Pelvic Exenteration for the Management of Pelvic Malignancies

Pelvic exenteration is a surgical procedure first described by Brunschwig in 1948 as a curative or palliative treatment for pelvic and perineal tumors. It is actually a radical operation, involving en bloc resection of pelvic organs, including reproductive structures, bladder, and rectosigmoid. In patients with recurrent cervical and vaginal malignancy, it is associated with a 5-year survival of more than 50%. In spite of advances in surgical management, consequences such as stomas, are still frequently unavoidable for radical tumor excision. Most candidates for this procedure have been diagnosed with recurrent cervical cancer that has previously been treated with surgery and radiation, or radiation alone. Complications of pelvic exenteration are more severe than those of standard resection of a colorectal carcinoma, so it is not commonly performed, including wound infection, wound dehiscence (also described as burst abdomen) the creation of fistulae (perineal-fecal, uretero-vaginal, between conduit and perineal wound), urinary tract infections, perineal hernias and intestinal obstruction. Patients need to be carefully selected and counseled about risks and long-term issues related to the surgery. A comprehensive evaluation is required in order to exclude unresectable or metastatic disease. Evolution of the technique through laparoscopy and minimally invasive surgery may result in a reduction of morbidity and mortality

Intra-abdominal pressure alterations after large pancreatic pseudocyst transcutaneous drainage

<p>Abstract</p> <p>Background</p> <p>Acute pancreatitis leads to abdominal hypertension and compartment syndrome. Weeks after the episodes pancreatic fluids sometimes organize to pseudocysts, fluid collections by or in the gland.</p> <p>Aims of the present study were to evaluate the intra-abdominal pressure (IAP) induced by large pancreatic pseudocysts and to examine the effect of their transcutaneous drainage on IAP.</p> <p>Methods</p> <p>Twenty seven patients with a pancreatic pseudocyst were included. Nine patients with pseudocysts greater than 1l (group A) had CT drainage and eighteen (volume less than 1l) were the control group. The measurements of group A were taken 6 hours before and every morning after the drainage, while for group B, two measurements were performed, one at the day of the initial CT and one 7 days after. Abdominal compliance (Cabd) was calculated. Data were analyzed using student's <it>t</it>-test.</p> <p>Results</p> <p>Baseline IAP for group A was 9.3 mmHg (S.D. 1.7 mmHg), while the first post-drainage day (PDD) IAP was 5.1 mmHg (S.D. 0.7 mmHg). The second PDD IAP was 5.6 mmHg (S.D. 0.8 mmHg), the third 6.4 mmH (S.D. 1.2 mmHg)g, the fourth 6.9 mmHg (S.D. 1.6 mmHg), the fifth 7.9 mmHg (S.D. 1.5 mmHg), the sixth 8.2 mmHg (S.D. 1.4 mmHg), and the seventh 8.2 mmHg (S.D. 1.5 mmHg). Group B had baseline IAP 8.0 mmHg (S.D. 1.2 mmHg) and final 8.2 mmHg (S.D. 1.4 mmHg). Cabd after drainage was 185.6 ml/mmHg (SD 47.5 ml/mmHg).</p> <p>IAP values were reduced between the baseline and all the post-drainage measurements in group A. IAPs seem to stabilize after the 5^thpost-drainage day. Baseline IAP was higher in group A than in group B, while the two values, at day 7, were equivalent.</p> <p>Conclusion</p> <p>The drainage of large pancreatic pseudocyst reduces IAP. Moreover, the IAP seems to rise shortly after the drainage again, but in a way that it remains inferior to the initial value. More chronic changes to the IAP are related to abdominal cavity's properties and have to be further studied.</p

Diagnostic Colonoscopy Leading to Perforated Appendicitis: A Case Report and Systematic Literature Review

Introduction. Intestinal perforation is a known complication after colonoscopy. However, appendiceal involvement with inflammation and perforation is extremely rare and only 37 cases of postcolonoscopy appendicitis have been reported so far. We describe a case of perforated appendicitis 24 hours after colonoscopy that was treated successfully in our Department. Case Report. A 60-year-old female patient underwent a colonoscopy during the investigation of nontypical abdominal pain without pathologic findings. 24 hours after the examination she presented gradually increased right lower quadrant abdominal pain and a CT scan was performed, showing an inflammation of the appendiceal area with free peritoneal air. Through laparotomy, perforated appendicitis was diagnosed and an appendectomy was performed. The patient was discharged on the tenth postoperative day in good health condition. Discussion. The characteristics of all cases reported in the literature are described, including our case. Perforated appendicitis soon after a colonoscopy is a rare, but serious complication; therefore, it is crucial to be included in the differential diagnosis of postcolonoscopy acute abdominal pain

A Rare Case of a Direct Incarcerated Inguinal Hernia Containing an Epiploic Appendage and a Literature Review

Inguinal hernias are a widespread condition, responsible for a large number of acute abdomen cases. Typically, indirect, rather than direct, hernias are the ones leading to complications, as a consequence of their narrower hernial defect. Our case concerns a rather rare incidence of a direct incarcerated hernia in a 71-year-old man who presented with acute pain in the left inguinal area. Upon clinical examination, an irreducible inguinal mass was palpated. Therefore, the existence of a complicated hernia was suspected. The patient underwent an emergency repair, during which it was established that the hernia was direct and incarcerated and that its sac contained an ischemic epiploic appendage. The hernia was successfully repaired with mesh, the patient recovered uneventfully and was discharged five days later. Despite the rarity of complicated direct inguinal hernias, they should always be included in the differential diagnosis of irreducible groin masses, because they can increase severe complications. Keywords: Direct inguinal hernia; Appendix epiploica

