सर्जरी जर्नल

Breast contralateral metachronous cancer is relatively rare. Familial history, BRCA 1 and BRCA 2 mutations, histopathologic type, stage of primary neoplasia and hormone status, is considered risk factors for breast metachronous cancer. The differential diagnosis between a breast contralateral metachronous cancer and a distant metastasis from the primary tumor is difficult and a subject of debate in the literature. We present herein two cases with breast metachronous contralateral tumors; the first is considered as distant metachronous metastasis and the second case, as a second primary tumor. A literature review was also performed.

Introduction: Giant abdominal tumors, as a result of volume mass and dimensions , even benign being, can develop serious complications. The differential diagnosis includes cystic or solid disorders of the female genitals, ascites, cysts or hydronephrosis, pancreatic cysts or pseudocysts, gastrointestinal stromal tumors.

Case presentation: A 44 years old patient, was hospitalized for an giant abdominal tumor formation, pain, weight loss, nausea and vomiting. Laboratory data show changes in the sense of acute renal failure. Ultrasound examination reveals layout of carcinomatous ascites and native CT scanning, a giant cyst, without being able to specify their organ affiliation. The central venous pressure monitoring showed low values (less then 1 cm water), and intra-abdominal pressure, measured indirectly using the urinary catheter, revealed an increased value (25 mmHg). Patient undergone a midline laparotomy and it was found a giant cyst developed from from the left ovary. It was performed cystectomy associated with hysterectomy and controlateral ovariectomyl. The postoperative course was favorable and the patient discharged on day 6. Histopathology confirmed a mucinous cystadenoma

Conclusions: Abdominal compartment syndrome is a severe complication of giant abdominal tumors, which must be solved immediatly by medical therapy and/or surgery. Choosing the type of surgery (open or laparoscopic) depends on tumor size and the possibility and establishing the preoperative histopathological diagnosis.

Objective: To explore the effect of laparoscopy on cancer cells and the expressions of adhesion molecules (ICAM‐1, CD44v6 & integrin β1) in peritoneal tissue and abdominal rinse in patients with colorectal carcinoma (CC).

Methods: A total of 65 CC cases undergoing radical resection at our hospital were analyzed. They were divided into two groups of LAP (laparoscopy, n=35) and OP (open surgery, n=30). Peritoneal tissues were collected at incision and beyond .Also abdominal rinse was collected before tumor resection and abdomen closure. The expressions of adhesion molecules (ICAM‐1 ,CD44v6 & integrin beta 1) in peritoneal and abdominal cavities of two groups were detected by immunohistochemistry and double‐antibody sandwich ABC‐ELISA. And cancer cells in abdominal rinse were detected by peritoneal lavage cytology (PLC) for comparing two surgical methods.

Results: In LAP group, PLC was positive in 3 cases (8.6%) before tumor resection and 8 cases (22.9%) before abdominal closure. In OP group, PLC was positive in 4 cases (13.3%) before tumor resection and 8 cases (26.7% ) before abdominal closure. No inter‐group difference existed in PLC (P>0.05). The expressions of CD44v6, ICAM‐1 and integrin beta 1 in abdominal cavity (before tumor resection & abdomen closure) were compared for LAP and OP groups. And there was no statistically significant difference ( P>0 05). The expressions of CD44v6 ,ICAM‐1 and integrin beta 1 in peritoneal tissues (at incision and beyond) were compared between LAP and OP groups .And there was no statistically significant difference (P>0.05).

Conclusion: Compared with CC patients undergoing traditional open surgery, the risk of exfoliated cancer cells in abdominal cavity shows no increase. And there is no impact `upon the expressions of adhesion molecules.

Solitary Peutz-Jeghers type hamartomatous polyp is a variant of PJS characterized by the presence of hamartomatous polyps in the absence of other manifestations of PJS. It is quite rare with only 19 cases reported in English literature. These cases present in older individuals are usually asymptomatic and carry increased risk of malignant transformation. Hamartomatous polyps are characterized histologically by tree-like branching of smooth muscle fibres covered by mucosal tissue of near normal appearance. Endoscopically, they are characterized by a lobular or nodular surface and whitish colour. We are presenting a case of giant Solitary Peutz-Jeghers type hamartomatous polyp of the duodenum who presented with symptoms of gastric outlet obstruction that was treated with pylorus preserving pancreaticoduodenectomy.

