Introduction: The finding of vermiform appendix in inguinal hernia, inflamed or not, is called Amyand's hernia. The aim of this study is to present the experience with Amyand’s hernia in a Greek surgical department.Patients and Methods: We studied retrospectively 963 patients with inguinal hernia who were admitted to our surgical department over a 12-year period. Four patients presented with Amyand’s hernia (0.4%). One of them had an inflamed vermiform appendix in his sac (acute appendicitis), presented as incarcerated right groin hernia and underwent simultaneous appendicectomy and Bassini’s suture hernia repair. Two patients with normal appendix had a plug-mesh hernia repair without appendicectomy. The fourth patient, a young adult with a big non-inflamed appendix in his sac had a plug-mesh hernia repair with appendicectomy.Discussion: A hernia surgeon may encounter unexpected intraoperative findings, such as Amyand’s hernia. It is important to be prepared and apply the appropriate treatment in any case.

Poster: ECR 2018 / C-2823 / Imaging of esophagectomy surgical techniques and post-esophagectomy complications by: M. Sidiropoulou, K. Ballas, G. Sapouridis, I. Gkoutziotis , E. Stergiopoulou, A. Kamparoudis, A. Anastasiou ; Thessaloniki/GR

Background: We present a unique case scenario of a periaortic liposarcoma masquerading as an impending rupture of an inflammatory abdominal aortic aneurysm (AAA). Methods and results: A 57-year-old man was referred to our unit for an emergency endovascular repair of "an inflammatory AAA with computed tomography (CT) features of impending rupture." He underwent an uneventful endovascular repair with a bifurcated endograft (C3; Gore, Flagstaff, AZ). Seven weeks later, CT showed that the periaortic "mass" grew larger and asymmetric, and a CT-guided needle biopsy suggested the presence of a high-grade malignant mesenchymal tumor. He underwent laparotomy and excision of the retroperitoneal tumor en bloc with the anterior wall of the infrarenal aorta. The endograft acted as an excellent "safety net" providing adequate hemostatic control and obviating the need for aortic cross-clamping and repair of the aortic defect with a patch or tube graft. Conclusions: The learning point from the present case is that when faced with an inflammatory AAA and/or retroperitoneal fibrosis, the rare possibility of a retroperitoneal neoplasm should be kept in mind.

PURPOSE:We have investigated the possible positive effect of iloprost in the healing of colonic anastomosis, in rats under intraperitoneal chemotherapy with irinotecan.METHOD:Forty male Wistar rats have been divided into four groups. They underwent a partial colectomy and a termino-terminal anastomosis. They were administered, intraperitoneally, saline (group 1), irinotecan (group 2), iloprost (group 3), or irinotecan and iloprost (Group 4). After the sacrifice of the animals what followed was an autopsy, a macroscopic examination and the measurement of the anastomotic rupture pressure. A portion of the anastomosis was sent over for histological examination and determination of hydroxyproline levels. Results: The frequency of the leakage from the anastomosis was considered as significantly increased in group 2 compared with the other groups. In group 2, a significantly greater degree of adhesions, compared to all the remaining groups, was observed. The bursting pressure of the anastomosis was significantly lower in group 2, as compared with all the remaining groups, and significantly increased in the group 4 compared with group 2. Leukocytosis, fibroblasts, the neocollagen and the levels of hydroxyproline in group 4 showed significantly increased values, compared with group 2. The angiogenesis was significantly increased in groups 3 and 4 compared with group 2. Conclusions: Intraperitoneal administration of iloprost after colectomy, termino-terminal anastomosis and intraperitoneal administration of irinotecan promotes the healing process of the colon anastomoses as it competes the inhibitory effect of irinotecan.

