Paraganglioma of the greater omentum: Case report and review of the literature

<p>Abstract</p> <p>Background</p> <p>Extra-adrenal, intra-abdominal paraganglioma constitutes a rare neoplasm and, moreover, its location in the greater omentum is extremely infrequent.</p> <p>Case presentation</p> <p>A 46-year-old woman with an unremarkable medical history presented with an asymptomatic greater omentum mass that was discovered incidentally during ultrasonographic evaluation due to menstrual disturbances. Clinical examination revealed a mobile, non-tender, well-circumscribed mass in the right upper and lower abdominal quadrant. Blood tests were normal. Contrast-enhanced abdominal computed tomography (CT) scan confirmed a huge (15 × 15 cm), well-demarcated, solid and cystic, heterogeneously enhanced mass between the right liver lobe and right kidney. Exploratory laparotomy revealed a large mass in the greater omentum. The tumor was completely excised along with the greater omentum. Histopathology offered the diagnosis of benign greater omentum paraganglioma. After an uneventful postoperative course, the patient was discharged on the 4^thpostoperative day. She remains free of disease for 2 years as appears on repeated CT scans as well as magnetic resonance imaging (MRI) and scintigraphy performed with radiotracer-labeled metaiodobenzyl-guanidine (MIBG) scans.</p> <p>Conclusion</p> <p>This is the second reported case of greater omentum paraganglioma. Clinical and imaging data of patients with extra-adrenal, intra-abdominal paragangliomas are variable while many of them may be asymptomatic even when the lesion is quite large. Thorough histopathologic evaluation is imperative for diagnosis and radical excision is the treatment of choice. Since there are no definite microscopic criteria for the distinction between benign and malignant tumors, prolonged follow-up is necessary.</p

Infections in a surgical intensive care unit of a university hospital in Greece

SummaryObjectivesWe aimed to evaluate the clinical and microbiological characteristics of the patients who developed an infection in our surgical intensive care unit (SICU).MethodsThis was a prospective study of all patients who sustained an ICU-acquired infection from 2002 to 2004.ResultsAmong 683 consecutive SICU patients, 123 (18.0%) developed 241 infections (48.3 infections per 1000 patient-days). The mean age of patients was 66.7±3.8 years, the mean APACHE II score (acute physiology and chronic health evaluation) on SICU admission was 18.2±2.4, and the mean SOFA score (sepsis-related organ failure assessment) at the onset of infection was 8.8±2. Of the study patients, 51.2% were women. Infections were: bloodstream (36.1%), ventilator-associated pneumonia (VAP; 25.3%, 20.3/1000 ventilator-days), surgical site (18.7%), central venous catheter (10.4%, 7.1/1000 central venous catheter-days), and urinary tract infection (9.5%, 4.6/1000 urinary catheter-days). The most frequent microorganisms found were: Acinetobacter baumannii (20.3%), Pseudomonas aeruginosa (15.7%), Candida albicans (13.2%), Enterococcus faecalis (10.4%), Klebsiella pneumoniae (9.2%), Enterococcus faecium (7.9%), and Staphylococcus aureus (6.7%). High resistance to the majority of antibiotics was identified. The complication and mortality rates were 58.5% and 39.0%, respectively. Multivariate analysis identified APACHE II score on admission (odds ratio (OR) 4.63, 95% confidence interval (CI) 2.69–5.26, p=0.01), peritonitis (OR 1.85, 95% CI 1.03–3.25, p=0.03), acute pancreatitis (OR 2.27, 95% CI 1.05–3.75, p=0.02), previous aminoglycoside use (OR 2.84, 95% CI 1.06–5.14, p=0.03), and mechanical ventilation (OR 3.26, 95% CI: 2.43–6.15, p=0.01) as risk factors for infection development. Age (OR 1.16, 95% CI 1.01–1.33, p=0.03), APACHE II score on admission (OR 2.53, 95% CI 1.77–3.41, p=0.02), SOFA score at the onset of infection (OR 2.88, 95% CI 1.85–4.02, p=0.02), and VAP (OR 1.32, 95% CI 1.04–1.85, p=0.03) were associated with mortality.ConclusionsInfections are an important problem in SICUs due to high incidence, multi-drug resistance, complications, and mortality rate. In our study, APACHE II score on admission, peritonitis, acute pancreatitis, previous aminoglycoside use, and mechanical ventilation were identified as risk factors for infection development, whereas age, APACHE II score on admission, SOFA score at the onset of infection, and VAP were associated with mortality

Small cell carcinoma arising in Barrett's esophagus: a case report and review of the literature

