus, hpRNase1-hIL-2 may be useful to selectively eliminate activated lymphocytes hyperproducing high affinity IL-2 receptors, as in allograft rejection, graft-versus-host disease, autoimmune disorders, adult T cell leukaemia and other lymphoproliferative or retroviral malignancies including HIV infection, without inducing general immunosuppression. As an entirely human "immunotoxin analogue" it may alleviate the dose limiting toxicity and immunogenicity of conventional immunotoxins.

Human pancreatic RNase1-human epidermal growth factor fusion: an entirely human 'immunotoxin analog' with cytotoxic properties against squamous cell carcinomas.

The gene encoding human pancreatic ribonuclease 1 (hpRNasel) was fused with a gene encoding human epidermal growth factor (hEGF). The hybrid human protein was isolated from Escherichia coli inclusion bodies, refolded and purified to homogeneity. The fusion protein competed with 125I-hEGF for binding to hEGF receptors (EGFR) and had ribonucleolytic activities approaching those of hpRNase1. Several conformations having different enzymatic activities could be detected after reversed-phase high-performance liquid chromatographic analysis, the less hydrophobic molecules being the most active. The hybrid protein was specifically cytotoxic to A431, an EGFR overexpressing squamous carcinoma cell line, with an IC50 of approximately 10(-7) M. In contrast, recombinant hpRNase1 had an IC50 higher than 10(-4) M. A mixture of free hEGF and free hpRNasel was not more cytotoxic than hpRNasel alone and no cytotoxicity was detected in EGFR-deficient control cells. Taken together, these data suggest that this construct might be useful for targeted therapy of esophageal, lung and other squamous cell carcinomas and also breast cancers overexpressing EGFR, which correlate with a poor prognosis and cannot be cured by surgery alone. Engineering hybrid molecules with endogenous human proteins for targeted therapy may alleviate the dose-limiting immunogenicity and toxicity of conventional immunotoxins.