Primary Stenting of Right-Sided Subclavian Artery Stenosis Presenting as Subclavian Steal Syndrome: Report of 3 Cases and Literature Review.

BACKGROUND: Right-sided subclavian artery stenosis (SAS) is a rare cerebrovascular disease involving the upper extremities. Considering an endovascular approach for its management requires increased endovascular and catheterization skills when compared with the left side, due to the close approximation of the right subclavian artery origin, vertebral, and common carotid arteries. METHODS: Three patients suffering from proximal right-sided SAS were treated in our center through primary stenting. Percutaneous transfemoral and transbrachial approaches were used for vascular access, whereas in 2 cases an additional carotid protection device was deployed intraoperatively. RESULTS: Technical success was met in all 3 cases, with no intraoperative or postoperative complications being observed. All patients resumed ambulation and were uneventfully discharged the next day with dual antiplatelet medication. No recurrent stenosis was reported in duplex ultrasound scan during 6-month follow-up, with all patients reporting resolution of their symptoms. DISCUSSION: Subclavian artery stenosis is an uncommon vascular disease, showing a 4-fold left, rather than right-sided predisposition. Although a low-grade stenosis is usually asymptomatic and may remain unobserved, a severe stenosis may cause retrograde blood flow in the ipsilateral vertebral artery, leading to a medical condition with various clinical symptoms, known as subclavian steal syndrome. A number of open surgical techniques exist for management of subclavian artery stenosis, although a paradigm shift in the 21st century has led to the introduction of minimally invasive techniques for its treatment, with available modalities including angioplasty, stenting, and the kissing stent technique.

Endovascular laser treatment of incompetent saphenous veins using the 1470 nm diode laser and radial fiber.

OBJECTIVES: To assess the technical success, complications, and patients' quality of life (QoL) after treatment of chronic venous disease (CVD) using the 1470 nm radial fiber laser. METHODS: A total of 170 patients with chronic venous disease, classified as C2 to C4 according to CEAP classification, were treated for incompetent greater (GSV) and small (SSV) saphenous veins, using the 1470 nm radial fiber laser and application of tumescent anesthesia. Additional phlebectomies were performed through stab microincisions, while 11 patients further underwent sclerotherapy intraoperatively. Patients' QoL was recorded using a CIVIQ-20 questionnaire pre and post-operatively. RESULTS: Technical success regarding GSV vein occlusion was recorded at 100% and 98% during 12 and 24 month follow up respectively. SSV occlusion rates were recorded at 100% for the same period. 55% of patients were classified as C2. Mean laser application time was 401.1 ± 92.6 s and 169.4 ± 56.8 s, while an average of 3986.6 ± 934.9 and 1643.5 ± 534.1 J were applied during ablation of GSV and SSV respectively. Three incidents of postoperative pain were recorded. Two patients exhibited partial proximal GSV recanalization, while two patients reported mild post-operative temporal paresthesia. No major complications were observed post-operatively. A significant improvement in patients' QoL was demonstrated through the CIVIQ-20 questionnaires. Mean pre-operative CIVIQ-20 total score was recorded at 77 ± 3.9, with a total score of 32.8 ± 2.8 being observed during 12 month follow-up. CONCLUSIONS: Endovascular laser treatment using the 1470 nm radial fiber laser constitutes an effective and safe modality for treatment of CVD.

Endovascular Treatment of Infrarenal Isolated Abdominal Aortic Dissection with Application of the Kissing Stents Technique: A Case Report and Review of the Literature.

Isolated abdominal aortic dissection (IAAD) is a rare form of aortic dissection involving usually the infrarenal part of the abdominal aorta. A 45-year-old male presented with lumbar pain and claudication. Computed tomography angiography (CTA) revealed an infrarenal IAAD extending to the left external iliac artery (EIA), causing ≥90% narrowing of the lumen. An endovascular approach was decided, with deployment of an aortic stent-graft and two balloon expandable stents in both common iliac arteries (IAs), applying the kissing stents technique. Post-surgical course was uneventful; 12 month follow-up showed excellent vessel patency. Endovascular therapy seems to be a feasible treatment option with promising long-term follow-up results.

