In Vivo Antibacterial Activity of Dihydroanthracene Disulfonic Acid Derivative in a Case Diagnosed with Necrotizing Fasciitis

This paper focuses on reporting the in vivo antibacterial activity of dihydroanthracene disulfonic acid derivative preparation in a case diagnosed with mixed flora infection with streptococci, enterobacteria, bacterium coli, pseudomonas and anaerobic proteus that resulted in a resistant to ampicillin, piperacillin, ceftazidim, imipenem, and which is moderately sensitive to cotrimoxazole and azithromycin. This resistant infection affected a patient with history of alcohol and tobacco consumption. It later became complicated with Necrotizing Fasciitis after colon cancer surgery. This study is an in vivo study, which is aimed to measure the antibacterial activity of our new preparation against multiresistant mixed bacterial infection. In the situation of this difficult and almost hopeless case, the patient started oral and local treatment with dihydroanthracene disulfonic acid derivative. Although the fatality of the case was due to the antibiotics resistance, the patient's treatment was attributed to the antibacterial effect of the preparation used. A significant improvement was observed in the first 24 hours after the beginning of the treatment. This happened when all parenteral antibiotics were interrupted. The improvement continued and within a couple of weeks, the wounds were clean and with visible granulation. After three months, the wounds cicatrized “per secundam”. In order to have a general conclusion regarding the in vivo study related to the treatment with dihydroanthracene disulfonic acid derivative preparation, other results are needed. The significant effect shown in the above case, demonstrates that this preparation is promising for treating life threatening resistant microorganisms infections. Further studies are needed to evaluate the full pharmacological activity of the new preparation

Recurrent Hepatolithiasis and Hepatic Abscess Secondary to Caroli’s Disease – Case Report

Background Hepatolithiasis is the presence of gallstones in the intrahepatic ducts due to primary, idiopathic or infectious causes (lithogenic bile) or secondary causes such as congenital cysts and strictures or past hepatobiliary surgery. Typically, hepatolithiasis patients presents with the Charcot’s triad (abdominal pain, jaundice, fever) suggestive of cholangitis. It is not uncommon for severe cholangitis to be accompanied with a hepatic abscess. The treatment consists in supportive measures for cholangitis, subsequent stone extraction and surgical removal of strictures and bile drainage. Patients should be closely monitored because of the high risk of recurrence, liver cirrhosis or cholangiocarcinoma. Case presentation Our patient is a 61 years old male with the following medical history and presentation: Right nephrectomy before approximately 15 years, for polycystic renal disease. Seven years ago, he underwent the surgical procedure of cholecystectomy and choledocho-duodenal anastomosis for gallbladder and CBD stones. A year later, he undergoes an urgent surgical procedure for an intra-abdominal abcess (right subphrenic). For the next five years the patient had no complaints. Three months prior to the surgery he is admitted to the hospital for persistent, recurring episodes of fever (38.5 °C), which did not respond well to antibiotic therapy. Radiology confirms intrahepatic stones, bilateral cystic dilations of bile ducts (Caroli’s Disease) and an abscess of the VIIth liver segment. The patient continues a conservative treatment until optimal parameters are reached for the eventual procedure. The VIIth liver segment is partially resected, the hepatic calculi are extracted and a hepatico-jejunostomy performed, joining a Roux limb with the biliary confluence. Discussion Depending on patient history and current presentation in terms of the severity of the disease and the classification of hepatolithiasis, the surgeon has to weigh and decide upon possible treatment options. Among them we mention supportive measures to treat acute cholangitis, pharmacologic therapy (statins), percutaneous transhepatic cholangioscopic lithotomy, peroral cholangioscopic lithotripsy and surgery. Conclusion Patients with hepatolithiasis recurrence experience chronic cholangitis and eventually develop cirrhosis over a period of 10 to 20 years. Furthermore, the incidence of intrahepatic cholangiocarcinoma is about 5% to 10%. These patients require a long-term follow-up because of an increased risk of cancer after 10 to 20 years. Keywords: General Surgery, Hepatobiliary Surgery, Hepatolithiasis, Caroli’s Disease, Congenital Biliary Cysts. DOI: 10.7176/ALST/97-01 Publication date: January 31st 202

