Hellenic Journal of Surgery

Diffuse Large B-cell Lymphoma of the Ileum in a 41-year-old Greek Male with Undiagnosed HIV Infection Presenting with Iliac Fossa Pain Abstract Introduction The incidence of lymphoma in patients with HIV infection is higher than in the general population. Case report Here, we present the case of a 41-year-old Greek male with recurrent episodes of fever for one year, who presented with the symptoms and signs of acute abdomen, right pelvic pain, anorexia and nausea starting 8 hours prior to admission. Laparotomy revealed complete obstruction of the terminal ileum and cecum due to a ruptured mass. A right colectomy with a latero-lateral ileotransverse anastomosis was performed. On histology, the mass proved to be an extranodal localization of diffuse large B-cell lymphoma (DLBCL) of the ileum. Based on the history and histopathological findings, HIV infection was suspected and testing proved positive. We hypothesize that although this patient had been suffering from intermittent fever for a year, he was never investigated thoroughly, and delay in the diagnosis and treatment of the HIV infection favored the development of lymphoma. In conclusion All patients with lymphoma should be investigated for underlying immunosuppression, especially in the case of extranodal localization of the disease.

Surgery at the End of Life. Is it Necessary?

Neoadjuvant Chemotherapy for Male Breast Cancer - "Pushing the Boundaries" Abstract Male breast cancer accounted for around 370 new cases in 2015 in the UK and about 20 cases per year are reported in Scotland. Most male breast cancers are sporadic and are associated with risk factors such as race, genetic predisposition, estrogen exposure and radiation exposure. We report the case of a 67-year-old male with Grade III invasive ductal carcinoma and lymph node metastasis who underwent neoadjuvant chemotherapy prior to surgical treatment. In addition, we discuss the current rationale and evidence behind neoadjuvant chemotherapy for breast cancer, and the justification for providing this treatment in male breast cancer. Due to the rarity of male breast cancer, it is difficult to determine its optimal management, but it would appear reasonable to extrapolate from studies on the management of female breast cancer.

Comparison of Open Versus Closed Lateral Internal Sphincterotomy in the Management of Chronic Anal Fissure Abstract Background An anal fissure is a longitudinal split in the anoderm of the distal anal canal, extending from the anal verge proximally towards, but not beyond, the dentate line. Various surgical methods of treatment of chronic anal fissure (CAF) are available, including anal dilatation, fissure excision, fissure excision with sphincterotomy, open lateral anal internal sphincterotomy and closed lateral anal internal sphincterotomy. Method This prospective study compared the results and complications of the open and closed techniques of lateral internal anal sphincterotomy in patients with CAF. Results A total of 60 patients with CAF were enrolled in this study, of which 30 underwent open lateral sphincterotomy and 30 underwent closed lateral sphincterotomy. Post-operative complications (pain, bleeding, constipation, perianal abscess, incontinence) were compared between the two groups. Postoperative pain, bleeding, and constipation were significantly less in the group undergoing closed surgery (p > 0.05). Perianal abscess and incontinence did not occur in any study subject. Conclusions Closed lateral anal sphincterotomy is the treatment of choice for CAF. It can be performed effectively and safely, with a low rate of complications and a reduced cost burden.

Laparoscopic Repair of Lumbar Hernia: A Case Report and Mini Review Abstract Background Lumbar hernias are quite rare, constituting 2% of all abdominal wall hernias, and they are usually secondary to trauma or previous surgery. Approximately 300 cases have been reported so far. There are two different types, depending on the location: superior lumbar or Grynfeltt's hernia and inferior or Petit's hernia. Abdominal computed tomography (CT) will provide accurate diagnosis. Laparoscopic repair with mesh is the treatment of choice, especially when the hernia is symptomatic. Methods We describe the diagnosis and laparoscopic repair of a symptomatic right superior lumbar hernia in a female patient, with a review of the relevant literature. The patient provided her written consent for publication of the case and the photographs. Case report A 48-year-old female was referred to the surgical clinic with a symptomatic right sided abdominal hernia. Clinical examination revealed an abdominal wall defect in the right superior lumbar region. Abdominal CT confirmed a right Grynfeltt's hernia, containing ascending colon and fat, but with no signs of strangulation. She underwent laparoscopic lumbar hernia repair with mesh under general anaesthesia, with uneventful recovery. Conclusion Lumbar hernia is a rare abdominal wall defect, which is usually secondary to trauma or previous surgery. A thorough history and clinical examination, along with abdominal CT, will provide accurate confirmation of the diagnosis. CT should always be included in the investigation prior to surgery, even in uncomplicated cases. The relevant literature is limited, but confirms that laparoscopic repair with mesh is the treatment of choice, especially when the hernia is symptomatic.

