Giant extra gastrointestinal stromal tumor of lesser omentum obscuring the diagnosis of a choloperitoneum

AbstractINTRODUCTIONHerein we present an extremely rare case of a giant extra gastrointestinal stromal tumor (EGIST) of the lesser omentum obscuring the diagnosis of a choloperitoneum.PRESENTATION OF CASEA 79 years old female was admitted to our hospital with symptoms of vomiting and epigastric pain. Abdominal computer tomography revealed a sizable formation that was diagnosed as a tumor of the pancreas. In laparotomy, a choloperitoneum was diagnosed as the cause of patient's symptoms. A tumor adherent firmly to the lesser curvature of stomach was also discovered. Cholecystectomy and subtotal gastrectomy were performed. Histologically, the tumor was diagnosed as a EGIST of the lesser omentum. The patient did not receive any adjuvant therapy and after two years of follow up she is without any recurrence.DISCUSSIONOmental EGISTs may remain clinically silent despite the large tumor's size. It is difficult to differentiate a EGIST in the lesser omentum from a GIST of the lesser curvature of the stomach, despite the use of advanced radiological imaging techniques. Our case of a giant EGIST of lesser omentum obscuring the diagnosis of acute choloperitoneum is the only one reported in literature.CONCLUSIONEGISTs that arise from the omentum are very rare and complete surgical resection is the only effective treatment approach. Adjuvant therapy following resection of localized disease has become standard of care in high risk cases

Changes of plasma levels of gastrin, secretin, somatostatin and cholecystokinine after complete abolishment of exocrine pancreatic function: Experimental study

