Lymph node harvesting in colorectal carcinoma specimens.

INTRODUCTION: Adequate lymph node evaluation is an important determinant of prognosis in patients with colorectal cancer. Current guidelines recommend evaluation of at least 12 lymph nodes; however, a significant number of patients fail to meet these criteria. AIM: To investigate the factors that influence adequate recovery and evaluation of lymph nodes in colorectal cancer. METHODS: We retrospectively analyzed 454 consecutive cases of colorectal cancer surgically treated from September 2000 to September 2006. Univariate and multivariate linear and logistic regression analysis was used to study the effect of various factors in lymph node recovery. RESULTS: The number of lymph nodes retrieved ranged from 0 to 62 with a median of 13 nodes. Overall, 189 (41.6%) patients had fewer than 12 nodes removed. Patient age, tumor stage, location and size were associated with lymph node retrieval. Multivariable regression revealed that the aforementioned variables, including gender and hospital type, explained 17% of the observed variance of the lymph node number. CONCLUSION: Patient and tumor characteristics, although important, are only partly responsible for the variation of lymph node yield. Quality of surgical resection and/or the thoroughness of examination of the tissue by the pathologist might explain the wider proportion of this variance. Training in colorectal node evaluation could help to improve the quality of cancer care.

Management of incidental left-sided gallbladder.

A left-sided gallbladder is a gallbladder located on the left side of the round ligament. It constitutes an uncommon anatomic abnormality. We report on a case of left-sided gallbladder discovered incidentally during laparoscopic cholecystectomy, and we discuss the different forms of this anatomic anomaly and its surgical relevance.

Collision tumour of the stomach with a cancer to cancer metastasis: a case report.

INTRODUCTION: Coexistence of a primary gastric lymphoma and a gastric adenocarcinoma is a rare event. The diagnosis is suspected after the pathologic examination of the endoscopic biopsies and definitely documented with the examination of the surgical specimen. CASE PRESENTATION: We are presenting a rare case of a 77-year-old Greek man with epigastric pain of one and a half month duration, nausea, anorexia and weight loss. The pathologic examination of the endoscopic biopsies and a lymph node biopsy excised at laparotomy, presented the interpenetration of synchronous occurring primary gastric lymphoma and a gastric adenocarcinoma with a documented cancer to cancer metastasis. CONCLUSION: Prognosis of these rare tumours is largely dependent on the stage of the adenocarcinoma at presentation but due to lack of large series there are no data on the biological behavior of these tumours in comparison to adenocarcinoma.

Vertical rotation and impaction to the choledochal duct of a migrated biliary self-expanding metal stent.

Self-expanding metal stent (SEMS) placement is a well accepted and highly effective method for both treating and palliating obstructive lesions of the biliary tree, still complications may occur including premature occlusion and stent migration. Migration can occur either proximally or distally, usually early after SEMS placement and almost exclusively in covered ones. Distal migration is the most common type and is reported in 5.8% to 6% of cases. In our case, proximal migration of the stent occurred and surprisingly it rotated and impacted to the common bile duct transversally. This precluded any attempt to reposition or remove the SEMS. We effectively treated this unusual complication by placing an additional plastic stent into the common bile duct that restored biliary drainage.

Lipoma induced jejunojejunal intussusception.

Intussusception in adults is rare. The clinical picture of intussusception in adults is subtle and the diagnosis is, therefore, elusive. The presence of a structural abnormality in the great majority of the adult cases mandates high clinical suspicion. Gastrointestinal lipomas are rare benign tumors and intussusception due to a gastrointestinal lipoma constitutes an infrequent clinical entity. The present report describes a case of jejunojejunal intussusception in an adult with a history of severe episodes of hematochezia and colicky upper abdominal pain. The diagnosis was suspected preoperatively but computed tomography scan could not rule out malignancy. Exploratory laparotomy revealed jejunojejunal intussusception secondary to a lipoma which was successfully treated with segmental intestinal resection.

Sutureless open low anterior resection with total mesorectal excision for rectal cancer with the use of the electrothermal bipolar vessel sealing system.