Introduction Rectovaginal tears are usually associated with the insertion of foreign bodies, accidental trauma, and nonconsensual intercourse. Aim The aim of this study was to describe an extremely rare case of extensive rectovaginal tear as a result of consensual vaginal and anal intercourse. Methods A case is presented along with review of the literature. Results A 20-year-old woman presented with acute perineal pain and minor vaginal bleeding following consensual vaginal and anal intercourse. No insertion of sex toy or any other object was reported. Vaginal and rectal examination revealed a ruptured posterior vaginal wall with wide communication with the rectum, without involvement of the anal sphincters. Surgical treatment with primary repair of the tear and diverting colostomy was performed. Conclusions Although consensual intercourse is usually associated with minor genital trauma, rare but potentially serious injuries can occur. Clinicians should be aware of the possibility of such injuries because failure to identify them can lead to delayed treatment and poor outcome.

BACKGROUND:The aim of this experimental study was to investigate whether the perioperative administration of the selective cyclooxygenase-2 inhibitor celecoxib affects the angiogenetic process and the healing of colonic anastomoses.METHODS:Seventy-two male Wistar rats underwent colonic resection and anastomosis. Celecoxib (10 mg/kg/day-celecoxib group) or placebo (control group) was administered perioperatively. Rats of both groups were sacrificed on either the third or the seventh postoperative day and bursting pressures of the anastomoses were measured. Gelatine-degrading matrix metalloproteinases (MMPs) were identified with gelatine zymography, and proMMP-2 and vascular endothelial growth factor (VEGF) levels from both anastomotic site and tissue adjacent to the anastomosis were evaluated. Histologic evaluation of microvessels was performed by immunohistochemistry using an anti-CD34 monoclonal antibody.RESULTS:Celecoxib did not significantly decrease anastomotic bursting pressures. Gelatin zymography revealed the presence of MMP-2, proMMP-2, and proMMP-9. MMP concentration was higher at the anastomotic tissue as compared with tissue distant to the anastomosis. Celecoxib resulted in a significant reduction in proMMP-2 levels at the anastomosis at both third and seventh postoperative day. VEGF levels from the anastomotic tissue were also found lower in the celecoxib group. Histological examination showed a celecoxib-induced reduction of newly formed CD34-stained vessels.CONCLUSIONS:Although the perioperative administration of celecoxib resulted in suppression of angiogenesis in the newly formed anastomoses, bursting pressures remained unaffected and subsequently safety was not compromised.

BACKGROUND AND AIMS:Although declining, cystic echinococcosis is still a serious public health issue in Greece. This study evaluated the clinical features, management, and short-term outcome of patients with complicated liver echinococcosis.MATERIAL AND METHODS:A total of 227 patients who were operated on for 322 echinococcal cysts of the liver were retrospectively evaluated. Patients were divided into those with complicated disease (53.7%) and those with noncomplicated disease (46.3%). Intrabiliary rupture (34.4%), cyst infection (32.7%), and their combination (24.5%) were the most common complications. Demographic characteristics, previous hydatid cyst surgery, cyst multiplicity and location, presenting symptoms and signs, types of complicated disease, operative procedures performed, postoperative complications, and hospital stay were assessed.RESULTS:Patient demographics and cyst characteristics demonstrated no significant difference between the two groups. The complicated disease group had significantly more pronounced clinical presentations and higher postoperative morbidity. Choice of surgical procedure depended upon cyst location and surgeon preference. Both conservative and radical procedures were performed, supplemented with additional management of the biliary tree when indicated.CONCLUSIONS:Complicated liver echinococcosis demonstrates several distinct features that differentiate it from the noncomplicated disease. Frequently severe clinical manifestations, complexity of surgical management, and the increased postoperative complications characterize complicated liver echinococcal disease.

Introduction: Tension pneumoperitoneum is defined as the massive accumulation of air in the peritoneal cavity, which results in a sudden increase in intraabdominal pressure.Various iatrogenic procedures are responsible for this complication.We herein report a case of tension pneumoperitoneum resulting from upper gastrointestinal endoscopy.Case Description: A 45-y-old man was referred to our department because of melena.Esophagogastroscopy was unsuccessful because of failure to inflate the stomach, and sudden abdominal distension was noted immediately after the procedure.The hemodynamic status of the patient was compromised, and the imminent collapse was prevented with emergent needle paracentesis.Decompression of the abdominal cavity restored vital signs to normal allowing definitive surgical treatment.Discussion: Upper gastrointestinal endoscopy is a rare cause of this life-threatening complication.The combination of acute abdominal distension with hemodynamic instability following endoscopic procedures should raise suspicion of tension pneumoperitoneum.Needle decompression is life-saving and should be performed instantly upon recognition of this condition.