Retroperitoneal, Para-aortocaval Lymphatic Resection as the Surgical Treatment of Choice in Seminoma Grade II

Background Testicular cancer remains one of the most common malignant diseases in young men. The highest incidence was seen in the ages of 25-29 years. A significant part of them come from germ cell tumors, which are divided into seminoma and non-seminoma. Although the aggressiveness of tumors with germ cells remains high, it should be noted that there is a very high response to surgical and chemotherapeutic treatment, where a 5-year disease-free survival is evident in more than 95% of cases. The metastatic spread of these tumors follows the lymphatic drainage of the testes. The retroperitoneal and pre-aortocaval spread, which are resistant to chemotherapy, requires the intervention of an extended surgical procedure, which consists in the removal of the lymph nodes in these regions. The purpose of this procedure is the resection of pre-aortocaval lymph nodes remaining after orchidectomy, a procedure which represents one of the major components of the curative treatment. Case presentation There are three cases of patients, aged 37/32/39-years-old, who have undergone the surgical procedure of right orchidectomy. The biopsy obtained after the surgical intervention showed grade II seminoma. All three patients, who underwent orchidectomy in different years, were subjected to chemotherapeutic treatment with the 3 preparations bleomycin, etoposide and cisplatin. After that, for a period of 1.5-2 years, they carried out occasional checks, which they then stopped. The lack of control for a 5-year period, as well as the limitation of the surgical procedure only in the right orchidectomy, has led to the metastasis of the seminoma in the pre-aortocaval region. In this study, we consider the fact of performing the retroperitoneal lymphatic drainage procedure according to the lymphatic drainage route of the tests, in the cases of the biopsy result "Seminoma grade II" and above, as one of the major components of the curative treatment in addition to Chemotherapeutic treatment. Discussion The implementation of retroperitoneal, pre-aortocaval lymphadenectomy is considered mandatory, especially in the results of "Seminoma grade II" biopsy. In cases where laboratory and imaging examinations indicate residual retroperitoneal, pre-aortocaval masses, the surgical procedure of lymphadenectomy should be performed as soon as possible. The principle of the lymphadenectomy according to the way of drainage of the testes is important when we talk about oncological principles. Statistical data show the advantage of the extended surgical procedure, consisting of a disease-free survival period of 5 years at a rate of 95%. The choice of the retroperitoneal lymphadenectomy procedure has resulted in the normalization of tumor markers for at least a 2-year period after the intervention, also showing an improvement in the patient's prognosis. Conclusion In cases of histopathological response, where the result of Seminoma grade II and above is concluded, the surgical procedure should not be limited to simple orchidectomy or radical inguinal orchidectomy with the aim of avoiding metastatic spread along the lymphatic drainage route. Keywords: General surgery, Testicular cancer, Seminoma, Para-aortocaval retroperitoneal lymphatic resection, RPLND. DOI: 10.7176/ALST/95-06 Publication date: November 30th 202