Chromophobe Renal Cell Carcinoma and the Synchronous Presence of Primary Colon Malignancies. Is There a Relation?

While the presence of multiple primary malignancies in the same patient is a well described phenomenon, there is no clear association between various histological subtypes of renal cell carcinoma (RCC) and the synchronous presence of colon malignancies. We present the rare case of an 81-year-old female patient suffering from chromophobe renal cell carcinoma (chRCC) and an angiomyolipoma of her left kidney, synchronous with an adenocarcinoma of the caecum. While there is an established connection between RCC and colon cancer, a literature review is performed to specify this association in regard to chRCC and the synchronous presence of colon malignancies.

Neuroendocrine carcinoma as a rare cause of jejunal intussusception in an adult. Management and literature review.

Intussusception of the small bowel is an uncommon condition, with the majority of cases being observed during infancy. A number of points are responsible, with benign and malignant lesions of the small intestine being the most common. Herein, we present the case of a 75-year-old male patient with vague abdominal pain and black stool during defecation, who underwent surgery due to jejunal intussusception. Pathology report demonstrated a neuroendocrine carcinoma as the underlying cause for his condition, with no additional metastases during the initial diagnosis. Although a conservative approach for management of intussusception is viable, the possibility of gastric outlet obstruction and the presence of malignancy as the primary point usually lead to urgent surgery. In the case of malignancy, adjuvant chemotherapy or additional symptomatic therapy with close follow-up may be required depending on tumor's grade and aggressiveness.

Strangulated Richter's incisional hernia presenting as an abdominal mass with necrosis of the overlapping skin. A case report and review of the literature.

Although rare, clinicians must be alerted of Richter hernias in patients presenting with innocuous gastrointestinal obstruction symptoms, synchronous with an erythematous hernia. An incarcerated incisional hernia located in a previous laparoscopic insertion site further raises suspicion, while timely surgical management is essential to avoid bowel perforation or resection.

Semi-closed surgical technique for treatment of pilonidal sinus disease.

INTRODUCTION: Pilonidal sinus disease (PSD) is a highly debatable disorder regarding its surgical management, despite an assortment of surgical techniques described in the medical literature. The aim of this report is to provide an alternate semi-closed surgical method for treatment of PSD, with early recovery and a satisfactory cosmetic result. METHODS: In this retrospective study, 34 patients underwent surgical treatment for primary PSD; 32 male and 2 female. Patients were suffering from primary PSD, with the cyst located in the gluteal midline. Total excision of the cyst was performed, while the skin flaps were fixed on the postsacral fascia using absorbable sutures, leaving the wound semi-closed. RESULTS: Technical success was 100%, with an average operation time of 48.7 ± 3.8 min. No wound dehiscence or infections were recorded postoperatively. One reoperation was performed due to hemorrhage. All patients were discharged on the day after surgery, with a VAS pain score of 1.3 ± 1. Two incidents of late wound dehiscence were recorded at 4th and 6th postoperative day due to strenuous exercise. Patients resumed their work after the 5th postoperative day with no complications. The 6 month follow up was completed in 29 patients, with a VAS cosmetic score of 8.1 ± 0.9. No recurrences were observed during the follow up period. CONCLUSION: The presented semi-closed technique is a viable alternative for surgical management of PSD. It provides patients with a satisfying cosmetic result, while it allows for early and safe return to everyday activities with less pain experienced.

Surgical management of a giant parathyroid adenoma through minimal invasive parathyroidectomy. A case report.