The inadvertent insertion of a nasogastric tube (NGT) into the brain of a trauma patient with skull base fractures is reported. A 52-year-old male with head trauma was referred following a car accident with an NGT in situ. Serosanguineous fluid was withdrawn from the NGT, which was considered to be an indication of gastrointestinal bleeding, and cold saline lavage was performed. Skull X-rays revealed intracranial position and coiling of the NGT and pneumocranium. The NGT was immediately removed manually. The patient finally went through neurosurgical operation because of an extradural hematoma, with normal postoperative course and outcome.

Isolated perforation of the small bowel after blunt abdominal trauma is infrequent and the diagnosis can be elusive. Although computerized tomography is the modality most commonly used, there is no consensus over the optimal diagnostic approach. Diagnostic difficulties result in delayed surgical treatment and eventually in increased morbidity and mortality. We report two cases of isolated small bowel perforation after blunt abdominal trauma in patients involved in car accidents. Seat belts were used in both cases. Thorough physical examination and immediate diagnostic radiology and laboratory workup failed to detect evidence of any intraabdominal injury. Deterioration of the clinical picture raised suspicion of small bowel perforation and the delayed surgical intervention resulted in postoperative complications and prolonged clinical course.

Introduction Injury of the gallbladder after blunt abdominal trauma is an unusual finding; the reported incidence is less than 2%. Three groups of injuries are described: simple contusion, laceration, and avulsion, the last of which can be partial, complete, or total traumatic cholecystectomy. Case presentation A case of isolated complete avulsion of the gallbladder (near traumatic cholecystectomy) from its hepatic bed in a 46-year-old Caucasian man without any other sign of injury is presented. The avulsion was due to blunt abdominal trauma after a car accident. The rarity of this injury and the stable condition of our patient at the initial presentation warrant a description. The diagnosis was made incidentally after a computed tomography scan, and our patient was treated successfully with ligation of the cystic duct and artery, removal of the gallbladder, coagulation of the bleeding points, and placement of a drain. Conclusions Early diagnosis of such injuries is quite difficult because abdominal signs are poor, non-specific, or even absent. Therefore, a computed tomography scan should be performed when the mechanism of injury is indicated.

Background: Bevacizumab is a monoclonal antibody targeted at vascular endothelial growth factor (VEGF) to treat advanced colorectal cancer as well as other malignancies, but the ideal time point for its administration in patients scheduled for surgery is not well defined due to serious concerns regarding possible side effects on wound healing. Therefore, we conducted an experimental study in rats to clarify this issue. Methods: Four groups of 10 Wistar rats each underwent a 4-cm midline laparotomy and closure of the wound in 2 layers. In the treatment groups (A and B), bevacizumab (Avastin®) received a single dose of 5 mg/kg i.p., and an equal amount of saline was given to the control groups (C and D). Groups A and C were sacrificed on the 7th postoperative day, and groups B and D on the 14th postoperative day. Wounds were inspected by two independent observers upon sacrifice and results were recorded; wound tissues were sent for histology to assess the degree of fibrosis and measurement of tissue hydroxyproline levels. Serum levels of endothelin-1, C-reactive protein, pro-oxidant/antioxidant balance and carbonylated proteins were also determined. For statistical analysis, the Mann-Whitney U test was used. Results: Wound healing did not differ among groups both on the 7th and the 14th postoperative days, and there was also no significant difference regarding the degree of inflammation, fibroblast proliferation and collagen synthesis, as well as hydroxyproline and biochemical marker levels among the groups. Conclusions: Intraperitoneal bevacizumab administered intraoperatively does not significantly affect abdominal wound healing in rats.

