Treatment of Caudate Lobe Metastasis Post Colon Cancer Surgery – Case Report

Background Colorectal carcinoma is the third cause of mortality from malignant cancers. Upon diagnosis about 1 in 5 patients have metastatic disease. Furthermore, patients with local disease will on average have an incidence of 25% for distant metastases. Most common locations of CRC metastases are the liver, lungs, peritoneum and lymph nodes in distance. The diagnosis of metastatic disease in colorectal cancer should always be confirmed before any surgical or systemic treatment via adequate histological and imaging methods. Biochemical tests for carcinoembryonic antigen, CEA and carbohydrate antigen, CA19-9 are strongly advised. For the accurate staging of the disease IV contrast enhanced Computed Tomography is recommended, whereas MRI is useful in detection of exact number and location of liver metastases. Surgical treatment options may vary depending on the stage, locoregional involvement of the primary disease and the resectability of metastatic disease. It is a topic of ongoing investigation; however, guidelines recommend R0 surgical resection where possible as it may be potentially curative in 20-45% of cases. Case presentation We present the case of a 62 years old patient diagnosed with a right colon cancer and a solitary metastasis of the Ist segment of liver. He underwent the surgical procedure of right hemicolectomy and followed a course of 6 chemotherapy cycles. After an abdominal CT with IV contrast and abdominal MRI, a solitary caudate lobe metastasis is confirmed. A joint staff of oncologists, gastroenterologists and surgeons it is decided for a surgical intervention. He underwent the surgical procedure of the resection of liver metastasis in the caudate lobe. He tolerated the procedure well and was discharged in good health. Discussion In patients where metastases can be safely resected from the technical aspect, surgery is recommended. In cases where clear margins are difficult to achieve or patient prognosis is unclear, perioperative chemotherapy is mandatory, with FOLFOX or CAPOX regimens. In patients potentially curable with conversion therapy it is required to consider the molecular profile and tumor location. After starting conversion therapies patients should be evaluated periodically to avoid overtreatment. If surgery is feasible, metastases should be resected completely, maintaining at least 30% liver remnant. Conclusion Patient outcomes improve significantly when individual cases of metastatic colorectal disease are discussed between a team of oncologists, surgeons, radiologists, radiotherapists and other experts. We advise regular consultations of multidisciplinary teams to ensure the best therapeutic strategy. In conclusion, colorectal carcinoma is a complex disease, for which a therapeutic algorithm should be initially chosen and adhered to, by the multidisciplinary team to ensure the continuum of care. Keywords: General Surgery, Colon Cancer, Liver Metastasis, Caudate Lobe Resection, I-st Segment Liver. DOI: 10.7176/JEP/14-29-01 Publication date:October 31st 202