Evaluation of Laparoscopic Total Extraperitoneal Repair of Inguinal Hernia Under Regional Anesthesia: A Prospective Case Series Abstract Introduction This study evaluated the feasibility and safety of laparoscopic total extraperitoneal (TEP) inguinal hernioplasty under regional (spinal/epidural) anesthesia, on the basis of duration of surgery, conversion to general anesthesia (GA), intra-operative and post-operative complications, post-operative hospital stay, time taken to resume normal activity and recurrence. Material and Methods A prospective observational study was conducted from 1st November 2014 to 31st December 2015 on a series of 33 patients with direct or indirect inguinal hernia treated in the Department of General Surgery. All the patients underwent laparoscopic TEP hernia repair under regional anesthesia and the outcome was evaluated. Results The study included 33 patients, 32 male and 1 female. All the patients were operated on under regional anesthesia and the operative procedure performed was laparoscopic TEP. There was no conversion of the operative procedure from TEP to the transabdominal preperitoneal (TAPP) procedure or to open hernioplasty, but conversion of regional anesthesia to GA was needed in 5 cases, because of hypotension, shoulder tip pain, pneumoperitoneum, intraoperative straining and/or inadequate preperitoneal space. A sensory level achieved after regional anesthesia below T6 was found to be a significant reason for conversion to GA. The mean post-operative hospital stay was 3.9 ± 0.9 days (range 2–6 days). The mean time taken to resume normal activity was 13.3 ± 1.8 days (range 10–15 days). Conclusion TEP hernioplasty is a feasible and safe procedure which can be performed under regional anesthesia and on patients who are at high risk or unfit for GA as well as in patients with no other problems.

Xanthogranulomatous Cholecystitis Masquerading as Gallbladder Cancer: Case Series and Literature Review Abstract Background Xanthogranulomatous cholecystitis (XGC) is an uncommon variant of chronic cholecystitis, often misdiagnosed as gallbladder malignancy. The clinical and radiological features often mimic gallbladder carcinoma, and the association of this entity with carcinoma makes the treatment decision difficult. Methods An analysis of patients operated on between July 2017 and December 2018 with a preoperative diagnosis of gallbladder malignancy, which ultimately turned out to be XGC, was conducted, in an attempt to determine the clinical and radiological features which could facilitate the preoperative diagnosis of XGC. Results The study included 6 patients who underwent radical cholecystectomy with a preoperative diagnosis of gallbladder malignancy, which proved on histological examination to be XGC. All 6 patients presented with mild upper abdominal pain, discomfort, anorexia and weight loss. Three of them had been diagnosed with diabetes mellitus (DM) in the past. Contrast enhanced computed tomography (CECT) scan showed gallbladder wall thickening, liver infiltration and lymphadenopathy in all cases. The surgery performed was radical cholecystectomy alone in 3 cases, radical cholecystectomy with right hemicolectomy in 2, and radical cholecystectomy with right hemicolectomy along with a Whipple procedure in one case. The postoperative course was uneventful, only two patients developed superficial wound infection, with an average hospital stay of 8.1 days. Conclusion Differentiation of XGC from gallbladder carcinoma is difficult, and a definitive diagnosis necessitates histopathological examination. An accurate preoperative diagnosis requires an integrated review of the clinical and characteristic radiological features, the presence of which may help to avoid radical resection and avoidable morbidity in selected cases. Knowledge of the entity, a high degree of suspicion and involvement of an expert surgeon should provide the optimal management. An incorrect diagnosis may lead to inappropriate surgery - either over-treating it by performing a radical cholecystectomy for XGC or perfoming a simple laparoscopic cholecystectomy for a malignant lesion.