Exocrine pancreas enzymes activation is always getting involve in pathogenesis and evolution of acute and chronic pancreatitis as well as in the development of complications after pancreatic surgery. Suppression of the exocrine pancreatic function offers a great help in early prevention and treatment of these diseases. Ligation or occlusion of pancreatic ducts although causes a complete exocrine pancreatic insufficiency does not seem to have any significant effect on the endocrine pancreatic function (insulin and glucagon secretion). However the impact of exocrine pancreatic insufficiency on the secretion of the rest gastrointestinal peptides has not been studied extensively. In this experimental study in 16 dogs, plasma levels of the gastrointestinal hormones gastrin, secretin, somatostatin and cholecystokinin were measured before and after exocrine pacreatic function abolishement, by occlusion (using prolamine) and surgical ligation of the pancreatic ducts for a time period up to 90 days. The operation performed under general anesthesia. Exploration and preparation of both pancreatic ducts was made in 12 dogs while in the rest four only one pancreatic duct was used. Immediately after pancreatic ducts catheterization prolamine infusion and surgical ligation was followed. Steatorrhea, lasted from 1 to 6 days, developed only in 5 dogs. After an overnight fast blood samples were taken preoperative and then on the 1st, 3rd, 7th, 15th, 30th, 60th and 90th day postoperative. Plasma peptides levels were measured by radioimmunoassay (RIA). Secretin and cholecystokinin was extracted from plasma by chromatography before final measurement. There were no significant fluctuations in plasma gastrin levels during the study period. Secretin levels increased significantly up to the 7th postoperative day (7th day 367±140 pg/ml-preoperative 73,7±34,7 pg/ml, p<0,0001) and then declined gradually upon restoration at 60th day. Somatostatin levels increased significantly from the first postoperative day (1st day 134±16,3 pg/ml-preoperative 59,1±18 pg/ml, p<0,001). Cholecystokinine increased significantly up to the 7th postoperative day (7th day 836±398 pg/ml - preoperative 204,9±76,5 pg/ml p<0,001) followed then same course as somatostatine (90th day 338±110 pg/ml, p<0,007 comparing to preoperative levels). From our study is concluded that after complete exocrine pancreatic insufficiency and up to 3 months: 1. Gastrin levels do not shown any significant fluctuation. 2. Secretin levels increased significantly up to the 7th postoperative day and then decline gradually upon restoration at 60th day. 3. Somatostatin levels increased significantly, from the first postoperative day and then decline gradually remaining significantly higher in comparison to preoperative levels up to the 90th day. 4. Cholecystokinin levels increased significantly up to the 7th postoperative day and then decline gradually remaining significantly higher in comparison to preoperative levels up to the 90th day.Η ενεργοποίηση των ενζύμων της εξωκρινούς έκκρισης του παγκρέατος εμπλέκεται στην παθογένεια και εξέλιξη της οξείας και χρόνιας παγκρεατίτιδας, καθώς και στην εμφάνιση επιπλοκών στη χειρουργική του οργάνου. Η κατάργηση της εξωκρινούς παγκρεατικής λειτουργίας συμβάλλει στην πρόληψη ή αντιμετώπιση αυτών των καταστάσεων. Η απολίνωση ή έμφραξη των παγκρεατικών πόρων, ενώ προκαλεί πλήρη εξωκρινή παγκρεατική ανεπάρκεια, δε φαίνεται να επηρεάζει σημαντικά την ενδοκρινή παγκρεατική λειτουργία (έκκριση ινσουλίνης και γλουκαγόνου). Η επίπτωση όμως της πλήρους εξωκρινούς παγκρεατικής ανεπάρκειας στην έκκριση των υπολοίπων ΓΕΠ πεπτιδίων δεν έχει μελετηθεί ικανοποιητικά. Στην πειραματική αυτή εργασία σε σκύλους καταργήθηκε η εξωκρινής παγκρεατική λειτουργία με έμφραξη με προλαμίνη και απολίνωση των παγκρεατικών πόρων και μετρήθηκαν τα επίπεδα των ΓΕΠ πεπτιδίων γαστρίνης, σεκρετίνης, σωματοστατίνης και χολοκυστοκινίνης για χρονικό διάστημα 90 ημερών. Η επέμβαση έγινε με γενική αναισθησία, έγινε αποκάλυψη-παρασκευή και των δύο παγκρεατικών πόρων σε 12 σκύλους, ενώ σε άλλους 4 μόνο του ενός παγκρεατικού πόρου. Ακολούθησε καθετηριασμός, έγχυση της προλαμίνης και απολίνωση των πόρων. Από τα 16 πειραματόζωα μόνο 5 παρουσίασαν στεατόρροια διάρκειας 1 έως 6 ημερών. Οι αιμοληψίες έγιναν προεγχειρητικά και στη συνέχεια την 1η, 3η, 7η, 15η, 30η, 60η και 90η μετεγχειρητική ημέρα με το πειραματόζωο νηστικό. Η μέτρηση των πεπτιδίων έγινε με ραδιοανοσοβιολογικό προσδιορισμό (RIA), αφού πρώτα, ειδικά για τη σεκρετίνη και χολοκυστοκινίνη, έγινε εξαγωγή τους από το πλάσμα με χρωματογραφία. Δε βρέθηκε σημαντική μεταβολή των επιπέδων της γαστρίνης στον ορό. Η σεκρετίνη παρουσίασε σημαντική αύξηση μέχρι την 7η μετεγχειρητική ημέρα (7η ημέρα: 367±140 pg/ml, προεγχειρητικά 73,7±34,7 pg/ml, p<0,0001) και στη συνέχεια βαθμιαία πτώση και αποκατάσταση μετά 60 ημέρες. Η σωματοστατίνη παρουσίασε σημαντική αύξηση την 1η μετεγχειρητική ημέρα (1η ημέρα : 134±16,3 pg/ml, προεγχειρητικά 59,1±18 pg/ml, p<0,0001) και στη συνέχεια προοδευτική ελάττωση, αλλά πάντοτε σε σημαντικά υψηλότερα επίπεδα σε σχέση με τα προεγχειρητικά (90η ημέρα 98,2±24 pg/ml, p<0,001). Η χολοκυστοκινίνη παρουσίασε σημαντική αύξηση μέχρι την 7η μετεγχειρητική ημέρα (7η ημέρα 836±398 pg/ml προεγχειρητικά 204,9±76,5 pg/ml, p<0,007). Τα συμπεράσματα στα οποία κατέληξε η μελέτη είναι ότι σε πρόκληση πλήρους εξωκρινούς παγκρεατικής ανεπάρκειας και για χρονικό διάστημα μέχρι 3 μήνες: 1. Τα επίπεδα της γαστρίνης στον ορό δε μεταβάλλονται σημαντικά. 2. Τα επίπεδα της σεκρετίνης στον ορό αυξάνονται σημαντικά μέχρι την 7η μετεγχειρητική ημέρα και στη συνέχεια ελαττώνονται σταδιακά για να επανέλθουν μετά δίμηνο περίπου στα προεγχειρητικά επίπεδα. 3. Τα επίπεδα της σωματοστατίνης στον ορό αυξάνονται σημαντικά την 1η μετεγχειρητική ημέρα και στη συνέχεια ελαττώνονται βαθμιαία, αλλά πάντοτε σε επίπεδα σημαντικά αυξημένα σε σχέση με τα προεγχειρητικά. 4. Τα επίπεδα της χολοκυστοκινίνης στον ορό αυξάνονται σημαντικά μέχρι την 7η μετεγχειρητική ημέρα και στη συνέχεια ελαττώνονται βαθμιαία, αλλά πάντοτε σε επίπεδα σημαντικά αυξημένα σε σχέση με τα προεγχειρητικά