The most catastrophic postoperative gastrointestinal complication in cardiac surgery is mesenteric ischemia, which is frequently fatal. This may result from atheroembolization, heparin-induced thrombocytopenia or hypoperfusion. We reported the case of 72 year old man undergone to coronary artery bypass and aortic valve replacement, presented isolated celiac trunk dissection after surgery. CT scan described a dissection flap of the first part of celiac trunk possible due to ulcerative plaque without note of anterograde or retrograde development. Considering patient's hemodynamic, respiratory and general trend, we decided to choose conservative management. The sequent postoperative period was uneventfully, the patient was hemodynamically stable and he was discharged at the 20th postoperative day. The atheroembolization was a life-threatening problem of all vascular districts: a correct CPB pressure and postoperative BP monitoring could help to reduce the incidence of its complications.

The Meigs’ syndrome, of infrequent presentation in approximately 4% of benign ovarian tumors, is characterized by the association of a benign tumor of gynecological origin with ascites and pleural effusion, which, in the majority of cases, induces the Clinician to suspect a malignant etiology. However, these conditions are resolved after tumor excision. Fewer than 60 cases of Meigs’ syndrome have been reported in the literature to date that have a rise in the CA 125 antigen. The first case was documented by Jones and Survit in 1989 in a 70-year-old patient with a fibrothecoma and with an elevation of CA 125 of 226 IU/ml. The association of a Meigs’ syndrome with Sertoli–Leydig tumors is extremely rare, we present the second case reported in the literature. The fact of being able to find the association of these two entities renders it evident that the Clinician should bear this in mind at the time of carrying out the evaluation of a patient with a pelvic injury that is bears a resemblance to advanced-stage ovarian cancer, and even more so if it presents with elevations of CA 125, in that Meigs syndrome will present complete resolution after the tumor excision.

Giant condyloma acuminatum (GCA) commonly known as Buschke-Lowenstein tumor is a rare, aggressive, slow growing; fungating variant of condyloma that is usually found in the genital and perianal regions but may affect any portion of the anogenital region. Although clinically malignant, its histology is benign without distant metastases. The incidence is 0.1% in the general population and while the prognosis is generally good with early diagnosis and proper treatment, mortality rates as high as 20% have been reported. Human papilloma virus (HPV) types 6 and 11are implicated as etiologic factors in the development of GCA. Radical surgical excision with clear histologic margins and plastic reconstruction remains the cornerstone treatment of choice, while preventing the incidence of recurrence. Topical agents and local destructive methods can be helpful for smaller lesions and immunotherapy as an alternative for widespread and relapsed cases. The authors report the case of a 51-year-old male patient with a perianal 8 × 7 cm Buschke-Lowenstein tumor who underwent total excision and plastic reconstruction with V-Y flap technique.

Introduction: The main goal of surgery and multidisciplinary behavioral therapy in anorectal malformations (ARMs) is to achieve good anatomical and functional outcomes and a better quality of life.

Material and Methods: A retrospective analysis of 146 patients with ARMs was conducted over a 20 years period in our pediatric surgery department. The clinical and demographical data, operative protocols, short and long term outcomes were subject to assessment.

Results: The patient series included 85 boys and 61 girls aged between one day and two years, of which 82.19% were diagnosed in the first few days of life by means of clinical examination and current imaging tests. In 26.02% of cases we found associated congenital abnormalities. A total of 142 (97.25%) cases of all our series underwent surgical treatment; four patients died before surgery. For 131 children the definitive treatment involved posterior sagittal anorectoplasty (PSARP) respectively 11 posterior sagittal anorectovaginourethroplasty (PSARVUP). Long-term followup in 115 patients showed good clinical continence in 82 cases (71.30%) but more than half of the teenagers had body dissatisfaction and social difficulties.