Internal Drainage of Infected Pancreatic Necrosis: A Fail-Safe Alternative to Percutaneous Catheter Drainage Abstract Introduction Necrosectomy and external drainage has been the traditional surgical treatment for infected pancreatic necrosis (IPN) following acute pancreatitis. It is a highly invasive and high risk procedure in an already compromised individual and demands multiple trips to the operating room for subsequent debridement. Recent evidence suggests that minimally invasive procedures, including surgical video-assisted retroperitoneal debridement and percutaneous catheter drainage (PCD) can often "take the heat out of the fire" and thereby delay or even avoid surgery, but these procedures sometimes fail and surgical intervention needs to be undertaken. In order to avoid multiple surgical procedures we decided to drain the IPN internally into the stomach. Aims and Objectives To ascertain the efficacy and safety of open necrosectomy and internal drainage into the stomach as a feasible alternative in patients with IPN. Materials and Methods We conducted a prospective study of the results of open surgical necrosectomy and internal drainage performed on patients with IPN from March 2012 to February 2019. This was a record based qualitative study. The patients were initially managed in the intensive care unit (ICU) with goal-directed therapy and organ support where indicated. All patients with IPN requiring PCD or surgical intervention were included in this study. Results A total of 44 patients with acute necrotizing pancreatitis who underwent either PCD or surgical drainage were included in the study. Of the 44 patients, 16 (36.4%) were treated with open transgastric debridement and internal drainage into the stomach for IPN. The mean age of this subgroup of patients was 51.3 ± 11.1 years, the most common etiology of the pancreatitis was alcoholic, the mean acute physiology and chronic health (APACHE II) score of these patients was 15.9 ± 4.72, and the mean bedside index of severity in acute pancreatitis (BISAP) score was 4.92 ± 0.11. On contrast enhanced computed tomography (CECT) scan of the abdomen, 93.8% of the patients had >50% necrosis, with a mean CT severity index (CTSI) of 9.3 ± 0.7. The mean operating time was 137 ± 42.4 minutes, with a mean blood loss of 225.4 ± 50.5 ml. Two patients required reoperation because of persistence of necrosum and signs of collection on repeat CT, and there were two mortalities. None of the patients had any late complications related to the surgery and the procedure was successful in 91%. Conclusion Internal drainage into the stomach in IPN is a feasible and relatively safe procedure when indicated. It is more effective in avoiding repeated surgical procedures when compared to external drainage.

Transgastric and Reverse Sleeve Resection of Gastric Submucosal Tumors: Analysis of 7 Cases Abstract Background Gastric submucosal tumors (SMTs) are tumors originating in the subepithelial layer of the stomach. Excision of the tumors in the esophagogastric junction and lesser curvature of the stomach by simple wedge resection is technically difficult and the risk of complications is high. Here, we present a series of cases of submucosal lesions located in the esophagogastric junction and lesser curvature which were successfully treated by reverse sleeve gastrectomy or combined endoscopic laparoscopic surgery (CELS). Methods Between January 2018 and February 2019, 7 patients with gastric SMTs in the esophagogastric junction or lesser curvature underwent surgery at the Turkiye Yuksek Ihtisas Training and Research Hospital. The patients were evaluated in terms of age, gender, additional disease, localization, symptoms, operation type, operation time, intraoperative complications, conversion requirement, pathology, negative surgical margin (R0) resection, tumor size, time of oral intake, post-operative complications and duration of hospitalization. Results The tumor was located in the cardia in three patients, in the lesser curvature in three and in the corpus posterior wall in one patient. In three of the cases, preoperative dysphagia was present, in one dyspepsia and in one upper gastrointestinal (GI) bleeding. Transgastric CELS was performed in 4 cases and laparoscopic reverse sleeve gastrectomy in three cases. One patient developed pneumonia postoperatively, but no other complications were observed. Histopathological examination showed leiomyoma in 3 cases and GI stromal tumor (GIST) in four. In all patients surgical margins were negative. Conclusions Transgastric CELS and reverse sleeve gastrectomy can be performed safely for gastric submucosal lesions located in the esophagogastric junction and lesser curvature.

Alexandros Sfakianakis
Anapafseos 5 . Agios Nikolaos
Crete.Greece.72100
2841026182

6948891480

alsfakia@gmail.com