Abdominal rectus muscle pyomyositis: Report of a case and review of the literature

Pyomyositis is an uncommon primary bacterial infection of skeletal muscles, usually caused by Staphylococcus aureus. Predisposing factors for pyomyositisinclude immunodeficiency, trauma, injection drug use, concurrent infection and malnutrition. The diagnosis, staging of the disease and differential diagnosis are established by ultrasound, CT and MRI. Treatment involves surgical drainage and antibiotic therapy. We report a case of abdominal rectus muscle pyomyositis, which constitutes, as far as we know, thesecond reported in bibliography, while Prevotella disiens is firstly reported as causative agent

Left Brachiocephalic Vein Stenosis due to the Insertion of a Temporal Right Subclavian Hemodialysis Catheter

Central vein stenosis/occlusion is a common well-described sequel to the placement of hemodialysis catheters in the central venous system. The precise mechanisms by which central vein stenosis occurs are not well known. Current concepts in central vein stenosis pathophysiology focus on the response to vessel injury model, emphasizing the process of trauma. A case of left brachiocephalic vein stenosis due to the insertion and function of a temporary right subclavian hemodialysis catheter is presented. The purpose of the manuscript is to emphasize that, with the introduction of a temporary subclavian hemodialysis catheter via the right subclavian vein apart from causing concurrent stenosis/infarction of the right subclavian and right brachiocephalic vein, it is also possible to cause stenosis of the left brachiocephalic vein (close to its contribution to the superior vena cava) although the catheter tip is placed in the correct anatomical position in the superior vena cava

Giant Posttraumatic Angiolipoma of the Forearm: A Case Report and Review of the Literature

Angiolipoma is a type of lipoma, a benign soft tissue tumor. It is distinguished by the excessive degree of vascular proliferation and the presence of mature adipocytes. It occurs commonly on the trunk and extremities. Angiolipomas larger than 4 cm are classified as “giant,” and due to their size, histological evaluation is necessary to exclude malignancy. We report a case of a male patient who suffered from a giant noninfiltrating intramuscular angiolipoma which formed after venipuncture in the antecubital fossa. Clinical examination showed a palpable painless soft mass. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a giant angiolipoma on the right forearm. Surgical removal of the mass was performed, and the biopsy was negative for malignancy. To the best of our knowledge, this is the first report in the literature of posttraumatic intramuscular angiolipoma. Physicians and orthopedic/general surgeons should be aware of the possibility of soft tissue masses in a posttrauma situation

Silicon nitride for enhanced integrated photonics

We present recent progress in the development of silicon nitride integration schemes for high-speed modulation, broadband non-linear photonics, device trimming and photonic memories

Fournier’s Gangrene: Lessons Learned from Multimodal and Multidisciplinary Management of Perineal Necrotizing Fasciitis

BackgroundFournier’s gangrene (FG) is a rapidly evolving necrotizing fasciitis of the perineum and the genital area, the scrotum as it most commonly affects man in the vast majority of cases. It is polymicrobial in origin, due to the synergistic action of anaerobes and aerobes and has a very high mortality. There are many predisposing factors including diabetes mellitus, alcoholism, immunosuppression, renal, and hepatic disease. The prognosis of the disease depends on a lot of factors including but not limited to patient age, disease extent, and comorbidities. The purpose of the study is to describe the experience of a general surgery department in the management of FG, to present the multimodal and multidisciplinary treatment of the disease, to identify predictors of mortality, and to make general surgeons familiar with the disease.MethodsThe current retrospective study is presenting the experience of our general surgery department in the management of FG during the last 20 years. The clinical presentation and demographics of the patients were recorded. Also we recorded the laboratory data, the comorbidities, the etiology, and microbiology and the therapeutic interventions performed, and we calculated the various severity indexes. Patients were divided to survivors and non-survivors, and all the collected data were statistically analyzed to assess mortality factors using univariate and then multivariate analysis.ResultsIn our series, we treated a total of 24 patients with a mean age 58.9 years including 20 males (83.4%) and 4 females (16.6%). In most patients, a delay between disease onset and seeking of medical help was noted. Comorbidities were present in almost all patients (87.5%). All patients were submitted to extensive surgical debridements and received broad-spectrum antibiotics until microbiological culture results were received. Regarding all the collected data, there was no statistically significant difference between survivors and non-survivors except the presence of malignancy in non-survivors (p = 0.036) and the lower hemoglobin (p &lt; 0.001) and hematocrit (p = 0.002) in non-survivors. However, multivariate analysis did not reveal any predictor of mortality.ConclusionEarly diagnosis, aggressive thorough surgical treatment, and administration of the proper antibiotic treatment comprise the cornerstone for the outcome of this disease. In small populations like in the present study, it is difficult to recognize any predictors of mortality and even the severity indexes, which take into account a lot of data cannot predict mortality

