Vertebral artery variations revised: origin, course, branches and embryonic development.

BACKGROUND: The vertebral artery originates from the subclavian artery and is divided into four segments. The aim of this study is to investigate the anatomical variations in the course and branches of the vertebral artery. MATERIALS AND METHODS: A research was performed via PubMed database, using the terms: "variations of vertebral artery AND cadaveric study", "variations of vertebral artery AND cadavers" and "anomalies of vertebral artery AND cadavers". RESULTS: A total of 24 articles met the inclusion criteria, 13 of them referring to variations of the origin of the vertebral artery, 9 to variations of the course and 3 to variations of its branches. On a total sample of 1192 cadavers of different populations, origin of the left vertebral artery directly from the aortic arch was observed at 6.7%. In addition, among 311 cadavers, 17.4% were found with partially or fully ossified foramen of the atlas for the passage of the vertebral artery, while the bibliographic review also showed variants at the exit site of the artery from the transverse foramen of the axis. CONCLUSIONS: Despite the fact that variations of both the course and the branches of vertebral artery are in most cases asymptomatic, good knowledge of anatomy and its variants is of particular importance for the prevention of vascular complications during surgical and radiological procedures in the cervix area.

Obturator hernias: a systematic review of the literature.

PURPOSE: Obturator hernias (OH) are extremely rare hernias, accounting for 0.07-1% of all hernias. This is the first systematic review investigating their presentation, imaging, treatment outcomes, and recurrence rate. METHODS: After a detailed search in electronic search engines, 74 studies matched our criteria. A review of these reports was conducted and the full texts were examined. RESULTS: A total of 146 patients with a mean age of 78.8 years were included in our analysis, with 40.1%, 29.9%, and 25.2% of patients suffering from either a right, a left or bilateral OH, respectively. OH were associated with non-specific symptoms and signs; bowel obstruction being the most common. Howship-Romberg sign was present in 56.2% of patients. Computed tomography (CT) scan was the most frequently used diagnostic modality, inversely associated with perioperative mortality. Mesh repair demonstrated a significantly improved perioperative morbidity rate, compared with non-mesh repair. Approximately 30% of patients underwent a laparoscopic operation, which was associated with significantly decreased morbidity and mortality rate as well as length of hospital stay, compared with the open repair. CONCLUSION: OHs are not associated with specific symptoms and signs; thus, they constitute a diagnostic challenge, requiring a high level of clinical suspicion. Undoubtedly, CT scan of the abdomen is the gold standard diagnostic tool. Their operative repair is mandatory, with the laparoscopic approach demonstrating significant advantages over the open repair.

Smoking habits and gallbladder disease: a systematic review and meta-analysis study.

BACKGROUND: It has been claimed that smoking is linked with an increased risk for gallbladder disease (GBD); however, related issues need further consolidation and clarification. The present systematic review and meta-analysis aimed to further investigate the potent correlation between GBD and smoking. METHODS: We conducted a comprehensive literature review to identify every study published from January 1989 to December 2019, reporting risk estimates regarding GBD and smoking. The random-effect, generic inverse variance method, according to description by DerSimonian and Laird, was used to compute pooled estimates. We used the Newcastle-Ottawa quality assessment scale to appraise the included studies' quality. RESULTS: Thirty published case-control, cross-sectional, and cohort studies including 4,623,435 individuals met the eligibility criteria and were considered for data synthesis. Compared to the non-smokers, ever smokers had 1.25 times higher odds of developing GBD [95 % confidence interval (CI): 1.09-1.44]; however, increased heterogeneity was observed (I2 =96 %, 95 % CI: 62-100 %, p <0.001). Publication bias was non-significant (Eggers' regression p =0.072). The main sources of heterogeneity, as detected by meta-regression analyzing study characteristics, biases and confounders, were non-adjustment for family history (p =0.007) and alcohol (p =0.020), respectively. Subgroup analysis indicated a comparable risk for GBD as far as current, former and ever smokers are concerned (p =0.520). Quantitative analysis suggested a dose-effect for current smoking and GBD (p =0.010). CONCLUSIONS: Non-smokers were demonstrated to be at a lower risk of presenting GBD when compared with ever smokers; all relevant risk estimates necessitate adjustment for family history and alcohol intake. HIPPOKRATIA 2020, 24(4): 147-156.

Carcinoid tumor of the appendix during pregnancy. A rare case and a review of the literature.

We present a rare case of a carcinoid tumor of the appendix that was diagnosed during pregnancy in a 24-year-old female. The patient was admitted to our department for acute abdominal pain localized on the right half of the abdomen, mimicking acute appendicitis. Open appendectomy was carried out and at the histological examination carcinoid was found in the surgical specimen. Only few similar cases were found in the literature reporting appendiceal carcinoid tumor during pregnancy.

New concepts in the therapeutic options of liver metastases from colorectal cancer.

Colorectal cancer is one of the most frequent malignant neoplasms causing approximately 10% of cancer deaths. Up to 30% of patients with primary colorectal cancer have already liver metastatic disease at the time of diagnosis. Untreated patients with liver metastases share a poor prognosis with an average survival of 12 months. In contrast, patients whose metastatic lesions are surgically treated have an average 5-year survival rate of 40%. Only 10-15% of initial colorectal liver metastases are considered as being resectable. In the remaining patients, the current trend is to downstage initially unresectable metastases by neoadjuvant therapy (systemic or regional chemotherapy, portal vein embolization - PVE - or hepatic artery chemoembolization), tumor ablation and two-stage hepatectomy, alone or in combinations. This study reviews the current therapeutic options for colorectal liver metastases and their contribution to improve survival rates.