INTRODUCTION: Primary hyperparathyroidism is a common endocrine disorder mostly associated to parathyroid adenomas. Although those tend to be small in size, rare cases of giant parathyroid adenomas may be present. CASE PRESENTATION: A 42year old female was admitted in our department due to weakness and vague abdominal pain for the past 8 months. Preoperative laboratory exams indicated primary hyperparathyroidism as a cause to her symptomatology, with elevated values of parathormone and normal values of serum calcium. Ultrasound scan and 99m Tc-MIBI of her cervical region uncovered a giant 3×2cm parathyroid adenoma, located in the lower left thyroid lobe. Despite its size, the gland was successfully removed through implementation of minimal invasive parathyroidectomy. She was uneventfully discharged on the 1st postoperative day. DISCUSSION: Although a common reason for developing hyperparathyroidism, parathyroid adenomas may rarely present with exaggerated dimensions and weight. Physical examination is usually unremarkable, while patients may present with symptomatology associated with elevated calcium levels. Treatment of this medical condition consists of surgical removal of the pathologic parathyroid gland either by bilateral neck exploration or through minimal invasive parathyroidectomy. Preoperative localization plays an important role in the second case, since the method focuses on resection of a pre-op marked hyperactive parathyroid gland, through a small incision. CONCLUSION: Clinicians must be alerted of hyperparathyroidism in patients presenting with calcium associated symptomatology. Diagnosis is straightforward through laboratory exams, while surgery offers the only permanent treatment option.

Patient-tailored management of an asymptomatic massive substernal goiter presenting as brachiocephalic vein occlusion. Report of a case and review of sternotomy indications.

INTRODUCTION: Substernal goiters are characterized by the protrusion of at least 50% of the thyroid mass below the level of the thoracic inlet. Still their definition is controversial. CASE PRESENTATION: The case refers to a 44year old male who presented to our department due to swelling and a feeling of 'heaviness' of his left upper extremity for the past 6 months. CT scan revealed a massive substernal goiter extending to the great vessels. Intraoperatively, a median sternotomy was performed due to the size of the gland and the close adhesion of the isthmus and lower left thyroid lobe to the brachiocephalic vein. Resection of the gland revealed the vein to have a cord-like shape, leading to reduced venous return and upper extremity symptoms. Recovery was uneventful for the patient who was discharged on the 7th postoperative day. DISCUSSION: While most substernal goiters can be surgically managed through a cervical incision, there are cases in which a median sternotomy is indicated. Those cases include excessive gland size, thoracic pain, ectopic thyroid tissue and the extent of the goiter to the aortic arch. Median sternotomy is associated with a number of intra and postoperative complications, although when performed by an experienced surgeon, mortality and morbidity rates along with long-term recovery are not affected. CONCLUSSION: The lack of a uniform definition and variety of indications, lead to a patient-tailored approach regarding the execution of sternotomy during surgical management of massive substernal goiters.

Laparoscopic repair of an excessive Morgagni hernia in an adult presenting as upside-down stomach.

INTRODUCTION: Morgagni hernia is defined as the intrathoracic protrusion of abdominal viscera through a defect in the anterior diaphragm. It represents an uncommon type of diaphragmatic congenital hernia. CASE PRESENTATION: A 68-year-old female patient was admitted in our department due to progressive epigastric discomfort for the past four months. A preoperative diagnosis of a paraesophageal hernia was set through computer tomography, with gastric portions and parts of small bowel protruding inside the thoracic cavity. Intraoperatively, an excessive diaphragmatic defect was detected in the anterior side of the diaphragm. Reduction of the hernia's contents inside the abdominal cavity was achieved through laparoscopy, with the additional fixation of an intraperitoneal non-absorbable mesh for reinforcement of the diaphragmatic wall. Patient was discharged uneventfully on the 4th postoperative day. DISCUSSION: Morgagni hernias refer to a rare type of diaphragmatic congenital hernias, usually identified during childhood, leaving only a small number of cases observed in the adult population. Its diagnosis can pose a challenge due to the non-specific and usually asymptomatic presentation. An early surgical management is advised due to an increased number of potentially lethal complications, such as gastric incarceration and obstruction. Treatment consist of open surgical techniques through a trans-thoracic or a trans-abdominal approach, although a paradigm shift in the 21st century considers minimal invasive laparoscopic surgery the treatment of choice. CONCLUSSION: A high index of clinical suspicion is required for diagnosis of Morgagni hernias, while prompt management is advised. Laparoscopy is considered the best approach in the hands of an experienced surgeon.

