Subtotal gastrectomy for diffused hemorrhagic gastritis induced by radiation, following liver resection for hilar cholangiocarcinoma. A case report.

INTRODUCTION: A rare case of hemorrhagic gastritis induced by radiation is presented, which was resistant to conservative treatment and required subtotal gastrectomy. PRESENTATION OF CASE: A 56-year-old male was initially undergone right hepatectomy, resection of the extrahepatic biliary tree, hilar lymph node dissection and hepatico-jejunostomy due to advanced hilar cholangiocarcinoma. Because of the extent of the disease, chemo-radiotherapy was administered. The patient received a total radiotherapy dose of 57.6Gy in 32 sessions. Unfortunately, diffused hemorrhagic gastritis induced by radiation was developed, which was resistant to conservative treatment (endoscopic hemostasis, transfusion). A subtotal gastrectomy was performed. The patient is in good condition 45 months after the liver resection, but with local recurrence. CONCLUSION: In resistant situations to conservative treatment and recurred bleeding of diffused hemorrhagic gastritis induced by radiation, surgical management may have a role.

Silent ulcerative colitis adjacent to a regular sigmoid adenocarcinoma.

There have been studies trying to elucidate the large spectrum and the variety of inflammatory bowel disease (IBD)-related colorectal cancer manifestations and natural history. A 57-year-old male patient underwent a regular screening colonoscopy in our department, which revealed a flat ulcerated mass in the sigmoid whereas the remaining bowel was normal on endoscopic appearance. Biopsies from the mass were compatible with sigmoid adenocarcinoma and the patient underwent left hemicolectomy. Pathology examination of the resected specimen also diagnosed ulcerative colitis adjacent to cancer. The otherwise healthy patient denied any history that could be related to IBD symptoms. Patient was started on 1.6 g of mesalazine and was advised to adhere to an endoscopic surveillance program. This case points toward a need for a more thorough understanding of the natural history of colorectal cancer in IBD to set clinically meaningful guidelines.

Fournier's gangrene complicating ulcerative pancolitis.

Fournier gangrene is a very rare and a rapidly progressing, polymicrobial necrotizing faciitis or myonecrosis of the perineal, perianal and genital regions, with a high mortality rate. Infection is associated with superficial traum, urological and colorectal diseases and operations. The most commonly found bacteria are Escherichia coli followed by Bacteroides and streptococcal species. Diabetes mellitus, alcoholism, and immunosuppression are perpetuating co-factors. Fournier's gangrene complicating inflammatory bowel disease has been reported in three patients so far, two with Crohn's disease. A 78-year-old man diagnosed with ulcerative pancolitis was referred for fever, and painful perianal and scrotal swelling after perianal surgery for a horseshoe-type perianal abscess. Since bowel disease diagnosis, patient was on mesalazine and achieved long-term remission. Perianal abscess occurred suddenly one week before perianal surgery without any evidence of pre-existing fistula or other abnormalities. Physical examination showed extensive edema and crepitus of perineum and genitalia and patient had symptoms of significant toxicity. The diagnosis of Fournier's gangrene was made and patient underwent emergency surgery with extensive surgical debridement of the scrotal and perianal area and Hartman procedure with a diverting colostomy. In addition, patient started on therapy with mesalazine 3gr, methylprednisolone 16 mg, parenteral nutrition and broad spectrum of antibiotics. Two days after the first operation the patient needed a second operation for perianal debridement. On the fourth day, blood cultures showed E. coli. Patient had an uneventful recovery and was discharged after 34 days of hospitalization. On follow up, disease review is scheduled and colostomy closure is planned.

The role of colonoscopy in the management of intestinal obstruction: a 20-year retrospective study.