INTRODUCTION: Idiopathic spontaneous intra-abdominal haemorrhage is a rare, but challenging condition, associated with high mortality if not managed appropriately. The preoperative diagnosis is difficult, despite the recent advances in imaging. We present the clinical manifestations of this condition, as well as the available diagnostic and therapeutic modalities.PRESENTATION OF CASE: We report a case of a spontaneously ruptured dissecting aneurysm of the middle colic artery, which was managed with an emergency laparotomy and aneurysmatectomy. Interestingly, no evidence of vasculitis, infection or collagen disease was discovered during the histopathology examination of the specimen.DISCUSSION: The treatment of idiopathic spontaneous intra-abdominal haemorrhage revolves around patient resuscitation and management of the source of bleeding. In case of a ruptured aneurysm of the middle colic artery, the surgical management includes emergency laparotomy, arterial ligation and resection of the aneurysm. Transarterial embolisation has been suggested as a safe and less invasive alternative approach.CONCLUSION: A ruptured middle colic artery aneurysm should be included in the differential diagnosis of any unexplained intra-abdominal haemorrhage. Aneurysmatectomy is the treatment of choice, with radiologic interventional techniques gaining ground in the management of this entity. (C) 2011 Surgical Associates Ltd. Elsevier Ltd. Open access under CC BY-NC-ND license.

INTRODUCTION:A vermiform appendix in an inguinal hernia, inflamed or not, is known as Amyand's hernia. Here we present a case series of four men with Amyand's hernia.CASE PRESENTATIONS:We retrospectively studied 963 Caucasian patients with inguinal hernia who were admitted to our surgical department over a 12-year period. Four patients presented with Amyand's hernia (0.4%). A 32-year-old Caucasian man had an inflamed vermiform appendix in his hernial sac (acute appendicitis), presenting as an incarcerated right groin hernia, and underwent simultaneous appendectomy and Bassini suture hernia repair. Two patients, Caucasian men aged 36 and 43 years old, had normal appendices in their sacs, which clinically appeared as non-incarcerated right groin hernias. Both underwent a plug-mesh hernia repair without appendectomy. The fourth patient, a 25-year-old Caucasian man with a large but not inflamed appendix in his sac, had a plug-mesh hernia repair with appendectomy.CONCLUSION:A hernia surgeon may encounter unexpected intraoperative findings, such as Amyand's hernia. It is important to be prepared and apply the appropriate treatment.

AIMTo evaluate the efficacy of the isolated Roux loop technique in decreasing the frequency of pancreaticojejunal anastomosis failure.METHODSWe retrospectively reviewed 88 consecutive patients who underwent pancreaticoduodenectomy (standard or pylorus-preserving). Single jejunal loop was used in 42 patients (SL group) while isolated Roux loop was used in 46 patients (RL group). Demographic characteristics (age, gender) and perioperative results (major/minor complications, mortality, hospital stay) were compared between the two groups.RESULTSMortality was almost equal in both groups and overall mortality was 2.27%. Leak rate from the pancreaticojejunal anastomosis and hospital stay were lower in the RL group without significant difference. Morbidity was 39.1% in the RL group, insignificantly higher than the SL group. Operative time was almost 30 min longer in the RL group.CONCLUSIONThe isolated Roux loop, although an equally safe alternative, does not present advantages over the traditional use of a single jejunal loop. Randomized controlled studies are required to further clarify its efficacy.