Surgical Treatment of Insulinoma – Case Report

Background Among the rare functional pancreatic neuroendocrine tumors, insulinoma is the most common. The tumor is on most cases an intraparenchymal solitary mass. The pathophysiological finding of insulinoma is hypoglycaemia, often severe, manifested with non-specific symptoms, which makes the diagnosis difficult. Hypoglycaemia in insulinoma is organic and confirmed with elevated levels of serum insulin after a prolonged fasting test. Localization of the tumor is the next diagnostic challenge. A combination of tomographic imaging techniques such as MRI and CT scan, endoscopic ultrasonogram and nuclear medicine has improved the preoperative evaluation. The mainstay treatment of insulinoma is surgery, which has evolved from blind pancreatectomy to surgical excision by enucleation. Case presentation The 44 years old female patient was transferred to the Endocrinology Department of “Mother Theresa” University Hospital Tirana, Albania for examining the cause of hypoglycaemia. Following a MRCP with contrast, an insulinoma at the level of the body of pancreas was noted. Its dimensions reach 11mm. The joint staff consult recommended a surgical treatment. Reviewing omental bursa, we find a formation at the level of the body of pancreas.The margins of the pancreas are carefully dissected and simultaneously the pancreatic capsula at the formation level is prepared step by step, ensuring hemostasis and continuity of the ductus of Wirsung. The extirpation of insulinoma is achieved, without damaging the pancreatic duct, as such a complication would require another treatment modality. Discussion The preoperative evaluation of insulinoma patients is a crucial aspect of the successful treatment. Patients should be thoroughly questioned for the lifestyle habits and diet; also, complete hormonal panel and tests should be performed for organic hypoglycaemia. Next step on the correct diagnosis is the imaging and tumor location. It is advised to perform triphasic abdominal Computed Tomography. With the development of Endoscopic Ultrasound, it has cemented its role as a sensitive and reliable examination, capable of fine needle aspiration when indicated. Other procedures include Magnetic Resonance Imaging (MRCP), PET/CT and somatostatin receptor scintigraphy. The surgical approach is dependent on the location of the tumor and its distance to the Wirsung ductus. Some procedures include caudal pancreatectomy, resection of the uncinate process, central pancreatectomy. Enucleation is advised wherever possible to preserve parenchyma. Conclusion When the tumor has been evidenced, the next step for the surgeons to decide the best surgical procedure (excision and parynchyma sparing, or pancreatectomy). The open surgical approach is currently advised as there is no clear consensus on the benefits of the minimal invasive laparoscopic route. On this specific case the abdominal computed tomography was unable to identify the location of the tumor. Other diagnostic options are thus indicated. Following MRCP, the localization in the body of pancreas of insulinoma was confirmed. During the surgery the continuity of Wirsung ductus was preserved, and a complete enucleation of the tumor performed. Keywords: General Surgery, Pancreatic Cancer, Pancreas Tumor, Insulinoma, Pancreatic Resection. DOI: 10.7176/JEP/14-29-03 Publication date:October 31st 202

Surgical Treatment of a Severe Anogenital Condyloma Acuminata – Case Report

Background Condyloma acuminata is a medical condition caused by human papillomavirus (HPV). It is manifested in the form of warts of the anogenital region. HPV is one of the most common sexually transmitted diseases. Other factors that increase condyloma prevalence are the number of lifetime sexual partners, chlamydia and gonorrhoea infections, HIV and smoking. Lesions appear as skin-coloured papules which can be pedunculated, flat or in severe cases take a cauliflower shape. An advanced condyloma acuminata may transform into Buschke-Lowenstein tumour, a large mass that occupies the entire anogenital area. Among other medical options, surgical excision is the only treatment with close to 0% recurrence rates. Case presentation A 63 years old female patient presents to the surgical consult clinic with the complaint of a gigantic anogenital lesion which occludes the anal canal and vaginal orifice. The lesion causes pruritus, pain and difficulty in passing stool. She refers performing a surgical procedure for the excision of anogenital warts 8 years prior, in a hospital of a foreign country. The mass has grown vastly, hindering normal daily activity. After obtaining patient consent a radical surgical procedure is performed, with the extirpation of the whole vagino-perianal condyloma. Discussion Condyloma acuminata remains a serious disorder that, if caught early, has a variety of therapeutic options. In most extreme cases abdominoperineal resection becomes the only option left after malignant transformation as a result of delayed diagnosis. We recommend an aggressive surgical approach to treat advanced ano-genital condyloma acuminata to prevent recurrence and possible malign transformation. Conclusion Condyloma acuminata is a complex and difficult to treat condition. Doctors should inform patients upon the diagnosis of condyloma for the route of transmission, safe sexual behaviour, which includes utilizing barrier protection, avoiding anal intercourse and having multiple partners. They should be advised to inform partners of their diagnosis. Surgical resection is the only treatment option with almost 0% recurrence rates. Patients with large lesions, recurrent condyloma or ineffective medical treatment should be referred to a specialist for surgical removal. Keywords: General Surgery, Condyloma Acuminata, Anogenital Wart, Buschke-Lowenstein Tumor, HPV DOI: 10.7176/JEP/14-16-01 Publication date:June 30th 202