Akiyama Procedure as a Surgical Option for Esophageal Cancer

Background The purpose of this study is to introduce our experience with the Akiyama procedure as a surgical option for treatment of esophageal cancer in the Mother Theresa Hospital Center of Tirana, Albania. Selection of the suitable site for anastomosis after esophagectomy, whether cervical or thoracic is the key for optimal oncological results. The goal is to minimize recurrence in oncological patients and to avoid complications related to surgery. Controversy still exists among surgeons as the optimal site for anastomosis as well as whether the anastomosis is done manually or with a stapler. Material and methods From October 2018 to June 2021, 27 surgical interventions of esophageal cancer were performed in our surgical unit. In 15 patients, subtotal esophagectomy Ivor-Lewis with a mediastinal esophago-gastric anastomosis was performed. In 8 patients, distal esophagectomy and proximal gastrectomy with an abdominal esophago-gastric anastomosis was performed. In 4 patients, subtotal esophagectomy with a cervical esophago-gastric anastomosis, Akiyama procedure was performed. In this study we are evaluating the Akiyama procedure with description of the technique, patient criteria of inclusion, oncological protocol and postoperative care. Discussion In our practice we used chemotherapy and radiotherapy as part of a multimodality treatment plan. All of our patients with carcinoma had radiation and chemotherapy prior to surgery. The use of stapler devices in cervical anastomoses in some studies is linked with higher rate of leakage but we consider it a preferential choice of the surgeon. We opted for a one-layer esophagogastric anastomosis in the neck as shown in some studies instead of the two-layer technique because of lower rates of stricture formation. The level of exposure in the cervical route is advantageous in making an accurate anastomosis. In our patients we used the retrosternal space for esophageal replacement to avoid local tumor recurrence in the posterior mediastinum. Conclusion As in other cancers there is a mandatory evaluation in congruence to the guidelines in order to each patient have a surgical or adjuvant therapy according to its stage. As per guidelines patients in a T1-2, N0 stage are treated with surgery alone and a close follow up for recurrence and patients in a T3 or N1/M1 stage should be considered for adjuvant therapy prior to surgery. In patients that have extensive disease and are not surgical candidates are considered for chemotherapy and radiation alone. It is advised that the type of surgery performed is the one in which the surgeon is more experienced and has the best outcome in terms of surgical strategy in terms of morbidity and mortality. Keywords: General surgery, Esophageal cancer, Akiyama procedure, Cervical esophago-gastric anastomosis. DOI: 10.7176/ALST/96-02 Publication date: December 31st 202

Cholangiocarcinoma of the Common Bile Duct and Hepatic Hilum (Bismuth II) Complicated by Covid-19 – Case Report

Background Cholangiocarcinoma is a rare tumour that originates from the epithelial lining and the peribiliary glands of the bile ducts. Our report’s scope pertains to the diagnosis of perihilar cholangiocarcinoma, which was first described by Klatskin. Unfortunately, patients ask for medical assistance only after the development of jaundice due to biliary obstruction. Achieving the best standard of care requires meticulous workup and evaluation through a multidisciplinary team to correctly determine the eligibility of a patient for resection surgery. Case presentation A 78 years old male patient presents with jaundice and pruritus. Total bilirubin level is 24 mg/dl and imaging studies show a 2×2.5 cm tumour of the hepatic hilum. After the necessary preoperative consults, the patient underwent a surgical procedure, consisting of hepatic hilum resection, separate left and right hepatico-jejunal anastomoses en-Roux. Anastomoses are protected by 2 Kehr drains on the ducts. The first six postoperative days were uneventful, but on the 7th day the patient develops notable abdominal meteorism and diarrhoea of mostly biliary content for the following 3 days. The case is complicated by episodes of excessive haematochezia. Fibroscopy shows no active haemorrhaging site, but CT scan notes small bowel microinfarctions thus explaining haematochezia. It also confirms COVID-19 with a bilateral interstitial pneumonia and a microthrombus on the right peripheral lung segments. Following a careful treatment regimen, the patient was discharged in good health from the hospital. Discussion Studies show that COVID-19 gastro-intestinal symptoms were anorexia, diarrhoea, nausea, vomiting or diffuse abdominal pain. Haematochezia has been unusual. Hospitalized patients, on a bed-rest regimen with comorbidities had a tendency for small bowel microinfarctions. It is widely thought that ischaemia and bowel hypoperfusion is related to the cytokine storm, not a direct effect of the virus. A cytokine storm may be followed by an abnormal coagulation function, as in our patient. Conclusion Prior to major surgeries, especially in the hepato-biliary apparatus there is a mandatory evaluation to determine the operability of a patient. Not only the extent of the primary tumour, but also the comorbidities need to be taken into account. Following a rigorous surgical technique, a close monitoring of the patient and involving a multidisciplinary team of radiology, infectious disease, gastro-hepatology, oncology and intensive care doctors in the treatment plan has successfully treated such a rare and complex case. Keywords: General Surgery, Bile Duct Tumor, Cholangiocarcinoma, Bismuth-Corlette, COVID-19. DOI: 10.7176/ALST/96-03 Publication date: December 31st 202