Left Colon Diverticulitis Presenting as Perforated Lumbar Abscess: A Case Report and Review of the Current Literature

Diverticular perforation is a common complication of diverticulitis and can lead to the creation of abscesses. The presence of such abscesses on the abdominal wall is rare and can lead to misdiagnosis. We present the case of a patient with abdominal pain and the formation of a large left lumbar abscess due to perforation of a diverticulum of the left colon and our surgical treatment of choice with favorable results

Emphysematous cholecystitis: a case report

A 65-year-old Greek man with a history of diabetes mellitus and hypertension was admitted because of right upper quadrant pain, nausea and palpable right quadrant mass. On admission the patient was febrile (38.8°C) with a total bilirubin level of 1.99 mg/dl (direct 0.59 mg/dl); SGOT 1.26 mg/dl; Na 135 mmol/l and K 2.9 mmol/l. The white blood count was 15200/μl with 92.2% neutrophiles. Axial sections of single slice CT imaging (section thickness 10 mm), revealed emphysematous cholecystitis with thickening of gallbladder wall and wall enhancement after iv contrast enhancement, as well as, dilatation of the gallbladder with multiple gallstones precipitate and intraluminal air. The patient underwent subtotal cholecystectomy and a cholecystostomy was placed. The culture of the bile showed positivity to toxin A of Clostridium Difficile and to Escherichia Coli. The postoperative course of the patient was uneventful

Anterior chest wall tuberculous abscess: a case report

The granulomatous inflammation of tuberculosis usually involves the lungs and the hilar lymph nodes. Musculoskeletal tuberculosis (TB) occurs in 1–3% of patients with TB, while TB of the chest wall constitutes 1% to 5% of all cases of musculoskeletal TB. Furthermore, nowadays it is rarer to find extrapulmonary TB in immunocompetent rather that non-immunocompetent patients. The present case reports a fifty-six-year-old immunocompetent man with an anterior chest wall tuberculous abscess. The rarity of the present case relates both to the localization of the tuberculous abscess, and to the fact that the patient was immunocompetent. The diagnosis of musculoskeletal tuberculous infection remains a challenge for clinicians and requires a high index of suspicion. The combination of indolent onset of symptoms, positive tuberculin skin test, and compatible radiographic findings, strongly suggests the diagnosis. TB, however, must be confirmed by positive culture or histologic proof. Prompt diagnosis and treatment are important to prevent serious bone and joint destruction

Acute appendicitis secondary to Enterobius vermicularis infection in a middle-aged man: a case report

<p>Abstract</p> <p>Introduction</p> <p>Acute appendicitis due to <it>Enterobius vermicularis </it>is very rare, affecting mostly children. Whether pinworms cause inflammation of the appendix or just appendiceal colic has been a matter of controversy.</p> <p>Case presentation</p> <p>A Caucasian 52-year-old man was referred to our Emergency Department with acute abdominal pain in his right lower quadrant. The physical and laboratory examination revealed right iliac fossa tenderness and leukocytosis with neutrophilia. An open appendectomy was performed. The pathological examination showed the lumen containing pinworms. Two oral doses of mebendazole were administered postoperatively. The follow-up to date was without incident and he was free of symptoms one year after the operation.</p> <p>Conclusion</p> <p>The finding of <it>E. vermicularis </it>in appendectomy pathological specimens is infrequent. Parasitic infections rarely cause acute appendicitis, especially in adults.</p> <p>One should keep in mind that the clinical signs of intestinal parasite infection may mimic acute appendicitis, although rare. A careful evaluation of symptoms such as pruritus ani, or eosinophilia on laboratory examination, could prevent unnecessary appendectomies.</p

Massive variceal bleeding secondary to splenic vein thrombosis successfully treated with splenic artery embolization: a case report

<p>Abstract</p> <p>Introduction</p> <p>Splenic vein thrombosis results in localized portal hypertension called sinistral portal hypertension, which may also lead to massive upper gastrointestinal bleeding. Symptomatic sinistral portal hypertension is usually best treated by splenectomy, but interventional radiological techniques are safe and effective alternatives in the management of a massive hemorrhage, particularly in cases that have a high surgical risk.</p> <p>Case presentation</p> <p>We describe a 23-year-old Greek man with acute massive gastric variceal bleeding caused by splenic vein thrombosis due to a missing von Leiden factor, which was successfully managed with splenic arterial embolization.</p> <p>Conclusions</p> <p>Interventional radiological techniques are attractive alternatives for patients with a high surgical risk or in cases when the immediate surgical excision of the spleen is technically difficult. Additionally, surgery is not always successful because of the presence of numerous portal collaterals and adhesion. Splenic artery embolization is now emerging as a safe and effective alternative to surgery in the management of massive hemorrhage from gastric varices due to splenic vein thrombosis, which often occurs in patients with hypercoagulability.</p