D4 Duodenal GIST Presenting with Acute GI Hemorrhage – Case Report

Background A gastro-intestinal stromal tumour is a type of cancer that develops in the wall of the digestive tract. Its origin is a debated topic. The most common location in the gastrointestinal tract is the stomach, small intestine, colon esophagus and in rare occasions in the duodenum (approximately 4% incidence). For the most part GISTs may be asymptomatic, as the volume of the tumor grows, so do complications and signs arise. Current protocols support the treatment by resectional surgery and targeted therapy, most commonly with imatinib. As lymph node involvement is uncommon, lymphatic curage is not recommended and a more conservative surgical approach is possible, depending on the location of the tumor. Case presentation Our patient is a 60 years old male admitted to the Gastro-enterology department for the diagnosis of acute gastro-intestinal hemorrhage, manifested with haematochezia. He was treated on the course of 3 days conservatively and resuscitated to correct anaemia. The diagnosis of D4 GIST is confirmed via fibro-gastro-duodenoscopy. The patient is prepared for surgery. Due to clear margins of resection an no involvement of pancreas and superior mesenteric vessels, a segmental resection of D4 and part of D3 is performed, followed by a duodeno-jejunal end-to-end anastomosis. The patient was discharged in good health on the 14th post-operative day. Discussion Due to the complex anatomy of the duodenum and special relationships with adjacent organs many authors recommend a pancreatico-duodenectomy as clear margins are difficult to attain. Other authors support the local excision of the tumor due to the high morbidity and risk of a Whipple procedure. In cases where local excision is feasible, the defect is closed by primary rraphy or Roux-en-Y duodeno-jejunostomy. On the technical aspect, studies do not support the excision of wider clear margins around the tumor. Local recurrence is a more prominent feature of adenocarcinomas, whereas GISTs do recur in distant locations. Surgical resection of GISTs is guided by tumor size, infiltration and adjacency to other organs, most importantly the papilla Vater. Conclusion Current protocols for D4 or jejunal GISTs support the segmental resection and end-to-end duodeno-jejunal anastomosis or side-to-side anastomosis. In our case the pancreas and the superior mesenteric vessels were not involved and the tumor was 30mm in size. As a result of the non-infiltrative nature of this tumor and relatively small size its resection was successfully performend, followed by end-to-end anastomosis of the duodenum and jejunum. Keywords: General Surgery, Duodenal Cancer, GIST, Duodenal Resection, Duodeno-Jejunal Anastomosis. DOI: 10.7176/JEP/14-29-02 Publication date:October 31st 202

Foreign Body in the Fallopian Tube – Case Report

Background Foreign bodies in the female pelvic cavity are rare cases that demand expert imaging skills to interpret and evaluate the correct anatomic location, shape and consistency. More often than not these foreign bodies have transmigrated from the utero-vaginal cavity. After literature research we have found several instances of contraceptive devices, tubal ligation clips, intrauterine devices, vaginal rings, etc. However, the traumatic, extracorporeal and intestinal perforation origin should not be overlooked. Case presentation The 59-year-old female patient presents to the surgical consult clinic with the complaints of pelvic region pain for over three months. After several other specialties consults a radio-opaque foreign body was found in the pelvic cavity on a pelvic x-ray. The patient refers that during an MRI examination the machine had an emergency stop. According to the technician this could happen when a ferro-magnetic body is encountered. She denies having inserted any intrauterine device, nor other gynaecologic procedures. Also, she denies having knowingly ingested any foreign bony or metallic body. We suggested a CT scan, which shows a dense, fragmented foreign body of an approximate 4cm length in the intraperitoneal pelvic cavity, in close contact to the fallopian tube. After a median inferior laparotomy. This bipartite, rusty, metallic foreign body had perforated the fallopian tube and was partially intraperitoneally enveloped by the greater omentum. We proceeded with the foreign body extirpation and a cuneiform oophorectomy of the same side due to an ovarian cyst. The patient had a full recovery. Discussion In our literature review we have found only a small number of instances of intraperitoneal foreign bodies of unknown origin. Our patient denied having ingested metallic or bony materials, also denied any gynaecologic procedures or having inserted intrauterine devices. Transmigration of metallic uterine devices is a well-known fact. Thus, patient history does not offer much information on this case. Imaging studies and an expert evaluation of the foreign body location was a determinant factor for the surgical treatment strategy. Conclusion Due to the rarity of such cases of non-ingested intraperitoneal foreign bodies, this patient presented a diagnostic and therapeutic dilemma. After verifying the presence of the opaque body in the pelvic cavity, in close relationship to the Fallopian tube, an open surgical approach was concluded to be the most feasible option, taking in consideration the possibility of intestinal integrity compromise. Keywords: General Surgery, Foreign Body, Fallopian Tube, Intraperitoneal, Perforation. DOI: 10.7176/JEP/14-16-03 Publication date:June 30th 202