Right Hepatectomy (Réglée) for Liver Metastasis Post Pancreatic Adenocarcinoma – Case Report

Background Metastatic tumors of the liver are the most common hepatic malignant disease, responsible for more than 95% of the total. The size and number of metastases of the liver varies considerably. They maintain the anatomo-pathologic features of the primary cancer, but often are complicated by central necrosis. Pancreatic tumors often metastasize to the liver because of venous drainage to the portal vein. In cases of this occurrence, the disease is considered to be at stage IV with minimal to no consideration for a surgical approach despite the late improvements in liver resection and more efficient chemotherapy. There is a severely limited number of studies for patients undergoing liver resection for liver metastases that arise after a surgical treatment of pancreatic adenocarcinoma. However, these studies, which take in consideration the surgical liver resection versus chemotherapy alone in patients with metachronous metastases of pancreatic cancer demonstrate a significantly longer survival rate. Case presentation The 65 y/o male patient­­­­­­ was diagnosed one year prior to the current events with an adenocarcinoma of the pancreas tail, for which he underwent the surgical procedure of pancreatic tail resection and splenectomy. Ten months after the surgery he complains of fever and body temperature of 38 - 39°C. Despite taking antibiotics for over a month and a half he has no improvement. He is hospitalized in a febrile state, asthenic and pale skin and mucosa. Following an MRI the diagnosis leans towards a liver metastasis. A right réglée hepatectomy is performed. The patient tolerated the procedure well and was discharged in good health. Discussion Determining the amount of liver parenchyma to be removed is an important decision. Anatomic resections mostly include two or more hepatic segments, whereas non-anatomic resection involves the resection of the metastases with a margin of healthy tissue (segmentectomy). The decision concerning the extent of resection is more relevant for the post-operative chemotherapy in colorectal metastasis, where an effort is made to conserve as much as possible remnant liver tissue. A preoperative chemotherapy allows more patients to be considered resectable, but may damage hepatic function and increase the risk of post-operative liver insufficiency. Conclusion In conclusion, hepatic resection for metastatic non-colorectal non-neuroendocrine tumors is safe and is linked to better outcomes in chosen patients. However primary tumour type and disease-free intervals seem to be important variables. Sometimes, hepatic resection may be the only option offering a potential cure, so it should be considered in some patients with liver metastases of non-colorectal non-neuroendocrine tumors. Keywords: General Surgery, Right Hepatectomy, Liver Metastasis, Pancreatic Adenocarcinoma. DOI: 10.7176/JEP/14-9-07 Publication date:March 31st 202

Recurrent Retroperitoneal and Subhepatic EGIST – Case Report

Background GISTs (gastrointestinal stromal tumors) are a common mesenchymal tumor of the gastrointestinal tract. It is a diverse pathology that can occur in any portion of the gastrointestinal tract, from distal esophagus to anus. However, the stomach is the most common origin. GISTs evolve from small neoformations, to a large, metastasizing sarcoma. Their pathogenesis is linked with the KIT or PDGFRA mutations. GIST is to be suspected in cases where a round mass is encountered in close relations to the stomach, intestine or lower esophagus. It has to be differentiated with other neuroendocrine tumors, lymphomas and other rare cancers by means of a biopsy. Case presentation The 62 y/o male patient was diagnosed 4 years prior to the current events with GIST for which a surgical procedure of distal pancreatectomy, splenectomy and partial resection of curvatura major of the stomach was performed at another hospital. This was followed by chemotherapy as advised by the treating doctors. The patient presents to our clinic with the complaints of left flank pain for over a week, dysphagia and weight loss. CT shows a giant formation of the left flank, at the splenic lodge, with dimensions of 30 × 32 cm, with close proximity to the left kidney, abdominal aorta, the lienal flexure of colon, the stomach, superior mesenteric artery. Besides this, another 8 × 9 cm subhepatic formation is noted, which has a close vicinity to the portal vein and hepatic hilum. He underwent the surgical procedure for the extirpation of the both masses, also partial resection of curvatura major, vagotomy, Heineke-Mikulicz pyloroplasty, segmental hepatic flexure colon resection and end-to-end anastomosis. The procedure was tolerated well and he was discharged in good health. The following pathology report confirms GIST. Discussion Treatment of GISTs and EGISTs consists on the R0 resection of the mass, without the need for radical removal of healthy tissue since these types of tumors do not normally infiltrate adjacent tissue. If other organs are invaded it is recommended to perform an en-bloc resection, taking care to avoid the rupture of the mass, as to minimize the chances of peritoneal dissemination. A prompt adjuvant therapy including the use of selective tyrosine kinase inhibitors (imatinib) is strongly advised. The patient should be followed with periodic controls for recurrence. Conclusion There is a clear role surgery can play in improving the outcomes in such patients. However, some authors still debate whether surgery improves results in such patients. For this purpose, it is necessary to involve a team of oncologists, imaging specialists and experienced surgeons in the treatment plan of GIST patients to provide the best treatment. Keywords: General Surgery, Retroperitoneal EGIST, Hepatic EGIST, GIST. DOI: 10.7176/JEP/14-9-06 Publication date:March 31st 202