Intra-abdominal myositis ossificans in an asymptomatic patient during closure of a Hartmann's colostomy.

Intra-abdominal myositis ossificans, also known as heterotopic mesenteric ossification, defines the formation of bone-like lesions inside the abdominal cavity. It is a rare medical condition, usually following abdominal surgery or trauma. A 55-year-old male presented for closure of a Hartmann's colostomy, created 6 months ago because of sigmoid adenocarcinoma. Intraoperative findings consisted of an elongated bone-like lesion attached on the peritoneum and protruding inside the abdominal cavity, while two more stiff calcified nodules were found in the mesocolon. All lesions were excised. The presence of a hard consistency sigmoid stump led to cancelation of the operation. Heterotopous bone formation constitutes a challenging surgical condition, since its clinical presentation is innocuous and repetitive surgery acts a stimuli for additional bone creation. Computed tomography scan plays a major role in its diagnosis, while nonsteroidal anti-inflammatory drugs and cimetidine are helpful in preventing further recurrence of the disease.

Bowel obstruction and perforation due to a large gallstone. A case report.

INTRODUCTION: Gallstone bowel obstruction is a rare form of mechanical ileus usually presenting in elderly patients, and is associated with chronic or acute cholecystitis episodes. CASE PRESENTATION: We present the case of an 80year old female with abdominal pain, inability to defecate and recurrent episodes of diarrhea for the past 8 months. CT examination uncovered a cholecystoduodenal fistula along with gas in the gall bladder and the presence of a ≥2cm gallstone inside the small bowel lumen causing obstruction. Patient was admitted to the operating room, where a 3.2cm gallstone was located in the terminal ileus. A rupture was found in the antimesenteric part of a discolored small bowel segment, approximately 60cm from the ileocaecal valve, through which the gallstone was recovered. The bowel regained its peristalsis, and the rupture was debrided and sutured. Patient was discharged uneventfully on the 6th postoperative day. DISCUSSION: Gallstone ileus is caused due to the impaction of a gallstone inside the bowel lumen. It usually passes through a fistula connecting the gallstone with the gastrointestinal tract. It can present with nonspecific or acute abdominal symptoms. CT usually confirms the diagnosis, while there are a number of treatment options; conservative, minimal invasive and surgical. Our patient was successfully relieved of the obstruction through recovery of the gallstone using open surgery, with no repair of the fistula. CONCLUSSION: Although rare, gallstones must be suspected as a possible cause of bowel obstruction, especially in elderly patients reporting biliary symptoms.

Treatment of a half century year old giant inguinoscrotal hernia. A case report.

INTRODUCTION: Inguinal hernias, although a common medical entity, can on rare occasions present as giant inguinoscrotal hernias, mostly because of the patient's rejection of timely surgical management. PRESENTATION OF CASE: A 77year old patient, with a giant inguinoscrotal hernia history for more than 50 years, was advised to undergo surgical treatment due to recurrent urinary tract infections and vague abdominal pain. Physical examination showed a right sided giant inguinoscrotal hernia extending below the midpoint of the inner thigh. Preoperative CT examination confirmed a giant inguinoscrotal hernia containing the whole of the small bowel along with its mesentery. DISCUSSION: Giant inguinoscrotal hernias are classified into three types based on size, with each one posing a challenge to treat. There are a number of surgical options and recommendations available, depending on the type of hernia. They require close postoperative observation, because the sudden increase in the intra-abdominal pressure can account for a number of complications. Our case was classified as a type II hernia, having longevity of more than 50 years. Despite this, it was treated with forced reduction and no debulking through an extended inguinal and lower midline incision, forming a 'V shaped' incision. Patient recovery was uneventful and he was discharged on the 10th postoperative day. CONCLUSION: Preoperative management and the correct surgical plan depending on the case are key elements in the successful treatment of this rare surgical entity.