BACKGROUND: There is no report of electrothermal bipolar vessel sealer utilization in rectal surgery. The objective here was to evaluate the results of the use of this device in open low anterior resection for rectal cancer regarding reduction of operative time, hemostasis, and postoperative complications compared with the conventional technique. An additional aim was to describe and standardize this operative technique. MATERIAL/METHODS: All open low anterior resections with total mesorectal excision for rectal cancer performed by the same surgical team from January 2003 to December 2003 were reviewed. Patients were divided in two groups: those operated with the classic technique (group A) and those with a bipolar vessel sealer (group B). Main outcomes measured were operative and hospitalization time, intraoperative blood loss, postoperative drainage volume and duration, postoperative complications, perioperative blood transfusions, and final outcome. RESULTS: Forty-one patients were included (group A: 19, group B: 22). The groups were similar in demographics, TNM classification, number of lymph nodes dissected, complications, blood transfusions, hospital stay, and outcome. Comparing group B with group A, operative time (171+/-10 vs. 203+/-20 min, p=0.002), intraoperative blood loss (20+/-6 vs. 60+/-4 ml, p=0.04), drainage volume (70+/-8 vs. 120+/-10 ml, p=0.001), and drainage duration (1.7+/-0.3 vs. 2.6+/-0.2 days, p=0.01) were significantly reduced. CONCLUSIONS: The bipolar vessel sealer is a safe and effective adjunct for low anterior resection. The device simplifies the procedure while achieving efficient hemostasis and results in reduced operative time, intraoperative blood loss, and drainage volume and duration.

Nonocclusive mesenteric ischemia: a lethal complication in peritoneal dialysis patients.

Nonocclusive mesenteric ischemia (NOMI) is a relatively uncommon disorder, seen primarily in elderly patients with cardiac disease, and is characterized by progressive intestinal ischemia leading to infarction, sepsis, and death. It is suspected of being the underlying cause in at least 20% - 30% of acute mesenteric ischemia patients. End-stage renal disease patients are among the highest risk populations for developing this lethal complication; however, NOMI is not unique to hemodialysis and can occur in peritoneal dialysis patients as well. Unfortunately, the presentation of NOMI is very similar to that of peritonitis. The key to correct diagnosis is a high index of suspicion in predisposed patients. The high mortality rate is a clear reflection of failure to recognize the syndrome at an earlier, treatable stage. We present our case experience and an extensive review of the literature regarding this dreadful complication that may be reversible if considered early as a possible etiology and the appropriate diagnostic maneuvers undertaken.

Unusual site of recurrent musculoskeletal hydatid cyst: case report and brief review of the literature.

A case of a large multiplex recurrent hydatid cyst involving the left gluteal muscle and the left iliopsoas, accompanied with degeneration of the musculature of the left upper leg is presented along with a review of the relevant literature. Very few such cases have been reported worldwide. The presented case is also distinguished by the involvement of muscles of distant anatomic areas.

Primary gastric melanoma: a case report.

Melanoma accounts for 1-3 per cent of all malignant tumors. Except cutaneous, other less common melanomas include, among others, those in the GI tract. However, their primary or secondary nature is often difficult to establish. Referring to the stomach, scattered cases of primary melanomas have been reported in the literature. We report a case of a man with an ulcerated sub-mucosal mass at the antrum of the stomach, manifested with dull upper abdominal pain, nausea, vomiting, fatigue and anemia. This lesion was histologically proved to be melanoma. A detailed clinical and laboratory investigation revealed no primary site elsewhere. To our knowledge, very few cases of primary gastric melanoma have been reported. Our case is the fourth ever published and the first located at the antrum of the stomach. The debate upon the primitive nature of such lesions still persists. Thus, specific diagnostic criteria have been proposed.

Rectal carcinosarcoma: a case report and review of literature.

A 60-years old male was admitted to our department for investigation of constipation and hypogastric discomfort intensified during defecation of a few weeks duration. The cause proved to be a rectal carcinosarcoma that was treated by abdominoperineal resection and postoperative chemo-radiotherapy. The patient died 6 months later due to hepatic failure, showing evidence of disseminated disease. In general colonic carcinosarcomas constitute a rare category of malignant neoplasms whose nature is still incompletely understood. No specific treatment guidelines exist. Surgery is the mainstay of treatment and regardless of the addition of adjuvant therapy the prognosis is very poor. Systematic genetic analysis may be the clue for understanding the pathogenesis of these mysterious tumors.

Pretreatment tumor lysis syndrome associated with bulky retroperitoneal tumors. Recognition is the mainstay of therapy.

Acute pretreatment tumor lysis syndrome is a rare complication of cancer. Early recognition and aggressive management are mandatory for prevention of the adverse sequelae of the syndrome. Here we present 2 cases of pretreatment tumor lysis syndrome, concluding that this clinical entity should be in the differential diagnosis of acute renal failure associated with malignancy, as early recognition is in fact the mainstay of treatment.