Histology and Immunohistochemistry of Radial Arteries Are Suggestive of an Interaction between Calcification and Early Atherosclerotic Lesions in Chronic Kidney Disease

Background and Objectives: recent studies suggest an implication of immune mechanisms in atherosclerotic disease. In this paper, the interaction between inflammation, calcification, and atherosclerosis on the vessel walls of patients with chronic kidney disease (CKD) is described and evaluated. Materials and Methods: patients with stage V CKD, either on pre-dialysis (group A) or on hemodialysis (HD) for at least 2 years (group B), in whom a radiocephalic arteriovenous fistula (RCAVF) was created, were included in the study. The control group included healthy volunteers who received radial artery surgery after an accident. The expressions of inflammatory cells, myofibroblasts, and vascular calcification regulators on the vascular wall were estimated, and, moreover, morphometric analysis was performed. Results: the expressions of CD68(+) cells, matrix carboxyglutamic acid proteins (MGPs), the receptor activator of nuclear factor-kB (RANK) and RANK ligand (RANKL), and osteoprotegerin (OPG), were significantly increased in CKD patients compared to the controls p = 0.02; p = 0.006; p = 0.01; and p = 0.006, respectively. In morphometric analysis, the I/M and L/I ratios had significant differences between CKD patients and the controls 0.3534 ± 0.20 vs. 0.1520 ± 0.865, p = 0.003, and 2.1709 ± 1.568 vs. 4.9958 ± 3.2975, p = 0.03, respectively. The independent variables correlated with the degree of vascular calcification were the intensity of CD34(+), aSMA(+) cells, and OPG, R2 = 0.76, p 2 = 0.3, p Conclusion: atherosclerosis and vascular calcification in CKD seem to be strongly regulated by an immunological and inflammatory activation on the vascular wall

Histology and Immunohistochemistry of Radial Arteries Are Suggestive of an Interaction between Calcification and Early Atherosclerotic Lesions in Chronic Kidney Disease

Background and Objectives: recent studies suggest an implication of immune mechanisms in atherosclerotic disease. In this paper, the interaction between inflammation, calcification, and atherosclerosis on the vessel walls of patients with chronic kidney disease (CKD) is described and evaluated. Materials and Methods: patients with stage V CKD, either on pre-dialysis (group A) or on hemodialysis (HD) for at least 2 years (group B), in whom a radiocephalic arteriovenous fistula (RCAVF) was created, were included in the study. The control group included healthy volunteers who received radial artery surgery after an accident. The expressions of inflammatory cells, myofibroblasts, and vascular calcification regulators on the vascular wall were estimated, and, moreover, morphometric analysis was performed. Results: the expressions of CD68(+) cells, matrix carboxyglutamic acid proteins (MGPs), the receptor activator of nuclear factor-kB (RANK) and RANK ligand (RANKL), and osteoprotegerin (OPG), were significantly increased in CKD patients compared to the controls p = 0.02; p = 0.006; p = 0.01; and p = 0.006, respectively. In morphometric analysis, the I/M and L/I ratios had significant differences between CKD patients and the controls 0.3534 ± 0.20 vs. 0.1520 ± 0.865, p = 0.003, and 2.1709 ± 1.568 vs. 4.9958 ± 3.2975, p = 0.03, respectively. The independent variables correlated with the degree of vascular calcification were the intensity of CD34(+), aSMA(+) cells, and OPG, R2 = 0.76, p &lt; 0.0001, and, with intima-media thickness (IMT), the severity of RANKL expression R2 = 0.3, p &lt; 0.0001. Conclusion: atherosclerosis and vascular calcification in CKD seem to be strongly regulated by an immunological and inflammatory activation on the vascular wall