Perihepatic Abscess due to Remnant Gallstones Post-Cholecystectomy – Case Report

Background Intraabdominal abscesses are collections of pus or infected material, surrounded by inflammatory tissues in the abdominal cavity. Clinically they are manifested with fever, abdominal pain, malaise, weakness, change in bowel habits, etc. On physical examination a palpable, swollen and tender mass of the abdomen may be noted. Blood tests may show an elevated number of leucocytes with the predominance of neutrophiles. Also, inflammation markers such as CRP, ESR and procalcitonin may be elevated. Diagnosis of an abdominal abscess is confirmed, but not limited to Computed Tomography, Ultrasound, MRI. Antibiotic therapy may be of use treating the cause of the abdominal abscess, however once the abcess is formed, antibiotics lose their effectiveness. Percutaneous drainage, laparoscopic or open surgery are the options for the definite treatment of intraabdominal abscesses. Case presentation Our patient is a 70 years old male with a past surgical history of a laparoscopic cholecystectomy 5 years prior to the current events. He presents to the surgical department for a lumbar region abscess which had been drained three times for the past 6 months. On clinical examination a considerable reddish tumefaction on the right lumbar region evacuates upon incision a moderate amount of odourless pus. An abdominal CT shows a subphrenic and subhepatic abscess with a communicating trajectory from the abscess to the skin opening in the lumbar region. Contrast MRI confirms the presence of numerous stones inside the subhepatic collection. The abscess was drained via open surgery and residual gallstones were removed. The patient recovers well. Discussion Only after the development of laparoscopic technique, cases of abdominal abscesses due to residual stones have started to appear in the literature, hence the name “disease of medical progress”. Studies show that between 5-40% of laparoscopic cholecystectomies are complicated by gallbladder perforation and stone spillage, more commonly in acute inflammation cases. 15-50% of the spilled stones are not retrieved and may migrate and cause significant complications. Most of the abdominal abscesses from residual gallstones form in the first year after cholecystectomy, or many years later. Compliances rate following gallstone spillage vary widely from 0.04% to 19%. Cases of acute cholecystitis, male sex, old age, number of lost stones greater than 15, diameter over 15mm and perihepatic localization are predictors of severe morbidity. Conclusion There is no clear consensus on the treatment and management of lost gallstones during cholecystectomy, but every attempt should be made to collect spilled stones. Surgeons should document cases of lost and unretrievable gallstones and inform patients, as complications may be rare but severe and demand more often than not open surgery. Keywords: General Surgery, Laparoscopic Cholecystectomy, Residual Gallstones, Perihepatic Abscess. DOI: 10.7176/JEP/14-29-04 Publication date:October 31st 202

Surgical Repair of Rectocele – Case Report

Background Rectocele is the herniation of the rectum through the posterior wall of the vagina due to the loss of integrity of the rectovaginal fascia. Many parous women have a sort of pelvic organ prolapse, though most of the time this is asymptomatic. Over time, as the defect becomes larger, the patient may complain of constipation, difficult defecation, pelvic pain, mucosal erosion and the presence of a visible bulge. Among treatment options, dietary and lifestyle changes are recommended, medications, devices such as vaginal pessaries and surgical procedures. Case presentation Our 60 years old female patient was diagnosed 7 years before with rectocele. On the last 2 months it had reached considerable dimesions (grade III-IV). She complained of difficulty in urination and had a urinary catheter placed. The surgical procedure was proposed and patient consent obtained. A posterior colpo-perineorraphy was performed, without mesh placement. The patient made a full recovery and was discharged. Discussion The initial treatment of rectocele starts with the modification of the risk factors and relief of obstructive defecation syndrome. Patients are prescribed osmotic laxatives along with dietary changes for more fibre intake. Usage of pessaries, space occupying vaginal devices may be of help in select patients and it should be mentioned as a therapeutic alternative, though care must be taken to ensure proper usage as mucosal damage has been reported. The patients with severe and symptomatic rectocele should undergo a surgical intervention. From the list of possible approaches, we can mention: a) posterior colporraphy with the reinforcing of the rectovaginal septum, with or without the placement of a reinforcing prosthetic mesh. Some studies report higer recurrence rates where mesh was applied; b) transanal plication; c) transanal resection; d) abdominal suspension. Ultimately each of the procedures comes with the associated risks. Conclusion To conclude, it is the decision of the surgeon to find the best surgical approach for the treatment of rectocele. Not only he should be comfortable with the procedure, but care should be taken to achieve the full relief of the symptoms of the patient. For this specific case, due to the higher stage of rectocele, a posterior colporraphy, with the transvaginal plication of rectovaginal septum was chosen as a safe and efficient surgical approach. Keywords: General Surgery, Rectocele, Perineum, Pelvic Floor, Colpo-perineorraphy, Colporraphy. DOI: 10.7176/JEP/14-32-05 Publication date: November 30th 2023