<p>Abstract</p> <p>Introduction</p> <p>Gastrointestinal tract small cell carcinoma is an infrequent and aggressive neoplasm that represents 0.1–1% of gastrointestinal malignancies. Very few cases of small cell esophageal carcinoma arising in Barrett's esophagus have been reported in the literature. An extremely rare case of primary small cell carcinoma of the distal third of the esophagus arising from dysplastic Barrett's esophagus is herein presented.</p> <p>Case presentation</p> <p>A 62-year-old man with gastroesophageal reflux history presented with epigastric pain, epigastric fullness, dysphagia, anorexia, and weight loss. Esophagogastroscopy revealed an ulceroproliferative, intraluminar mass in the distal esophagus obstructing the esophageal lumen. Biopsy showed small cell esophageal carcinoma. Contrast-enhanced chest and abdominal computed tomography demonstrated a large tumor of the distal third of the esophagus without any lymphadenopathy or distant metastasis. Preoperative chemotherapy with cisplatine and etoposide for 3 months resulted in a significant reduction of the tumor. After en block esophagectomy with two field lymph node dissection, proximal gastrectomy, and cervical esophagogastric anastomosis, the patient was discharged on the 14^thpostoperative day. Histopathology revealed a primary small cell carcinoma of the distal third of the esophagus arising from dysplastic Barrett's esophagus. The patient received another 3 month course of postoperative chemotherapy with the same agents and remained free of disease at 12 month review.</p> <p>Conclusion</p> <p>Although small cell esophageal carcinoma is rare and its association with dysplastic Barrett's esophagus is extremely infrequent, the high carcinogenic risk of Barrett's epithelium should be kept in mind. Prognosis is quite unfavorable; a better prognosis might be possible with early diagnosis and treatment strategies incorporating chemotherapy along with oncological radical surgery and/or radiotherapy as part of a multimodality approach. Since treatment protocols are not well established due to the rarity of the neoplasm, multi-institutional studies are needed to obtain sufficiently large populations for investigation and optimization of therapy of the disease.</p

Adenocarcinoma of the third and fourth portion of the duodenum: a case report and review of the literature

A 65-year-old woman presented with abdominal pain, weight loss, fatigue, and microcytic anemia. Esophagogastroduodenoscopy, until the second part of duodenum, was normal. Ultrasound and computed tomography demonstrated a solid mass in the distal duodenum. A repeat endoscopy confirmed an ulcerative, intraluminar mass in the third and fourth part of the duodenum. Segmental resection of the third and fourth portion of the duodenum was performed. Histology revealed an adenocarcinoma. On the 4th postoperative day, the patient developed severe acute pancreatitis leading to multiple organ failure and died on the 30th postoperative day

Predictive Role of Stress Echocardiography before Carotid Endarterectomy in Patients with Coronary Artery Disease

ObjectivesOur aim was to examine the predictive value of preoperative stress echocardiography regarding early myocardial ischemia and late cardiac events after carotid endarterectomy (CEA). MethodsPatients with coronary artery disease undergoing CEA were prospectively included in this study. All patients (n=162) were classified into low, medium, and high cardiac risk group, according to preoperative stress echocardiography. Classification was based on the criteria of the American Society of Echocardiography. For all patients, cTnI was measured before surgery and on postoperative days 1, 3, and 7. Postoperative cTnI values ranging from 0.05 to 0.5ng/mL were classified as myocardial ischemia; values &gt;0.5ng/mL were classified as myocardial infarction. Cardiac damage was defined as either myocardial ischemia or infarction. ResultsNo deaths, strokes, or symptomatic coronary events were observed during the early postoperative period. There were 112 low cardiac risk patients, 42 medium-risk patients, and 8 high-risk patients, according to stress echocardiography findings. Overall, there were 22 patients (14%) that increased their cTnI values postoperatively (12 of low cardiac risk and 10 of medium cardiac risk), and all of them were asymptomatic. None of the high-risk patients showed any troponin increase. Late cardiac events were associated with cTnI increase, although no high-risk patients showed any late event. ConclusionsPreoperative stress echocardiography does not seem to independently recognize patients in high risk for asymptomatic cardiac damage after CEA. Postoperative troponin elevation seems to be more predictive for late adverse cardiac events than preoperative stress echocardiography

Cardiac Troponin I after Carotid Endarterectomy in Different Cardiac Risk Patients