OBJECTIVES: The aim of this study was to compare the effectiveness of atorvastatin with the sodium hyaluronate/carboxymethylcellulose (HA/CMC, Seprafilm; Genzyme; Genzyme Biosurgery Corporation, Cambridge, MA) in preventing postoperative intraperitoneal adhesion formation in rats.METHODS: Sixty Wistar rats underwent a laparotomy, and adhesions A were induced by cecal abrasion. The animals were divided into 4 groups: group 1, control A; group 2, (A + atorvastatin); group 3, (A + HA/CMC), and group 4, (A + atorvastatin + HA/CMC). The atorvastatin (groups 2 and 4) and HA/CMC (groups 3 and 4) were administered intraperitoneally before the abdominal wall was closed. After 14 days, adhesions were classified by 2 independent surgeons.RESULTS: The adhesion scores (mean standard deviation) for groups I, 2, 3, and 4 were 2.93 +/- .59, 1.85 +/- 1.07, 1.80 +/- .86, and 1.93 +/- .70, respectively. The differences in adhesion scores among all 3 preventive groups (groups 2, 3, and 4) were statistically significant when compared with the control group (P = .005, P = .002, and P = .009, respectively).CONCLUSIONS: These data suggest that atorvastatin, administered intraperitoneally, is as effective as HA/CMC without an expectable additive effect in preventing postoperative adhesions in rats. (C) 2010 Elsevier Inc. All rights reserved.

BACKGROUND:Sigmoidorectal endometriosis accounts for 70% of the cases of intestinal endometriosis. Symptoms are non-specific, frequently resembling adenocarcinomas.CASE:A 45-year-old woman complaining of recurrent rectal bleeding underwent colonoscopy in which a rectal polypoid mass was found. She underwent anterior rectosigmoidectomy and the histological examination of the resected bowel revealed rectal endometriosis with lymph node involvement.CONCLUSION:Lymphatic infiltration of epicolic lymph nodes raises questions about the benign nature of this presumed innocent disease.

To the Editor: We read with interest the article by SerraAracil et al and we would like to congratulate the authors for the well designed and conducted prospective randomized study about preventing parastomal hernias (PH), a subject that remains the “Achilles heel” of colostomy construction. We agree with the authors that it is necessary to find a way to prevent parastomal herniation mainly due to the extremely high prevalence of PH. According to Goligher “Some degree of herniation around the colostomy is so common that this complication may be regarded as virtually inevitable.” Although there are no specific data about the incidence of PH, it is believed that its incidence is around 20% to 40% and most of them develop in the first few years after stoma construction. Fortunately, the majority of PH are asymptomatic and according to general estimates only 10% of them require surgical correction. However, results of surgical treatment of PH are completely disappointing. Conventional techniques for the reconstruction of PH have consistently been related to a very high recurrence rate, ranging from 36% to 100%. Only use of absorbable or nonabsorbable meshes placed in either a sublay or an onlay position give promising results. The early fear of using synthetic material in a probably contaminated field overcame by time after publication of an increasing number of studies with the use of meshes for such kind of repair. Based on these results, early in 1986, Bayer et al first tried to use a synthetic mesh around the stoma for the prevention of PH. Although the results were very impressive, the method was not widely accepted mainly because of the fear of complications associated with the mesh. In the last decade, a few articles have been published with the use of meshes for prevention of parastomal herniation (Table 1, Supplemental Digital Content 1, available online only at: http://links.lww.com/SLA/A28). However almost all of these studies, including the study published into your journal, have some common weak points. We would like to ask the authors why emergency cases as well as patients with increased BMI, malnourished, or patients with hepatic cirrhosis, severe chronic obstructive disease, and corticoid treatment have been excluded from the study. We are asking this because it is this subpopulation that is more susceptible to early herniation and consequently in this subgroup of patients prevention is more imperatively needed. And it is very strange that this subpopulation is also excluded in all previously published studies. Only Jänes et al have included 5 patients in their study. Furthermore in this as well as in all other studies although there is a detailed description of the technique used for the mesh placement there is only a brief report without details about the method used for the conventional stoma construction. It is very dangerous, according to our opinion, especially for the younger surgeon, only to rely in some technologically produced materials to prevent PH and not to learn the proper surgical technique. It is well known that careful and exact surgical technique plays an important role in avoidance of PH. Measures such as properly sited stoma (through the rectus abdominis muscle), and proper size and construction of trephine are important in prevention of PH. In conclusion, based on published data, we believe that prophylactic mesh placement at the time of stoma formation in conjunction with proper surgical technique could be the solution to parastomal herniation. However, it is premature to advice the use of meshes for PH prevention. A much larger population must be studied to decide about effectiveness and safety of such preventive measures.