Gastro-Duodenal Artery Aneurysm Rupture – Case Report

Background The definition of an aneurysm is a dilation of an artery more than 1.5 to 2 times its normal diameter. Visceral (or splanchnic) artery aneurysms include those concerning the celiac truncus, superior mesenteric artery, inferior mesenteric artery, and their branches. This classification does not include aortic and renal artery aneurysms. It is a rare, but clinically significant pathology because of the high mortality risk. Despite this rarity, cases have been accumulated and this pathology is better understood. Novel techniques for the management of aneurysms have been developed with the advent of interventional radiology. However, our case concerns the emergent surgical repair of a ruptured aneurysm, rather than the elective repair. Case presentation The 61-year-old female patient complains of diffuse, intermittent abdominal pain lasting for almost one week. On the last day the patient suffers from excruciating abdominal pain and is brought to the emergency department. Objective evaluation shows pallor, diaphoresis, low blood pressure, tachycardia and abdominal guarding in all quadrants. An abdominal ultrasound spots the presence of free fluid in all recesses. A diagnostic peritoneal needle aspiration shows pure blood. AB0 and Rhesus blood type is identified and the patient is prepared for the operating theatre. Following a laparotomy, peritoneal lavage, a rupture of gastro-duodenal aneurysm is identified and the artery is ligated in its origin. The patient tolerated the procedure well and was discharged in good health. Discussion Rare case reports in literature have reported Gastro-duodenal artery aneurysms. Because of this rarity in incidence there is no clear protocol on how to diagnose and manage it. Possible risk factors and associated conditions include: chronic pancreatitis, liver cirrhosis, vascular abnormalities as fibromuscular dysplasia and polyarteritis nodosa. Other events and diseases such as trauma, septic emboli, hypertension and atherosclerosis are also mentioned. The main symptoms of visceral artery aneurysms, with or without rupture are abdominal pain, hypotension, gastric emptying delay and other non-specific manifestations such as vomiting, diarrhoea, jaundice, upper gastro-intestinal tract haemorrhage (which occurs in about 50% of the cases with gastro-duodenal artery aneurysms) and retro and intra-peritoneal bleeding. Conclusion The rupture of gastro-duodenal artery is a serious fatal presentation of a rare condition. It requires high alertness and decisive action, as warning signs and symptoms may be dull or absent. Quick diagnosis before rupture can change the course of this disease and prevent lethal complications. As this disorder is so uncommon, there are no specific screening or follow-up recommendations. Treatment and diagnostic options should be decided on a case basis. Keywords: General Surgery, Visceral Artery Aneurysm, VAA, Splanchnic Aneurysm, Aneurysm Rupture. DOI: 10.7176/JEP/14-8-02 Publication date:March 31st 202

A Rare Case of Advanced Duodenal Cancer Infiltrating the Head of Pancreas and the Mesocolon of the Hepatic Flexure