PURPOSE: The aim of the study was to assess the use colonoscopy over time in the assessment of large bowel obstruction in a tertiary university hospital. METHODS: Retrospective analysis of surgical and colonoscopy records for the years 1990-2009 in a university hospital. All patients diagnosed with non-conservatively managed bowel obstruction were included. RESULTS: We recorded 644 patients diagnosed with non-conservatively managed bowel obstruction. Four hundred forty-one (67.3%) were managed only by surgery, 157 (23.6%) were managed by colonoscopy, and 46 (6.9%) by combined colonoscopy and surgery. Patients over 77 years were more likely to receive colonoscopy as monotherapy or combined with surgery as compared to younger patients. Management by colonoscopy only and by combined colonoscopy and surgery increased over time. CONCLUSIONS: Colonoscopy in the management of non-conservatively treated bowel obstruction increased over time. However, therapeutic colonoscopy still has a limited role in bowel obstruction either as monotherapy or combined with surgery.

Non-toxic megacolon due to transverse and sigmoid colon volvulus in a patient with ulcerative colitis.

Intestinal volvulus in patients with inflammatory bowel disease is rare. A 83-year-old woman diagnosed with ulcerative colitis five years ago was referred to our hospital due to abdominal distension. The patient had been diagnosed with pancolitis and dolichocolon and was started on mesalazine 1.5 g/day treatment resulting in long-term remission. Physical examination showed abdominal distention with no rebound; however on auscultation abdominal sounds were absent. Patient had no signs of toxicity. Temperature was 38.2 °C, heart rate was 82 bpm and respirations were 16/min. Laboratory investigation showed elevated white blood cell count (20,000/mm(3)) with hemoglobin at 13.2 g/dl and C-reactive protein at 310 mg/dl. Radiology was suggestive of megacolon and volvulus. Patient underwent endoscopy, which revealed normal rectal mucosa; there were however present areas of bowel gangrene. Urgent laparotomy was performed which revealed double transverse and sigmoid colon volvulus. A left hemicolectomy and transversectomy were performed. A case of a patient with ulcerative colitis is being presented here, exhibiting a non-toxic megacolon, resulting from a double transverse and sigmoid volvulus probably stemming from congenital dolichocolon. This case is stressing the importance of prompt differential diagnosis in such cases of megacolon as any symptom misinterpretation may result in unfavorable outcomes.

The predominant role of surgery in the prevention and new trends in the surgical treatment of women with BRCA1/2 mutations.

BACKGROUND: Advances in understanding molecular and genetic mechanisms underlying cancer promise an "individualized" management of the disease. Women with a BRCA1 or BRCA2 germ-line mutation are at very high risk of breast and/or ovarian cancer. Because high-quality data are lacking from randomized trials, prevention strategies and treatment of patients with BRCA-associated breast cancer are complex. METHODS: The data for this review were obtained by searching PubMed and Medline for articles about optimizing prevention and treating women with familial susceptibility to breast and ovarian cancer. RESULTS: Prophylactic surgery is the rational approach for women who carry the BRCA mutation; chemoprevention and/or intensified surveillance represent alternative approaches. Prophylactic bilateral salpingo-oophorectomy is superior to bilateral prophylactic mastectomy. However, reaching a definitive clinical decision is complex, and several variables should be considered for an individualized approach. Accumulating data support the concept of more extensive surgery for newly diagnosed breast cancer in women with a BRCA mutation but new unbaised studies are needed for an evidence-based approach . Such patients treated with breast conservation therapy for early-stage breast cancer are at higher risk of contralateral breast cancer than noncarriers. Primary bilateral mastectomy could also be considered and discussed with these patients. Breast tumors from BRCA1 mutation carriers are predominantly of basal subtype (i.e., triple negative), and BRCA2 mutation carriers are of luminal subtype (i.e., estrogen receptor positive). Decisions on adjuvant treatment are based on estrogen receptor, progesterone receptor, and HER2 status. CONCLUSIONS: The complex management of healthy women and breast cancer patients with familial susceptibility to breast and ovarian cancer requires an individualized prevention or treatment strategy by an experienced team.