Subcutaneous metastasis from a gastrointestinal stromal tumor of the stomach: a case report.

Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the stomach, which account for approximately 3.6% of all gastric tumors. They may or may not be malignant. Malignant GIST rarely metastasizes to distant organs. We report a case of a gastric GIST diagnosed in a 69- year-old woman presented with a synchronous subcutaneous paraumbilical metastasis. Computed tomography (CT) scan demonstrated a space-occupying lesion arising from the gastric wall with a second well-circumscribed lesion in the subcutaneous tissue which infiltrated the aponeurosis of the right rectus abdominis. The patient underwent total gastrectomy and resection of the subcutaneous mass. Pathologic examination of the gastric tumor and subcutaneous mass showed histological and immunohistochemical characteristics of a GIST. The patient succumbed on the 4th postoperative day. Gastric stromal tumor metastasis must be taken into consideration in the differential diagnosis of a palpable paraumbilical mass in a patient diagnosed with malignant GIST.

Screening of patients after colectomy: virtual colonography.

BACKGROUND: Virtual colonography is a powerful new method of imaging the entire colon and is useful to assess polyps and diagnose colon cancer. We evaluated virtual colonography in the postoperative screening of patients who had colon cancer. METHODS: Fifty-three patients were examined with virtual colonography 12 to 48 months postoperatively. Forty-four patients had received segmental colectomy with restoration of the gastrointestinal tract, and nine patients underwent abdominoperineal resection and permanent colostomy. After proper cleaning of the colon and distention with air, spiral computed tomographic examination of the abdomen with a slice thickness of 5 mm (table speed [TS] 10 mm, reconstruction interval [RI] 2.5 mm) was performed in the supine and prone positions (including intravenous contrast medium infusion). Images were transferred to a separate workstation (Philips Easy Vision) for postprocessing, three-dimensional rendering, and endoluminal viewing. RESULTS: Eleven recurrences (16.41%) were identified in 10 patients by virtual colonography, but one recurrence was missed. Conventional colonoscopy was incomplete in six cases, and two patients with colostomy refused colonoscopy. In these eight cases (15%), virtual colonoscopy was completed without problems. A second tumor in one patient who had received abdominoperineal resection was demonstrated by virtual colonography, but conventional colonoscopy failed to demonstrate the lesion. Liver metastases were identified in only one patient. CONCLUSIONS: Virtual colonography seems to provide a good alternative in the follow-up of patients after colectomy. The technique is effective in the diagnosis of locoregional recurrences and distant metastases and is well accepted by patients, and results are equal to those of the conventional colonoscopy.

Alternative interventional multimodality therapies for the management of liver malignancies.

Primary and secondary liver tumors are highly malignant with a very high morbidity and mortality. Although surgical resection is generally accepted as the mainstay of treatment, only a small number of patients are suitable for curative resection. Interventional multimodality therapies provide an alternative to liver resection with minimal morbidity and mortality and quite promising outcomes. These include transcatheter arterial chemoembolization (TACE), percutaneous ethanol (PEI) or other injection techniques, radiofrequency ablation (RFA), microwave coagulation therapy (MCT), cryoablation and interstitial laser photocoagulation (ILP). Techniques, indications and outcomes are discussed.

Adult ileocolic intussusception secondary to a submucosal cecal lipoma.

Intussusception is a relatively common cause of intestinal obstruction in children but a rare clinical entity in adults, representing fewer than 1% of intestinal obstructions in this patient population. We present a rare case of a 44-year-old female patient with intestinal obstruction due to ileocolic and colocolonic intussusception secondary to an intramural cecal lipoma. Diagnosis was made by barium enema and abdominal computed tomography and was confirmed by colonoscopy. After failure of conservative treatment, the patient underwent surgery.

Alterations of platelet function, number and indexes during acute pancreatitis.

BACKGROUND/AIMS: Acute pancreatitis constitutes a systemic inflammatory process which is often accompanied by thrombosis and bleeding disorders. The role of platelets in the pathophysiology of the disease has not been elucidated yet. The present study focuses on two successive end-points: (1) the activation of platelets during acute pancreatitis and (2) the alterations of platelet number and indexes between onset and remission of the disease, which reflect the bone marrow response. METHODS: A cohort of 54 patients with acute pancreatitis was enrolled. Cause and severity of the disease (APACHE II score) were estimated. Activated platelet ratio (APR) was estimated using flow cytometry at onset and remission. Platelet number (PLT), mean platelet volume (MPV), platelet large cell ratio (P-LCR) and platelet distribution width (PDW) were collected at onset and remission. RESULTS: The first end-point was reached in patient 14 as APR was found elevated at onset of acute pancreatitis (p = 0.01). The second end-point was fulfilled in patient 12 for MPV, P-LCR and PDW, which were found elevated at remission of the disease (p < 0.01) but not for PLT until the last patient (p = 0.34). CONCLUSION: Platelets are directly involved in the systemic inflammatory process of acute pancreatitis, which leads to consumption, compensated by an immediate bone marrow response.

Adamantinoma of tibia: a case of late local recurrence along with lung metastases.

Adamantinomas of long bones are rare primary low-grade malignant tumours composed of cells with epithelial and fibrous characteristics. Local recurrence, though scarce, occurs 5-15 years after the onset of diagnosis. We report a case of local recurrence of an adamantinoma localised in tibia, along with the presence of two lung metastases, 24 years after diagnosis and surgical therapy of the primary tumour. The local recurrence and the lung metastases were removed surgically. The patient remains free of the disease for 3 years.