Severe Acute Necrotizing Pancreatitis – Case Report

Background Acute necrotizing pancreatitis is a severe form of pancreatitis. It is confirmed with an MRI (MRCP) or IV contrast CT, which shows that more than 30% of the pancreas is not enhanced. A prompt diagnosis of necrotizing pancreatitis is important because it has implications in morbidity and mortality. Treatment of the necrotizing type is different compared to the interstitial pancreatitis. More often than not, patients with necrotizing pancreatitis appear unwell, in shock or in multiple organ failure. The decision when and what type of surgery is needed for necrosis debridement, should be made by the pancreatic surgeon, after discussions with gastro-enterologists. Case presentation The patient was surgically treated for acute cholecysto-pancreatitis with empyema and peritonitis. For 10 days he was treated at the hospital, but was not improving. He presented signs of septic shock, hypotension, fever, leucocytosis and purulent discharge from abdominal drains. After initial resuscitative measures, it is concluded the patient need and urgent laparotomy for necrosis debridement. One month after the necrectomy and multiple drainage procedure the case is complicated by bile leak after the removal of a T-tube. Failure of ERCP prompted a reintervention for the surgical placement of a common bile duct stent. The patient recovered well and was discharged from the hospital. Discussion Patients diagnosed with acute pancreatitis should be looked up finding the possible cause. 50-60% of the incidence is due to gallstones or related problems. Approximately 20% of the cases are caused by alcohol intake and the rest have an idiopathic etiology. The first step in managing acute pancreatitis is fluid and electrolyte rehydration, maintaining adequate systemic circulation. Antibiotic treatment is a controversial topic regarding the timing. Antibiotic use has shown benefit when administered early in patients with necrotic pancreatitis. There is an ongoing debate if the patient should be kept nil per or should continue enteral nutrition as tolerated. However nutritional support is an important component, as catabolic states are associated with higher mortality. Conclusion It is generally recommended that sterile necrotic pancreatitis is treated conservatively with early antibiotics. Meanwhile, patient with infected necrosis should be treated surgically, via endoscopy, laparoscopy, percutaneous drainage or open surgery. Keywords: General Surgery, Acute Pancreatitis, Necrotizing Pancreatitis, Debridement. DOI: 10.7176/JEP/14-16-02 Publication date:June 30th 202