Conclusions: Through this review of 20 years of experience our findings are consistent with other reports regarding male predominance, low birth weight, clinical and imaging diagnosis. We found however a lower incidence of associated abnormalities. The most frequent surgical intervention was posterior sagittal anorectoplasty (PSARP) or posterior sagittal anorectovaginourethroplasty (PSARVUP), both followed by satisfactory functional outcome reporting nevertheless moderate social insertion. Our experience in ARMs proved the effectiveness of the consecrated surgical strategy; long-term assistance for patients and their families should be improved.

Study design

To evaluate the role played by the Layershield matrix (L.S.M.) in avoiding scar tissue and adhesion of the median nerve after decompression in carpal tunnel syndrome.

Objective

Prospective randomized trial to examine this technique. The idea was to investigate the potential benefits when dealing with complications (adherence of the flexor tendons and severing or scarring of the median nerve using the twoinch matrix as an adhesion barrier following mini-open carpal tunnel release).

Summary of background

The study cohort (L.S.M group) consisted of consecutive patients (200 patients) treated with L.S.M. Patients in the standard procedure group (200 patients in all) underwent operations using the same technique in carpal tunnel surgery in both groups, completing follow-up evaluations at no less than 3 to 6 months post-operation. The male to female ratio was 1:6. In twenty patients, there was bilateral involvement.

Method

All operations were conducted by the author at the Hospital General Universitario de Valencia, and the Clínica La Salud, Valencia, Spain, between 2012 and 2013. All patients complained of numbness and/or sensory disturbance or weakness in the median nerve distribution of the hand. Tinel and Phalen sign tests were positive in about two-thirds of patients. EMG studies were performed in all patients and were positive, ranging from mild to severe.

Results

Numbness and paresthesia were relieved in 95% of patients in the L.S.M. group and 89% in the control group (CG). Pain was relieved in 95% DG and 90% CG. Motor weakness was relieved in 95% DG and 92% CG. Normal grip strength was evident in 93% DG and 91% had normal pinch strength.

Re-operation rate

Adherence of the flexor tendons in 3 CG patients and 8 patients due to scarring involving the median nerve, with the L.S. matrix group undergoing re-operation for the following reasons: recurrent pain (3 patients due to scarring around the median nerve). The difference in the re-operation rate between the collagen matrix group and the standard procedure group is statistically significant (p<0.01).

Conclusion

Findings in this study (reduced pain and lower incidence of adhesions) are consistent with the L.S. matrix acting as an effective adhesion barrier. By preventing median nerve adhesions, the L.S. matrix may significantly reduce the incidence of disabling pain associated with re-operation. Ultimately, the prophylactic use of the Layershield Matrix to prevent adhesions may result in improved patient outcomes.

Background: The use of Primary Resection-Anastomosis with or without protective ileostomy

(PRA) or Hartmann’s Procedure (HP) in the surgery of complicated acute diverticulitis is still an open question. The latest published meta-analyses were limited to the most severe stages (Hinchey III and IV). Our systematic review aimed to compare PRA with the HP in all non-elective surgical patients with complicated acute diverticulitis (perforation or obstruction).

Methods: A computerized literature search was performed on Medline databases until July 2014. The studies included in the meta-analysis were 24 with a total of 4,062 patients. Study outcomes included postoperative surgical complications, reintervention, 30-day mortality, overall mortality as well as the length of stay as secondary outcome. The pooled effects were estimated using a fixed effect model or random effect model based on the heterogeneity test. Results were expressed as odds ratio (OR) and 95% confidence interval (CI) for dichotomous outcomes and as mean difference (MD) with 95% CI for continuous outcomes. Subgroup analyses by study type were performed.

Results: The PRA group had a lower rate of postoperative surgical complications (OR=0.525, 95% CI 0.387-0.713), reintervention (OR=0.688, 95% CI 0.525-0.902), 30-day mortality (OR=0.389, 95% CI 0.259-0.586), overall mortality (OR=0.467, 95% CI 0.272-0.803) and length of stay (MD=9.129, 95% CI 2.391-15.867) compared to the HP group.

Conclusion: Our meta-analysis shows that the PRA technique is better than HP for all considered outcomes. Due to the high variability of the included studies, further randomized controlled trials would be required to confirm these results.