Background Primary small bowel carcinoma is a very rare tumor, with non-specific symptoms that usually cause a delay in diagnosis and, consequently, a negative outcome. Duodenal carcinoma is on its own an uncommon tumor of the intestinal tract. Our case presented further local advancement with infiltration of the hepatic flexure mesocolon. En-block pancreaticoduodenectomy plus right hemicolectomy or Colo-Pancreatico- Duodenectomy (cPD) is feasible in highly selected patients if performed by experienced surgeons. Case presentation We are introducing the case of a 48 y/o male patient presenting with a dull pain of the lower abdomen and dark stools (melena) in the recent episodes of defecation; considerable weight loss; jaundice (total bilirubin level 10 mg/dL). In the radiologic investigations, IV contrast CT of the abdomen revealed the presence of a 7.7 cm x 8.5 cm mass of duodenum (D3) which infiltrates the head of pancreas as evidenced by homogeneous contrast enhancement. The pancreatic duct of Wirsung was dilated, 4.4 mm. Gastroduodenoscopy visualizes a non-circumferential ulcerative proliferation. Exploratory laparotomy was performed. Intraoperatively we encountered the presence of local progression of the primary duodenal lesion into head of the pancreas, the mesocolon of the hepatic flexure with infiltration of the right colic vessels. Colo-Pancreatico-Duodenectomy (cPD) and Whipple’s procedure was performed, with Blumgart type pancreatico-jejunal and ileo-colic anastomoses. Discussion En-block pancreaticoduodenectomy plus right hemicolectomy or Colo-Pancreatico-Duodenectomy (cPD) is feasible in highly selected patients if performed by experienced surgeons. The most common indication of cPD is locally advanced pancreatic head cancer that directly invades the colon or mesocolon, followed by locally invaded colon cancer at the duodenum and/or pancreatic head. The cPD procedure is rarely performed in gastrointestinal surgery. This is due to its complexity, difficulty, and high risks. In certain acute situations, cPD is the efficacious path forward. Conclusion Following a careful evaluation plan, along with necessary consults for accompanying disorders, the indications for colo-pancreatico-duodenectomy were clearly set for this patient with locally advanced duodenal adenocarcinoma infiltrating the pancreas head and hepatic flexure mesocolon. Our experience highlights the importance of meticulous and experienced perioperative care to minimize complications and mortality. Keywords: General surgery, Duodenal cancer, Whipple procedure, colo-pancreatico-duodenectomy, cPD, Blumgart pancreatico-jejunal anastomosis DOI: 10.7176/ALST/95-01 Publication date: November 30th 202

The Benefit of Open Rives-Stoppa Procedure in Complex Incisional Hernia.

Introduction: Ventral hernia is one of the most common general surgical pathologies. An incisional hernia will develop in 10–15% of patients with an abdominal incision, and the risk increases to up to 23% in those who develop surgical site infections. Ventral hernia repairs are mostly elective (90%) procedures, but the repair methods are highly variable. Popularized in Europe by Rives and Stoppa, the retromuscular technique has proven to be very effective, with a 94.2% probability of having the lowest odds for recurrence and a 77.3% probability of having the lowest odds for SSI. The study aimed to evaluate our experience at a secondary care center performing Rives-Stoppa repair for abdominal ventral and incisional hernias. Materials and Methods: Between April 2019 and August 2021, 46 patients in the practice at a secondary regional hospital, Teni Konomi, Korce, Albania, underwent a Rives-Stoppa incisional hernia repair. Results: There were 14 (31%) males and 32(69%) females (age range 31-75). Most incisional hernias were midline xiphoid-pubic incision and supraumbilical, with several subcostals (2 right and 1 left) hernias.At the time of repair, most incisional hernias were symptomatic and evident on physical exam. In four cases, the hernia sac was incarcerated at the presentation time. Conclusion: The Rives-Stoppa technique has excellent long-term results and low morbidity in patients with large primary or recurrent incisional hernias. It is the gold standard for most surgeons. Keywords: Incisional Hernia, mesh, polypropylene, abdominal wall surgery, rectus muscl