Ruptured Hemorrhagic Liver Metastasis in a Gastric Cancer Patient – Case Report

Background Gastric cancer is a type of tumor that develops in the lining of the stomach. Most common histological type is adenocarcinoma of varying degree of differentiation. Other known types are gastric lymphomas or mesenchymal tumors. Treatment of gastric cancer depends on the stage, but surgery can be the only curative option. Early gastric cancer patients benefit from mini-invasive techniques such as endoscopic mucosal resection. However, more advanced stages require major surgical resection. Gastric cancer treatment is complemented by chemotherapy, radiotherapy and targeted immunotherapy. There is a common consensus that most cases of advanced gastric cancer (stage IV) with liver metastases do not benefit from major surgery, but should continue other treatment options. In emergency cases surgical intervention may be unavoidable. Case presentation Our patient is a 49 years old male diagnosed 4 months prior to the current events with gastric adenocarcinoma, with a liver metastasis of 4×5cm in the VI-th segment. He was ongoing a chemotherapy course. During the 3rd cycle of chemotherapy, he suffers from major hemorrhage manifested with melena and hematemesis. He was treated at the nearest regional hospital. The surgeons concluded that the patient should undergo emergent surgery to stop the hemorrhage. A subtotal gastrectomy was performed. Just about the moment for the abdominal closure, the metastasis of the VI-th segment ruptures, with a following abundant intraperitoneal hemorrhage. Under the conditions of unattainable hemostasis, the surgeons bandage the lesion and the right lobe with gauzes and prepare the immediate transfer of the patient in our clinic where he underwent a second intervention for the resection of the segment VI of the liver where metastasis was ruptured. On the 10th postoperative day, the patient was discharged in an improved condition. Discussion Gastric cancer with hepatic metastases is an advanced stage and thus has a poor prognosis. In these cases, the first-line treatment is systemic chemotherapy. Surgery is most often performed only in severe gastro-intestinal symptoms such as hematemesis and melena that do not respond to conservative measures, or to overcome obstruction. Conclusion The majority of retrospective studies does not support the surgical resection surgery in advanced cases, as it is detrimental to the overall prognosis. On the other hand, the benefits hepatic resection for colorectal cancer metastases have been clearly established. Conversion therapy for stage IV gastric cancer is a topic of ongoing investigation and the frontier of oncologists and general surgeons. Keywords: General Surgery, Gastric Cancer, Liver Metastasis, Liver Resection, Ruptured Metastasis. DOI: 10.7176/JEP/14-27-05 Publication date:September 30th 202

Hepatic Resection for Liver Abscess – Case Report

Background Hepatic abscesses are confined masses of pus in the liver that generally form following liver trauma or abdominal infections. They can be classified by the causing organism as bacterial or amoebic (pyogenic abscesses), parasitic (hydatiform) or fungal. By location, most solitary abscesses form on the right lobe due to greater blood circulation, thus left sided abscesses are less commonly found. Intraabdominal inflammatory processes with bacterial infestation may use the the portal system to disperse the pathogen into the liver. Other mechanisms follow a more direct route. Acute cholangitis, or infection of the biliary tree can form a liver abscess per continuitatem. Risk factors for a liver abscess include all the risk factors for cholangitis or intraabdominal infections such as: appendicitis, cholecystitis, diverticulitis, bacteremia, endocarditis, biliary tract malformations, cysts and strictures or hepatocalculosis. Culprit pathogens include: E. Coli, Streptococcus, Staphylococcus, Klebsiella, E. Histolytica, but usually liver abscesses are multimicrobial. Liver metastases may also cause a liver abscess, which is not to be overlooked. Case presentation The patient is a 32 years old female who was transferred from a regional hospital. She had the complaints of abdominal pain of the right upper quadrant, high temperature (39-40°C) for three weeks. The patient was treated with a wide range of antibiotics, but no improvement was noted. An abdominal CT scan evidenced a large multi-cameral hepatic abscess involving segments VI-VII and VIII. The patient was transferred to the Intensive Care Department where she was resuscitated due to the severe septic state. She underwent the procedure of surgical drainage and resection of hepatic segments VI-VII. On the 10th postoperative day she was discharged in good health. Discussion Size and location are important determining factors in the treatment strategy. For most of the cases of abscesses small and responsive to medical therapy the preferred route is the percutaneous drainage. However, it is in the surgeon’s discretion to decide whether an open approach is more beneficial for the patient. Conclusion Surgical drainage remains a cornerstone in the treatment of liver abscesses, especially those unresponsive to medical therapy. Patients with delayed diagnosis are more likely to need drainage or surgery. Our case underlines the importance the involvement of a multidisciplinary team and especially the surgeons in the treatment of patients with liver abscesses, as in advanced stages empiric medical therapy may be ineffective. Keywords: General Surgery, Liver Abscess, Pyogenic Abscess, Liver Resection, Segmental Resection. DOI: 10.7176/JEP/14-27-04 Publication date:September 30th 202