Background: We compared postoperative cardiac damage, defined as cardiac troponin I (cTnI) elevation, in low, medium, and high cardiac risk patients, after carotid endarterectomy (CEA). Methods: The Vascular Study Group of New England Cardiac Risk Index (VSG-CRI) criteria for stratifying patients considered for vascular surgery into low, medium, and high cardiac risk groups were used prospectively. For all patients (n = 324), cTnI value assessments were made before surgery and on postoperative days 1, 3, and 7. Postoperative cTnI values ranging from .05 to .5 ng/mL were classified as myocardial ischemia; values more than .5 ng/mL were classified as myocardial infarction. Cardiac damage was defined as either myocardial ischemia or infarction. Results: Mortality was .003%, stroke rate was null, and symptomatic myocardial infarction was null as well. Low-risk patients (16 of 140) and medium-risk patients (28 of 160) increased their troponin levels on days 1 and 3 postoperatively. However, none of the high-risk patients (n 5 24) showed any postoperative cardiac damage. Low and medium cardiac risk patients showed higher troponin values on each separate day, in comparison with high cardiac risk patients. Conclusions: CEA is followed by a high incidence of asymptomatic cTnI increase that is associated with late cardiac events. However, high cardiac risk patients as defined by the VSG-CRI criteria do not seem to suffer higher cardiac damage after CEA compared with low and medium cardiac risk patients

Fecopneumothorax: A rare complication of Esophagectomy

Intrathoracic colon herniation after esophagectomy is rare. Furthermore, fecopneumothorax is an extremely infrequent clinical entity. We believe this is the first report in the literature of a patient with fecopneumothorax due to diverticular perforation of intrathoracically herniated transverse colon 2 months after transthoracic esophagectomy and cervical esophagogastric anastomosis. The relative literature addressing cause, clinical presentation, diagnosis, management, and prevention of this life-threatening complication of esophagectomy is reviewed

Infections in a surgical intensive care unit of a university hospital in Greece

Objectives: We aimed to evaluate the clinical and microbiological characteristics of the patients who developed an infection in our surgical intensive care unit (SICU). Methods: This was a prospective study of all patients who sustained an ICU-acquired infection from 2002 to 2004. Results: Among 683 consecutive SICU patients, 123 (18.0%) developed 241 infections (48.3 infections per 1000 patient-days). The mean age of patients was 66.7 +/- 3.8 years, the mean APACHE II score (acute physiology and chronic health evaluation) on SICU admission was 18.2 +/- 2.4, and the mean SOFA score (sepsis-related organ failure assessment) at the onset of infection was 8.8 +/- 2. Of the study patients, 51.2% were women. Infections were: bloodstream (36.1%), ventilator-associated pneumonia (VAP; 25.3%, 20.3/1000 ventilator-days), surgical site (18.7%), central venous catheter (10.4%, 7.1/1000 central venous catheter-days), and urinary tract infection (9.5%, 4.6/1000 urinary catheter-days). The most frequent microorganisms found were: Acinetobacter baumannii (20.3%), Pseudomonas aeruginosa (15.7%), Candida albicans (13.2%), Enterococcus faecalis (10.4%), Klebsiella pneumoniae (9.2%), Enterococcus faecium (7.9%), and Staphylococcus aureus (6.7%). High resistance to the majority of antibiotics was identified. The complication and mortality rates were 58.5% and 39.0%, respectively. Multivariate analysis identified APACHE 11 score on admission (odds ratio (OR) 4.63, 95% confidence interval (CI) 2.69-5.26, p = 0.01), peritonitis (OR 1.85, 95% CI 1.03-3.25, p = 0.03), acute pancreatitis (OR 2.27, 95% CI 1.05-3.75, p = 0.02), previous aminoglycoside use (OR 2.84, 95% CI 1.06-5.14, p = 0.03), and mechanical ventilation (OR 3.26, 95% CI: 2.43-6.15, p = 0.01) as risk factors for infection development. Age (OR 1.16, 95% CI 1.01-1.33, p = 0.03), APACHE 11 score on admission (OR 2.53, 95% CI 1.77-3.41, p = 0.02), SOFA score at the onset of infection (OR 2.88, 95% CI 1.85-4.02, p = 0.02), and VAP (OR 1.32, 95% CI 1.04-1.85, p = 0.03) were associated with mortality. Conclusions: Infections are an important problem in SICUs due to high incidence, multi-drug resistance, complications, and mortality rate. In our study, APACHE II score on admission, peritonitis, acute pancreatitis, previous aminoglycoside use, and mechanical ventilation were identified as risk factors for infection development, whereas age, APACHE II score on admission, SOFA score at the onset of infection, and VAP were associated with mortality. (C) 2008 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved